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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.

Mail order

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.

Preferred pharmacies

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 the right.

Pre-authorizing medications

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.

Note: Effective November 1, 2018, pre-authorization for certain specialty medications will be required for CHG Healthcare Services (group #70000004) members. See the Pre-authorization for CHG Healthcare Services members section below.

Pre-authorization for CHG Healthcare Services

Effective November 1, 2018, pre-authorization for certain specialty medications will be required for CHG Healthcare Services (group #70000004) members. These members are part of our joint administration partnership with AmeriBen.

Submit pre-authorizations for these specialty medications to VIVIO Health Help Desk at 1 (800) 470-4034:

J0638, J0795, J1300, J1726, J1931, J2170, J2793, J2941, J3285, J3490, J3590, J7686, J7687, J7688, J7689, J8499, J8565, J9226, J9262, J9266, J9305

Please review the complete list of specialty medications that require pre-authorization (PDF) for these members because some of the medications do not have J codes and are therefore not listed above.

Submitting claims for medications provided in your office

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
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 by the program.
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.

 

Please include the National Drug Code (NDC) on medical drug claims. Learn more about NDCs.

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.

Please sign up to use TransactRx and review other provider support materials on their website.