1. health and fitness
2. drugs

DRAFT
Prime Therapeutics
Provider Manual
Effective September 1, 2013
© 2013 by Prime Therapeutics LLC. All rights reserved.
No part of this book may be reproduced in any form or by any
means without the prior written permission of Prime Therapeutics.
Prime Therapeutics LLC
Table of Contents
Introduction to Prime Therapeutics LLC . . . 3
Provider Manual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Section 1: Prime Contact Information . . . . . 4
Requirements for Participating Pharmacies
Contracted with 340B Covered Entities . . . . . . . . . 11
Compound Drugs Billing Guidelines . . . . . . . . . . . . . . . 11
General Insulin Benefits . . . . . . . . . . . . . . . . . . . . . . . . . 12
Prime Mailing Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Insulin Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Prime Contact Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Prime’s Website . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Long-Term Care (LTC) and Home Infusion
Therapy (HIT) Processing Guides . . . . . . . . . . . . . . 13
Compliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Medicare Programs Coordination of Benefits (COB) . 13
Fraud, Waste and Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Time Limits for Coordination of Benefits . . . . . . . . . . . 13
Section 2: Claims Processing . . . . . . . . . . . . . . . 8
General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Online Claims Submission . . . . . . . . . . . . . . . . . . . . . . . . 8
Online Availability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Claim Formats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Medicare Reference Materials . . . . . . . . . . . . . . . . . . . . . 8
Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Member ID Card . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Covered Person Eligibility . . . . . . . . . . . . . . . . . . . . . . . . 8
Medicare Parts A & B vs. D Claims Adjudication . . . . 13
Utilization Management Program . . . . . . . . . . . . . . . . . . . . 14
Drug Formularies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Medicare Drug Formularies . . . . . . . . . . . . . . . . . . . . . . 14
Prior Authorization (PA) . . . . . . . . . . . . . . . . . . . . . . . . . 14
Step Therapy/Contingent Therapy Programs . . . . . . . 15
Quantity Limit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Drug Utilization Review (DUR) . . . . . . . . . . . . . . . . . . . . 16
Maximum Allowable Cost (MAC) . . . . . . . . . . . . . . . . . . 16
Post Claim Adjudication . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Schedule II Prescription Dispensing
Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Return to Stock – Unclaimed Prescriptions . . . . . . . . . 16
Same Gender Multiples . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Section 3: Benefit Plan . . . . . . . . . . . . . . . . . . . . . . . 17
Medicare E1 Eligibility Query . . . . . . . . . . . . . . . . . . . . . . 9
Product Selection Code (PSC) . . . . . . . . . . . . . . . . . . . . . . . 17
Best Available Evidence (BAE) . . . . . . . . . . . . . . . . . . . . . 9
Generic Substitution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Submitting the Claim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Generic Drug Standards . . . . . . . . . . . . . . . . . . . . . . . . . 17
Bank Identification Number (BIN) and
Processor Control Number (PCN) . . . . . . . . . . . . . . . 9
Enhanced Pharmacy Programs . . . . . . . . . . . . . . . . . . . . . . 17
National Provider Identifier (NPI) . . . . . . . . . . . . . . . . . 10
Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Days Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Vaccine Administration . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Medication Therapy Management (MTM) . . . . . . . . . . 18
Medicare Part D Transition Process . . . . . . . . . . . . . . . . . . 18
Accurate Quantity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Medicare General Dispensing Long-Term Care
Guidelines and Procedures . . . . . . . . . . . . . . . . . . . 20
Dispensed Package Size/
National Drug Code (NDC) . . . . . . . . . . . . . . . . . . . . 10
Medicare Short Cycle Dispensing Long-Term Care
Guidelines and Procedures . . . . . . . . . . . . . . . . . . . 20
Timely Filing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Medicare ePrescribing and Prescription
Origin Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Provider Manual
(Continued)
1
Table of Contents (Continued)
Section 4: Responsibility of
Participating Pharmacy . . . . . . . . . . . . . . . . . . . 21
Section 5: Participating Pharmacy Audit . . . 23
Update Information with NCPDP . . . . . . . . . . . . . . . . . . . . . 21
Reason for Audits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Participating Pharmacy’s Affiliation with PSAO . . . . . . . . 21
Audit Notification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Third Party Payment Reconciliation Vendors . . . . . . . . . . 21
Access to Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Responsibilities of the Participating Pharmacy for
Medicare Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Audit Expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Additional Participating Pharmacy Information . . . . . . . 22
Pharmacy Credentialing . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Termination Appeals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Audit Time Frame . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Reporting Audit Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Types of Audit Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Pre-payment Daily Claims Review . . . . . . . . . . . . . . . . . 24
Desktop Audits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
On-site Audits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Drug and Supply Requirements . . . . . . . . . . . . . . . . . . . . . . 26
Prescription Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Prescription Label Requirements . . . . . . . . . . . . . . . . . . . . 28
Review of Claim Submission . . . . . . . . . . . . . . . . . . . . . . . . 28
Distributor and Manufacturer Invoices and
Pharmacy Dispensing Records . . . . . . . . . . . . . . . . . . . 30
Common Billing Errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Unacceptable Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Audit Appeal Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Corrective Action Plan (CAP) . . . . . . . . . . . . . . . . . . . . . . . . 31
Confidentiality and Proprietary Rights . . . . . . . . . . . . . . . . 32
Confidentiality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Proprietary Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
2
Prime Therapeutics LLC
Introduction to Prime Therapeutics LLC
Prime Therapeutics LLC (Prime) is a pharmacy
benefit management (PBM) company that provides
comprehensive pharmacy management solutions to
Prime’s clients. Some of Prime’s services include:
• Pharmacy networks
• Formulary management
Provider Manual
The purpose of this Provider Manual (“Manual”) is to
explain Prime’s administrative and compliance policies
and procedures. The Manual is incorporated into the
Prime Therapeutics Pharmacy Participation Agreement
(“Agreement”). This Manual will be updated as necessary
• Pharmacy communication
at Prime’s sole discretion. Prime posts the most
• Drug utilization review (DUR)
current version of the Provider Manual on its website at
• Clinical programs
• Physician education
• Claims processing
Prime encourages the use of safe and cost-effective
therapies for clients’ members while maintaining a valued
relationship with pharmacies participating in Prime’s
network. Prime promotes the use of local programs to
PrimeTherapeutics.com.
Additionally, relevant instructions, notices, information
and supplements or changes to the Manual are posted
on the Prime website. Consult PrimeTherapeutics.com
for up-to-date information and processing instructions.
All capitalized terms that are otherwise not defined in this
Manual refer to those defined in the Agreement.
meet the needs of Covered Persons and Benefit Sponsors
Important:
and encourages the important connection a pharmacist
This Manual applies to Commercial, Medicare and
maintains with his or her patients.
Medicaid business.
Prime manages pharmacy networks to provide
Prescription Drug Services for its clients through Prime’s
online claims processing system. The claims processing
system gives Participating Pharmacies real-time access
to patient eligibility, drug coverage information, drugs
requiring prior authorization and DUR information.
Prime is committed to doing business with integrity and
in accordance with all applicable federal, state and local
laws. Prime has adopted a compliance program and
code of conduct which includes policies and procedures
to avoid potential conflicts of interest and fraud, waste
and abuse. Prime strongly encourages all Participating
Pharmacies to adopt appropriate compliance programs;
codes of conduct; fraud, waste and abuse programs;
and conflict of interest policies and procedures.
Provider Manual
3
Section 1: Prime Contact Information
Prime Mailing Address
Prime’s Website
If you would like additional information, contact Prime at:
Visit Prime’s website (PrimeTherapeutics.com)
Prime Therapeutics LLC
for the following information:
P.O. Box 64812
• Payer Specification Sheets
St. Paul, MN 55164-0812
• Medicare Plan-Specific Reference Guides
Prime Contact Center
• Medicare Coverage and Rights
• Formulary Information/Formulary Updates
800.821.4795
• Pharmacy Remittance Request
The Prime Contact Center has dedicated staff to
• Prime Perspective Newsletters
assist pharmacies with contract requests, processing
• Fraud, Waste and Abuse Training, Requirements
questions, and to address any comments and concerns.
Prime’s representatives are available 24 hours a day,
365 days a year.
and Certification Materials
• FWA Referral Form
• Plan Announcements
• Network Request Form General Information
and Services
• 835 Electronic Remittance Request Form
• Common Billing Errors
• Minimum Performance and Service Criteria
for Medicare Programs
• Minimum Performance and Service Criteria
for Medicare Programs LTC
• Medicare Part B vs. Part D Coverage Issues
• Pharmacy Audit Appeal Form
• Pharmacy Audit Guidelines
• Prescriber Attestation Form
(For Commercial Claims Only)
• Prime Audit Advisor Fax Series
4
Prime Therapeutics LLC
Section 1: Prime Contact Information (Continued)
Compliance
Fraud, Waste and Abuse
Network Pharmacies must develop policies and
Both Participating Pharmacies and Prime have an
procedures in compliance with all applicable rules
obligation to help protect and maintain the integrity
and regulations, including but not limited to, Medicare
of the health care system by promptly reporting
Programs. All Network pharmacies should have someone
suspicious activity.
who is responsible for establishing a plan to meet
Medicare Programs requirements and appropriate
documentation of that plan. The Network Pharmacies
should communicate the plan and any means of enforcing
the plan to all employees.
If the Participating Pharmacies suspect fraud, waste or
abuse (FWA), whether by a Covered Person, Prescriber,
another Participating Pharmacy, or anyone else, notify
Prime by calling Prime’s FWA Hotline at 800.731.3269,
emailing [email protected], calling
If you feel that your pharmacy does not have an effective
Prime’s 24‑hour Anonymous Compliance Hotline at
compliance program in place, please refer to the CMS
800.‌474.‌8651, calling the Compliance Question Line at
website for a complete list of guidelines at CMS.gov.
