Prime PerspectiveQuarterly Pharmacy Newsletter from Prime Therapeutics LLC
December 2015: Issue 62
INSIDEFrom the auditor’s desk . . . . . . . . . 1
Medicare news/Medicaid news . . 3
Arkansas news . . . . . . . . . . . . . . . .7
Florida news . . . . . . . . . . . . . . . . . .7
Illinois news . . . . . . . . . . . . . . . . . .8
Minnesota news . . . . . . . . . . . . . . .8
Montana news . . . . . . . . . . . . . . . .9
New Mexico news . . . . . . . . . . . . . .9
North Dakota news . . . . . . . . . . . .10
Oklahoma news . . . . . . . . . . . . . .10
Texas news . . . . . . . . . . . . . . . . . . 11
New Plan Announcement: Blue Cross and Blue Shield of Texas STAR and CHIP Medicaid Programs . . . . . . . . . . .12
Prime news . . . . . . . . . . . . . . . . . . 14
MAC list updates . . . . . . . . . . . . . 15
How to reach Prime Therapeutics . . . . . . . . . . . . 15
From the auditor’s desk
Covered person eligibility look-up
Participating Pharmacies are responsible for confirming a Covered Person’s eligibility prior to
dispensing a product. As a reminder, the Covered Person’s ID card does not ensure eligibility.
A Covered Person’s eligibility can be verified through the Point-of-Sale system during claim
adjudication. If a Covered Person does not have a Covered Person ID card and eligibility cannot
be confirmed, the Participating Pharmacy must contact Prime’s Contact Center at 800.821.4795 to
obtain accurate Covered Person information.
If a Covered Person’s eligibility is being obtained through an eligibility look-up system, this
information must be confirmed prior to dispensing the product. Eligibility systems may provide
potential matches that are incorrect due to similar name, DOB, and gender matches. The Eligibility
system may not verify all fields submitted (last name, first name, DOB, address, gender) on a claim
for the Covered Person and may not reject claims submitted under the incorrect Covered Person’s
ID number. When a claim is submitted under an incorrect Covered Person, it is the Participating
Pharmacy’s obligation to reverse claim(s) submitted under the incorrect Covered Person’s ID number.
Prime may, at its discretion, reverse ineligible claims if the Participating Pharmacy does not comply
with requests to reverse the claim(s).
Claims accuracy with National Drug Code (NDC)
When a Participating Pharmacy submits a claim for a Prescription Drug Service provided, the
Participating Pharmacy must submit the NDC number that identifies the specific manufacturer, drug,
strength and package size from which the Prescription Drug Service was dispensed. The NDC on the
claim must correspond to the NDC used to dispense the prescription.
Examples of unacceptable practices:
→ Billing an NDC not used to dispense the prescription
→ Billing an NDC or drug that was never ordered
Failure to submit the correct NDC may result in full recovery on the claims during an audit.
3833 © Prime Therapeutics LLC 12/15
2 © Prime Therapeutics LLC
Prime Perspective | December 2015
Billing of compound claims and following Point-of-Sale messaging
Prime Therapeutics (Prime) administers pharmacy benefits
on behalf of many different plan sponsors. Each plan sponsor
selects benefit plan designs, such as:
→ Specific drugs covered (formulary)
→ Specific ingredients covered
→ Other benefit design attributes
→ Cost-sharing
→ Days’ supply limitations
Each formulary and benefit set-up determines claim coverage
and may vary by Covered Person. As the claim is processed, the
Participating Pharmacy receives system messaging on the status
of the submission. Participating Pharmacies are required to
follow all system messaging.
Compound claims
Claims for compound drugs can pose a challenge for Participating
Pharmacies because they include multiple ingredients.
Participating Pharmacies need to submit a list of all ingredients
for compound claims, including ingredients that may not be
covered. If you receive primary system messaging: “Product or
service not covered” for a compound claim, then one or more of
the individual ingredient(s) may not be covered. The Participating
Pharmacy should also review for any secondary messaging.
If you see one of the following system messages, please obtain
a prior authorization or call the phone number listed before
dispensing the compound prescription to the Covered Person:
→ Drug requires prior authorization.
