Out-of-Network Information

Prescriptions that are included in the plan’s formulary (called covered drugs) must be filled at a network pharmacy in order to receive benefit coverage. However, there are circumstances for which you can obtain benefit coverage for a covered drug that is not filled at a network pharmacy. Out-of-network pharmacies might include home infusion therapy, long-term care facility pharmacies, and retail pharmacies that are not in the plan’s network.

Instances where you will receive benefit coverage for a prescribed coverage drug would include:

  • When you are traveling outside of your plan’s service area.
  • If you lose or run out of your covered drugs or you become ill and need a covered drug immediately and cannot access a network pharmacy.
  • If you cannot obtain a covered drug within your service area in a timely manner due to lack of availability of a participating network pharmacy.
  • If your covered drug is provided by an out-of-network institution-based pharmacy while you are in an emergency department, provider-based clinic, outpatient surgery, or other outpatient setting.
  • If you are administered a vaccine covered by your plan in a physician’s office.
  • If you must fill a covered drug prescription and the drug is not regularly stocked at accessible network retail or mail service pharmacies.

How to submit a paper claim for an out-of-network prescription.
When you fill a prescription for a covered drug at a network pharmacy you only pay your co-payment portion and your claim is automatically submitted to us by the pharmacy. If you go to an out-of-network pharmacy for any of the reasons listed above, you will need to pay the full cost for your prescription. They do not submit a claim to us. To receive reimbursement for your costs that would normally be covered, and for us to have record of this purchase, you will need to submit a claim. You must mail us the completed claim form which you can download here (PDF), along with the receipt for your covered prescription drug, and mail it to:

SilverScript
Medicare Part D Paper Claim
P.O. Box 52066
Phoenix, AZ 85072-2066

We will review the claim form and make an initial coverage determination. Your claim will be processed according to your benefit coverage and you will be notified of the outcome. For more information on initial coverage determinations, limits and financial responsibilities, please refer to your Evidence of Coverage or call Customer Care.