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 Service to see if there is a network
pharmacy available.
What if I need a prescription because of a medical emergency?
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 urgently needed care.
In this situation, you will have to pay the full cost (rather than paying just you
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 below.
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 medication you will
need. You may be able to order you prescription drugs ahead of time through our
network mail order pharmacy service or through a retail network pharmacy that offers
an extended supply.
If you are traveling within the US, but outside of the Plan's
service area, and you become ill, lose or run out of your prescription drugs, we
will cover prescriptions that are filled at an out-of-network pharmacy if you follow
all other coverage rules identified within this document and a network pharmacy
is not available. 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
below.
Prior to filling your prescription at an out-of-network pharmacy, call our
Member 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, our Member 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
the United States, even for a medical emergency.
Other times you can get your prescription
coverage 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 get a coverage drug in a timely manner within our service are because
there are no network pharmacies within a reasonable driving distance that provide
24 hour-service.
If you are trying to fill a covered prescription drug that is
not regularly stocked at an eligible network retail or mail order pharmacy (these
drugs include orphan drugs or other specialty pharmaceuticals).
Before you fill
your prescription in either of these situations, call Member 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. 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 for one of the reasons listed above, the
pharmacy may not be able to submit the claim directly to us. When that happens, you
will have to pay the fill cost of your prescription. You may then follow the following
process to obtain a reimbursement for our share of the cost:
Fill out a Central
Health Medicare Plan claims for reimbursement form, with all required information
filled in.
Attach a copy of the receipt obtained from the pharmacy where drug
was purchased.
Mail the claims form with the pharmacy receipt to the following
address:
Central Health Medicare Plan,
ATTN: Claims Department,
1051 Park View Drive,
Suite 120,
Covina, CA 91724.
Call Member Services Department if you need help
with obtaining or filling out claims for reimbursement form and our representatives
will be more than happy to help you.
Prescription claim drug form (72.4 KB)