OUT OF NETWORK COVERAGE
Provider Network
We call the providers and pharmacies in the provider directory our "provider network"
because we have made arrangements with them to provide services and prescription drugs to
Mercy Care Advantage members. In most cases, your health care services and prescriptions
are covered under Mercy Care Advantage only if you get them from a network provider.
Filling prescriptions at a non-network pharmacy
Getting coverage when you travel or are away from the plan's service area
If you take a prescription drug on a regular basis and you are going on a trip, be sure to check your
supply of the drug before you leave. When possible, take along all the medication you will need. You
may be able to order your prescription drugs ahead of time through our mail order pharmacy service.
If you are traveling within the United States and territories and become ill, lose or run out of your
prescription drugs, we will cover prescriptions that are filled at an out-of-network pharmacy. In this
situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your
prescription. You can ask us to reimburse you for our share of the cost by submitting a claim form. To
learn how to submit a paper claim, please refer to the paper claims process described later.
You can also call Member Services to find out if there is a network pharmacy in the area where you are
traveling. If there are no network pharmacies in that area, Member Services may be able to make
arrangements for you to get your prescriptions from an out-of-network pharmacy. We cannot pay for any
prescriptions that are filled by pharmacies outside of the United States and territories, even for a medical
emergency.
What if I need a prescription because of a medical emergency or because I needed urgent care?
We will cover prescriptions that are filled at an out-of-network pharmacy if the prescriptions are related
to care for a medical emergency or urgent care. In this situation, you will have to pay the full cost
(rather than paying just your copayment) when you fill your prescription. You can ask us to reimburse
you for our share of the cost by submitting a paper claim form. To learn how to submit a paper claim,
please refer to the paper claims process described later.
Other times you can get your prescription covered if you go to an out-of network pharmacy
We will cover your prescription at an out-of-network pharmacy if at least one of the following applies:
- If you are unable to obtain a covered drug in a timely manner within our service area because
there is no network pharmacy within a reasonable driving distance that provides 24 hour service.
- If you are trying to fill a prescription drug that is not regularly stocked at an accessible network
retail or mail-order pharmacy (including high cost and unique drugs).
- If you are getting a vaccine that is medically necessary but not covered by Medicare Part B and
some covered drugs that are administered in your doctor's office.
Before you fill your prescription in either of these situations, call Member Services to see if there is
a network pharmacy in your area where you can fill your prescription.
If you do go to an out of network pharmacy for the reasons listed above, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a claim form. To learn how to submit a paper claim, please refer to the paper claims process described next.
How do I submit a paper claim?
When you go to a network pharmacy, your claim is automatically submitted to us by the pharmacy.
However, if you go to an out-of-network pharmacy because of the reasons listed above, the pharmacy
may not be able to submit the claim directly to us and you will have to pay the full cost of your
prescription. When you return home, simply submit your claim and your paid receipt to:
Mercy Care Advantage
Attn: Member Services
4350 E Cotton Center Blvd.
Bldg. D
Phoenix, AZ 85040
Upon receipt, we will make an initial coverage determination on the claim. Please refer to your
Evidence of Coverage or call Member Services for more information on initial coverage determinations.
For more information
For more detailed information about your Mercy Care Advantage prescription drug coverage, please
review the
Evidence of Coverage and
Mercy Care Advantage's formulary.
If you have questions about Mercy Care Advantage, please call our Member Services Department at
(602) 263-3000 or toll-free at (800) 624-3879 (TTY users should call (602) 248-9273 or toll-free at
(866) 602-1982). We are available 24-hours a day, 7 days a week.