PROVIDER MANUAL PRIME THERAPEUTICS FOR PHARMACY PROVIDERS
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PRIME THERAPEUTICS
PROVIDER
MANUAL
FOR PHARMACY PROVIDERSEffective April 15, 2021
© 2021 Prime Therapeutics LLC. All rights reserved.
Trademarks are the property of their respective owners.
No part of this Manual may be reproduced in any form or by any
means without the prior written permission of Prime Therapeutics.
Prime Therapeutics LLCTABLE OF CONTENTS
INTRODUCTION TO PRIME THERAPEUTICS . . . 1 Submitting the Claim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Bank Identification Number (BIN) and Processor
Control Number (PCN) . . . . . . . . . . . . . . . . . . . . . . . . 10
Provider Manual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
National Provider Identifier (NPI) . . . . . . . . . . . . . . . . . 10
SECTION 1: PRIME CONTACT INFORMATION . 2 Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Prime Mailing Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Days’ Supply for Non-Medicare Part D Claims . . . . . . 11
Prime’s Contact Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Days’ Supply for Medicare Part D Claims . . . . . . . . . . . 11
Prime’s website . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Accurate Quantity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Dispensed Package Size/National Drug Code (NDC) .12
SECTION 2: COMPLIANCE . . . . . . . . . . . . . . . . . . . . . . . 3
NDC Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Report Compliance, Privacy, or Fraud, Waste
and Abuse Concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Timely Filing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Compliance Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 ePrescribing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Fraud, Waste and Abuse (FWA) . . . . . . . . . . . . . . . . . . . . . . . 4 Prescription Origin Code . . . . . . . . . . . . . . . . . . . . . . . . . 12
Annual Attestation Requirement . . . . . . . . . . . . . . . . . . . 4 Requirements for Pharmacies Contracted with 340B
Covered Entities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Medicare Part D FWA and General Compliance
Pharmacy Training and Certification . . . . . . . . . . . . . 4 Compound Prescription Billing Guidelines . . . . . . . . . 12
Reporting of Suspicious Activity . . . . . . . . . . . . . . . . . . . 4 Insulin and Diabetic Supply Benefits . . . . . . . . . . . . . . 14
Notice to California Pharmacies . . . . . . . . . . . . . . . . . . . . . . 6 Insulin Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Pharmacy Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Long-Term Care (LTC) and Home Infusion (HI)
Processing Requirements . . . . . . . . . . . . . . . . . . . . . 15
Pharmacy Bill of Rights . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Hemophilia Billing Guidelines . . . . . . . . . . . . . . . . . . . . 15
SECTION 3: CLAIMS PROCESSING . . . . . . . . . . . . . 7 Medicare Programs Coordination of Benefits (COB) . 15
General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Time Limits for Coordination of Benefits . . . . . . . . . . . 15
Online Claims Submission . . . . . . . . . . . . . . . . . . . . . . . . 7 Medicare Parts A & B vs. D Claims Adjudication . . . . 16
Online Availability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Utilization Management Program . . . . . . . . . . . . . . . . . . . . 17
Claim Formats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Drug Formularies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Medicare Reference Materials . . . . . . . . . . . . . . . . . . . . . 7 Medicare Drug Formularies . . . . . . . . . . . . . . . . . . . . . . 17
Collection of Copay/Cost Share . . . . . . . . . . . . . . . . . . . . 7 Prior Authorization (PA) . . . . . . . . . . . . . . . . . . . . . . . . . 17
Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Electronic Submission of PA Requests Supported by
Covered Person Identification Card . . . . . . . . . . . . . . . . 7 CoverMyMeds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Covered Person Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . 8 Step Therapy (ST)/Contingent Therapy Programs . . . 19
Covered Person Protection . . . . . . . . . . . . . . . . . . . . . . . . 8 Quantity Limit (QL) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Controlled Substance Prescription Dispensing Drug Utilization Review (DUR) . . . . . . . . . . . . . . . . . . . . 20
Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Maximum Allowable Cost (MAC) . . . . . . . . . . . . . . . . . . 20
Claims Process for Multiples . . . . . . . . . . . . . . . . . . . . . . 8
Medicare E1 Eligibility Query . . . . . . . . . . . . . . . . . . . . . . 9
Medicare and Medicaid Dual Eligible
Covered Persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Qualified Medicare Beneficiary Program . . . . . . . . . . . . 9
Best Available Evidence (BAE) . . . . . . . . . . . . . . . . . . . . . 9
Hospice Best Available Evidence (BAE) . . . . . . . . . . . . 10
Provider Manual ITABLE OF CONTENTS (CONTINUED)
SECTION 4: BENEFIT PLAN . . . . . . . . . . . . . . . . . . . . . 21 Appropriate Dispensing Practices . . . . . . . . . . . . . . . . . . . . 29
Post Claim Adjudication . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Unacceptable Dispensing Practices . . . . . . . . . . . . . . . 30
Return to Stock — Unclaimed Prescriptions . . . . . . . . 21 Patient-Prescribing Provider Relationship . . . . . . . . . . 30
Notice of Payment Error . . . . . . . . . . . . . . . . . . . . . . . . . 21 Marketing and Communications Practices . . . . . . . . . 30
Benefit Plan Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Pharmacy Nondiscrimination . . . . . . . . . . . . . . . . . . . . . 30
Pharmacy Networks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Signature or Delivery Logs . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Long-Term Care (LTC) Guidelines . . . . . . . . . . . . . . . . . . . . . 21 Long-Term Care (LTC) and Home Infusion (HI) Annual
Validation Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Services Provided to Family Members . . . . . . . . . . . . . . . . 21
Termination Appeals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Product Selection Code (PSC) . . . . . . . . . . . . . . . . . . . . . . . 21
Confidentiality and Proprietary Rights . . . . . . . . . . . . . . . . 32
Generic Substitution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Confidentiality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Generic Drug Standards . . . . . . . . . . . . . . . . . . . . . . . . . 22
Proprietary Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Enhanced Pharmacy Programs . . . . . . . . . . . . . . . . . . . . . . 22
Recall Notices and Expired Medication . . . . . . . . . . . . 33
Vaccine Administration . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Manufacturer Assistance Reporting . . . . . . . . . . . . . . . . . . 33
Medication Therapy Management (MTM) . . . . . . . . . . 22
Medicare Part D Transition Process . . . . . . . . . . . . . . . . . . 22 SECTION 6: PHARMACY OVERSIGHT . . . . . . . . . . 34
Prescription Drugs Not on Medicare Part D Pharmacy Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Benefit Sponsor’s Drug Formulary or
Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Subject to Certain Limits . . . . . . . . . . . . . . . . . . . . . 22
Access to Pharmacy Records . . . . . . . . . . . . . . . . . . . . . . . . 34
