Resource - Pharmacy and provider

You’re the link between our members and their medicine. 
They count on you for the information they need
about their prescriptions.

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Your resources

Your resources

You can count on us to help you find the information you need:

  • A dedicated 24-hour pharmacy contact center
  • Ongoing communications about plan changes and additions
  • Regular news and updates on current pharmacy topics
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Pharmacy providers


24-hour contact center

Commercial

General (HCSC, MN, ND, NE) – 800.821.4795

Capital Health Plan – 866.469.5662 

Blue Cross and Blue Shield of Alabama – 800.216.9920

Florida Blue – 888.877.6323

Blue Cross and Blue Shield of Kansas – 877.893.8485

Blue Cross and Blue Shield of Montana – 866.590.3012

Horizon Blue Cross Blue Shield of New Jersey – 877.686.6875

Blue Cross and Blue Shield of North Carolina – 888.274.5186

Blue Cross and Blue Shield of Oklahoma – 877.353.0992

Blue Cross Blue Shield of Wyoming – 800.424.7094

Mississippi State and School Employees' Health Insurance – 855.457.0408

Medtronic – 855.457.0624


Medicare Part D

Alignment – 855.457.0622

Capital Health Plan – 866.590.3010

Arkansas Blue Cross and Blue Shield – 800.693.3815

Blue Cross and Blue Shield of Alabama – 877.878.8668

Florida Blue – 888.877.6420

IL, MT, NM, TX > MAPD – 877.277.7898

IL, NM, OK, TX > MAPD, PDP – 800.693.6704

Illinois > MAPD.Special Needs Program, Dual Eligible Special Needs Program – 888.274.5246

Illinois > Medicare, Medicaid Alignment Initiative – 888.840.3068

Blue Cross and Blue Shield of Minnesota > Secure Blue, Platinum Blue – 800.648.2778

Horizon Blue Cross Blue Shield of New Jersey – 800.391.1926

Blue Cross and Blue Shield of North Carolina – 877.277.7893

Blue Cross and Blue Shield of South Carolina – 800.545.8512

Medicaid, Illinois > Family Health Plan – 855.457.0173

Medicaid, Illinois > Integrated Care Program – 888.274.5218

Medicaid, New Mexico – 888.840.3044

Texas Medicaid CHIP – 855.457.0403

Texas Medicaid STAR – 855.457.0405

Formularies – Commercial

Formularies – Medicare Part D

November 2016 Medicare Part D Negative Formulary Change(s) Notification

October 2016 Medicare Part D Negative Formulary Change(s) Notification

September 2016 Medicare Part D Negative Formulary Change(s) Notification

August 2016 Medicare Part D Negative Formulary Change(s) Notification

July 2016 Medicare Part D Negative Formulary Change(s) Notification

June 2016 Medicare Part D Negative Formulary Change(s) Notification

May 2016 Medicare Part D Negative Formulary Change(s) Notification

April 2016 Medicare Part D Negative Formulary Change(s) Notification

March 2016 Medicare Part D Negative Formulary Change(s) Notification

February 2016 Medicare Part D Negative Formulary Change(s) Notification

2015 Value 5T w S to 2016 Value 5T w S

2015 Value 5T w S to 2016 NC Value 5T w S

2015 Ideal 4T w S to 2016 Ideal 4T w S

2015 Ideal 4T w S to 2016 Ideal STARS 6T w S

2015 Ideal 4T no S to 2016 Ideal STARS 6T w S

2015 Ideal 5T w S to 2016 Ideal 5T w S

2015 Ideal 5T w S to 2016 Ideal STARS 6T w S

2015 Ideal 1T to 2016 Ideal 1T

2015 Expanded 3T no S to 2016 Expanded 5T w S

2015 Expanded 5T w S to 2016 Expanded 5T w S

2015 FL 5T Custom to 2016 FL 5T Custom

2015 Ideal 5T w S to 2016 NC Value 5T w S

2015 NC Ideal 5T w S to 2016 NC Value 5T w S

2015 NC Ideal 5T w S to 2016 NC Value STARS 6T w S

2015 NC Ideal 5T w S to 2016 Ideal 5T w S

2015 SB 1T Custom to 2016 SB 1T Custom

2015 HCSC 2T to 2016 HCSC 2T

2015 HCSC 5T w S to 2016 HCSC 5T w S

2015 HCSC 5T w S to 2016 HCSC 5T Alternative w S

2016 Alignment 5T w S to 2017 Alignment 6T w S

2016 Alignment 5T w S to 2017 Ideal 1T

2016 BeHealthy 5T w S to 2017 Ideal STARS 6T w S

2016 Expanded 5T w S to 2017 Expanded 5T w S

2016 FL 5T Custom to 2017 Expanded 5T w S

2016 HCSC 2T to 2017 HCSC 2T

2016 HCSC 5T Alternative w S to 2017 HCSC 5T Alternative w S

2016 HCSC 5T w S to 2017 HCSC 5T w S

2016 Ideal 1T to 2017 Ideal 1T

2016 Ideal 4T w S to 2017 Ideal 4T w S

2016 Ideal 5T w S to 2017 Ideal 5T w S

2016 Ideal STARS 6T w S to 2017 Ideal STARS 6T w S

2016 NC Value 5T w S to 2017 NC Value 5T w S

2016 NC Value STARS 6T w S to 2017 NC Value STARS 6T w S

2016 SB 1T Custom to 2017 SB 1T Custom

2016 Value 5T w S to 2017 HCSC Value 5T w S

2016 Value 5T w S to 2017 Value 5T w S

 

Electronic prior authorization

You can sign up to use the electronic prior authorization (ePA) system through CoverMyMeds, all that is needed is a computer, and an internet connection.

