Pharmacy Services assists our providers and members with prescription benefits, toolkits and other relevant information.
Some medications require pre-authorization (also called prior authorization) to be covered by the member's insurance plan.
The resources on the right will help you find:
- Medication list updates
- Pre-authorization requirements
- Explanation of limits or quotas
- Medication policies (Note: All medications with associated medication policies require pre-authorization)
- Instructions for ordering specialty medications
- Instructions to request an exception
- Information about our special member programs
- Process for generic substitution, therapeutic interchange and step-therapy protocols
Pain management toolkit
We've brought related policies, programs and other resources together in a Pain management toolkit to support your efforts to help our members.
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.
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 that the information sent will be 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.
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 visit/stay|
|Ambulatory surgery center (ASC)||
|Hospital or other inpatient setting||
|Medical or dental provider/clinic||
|Skilled nursing facility (SNF)||
When a claim for an outpatient medication or vaccine that is only covered under the pharmacy benefit is submitted to the medical plan, we deny the claim as a member responsbility. You have two options for receiving reimbursement in this situation. You can:
- Submit the medication through TransactRx and be reimbursed directly, or
- Bill the patient and the member can submit their receipts to us for reimbursement
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 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.