Pharmacy benefits manager
Prime Therapeutics (Prime) is our pharmacy benefits manager (PBM). Prime administers our pharmacy benefits, provides customer service and manages an extensive retail network. Home delivery and specialty pharmacy services are delivered through AllianceRx Walgreens Prime, a joint venture between Prime and Walgreens.
This PBM is in place for our group, Individual and Medicare members. BlueCross BlueShield Federal Employee Program (BCBS FEP®) and BlueCard members are excluded, as well as members on administrative services only (ASO) groups and joint administration groups that use a different PBM.
Prime has web-based tools to help you submit pharmacy pre-authorization requests and submit claims for medications administered in your office.
Members who take maintenance medications for a chronic condition can eliminate trips to the pharmacy and have prescriptions shipped directly to them. Our home delivery program through AllianceRx Walgreens Prime also allows them to get 90-day supplies and automatic shipments to ensure patients don't miss a dose.
Some of our benefit plans may require patients to get long-term medicines through our home delivery program.
We have negotiated lower prices with our preferred network of pharmacies. Some of our prescription benefits include lower copays and coinsurance for prescriptions filled at preferred pharmacies.
When your patients receive their prescription medications from our preferred pharmacy network, they will generally pay less out-of-pocket. There are thousands of pharmacy locations in our preferred network, including regional chains such as Walgreens.
Members can still get prescriptions at any pharmacy, but they will generally get the best price at a preferred pharmacy. Search for pharmacies and compare costs using the Find a Pharmacy links on this page.
Pre-authorization is required on some medications before they will be covered. Review the medication policies and pre-authorization requirements link on the right.
CoverMyMeds works with electronic medical record systems (EMRs), health plans, pharmacy systems and providers to streamline the process of requesting pre-authorization for medications.
We recommend you use this web-based tool to submit and track requests online for our members. You can be assured the information you've sent is complete, eliminating extra phone calls or faxes, and allowing a faster determination and response.
You can also access a variety of provider support tools including a user guide and training videos from CoverMyMeds.
Pre-authorization for specialty medications
Pre-authorization for certain specialty medications is required for CHG Healthcare Services (group #70000004) members and IEC Group (group #70000000) members. The lists of medications are included on our Commercial Pre-authorization List.
Submit pre-authorizations for these specialty medications to VIVIO Health Help Desk at 1 (925) 365-6600. This phone number should only be used for pre-authorizing specialty medications for these members.
Note: Effective January 1, 2020, pre-authorization for specialty medications will be required for Alsco Inc. (group #70000002) members. The list of medications is included on our Commercial Pre-authorization List.
Pharmacy Peer-to-Peer Review Request form
If you would like to speak with a clinical reviewer about the denial of a provider-administered medication pre-authorization request, please complete the Pharmacy Peer-to-Peer Review Request form to arrange for a peer-to-peer (P2P) discussion. For retail (self-administered) medications, please call Pharmacy Customer Service at 1 (844) 765-6827.
Note: All medication-related calls will be routed to a Regence clinical pharmacist. If there are questions that the clinical pharmacist is unable to answer, the clinical pharmacist will schedule a call with a Regence medical director.
Submitting claims for medications provided in your office
Please include the National Drug Code (NDC) on medical drug claims. Learn more about NDCs.
Specific information is required for pharmacy claims, which cannot be submitted on a standard electronic medical claim. If a claim for a medication that is only covered under the member's pharmacy benefit is submitted to the medical plan, it will be denied as a member responsibility.
If the patient pays you directly for the medication, the patient can submit proof of payment to us for reimbursement under their pharmacy benefit. However, this may be cost-prohibitive for patients receiving expensive medications. Please submit claims for pharmacy benefits through TransactRx.
TransactRx is an online billing solution that allows you to submit claims online for outpatient medications and vaccines that are covered under your patient's pharmacy benefits, but provided in your office or outpatient setting. This will ensure that we receive the correct information to process the pharmacy claim. This tool can help you to streamline and automate claims processing for medications administered or dispensed in your office.
Register to use TransactRx and review other provider support materials.
Claims for medications should be submitted to either the health plan or our PBM as follows:
|Services provided||To be reimbursed directly for medications provided during a visit/stay|
|Ambulatory surgery center (ASC)||Include in medical claim|
|Emergency room||Include in medical claim|
|Home health||Include in medical claim|
|Hospital or other inpatient setting||Include in medical claim|
|Medical or dental provider/clinic||Include in medical claim if covered under medical benefits Submit claim to TransactRx if covered under Rx benefits|
|Pharmacy||Pharmacy submits claim through PBM|
|Skilled nursing facility (SNF)||Include in medical claim|
|Urgent care||Include in medical claim|