Co-Ordination of Benefits

On-line Co-ordination of Benefits (COB) is available for both public-sector and private-sector plans. This section describes how COB works with private drug plans. Collecting COB information is important at plan inception, and updating it frequently is also necessary to ensure that claims are paid by the appropriate carrier.

Although pay-direct drug cards only show the plan member’s name, the plan member’s covered family members can also use the card at the pharmacy when filling prescriptions. The plan member’s spouse may also have a drug plan which covers drug costs for family members, including the plan member.

The plan that pays first for any claim is based on the following insurance industry guidelines and referred to as the primary plan:

• The pharmacist submits the claim to the plan member’s drug plan.
• Claims for the plan member’s spouse are submitted to his/her own benefit plan first.

For dependent-children claims, the spouse whose birthday falls first in the year should submit these claims to his/her drug plan first.

On-line COB allows the pharmacy to transmit to the secondary plan any claim expense not covered by the primary plan.

Once the order of payment is determined using the aforementioned steps, the following methods are used to submit prescription claims:

(a) If the plan member and the spouse each have a pay-direct drug card.

1. If the Express Scripts Canada plan is first payer, the pharmacist submits the claim electronically, then the pharmacy attempts to submit the unpaid balance to the secondary plan electronically. If that does not work, the plan member must submit a manual claim form.

2. If both of the pay-direct cards are Express Scripts Canada cards, the pharmacist submits the claim electronically first to the plan member’s plan, and then the pharmacist submits the unpaid balance electronically to the spousal plan.

3. If another drug card is first payer, the claim is adjudicated electronically first under that plan; the pharmacy then submits the unpaid balance of the claim electronically to Express Scripts Canada.

(b) If the plan member has a drug card and the spouse has a paper claim reimbursement plan.

1. If the Express Scripts Canada card is first payer, the pharmacy submits the claim electronically; the plan member must then submit a manual claim for the unpaid portion to the secondary plan.

Please note:  Express Scripts Canada offers its customers different products. Customers decide which of these products will be offered through their own branded programs. Some products may not be available in all provinces/territories.