Out of Network
Don’t worry, you’re covered with Capital Health Plan! Out of network coverage consists of the services Capital Health Plan (CHP) covers when you are outside of our service area or network of care for a medical emergency, urgently needed care, renal dialysis (while you are temporarily out of the service area), and/or care that we have approved in advance.
A medical emergency is when you, or a prudent layperson with an average knowledge of health and medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse. CHP members are covered for medical emergencies anywhere in the world.
If you have a medical emergency:
- Get help as quickly as possible. Call 911 for help or go to the nearest emergency room or hospital. Call for an ambulance if you need it. You do not need to get approval or a referral first from your primary care physician.
- As soon as possible, make sure your health plan has been notified about your emergency. Health plans need to follow up on your emergency care. You or someone else should call to tell your health plan about your emergency care, usually within 48 hours. Member Services can assist you if you call the number located on your plan membership card.
Urgently needed care is a non-emergency, unforeseen medical illness, injury, or condition that requires immediate medical care. Urgently needed care may be furnished by in-network providers or by out-of-network providers when network providers are temporarily unavailable or inaccessible. The unforseen condition could, for example, be an unforeseen flare-up of a known condition that you have. CHP members are covered for urgently needed care anywhere in the world.
Out of Network Pharmacies
If you are traveling within the United States and territories and become ill, or lose your prescription, or run out of your prescription drugs, remember that Capital Health Plan (CHP) has over 50,000 retail pharmacies in our pharmacy network.
Getting coverage when you travel or are away from the Plan’s service area.
Generally, CHP covers drugs filled at an out of network pharmacy in limited circumstances when a network pharmacy is not available. CHP will not pay for any prescriptions that are filled by pharmacies outside of the United States and territories, even for a medical emergency.
If you need a prescription because of a medical emergency or for urgent care.
CHP 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 either of these situations, you will have to pay the full cost (rather than paying just your copayment) when you fill your prescription. Complete the attached Prescription Drug for Reimbursement Form or contact Member Services to request reimbursement for CHP’s share of the costs.
CHP 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 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.
For more detailed information about your prescription drug coverage, please review your specific plan details. You can also contact Member Services.
Capital Health Plan Silver Advantage (HMO), Advantage Plus (HMO), Preferred Advantage (HMO), and Retiree Advantage (HMO) are HMO plans with a Medicare contract. Enrollment in Capital Health Plan Silver Advantage, Advantage Plus, Preferred Advantage, and Retiree Advantage depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums, and/or copayments/coinsurance may change on January 1 of each year. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.
If you have questions, please call Member Services at (850) 523-7441 or 1 (877) 247-6512 8:00 a.m. – 8:00 p.m., seven days a week, October 1 – March 31; 8:00 a.m. – 8:00 p.m., Monday – Friday, April 1 – September 30. State of Florida members call 1 (877) 392-1532, 7:00 a.m. – 7:00 p.m. TTY/TTD (850) 383-3534 or 1 (877) 870-8943.