This section addresses claims and appeals for services under the Express Scripts Pharmacy Benefit for prescription drugs. If you have a claim or appeal involving an HMO, Medicare Advantage, or other plan option, you should consult that Carrier’s booklet for the proper procedures for resolving claims and appeals.
HOW TO FILE A CLAIM
You should present your health care identification card whenever you go to the Pharmacy. This will ensure the pharmacy has the correct information to submit your prescription claim.
When the Pharmacy does not file the claim for you, the charges should be submitted directly to the Carrier, Express Scripts, using the form provided. All claims for Medicare enrolled individuals should be submitted to Medicare before being submitted to a Carrier.
In many states, a Carrier may have a “crossover” arrangement with the Medicare Carrier. This means that when Medicare processes the claim, it provides information directly to the Carrier, which then processes the secondary balance. In that case, you will receive a combined Explanation of Benefits (EOB) statement that illustrates how both Medicare and the Plan paid the claim.
In the instance that you are attempting to fill a claim at an out of network pharmacy, you will need to submit a direct claim form. A copy of a direct claim form has been provided for your convenience. In the event you choose to fill a prescription out of network, you will be reimbursed for the approved amount minus 25% . If you are filling out of network due to a medical emergency, the penalty will be waived. Your pharmacy network is extensive, if you have any questions regarding whether a specific pharmacy is within your network, please visit Express Scripts at www.express-scripts.com.
DEADLINE FOR FILING CLAIMS
Claims are due within 12 months of the date of service. Claims received after the one-year period will be denied unless you can show that it was not possible to provide such notice of claim within the required time and that the claim was filed as soon as reasonably possible.
NOTICE OF CLAIM DECISION / APPEALS
The Carrier will give you notice of the decision on a claim. The notice will be in writing, and will tell you about the specific reasons for the action. It will refer to the specific provisions of the Plan on which the denial is based and explain whether any additional information is required from you. In the notice, the Carrier will identify the address to use for your appeal. The Carrier will decide your claim within the deadline for the type of claim involved (i.e., urgent claim, prior authorization).
If you have submitted a claim for a Prescription Drug benefit and it has been denied due to the Plan’s determination regarding your enrollment or eligibility status, it will also be subject to these rules and deadlines.
A detailed description of the claims and appeals procedures is in the plan document. If these descriptions inadvertently disagree with the plan documents, the plan documents will prevail. To initiate a review or appeal of a decision, please call or write Express Scripts at :
Attn: Coverage Reviews
8111 Royal Ridge Pkwy
Irving, TX 75063
Contact information for Express Scripts, including addresses, is also included in your Schedule of Benefits or Certificate of Coverage.