Quarterly Pharmacy Newsletter from Prime Therapeutics LLC

Prime PerspectiveQuarterly Pharmacy Newsletter from Prime Therapeutics LLC

November 2014: Issue 58

3833 © Prime Therapeutics LLC 11/14

From the auditor’s desk

Part D post point-of-sale claim adjustments

Part D Benefit Sponsors are required to submit Part D claim records, referred to as a prescription

drug event (PDE), to the Centers for Medicare and Medicaid Services (CMS) on a regular basis.

This information is relied upon for a variety of purposes such as financial reconciliation, assessment

of Part D program costs and for CMS audits.

For claims with fill dates in 2012 and forward, CMS now requires that post point-of-sale (POS)

claim adjustments be done for claims with identified administrative, coverage and financial errors.

Through these claim adjustments, claims data is corrected and is then resubmitted to CMS.

The intent of adjusting the claim is to support that the CMS claims data and their records of the

associated Covered Person cost share are as accurate as possible.

How will these changes impact the pharmacy?

Retrospective desk and onsite pharmacy audits are the primary source of post POS claim

adjustments. Prime Therapeutics LLC (Prime) will adjust claims data after the pharmacy audit is

considered final and any appeals have been processed. Participating Pharmacies with identified

Part D claim errors will be informed of the post POS claim adjustment process through the standard

pharmacy audit communications. This will include a Frequently Asked Questions (FAQ) document.

In addition, Participating Pharmacies will be sent a Final Part D Audit Report after adjustments

have been completed.

Participating Pharmacies are responsible for the Covered Person cost share process. The claim

adjustment is being made due to the Participating Pharmacy’s error. For this reason, the

Participating Pharmacy is expected to manage the Covered Person refunds. Prime’s Pharmacy

Participation Agreement does not allow a Participating Pharmacy to charge Covered Persons

for audit identified errors. Therefore, Participating Pharmacies are not permitted to collect any

additional monies from Covered Persons due to post POS claim adjustments. Along with the

Final Part D Audit Report, Prime will provide a summary of the total amount of any refunds the

Participating Pharmacy owes to the Covered Person.

What you can do going forward

In order to support accurate claim data and Covered Person out of pocket expenses at the POS, it is

important that Participating Pharmacies continue to monitor their accuracy when submitting claims.

Pharmacy Audit information

For more information regarding Pharmacy Audit, including common billing errors, pharmacy audit

appeals and pharmacy audit guidelines please visit Prime’s website at: PrimeTherapeutics.com > Pharmacists

INSIDE From the auditor’s desk . . . . . . . . . 1

Medicare news/ Medicaid news . . . . . . . . . . . . . . . .2

Florida news . . . . . . . . . . . . . . . . . .7

Kansas news . . . . . . . . . . . . . . . . . .7

Illinois news . . . . . . . . . . . . . . . . . .7

Montana news . . . . . . . . . . . . . . . .7

New Mexico news . . . . . . . . . . . . . .7

North Carolina news . . . . . . . . . . . .8

Oklahoma news . . . . . . . . . . . . . . .8

Texas news . . . . . . . . . . . . . . . . . . .8

New Plan Announcements . . 9 – 12

Medicare Part B Processing Update . . . . . . . . . . . . 13

Prime news . . . . . . . . . . . . . . . . . . 14

MAC list updates . . . . . . . . . . . . . 15

How to reach Prime Therapeutics . . . . . . . . . . . 15

http://www.primetherapeutics.com/pharmacists.html

2 © Prime Therapeutics LLC

Prime Perspective | November 2014

Medicare news/Medicaid newsMedicare Part D FWA Participating Pharmacy training and certification

The Centers for Medicare and Medicaid Services (CMS) requires

any staff providing Medicare Part D services to receive qualified

Fraud, Waste and Abuse (FWA) training upon hire, and annually

thereafter. Every year, on behalf of the Part D Plan Sponsors it

serves, Prime is required to track completion of this training by

all Participating Pharmacies within its network(s). Accordingly,

Participating Pharmacies must submit certification to Prime that

the Participating Pharmacy has completed a qualified FWA

training program.

Participating Pharmacies can take one qualified FWA training

program to fulfill the requirement for Prime, even if the qualified

training was offered by different organization (ex: other PBM’s

training or vendor offered training).

All pharmacy certifications for calendar year 2014 are due to

Prime by December 31, 2014. Not submitting the certification

by the due date will impact continued participation in Prime’s

networks.

