Prescriptions Outside of Network
We have network pharmacies outside of the service area throughout the United States where you can get your drugs covered as a participant of SWH Whole Health FIDA Plan. Generally, we only cover drugs filled at an out-of-network pharmacy in limited, non-routine circumstances when a network pharmacy is not available.
If you are in the United States and temporarily out of the area and unable to use a network pharmacy, your covered prescriptions will be reimbursed. 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 you do go to an out-of-network pharmacy, you may have to pay the full cost when you fill your prescription.
- You may ask us to reimburse you for our share of the cost of the prescription by submitting a claim form.
- 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 qualify for catastrophic coverage.
Before you fill your prescription in these situations, call Participant Services to see if there is a network pharmacy in your area where you can fill your prescription.
Submitting a Paper Claim
You may submit a paper claim for reimbursement of your drug expenses in the situations described below:
Drugs purchased out-of-network. When you go to a network pharmacy and use our membership card, your claim is automatically submitted to us by the pharmacy. However, if you go to an out-of-network pharmacy and attempt to use our membership card, the pharmacy may not be able to submit the claim directly to us. When that happens, you will have to pay the full cost of your prescription and submit a paper claim to us along with your receipt from the pharmacy.
Drugs paid for in full when you don't have your membership card. If you pay the full cost of the prescription because you don't have your membership card with you when you fill your prescription, you may ask us to reimburse you for our share of the cost by submitting a paper claim to us.
These types of reimbursement requests are considered requests for coverage determination and are subject to the rules listed in your Participant Handbook.
Drugs paid for in full in other situations. If you need a prescription that is not on the formulary or is subject to coverage restrictions or limits and you need the prescription immediately, you will have to pay the full cost of the prescription drug. You may ask us to reimburse you for our share of the cost by submitting a paper claim to us.
In these situations, your doctor may need to submit additional information to support your request. This type of reimbursement request is considered a request for a coverage determination and is subject to the rules contained in your Participant Handbook.
For more information on reimbursement or coverage determination requests, please call Senior Whole Health Participant Services.
Last Updated 10/29/2015
H8851_2015_099 Approved 12/18/2014