The James Zadroga 9/11 Health and Compensation Act of 2010 (Zadroga Act), as amended, requires the World Trade Center (WTC) Health Program medical and pharmacy claims for Survivor members go through a process called Coordination of Benefits (COB).
COB sets the order in which different payors (e.g., private insurance, public insurance, the WTC Health Program) pay their share of costs for treatment of a Survivor’s certified WTC-related health condition.
The WTC Health Program recently mailed letters about coordination of benefits to Survivor members. Letters are available in English, Español, and 中文:
What are the Steps for COB?
As a Survivor member of the WTC Health Program, you play an important role in helping us coordinate your benefits. All Survivors must follow these steps so the WTC Health Program can make payments for your medical treatment and/or prescriptions for your certified WTC-related health condition(s):
1
Sign up for primary health insurance.
If you already have primary health insurance, continue to step 2. If not, you must sign up for public or private health insurance, such as Medicaid, Medicare, private health insurance offered through your employer or the Marketplace , or other options.
All members of the WTC Health Program are required to have primary health insurance, including pharmacy and medical coverage. Your benefits counselor at your Clinical Center of Excellence (CCE) or the Nationwide Provider Network (NPN) can help you find and apply for health insurance. Learn more about the WTC Health Program health insurance requirement.
2
Share your current primary health insurance information with your CCE or the NPN as soon as possible.
You will be asked to provide your primary insurance information during each visit or phone call with your CCE or the NPN. If your insurance information changes, let your CCE or the NPN know right away. If your CCE or the NPN does not have up-to-date information, it may impact payment for your treatment or pharmacy claims.
3
Show your primary health insurance card at every treatment visit.
Once you begin your WTC-related care, your WTC Health Program provider must have up-to-date insurance information to process your claims and ensure that you do not receive a bill for WTC-related services.
4
Make sure that any WTC Health Program provider you see is also in your primary health insurance plan’s network.
In order for the Program to pay for any treatment of your certified WTC-related health condition, the treatment must be received through a Program-affiliated provider. In addition, Survivors must make sure that provider is also in their primary health insurance plan’s network.
Your CCE or the NPN will confirm the provider is in network with your primary insurance prior to referring you for treatment. If the Program-affiliated provider is not in network with your primary health insurance, talk to your CCE or the NPN about your options.
5
Show your primary health insurance card at every pharmacy visit.
Your WTC Health Program pharmacy must have up-to-date insurance information to process your pharmacy claims and ensure that you do not receive a bill for WTC-related prescriptions. Survivors must get all WTC-related prescriptions filled at a pharmacy (home delivery, specialty, or retail) that is both in the Program’s Express Scripts network and your primary health insurance plan’s pharmacy network.
If you need help finding an in-network pharmacy, talk to your CCE or the NPN or call Express Scripts 1-800-935-7179.
6
Follow all requirements of your primary health insurance.
For example, if a medically necessary procedure or prescription to treat your certified WTC-related health condition requires a prior authorization from your primary health insurance, this prior authorization must be received before the WTC Health Program can pay for your treatment.
WTC Health Program Survivors should not receive bills for treatment of their certified WTC-related health condition(s). You also should not pay a copay at your provider’s office, clinic, or pharmacy.
If you receive a bill or are asked to pay a copay or coinsurance charge for a prescription or treatment of your certified WTC-related health condition, please contact your CCE or NPN as soon as possible before paying the bill.
Learn more about what to do if you receive a bill.
The following frequently asked questions describe more information you need to know about Coordination of Benefits for Survivors in the WTC Health Program. If you have any additional questions, contact your CCE or the NPN.
General COB Questions
As a WTC Health Program Survivor member, your Program provider will bill your primary health insurance first, including any public insurance such as Medicare or Medicaid. Any secondary insurance you may have will be billed next. Finally, they will bill the WTC Health Program for the remaining amount. This leaves no out-of-pocket cost to you for treatment or prescriptions of a certified WTC-related health condition, including any coinsurance charges, copayments, or deductibles for care.