Once the certification form is completed and submitted by the

Participating Pharmacy, a “Thank you” screen should appear.

If you do not receive that screen, please try to submit the

information using the Microsoft Internet Explorer (IE) browser.

If IE is not available, please fill out the form online, print it

and submit it via fax to 877.822.6373 or send through email to

[email protected].

The FWA training program and certification can be found at:

PrimeTherapeutics.com > Pharmacists > Annual Fraud, Waste

and Abuse (FWA) Training and Attestation > FWA Training and

Certification Options.

CMS standardized pharmacy notice

CMS requires all Medicare Part D Benefit Sponsors to use a single

uniform exceptions and appeals process with respect to the

determination of prescription drug coverage for a Covered Person

under the plan. Medicare Part D claims will reject when a claim

cannot be covered under the Medicare Part D benefit at point-of-

sale (POS).

Pharmacy claims will reject with the following POS rejection

message:

→ NCPDP Reject Code 569

Participating Pharmacies are required to provide the CMS

Notice of Medicare Prescription Drug Coverage and Your Rights

to Covered Persons when they receive National Council for

Prescription Drug Programs (NCPDP) reject code 569. The

CMS Notice of Medicare Prescription Drug Coverage and Your

Rights is posted on Prime’s website at PrimeTherapeutics.com >

Pharmacists > Medicare Part D > Medicare Resources > More >

Additional Links > Medicare Coverage & Rights

Home Infusion Participating Pharmacies receiving the NCPDP

reject code 569, must distribute the CMS notice to the Covered

Person either electronically, by fax, in person or by first class

mail within 72 hours of receiving the claim rejection.

Long Term Care (LTC) Participating Pharmacies receiving the

NCPDP reject code 569, must contact the Prescribing Provider

or LTC facility to resolve the rejected claim to ensure the

Covered Person receives their medication. If the Participating

Pharmacy must distribute the CMS notice, they must fax or

deliver the notice to the Covered Person, the Covered Person’s

representative, Prescribing Provider or LTC facility within

72 hours of receiving the rejection.

In addition, a copy of the CMS Notice of Medicare Prescription

Drug Coverage and Your Rights has been included on page 3

of this publication.

http://www.primetherapeutics.com/pharmacistsFWA.html



http://www.primetherapeutics.com/pharmacistsmedicared.html



3© Prime Therapeutics LLC


OMB Approval No. 0938-0975

Enrollee’s Name: (Optional)

Drug and Prescription Number: (Optional)

Medicare Prescription Drug Coverage and Your Rights

Your Medicare rights

You have the right to request a coverage determination from your Medicare drug plan if you disagree with information provided by the pharmacy. You also have the right to request a special type of coverage determination called an “exception” ifyou believe:

you need a drug that is not on your drug plan’s list of covered drugs. The list of covered drugs is called a “formulary;”

a coverage rule (such as prior authorization or a quantity limit) should not apply to you for medical reasons; or

you need to take a non-preferred drug and you want the plan to cover the drug at the preferred drug price.

What you need to do

You or your prescriber can contact your Medicare drug plan to ask for a coverage determination by calling the plan’s toll-free phone number on the back of your plan membership card, or by going to your plan’s website. You or your prescriber canrequest an expedited (24 hour) decision if your health could be seriously harmed by waiting up to 72 hours for a decision. Be ready to tell your Medicare drug plan:

1. The name of the prescription drug that was not filled. Include the dose and strength, if known.

2. The name of the pharmacy that attempted to fill your prescription.3. The date you attempted to fill your prescription.4. If you ask for an exception, your prescriber will need to provide your drug plan

with a statement explaining why you need the off-formulary or non-preferred drug or why a coverage rule should not apply to you.

Your Medicare drug plan will provide you with a written decision. If coverage is not approved, the plan’s notice will explain why coverage was denied and how to request an appeal if you disagree with the plan’s decision.

Refer to your plan materials or call 1-800-Medicare for more information.

Form CMS -10147



BCBS of Arizona Blue MedicareRx and Northern Plains Alliance MedicareBlue Rx transition to new PBM

Effective January 1, 2015, BCBS of Arizona and Northern Plains

Alliance will transition their stand-alone Medicare Part D (PDP)

products from Prime to CVS Caremark.

