PRIME THERAPEUTICS  
                             PROVIDER  
                               MANUAL
                           FOR PHARMACY PROVIDERS
                                                                                                                                                                           PRIME THERAPEUTICS  
            Effective April 15, 2021                                                                                                                                     PROVIDER  
               2021 Prime Therapeutics LLC. All rights reserved.
            ©                                                                                                                                                                MANUAL
            Trademarks are the property of their respective owners.                                                                                               WFOR PHARMACY PROVIDERS
            No part of this Manual may be reproduced in any form or by any  
            means without the prior written permission of Prime Therapeutics.
                                                                                 Prime Therapeutics LLC
                                         TABLE OF CONTENTS
                                         INTRODUCTION TO PRIME THERAPEUTICS  . .1                                                                                                          Submitting the Claim  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
                                                Introduction   . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1                                                       Bank Identification Number (BIN) and Processor 
                                                                                                                                                                                                                                                       . . . . . . . . . . . . . . . . . . . . . . .10
                                                Provider Manual  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1                                                                 Control Number (PCN)
                                                                                                                                                                                                  National Provider Identifier (NPI) . . . . . . . . . . . . . . . . .10
                                         SECTION 1: PRIME CONTACT INFORMATION .2                                                                                                                  Documentation  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
                                                Prime Mailing Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2                                                                Days’ Supply for Non-Medicare Part D Claims . . . . . .11
                                                Prime’s Contact Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2                                                               Days’ Supply for Medicare Part D Claims  . . . . . . . . . .11
                                                Prime’s website . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2                                                          Accurate Quantity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
                                         SECTION 2: COMPLIANCE  . . . . . . . . . . . . . . . . . . . . . .3                                                                                      Dispensed Package Size/National Drug Code (NDC) 12
                                                Report Compliance, Privacy, or Fraud, Waste                                                                                                       NDC Codes  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
                                                      and Abuse Concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3                                                               Timely Filing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
                                                Compliance Program  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3                                                                ePrescribing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
                                                Fraud, Waste and Abuse (FWA)  . . . . . . . . . . . . . . . . . . . . . .4                                                                        Prescription Origin Code  . . . . . . . . . . . . . . . . . . . . . . . .12
                                                      Annual Attestation Requirement  . . . . . . . . . . . . . . . . . .4                                                                        Requirements for Pharmacies Contracted with 340B 
                                                                                                                                                                                                                                            . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
                                                      Medicare Part D FWA and General Compliance                                                                                                        Covered Entities
                                                                                                                                        . . . . . . . . . . . .4                                  Compound Prescription Billing Guidelines . . . . . . . . .12
                                                             Pharmacy Training and Certification
                                                      Reporting of Suspicious Activity  . . . . . . . . . . . . . . . . . .4                                                                      Insulin and Diabetic Supply Benefits  . . . . . . . . . . . . .14
                                                Notice to California Pharmacies . . . . . . . . . . . . . . . . . . . . . .6                                                                      Insulin Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
                                                      Pharmacy Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6                                                               Long-Term Care (LTC) and Home Infusion (HI) 
                                                                                                                                                                                                                                                              . . . . . . . . . . . . . . . . . . . .15
