Pharmacy

Resources

Visit our pharmacy website for:

CoverMyMeds

Submit pre-authorization requests with CoverMyMeds.

Find a pharmacy

Pain Management Toolkit

Our toolkit includes guidelines, tools and resources to help support you as you care for patients needing pain management or who are struggling with opioid addiction.

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.

  • In most of our commercial networks, members home delivery prescriptions will transfer to Express Scripts Home Delivery effective April 1, 2021 (small custom networks are an exception)
  • In most of our commercial networks, specialty prescriptions will transfer to Accredo effective April 1, 2021 (small custom networks are an exception)
  • Accredo and Express Scripts Home Delivery will be added as an option to our Medicare networks as an additional choice for members

This PBM is in place for our group, Individual and Medicare members. Members on administrative services only (ASO) groups that use a different PBM are excluded.

Prime has web-based tools to help you submit pharmacy pre-authorization requests and submit claims for medications administered in your office.

Home delivery

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 Express Scripts Pharmacy and AllianceRx Walgreens Pharmacy for Medicare members) also allows them to get 90-day (up to 100 for certain Medicare members) 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.

Specialty Pharmacy

Accredo has Therapeutic Resources Centers located throughout the United States with specially trained nurses and pharmacists specific to the member’s condition.

  • Submitting a prescription to Accredo for growth hormone therapy: Accredo requires the authorizing prescriber to complete a Prescriber Certification for Human Growth Hormone Indication form prior to dispensing for:
  • Any patient who is currently 18 years or older
  • Pediatric patients under 18 years who are not seeing a pediatric endocrinologist or nephrologist (for certain diagnoses)

If the prescriber does not complete this form, Accredo is unable to dispense growth hormone. The certification remains in place as long as the prescriber does not change. Refills are monitored for clinical changes.

For more information, please visit the Accredo website at: accredo.com/prescribers/manage_referrals

MyAccredoPatients.com: Accredo has an all-in-one portal for specialty prescribing where you can get the information you need, when you need it, and get back to caring for your patients. After registering, you and your staff can use MyAccredoPatients.com to easily manage your patient’s specialty prescriptions. You’ll be able to:

  • Check on pre-authorizations
  • Upload supporting clinical documents
  • Flag patients or prescriptions for follow-up
  • Track prescriptions as they’re processed and filled
  • See referrals, refills, renewals and even track shipments

You can also use Accredo’s chat feature to:

  • Interact with a live Accredo agent
  • Expedite requests and solve problems without a phone call
  • Get real-time help with patient info at the agent’s fingertips

Watch this 1-minute video to learn more or register now.

Asuris EquaPathRx

Asuris EquaPathRx is effective January 1, 2024, for fully insured group and Individual plan members, through a filed Provider-Administered Specialty Medication benefit. Medicare Advantage and administrative services only (ASO) members will not have this new benefit in 2024.

Implementation of this program will continue into 2024. Here’s what this means for you:

  • From January 1, 2024, to June 30, 2024: As we work with providers to contract with the Prime IntegratedRx - Medical® network and become a designated provider for this program, from January 1, 2024, to June 30, 2024, all Asuris network providers are designated as eligible to provide medications included in the Asuris EquaPathRx program (subject to otherwise applicable conditions) to members with this benefit. This means that members can continue to receive medications from you as they do today, and claims for medications included in this program will be processed based on your existing contract terms with us.

    • Medications included in this program must be pre-authorized according to our medication policies, including the new Provider-Administered Specialty Drugs (dru764) policy, effective January 1, 2024.
  • Effective July 1, 2024: We expect providers to be contracted with the IntegratedRx - Medical network to be reimbursed for administering medications included in the Asuris EquaPathRx program to members with this benefit.

    • The medication portion of the claim will be adjudicated under the terms and rates of the agreement you have with Prime.
    • Medications included in this program must be pre-authorized according to our medication policies and require administration by a participating IntegratedRx - Medical provider to be covered under the member’s benefits.
    • If you have not contracted with Prime by July 1, 2024, provider-administered medications included in the Asuris EquaPathRx program will not be covered for members with that benefit. There will be no change in reimbursement or experience for members who do not have this benefit.

    Notes:

  • With this program, you will continue to submit claims directly to us as you do today.
  • For members included in the Asuris EquaPathRx program, any provisions in existing provider agreements between Asuris and the provider group or facility that address provider-administered medications and reimbursement schedules do not apply for the select list of provider-administered specialty medications in Asuris EquaPathRx.
  • For members not included in the Asuris EquaPathRx program, reimbursement for provider-administered medications will continue under your existing Asuris provider agreement terms.

Join the Prime Therapeutics IntegratedRx - Medical Network

Prime Therapeutics is currently credentialing and contracting providers for this new network. If you have not already, please reach out to your Prime contact now to complete the process of credentialing and contracting for the IntegratedRx - Medical Network.

If you have not yet contracted with Prime by July 1, 2024, we will work closely with you and our members to ensure they continue to have uninterrupted access to their treatment.

  • Each provider group or facility that administers specialty medications needs to be credentialed and contracted as a dispensing provider with Prime Therapeutics.
  • If your organization operates a specialty pharmacy that you want included in this network, your specialty pharmacy will need to complete the credentialing process to be included, even if they have an existing pharmacy contract with Prime Therapeutics.
  • Your contract with Prime will have a reimbursement schedule that includes the medications in the Asuris EquaPathRx 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 this page.

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 this page.

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.

Pharmacy Peer-to-Peer Review Request form

If you would like to speak with a clinical reviewer about the denial of a provider-administered medication pre-authorization request, please complete the Pharmacy Peer-to-Peer Review Request form to arrange for a peer-to-peer (P2P) discussion. For retail (self-administered) medications, please call Pharmacy Customer Service at 1 (844) 765-6827.

Note: All medication-related calls will be routed to an Asuris clinical pharmacist. If there are questions that the clinical pharmacist is unable to answer, the clinical pharmacist will schedule a call with a Asuris medical director.

Submitting claims for medications provided in your office

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

Specific 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.

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 in the Washington Vaccine Association Private Insurance Assessment Billing Provider Guide.

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.