2018 Provider and Pharmacy Network
- A participant cannot obtain a covered drug in a timely manner within the plan’s service area because there is no network pharmacy available within a reasonable driving distance.
- A drug that has been dispensed by an out-of-network institution-based pharmacy while a participant is in the emergency room.
- A participant, while out of the service area, becomes ill or runs out of his/her medications and cannot access a network pharmacy.
- Filling a prescription for a covered drug and that drug is not regularly stocked at an accessible network pharmacy.
- In these cases, please check first with Participant Services to see if there is a network pharmacy nearby.
Participant Reimbursement If you pay “out-of-pocket” for a prescription drug from an out-of-network provider and you think that we should cover the expense – save your receipt and contact Participant Services or send us a request to review your claim for reimbursement. Prescription Drug Claim Form (pdf) Medical Participant Reimbursement Claim Form (coming soon) Once your request for payment is received, we will let you know if we need additional information. Otherwise, we will consider your request and make a coverage determination. If we decide that the plan should pay for the drugs or services, we will mail the reimbursement to you. If we decide that the drugs or services are not covered, or you did not follow all the plan’s rules – we will not provide any payment. Instead, we will send you a letter explaining the reasons why we are not sending the payment and your rights to appeal that decision. Learn more about appeals.