Outside Pharmacy Use
When you use an outside pharmacy (not the Yale Health Pharmacy at 55 Lock Street) you will be treated as a cash customer and they will not check to see if your prescription is covered under your insurance plan. This means that when you submit your claim it could be denied because:
- the drug is not covered under the benefit
- the drug required prior authorization (see the Yale Health Drug List)
- it is too early to fill the prescription
- the Yale Health co-pay is greater than the amount you paid for the drug (your cost for the drug is $28, but it is a Tier 3 drug, so the co-pay is $30)
- there is no “days supply” listed on the receipt (see instructions on claim form)
Pharmacy Reimbursement for an Outside Pharmacy
You are responsible for the greater of 20% of the cost or the co-pay.
Cost of drug purchased at outside pharmacy: $120
Co-pay (found on the Yale Health Drug List): $20
20% of your cost of $120: $24
You are responsible for $24 (when purchased at an outside pharmacy). If you had the prescription filled at the Yale Health Pharmacy you would only need to pay $20.
Your pharmacy benefit is subject to the rules and limitations of the formulary (Member Coverage Booklet) even when you use an outside (out-of-network) pharmacy.
For all of the reasons above plus the care that you receive because our pharmacists have direct access to your clinicians and your electronic health record – you may want to reconsider using the Yale Health Pharmacy.
If you use an outside pharmacy, you must submit a claim form for reimbursement.