Direct to Member Reimbursement Request

In certain cases, we will pay for your prescriptions if you use an out-of-network pharmacy. For example, you may submit a claim for a Part D covered medication dispensed by a nonparticipating pharmacy for the following reasons:

• If you traveled outside of the plan's service area and ran out of (or lost) your medication or if you became ill and could not access a network pharmacy.
• If you were unable to obtain your medication in a timely manner within the service area. For example, there was no network pharmacy within a reasonable driving distance that provides 24/7 service.
• If your medication is not stocked regularly at an accessible network pharmacy.
• If your medication was dispensed from an emergency department, provider-based clinic, outpatient surgery facility, or other outpatient setting
• If you received a vaccine at your doctor's office
• If you were evacuated or displaced from your residence due to a State or Federally declared disaster or health emergency.

Direct to Member Reimbursement

Download this form (PDF) to submit a claim for a Part D covered medication dispensed by a non-participating pharmacy.

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