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 31 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; and
  • 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 PHIP Providence Medicare Advantage Plans. 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 31-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.

Providence Medicare Advantage Plans is an HMO, HMO‐POS and HMO SNP with Medicare and Oregon Health Plan contracts. Enrollment in Providence Medicare Advantage Plans depends on contract renewal.

Website is current as of 10/11/2019