3.18 Claims for Drug Cost Exceeding $9999.99

General Policy Description

The maximum drug cost that can be entered in PharmaNet is $9,999.99. However, drug claims that exceed this amount are not uncommon. The following is information on how these claims should be submitted.

Policy Details

Claims in excess of $9,999.99 must be split, with the drug cost, dispensed quantity, and days' supply kept in proportion.

Dispensing fees may not be split.

Procedure

To ensure correct adjudication of claims exceeding the maximum,

• Split the claim and submit as separate claims of less than $9,999.99
• Accurately divide the drug cost in proportion to the dispensed quantity entered for each claim
• Pro-rate the days' supply between the claims in proportion to the dispensed quantity entered for each claim (see example below)
• Do not split the dispensing fee; include it in only one of the claims (entering a $0 dispensing fee on the remaining claims)
• Enter the intervention code MP for all claims except the first claim

When you must submit multiple claims due to drug cost exceeding $9,999.99, you are required to ensure any portion of the days’ supply claimed in excess of the PharmaCare maximum for the drug (i.e., 30 or 100 days, as applicable) is entered into PharmaNet with the intervention code DE—Adjudicate to $0.00 as requested.

Sample of submission of a claim in excess of $9,999.99

Claims for a 28-day supply of a drug with a dispensed quantity of 28 and drug cost of $24,000

Field	Claim 1	Claim 2	Claim 3
Dispensed quantity	10	10	8
Days' supply	10	10	8
Drug cost	$8,571.43	$8,571.43	$6,857.14
Dispensing fee	Yes (usual fee claimed)	No (zeroed out)	No (zeroed out)
Intervention code	N/A	MP	MP