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Prescriptions Outside of Network

We have network pharmacies outside of the service area throughout the United States where you can get your drugs covered as a member of Senior Whole Health. Generally, we only cover drugs filled at an out-of-network pharmacy in limited, non-routine circumstances when a network pharmacy is not available.

Below are some circumstances when we would cover prescriptions filled at an out-of-network pharmacy. 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 do go to an out-of-network pharmacy for the reasons listed below, you may have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. You may 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 for a covered Part D drug will help you qualify for catastrophic coverage. To learn how to submit a paper claim, please refer to the paper claims process described in the subsection below called "How do you submit a paper claim?"

If you are in the United States and temporarily out of the area and unable to use a network pharmacy, your covered prescriptions will be reimbursed if you follow the following procedure.


Submitting a paper claim

You may submit a paper claim for reimbursement of your drug expenses in the situations described below:

Drugs purchased out-of-network. When you go to a network pharmacy and use our membership card, your claim is automatically submitted to us by the pharmacy. However, if you go to an out-of-network pharmacy and attempt to use our membership card for one of the reasons listed in the section above ("How do you fill prescriptions outside the network?"), the pharmacy may not be able to submit the claim directly to us. When that happens, you will have to pay the full cost of your prescription and submit a paper claim to us. Obtain a detailed receipt from the pharmacy. Please call Senior Whole Health Member Services and we will tell you where to send the receipt for reimbursement. The timeframe for submitting paper claims is within 90 days. This type of reimbursement request is considered a request for a coverage determination and is subject to the rules contained in your Evidence of Coverage.

Drugs paid for in full when you don't have your membership card. If you pay the full cost of the prescription because you don't have your membership card with you when you fill your prescription, you may ask us to reimburse you for our share of the cost by submitting a paper claim to us. This type of reimbursement request is considered a request for a coverage determination and is subject to the rules contained in your Evidence of Coverage.

Drugs paid for in full in other situations. If you pay the full cost of the prescription because it is not covered for some reason (for example, the drug is not on the formulary or is subject to coverage requirements or limits) and you need the prescription immediately, you may ask us to reimburse you for our share of the cost by submitting a paper claim to us. In these situations, your doctor may need to submit additional documentation supporting your request. This type of reimbursement request is considered a request for a coverage determination and is subject to the rules contained in your Evidence of Coverage.

Last Updated 01/13/2014
H2224_2014_112 Approved 01/13/2014