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1 Prime TherapeuticsProvider ManualEffective March 1, 2015 2015 by Prime Therapeutics LLC. All rights reser part of this book may be reproduced in any form or by any means without the prior written permission of Prime Therapeutics LLC3 Provider ManualTable of ContentsIntroduction to Prime Therapeutics LLC ..1 Provider Manual ..1 Section 1: Prime Contact Information ..2 Prime Mailing Contact Center ..2 Prime s 2: Compliance ..3 Compliance ..3 Fraud, Waste and Abuse ..4 Section 3: Claims Information .. 6 Online Claims Submission ..6 Online Availability ..6 Claim Formats ..6 Medicare Reference Materials .. ID Card ..6 Covered Person Eligibility ..6 Same Gender Multiples ..7 Medicare E1 Eligibility Query ..7 Best Available Evidence (BAE) ..7 Hospice Best Available Evidence (BAE).

2 7 Submitting the Claim ..8 Bank Identification Number (BIN) and Processor Control Number (PCN) ..8 National Provider Identifier (NPI) ..8 Medicare Enrollment .. 8 Documentation ..8 Days Supply for Non-Medicare Part D Supply for Medicare Part D Claims ..9 Accurate Quantity ..9 Dispensed Package Size/ National drug Code (NDC) ..9 Timely Filing ..9 Medicare E-prescribing ..9 prescription Origin Code ..10 Requirements for Participating Pharmacies Contracted with 340B Covered Entities ..10 Compound Drugs Billing Guidelines ..10 General Insulin and Diabetic Supply benefits ..11 Insulin Supplies ..12 Long-Term Care (LTC) and Home Infusion Therapy (HIT ) Processing Guides ..12 Medicare Programs Coordination of benefits (COB) ..12 Time Limits for Coordination of benefits ..12 Medicare Parts A & B vs.

3 D Claims Adjudication ..12 Utilization Management Program ..13 drug Formularies ..13 Medicare drug Formularies ..13 Prior Authorization (PA) ..13 Step Therapy/Contingent Therapy Programs ..15 Quantity Limit ..15 drug Utilization Review (DUR) ..16 Maximum Allowable Cost (MAC) ..16 Post Claim Adjudication ..16 Return to Stock Unclaimed Prescriptions ..16(Continued)4 Prime Therapeutics LLC Table of Contents (Continued)Section 4: Benefit Selection Code (PSC) ..17 Generic Substitution .. 17 Generic drug Standards ..17 Enhanced Pharmacy Programs ..17 Vaccine Administration ..17 Medication Therapy Management (MTM) ..18 Medicare Part D Transition Process ..18 Medicare General Dispensing Long-Term Care Guidelines and Procedures ..20 Medicare Short Cycle Dispensing Long-Term Care Guidelines and Procedures.

4 20 Section 5: Responsibility of Participating Information with NCPDP ..21 OIG/GSA Exclusion Pharmacy s Affiliation with PSAO ..21 Third Party Payment Reconciliation Vendors ..21 Responsibilities of the Participating Pharmacy for Medicare Programs ..21 Pharmacy Credentialing ..22 Termination Appeals ..22 Confidentiality and Proprietar y Rights ..23 Confidentiality ..23 Proprietary Rights ..23 Section 6: Participating Pharmacy Audit ..24 Education ..24 Reason for Audits ..24 Audit Notification ..24 Access to Records ..24 Audit Expenses ..25 Audit Time Frame ..25 Reporting Audit Results ..25 Types of Audit Activities ..25 Pre-payment Daily Claims Review ..25 Desktop Audits ..26On-site Audits ..26 drug and Supply Requirements ..27 prescription Requirements ..28 prescription Label Requirements.

5 29 Review of Claim Submission ..29 Distributor and Manufacturer Invoices and Pharmacy Dispensing Records ..30 Common Billing Errors ..30 Unacceptable Practices ..31 Audit Appeal Process ..31 Corrective Action Plan (CAP) ..311 Provider ManualIntroduction to Prime Therapeutics LLCP rime Therapeutics LLC (Prime) is a Pharmacy benefit management (PBM) company that provides comprehensive Pharmacy management solutions to Prime s clients. Some of Prime s ser vices include: Pharmacy networks Formulary management Pharmacy communication drug utilization review (DUR) Clinical programs Physician education Claims processing Prime encourages the use of safe and cost-effective therapies for clients members while maintaining a valued relationship with pharmacies participating in Prime s network.

