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Prime PerspectiveQuarterly Pharmacy Newsletter from Prime Therapeutics LLC

December 2015: Issue 62

INSIDEFrom 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.

→ 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:

http://www.PrimeTherapeutics.com/Files/Updated_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:

PrimeTherapeutics.com > Pharmacists.

3© Prime Therapeutics LLC


Medicare news/Medicaid newsCMS 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

indication:

→ 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 certification

The Centers for Medicare & Medicaid Services (CMS) require any

staff providing Medicare Part D services to receive qualified Fraud,

Waste and Abuse (FWA) training upon hire, and annually thereafter.

Every year, on behalf of the Part D Plan Sponsors it serves, Prime

is required to track completion of this training by all Participating

Pharmacies in its network. Accordingly, Participating Pharmacies

must submit to Prime certification that the Participating Pharmacy

has completed a qualified FWA training program and is therefore in

compliance with the training requirement.

All pharmacy certifications for calendar year 2015 are due to Prime

by December 31, 2015. Not submitting the certification by the due

date may impact continued participation in Prime’s Network.

FWA training program and certification can be found at

PrimeTherapeutics.com > Pharmacists > Annual Fraud, Waste and Abuse (FWA) Training and Attestation > FWA Training and Certification Options.



CMS standardized pharmacy notice

CMS requires all Medicare Part D Benefit Sponsors to use a single

uniform exceptions and appeals process with respect to the

determination of prescription drug coverage for a Covered Person

under the plan. Medicare Part D claims will reject when a claim

cannot be covered under the Medicare Part D benefit at Point-of-

Sale (POS).

Pharmacy claims will reject with the following POS rejection

message:

→ NCPDP Reject Code 569

Participating Pharmacies are required to provide the CMS

Notice of Medicare Prescription Drug Coverage and Your Rights

to Covered Persons when they receive National Council for

Prescription Drug Programs (NCPDP) reject code 569. The CMS

Notice of Medicare Prescription Drug Coverage and Your Rights

is posted on Prime’s website at PrimeTherapeutics. com > Pharmacists > Medicare Part D > Medicare Resources > More > Additional Links > Medicare Coverage & Rights.

Home Infusion Participating Pharmacies receiving the NCPDP

reject code 569, must distribute the CMS notice to the Covered

Person either electronically, by fax, in person or by first class

mail within 72 hours of receiving the claim rejection.

Long Term Care (LTC) Participating Pharmacies receiving the

NCPDP reject code 569, must contact the Prescribing Provider

or LTC facility to resolve the rejected claim to ensure the

Covered Person receives their medication. If the Participating

Pharmacy must distribute the CMS notice, they must fax or

deliver the notice to the Covered Person, the Covered Person’s

representative, Prescribing Provider or LTC facility within

72 hours of receiving the rejection.

In addition, a copy of the CMS Notice of Medicare Prescription

Drug Coverage and Your Rights has been included on page five of

this publication.

Blue Cross and Blue Shield of Alabama and Horizon Blue Cross and Blue Shield of New Jersey Synchronized Claims Adjudication

Effective January 1, 2016, Blue Cross and Blue Shield of

Alabama and Horizon Blue Cross and Blue Shield of New Jersey

Employer Group business will implement synchronized claims

adjudication. This new process will allow for proper adjudication

of co-administered benefits between Part D and Other Health

Insurance for Employer Group Waiver plans.

There will be no operational impact to Participating Pharmacies

as a result of synchronized claims adjudication. Participating

Pharmacies will continue to submit pharmacy claims as they

normally do today.

From a reconciliation perspective you will receive two payments

that will total the full claim adjudication amount.

If you have questions regarding claims processing, please contact

Prime’s Pharmacy Help Desk at 877.878.8668 for Blue Cross and

Blue Shield of Alabama or 800.391.1926 for Horizon Blue Cross

and Blue Shield of New Jersey.

PrimeWest Health transitions to new PBM

Effective January 1, 2016, PrimeWest Health will transition their

Medicaid and Medicare Part D products from Prime Therapeutics

to MedImpact.

