Submitting a pharmacy care program claim

Submit Pharmaceutical Care Program* claims online just as any regular prescriptions using the following data:

  • Patient Name: Submit a prescription under the patient for which the intervention was performed.
  • Prescriber: If the patient’s prescription was changed, use the name of the prescriber who authorized the change. If submitting a claim for patient compliance monitoring, submit the name of the prescriber who was notified of the compliance issue. If submitting a claim for patient education, use the name of the prescriber who authorized the prescription.
  • Date of Care: Use the actual date the intervention was performed.
  • NDC Number: Use the appropriate NDC number which corresponds to the intervention performed. Refer to the document covering qualifying services for more information.
  • Reimbursement: Reimbursement for the defined interventions will be included in the normal bimonthly pharmacy payment cycle.
  • Reporting: Prescribers will be notified on a regular basis of the interventions being performed by pharmacists on behalf of their patients. This is done to highlight the pharmacies that are having the greatest impact on patient care.
  • Records: Pharmacies will need to have the patient sign the hard copy of the prescription which should then be kept in the prescription file. Please write the appropriate NDC number for the care given on the prescription hard copy. These records may be requested for auditing purposes.

*Claims for Pharmaceutical Care Program interventions do not need to be submitted concurrently with claims for the medication dispensed. The intervention claims may be submitted at any non-peak time by the pharmacy, however, the date that care was provided must be submitted. Please remember that the hard copy of the prescription signed by the patient with the NDC shown for the care given is the only documentation pharmacies need to retain. Optional Clinical Services and Patient Training Pharmacy Care forms can be found in the Pharmacy area of wellfirstbenefits.com.