CVS Pharmacy Insurance

What is BIN?

Bank Identification Number - tells CVS which insurance company to send the claim to

Why is BIN important?

If BIN is wrong, the claim rejects instantly

What is PCN?

Processor Control Number - routes the claim inside the insurance company

Why does PCN matter?

Wrong PCN = “patient not covered”

What is group number?

Identifies the patient’s specific plan

Why does group number matter?

Determines coverage rules

What is Member ID?

Identifies the patient

Why is Member ID important?

Wrong ID = claim rejects

What does PA required mean?

Insurance needs doctor approval before covering the medication

How do you fix PA required?

Patient must contact doctor; CVS cannot complete PA

What does NDC Not Covered mean?

Insurance does not cover that manufacturer’s version

How to fix NDC Not Covered?

Switch to a different NDC

How to respond to Refill Too Soon?

Tell the patient the date they can refill

What is Generic Required?

Insurance won’t pay for brand

How to respond to Generic Required?

Switch to generic unless DAW 1

What is DAW 0?

Use generic

What is DAW 1?

Doctor requests brand

What is DAW 2?

Patient requests brand

What is primary insurance?

The plan that pays first and handles the bulk of the cost and sets the rules for coverage

What does primary insurance decide?

Whether the medication is covered, how much they will pay, what the patient owes, whether a PA is required, whether brand or generic is allowed

What if primary insurance rejects the claim?

CVS cannot bill the secondary until the primary is fixed

What is secondary insurance?

It pays whatever the primary didn’t cover; it can reduce the copay, cover remaining costs, sometimes pay for meds that primary doesn’t, help patients with high deductibles

What is copay?

A fixed amount the patient pays each time they pick up a medication; copays do not change based on medication price, they are set by the insurance plan, and they apply after the deductible is met (if the plan has one)

What is deductible?

The amount a patient must pay out of pocket before insurance starts covering medications

They reset every year

Until the deductible is met the patient pays full price or partial price

Deductibles often apply to brand-name drugs, specialty meds, and certain plans

Difference between copay and deductible

Copay = fixed amount

Deductible = pay full price until you reach a limit

What is GoodRx?

A discount program that gives patients a lower cash price on medications (NOT insurance); a coupon that replaces insurance for that prescription only

Why might patients use GoodRx?

They don’t have insurance, their insurance copay is too high, their insurance doesn’t cover that medication, they want the cheapest price possible

When is GoodRx better than insurance?

High deductible plans, non-covered medications, brand-name drugs, patients without insurance

When is insurance better than GoodRx?

Controlled substances, very cheap generics, patients with secondary insurance