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Prime Therapeutics is a pharmacy benefit manager
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Prime is a pharmacy benefit manager
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Please pick one of the following

Please pick one of the following

  • Providers wishing to apply for Express Scripts networks must go to www.ESIProvider.com and follow the steps below:

    - Select create “New Account” or log into your existing account

    - Once logged in, select Begin New Process

    - Under Begin New Process, select “Apply to be a network provider”

    - Complete the application and submit all required documentation

    - Wait for next steps and confirmation from Express Scripts’ Credentialing team

    If you have any questions, please email us at PrimeCredSupport@Express-Scripts.com.

    In order to complete the credentialing application, please have the following documentation ready to attach. Documents must be in PDF format to attach. After you have the documentation ready click the submit button below to access the application. The application needs to be completed once it has started, partial applications will not be saved.

    Pharmacy checklist

    - All documents must be in PDF format.

    - Copy of State Pharmacy License(s) and Pharmacy Licenses for all states that the pharmacy delivers or mails to

    - Copy of Pharmacist-in-Charge license and all Pharmacists licenses

    - Copy of DEA certificate (must have schedules 2, 2N, 3, 3N, 4, 5)

    - Copy of Certificate for General Liability and Professional Liability insurance ($1 million each occurrence and $3 million aggregate are required for both General and Professional) Certificate MUST clearly state General Liability and Professional Liability

    - List of all LTC facilities including city/state (if applicable)

    - All additional information required to respond to questions in this exhibit

  • In order to complete the re-credentialing application, please have the following documentation ready to attach. Documents must be in PDF format to attach. After you have the documentation ready click the submit button below to access the application. The application needs to be completed once it has started, partial applications will not be saved.

    Pharmacy checklist

    - All documents must be in PDF format.

    - Copy of State Pharmacy License(s) and Pharmacy Licenses for all states that the pharmacy delivers or mails to

    - Copy of Pharmacist-in-Charge license and all Pharmacists licenses

    - Copy of DEA certificate (must have schedules 2, 2N, 3, 3N, 4, 5)

    - Copy of Certificate for General Liability and Professional Liability insurance ($1 million each occurrence and $3 million aggregate are required for both General and Professional) Certificate MUST clearly state General Liability and Professional Liability

    - List of all LTC facilities including city/state (if applicable)

    - All additional information required to respond to questions in this exhibit

    In order to complete the re-credentialing application, please have the following documentation ready to attach. Documents must be in PDF format to attach. After you have the documentation ready click the submit button below to access the application. The application needs to be completed once it has started, partial applications will not be saved.
     

  • New Chain Entity or PSAO Entity Application?
  • In order to complete the Insurance Renewal update, please have the following documentation ready to attach. Copies must be in PDF format to attach. After you have the documentation ready, click on the button below to access the form.

    PHARMACY CHECKLIST

    - Copy of Certificate for General Liability and Professional Liability insurance ($1 million liability, $3 million aggregate are required for both General and Professional) Certificate MUST state General Liability and Professional Liability

    - New Insurance Expiration Date and Coverage Amounts

    - All documents must be in PDF format.

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Please enter the below details to proceed

Please enter the below details to proceed

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I.Pharmacy Information

A.Pharmacy Identification

Pharmacy

Pharmacy Ownership:
Pharmacy owned by a Company:
Pharmacy owned by Individual(s)
Pharmacy Staff:
B.  Pharmacy History (Additional information may be requested)

II.Pharmacy Attestations

Please read these questions carefully and answer them accurately.  Inaccurate attestations may result in immediate termination of pharmacy from all Prime networks.

Please read these questions carefully and answer them accurately.  Inaccurate attestations may result in immediate termination of pharmacy from all Prime networks.

