Out of Network Coverage (Part D)
Sunshine Health has a network of 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:
- You travel outside the plan’s service area and run out of covered Part D drugs, or become ill and need a covered Part D drug emergently or urgently and cannot access a network pharmacy.
- You are unable to obtain a covered Part D drug in a timely manner within the service area because, for example, there is no network pharmacy within a reasonable driving distance that provides 24/7 service.
- During a declared disaster in your geographic area if you cannot use a network pharmacy.
In these situations, please check first with Member Services to see if there is a network pharmacy nearby. SNP members, please call 1-877-935-8022 (TTY:711). HMO members, please call 1-844-293-2636 (TTY: 711). From October 1 to February 14, you can call us 7 days a week from 8 a.m. to 8 p.m. From February 15 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. On weekends and holidays, an automated system will handle your call.
We recommend that you fill all prescriptions prior to traveling out of the area so that you have an adequate supply. If you need assistance with obtaining an adequate supply prior to your departure, please contact Member Services.
If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than paying your normal share of the cost) when you fill your prescription. You can ask us to reimburse you for our share of the cost.
How do you ask for reimbursement from the plan?
- Complete the Prescription Claim Form - HMO SNP Form | HMO Form
- Attach the original copy of your prescription receipts to the form. If you do not have the original receipt, a copy can be obtained from the dispensing pharmacy. Cash register receipts may not be used when submitting a claim form.
- Mail the completed form and receipts to the address on the form.
Once we receive your claim, we will mail our determination with a reimbursement check, if applicable, within 14 days. Refer to you Evidence of Coverage for specific information about drug coverage and limitations.
Last Updated: 09302016