Reference Guide For Alberta Pharmacies - Blue Cross

Standard card layout - backAcross the top, you will find the GROUP andSECTION of the group providing coveragefor the plan member.Beside the section, you will see the CLASSof coverage, such as “FAMILY”, “COUPLE”or “SINGLE.”Listed on the back of the card are all thefamily members covered by the plan. Besideeach family member's name, you will seetheir ID NUMBER. The cardholder is alwayslisted first, followed by any dependents.Tips for successful online claim entryThrough Alberta Blue Cross’s real-time claim adjudication network, you will immediatelyknow of any portion your Alberta Blue Cross customer is required to pay or any prescriptionthat may be ineligible under their drug benefit plan. Their card contains the followingcoverage and eligibility information required to submit pay-direct prescription claims: GROUP: enter as a 7-digit number (fill with leading zeros if necessary) followed bysection (up to 3 digits, no zero filling). If your software does not utilize a separatefield for the section, the group and section are to be entered as one string. IDENTIFICATION NUMBER: (for example, 1234567-45) “1234567” enter as a 10digit number (fill with leading zeros if necessary) followed by the two digit patientcode (‘45” in this case). If your software does not utilize a separate field for thepatient code, the ID number should be directly followed by a / or – symbol, then thetwo digit patient code as show above. CARDHOLDER (member/subscriber) LAST NAME: must be indicated on allclaims.You must indicate one of the following carrier codes for each claim: CARRIER CODE 12: To be used for all Government of Alberta Human Servicesclaims. CARRIER CODE 16: To be used for Compensation Plan for Pharmacy Services andAlberta Public Health Activities Programs claims. CARRIER CODE VL: To be used for Veterans Affairs Canada claims. CARRIER CODE RL: To be used for Royal Canadian Mounted Police claims. CARRIER CODE DL: To be used for Department of National Defense claims.CARRIER CODE 11 is to be used when submitting for all other claims.In addition, you must submit the following: The correct BIRTH DATE of the member the claim is being submitted for. The RELATIONSHIP CODE for the member the claim is being submitted for. Forexample, the cardholder, spouse, or dependant.Card variationsSome plans administered by Alberta Blue Cross have a unique card design. These cardsmay look different, but they still contain all the elements you require to submit claims.These plans and their unique cards are shown below:Pharmacy Reference Guide AB 10

Alberta School Employee Benefit PlanCovered member’s ID numberMember’s nameSAMPLESAMPLEIssue dateDependants’ID numberGroup Section Dependants’numbernumbernamesAlberta Adult Health Benefit PlanAlberta Child Health Benefit PlanPharmacy Reference Guide AB 11

Learner's ProgramChild and Youth Support ProgramNational Blue Cross groups – old cardThe group number is reflected inthe first seven digits of the PolicyNumber while the section number isincluded as the last three digits.“P” indicates direct-bill prescriptiondrug benefits. Refer to the back of cardfor more information.Pharmacy Reference Guide AB 12

National Blue Cross groups – new cardGovernment of Northwest TerritoriesPharmacy Reference Guide AB 13

