Pharmacy pre-authorization

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.

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.

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 is effective for fully insured group and Individual plan members, through a Provider-Administered Specialty Drugs benefit.

The medications included in this program are listed in the Provider-Administered Specialty Drugs (dru764) medication policy.

The Provider-Administered Specialty Drugs benefit is in effect as plans renew throughout 2024 for fully insured group and Individual plan members. While we continue network development, we have delayed the benefit administration transition to the IntegratedRx – Medical network. Look for updates to the timeline in future issues of our provider newsletter. Here's how that will work to ensure a smooth transition for our members:

Join the Prime Therapeutics IntegratedRx - Medical Network

Prime Therapeutics is currently credentialing and contracting providers for this network. You can reach out to your Prime contact to complete the process. If you do not have a Prime contact established, please email Prime Provider relations.

To start IntegratedRx - Medical Network credentialing, you can also visit Prime's credentialing website.

• 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.

Using real-time benefit check can improve the patient experience, decreasing their financial strain and improving medication adherence. It can also lead to better provider and patient conversations about treatment plans and reduce your time spent on administrative tasks.

To create easier access to a preferred medication database for our members, we’ve partnered with Arrive Health to integrate a real-time benefit check tool for prescribed medications that works within your electronic medical record (EMR) system.

Arrive Health works with many of the larger, national EMR systems (e.g., Epic and Cerner) to provide you quick access to pharmacy benefit checks. With 99% transaction accuracy and over 10 million transactions per month, Arrive Health is a trusted partner to help patients get the right medication at the right price.

How it works

Real-time benefit check information will display when the following criteria are met:

• Patient eligibility has been pulled (workflow varies by EMR system)
• Patient’s pharmacy benefits are covered by a participating pharmacy benefits manager (PBM) (e.g., Prime Therapeutics)
• You’ve entered the national drug code (NDC), preferred pharmacy NPI, quantity and days supply

The tool will present the following patient-specific coverage information:

• Coverage status (covered, not covered, covered with restrictions)
• Coverage alerts (pre-authorization required, quantity limit issue, refill too soon, step therapy, etc.)
• Out-of-pocket costs for the patient
• Formulary-driven medication alternatives
• Pharmacy options

Note: This tool is only for medications filled at pharmacies, not those dispensed or administered in the provider office.

Available now

The real-time benefit check tool is available for all Asuris Medicare Advantage and commercial members now. Contact your EMR vendor to find out how to connect your system to the Arrive Health solution.

Learn more about Arrive Health for providers.

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-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.

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.

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.

• Register to use TransactRx and review other provider support materials.

Claims for medications should be submitted to either the health plan or our PBM as follows: