Plan Policies for Catastrophic Events - Bluerxalatenn
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Plan Policies for Catastrophic Events
Your prescription may be covered in certain situations Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. To help you, we have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan. If you cannot use a network pharmacy, here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:
- You are traveling outside your Plan service area and you become ill and need a covered Part D drug, and you cannot access a network pharmacy;
- You are not able to obtain a covered Part D drug in a timely manner within your service area, for example, there is no network pharmacy within a reasonable driving distance that provides 24 hour service seven days a week;
- You are filling a prescription for a covered Part D drug and that particular drug is not regularly stocked at an accessible network retail or mail-order pharmacy;
- You are provided with covered Part D drugs that are dispensed by an out-of-network institution-based pharmacy while a patient is in an emergency department, provider-basedclinic, outpatient surgery, or other outpatient setting;
- Or, in case of any other emergency when a covered Part D drug is required and a network pharmacy is not available.
In these situations, please check first with Member Services to see if there is a network pharmacy nearby.
You may be required to pay the difference between what you pay for the drug at the out-of-network pharmacy and the cost that we would cover at an in-network pharmacy.
How do you ask for reimbursement from the plan?
If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than your normal share of the cost) at the time you fill your prescription. You can ask us to reimburse you for our share of the cost.
To request reimbursement for our share of cost, send us your request for payment, along with your bill and documentation of any payment you have made. It's a good idea to make a copy of your bill and receipts for your records.
To make sure you are giving us all the information we need to make a decision, you can fill out our claim form to make your request for payment.
- You don't have to use the form, but it will help us process the information faster.
- Either download a copy of the form from our website or call Member Services and ask for the form.
Mail your request for payment together with any bills or receipts to us at this address:
Mail drug claims to:
Part D Claims
P.O. Box 20970
Lehigh Valley, PA 18002-0970
You must submit your claim to us within 15 months of the date you received the service, item, or drug.
Contact Member Services if you have any questions. If you don't know what you should have paid, or you receive bills and you don't know what to do about those bills, we can help. You can also call if you want to give us more information about a request for payment you have already sent to us.