Product Identification Numbers (PINs)For your reference, here is a list of pseudo Product Identification Numbers (PINs). Whenbilling these products to Alberta Blue Cross, please use the appropriate PIN.Note: These products may not be eligible for coverage through all of your customers’ benefitplans. Please contact the Alberta Blue Cross Provider Relations Contact Centre if you areuncertain whether a customer is eligible for coverage of such products. The following listsare accurate as of the date on the cover of this document and are subject to change withoutnotice. The most updated lists can be found athttps://www.ab.bluecross.ca/dbl/idbl main1.htmlAEROSOL HOLDING CHAMBER/MASK DEVICEPRODUCT DESCRIPTIONPINAEROCHAMBER AC BOYZ0990100CHAMBERAEROCHAMBER AC GIRLZ0990099CHAMBERAEROCHAMBER PLUS FLOW-VU0990094W/ LARGE MASKAEROCHAMBER PLUS FLOW-VU0990093W/ MEDIUM MASKAEROCHAMBER PLUS FLOW-VU0990091W/ MOUTHPIECEAEROCHAMBER PLUS FLOW-VU0990092W/ SMALL MASKOPTICHAMBER ADVANTAGE II0990095(CHAMBER ONLY)OPTICHAMBER ADVANTAGE II0990098(WITH LARGE MASK)OPTICHAMBER ADVANTAGE II0990097(WITH MEDIUM MASK)OPTICHAMBER ADVANTAGE II0990096(WITH SMALL MASK)OPTICHAMBER DEVICE0990059OPTICHAMBER DIAMOND0999399(CHAMBER ONLY)OPTICHAMBER DIAMOND (WITH0999396LARGE MASK)OPTICHAMBER DIAMOND (WITH0999397MEDIUM MASK)OPTICHAMBER DIAMOND (WITH0999398SMALL MASK)OPTICHAMBER LARGE FACE0990061MASK DEVICEOPTICHAMBER MEDIUM FACE0990062MASK DEVICEOPTICHAMBER SMALL FACE0990063MASK DEVICEOPTIHALER DEVICE0990060PRODUCT DESCRIPTIONPINPOCKET CHAMBER DEVICE0990067POCKET CHAMBER PEDIATRICLARGE MASK DEVICEPOCKET CHAMBER PEDIATRICMEDIUM MASK DEVICEPOCKET CHAMBER PEDIATRICSMALL MASK DEVICEPOCKET SPACER DEVICEPRIMEAIRE ADULT LARGE MASKDEVICEPRIMEAIRE ADULT MEDIUM MASKDEVICEPRIMEAIRE ADULT SMALL MASKDEVICEPRIMEAIRE DEVICEPRIMEAIRE PEDIATRIC MASKDEVICESEREVENT DISKHALER DEVICESPACE CHAMBER ADULT MASKDEVICESPACE CHAMBER DEVICESPACE CHAMBER INFANT MASKDEVICESPACE CHAMBER PEDIATRICMASK DEVICEVORTEX BABY WHIRL INFANTMASK 00160990081VORTEX DEVICE0990080VORTEX SPINNER PEDIATRICMASK DEVICE0990082Pharmacy Reference Guide AB 14

DIABETES SUPPLIESPRODUCT DESCRIPTIONALCOHOL SWABS-DIABETESBLOOD GLUCOSE METERBLOOD GLUCOSE TEST STRIPSBLOOD KETONE TEST METERPIN0999984099002409999550999601PRODUCT DESCRIPTIONPININSULIN INJECTORS0990030INSULIN PEN NEEDLES0999985INSULIN PUMPS0999988INSULIN SYRINGES09999520999942BLOOD KETONE TEST STRIPS0990072BLOOD LETTING LANCET0999941COTTON SWABS-DIABETESGLUCOSE CALIBRATIONSOLUTIONGLUCOSE MONITORINGTRANSMITTERGLUCOSE MONITORINGTRANSMITTER SENSORSINFUSION SETS (TUBING &NEEDLE)INSULIN CARTRIDGES /RESERVOIRS0990064LANCING DEVICENEEDLELESS SYRINGE FORINSULIN INJECTORRUBBING ALCOHOL-DIABETES0990058SERTER0999471SKIN PREPARATION0999472SYRINGE/VIAL ADAPTER KIT FORINSULIN INJECTOR09990180990045URINE TEST STRIPS09999570990057VIAL ADAPTER/ADAPTER CAPFOR INSULIN INJECTOR0999016IV SUPPLIESPRODUCT DESCRIPTIONPINALCOHOL SWABS0990025CARTRIDGES0990026HEP-LOCKS0990023IV SOLUTIONS0990022IV TUBING0990021LACTATED RINGER'S LLANEOUSPRODUCT DESCRIPTIONALLERGY SERUM ODUCT DESCRIPTION0.9% SODIUM CHLORIDEINJECTION3.3% DEXT/ 0.3% NACL (2/3-1/3)INJECTION3.3% DEXT/ 0.3% NACL/ 20 MEQKCL INJECTION3.3% DEXT/ 0.3% NACL/ 40 MEQKCL INJECTION5% DEXTROSE (D5W) INJECTION5% DEXTROSE/ 0.15% KCL 20MEQ INJECTION5% DEXTROSE/ 0.3% KCL 40 MEQINJECTIONPINPRODUCT 9900350990036Pharmacy Reference Guide AB 15

