From the Auditor s Desk. How to Avoid Common Billing Errors

Transcription

1 Prime Perspective Quarterly Pharmacy Newsletter from Prime Therapeutics LLC November 2012: Issue 54 From the Auditor s Desk INSIDE Medicare News/Medicaid News..3 Alabama News...6 Florida News...6 HCSC News (BCBSIL, BCBSNM, BCBSOK and BCBSTX)...6 Kansas News...7 Nebraska News...7 Clearstone News...7 New Plan Announcements MAC List Updates...19 How to Reach Prime Therapeutics Notes...21 How to Avoid Common Billing Errors Some drugs are supplied in complex packaging and the correct billing quantity for the product may not be immediately apparent to the Participating Pharmacy. For this reason, Prime Therapeutics (Prime) has provided a listing of common billing errors on the Prime corporate website. The information includes drug-specific information and correct billing methods. The Common Billing Errors Guide can found at: PrimeTherapeutics > Pharmacists > Pharmacy Audit > Common Billing Errors Prescriber Identification Submissions Prime and its Benefit Sponsors rely on accurate prescriber identification numbers (Prescriber IDs) to be submitted on pharmacy claims in order to facilitate proper payment of pharmacy claims, carry out health care operations, and conduct disease management initiatives. Inaccurate Prescriber ID information on claims can cause significant downstream impacts that may not be apparent to the Prescribing Provider and the Participating Pharmacy. Below are some of the ways Prime and our Benefit Sponsors use Prescriber IDs:* Prescriber Debarment and SanctionChecks at Point-of-Sale: Pharmacy claims related to an order authorized by a Prescribing Provider who is sanctioned or debarred from state or federal healthcare programs are not eligible for coverage under Medicare Part D and other government products. The Center for Medicare and Medicaid Services (CMS) requires Medicare Part D plans to edit claims to check for sanctioned or debarred Prescribing Providers during adjudication and reject these claims at the point-of-sale. Submission of inaccurate Prescriber ID data prevents the claims system from accurately identifying and rejecting claims prescribed by sanctioned or debarred Prescribing Providers and may result in the Participating Pharmacy dispensing a prescription that is not eligible for coverage and therefore subject to audit recovery. continued 3833 Prime Therapeutics LLC 11/12

2 Medication therapy management programs Prime provides a medication therapy management (MTM) program to certain Medicare Part D Covered Persons who meet specific criteria. This program utilizes claims data, including the Prescriber ID submitted by the Participating Pharmacy, to help Covered Persons coordinate multiple prescription therapies for complex health conditions. Inaccurate Prescribing Provider data on claims may delay the delivery of MTM services to these Covered Persons, and/or cause inadvertent Personal Health Information (PHI) disclosures when the incorrect Prescriber ID is submitted. Disease management programs Prescriber IDs are also used in the delivery of disease management programs administered by Prime or our Health Plan Sponsors. Disease management programs review prescription claims data to identify situations where there may be an opportunity to reach out to Prescribing Providers to improve a Covered Person s care. Submission of inaccurate Prescriber ID data can cause communications to be sent to the incorrect Prescribing Provider, resulting in a PHI disclosure. Additionally, inaccurate Prescriber ID submissions may impair the effectiveness of disease management programs because the correct Prescribing Provider data is not available on the claim to facilitate these important outreaches. *Not intended to be an exhaustive list. Prescriber Identification Submissions Inaccurate Prescribing Provider data may also cause issues at the Participating Pharmacy. Attributing a prescription to the wrong Prescribing Provider in the Participating Pharmacy system may cause treatment delays when there is a need to reach out to the Prescribing Provider to ask a question or request additional refills, in addition to inadvertent PHI disclosures made when the Participating Pharmacy contacts the incorrect Prescribing Provider. Due to the negative downstream impacts caused by inaccurate prescriber identifiers on pharmacy claims, the issue has become a topic of concern at the federal level. Regulatory agencies that oversee federal health programs, such as CMS and the Office of the Inspector General (OIG), have issued reports regarding the prevalence of inaccurate prescriber data. In turn, Benefit Sponsors are requiring increased monitoring and oversight of Prescriber ID submissions. Please take the following steps to ensure Prescriber IDs submitted to Prime are accurate: Ensure the Prescriber ID submitted on the claim matches the information on the prescription hardcopy. Note that submitting a claim with the incorrect Prescriber ID will result in recovery during an audit. For example, prescription is written by Dr. Smith and pharmacy bills with the National Provider Identifier (NPI) for Dr. Nelson. Be alert to similar Prescribing Provider names. Do not submit dummy Prescriber ID numbers, such as AR Note that if Prime identifies a trend with a Participating Pharmacy billing dummy Prescriber IDs during an audit, the claims may be subject to recovery. If the Prescribing Provider s signature cannot be identified on the prescription, take action to identify the correct Prescribing Provider. Ask the Covered Person which Prescribing Provider they saw, or call the Prescribing Provider s office to clarify. Document the clarified information on the hardcopy. Implement controls to ensure the Prescriber IDs populated in the Participating Pharmacy s computer system are complete and accurate. In addition to causing processing problems that may lead to audit recoveries, Participating Pharmacies are subject to obligations to maintain accurate records and provide those records to Covered Persons on demand under the Health Insurance Portability and Availability Act of 1996 (HIPAA). Failure to accurately capture and transmit an accurate Prescriber ID can lead to between $100 $50,000 in fines per claim submitted. 2 Prime Therapeutics LLC