→ This compound may require review. Please call customer
service at 1.800.216.9920.
→ Compounds dollar amount exceeds max, call pharmacy help
desk at 1.866.590.3012. Maximum amount due of $XXX.
→ This compound may require review or may not be covered;
Check ingredients. Call 1.800.821.4795.
→ This claim requires review, please call 1.800.442.2376.
→ REQ REVIEW. CALL PHARMACY HELP DESK.
→ Maximum amount due of $XXX.
When the prior authorization is received, for the Participating
Pharmacy to receive reimbursement for covered ingredients, the
Participating Pharmacy should submit the compound claim with
the 08 clarification code.
Following Point-of-Sale messaging
Claim submissions, including resubmissions, must be entered
according to the written prescription and both primary and
secondary Point-of-Sale (POS) messaging for your Participating
Pharmacy to be in compliance with Prime’s terms and conditions
of pharmacy network participation. If the Participating Pharmacy
received any of the messaging listed above, the Participating
Pharmacy must call Prime or the number listed within the reject
messaging for further instructions.
This article is not intended to provide an exhaustive list of
requirements. Please see your Pharmacy Participation Agreement
and the Prime Provider Manual for a full listing of requirements.
The Prime Provider Manual is available online at:
http://www.PrimeTherapeutics.com/Files/Updated_September_2015_Provider_Manual.pdf
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.
3© Prime Therapeutics LLC
Prime Perspective | December 2015
Medicare news/Medicaid newsCMS National Provider Identifier requirement changes
Effective January 1, 2016, the existing requirement under the
Center for Medicare & Medicaid Services (CMS) regulation
§423.120(c)(5)(iii)(B)(2), which states that Part D Benefit
Sponsors must pay a claim even when the pharmacy does not
correct the National Provider Identifier (NPI) or confirm that it is
active and valid, will no longer be applicable.
The new requirement as specified in Section 507 of the Medicare
Access and CHIP Reauthorization Act of 2015 (MACRA), states that
a Part D sponsor cannot pay a claim that does not have an active
and valid Type 1 Prescriber NPI, unless the pharmacy corrects the
NPI or confirms that it is active and valid.
Participating Pharmacies must have processes in place to ensure
that they are submitting an active and valid Type 1 Prescriber
NPI at Point-of-Sale (POS). In addition, making any pharmacy
system updates necessary to allow for processing a new and
refill prescriptions.
As a result, Prime began rejecting Medicare Part D claims in a
staggered approach by Part D Benefit Sponsor on August 17, 2015.
Implementation dates will vary by Part D Benefit Sponsor and all
NPI edits will be in place by December 28, 2015. If the NPI is not
submitted on the claim, the claim will reject.
If you have any questions regarding claims processing, please call
Prime’s Contact Center at 800.821.4795.
Cyclobenzaprine utilization management program update for 2016
Effective January 1st, 2016, Prime will replace its existing
step therapy program for cyclobenzaprine with a prior
authorization program for Medicare Part D plans. All step therapy
authorizations will cease to cover cyclobenzaprine on 1/1/16
regardless of the previous approval period. Beginning on the
effective date, all claims for Covered Persons will reject and
require prior authorization, including those for a Covered Person
in transition to ensure that cyclobenzaprine is being used for a
Medicare Part D accepted indication.
Participating Pharmacies will receive a Point-of-Sale message
(see below for an example) indicating that a coverage
determination will be required to assess for a medically accepted
indication:
→ NCPDP Reject Code 75
> COVERAGE DETERMINATION REQUIRED
> FOR VERIFICATION OF A MEDICARE PART D
> MEDICALLY ACCEPTED INDICATION
Medicare Part D FWA Participating Pharmacy training and certification
The Centers for Medicare & Medicaid Services (CMS) require 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 in its network. Accordingly, Participating Pharmacies
must submit to Prime certification that the Participating Pharmacy
has completed a qualified FWA training program and is therefore in
compliance with the training requirement.
All pharmacy certifications for calendar year 2015 are due to Prime
by December 31, 2015. Not submitting the certification by the due
date may impact continued participation in Prime’s Network.
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.