NUTRITIONAL PRODUCTSPRODUCT DESCRIPTIONPINBENEPROTEIN ORAL POWDER0999415BOOST 1.0 STANDARD ORALLIQUID0999960BOOST 1.5 PLUS CALORIES ORALLIQUIDBOOST DIABETIC ORAL LIQUIDBOOST FRUIT FLAVOUREDBEVERAGE ORAL LIQUIDBOOST HIGH PROTEIN ORALLIQUIDBOOST ORAL LIQUIDBOOST ORAL PUDDINGBOOST PLUS CALORIES ORALLIQUIDCOMPLEAT ORAL LIQUIDCOMPLEAT PEDIATRIC ORALLIQUIDPRODUCT DESCRIPTIONNUTRAMIGEN A HYPOALLERGENIC INFANTFORMULA LIQUIDNUTRAMIGEN A HYPOALLERGENIC INFANTFORMULA POWDERPIN0999932NUTREN 1.5 ORAL LIQUID09999360999483NUTREN 2.0 ORAL LIQUIDNUTREN JUNIOR FIBRE WITHPREBIO 1 ORAL LIQUID09999640999427NUTREN JUNIOR ORAL LIQUID099941809999200999440NUTRIHEP ORAL LIQUIDOPTIMENTAL ORAL LIQUID099934709994200999921OSMOLITE HN ORAL LIQUID0999937099996609999330999901PEDIASURE ORAL LIQUIDPEDIASURE PLUS WITH FIBREORAL LIQUIDPEDIASURE WITH FIBRE ORALLIQUIDPEPTAMEN 1.5 ORAL LIQUIDPEPTAMEN AF 1.2 ORAL LIQUIDPEPTAMEN JUNIOR 1.5 ORALLIQUIDPEPTAMEN JUNIOR ORAL LIQUID0999934PEPTAMEN ORAL LIQUID099994409994020999426CONSIST-RITE ORAL POWDER0999455DUOCAL ORAL POWDERE028 SPLASH ORAL LIQUIDENFAMIL ENFACARE A INFANTFORMULA POWDERENSUREENSURE HIGH-PROTEIN ORALLIQUID09994440999524ENSURE LIQUID WITH FIBRE0999918ENSURE ORAL PUDDINGENSURE PLUSENSURE PREBIOTICS ORALLIQUID09994040999902PEPTAMEN WITH PREBIO 1 ORALLIQUIDPERATIVE ORAL LIQUIDPOLYCOSE ORAL POWDER0999525PULMOCARE ORAL LIQUIDGLUCERNA ORAL LIQUID0999940ISOSOURCE 1.5 CAL ORAL LIQUID0999425ISOSOURCE HN ORAL LIQUID0999410ISOSOURCE HN WITH FIBREORAL LIQUID0999424ISOSOURCE VHN ORAL LIQUID0999428ISOSOURCE VHP FIBRE-FREEORAL LIQUID0999550JEVITY 1 CAL ORAL LIQUID0999938JEVITY 1.2 CAL ORAL LIQUID0999416JEVITY 1.5 CAL ORAL LIQUID09994750999564PURAMINO A INFANT FORMULAPOWDERRESOURCE 2.0 ORAL LIQUIDRESOURCE DAIRY THICK ORALLIQUIDRESOURCE DIABETIC ORALLIQUIDRESOURCE JUST FOR KIDS 1.5CAL WITH FIBRE LIQUIDRESOURCE KID ESSENTIALSORAL LIQUIDRESOURCE THICKENED JUICEORAL LIQUIDRESOURCE THICKENUP CLEARORAL POWDERRESOURCE THICKENUP 09995610999453Pharmacy Reference Guide AB 16