Participating Pharmacies will no longer be able to submit claims

to Prime Therapeutics for Medicaid or Medicare Part D Covered

Persons for dates of service after 12/31/15 for the following BIN

and PCN combinations:

Plan name BIN PCN

PrimeWest Health Medicaid Programs (PMAP, MinnesotaCare, MSC+, SNBC and HMO SNP)

61Ø455 PWEST

PrimeWest Prime Health Complete Part D 61Ø455 MPDPH

PrimeWest Senior Health Complete Part D 61Ø455 MPDPW

For claims processing questions for 2016 claims and subsequent

dates of service, please call the MedImpact Pharmacy Help Desk at:

Pharmacy Help Desk Medicaid Medicare Part D

MedImpact 1.800.788.2949 1.877.391.9294



OMB Approval No. 0938-0975

Enrollee’s Name: (Optional)

Drug and Prescription Number: (Optional)

Medicare Prescription Drug Coverage and Your Rights

Your Medicare rights

You have the right to request a coverage determination from your Medicare drug plan if you disagree with information provided by the pharmacy. You also have the right to request a special type of coverage determination called an “exception” ifyou believe:

you need a drug that is not on your drug plan’s list of covered drugs. The list of covered drugs is called a “formulary;”

a coverage rule (such as prior authorization or a quantity limit) should not apply to you for medical reasons; or

you need to take a non-preferred drug and you want the plan to cover the drug at the preferred drug price.

What you need to do

You or your prescriber can contact your Medicare drug plan to ask for a coverage determination by calling the plan’s toll-free phone number on the back of your plan membership card, or by going to your plan’s website. You or your prescriber canrequest an expedited (24 hour) decision if your health could be seriously harmed by waiting up to 72 hours for a decision. Be ready to tell your Medicare drug plan:

1. The name of the prescription drug that was not filled. Include the dose and strength, if known.

2. The name of the pharmacy that attempted to fill your prescription.3. The date you attempted to fill your prescription.4. If you ask for an exception, your prescriber will need to provide your drug plan

with a statement explaining why you need the off-formulary or non-preferred drug or why a coverage rule should not apply to you.

Your Medicare drug plan will provide you with a written decision. If coverage is not approved, the plan’s notice will explain why coverage was denied and how to request an appeal if you disagree with the plan’s decision.

Refer to your plan materials or call 1-800-Medicare for more information.

Form CMS -10147



Minnesota Medicaid regulations

Effective May 1, 2015, Participating Pharmacies may accept

cash for phentermine claims as advised by the Minnesota

Health Care Programs (MHCP). Phentermine is not covered by

Medical Assistance because weight loss drugs are excluded from

coverage per state law.

A Participating Pharmacy may accept cash payment for a

phentermine prescription drug provided that:

→ The phentermine is being used as part of a comprehensive

weight loss program and is prescribed at the FDA-approved

dosage.

→ The Prescription Drug Monitoring Program has been reviewed

and determined that the prescription is not being abused or

overused.

→ The Covered Person has been informed about the

responsibility for payment before the phentermine

prescription was dispensed.

→ The Participating Pharmacy or an authorized health care

representative completes the Advance Recipient Notice of Non-covered Prescription (DHS-3641) (PDF) and the Covered

Person signed the form.

For further information on Minnesota’s Medicaid regulations:

http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod= LatestReleased&dDocName=dhs16_194592.

As a general reminder, Participating Pharmacies may not accept

cash payment from a Covered Person or from someone paying

on behalf of the Covered Person, for any Minnesota Health Care

Programs (MHCP) covered prescription drug.

A Participating Pharmacy may accept cash payment for a non-

covered prescription drug provided that:

→ The Covered Person is not enrolled in the restricted recipient

program.

→ All available covered alternatives have been reviewed with

the Covered Person.

→ The Participating Pharmacy obtains a Covered Person

signature on the MHCP Acknowledgement form.

→ The prescription is not a controlled substance, (except

phentermine in certain circumstances) tramadol or

gabapentin.

A Participating Pharmacy may only accept a cash payment for a

controlled substance, tramadol or gabapentin, if the Participating

Pharmacy has received authorization from MHCP to do so on the

date of service. To be considered for cash payment authorization,

the Prescribing Provider must contact the MHCP help desk

at 800.366.5411 and provide rationale as to why the covered

alternatives are not viable options for the Covered Person.

If a Covered Person’s MHCP eligibility status is in question and

the Covered Person offers a cash payment for prescriptions, the

Participating Pharmacy must verify eligibility through Minnesota

Information Technology Services (MN-ITS) or Eligibility

Verification System (EVS). If the person does not have coverage

through MHCP you can accept cash as payment.