612.777.5523 or mail at:
Please contact Prime’s Compliance Department with
Prime Therapeutics LLC
any concerns. Examples are as follows:
• Violation of a state, federal, local law, regulation or
any governmental guidance
• Conflict of Interest
• Acceptance and/or offers of gifts or entertainment
• Fraud, Waste or Abuse
• Improper disclosure of Prime’s confidential or
proprietary information
Attn: Chief Compliance Officer
P.O. Box 64812
St. Paul, MN 55164-0812
Participating Pharmacies are expected to exercise due
diligence to ensure prescriptions are valid. For example,
upon receipt of a prescription order that appears
potentially altered or forged, contact the Prescriber to
validate the prescription. Remain mindful of and promptly
report potential fraud, waste or abuse.
• Retaliation for reporting a compliance issue
Examples of fraud, waste or abuse include:
• Falsification of reports, records or files
• Misrepresentation of status – A Covered Person or
• Theft
other individual misrepresents personal information,
Ways to contact Prime’s Compliance Department:
order to illegally receive a drug benefit; or an individual
• 24-hour Anonymous Compliance Hotline
(800.474.8651)
• Compliance Question Line (612.777.5523)
• Privacy Hotline (888.849.7840)
• Fraud, Waste and Abuse Hotline (800.731.3269)
• Compliance email address at
[email protected]
• Privacy email address at
[email protected]
• Fraud, Waste and Abuse email address at
[email protected]
Provider Manual
such as identity, eligibility, or medical condition in
who no longer has prescription drug coverage attempts
to use his/her identity card to obtain prescriptions.
• Identity theft – An individual uses another person’s
Medicare or health insurance card to obtain
prescriptions.
• Illegal resale of drugs – A Covered Person falsely
reports loss or theft of drugs or feigns illness to obtain
drugs for illegal resale.
• Prescriber shopping – A Covered Person consults
a number of Prescribers for the purpose of
inappropriately obtaining multiple prescriptions
for narcotic painkillers or other drugs.
5
Section 1: Prime Contact Information (Continued)
• Script mills – A Prescriber writes prescriptions for
• Prescription drug shorting – A pharmacy provides
drugs that are not medically necessary, often in mass
less than the prescribed quantity and intentionally
quantities, and often for Covered Persons that are not
does not inform the Covered Person or make
the Prescriber’s. These scripts are usually written, but
arrangements to provide the balance but bills for
not always, for controlled drugs for illegal sale, and
the fully‑prescribed amount.
might include improper payments to the Prescriber.
• Theft of Prescriber’s DEA number or
• Bait and switch pricing – A pharmacy leads a
Covered Person to believe that a drug will cost one
prescription pad – Prescription pads and/or DEA
price, but at the point-of-sale, the Covered Person
numbers stolen from Prescribers which are used to
is charged a higher amount.
write prescriptions, often for controlled substances
or other medications which typically are either abused
or sold on the black market.
• Inappropriate billing practices – Inappropriate billing
practices occur when pharmacies engage in billing
practices which include, but are not limited to:
›› Incorrect billing for secondary payers to receive
increased reimbursement;
›› Billing for non-existent prescriptions;
›› Billing multiple payers for the same prescriptions,
except as required for coordination of benefits
transactions;
›› Billing for brand drugs when generic drugs are
dispensed;
›› Billing for non-covered prescriptions as covered items;
›› Billing for prescriptions that are never picked up
(i.e., not reversing claims that are processed when
prescriptions are filled but never picked up);
›› Billing based on “gang visits,” e.g., a pharmacist
visits a Long-Term Care Facility and bills for numerous
pharmaceutical prescriptions without furnishing
prescriptions to the Covered Person;
›› Inappropriate use of product select codes (PSC);
›› Billing an NDC not used to dispense the prescription;
›› Billing an NDC or drug that was never ordered;
›› Billing an incorrect dosage form. (i.e., billing for tablet
when powder is used to dispense the prescription);
• Prescription forging or altering – Existing
prescriptions are altered by a Covered Person without
the Prescriber’s permission to increase the quantity
or number of refills.
• Dispensing expired or adulterated prescription
drugs – Pharmacies dispense drugs that are expired
or have not been stored or handled according to the
manufacturer or FDA requirements.
• Prescription refill errors – A pharmacy provides a
higher number of refills than what was prescribed
by the Prescriber.
• Illegal remuneration schemes (kickbacks) –
A pharmacy is offered, solicits, or receives unlawful
remuneration which results in inducement or reward
for switching Covered Persons to different drugs,
influencing Prescribers to prescribe different drugs,
or steering Covered Persons to plans.
• TrOOP manipulation – Manipulation of true out-ofpocket (TrOOP) costs by the pharmacy to either push
a Covered Person through the coverage gap so that
the Covered Person can reach catastrophic coverage
before they are eligible, or to keep a Covered Person
in the coverage gap so that catastrophic coverage is
never realized.
• Failure to offer negotiated prices – A pharmacy’s
failure to offer a Covered Person the negotiated price
of a drug available to the member through his or her
benefit plan.
›› Prescription splitting to receive additional dispensing
fees; or
›› Drug diversion.
6
Prime Therapeutics LLC
Section 1: Prime Contact Information (Continued)
Pharmacies participating in Prime’s Medicare Networks
must attest on an annual basis to the completion of
Fraud, Waste and Abuse training required by the Centers
for Medicare and Medicaid Services (CMS). For your
convenience, training and the Certification of Compliance
form are available on Prime’s website. Failure to attest to
the annual FWA training may result in termination from
Prime’s Medicare networks.
Provider Manual
7
Section 2: Claims Processing
General Information
Online Claims Submission
• The Participating Pharmacy is required to electronically
submit all claims to Prime for all Prescription Drug
• Supplemental to Medicare Part D Payer
Specification Sheet
• Medicare Prescription Drug Coverage and Your Rights
• Medicare Processing Guide
Services provided to a Covered Person including
• CMS Mandated Fraud, Waste and Abuse Training
situations where no payment from Prime is due.
• Prime Perspective
Online Availability
The online system is generally available for claims
• Prime Audit Advisor
processing 24 hours a day, 365 days a year.
Eligibility
Claim Formats
Member ID Card
• Point-of-sale (POS) claims must be submitted in
The Participating Pharmacy shall require a Covered Person
the current NCPDP format or current industry-
to produce a member identification (ID) card prior to
utilized version.
providing a Prescription Drug Service. The member ID
• Batch claims must be submitted in the NCPDP Batch
format or current industry-utilized version.
• The Universal Claim Form (UCF) must be submitted for
paper claim submissions. UCFs are available on the
NCPDP website at NCPDPOnline.org.
For a complete list of required and/or situational
processing requirements, refer to Prime’s Payer
Specification Sheets located on Prime’s website.
card does not ensure a Covered Person’s eligibility. If a
Covered Person does not have a member ID card and
the Participating Pharmacy is unsure of eligibility, the
Participating Pharmacy must contact Prime’s Contact
Center to obtain accurate member information prior to
dispensing a product or processing a claim.
Covered Person Eligibility
A Covered Person’s eligibility can be verified through the
POS system during claim adjudication or by contacting
The Participating Pharmacy must review all POS
the Prime Contact Center. Unless expressly allowed in
messaging for processing information and Benefit Payer
this Manual, a Covered Person whose eligibility has been
Specification Sheets for software set up.
verified should never:
In order for Prime to assist Participating Pharmacies
1. B
e denied a Prescription Drug Service (subject to a
with claims adjudication, email your unique
processing codes CONDOR CODES/INPUT CODES
to [email protected].
pharmacist’s professional judgment).
2. B
e asked to pay more than is due under the terms
of the Agreement.
Medicare Reference Materials
3. B
e asked to pay cash and submit a paper claim.
The following documents are available on Prime’s website:
Schedule II Prescription Dispensing Considerations
• MA-PD Contact Reference Guide
Schedule II prescription drugs may not be refilled, unless
• PDP Contact Reference Guide
patients are residing in a long-term care facility or are
• Employer Groups Contact Reference Guide
• Medicare Part D Payer Specification Sheet
8
terminally ill. In both cases where a Schedule II drug can
be refilled, the total quantity dispensed cannot exceed
the total quantity prescribed.
Prime Therapeutics LLC
Section 2: Claims Processing (Continued)
Schedule II prescriptions for patients residing in a long-
For Covered Persons with supporting BAE documentation:
term care facility or terminally ill patients may be partial
• The Participating Pharmacy must call Prime’s Contact
filled, not to exceed the quantity prescribed and must be
dispensed within 60 days from the issue date.
Except in emergency situations or when dispensed
directly by a prescriber, Schedule II drugs may not be
dispensed without a prescriber’s written prescription.
Center to request an immediate LIS status update in
the claims system.
• The Participating Pharmacy may submit the claim once
the claim system is updated with LIS status.
• The Participating Pharmacy must fax a copy of the
Same Gender Multiples
Covered Person’s supporting BAE documentation to
When processing claims for multiples of the same gender
the Prime Contact Center at 888.285.2242.
with the same birth date and same medication, use the
• Prime will forward the BAE documentation to the Part D
following procedure:
Sponsor, who will then work with CMS to update the
1. P
rocess the first claim as usual.
Covered Person’s LIS status in CMS’ system.
2. A
ttempt to process the second claim as usual.
For Covered Persons without supporting BAE
3. I f the second claim rejects, contact the Prime Contact
documentation:
Center to verify the multiple-birth eligibility flag has
been set.
Medicare E1 Eligibility Query
The E1 Eligibility Query is a real-time transaction
submitted by the Pharmacy to the RelayHealth Medicare
Part D Transaction Facilitator, to help determine a
Covered Person’s Part D coverage and payer order if they
have multiple insurance coverage. Pharmacies generally
submit E1 Queries when a Covered Person does not have
their Part D ID card.
Additional information on E1 Transactions can be found at
http://medifacd.relayhealth.com/e1
• The Participating Pharmacy should determine if the
Covered Person has less than three days of medication
remaining (an “immediate need”).
• The Participating Pharmacy should contact Prime’s
Contact Center to begin the process of updating the
Covered Person’s LIS status; the request must indicate
an immediate or non-immediate need.
• Prime will contact the Part D Sponsor, who will
complete the BAE Assistance Worksheet and submit
to CMS to validate and/or update the Covered Person’s
LIS status in CMS’ system.
• CMS will update the Covered Person’s LIS status within
one business day for immediate needs.
