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Coordination of Benefits

Coordination of Benefits is the process required to pay medical and pharmacy claims for WTC-certified Survivors with an eligible condition. To fully cover any medical and/or pharmacy costs for Survivors, the WTC provider must bill your primary insurance first, including any public insurance such as Medicare or Medicaid, and then bill the Program the remaining amount. This leaves no out-of-pocket cost to you. Coordination of Benefits is a requirement for Survivors according to the James Zadroga 9/11 Health and Compensation Act of 2010 (Zadroga Act)

Make sure your Clinical Center of Excellence (CCE) or Nationwide Provider Network (NPN) has your updated primary insurance information to avoid issues processing coverage for your WTC-related medical and pharmacy claims.

Coordination of benefits only applies to Survivor members.

For Responders, the Program directly pays the full amount for all monitoring, treatment, and medication costs for certified WTC-related health condition, except if a Responder has a workers’ compensation claim for the certified condition.

Learn more about workers’ compensation and Coordination of Benefits in the Member Handbook.

How does Coordination of Benefits apply to my WTC-related care as a Survivor?

For treatment and medication costs of a certified WTC-related health condition, The provider or pharmacy must bill your primary health insurance first, including any public insurance such as Medicare or Medicaid. Once your other health insurance providers have paid, the Program pays any remaining amount.

This includes any co-insurance charges, copayments, or deductibles for care of your certified WTC-related health conditions if that care is from a Program provider. This leaves no out-of-pocket cost to you.

Please note: For initial health evaluations and annual monitoring exams, the Program pays in full. If your certified condition is work-related and you have a workers' compensation claim for the condition, the Program will pay initially and then seek recoupment from either the workers' compensation carrier or the settlement, where applicable. Learn more about workers’ compensation and Coordination of Benefits in the Member Handbook.

What do I need to do?

As a Survivor, you must provide your primary health insurance information when receiving services from the WTC Health Program.

This means you need to give it to:

  • Your Clinical Center of Excellence (CCE) or the Nationwide Provider Network (NPN).
  • Any specialist or external provider you see for your certified WTC-related health condition. Tell the provider’s staff your visit is for a WTC-related condition. This will help make sure that they bill your visit properly.
  • Any pharmacy you use for filling a WTC-related prescription, along with your Express Scripts Prescription ID Card. Make sure the pharmacy knows to bill your primary insurance first and WTC Health Program last.

What if I don’t have health insurance?

The WTC Health Program is a limited health benefit plan that provides monitoring and treatment for certified WTC-related health conditions only. The Zadroga Act requires that Program members have primary health insurance in order to coordinate benefits and to cover costs for conditions that are not certified by the Program.

If you do not have health insurance, you might be eligible for public or private health insurance, such as Medicaid, Medicare, health insurance offered through the Marketplace or other options. Your benefits counselor or case manager at your CCE or the NPN can help you find and apply for health insurance.

How does Coordination of Benefits work for prescription drugs?

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.

Same as with WTC-related medical care for Survivors, 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 for WTC-related prescriptions covered by the Program.

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).

How do I get my prescriptions filled?

Your WTC Health Program doctor or specialist will write the prescription for your WTC-related certified condition.

Step 1: You may fill your prescriptions at any in-network retail pharmacy or through certain home delivery pharmacies in the Express Scripts network.


Step 2: In both cases, you will always need to present your primary insurance card and WTC Health Program Prescription ID card to the pharmacy.


Step 3: Tell the pharmacist that the WTC Health Program is the secondary payer.


Step 4: The pharmacy will bill your primary insurance first, and then bill any remaining costs to the WTC Health Program.


For more information about how to fill your prescriptions, please visit our Pharmacy Benefits webpage or the FAQs webpage .

What happens if there is a problem filling my prescription?

If there is a problem billing your prescription to your primary insurance, you or the pharmacy will need to contact that insurance company to resolve the issue.

If there is a problem billing the WTC Health Program, you or the pharmacy must contact Express Scripts at 1-800-935-7179 or prescribing provider to resolve the issue. Note: If you pay for the prescription out-of-pocket before resolving the issue with Express Scripts, and the prescription is covered, you can fill out a Direct Claims form for reimbursement from Express Scripts. For questions about this process, please contact Express Scripts directly. The WTC Health Program cannot guarantee reimbursement.

How do I find a pharmacy that works with the WTC Health Program?

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.

Print Material

Fact Sheet How Coordination of Benefits Works in the WTC Health Program






What if I have additional questions?

Contact the Program, your CCE, or the NPN with any questions related to coordination of benefits or your WTC-related care.