Participating Pharmacies will no longer be able to submit

claims to Prime for Medicare PDP Covered Persons for dates of

service after December 31, 2014 for the following BIN and PCN

combinations:

Plan name BIN PCN

BCBS of Arizona Blue MedicareRx PDP Individual

61Ø455 PDPAZ

MedicareBlue Rx Wellmark BCBS of Iowa PDP Region 25

61Ø455 PDP25

MedicareBlue Rx Wellmark BCBS of South Dakota PDP Region 25

61Ø455 PDP25

MedicareBlue Rx BCBS of Wyoming PDP Region 25

61Ø455 PDP25

MedicareBlue Rx BCBS of Minnesota PDP Region 25

61Ø455 PDP25

MedicareBlue Rx BCBS of Montana PDP Region 25

61Ø455 PDP25

MedicareBlue Rx BCBS of North Dakota PDP Region 25

61Ø455 PDP25

MedicareBlue Rx BCBS of Nebraska PDP Region 25

61Ø455 PDP25

MedicareBlue Rx BCBS of Minnesota Employer Groups PDP Region 25

61Ø455 PDG25

MedicareBlue Rx BCBS of North Dakota Employer Groups PDP Region 25

61Ø455 PDG25

MedicareBlue Rx BCBS of Nebraska Employer Groups PDP Region 25

61Ø455 PDG25

MedicareBlue Rx Wellmark BCBS of Iowa Employer Groups PDP Region 25

61Ø455 PDG25

For claims processing questions for 2015 claims and subsequent

dates of service, please call CVS Caremark Pharmacy Help Desk at:

CVS Pharmacy Help Desk

Northern Plains Alliance MedicareBlue Rx

BCBS of Arizona Blue MedicareRx

CVS Pharmacy Services –Individual

1.888.639.3670 1.888.639.3669

CVS Pharmacy Services –Group

1.888.639.3670 1.888.639.3669

Blue Cross Blue Shield of Minnesota Blue Essentials (HMO-POS) termination

Effective January 1, 2015, Blue Cross Blue Shield of Minnesota

(BCBSMN) will be terminating their Blue Essentials (HMO-

POS) product. Participating Pharmacies will no longer be able

to submit claims for Medicare Covered Persons for dates of

service after December 31, 2014 for the following BIN and PCN

combinations:

Plan name BIN PCN

BCBS of Minnesota Blue Essentials 61Ø455 MPDBE

BCBS of Minnesota Blue Essentials Part B

61Ø455 PARTB

If you need assistance with claims processing, please call the

Prime Contact Center at 877.277.7913.

Medicare Part B benefit opportunity — diabetic test strips

Effective January 1, 2015, glucose test strips from Bayer Diabetes

Care (i.e. BREEZE®2, CONTOUR®, CONTOUR® NEXT) and Roche

Diagnostics (i.e. ACCU-CHEK®) will be the preferred glucose test

strips for Blue Cross Medicare Advantage Covered Persons of

Health Care Service Corporation (HCSC) in Illinois, Montana,

New Mexico, Oklahoma and Texas, through their part B coverage.

Blood Glucose meters and test strips from Bayer Diabetes Care

and Roche Diagnostics will be available at a 0% co-insurance.

All other test strips will have a 20–35% co-insurance, depending

on the plan.

All Covered Persons were notified of this benefit opportunity

through their Plan Annual Notice of Change letter. In addition,

Covered Persons utilizing test strips by other manufacturers and

their Prescribing Providers were sent a notification regarding the

change in benefit.

To help ensure a smooth transition for impacted Covered Persons,

Participating Pharmacies are encouraged to assist their Covered

Persons to get a new prescription for the chosen preferred-brand

blood glucose meter and test strips from their Prescribing Provider

prior to January 1, 2015.



Point-of-sale prior authorization

Effective January 1, 2015, in accordance with the 2015 CMS Call

Letter, Prime will implement additional Point-of-Sale (POS) prior

authorization (PA) edits. These edits will target drugs which have

a high likelihood that the drug is excluded from Part D coverage

(e.g., a drug or drug class or its medical use that is excluded from

coverage or otherwise restricted under Part D) or use for non-

medically accepted indications. These new edits will apply even

when a Covered Person is in the transition period in order to

appropriately determine their eligibility for coverage under

Part D, through the coverage determination process.

Participating Pharmacies receiving the following POS messages

must reach out to the Prescribing Provider to submit a coverage

determination request in order to determine eligibility for Part D

coverage.

