How to Avoid Out-of-Network Pharmacy Surprises for Medications

Imagine this: you walk into your local pharmacy to pick up a monthly prescription, and the pharmacist says, "That’ll be $285." You’re stunned. Last month, the same drug cost $32. You didn’t change plans. You didn’t switch pharmacies. You didn’t even get a notice. This isn’t a mistake. It’s a pharmacy network surprise - and it’s happening to millions of people every year.

The No Surprises Act, which went into effect in January 2022, was supposed to stop unexpected medical bills. But here’s the catch: it doesn’t cover prescriptions. That’s right. While emergency room visits, anesthesiology, and radiology services are protected from surprise billing, your insulin, your blood pressure pill, or your cancer drug? Not protected. The law was never designed to touch pharmacy benefits. Those are handled by separate systems - pharmacy benefit managers (PBMs) like CVS Caremark, Express Scripts, and OptumRx - and they operate under completely different rules.

Why Your Pharmacy Isn’t Covered by the No Surprises Act

The No Surprises Act targets balance billing - when an out-of-network provider charges you the difference between what your insurance agreed to pay and what they billed. That’s why you won’t get a $5,000 bill after an ER visit if the doctor wasn’t in-network. But pharmacy costs don’t work that way. Instead of balance billing, you face higher copays or full retail prices when you use an out-of-network pharmacy. There’s no cap. No negotiation. No automatic protection.

Here’s how it breaks down: your health plan has two separate networks - one for doctors and hospitals, and another for pharmacies. Just because your doctor is in-network doesn’t mean your local CVS or Walgreens is. In fact, 92% of large employers use separate PBMs to manage drug coverage, which means your pharmacy network might be narrower than your medical network. A 2023 Kaiser Family Foundation survey found that 28% of insured adults faced unexpected pharmacy costs in the past year. Of those, 63% paid over $100, and nearly one in five paid more than $500.

How Out-of-Network Pharmacies Work

When you fill a prescription at an in-network pharmacy, your insurer has already negotiated a discounted price. The pharmacy agrees to accept that price as payment in full (minus your copay). But if you go to a pharmacy outside your plan’s network, they don’t have that deal. They charge you the full list price - sometimes called the “cash price.” And since most people don’t know what that price is, they assume their insurance will cover it like usual.

Specialty medications are especially risky. About 78% of Medicare Part D plans and 65% of commercial plans require you to use specific specialty pharmacies for drugs like those for MS, rheumatoid arthritis, or rare cancers. If you accidentally use a different pharmacy - even one that’s in-network for other drugs - you could pay 3 to 5 times more. One patient on Reddit reported paying $300 for a medication that normally cost $30. That’s not a glitch. That’s how the system works.

How to Check Your Pharmacy Network Before You Fill a Prescription

You can’t rely on your insurance card, your doctor’s office, or even your pharmacy’s website. You need to check directly with your plan or PBM. Here’s how:

• Use your plan’s online portal - Log in to your insurer’s website or app. Look for a section labeled “Pharmacy Network,” “Find a Pharmacy,” or “Drug Benefits.” Don’t just search for your doctor.
• Call your PBM - The number is usually on the back of your insurance card. Ask: “Is this pharmacy in my network for this specific medication?” Give them the name of the drug and the pharmacy’s address.
• Use the Medicare Plan Finder - If you’re on Medicare Part D, go to Medicare.gov/plan-compare. You can compare plans by drug coverage and pharmacy networks side by side.
• Ask for the pharmacy directory - Consumer Reports says most people ask for the “provider directory,” which only lists doctors. You need the separate “pharmacy network directory.”

Pro tip: If you’re switching plans, always check pharmacy networks before enrollment. A plan that looks cheaper might have a tiny pharmacy network that forces you to drive 30 miles just to fill a prescription.

What to Do If You’re Already Hit With a Surprise Bill

Even if you didn’t know, you’re not stuck. Here’s what to do:

• Call the pharmacy - Ask if they can reprocess the claim through an in-network pharmacy. Sometimes, they can transfer it to a nearby partner pharmacy.
• Contact your PBM - Explain the situation. Some PBMs have exceptions for hardship cases, especially if it was your first time using that pharmacy.
• Request a price match - If you know the in-network price (you can find it on GoodRx or SingleCare), ask the pharmacy if they’ll honor it. Some will, especially if you pay cash.
• File a complaint - If you’re on Medicare, contact 1-800-MEDICARE. For private insurance, file a complaint with your state’s insurance commissioner. In 2022, the Patient Advocate Foundation documented over 12,000 pharmacy billing disputes - many were resolved after complaints.

Special Cases: Specialty Drugs and Mail-Order Risks

Drugs for chronic conditions - like biologics, cancer treatments, or rare disease therapies - are often restricted to specialty pharmacies. These aren’t your local CVS. They’re mail-order or limited distribution pharmacies that require prior authorization. If you don’t follow the rules, you pay full price.

Here’s what to do:

• Ask your doctor: “Which specialty pharmacy does my plan use for this drug?”
• Confirm the pharmacy will accept your insurance before they ship.
• Never assume your regular pharmacy can fill it. Even if they carry the drug, they might not be authorized to dispense it under your plan.

Mail-order pharmacies are another trap. Some plans require you to use mail-order for 90-day supplies - and if you go to a local pharmacy instead, you’ll pay more. Check your plan’s rules before you refill.

What’s Being Done to Fix This?

There’s growing pressure to fix this gap. In 2023, Congress introduced the Pharmacy Benefit Manager Transparency Act, which would require PBMs to show real-time pharmacy network status at the point of sale. The Biden administration proposed $25 million in funding to study solutions. States like California and New York have introduced bills to extend surprise billing protections to prescriptions - but as of now, none have passed.

Meanwhile, the Department of Health and Human Services admitted in its 2023 report that pharmacy benefits were “outside the scope” of the No Surprises Act and that “additional consumer protections may be warranted.”

That means right now, you’re on your own. The system isn’t broken - it’s designed this way. And until laws change, the responsibility falls on you to check, double-check, and verify.

Bottom Line: Don’t Assume. Verify.

You can’t rely on luck, memory, or your doctor’s word. Every time you fill a prescription - even if it’s the same drug you’ve taken for years - check the pharmacy network. Use your plan’s tools. Call your PBM. Ask for the pharmacy directory. Don’t let a $300 bill become your new normal.

Pharmacy networks aren’t just a billing issue - they’re a health issue. If you skip your medication because you can’t afford it, you’re at risk. That’s why knowing your network isn’t about saving money. It’s about staying alive.