Best Available Evidence (BAE)
Covered Persons who are eligible for Low Income
Subsidy (LIS) under the Medicare Part D prescription
drug program are enrolled in the claim system with the
Submitting the Claim
Bank Identification Number (BIN) and
appropriate LIS copay level. In the event the claims
Processor Control Number (PCN)
system does not show the correct LIS status for the
A bank identification number (BIN) is required when
Covered Person, the Participating Pharmacy is required
adjudicating claims through the point-of-sale (POS)
by Medicare to accept BAE when presented at the point
system. A list of the BINs and PCNs used to adjudicate
of sale. Medicare also requires Participating Pharmacies
claims through Prime’s POS system is listed on
to assist Covered Persons who believe they are eligible
Prime’s website.
for LIS, but do not have BAE documentation.
Provider Manual
9
Section 2: Claims Processing (Continued)
National Provider Identifier (NPI)
• Pharmacy NPI – All online claims must be submitted
with the Pharmacy NPI. Online claims submitted with
the Pharmacy NCPDP number will reject.
• Prescriber Identifiers – Prime will accept the
Prescriber’s DEA, State Licenses or Individual NPI
(preferred). Pharmacy must have processes in place
to ensure they are submitting the correct Prescriber
Identifier at POS. Claims submitted without a valid
DEA, State License or Individual NPI number will
reject at POS (some rejected claims may allow for a
Submission Clarification Code [SCC] Override Code).
Claims will be monitored on a daily basis to ensure they
are submitted with the correct Prescriber Identifier.
Prime will contact the Pharmacy to correct any claims
identified as submitted with an invalid Prescriber
Identifier to update their system for future claims.
Failure to resubmit the claim or update your system for
future claims with the correct identifier may result in
audit recoveries or termination from Prime’s networks.
Documentation
Verbal changes and clarifications to the Prescriber’s
prescription order must be documented on the original
hard copy or electronically noted in the pharmacy’s online
system prior to dispensing. Electronic documentation
must be noted prior to dispensing and have a system
assigned user, date and time stamp in order to take the
place of hard copy documentation. When additional refills
are ordered, a new prescription number must also be
assigned and appropriately documented on a hard copy.
Days Supply
The Participating Pharmacy must submit the number
of consecutive days supply the prescription product
will last that falls within the Covered Person’s benefit.
Future refills may be rejected, if the days supply is
inaccurately submitted.
For prescription products that cannot be broken
(e.g., inhalers), where the smallest unit available exceeds
the benefit days supply, the Participating Pharmacy
must submit the maximum days supply allowed under
the benefit.
10
Example: Covered Person’s benefit allows a 34-day
supply. One inhaler will last 40 days. The Participating
Pharmacy must bill the inhaler as a 34-day supply.
In situations where one unit does not maximize the
benefit’s days supply (e.g., inhalers) the Participating
Pharmacy must submit only the quantity that falls within
the benefit.
Example: Covered Person’s benefit allows a 34-day supply.
One inhaler will last 28 days. The Covered Person receives
one inhaler as a 28-day supply. Varies by Benefit Plan.
Accurate Quantity
The quantity dispensed must be entered exactly as
written. Submit quantities as metric quantity (including
decimal points). The Participating Pharmacy must enter
the exact metric decimal quantity on claims, without
rounding up or down.
Dispensed Package Size/National Drug Code (NDC)
When the Participating Pharmacy submits a claim for
a Prescription Drug Service provided, the Participating
Pharmacy must submit the NDC number for the original
package size from which the Prescription Drug Service
was dispensed. The quantity of the prescription drug
dispensed shall comply with the dispensing limitations
obtained through the online point-of-sale (POS) system.
Prescriptions may not be separated and dispensed by
doses. If separate packaging is required, the Participating
Pharmacy must use a duplicate label. For example, a
dose required in school or adult care center should not
be dispensed as a separate prescription.
Timely Filing
The Participating Pharmacy agrees to submit all claims
online within 90 days of the date of service.
Medicare ePrescribing and Prescription Origin Code
In the event the Participating Pharmacy participates in
the Medicare electronic prescribing (“ePrescribing”)
program by receiving or transmitting electronic
prescriptions or prescription-related information, the
Participating Pharmacy agrees to comply with applicable
ePrescribing standards as established by CMS.
Prime Therapeutics LLC
Section 2: Claims Processing (Continued)
Regardless of whether a Participating Pharmacy is
participating in ePrescribing all claims submissions must
indicate the Prescription Origin Code, in order to facilitate
CMS reporting and tracking of ePrescribe participation.
Requirements for Participating Pharmacies Contracted
with 340B Covered Entities
Under the 340B Drug Pricing Program established
by Section 340B of the Public Health Services Act,
pharmaceutical manufacturers agree to charge at
or below statutorily defined prices known as the
340B ceiling prices when selling to certain qualified
entities. State Medicaid and Medicaid Managed Care
• Submit the Total Ingredient Cost. For Total Ingredient
Cost, multiply (the quantity used for the individual
ingredient) and (the AWP for the individual ingredient
according to the Pricing Source at the time of
dispensing) for each eligible ingredient used. Then,
add all of the individual ingredient costs to submit
as the Total Ingredient Cost.
›› Plan-excluded drugs and invalid NDCs are not eligible
for reimbursement.
›› Eligible ingredient costs do not include costs for
labor, equipment, professional fees or flavoring.
• Maintain compound log documentation to document
Organization programs (collectively, Medicaid Programs)
quantities and NDCs of the ingredients used to prepare
cannot invoice a manufacturer for 340B drugs under
the compound. NDCs submitted for the compound
the drug rebate program. Section 2501(c) of the Patient
must be the exact formulation of what is dispensed
Protection and Affordable Care Act extended rebates
in the compound.
under the drug rebate program to drugs dispensed to
individuals enrolled with a Medicaid Managed Care
Organization.
To view the specific claim processing requirements for
• Prime will accept a multiple ingredient compound
submission utilizing NCPDP’s Compound Segment
for up to 25 ingredients.
• Dynamic prior authorizations for processing
Prime’s Medicaid programs, please go to Pharmacists/
compounds which contain situational Medicare
Medicaid Programs.
Part B versus Medicare Part D drugs will not apply,
Compound Drugs Billing Guidelines
Participating Pharmacies must submit compound drugs
through the Prime point-of-sale (POS) system using the
following directions:
• Flag the compound as a compound drug in the
pharmacy’s system prior to adjudication.
• Submit a zero (0) in the NDC portion of the claim using
the Compound segment.
• Enter the qualifier, NDC, quantity, cost and cost basis
for each ingredient in the compound.
even if the compound meets the criteria for inclusion
as a Medicare Part D covered drug. A one-time prior
authorization will be issued if the claim meets the
criteria for coverage under Medicare Part D.
• Prime will support submission clarification codes
for most of Prime’s business. The Participating
Pharmacy must submit the submission clarification
code of “08” for all compounds to allow payment of
all covered ingredients.
• Compounds containing a Medicare Part B ingredient
must be processed under Medicare Part B.
• Submit the Final Product Quantity. The Final Product
Quantity is the quantity of the finished compound
product.
›› For a liquid, submit the number of mL of the finished
compound product. For capsules, submit the total
number of capsules being dispensed. For bulk
powders, submit the total number of grams being
dispensed.
Provider Manual
11
Section 2: Claims Processing (Continued)
Participating Pharmacies are expected to observe
Prime does not consider the following a compound
applicable state and federal laws, relevant
drug and these drugs cannot be submitted to Prime as
U.S. Pharmacopoeia (USP) Chapter Guidelines,
a compound drug:
professional standards and FDA communications when
• Reconstituted non sterile products, in which only
preparing and dispensing compound drugs. Evidence of
water, alcohol or sodium chloride solution are added to
unprofessional or unsafe compounding found during the
the active ingredient (for example, children’s antibiotic
pharmacy audit process or otherwise, may be reported
suspensions).
to the applicable State Board of Pharmacy, the FDA,
and/or may result in termination of your Pharmacy
Participation Agreement.
Prime administers pharmacy benefits on behalf of many
different plan sponsors. Each individual plan sponsor
determines benefit plan design, such as the specific
drugs/ingredients covered, cost-sharing and day supply
limitations, among other benefit design attributes.
The following are examples of compound drugs where
benefit designs may vary:
• Modified-release compounds (based on member
benefit design).
• Any compound that contains active ingredients not
approved by the FDA.
• A compound for which the stability is unknown at
the time of dispensing or cannot be determined by
reference of an USP-approved reference material.
• For Medicare business, compound components,
methods of administration, or other criteria that do
not satisfy the definition of a Medicare drug.
• Experimental/investigational items, products
or services.
• Any finished product intended to address medical
diagnosis (such as sugar-free products) where the
Covered Person’s medical diagnosis does not support
the need for the finished product.
• Any compound that differs from the equivalent
commercial form only by the addition of cosmetic
agents or agents intended to produce a cosmetic effect.
• Any prescription that is sub-divided into unit dose(s).
• Injectable drugs that are drawn into syringes for
administration.
• Any finished product that does not include a
Federal Legend Drug as an ingredient.
• Any compound that has an equivalent commercial
form except in some limited situations in which the
compound is preferred according to the benefit plan.
This exception may vary by state.
Prime considers the following additional unacceptable
billing practices for compound drugs:
• Billing for a different NDC than what was used in
the compound.
• Billing for the full package size when only a partial
amount was dispensed to the patient.
• Billing for a different dosage form than what was used
in the compound.
• Billing for a quantity larger than what was actually used
to prepare the compound.
• Any compound to which active ingredients are added
that were not part of the prescription order.
If you have questions regarding compound drugs, please
contact Prime’s Contact Center at 800.821.4795.
General Insulin Benefits
• A valid prescription must be on file for insulin
dispensed to a Covered Person.
• Insulin should be dispensed within the days supply
limits set by the Covered Person’s Benefit Sponsor.
• Specific dosing directions must be documented at
the time of dispensing. If a sliding scale is used, the
Participating Pharmacy must document maximum
and minimum quantities at the time of dispensing.
Directions limited to “Use as Directed” are not accepted.
12
Prime Therapeutics LLC
Section 2: Claims Processing (Continued)
Insulin Supplies
Time Limits for Coordination of Benefits
• Unless indicated by the POS system, insulin syringes
The time limits for coordinating benefits with State
and needles are generally a covered benefit.