Supply Limits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Partial Fills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Prescription Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Status Alerts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Prescription Label Requirements . . . . . . . . . . . . . . . . . . . . 36
Sample POS Messaging . . . . . . . . . . . . . . . . . . . . . . . . . 23
Product Purchase Requirements . . . . . . . . . . . . . . . . . . . . . 36
Medicare General Dispensing LTC Guidelines
and Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Purchase Invoices and Pedigrees . . . . . . . . . . . . . . . . . . . . 36
Medicare Short Cycle Dispensing LTC Guidelines Review of Claim Submission . . . . . . . . . . . . . . . . . . . . . . . . 36
and Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Insulin Vials Billing Guide . . . . . . . . . . . . . . . . . . . . . . . . 37
Prescribed Units Per Day . . . . . . . . . . . . . . . . . . . . . . . . 37
SECTION 5: RESPONSIBILITY OF
PHARMACY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Common Billing Errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Compliance with the Participation Agreement and Unacceptable Billing Practices . . . . . . . . . . . . . . . . . . . . . . 38
Provider Manual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Recovery of Pharmacy Payments . . . . . . . . . . . . . . . . . . . . 39
Update Information with NCPDP . . . . . . . . . . . . . . . . . . . . . 26 Reasons for Audits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
OIG and GSA Exclusion and Preclusion List Checks . . . . 26 Audit Time Frame . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Pharmacy’s Affiliation with PSAO . . . . . . . . . . . . . . . . . . . . 27 Types of Audit Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Third Party Payment Reconciliation Company . . . . . . . . . 27 Daily and Historical Claim Audits . . . . . . . . . . . . . . . . . 40
Re-Creation Fee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Onsite Audits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Responsibilities of the Pharmacy for Reporting Onsite Audit Results . . . . . . . . . . . . . . . . . . . . . . 42
Medicare Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Onsite Audit Appeal Process . . . . . . . . . . . . . . . . . . . . . . . . 43
Pharmacy Credentialing . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Corrective Action Plan (CAP) . . . . . . . . . . . . . . . . . . . . . . . . 43
Ownership or Control Changes . . . . . . . . . . . . . . . . . . . 29
Pharmacy Investigations . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Specialty Pharmacy Credentialing . . . . . . . . . . . . . . . . . . . 29
Remediation Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Provider Manual IITABLE OF CONTENTS (CONTINUED)
SECTION 7: MEDICAID REQUIREMENTS . . . . . . 44 Prescription Drug Benefits . . . . . . . . . . . . . . . . . . . . . . . 49
General Medicaid Program Inquiries . . . . . . . . . . . . . . . . . 44 How to Use the Drug Formulary . . . . . . . . . . . . . . . . . . . 49
General Medicaid Requirements . . . . . . . . . . . . . . . . . . . . . 44 Prior Authorization (PA) . . . . . . . . . . . . . . . . . . . . . . . . . 50
Pharmacy Disclosure Statement . . . . . . . . . . . . . . . . . . 44 Emergency Prescription Supply . . . . . . . . . . . . . . . . . . . 50
Quantity Supply Limits . . . . . . . . . . . . . . . . . . . . . . . . . . 51
APPENDIX A: ILLINOIS MEDICAID
Dose Optimization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
REQUIREMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Benefit Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Illinois Medicaid Requirements . . . . . . . . . . . . . . . . . . . . . . 45
Where Prescription Drug Services are Filled . . . . . . . . 51
Automatic Refills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Prime’s Information for Claims Processing . . . . . . . . . 51
APPENDIX B: MINNESOTA MEDICAID Member Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
REQUIREMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Cost to Member . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Minnesota Medicaid Requirements . . . . . . . . . . . . . . . . . . 46
Advance Directives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Automatic Refills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Child Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Do Not Accept Cash Payment . . . . . . . . . . . . . . . . . . . . . 46
Cancellation of Product Orders . . . . . . . . . . . . . . . . . . . 52
Cash for Phentermine . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Coordination of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . 52
APPENDIX C: TEXAS MEDICAID Tuberculosis (TB) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
REQUIREMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Non-covered Services . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Texas Medicaid Requirements . . . . . . . . . . . . . . . . . . . . . . . 47 Delivery Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
National Provider Identifier (NPI) . . . . . . . . . . . . . . . . . 47 Covered Person Protections . . . . . . . . . . . . . . . . . . . . . . 52
Pharmacy Credentialing . . . . . . . . . . . . . . . . . . . . . . . . . 47 Durable Medical Equipment . . . . . . . . . . . . . . . . . . . . . . 53
Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Important Toll-free Contact Numbers . . . . . . . . . . . . . . 53
Compound Drugs Billing Guidelines . . . . . . . . . . . . . . . 47
Maximum Allowable Cost (MAC) and Appeals . . . . . . 49
Provider Manual IIIINTRODUCTION TO PRIME THERAPEUTICS
INTRODUCTION PROVIDER MANUAL
Prime Therapeutics LLC (Prime) provides pharmacy This Provider Manual (“Manual”), as revised, explains
benefit management (“PBM”) services for Benefit Prime’s administrative and compliance policies and
Sponsors, including access to contracted pharmacy procedures for participation in Networks managed
networks. Prime is not itself a health insurer, nor does it by Prime. This Manual is incorporated into the Prime
provide health insurance policies or plans or employee Therapeutics Pharmacy Participation Agreement
benefit plans. (“Agreement”). All Prime contracted Pharmacies must
comply with the terms and conditions of this Manual, as
Prime’s services include:
revised, in providing Prescription Drug Services pursuant
• Pharmacy network management to such an Agreement.
• Specialty network services
Prime will update this Manual as necessary at
• Claims adjudication its sole discretion. This version of the Manual
• Drug Formulary management supersedes all previous versions of the Manual.
• Pharmacy communication Prime posts the most current version of the Manual at
www.PrimeTherapeutics.com.
• Drug utilization review (DUR)
• Clinical programs Prime posts relevant instructions, notices, information
and supplements or changes to this Manual on the
• Knowledge, data, and analytic services
Prime website. Visit www.PrimeTherapeutics.com for
• Product development up‑to‑date information and processing instructions.
• Prescribing Provider outreach
All capitalized terms that are otherwise not defined in this
• Member communications and support Manual refer to those defined in the Agreement.
Prime supports Prescription Drug Services for our Benefit Important: This Manual applies to all lines of business.
Sponsors through our online claims processing system.
