Reminder: Here are requirements for prescription billing

Pharmacies are required to follow important billing procedures when submitting Blue Cross Blue Shield of Michigan and Blue Care Network prescription drug program claims.

Our reimbursements for prescription drug claims are based on the lesser of the:

• Average wholesale price, minus the contractual percent discount
• Pharmacy’s submitted ingredient cost
• Pharmacy’s usual and customary charge (retail charge)
• Maximum allowable cost price, where applicable

It’s your responsibility to submit these amounts in accordance with your provider agreement requirements.

The retail charge is the pharmacy’s charge per prescription for cash-paying customers. Any retail charge specific to certain groups will be given to Blue Cross or BCN for similar enrollees. When reimbursement is based upon the retail charge, Blue Cross or BCN doesn’t pay a dispensing fee.

For details, please refer to your Blue Cross and BCN Pharmacy Participation Agreement.

Note: Some of our members are part of demographic groups that qualify for a special price drug program — for example, the federal 340B program. In those instances, the pharmacy’s retail charge submitted on the claim for the member must reflect the special drug price of that program.

Blue Cross or BCN will seek recoveries following an audit for claims that don’t follow the Pharmacy Participation Agreement billing requirements. We appreciate your cooperation in complying with this contractual requirement.