Change to secondary coordination of benefit claims calculation for drugsSeptember 1, 2015
GSC is changing the way we handle the coordination of benefits (COB) for drug claims when GSC is the secondary payer. Starting October 1, 2015, we will apply GSC drug pricing to claims that have already been processed for payment by another private plan (the primary plan). This new administrative guideline applies to all drug plans.
Why are we doing this? In the past, we have typically paid the full balance of the secondary claim once the primary plan has reimbursed their portion. However, we noticed that some pharmacies are submitting amounts to the secondary plan above what would be allowed under our pricing file guidelines. We are implementing this cost control measure to protect against these types of excessive charges. This new administrative practice is consistent with Canadian Life and Health Insurance Association (CLHIA) guidelines and is expected to be adopted by others in the industry.
HERE’S AN EXAMPLE OF HOW THIS WOULD WORK:
- The GSC drug pricing file has an eligible price of $100 for this drug
- The pharmacy submits the remaining $40 to GSC as secondary plan
- GSC as secondary plan pays $20 (the difference between $100 and $80)
- The excess $20 amount will no longer be reimbursed by GSC. rent to it
We expect the impact to plan members will be minimal as GSC’s pharmacy agreement states that billing the difference of the allowed cost to the plan member is not permitted. We are communicating the new policy to pharmacies and reminding them of their obligation to comply with this agreement. A small number of plan members who submit their own drug claims (by claim form or through Plan Member Online Services) may experience some out-of-pocket costs if, despite our agreement, the pharmacy does charge more than the allowed cost according to the GSC pricing file. If this happens, the plan member should be speaking with their pharmacist.