2017 Provider and Pharmacy Network
Every year that you are a participant in our plan, we will send you either a new provider directory or an update to your provider directory. This directory lists our network providers and pharmacies. Network providers are doctors, other health care professionals, medical groups, hospitals and other health care facilities that have an agreement with VillageCareMAX Full Advantage Plan to deliver covered services to participants.
You must use network providers and pharmacies to get your medical care, services and prescription drugs, with limited exceptions.
As a participant, you must choose one of our network providers to be your Primary Care Provider (PCP). Your PCP will coordinate services with specialists and other network providers if needed. There is no prior authorization required to get care from network specialists. If you need a service that requires prior authorization from the plan, your PCP or specialist will contact us to get necessary prior authorization.
The providers in the network may change throughout the year. Please check the links below for the most updated information about the providers in the network. You may also call Participant Services at 800-469-6292 (TTY 711) for help in finding a provider near your home or request a hard copy directory.
If you need specialized medical care that we cover (see your Participant Handbook) and the providers in our network cannot provide this care, you can get care from an out-of-network provider.
You must get prior authorization from our plan before you can see out-of-network providers. If you don’t get approval before you receive services from an out-of-network provider, VillageCareMAX Full Advantage FIDA Plan may not cover these services. If you need to see that provider for more care, check with us first to be sure that the approval covers more than one visit.
Emergency medical care is available anywhere in the United States or its territories.
Generally, we pay for drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy.
We will pay for prescriptions filled at an out-of-network pharmacy in the following cases:
- A participant cannot obtain a covered drug in a timely manner within the plan’s service area because there is no network pharmacy available within a reasonable driving distance.
- A drug that has been dispensed by an out-of-network institution-based pharmacy while a participant is in the emergency room.
- A participant, while out of the service area, becomes ill or runs out of his/her medications and cannot access a network pharmacy.
- Filling a prescription for a covered drug and that drug is not regularly stocked at an accessible network pharmacy.
- In these cases, please check first with Participant Services to see if there is a network pharmacy nearby.
If you pay “out-of-pocket” for a prescription drug from an out-of-network provider and you think that we should cover the expense – save your receipt and contact Participant Services or send us a request to review your claim for reimbursement.
Prescription Drug Claim Form (pdf)
Medical Participant Reimbursement Claim Form (coming soon)
Once your request for payment is received, we will let you know if we need additional information. Otherwise, we will consider your request and make a coverage determination. If we decide that the plan should pay for the drugs or services, we will mail the reimbursement to you. If we decide that the drugs or services are not covered, or you did not follow all the plan’s rules – we will not provide any payment. Instead, we will send you a letter explaining the reasons why we are not sending the payment and your rights to appeal that decision. Learn more about appeals.