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CoxHealth Medicare Advantage
Out-of-Network Pharmacy Coverage
CoxHealth Medicare Advantage (HMO) partners with Pharmacy Benefit Manager (PBM), to help administer the prescription drug benefit plan. The PBM contracts with thousands of pharmacies in our network to make it easy to get your drugs. We know there may be times when you can’t use a network pharmacy. We may cover prescriptions filled at an out-of-network pharmacy if:
- No network pharmacy is close to you and open, or
- You need a drug that you can’t get at a network pharmacy close to you, or
- You need a drug for emergency or urgent medical care, or
- You must leave your home due to a federal disaster or other public health emergencies.
Before filling your prescription in these situations, call Customer Service to see if there is a network pharmacy in your area where you can fill your prescription.
If you must use an out-of-network pharmacy, you may have to pay a higher cost instead of a copay when filling your prescription. You can ask us to pay you back (reimbursement) for our share of the cost. 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.
How do you ask for reimbursement from us?
- Complete the prescription claim form (Reimbursement Request Form)
- Attach the original prescription receipt to the form. You can ask your pharmacy for a printout if you do not have the original receipt. Do not use cash register receipts as they do not contain the necessary information to process your request.
- Mail the completed form and receipt to the address on the form.
The information we need to process your request should include the following information:
- 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/responsibility
After receiving your request, we will mail our decision (determination) with a reimbursement check (if applicable) within 14 days. For specific information about drug coverage, refer to your Evidence of Coverage or contact Customer Service. We are here to help.
Please note that Medicare rules prevent CoxHealth Medicare Advantage (HMO) from paying for drugs not sold in the United States.