Services and Customer Base

A.   Services and Customer Base: (Each of the three sections must total 100%)
      (Definitions for all the terms below are included in Attachment A)

Creation and dispensing of 1) drug products in dosage delivery forms and/or formulations that are commercially available; 2) sustained release medications; 3) compounding medications that have been withdrawn from the commercial market or have had warning letters issued by the FDA; or 4) products that are not medically necessary including but not limited to cosmetic products.  Non-traditional compounds frequently include bulk powder ingredients and requires a sterile environment as defined by USP Chapter 797, Pharmaceutical Compounding – Sterile Preparation standards

Creation and dispensing of 1) drug products in dosage delivery forms and/or formulations that are commercially available; 2) sustained release medications; 3) compounding medications that have been withdrawn from the commercial market or have had warning letters issued by the FDA; or 4) products that are not medically necessary including but not limited to cosmetic products.  Non-traditional compounds frequently include bulk powder ingredients and requires a sterile environment as defined by USP Chapter 797, Pharmaceutical Compounding – Sterile Preparation standardsCreation and dispensing of 1) drug products in dosage delivery forms and/or formulations that are commercially available; 2) sustained release medications; 3) compounding medications that have been withdrawn from the commercial market or have had warning letters issued by the FDA; or 4) products that are not medically necessary including but not limited to cosmetic products.  Non-traditional compounds frequently include bulk powder ingredients and requires a sterile environment as defined by USP Chapter 797, Pharmaceutical Compounding – Sterile Preparation standards

Creation and dispensing of 1) drug products in dosage delivery forms and/or formulations that are commercially available; 2) sustained release medications; 3) compounding medications that have been withdrawn from the commercial market or have had warning letters issued by the FDA; or 4) products that are not medically necessary including but not limited to cosmetic products.  Non-traditional compounds frequently include bulk powder ingredients and does not require a sterile environment as defined by USP Chapter 795, Pharmaceutical Compounding-Non-Sterile Preparation standards.

Creation and dispensing of 1) drug products in dosage delivery forms and/or formulations that are commercially available; 2) sustained release medications; 3) compounding medications that have been withdrawn from the commercial market or have had warning letters issued by the FDA; or 4) products that are not medically necessary including but not limited to cosmetic products.  Non-traditional compounds frequently include bulk powder ingredients and does not require a sterile environment as defined by USP Chapter 795, Pharmaceutical Compounding-Non-Sterile Preparation standards.

Creation and dispensing of FDA approved drug products in dosage delivery forms medically necessary to the patient and not commercially available and requires a sterile environment as defined by USP Chapter 797, Pharmaceutical Compounding – Sterile Preparation standards.

Creation and dispensing of FDA approved drug products in dosage delivery forms medically necessary to the patient and not commercially available and requires a sterile environment as defined by USP Chapter 797, Pharmaceutical Compounding – Sterile Preparation standards.

Creation and dispensing of FDA approved drug products in dosage delivery forms medically necessary to the patient and not commercially available and does not require a sterile environment as defined by USP Chapter 795, Pharmaceutical Compounding –Non-Sterile Preparation standards.

Creation and dispensing of FDA approved drug products in dosage delivery forms medically necessary to the patient and not commercially available and does not require a sterile environment as defined by USP Chapter 795, Pharmaceutical Compounding –Non-Sterile Preparation standards.

Outpatient drug product, item or service which is not compounded.

https://mklcqa001q.primetherapeutics.com:9443/content/primetherapeutics/en/resources/pharmacists/ac/a1p-form.html 

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A licensed pharmacy located in an institution for health care providing inpatient treatment by specialized staff and equipment.

A licensed pharmacy located in an institution for health care providing inpatient treatment by specialized staff and equipment.

A pharmacy that dispenses parenteral drugs or biologicals administered via an intravenous, intraspinal, intra-arterial, intrathecal, epidural, subcutaneous, or intramuscular access device inserted into the body, and includes a drug used for catheter maintenance and declotting, a drug contained in a device, vitamins, intravenous solutions, diluents and minerals, and other components used in the provision of home infusion therapy.

A pharmacy that dispenses parenteral drugs or biologicals administered via an intravenous, intraspinal, intra-arterial, intrathecal, epidural, subcutaneous, or intramuscular access device inserted into the body, and includes a drug used for catheter maintenance and declotting, a drug contained in a device, vitamins, intravenous solutions, diluents and minerals, and other components used in the provision of home infusion therapy.

Pharmacy sells prescription medication via website.

