Coronavirus information: General information | Pharmacy FAQs

You’re the link between our members and their medicine.
They count on you for the information they need
about their prescriptions.


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

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 – Commercial
NetResults A-Series Prescription Drug Guide
NetResults F-Series Prescription Drug Guide
PrimeChoice Accord Formulary Updates
July 2021 BCBSAL Prescription Drug Guide Updates
July 2021 BCBSAL Generics Plus Drug Guide Updates
July 2021 BCBSMN FlexRx Formulary Updates
July 2021 BCBSMN GenRx Formulary Updates
July 2021 BCBSND Formulary Updates
July 2021 BCBSNE Formulary Updates
July 2021 BCBSWY Preferred Drug List Updates
July 2021 IL Basic Annual Drug List Updates
July 2021 HCSC Basic Drug List Updates
July 2021 IL Enhanced Annual Drug List Updates
July 2021 TX Enhanced Annual Drug List Updates
July 2021 IL Multi Tier Enhanced Annual Drug List Updates
July 2021 TX Multi Tier Enhanced Annual Drug List Updates
July 2021 IL Multi Tier Basic Annual Drug List Updates
July 2021 TX Multi Tier Basic Annual Drug List Updates
July 2021 BCBSTX Basic Annual Drug List Updates
July 2021 HCSC Enhanced Drug List Updates
July 2021 HCSC Multi Tier Enhanced Drug List Updates
July 2021 HCSC Multi Tier Basic Drug List Updates
July 2021 Florida Blue Closed Formulary Medication Guide Updates
July 2021 Florida Blue Medication Guide Updates
July 2021 BCBSKS Formulary Updates
July 2021 BCBSNC 4 Tier Formulary Updates
July 2021 BCBSNC 5 Tier Formulary Updates
July 2021 Horizon BCBSNJ Formulary Updates
July 2021 U of M Formulary Updates
Formularies – Medicare Part D
October 2021 Medicare Part D Negative Formulary Change(s) Notification
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
Pharmacy credentialing
Use the link below to:
- 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
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
Payer sheet
North Dakota Medicaid D.0 Pharmacy Payer Sheet
BCBS of Illinois Blue Cross Community ICP and FHP (Medicaid) D.0 Payer Sheet
BCBSNM Medicaid Pharmacy Payer Sheet
BCBS of Texas Chip, STAR and Star Kids Programs (Medicaid) D.0 Payer Sheet
Commercial D.0 Pharmacy Payer Sheet
Commercial D.o Payer Sheet OPPRA
Medicare Part B D.0 Pharmacy Payer Sheet
Medicare Part D D.0 Pharmacy Payer Sheet
Medicare Part D Supplemental D.0 Pharmacy Payer Sheet
Plan announcements
2021
Alignment Health Plan Medicare HMO and DSNP
BCBSIL - Blue Medicare Advocate Health (HMO)
Braven Health Medicare Part D & B
2020
Alignment Health Plan Medicare
BlueCross BlueShield of Kansas Preferred Blue Medicare Advantage
Blue Cross & Blue Shield of Nebraska Medicare Part D
Blue Cross & Blue Shield of Rhode Island – Healthmate for Medicare
BlueCross BlueShield of Texas Medicare Advantage
Capital Blue Cross Medicare Part D, B and PDP
BlueCross BlueShield of New Mexico – Medicare Advantage Dual Care
Regence BlueShield Align HMO NoRX
Regence BlueCross BlueShield of Oregon Align HMO NoRX
Network Reimbursement IDs
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.
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.
More resources
Medicare Prescription Drug Coverage and Your Rights Standardized Phcy Notice Instructions
Medicare Prescription Drug Coverage and Your Rights form
Medicare Prescription Drug Coverage and Your Rights form (Spanish)
Minimum Performance and Service Criteria for Medicare Part D
Minimum Performance and Service Criteria for LTC
High Risk Medications for the Elderly
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.
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)