Coronavirus information: General information | Pharmacy FAQs


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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Important: A new pharmacist and provider digital experience is being designed on our website. You will see significant changes starting Oct. 1. If you have saved URLs, you will be directed to the main landing page of the new design.

Pharmacy providers


24-hour contact center

Commercial

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

Baptist Health Plan — 855.457.0006

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 Health Plan — 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

Horizon dSNP — 855.457.1347

BlueCross BlueShield of North Carolina— 877.277.7893

BlueCross BlueShield 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

Medicaid TX STAR Kids Travis — 855.457.0757

Medicaid TX STAR Kids/MRSA Central (Medicaid Rural Service Area) — 855.457.0758

Nebraska MAPD — 855.457.1351

Vibra Health Plan — 855.457.1209

BlueCross BlueShield of Rhode Island — 855.457.1207

Formularies – Medicare Part D

September 2021 Medicare Part D Negative Formulary Change(s) Notification

August 2021 Medicare Part D Negative Formulary Change(s) Notification

July 2021 Medicare Part D Negative Formulary Change(s) Notification

June 2021 Medicare Part D Negative Formulary Change(s) Notification

May 2021 Medicare Part D Negative Formulary Change(s) Notification

April 2021 Medicare Part D Negative Formulary Change(s) Notification

March 2021 Medicare Part D Negative Formulary Change(s) Notification

February 2021 Medicare Part D Negative Formulary Change(s) Notification

January 2021 Medicare Part D Negative Formulary Change(s) Notification

December 2020 Medicare Part D Negative Formulary Change(s) Notification

November 2020 Medicare Part D Negative Formulary Change(s) Notification

October 2020 Medicare Part D Negative Formulary Change(s) Notification

September 2020 Medicare Part D Negative Formulary Change(s) Notification

August 2020 Medicare Part D Negative Formulary Change(s) Notification

July 2020 Medicare Part D Negative Formulary Change(s) Notification

June 2020 Medicare Part D Negative Formulary Change(s) Notification

May 2020 Medicare Part D Negative Formulary Change(s) Notification

April 2020 Medicare Part D Negative Formulary Change(s) Notification

March 2020 Medicare Part D Negative Formulary Change(s) Notification

February 2020 Medicare Part D Negative Formulary Change(s) Notification

January 2020 Medicare Part D Negative Formulary Change(s) Notification

December 2019 Medicare Part D Negative Formulary Change(s) Notification

November 2019 Medicare Part D Negative Formulary Change(s) Notification

October 2019 Medicare Part D Negative Formulary Change(s) Notification

September 2019 Medicare Part D Negative Formulary Change(s) Notification

August 2019 Medicare Part D Negative Formulary Change(s) Notification

July 2019 Medicare Part D Negative Formulary Change(s) Notification

June 2019 Medicare Part D Negative Formulary Change(s) Notification

May 2019 Medicare Part D Negative Formulary Change(s) Notification

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 | MAC Pricing
  • Specialty fee schedule(s)
  • Compound fee schedule
  • 835 health care electronic remittance advice
  • Electronic funds transfer (EFT)
  • Prime’s Credentialing Threshold

Log in | Sign up

Pharmacy credentialing

Use the link below to:

Pharmacy Credentialing

  • Responding to a solicitation for a Credentialing application
  • Complete a Re-Credentialing application
  • Submit updated insurance coverage information

Effective Date: September 9, 2020

Prime requires that, unless otherwise credentialed by Prime, pharmacies participating in retail networks managed by Prime comply with the following specialty, compounding, and single ingredient dispensing thresholds:

1) Specialty threshold: Pharmacy will not be greater than 70% specialty dispensing rate

2) Compounding threshold: Pharmacy will not be greater than 10% compound dispensing rate

3) Mail order threshold: Pharmacy will not be greater than 10% mail order dispensing rate

4) Single ingredient threshold: Pharmacy will not be greater than 10% single ingredient dispensing rate based on the drug list located here under the Pharmacy Provider Tools:

https://www.primetherapeutics.com/en/resources/pharmacists.html.

Specialty, compounding, mail order and single ingredient thresholds may be changed by Prime in its sole discretion at any time.

During Credentialing, Prime reviews a pharmacy’s location to determine if they are located in either a federally defined or Prime defined "heat"zone.

Provider directory questionnaire

Use the link to:

  • Complete directory questionnaire to capture pharmacy URL
  • Confirm completion of cultural competency training
  • Submit whether the pharmacy offers American Sign Language

Directory questionnaire

Specialty Pharmacy Networks/Performance Guarantees

Each Pharmacy or Pharmacy Services Administration Organization (PSAO) participating in Prime’s Specialty Pharmacy Networks must adhere to requirements for reporting as outlined in Prime’s contractual reporting requirements, including but not limited to clinical reporting, performance guarantees and manufacture assistance reporting.  

If your pharmacy needs access to the reporting requirements or you have questions about contractual reporting requirements - please contact the Specialty Network Contracting team at: specialtycontracting@primetherapeutics.com

 


Pharmacy claim processing


Network Reimbursement IDs

May NRIDs

Prime Therapeutics LLC, (“Prime”) provides a Network Reimbursement ID (NRID) on pharmacy claims at point-of-sale. Based on the NRID, the pharmacy can identify the network that adjudicated each claim to help reconcile the pharmacy’s network agreements.

The NRID is transmitted back to pharmacies in the reimbursement ID field (NCPDP field 545-2F) and represents the contractual exhibit from which the claim is adjudicating. The reimbursement ID will be available at point of sale and will not be reflected on the pharmacy’s remittance.

If your pharmacy does not currently receive information in NCPDP field 545-2F, and want to see the reimbursement ID, you will need to work with your claims software vendor to include this.

If the reimbursement ID is for a network contracted and managed by Prime, pharmacies can direct inquires to Prime’s Provider Relations Team at pharmacyops@primetherapeutics.com. Prime’s pricing appeals process is available on Prime’s website under Pharmacy provider tools (www.primetherapeutics.com/en/resources/pharmacists.html). 

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.


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' "Medicare Parts C and D General Compliance (April 2020)" and "Medicare Fraud & Abuse: Prevent, Detect, and Report (February 2020)" training to each pharmacist and pharmacy staff member upon hire and annually thereafter. CMS training is available on the CMS website through their MLN Learning Management System (LMS).

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.

Prime’s Code of Conduct


Pharmacy audits



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 fraudtiphotline@primetherapeutics.com.

For suspected FWA involving the Federal Employee Plan, please notify: 

844.765.9990
FEPreportfraud@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


Drug pricing information

Georgia NADAC Reports

Jan-Apr 2021 (last posted Aug. 31, 2021)