Usually, we only cover drugs obtained from an out-of-network pharmacy in limited circumstances:
- When you travel out of the plan’s service area.
- If you lose or you lack your medication, or get sick and need a covered drug immediately and you do not have access to a network pharmacy.
- If you cannot obtain a covered drug in your service area in a timely manner due to lack of availability of a network pharmacy.
- If your covered drug is provided in an out-of-network pharmacy while you are in an emergency room, in a provider’s clinic, outpatient surgery, or in another facility.
- If a covered prescription is not in inventory at an accessible in-network retail pharmacy
For detailed information consult your plan’s Evidence of Coverage (Chapter 5, Section 2.5 “When can you use a pharmacy that is not in the plan’s network?”) or call Member Services.
Please note that if you do go to an out-of-network pharmacy, you may have to pay the full cost (rather than paying just your copay) when you fill your prescription. You can request a reimbursement 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.