What if I need a prescription because of a medical emergency?

We will cover prescriptions filled at an out-of-network pharmacy if the prescriptions are related to care for a medical emergency or urgently needed care. In this situation, you will have to pay the full cost (rather than paying just your copayment) when you fill your prescription. You can ask us to reimburse you for our share of the cost, if applicable, by submitting a paper claim form. To learn how to submit a paper claim, please refer to the paper claims process described below.

We cannot pay for any prescriptions that are filled by pharmacies outside the United States, even for a medical emergency.

Other times you can get your prescription covered if you go to an out-of-network pharmacy

We will cover your prescription at an out-of-network pharmacy if at least one of the following applies:

• If you are unable to obtain a covered drug in a timely manner within our service area because there is no network pharmacy within a reasonable driving distance that provides 24 hour service.
• If you are trying to fill a covered prescription drug that is not regularly stocked at an accessible network retail or mail order pharmacy (these drugs include orphan drugs or other specialty pharmaceuticals).
• Before you fill your prescription in either of these situations, call Advantra Customer Service to see if there is a network pharmacy in your area where you can fill your prescription. Click here for contact information.
• If you do go to an out of network pharmacy for the reasons listed above, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. You can ask us to reimburse you for our share of the cost, if applicable, by submitting a claim form. To learn how to submit a paper claim, please refer to the paper claims process described next.

How do I submit a paper claim

When you go to a network pharmacy, your claim is automatically submitted to us by the pharmacy. However, if you go to an out-of-network pharmacy for one of the reasons listed above, 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. When you return home, simply submit your claim and your receipt to the following address:

Medco® - Medicare D Claim
P.O. Box 14724
Lexington, KY 40512

Upon receipt, we will make an initial coverage determination on the claim. Please see the rights and responsibilities spelled out in your Evidence of Coverage (EOC) or call Customer Service for more information on initial coverage determinations.

Getting coverage when you travel or are away from the plan’s service area

If you take a prescription drug on a regular basis and you are going on a trip, be sure to check your supply of the drug before you leave. When possible, take along all the medication you will need. You may be able to order your prescription drugs ahead of time through our mail order pharmacy service. Coventry has a nationwide pharmacy network which includes over 60,000 pharmacies, so even if you are outside the service area, you will probably be able to find a network pharmacy in the area in which you are traveling.

If you are traveling within the US and become ill, lose or run out of your prescription drugs, we will cover prescriptions that are filled at an out-of-network pharmacy if you follow all other coverage rules. Prior to filling your prescription at an out-of-network pharmacy, call Customer Service to find out if there is a network pharmacy in the area where you are traveling. If there are no network pharmacies in that area, Customer Service may be able to make arrangements for you to get your prescriptions from an out-of-network pharmacy.

We cannot pay for any prescriptions that are filled by pharmacies outside the United States, even for a medical emergency.