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.
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.
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.
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.
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 our member experience department at 800-378-5234 (TTY 800-947-3529), Monday-Friday, from 8 a.m. to 8 p.m. October 1-March 31, they are available every day from 8 a.m. to 8 p.m.