NUTRITIONAL PRODUCTSPRODUCT DESCRIPTIONPINKETOCAL ORAL LIQUID0999565KETOCAL ORAL POWDER0999445MCT OIL ORAL LIQUID0999927MODULEN IBD ORAL POWDERNEOCATE JUNIOR ORAL PWDRNEOCATE JUNIOR WITHPREBIOTIC FIBRE ORAL POWDERNEOCATE WITH DHA & ARA ORALINFANT FORMULANEPRO CARB STEADY ORALLIQUIDNEPRO ORAL LIQUIDNOVASOURCE RENAL LIQUIDPIN09995590999447PRODUCT DESCRIPTIONSCANDISHAKE ORAL FOODSUPPLEMENT POWDERSIMILAC ADVANCE NEOSUREORAL POWDERSIMILAC ALIMENTUM WITH IRONORAL INFANT FORMULASUPLENA ORAL LIQUIDTOLEREX ORAL POWDER0999560TWOCAL HN ORAL LIQUID09994300999568VITAL HN ORAL POWDER0999965099954509999220990056VIVONEX PEDIATRIC ORALPOWDERVIVONEX PLUS ORAL POWDERVIVONEX T.E.N. ORAL 994050999983Pharmacy Reference Guide AB 17

Units of issue for pricingProducts should be billed with the correct unit of issue when submitting a claim to AlbertaBlue Cross. The following units of issue are applicable to private/employer-sponsored plansas well as government-sponsored plans maintained by Alberta Blue Cross.Nutritional supplements, birth control products and inhalation products are subject to aminimum unit of issue. The minimum quantity required at the time of claim is based on theunit of issue defined for these products in the list below.Examples of some of the minimum quantity limits applied are:ProductEnsure/BoostAdvair 100 DiskusPowder for InhalationAlesse (21 Day) TabletUnit of IssuemlMinimum Quantity235 mlsIncorrect Quantity1 canDose60 doses1 diskusTablet21 tablets1 packetThe quantity field allows for a maximum of four characters to be entered, resulting in a directbill claim quantity maximum of 9999 units when entering product quantity for claimsubmission. Providers are required to submit any claims with a quantity in excess of 9999units through the use of a manual claim form to be processed at Alberta Blue Cross. Thefollowing list is accurate as of the date on the cover of this document and is subject tochange without notice. The most updated lists can be found athttps://www.ab.bluecross.ca/dbl/idbl main1.htmlDosage FormBladder Irrigation Powder for SolutionBladder Irrigation SolutionsBlock or Infiltration CreamBuccal SprayDental Paste/GelDevicesInfant /Pediatric/Adult DeviceInhalation AerosolInhalation CapsulesInhalation CartridgesInhalation DisksInhalation LiquidInhalation Powder for SolutionInhalation Solutions or ectionInjection – CartridgesInjection – EmulsionInjection – ImplantInjection – LiquidInjection – Lock FlushInjection – SyringeUnit of IssueVialMillilitreGramDose or tridgeDiskMillilitreVialMillilitreGramMillilitre (where no reconstitution required)Syringe (prefilled syringe)Vial (where reconstitution illilitreSyringe (or Millilitre where indicated)Pharmacy Reference Guide AB 18

Dosage FormInjection Syringe/CapsuleInjection Syringe/TabletInjection Syrup SyringeInjection Vial/ CapsuleIntraintestinal GelIntrauterine InsertIrrigating SolutionsMetered Dose AerosolsMetered Inhalation PowderNasal GelNasal Metered Dose AerosolsNasal Metered or Unit Dose SpraysNasal SolutionNasal SpraysOphthalmic ImplantOphthalmic Insert/DeviceOphthalmic Gels or OintmentOphthalmic Solution/Drops/Liquid/Suspension/EmulsionOral BarOral Capsules – all formulationsOral Disintegrating TabletOral Disintegrating Tablet/FilmOral EmulsionOral Enteric Coated Tablet/PowderOral GelOral GranulesOral GumOral Liquids – all formulationsOral Powder – all formaOral PuddingOral Rinses/MouthwashOral SolutionOral SprayOral Tablets – all formulationsOral Tablet/CapsuleOral/Vaginal/Topical Capsule/CreamOtic Ointments or GelsOtic Solutions/Suspensions/Drop/LiquidRectal EnemasRectal FoamsRectal GelRectal OintmentsRectal SolutionRectal Suppositories - all formulationsScalp Lotions/ SolutionsStripSublingual Metered Dose SprayUnit of IssueKitKitVial or PieceCapsuleWaferFilmMillilitreKitGramBulk size – Gram Individual Packet – ositoryMillilitreStripDosePharmacy Reference Guide AB 19

