What are “network pharmacies”?
Our Providers and Pharmacy Directory gives you a complete list of our network pharmacies – that means all of the pharmacies that have agreed to fill covered prescriptions for our plan members.
Why do you need to know about network pharmacies?
You can use the Providers and Pharmacy Directory to find the network pharmacy you want to use. This is important because, with few exceptions, you must get your prescriptions filled at one of our network pharmacies if you want our plan to cover (help you pay for) them.
If you’d like to receive a copy of our Providers and Pharmacy Directory you can call our customer service call center or you can download here. Our Customer Service Call Center number is at the end of this page.
You may go to any of our network pharmacies. If you switch from one network pharmacy to another, and you need a refill of a drug you have been taking, you should request your doctor a new prescription.
Your prescriptions should be written by a network provider
You must receive your prescription from a network provider. This person is often your Primary Care Physician (PCP). It can also be any other provider within the network if your PCP referred you for health care.To access providers within the network you can refer to your Provider Directory. The prescribing professional must be a Medicare provider or present documentation to MCS that demonstrate he/she is qualified to prescribe medications, or the Part D claim will be denied.
The plan will cover prescriptions from providers who are not in the plan’s network only in a few special circumstances. These include:
Other than these circumstances, you must have approval in advance (“prior authorization”) from the plan to get coverage of a prescription from an out-of-network provider. If you pay “out-of-pocket” for a prescription written by an out-of-network provider and you think we should cover this expense, please contact our CustomerService Call Center (phone numbers are at the bottom of this page) or send the bill to us for payment.
To have your prescription covered, use a network pharmacy
In most cases, your prescriptions are covered only if they are filled at the plan’s network pharmacies. A network pharmacy is a pharmacy that has a contract with the plan to provide your covered prescription drugs. The term “covered drugs” means all of the Part D prescription drugs that are covered by the plan.
When you use an out-of-network pharmacy to get a prescription filled
If you go to an out-of-network pharmacy and try to use your membership card to fill a prescription, 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. Save your receipt and send a copy to us when you ask us to pay you back for our share of the cost. The reimbursement will apply if is a covered Part D drug by the health plan.
What if the pharmacy you have been using leaves the network?
If the pharmacy you have been using leaves the plan’s network, you will have to find a new pharmacy that is in the network. To find another network pharmacy in your area, you can get help from our Customer Service Call Center (phone numbers are at the bottom of this page) or use the Providers and Pharmacy Directory.
When can you use a pharmacy that is not in the plan’s network?
Generally, we cover Part D drugs processed at an out-of-network pharmacy only when you are not able to use a network pharmacy
Plan drugs may be covered in special circumstances including illness, emergency, urgency or loss of prescription drugs while traveling outside of our Plan’s services area where there is no network pharmacy.
Getting coverage when you travel or are away from our Plan’s service area and how to request a reimbursement
If you must use an out-of-network pharmacy, generally you will have to pay the full cost (rather than just paying your normal share of the cost) when you fill your prescription. You can ask us to (as long the drug is Part D and covered by the plan) reimburse you for our share of the cost by submitting a claim form. If you fill your prescription drugs in an out-of-network pharmacy, you will be responsible of paying the difference between the amounts our Plan would pay for a prescription filled in a network pharmacy and the amount charged to you by the out-of-network pharmacy. To learn how to submit a paper claim, please refer to the paper claims process described below. In these situations, please check first with our Customer Service Call Center to see if there is a network pharmacy nearby.
How and where to send us your request for payment
Send us your request for payment, along with your bill and documentation of any payment you have made. It is recommended to keep a copy of your bill and receipts for your records.
To make sure you are giving us all the information we need to make a decision, you can complete our claim form to make your request for payment.
Mail your request for payment together with any bills or receipts to us at this address:
Request of payment for Part D Prescription DrugsMCS Advantage, Inc.Attn: Pharmacy DepartmentPO BOX 191720San Juan, PR 00919-1720
Please be sure to contact our Customer Service Call Center (phone numbers are at the bottom of this page) if you have any questions. If you don’t know what you owe, or you receive bills and you don’t know what to do about those bills, we can help. You can also call if you want to give us more information about a request for payment you have already sent to us.
Information about our network pharmacies
Customer Service Call Center: 787-620-2530 (Metro Area) or 1-866-627-8183 (Toll Free). TTY users should call 1-866-627-8182 (Toll Free). Our representatives will be available from Monday to Sunday from 8:00 a.m. at 8:00 p.m. from October 1 to March 31. Our hours of operation from April 1 to September 30 are Monday through Friday 8:00 a.m. to 8:00 p.m. and Saturday from 8:00 a.m. to 4:30 p.m.