4 © Prime Therapeutics LLC
Prime Perspective | December 2015
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 five of
this publication.
Blue Cross and Blue Shield of Alabama and Horizon Blue Cross and Blue Shield of New Jersey Synchronized Claims Adjudication
Effective January 1, 2016, Blue Cross and Blue Shield of
Alabama and Horizon Blue Cross and Blue Shield of New Jersey
Employer Group business will implement synchronized claims
adjudication. This new process will allow for proper adjudication
of co-administered benefits between Part D and Other Health
Insurance for Employer Group Waiver plans.
There will be no operational impact to Participating Pharmacies
as a result of synchronized claims adjudication. Participating
Pharmacies will continue to submit pharmacy claims as they
normally do today.
From a reconciliation perspective you will receive two payments
that will total the full claim adjudication amount.
If you have questions regarding claims processing, please contact
Prime’s Pharmacy Help Desk at 877.878.8668 for Blue Cross and
Blue Shield of Alabama or 800.391.1926 for Horizon Blue Cross
and Blue Shield of New Jersey.
PrimeWest Health transitions to new PBM
Effective January 1, 2016, PrimeWest Health will transition their
Medicaid and Medicare Part D products from Prime Therapeutics
to MedImpact.
Participating Pharmacies will no longer be able to submit claims
to Prime Therapeutics for Medicaid or Medicare Part D Covered
Persons for dates of service after 12/31/15 for the following BIN
and PCN combinations:
Plan name BIN PCN
PrimeWest Health Medicaid Programs (PMAP, MinnesotaCare, MSC+, SNBC and HMO SNP)
61Ø455 PWEST
PrimeWest Prime Health Complete Part D 61Ø455 MPDPH
PrimeWest Senior Health Complete Part D 61Ø455 MPDPW
For claims processing questions for 2016 claims and subsequent
dates of service, please call the MedImpact Pharmacy Help Desk at:
Pharmacy Help Desk Medicaid Medicare Part D
MedImpact 1.800.788.2949 1.877.391.9294
5© Prime Therapeutics LLC
Prime Perspective | December 2015
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
6 © Prime Therapeutics LLC
Prime Perspective | December 2015
Minnesota Medicaid regulations
Effective May 1, 2015, Participating Pharmacies may accept
cash for phentermine claims as advised by the Minnesota
Health Care Programs (MHCP). Phentermine is not covered by
Medical Assistance because weight loss drugs are excluded from
coverage per state law.
A Participating Pharmacy may accept cash payment for a
phentermine prescription drug provided that:
→ The phentermine is being used as part of a comprehensive
weight loss program and is prescribed at the FDA-approved
dosage.
→ The Prescription Drug Monitoring Program has been reviewed
and determined that the prescription is not being abused or
overused.
→ The Covered Person has been informed about the
responsibility for payment before the phentermine
prescription was dispensed.
→ The Participating Pharmacy or an authorized health care
representative completes the Advance Recipient Notice of Non-covered Prescription (DHS-3641) (PDF) and the Covered
Person signed the form.
For further information on Minnesota’s Medicaid regulations:
http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod= LatestReleased&dDocName=dhs16_194592.
As a general reminder, Participating Pharmacies may not accept
cash payment from a Covered Person or from someone paying
on behalf of the Covered Person, for any Minnesota Health Care
Programs (MHCP) covered prescription drug.
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, (except
phentermine in certain circumstances) tramadol or
gabapentin.
A Participating Pharmacy may only accept a cash payment for a
controlled substance, tramadol or gabapentin, 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
at 800.366.5411 and provide rationale as to why the covered
alternatives are not viable options for the Covered Person.
If a Covered Person’s MHCP eligibility status is in question and
the Covered Person offers a cash payment for prescriptions, the
Participating Pharmacy must verify eligibility through Minnesota
Information Technology Services (MN-ITS) or Eligibility
Verification System (EVS). If the person does not have coverage
through MHCP you can 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.
