Out of Network Coverage (Part D)

has a network of pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan. Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use an in-network pharmacy. However, please call us to see if there is an in-network pharmacy nearby. 

Here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:

  • You travel outside the plan’s service area and run out of covered Part D drugs, or become ill and need a covered Part D drug emergently or urgently and cannot access a network pharmacy. We recommend that you fill all prescriptions prior to traveling out of the area so that you have an adequate supply. If you need assistance with obtaining an adequate supply prior to your departure, please call Member Services.
  • You are unable to obtain a covered Part D drug in a timely manner within the service area because, for example, there is no network pharmacy within a reasonable driving distance that provides service 24 hours a day/ 7 days a week.
  • During a declared disaster in your geographic area if you cannot use a network pharmacy.

If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than paying your normal share of the cost) when you fill your prescription. If this happens, please call Member Services and ask us to reimburse you for our share of the cost.

How do you ask for reimbursement from the plan?

  1. Print and fill out  the Prescription Claim Form - HMO Form | HMO SNP Form | PPO Form
  2. Attach the original copy of your prescription receipts to the form.  If you do not have the original receipt, a copy can be obtained from the dispensing pharmacy.  Cash register receipts may not be used when submitting a claim form.
  3. Mail the completed form and receipts to the address listed on the form. 

Once we receive your claim, we will mail our determination with a reimbursement check (if applicable), within 14 days.  For specific information about drug coverage limitations, please refer to your Evidence of Coverage or call Member Services.  We are here to help!


Last Updated: 09302016
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