Please note: In most situations outside of the WTC Health Program, Medicaid is the payor of last resort; however, under the Zadroga Act, the WTC Health Program is the payor of last resort after Medicaid for a Survivor’s certified WTC-related health condition.
There are no out-of-pocket costs for treatment of Survivor’s certified WTC-related health conditions if the WTC-related care is provided by a Program-affiliated provider or pharmacy. The Zadroga Act establishes different requirements for accomplishing this for Responders and Survivors.
For Survivors, the Zadroga Act requires that the WTC Health Program follow the Coordination of Benefits process for treatment and medication costs of a certified WTC-related health condition. Coordination of Benefits is also required for annual monitoring exams.
If your certified WTC-related health condition is work-related and you have a workers' compensation claim for the condition, the WTC Health Program will pay for treatment costs initially and then seek recoupment from either the workers' compensation carrier or settlement, where applicable. This applies to both Survivors and Responders. The WTC Health Program does not recoup from workers’ compensation for either initial health evaluations or annual monitoring exams. Learn more about workers’ compensation and Coordination of Benefits in the Member Handbook.
Medical Benefits COB Questions
The one-time initial health evaluation given to newly enrolled Survivors is paid for, in full, by the WTC Health Program. Initial health evaluations are performed through your CCE or the NPN. Coordination of benefits is not required for the initial health evaluation and you do not need to check to make sure the provider performing this evaluation is in your primary insurer’s network.
As a Survivor, if you are certified for a WTC-related health condition, you are eligible for annual monitoring exams. These annual monitoring exams follow the same coordination of benefits process as treatment, which means your primary health insurance pays first. However, similar to initial health evaluations, these annual monitoring exams are performed through your CCE or the NPN and do not require that you check to make sure the provider performing this exam is in your primary insurer’s network.
As a Survivor, you must provide your primary health insurance information any time you receive WTC-related care. This means you need to give it to:
- Your CCE or the NPN.
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Any specialist or external Program-affiliated provider you see for your certified WTC-related health condition. Tell the provider’s staff your visit is for a WTC-related health condition. This will help make sure that they bill your visit properly.
- Before scheduling an appointment, you must make sure that any specialist and/or external provider is a Program-affiliated provider and is in your primary health insurance network.
- If your primary health insurance has any requirements for treatment coverage, such as prior authorizations, those must be met before the WTC Health Program can be billed.
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Any pharmacy you use for filling a WTC-related prescription, along with your WTC Health Program Express Scripts Prescription ID Card.
- Before picking up your prescription or ordering home delivery or specialty, make sure the pharmacy is in both your primary health insurance network and Program’s Express Scripts’ pharmacy network.
- If the pharmacy is not in both networks, you will need to find another pharmacy that is. You can call Express Scripts, your CCE, or the NPN for assistance.
- Make sure the pharmacy knows to bill your primary insurance first and WTC Health Program last.
If your primary health insurance ever changes, make sure you let your CCE or the NPN know.
WTC Health Program members should not receive bills or be asked to pay any co-pays for treatment of their certified WTC-related health condition(s). However, if you are asked for a co-pay or do receive a bill for a co-pay or coinsurance by mistake, please call your CCE or NPN as soon as possible to alert them to the problem.
Coordination of benefits is complex, and sometimes there are administrative errors. If you do receive a bill. Your CCE or the NPN will help you figure out next steps to ensure there are no out-of-pocket costs for your WTC-related healthcare.
Pharmacy COB Questions
The WTC Health Program covers prescription drugs to treat certified WTC-related health conditions. Express Scripts is the company that manages the WTC Health Program pharmacy benefits, known as the Pharmacy Benefit Manager.