7© Prime Therapeutics LLC
Prime Perspective | December 2015
Arkansas newsMedicare Part B processing changes
Effective January 1, 2016, Prime Therapeutics will no longer
process claims for Arkansas Blue Cross and Blue Shield (ABCBS)
Medi-Pak Advantage Part B for the following:
BIN PCN
016895 MPPARTB
This change will impact how Participating Pharmacies submit
Part B prescription drugs, Part B immunizations and diabetic
supplies for Covered Persons of ABCBS Med-Pak Advantage.
Participating Pharmacies will have to submit Part B eligible
services for Covered Persons using the following methods:
→ Submit these claims through a clearinghouse via your
supported submission method
→ Submit a CMS-1500 form to the medical claims processor
→ Submit an electronic 837 claim to the medical claims
processor
New Covered Person ID cards for Medicare Part D
Medicare Part D Covered Persons of Arkansas Blue Cross and
Blue Shield will receive new ID cards. Covered Persons have been
instructed to present their new ID card when filling a prescription
at a Participating Pharmacy.
Effective January 1, 2016 when submitting a Medicare Part D
claim, Participating Pharmacies are not required to enter the
alpha characters. Only submit the claims with the nine-digit ID
number without the leading alpha characters.
Florida newsMedications for the treatment of HIV will be added to the prior authorization program
Florida Blue will be requiring prior authorization on medications
used in the treatment of Human Immunodeficiency Virus (HIV)
beginning October 1, 2015. This is intended to ensure appropriate
use. The requirements to obtain coverage include diagnosis in
accordance with FDA approved indications. This program only
affects new users of these medications with current users not
being impacted. New users will have one grace fill to allow time
for authorization submission and review.
The table below indicates drugs included in the HIV prior
authorization program:
Drug
APTIVUS ISENTRESS TIVICAY
ATRIPLA KALTETRA TRIUMEQ
COMBIVIR LEXIVA TRIZIVIR
COMPLERA NEVIRAPINE susp
and tabs
TRUVADA
CRIXIVAN NORVIR TYBOST
ENDURANT PREZISTA susp and
tabs
VIDEX, VIDEX EC
EMTRIVA RESCRIPTOR VIRACEPT
EPIVIR soln and tabs RETROVIR VIRAMUNE susp and
tabs
EPZICOM REYATAZ VIRAMUNE XR
FUZEON SELZENTRY VIREAD
INTLENCE STRIBILD ZERIT
INVIRASE SUSTIVA ZIAGEN soln and
tabs
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.
8 © Prime Therapeutics LLC
Prime Perspective | December 2015
Illinois news2016 Benefit changes
Effective January 1, 2016, some Blue Cross and Blue Shield of
Illinois (BCBSIL) Covered Persons may be impacted by one or
more of the following pharmacy benefit changes. These changes, if applicable, will become effective as the Covered Person’s coverage renews during 2016:
→ Select drugs may move to a higher non-formulary brand
copayment/coinsurance.
→ Brand-name proton pump inhibitor drugs, non-FDA approved
medications and compound medications may no longer be
covered under the prescription drug benefit. Select drug
classes and/or brand-name medications may also no longer
be covered under the prescription drug benefit.
→ Covered Persons may be required to use a specialty
pharmacy in the BCBSIL preferred specialty network or will
incur an out-of-network penalty.
→ Select drugs may be required to have a prior authorization
request approved in order to be considered for coverage
under the prescription drug benefit.
→ Covered Persons may be required to fill prescriptions
at a retail pharmacy in the Preferred Pharmacy Network
in order to obtain the lowest copayment/coinsurance.
Covered Persons may fill prescriptions at Participating
Pharmacies outside of this network but benefits will be
at a higher copayment/coinsurance. Additionally, 90-day
supply prescriptions filled at retail will only be allowable at
Participating Pharmacies within this network.
If you have questions regarding claims processing, please
contact Prime’s Contact Center at 1.800.821.4795.
Vaccine coverage
BCBSIL Covered Persons may also receive vaccinations
for meningitis and HPV at Participating Pharmacies in the
Prime Therapeutics Commercial Vaccine Network. This is in addition
to vaccinations for influenza (flu), pneumococcal (pneumonia),
zoster (shingles), rabies, hepatitis B, tetanus, diphtheria, pertussis
and T-Dap (diphtheria, tetanus and pertussis). 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.
