Out-of-Network Pharmacy

For Capital Blue Cross HMO and Capital Blue Cross PPO Members

We have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan. Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. If you take a prescription drug on a regular basis and you are going on a trip, be sure to check your supply of the drug before you leave. When possible, take along all the medication you will need. You may be able to order your prescription drugs ahead of time through our mail-order pharmacy service.

Here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:

• If you are unable to obtain a covered drug within our service area at a network pharmacy that provides 24-hour service. We will cover up to a 30-day supply.
• If you are trying to fill a prescription drug that is not regularly stocked at a network pharmacy. We will cover up to a 30-day supply.
• If you are traveling within the United States and its territories and become ill, lose, or run out of your prescription drugs, call your plan first to see if there is a network pharmacy nearby.

In these situations, please contact Member Services first to see if there is a network pharmacy nearby. (Member Services:1.866.987.4213 or Capital Blue Cross PPO or 1.800.779.6962 for Capital Blue Cross HMO; TTY 711)

If there are no network pharmacies available, we will cover up to a 30-day supply of a prescription that is filled at an out-of-network pharmacy. In this situation, you will pay the full cost (rather than only paying your copayment or coinsurance) when you fill your prescription. You may be responsible for paying the difference between what we would pay for a prescription filled at an in-network pharmacy and what the out-of-network pharmacy charged for your prescription. You can request reimbursement for our share of the cost by submitting a claim form.

How do you ask for reimbursement from the plan?

If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than your normal share of the cost) when you fill your prescription. You can ask us to reimburse you for our share of the cost. Chapter 7, Section 2 of your Evidence of Coverage explains how to ask the plan to pay you back.

How and where to send us your request for payment:

Send your request for payment, along with your bill and documentation of any payment you have made. Make copies of your bill and receipts for your records.

Prime Therapeutics
PO Box 20970
Lehigh Valley, PA 18002-0970

We will consider your request for payment:

When we receive your request for payment, we will let you know if we need any additional information from you. Otherwise, we will consider your request and make a coverage decision.

• If we decide that the drug is covered and you followed all the rules for getting the drug, we will pay for our share of the cost. We will mail your reimbursement of our share of the cost to you. Chapter 5 of your Evidence of Coverage explains the rules you need to follow for getting your Part D prescription drugs covered.
• If we decide that the drug is not covered, or you did not follow all the rules, we will not pay for our share of the cost. Instead, we will send you a letter that explains the reasons why we are not sending the payment you have requested and your rights to appeal that decision.

Please call Member Services to obtain a claim form. Capital Blue Cross PPO and Capital Blue Cross HMO Member Services can be reached at 1.866.987.4213 (TTY: 711) for Capital Blue Cross PPO or 1.800.779.6962 (TTY: 711) for Capital Blue Cross HMO, 24 hours a day, 7 days a week.

Download a pharmacy reimbursement form.