If a member has dual pharmacy coverage and ODS is the secondary plan, how will the secondary claim be paid?
When the primary plan has approved and paid toward a pharmacy claim, ODS will pay up to what would have been covered had the claim been submitted to ODS for primary processing. ODS will not pay more on the secondary claim than a member’s total out-of-pocket expense on the primary claim. In instances where the primary plan has denied the claim or paid nothing toward the claim (e.g., the cost of the medication is less than the copay), then the secondary plan will process the claim as if it is a primary claim.