For further information on Minnesota’s Medicaid regulations,

please refer to MHCP Provider Manual at:

http://www.dhs.state.mn.us/main/idcplg?IdcService= GET_DYNAMIC_CONVERSION&RevisionSelectionMethod= LatestReleased&dDocName=id_008992#P274_26700.



Arkansas newsMedicare Part B processing changes

Effective January 1, 2016, Prime Therapeutics will no longer

process claims for Arkansas Blue Cross and Blue Shield (ABCBS)

Medi-Pak Advantage Part B for the following:

BIN PCN

016895 MPPARTB

This change will impact how Participating Pharmacies submit

Part B prescription drugs, Part B immunizations and diabetic

supplies for Covered Persons of ABCBS Med-Pak Advantage.

Participating Pharmacies will have to submit Part B eligible

services for Covered Persons using the following methods:

→ Submit these claims through a clearinghouse via your

supported submission method

→ Submit a CMS-1500 form to the medical claims processor

→ Submit an electronic 837 claim to the medical claims

processor

New Covered Person ID cards for Medicare Part D

Medicare Part D Covered Persons of Arkansas Blue Cross and

Blue Shield will receive new ID cards. Covered Persons have been

instructed to present their new ID card when filling a prescription

at a Participating Pharmacy.

Effective January 1, 2016 when submitting a Medicare Part D

claim, Participating Pharmacies are not required to enter the

alpha characters. Only submit the claims with the nine-digit ID

number without the leading alpha characters.

Florida newsMedications for the treatment of HIV will be added to the prior authorization program

Florida Blue will be requiring prior authorization on medications

used in the treatment of Human Immunodeficiency Virus (HIV)

beginning October 1, 2015. This is intended to ensure appropriate

use. The requirements to obtain coverage include diagnosis in

accordance with FDA approved indications. This program only

affects new users of these medications with current users not

being impacted. New users will have one grace fill to allow time

for authorization submission and review.

The table below indicates drugs included in the HIV prior

authorization program:

Drug

APTIVUS ISENTRESS TIVICAY

ATRIPLA KALTETRA TRIUMEQ

COMBIVIR LEXIVA TRIZIVIR

COMPLERA NEVIRAPINE susp

and tabs

TRUVADA

CRIXIVAN NORVIR TYBOST

ENDURANT PREZISTA susp and

tabs

VIDEX, VIDEX EC

EMTRIVA RESCRIPTOR VIRACEPT

EPIVIR soln and tabs RETROVIR VIRAMUNE susp and

tabs

EPZICOM REYATAZ VIRAMUNE XR

FUZEON SELZENTRY VIREAD

INTLENCE STRIBILD ZERIT

INVIRASE SUSTIVA ZIAGEN soln and

tabs

Florida Blue utilization management programs

Utilization management program updates for the upcoming

quarter, when available, will be posted at PrimeTherapeutics. com > Pharmacists > Formulary > UM Program Updates.



Illinois news2016 Benefit changes

Effective January 1, 2016, some Blue Cross and Blue Shield of

Illinois (BCBSIL) Covered Persons may be impacted by one or

more of the following pharmacy benefit changes. These changes, if applicable, will become effective as the Covered Person’s coverage renews during 2016:

→ Select drugs may move to a higher non-formulary brand

copayment/coinsurance.

→ Brand-name proton pump inhibitor drugs, non-FDA approved

medications and compound medications may no longer be

covered under the prescription drug benefit. Select drug

classes and/or brand-name medications may also no longer

be covered under the prescription drug benefit.

→ Covered Persons may be required to use a specialty

pharmacy in the BCBSIL preferred specialty network or will

incur an out-of-network penalty.

→ Select drugs may be required to have a prior authorization

request approved in order to be considered for coverage

under the prescription drug benefit.

→ Covered Persons may be required to fill prescriptions

at a retail pharmacy in the Preferred Pharmacy Network

in order to obtain the lowest copayment/coinsurance.

Covered Persons may fill prescriptions at Participating

Pharmacies outside of this network but benefits will be

at a higher copayment/coinsurance. Additionally, 90-day

supply prescriptions filled at retail will only be allowable at

Participating Pharmacies within this network.

If you have questions regarding claims processing, please

contact Prime’s Contact Center at 1.800.821.4795.

