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

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

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:

Pharmacy Credentialing

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

Directory questionnaire

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

Minnesota Medicaid D.0 Pharmacy Payer Sheet

Capital Blue Cross Keystone - Capital Cares 4 Kids

Plan announcements

2021

ABCBS Medicare Processing

Alignment Health Plan Medicare HMO and DSNP

AL Streamline Part B

BCBSIL - Blue Medicare Advocate Health (HMO)

Braven Health Medicare Part D & B

Florida Blue

Horizon St. Joseph's

NC MA Only Part 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

Experience Health MAPD Part D

Highmark

BlueCross BlueShield of New Mexico – Medicare Advantage Dual Care

Capital Blue Cross CHIP

Capital Blue Cross Commercial

Regence BlueShield Align HMO NoRX

Regence BlueCross BlueShield of Oregon Align HMO NoRX

Regence BlueShield of Idaho SLHP Align NoRX

Vibra Health Plan Employer Group - Essential PPO

Network Reimbursement IDs

May NRIDs

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).

Home infusion/Long-term care processing

Long Term Care and Home Infusion General Dispensing Requirements

Long Term Care Short Cycle Dispensing Requirements

Medicaid processing requirements

BCBS of Illinois Blue Cross Community ICP and FHP 340B Processing Requirements

BCBSNM Blue Cross Community Processing Requirements for Naxolone Rescue Kit

Minnesota Medicaid Naloxone Processing Requirements

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

More resources

Check Inquiry Form
Network Request Form
Pharmacy Remittance Request

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)

Medicare Part B vs D

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.

Prime’s Code of Conduct