Out of Network Coverage (Part D)

Health Net 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:

  • There is no network pharmacy that is close to you and open.
  • You need a drug that you can’t get at a network pharmacy close to you.
  • You need a drug for emergency or urgent medical care.
  • You must leave your home due to a federal disaster or other public health emergency.

In these situations, please contact Member Services to see if there is a network pharmacy nearby. 

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
  • 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 your Evidence of Coverage for specific information about drug coverage and limitations.