How to file a claim

If you get a prescription filled at an out-of-network pharmacy for one of the reasons below, you can request to be reimbursed by filing a claim. Our decisions on reimbursement are based on your Evidence of Coverage (EOC).

Circumstances for out-of-network prescription coverage:

• Medical emergencies
• If a 24-hour pharmacy is not within a reasonable driving distance
• An in-network pharmacy does not have your prescription in stock
• You’re traveling outside your plan service area and run out of or lose your covered Part D drugs
• You can’t access a network pharmacy when you’re ill and need a covered Part D drug

Follow these steps to submit a claim:

1. Complete our pharmacy paper claim form
2. Mail it and your prescription receipt to the address shown on the form.

Please note: You will need to submit the claim within 60 days of getting your out-of-network prescription filled.