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Medicare

Out-of-network coverage for prescription drugs

Learn more about situational coverage for Medicare members.

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 below 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:

You are in an emergency situation and need access to a covered Part D drug.

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 are evacuated or displaced from your residence due to a state or federally declared disaster or health emergency.

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 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).

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 drug minus any applicable copay or coinsurance.

What to expect in an out-of-network situation

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

  • Pay full charges at the non-network pharmacy
  • File the claim via paper claim form for reimbursement
Reimbursement options

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 outlined above. Routine use of an out-of-network pharmacy will require that you pay 100% of the charges.
Prior approval requirement for some drugs and vaccines

Some drugs 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 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.
Pharmacy access standards

Urban

On average, 90% of members who live in an urban area have access to a retail network pharmacy within two miles of their residence.

Suburban

On average, 90% of members who live in an suburban area have access to a retail network pharmacy within five miles of their residence.

Rural

On average, 70% of members who live in a rural area have access to a retail network pharmacy within 15 miles of their residence.

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