Your pharmacist submits on-line prescription claim information to the Drug Plan claims system. The claim is then checked against stored data to determine whether it can be approved for payment.
The check determines:
- if the drug is a benefit;
- if you have health coverage and what type;
- if the quantity dispensed is within appropriate levels;
- if the unit costs are within the approved cost;
- if the number of prescriptions for the beneficiary is within limits;
- if the prescription is a duplicate or possible duplicate of another dispensed prescription;
- if the prescriber is authorized; and
- if the pharmacy is authorized.
The results of the check and prescription cost information is transmitted back to the pharmacy, detailing the consumer share (your cost) and the Drug Plan share.