Out of Network Coverage
Generally, Absolute Total Care pays for drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. We have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan. We will pay for your prescriptions filled at an out-of-network pharmacy in the following cases:
- When you are out of the area, require a prescription filled unexpectedly, and are unable to obtain medication at a network pharmacy.
- During a declared disaster in your geographic area. If you cannot use a network pharmacy during a declared disaster, you will be able to fill your prescription drugs at an out-of-network pharmacy.
Generally, we only cover drugs filled at an out-of-network pharmacy in rare situations when a network pharmacy is not available, up to a 30-day supply.
You can use our Find a Doctor or Pharmacy Tool to help you locate a pharmacy that is in our network.
In these situations, please check first with Member Services at 1-855-735-4398. Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711.
Will the plan pay you back for a prescription?
If you need an exception, a Member Services representative will work with you and your provider to help you ask for one.
We have thousands of pharmacies in our nationwide network to make it easy to get your drugs. We know there may be times when you can't use a network pharmacy. We may cover prescriptions filled at an out-of-network pharmacy:
- If you do not receive more than a 30-day supply, and
- If there is no network pharmacy that is close to you and open, or
- If you need a drug that you can’t get at a network pharmacy close to you, or
- If you need a drug for emergency or urgent medical care, or
- If you must leave your home due to a federal disaster or other public health emergency.
Always contact Member Services first to see if there is a network pharmacy close to you.
If you must use an out-of-network pharmacy, you will generally have to pay the full cost of your drug. You can ask us to pay you back for our share of the cost.
How do you ask us to pay you back?
- Complete the Prescription Claim Form (pdf) - Coming Soon
- Attach the original prescription receipt to the form. If you do not have the original receipt, you can ask your pharmacy for a printout. Do not use cash register receipts.
- Mail the completed form and receipt to the address on the form.
After we receive your request, we will mail our decision (determination) with a reimbursement check (if applicable) within 14 days. For specific information about drug coverage, refer to your Member Handbook or contact Member Services. We are here to help.