Pharmacy

Resources

Visit our pharmacy website for:

Forms
Quantity limits
Member programs
Coverage exceptions
Specialty medications
Medication lists/formularies
Medication policies and pre-authorization requirements

Submit claims

CoverMyMeds

Submit pre-authorization requests with CoverMyMeds.

Find a pharmacy

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.

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 BridgeSpan EquaPathRx program.

Real-time pharmacy benefit check tool

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 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.

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. 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.