[PDF] Prime Therapeutics Provider Manual for Pharmacy Providers 1Q2021





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Prime Therapeutics Provider Manual for Pharmacy Providers 1Q2018

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Key Takeaways

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PRIME THERAPEUTICS

PROVIDER MANUAL

FOR PHARMACY PROVIDERS

Eective April ,

???? 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 LLC

PRIME THERAPEUTICS

PROVIDER MANUAL

WFOR PHARMACY PROVIDERS

I

Provider Manual

TABLE OF CONTENTS

INTRODUCTION TO PRIME THERAPEUTICS ..?

Introduction ......................................? Provider Manual ...................................?

SECTION : PRIME CONTACT INFORMATION.?

Prime Mailing Address..............................? Prime's Contact Center..............................? Prime's website....................................?

SECTION : COMPLIANCE ......................?

Report Compliance, Privacy, or Fraud, Waste

and Abuse Concerns Compliance Program ...............................? Fraud, Waste and Abuse (FWA) ......................? Annual Attestation Requirement ..................?

Medicare Part D FWA and General Compliance

Pharmacy Training and Certi?cation

Reporting of Suspicious Activity ..................? Notice to California Pharmacies......................?

Pharmacy Reporting.............................?

Pharmacy Bill of Rights ..........................?

SECTION : CLAIMS PROCESSING.............?

General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ?

Online Claims Submission........................?

Online Availability...............................?

Claim Formats ..................................?

Medicare Reference Materials ....................? Collection of Copay/Cost Share ...................? Covered Person Identi?cation Card................? Covered Person Eligibility ........................

Covered Person Protection .......................

Controlled Substance Prescription Dispensing

Considerations

Claims Process for Multiples...................... Medicare E? Eligibility Query .....................

Medicare and Medicaid Dual Eligible

Covered Persons

Quali?ed Medicare Bene?ciary Program ...........

Best Available Evidence (BAE) .................... Hospice Best Available Evidence (BAE) ...........? Submitting the Claim ..............................?

Bank Identi?cation Number (BIN) and Processor

Control Number (PCN)

National Provider Identi?er (NPI).................?

Documentation ................................??

Days" Supply for Non-Medicare Part D Claims......?? Days" Supply for Medicare Part D Claims ..........??

Accurate Quantity..............................??

Dispensed Package Size/National Drug Code (NDC) ??

NDC Codes ....................................??

Timely Filing...................................?? Prescription Origin Code ........................??

Requirements for Pharmacies Contracted with ??B

Covered Entities

Compound Prescription Billing Guidelines.........?? Insulin and Diabetic Supply Bene?ts .............??

Insulin Supplies................................?

Long-Term Care (LTC) and Home Infusion (HI)

Processing Requirements

Hemophilia Billing Guidelines ...................?

Medicare Programs Coordination of Bene?ts (COB).?

Time Limits for Coordination of Bene?ts...........? Medicare Parts A & B vs. D Claims Adjudication . . . . ?? Utilization Management Program ...................??

Drug Formularies...............................??

Medicare Drug Formularies......................??

Prior Authorization (PA).........................??

Electronic Submission of PA Requests Supported by

CoverMyMeds

Step Therapy (ST)/Contingent Therapy Programs...?

Quantity Limit (QL) .............................? Drug Utilization Review (DUR)....................?

Maximum Allowable Cost (MAC) .................?

II

Provider Manual

SECTION ?: BENEFIT PLAN ....................??

Post Claim Adjudication............................?? Return to Stock — Unclaimed Prescriptions........?? Notice of Payment Error.........................?? Bene?t Plan Design ...............................?? Pharmacy Networks...............................?? Long-Term Care (LTC) Guidelines ....................?? Services Provided to FamilyMembers ...............?? Product Selection Code(PSC).......................?? Generic Substitution ..............................??

Generic Drug Standards.........................??

Enhanced Pharmacy Programs......................?? Vaccine Administration .........................??

Medication Therapy Management (MTM)..........??

Medicare Part D Transition Process..................??

Prescription Drugs Not on Medicare Part D

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