PRESCRIPTION DRUG BENEFIT

Pay–Direct and Your Pay–Direct Number

Electronic submission of Prescription Drug expenses will be possible in many situations. Within two weeks of your enrollment into the Plan, you will receive a welcome letter that has your certificate and group number on it. You and your eligible dependants will use those numbers when claiming benefits at the pharmacy.

It is important that your pharmacist have this new information. Without it, they will not be able to process an eligible claim electronically.

Transmitting Claims Electronically

In most cases, your pharmacist will transmit your prescription claim electronically. AFBS works with ClaimSecure to provide members and their covered dependants with pay-direct claims payments for Prescription Drug coverage. Since these claims are processed through the ClaimSecure network, the pharmacy requires the information contained on your welcome letter in your insurance package to process your claim.

When Electronic Submission is Not Possible

Electronic submission is not possible for all prescription drug claims. For example, compound prescriptions cannot be submitted electronically.

When electronic transmission is not possible for a prescription drug expense, please send the original official receipt from the pharmacy with a completed Prescription Drug claim form to AFBS. Your pharmacist will let you know when electronic claims processing isn’t possible and a paper claim form must be completed.

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Second Payor Claims/ Explanation of Benefits (EOB)

If AFBS is the second payor, please include the receipt of the claim settlement information, often called an Explanation of Benefits (EOB), from the other insurance company along with copies of the official receipt from the pharmacy or a completed prescription drug form to AFBS.

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Deadlines for Claims Submission

Claims for a previous Benefit Year must be submitted within 90 days of the close of the Benefit Year indicated on your Certificate of Insurance to remain eligible for payment. When coverage is terminated AFBS must receive your claim submissions within 30 days of your coverage termination.

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ClaimSecure

ClaimSecure provides many employee benefits administrative and claims adjudication services to insurance companies and employers. AFBS uses ClaimSecure's prescription drug and dental care claims adjudication systems in order to be able to provide online adjudication to the membership. However, with the exception of online adjudication (which is handled by a computer) all claims are adjudicated by AFBS staff. Because AFBS uses the ClaimSecure computer platform, any prescription drug cheques are issued by their system even when the claim has been adjudicated by AFBS staff.

AFBS wants to provide your reimbursement to you as quickly as possible. Online adjudication reimbursement cheques are processed the next day. Delays in processing are prevented when claim forms are sent to directly to AFBS. Never contact or send claims to ClaimSecure.

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