Out-of-Network Coverage

Generally, we only cover drugs filled at an out-of-network pharmacy in limited, non-routine circumstances when a network pharmacy is not available. Before you fill your prescription in these situations, call Customer Service at 866-992-6600 or your Team to see if there is a network pharmacy in your area where you can fill your prescription. If there are no network pharmacies in that area, your Team may be able to make arrangements for you to get your prescriptions from an out-of-network pharmacy.

The following are some circumstances when we would cover prescriptions filled at an out-of-network pharmacy:

You are or plan to be away from our 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 and take along all the medication you will need. 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, Partnership members will have to pay the full cost (rather than paying just the co-payment) when filling the prescription. You can ask us to reimburse you for our share of the cost by submitting a claim form. Please refer to Chapter 7 of your Evidence of Coverage (EOC)/ Member Handbook to learn how to submit a paper claim.

We cannot pay for any prescriptions that are filled by pharmacies outside of the United States and territories, even for a medical emergency.

Getting a prescription because of a medical emergency or 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, Partnership members will have to pay the full cost (rather than paying just the co-payment) when filling the prescription. You can ask us to reimburse you for our share of the cost by submitting a paper claim form. Please refer to Chapter 7 of your Evidence of Coverage (EOC)/ Member Handbook to learn how to submit a paper claim.

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 pharmacy (including high cost and unique drugs).

How do you ask for reimbursement from the plan?

If you must use an out-of-network pharmacy, Partnership members will generally have to pay the full cost (rather than paying their normal share of the cost) when filling the prescription. You can ask us to reimburse you for our share of the cost by submitting a paper claim.

If we reimburse you for the drugs you get at an out-of-network pharmacy, we will only pay the amount we would have paid if you had gone to an in-network pharmacy.  This means that you may pay more for your drugs than you would have paid if you had gone to an in-network pharmacy.

If you have Medicare Part D, any amount you pay, or others pay on your behalf, for a covered Medicare Part D drug will help you qualify for catastrophic coverage.