Touchstone Health Out-of-Network Coverage

We have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan. Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. Here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:

• In 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.
• When traveling away from the Plan’s service area. If you take a prescription on a regular basis and you are going on a trip, be sure to check your supply of drug before you leave. When possible, take along all the medications that you will need. You may be able to order your prescription drugs ahead of time through our mail order pharmacy service. If you are traveling within the U.S. and need to fill a prescription because you become ill, lose or run out of your medication, we will cover prescriptions that are filled at an out of network pharmacy if you follow all other coverage rules. Prior to filling your prescription at an out of network pharmacy, call Member Services 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, Member Services may be able to make arrangements for you to get your prescription form an out of network pharmacy. We cannot pay for any prescription that is filled by pharmacies outside of the United States, even in a medical emergency situation.
• To obtain a covered drug in a timely manner. In some cases, you may be unable to obtain a covered drug in a timely manner within the Plan’s service area. If there is no network pharmacy within a reasonable driving distance that provides 24 hour service, we will cover your prescription at an out of network pharmacy.
• If a network pharmacy does not stock a covered drug. Some covered prescription drugs (including orphan drugs or other specialty pharmaceuticals) may not be regularly stocked at an accessible retail network pharmacy or through our mail order pharmacy. We will cover prescriptions at an out of network pharmacy under these circumstances.

In these situations, please check first with Member Services to see if there is a network pharmacy nearby.

If you go to an out of network pharmacy for the reasons listed above, you may have to pay the full cost (rather than just paying a co-payment of coinsurance) when you fill your prescription. You may ask us to reimburse you for our share of the cost by sending in your receipts. (Chapter 7, Section 2.1 of the EOC explains how to ask the plan to pay you back.) You should submit your receipts 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. You can submit your receipts to the following address:

Medicare Part D Paper Claims
PO Box 407
Boys Town, NE 68010