This system gives Pharmacies real-time access to: Failure to comply with Prime’s terms and conditions,
including, but not limited to, those described in
• Covered Person eligibility
this Manual, as revised, may result in placement
• Drug coverage information on a corrective action plan, full or partial financial
• Drugs requiring prior authorization recoupment, termination of participation in one or
• DUR information more Networks, termination of the Agreement, and
other remediation actions, as determined by Prime and
Prime is committed to doing business with integrity in permitted by applicable law.
accordance with all applicable federal, state and local
laws. Prime has adopted a compliance program and code
of conduct. This includes policies and procedures to avoid
potential conflicts of interest and Fraud, Waste or Abuse
(FWA). Click here to access Prime’s Code of Conduct.
Provider Manual 1SECTION 1: PRIME CONTACT INFORMATION
PRIME MAILING ADDRESS PRIME’S WEBSITE
If you would like additional information, contact Prime at: Visit Prime’s website (www.PrimeTherapeutics.com) for
the following information:
Prime Therapeutics
P.O. Box 64812 • Payer sheet
St. Paul, MN 55164-9403 • Medicare Prescription Drug Coverage and Your Rights
• Formularies – Commercial
PRIME’S CONTACT CENTER • Formularies – Medicare Part D
800.821.4795 • Prime Perspective newsletters
Prime’s Contact Center has dedicated staff to assist • Compliance/Fraud, Waste and Abuse (FWA)
Pharmacies. They can help with contract requests, • Plan announcements
processing questions, and any comments and concerns
• Network request form
you may have. Prime’s representatives are available
• Common billing errors
24 hours a day, 7 days a week.
• Minimum Performance and Service Criteria for
Medicare Part D
• Minimum Performance Criteria for LTC
• Medicare Part B vs. Part D coverage issues
• Pharmacy Audit Appeal form
• Prime Audit Advisor/Fax series
• Audit Guidelines
• FAQ: Claim Adjustments
• Long-Term Care and Home Infusion General Dispensing
Requirements
• Home Infusion (HI) validation
• Long-term care (LTC) validation
• Medicaid program
• Vaccine program
• Check Inquiry form
• Maximum Allowable Cost (MAC) lists
• Instructions for viewing Network Reimbursement IDs
(NRIDs) for adjudicated claims
• Dispensing Thresholds
• Provider Manual
• COVID-19 Testing and Vaccine Payer Sheets
(as applicable)
Provider Manual 2SECTION 2: COMPLIANCE
REPORT COMPLIANCE, PRIVACY, Please contact Prime’s compliance department with any
concerns, including, but not limited to:
OR FRAUD, WASTE AND ABUSE
CONCERNS • Violation of a state, federal, local law, regulation or any
governmental guidance
Compliance
• Conflict of interest
Report suspected compliance concerns: • Acceptance or offers of gifts or entertainment
• Phone: 612.777.5523 • Fraud, Waste and Abuse (FWA)
• Email: compliance@PrimeTherapeutics.com • Improper disclosure of Prime’s confidential or
Privacy proprietary information
• Retaliation for reporting a compliance issue
Report privacy concerns or potential protected health
information (PHI) disclosures: • Falsification of reports, records or files
• Privacy Hotline: 888.849.7840 • Theft
• Email: privacy@PrimeTherapeutics.com
COMPLIANCE PROGRAM
Fraud, Waste and Abuse
Prime requires all Pharmacies to adopt appropriate
If you suspect Fraud, Waste or Abuse (FWA) by a compliance programs, including, but not limited to:
Covered Person, Prescribing Provider, Pharmacy or
• Codes of conduct
anyone else, notify Prime:
• FWA programs
• Phone: 800.731.3269
• Conflict of interest policies and procedures
• Email: FraudTipHotline@PrimeTherapeutics.com
Pharmacies must develop policies and procedures in
If you suspect FWA involving the Federal Employees
compliance with all applicable rules and regulations,
Plan by a Covered Person, Prescribing Provider,
including, but not limited to, Medicare Programs.
Pharmacy or anyone else, notify Prime:
Pharmacies should have someone who is responsible
• Phone: 844.765.9990 for establishing and documenting a plan to meet
• Email: FEPreportfraud@PrimeTherapeutics.com Medicare Program requirements. Pharmacies should
communicate the plan and any means of enforcing the
Anonymous Reporting:
plan to all employees.
Report a compliance concern or suspected Fraud, Waste
Refer to the Centers for Medicare & Medicaid Services
or Abuse anonymously by contacting Prime’s 24-hour
(CMS) website, CMS.gov, for a complete list of
anonymous compliance hotline:
compliance program requirements.
• Phone: 800.474.8651
• Email: reports@lighthouse-services.com
• Mobile app: App Store > Search for Anonymous
Reporting (Lighthouse) > Download the app > Keyword
”prime” > Select ”save”
• Third party vendor’s website:
www.lighthouse-services.com/prime
Provider Manual 3SECTION 2: COMPLIANCE (CONTINUED)
FRAUD, WASTE AND ABUSE Medicare Part D FWA and General Compliance
Pharmacy Training and Certification
(FWA)
Every year, on behalf of the Part D Benefit Sponsors it
“Fraud,” “Waste” and “Abuse” or “FWA” means an
serves, Prime requires any staff providing Medicare
inappropriate use of health care benefits or Benefit
Part D services to receive qualified Fraud, Waste and
Plan in connection with the Pharmacy’s delivery of,
Abuse (FWA) and General Compliance training upon hire
billing of, claiming of, or payment for Prescription Drug
and annually thereafter. Prime also tracks completion
Services, items or supplies. Fraud may be perpetrated by
of this training by all participating Pharmacies.
a Pharmacy, Covered Person, Prescribing Provider and/
Pharmacies can submit a single attestation to NCPDP
or other individual or entity involved in the production,
(as part of your Pharmacy profile), which will be
distribution, prescribing, ordering, dispensing or
submitted to Prime. When a Pharmacy indicates that
receiving of Prescription Drug Services, items or supplies.
offshore services are provided in their FWA and General
Fraudulent acts committed by other parties do not
Compliance training attestations, the Pharmacy must
absolve the Pharmacy’s responsibility for the integrity of
complete an additional offshore questionnaire regarding
delivery, billing, claims or payment for Prescription Drug
the offshore services vendor.
Services, items or supplies.