Vaccine coverage

BCBSIL Covered Persons may also receive vaccinations

for meningitis and HPV at Participating Pharmacies in the

Prime Therapeutics Commercial Vaccine Network. This is in addition

to vaccinations for influenza (flu), pneumococcal (pneumonia),

zoster (shingles), rabies, hepatitis B, tetanus, diphtheria, pertussis

and T-Dap (diphtheria, tetanus and pertussis). Coverage is

dependent on the Covered Person’s prescription drug benefit. For

vaccine processing information, please visit Prime’s website at:

PrimeTherapeutics.com > Pharmacists > Commercial Vaccination Administration Network.

Minnesota newsBlue Cross and Blue Shield of Minnesota New ID Cards

Effective November 1, 2015, Blue Cross and Blue Shield of

Minnesota started a three-year conversion to a new claims

processing platform. As a result, Minnesota groups will convert

to the new claims system in a phased approach starting in

November 2015 and concluding in 2018. Minnesota Covered

Persons will receive new ID cards upon conversion and/or

renewal. All Covered Person IDs will change as a result of this

change. Covered Persons have been instructed to present

their new ID cards when filling a prescription at a Participating

Pharmacy. As a reminder, this change resulted in a processing

change for Participating Pharmacies.

Pharmacy claims should be submitted using the following:

BIN PCN

610455 HMHS



Montana news2016 Benefit changes


Montana (BCBSMT) Covered Persons may be impacted by one or




→ Brand-name proton pump inhibitor drugs and non-FDA

approved medications may no longer be covered under the

prescription drug benefit. Select drug classes and/or brand-

name medications may also no longer be covered under the

prescription drug benefit.


pharmacy in the BCBSMT preferred specialty network or will

not be covered under the prescription drug benefit.




→ Covered Persons may be required to fill prescriptions at a

retail pharmacy in the Value Pharmacy Network in order to

obtain the lowest copayment/coinsurance. Covered Persons

may fill prescriptions at Participating Pharmacies outside

of this network but benefits will be at a higher copayment/

coinsurance. Additionally, 90-day supply prescriptions filled

at retail will only be allowable at Participating Pharmacies

within this network.



Vaccine coverage

BCBSMT Covered Persons may also receive vaccinations for

rabies, hepatitis B, pertussis and T-Dap (diphtheria, tetanus and

pertussis) at Participating Pharmacies in the Prime Therapeutics

Commercial Vaccine Network. This is in addition to vaccinations

for meningitis, HPV, influenza (flu), pneumococcal (pneumonia),

zoster (shingles), tetanus and diphtheria. Coverage is dependent

on the Covered Person’s prescription drug benefit.

New Mexico news2016 Benefit changes

some Blue Cross and Blue Shield of New Mexico (BCBSNM)

Covered Persons may be impacted by one or more of the following

pharmacy benefit changes. These changes, if applicable, will become effective as the Covered Person’s coverage renews during 2016:









pharmacy in the BCBSNM preferred specialty network or will















Vaccine coverage

BCBSNM Covered Persons may also receive vaccinations


Prime Therapeutics Commercial Vaccine Network. This is in addition

to vaccinations for influenza (flu), pneumococcal (pneumonia),

zoster (shingles), rabies, hepatitis B, tetanus, diphtheria, pertussis

and T-Dap (diphtheria, tetanus and pertussis). Coverage is

dependent on the Covered Person’s prescription drug benefit.

For vaccine processing information, please visit Prime’s website at: PrimeTherapeutics.com > Pharmacists > Commercial Vaccination Administration Network.



North Dakota newsVaccine coverage

Effective October 1, 2015, Blue Cross Blue Shield of

North Dakota (BCBSND) added vaccine coverage for Covered

Persons of BCBSND. Covered Persons of BCBSND may have

the option to receive vaccinations for influenza, Pneumovax®,

Zostavax®, diphtheria-tetanus combinations (toxoids), human

papillomavirus (HPV), measles mumps and rubella virus

(MMR), meningitis, tetanus, and varicella (chickenpox) when

administered by a pharmacist at a Participating Pharmacy

location and permissible by law.

Covered Persons simply present their BCBSND ID card to a

Participating Pharmacy and pay their applicable pharmacy

deductible, copayment, or coinsurance amount. Participating

Pharmacies within this network are reimbursed an administration

fee in addition to the cost of the vaccine product. For vaccine

processing information, please visit Prime’s website at:

PrimeTherapeutics.com > Pharmacists > Commercial Vaccination Administration Network.