                                                      Pharmacy Bill of Rights  . . . . . . . . . . . . . . . . . . . . . . . . . .6                                                                     Processing Requirements
                                                                                                                                                                                                  Hemophilia Billing Guidelines  . . . . . . . . . . . . . . . . . . .15
                                         SECTION 3: CLAIMS PROCESSING . . . . . . . . . . . . .7                                                                                                  Medicare Programs Coordination of Benefits (COB) .15
                                                General Information  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 7                             Time Limits for Coordination of Benefits . . . . . . . . . . .15
                                                      Online Claims Submission . . . . . . . . . . . . . . . . . . . . . . . .7                                                                   Medicare Parts A & B vs . D Claims Adjudication  .  .  .  . 16
                                                      Online Availability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7                                                   Utilization Management Program  . . . . . . . . . . . . . . . . . . .17
                                                      Claim Formats  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7                                                         Drug Formularies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17
                                                      Medicare Reference Materials  . . . . . . . . . . . . . . . . . . . .7                                                                      Medicare Drug Formularies . . . . . . . . . . . . . . . . . . . . . .17
                                                      Collection of Copay/Cost Share  . . . . . . . . . . . . . . . . . . .7                                                                      Prior Authorization (PA) . . . . . . . . . . . . . . . . . . . . . . . . .17
                                                Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7                                                  Electronic Submission of PA Requests Supported by 
                                                                                                                                                                                                                                       . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19
                                                      Covered Person Identification Card . . . . . . . . . . . . . . . .7                                                                               CoverMyMeds
                                                      Covered Person Eligibility  . . . . . . . . . . . . . . . . . . . . . . . .8                                                                Step Therapy (ST)/Contingent Therapy Programs . . .19
                                                      Covered Person Protection  . . . . . . . . . . . . . . . . . . . . . . .8                                                                   Quantity Limit (QL)  . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20
                                                      Controlled Substance Prescription Dispensing                                                                                                Drug Utilization Review (DUR) . . . . . . . . . . . . . . . . . . . .20
                                                                                              . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
                                                             Considerations                                                                                                                       Maximum Allowable Cost (MAC)  . . . . . . . . . . . . . . . . .20
                                                      Claims Process for Multiples . . . . . . . . . . . . . . . . . . . . . .8
                                                      Medicare E1 Eligibility Query  . . . . . . . . . . . . . . . . . . . . .9
                                                      Medicare and Medicaid Dual Eligible  
                                                                                                 .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 9
                                                             Covered Persons
                                                      Qualified Medicare Beneficiary Program  . . . . . . . . . . .9
                                                      Best Available Evidence (BAE)  . . . . . . . . . . . . . . . . . . . .9
                                                      Hospice Best Available Evidence (BAE)  . . . . . . . . . . .10
                                         Provider Manual
                                                                                                                                                                                                                                                                                                               I
                            TABLE OF CONTENTS (CONTINUED)
                            SECTION 4: BENEFIT PLAN  . . . . . . . . . . . . . . . . . . . .21                                   Appropriate Dispensing Practices  . . . . . . . . . . . . . . . . . . .29
                                 Post Claim Adjudication . . . . . . . . . . . . . . . . . . . . . . . . . . . .21                    Unacceptable Dispensing Practices   . . . . . . . . . . . . . .30
                                      Return to Stock — Unclaimed Prescriptions . . . . . . . .21                                     Patient-Prescribing Provider Relationship  . . . . . . . . .30
                                      Notice of Payment Error . . . . . . . . . . . . . . . . . . . . . . . . .21                     Marketing and Communications Practices . . . . . . . . .30
                                 Benefit Plan Design  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21                 Pharmacy Nondiscrimination  . . . . . . . . . . . . . . . . . . . .30
                                 Pharmacy Networks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21               Signature or Delivery Logs  . . . . . . . . . . . . . . . . . . . . . . . . .31
                                 Long-Term Care (LTC) Guidelines  . . . . . . . . . . . . . . . . . . . .21                      Long-Term Care (LTC) and Home Infusion (HI) Annual 
                                                                                                                                                                  . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31
