Most claims paid by the Newfoundland and Labrador Prescription Drug Program (NLPDP) are processed through the Online Adjudication System. However, in some circumstances the NLPDP will reimburse a beneficiary for prescription purchases in accordance with their eligibility.
- Online Adjudication System
- Waiting on Eligibility Assessment
- Coordination of Benefits
- Medications not covered by Private Insurer
- Out of Province Claims
Online Adjudication System
The Online Adjudication System is a software system used by pharmacies to directly bill the NLPDP. This system provides immediate access to client and drug information, to determine if a claim is eligible for coverage.
Waiting on Eligibility Assessment
When an application is received by the Assessment Office it is date stamped. This date is used as a start date of the applicant’s coverage period when they are deemed eligible for coverage under the Access or Assurance Plan.
The applicant is informed in their letter that any prescriptions purchased out of pocket from their start date up to the time they receive confirmation of their eligibility may be submitted for reimbursement.
The NLPDP will require the following to process reimbursement request:
- the original prescription receipts,
- the beneficiary’s NLPDP ID number as noted on their letter
This information can be forwarded to:
Newfoundland and Labrador Prescription Drug Program
P.O. Box 8070
Postal Station A
St. John’s, NL A1B 4A6
Coordination of Benefits
It is a policy of some private insurers that the beneficiary must purchase his/her medications up front and submit his/her receipts for reimbursement. In these cases, co-ordination of benefits with the NLPDP cannot be processed at the pharmacy. Instead, the beneficiary must photocopy their paid in full receipts, submit the originals to their private insurer and wait for his/her reimbursement and explanation of benefits statement from the private insurer. Only then, can the beneficiary seek reimbursement from the NLPDP.
The NLPDP will require the following to process the co-ordination of benefits reimbursement request:
- the photocopied prescription receipts,
- the explanation of benefits sent by the private insurer, and
- the beneficiary’s NLPDP ID number as noted on the drug card
Information can be forwarded to:
Newfoundland and Labrador Prescription Drug Program
P.O. Box 8070
Postal Station A
St. John’s, NL A1B 4A6
Medications not covered by Private Insurer
A private insurer may not consider all medications as benefits of the beneficiary’s plan for any number of reasons such as a pre-existing medical condition. If the pharmacy is billing through the Online Adjudication System, the system will track the response from the private insurer and the claim will be paid based on NLPDP reimbursement policy. However, if the beneficiary manually submits a receipt to his/her private insurer and it is rejected, he/she will need to submit the documentation received from the private insurer with a photocopy of the prescription receipt, noting his/her NLPDP Drug Card Number, to obtain maximum reimbursement for the medication. Maximum reimbursement refers to the amount NLPDP would pay minus any upcharge costs, dispensing fees, or copay amounts for which the beneficiary is responsible.
Information can be forwarded to:
Newfoundland and Labrador Prescription Drug Program
P.O. Box 8070
Postal Station A
St. John’s, NL A1B 4A6
Out of Province Claims
The NLPDP will require the following to process the Out of Province reimbursement request:
- documentation of referral out of province by a physician of Newfoundland and Labrador or documentation of hospitalization if not referred out of province
- the original prescription receipts, and
- the beneficiary’s NLPDP ID number as noted on the drug card
Information can be forwarded to:
Newfoundland and Labrador Prescription Drug Program Assessment Office
P.O. Box 510
Stephenville, NL A2N 3B4