The drugs targeted by this POS edit are Transmucosal Immediate

Release Fentanyl (TIRF) drugs, Cialis (tadalafil tabs, 2.5mg and

5mg), and Lidoderm (lidocaine patch, 5%). Claims for these drugs

will reject with the following POS reject code and message:

→ NCPDP Reject Code 75: “DRUG REQUIRES PRIOR

AUTHORIZATION”

→ NCPDP Reject Code 569: “PROVIDE NOTICE: MEDICARE

PRESCRIPTION DRUG COVERAGE AND YOUR RIGHTS”

→ Secondary Message: “VERIFICATION OF MEDICALLY-

ACCEPTED INDICATION

→ REQUIRED FOR COVERAGE UNDER PART D”

Medicaid requirements

As a contracted Participating Pharmacy with Prime, Participating

Pharmacies must follow all state and federal regulations,

including those governing Medicaid. Prime currently provides

PBM services for four Medicaid clients:

→ Blue Cross and Blue Shield of Illinois (Blue Community ICP

and FHP)

→ Blue Cross and Blue Shield of New Mexico (Blue Cross

Community Centennial)

→ Blue Cross and Blue Shield of Minnesota (BluePlus)*

→ PrimeWest Health (PWH)*

* Please note that BluePlus and PWH cover Minnesota Medicaid

Covered Persons.

Minnesota Medicaid regulations

Participating Pharmacies may not accept cash payment from

a recipient, or from someone paying on behalf of the recipient,

for any Minnesota Health Care Programs (MHCP) covered

prescription drug.

The MHCP requires that a Participating Pharmacy may accept

cash payment for a non-covered prescription drug provided that:

→ The Covered Person is not enrolled in the restricted recipient

program

→ All available covered alternatives have been reviewed with

the Covered Person

→ The Participating Pharmacy obtains a Covered Person

signature on the MHCP Acknowledgement form

→ The prescription is not a controlled substance, tramadol

or gabapentin

A Participating Pharmacy may only accept a cash payment

for a controlled substance, tramadol or gabapentin only if

the Participating Pharmacy has received authorization from

MHCP to do so on the date of service. To be considered for cash

payment authorization, the Prescribing Provider must contact

the MHCP help desk and provide rationale as to why the covered

alternatives are not viable options for the recipient.

If a Covered Person’s MHCP eligibility status is in question

and the recipient offers a cash payment for prescriptions, the

Participating Pharmacy must verify eligibility through MN-ITS

or EVS. If the person does not have coverage through MHCP

you may charge that person and accept cash as payment.

For further information on Minnesota’s Medicaid regulations,

please refer to MHCP Provider Manual at: http://www.dhs.state.

mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&

RevisionSelectionMethod=LatestReleased&dDocName=id_

008992#P274_26700

http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION& RevisionSelectionMethod=LatestReleased&dDocName=id_ 008992#P274_26700






Opiate management changes for Prime West Medicaid and BCBS MN Medicaid

Effective January 1, 2015, Prime West Medicaid and BCBS MN

Medicaid will be implementing new policies for management

of Opiate-containing drugs and common drugs of abuse. These

policy changes are part of a larger effort to have uniform Opiate

management controls by the Minnesota Department of Human

services, fee-for-service and managed Medicaid programs in

Minnesota. The health plans will also be sending communication

to Prescribing Providers and Covered Persons regarding these

new Opiate policies.

The new policies for Prime West Medicaid and BCBS MN Medicaid

include:

→ OxyContin® will require a prior authorization (PA) and

quantity limit (QL). The Covered Persons must demonstrate

previous use of morphine. This PA will follow the standard

PA/QL process through Prime

→ Long term Opiate use (all Opiate-containing products) will

be limited to a 120 morphine equivalents dose (MED) per

day over an average of 90 days. If a Covered Person requires

greater than 120 MEDs, a PA must be requested

> A Covered Person who has cancer-related pain will meet the

PA criteria

> The other MED criteria are to ensure that a Prescribing

Provider is managing and monitoring the Covered Person’s

pain and Opiate use

→ Controlled substances of DEA schedule IV, III and II will be

subject to a refill-too-soon allowance, which requires that

85% of the previous fill be used before the next fill will be

paid. If a Covered Person meets the 85% refill-too-soon

allowance, and requires another fill of the medication due

to medical necessity, a Participating Pharmacy may call the

Prime provider contact center to request an override

→ Promethazine with codeine cough syrup will be removed from

the formulary

→ Carisoprodol will be removed from the formulary

A component of the Minnesota managed Medicaid plans Opiate

program is to increase awareness and use of the Minnesota

Prescription Monitoring Program (PMP). If you have not already

done so, create an account with the MN Prescription Monitoring

Program, which allows you access to data about the prescribers

and pharmacies a Covered Person is using to obtain controlled

substances.