Pharmacy sells prescription medication via website.

A pharmacy operated by Indian Health Services as established by Sec. 601 of the Indian Health Care Improvement Act, 25 USC §1661, or an Indian Tribe, Tribal Organization, or an Urban Indian Organization as those terms are defined in Sec. 4 of the Indian Health Care Improvement Act, 25 USC §1603.

A pharmacy operated by Indian Health Services as established by Sec. 601 of the Indian Health Care Improvement Act, 25 USC §1661, or an Indian Tribe, Tribal Organization, or an Urban Indian Organization as those terms are defined in Sec. 4 of the Indian Health Care Improvement Act, 25 USC §1603.

A pharmacy owned by, under contract with, or delivering medications to a long-term facility to provide prescription drugs to the facility’s residents.

 

A pharmacy owned by, under contract with, or delivering medications to a long-term facility to provide prescription drugs to the facility’s residents.

 

A licensed, non-wholesale pharmacy that is not open to the public and delivers dispensed prescriptions directly to patients through the mail or other shipping carriers.

A licensed, non-wholesale pharmacy that is not open to the public and delivers dispensed prescriptions directly to patients through the mail or other shipping carriers.

Traditional pharmacy services provided by a licensed, non-wholesale pharmacy that maintains a reasonable stock of commonly dispensed medications in anticipation of walk-in customers, is open to the general public, and where patients can obtain medication while they wait.

Traditional pharmacy services provided by a licensed, non-wholesale pharmacy that maintains a reasonable stock of commonly dispensed medications in anticipation of walk-in customers, is open to the general public, and where patients can obtain medication while they wait.

Traditional pharmacy services provided by a licensed, non-wholesale pharmacy that maintains a reasonable stock of commonly dispensed medications in anticipation of walk-in customers, is only open to a limited population such as employees or patients of certain doctors, and where patients obtain medication while they wait.

Traditional pharmacy services provided by a licensed, non-wholesale pharmacy that maintains a reasonable stock of commonly dispensed medications in anticipation of walk-in customers, is only open to a limited population such as employees or patients of certain doctors, and where patients obtain medication while they wait.

A pharmacy that dispenses specialty medications which are generally prescribed for people with complex or ongoing medical conditions which typically have one or more of the following characteristics: high cost, injected or infused method of administration, unique storage or shipment requirements, additional education and support required from a health care professional, and /or they are not typically stocked at retail pharmacies.

A pharmacy that dispenses specialty medications which are generally prescribed for people with complex or ongoing medical conditions which typically have one or more of the following characteristics: high cost, injected or infused method of administration, unique storage or shipment requirements, additional education and support required from a health care professional, and /or they are not typically stocked at retail pharmacies.

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Dispensed prescriptions are picked up at the pharmacy by the patient or patient’s representative.

Dispensed prescriptions are picked up at the pharmacy by the patient or patient’s representative.

Pharmacy services that are mailed or delivered rather than picked up at a retail location.  This includes delivery directly to a patient or to a patients facility.

Pharmacy services that are mailed or delivered rather than picked up at a retail location.  This includes delivery directly to a patient or to a patients facility.Pharmacy services that are mailed or delivered rather than picked up at a retail location.  This includes delivery directly to a patient or to a patients facility.Pharmacy services that are mailed or delivered rather than picked up at a retail location.  This includes delivery directly to a patient or to a patients facility.

 A prescriber whose state license permits dispensing take-home medication from the physician’s office.  A state may permit this practice as a part of the general medical license and/or may require a separate dispensing license to be obtained.

 A prescriber whose state license permits dispensing take-home medication from the physician’s office.  A state may permit this practice as a part of the general medical license and/or may require a separate dispensing license to be obtained.

 A vending machine that requires prescribers to create prescriptions electronically which are then transmitted to the vending location and/or from which medications are dispensed for individual patient administration, and are typically placed in doctors’ offices, clinics, emergency rooms and other healthcare facilities.

 A vending machine that requires prescribers to create prescriptions electronically which are then transmitted to the vending location and/or from which medications are dispensed for individual patient administration, and are typically placed in doctors’ offices, clinics, emergency rooms and other healthcare facilities.

