Menu
  • Divider
  • Medicare Icon Out-of-Network Drug Coverage

    MedicarePlus members must buy their prescription drugs at network pharmacies except under special or emergency circumstances. Being familiar with the rules for using out-of-network pharmacies will help you make the most of your MedicarePlus prescription drug benefits. Network pharmacies are listed in the Pharmacy Directory.

    MedicarePlus Pharmacy Directory 

    When can you use a pharmacy that is not in the MedicarePlus network?

    Your prescription might be covered in certain situations

    We have in-network pharmacies outside of our Service Area where you can get your prescriptions filled as a subscriber of a MedicarePlus plan. Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use an in-network pharmacy.

    Getting Pharmacy coverage when you travel or are away from the MedicarePlus 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 order pharmacy service or through a retail in-network pharmacy that offers an extended supply on the Ask for 90 Rx Program.

    If you are traveling within the US, but outside the MedicarePlus service area, and you become ill, lose or run out of your prescription drugs, we will cover prescription drugs that are filled at an out-of-network pharmacy if you follow all other coverage rules identified within this document and a in-network pharmacy is not available. In this situation, you will have to pay the full cost (rather than paying just your copayment) 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 below.

    Prior to filling your prescription at an out-of-network pharmacy, call our Customer Service to find out if there is a in-network pharmacy in the area where you are traveling. If there are no in-network pharmacies in that area, our Customer Service may be able to make arrangements for you to get your prescription drugs from an out-of-network pharmacy.

    We cannot pay for any prescription drugs that are filled by pharmacies outside the United States, even for an emergency medical condition or urgently needed services.

    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 get a covered drug in a timely manner within our service area because there are no in-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 retail or mail order pharmacy (these drugs include orphan drugs or other specialty pharmaceuticals).

    Before you fill your prescription in either of these situations, call Customer Service to see if there is an in-network pharmacy in your area where you can fill your prescription. If you do go to an out-of-network pharmacy for the reasons listed above, you will have to pay the full cost (rather than paying just your copayment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a claim form.

    How do you fill prescription drugs outside the network (at out-of-network pharmacies)?

    Generally, we only cover prescription drugs filled at an out-of-network pharmacy in limited, non-routine circumstances when an in-network pharmacy is not available. Before you fill your prescription in these situations, call Customer Service to see if there is an in-network pharmacy in your area where you can fill your prescription.

    If you do go to an out-of-network pharmacy for the allowed reasons, you may have to pay the full cost (rather than paying just your copayment) when you fill your prescription drugs. You may ask us to reimburse you for our share of the cost by submitting a paper claim form. You should submit a claim to us if you fill a prescription drug 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 claims process description attached to the Request for Reimbursement form. If we do pay for the drugs you get at an out-of-network pharmacy, you may still pay more for your drugs than what you would have paid if you had gone to an in-network pharmacy.

    What if you need a prescription drug because of an emergency medical condition?

    We will cover prescription drugs that are filled at an out-of-network pharmacy if the prescription drugs are related to care for an emergency medical condition or urgently needed services. In this situation, you will have to pay the full cost (rather than paying just your copayment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a paper claim form.

    How do you ask for reimbursement from MedicarePlus?

    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. You can ask us to reimburse you for our share of the cost.