Provider and Pharmacy Network
VillageCareMAX Medicare Total Advantage has a large network of doctors, hospitals, long-term services providers, pharmacies, and other providers. We work closely with you and your providers to help ensure that your healthcare needs are met.
You must receive your care from an in-network provider or an out-of-network provider included in the Point-of-Service (POS) benefit.
The exceptions to use out-of-network providers include:
- The plan covers a Point-of-Service (POS) option that allows you to get routine medical care from certain out-of-network providers for the following services:
- Doctor Office Visits (Primary Care Provider and Specialists)
- Outpatient Rehabilitation (Physical Therapy, Occupational Therapy, and Speech Language Therapy)
- Chiropractor Services
- Podiatry Services
- The plan covers emergency care or urgently needed services that you get from an out-of-network provider.
- If you need medical care that Medicare or Medicaid requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider.
- The plan covers kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area.
For more information and prior authorization requirements, see your Evidence of Coverage.
As a member, you must choose an in-network or out-of-network provider to be your Primary Care Provider (PCP). Your PCP will coordinate services with specialists and other providers if needed. You do not need a referral from your PCP to see a specialist for routine care. If you need a service that requires prior authorization (approval in advance) from the plan, your provider will need to contact VillageCareMAX to get prior authorization. Please refer to your Evidence of Coverage for a complete listing of services that require prior authorization.
Provider & Pharmacy Directory
The 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 Medicare Total Advantage Plan to deliver covered services to members.
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 Member Services at 800-469-6292 (TTY: 711) for help in finding a provider near your home or to request a hard copy of the directory.
If you need specialized medical care that we cover (see your Evidence of Coverage) 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 Medicare Total Advantage 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 member 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 member is in the emergency room.
- A member, 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 Member 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 Member Services or send us a request to review your claim for reimbursement.
Prescription Drug Claim Form
Medical Member 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.
This page was last modified on September 26, 2017