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  • Prime Perspective Quarterly Pharmacy Newsletter from Prime Therapeutics LLC

    December 2015: Issue 62

    INSIDE From 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.


    → 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: 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:  > Pharmacists.

  • 3© Prime Therapeutics LLC

    Prime Perspective | December 2015

    Medicare news/Medicaid news CMS 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


    → NCPDP Reject Code 75




    Medicare Part D FWA Participating Pharmacy training and certificat