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Please choose the appropriate selections.

Licensing Information
Insurance Information
Is non-standard insurance coverage allowed due to State or Federal regulations? (Examples: Self-Insured coverage, Federal Tort, etc.)

General Liability:


Professional Liability:


III. Additional Documentation (PDF)

Attachment  A

Attachment  B

Dosage Forms - what types of dosage forms are compounded? (check all that apply)

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Pharmacy Insurance Coverage Update
Pharmacy Information

Insurance Information
Is non-standard insurance coverage allowed due to State of Federal regulations? (Examples: Self-Insured coverage, Federal Tort, etc.)

General Liability:


Professional Liability:


Additional Documentation(PDF)

Please include the following attachments:

  1. Proof of General and Professional Liability, ($1 million individual; $3 million aggregate) insurance coverage.

Please include the following attachments:

  1. Proof of General and Professional Liability, ($1 million individual; $3 million aggregate) insurance coverage.
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I. Enrolling Provider's Information

Complete this section with information about the provider entity. Specify the provider's name, (legal name reported to the IRS), the Federal Tax ID associated with the provider (FEIN or SSN), the National Provider Identifier (NPI), and the Doing Business As (DBA) name, if applicable.s

II. Individuals with Ownership Interest

Complete this section with information about individuals who have direct or indirect ownership interest of 5%* or more of the provider listed in Section I. For each owner, specify the name, date of birth, Social Security number, percentage of ownership, street address, and the start date of ownership interest with the provider

III. Managing Employees and other Controlling Interests

Complete this section with information about managing employees and/or controlling interests of the provider listed in Section I. Include the general manager, business manager, administrator, director, or other individual who exercises operational or managerial control over, or who directly or indirectly conducts the day-to-day operation of an institution, organization, or agency. Also list controlling interests including each member of the board of directors, agents with the authority to act on behalf of the provider listed in Section I, and officers or directors of a provider entity that is organized as a corporation.

IV. Organizations with Ownership or Management Interest

Complete this section with information about organizations that have direct or indirect ownership interest of 5%* or more of the provider listed in Section I. Also include organizations that have management interest in the provider listed in Section I. For each organization listed, specify the legal name (as reported to the IRS), Federal Tax ID (FEIN), check whether the organization has ownership or management interest in the provider listed in Section I, Doing Business As (DBA) name, if applicable, the first date the organization started with ownership interest (or management interest), the percentage of ownership (if applicable), and the primary business address.Attach additional pages as necessary

V. Subcontractor Information

Complete this section with information about each person who has an ownership or controlling interest in any subcontractor in which the provider listed in Section I has direct or indirect ownership of 5%* or more. List any individuals with ownership or controlling interest in the provider listed in Section I that also has an ownership or controlling interest of 5%* or more in any other entity. Attach additional pages as necessary.

VI. Criminal Offences

Complete this section with information about each individual who has ownership, controlling interest, is an agent, managing employee, officer, or member of the board of directors of the provider listed in Section I and has been convicted of a criminal offense related to that person's involvement in any program under Medicare, Medicaid, or Title XVIII, XIX, or XX, since the inception of those programs. Attach additional pages as necessary.

VII. Suspension or Debarment

Complete this section with information about each individual who is an officer, owner, agent, or managing employee of the provider listed in Section I who has been suspended or debarred from participation in Medicare, Medicaid, or the Title XVIII, XIX or XX services programs. These individuals would have been placed on the federal Office of the Inspector General, Health and Human Services (OIG/HHS) exclusions list. Attach additional pages as necessary.

VIII. Status Changes

Indicate any changes within the next year or previous year.

  • Yes
  • No
  • Yes
  • No
  • Yes
  • No
IX. Signature

By signing this form, I certify that the information provided on this form is complete, true, and accurate.I agree to notify Prime in writing immediately if any of these representations, warranties or covenants becomes untrue. I understand that misleading, inaccurate, or incomplete information or a failure to provide timely notice of a change in the information provided may result in a denial of participation or termination of an existing Pharmacy Participation Agreement.

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