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Out-Of-Network Coverage

When can you use a pharmacy that is not in the plan´s network?

Your prescription may be covered in certain situations

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

  • Travel: 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 through our mail pharmacy service.

    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 or coinsurance) when you fill your prescription.

    You can ask us to reimburse you for our share of the cost by submitting a reimbursement form. If you go to an out-of-network pharmacy, you may be responsible for paying the difference between what we would pay for a prescription filled at an in-network pharmacy and what the out-of-network pharmacy charged for your prescription. To learn how to submit a reimbursement claim, please call Customer Service.

    You can also call Customer Service to find out if there is a network pharmacy in the area where you are traveling. We cannot pay for any prescriptions that are filled by pharmacies outside of the United States and territories, even for a medical emergency.

  • Medical Emergency: What if I need a prescription because of a medical emergency or because I needed 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 or coinsurance) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a reimbursement form. If you go to an out-of-network pharmacy, you may be responsible for paying the difference between what we would pay for a prescription filled at an in-network pharmacy and what the out-of-network pharmacy charged for your prescription.

  • Additional Situations: 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).
    • 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.

For all of the above listed situations, you may receive up to a 31-day supply of prescription drugs. In addition, you will likely have to pay the out-of-network pharmacy´s charge for the drug and submit documentation to receive reimbursement from the plan. Please be sure to include an explanation of the situation concerning why you used a pharmacy outside of our network. This will help with the processing of your reimbursement request. In these situations, please check first with Customer Service to see if there is a network pharmacy nearby.

You can also call Customer Service at (Toll-free: 866-999-3945 TTY: 800-735-2929) to find out if there is a network pharmacy in the area where you are traveling. We cannot pay for any prescriptions that are filled by pharmacies outside of the United States and territories, even for a medical emergency.

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) when you fill your prescription. You can ask us to reimburse you for our share of the cost.

For questions you can contact Customer Service at (Toll-free: 866-999-3945 TTY: 800-735-2929).