Payer Specification Sheet

Payer Specification Sheet For Prime Therapeutics' Commercial Clients General information Prime Therapeutics LLC December 13, 2021. Plan Name BIN PCN. BCBS of Alabama Not Required 4915. BCBS of Alabama Work Related Injury Benefit WRI. BCBS of Florida FLBC. 12833. Truli for Health THP. BCBS of North Carolina 159 5 Not Required BCBS of Illinois ILDR. BCBS of Illinois (Blue Script) ILSC. BCBS of Illinois Trustmark ILTM. BCBS of New Mexico NMDR. BCBS of Oklahoma ( drug Card) 11552 1215. BCBS of Oklahoma (Comp Card) 1217. BCBS of Texas BCTX. Boeing BOE. HCSC Collective Health HCCH. Horizon BCBS of New Jersey HZRX. Horizon BCBS of New Jersey Medigap 16499. Horizon Casualty Services, Inc Personal Injury Protection HZNPIP.

455-EM PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER 1-Rx Billing M 4Ø2-D2 PRESCRIPTION/SERVICE REFERENCE NUMBER M 436-E1 PRODUCT/SERVICE ID QUALIFIER Ø3-National Drug Code (NDC) M If billing for a Multi-Ingredient Compound, value is “ØØ”-Not Specified 407-D7 PRODUCT/SERVICE ID M NDC Number If billing for a

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