Out-of-network coverage policy

What does out-of-network mean?

Generally, out-of-network situations occur when you reside in an area that does not have adequate access to physician offices or pharmacies for drugs and vaccines covered by your Blue Medicare Rx plan.

There are 5 specific out-of-network situations. These occur when:

• You are in an emergency situation and need access to a covered Blue Medicare Rx drug
• You are traveling outside of the state; 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)

What is excluded from out-of-network coverage?

• Routine use of an out-of-network pharmacy by a member who resides in a location where adequate pharmacy access exist (please refer to the pharmacy access standards).

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

Yes, you have coverage, but you will be liable for any additional amounts that may be charged as a result of the use of an out-of-network pharmacy. In other words, we will pay up to our allowed amount for the drug, but you are responsible for your copayment or coinsurance and any difference between the allowed amount and the amount charged by the out-of-network pharmacy.

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

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

What will I be reimbursed?

We will pay up to the allowed amount for the drug, but you are responsible for your copayment or coinsurance and any difference between the allowed amount and the amount charged by the out-of-network pharmacy.

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
• 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 the pharmacy list.

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 your Blue Medicare Rx Plan. In many cases these drugs and vaccines will require prior approval to be requested and approved before coverage can be provided under the Blue Medicare Rx benefit.