Description:
We reserves the right to accept or not to accept assignment of benefits on drug claims that are processed by us and not the Pharmacy Benefit Manager.  We will not accept assignment of benefits from a pharmacy on a prescription drug claim unless certain criteria is met.

Drug co-pays are a covered benefit when there is dual coverage.  Procedures for processing these claims are outlined below.

Policy:
Assignment may be honored on some claims as individual consideration due to the cost of the drugs.  Some examples of these are growth hormone drugs, chemotherapy drugs, AIDS drugs and drugs related to transplants.  If an assigned claim is received for any of these drugs, it may be processed without obtaining management approval.  Any other exceptions must be approved and documented by the claims managers.

Note:
Some ASO accounts may have agreements with some pharmacies to honor assignment.  These exceptions should be determined by the group representatives and documented in the departmental desk procedures.

The following procedure will be used when processing claims submitted for drug co-payments:

• The claim should be drug screened and marked appropriately; i.e., generic, etc.
  The charge would then be processed using the correct procedure code.  Key "Rx co-pay" in the micro support field on the header and key the "B" in the OCL indicator field so the claim will defer second pass for DOCAC.
• Once the claim defers, the COB processor must check TPR to determine if we are primary or secondary.
• If we are primary, the processor will need to override the DOCAC and let the claim resolve manually.
• If we are secondary, the COB processor should key bypass indicator "1" on the header and the claim will pay the appropriate benefit on the co-payment amount.

If we receive the bill that has the actual charge of the drug, an adjustment will need to be done to the original claim to reflect the correct charge instead of the co-pay.  Key "Rx Adj." in the micro support field in the header of the adjusted claim.

For correct processing of Group and Individual drug co-pay claims, please refer to the Area COB desk procedures.