Dosage FormSublingual TabletTopical AerosolTopical BarsTopical CleansersTopical Creams/Ointments - allformulationsTopical FoamTopical GauzesTopical Gels - all formulationsTopical JelliesTopical LiquidTopical LotionsTopical OilTopical PadTopical PatchTopical PowdersTopical RinseTopical ShampooTopical SolutionsTopical SprayTopical WashesTransdermal GelTransdermal PatchesUrethral JellyUrethral SuppositoryVaginal CreamsVaginal GelVaginal InsertVaginal Slow Release RingsVaginal Tablet or OvuleVaginal/Topical Ovule or Tablet/CreamUnit of illilitreMillilitreMillilitre or GramMillilitrePadPatchGram/ MillilitreMillilitreMillilitreMillilitre or GramMillilitreMillilitre or GramGram/PacketPatchMillilitreSuppositoryGramDose or GramSystemRingTablet or OvuleKitFor the most current information, please refer tohttps://www.ab.bluecross.ca/dbl/idbl main1.htmlPharmacy Reference Guide AB 20

Drug cost pricingManufacturer’s List Price - Manufacturer’s List Price is the price for drug benefits listed inthe Alberta Drug Benefit List (ADBL) as determined through pricing confirmations betweenAlberta Health and the drug manufacturers. Manufacturers agree to sell the drug in theAlberta marketplace at this price. It is the maximum price for these drugs that can becharged to an Alberta Blue Cross plan member.The Alberta Drug Benefit List can be found l.Base Price - Base Price is a price established by Alberta Blue Cross for drug benefits notlisted in the Alberta Drug Benefit List but covered under the Alberta Blue Cross Price List. Itis the maximum price for these drugs that can be charged to an Alberta Blue Cross planmember.Alberta Blue Cross uses multiple Alberta pricing references to determine a reasonable BasePrice for drugs not listed on the Alberta Drug Benefit List. Alberta Blue Cross makes everyeffort to maintain reasonable and fair pricing.The Alberta Blue Cross Price List is made available to pharmacies through the Alberta BlueCross website at e.html. Alberta BlueCross works directly with pharmacy software vendors to ensure pricing is availableelectronically as required. The Alberta Blue Cross Price List will be updated on a quarterlybasis.Diabetic supplies and medical supplies are to be submitted at the usual and customary retailprice in the drug cost field. Allowable Upcharge #1 & #2 and dispensing fees cannot becharged for these products.Pharmacy Reference Guide AB 21

Pricing component chartDrug Listed inADBLBrand orGenericWhat do I usefor the drugcostAllowableUpcharge #1Calculated drugcost*(Aggregate ofthe drug costand theAllowableUpcharge#1)Software fieldManufacturerList Price (MLP)– as publishedin the AlbertaDrug BenefitList (ADBL)3% of MLPMLP AllowableUpcharge 3%Drug listed onAlberta BlueCross DrugPrice List(ABCDPL)Base Price –as published inthe AlbertaBlue CrossDrug Price List(ABCDPL)7.5% of BasePriceBase Price ade in store)Purchasedcompound price(invoice price)ManufacturerList Price (MLP)or Base PriceNA7.5% of MLP &or Base PricePurchasedcompound price(invoice price)ManufacturerList Price (MLP)or Base Price 7.5% of MLP &or Base PriceDrug Cost fieldYear 1 5.5% of Drug Cost*Year 2 6.0% of Drug Cost*AllowableYear 3 6.5% of Drug Cost*Upcharge #2Year 4 7.0% of Drug Cost*All to a maximum of 100Upcharge field (previously the Additional InventorySoftware fieldAllowance Field)Dispensing Fee 12.30 18.45Software fieldDispensing Fee fieldCalculated Drug Cost* Allowable Upcharge #2 Total PriceDispensing Fee* With the exception of purchased compounds, the price on your invoice is no longer theprice submitted.Best Price PolicyThe Best Price Policy ensures Alberta Blue Cross plan members are entitled to receive thelowest price for a drug that you charge to anyone else. If you are giving discounts to otherthird party plan members or cash paying customers, you must give the same discount toAlberta Blue Cross plan members.Pharma

Alberta Blue Cross issues an ID card to every adult covered by an Alberta Blue Cross plan. Plan members must present this card each time a prescription is dispensed. This card contains important information that is required to submit claims to Alberta Blue Cross. Standard card la