Out-of-network pharmacies

Using out-of-network pharmacies

In certain situations, prescriptions filled at an out-of-network pharmacy may be covered. Generally, we only cover drugs filled at an out-of-network pharmacy in limited, non-routine circumstances when a network pharmacy is not available.
Before you fill your prescription at an out-of-network pharmacy, call Member Services to see if there's a network pharmacy in your area. If you go to an out-of-network pharmacy, you may have to pay the full cost (rather than paying just coinsurance or copayment when you fill your prescription). You may ask us to reimburse you for our share of the cost by submitting a paper claim. You should submit a claim to us if you fill a prescription at an out-of-network pharmacy, as any amount you pay for a covered Part D drug will help you meet required deductibles.

How to submit a paper claim

You can mail or fax us a copy of the itemized prescription receipt with the pharmacy claim form. If the register receipt is available, include that as well. The register receipt alone does not have all necessary information for a Direct Member Reimbursement (DMR).

Your itemized receipt should include:

• Pharmacy name, address, phone number
• Prescription (Rx) number
• Date of service
• Drug name
• National Drug Code (NDC)
• Quantity and day supply
• Provider name
• Member cost and responsibility

Mail to:

Dean Advantage Plans

Attn: Part D Member Claims Department

P.O. Box 1039

Appleton, WI 54912-1039

Fax toll-free to 1-855-673-6507 or local to 1-920-221-4650

If we do pay for the drugs you get at an out-of-network pharmacy, you may still pay more for your drugs than what you would have paid if you had gone to an in-network pharmacy.

Coverage and limitations for out-of-network pharmacies

We'll cover up to a 30-day supply of prescriptions filled at an out-of-network pharmacy for medical emergencies and some routine situations. Drugs excluded by federal statute from the Medicare Part D formulary are not eligible for coverage even in emergency or urgent situations.

Here are some situations that may make you eligible to get coverage for emergency drugs at out-of-network pharmacies:

• You've become ill or run out of your medications while traveling outside the service area and can't access an in-network pharmacy.
• You can't get a covered drug in a timely manner at an in-network pharmacy in your service area (e.g. no access to a 24/7 in-network pharmacy).
• Your covered medication isn't regularly stocked at an accessible in-network or mail order pharmacy (e.g. orphan or specialty drug with a limited distribution).
• You run out of covered medication because an in-network mail order pharmacy can't get it to you in a timely manner.
• You get your drug from an out-of-network, institution-based pharmacy while in an emergency department, provider-based clinic, outpatient surgery, or other outpatient setting.

We can choose not to renew our contract with a partner pharmacy. The pharmacy can also refuse to renew the contract, resulting in a termination or non-renewal. This could end your in-network coverage at the non-renewing pharmacy. If this happens, you'll have a transition period to find another in-network pharmacy.
The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium, copays, and coinsurance may change on Jan. 1 of each year.