6 Prime promotes the use of local programs to meet the needs of Covered Persons and Benefit Sponsors and encourages the important connection a pharmacist maintains with Covered Persons. Prime manages Pharmacy networks to provide prescription drug Ser vices for its clients through Prime s online claims processing system. The claims processing system gives Participating Pharmacies real-time access to member eligibility, drug coverage information, drugs requiring prior authorization and DUR information. Prime is committed to doing business with integrity and in accordance with all applicable federal, state and local laws. Prime has adopted a compliance program and code of conduct which includes policies and procedures to avoid potential conflicts of interest and fraud, waste and abuse. Prime requires all Participating Pharmacies to adopt appropriate compliance programs; codes of conduct; fraud, waste and abuse programs; and conflict of interest policies and Manual The purpose of this Provider Manual ( Manual ) is to explain Prime s administrative and compliance policies and procedures.

7 The Manual is incorporated into the Prime Therapeutics Pharmacy Participation Agreement ( Agreement ). This Manual will be updated as necessar y at Prime s sole discretion. This version of the Provider Manual supersedes all previous versions of the Manual . Prime posts the most current version of the Provider Manual on its website at Relevant instructions, notices, information and supplements or changes to the Manual are posted on the Prime website. Consult for up-to-date information and processing instructions. All capitalized terms that are otherwise not defined in this Manual refer to those defined in the Agreement. Important: This Manual applies to all lines of business, including, but not limited to Medicare, Medicaid, and commercial business. 2 Prime Therapeutics LLC Section 1: Prime Contact InformationPrime Mailing AddressIf you would like additional information, contact Prime at:Prime Therapeutics LLC Box 64812 St.

8 Paul, MN 55164-0812 Prime Contact Prime Contact Center has dedicated staff to assist pharmacies with contract requests, processing questions, and to address any comments and concerns. Prime s representatives are available 24 hours a day, 365 days a s WebsitePrime maintains its website to ser ve Covered Persons and Participating Pharmacies. Information on the site includes: Current formular y and negative formular y information (updated on a regular basis) Grievances, coverage determinations, appeal procedures, exception process management and/or drug utilization management Participating Pharmacy addresses and types ( , retail, mail ser vice Pharmacy , home infusion, long-term care) Quality control policies and procedures, including Medication Therapy Management (MTM) and/or drug Utilization ManagementVisit Prime s website ( )for the following information.

9 Payer Specification Sheets Medicare Plan-Specific Reference Guides Medicare Coverage and Rights Formulary Information/Formulary Updates Prime Perspective Newsletters Fraud, Waste and Abuse Training, Requirements and Certification Materials FWA Referral Form Plan Announcements Network Request Form General Information and Services Common Billing Errors Minimum Performance and Service Criteria for Medicare Programs Minimum Performance and Service Criteria for Medicare Programs LTC Medicare Part B vs. Part D Coverage Issues Pharmacy Audit Appeal Form Pharmacy Audit Guidelines Prime Audit Advisor Fax Series Long Term Care and Home Infusion Processing Requirements National Provider Number (NPI) Medicaid Programs Vaccine Administration Processing Requirements Check Inquiry Form Maximum Allowable Cost (MAC)3 Provider ManualSection 2: ComplianceComplianceIf you have a compliance concern or suspect or have knowledge of fraud, waste or abuse, please report the issue using the email or telephone numbers Compliance An independent operator is available 24 hours per day, 7 days a Online Reporting Waste and Abuse this number to report suspected fraud, waste or abuse.

10 You will be asked to leave a voice mail. You do not need to leave your name or contact Question TherapeuticsChief Compliance Box 64812St. Paul, MN 55164-0812 Privacy Pharmacies must develop policies and procedures in compliance with all applicable rules and regulations, including but not limited to, Medicare Programs. All Participating Pharmacies should have someone who is responsible for establishing a plan to meet Medicare Programs requirements and appropriate documentation of that plan. The Participating Pharmacies should communicate the plan and any means of enforcing the plan to all employees. Refer to the CMS website, , for a complete list of compliance program requirements. Please contact Prime s Compliance Department with any concerns, including concerns regarding: Violation of a state, federal, local law, regulation or any governmental guidance Conflict of interest Acceptance and/or offers of gifts or entertainment Fraud, waste or abuse Improper disclosure of Prime s confidential or proprietary information Retaliation for reporting a compliance issue Falsification of reports, records or files Theft4 Prime Therapeutics LLC Section 2: Compliance (Continued)Fraud, Waste and Abuse (FWA)Both Participating Pharmacies and Prime have an obligation to help protect and maintain the integrity of the health care system by promptly reporting suspicious activity.