Out-of-network coverage for prescription medications

Generally, the term out-of-network refers to the use of providers that are not contracted to provide services to Blue Medicare HMO^℠, Blue Medicare PPO^℠, or Blue Medicare Rx^℠ PDP members. Routine use of an out-of-network 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 out-of-network situations listed applies. In these situations, the use of out-of-network providers is permissible.

By law, prescriptions purchased outside of the US or its territories cannot be reimbursed. There are several specific situations, or allowable circumstances, in which coverage may be available out-of-network:

In these situations, members may have prescription drug coverage and Blue Cross and Blue Shield of North Carolina (Blue Cross NC) may pay up to the allowed amount for the medication minus any applicable copay or coinsurance.

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

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.
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 six allowable circumstances described. Routine use of an out-of-network pharmacy will require that you pay 100% of the charges.

Some medications and vaccines are generally dispensed and administered in the physician office setting. Those not covered under Medicare Part B may be covered by Blue Medicare HMO^℠ or Blue Medicare PPO^℠. In many cases these medications and vaccines will require prior approval to be requested and approved before coverage can be provided under Blue Medicare HMO or PPO benefit.

You can call the Customer Service number on the back of your member ID card and ask the representative or log in to your member portal to determine if there is a pharmacy that meets the access standards where you live.