Filling prescriptions at an out-of-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.
If you are traveling outside our service area, but 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. If you go to an out-of-network pharmacy, keep
in mind that 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 later.
You can also call Member Services 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, Member Services 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.
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
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
in the following situations:
- 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 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 provider's office.
Before you fill your prescription in any of these situations,
call Member Services 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 use an out-of-network pharmacy
and your charges are greater than what we would pay a network
pharmacy, however, you may not be reimbursed for the full amount.
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. You can ask
us to reimburse you for our share of the cost by submitting
a claim form.
Download
a copy of a Claim Form.
Submit your claim and your receipt to the following address.
Passport Advantage/Perform Rx - Medicare Claims
PO Box 516
Essington, PA 19029
Once we receive your claim, we will make an initial coverage
determination. Please refer to your Evidence
of Coverage or call Member Services for more information
on initial coverage determinations.
|