Minnesota newsBlue Cross and Blue Shield of Minnesota New ID Cards
Effective November 1, 2015, Blue Cross and Blue Shield of
Minnesota started a three-year conversion to a new claims
processing platform. As a result, Minnesota groups will convert
to the new claims system in a phased approach starting in
November 2015 and concluding in 2018. Minnesota Covered
Persons will receive new ID cards upon conversion and/or
renewal. All Covered Person IDs will change as a result of this
change. Covered Persons have been instructed to present
their new ID cards when filling a prescription at a Participating
Pharmacy. As a reminder, this change resulted in a processing
change for Participating Pharmacies.
Pharmacy claims should be submitted using the following:
BIN PCN
610455 HMHS
9© Prime Therapeutics LLC
Prime Perspective | December 2015
Montana news2016 Benefit changes
Effective January 1, 2016, some Blue Cross and Blue Shield of
Montana (BCBSMT) Covered Persons may be impacted by one or
more of the following pharmacy benefit changes. These changes, if applicable, will become effective as the Covered Person’s coverage renews during 2016:
→ Select drugs may move to a higher non-formulary brand
copayment/coinsurance.
→ Brand-name proton pump inhibitor drugs and non-FDA
approved medications may no longer be covered under the
prescription drug benefit. Select drug classes and/or brand-
name medications may also no longer be covered under the
prescription drug benefit.
→ Covered Persons may be required to use a specialty
pharmacy in the BCBSMT preferred specialty network or will
not be covered under the prescription drug benefit.
→ Select drugs may be required to have a prior authorization
request approved in order to be considered for coverage
under the prescription drug benefit.
→ Covered Persons may be required to fill prescriptions at a
retail pharmacy in the Value Pharmacy Network in order to
obtain the lowest copayment/coinsurance. Covered Persons
may fill prescriptions at Participating Pharmacies outside
of this network but benefits will be at a higher copayment/
coinsurance. Additionally, 90-day supply prescriptions filled
at retail will only be allowable at Participating Pharmacies
within this network.
If you have questions regarding claims processing, please
contact Prime’s Contact Center at 1.800.821.4795.
Vaccine coverage
BCBSMT Covered Persons may also receive vaccinations for
rabies, hepatitis B, 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 meningitis, HPV, influenza (flu), pneumococcal (pneumonia),
zoster (shingles), tetanus and diphtheria. Coverage is dependent
on the Covered Person’s prescription drug benefit.
New Mexico news2016 Benefit changes
some Blue Cross and Blue Shield of New Mexico (BCBSNM)
Covered Persons may be impacted by one or more of the following
pharmacy benefit changes. These changes, if applicable, will become effective as the Covered Person’s coverage renews during 2016:
→ Select drugs may move to a higher non-formulary brand
copayment/coinsurance.
→ Brand-name proton pump inhibitor drugs and non-FDA
approved medications may no longer be covered under the
prescription drug benefit. Select drug classes and/or brand-
name medications may also no longer be covered under the
prescription drug benefit.
→ Covered Persons may be required to use a specialty
pharmacy in the BCBSNM preferred specialty network or will
incur an out-of-network penalty.
→ Select drugs may be required to have a prior authorization
request approved in order to be considered for coverage
under the prescription drug benefit.
→ Covered Persons may be required to fill prescriptions
at a retail pharmacy in the Preferred Pharmacy Network
in order to obtain the lowest copayment/coinsurance.
Covered Persons may fill prescriptions at Participating
Pharmacies outside of this network but benefits will be
at a higher copayment/coinsurance. Additionally, 90-day
supply prescriptions filled at retail will only be allowable at
Participating Pharmacies within this network.
If you have questions regarding claims processing, please
contact Prime’s Contact Center at 1.800.821.4795.
Vaccine coverage
BCBSNM Covered Persons may also receive vaccinations
for meningitis and HPV at Participating Pharmacies in the
Prime Therapeutics Commercial Vaccine Network. This is in addition
to vaccinations for influenza (flu), pneumococcal (pneumonia),
zoster (shingles), rabies, hepatitis B, tetanus, diphtheria, pertussis
and T-Dap (diphtheria, tetanus and pertussis). 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.
