What Happens If You Go to an Out-of-Network Pharmacy? - dummies

What Happens If You Go to an Out-of-Network Pharmacy?

By Patricia Barry

Copyright © 2015 AARP. All rights reserved.

Except in emergencies, you should always fill prescriptions at one of your Medicare Part D plan’s in-network pharmacies. Otherwise, you encounter both of the following consequences:

  • You pay a lot more for your drugs. In most cases, you pay the full price. Sending the receipts to your plan won’t work. The plan won’t pay.

  • These payments don’t count toward your out-of-pocket limit. If you fall into the doughnut hole, your plan disregards payments for drugs bought outside its pharmacy network when calculating the expense limit that gets you out of the coverage gap and into catastrophic coverage.

However, situations may arise when you need to have a prescription filled outside your plan’s pharmacy network. Medicare expects all Part D plans to guarantee coverage at out-of-network pharmacies in any of the following circumstances, providing that the plan covers the drugs in question and the request is reasonable:

  • If you’re traveling outside your plan’s service area within the United States (and maybe abroad, if your plan allows this exception for emergencies) and you run out of your meds, lose them, or become ill and need drugs for treatment

  • If you need to fill a prescription quickly outside business hours but can’t find a 24/7 network pharmacy within a reasonable driving distance

  • If you need to start taking a specialty drug quickly and don’t have access to in-network pharmacies that stock it

  • If you’re undergoing emergency or urgent treatment in a hospital, clinic, or outpatient facility and receive Part D-covered drugs from the facility’s pharmacy, which isn’t in your plan’s network

  • If you have to leave your home area after a local calamity that’s been declared a state or federal disaster or a public health emergency

The process for claiming these exceptions is to pay full cost at the pharmacy and later send the receipts to the plan, asking for the appropriate refund. If you can’t afford the full cost, call the plan and request assistance. If the plan rejects your claim, you can file a complaint and appeal the decision.

A plan is allowed to charge you more for going out of network, even in these circumstances; whether it actually does depends on the plan’s policy. (If you do have to pay more, though, the extra counts toward your out-of-pocket limit.) However, if you receive Extra Help, you can’t be charged more than you would be at an in-network pharmacy.