3 Medicare news/medicaid news Medicare Part D FWA Participating Pharmacy Training and Certification The Centers for Medicare and Medicaid Services (CMS) requires any staff providing Medicare Part D services to receive qualified Fraud, Waste and Abuse (FWA) training upon hire, and annually thereafter. Every year, on behalf of the Part D Plans Sponsors it serves, Prime is required to track completion of this training by all Participating Pharmacies in its network. Accordingly, Participating Pharmacies must submit to Prime certification that the Participating Pharmacy has completed a qualified FWA training program and is therefore in compliance with the training requirement. All pharmacy certifications for calendar year 2012 are due to Prime by December 31, FWA training program and certification can be found at PrimeTherapeutics.com > Pharmacists > Annual Fraud, Waste and Abuse (FWA) Training and Attestation > FWA Training and Certification Options Pharmacy Re-credentialing In accordance with 42 CFR Code of Federal Regulations Title Provider Selection and Credentialing, Prime is currently in the process of re-credentialing all Participating Pharmacies within its pharmacy network. This initiative supports Prime s Medicare Part D oversight requirements and obligations to maintain a high quality pharmacy network. Please complete the Exhibit A Pharmacy Location and Credentialing Verification form, which was mailed to all Participating Pharmacies, and return it with the supporting documentation as quickly as possible in order to ensure your pharmacy s continued participation. The re-credentialing Exhibit must be completed within 30 days of receipt in order to prevent any interruption in reimbursement for Medicare Part D services. Long term Care facility Short Cycle Drug Dispensing Update CMS considers waste to occur when a Medicare Part D drug is dispensed to Medicare Part D Covered Persons residing in a Long Term Care (LTC) facility and billed to a Medicare Part D Health Plan Sponsor, but is not consumed by the Medicare Part D Covered Person. Unused drugs may occur if a drug is discontinued, the Covered Person is discharged, is hospitalized, or died leaving unused dispensed drugs. Effective January 1, 2013, all Participating Pharmacies servicing LTC facilities must dispense solid oral doses of brand-name drugs to Medicare Part D Covered Persons residing in LTC facilities in no greater than 14-day increments at a time in accordance with 42 CFR , except to the extent such requirements have been waived. Below are Prime s processing guidelines for LTC Short Cycle claims: Covered Person copays will be pro-rated for daily cost sharing as directed by CMS, based on the days supply of the incoming pharmacy claim Prime will pay a dispensing fee on each dispensing event (Billed as Dispensed). If a LTC pharmacy bills only once a month, Prime will pay up to three dispensing fees on the one point-of-sale (POS) billing transaction. Effective January 1, 2013, Prime will reject LTC facility claims that are submitted with invalid or missing Submission Clarification Code (SCC) combinations The following NCPDP fields must be submitted on all LTC Short Cycle claims: NCPDP Field 147-U7 Pharmacy Service Type NCPDP Field 307-C7 Place of Service NCPDP Field 384-4X Patient Residence NCPDP Field 997-G2 CMS Part D Defined Qualified Facility Further processing guidelines for LTC Facility Short Cycle Dispensing will be communicated in the near future. Prime Therapeutics LLC 3