10 © Prime Therapeutics LLC
Prime Perspective | December 2015
North Dakota newsVaccine coverage
Effective October 1, 2015, Blue Cross Blue Shield of
North Dakota (BCBSND) added vaccine coverage for Covered
Persons of BCBSND. Covered Persons of BCBSND may have
the option to receive vaccinations for influenza, Pneumovax®,
Zostavax®, diphtheria-tetanus combinations (toxoids), human
papillomavirus (HPV), measles mumps and rubella virus
(MMR), meningitis, tetanus, and varicella (chickenpox) when
administered by a pharmacist at a Participating Pharmacy
location and permissible by law.
Covered Persons simply present their BCBSND ID card to a
Participating Pharmacy and pay their applicable pharmacy
deductible, copayment, or coinsurance amount. Participating
Pharmacies within this network are reimbursed an administration
fee in addition to the cost of the vaccine product. For vaccine
processing information, please visit Prime’s website at:
PrimeTherapeutics.com > Pharmacists > Commercial Vaccination Administration Network.
Oklahoma news2016 Benefit changes
Effective January 1, 2016, some Blue Cross and Blue Shield of
Oklahoma (BCBSOK) Covered Persons may be impacted by one or
more of the following pharmacy benefit changes. These changes, if applicable, will become effective as the Covered Person’s coverage renews during 2016:
→ Select drugs may move to a higher non-formulary brand
copayment/coinsurance.
→ Brand-name proton pump inhibitor drugs and non-FDA
approved medications may no longer be covered under the
prescription drug benefit. Select drug classes and/or brand-
name medications may also no longer be covered under the
prescription drug benefit.
→ Covered Persons may be required to use a specialty
pharmacy in the BCBSOK preferred specialty network or will
incur an out-of-network penalty.
→ Select drugs may be required to have a prior authorization
request approved in order to be considered for coverage
under the prescription drug benefit.
→ Covered Persons may be required to fill prescriptions
at a retail pharmacy in the Preferred Pharmacy Network
in order to obtain the lowest copayment/coinsurance.
Covered Persons may fill prescriptions at Participating
Pharmacies outside of this network but benefits will be
at a higher copayment/coinsurance. Additionally, 90-day
supply prescriptions filled at retail will only be allowable at
Participating Pharmacies within this network.
If you have questions regarding claims processing, please
contact Prime’s Contact Center at 1.800.821.4795.
Vaccine coverage
BCBSOK Covered Persons may also receive vaccinations
for meningitis and HPV at Participating Pharmacies in the
Prime Therapeutics Commercial Vaccine Network. This is in
addition to vaccinations for influenza (flu), pneumococcal
(pneumonia), zoster (shingles), rabies, hepatitis B, tetanus,
diphtheria, pertussis and T-Dap (diphtheria, tetanus and
pertussis). 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.
11© Prime Therapeutics LLC
Prime Perspective | December 2015
Texas news2016 Benefit changes
Effective January 1, 2016, some Blue Cross and Blue Shield of
Texas (BCBSTX) Covered Persons may be impacted by one or
more of the following pharmacy benefit changes. These changes, if applicable, will become effective as the Covered Person’s coverage renews during 2016:
→ Select drugs may move to a higher non-formulary brand
copayment/coinsurance.
→ Brand-name proton pump inhibitor drugs and non-FDA
approved medications may no longer be covered under the
prescription drug benefit. Select drug classes and/or brand-
name medications may also no longer be covered under the
prescription drug benefit.
→ Covered Persons may be required to use a specialty
pharmacy in the BCBSTX preferred specialty network or will
incur an out-of-network penalty.
→ Select drugs may be required to have a prior authorization
request approved in order to be considered for coverage
under the prescription drug benefit.
→ Covered Persons may be required to fill prescriptions
at a retail pharmacy in the Preferred Pharmacy Network
in order to obtain the lowest copayment/coinsurance.
Covered Persons may fill prescriptions at Participating
Pharmacies outside of this network but benefits will be
at a higher copayment/coinsurance. Additionally, 90-day
supply prescriptions filled at retail will only be allowable at
Participating Pharmacies within this network.