• A valid prescription is required for insulin syringes
and needles to be dispensed to a Covered Person.
• Some Benefit Sponsors will waive the copayment
Pharmaceutical Assistance Programs (SPAPs), other
entities providing prescription drug service or other
payers cannot exceed three years from the date on which
the prescription for the Medicare drug was filled.
for insulin supplies that are dispensed at the same
This does not affect time frames for Medicare secondary
time as insulin. In this situation, the insulin must be
payer (MSP) prescription drug claims and the ability to
processed first.
recover amounts.
Long-Term Care (LTC) and Home Infusion Therapy (HIT)
Processing Guides
Medicare Parts A & B vs. D Claims Adjudication
Medicare Part D excludes from coverage any drugs
Prime requires LTC and HIT Participating Pharmacies
covered under Medicare Part A or Part B. Participating
to submit NCPDP D.0 fields as outlined on the
Pharmacies are responsible for ensuring that claims
Payer Sheets. Processing guidelines for submitting
eligible for coverage under Part A or Part B are not
LTC and HIT claims are located on Prime’s website.
adjudicated under Part D.
Medicare Programs Coordination of Benefits (COB)
Participating Pharmacies that serve Long-Term Care (LTC)
COB claims for Medicare Programs should be processed
facilities are required to determine potential Part A
in Prime’s claims processing system. Participating
eligibility by reviewing Part A eligibility information with
Pharmacies must submit the primary claim to Prime
their contracted LTC facilities. Participating Pharmacies
electronically. After Prime adjudicates the claim, Prime
should seek payment from the LTC facility for services
will provide POS messaging that contains the claim
for Covered Persons under a qualifying and covered
transaction information and the Covered Person’s
Part A stay.
supplemental coverage record if Prime is aware of
other supplemental coverage. This POS messaging
generally accommodates multiple supplemental plans
and includes information required to process the
supplemental claim(s).
Prime provides POS messaging on certain claims that
may be eligible for coverage under Medicare Part A or
Part B depending on the Covered Person’s circumstance.
The Participating Pharmacy must take appropriate steps
as necessary to ensure Part A and Part B eligible claim(s)
Supplemental claims must be processed through a
are not adjudicated under Part D.
switch in order to correctly capture these transactions
• During the claim adjudication, the Participating
for accurate TrOOP calculations. This process is designed
Pharmacy is prompted through messages to submit a
to function in real-time and to process all levels of
prior authorization (PA) code for Part D adjudication.
payer submissions for a claim at the POS. When the
Claims not meeting the Part D requirements are to be
primary payer or payer order information is not known
billed to Part A or Part B, as appropriate.
or is in doubt, the pharmacist has the ability to send an
E1 Eligibility Query to the Medicare Part D Transaction
Facilitator (formerly TrOOP Facilitator) to determine
proper payer order. Prime’s Supplemental to Medicare
Payer Specification Sheet is available on Prime’s website.
• If the pharmacist cannot determine through the PA
process whether a drug should be billed under Part A,
Part B or Part D after talking with the Covered Person
or Prescriber, then the Covered Person/Prescriber may
submit a request for coverage determination.
Additional information on Medicare COB can be found at
CMS.gov/COBPartD.
Provider Manual
13
Section 2: Claims Processing (Continued)
A Participating Pharmacy must promptly reverse the
Medicare Drug Formularies
Part D claim(s) after determining that it was eligible
Medicare formularies for the following year are published
for coverage under Part A or Part B, and refund any
on Prime’s website beginning in October; prior to the year
Part D cost-sharing collected from the Covered Person.
they become effective. Medicare formularies are updated
Notwithstanding the Participating Pharmacy’s obligation
on a monthly basis to reflect additions, deletions,
to reverse ineligible claims, Prime may, at its discretion,
tier changes and utilization management changes.
reverse ineligible Part D claims. If a Participating
Updated publications are posted on Prime’s website
Pharmacy erroneously bills Part D for a drug for which
on a monthly basis.
coverage is available under Part A or Part B, Prime will
recoup any money incorrectly paid through the Pharmacy
audit process and educate the Participating Pharmacy of
the error.
During the benefit year, if drugs are removed from the
formulary, or prior authorization, quantity limits and/
or step therapy restrictions are modified to be more
restrictive, or a drug is moved to a higher cost‑sharing
For more information, refer to the Medicare Part B vs.
tier, Prime will notify utilizing Covered Persons and
Part D Coverage Issues document on Prime’s website.
Prescribers of the change at least 60 days before the
For additional processing requirements, refer to the
Payer Specification Sheets on Prime’s website.
Utilization Management Program
Drug Formularies
change becomes effective. If the FDA deems a drug to
be unsafe or the drug’s manufacturer removes the drug
from the market, then Prime will remove the drug from
the formulary and provide notice to Covered Persons who
have received the drug.
National Pharmacy and Therapeutics (P&T) Committee
Covered Person notification is a combination of direct
mailing, web publication and notification. The Prescribers
and Participating Pharmacy formulary notifications are
available on Prime’s website. To view the comprehensive
list of Medicare formularies, visit Prime’s website.
and client-specific P&T or Business Committees, which
Prior Authorization (PA)
Prime manages many Drug Formularies for Benefit
Sponsors and administers them through the POS system.
The formularies are developed and approved by Prime’s
are independent panels of physicians and pharmacists
representing various practice disciplines. P&T and
Business Committees meet quarterly to review the
There are four types of prior authorizations used by Prime:
• One-time override – Used for a dosage change,
current formularies and add or delete drugs.
vacation, lost, spilled or damaged medication. At
Pursuant to Prime’s Pharmacy Participation Agreement,
document the reason for the override on the hard copy
when providing any Prescription Drug Service to a
Covered Person, the Participating Pharmacy shall comply
with the pharmacy benefit administered by the Benefit
Sponsor for that Covered Person.
When a non-formulary product is prescribed, and the
Covered Person has a closed formulary benefit, the claim
the time of the fill, the Participating Pharmacy must
or within an electronic system. Electronic notes are
only considered acceptable documentation when the
Participating Pharmacy’s system automatically dates
and time stamps the entry. The Participating Pharmacy
may request prior authorization for a dosage change or
vacation request by calling the Prime Contact Center.
will reject with NCPDP rejection code MR Non Formulary.
The Participating Pharmacy should make an effort to
contact the Prescriber to ask if the prescription can be
changed to a formulary product.
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Prime Therapeutics LLC
Section 2: Claims Processing (Continued)
• Formulary exception – Used for Covered Persons
sensitive or unresponsive to the formulary medication
requested by the Prescriber. If the Benefit Sponsor
has elected to utilize this PA, Prime will provide the
Participating Pharmacy POS messaging for additional
instructions on requesting a formulary exception.
There are three ways to obtain a Request for a
Formulary Exception form:
1.The Prescriber can contact the Benefit Sponsor
• Dynamic prior authorization (DPA) – Some Benefit
Sponsors use an automatic override process referred
to as dynamic PA. A Participating Pharmacy enters
a pre-determined prior authorization number for
certain conditions, such as a vacation request or
dosage change. At the time of the fill, the Participating
Pharmacy must document the reason for the override
on the hard copy or within an electronic system.
Only electronic notes are considered acceptable
by phone or in writing based on the information
documentation when the Participating Pharmacy’s
provided on the Covered Person’s ID card.
system automatically dates and time stamps the
2.The Covered Person can call the member service
toll‑free number on the back of the Covered Person’s
ID card.
3.The Covered Person can visit their Benefit Sponsor’s
website.
• Clinical prior authorization – Used for medication
that requires clinical review specific criteria to be
met before the medication is covered by the Benefit
Sponsor. If the Benefit Sponsor has delegated
this function to Prime, then Prime will review the
prior authorization requests to determine if the
Covered Person is eligible for coverage. In these
cases, Prime requires clinical documentation from the
Prescriber. Regardless, the Covered Person should
always contact the service department at their Benefit
Sponsor if they have any questions. Examples of
medications included in the clinical prior authorization
program are growth hormones or pegylated
interferons. These drugs will reject with the NCPDP
reject codes of 75 or 76, ‘PA required.’ POS messages
will vary based on the drug or program and may include
quantity limit or step therapy requirements in addition
to prior authorization. For the most current information
on medication that requires prior authorization, visit
the Covered Person’s Benefit Sponsor’s website.
Provider Manual
entry. A Participating Pharmacy may request prior
authorization for a dosage change or vacation override.
Step Therapy/Contingent Therapy Programs
Some Benefit Sponsors require the Covered Person to try
one or more preferred medications before a non-preferred
medication is considered for payment. This is referred to
as step therapy. Refer to the Benefit Sponsor formulary to
determine if a drug is subject to step therapy. Examples
of medications that may be included in the step therapy
programs include ARBs/renin inhibitors and proton pump
inhibitors. For the most current information on step therapy,
visit the Covered Person’s Benefit Sponsor’s website.
Quantity Limit
Many Benefit Sponsors restrict the quantity that may
be dispensed on certain drugs, such as proton pump
inhibitors or tobacco cessation medications. These
limits follow clinical dosing guidelines and restrict the
dispensing of the drug to a maximum quantity. When
submitting a claim that exceeds the maximum quantity,
the claim will receive NCPDP reject code 76 ‘Plan Limits
Exceeded.’ A free-form text message accompanies the
rejection and indicates the maximum quantity that may
be dispensed, assuming the prescription order is for
at least that amount. A Participating Pharmacy must
electronically accept Prime’s POS messaging.
15
Section 2: Claims Processing (Continued)
If the quantity exceeds the Covered Person’s benefit,
Prime requires Participating Pharmacies to review,
the Participating Pharmacy must reduce the quantity
update and/‌or implement quality assurance systems
prescribed and provide refills. If the Covered Person
and procedures at the POS to ensure compliance with
requests a smaller amount, the Participating Pharmacy
CMS regulations. Participating Pharmacies are required
may reduce the quantity prescribed. The pharmacist
to obtain the Covered Person’s allergy information and
should document this on the hard copy at the time of the
refer to it before dispensing. In addition, Participating
fill or prior to dispensing on the electronic documentation
Pharmacies must ensure that all employees or
to reflect the Covered Person’s request. Electronic
other agents who dispense medication are aware of
documentation must have a system assigned user, date
and use these drug utilization review systems and
and time stamp in order to take the place of hard copy
procedures and follow currently accepted standards for
documentation.
contemporary pharmacy practice as established by the
Drug Utilization Review (DUR)
applicable jurisdiction.
