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

You fill your prescription at the pharmacy, hand over your card, and expect to pay your usual $20 copay. Instead, the cashier says, "That’ll be $285." You didn’t change plans. You didn’t switch pharmacies. You didn’t even know your pharmacy was out-of-network. This isn’t a glitch-it’s a common trap. And the out-of-network pharmacy surprise isn’t covered by the No Surprises Act, even though it leaves you with the same shock as a surprise hospital bill.

The No Surprises Act, which took effect in January 2022, protects you from unexpected medical bills for emergency care, air ambulances, and certain non-emergency services at in-network hospitals. But it says nothing about prescriptions. Pharmacy benefits are handled by separate companies called pharmacy benefit managers (PBMs)-like CVS Caremark, Express Scripts, or OptumRx. These PBMs run their own networks, completely separate from your medical insurance network. You could be covered at your doctor’s office and still get hit with a massive pharmacy bill because the local pharmacy you’ve used for years isn’t on their list.

Why Your Pharmacy Might Be Out-of-Network

It’s not random. PBMs negotiate deals with pharmacies to get lower prices on drugs. In return, they put those pharmacies on their in-network list. But they also cut deals with specialty pharmacies for high-cost medications like cancer drugs or injectables. If your plan requires you to use one of those specialty pharmacies-and you walk into your local CVS instead-you’re automatically out-of-network.

Even if you’re not on a specialty drug, your PBM might have dropped your neighborhood pharmacy from its network. You won’t get a letter. You won’t get a text. The only sign is when you’re charged full retail price at the register. A Kaiser Family Foundation survey found that 28% of commercially insured adults faced unexpected pharmacy costs in 2022. Nearly one in five of those bills were over $500.

How to Check Your Pharmacy Network Before You Fill a Prescription

You can’t rely on your insurance card or your doctor’s office. You need to check two things: your plan’s pharmacy network and your drug’s formulary.

• Go to your health plan’s website and look for the “pharmacy network directory.” Don’t settle for the general provider directory-that’s for doctors, not pharmacies.
• Search for your pharmacy by name and zip code. If it doesn’t show up, it’s out-of-network.
• Check your drug’s tier. Some plans put certain medications on higher tiers, meaning higher costs even at in-network pharmacies.
• If you’re on Medicare Part D, use the Medicare Plan Finder tool. It separates medical and pharmacy networks, so you can see exactly what’s covered.

Specialty drugs are the biggest risk. About 78% of Medicare Part D plans and 65% of commercial plans require you to use specific specialty pharmacies for drugs like Humira, Enbrel, or Orencia. If you don’t, you’ll pay the full price-sometimes over $10,000 a month. Always ask your doctor or pharmacist: “Is this drug restricted to a specialty pharmacy?”

What to Do If You’re Already at the Pharmacy

If you’re already at the counter and the price is way higher than expected, don’t just pay it. You have options.

• Ask the pharmacist: “Is this pharmacy in my plan’s network?” They can often check in real time.
• Ask if they can transfer your prescription to an in-network pharmacy. Many will do it for free.
• Call your PBM’s customer service number-usually on the back of your card. Ask: “What’s the lowest cost pharmacy for this drug near me?” They’re required to give you that info.
• Ask if your drug has a generic version or a lower-cost alternative. Sometimes switching brands cuts the cost by 80%.

Don’t assume the pharmacist knows your plan. Many don’t. They’re trained to process transactions, not explain coverage. If they say, “It’s just how your plan works,” push back. You have rights.

Real People, Real Bills

Reddit threads are full of stories like this: “I’ve been going to my local Walgreens for 10 years. One day, my $45 copay became $310. I called my insurer. Turns out, they switched to a new PBM and dropped Walgreens last month. No notice.”

Another person wrote: “My son needs a $1,200 monthly injection. We used a local pharmacy. The bill came back $12,000. We had to appeal. Took six weeks. We almost lost his coverage.”

These aren’t rare cases. The Patient Advocate Foundation documented over 12,000 pharmacy billing disputes in 2022. Eighty-nine percent were caused by out-of-network charges that patients thought were covered.

What’s Being Done About It?

There’s growing pressure to fix this. The Consolidated Appropriations Act of 2023 required insurers to offer real-time benefit tools that show pharmacy network status at checkout. But the deadline keeps getting pushed-now it’s 2025.

States are stepping in. California and New York have introduced bills to extend surprise billing protections to pharmacy costs. The Biden administration’s 2024 budget includes $25 million to study how to protect patients from these hidden costs.

But until federal or state laws change, the responsibility falls on you. The No Surprises Act doesn’t cover you here. No one else will check for you.

Pro Tips to Stay Protected

• Keep a printed copy of your pharmacy network list. Update it every time you renew your plan.
• Use mail-order pharmacies if your plan offers them. They’re almost always in-network and often cheaper.
• Set up alerts with your PBM. Some let you sign up for notifications if your pharmacy changes.
• If you’re switching plans, check the pharmacy network before you enroll. Don’t wait until you need your medication.
• For expensive drugs, always ask your doctor to write a prior authorization request. It forces the plan to confirm coverage before you fill it.

There’s no law that stops a pharmacy from charging you full price if they’re out-of-network. But there’s a simple habit that can save you hundreds-or thousands-every year: Always check your pharmacy network before you fill a prescription.

Frequently Asked Questions

What to Do Next

If you take even one prescription, you need to act now. Don’t wait until you’re hit with a $500 bill. Open your plan’s website and look for the pharmacy network directory. Print it or save it on your phone. Keep it with your insurance card. Every time you get a new prescription, check that pharmacy before you walk in. If you’re on Medicare, use the Medicare Plan Finder. If you’re on an employer plan, call your PBM and ask for their current pharmacy list.

Pharmacy network surprises are preventable. But they won’t fix themselves. You have to be your own advocate. The system isn’t designed to protect you here. So protect yourself-before it’s too late.