4 Medicare news/medicaid news (continued) 2013 NPI Prescriber ID Effective January 1, 2013, Prime will begin to reject Medicare Part D claims that do not have an active and valid individual Prescriber Id. Claims will reject with the following point-of-sale (POS) rejection message(s): NCPDP Reject Code 71: Sanctioned Provider > This reject cannot be overridden by the Participating Pharmacy NCPDP Reject Code A2: Deceased Prescriber (March 2013 Reject Implementation) NCPDP Reject Code 42: NPI inactive or Not found NCPDP Reject Code 43: DEA inactive NCPDP Reject Code 44: DEA not found NCPDP Reject Code46: DEA not authorized for DEA drug class Per CMS, participating Pharmacies are required to resubmit the rejected claim within 24 hours after they confirm the submitted Prescriber ID is active, valid and the Prescribing Provider has prescriptive authority. The rejected claim can be resubmitted using a valid NCPDP Submission Clarification Code (SCC). For software setup information, please visit Prime s website at: PrimeTherapeutics.com > Pharmacists > Payer Sheets > Medicare Part D D.0 Payer Sheet Prime will be monitoring Medicare Part D claims that have been rejected and submitted with SCC codes. Prime will contact the Participating Pharmacy to correct any claims identified that were submitted with either an incorrect or invalid prescriber Identification number. In addition, Participating Pharmacies are required to update their system for future claims. Participating Pharmacies must have processes in place to ensure that they are submitting an active and valid Prescriber ID at POS. Failure to resubmit the claim or update the pharmacy system for future claims may result in audit recoveries. MTM Program Enhancements Prime s Medication Therapy Management (MTM) program continues to provide care to Medicare Part D Covered Persons that meet the 2013 MTM criteria: Three chronic disease states Six or more chronic Part D medications A drug spend of $3,144 or more annually As required by Section of the Affordable Care Act amended section 1860D-4 (c) (2) (ii), CMS and Prime Therapeutics on behalf of its Medicare Part D Benefit Sponsors must implement two significant changes to the 2013 MTM program. Effective January 1, 2013, the following CMS required MTM program enhancements will be implemented: 1. All Medicare Part D plan sponsors must begin the use of three (3) standardized document formats developed by CMS. After the completion of an MTM comprehensive medication review (CMR) the Medicare Part D Covered Person is sent the following information in CMS standardized formats: Cover Letter (CL) Medication Action Plan(MAP) Personal Medication List (PML) 2. Medicare Part D MTM enrolled Covered Persons residing in a Long Term Care (LTC) facility will be sent an MTM invitation letter to encourage the Covered Person to complete a CMR. Prime s MTM program may also perform outreach to LTC pharmacies to ascertain which skilled nursing facility LTC Covered Persons reside in to extend the CMR offer. Prime s MTM program may also contact LTC facilities to obtain Brief Interview for Mental Status (BIMS) scores to determine if Covered Persons are cognitively impaired. If a Covered Person is cognitively impaired, Prime s MTM program will perform additional outreach to a Covered Person s other authorized representative or provider to complete a CMR. Fulfillment of these 2013 CMS MTM requirements will enable Prime to provide its Medicare Part D Benefit Sponsors with a compliant program. MTM provides Covered Persons with important and useful medication information. The information helps Covered Persons use medications safely and provides knowledge and encouragement for medication use adherence. 4 Prime Therapeutics LLC

5 Discounts for Medicare Beneficiaries Effective January 1, 2013, the Medicare Coverage Gap Discount Program will make two discounts available to eligible Medicare Covered Persons receiving applicable covered Part D drugs while in the coverage gap. The discount on the drug will be provided at POS on behalf of participating manufacturers. These discounts are part of an effort to close the coverage gap phase by The two discounts available are as follows: Brand Drug Discount: For 2013, a 50 percent manufacturer discount and a 2.5 percent Benefit Sponsor discount will be applied toward the amount the Covered Person would normally pay for claims processed wholly or partially in the coverage gap. Generic Drug Discount: For 2013 a 21 percent discount will be applied toward the amount the Covered Person would normally pay on generic drug claims processed wholly or partially in the coverage gap. In order to participate in the Medicare Coverage Gap Discount Program, manufacturers must sign an agreement with CMS to provide the discount on all of their applicable drugs (i.e. prescription drugs approved or licensed under new drug applications or biologic license applications). Additive Toxicity Monitoring Effective January 1, 2013, Benefit Sponsors will begin implementing additive toxicity monitoring at POS. This Covered Person monitoring program is designed to monitor the adjudication of acetaminophen (APAP) targeted drugs and prevent the dispensing of unsafe daily doses of APAP by calculating the total APAP consumption across multiple active prescriptions. Participating Pharmacies are expected to review additive toxicity DUR alerts with Covered Persons and/or Prescribing Providers before professional pharmacy service (PPS) codes are used to override an associated claim reject. When a target drug, in conjunction with other active prescriptions, creates a potential unsafe daily dose of APAP, the claim for the target drug will reject at POS with the following reject message: NCPDP Reject Code 88: DUR Reject Error. Additive toxicity: Acetaminophen daily dose > 4 grams Secondary messaging: Intervention req, Submit PPS codes to override reject, Call Only those applicable drugs that are covered under a signed manufacturer agreement with CMS will be covered under Part D. If a particular drug is not covered under Part D, it will reject with the following POS rejection messages: NCPDP Reject Code 70: Prod/Service Not Covered Secondary Message: Manufacturer not participating in Manufacturer Discount Program To minimize Covered Person disruption, Participating Pharmacies must contact the Prescribing Provider to ask if the prescription can be changed to a covered manufacturer s alternate product. For more information or a list of participating manufacturers (Labeler List), please refer to the CMS website at: cms.gov > Medicare > Prescription Drug Coverage General Information > Part 2013 NPI Prescriber ID Prime Therapeutics LLC 5