Oklahoma news2016 Benefit changes


Oklahoma (BCBSOK) Covered Persons may be impacted by one or










pharmacy in the BCBSOK preferred specialty network or will















Vaccine coverage

BCBSOK Covered Persons may also receive vaccinations


Prime Therapeutics Commercial Vaccine Network. This is in

addition to vaccinations for influenza (flu), pneumococcal

(pneumonia), zoster (shingles), rabies, hepatitis B, tetanus,

diphtheria, pertussis and T-Dap (diphtheria, tetanus and

pertussis). Coverage is dependent on the Covered Person’s

prescription drug benefit. For vaccine processing information,

please visit Prime’s website at: PrimeTherapeutics.com > Pharmacists > Commercial Vaccination Administration Network.



Texas news2016 Benefit changes


Texas (BCBSTX) Covered Persons may be impacted by one or










pharmacy in the BCBSTX preferred specialty network or will















Vaccine coverage

BCBSTX Covered Persons may also receive vaccinations for

pneumococcal (pneumonia), zoster (shingles), rabies, hepatitis B,

meningitis, HPV, tetanus, diphtheria, pertussis and T-Dap

(diphtheria, tetanus and pertussis) at Participating Pharmacies

in the Prime Therapeutics Commercial Vaccine Network. This

is in addition to vaccinations for influenza (flu). Coverage is

dependent on the Covered Person’s prescription drug benefit. For

vaccine processing information, please visit Prime’s website at: PrimeTherapeutics.com > Pharmacists > Commercial Vaccination Administration Network.

Texas HB 751 interchangeable biological product

Effective December 1, 2015, a new law enacted by the Legislature

of the State of Texas, Participating Pharmacies may substitute

lower-priced generically equivalent drug products for certain

brand-name drug products and interchangeable biological

products for certain biological products without the need of a

Prescribing Provider’s consent.

Participating Pharmacies and pharmacists shall pass on the

net benefit of the lower costs of the generically equivalent drug

product or interchangeable biological product to the Covered

Person. In the event the price of a drug or interchangeable

biological product to a Covered Person is lower than the amount

of the Covered Person’s copayment under the Covered Person’s

Benefit Plan, then Participating Pharmacies shall offer Covered

Persons the option of paying for the drug or biological product at

the lower price instead of paying the amount of the copayment.

If substituting a generic drug or interchangeable biologic product,

the Participating Pharmacy shall communicate to the Prescribing

Provider no later than the third business day the specific product

provided to the Covered Person, including the name of the

product, strength, and the manufacturer or national drug code

number. The communication must be conveyed in the following

methods:

→ Interoperable electronic medical records system; or

→ Electronic prescribing technology; or

→ Pharmacy benefit management system; or

→ Pharmacy record, including information submitted for the

payment of claims; or

→ Facsimile, telephone, electronic transmission, or other

prevailing means.

Communication to the Prescribing Provider is not required if

there is no interchangeable biological product approved by the

United States Food and Drug Administration for the product

prescribed; or a refill prescription is not changed from the

product dispensed on the prior filling of the prescription.

Substitution of a generic drug or interchangeable biological

product for a brand-name drug or biological product is prohibited

if the phrase “brand necessary” or “brand medically necessary”

is written on a prescription.


New Plan AnnouncementBlue Cross and Blue Shield of Texas STAR and CHIP Medicaid Programs

Effective December 1, 2015

Effective December 1, 2015, Prime Therapeutics (Prime) will begin

processing pharmacy claims for eligible BCBSTX STAR and CHIP

Covered Persons.

Processing Requirements

To ensure uninterrupted service to Participating Pharmacies and

Covered Persons, please use the following information to set up

your system prior to the effective date December 1, 2015.

Blue Cross and Blue Shield of Texas STAR and CHIP Program

BIN: 011552

PCN: TXCAID

Covered Person Medicaid ID Number (9 digits)

→ Date of Birth

→ Gender

→ Group Number

→ U&C

→ Days Supply

→ Pharmacy NPI

→ Active/Valid Prescriber ID (NPI, DEA or State License)

→ Date Rx Written

→ Rx Origin Code

For more information

→ If you have questions regarding claims processing, please

contact Prime’s Contact Center at 855.457.0403 for CHIP and

855.457.0405 for STAR

→ For software setup information, please visit Prime’s website

at Primetherapeutics.com > Pharmacists > Payer sheets > TX Medicaid D D.0 Payer Sheet.

