CO-280: Claim Received but Benefits Not Covered — Submit to Pharmacy Plan

What Does CO-280 Mean?

CO-280 means the medical plan will not cover the service because it belongs under the pharmacy benefit. The provider cannot bill the patient — instead, submit the claim to the patient's pharmacy plan. This is a routing issue, not a service denial.

CARC 280 is a redirection, not a true denial. The medical plan received the claim and determined that the billed services — typically medications, infusion therapies, or specialty drugs — fall under the patient's pharmacy benefit rather than the medical benefit. The payer is instructing you to submit the claim to the patient's pharmacy benefit manager (PBM) instead.

This situation is increasingly common as health plans carve out pharmacy benefits from medical benefits. Self-administered specialty medications, certain injectable drugs, and some infusion therapies may be covered under the pharmacy benefit even when administered in a clinical setting. The medical plan simply cannot adjudicate these claims because the coverage sits with the PBM.

Note the distinction between CARC 280 and CARC 292: use 280 when the medical plan did not forward the claim to the pharmacy plan, and 292 when the claim was automatically forwarded. With 280, you need to handle the resubmission to the pharmacy plan yourself.

Common Causes

How to Resolve

Obtain the patient's pharmacy plan information and resubmit the claim to the pharmacy benefit manager.

1. Identify the pharmacy plan Collect the patient's PBM information — BIN, PCN, group number — from their pharmacy insurance card.
2. Check pharmacy formulary Verify the medication or service is covered under the pharmacy benefit by checking the PBM's formulary.
3. Resubmit to pharmacy Submit the claim to the PBM using pharmacy billing format.
4. Escalate if both deny If both the medical and pharmacy plans deny coverage, contact the plans to determine the correct benefit path.

How to Prevent CO-280

• Verify whether services are covered under medical or pharmacy benefits before submitting claims
• Collect both medical and pharmacy insurance cards at registration
• Maintain a reference of drugs and services commonly billed under pharmacy vs. medical for each major payer
• Stay updated on payer-specific medical/pharmacy benefit carve-out policies

General Prevention

• Verify whether services are covered under the medical or pharmacy benefit before submitting claims
• Collect both medical and pharmacy insurance information from patients at registration
• Maintain a reference of which drugs and services are typically billed under pharmacy vs. medical benefits for each major payer
• Coordinate with the patient's pharmacy plan when billing specialty medications or infusion therapies
• Stay updated on payer-specific medical vs. pharmacy benefit carve-out policies

Also Filed As

The same CARC 280 may appear with different Group Codes:

Related Denial Codes