6 Alabama news Generics Plus Formulary Update Effective October 1, 2012, the ALL Kids health benefit plan began using the Generics Plus Formulary. This change will help reduce the overall growth in health care costs. The Generics Plus Formulary includes generic drugs plus a select number of brand drugs. Please refer to the Blue Cross and Blue Shield of Alabama website at: bcbsal.com > Providers > Pharmacy Resources > Prescription Drug Guide Florida news Florida Blue Welcomes the Following New Client Groups: Effective October 1, 2012 > St. Lucie County Sheriff s Office Effective January 1, 2012 > City of Jacksonville > Aon Hewitt Exchange Darden > Charlotte County Sheriff s Office Florida Blue Utilization Management Programs UM program updates for the upcoming quarter, when available, will be posted at PrimeTherapeutics.com > Pharmacists > Formulary > UM Program Updates. HCSC news (BCBSIL, BCBSNM, BCBSOK and BCBSTX) Utilization Management Programs Effective January 1, 2013, HCSC plans, unless otherwise noted will implement the following utilization management programs listed below. Prior authorization: Kalydeco Letairis/Tracleer (formerly step therapy; now prior authorization) Acthar HP Gel (TX, HCSC GenericsPlus; effective 10/1/2012 for IL, OK & NM) Step therapy: Iron Chelator (targets Ferriprox) Dispensing Limits: Medications used in the treatment of Attention Deficit Hyperactivity Disorder (ADHD) and related conditions (IL, OK and TX; effective 10/1/2012 for NM). Gabapentin Extended Release: Gralise, Horizant Hereditary Angioedema (HAE): Firazyr, Kalbitor Kansas news Utilization Management Programs Effective January 1, 2013, Blue Cross and Blue Shield of Kansas will implement the following utilization management programs for fully insured Covered Persons: Prior authorization for oral, topical and injectable Androgens and Anabolic Steroids, with topical products requiring the use of the preferred products Androderm and AndroGel Use of preferred glucose test strips by Bayer and Roche (ACCU-CHEK Nano, ACCU-CHEK Aviva Plus, Bayer CONTOUR, Bayer CONTOUR NEXT EZ, and Bayer BREEZE 2). Prior authorization required for use of a non-preferred glucose test strip. No coverage for brand name statins with a generic available: Lipitor, Lescol, Mevacor, Pravachol and Zocor 6 Prime Therapeutics LLC

7 Nebraska news Extended Supply Network Effective January 1, 2013, Covered Persons of Valmont Industries, a group of Blue Cross and Blue Shield of Nebraska, will begin utilizing Prime's National Extended Supply Network. Covered Persons will continue to use current ID cards and there will be no change to the processing requirements. Participating Pharmacies not currently enrolled in Prime s National Extended Supply Network may contact [email protected] to enroll. Clearstone news Northern Plains Alliance (ClearStone) terming Region 19 MA-PD (MedicareBlue PPO and Group MedicareBlue PPO) product Effective January 1, 2013, Northern Plains Alliance (ClearStone) will be terminating their Region 19 MA-PD (MedicareBlue PPO and Group MedicareBlue PPO) product. Participating Pharmacies will no longer be able to submit claims for dates of service after December 31, 2012, for Medicare Covered Persons for the following BIN and PCN combinations: Plan Name BIN PCN Northern Plains Alliance BCBS of Minnesota Employer Groups MA-PD Region 19 61Ø455 MPD19 Northern Plains Alliance BCBS of Montana Employer Groups MA-PD Region 19 61Ø455 MPD19 Northern Plains Alliance BCBS of North Dakota Employer Groups MA-PD Region 19 61Ø455 MPD19 Northern Plains Alliance BCBS of Nebraska Employer Groups MA-PD Region 19 61Ø455 MPD19 BCBS of Iowa Employer Groups MA-PD Region 19 61Ø455 MPD19 BCBS of South Dakota Employer Groups MA-PD Region 19 61Ø455 MPD19 Northern Plains Alliance BCBS of Wyoming Employer Groups MA-PD Region 19 61Ø455 MPD19 If you have any questions regarding processing claims, please call the Prime Contact Center at Prime Therapeutics LLC 7

