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

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

Flroida 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

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)

Log in | Sign up

Pharmacy credentialing

Use the link below to:

Complete a new application
Complete re-credentialing
Submit new license and insurance information (when available)
Complete an Ownership Disclosure Form (when available) 

Pharmacy credentialing


Pharmacy claim processing


Plan announcements

Adient USA, LLC

Alignment Health Plan

AmeriHealth Administrators, Inc.

BlueCross BlueShield of Minnesota SecureBlue Processing Update

BlueCross BlueShield of Minnesota Medicaid Processing Update

Blue Cross & Blue Shield of North Dakota Healthy Steps

Blue Cross & Blue Shield of North Dakota Processing Update

Blue Cross & Blue Shield of Rhode Island

Blue Cross & Blue Shield of Rhode Island BlueCHiP for Medicare

Blue Cross & Blue Shield of Rhode Island Naloxone Processing Update

BCBSIL Medicare Advantage (PPO) Chicago Teachers' Pension Fund

BCBSTX Blue Cross Medicare Advantage (HMO SNP)

BCBSTX STAR and CHIP Medicaid Programs

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

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

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

Blue Cross and Blue Shield of Texas STAR Kids Medicaid Program

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

Blue Cross Blue Shield of Oklahoma Blue Cross Medicare Advantage Basic (HMO) and Premier Plus (HMO POS)

Blue Cross Blue Shield of New Mexico Blue Cross Medicare Advantage (HMO)

Horizon Blue Cross Blue Shield of New Jersey Horizon NJ TotalCare (HMO SNP)

BlueCross BlueShield of Minnesota Platinum Blue℠ with Rx (Cost) and Platinum Blue℠ (Cost)

BlueCross BlueShield of Minnesota and Blue Plus Medicare Supplement Plans

Blue Cross and Blue Shield of Nebraska Medicare Advantage Core (HMO) and Choice (HMO-POS)

Blue Cross & Blue Shield of Wyoming Processing Update

HCSC Medicare Part B Processing Update

Medtronic

Mississippi State and School Employees' Health Insurance Plan

Vibra Health Plan

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 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 reportfraud@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