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Out of Network Drug Coverage

Generally, we only cover drugs filled at an out-of-network pharmacy in limited 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 a prescription at an out-of-network pharmacy, please call Member Services to see if there is a network pharmacy available.

What if I need a prescription because of a medical emergency?
We will cover prescriptions that are filled at an out-of-network pharmacy if the prescriptions are related to care for a medical emergency or urgently needed care. In this situation, you will have to pay the full cost (rather than paying just you co-payment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a paper claim form. To learn how to submit a paper claim, please refer to the paper claims process described below.

Getting coverage when you travel or are away from the plan's service area
If you take a prescription drug on a regular basis and you are going on a trip, be sure to check your supply of the drug before you leave. When possible, take along all medication you will need. You may be able to order you prescription drugs ahead of time through our network mail order pharmacy service or through a retail network pharmacy that offers an extended supply.

If you are traveling within the US, but outside of the Plan's service area, and you become ill, lose or run out of your prescription drugs, we will cover prescriptions that are filled at an out-of-network pharmacy if you follow all other coverage rules identified within this document and a network pharmacy is not available. In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a paper claim form. To learn how to submit a paper claim, please refer to the paper claims process described below.

Prior to filling your prescription at an out-of-network pharmacy, call our Member Services Department to find out if there is a network pharmacy in the area where you are traveling. If there are no network pharmacies in that area, our Member Service may be able to make arrangements for you to get your prescriptions from an out-of-network pharmacy.

We cannot pay for any prescriptions that are filled by pharmacies outside the United States, even for a medical emergency.

Other times you can get your prescription coverage if you go to an out-of-network pharmacy.

We will cover your prescription at an out-of-network pharmacy if at least one of the following applies: 

  • If you are unable to get a coverage drug in a timely manner within our service area because there are no network pharmacies within a reasonable driving distance that provide 24 hour-service.

  • If you are trying to fill a covered prescription drug that is not regularly stocked at an eligible network retail or mail order pharmacy (these drugs include orphan drugs or other specialty pharmaceuticals).

Before you fill your prescription in either of these situations, call Member Services 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 above, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a paper claim form. To learn how to submit a paper claim, please refer to the paper claim process described next.

How do I submit a paper claim?
When you go to a network pharmacy, your claim is automatically submitted to us by the pharmacy. However, if you go to an out-of-network pharmacy for one of the reasons listed above, the pharmacy may not be able to submit the claim directly to us. When that happens, you will have to pay the fill cost of your prescription. You may then follow the following process to obtain a reimbursement for our share of the cost:

  • Fill out a Central Health Medicare Plan Prescription Drug Claim form, with all required information filled in.

  • Attach a copy of the receipt obtained from the pharmacy where drug was purchased.

  • Mail the claim form with the pharmacy receipt to the following address:
    Central Health Medicare Plan
    ATTN: Claims Department
    1540 Bridgegate Drive
    Diamond Bar, CA 91765. 

  • Call Member Services if you need help with obtaining or filling out a claim and our representatives will be more than happy to help you.


Prescription Claim Drug Form (PDF - 44 KB)


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