Reporting of Suspicious Activity
Fraud is the intentional deception or misrepresentation
that an individual or organization knows to be false Pharmacies and Prime have an obligation to help protect
or does not believe to be true and that the individual and maintain the integrity of the health care system by
or organization makes knowing that the deception or promptly reporting suspicious activity.
misrepresentation could result in some unauthorized
Pharmacies have a corresponding responsibility to
benefit to a person or organization. It also includes
ensure prescriptions are valid. For example, if the
any act that constitutes fraud under the applicable
Pharmacy receives a prescription order that appears
federal or state law. Waste means the inappropriate
potentially altered or forged, the Pharmacy must contact
or inefficient use of resources. Abuse means the
the Prescribing Provider to:
occurrence, or pattern, when an individual or
organization unintentionally provides information to • Validate the prescription
another individual or organization that results in higher • Document the prescription order with date and time
payments than an individual or organization is entitled to
• Include the representative name from the Prescribing
receive. Abuse can be distinguished from fraud only by
Provider’s office
the specific facts and circumstances of the situation.
At all times, Pharmacies must remain mindful of FWA and
Annual Attestation Requirement
report suspicious activity to Prime promptly.
The annual FWA attestation form is now part of your
Please contact Prime’s FWA department as set forth in
Pharmacy NCPDP profile. Please complete the form via
the Compliance section of this Manual with any FWA
the NCPDP website. For your convenience, instructions
concerns. Examples of potential FWA include, but are not
for completing the NCPDP form are on Prime’s website.
limited to:
Failure to attest to the annual general compliance and
• Misrepresentation of status — A Covered Person or
FWA training may result in termination of participation in
other individual misrepresents personal information,
one or more Networks or termination of the Agreement.
such as identity, eligibility or medical condition in
order to illegally receive a drug benefit; or an individual
who no longer has prescription drug coverage attempts
to use their identity card to obtain prescriptions.
Provider Manual 4SECTION 2: COMPLIANCE (CONTINUED)
• Identity theft — An individual uses another person’s • Script mills — A Prescribing Provider writes
Medicare or health insurance card to obtain prescriptions for drugs that are not medically
prescriptions. necessary, often in mass quantities, and often for
• Illegal resale of drugs — A Covered Person falsely Covered Persons who are not the Prescribing Provider’s
reports loss or theft of drugs or fakes illness to obtain patients. These prescriptions are sometimes written
drugs for illegal resale. for drugs found on a schedule of controlled substances
for illegal sale. These prescriptions may also result in
• Prescribing Provider shopping — A Covered Person
improper payments to the Prescribing Provider.
consults more than one Prescribing Provider to
inappropriately obtain multiple prescriptions. • Theft of Prescribing Provider’s Drug Enforcement
Pharmacists must make every reasonable effort to Administration (DEA) number or prescription pad
ensure that any prescription drug order, regardless — Prescription pads may be stolen from Prescribing
of the means of transmission, has been issued for a Providers and used to write prescriptions, including
legitimate medical purpose by a Prescribing Provider in for controlled substances or medications that can be
the course of the valid and lawful practice of medicine. abused or illegally sold.
A pharmacist must not dispense a prescription drug • Inappropriate billing practices — Inappropriate billing
if the pharmacist knows or should have known that practices occur when Pharmacies engage in billing
the order for such drug was issued without a valid practices that include, but are not limited to:
pre‑existing Patient-Prescribing Provider relationship › Incorrect billing to secondary payers to receive
or without a valid prescription drug order. increased reimbursement
Patient-Prescribing Provider Relationship Definition: › Billing for non-existent prescriptions
There are three (3) ways a Patient-Prescribing Provider
› Billing multiple payers for the same prescriptions,
relationship can be established:
except as required for coordination of benefits
1. There is a pre-existing Patient-Prescribing Provider transactions
relationship;
› Billing for brand-name drugs when generic drugs
2. The Prescribing Provider communicated with the are dispensed
patient as part of a call coverage agreement with the
› Billing for non-covered prescriptions as
patient’s established Prescribing Provider; or
covered items
3. The Prescribing Provider communicates with the
› Billing for prescriptions that are never picked up
patient using:
(including not reversing claims that are processed
a. real-time audiovisual interaction, such as when prescriptions are filled but never picked up)
video calls;
› Billing for numerous prescriptions without providing
b. real-time audio (telephone), along with having prescriptions to Covered Persons
access to clinically relevant information, such as
› Inappropriate use of product selection codes (PSC),
videos/images, medical records, and test results; or
submission clarification codes (SCC) and dynamic
c. any other communication technology that allows Prior Authorizations (PAs)
the Prescribing Provider to meet the applicable
› Billing an NDC not used to dispense the prescription
standard of care.
› Billing an NDC or drug that was never ordered
› Billing an incorrect dosage form (e.g., billing for
a tablet when a powder is used to dispense the
prescription)
› Drug diversion
Provider Manual 5SECTION 2: COMPLIANCE (CONTINUED)
› Phishing to identify a drug that is covered (e.g., a • TrOOP manipulation — Manipulation of true out-of-
Pharmacy submits a claim for one drug, receives a pocket (TrOOP) costs by the Pharmacy, including to
reject or reverses the claim, and resubmits for a new either push a Covered Person through the coverage gap
drug within a short period of time) so the Covered Person can reach catastrophic coverage
› Prescription splitting to bypass Point of Sale (POS) before being eligible, or to keep a Covered Person
messaging requiring a PA in the coverage gap so that catastrophic coverage is
never realized.
› Billing a greater vial size than what is necessary to
supply the ordered dose • Failure to offer negotiated prices — The Pharmacy’s
failure to offer a Covered Person the negotiated price
› Waiving Copays — The Pharmacy does not collect
of a drug available to the Covered Person through the
the copay due from the Covered Person, when
Benefit Plan.
required by the Agreement
• Inappropriate application of therapeutic interchange
› Misrepresenting or falsifying information to obtain a
protocols — The Pharmacy dispensing a different
paid claim
covered medication than the prescribed medication
• Prescription drug shorting — The Pharmacy provides without obtaining and documenting the Prescribing
less than the prescribed quantity and intentionally Provider’s consent prior to dispensing or without
does not inform the Covered Person or make informing the Covered Person of the substitution.
arrangements to provide the balance, but bills for the
full amount ordered on the prescription.
NOTICE TO CALIFORNIA
• Bait and switch pricing — The Pharmacy leads a PHARMACIES
Covered Person to believe that a drug will cost one
price, but at POS, the Covered Person is charged a This serves as notice to Pharmacies in California about
higher amount. rights under California Health & Safety Code.