For further information regarding the Minnesota Prescription

Monitoring Program, please refer to their website at:

http://pmp.pharamacy.state.mn.us/access-request-froms.html

http://www.pmp.pharamacy.state.mn.us/access-request-froms.html



Florida newsFlorida Blue welcomes the following new client groups:

→ Effective October 1, 2014:

> City of Coral Gables

→ Effective January 1, 2015:

> Indian River Medical Center

> Flagler Hospital

> Polk County School Board (Retirees)

> Pacific Tomato Growers

> Armellini Express Lines

> County Medical Societies

Florida Blue utilization management programs

Utilization Management program updates for the upcoming

quarter, when available, will be posted at PrimeTherapeutics.com >

Pharmacists > Formulary > UM Program Updates.

Kansas newsPharmacy benefit immunizations

Effective January 1, 2015, immunizations administered at

Participating Pharmacies will be covered by the Covered Person’s

prescription drug benefit. This change will become effective as the Covered Person’s coverage renews during 2015. The benefit

coverage for Covered Persons at the Participating Pharmacy

includes:

→ Flu vaccine with no cost share for all Covered Persons

→ If an Affordable Care Act (ACA) compliant benefit, other

preventive vaccines will also have no cost share

→ Without an ACA compliant benefit, other preventive vaccines

will have brand formulary cost share

Covered Persons who do not have a prescription drug benefit will

need to continue receiving their immunization in the Prescribing

Providers office. Immunization services will remain a covered

medical benefit for all Covered Persons who choose to visit a

Prescribing Provider’s office.

Illinois newsEffective January 1, 2015, some Blue Cross and Blue Shield of

Illinois (BCBSIL) Covered Persons may be impacted by one or

more of the following pharmacy benefit changes. This change will become effective as the Covered Person’s coverage renews during 2015.

→ Day supply limit changing from a 34-day supply to a 30-day

supply

→ Weight loss drugs, non-sedating antihistamines and

compound medications will no longer be covered under the

prescription drug benefit

If you have questions regarding claims processing, please

contact Prime’s Contact Center at 1.800.821.4795.

Montana newsEffective January 1, 2015, some Blue Cross and Blue Shield of

Montana (BCBSMT) Covered Persons may be impacted by one

or more of the following pharmacy benefit changes. This change will become effective as the Covered Person’s coverage renews during 2015.

→ Day supply limit changing from a 34-day supply to a 30-day

supply

→ Non-sedating antihistamines, compound medications, glucose

meters, glucose control systems and insulin pump supplies

will no longer be covered under the prescription drug benefit.

Glucose meters, glucose control systems and insulin pump

supplies will be covered under the medical benefit



New Mexico newsEffective January 1, 2015, some Blue Cross and Blue Shield of

New Mexico (BCBSNM) Covered Persons may be impacted by the

following pharmacy benefit change. This change will become effective as the Covered Person’s coverage renews during 2015.

→ Non-sedating antihistamines will no longer be covered under

the prescription drug benefit







North Carolina newsEffective January 1, 2015, compound claims that are submitted

with bulk chemical ingredients (e.g. liquids, powders) will

no longer be covered. This change is based on bulk chemical

ingredients not being approved by the U.S. Food and Drug

Administration (FDA). As a reminder, Covered Persons do not

have benefits for drugs not approved by the FDA and these drugs

are not eligible for review under our utilization management

program.

Oklahoma news2015 Benefit changes

Effective January 1, 2015, some Blue Cross and Blue Shield of

Oklahoma (BCBSOK) Covered Persons may be impacted by the


→ Non-sedating antihistamines will no longer be covered under

the prescription drug benefit



Vaccine coverage

Effective October 1, 2014, BCBSOK Covered Persons may also

receive vaccinations for rabies, hepatitis B, tetanus, diphtheria,

pertussis and T-Dap (diphtheria, tetanus and pertussis) at

Participating Pharmacies in the Prime Therapeutics Commercial

Vaccine Network. This is in addition to vaccinations for influenza

(flu), pneumococcal (pneumonia) and zoster (shingles). Coverage

is dependent on the Covered Person’s prescription drug benefit.

For vaccine processing information, please visit Prime’s website at:

PrimeTherapeutics.com > Pharmacists > Commercial Vaccination

Administration Network.

