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Important Legal Information and Disclaimers

Blue Medicare HMO, Blue Medicare PPO, and Blue Medicare Rx (PDP) Members

Policies and Procedures

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Out-of-network coverage for prescription drugs

How is out-of-network defined?
Generally the term Out-of-network refers to the use of providers that are not contracted to provide services to Blue Medicare HMO or Blue Medicare PPO members. In some situations, the use of out-of-network providers is permissible. There are several specific situations in which coverage may be available out-of-network:1

  • You are in an emergency situation and need access to a covered Part D drug;
  • You are traveling outside of the service area; run out of or lose the covered drug(s)or become ill and need a covered drug and cannot access a network pharmacy;
  • You cannot obtain a covered drug in a timely manner within your service area, because for example, there is no network pharmacy within a reasonable driving distance that provides 24-hour-a-day/7-day-per-week service;
  • You reside in a long term care facility and the contracted long term care pharmacy does not participate in the plan's pharmacy network;
  • You must fill a prescription for a covered drug, and that particular drug is not regularly stocked at accessible network retail or mail-order pharmacies (for example, an orphan drug or other specialty pharmaceutical typically shipped directly from manufacturers or special vendors).
  • You are evacuated or displaced from your residence due to a state or federally declared disaster or health emergency.

What is excluded from out-of-network coverage?

Routine use of an OON pharmacy is not permitted by a member who resides in a location where adequate pharmacy access exists (please refer to the pharmacy access standards). Members are encouraged to use network pharmacies unless one of the specific OON situations listed above applies.1

In the situations listed above, will I have prescription drug coverage?

Yes, we will pay up to our allowed amount for the drug minus any applicable copay or coinsurance.

What do I need to do if I need to get a prescription drug at an out-of-network retail pharmacy?1

For one of the out-of-network situations described above, you will need to do the following:

  1. Pay full charges at the non-network pharmacy.
  2. File the claim via paper claim form for reimbursement.

What will I be reimbursed?

There are two reimbursement scenarios for the out-of-network benefit. These are:

  1. If you live in a county that does not have adequate access to a participating pharmacy - in this situation, after you submit your paper claim, you will be reimbursed up to the plan's allowed amount minus your cost share.1
  2. If you live in a county with adequate access to a participating pharmacy - if you use an out-of-network (or non-participating) pharmacy in counties with adequate access, you will be reimbursed up to the plan's allowed amount minus your cost share. You must meet one of the five allowable circumstances outlined above. Routine use of an out-of-network pharmacy will require that you pay 100% of the charges.1

Please note that in emergency situations, you will be reimbursed the entire amount minus your member cost share amount.

What are the pharmacy access standards?

Medicare categorizes the pharmacy access standards into three categories: urban, suburban and rural. These access standards vary based upon locale as listed below.

  • Urban - On average, 90% of members who live in an urban area have access to a retail network pharmacy within 2 miles of their residence;
  • Suburban - On average, 90% members who live in an suburban area have access to a retail network pharmacy within 5 miles of their residence; and
  • Rural - At least 70% of members, on average, have access to a retail network pharmacy within 15 miles of their residence.

How do I know if there is a pharmacy that meets the access standards for where I live?

You can either call the Customer Service number on the back of your ID card and ask the representative, or search our online pharmacy directory.1

What drugs and vaccines are generally dispensed and administered in the physician office setting?

Certain drugs and vaccines not covered under Medicare Part B may be covered by Blue Medicare HMO or PPO. In many cases these drugs and vaccines will require prior approval to be requested and approved before coverage can be provided under Blue Medicare HMO or PPO benefit.

1 Formulary, pharmacy and provider networks may change at any time. You will receive notice when necessary.

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Important Legal Information and Disclaimers

The information on this page is current as of 10/1/2017.

Y0079_7833 CMS Approved 10172017