• Prescription forging or altering — Existing Pharmacy Reporting
prescriptions are altered without the Prescribing Pharmacies may report to the department through the
Provider’s permission to increase the quantity or toll-free Pharmacy line, email address or other method
number of refills. designated by the California Department of Managed
• Dispensing expired or adulterated prescription Health Care, instances in which the Pharmacy believes a
drugs — The Pharmacy dispenses drugs that are Benefit Sponsor is engaging in an unfair payment pattern.
expired or have not been stored or handled according (Cal. Health & Safety Code §1371.39)
to the manufacturer or FDA requirements.
Pharmacy Bill of Rights
• Prescription refill errors — The Pharmacy provides a
Pharmacy has certain rights as a Pharmacy under Cal.
higher number of refills than what was prescribed.
Health & Safety Code §1371.39.
• Illegal remuneration schemes (kickbacks) — The
Pharmacy is offered, solicits, or receives unlawful
payment that results in an incentive or reward for
switching Covered Persons to different drugs,
influencing Prescribing Providers to prescribe
different drugs or steering Covered Persons to plans.
Provider Manual 6SECTION 3: CLAIMS PROCESSING
GENERAL INFORMATION Medicare Reference Materials
Online Claims Submission These documents are available on Prime’s website:
• Medicare Prescription Drug Coverage and Your Rights
The Pharmacy must electronically submit all claims
Standardized Pharmacy Notice Instruction
to Prime for all Prescription Drug Services provided to
• Medicare Prescription Drug Coverage and Your Rights
a Covered Person. This includes situations where no
• Medicare Part B vs. D Coverage Issues
Pharmacy Payment from Prime is due.
• Minimum Performance and Service Criteria for
The Pharmacy must provide a Covered Person adequate Medicare Part D
information as to where the prescription service can be
• Minimum Performance and Service Criteria for LTC
electronically submitted in situations in which pharmacist
judgment or applicable law permits the denial of Collection of Copay/Cost Share
Prescription Drug Service. The Pharmacy must collect from the Covered Person
Online Availability Payor Copayments, or other charges for services not
covered under the Covered Person’s Benefit Plan,
“Point of Sale” or “POS” means the method of provided the Covered Person has agreed up front to
submitting claims electronically through an automated pay for such non-covered services, unless otherwise
claims adjudication process. POS messaging and the prohibited by applicable law. The Pharmacy cannot
POS System include interactive POS communications. waive, discount, reduce or increase the Copayment
The POS is not a separate contract and does not create communicated to the Pharmacy at POS unless otherwise
any contractual rights for a submitting Pharmacy. authorized in writing by Prime or the Benefit Sponsor
The online system is generally available for claims or unless otherwise required by applicable law. In no
processing 24 hours a day, 7 days a week. event, including, but not limited to, non-payment by a
Benefit Sponsor Payor for Prescription Drug Services
Claim Formats rendered to Covered Persons by Pharmacy, insolvency of
• POS claims must be submitted in the current NCPDP a Benefit Sponsor Payor, or breach by Prime of any term
format or current industry version. or condition of the Agreement, will Pharmacy bill, charge,
• Batch claims must be submitted in the NCPDP Batch collect a deposit from, seek compensation, remuneration
format or current industry version. or reimbursement from, or have any recourse against
any Covered Person or persons acting on behalf of the
• The Universal Claim Form (UCF) must be submitted for
Covered Person for Prescription Drug Services eligible for
paper claim submissions. UCFs are available on the
reimbursement under the Agreement.
NCPDP website at NCPDPOnline.org.
For a complete list of required and situational ELIGIBILITY
processing requirements, refer to the Payer sheets
Covered Person Identification Card
located on Prime’s website.
Prime is not obligated to pay the Pharmacy for services
The Pharmacy must review all POS messaging for
provided to an individual who, at the time services
processing information and Payer sheets located on
are provided, is not eligible to receive benefits for the
Prime’s website for software set up.
services provided. The Pharmacy must verify a Covered
In order for Prime to assist Pharmacies with claims Person’s eligibility and must require a Covered Person
adjudication, please email your unique processing codes, to present a Covered Person Identification Card prior to
condor codes, and/or input codes: providing a Prescription Drug Service.
PharmacyOps@PrimeTherapeutics.com.
Provider Manual 7SECTION 3: CLAIMS PROCESSING (CONTINUED)
The Covered Person Identification Card does not ensure Covered Person Protection
a Covered Person’s eligibility. If a Covered Person does
Other than the required cost share or copay, the
not have a Covered Person Identification Card and the
Pharmacy may not bill, charge or collect from a Covered
Pharmacy is unsure of eligibility, the Pharmacy must
Person payment for Prescription Drug Services. The
take reasonable steps to confirm the identity of the
Pharmacy may not seek compensation from, condition
Covered Person through validation of a government
the provision of services on payment from, or have any
issued identification card or call Prime’s Contact Center
recourse against any Covered Person or other person
at 800.821.4795 to obtain accurate information about
acting on behalf of the Covered Person, other than
a Covered Person prior to dispensing a product or
Prime, including in instances where Prime has denied
processing a claim.
or reversed payment to the Pharmacy for failing to
Covered Person Eligibility comply with terms and conditions of the Agreement or
this Manual.
A Covered Person’s eligibility can be verified through
the POS system during claim adjudication or by calling Controlled Substance Prescription Dispensing
Prime’s Contact Center. Unless expressly allowed in this Considerations
Manual, a Covered Person whose eligibility has been
Pharmacies may not use or accept form or pre-filled
verified should never:
prescriptions to dispense controlled substances.
• Be denied a covered Prescription Drug Service (subject Pharmacies may only dispense Schedule II controlled
to a pharmacist’s professional judgment or as allowed substances based on a written or electronic prescription
by applicable law). If drug service is denied based on that complies with all applicable laws and regulations for
professional judgment or applicable law, the Pharmacy prescribing and dispensing controlled substances.
or pharmacist must provide the Covered Person
adequate information as to where the prescription The quantity prescribed must be submitted on each
service can be provided. claim for Schedule II controlled substances. The total
quantity prescribed may be dispensed in incremental
• Be asked to pay more than is due under the terms of
fills to the extent permitted by law. The sum of quantities
the Agreement.
dispensed in incremental fills cannot exceed the
• Be asked to pay cash and submit a paper claim, unless quantity prescribed.
otherwise allowed by applicable law.
A prescription for a Schedule II controlled substance may
If a Covered Person’s eligibility is obtained using an not be refilled. A separate prescription is required if a
eligibility lookup system, this information must be Prescribing Provider wishes to authorize continuation of
confirmed with the Covered Person prior to dispensing a patient’s use of a Schedule II prescription drug beyond
the Prescription Drug Service. the amount specified on the first prescription.
