Your pharmacist submits online 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.