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FAQs For Pharmacists and Pharmacy Staff

Check out some common questions asked by pharmacists and pharmacy employees like you and get real answers. Here you’ll find a wealth of information about eligibility, claim submissions and prior authorization. If you do not find the answers you are looking for, please do not hesitate to contact us .
Q: What date of birth, sex and/or person code do you have on file for this eligible person?
A:If a member’s eligibility information is incorrect and a provider submits a claim using the correct eligibility information, the claim will be rejected. In most cases, we’ll be able to assist the provider at the point-of-service with any discrepancies in the eligibility information, such as date of birth or sex. But, advise your customers that they should let their plan sponsors know about any incorrect information and remind them that until it is corrected, claims will continue to be rejected.
Q: What is the identification number for this eligible person?
A:Providers must request to see the eligible person’s ID card to ensure that the prescription is written by the prescriber for an eligible person. The Help Desk cannot conduct an ALPHA search utilizing the name of the eligible person. Disclaimer Note: Many plan sponsors — in compliance with HIPAA and Personal Health Information (PHI) privacy protection—are issuing alternate identification numbers. It is important that providers request the member’s new ID card information and update the member’s profile accordingly to ensure the most current information is submitted with the claim.
Q: What is the RXGRP number for this eligible person?
A:Providers must request to see the eligible person’s ID card to ensure the claim is submitted to the correct prescription benefit management organization under the correct plan sponsor. Providers must examine both sides of the card for the RXGRP number and other data requirements.
Q: Is a processor control number (RXPCN) required for a claim submission?
A:Providers must request to see the identification card for the eligible person and examine the card to determine if the RXPCN information is available. Submit the RXPCN information as it appears on the identification card. If there is no RXPCN, submit the default number according to the banking identification number (RXBIN) as follows:
Q: What is the amount this patient must pay?
A:Providers must submit claims through the claims system to receive the adjudicated response, which will include the amount to collect from the eligible person as well as information about eligibility, plan coverage, pricing, and applicable clinical programs and services. The representatives at the Help Desk cannot release information about the amount the eligible person must pay due to the variables that may impact cost share.
Q: Is this eligible person qualified to receive a vacation supply?
A:Many plan sponsors allow eligible persons to secure an early refill for vacation. In which case, a provider must submit the claim as usual. If the claim is rejected, the provider should contact the appropriate Help Desk for coverage verification. If the plan sponsor does allow for an early refill for vacation supply, the representative from the Help Desk will provide a prior authorization code.
Q: What is the prior authorization procedure for this eligible person?
A:Here at CVS/caremark, we only administer prior authorization programs for some of our plan sponsors. Providers should note the adjudication response, which generally includes the online re-transmission instruction or appropriate contact information and telephone numbers.
Q: What are the plan limits for this eligible person?
A:Providers must submit a claim through the claims system to receive the adjudicated response, which will include messaging about plan coverage. The representatives at the Help Desks cannot release plan limitation information due to the variable that may impact the coverage for a given drug.
Q: What data field do I use for the <specific data>?
A:Representatives from the Help Desks will assist providers where possible to determine which data fields should be used for specific data. However, due to the numerous types of software, it is difficult for our representatives to know how each system is set up. Providers should consult with their software vendor or chain headquarters for technical assistance.
Q: How do I bypass the Interactive Voice Response (IVR) system to get a representative?
A:The IVR system provides easy access to necessary information. If the response from the IVR is not comprehensive, a provider can press 0 at anytime during the call to connect with a representative.
Q: What RXBIN do I use for all CVS/caremark eligible persons?
A:Providers should submit claims utilizing the corresponding RXBIN 610415, 004336 or 610029, unless otherwise specified. In most cases, the RXBIN is illustrated on the identification card.
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