In the event a claim is processed using incorrect eligibility, Claims Process for Multiples
upon notice, Prime may adjust the claim to reflect correct
eligibility and corresponding Benefit Plan coverage. When processing claims for multiples with the same birth
date and same medication, use the following procedure:
In accordance with 45 CFR § 155.430, Prime may direct
• Process the first claim as usual.
the Pharmacy to reverse claims for Prescription Drug
Services and any other related actions. If the Pharmacy • Attempt to process the second claim as usual.
is unwilling or unable to reverse requested claims, • If the second claim rejects, call Prime’s Contact Center
Prime will reverse claims on behalf of the Pharmacy by at 800.821.4795 to verify the multiple-birth eligibility
providing written notice to the Pharmacy. flag has been set.
Provider Manual 8SECTION 3: CLAIMS PROCESSING (CONTINUED)
Medicare E1 Eligibility Query The Pharmacy should not attempt to collect cost
share for Medicare Part B covered drugs, but instead
The E1 Eligibility Query is a real-time transaction
should attempt to bill Coordination of Benefits (COB),
submitted by the Pharmacy to RelayHealth, the
the beneficiary’s Medicaid benefit plan. Pharmacies
Transaction Facilitator. It helps determine a Covered
who inappropriately balance bill the QMB individuals
Person’s Medicare Part D coverage and payer order if
are subject to sanctions and possible termination of
the Covered Person has insurance through more than
participation in one or more Networks or termination of
one insurer. Pharmacies generally submit E1 Queries
the Agreement.
when Covered Persons do not have their Medicare Part D
Identification Card. Best Available Evidence (BAE)
Additional information on E1 Transactions can be found Covered Persons eligible for the low-income subsidy (LIS)
at RelayHealth. under the Medicare Part D prescription drug program are
enrolled in the claims system with the correct LIS copay
Pharmacies should not submit an E1 for pharmaceutical
level. If the claims system does not show the correct LIS
manufacturer copay assistance coupon programs as they
status for the Covered Person, Medicare requires the
are not considered Prescription Drug Services.
Pharmacy to accept BAE when the Covered Person or their
Medicare and Medicaid Dual Eligible Covered Persons representative presents it at the POS.
According to 42 CFR 422.504(g)(1)(iii), if a Pharmacy Medicare also requires Pharmacies to assist Covered
provides Prescription Drug Services to a Covered Person Persons who think they are eligible for LIS, but do not
who is eligible for both Medicare and Medicaid, the have BAE documentation.
Covered Person will not be held liable for payment and
For Covered Persons with supporting BAE documentation:
the Pharmacy must accept the Medicare plan payment as
payment in full or bill the Medicaid benefit plan. • The Pharmacy must call Prime’s Contact Center to ask
for an immediate LIS status update in the claims system.
Qualified Medicare Beneficiary Program
• The Pharmacy may submit the claim once the claims
The Qualified Medicare Beneficiary (QMB) program is system is updated with the LIS status.
a State Medicaid benefit that assists low-income dual • The Pharmacy must fax a copy of the Covered Person’s
eligible beneficiaries with Medicare Part A and Part B supporting BAE documentation to Prime’s Contact
premiums and cost-sharing, including deductibles, Center at 800.445.7085.
coinsurance and copayments.
• Prime forwards the supporting BAE documentation
Section 1902(n)(3)(B) of the Social Security Act, as to the Medicare Part D Sponsor, who works with
modified by Section 4714 of the Balanced Budget Act of CMS to update the Covered Person’s LIS status in the
1997, states that all Medicare and Medicare Advantage CMS system.
providers may not balance bill QMB individuals for
For Covered Persons without supporting BAE
Medicare cost-sharing under any circumstances.
documentation:
A value of 51 will be sent in the Benefit Stage Qualifier • The Pharmacy asks the Covered Person if they
field (NCPDP field 393-MV) to notify the Pharmacy that have less than three (3) days of medication (an
this claim is submitted under the Part D BIN/PCN, but the “immediate need”).
claim is NOT paid for by the Part D benefit plan. It is paid
• The Pharmacy calls Prime’s Contact Center to begin
for by the Part B benefit.
the process of updating the Covered Person’s LIS
status; the request must say if the need is immediate
or not immediate.
Provider Manual 9SECTION 3: CLAIMS PROCESSING (CONTINUED)
• Prime calls the Medicare Part D Sponsor, who SUBMITTING THE CLAIM
completes the BAE Assistance Worksheet and submits
it to CMS to validate or update the Covered Person’s LIS Pharmacies must submit all claims according to
status in the CMS system. the processing rules and guidelines outlined in the
Agreement, this Manual, as revised, and in compliance
• CMS updates the Covered Person’s LIS status within
with regulations and POS messaging.
one (1) business day for an immediate need.
Bank Identification Number (BIN) and Processor Control
Hospice Best Available Evidence (BAE)
Number (PCN)
A Covered Person’s hospice provider pays for the
A BIN and PCN are required when adjudicating claims
medications for their terminal illness and related
through the POS system. A list of the BINs and PCNs used
conditions. Some medications submitted under Medicare
to adjudicate claims through Prime’s POS system can be
Part D will reject at POS for Covered Persons in hospice
found in the Payer sheets on Prime’s website.
care. If the claims system does not show the correct
hospice status for the Covered Person, CMS requires the National Provider Identifier (NPI)
Pharmacy to accept BAE when presented at the POS, and • Pharmacy NPI — The Pharmacy must have a Pharmacy
the Pharmacy must forward any copies of the BAE to the NPI, and all online claims must be submitted with
Contact Center. the Pharmacy NPI. Online claims submitted with the
If the Covered Person has never previously been Pharmacy NCPDP number will reject.
in hospice: • Prescribing Provider Identifiers — Prime will only
• The Pharmacy must call Prime’s Contact Center and accept a valid, active, individual (Type 1) NPI. The
ask for a Hospice Prior Authorization (PA). If Prime Pharmacy must submit the correct Prescribing Provider
does not have dual system authentication of hospice Identifier at POS. Claims submitted without a valid
admission, Prime asks the hospice to fax a signed Prescribing Provider NPI number will reject at POS.
hospice determination form to Clinical Review so the Reject code “619” will be displayed with message
Contact Center can notify the plan. “PrescrTyp1NPI Required.” The Pharmacy may, through
use of a Submission Clarification Code (SCC), attest
If the Covered Person was in hospice, but has since that the Prescribing Provider NPI number supplied at
been released and Prime does not have dual system POS is or will soon be a valid NPI. The Pharmacy must
authentication of hospice revocation: submit the Prescribing Provider’s NPI for all Medicare
• Prime asks the hospice to fax both the signed hospice Part D claims. Claims will be monitored on a daily
determination form and the Covered Person’s letter of basis to ensure they are submitted with the correct
revocation to Prime’s Clinical Review at 800.693.6703, Prescribing Provider Identifier.
with one of the following facts:
Prime will contact the Pharmacy to request that it correct
› The date the revocation is to be effective any claims submitted with an invalid Prescribing Provider
› The Notice of Medicare Coverage from the hospice Identifier and update its system for future claims. Failure
› The Notice of Medicare Non-Coverage (NOMNC); or to resubmit the claim(s) or update the Pharmacy’s system
for future claims with the correct identifier may result in
› The discharge notice from the hospice saying the
termination of participation in one or more Networks or
Covered Person has left hospice.
termination of the Agreement.
