Name of Manual - Blue Cross and Blue Shield of Minnesota

Coding Policies and Guidelines (Pharmacy Services)
Claim Processing
NDC Numbers The NDC numbers submitted on the pharmacy claim must be
taken from the container from which the drug was dispensed. The
NDC number must match the manufacturer and package size.
Copays/Coinsurance The drug copay/coinsurance amount varies for each subscriber.
Rely on “claim response” to correctly identify the amount to
collect from the member. If a member’s contract contains the
formulary amendment, a dual copay may be in effect. Again, rely
on “claim response” to determine the correct amount to collect
from the member.
Vacation Prescription
Requests
Prescription Cost Less
Than Copay
Discounting or Waiving
Copays
Requests for additional drug quantities may be made by the
member, physician, or pharmacist. The member would contact the
customer service number listed on the back of their member ID
card. The physician or pharmacist would contact the pharmacy
help desk. Please keep in mind that some drugs are controlled
substances and may require a new prescription.
If the cost of the prescription is less than a member’s copay, the
member should pay the lesser of the allowed amount as shown on
the claims response.
In order to maintain the level of subscriber responsibility specified
in Blue Cross contracts, it is essential that members pay the
agreed-upon copay for preferred and non-preferred drugs. Both
member and provider agreements specifically state that the copay
must be collected in full. Noncompliance of this provision, through
discount or waiver, could result in termination of the provider
agreement.
Pharmacy Audits Blue Cross performs comprehensive pharmacy program integrity
audits to ensure compliance with its programs.
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Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/09/11)