How to get started:

Visit pharmacysystems.covermymeds.com to see if CoverMyMeds is already integrated with your pharmacy system, and start saving time today. 

If your pharmacy system is not integrated, please contact the pharmacy system directly to request an integration.

 

Pharmacy provider tools

Access Prime’s:

Prime’s maximum allowable cost (MAC) list
Specialty fee schedule(s)
Compound fee schedule
835 health care electronic remittance advice
Electronic funds transfer (EFT)

Log in | Sign up


Pharmacy claim processing


Plan announcements

Adient USA, LLC

Alignment Health Plan

Blue Cross & Blue Shield of Rhode Island

Blue Cross & Blue Shield of Rhode Island BlueCHiP for Medicare

BCBSIL Medicare Advantage (PPO) Chicago Teachers' Pension Fund

BCBSTX Blue Cross Medicare Advantage (HMO SNP)

Medtronic

Mississippi State and School Employees' Health Insurance Plan

BCBSTX STAR and CHIP Medicaid Programs

Blue Cross Blue Shield of Texas Blue Cross Medicare Advantage (PPO)

BlueCross BlueShield of Minnesota Platinum Blue with Rx (Cost)

BlueCross Blueshield of Minnesota Platinum Blue (Cost)

Blue Cross Blue Shield of Illinois Blue Cross Medicare Advantage (PPO)

Blue Cross Blue Shield of Texas Blue Cross Medicare Advantage (HMO)

HCSC Medicare Part B Processing Update

BlueCross BlueShield BluePlus of Minnesota Medicaid Processing Update

BlueCross BlueShield BluePlus of Minnesota SecureBlue (HMO SNP) Part B Processing Update

Arkansas Blue Cross Blue Shield Medicare Part D

Blue Cross Blue Shield of Illinois Blue Cross Medicare Advantage (HMO)

Blue Cross Blue Shield of New Mexico Blue Cross Medicare Advantage (HMO, PPO and SNP)

Blue Cross Blue Shield of Oklahoma Blue Cross Medicare Advantage (HMO and PPO)

Blue Cross Blue Shield of Minnesota MedicareBlue Rx (PDP) Employer Group

BlueCross BlueShield of South Carolina Medicare Part D

Blue Cross Community FHP

Blue Cross Community ICP

Blue Cross Community MMAI (Medicare-Medicaid Plan)

Capital Health Plan

Horizon Blue Cross Blue Shield of New Jersey Medicare Part D

Blue Cross and Blue Shield of Texas STAR Kids Medicaid Program

BCBSNM Blue Cross Medicare Advantage Select (HMO) and Flex (HMO POS)

Vaccine program

Our national network allows participating pharmacies to submit a claim when administering vaccines.

Details

Blue Cross & Blue Shield of Rhode Island Vaccine Processing Requirements


Prior authorization


Medicare


Home infusion (HI)/Long-term care (LTC) validation

Each Pharmacy or Pharmacy Services Administration Organization (PSAO) participating in Prime’s HI and LTC networks must annually validate they are able to follow the guidelines outlined in Prime’s HI and/or LTC pharmacy networks.

Failure to validate may result in termination from Prime’s HI or LTC networks.

Long Term Care Validation 
Home Infusion Validation

Please note, if you are participating in both Prime's Long Term Care and Home Infusion networks, you need to complete both validation forms.


Medicaid



Compliance/Fraud, waste and abuse


Training and certification requirements

Every pharmacy in Prime’s network must do the following to meet compliance requirements:

Training: Provide CMS’ general compliance and fraud, waste and abuse training to each pharmacist and pharmacy staff member upon hire and annually from then on.

Certification: Complete the FWA Certification form that is part of your pharmacy profile on NCPDP. Download instructions

Record keeping: Maintain internal training logs.

Policies and procedures: Maintain internal training protocols.

The resources needed to meet these requirements are:

CMS General Compliance Training
CMS Fraud, Waste and Abuse Training
Prime’s Code of Conduct


Pharmacy audit



Report compliance, privacy, or fraud, waste and abuse concerns


Compliance

Report suspected compliance concerns:

612.777.5523
compliance@primetherapeutics.com

Privacy

Report privacy concerns or potential protected health information (PHI) disclosures:

888.849.7840
privacy@primetherapeutics.com

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 reportfraud@primetherapeutics.com.

Anonymous reporting

Report a compliance concern or suspected fraud, waste or abuse anonymously, by contacting Prime’s 24-hour anonymous compliance hotline:

800.474.8651
reports@lighthouse-services.com 
www.lighthouse-services.com/prime