8 New Plan Announcement Blue Cross Blue Shield of Alabama BlueRx (PDP) Employer Group Effective January 1, 2013 Effective January 1, 2013, Prime Therapeutics (Prime) will begin processing Medicare Part D for the following employer groups of Blue Cross Blue Shield of Alabama: State of Alabama and Local Government Medicare eligible Covered Persons. To ensure uninterrupted service to Participating Pharmacies and Covered Persons, please use the following information to set up your system prior to January 1, BCBSAL BlueRx (PDP) Employer Group Part D BIN: PCN:... RPDG Covered Person ID Number For More Information Medicare Part D claims with a fill date after January 1, 2013 must be submitted with the BIN/PCN outlined on the left If you have questions regarding claims processing, please contact Prime s Contact Center at For software setup information, please visit Prime s website at PrimeTherapeutics.com > Pharmacists > Payer sheets > Medicare Part D D.0 Payer Sheet For Prime s helpful resources for Medicare Part D coverage and issues, please visit: PrimeTherapeutics.com > Pharmacists > Medicare Part D > Medicare Resources > Helpful Resources Date of Birth Gender Group Number U&C Days Supply Pharmacy NPI Prescriber ID (NPI or DEA) Date Rx Written Rx Origin Code Featured below are examples of most common ID cards used: 8 Prime Therapeutics LLC

9 New Plan Announcement Blue Cross and Blue Shield of North Carolina Senior Market Effective January 1, 2013 Effective January 1, 2013, Prime Therapeutics (Prime) will begin processing claims for Covered Persons of Blue Cross and Blue Shield of North Carolina (BCBSNC) Senior Market. To ensure uninterrupted service to Participating Pharmacies and Covered Persons, please use the following information to set up systems prior to January 1, Covered Person ID Number Date of Birth Gender Group Number U&C Days Supply Pharmacy NPI Prescriber ID (NPI or DEA only; UPIN when allowed) 2012 Outstanding Claims Reversals and Processing To prepare for this transition, Participating Pharmacies should complete all claims processing and reversals by close of business December 31, Medicare Part D claims with a submission or reversal date prior to January 1, 2013 will reject at point-of-sale. The claim will reject with the following message: DOF prior to 1/1/13 submit to BIN Please use the following information to set up systems for submissions or reversals with a date of fill prior to January 1, 2013: BIN: PCN Medicare Part D: MEDDPRIME Rx Group: NCPARTD For assistance with claims that have a date of fill prior to January 1, 2013, please contact MEDCO at For More Information Date Rx Written Prescription Origin Code Plan Sponsor Plan Name BIN PCN Group Number BCBSNC Blue Medicare HMO Standard (MA-PD) HMONC NCPART D Blue Medicare HMO Enhanced (MA-PD) BCBSNC Blue Medicare PPO Enhanced (MA-PD) PPONC NCPART D Blue Medicare PPO Enhanced Freedom (MA-PD) BCBSNC Blue Medicare Rx Standard (PDP) PDPNC NCPART D Blue Medicare Rx Enhanced (PDP) BCBSNC Blue Medicare HMO Enhanced Employer Group (MA-PD) HMONCG NCPART D BCBSNC Blue Medicare PPO Enhanced Freedom Employer Group (MA-PD) PPONCG NCPART D BCBSNC Blue Medicare Rx (PDP) Enhanced Employer Group PDPNCG NCPART D (continued) Prime Therapeutics LLC 9

10 Blue Cross and Blue Shield of North Carolina Senior Market (continued) For More Information Beginning January 1, 2013, for assistance with claims processing on Prime s platform, please contact the Prime Contact Center at Prime s Medicare Part D payer specification sheet is available at: PrimeTherapeuticstics.com > Pharmacists > Payer Sheet > Medicare Part D D.0 For Prime s helpful resources for Medicare Part D coverage and issues, please visit: PrimeTherapeutics.com > Pharmacists > Medicare Part D > Medicare Resources > Helpful Resources Featured below are examples of most common ID cards used: Front and back of BCBSNC BlueMedicare HMO (MA-PD) ID Card Front and back of BCBSNC BlueMedicare PPO (MA-PD) ID Card Front and back of BCBSNC BlueMedicareRx (PDP) ID Card 10 Prime Therapeutics LLC

11 Blue Cross and Blue Shield of North Carolina Senior Market (continued) Front and back of BCBSNC Employer Group BlueMedicare HMO (MA-PD) ID Card Front and back of BCBSNC Employer Group BlueMedicare PPO (MA-PD) ID Card Front and back of BCBSNC Employer Group BlueMedicareRx (PDP) ID Card Prime Therapeutics LLC 11

