Text Size:A A A

What should I know about my access to pharmacies?

Your Medicare Prescription Drug Plan will have identified drugstores – or pharmacies – in your area to be part of its network. These are the pharmacies you will have to use to get your drugs.

Medicare has set guidelines so that the network of pharmacies will be convenient for you. These network pharmacies should be within a certain distance from where you live.

Distance pharmacies should be from your home:
Urban area within 2 miles
Suburban area within 5 miles
Rural area within 15 miles

You will be able to ask the plans which pharmacies are in their network.  You may want to look for a plan that has your favorite pharmacy and the lowest cost for your drugs.  The Medicare.gov Plan Finder will let you enter both your choice for pharmacy and drugs to see which plans might work for you.

How do I use of out-of-network pharmacies?

Sometimes, you may need to get drugs from a drugstore that is not in your network, called an out-of-network pharmacy.  Plans must give you “adequate access” to drugs at out-of-network pharmacies when you cannot get your drugs at a network pharmacy. Plans want balance – they want to make sure you can get drugs when you need them but not use of out-of-network pharmacies unless you have to.

Plans must let you use an out-of-network pharmacy when you:

  1. Are traveling a long way from your network pharmacy and run out of your drugs or lose them.
  2. Get sick and need a drug and cannot get to a network pharmacy.
  3. Are not able to get a drug quickly in your network. For example, there is not a network pharmacy near you that is open 24 hours a day.
  4. Are filling a prescription for a drug that your network pharmacy does not normally carry, but that you can get by mail.
  5. Get a vaccine in the doctor’s office.
  6. Get the drug while in an emergency department, provider-based clinic, outpatient surgery, or other outpatient setting that is not in your network.

Plans have some flexibility to set rules so that you use out-of network pharmacies only when you need them. However, Medicare will check to see how often you use an out-of-network pharmacy to be sure the plan is giving you what you need.

How do I pay for drugs I buy at an out-of-network pharmacy?

When you buy a drug at an out-of-network pharmacy, you will have to pay for the drug out of pocket. You will then submit a receipt to your plan and ask them to pay for that drug. You will probably need to explain why you were not able to use a network pharmacy.

You will pay the same price you would have at a network pharmacy—plus the differences between the out-of-network pharmacy’s price and the network pharmacy’s price for that drug.

What if I travel often or live in different parts of the country during the year?

You will want to look for a drug plan with a wider network of pharmacies, such as a regional or national network.

You may also want to look at each plan to see if you can get your drugs by mail.

Continue
Preparing

The material on the Medicare.gov site may make more sense if you read this information first:

These sections explain terms such as deductibles, cost-sharing, coverage gap and other information you will find on the Medicare site.

When you
are ready

Find and compare specific plans on the Medicare site. Enroll in a plan when you are ready:

Find out if you qualify forExtra Help with Costs

Print these instructions for using the Medicare.gov Plan Finder

  • This field is for validation purposes and should be left unchanged.