Orchard - Unchanged

Coordination of Benefits

Coordination of benefits (COB) claims are those claims your primary insurance has already paid and PEHP becomes your secondary insurance. Cash-paid (direct) claims are those you paid the cash price for your medicine without using your pharmacy card. When PEHP is your secondary carrier, you must buy your prescriptions through your primary carrier.

PEHP will coordinate coverage of eligible co-payments and unpaid pharmacy claims if they meet PEHP’s benefit, coverage, preauthorization, and quantity requirements. You’ll need to submit an original itemized receipt (a pharmacy printout is not a valid receipt) and an Express Direct Claim Form to Express Scripts that includes:

  1. Date of service
  2. Name, address, and NPI or NCPDP number of pharmacy
  3. Prescription number
  4. Doctor name or NPI number
  5. Name and strength of drug
  6. NDC number (identified drug)
  7. Quantity dispensed
  8. How many days' supply
  9. Amount paid

Express Scripts will reimburse you up to PEHP’s usual and customary contract rate and benefit rules minus the required co-payment.