We cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. To help you, we have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan. If you cannot use a network pharmacy, here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:
- 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 a network retail or mail order pharmacy (these drugs include orphan drugs or other specialty pharmaceuticals)
- If you are traveling outside of our service area and run out of, lose, or become ill and need a covered drug
- If you are provided a covered drug while in an emergency department, provider-based clinic, outpatient surgery or other outpatient setting and unable to get the drug filled at a network pharmacy
- If you are evacuated or displaced from your residence, due to a federally- declared disaster or other public health emergency declaration, and unable to get the covered drug at a network pharmacy
In these situations, please check first with Member Services to see if there is a network pharmacy nearby. You may be required to pay the difference between what you pay for the drug at the out-of-network pharmacy and the cost that we would cover at an in-network pharmacy.
How do you ask for reimbursement from the plan?
If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than your normal share of the cost) at the time you fill your prescription. You can ask us to reimburse you for our share of the cost. Please refer to your plan’s Evidence of Coverage for a complete explanation of how to ask the plan to pay you back.