12 New Plan Announcement Blue Cross Blue Shield of Minnesota Blue Essentials Medicare Part D and Part B Effective January 1, 2013 Effective January 1, 2013, Prime Therapeutics (Prime) will begin processing Medicare Part D and Part B claims for Covered Persons of Blue Cross Blue Shield of Minnesota (BCBSMN) Blue Essentials (HMO-POS) To ensure uninterrupted service to Participating Pharmacies and Covered Persons, please use the following information to set up your system prior to January 1, BCBSMN Blue Essentials Part D BIN: PCN:...MPDBE BCBSMN Blue Essentials Part B BIN: PCN:...PARTB Covered Person ID Number Date of Birth For More Information Medicare Part D and Part B claims with a fill date on or after January 1, 2013 must be submitted with the BIN/PCN outlined on the left If you have questions regarding claims processing, please contact Prime s Contact Center at For software setup information, please visit Prime s website at Primetherapeutics.com > Pharmacists > Payer sheets > Medicare Part D D.0 Payer Sheet and Medicare Part B D.0 Payer Sheet For Prime s helpful resources for Medicare Part D coverage and issues, please visit: PrimeTherapeutics.com > Pharmacists > Medicare Part D > Medicare Resources > Helpful Resources Medicare Part B may be found on Prime s website at PrimeTherapeutics.com > Pharmacists > Plan Announcements > Medicare Part B Gender Group Number U&C Days Supply Pharmacy NPI Prescriber ID (NPI or DEA) Date Rx Written Rx Origin Code Featured below are examples of most common ID cards used: 12 Prime Therapeutics LLC

13 New Plan Announcement Blue Cross Blue Shield of Illinois Blue Medicare Advantage (HMO) Effective January 1, 2013 Effective January 1, 2013, Prime Therapeutics (Prime) will begin processing Medicare Part D and Part B claims for Covered Persons of Blue Cross Blue Shield of Illinois (BCBSIL) Blue Medicare Advantage (HMO) To ensure uninterrupted service to Participating Pharmacies and Covered Persons, please use the following information to set up your system prior to January 1, BCBSIL Blue Medicare Advantage Part D BIN: PCN:...MAPDIL BCBSIL Blue Medicare Advantage Part B BIN: PCN:...ILPARTB Covered Person ID Number Date of Birth For More Information Medicare Part D and Part B claims with a fill date on or after January 1, 2013 must be submitted with the BIN/PCN outlined on the left If you have questions regarding claims processing, please contact Prime s Contact Center at For software setup information, please visit Prime s website at Primetherapeutics.com > Pharmacists > Payer sheets > Medicare Part D D.0 Payer Sheet and Medicare Part B D.0 Payer Sheet For Prime s helpful resources for Medicare Part D coverage and issues, please visit: PrimeTherapeutics.com > Pharmacists > Medicare Part D > Medicare Resources > Helpful Resources Medicare Part B may be found on Prime s website at PrimeTherapeutics.com > Pharmacists > Plan Announcements > Medicare Part B Gender Group Number U&C Days Supply Pharmacy NPI Prescriber ID (NPI or DEA) Date Rx Written Rx Origin Code Featured below are examples of most common ID cards used: Prime Therapeutics LLC 13

14 New Plan Announcement Blue Cross Blue Shield of New Mexico Blue Medicare Advantage (HMO) Effective January 1, 2013 Effective January 1, 2013, Prime Therapeutics (Prime) will begin processing Medicare Part D and Part B claims for Covered Persons of Blue Cross Blue Shield of New Mexico (BCBSNM) Blue Medicare Advantage (HMO) To ensure uninterrupted service to Participating Pharmacies and Covered Persons, please use the following information to set up your system prior to January 1, BCBSNM Blue Medicare Advantage Part D BIN: PCN:...MAPDNM BCBSNM Blue Medicare Advantage Part B BIN: PCN:...NMPARTB Covered Person ID Number Date of Birth For More Information Medicare Part D and Part B claims with a fill date on or after January 1, 2013 must be submitted with the BIN/PCN outlined on the left If you have questions regarding claims processing, please contact Prime s Contact Center at For software setup information, please visit Prime s website at PrimeTherapeutics.com > Pharmacists > Payer sheets > Medicare Part D D.0 Payer Sheet and Medicare Part B D.0 Payer Sheet For Prime s helpful resources for Medicare Part D coverage and issues, please visit: PrimeTherapeutics.com > Pharmacists > Medicare Part D > Medicare Resources > Helpful Resources Medicare Part B may be found on Prime s website at PrimeTherapeutics.com > Pharmacists > Plan Announcements > Medicare Part B Gender Group Number U&C Days Supply Pharmacy NPI Prescriber ID (NPI or DEA) Date Rx Written Rx Origin Code Featured below are examples of most common ID cards used: 14 Prime Therapeutics LLC