If you have questions regarding claims processing, please
contact Prime’s Contact Center at 1.800.821.4795.
Vaccine coverage
BCBSTX Covered Persons may also receive vaccinations for
pneumococcal (pneumonia), zoster (shingles), rabies, hepatitis B,
meningitis, HPV, 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). 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 HB 751 interchangeable biological product
Effective December 1, 2015, a new law enacted by the Legislature
of the State of Texas, Participating Pharmacies may substitute
lower-priced generically equivalent drug products for certain
brand-name drug products and interchangeable biological
products for certain biological products without the need of a
Prescribing Provider’s consent.
Participating Pharmacies and pharmacists shall pass on the
net benefit of the lower costs of the generically equivalent drug
product or interchangeable biological product to the Covered
Person. In the event the price of a drug or interchangeable
biological product to a Covered Person is lower than the amount
of the Covered Person’s copayment under the Covered Person’s
Benefit Plan, then Participating Pharmacies shall offer Covered
Persons the option of paying for the drug or biological product at
the lower price instead of paying the amount of the copayment.
If substituting a generic drug or interchangeable biologic product,
the Participating Pharmacy shall communicate to the Prescribing
Provider no later than the third business day the specific product
provided to the Covered Person, including the name of the
product, strength, and the manufacturer or national drug code
number. The communication must be conveyed in the following
methods:
→ Interoperable electronic medical records system; or
→ Electronic prescribing technology; or
→ Pharmacy benefit management system; or
→ Pharmacy record, including information submitted for the
payment of claims; or
→ Facsimile, telephone, electronic transmission, or other
prevailing means.
Communication to the Prescribing Provider is not required if
there is no interchangeable biological product approved by the
United States Food and Drug Administration for the product
prescribed; or a refill prescription is not changed from the
product dispensed on the prior filling of the prescription.
Substitution of a generic drug or interchangeable biological
product for a brand-name drug or biological product is prohibited
if the phrase “brand necessary” or “brand medically necessary”
is written on a prescription.
12 © Prime Therapeutics LLC
New Plan AnnouncementBlue Cross and Blue Shield of Texas STAR and CHIP Medicaid Programs
Effective December 1, 2015
Effective December 1, 2015, Prime Therapeutics (Prime) will begin
processing pharmacy claims for eligible BCBSTX STAR and CHIP
Covered Persons.
Processing Requirements
To ensure uninterrupted service to Participating Pharmacies and
Covered Persons, please use the following information to set up
your system prior to the effective date December 1, 2015.
Blue Cross and Blue Shield of Texas STAR and CHIP Program
BIN: 011552
PCN: TXCAID
Covered Person Medicaid ID Number (9 digits)
→ Date of Birth
→ Gender
→ Group Number
→ U&C
→ Days Supply
→ Pharmacy NPI
→ Active/Valid Prescriber ID (NPI, DEA or State License)
→ Date Rx Written
→ Rx Origin Code
For more information
→ If you have questions regarding claims processing, please
contact Prime’s Contact Center at 855.457.0403 for CHIP and
855.457.0405 for STAR
→ For software setup information, please visit Prime’s website
at Primetherapeutics.com > Pharmacists > Payer sheets > TX Medicaid D D.0 Payer Sheet.
Prior Authorization
→ If you need assistance with a Prior Authorization, contact
Prime at 855.457.0407, print the Prior Authorization request
form online at Primetherapeutics.com > Pharmacists, or
submit the request online at covermymeds.com.
Outstanding Claim Reversals and Processing
→ To prepare for this transition, Participating Pharmacies
should complete all claims processing and reversals by close
of business November 30, 2015.
→ Medicaid claims with a submission or reversal date prior to
November 30, 2015 should be submitted to Express Scripts
using the following processing information:
> BIN: 003858
> PCN: A4
> Rx Group: WFTA
→ For assistance with claims that have a date of fill prior to
December 1, 2015, please contact Express Scripts Pharmacy
Help Desk at 866.323.2088 for CHIP or 866.294.1562 for STAR.
