Out-of-Network coverage

Filling prescriptions outside the network  

We have network pharmacies outside of the service area where you can get your drugs covered as a member of our Plan.  Generally, we only cover drugs filled at an out-of-network pharmacy in limited circumstances when a network pharmacy is not available.

Below are some circumstances when we would cover prescriptions filled at an out-of-network pharmacy.  Before you fill your prescription in these situations, call Member Services 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. If you do go to an out-of-network pharmacy for the reasons listed below, you may have to pay the full cost (rather than paying just your co-payment) when you fill your prescription.  You may ask us to reimburse you for our share of the cost by submitting a claim form.  You should submit a claim to us if you fill a prescription at an out-of-network pharmacy, as any amount you pay will help you qualify for catastrophic coverage. To learn how to submit a paper claim, please refer to the paper claim process described in the subsection below called “How do you submit a paper claim?

Generally, we only cover drugs filled at an out-of-network pharmacy in limited circumstances when our pharmacy is not available or accessible. We will cover your prescription at an out-of-network pharmacy if at least one of the following applies:

• If you are unable to get a covered drug in a timely manner within our service area because there are no network pharmacies within a reasonable driving distance that provide 24-hour service.
• If you are trying to fill a covered prescription drug that is not regularly stocked at an eligible network retail pharmacy (these drugs include orphan drugs or other specialty pharmaceuticals).
• If the prescriptions are related to care for a medical emergency or urgently needed care when you are out of the service area.
• 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.
• You may receive prescription drugs for a one-month (30 days) supply.

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.

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 Customer Service at (866) 992-6600 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, Customer Service 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 need 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 co-payment) 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).

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.