When can I use out-of-network pharmacies?

December 5, 2014

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

  • Are traveling a long way from your network pharmacy and run out of your drugs or lose them
  • Get sick and need a drug and cannot get to a network pharmacy
  • 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.
  • Are filling a prescription for a drug that your network pharmacy does not normally carry, but that you can get by mail
  • Get a vaccine in the doctor’s office
  • 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.