Does my Medicaid plan cover medicines and tests prescribed by out-of-network doctors?

Question

I just enrolled in Medicaid, specifically the UnitedHealthCare Community Plan in New Jersey. Now most of my existing doctors are part of the network of this plan, but there's one doctor who I really like who is not in the network. So I'd like to continue going to her, paying for my visits out of pocket since my plan wouldn't cover care by an out-of-network doctor.

But my question is, when an out-of-network prescribes medicines and lab tests, will my Medicaid plan pay for those? The specific medicines and test types are already on the list of things covered by the plan, but will the plan only pay for those things if they have been prescribed by an in-network doctor?

If it helps, here is the member handbook of my Medicaid plan.

Answer 1

This is a quote from the member handbook you linked to:

What is a Network Provider? Network Providers have contracted with UnitedHealthcare to care for our members. You don’t need to call us before seeing one of these providers. There may be times when you need to get services outside of our network. Call Member Services to learn if they are covered in full. You may have to pay for those services.

The best advice is to call the insurance company. Ask them to send an explanation, and ask them to quote from one of the guides they give you.

Because the cost of an prescription/test can be hundreds of $s if it isn't covered but can be completely covered if it is in-network, you need to get their opinion before getting it filled. If you don't agree with the answer the book tells you how to appeal. If they won't cover it, you may have to find a in-network way of getting it prescribed.

Answer 2

Generally, yes, a prescription written by an MD is fillable at an in-network pharmacy regardless of the network status of the doctor writing the prescription.

There is some nuance that you, the patient, need to keep in mind. An in-network doctor has the ability to check formulary status of a drug. In this day and age drug formularies are sliced and diced a million different ways. This drug will be covered in 5mg and 20mg doses but not 10mg or 15mg. This drug will be covered only if this other one was attempted first with no effect. This drug needs pre-approval from the insurer. Etc. You need to be sure the drug being prescribed fits in to the formulary rules because your out of network doctor has no way of checking for you.