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Using an Out-of-Network Retail Pharmacy

When you fill a prescription at a retail pharmacy that does not participate in the CVS Caremark Network, you pay the full cost of the prescription drug when you have the prescription filled. You must obtain a detailed receipt for each prescription drug that you purchase. Then you must complete a claim form supplied by CVS Caremark or MILA and send the claim form and each receipt from the pharmacy to CVS Caremark for processing. The receipts must include the following:

  • The name and address of the dispensing pharmacy;
  • The prescription number;
  • The name of the drug;
  • The quantity dispensed;
  • The date the prescription was filled; and
  • The cost of the prescription.

You can receive claim forms by calling the telephone number on your ID card, through Caremark®’s website or from MILA. Mail your claim form and pharmacy receipt to CVS Caremark at the address shown on the form. CVS Caremark will deduct the appropriate copay and then reimburse you up to the amount the prescription would have cost at an In-Network pharmacy. You are responsible for any additional cost.

For example, let’s say a preferred brand drug costs $200 at an In-Network pharmacy and $250 at an Out-of-Network pharmacy. As a MILA National Health Plan participant (the Core Plan copay differs), you would pay only $10 at the In-Network pharmacy and the Plan would pay $190. At the Out-of-Network pharmacy, you would pay $250, then file a claim along with the pharmacy receipt and wait for reimbursement. The Plan would pay you $190, and you would be responsible for $60 ($250 minus $190).