(JOHN HANCOCK) PAID PRESCRIPTIONS-MISSOURI Drugs covered: Legend drugs; compounds w/a legend; insulin. Drugs not covered: Contraceptives, whether prescribed for contraception or not; Rx's whose usual retail is $2 and under. Generics: When written for use lowest cost drug in stock. Maximum quantities: 34-day supply except for 100's in thyroid and nitrogly Imprinter: Yes. Drug identification on claim: Write drug name. Claim distribution: All copies to G.O. accounting. When forwarded: End of each week with sales and cash report. Reorder claim forms from: Paid Prescriptions Data Center, Box 2964, Phoenix, Ariz. 85036. TERMINOLOGY (THIRD PARTY PRESCRIPTIONS) (1) Third party prescription: A prescription paid for (all or part) by a Government agency (Federal, State, local) or by a private organization. (2) Sponsor: A Government agency or private organization who pays all or part of the cost of a prescription. We consider the administrator as the sponsor of a plan, since we do business with the administrator, rather than the organization which funds the plan. (3) Subscriber (member): The individual who has his prescription paid for by a third party plan. His dependents may or may not be covered, depending on the type of coverage the subscriber has. Subscribers are normally given an ID card with a number which identifies the subscriber. This number may also be called a contract number in the literature of some plans. (4) Provider, Provider No.: The organization which fills the prescriptions.. We are the provider for each third party plan under which we fill prescriptions. Most plans will give us a provider number. There may be one for each store, or only one for the company, depending on the plan. (5) Acquisition cost: Our cost of the medication dispensed. For all new nongovernment plans, we can use Rolodex costs. There is no change in the costs you use with current Government or welfare plans. (6) Professional fee: Most plans reimburse us for the third party prescriptions we fill on the basis of the cost of the product (acquisition cost), plus a set professional or dispensing fee. This fee varies by geographic area and by plan, and you must know the correct fee to use in completing each claim form. Professional fees are shown on the recap sheet for each plan in this booklet. (7) Co-pay: The amount the customer pays toward the total cost of a prescription. Initially, most co-pay amounts will be $2. Some sponsors, such as Blue CrossBlue Shield, may have more than one plan, and the co-pay amount may vary by plan. The co-pay amount is usually shown on the subscriber's ID card. (8) Claim amount: The amount we bill a sponsor, after computing the total price of a prescription under the plan and deducting any co-pay amount collected from the customer. The claim's amount is sometimes called "net amount" or "amount due". Acquisition cost, $2.52 plus professional fee, $1.95 equals Rx total, $4.47 minus copay, $2 equals claim amount, $2.47. (9) Drug code: A number assigned to each drug by the sponsor and listed in their manual. For most plans initially, you write out the drug name instead of using a drug code, but drug codes will probably be used more in the future. Acquisition cost plus fee or "usual charge," whichever is lower. 2 For all States with tax on insulin, the tax is added to the acquisition cost when "usual charge" is used. If professional fee is used, the fee includes tax. (10) Legend drug: Under third party plans, these are drugs and medications that may only be dispensed by prescription under either Federal law or the laws of your state. (11) Compound prescriptions: Under most third party plans only those compounded prescriptions are covered which contain at least one legend drug. (12) Prescription devices: Are specifically not covered under most third party plans. Includes diaphragms, hypodermic needles, syringes, etc. (13) Imprinter: A machine that will put certain information on a claim form after an ID card and claim are inserted into it. The imprinters currently in our stores will usually not work with third party claims. (14) Hot list: A list of subscribers and their card numbers who are no longer covered by the sponsor. Is published by some plan sponsors and we'll get credit for all claims up until we receive a "hot list" notice. (15) Flag code: This is a code number used by some sponsors to explain why a particular claim was rejected, should a rejection be made. NON-GOVERNMENT PLAN HANDLING PROCEDURE (1) Customer will present ID card with prescription or request for insulin. Be sure the prescribed medication is covered by this plan. (2) Determine if the prescription price is high enough to be covered by this plan. (a) If the prescription is paid for 100 percent or if our retail is more than the co-pay amount, write the "acquisition cost" on the prescription copy (AQ $X.XX). An example follows this section. = (b) If our regular retail price is less than the co-pay amount, fill the prescription on a normal basis. (3) Check the ID card for eligibility code (if any), expiration date (if any), and if on your list of "bad cards." (4) Imprint or copy the ID card information on a claims form. (5) Give the claims form to the customer to complete his or her portion and sign (if the customer signature must be on the claims form). Note-If using an imprinter which prints the claim amount on the claim form, reverse steps 4 and 5. (6) Fill the prescription and complete the pre-rec while the customer signs the claims form. (a) If no co-pay, write "N.O." on the pre-rec under price. (b) If a co-pay, enter the co-pay amount on the pre-rec under price. (c) If tax is authorized to be collected from the customer in your area, put a slash mark after the price and enter the tax on the total prescription ($3.52/.14). Note-If tax is charged to the customer, you must complete the claim form and note tax on the pre-rec before giving the prescription to the customer. (7) Check the customer portion of the claims form for completeness. (8) Give the prescription medication to the customer. (9) Clip the prescription copy and claims form together to be completed later. AMENDMENT TO THE PARTICIPATING PHARMACY AGREEMENT BY AND Between BLUE CROSS HOSPITAL SERVICE, INC. AND PARTICIPATING PHARMACY EFFECTIVE DATE OF AMENDMENT: APRIL 1, 1971 It is hereby agreed that for prescription drugs dispensed to covered members on and after April 1, 1971, the above referenced agreement is amended as follows: 1. Wherever in section 3 of the agreement the amount of "one dollar and eighty-five cents ($1.85)" appears, the amount of "two dollars and five cents ($2.05)" shall be substituted therefor. 2. Section 8 shall include: i. Prescription drugs, the usual and customary charge of which does not exceed the program deductible. This amendment is part of the agreement and is to be attached thereto. All terms and provisions of the agreement not changed by this amendment remain in full force and effect. In witness whereof, the parties hereto have executed and delivered this amendment to the agreement as above stated. Date: February 8, 1971. BLUE CROSS HOSPITAL SERVICE, INC. |