Prime Perspective Quarterly Pharmacy Newsletter from Prime ... Prime Perspective Quarterly Pharmacy
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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
→ 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.
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:
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 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
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
> COVERAGE DETERMINATION REQUIRED
> FOR VERIFICATION OF A MEDICARE PART D
> MEDICALLY ACCEPTED INDICATION
Medicare Part D FWA Participating Pharmacy training and certificat