Prime monitors drug utilization to support your
Maximum Allowable Cost (MAC)
role as a professional in providing quality care to
Prime’s MAC program includes drugs that are reimbursed
all Covered Persons. Prime will alert Participating
at an upper limit per unit price. Highly utilized products
Pharmacies through the POS system in situations that
are reviewed on a regular basis. However, individual
include, but are not limited to:
products may be adjusted as-needed based on market
• Drug regimen compliance screening
conditions. If the availability of a drug becomes limited,
• Drug-drug interaction screening
• Drug-inferred health state screening
the MAC will be temporarily suspended or the drug may
be permanently removed from the MAC list(s) at Prime’s
sole discretion. The drug may be added back when
• Dosing/duration screening
Prime’s market sources confirm adequate supply and
• Drug-age caution screening
distribution.
• Drug-sex caution screening
If a Participating Pharmacy would like access to Prime’s
• Duplicate prescription screening
MAC list(s), weekly MAC changes and the sources used
• Duplicate therapy screening
• Additive toxicity screening
The Participating Pharmacy is responsible for
reviewing any claim with a DUR alert from the POS.
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 to access
Prime’s MAC list(s).
The Participating Pharmacy is responsible to ensure
that their systems accept DUR messaging. Pharmacists
should use professional judgment to follow up with
Post Claim Adjudication
the Covered Person and counsel them regarding the
Return to Stock – Unclaimed Prescriptions
DUR messages.
Participating Pharmacies are required to reverse
While Prime’s concurrent DUR edits utilized during the
claim submission and adjudication process are important
steps toward complying with CMS regulations, they are
not the only appropriate measures. As a Participating
any claim that is not delivered to or received by the
Covered Person within 14 days of submission, per
the terms of the Prime Therapeutics Pharmacy
Participation Agreement.
Pharmacy in Prime’s Medicare Programs network,
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Prime Therapeutics LLC
Section 3: Benefit Plan
Existing benefits may change without prior notice to the
The Covered Person’s copayment for PSC 1 or 2 may vary
Participating Pharmacy. New Benefit Plans may be added
based on the Benefit Plan design. Some Benefit Sponsors
at the request of a Benefit Sponsor. The point-of-sale
may require the Covered Person to pay the difference
(POS) system will provide the Participating Pharmacy
between the brand-name product and the generic
with current benefit information.
equivalent.
Brief explanations of common benefit designs are
Generic Drug Standards
listed in the following sections. Keep in mind that these
A Participating Pharmacy must dispense a generic
conditions may or may not apply to a particular Benefit
Sponsor.
Product Selection Code (PSC)
drug whenever permitted and in accordance with
applicable laws.
A Participating Pharmacy must stock a variety of generic
drugs coinciding with the habits of Prescribers and/or
For purposes of this Manual, Dispense as Written (DAW)
Benefit Sponsor’s formulary as indicated by the claims
and PSC are used interchangeably. A Participating
system response and other correspondence, or the
Pharmacy must submit an accurate PSC, in accordance
generic formulary of the state in which the Participating
with NCPDP specifications, when processing claims
Pharmacy is located.
electronically. PSC submissions may change the
calculation of the claims adjudication, depending
upon the Benefit Plan.
Enhanced Pharmacy Programs
Vaccine Administration
Generic Substitution
Participating Pharmacies that dispense and administer
Prime encourages its Participating Pharmacies to
and guidelines governing the sale and administration of
dispense generics whenever possible. However, there
Vaccines including ensuring proper personnel compliance
are instances where the Prescriber may request that
and licensing.
a brand-name product be dispensed instead of the
equivalent generic. These claims must be submitted with
a PSC of 1. If a PSC of 1 is used in processing a claim, the
written prescription, at the time of the fill, must contain
documentation of the DAW order from the Prescriber.
If the prescription is telephoned in, the pharmacist
must manually write “DAW” on the prescription so it is
Vaccines must follow all applicable laws, regulations
“Vaccine” means a specially prepared antigen, which
upon administration to a person, will result in immunity,
or any other definition that is required by applicable law.
“Vaccine Administration Fee” means a fee payable to the
Participating Pharmacy for administering a Vaccine by
the act of injection in accordance with applicable law.
documented in writing. In addition, Covered Persons may
A Participating Pharmacy must submit its claim for the
request a brand-name product be dispensed instead of
Vaccine Administration Fee to Prime electronically and
the generic equivalent. A Participating Pharmacy must
must accompany the related ingredient cost submission
indicate on the prescription that the Covered Person
and dispensing fee. Thus, the ingredient cost, dispensing
requested the brand-name product and submit the claim
fee and Vaccine Administration Fee must be submitted to
using a PSC of 2.
Prime as a single claim.
Visit Prime’s website for processing instructions, including
software set up for the vaccine administration program.
Provider Manual
17
Section 3: Benefit Plan (Continued)
Medication Therapy Management (MTM)
When a Covered Person in their transition period
Prime is committed to optimizing therapeutic outcomes
(i.e., within 90-days of their eligibility) presents a
through improved medication use and the reduction
of adverse drug events. Prime utilizes an internal
MTM that provides annual telephonic Comprehensive
Medication Review (CMR) and quarterly, criteria-based
prescription for a drug that is not on the Part D Benefit
Sponsor’s formulary and is not excluded from coverage
by CMS, the paid transition claim will return with a
message to the Participating Pharmacy. It explains that
Targeted Medication Review (TMR) for MTM enrolled
the drug will not be covered after the transition period.
Covered Persons.
If the claim is submitted for a day supply greater than
For 2013, Participating Pharmacies are able to provide
what is allowed during the transition period, or if the
MTM enrolled Covered Persons direct MTM intervention
Covered Person had already obtained a transition supply
for severe drug-drug interactions.
and the claim is rejected, the reject message to the
Professional Pharmacy Service (PPS) code entry, for the
Participating Pharmacy explains the reason, as noted
Pharmacist’s intervention effort, needs to be submitted
in the messaging examples.
for online fee processing.
At retail, Covered Persons will be limited to a 30‑day
See Retail MTM online fee processing instructions posted
transitional fill of a non-formulary drug. If a previous
on Prime’s website.
retail claim was submitted for 15-day supply, they are still
In 2014, Prime will be working with OutcomesMTM
their transition period. LTC Covered Persons are allowed
to offer expanded MTM services in the retail setting.
Additional information will be available in 2014 and
will be posted on Prime’s website.
eligible for another 15-day supply of that drug while in
up to a 31‑day supply per fill to a maximum of 98-days
supply with multiple fills, during their transition period.
The 98-day supply maximum takes into consideration
those drugs that require Short Cycle Dispensing. (Refer
Medicare Part D Transition Process
To address the needs of individuals who use certain
to section, “Medicare Short Cycle Dispensing Long-Term
Care Guidelines and Procedures”)
drug regimens and educate Covered Persons on
Pharmacies, including Extended Supply Network (ESN)
what drugs are covered by their Part D Benefit
and Mail Order, must remember that they may get a reject
Sponsor, CMS requires that Part D Benefit Sponsors
message indicating that a Covered Person may not obtain
establish an appropriate transition process to provide
more than the day supply limits noted above — however,
Covered Persons with a temporary supply of prescription
please refer to all messaging. A claim may require other
drugs in certain circumstances, including, but not limited
corrections or override codes. For example, the claim
to, Covered Persons whose current drug therapies
message may ask for confirmation that the drug is
are not included in their new Part D Benefit Sponsor’s
Part D or Part B and if it is a Part D drug to enter in an
formulary or are subject to certain limits such as a prior
override code. This should be done prior to reducing the
authorization or step therapy. The transition process
day supply to accommodate the transition day supply
gives Covered Persons time to work with their Prescriber
limit as the claim may allow benefits without doing so.
to switch to a therapeutically equivalent medication or
If the claim remains rejected after all other corrections
to complete a formulary exception request.
or overrides have been completed and the transition
message is advising of the day supply limit, at that time
the day supply should be reduced.
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Section 3: Benefit Plan (Continued)
Important Notice — To meet CMS requirements Covered
›› “AUTH OR FORM ALT REQ/NONFORM/UM MEDS.
Persons in transition must not leave the Pharmacy
MAX 30 DAY SUPPLY IN TRANSITION PERIOD.
without their medications as a result of the day supply
CALL 8008214795 IF NEW MBR<OR=90 DAYS.”
being greater than what is allowed.
For Covered Person’s who continue enrollment in the
same Part D Benefit Plan whose drugs are no longer
• When there is a paid claim or neither of the above
situations applies, the default message for claims
during a Covered Person’s transition period will remain
on the Benefit Sponsor’s formulary, Prime will make a
as follows:
meaningful transition within the first 90 days of the new
›› “NON-FORM OR UM MED MAX 30 DAYS SUPPLY
year. The transition will be made by providing a transition
IN TRANS PERIOD. AUTH OR FORM ALT REQ.
process consistent with the transition process required
CALL 800.821.4795 IF NEW MBR<OR=90 DAYS.”
by new enrollees beginning in the new contract year or
making a transition prior to the beginning of the new
contract year.
A primary goal of the transition process is to alert
the Covered Person of non-formulary circumstances.
Prime will provide instructions to Participating
Pharmacies through POS messaging if a Covered Person
receives a prescription drug during their transition
period that will not be covered post-transition because
the drug is not on the formulary or subject to utilization
Reasons for and examples of LTC POS messaging during
the transition period:
• If the claim is rejecting because the day supply being
submitted is greater than the allowed day supply during
the transition period (up to 31 days) (Day Supply reject)
›› “MAX OF 31 DS/FILL IN TRANSITION PERIOD.
›› RESUBMIT W/LESSER DS. AUTH OR FORM ALT REQ.
CALL 8008214795 IF NEW/RE-ENROLLEE.”
