Medicare Plans

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.

The following examples are exceptions when Network Health might cover Part D prescriptions filled at an out-of-network pharmacy.

  • You are traveling outside of our service area, need a covered Part D drug and cannot reasonably access an in-network pharmacy.
  • You receive a vaccine in your doctor's office.
  • You can’t get a covered Part D drug in a timely manner within our service area, because there is no in-network pharmacy within a reasonable driving distance that provides 24-hour, seven-days a week service.
  • You must fill a prescription in a timely manner and that drug is not regularly stocked at an accessible in-network retail or mail-order pharmacy.
  • You received a covered Part D drug dispensed by an out-of-network institution-based pharmacy while you were a patient in an emergency department, provider-based clinic, outpatient surgery or other outpatient setting.
  • During any Federal disaster declaration or other public health emergency declaration in which you are evacuated or moved from your place of residence and you can’t reasonably be expected to obtain covered Part D drugs at an in-network pharmacy.

In all out-of-network situations, contact customer service 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.


Network Health
1570 Midway Place
Menasha, WI 54952
Hours
Mon., Wed.-Fri.: 8 a.m. to 5 p.m.
Tuesday: 8 a.m. to 4 p.m.