Generally, we only cover prescription drugs covered under your Medicare Part D coverage when prescriptions are filled by network pharmacies. Horizon Healthcare of New Jersey, Inc. ("Horizon") can provide access through its pharmacy benefits manager to network pharmacies even outside the service area, if needed. Generally, we only cover drugs filled at out-of-network pharmacies in limited circumstances when a network pharmacy is not available.
We will cover your Medicare Part D prescriptions at an out-of-network pharmacy if at least one of the following applies:
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 meet any of the criteria above and you go to an out-of-network pharmacy, you may have to pay the full cost (rather than paying just your copayment or coinsurance) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a claim form.
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. To learn how to submit a paper claim, please refer to the instructions noted below:
How do I submit a paper claim?
If you go to an out-of-network pharmacy, the pharmacy may not be able to submit the claim directly to us. When this occurs, you will have to pay the full cost of your prescription drug directly to the pharmacy. Then simply submit your claim and your receipt to the following address:
Caremark P.O. Box 52066 Phoenix, AZ 85072-2066
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 physician may need to submit additional documentation supporting your request.