Can OON Dr Prescribe RX in HMO?

Yagents

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Arizona
If a client buys an HMO, but primary care doctor is NOT in network, and she is willing to pay cash to that primary OON doctor (to keep her doctor), can that doctor prescribe Rx and have it covered under Rx benefits of the plan?

Or, in order for Rx to be covered, it has to be from an IN network PCP???
 
I am on an HMO and had Rx prescribed by NON in network doctor and the pharmacy filled per the plan, i.e. generic co-pay.

I am betting this would be a carrier by carrier or plan by plan type thing though...
 
FWIW a few years ago I wrote a handful of cases with Aetna, PPO, not HMO. Client went to have his Rx filled and claim was denied.

Aetna (or their PBM) denied the claim because it was not written by an Aetna par doc. He had to get his doc to call Aetna, bow to the east and get their blessing before Aetna would approve his scripts.
 
FWIW a few years ago I wrote a handful of cases with Aetna, PPO, not HMO. Client went to have his Rx filled and claim was denied.

Aetna (or their PBM) denied the claim because it was not written by an Aetna par doc. He had to get his doc to call Aetna, bow to the east and get their blessing before Aetna would approve his scripts.

Aetna (like KP) own their PBM
 
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