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.

Below are some circumstances when we would cover prescriptions filled at an out-of-network pharmacy.

Before you fill your prescription in these situations, call our Customer Care Center to see if there is a network pharmacy in your area where you can fill your prescription. If you do go to an out-of-network pharmacy for the reasons listed below, you may have to pay the full cost (rather than paying just co-insurance 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. To learn how to submit a paper claim, please refer to the paper claims process described in the subsection below called “How do you submit a paper claim?”

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

  • Coverage for out-of-network access of emergency drugs and some routine drugs will be provided when the member cannot access a network pharmacy and one of the following conditions exist: You are traveling outside the service area and run out or become ill and need a covered Part D drug.
  • You are unable to obtain a covered drug in a timely manner at a network pharmacy in your service area (e.g. no access to 24 hour/7 days-a-week network pharmacy).
  • You are unable to obtain a particular drug as it is not regularly stocked at an accessible network pharmacy or mail order pharmacy (e.g. orphan or specialty drug with limited distribution).
  • The network mail-order pharmacy is unable to get the covered Part D drug to you in a timely manner and you run out of your drug.
  • Drug is dispensed to you by an out-of-network institution-based pharmacy while you are in an emergency department, provider-based clinic, outpatient surgery or other outpatient setting.

WellFirst Health — provided by SSM Health Plan — can choose not to renew its contract with a partner pharmacy and any pharmacy may also refuse to renew the contract resulting in a termination or non-renewal. This may result in termination of the member’s in-network coverage at the non-renewing pharmacy. If this happens, you 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 and/or copayments/coinsurance may change on January 1 of each year.

How do you submit a paper claim?

Mail or fax in a copy of the itemized prescription receipt along with a copy of the register receipt if available. Please note the register receipt alone is not adequate as it doesn’t have all pertinent information needed for a Direct Member Reimbursement (DMR).

The itemized receipt should contain 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

Mail to:

WellFirst Health Medicare Advantage Plans

Attn: Part D Member Claims Department

P.O. Box 1039

Appleton, WI 54912-1039

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

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Updated 10/1/20