For Survivors, Coordination of Benefits applies to prescription drug coverage for WTC-related health conditions the same as WTC-related medical care—the pharmacy must bill your primary insurance first, including any public insurance such as Medicare or Medicaid, and then bill the WTC Health Program any remaining amount. This leaves no cost to you. There are no copayments, coinsurance, or deductibles for WTC-related prescriptions covered by the Program.
Important! Make sure that your Clinical Center of Excellence or Nationwide Provider Network has your updated primary insurance information to avoid issues processing coverage for your WTC-related medication(s).
Your WTC Health Program doctor or specialist will write the prescription for your certified WTC-related health condition(s).
Step 1: You may fill your prescriptions at any in-network retail pharmacy or through certain home delivery pharmacies in the Express Scripts network as long as the retail pharmacy and home delivery pharmacy is also in network for your primary health insurance’s prescription coverage plan.
Step 2: You must make sure any pharmacy you use has your most up-to-date primary health insurance information as well as your WTC Health Program Prescription ID card.
Step 3: Tell the pharmacy that the WTC Health Program is the secondary payor.
Step 4: The pharmacy will bill your primary health insurance first, and then bill any remaining costs to the WTC Health Program. If the pharmacy tries to bill the Program directly, the claim will be rejected with a message for them to bill your primary insurance first.
Please note: Your primary insurance may have certain requirements that need to be met, such as a prior authorization; such requirements must be processed prior to the WTC Health Program paying the remaining the amount.
Step 5: Call your pharmacy before going to pick up your prescription to ensure the COB process has been followed and you can pick up your prescriptions at no out-of-pocket cost.
For more information about how to fill your prescriptions, please visit our Pharmacy Benefits page.
Coordination of Benefits is a requirement for Survivor members of the WTC Health Program under to the James Zadroga 9/11 Health and Compensation Act of 2010. To fully cover pharmacy costs for Survivors, the pharmacy must bill your primary insurance first, including any public insurance such as Medicare or Medicaid, and then bill the Program the remaining amount.
Follow the steps in the questions above to ensure your pharmacy bills the WTC Health Program appropriately.
If the pharmacy is unable to fill your prescription it may be due to a problem billing the prescription to your primary health insurance. You or the pharmacy should contact your primary insurance company to resolve the issue.
If the pharmacy is having difficulty processing the WTC Health Program as secondary payor, they should contact the WTC Health Program Pharmacy Help Desk.
If the Pharmacy submits the claim to the WTC Health Program after your primary health insurance has paid its share, and there is an issue, you may contact Express Scripts at 1-800-935-7179, your CCE, or the NPN to resolve the issue.
Important! If you pay for a prescription out-of-pocket before resolving the issue with Express Scripts, and you believe the prescription should be covered by the WTC Health Program, you can fill out an Express Scripts Direct Claims form [PDF, 2 pages, 462 KB] for reimbursement.
For questions about this process, please contact Express Scripts directly at the above number. The WTC Health Program cannot guarantee reimbursement and does not have the legal authority to reimburse you directly itself.
The direct claims form is also available in Español [PDF, 2 pages, 462 KB]
Find a retail pharmacy near you through the Express Scripts pharmacy locator in the Express Scripts Member Portal or by calling Express Scripts at 1-800-935-7179. Survivors must make sure that the pharmacy you select is also in your primary health insurance's network.
The James Zadroga 9/11 Health and Compensation Act of 2010, as amended, requires that all members of the WTC Health Program have primary health insurance, including pharmacy and medical coverage, unless a limited exception applies.
If you have medical insurance, but don’t have pharmacy coverage, you should obtain pharmacy coverage as soon as possible or it will impact the Program’s ability to pay for your prescriptions.
In the meantime, Survivors without pharmacy coverage will need to call Express Scripts customer service every time a prescription is needed and let them know you do not have pharmacy coverage. Express Scripts may issue a limited override to allow the pharmacy to process your prescription. These overrides will only be allowed temporarily.