• If the claim is rejecting because the Covered Person
management programs. Pharmacists receiving this
has already received a transition supply (based on
message must communicate the information to the
the NDC 9) during their transition period (Period to
Covered Person and suggest that the Covered Person
Date reject)
contact their Prescriber to explore transitioning to a
›› “AUTH OR FORM ALT REQ/NONFORM/UM MEDS.
formulary drug. Covered Persons will receive a letter from
the Benefit Sponsor notifying them how to proceed in
transitioning to a formulary drug.
MAX 98 DAY SUPPLY IN TRANSITION PERIOD.
CALL 8008214795 IF NEW MBR<OR=90 DAYS.”
• When there is a paid claim or neither of the above
Reasons for and examples of RETAIL POS messaging
situations applies, the default message for claims
during the transition period:
during a Covered Person’s transition period will remain
• If the claim is rejecting because the day supply
as follows:
being submitted is greater than the allowed day
›› “NON-FORM OR UM MED LMTD TO 31 DAY SUPPLY
supply during the transition period (up to 30 days)
MAX 98 IN TRANS PERIOD. AUTH OR FORM ALT REQ.
(Day Supply reject)
CALL 800.821.4795 IF NEW MBR<OR=90 DAYS.”
›› “MAX OF 30DS DURING TRANSITION PERIOD.
RESUBMIT W/LESSER DS. AUTH OR FORM ALT REQ.
CALL 8008214795 IF NEW/RE-ENROLLEE.”
• If the claim is rejecting because the Covered Person
has already received a transition supply (based on
the NDC 9) during their transition period (Period to
Refer to Prime’s website for current formulary listings.
Covered Persons in transition must leave the pharmacy
with the appropriate medications. If you have questions
regarding the transition process or claims processing,
please contact Prime’s Contact Center at 800.821.4795.
Date reject)
Provider Manual
19
Section 3: Benefit Plan (Continued)
Medicare General Dispensing Long-Term Care Guidelines
Medicare Short Cycle Dispensing Long-Term Care
and Procedures
Guidelines and Procedures
Participating Pharmacies that provide services to
Effective January 1, 2013 all Participating Pharmacies
Covered Persons in an LTC facility must be familiar with
servicing LTC facilities must dispense solid oral doses of
the following guidelines:
brand-name drugs to Medicare Covered Persons residing
• Claims must be billed in 30-day increments no more
in LTC facilities in no greater than 14-day increments at
than once per month.
• Seven-day unit packages must be logged and billed
no more than once per month.
• Over-the-Counter (OTC) products must be dispensed
in the original container.
• OTC products may not be priced higher than the
shelf price.
• Items that are normally supplied by the LTC facility
on a per-diem basis, such as test strips and syringes,
are not billable to Prime.
• Unique dispensing methods such as tray changes
every two or seven days, do not justify additional
a time in accordance with 42 CFR §423.154. Prime will
reject LTC facility claims that are submitted with invalid
or missing SCC combinations.
The following fields must be submitted on all LTC short
cycle claims:
• NCPDP Field 147-U7 Pharmacy Service Type
• NCPDP Field 307-C7 Place of Service
• NCPDP Field 384-4X Patient Residence
• NCPDP Field 997-G2 CMS Part D Defined Qualified
Facility
Please visit Prime’s website for detailed processing
requirements.
dispensing fees. One dispensing fee per month is
reimbursable even when the product is delivered
to an LTC facility.
• If providing Prescription Drug Services to
Covered Persons residing in an LTC facility, or through
mail order services, the Participating Pharmacy
shall maintain a delivery log — which includes the
prescription number, date of fill, delivery date
and signature of Covered Person(s) receiving
medication — or other evidence specifically approved
by Prime at each pharmacy location to acknowledge
delivery of Prescription Drug Services to the
Covered Person or the Covered Person’s LTC facility,
as applicable.
• For the most up to date guidelines and procedures
for Long-Term Care, please visit Prime’s website.
20
Prime Therapeutics LLC
Section 4: Responsibility of Participating Pharmacy
Update Information with NCPDP
The National Council for Prescription Drug Programs
Third Party Payment Reconciliation
Vendors
(NCPDP) requires that Participating Pharmacies submit
Participating Pharmacies must notify Prime Therapeutics
pharmacy information updates to NCPDP directly as
immediately upon change of Payment Reconciliation
soon as the Participating Pharmacies are aware of them.
Vendors. Failure to do so can result in a violation of HIPAA.
To submit adds, changes, deletes, current address,
fax number and phone number to NCPDP, go to NCPDP’s
website at NCPDPOnline.org.
Prime receives and incorporates NCPDP’s updates, which
include changes to a Participating Pharmacy address,
fax number, phone number and Pharmacy Chain/
Pharmacy Service Administration Organization (PSAO)
affiliation updates. Prime’s system supports only one
NCPDP affiliation at this time.
Responsibilities of the Participating
Pharmacy for Medicare Programs
In order to ensure compliance with CMS regulations,
Participating Pharmacies in Prime’s Medicare Network(s)
must adhere to the guidelines outlined on Exhibit C(s) –
Prime Medicare Networks which is part of Prime’s
Pharmacy Participation Agreement. A copy of minimum
performance and service criteria for Prime’s Medicare
In order to ensure the integrity of Prime’s data, it is the
Networks is available on Prime’s website.
Participating Pharmacy’s responsibility to contact NCPDP
Participating Pharmacies are required (when
when information changes. This will ensure that correct
data is in Prime’s database.
instructed through POS messaging) to hand out with
the Covered Person’s prescription order, a copy of the
‘Medicare Prescription Drug Coverage and Your Rights’
Participating Pharmacy’s Affiliation
with PSAO
document. To print a copy of this CMS‑required document
(in English or Spanish) please visit Prime’s website.
For a copy of Prime Therapeutics Pharmacy Participation
Agreement, a Participating Pharmacy should contact
their PSAO.
Participating Pharmacies must notify NCPDP immediately
upon change of affiliations with a PSAO. Failure to do so
can result in a violation of HIPAA.
Provider Manual
21
Section 4: Responsibility of Participating Pharmacy (Continued)
Additional Participating Pharmacy
Information
Pharmacy Credentialing
Prime maintains websites to serve Covered Persons
Prime’s Pharmacy Network. A new pharmacy must
and Participating Pharmacies. Information on the
complete a credentialing exhibit and supply all of the
site includes:
supporting documents so that Prime can review and
• Current formulary information (updated on a
regular basis).
• Grievances, coverage determinations, appeal
procedures, exception process management and/or
Prime credentials pharmacies prior to entry into
process the application.
Prime recredentials all Participating Pharmacies at least
once every three years in accordance with applicable law
and contractual obligations.
drug utilization management.
• Participating Pharmacy addresses and types
(e.g., retail, mail service pharmacy, home infusion,
long-term care).
• Quality control policies and procedures, including
Medication Therapy Management Program (MTMP)
and/or Drug Utilization Management (DUM).
Termination Appeals
Pharmacy termination appeals must be submitted in
writing to the Pharmacy Network Contracting Department
by fax at 877.823.6373 or by email to:
[email protected]
A Participating Pharmacy that has been terminated from
Prime’s pharmacy networks may reapply one year after
the effective date of their termination.
22
Prime Therapeutics LLC
Section 5: Participating Pharmacy Audit
Auditing is a critical component of responsible pharmacy
benefit management. Prime manages a robust program to
detect inaccurate payments, drug, waste and fraudulent
claims or other benefit coverage abuses. As part of this
program, Prime regularly samples and audits claims
Education
Prime may provide information to network pharmacies
via a monthly Prime Audit Advisor Fax Blast and quarterly
via the Prime Perspective. These documents may serve as
submitted by pharmacies in our network.
a tool for pharmacies to use to strengthen documentation
Prime conducts pre-payment daily claims reviews as well
common billing errors.
as desktop and on-site audits to monitor compliance
with state and federal regulations, Prime Therapeutics
and billing practices, prepare for Prime audits and reduce
Pharmacy Participation Agreements and this Manual.
Reason for Audits
Audits verify the integrity of claims submitted to Prime
Several situations could trigger an audit. These situations
and payments made to the Participating Pharmacy. They
include, but are not limited to:
also confirm the accuracy of claim information submitted
to identify instances of potential fraud, waste and abuse.
Audits comply with federal and state laws to ensure
privacy and confidentiality of all patient records.
Audits also comply with Health Insurance Portability
and Accountability Act (HIPAA) guidelines related
to disclosure for treatment, payment or health care
operations.
Audit findings may result in payment recoveries,
corrective action plans and/or contract terminations.
For purposes of the Participating Pharmacy Audit section,
• Request or inquiry by a Benefit Sponsor, Covered Person
or government agency.
• Pharmacy billing history.
• Pharmacy does not respond to or has significant
issues identified through the pre-payment inquiry
or pre‑payment daily claims review.
• Referral from Prime’s Fraud Waste and Abuse Hotline
or other sources that indicate potential fraud, waste
or abuse.
• Routine audit of pharmacies selected on a random basis.
please see the Pharmacy Audit Recovery Guidelines for
Audit Notification
specific criteria on Prime’s website.
Participating Pharmacies selected for audit may receive
advanced written notice. Advanced notice may not be
provided at Prime Therapeutics’ discretion or during
fraud investigations, as allowed by law.
Provider Manual
23
Section 5: Participating Pharmacy Audit (Continued)
Access to Records
Reporting Audit Results
Participating Pharmacies must provide adequate access
On-site and desktop audit results are provided to the
to Participating Pharmacy records related to Prescription
Participating Pharmacy in writing and include details
Drug Services provided under the Agreement, including
of any issues of non-compliance with federal and state
but not limited to: wholesaler invoices, prescription
regulations, the Pharmacy Participation Agreement,
orders, licensing and proof of insurance. During an audit,
Prime’s Provider Manual and/or discrepancies between
Prime uses these records to compare the submitted
the original prescription order documentation available at
claims information to the original source documentation
the time of dispensing and the Participating Pharmacy’s
of the prescription orders and other relevant
claim submission. Prime may place the Participating
documentation.
Pharmacy on a formal corrective action plan (CAP)
If Participating Pharmacies cannot accommodate
an on-site audit on the scheduled date and previous
arrangements have not been agreed to by Prime,
Prime reserves the right to assess a full recovery of
any unverified claims. Additionally, if a Participating
Pharmacy is uncooperative during an audit, a full
recovery of any unverified claims may be assessed.
