Out-of-Network Pharmacies

When Can I Use an Out-of-Network Pharmacy?

Network Health has agreements with in-network pharmacies to provide prescription drug coverage to members at a lower cost. To have your prescriptions covered, you must use in-network pharmacies. We understand, however that there are limited circumstances where this might not be possible.

Special Exceptions

Covered drugs may be filled at an out-of-network pharmacy in limited circumstances, when you cannot reasonably be expected to get covered Part D drugs at an in-network pharmacy.
The use of out-of-network pharmacies cannot be routine.

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

• You are unable to obtain 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.
• You travel outside our service area and cannot access an in-network pharmacy.
• You are trying to fill a prescription that is not regularly stocked at an accessible in-network retail or mail order pharmacy (including high cost and/or unique drugs).
• 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.
• You are evacuated or displaced from your residence due to a state or federally declared disaster or health emergency.
• You were a patient in an emergency department, provider-based clinic, outpatient surgery or other outpatient facility, and your medication was dispensed from an out-of-network pharmacy located in one of these institutions.

In all out-of-network situations, contact member experience first to see if there is an in-network pharmacy nearby. If you must use an out-of-network pharmacy, you’ll pay the full cost when you fill your prescription (rather than your normal copayment), then you can request reimbursement for our share of the cost.

Request Reimbursement

Submit a prescription drug claim form, along with your receipt, for reimbursement. Please understand, you may pay more for the drug because the out-of-network pharmacy’s price is higher than what an in-network pharmacy would charge.

Out-of-network claims will be covered for up to a 30-day supply for each claim. More than one out-of-network fill (per drug) may be allowed during the plan year so long as the situation is one of those listed above, and you are not routinely filling that prescription out-of-network.

More Information

For more information about in-network pharmacies, see your Evidence of Coverage, Chapter 5, Section 2. For help finding a participating pharmacy or to request a claim form, you can also call 800-316-3107 (TTY 800-899-2114), 24 hours a day, seven days a week.