Out-of-network coverage with Blue Shield of California

As a Blue Shield of California Medicare Advantage or Medicare Prescription Drug Plan member, you must use network providers to get your medical care and services. The only exceptions are:

  • Emergencies
  • Urgently needed care when a network provider is not available (generally, when you are out of the area)
  • Out-of-area dialysis services
  • Cases in which Blue Shield of California Medicare health plan authoDrizes use of out-of-network providers

You are responsible for paying the full cost of services of unauthorized out-of-network services.

Please refer to Chapter 3 of your plan's Evidence of Coverage for full information on out-of-network medical coverage.


Out of network prescription coverage

Using a pharmacy that is not in the Blue Shield of California network

We have a network of pharmacies outside of our service area where you can fill prescriptions. Generally, we only cover drugs filled at an out-of-network pharmacy when you are not able to use a network pharmacy. To help you, we have designated network pharmacies outside of our service area where you can fill your prescriptions as a member of our plan. If you cannot use a network pharmacy, here are the circumstances under which we would cover prescriptions filled at an out-of-network pharmacy:

  • If you are unable to get a covered drug in a timely manner within our service area because there are no network pharmacies within a reasonable driving distance that provide 24-hour service
  • If you are trying to fill a covered prescription drug that is not regularly stocked at an eligible network retail or mail service pharmacy (these drugs include orphan drugs, high-cost and unique drugs, or other specialty pharmaceuticals) 
  • Some vaccines administered in your physician’s office that are not covered under Medicare Part B and cannot reasonably be obtained at a network pharmacy may be covered under our out-of-network access
  • Prescriptions filled at out-of-network pharmacies are limited to a 30-day supply of covered medications

In these situations, please check with Customer Service at the number on your member ID card to locate a network pharmacy near you.

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 Customer Service.

You may pay more for any drugs you get at an out-of-network pharmacy than you would have paid at an in-network pharmacy. We reimburse for out-of-network pharmacy claims at our contracted rates. The difference will be your responsibility.

Direct member reimbursement

As an eligible Medicare Part D member, any time you pay out-of-pocket for a prescription that is covered under your pharmacy benefit plan, you can submit a request for reimbursement.

The reimbursement form must be received within three years from the date you paid for the service. This process is called direct member reimbursement or DMR.

Submission of the form is not a guarantee of payment. Reimbursement requests will not be processed without prescription receipts.

If you need help completing the DMR form, please contact your pharmacist or call Customer Service at the number on your member ID card.

 DMR form for Medicare members, English (PDF, 239 KB)
 DMR form for Medicare members, Español (PDF, 148 KB)

 Mail the completed DMR form to:

Blue Shield of California
P.O. Box 52066
Phoenix, AZ 85072-2066

Y0118_23_388A1_C 08172023
H2819_23_388A1_C 08172023

Page last updated: 10/01/2023

*Free copy with no obligation to enroll.

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For Blue Shield Medicare Advantage Plans: Blue Shield of California is an HMO, HMO D-SNP, PPO and a PDP plan with a Medicare contract and a contract with the California State Medicaid Program. Enrollment in Blue Shield of California depends on contract renewal.

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