15 New Plan Announcement Blue Cross Blue Shield of Texas Blue Medicare Advantage (PPO) Effective January 1, 2013 Effective January 1, 2013, Prime Therapeutics (Prime) will begin processing Medicare Part D and Part B claims for Covered Persons of Blue Cross Blue Shield of Texas (BCBSTX) Blue Medicare Advantage (PPO) To ensure uninterrupted service to Participating Pharmacies and Covered Persons, please use the following information to set up your system prior to January 1, BCBSTX Blue Medicare Advantage Part D BIN: PCN:...MAPDTX BCBSTX Blue Medicare Advantage Part B BIN: PCN:...TXPARTB Covered Person ID Number Date of Birth For More Information Medicare Part D and Part B claims with a fill date on or after January 1, 2013 must be submitted with the BIN/PCN outlined on the left If you have questions regarding claims processing, please contact Prime s Contact Center at For software setup information, please visit Prime s website at Primetherapeutics.com > Pharmacists > Payer sheets > Medicare Part D D.0 Payer Sheet and Medicare Part B D.0 Payer Sheet For Prime s helpful resources for Medicare Part D coverage and issues, please visit: PrimeTherapeutics.com > Pharmacists > Medicare Part D > Medicare Resources > Helpful Resources Medicare Part B may be found on Prime s website at PrimeTherapeutics.com > Pharmacists > Plan Announcements > Medicare Part B Gender Group Number U&C Days Supply Pharmacy NPI Prescriber ID (NPI or DEA) Date Rx Written Rx Origin Code Featured below are examples of most common ID cards used: Prime Therapeutics LLC 15

16 New Plan Announcement General Dynamics Effective January 1, 2013 Effective January 1, 2013, Prime Therapeutics (Prime) will begin processing claims for approximately 108,000 Covered Persons for General Dynamics. Covered Persons will use the Prime Choice Plus Formulary. To ensure uninterrupted service to Participating Pharmacies and Covered Persons, please use the following information to set up your system prior to January 1, 2013, for processing all new and refill claims for Covered Persons of General Dynamics. BIN: PCN:...GDEMP Covered Person ID Number Date of Birth 2012 Outstanding Claims Reversals and Processing To prepare for this transition, Participating Pharmacies should complete all claims processing and reversals by close of business December 31, For assistance with claims that have a date of fill prior to January 1, 2013, please contact MEDCO at For More Information Effective January 1, 2013, if you have questions regarding claims processing, please contact Prime s Contact Center at For software setup information, please visit Prime s website at Primetherapeutics.com > Pharmacists > Payer sheets > Commercial D.0 Payer Sheet Gender U&C Days Supply Pharmacy NPI Prescriber ID (NPI or DEA) Date Rx Written Rx Origin Code Featured below are examples of most common ID cards used: 16 Prime Therapeutics LLC

17 New Plan Announcement Jennie-O Turkey Store Effective January 1, 2013 Effective January 1, 2013, Prime Therapeutics (Prime) will begin processing claims for approximately 9,700 Covered Persons for Jennie-O Turkey Store. Covered Persons will use the Prime Therapeutics Limited Network and Prime Choice Plus Formulary. To ensure uninterrupted service to Participating Pharmacies and Covered Persons, please use the following information to set up your system prior to January 1, 2013, for processing all new and refill claims for Covered Persons of Jennie-O Turkey Store. BIN: PCN:...JENNIE Covered Person ID Number Date of Birth 2012 Outstanding Claims Reversals and Processing To prepare for this transition, Participating Pharmacies should complete all claims processing and reversals by close of business December 31, For assistance with claims that have a date of fill prior to January 1, 2013, please contact Express Scripts (ESI) at For More Information Effective January 1, 2013, if you have questions regarding claims processing, please contact Prime s Contact Center at For software setup information, please visit Prime s website at PrimeTherapeutics.com > Pharmacists > Payer sheets > Commercial D.0 Payer Sheet Gender U&C Days Supply Pharmacy NPI Prescriber ID (NPI or DEA) Date Rx Written Rx Origin Code Featured below are examples of most common ID cards used: Prime Therapeutics LLC 17

18 New Plan Announcement Johnson Controls Inc. Effective January 1, 2013 Effective January 1, 2013, Prime Therapeutics (Prime) will begin processing claims for approximately 91,000 Covered Persons for Johnson Controls Inc. Covered Persons will use the Prime Choice Plus Formulary. To ensure uninterrupted service to Participating Pharmacies and Covered Persons, please use the following information to set up your system prior to January 1, 2013, for processing all new and refill claims for Covered Persons of Johnson Controls Inc. BIN: PCN:...JCEMP Covered Person ID Number Date of Birth Gender 2012 Outstanding Claims Reversals and Processing To prepare for this transition, Participating Pharmacies should complete all claims processing and reversals by close of business December 31, For assistance with claims that have a date of fill prior to January 1, 2013, please contact CVS/Caremark at For More Information Effective January 1, 2013, if you have questions regarding claims processing, please contact Prime s Contact Center at For software setup information, please visit Prime s website at PrimeTherapeutics.com > Pharmacists > Payer sheets > Commercial D.0 Payer Sheet U&C Days Supply Pharmacy NPI Prescriber ID (NPI or DEA) Date Rx Written Rx Origin Code Featured below are examples of most common ID cards used: 18 Prime Therapeutics LLC