Provider Manual 10SECTION 3: CLAIMS PROCESSING (CONTINUED)
Documentation Days’ Supply for Medicare Part D Claims
Approved or confirmed verbal changes and clarifications The Pharmacy must submit the number of consecutive
to the Prescribing Provider’s prescription order must be days’ supply for which the prescription product is
documented on the original hard copy or electronically dispensed within the Covered Person’s benefit. Future
noted in the Pharmacy’s online system prior to refills may be rejected if the days’ supply is inaccurately
dispensing. The Pharmacy should not request changes submitted. There are some prescription products that
to a prescription for the sole purpose of avoiding POS cannot be broken in which the calculated days’ supply
messaging. For example, if a Pharmacy receives a POS may exceed common values (e.g., greater than 30 days or
message indicating a PA is required or that it must call greater than 90 days). In these instances, the Pharmacy
Prime’s Contact Center, the Pharmacy is expected to should submit the accurately calculated days’ supply.
follow the POS messaging and Prime’s Contact Center
Example: Prolia for a 180-day administration should be
instructions. Electronic documentation must be noted
submitted with a 180-day supply.
prior to dispensing and must have a system assigned
user, date and time stamp in order to take the place A small subset of prescription products cannot be
of hard copy documentation. When additional refills broken. For this subset, the smallest unit exceeds the
are ordered, a new prescription number must also be maximum benefit days’ supply and there is subjectivity
assigned and appropriately documented on a hard copy. in calculating the days’ supply (such as topical products).
In this case, the Pharmacy must submit the maximum
Days’ Supply for Non-Medicare Part D Claims
days’ supply allowed under the Covered Person’s
The Pharmacy must submit the number of consecutive Benefit Plan.
days’ supply for which the prescription product is
dispensed within the Covered Person’s benefit. Example: Covered Person’s benefit allows up to a 30‑day
Future refills may be rejected if the days’ supply is supply. One unbreakable unit may last 40 days, depending
inaccurately submitted. upon the amount used, but a course of therapy should
be limited to 28 days (e.g., clobetasol shampoo). The
For prescription products that cannot be broken (such as Pharmacy must bill the bottle as a 30-day supply.
inhalers), where the smallest unit exceeds the benefit days’
supply, the Pharmacy must submit the maximum days’ In situations where one unit does not exceed the
supply allowed under the Covered Person’s Benefit Plan. maximum benefit days’ supply (such as inhalers) the
Pharmacy must submit only the quantity dispensed
Example: Covered Person’s benefit allows up to a 30-day within the benefit.
supply. One inhaler will last 40 days. The Pharmacy must
bill the inhaler as a 30-day supply. Example: The benefit allows up to a 30-day supply. One
inhaler lasts 28 days. The Covered Person receives one
In situations where one unit does not maximize the inhaler as a 28-day supply. This will vary by Benefit Plan.
benefit’s days’ supply (such as inhalers) the Pharmacy
must submit only the quantity that is dispensed within Accurate Quantity
the Covered Person’s benefit. The quantity dispensed must be equal to or less than
the quantity prescribed and accurately reflect the exact
Example: Covered Person’s benefit allows up to a 30-day
quantity dispensed to the Covered Person. Submit the
supply. One inhaler will last 28 days. The Covered Person
exact quantity, including decimal points, on claims and
receives one inhaler as a 28-day supply. This varies by
do not round up or down.
Benefit Plan.
Provider Manual 11SECTION 3: CLAIMS PROCESSING (CONTINUED)
Dispensed Package Size/National Drug Code (NDC) Requirements for Pharmacies Contracted with 340B
When the Pharmacy submits a claim for a Prescription Covered Entities
Drug Service, the Pharmacy must submit the NDC number The 340B Drug Pricing Program requires drug
for the original package size from which the Prescription manufacturers to provide outpatient drugs to eligible
Drug Service was dispensed. The quantity of the health care entities at significantly reduced prices.
Prescription Drug Service dispensed must comply with
the dispensing limitations obtained through the online Duplicate discounts are prohibited under Prime’s
POS system. agreements with manufacturers and 42 U.S.C. 256b(a)
(5) (A)(i), and drugs purchased at a discounted 340B
Prescriptions may not be separated, dispensed and price are not eligible for drug rebates. Pharmacies must
billed by doses. If separate packaging is required, the comply with Prime’s claims processing requirements
Pharmacy must use a duplicate label. For example, a for 340B claims by submitting “20” in the NCPDP
dose required in school or adult care center should not Submission Clarification Code (420-DK) field and “08” in
be dispensed as a separate prescription. the Basis of Cost NCPDP field (423-DN).
NDC Codes To view the specific claim processing requirements,
Pharmacies are required to use standard NDC codes. please go to Prime’s website.
Timely Filing Compound Prescription Billing Guidelines
The Pharmacy must submit all claims online within 90 Pharmacies must submit Compound Prescription claims
days of the date of dispensing the Prescription Drug through the POS system using the following directions:
Service, unless otherwise required by law.
• Submit Compound Prescription with a code of “2” in
ePrescribing the Compound Code field.
The Pharmacy agrees to comply with applicable laws • Submit a zero (0) in the Product/Service ID field in the
for ePrescribing. claim segment and submit the information for each
ingredient in the compound segment.
Prescription Origin Code
• Enter the product ID qualifier, the NDC used to
The Pharmacy must submit all claims with the
prepare the Compound Prescription, quantity, cost
corresponding prescription origin code as outlined in the
and cost basis for each ingredient in the Compound
applicable Payer sheets:
Prescription.
• Written
• Submit the final product quantity (the quantity of
• Telephone the finished Compound Prescription product) in the
• Electronic quantity dispensed field:
• Facsimile (fax) › For a liquid, submit the number of mL of the finished
• Pharmacy compound product
› For capsules, submit the total number of capsules
All claims submissions must indicate the prescription
being dispensed
origin code in order to facilitate CMS reporting and
tracking of ePrescribe participation. The documentation › For creams or ointments, submit the total number of
retained by the Pharmacy must support the prescription grams being dispensed
origin code submitted on the claim.
