For non-institutionalized patients on Medicare, there are very limited circumstances where patients can use an out-of-network pharmacy to fill their prescriptions.
According to the Code of Federal Regulations § 423.124, Medicare plans "must ensure that Part D enrollees have adequate access to covered Part D drugs dispensed at out-of-network pharmacies when enrollees cannot be reasonably expected to obtain such drugs at a network pharmacy" when at the same time the patient "do[es] not access covered Part D drugs at an out-of-network pharmacy on a routine basis."
Most plans will cover prescriptions filled at an out-of-network pharmacy in the following circumstances:
- The prescription is for a medical emergency or urgent care.
- An emergency or disaster has been declared in the patient's state and they can't reasonably access a network pharmacy.
- The patient is unable to get a covered drug in a time of need because there are no 24-hour network pharmacies within a reasonable driving distance.
- The prescription is for a drug that is out of stock at an accessible retail network pharmacy and through mail-order.
In most cases, the prescription(s) will need to be billed as cash and then the patient can submit a paper claim for reimbursement.
Learn more about out-of-network plans here!