Out of Network Pharmacies

We have thousands of pharmacies in our nationwide network to make it easy to get your drugs. We know there may be times when you can't use a network pharmacy. We may cover prescriptions filled at an out-of-network pharmacy if:

• There isn't a network pharmacy that is close to you and open, or
• You need a drug that you can’t get at a network pharmacy close to you, or
• You need a drug for emergency or urgent medical care, or
• You must leave your home due to a federal disaster or other public health emergency.

Always contact Member Services first to see if there is a network pharmacy close to you.

If you take a drug(s) on a regular basis and are planning to travel, be sure to check your supply of the drug(s) before you leave. When possible, take along all the drugs you will need. If you travel within the United States and territories, we may cover your drug at an out-of-network pharmacy for the same reasons as noted above. However, we cannot pay for any prescriptions filled by pharmacies outside of the United States and territories, even for medical emergency.

If you must use an out-of-network pharmacy, you generally will have to pay the full cost instead of a copay when you fill your prescription. You can ask us to pay you back for our share of the cost.

How do you ask for reimbursement from us?

1. Complete the Prescription Claim Form.
   • Prescription Claim Form – English (PDF)
   • Prescription Claim Form – En Español (Spanish) (PDF)
2. Attach the original prescription receipt to the form. If you do not have the original receipt, you can ask your pharmacy for a printout. Do not use cash register receipts. It is also a good idea to make a copy of your bill and receipts for your records.
3. Mail the completed form and receipt to the address on the form. You must submit your claim to us within three years of the date you received your drug.

After we receive your request, we will mail our decision (coverage determination) with a reimbursement check (if applicable) within 14 days.

For specific information about drug coverage, refer to your Evidence of Coverage or contact Member Services. We are here to help.

We have thousands of pharmacies in our nationwide network to make it easy to get your drugs. We know there may be times when you can't use a network pharmacy. We may cover prescriptions filled at an out-of-network pharmacy if:

• There isn't a network pharmacy that is close to you and open, or
• You need a drug that you can’t get at a network pharmacy close to you, or
• You need a drug for emergency or urgent medical care, or
• You must leave your home due to a federal disaster or other public health emergency.

Always contact Member Services first to see if there is a network pharmacy close to you.

If you take a drug(s) on a regular basis and are planning to travel, be sure to check your supply of the drug(s) before you leave. When possible, take along all the drugs you will need. If you travel within the United States and territories, we may cover your drug at an out-of-network pharmacy for the same reasons as noted above. However, we cannot pay for any prescriptions filled by pharmacies outside of the United States and territories, even for a medical emergency.

If you must use an out-of-network pharmacy, you may have to pay the full cost instead of a copay when you fill your prescription. You can ask us to pay you back for our share of the cost.

Prescription Reimbursement

If you need to ask us to pay you back for prescriptions paid out of pocket: 

1. Complete the Prescription Drug Claim Form using the link below.
2. If you want another person to complete this form on your behalf, please include the Appointment of Representative (AOR) Form CMS-1696 with your Prescription Drug Claim Form. This form is located at the link below and can also be found on the Centers for Medicare & Medicaid Services (CMS) website.
3. Add the prescription label information to the form and include a proof of payment receipt for each claim you submit. If you do not have the receipt or the information needed to fill out the form, you can ask your pharmacy to help.  
4. Mail the completed form(s) and receipt(s) to the address on the form. You must submit your claim to us within three years of the date you received your drug.
5. It is also a good idea to keep a copy of the forms and receipts for your records.

Updated October 1, 2023

• Prescription Claim Form – English (PDF)
• Prescription Claim Form – En Español (Spanish) (PDF)
  
  
• Appointment of Representative (AOR Form) CMS-1696 – English (PDF)
• Appointment of Representative (AOR Form) CMS-1696 – Spanish (PDF)

After we receive your request, we will mail our decision (coverage determination) with a reimbursement check (if applicable) within 14 days. 

For specific information about drug coverage, please refer to your Evidence of Coverage or contact Member Services. We are here to help.

For specific information about drug coverage, refer to your Evidence of Coverage or contact Member Services. We are here to help.