                                 Services Provided to Family Members  . . . . . . . . . . . . . . .21                                 Validation Process
                                 Product Selection Code (PSC) . . . . . . . . . . . . . . . . . . . . . . .21                    Termination Appeals  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31
                                 Generic Substitution  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21             Confidentiality and Proprietary Rights  . . . . . . . . . . . . . . .32
                                      Generic Drug Standards . . . . . . . . . . . . . . . . . . . . . . . . .22                      Confidentiality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
                                 Enhanced Pharmacy Programs . . . . . . . . . . . . . . . . . . . . . .22                             Proprietary Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
                                      Vaccine Administration  . . . . . . . . . . . . . . . . . . . . . . . . .22                     Recall Notices and Expired Medication . . . . . . . . . . . .33
                                      Medication Therapy Management (MTM) . . . . . . . . . .22                                  Manufacturer Assistance Reporting  . . . . . . . . . . . . . . . . .33
                                 Medicare Part D Transition Process . . . . . . . . . . . . . . . . . .22                    SECTION 6: PHARMACY OVERSIGHT  . . . . . . . . .34
                                      Prescription Drugs Not on Medicare Part D                                                  Pharmacy Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34
                                           Benefit Sponsor’s Drug Formulary or                                                   Education  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 34
                                            Subject to Certain Limits . . . . . . . . . . . . . . . . . . . . .22
                                      Supply Limits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23        Access to Pharmacy Records  . . . . . . . . . . . . . . . . . . . . . . .34
                                      Partial Fills  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23   Expenses  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34
                                      Status Alerts  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23       Prescription Requirements  . . . . . . . . . . . . . . . . . . . . . . . . .35
                                      Sample POS Messaging . . . . . . . . . . . . . . . . . . . . . . . . .23                   Prescription Label Requirements . . . . . . . . . . . . . . . . . . . .36
                                      Medicare General Dispensing LTC Guidelines                                                 Product Purchase Requirements  . . . . . . . . . . . . . . . . . . . .36
                                           and Procedures .  . . . . . . . . . . . . . . . . . . . . . . . . . . . .24           Purchase Invoices and Pedigrees  . . . . . . . . . . . . . . . . . . .36
                                      Medicare Short Cycle Dispensing LTC Guidelines                                             Review of Claim Submission . . . . . . . . . . . . . . . . . . . . . . . .36
                                                                   .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 25
                                           and Procedures                                                                             Insulin Vials Billing Guide  . . . . . . . . . . . . . . . . . . . . . . .37
                            SECTION 5: RESPONSIBILITY OF                                                                              Prescribed Units Per Day  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 37
                                 PHARMACY  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26               Common Billing Errors  . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38
                                 Compliance with the Participation Agreement and                                                 Unacceptable Billing Practices . . . . . . . . . . . . . . . . . . . . . .38
                                                               . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26
                                      Provider Manual                                                                            Recovery of Pharmacy Payments . . . . . . . . . . . . . . . . . . . .39
                                 Update Information with NCPDP  . . . . . . . . . . . . . . . . . . . .26                        Reasons for Audits  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39
                                 OIG and GSA Exclusion and Preclusion List Checks . . . .26                                      Audit Time Frame  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40
                                 Pharmacy’s Affiliation with PSAO  . . . . . . . . . . . . . . . . . . .27                       Types of Audit Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . .40
                                 Third Party Payment Reconciliation Company . . . . . . . . .27                                       Daily and Historical Claim Audits . . . . . . . . . . . . . . . . .40
                                 Re-Creation Fee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27         Onsite Audits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41
                                 Responsibilities of the Pharmacy for                                                            Reporting Onsite Audit Results . . . . . . . . . . . . . . . . . . . . . .42
                                      Medicare Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28              Onsite Audit Appeal Process . . . . . . . . . . . . . . . . . . . . . . . .43
                                 Pharmacy Credentialing . . . . . . . . . . . . . . . . . . . . . . . . . . . .28                Corrective Action Plan (CAP) . . . . . . . . . . . . . . . . . . . . . . . .43
                                      Ownership or Control Changes   . . . . . . . . . . . . . . . . . .29                       Pharmacy Investigations . . . . . . . . . . . . . . . . . . . . . . . . . . .43
                                 Specialty Pharmacy Credentialing . . . . . . . . . . . . . . . . . . .29                        Remediation Action  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43
                            Provider Manual
                                                                                                                                                                                                                II