Texas news2015 Benefit changes

Effective January 1, 2015, some Blue Cross and Blue Shield

of Texas (BCBSTX) Covered Persons may be impacted by the


→ Non-sedating antihistamines and compound medications will

no longer be covered under the prescription drug benefit

If you have questions regarding claims processing, please contact

Prime’s Contact Center at 1.800.821.4795.




New Plan Announcement BlueCross BlueShield of Minnesota Platinum BlueSM (Cost)

Effective January 1, 2015

Effective January 1, 2015, Prime Therapeutics (Prime) will begin

processing Medicare Part B and Part D claims for Covered

Persons of BlueCross BlueShield of Minnesota (BCBSMN)

Platinum Blue (Cost). This new plan will offer an Rx option with

a single ID card.

Processing Requirements

To ensure uninterrupted service to Participating Pharmacies and

Covered Persons, please use the following information to set up

your system prior to January 1, 2015.

BCBSMN Platinum Blue Cost Part B

BIN: 610455

PCN: MNPRTB

→ Covered Person ID Number

→ Date of Birth

→ Gender

→ Group Number

→ U&C

→ Days Supply

→ Pharmacy NPI

→ Active/Valid Prescriber ID (NPI,DEA or State License)

→ Date Prescription Written

→ Prescription Origin Code

→ Pharmacy Service Type

→ Patient Residence

For more information

→ Medicare Part B claims with a fill date on or after January 1,

2015 must be submitted with the BIN/PCN outlined on the left

→ If you have questions regarding claims processing, please

contact Prime’s Contact Center at 800.648.2778

→ For software setup information, please visit Prime’s website

at PrimeTherapeutics.com > Pharmacists > Payer sheets >

Medicare Part B D.0 Payer Sheet

→ Medicare Part B Processing Requirements may be found on

Prime’s website at PrimeTherapeutics.com > Pharmacists >

Plan Announcements > Medicare Part B Processing

Requirements

Featured below is an example of the most common ID card used:







New Plan Announcement


New Plan Announcement BlueCross BlueShield of Minnesota Platinum BlueSM with Rx (Cost)


processing Medicare Part B and Part D claims for Covered

Persons of BlueCross BlueShield of Minnesota (BCBSMN)

Platinum Blue with Rx (Cost). This new plan will offer an Rx option

with a single ID card.





BCBSMN Platinum Blue with Rx (Cost) Part D

BIN: 610455

PCN: MPDPB

BCBSMN Platinum Blue with Rx (Cost) Part B

BIN: 610455

PCN: MNPRTB


→ Date of Birth

→ Gender

→ Group Number

→ U&C

→ Days Supply

→ Pharmacy NPI







→ Medicare Part D and Part B claims with a fill date on or after

January 1, 2015 must be submitted with the BIN/PCN outlined

on the left





Medicare Part D D.0 Payer Sheet and Medicare Part B

D.0 Payer Sheet

→ For Prime’s helpful resources for Medicare Part D coverage

and issues, please visit: PrimeTherapeutics.com >

Pharmacists > Medicare Part D > Medicare Resources >

Helpful Resources


Prime’s website at PrimeTherapeutics.com > Pharmacists > Plan

Announcements > Medicare Part B Processing Requirements













New Plan Announcement Blue Cross Blue Shield of Illinois Blue Cross Medicare Advantage (PPO)


processing Medicare Part D and Part B claims for Covered

Persons of Blue Cross Blue Shield of Illinois (BCBSIL) Blue Cross

Medicare Advantage (PPO).





BCBSIL Blue Cross Medicare Advantage (PPO) Part D

BIN: 011552

PCN: MAPDIL1

BCBSIL Blue Cross Medicare Advantage (PPO) Part B

BIN: 011552

PCN: ILPARTB


→ Date of Birth

→ Gender

→ Group Number

→ U&C

→ Days Supply

→ Pharmacy NPI









on the left





Medicare Part D D.0 Payer Sheet and Medicare Part B

D.0 Payer Sheet

→ For Prime’s helpful resources for Medicare Part D coverage

and issues, please visit: PrimeTherapeutics.com >

Pharmacists > Medicare Part D > Medicare Resources >

Helpful Resources


Prime’s website at PrimeTherapeutics.com > Pharmacists > Plan

Announcements > Medicare Part B Processing Requirements











New Plan Announcement Blue Cross Blue Shield of Texas Blue Cross Medicare Advantage (HMO)



processing Medicare Part D and Part B claims for Covered

Persons of Blue Cross Blue Shield of Texas (BCBSTX) Blue Cross

Medicare Advantage (HMO).