Provider Manual 12SECTION 3: CLAIMS PROCESSING (CONTINUED)
• Submit the total ingredient cost. (For total ingredient • Compound Prescriptions containing a Medicare Part B
cost, multiply the quantity used for the individual ingredient must be processed under Medicare Part B.
ingredient and the AWP for the individual ingredient
Pharmacies are expected to observe applicable state
according to the Pricing Source at the time of dispensing
and federal laws, relevant U.S. Pharmacopoeia (USP)
for each eligible ingredient used. Then, calculate the
Chapter Guidelines, professional standards and FDA
total sum of the individual ingredient costs.)
communications when preparing and dispensing
› Plan-excluded drugs and invalid NDCs are not Compound Prescriptions. Evidence of unprofessional or
eligible for reimbursement unsafe compounding found during the Pharmacy’s audit
› Eligible ingredient costs do not include costs for process or otherwise may be reported to the applicable
labor, equipment, professional fees or flavoring State Board of Pharmacy or the FDA and may result in
• Maintain a Compound Prescription log with termination of the Pharmacy Participation Agreement.
documentation for each Compound Prescription Prime administers pharmacy benefits on behalf of many
dispensed. The log must document quantities different Benefit Sponsors. Each individual Benefit
and NDCs of the ingredients used to prepare the Sponsor determines Benefit Plan design, such as the
Compound Prescription. NDCs submitted for the specific drugs/ingredients covered, cost-sharing, days’
Compound Prescription must be the exact formulation supply limitations, and other benefit design attributes.
of what is dispensed.
The following are examples of Compound Prescription
• Prime will accept a multiple ingredient Compound
drugs where benefit designs may vary:
Prescription submission using NCPDP’s compound
segment for up to 25 ingredients. • Modified-release compounds (based on Covered
Person benefit design).
• Dynamic prior authorizations (PAs) for processing
Compound Prescriptions that contain situational • Any compound that contains active ingredients not
Medicare Part B versus Medicare Part D drugs will approved by the FDA.
not apply, even if the compound meets the criteria for • A compound for which the stability is unknown at
inclusion as a Medicare Part D covered drug. A one-time the time of dispensing or cannot be determined by
PA will be issued if the Compound Prescription claim reference of a USP-approved reference material.
meets the criteria for coverage under Medicare Part D. • For Medicare business:
• If a Compound Prescription claim rejects, the Pharmacy › Compound components
must follow POS messaging to determine if the
› Methods of administration
ingredients submitted require a PA.
› Other criteria that do not satisfy the definition of a
If a PA is required, the Pharmacy must follow the
Medicare drug
POS messaging to obtain a PA. If a PA is not required
and one or more ingredients is not covered by the • Experimental/investigational items, products or
Covered Person’s Benefit Plan, the Pharmacy may services.
use Submission Clarification Code of “08” to receive • Any finished product intended to address medical
payment for all covered ingredients. Not all benefit plans diagnosis (such as sugar-free products) where the
support the use of Submission Clarification Code “08.” Covered Person’s medical diagnosis does not support
• Each benefit set-up determines claim coverage and the need for the finished product.
may vary by Covered Person. As the Compound • Any compound that differs from the equivalent
Prescription claim is processed, the Pharmacy commercial form only by the addition of cosmetic
receives system messaging on the status of the agents or agents intended to produce a cosmetic effect.
submission. Pharmacies are required to follow all
system messaging.
Provider Manual 13SECTION 3: CLAIMS PROCESSING (CONTINUED)
The following drugs cannot be submitted to Prime as a Example: billing claims multiple times in a month to
Compound Prescription: avoid obtaining a PA or reaching plan dollar thresholds.
• Reconstituted non-sterile products, to which only • Billing claims for a new order prior to verifying the
water, alcohol or sodium chloride solution are added Prescribing Provider/Covered Person’s relationship.
to the active ingredient (e.g., children’s antibiotic • Billing Compound Prescription claims for a
suspensions, antibiotic IVs with only one legend drug). Covered Person:
• Any prescription that is subdivided into unit dose(s). › Where there is not literature that supports the
• Injectable drugs that are drawn into syringes clinical use
for administration. › Where the Pharmacy is not registered as a 503B
• Any finished product that does not include a Federal entity with the FDA
Legend Drug as an ingredient. › From a central fill pharmacy that is not contracted
• Any compound that has an equivalent commercial with Prime
form, except in situations where a Compound › In a manner that violates any federal, state or
Prescription is preferred according to the Benefit Plan. local law regarding compounding, marketing or
This exception may vary by state. dispensing compound medications
Prime also considers the following to be additional › That resulted in the Pharmacy giving or receiving
unacceptable billing practices for Compound payment to or from any Prescribing Provider
Prescription claims: for referrals
• Billing for a different NDC than what was used in the • Balance billing for any products that are not eligible for
Compound Prescription. payment determined by the Benefit Sponsor or CMS.
• Billing for the full package size when only a partial • Billing for compounds where the final product is not
amount was dispensed to the Covered Person. prepared in compliance with USP guidelines.
• Billing for a different dosage form than what was used If you have questions regarding compound drugs, please
in the Compound Prescription. call Prime’s Contact Center at 800.821.4795.
• Billing for a quantity other than what was used to
Insulin and Diabetic Supply Benefits
prepare the Compound Prescription.
• A valid prescription must be on file for insulin
• Any Compound Prescription to which active ingredients
dispensed to a Covered Person.
are added that were not part of the prescription order.
• An emergency fill can be dispensed by the pharmacist
• Not following POS messaging, including, but not
as allowed by applicable law.
limited to, messaging for rejected claims.
• Insulin should be dispensed within the days’ supply
• Obtaining changes to Compound Prescription orders to
limits set by the Covered Person’s Benefit Plan.
avoid POS messaging.
• Specific dosing directions must be documented at
• Phishing for a drug that pays (e.g., Pharmacy submits
the time of dispensing. If a sliding scale is used, the
a claim for one drug, received a reject or reverses the
Pharmacy must obtain and document maximum and
claim and resubmits for a new drug within a short
minimum quantities at the time of dispensing.
period of time).
Directions limited to “Use as Directed” are not accepted.
• Billing each compound ingredient as a separate
Prescription Drug Service claim.
• Billing claims in a manner that bypasses system
messaging requiring further review.
Provider Manual 14You can also read
