Pharmacy pre-authorization

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Regence LevelRx™

Regence LevelRx is effective January 1, 2024, for fully insured group and Individual plan members, through a filed Provider-Administered Specialty Medication benefit. Medicare Advantage and administrative services only (ASO) members will not have this new benefit in 2024.

Implementation of this program will continue into 2024. Here’s what this means for you:

From January 1, 2024, to June 30, 2024: As we work with providers to contract with the Prime IntegratedRx - Medical® network and become a designated provider for this program, from January 1, 2024, to June 30, 2024, all Regence network providers are designated as eligible to provide medications included in the Regence LevelRx program (subject to otherwise applicable conditions) to members with this benefit. This means that members can continue to receive medications from you as they do today, and claims for medications included in this program will be processed based on your existing contract terms with us.
- Medications included in this program must be pre-authorized according to our medication policies, including the new Provider-Administered Specialty Drugs (dru764) policy, effective January 1, 2024.
Effective July 1, 2024: We expect providers to be contracted with the IntegratedRx - Medical network to be reimbursed for administering medications included in the Regence LevelRx program to members with this benefit.
- The medication portion of the claim will be adjudicated under the terms and rates of the agreement you have with Prime.
- Medications included in this program must be pre-authorized according to our medication policies and require administration by a participating IntegratedRx - Medical provider to be covered under the member’s benefits.
- If you have not contracted with Prime by July 1, 2024, provider-administered medications included in the Regence LevelRx program will not be covered for members with that benefit. There will be no change in reimbursement or experience for members who do not have this benefit.
Notes:
With this program, you will continue to submit claims directly to us as you do today.
For members included in the Regence LevelRx program, any provisions in existing provider agreements between Regence and the provider group or facility that address provider-administered medications and reimbursement schedules do not apply for the select list of provider-administered specialty medications in Regence LevelRx.
For members not included in the Regence LevelRx program, reimbursement for provider-administered medications will continue under your existing Regence provider agreement terms.

Join the Prime Therapeutics IntegratedRx - Medical Network

Prime Therapeutics is currently credentialing and contracting providers for this new network. If you have not already, please reach out to your Prime contact now to complete the process of credentialing and contracting for the IntegratedRx - Medical Network.

If you have not yet contracted with Prime by July 1, 2024, we will work closely with you and our members to ensure they continue to have uninterrupted access to their treatment.

Each provider group or facility that administers specialty medications needs to be credentialed and contracted as a dispensing provider with Prime Therapeutics.
If your organization operates a specialty pharmacy that you want included in this network, your specialty pharmacy will need to complete the credentialing process to be included, even if they have an existing pharmacy contract with Prime Therapeutics.
Your contract with Prime will have a reimbursement schedule that includes the medications in the Regence LevelRx program.

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
Vaccines	Covered vaccines are usually eligible under medical benefits and can be included in the medical claim (for commercial and Medicare) except those that CMS has designated as Medicare Part D for Medicare patients. For Washington members: Vaccines provided under the Washington Universal Vaccine Program should be billed to the health plan as directed in the Washington Vaccine Association Private Insurance Assessment Billing Provider Guide.
Infusion medications	Certain infusion medications are subject to the Site of Care Program (dru408) medication policy (PDF) For other infusion medications, each medication policy states whether the drug is considered self-administered or not. Self-administered medications are generally covered by the patient's pharmacy benefit. Claims for those that are considered non-self-administered should be submitted as a medical claim.