Audit Expenses
Participating Pharmacies may not charge Prime for
pharmacy personnel time involved in performing an
audit. Each Participating Pharmacy is responsible for its
own expenses and each Participating Pharmacy shall
bear the expense of providing records to Prime.
based on the nature of any discrepancies. Prime may
also apply either full or partial recovery of the amount
paid for a specific claim. Recovery amounts are included
in the audit report. A Participating Pharmacy may be
immediately terminated from network participation
upon Prime’s receipt of any evidence of a pharmacy
participating in activities that may result in fraud, waste
or abuse.
Types of Audit Activities
Participating Pharmacies shall not record either
audio or video of interactions with Prime auditors,
including telephone discussions, on-site audits, or
other interactions without Prime’s written consent.
Such activity may result in termination of the Pharmacy
Participation Agreement.
Audit Time Frame
Pre-payment Daily Claims Review
Standard on-site audits generally include prescriptions
Prime monitors daily claims data to correct individual
billed to Prime within the previous twenty-four (24)
quantity and pricing errors on a pre-payment basis.
months. Desktop audits generally include prescriptions
This process educates Participating Pharmacies and
billed to Prime within the previous twelve (12) months.
helps avoid retroactive audit recoveries that may
However, Prime has the right to audit claims for up to
occur through a pharmacy desktop or on-site audit.
seven (7) years from the date of service for commercial
The pre‑payment daily claims review complements the
claims, and up to ten (10) years from the date of service
desktop and on-site audit processes and is not intended
for government programs claims, or as otherwise
to review all audit elements considered in
permitted by law.
a desk or on-site audit.
24
Prime Therapeutics LLC
Section 5: Participating Pharmacy Audit (Continued)
If a claim is identified for review, Prime will contact the
If the Participating Pharmacy processes LTC Facility
Participating Pharmacy via telephone, email or fax to
claims, the following additional information may also
inquire about the validity of the claim. If, after the review
be requested:
of the claim and/or prescription order, a determination
• Demographic information of any LTC facilities that were
is made that there is a billing error, Prime will request
that the Participating Pharmacy reverse and correctly
resubmit the claim. Prime will contact the Participating
Pharmacy only if a resubmission is requested. Other
discrepancies noted during the pre‑payment daily claims
review may be addressed through a desktop or on-site
pharmacy audit.
Participating Pharmacies are expected to respond to
Prime’s requests for information within two (2) business
days. Participating Pharmacies must return requested
information by the dates provided. Failure to do so
serviced by the Participating Pharmacy during the time
frame being audited;
• Medication administration records of the Participating
Pharmacy and/or the LTC facility; and
• LTC facility census information for members during
the time frame audited that provides information on
Part A stays.
Prime will provide the Participating Pharmacy with
a due date for submitting audit documentation.
The Participating Pharmacy may either fax, mail or email
may result in full or partial recovery of the amount
copies of requested documentation.
paid, escalation to a desktop and/or on-site audit or
Fax Number: 877.765.4551
termination of the Pharmacy Participation Agreement.
Email Address: [email protected]
Desktop Audits
Mailing Address:
When a desktop audit is initiated, the Participating
Prime Therapeutics LLC
Pharmacy is contacted via fax, email, United States
Attn: Pharmacy Audit
Postal Service or UPS. During a desktop audit, the
P.O. Box 64812
Participating Pharmacy is asked to provide photocopies
St. Paul, MN 55164-0812
of specific prescriptions in question related to claims
paid to the Participating Pharmacy during a specified
time period. Requested documentation may include,
but is not limited to:
• Photocopies of original prescriptions, front and back
• Signature or delivery logs
• Computer records
A Participating Pharmacy’s failure to submit the
requested documentation by the due date may result
in full or partial recovery of the amount paid, escalation
to an on-site audit or termination of the Pharmacy
Participation Agreement. Late fees may apply to missing
or late audit documentation.
A Prime auditor will review the requested claims for
• Wholesaler, manufacturer, and/or return vendor invoices
accuracy to verify that the claims have been submitted in
• Pedigree invoices
compliance with the Pharmacy Participation Agreement
• Compound information including all ingredients with
and Prime Provider Manual. Prime will provide the
NDCs and quantities
• Prescription labels
• Pharmacy Liability Insurance and Pharmacist-in-Charge
Participating Pharmacy with a written audit report, which
will include details of any discrepancies or relevant
audit findings.
Professional Insurance information
• Proof of Fraud, Waste and Abuse training
• License information
• Bill of Sale
Provider Manual
25
Section 5: Participating Pharmacy Audit (Continued)
On-site Audits
On-site audits will involve the disclosure of
Prime may conduct on-site audits of Participating
Covered Persons’ personal health information for
Pharmacies. A written audit notification will be provided
to the Participating Pharmacy prior to a scheduled
audit date. However, advanced notice may not be
provided for fraud investigations, as allowed by law.
This notification includes the audit time frame and
types of documentation that will be reviewed during
the on‑site audit.
On-site audits are conducted during regular business
hours. Prime makes reasonable efforts to minimize
disruption to all areas of the Participating Pharmacy.
Participating Pharmacies are expected to provide Prime
the purpose of disclosure for treatment, payment or
health care operations. In order for both parties to remain
HIPAA compliant, a pharmacy staff member will need
to retrieve documentation; however the auditor must
be present to observe the documentation retrieval.
Participating Pharmacies may not refuse to comply with
an audit on the grounds that it would violate HIPAA or
other relevant privacy laws.
A Prime auditor will review the requested claims for
accuracy in order to verify that the claims have been
submitted in compliance with the Pharmacy Participation
with access to all areas of the pharmacy and have the
Agreement and this Manual.
documentation to support the audit period readily
Audit documentation, including prescriptions and
retrievable and accessible. Participating Pharmacies
are also expected to be adequately staffed during the
audit and have a representative (either pharmacist
or technician) available to respond to questions and
supporting documentation, will be scanned by the
auditor as necessary.
When the audit is complete, the auditor will verbally
retrieve specific prescription hard copies and supporting
provide general feedback.
documentation that may be needed.
Prime will provide the Participating Pharmacy with
While on site, the auditor will observe the Participating
a written audit report, which will include details of
Pharmacy practices and review all related documentation.
any discrepancies or relevant audit findings, within
An interview will be completed, preferably with the
approximately thirty (30) days of the on-site visit.
Pharmacist in Charge (PIC). Requested documentation
A Participating Pharmacy’s failure to cooperate with
may include, but is not limited to:
an on-site audit may result in full or partial recovery
• Original prescriptions, front and back;
of the amount paid for the related claims reviewed or
• Signature or delivery logs;
termination of the Pharmacy Participation Agreement.
• Computer records;
• Wholesaler, manufacturer and/or return vendor invoices;
Drug and Supply Requirements
• Pedigree invoices;
Participating Pharmacies must purchase all medications
• Compound information including all ingredients with
NDCs and quantities;
• Pharmacy Liability Insurance and Pharmacist-in-Charge
Professional Insurance information;
and supplies being dispensed to Covered Persons
from verifiable licensed wholesalers. The ordering of
these medications and supplies must be tracked using
verifiable wholesale invoices and pedigree invoices
(when required by applicable law). Prime reserves the
• License information;
right to not accept documentation from any wholesalers
• Proof of Fraud, Waste and Abuse training; and
at anytime when the invoice documentation cannot
• Bill of Sale.
26
be verified.
Prime Therapeutics LLC
Section 5: Participating Pharmacy Audit (Continued)
Prescription Requirements
directions for use are required, “As Directed” is not
“Prescription Hard Copies” means written prescriptions,
communication with the Prescriber or, if the Prescriber
refill authorizations, institutional orders, verbal or
telephoned orders, facsimile orders, prescription
transfers and electronic prescriptions relied on by the
Participating Pharmacy at the time of dispensing. In order
to qualify as an electronic prescription, the electronic
prescription must be noted prior to dispensing and have
a system assigned user, date and time stamp in order to
take the place of hard copy documentation.
The Participating Pharmacy must retain all
allowed. Directions may be obtained through direct
is not available, the Covered Person. Directions
must be noted on the prescription hard copy and the
medication dispensed to the Covered Person must be
labeled with the specific directions for use obtained
from the prescriber. For drugs that are administrated
on a sliding scale, such as insulin, the Participating
Pharmacy must obtain the dosage range or maximum
per day prior to dispensing.
• Substitution instructions with appropriate
documentation related to a prescription claim in
documentation – when medically necessary, the
accordance with the Pharmacy Participation Agreement
Prescriber may write “Dispense as Written” on
and applicable state and federal laws. Prescriptions
the prescription, or in the case of a telephoned
or claims that do not comply with state and federal
prescription, the pharmacist must manually write
regulations may be subjected to audit recovery.
“Dispense as Written” on the written prescription
A prescription is considered valid when the original
order. If the Covered Person requests a brand-name
prescription contains the following information at the
drug, the Participating Pharmacy must document the
time of dispensing:
request on the prescription order.
• Full name, address and date of birth of the
Covered Person.
• Date of Issuance.
• Full name, NPI and telephone number of the Prescriber
and, if the prescription is for a controlled substance,
the Prescriber’s DEA number. If the Prescriber did not
include their NPI/DEA number(s) on the prescription
hard copy, then the pharmacy is responsible for
acquiring the Prescriber ID either from the pharmacy’s
claim system or by contacting the Prescriber. The
• Refill instructions – if there are no refills indicated
by the Prescriber, the Participating Pharmacy should
assume that there are no refills. If refills are added to
a prescription, the Participating Pharmacy must retain
written documentation of the authorization and assign
a new prescription number.
• Prescription number – the prescription hard copy
must be labeled with the corresponding
prescription number.
• If the prescription is for a drug under a federally
Participating Pharmacy must document the correct
regulated program (for example, iPledge or S.T.E.P.S.
Prescriber ID on the prescription hard copy or on
Data 2000), the Participating Pharmacy must
a prescription label, affixed to the back of the
document the authorization number obtained from
prescription hard copy.
the program on the prescription hard copy before
• Name of medication and strength prescribed.
• Quantity authorized by the Prescriber.
