Pharmacy Benefit Services

Touchstone Health has contracts with pharmacies that equals or exceeds CMS requirements for pharmacy access in your area. We have a network of 4657 pharmacies that work with Pharmaceutical Technologies Inc. / National Pharmaceutical Services (PTI/NPS), Touchstone Health’s pharmacy benefit manager.

We have network pharmacies outside of the service area where you can get your drugs covered as a member of our plan. 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 your prescription in 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 below, you may 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 your pharmacy receipts. You should submit a claim to us if you fill a prescription at an out-of-network pharmacy as any amount you pay will help you qualify for catastrophic coverage.

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

• If the prescriptions are related to care for a medical emergency or urgently needed care.
• If you are traveling within the United States, but outside of the service area, and you become ill, or lose or run out of your prescriptions.
• If you are unable to get a covered 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).
• If you are getting a vaccine that is medically necessary but not covered by Medicare Part B and is administered by your doctor’s office.

In these situations, you will have to pay the full cost (rather than just a co-payment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting your pharmacy receipts.

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 full cost of your prescription. When you return home, simply submit your paper claim form to us. The paper claim should include original receipts from your pharmacy provider that includes the following information:

• Pharmacy name and NABP / NCPDP / NPI number
• Pharmacy address and telephone number
• Date of prescription
• Physician name
• Name of the prescription and strength
• National Drug Code (NDC) for the prescription
• Quantity of medication
• Day supply of medication
• Amount Paid for the prescription
• Directions for use of the prescription

The paper claim and your pharmacy receipt should be sent to the following address:


If you submit a paper claim to us, the claim is treated as a request for a coverage determination. If you are asking us to reimburse you for a prescription drug that is not on our formulary or is subject to coverage requirements or limits, your doctor may need to submit additional documentation supporting your request. See below to learn more about requesting coverage determinations.