Prior Authorization

→ If you need assistance with a Prior Authorization, contact

Prime at 855.457.0407, print the Prior Authorization request

form online at Primetherapeutics.com > Pharmacists, or

submit the request online at covermymeds.com.

Outstanding Claim Reversals and Processing

→ To prepare for this transition, Participating Pharmacies

should complete all claims processing and reversals by close

of business November 30, 2015.

→ Medicaid claims with a submission or reversal date prior to

November 30, 2015 should be submitted to Express Scripts

using the following processing information:

> BIN: 003858

> PCN: A4

> Rx Group: WFTA

→ For assistance with claims that have a date of fill prior to

December 1, 2015, please contact Express Scripts Pharmacy

Help Desk at 866.323.2088 for CHIP or 866.294.1562 for STAR.

Provider Training

Please refer to Blue Cross Blue Shield of Texas’ website at:

www. bcbstx.com/provider for more information; including

cultural competency and training documentation on the TX CHIP

and TX STAR Programs

72-Hour Emergency Supply

→ A Participating Pharmacy is required to provide a 72-hour

emergency supply of a prescribed drug when a medication

is needed without delay and a Prior Authorization (PA) is not

available.

→ A 72-hour emergency supply should be dispensed any time a

Prescription claim rejects with NCPDP Reject Code 75: Prior

Authorization Required

→ The Participating Pharmacy should resubmit the rejected

claim using the following process:

NCPDP Segment Name

NCPDP Field Number

NCPDP Field Name Value

CLAIM SEGMENT

461-EU PRIOR AUTHORIZATION TYPE CODE

8

CLAIM SEGMENT

462-EV PRIOR AUTHORIZATION NUMBER SUBMITTED

801

CLAIM SEGMENT

405-D5 DAYS SUPPLY 3

CLAIM SEGMENT

442-E7 QUANTITY DISPENSED Varies


Blue Cross and Blue Shield of Texas STAR and CHIP Medicaid Programs (continued)

Featured below is an example of the most common ID cards used

Durable Medical Equipment (DME)

→ Participating Pharmacies are encouraged to become Medicaid-enrolled durable medical equipment (DME) providers. Please refer to

www.bcbstx.com/provider to request a DME application. To be listed as a DME provider, a pharmacy must be a VDP pharmacy and

attested with TMHP.

SAMPLE

SAMPLE

SAMPLE



Prime newsCommercial Vaccine Network

As a reminder, the following Plan Sponsors below utilize Prime’s

Commercial Vaccine Network:

→ BCBS of Alabama

→ BCBS of Illinois

→ BCBS of Minnesota

→ BCBS of Montana

→ BCBS of Nebraska

→ BCBS of New Mexico

→ BCBS of North Dakota

→ BCBS of Oklahoma

→ BCBS of Texas

→ FloridaBlue

→ Horizon BCBS of New Jersey

Participating Pharmacies administering vaccines, where allowed

by state law, shall abide by all applicable state and federal laws,

regulations and guidelines governing the sale and administration

of vaccines. Vaccine administration coverage is dependent upon

the Covered Person’s benefit plan.

Participating Pharmacies must submit the vaccine claim to

Prime electronically (online), which includes the applicable

ingredient cost, dispensing fee and vaccine administration fee

as a single claim.

Participating Pharmacies are required to submit the fields

defined below from the NCPDP D.0 Telecommunication Standard

for vaccine claims:

NCPDP Segment Name NCPDP Field #

NCPDP Field Name Value

Pricing Segment

438-E3 Incentive Amount Submitted

Pharmacy Submitted Incentive Fee

DUR/PPS Segment

473-7E DUR/PPS Code Counter

Value of 1

DUR/PPS Segment

440-E5 Professional Service Code

MA-Medication Administration

For software setup information, please visit Prime’s website at:

PrimeTherapeutics.com > Pharmacists > Payer Sheets.

