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
PSAO Affiliated Pharmacies:
Are you looking to join Prime’s Networks through your PSAO or change PSAO’s?
Please contact your PSAO and have them submit your pharmacy’s information to Prime directly.
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.
Please contact Prime via providerrelations@primetherapeutics.com to request a new Chain or PSAO 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
If you are currently participating provider and would like to join additional networks, please contact Prime via providerrelations@primetherapeutics.com.
If you are a Specialty pharmacy looking to join Prime’s Specialty Networks, then please contact Prime’s Specialty Credentialing team via specialtycredentialing@primetherapeutics.com
A.Pharmacy Identification
Ownership & Control Interests
Please provide the following information for each Managing Employee and Person with an Ownership or Control Interest in you as a Pharmacy, or in any Subcontractor in which you as a Pharmacy have direct or indirect ownership of 5% or more.
1. Managing Employee means an individual (including a general manager, business manager, administrator, or director) who exercises operational or managerial control over the Pharmacy, or part thereof, or who directly or indirectly conducts the day-to-day operations of the Pharmacy, or part thereof.
2. Person with an Ownership or Control Interest means a person or corporation that: A) has an ownership interest, directly or indirectly, totaling 5% or more in the Pharmacy; B) has a combination of direct and indirect ownership interests equal to 5% or more in the Pharmacy; C) owns an interest of 5% or more in any mortgage, deed of trust, note, or other obligation secured by the Provider, if that interest equals at least 5% of the value of the property or assets of the Provider; or D) is an officer or director of the Pharmacy (if organized as a corporation) or is a partner in the Pharmacy (if organized as a partnership).
Refer to descriptions of Ownership & Controlling interests above.
Please read these questions carefully and answer them accurately. Inaccurate attestations may result in immediate termination of pharmacy from all Prime networks.
Has the pharmacy, its principals, owners or its personnel (i.e. employees, temporary workers, agents, etc.): If yes, then attach PDF explanation.
A.Been denied access to a health plan's, Prime's or other pharmacy benefit management company's pharmacy network at any time in the previous five years?
B. Been removed or terminated by a health plan, preferred provider organization, third party payor, pharmacy benefit management company, PSAO, Prime or other similar organization?
C. Been subject to any government (i.e. federal, state or local) regulatory or disciplinary action?
D. Been charged with a criminal offense involving government or healthcare business?
E. Been convicted of a drug-related or pharmacy-related offense?
F. Been listed by a governmental agency as debarred from work with that agency, proposed for debarment from a government agency, or suspended from any government work, or otherwise precluded from participating in any government program?
G. Been debarred, suspended, proposed for debarment or suspension, or otherwise excluded, terminated for cause of default or declared ineligible for the award of contracts by or participation in any government program, department or agency (federal, state of local)?
H. Experienced a voluntary or involuntary revocation of a state or DEA license?
I. Been charged with, or convicted of, or had a civil judgment rendered against them for the commission of a fraud or criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state or local) contract or subcontract?
J.Been excluded from participation for a Federal program, including but not limited to Medicare, Medicaid, federal health care programs or federal behavioral health care programs pursuant to Title XI of the Social Security Act, 42 U.S.C. section 1320a-7 and other applicable federal statutes?
K.Does any pharmacy staff use illegal drugs? If yes, then attach PDF explanation.
Does your pharmacy compound any medications? (If Yes, complete the Compounding percentages below)
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 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 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.
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.
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 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.
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.
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.
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.
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.
1.Please provide the date of when the pharmacy started dispensing
2.Do you have a private patient counseling window/area?
3.Does the pharmacy offer 24-hour access to a pharmacist (i.e. on call, store open 24 hours)?
4.Does the pharmacy have a store front with the name posted?
5.Does the pharmacy maintain signature logs for all prescriptions?
6.Does the pharmacy maintain delivery logs for all delivered prescriptions?
7.Does the general public have access to walk into the pharmacy and get prescriptions filled while they wait?
