How to File a Prescription Drug Claim
Prescription drug claims are processed by Express Scripts, Inc. and should be submitted to:
Express Scripts, Inc.
P.O. Box 390873
Bloomington, MN 55439-0873
To process a prescription drug claim, ESI requires a prescription receipt/label which includes:
• Pharmacy Name/Address
• Date Filled
• Drug Name, Strength and NDC
• Rx Number
• Quantity
• Days Supply
• Price
• Patient’s Name
Claims received missing any of the above information may be returned or payment may be denied or delayed. Cash register receipts and canceled checks are not acceptable proof of your claim.
If you have other insurance which is primary, you need to submit an Explanation of Benefits (EOB) from the other insurance which shows the amount the primary insurance paid with each claim, or ask your provider to do so if the claim is being submitted for you.
You have six (6) months from the date of service to file a prescription claim. If PEIA is your secondary insurer, you have six (6) months from the date of your primary insurer’s Explanation of Benefits processing date to file your claim with PEIA. If you do not submit claims within this period, they will not be paid.
If your claim is for an illness or injury wrongfully or negligently caused by someone else, and you expect to be reimbursed by another party or insurance plan, you must file a claim with PEIA within six (6) months of the date of service to ensure that the covered services will be paid. Later, if you receive payment for the expenses, you will have to repay the amount you received from PEIA.
If you have any questions, call Express Scripts Customer Service Department at 1-877-256-4680 (toll-free).
Filing Claims for Court-Ordered Dependents (COD)
If you are the custodial parent of a child who is covered under the other parent’s PEIA plan as a result of a court order, you must use your I.D. card at a participating pharmacy to receive prescription benefits.
Claims Incurred Outside of the U.S.A.
If you or a covered dependent incur prescription drug expenses while outside the United States, you will be required to pay the provider yourself. Request an itemized bill containing all the information listed above from your provider and submit the bill along with a claim form to ESI.
ESI will determine, through a local banking institution, the currency exchange rate and you will be reimbursed according to the terms of PEIA PPB Plans A & B.
Medicare Part D
Medicare offers prescription drug coverage through Medicare Part D. Please be aware that you should NOT purchase a separate Medicare Part D plan. PEIA will provide prescription drug coverage to its Medicare members through a Medicare Part D Plan administered by Express Scripts, Inc.
If you are a Medicare Advantage plan member and enroll in a separate Medicare Part D plan, you will be disenrolled from all medical and prescription benefits from PEIA. You will have only original Medicare A & B for medical coverage and your Medicare Part D plan with no secondary coverage.
Medicare Part D Creditable Coverage Notice
The coverage you have now through West Virginia PEIA is considered by Medicare to be creditable coverage, or coverage as good as or better than that offered under Medicare’s standard Part D benefit. If you are eligible for Medicare and decide to opt out of this plan’s coverage, you should consider joining another plan as soon as possible to avoid having to pay a late enrollment penalty. If you choose to leave this plan and do not join another plan within 63 days of the termination date of this coverage, you will be charged a late enrollment penalty of at least 1% per month you went without coverage as good as or better than that offered under Medicare Part D.
When Can You Change to a Different Plan?
Generally, Medicare-eligible members can change plans during the yearly enrollment period (called the “annual coordinated election period”) from October 15 through December 7. Generally, this is the only time of year to choose a different Medicare plan. Certain individuals, such as those with Medicaid, those who get “Extra Help” paying for their drugs, or those who move out of the geographic service area, can make changes at other times.