BCBSTX Blue Cross Medicare Advantage (HMO) Part D

BIN: 011552

PCN: MAPDTX1

BCBSTX Blue Cross Medicare Advantage (HMO) Part B

BIN: 011552

PCN: TXPARTB


→ Date of Birth

→ Gender

→ Group Number

→ U&C

→ Days Supply

→ Pharmacy NPI

→ Active/Valid Prescriber ID (NPI, DEA or State License)








on the left





Medicare Part D D.0 Payer Sheet and Medicare Part B D.0

Payer Sheet

→ For Prime’s helpful resources for Medicare Part D coverage and

issues, please visit: PrimeTherapeutics.com > Pharmacists >

Medicare Part D > Medicare Resources > Helpful Resources


Prime’s website at PrimeTherapeutics.com > Pharmacists >


Requirements














Medicare Part B Processing UpdateBCBS of Illinois Blue Cross Medicare Advantage (HMO) Part B BCBS of Montana Blue Cross Medicare Advantage (PPO) Part B BCBS of New Mexico Blue Cross Medicare Advantage (HMO) and (PPO) Part B BCBS of Oklahoma Blue Cross Medicare Advantage (HMO) Part B

Effective January 1, 2015, Blue Cross Blue Shield of Illinois,

Montana, New Mexico and Oklahoma will be utilizing a new

Processor Control Number (PCN) for their Blue Cross Medicare

Advantage HMO and PPO Part B business.










Medicare Part B D.0 Payer Sheet

→ For Prime’s helpful resources for Medicare Part D coverage and

issues, please visit: PrimeTherapeutics.com > Pharmacists >

Medicare Part D > Medicare Resources > Helpful Resources


Prime’s website at: PrimeTherapeutics.com > Pharmacists >


Requirements

Plan name Current BIN Old PCNNew PCN effective 1/1/15

BCBS of Illinois Blue Cross Medicare Advantage (HMO) Part B Ø11552 ILPARTBG PARTBG

BCBS of Montana Blue Cross Medicare Advantage (PPO) Part B Ø11552 MTPARTBG PARTBG

BCBS of New Mexico Blue Cross Medicare Advantage (HMO) Part B Ø11552 NMPARTBG PARTBG

BCBS of New Mexico Blue Cross Medicare Advantage (PPO) Part B Ø11552 NMPARTBG1 PARTBG

BCBS of Oklahoma Blue Cross Medicare Advantage (HMO) Part B Ø11552 OKPARTBG PARTBG

BCBS of Oklahoma Blue Cross Medicare Advantage (PPO) Part B Ø11552 OKPARTBG1 PARTBG










Prime newsCommercial Vaccine Network

As a reminder, the following Plan Sponsors below participate in

the Commercial Vaccine Network:

→ BCBS of Alabama

→ BCBS of Illinois

→ BCBS of Minnesota

→ BCBS of Montana

→ BCBS of Nebraska

→ BCBS of New Mexico

→ BCBS of Oklahoma

→ BCBS of Texas

→ FloridaBlue

→ Horizon BCBS of New Jersey

Participating Pharmacies administering vaccines, where allowed

by state law, shall abide by all applicable state and federal laws,

regulations and guidelines governing the sale and administration

of vaccines. Vaccine administration coverage is dependent upon

the Covered Person’s benefit plan.

Participating Pharmacy must submit the vaccine claim to

Prime electronically (online), which includes the applicable

ingredient cost, dispensing fee and vaccine administration fee

as a single claim.

Participating Pharmacies are required to submit the fields

defined below from the NCPDP D.0 Telecommunication Standard

for vaccine claims:

NCPDP segment name NCPDP field #

NCPDP field name Value

Pricing segment

438-E3 Incentive amount submitted

Pharmacy submitted incentive fee

DUR/PPS segment

473-7E DUR/PPS code counter

Value of 1

DUR/PPS segment

440-E5 Professional service code

MA-medication administration

For software setup information, please visit Prime’s website at:

PrimeTherapeutics.com > Pharmacists > Payer Sheets

Formulary and utilization management changes for insulin products

Effective January 1, 2015, Novo Nordisk Levemir, Novolin Novolog,

and Sanofi Lantus will be the preferred insulin products for

Commercial and Exchange Market formularies*. Lilly Humulin,

Humalog, and Sanofi Apidra will be non-preferred, and in most

cases, will require a Prior Authorization (PA) or be excluded

entirely from the Covered Person’s formulary.

Participating Pharmacies are encouraged to assist their Covered

Persons to get a new prescription from their Prescribing Provider.