19 MAC List Updates Clinical format Effective date Description of change montelukast chew tabs, 4 mg, 5 mg; tabs, 10 mg (SINGULAIR) 8/15/12 Addition triamcinolone crm, 0.1%; oint, 0.1% 9/1/12 Addition desloratadine tabs, 5 mg (CLARINEX) 9/1/12 Addition nystatin oral powder 9/1/12 Addition pioglitazone tabs, 15 mg, 30 mg, 45 mg (ACTOS) 9/1/12 Addition desmopressin nasal spray, 0.01% (DDAVP) 8/15/12 Removal isosorbide dinitrate tabs, 5 mg (ISORDIL TITRADOSE) 8/15/12 Removal misoprostol tabs, 200 mcg (CYTOTEC) 8/15/12 Removal mesalamine enema, 4 g 8/15/12 Removal enoxaparin inj, 40 mg/0.4 ml (LOVENOX) 9/1/12 Removal dextroamphetamine tabs, 10 mg 9/1/12 Removal sodium sulfacetamide ophth soln, 10% (BLEPH-10) 9/1/12 Removal oxymorphone tabs, 5 mg (OPANA) 9/15/12 Removal estradiol/norethindrone tabs, mg (ACTIVELLA) 9/15/12 Removal DOXYCYCLINE HYCLATE delayed-release tabs, 100 mg 9/15/12 Removal TETRACYCLINE caps, 500 mg 9/15/12 Removal VANCOMYCIN in DEXTROSE inj, 1 g/200 ml 9/15/12 Removal CAPTOPRIL/HYDROCHLOROTHIAZIDE tabs, mg, mg 9/15/12 Removal METAPROTERENOL syrup, 10 mg/5 ml 9/15/12 Removal METOCLOPRAMIDE inj, 5 mg/ml 9/15/12 Removal CYTRA-K (potassium citrate/citric acid soln, mg/5 ml) 9/15/12 Removal PAXIL (paroxetine oral susp, 10 mg/5 ml) 9/15/12 Removal PHENDIMETRAZINE ext-release 24 hour caps, 105 mg 9/15/12 Removal MORPHINE tabs, 15 mg, 30 mg 9/15/12 Removal TRI-VIT/FLUORIDE/IRON pediatric drops, mg/ml 9/15/12 Removal benzoyl peroxide liquid, 4% (LAVOCLEN-4 CREAMY WASH) 9/15/12 Removal benzoyl peroxide liquid, 8% (LAVOCLEN-8 CREAMY WASH) 9/15/12 Removal benzoyl peroxide lotion, 3% (TRIAZ CLEANSER) 9/15/12 Removal ERYTHROMYCIN gel, 2% 9/15/12 Removal GENTAMICIN crm, 0.1% 9/15/12 Removal SANDIMMUNE (cyclosporine oral soln, 100 mg/ml) 9/15/12 Removal DEXTROSE inj, 20% 9/15/12 Removal Prime Therapeutics LLC 19

20 How to reach Prime Therapeutics As a service to Participating Pharmacies, Prime Therapeutics (Prime) publishes Prime Perspective quarterly to provide important information for claims processing. We value your opinion and your participation in our network. If you have comments or questions, you can reach us: By phone: Prime Pharmacy Contact Center (24 hours a day, seven days a week) By [email protected] Looking for formularies? For Commercial formularies go to either the Blue Cross Blue Shield plan website or PrimeTherapeutics.com > Pharmacists > Formulary Search For Medicare Part D formularies go to PrimeTherapeutics.com > Medicare Part D > Medicare Resources > 2012 Medicare Formularies Keep your pharmacy information current Prime uses the National Council for Prescription Drug Programs (NCPDP) database to obtain addresses for network pharmacy mailings. To update your pharmacy information go to > NCPDP Provider ID (on the left side). Report fraud, waste and abuse If you suspect fraud, waste or abuse, by a Covered Person, Prescribing Provider, Participating Pharmacy or anyone else, notify Prime at or send the information to: Prime Therapeutics LLC Attn: Compliance Officer P.O. Box St. Paul, MN By [email protected] If you would like an FWA Report to be anonymous, please contact Prime s 24-hour anonymous compliance hotline. Contact the hotline: By phone: By [email protected] By third party vendor s website: 20 Prime Therapeutics LLC

21 Notes Prime Therapeutics LLC 21

22 Notes 22 Prime Therapeutics LLC

23 Notes Prime Therapeutics LLC 23

24 Prime Therapeutics LLC P.O. Box St. Paul, MN PRESORTED STANDARD MAIL U.S. POSTAGE PAID PRIME THERAPEUTICS LLC Time Sensitive Information from Prime Therapeutics Claims processing instructions Utilization management updates from Blue Cross and Blue Shield plans Prime audit requirements Medicare Part D requirements