We have network pharmacies outside of the service area where you can get your drugs covered as a member of our plan. Generally, we only cover drugs filled at an out-of-network pharmacy in limited circumstances when a network pharmacy is not available. Below are some circumstances when we would cover prescriptions filled at an out-of-network pharmacy. Before you fill a prescription at an out-of-network pharmacy, please call Member Services to see if there is a network pharmacy available.

You will be allowed to fill each prescription at an out-of-network pharmacy three times within a calendar year. If you fill a prescription out-of-network, you will receive a message on your monthly Explanation of Benefits (EOB) Statement that will state, “Out-of-network pharmacy use is not allowed on a routine basis.”

If you request a fourth fill at an out-of-network pharmacy, your request for coverage will be denied. Your monthly EOB Statement will indicate, “Routine out-of-network pharmacy use not covered.” If you feel that the out-of-network claim should have been covered, contact the Member Services Department at 1-877-586-1648, 7:00 a.m. - 8:00 p.m. 7 days a week. TTY Users Should Call: 1-866-525-7833.

PRESCRIPTION DRUG CLAIM FORM - MEDICARE PART D