Diaper Billing Guide

• Diapers and/or training pants will be covered for children under 2 years old.
• Diapers and training pants will have a $0 copay to the member. Diapers will not count against monthly Rx limits.
• Up to 100 diapers/training pants will be covered every 30 days with a max of 200 diapers every 60 days.
  • Days’ supply should be calculated by dividing the number of diapers in the package by 3.3333.
  • Example: A box of 96 diapers would be a 29-day supply. Two boxes of 96 diapers (192 diapers total) should be processed for a 58-day supply.
• Diapers will be submitted by UPC, as they do not have an assigned NDC number.
  • Barcode UPC numbers are converted to 11 digits when loaded into Medi-Span.
  • To convert from a 12-digit UPC to an 11-digit UPC, remove both the leading digit and the check digit at the end, leaving a 10-digit code. A zero is added into the 6^th position to create the 11-digit code.
  • Generic Diaper UPCs will need to be added to the pharmacy’s system for processing. They will not sync from Medi-Span.
• Pharmacy must submit a full package quantity for reimbursement. See Covered UPC List for covered product package sizes. Pharmacies should not break packages of diapers unless the product is a case with multiple packages inside, and they are labeled for individual sale by the manufacturer.
  • For Generic Diaper UPCs, pharmacies should process claims for the quantity of the full package (or multiples of the full package) of the product being dispensed. Please note, claims will not reject when submitted if the package quantity and submitted quantity do not match.
• Claims may be submitted for multiples of the same UPC up to the maximum of 200 diapers per claim.
• Only one product UPC will be covered per claim submission. Another size, style, or brand of diapers may be used for the next available fill.
• Sales tax will be paid to the pharmacy on claims for diapers or training pants. Pharmacy must submit sales tax on the claim. Pharmacies should work with their software vendor to learn how to submit sales tax on prescription claims.
  • Sales tax rate will be based on the pharmacy’s local sales tax rate.
• An administration fee will be paid to pharmacies that submit claims for covered and generic UPCs within the specified product limits. An administration fee will show in the Incentive field.
  • The administration fee paid is $0.03 per diaper (max $6 for 200 diapers).
    • Example: A claim for 5 packages of 24 count diapers (120 diapers total) would have an admin fee paid of $3.60.
    • The admin fee is pro-rated based on quantity of diapers submitted.
• Pharmacies may submit claims for products on the Covered UPC list, or they may submit a Generic Diaper UPC to dispense a non-covered UPC. The pharmacy should submit the claim for the UPC that corresponds to the size of the diapers being submitted from the list below:

• At this time, only Covered UPCs of training pants may be dispensed under the benefit.
• A per-diaper, size and brand-specific MAC will be paid for dispensing covered diaper UPCs. A per-diaper, size specific MAC rate is also paid for Generic Diaper UPCs submitted for reimbursement.
• For information on MAC rate inquiries, please refer to the FAQs.
• The following MAC rates are effective February 15, 2025, for Covered UPCs and February 28, 2025, for Generic UPCs.

• The MACs above apply only to Covered UPCs within the stated brands. Non-covered UPCs may be submitted using the Generic Diaper UPC of the size diaper being dispensed.
• The MAC rates for Generic UPCs were calculated based on the following brands:
  • Parent’s Choice (Walmart)
  • Kirkland Signature (Costo)
  • Little Journey (Aldi)
  • Comforts (Kroger)
  • Member’s Mark (Sam’s Club)

An administration fee will be provided instead of the pharmacy’s set Professional Dispensing Fee (PDF). MAC rate paid and reimbursement will be calculated per diaper: Total paid to pharmacy= (MAC rate + sales tax calculated on MAC rate + admin fee ($0.03/diaper)) x quantity dispensed