Long-Term Care (LTC) and Home Infusion (HI) annual validation process

In order for Prime to maintain the integrity of our HI and LTC

networks, Prime requires each Participating Pharmacy or

Pharmacy Service Agreement Organization (PSAO) which

participates in Prime’s HI and LTC networks to validate on an

annual basis that they are able to continue to comply with

guidelines outlined for participation in the HI and/or LTC

pharmacy networks.

For your convenience, the required guidelines for participating

in the HI and LTC networks along with the validation form is

available at PrimeTherapeutics.com > Pharmacists.

Failure to validate may result in termination from the HI or LTC

networks.

Electronic prior authorization can save you time

Obtaining prior authorization (PA) for prescription medications

can be a time-consuming and frustrating process for Participating

Pharmacies and Prescribing Providers. The process has

traditionally required paper forms, faxes and follow-up phone

calls, having the potential to take time away from a Covered

Person’s care.

Electronic prior authorization (ePA) is an online method for

Prescribing Providers and Participating Pharmacies to submit

utilization management (UM) requests in a streamlined, structured

manner to Prime. PAs are a critical part of the medication delivery

process. PAs help to manage medicines that have a significant

potential for misuse, overuse or inappropriate use.

Prime has contracted with CoverMyMeds® to provide an ePA

solution that will allow Participating Pharmacies and Prescribing

Providers the ability to submit PA requests online. This online

solution allows Participating Pharmacies and Prescribing

Providers to submit and track PA results.

Pharmacy licensure

In order to ensure that all license documents are current,

Participating Pharmacies must provide Prime with copies of the

following documents on an annual basis:

→ Pharmacy License

→ DEA Certificate

→ Certificate of Insurance with proof of General and

Professional Liability Insurance



Please include your NCPDP number on each of the

documents when sending them to Prime. Submit the

documents via fax to 877.823.6373 or send through email to

pharmacyops@ primetherapeutics.com.

Provider Manual update

Prime is in the process of updating its Provider Manual.

The new Provider Manual will be effective March 1, 2016.

The updated Provider Manual will be posted in February at

PrimeTherapeutics. com > Pharmacist > Provider Manual.

MAC list updatesIf a Participating Pharmacy would like access to Prime’s MAC

list(s), weekly MAC changes, and the sources used to determine

MAC pricing, please refer to Prime’s website for registration

instructions. After network participation is verified, the

Participating Pharmacy will receive a secure user name and

password via email.

How to reach Prime TherapeuticsAs a service to Participating Pharmacies, Prime Therapeutics

(Prime) publishes Prime Perspective quarterly to provide

important information for claims processing. Prime values

your opinion and your participation in our network. If you have

comments or questions, you can reach us:

→ By phone: Prime Pharmacy Contact Center 800.821.4795

(24 hours a day, seven days a week)

→ By email: [email protected]

Looking for formularies?

For Commercial formularies access either the Blue Cross

Blue Shield plan website or PrimeTherapeutics.com > Pharmacists > Formulary Search.

For Medicare Part D formularies access PrimeTherapeutics.com >

Medicare Part D > Medicare Resources > 2015 Medicare Formularies.

Keep your pharmacy information current

Prime uses the National Council for Prescription Drug Programs

(NCPDP) database to obtain key pharmacy demographic

information. To update your pharmacy information go to

www.ncpdp.org > NCPDP Provider ID (on the left side).

Report 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 send the information to:

Prime Therapeutics LLC

Attn: Compliance Officer

P.O. Box 64812

St. Paul, MN 55164-0812

By email: [email protected]

If you would like an FWA Report to be anonymous, please

contact Prime’s 24-hour anonymous compliance hotline.

Contact the hotline:

By phone: 800.474.8651

By email: [email protected]

By third party vendor’s website:

www.lighthouse-services.com/prime

Product names listed are the property of their respective owners.

http://www.primetherapeutics.com/pharmacists.html

http://www.primetherapeutics.com/pharmacists.html

http://www.primetherapeutics.com/index.html

http://www.primetherapeutics.com/index.html

http://www.lighthouse-services.com/prime

Prime Therapeutics LLC P.O. Box 64812 St. Paul, MN 55164-0812

PRESORTED

STANDARD MAIL

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PRIME THERAPEUTICS LLC

→ Claims processing instructions

→ Utilization management updates from Blue Cross and Blue Shield plans

→ Prime audit requirements

→ Medicare Part D and Medicaid requirements

Time Sensitive Information from Prime Therapeutics

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