Pharmacy care qualifying services information

Participation in this program may vary by group

Formulary interchange

NDC Number: 99999-9999-32 | Reimbursement: $4

Use this code when a prescription for a medication not on the WellFirst Health formulary is switched to a formulary medication. Do not submit claims if the prescriber authorizes a medical exception or obtains a prior authorization.

Submit quantity of 1.

Therapeutic interchange

NDC Number: 99999-9999-33 | Reimbursement: $12

This code should be used when making a change in a patient’s prescription order to a more cost-effective option. This requires notification of the prescriber and a change in prescription order. Examples of this include: Changing to a B-rated generic product or switching to a half-tablet prescription. Changing from a brand name product to an A-rated generic is not reimbursable.

Submit quantity of 1.

Change of dose

NDC Number: 99999-9999-34 | Reimbursement: $5

Use this code when the prescribed dose is either higher or lower than the recommended dose, or the duration is either insufficient or excessive. This requires the prescriber to change the prescription. Do not submit claims if the prescriber omits essential information such as the strength of medication.

Submit quantity of 1.

Patient compliance monitoring

NDC Number: 99999-9999-35 | Reimbursement: $10

Use this code when the pharmacist educates the patient about the importance of taking medication regularly and notifies the prescriber that the patient is less than 70% compliant over the past 3 months.

Submit quantity of 1.

Patient training on glucose monitors

NDC Number: 99999-9999-36 | Reimbursement: $1 per minute, up to 30 minutes

Submit number of minutes as the quantity

Patient training on asthma inhaler/peak flow meter

NDC Number: 99999-9999-37 | Reimbursement: $1 per minute, up to 10 minutes

Submit number of minutes as the quantity.

Patient training on blood pressure monitors

NDC Number: 99999-9999-38 | Reimbursement: $1 per minute, up to 15 minutes

Submit number of minutes as the quantity.

Patient training on nasal inhalers

NDC Number: 99999-9999-39 | Reimbursement: $1 per minute, up to 5 minutes

Submit number of minutes as the quantity.