Ms. Edwards is enrolled in a Medicare Advantage plan that includes prescription drug plan (PDP) coverage. She is traveling and wishes to fill two of the prescriptions that she has lost. How would you advise her?
The Correct Answer and Explanation is:
Correct Answer:
Ms. Edwards should contact her Medicare Advantage plan to locate a network pharmacy in the area where she is traveling or seek assistance in obtaining a temporary supply of her medications through an out-of-network pharmacy if necessary.
Book-style Explanation
When a Medicare Advantage (MA) plan member, such as Ms. Edwards, is traveling and loses her prescription medications, it is important that she understands how to obtain replacements in accordance with her plan’s coverage rules. Medicare Advantage plans that include prescription drug coverage (MAPD plans) have specific networks of pharmacies through which members are expected to fill their prescriptions.
The first step Ms. Edwards should take is to contact her plan’s member services, using the phone number provided on her plan membership card. A representative can help identify local network pharmacies in her current location. If a network pharmacy is available, she can have her prescriptions filled there, possibly with minimal disruption and standard copayments.
However, in situations where no network pharmacy is accessible—such as when traveling to a remote area or in emergencies—plans may allow the member to use an out-of-network pharmacy. In such cases, Ms. Edwards may have to pay the full cost of the medication up front and then submit a claim for reimbursement. Reimbursement is subject to the plan’s rules, and not all expenses may be covered.
The plan may also allow for a temporary supply or emergency refill if her circumstances meet certain criteria. Documentation of the loss and a new prescription from her physician may be necessary.
To avoid future problems, members are generally advised to travel with an adequate supply of medications and a list of their prescriptions. Medicare Advantage plans typically provide guidance in their Evidence of Coverage (EOC) documents regarding what to do when members are away from their usual service area.
By promptly contacting her plan, Ms. Edwards can receive personalized instructions and ensure continued access to necessary medications while traveling.
