Out-of-Network Coverage

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Filling prescriptions at a non-network pharmacy
The following are a few exceptions when we will pay for a prescription filled at a pharmacy outside of our network.

Getting coverage when you travel or are away from the plan’s 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.

If you are traveling within the United States and territories and become ill, lose or run out of your prescription drugs we will cover prescriptions that are filled at an out-of-network pharmacy. In this situation, you will have to pay the full cost (rather than paying just your co-payment) 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 later.

You can also call Customer Service to find out if there is a network pharmacy in the area where you are traveling. If there are no network pharmacies in that area, Customer Service may be able to make arrangements for you to get your prescriptions from an out-of-network pharmacy.

We cannot pay for any prescriptions that are filled by pharmacies outside of the United States and territories, even for a medical emergency.

What if I need a prescription because of a medical emergency or because I needed urgent care?
We will cover prescriptions that are filled at an out-of-network pharmacy if the prescriptions are related to care for a medical emergency or urgent care. In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a paper claim form. To learn how to submit a paper claim, please refer to the paper claims process described later.

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 obtain a covered drug in a timely manner within our service area because there is no network pharmacy within a reasonable driving distance that provides 24 hour service.
•	If you are trying to fill a prescription drug that is not regularly stocked at an accessible network retail or mail-order pharmacy (including high cost and unique drugs).
•	If 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.

Before you fill your prescription in either of these situations, call Customer Service to see if there is a 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 co-payment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a claim form. If you go to an out-of-network pharmacy, you may be responsible for paying the difference between what we would pay for a prescription filled at an in-network pharmacy and what the out-of-network pharmacy charged for your prescription. To learn how to submit a paper claim, please refer to the paper claims process described next.

How do I submit a paper claim?
When you go to a network pharmacy your claim is automatically submitted to us by the pharmacy. However, if you go to an out-of-network pharmacy because of the reasons listed above, the pharmacy may not be able to submit the claim directly to us and you will have to pay the full cost of your prescription. When you return home, simply submit your claim and your receipt to the following address: Prescription Pathway - DMR, P.O. Box 52010, Phoenix, AZ 85072-2010. Upon receipt, we will make an initial coverage determination on the claim. Please refer to your Evidence of Coverage or call Customer Service for more information on initial coverage determinations.

Last updated: 01/25/2008