• Specific dosage directions – the medication dispensed
to the Covered Person must be labeled with the
Prescriber’s directions for use. The Participating
dispensing.
• Documentation of the date the prescription was
received and the name of the caller for verbal or
telephoned prescription orders or clarification to
any order.
Pharmacy must obtain specific directions for
Prescription hard copies that are missing one or more
use to accurately fill the prescription. Specific
of the required elements may be considered invalid
and subject to audit recovery.
Provider Manual
27
Section 5: Participating Pharmacy Audit (Continued)
Prescription Label Requirements
Review of Claim Submission
The prescription label must contain the following
Prime auditors will, at a minimum, verify the following
elements in addition to state and federal guidelines:
claim elements when evaluating a prescription:
• Full name of Covered Person
• Covered Person – The prescription must contain the
• Full name of Prescriber
• Full name and strength of medication dispensed
• Quantity of medication dispensed
• Specific directions for use
• Prescription number
full name of the Covered Person and be billed under
the correct Covered Person ID number.
• Date of Issuance – The date of issuance must be
present on the prescription.
• Drug name and strength – The NDC on the claim
must correspond with the specific drug and strength
• Number of refills authorized
prescribed and dispensed. Reasonable efforts must
• Date medication was dispensed
be made to select the most cost effective form of the
prescribed drugs or its generic equivalent.
• NDC – The NDC on the claim must correspond to the
NDC used to dispense the prescription.
• Price – The accuracy of calculating and submitting
compound prices, based on the NDCs and quantities
used to dispense product.
• Product selection codes (PSC) – PSC submissions will
be verified. If the Participating Pharmacy submits a
DAW-1 and no written substitution directive is present
on the prescription, the claim(s) will be subject to
recovery. When the Covered Person requests the
brand-name, the Participating Pharmacy must
document the Covered Person’s request on the original
hard copy and submit the claim with a DAW-2. If the
generic is not available to the market, the Participating
Pharmacy must document on the original hard copy
and submit the claim with a DAW-8.
28
Prime Therapeutics LLC
Section 5: Participating Pharmacy Audit (Continued)
• Quantity – The Participating Pharmacy must
• Claims edits – If the Participating Pharmacy receives
dispense the quantity as written, unless the
specific messaging when a claim is submitted,
quantity written exceeds the Covered Person’s
the Participating Pharmacy must ensure that
benefit. The Participating Pharmacy must comply
documentation is maintained to support the use of
with POS messaging, such as messaging regarding
dynamic prior authorization (override or DUR override)
the Covered Person’s benefit limit and document
numbers. Inappropriate use or lack of supporting
the reason for dispensing a lesser quantity on the
documentation related to dynamic prior authorizations
original prescription. In order to prompt accurate
will be subject to audit recovery.
POS messaging, the Participating Pharmacy must
accurately represent the day supply.
• Days supply – The Participating Pharmacy must submit
• Prescriber ID number – The Participating Pharmacy
must enter the correct Prescriber’s ID number on
the claim submission. Claims submitted under the
the correct days supply, based upon directions for use.
wrong Prescriber ID number or an invalid Prescriber ID
The Participating Pharmacy must submit the number
number may result in the pharmacy being placed on a
of consecutive days the prescription drug will last.
corrective action plan.
Overstating the days supply may affect future refills,
while understating the days supply may exceed the
Covered Person’s benefit. The most common days
supply errors occur when dispensing inhalers, insulin
and medication with intermittent dosing. Unit of uses
packages days supplies are calculated based on the
number of doses available. A Participating Pharmacy
is responsible for submitting the correct days supply.
For examples of medications commonly billed
erroneously, visit Prime’s website.
• Refill instructions – Refill history will be reviewed to
assure that the prescription was not refilled in excess
• Usual and Customary Charge (U & C) – The lowest
price the Participating Pharmacy would charge to a
particular customer if such customer were paying cash
for the identical Prescription Drug Services on the date
dispensed. This includes any applicable discounts
including, but not limited to, senior discounts, frequent
shopper discounts and other special discounts offered
to attract customers.
Discrepancies between the claim submission and original
prescription order may result in an audit recovery or a
formal corrective action plan.
of the prescription order. If additional refills are
authorized, the Participating Pharmacy must obtain the
appropriate prescription order based on the drug class.
Provider Manual
29
Section 5: Participating Pharmacy Audit (Continued)
Distributor and Manufacturer Invoices
and Pharmacy Dispensing Records
To substantiate that the drugs dispensed were purchased
from an authorized source, Prime may request that the
Participating Pharmacy authorize the wholesaler or
manufacturer to release invoices and/or Pedigrees for
purchase verification. The Participating Pharmacy must
promptly comply with such requests. If the Participating
Pharmacy fails to provide authorization, Prime has the
right to assess a full recovery of the amount paid for any
claims in question.
Common Billing Errors
• Quantity dispensed – Overstating the days supply
may affect future refills, while understating the days
supply may exceed the Covered Person’s benefit,
while assessing less copayments that are applicable.
The Participating Pharmacy must submit the correct
days supply, based on directions for use and benefit
limitations to avoid an audit recovery. For example,
incorrectly calculating the day supply of eye drops.
Calculate eye drops day supply using 15 drops per mL
for solutions and 12 drops per mL for suspensions.
• Reversal of claims – All prescriptions not received by
the Covered Person within fourteen (14) days must be
reversed through the electronic claims system.
• Use as directed – The Participating Pharmacy must
determine the specific dosing directions to accurately
calculate the days supply and correctly submit the
claim to Prime. The Participating Pharmacy must
contact the Prescriber to clarify any ambiguous
directions (i.e. “Use as Directed,” no directions
documented or “As Needed”) and document them
on the prescription hard copy. If the Prescriber is
unavailable, communication with the Covered Person
is acceptable and must be documented.
• One prescription for entire family – Prescriptions
written for an entire family on one prescription form
must be processed as separate claims for each
Covered Person.
For examples of medications commonly billed erroneously,
visit Prime’s website.
30
Prime Therapeutics LLC
Section 5: Participating Pharmacy Audit (Continued)
Unacceptable Practices
Audit Appeal Process
Based on the claims submission requirements, the
Participating Pharmacies have thirty (30) days from
following are examples of unacceptable and, in some
the date of notification of audit findings to submit an
cases, fraudulent practices which may be subject to
appeal or an extended time frame as required by law
audit recovery:
or regulation. Appeals must be submitted in writing
• Billing for a legend or OTC drug without a prescription
and include the Participating Pharmacy’s name, the
or benefit-sponsored voucher.
• Submitting incorrect information on claims which may
lead to the inappropriate bypass of benefit exclusions,
DUR messages, or other Benefit Plan edits.
• Billing for a quantity of a legend drug which is different
than the quantity prescribed.
claims/prescriptions in question and an explanation
of the appeal. Please see the Pharmacy Audit Recovery
Guidelines for accepted post-audit documentation.
Documentation accepted during the appeals process
may provide information that results in additional audit
findings. For a copy of Prime’s Pharmacy Audit Appeal
Form, visit Prime’s website.
• Billing for a higher priced drug when a lower priced drug
was prescribed and/or dispensed to the Covered Person.
• Dispensing a generic drug but billing for the
brand-name drug.
• Submitting a claim with an NDC other than the NDC from
the package from which the product was dispensed.
• For general LTC dispensing, billing more than once
per month for legend drugs for Covered Persons in
an LTC facility.
Corrective Action Plan (CAP)
Participating Pharmacies placed on corrective action
plans are monitored to determine whether the identified
issues have been remedied. If issues are not resolved,
additional action may be taken by Prime, as permitted
by the Agreement. Failure to comply with the terms of the
corrective action plan may result in termination of the
Pharmacy Participation Agreement.
• Dispensing drugs that are solid oral dose brand-name
drugs in greater than 14-day increments for Short Cycle
dispensing.
• Overriding DUR rejects without properly resolving and
documenting the resolution.
• Incorrectly billing Part A or Part B eligible drugs to a
Part D program.
• Billing compound products in a manner inconsistent
with the compound billing requirements described in
the Compound Billing Guidelines of this Manual.
• Misrepresenting U & C.
• Billing the Covered Person for any associated recovery.
• Misrepresenting the origin codes.
• Billing for drugs that were never purchased by the
pharmacy.
• Billing for drugs where the wholesaler invoices cannot
be substantiated by the wholesaler.
Provider Manual
31
Section 5: Participating Pharmacy Audit (Continued)
Confidentiality and Proprietary Rights
Confidentiality
Any information (including, but not limited to, products,
programs, services, business practices, procedures,
MAC lists or other information acquired from the contents
of the Pharmacy Participation Agreement, Provider
Manual or other Prime documents) or data obtained
from, or provided by, Prime or any Benefit Sponsor
to the Participating Pharmacy is highly confidential.
The Participating Pharmacy shall not sell, assign, transfer
or give such information to any third party without the
prior written consent of Prime.
• No information or data obtained from or provided by
Prime to the Participating Pharmacy may be quoted
or attributed to the Participating Pharmacy or Prime
without the prior written consent of Prime.
Proprietary Rights
Except as required to fulfill the Participating Pharmacy’s
obligations under the Agreement, the Participating
Pharmacy has no right to use, reproduce or adapt
any information, data, work, compilation, computer
programs, manual process or invention obtained from,
provided by, or owned by Prime and/or Benefit Sponsor
(including, but not limited to, products, programs,
services, business practices and procedures) without
Prime’s prior written consent.
Prime has the right to disclose, use, reproduce
and/or adapt any information or data obtained from
the Participating Pharmacy in any manner deemed
appropriate, even if such use is outside the scope of the
Pharmacy Participation Agreement, provided such use
is in accordance with applicable law.
• The Participating Pharmacy must use all necessary
security procedures to ensure protection of any
information or data records from improper access.
• The Participating Pharmacy must maintain the
confidentiality of a Covered Person’s personal
profile and records as required by applicable
law. The Participating Pharmacy may not use the
information provided by Covered Persons for any
purpose not related to the Agreement, except to the
extent such use is required by applicable law.
• The Participating Pharmacy must promptly notify
Prime if it becomes aware of any unauthorized use
of confidential information or data.
32
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Prime Therapeutics llc
P.O. Box 64812
St. Paul, MN 55164-0812
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800.821.4975
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