8.Does the pharmacy have multiple language capabilities?If yes, please provide the languages(separated by commas):
9.Has your pharmacy's malpractice coverage been denied or canceled in the past 5 years?(if yes) then provide explanation
10.Does the pharmacy provide services to long term care facilities?If yes, then attach list in pdf
11.Is the pharmacy located on public transit routes
12.Is the pharmacy accessible to the handicapped
13.If the pharmacy is a limited retail pharmacy, please indicate who the population is:
1. Copies of all pharmacy licenses in all states
2. Copies of all pharmacist-in-charge licenses
3. Copies of all pharmacist licenses
4. Copy of the DEA certificate (Must include ALL schedules: 2,2N, 3, 3N, 4, 5)
5. Proof of General and Professional Liability, ($1 million individual; $3 million aggregate) insurance coverage.
6. Copies of all manufacturer licenses (Compounding) - if applicable
7. Copies of all wholesale distributor licenses (Compounding) - if applicable
8. Any additional information required to respond to questions in this exhibit
9. Proof of completion of current year's Fraud Waste and Abuse (FWA) Training
10. Additional documentation (if requested by Prime) relevant to pharmacy's inventory, practices, or procedures
Pharmacy hereby acknowledges that the information provided in this document, including any attachments, is, to the best of its knowledge, accurate and complete. Pharmacy agrees that these are continuing representations, warranties and covenants. Pharmacy agrees to notify Prime in writing within seven (7) business days if any of these representations, warranties or covenants becomes untrue. Pharmacy acknowledges and agrees that failure to provide such timely notice may result in termination of pharmacy’s Network Participation Agreement.
Upon receipt of this completed Exhibit A-IP and related documentation, Prime will review the submitted application through its re-credentialing process. After the review is completed, Prime will send the pharmacy notification of its decision.
By signing below, the party is validating that they have the authority to provide and submit the information on this Exhibit A-1P/A-Irc. The pharmacy and authorizer understand they are responsible for all information contained in this application.
Pharmacy
By: (Pharmacy Owner Signature Initials)
Print Name
Print Title
Date
NCPDP Number
NPI Number
Address
A. Definitions
MEDICATIONS
Compounding
Traditional Sterile: 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.
Traditional Non-Sterile: 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.
Non-Traditional - Sterile: 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
Non-Traditional Non-Sterile: 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.
Non-compound: Outpatient drug product, item or service which is not compounded.
PHARMACY TYPE (a single pharmacy may qualify as more than one pharmacy type)
Institution/Hospital Pharmacy: A licensed pharmacy located in an institution for health care providing inpatient treatment by specialized staff and equipment.
Home Infusion Pharmacy: 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.
Internet Pharmacy: Pharmacy sells prescription medication via website.
I/T/U: 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.
Long Term Care: A pharmacy owned by, under contract with, or delivering medications to a long-term
facility to provide prescription drugs to the facility’s residents.
Mail Order Pharmacy: 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.
Retail Pharmacy - General: 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.
Retail Pharmacy - Limited: 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.
Specialty Pharmacy: 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.
DELIVERY METHODS
By Delivery Services: 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.
By Dispensing Physicians: 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.
In Person: Dispensed prescriptions are picked up at the pharmacy by the patient or patient’s representative.
Prescription Drug Vending Machine: 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.
Please complete the questions below if pharmacy indicates 10% or more Non Sterile Compounding or ANY amount of Sterile Compounding
1. Is pharmacy accredited with Pharmacy Compounding Accreditation Board (PCAB)?(if pharmacy is in process, please indicate expected date of accreditation MM/DD/YYYY
2.Has pharmacy ever had a recalled sterile or non-sterile compound product due to compounding error?(if yes, please provide information)
3.Does pharmacy have a clean room?If yes, then: Date of last inspection(MM/DD/YYYY)
4.Does pharmacy have a laminar flow hoods? (If yes, then: Date of last inspection(MM/DDYYYY)
5.Please provide a description of the purpose, including medical and non-medical indications, of the products compounded by the pharmacy:
6. Is pharmacy licensed as a manufacturer in any state? If yes, attach a pdf document
7.Is pharmacy licensed as a wholesale distributer in any state?
8. Has pharmacy's compounded products ever been subject to a voluntary or involuntary product recall?
Dosage Forms - what types of dosage forms are compounded? (check all that apply)
Please supply policy expiration date, policy coverage amounts and attach a PDF of the current certificate of coverage. The certificate must state that Professional and General Liability is included (or provide separate certificates for each).
If State or Federal regulations allow your pharmacy to have non-standard coverage, and you have questions about how to complete the form below, please email PrimeCredentialing@primetherapeutics.com with any questions.
Please include the following attachments:
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
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
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.
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
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.
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.
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.
Indicate any changes within the next year or previous year.
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.
