Out-of-network pharmacies

In certain situations, prescriptions filled at an out-of-network pharmacy may be covered. Generally, we only cover drugs filled at an out-of-network pharmacy in limited, non-routine circumstances when a network pharmacy is not available. Fills are limited to 30 days for out-of-network claims.

See coverage and limitations for out-of-network pharmacies below for circumstances when prescriptions filled at an out-of-network pharmacy would be covered.

Before using out-of-network pharmacies

Before you fill your prescription at an out-of-network pharmacy, call customer 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 below, you may have to pay the full cost (rather than paying just co-insurance or copayment) when you fill your prescription. You may ask us to reimburse you for our share of the cost by submitting a paper claim. You should submit a claim to us if you fill a prescription at an out-of-network pharmacy, as any amount you pay for a covered Part D drug will help you qualify for catastrophic coverage. See below for information on how to submit a paper claim.

If we do pay for the drugs you get at an out-of-network pharmacy, you may still pay more for your drugs than what you would have paid if you had gone to an in-network pharmacy.

How do you submit a paper claim?

Please mail or fax in a copy of the itemized prescription receipt along with a copy of the register receipt if available. Please note the register receipt alone is not adequate as it doesn’t have all pertinent information needed for a Direct Member Reimbursement (DMR).

The itemized receipt should contain the following information:

  • Pharmacy Name, Address, Phone Number
  • Prescription (Rx) Number
  • Date of Service
  • Drug Name
  • National Drug Code (NDC)
  • Quantity and Day Supply
  • Provider Name
  • Member Cost/Responsibility

Mail to:
Providence Medicare Advantage Plans
Attn: Pharmacy Services 
P.O. Box 4327
Portland, OR 97208-4327

Fax: 503-574-8646 or 1-800-249-7714

Most vaccines given in the provider’s office are considered out-of-network. Please use an in-network pharmacy to receive your vaccines. An in-network pharmacy can process your vaccines directly to Providence Health Assurance. If you receive a vaccine at your provider’s office, you will have to pay full price and submit your receipts for reimbursement. These reimbursements will be processed as out-of-network, and you may not receive full reimbursement for these vaccines.

Coverage and limitations for out-of-network pharmacies

We will cover prescriptions that are filled at an out-of-network pharmacy for medical emergencies and in some routine situations for up to a 30-day supply. Drugs excluded by federal statute from the Medicare Part D formulary are not eligible for coverage even in emergency or urgent situations.

Coverage for out-of-network access of emergency drugs and some routine drugs will be provided when the member cannot access a network pharmacy and one of the following conditions exist:

  • You are traveling outside the service area and run out or lose your covered Part D drugs or become ill and need a covered Part D drug.
  • You are unable to obtain a covered drug in a timely manner at a network pharmacy in your service area (e.g. no access to 24 hour/7 days a week network pharmacy).
  • You are unable to obtain a particular drug as it is not regularly stocked at an accessible network pharmacy or mail order pharmacy (e.g. orphan or specialty drug with limited distribution).
  • The network mail-order pharmacy is unable to get the covered Part D drug to you in a timely manner and you run out of your drug.
  • Drug is dispensed to you by an out-of-network institution-based pharmacy while you are in an emergency department, provider-based clinic, outpatient surgery or other outpatient setting.

Providence Medicare Advantage Plans can choose not to renew its contract with a partner pharmacy and any pharmacy may also refuse to renew the contract resulting in a termination or non-renewal. This may result in termination of the beneficiary’s in-network coverage at the non-renewing pharmacy. If this happens, you have a transition period to find another in-network pharmacy.