Provider Training
Please refer to Blue Cross Blue Shield of Texas’ website at:
www. bcbstx.com/provider for more information; including
cultural competency and training documentation on the TX CHIP
and TX STAR Programs
72-Hour Emergency Supply
→ A Participating Pharmacy is required to provide a 72-hour
emergency supply of a prescribed drug when a medication
is needed without delay and a Prior Authorization (PA) is not
available.
→ A 72-hour emergency supply should be dispensed any time a
Prescription claim rejects with NCPDP Reject Code 75: Prior
Authorization Required
→ The Participating Pharmacy should resubmit the rejected
claim using the following process:
NCPDP Segment Name
NCPDP Field Number
NCPDP Field Name Value
CLAIM SEGMENT
461-EU PRIOR AUTHORIZATION TYPE CODE
8
CLAIM SEGMENT
462-EV PRIOR AUTHORIZATION NUMBER SUBMITTED
801
CLAIM SEGMENT
405-D5 DAYS SUPPLY 3
CLAIM SEGMENT
442-E7 QUANTITY DISPENSED Varies
13© Prime Therapeutics LLC
Blue Cross and Blue Shield of Texas STAR and CHIP Medicaid Programs (continued)
Featured below is an example of the most common ID cards used
Durable Medical Equipment (DME)
→ Participating Pharmacies are encouraged to become Medicaid-enrolled durable medical equipment (DME) providers. Please refer to
www.bcbstx.com/provider to request a DME application. To be listed as a DME provider, a pharmacy must be a VDP pharmacy and
attested with TMHP.
SAMPLE
SAMPLE
SAMPLE
14 © Prime Therapeutics LLC
Prime Perspective | December 2015
Prime newsCommercial Vaccine Network
As a reminder, the following Plan Sponsors below utilize Prime’s
Commercial Vaccine Network:
→ BCBS of Alabama
→ BCBS of Illinois
→ BCBS of Minnesota
→ BCBS of Montana
→ BCBS of Nebraska
→ BCBS of New Mexico
→ BCBS of North Dakota
→ 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 Pharmacies 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.
Long-Term Care (LTC) and Home Infusion (HI) annual validation process
In order for Prime to maintain the integrity of our HI and LTC
networks, Prime requires each Participating Pharmacy or
Pharmacy Service Agreement Organization (PSAO) which
participates in Prime’s HI and LTC networks to validate on an
annual basis that they are able to continue to comply with
guidelines outlined for participation in the HI and/or LTC
pharmacy networks.
For your convenience, the required guidelines for participating
in the HI and LTC networks along with the validation form is
available at PrimeTherapeutics.com > Pharmacists.
Failure to validate may result in termination from the HI or LTC
networks.
Electronic prior authorization can save you time
Obtaining prior authorization (PA) for prescription medications
can be a time-consuming and frustrating process for Participating
Pharmacies and Prescribing Providers. The process has
traditionally required paper forms, faxes and follow-up phone
calls, having the potential to take time away from a Covered
Person’s care.
Electronic prior authorization (ePA) is an online method for
Prescribing Providers and Participating Pharmacies to submit
utilization management (UM) requests in a streamlined, structured
manner to Prime. PAs are a critical part of the medication delivery
process. PAs help to manage medicines that have a significant
potential for misuse, overuse or inappropriate use.
Prime has contracted with CoverMyMeds® to provide an ePA
solution that will allow Participating Pharmacies and Prescribing
Providers the ability to submit PA requests online. This online
solution allows Participating Pharmacies and Prescribing
Providers to submit and track PA results.
Pharmacy licensure
In order 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
15© Prime Therapeutics LLC
Prime Perspective | December 2015
Please include your NCPDP number on each of the
documents when sending them to Prime. Submit the
documents via fax to 877.823.6373 or send through email to
pharmacyops@ primetherapeutics.com.
Provider Manual update
Prime is in the process of updating its Provider Manual.
The new Provider Manual will be effective March 1, 2016.
The updated Provider Manual will be posted in February at
PrimeTherapeutics. com > Pharmacist > Provider Manual.
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 > 2015 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.
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 and Medicaid requirements
Time Sensitive Information from Prime Therapeutics
1000
1428