If a participant uses a pharmacy that does not participate in the prescription drug program, a paper claim must be filed. A participant can get a prescription drug claim form by contacting Catalyst Rx. The claim form must be completed in its entirety to avoid delays in processing. Pharmacy receipts must be attached to the claim form. The completed form must be mailed to Catalyst Rx. The participant will be reimbursed the difference between the Plan’s allowable charge and the co-payment amount, once the applicable deductible has been met. Any charge for a prescription drug that exceeds the Plan’s allowable charge will be the participant’s responsibility and will not be applied toward meeting the deductible or co-payment.
If another group plan is primary, the claim must be filed with that plan first. When an explanation of benefits (EOB) from the other plan has been received, the claim must be filed with Catalyst Rx. The claim must be filed with a copy of the other plan’s EOB and the pharmacy receipts. If the other plan’s EOB is not received, the claim will be denied until the information is received.
Time Limit for Claims Filing A claim should be filed as soon as possible after receiving care. However, the deadline for filing claims varies with the type of claim.
Deadline for Filing Medical Claims: All claims must be filed with Blue Cross & Blue Shield by the end of the calendar year following the year in which the services were provided.
Deadline for Filing Prescription Drug Claims: All claims to Catalyst Rx must be filed within 18 months of the date the prescription was filled.
A Special Note about Medical Claims: Blue Cross & Blue Shield does not consider a claim to be received for processing until the claim is actually received in the proper form, with all of the necessary information provided. If Blue Cross & Blue Shield needs additional information before the claim can be processed, that information must be promptly submitted but no later than the end of the calendar year following the year in which the services were provided. It is the participant’s responsibility to ensure that claims are filed within the time limits. Claims filed after the time limits have expired are not eligible for benefits and will be denied.
Tips for Filing Claims
9 9 9
9 9 9
Keep all receipts from non-participating pharmacies and physicians. File claims promptly. Use the correct form. (There are separate claim forms for medical and prescription drug benefits.) Complete the entire form. Keep a copy of all claims filed. Mail the claim to the correct address.