All Covered Persons and their Prescribing Providers will be

notified of this change.

* This change affects the following commercial BCBS plans:

Horizon BCBS-NJ, Alabama, FloridaBlue, Nebraska, Kansas,

Texas, Montana, Illinois, Wyoming, New Mexico, Oklahoma,

North Carolina, Minnesota, North Dakota, and Florida.

Patent Cliff — generic exclusion

In May 2014, Prime launched a program to manage blockbuster

(high use/cost) brand medications that lose patent protection

and now have an exclusive generic available. Following a patent

expiration, a Benefit Sponsor may temporarily exclude coverage

of the exclusive generic (or in the case of Medicare plans,

not add the exclusive generic to formulary). Covered Persons

would remain on the brand medication during the exclusivity

period, rather than switching to the exclusive generic. Once the

exclusivity period expires, and competition drives the cost of

the generics down, the Benefit Sponsor will provide coverage of

the generic (or in Medicare plans, add the generic to formulary).

At that time, Covered Persons can be converted from the brand

to the low-cost generic alternative.

Nexium is expected to lose patent protection in early 2015. All Medicare plans will continue coverage of brand Nexium at

the preferred brand tier. Further processing guidelines will be

communicated in the near future.




Pharmacy licensure

To ensure that all license documents are current, Participating

Pharmacies must provide Prime with copies of the following

documents on an annual basis:

→ Pharmacy License

→ DEA Certificate

→ Certificate of Insurance with proof of General and

Professional Liability Insurance

Please include your NCPDP number on each of the docu-

ments when sending them to Prime. Submit the documents

via fax to 877.823.6373 or send through email to

[email protected].

Submission of zero dollar (free drug product) claims

If a Participating Pharmacy receives a free drug product from a

pharmaceutical manufacturer or wholesaler, the claim for that

product must be submitted with the Ingredient Cost field (NCPDP

field 409-D9) populated with a value of $0.00.

MAC list updatesIf a Participating Pharmacy would like access to Prime’s MAC

list(s), weekly MAC changes, and the sources used to determine

MAC pricing, please refer to Prime’s website for registration

instructions. After network participation is verified, the

Participating Pharmacy will receive a secure user name and

password via email.

How to reach Prime TherapeuticsAs a service to Participating Pharmacies, Prime Therapeutics

(Prime) publishes Prime Perspective quarterly to provide

important information for claims processing. Prime values

your opinion and your participation in our network. If you have

comments or questions, you can reach us:

→ By phone: Prime Pharmacy Contact Center 800.821.4795

(24 hours a day, seven days a week)

→ By email: [email protected]

Looking for formularies?

For Commercial formularies access either the Blue Cross

Blue Shield plan website or PrimeTherapeutics.com >

Pharmacists > Formulary Search.

For Medicare Part D formularies access PrimeTherapeutics.com >

Medicare Part D > Medicare Resources > 2014 Medicare Formularies.

Keep your pharmacy information current

Prime uses the National Council for Prescription Drug Programs

(NCPDP) database to obtain key pharmacy demographic

information. To update your pharmacy information go to

www.ncpdp.org > NCPDP Provider ID (on the left side).

Report fraud, waste and abuse

If you suspect fraud, waste or abuse (FWA), by a Covered Person,

Prescribing Provider, Participating Pharmacy or anyone else,

notify Prime at 800.731.3269 or send the information to:

Prime Therapeutics LLC

Attn: Compliance Officer

P.O. Box 64812

St. Paul, MN 55164-0812

By email: [email protected]

If you would like an FWA Report to be anonymous, please

contact Prime’s 24-hour anonymous compliance hotline.

Contact the hotline:

By phone: 800.474.8651

By email: [email protected]

By third party vendor’s website:

www.lighthouse-services.com/prime

Product names listed are the property of their respective owners.



http://www.primetherapeutics.com/index.html

http://www.primetherapeutics.com/index.html

http://www.lighthouse-services.com/prime

Prime Therapeutics LLC P.O. Box 64812 St. Paul, MN 55164-0812

PRESORTED

STANDARD MAIL

U.S. POSTAGE PAID

PRIME THERAPEUTICS LLC

→ Claims processing instructions

→ Utilization management updates from Blue Cross and Blue Shield plans

→ Prime audit requirements

→ Medicare Part D requirements

Time Sensitive Information from Prime Therapeutics

Documents

Quarterly Pharmacy Newsletter from Prime Therapeutics LLC