Pharmacy

PrimeWest Health contracts with MedImpact Healthcare Systems, Inc. (MedImpact), to manage and pay pharmacy claims. MedImpact is a third-party administrator (TPA). Learn more about MedImpact.  

Medical pharmaceuticals are billed to PrimeWest Health.  For information how to bill a claim at PrimeWest https://www.primewest.org/claims-submission.

Pharmacy Utilization Management Programs

To see our Pharmacy Utilization Management program requirements for prior authorization, step therapy, and quantity limits, click on the links below.

PrimeWest has an open medical drug formulary.  A partial list of drugs is included at the bottom of this page.

For a list of covered drugs covered under the retail pharmacy benefit:

For members of Families and Children, MinnesotaCare, Minnesota Senior Care Plus (MSC+), or Special Needs BasicCare (SNBC):

• See the Medicaid List of Covered Drugs (Formulary)

For members of PrimeWest Senior Health Complete (HMO SNP) and Prime Health Complete:

• For Prior Authorizations requirements, see Prior Authorization criteria
• For Step Therapy requirements, see Step Therapy criteria
• For Quantity Limits, see the List of Covered Drugs

Learn more about the formulary exception process and documentation.

PrimeWest Health Contact Information

If you need additional information, please contact:

PrimeWest Health
3905 Dakota St
Alexandria, MN 56308

For general member questions, call the Provider Contact Center at 1-866-431-0802 (toll free).

PrimeWest Health website: www.primewest.org

Visit the PrimeWest Health website for the following information:

1. PrimePointers (provider) and PrimeLines (member) newsletters
2. Announcements
3. Requests and inquiries
4. Member services
5. Contact information
6. Exception request forms
7. Formulary information
8. Additional policies and procedures

MedImpact Help Desk Contact Information

MedImpact Healthcare Systems, Inc.
10181 Scripps Gateway Court
San Diego, CA 92131

Phone: 1-800-788-2949 (toll free)

The MedImpact Help Desk has staff to assist pharmacies with processing questions or problems. Representatives are available 24 hours a day, 365 days a year.

Federal Anti-Fraud Statutes

Pharmacies cannot use pharmaceutical manufacturers’ coupons, discounts, or similar promotions in order to attract prescription business from Medical Assistance (Medicaid) or Medicare recipients. Federal anti-fraud and abuse provisions prohibit certain types of business transactions or arrangements, per Title 42 United States Code (USC) Section 1320a-7b, Section 231(h) of the Health Insurance Portability and Accountability Act (HIPAA) and the Office of Inspector General (OIG) Special Fraud Alert, and Volume 59 Federal Register Issue 242 (1994) #94-31157. Review Requirements for Providers for more information.

How to Determine Drug Coverage

Visit our website for information regarding our drug formularies, pharmacy Utilization Management (UM) programs, and formulary exception process. Please choose the appropriate formulary, as they differ between coverage groups.

Questions regarding coverage of a particular medication can be directed to the Find a Drug search page on the PrimeWest Health website or by calling the MedImpact Help Desk at 1-800-788-2949 (toll free).

Labeler Codes

Each listed drug product is assigned a unique 11-digit, 3-segment number, known as the National Drug Code (NDC). The first segment (5 digits) identifies the manufacturer or labeler of the drug, the second segment (4 digits) identifies the drug, and the third segment (2 digits) identifies the package size. Minnesota Health Care Programs (MHCP) requires the 11-digit 5-4-2 format for billing or reporting an NDC.

Tamper-Resistant Prescription Blanks

The Appropriations Act of 2007 states that payment will not be made for prescriptions in non-electronic form for Medical Assistance (Medicaid)-covered outpatient drugs unless the prescription was executed on a tamper-resistant prescription blank. This law does not affect E-prescribed, faxed or prescriptions phoned in to the pharmacy by the prescriber.

Handwritten prescriptions must be executed on a tamper-resistant prescription blank with at least one characteristics from all three categories as outlined in the July 2008 National Council for Prescription Drug Programs (NCPDP) letter to Medicaid.

To help pharmacists identify tamper-resistant prescriptions and check for tampering, MHCP recommends tamper-resistant prescription blanks display preprinted text identifying the tamper-resistant features.

The “serial number” in Category 3 is not acceptable as a valid tamper-resistant feature. MHCP does not track serial numbers. A unique number on a prescription generated by an automated medical record does not satisfy the tamper-resistant requirements in any category.

General Claim Information

Processor Control Number (PCN)

MedImpact requires a separate PCN for each carrier. A bank identification number (BIN) is also required when adjudicating claims through the online system. Use the following codes for all PrimeWest Health members:

NDC (National Drug Code)

The NDC number used on the claim shall be the NDC number from the pharmacy’s in-stock package size from which the prescription product was dispensed.

Providers will be required to submit an NDC with all not otherwise specified (NOS) J Healthcare Common Procedure Coding System (HCPCS) codes. NOS J HCPCS code services billed over $100 will be subject to evaluation and may require authorization for further processing.

Providers are required to report the NDC number of the prescription product when billing certain HCPCS codes. A list of the codes requiring NDC is available on the Minnesota Department of Human Services (DHS) website.

Please use the individual field available on the 837 claim format to enter the NDC code when submitting your claim.

Days Supply

The pharmacy should submit the number of consecutive days supply the prescription product will last. Future refills may be rejected if the days supply is submitted inaccurately. For prescription products that cannot be broken (e.g., inhalers, topical creams, eye drops, over-the-counter [OTC] products), where the smallest unit available exceeds the benefit plan for the member, the pharmacy should submit the maximum days supply allowed under the member’s benefit.

For example, if a member’s benefit allows a 30-day supply, but one box of antihistamine tablets will last 40 days, the pharmacy should bill the box as a 30-day supply.

In situations where one unit does not maximize the member’s benefit (e.g., inhalers), the pharmacy should only submit the quantity that falls within the benefit.

For example, if a member’s benefit allows a 34-day supply, but one inhaler will last 28 days, the member should receive one inhaler (unless the prescription is written for two inhalers because the member needs one inhaler for home and one for school; two inhalers would then be covered for a 34-day supply).

Dispensed Package Size

When a pharmacy submits a claim for a prescription drug service provided by the pharmacy, the pharmacy must submit the NDC number for the original package size from which the prescription drug service was dispensed.

For example, if a drug is purchased in a 5,000-count bottle and repackaged in 100-count bottles prior to dispensing, the NDC for a 5,000-count bottle must be used. In this case, using the NDC for a 100-count bottle is not permitted. Many drugs distributed by repackagers are not covered by PrimeWest Health. A pharmacy may not dispense a repackager’s drug and then bill PrimeWest Health using the original manufacturer’s NDC.

Prescriptions may not be separated and dispensed by doses. If separate packaging is required, the pharmacy must use a duplicate label.

For example, a dose required in school or adult care center should not be dispensed as a separate prescription.

Benefit Plan

Existing benefits may change without prior notice to the pharmacy. The claim adjudication system will provide the pharmacy with current benefit information. Brief explanations of common benefit designs are listed in the following sections. If you have questions about any benefit limitation, please call the MedImpact Help Desk at 1-800-788-2949 (toll free).

Non-Covered Services

When a claim is submitted for a non-covered drug, the pharmacy will receive NCPDP reject code 70, “Product/service not covered.”

Drugs and costs not covered include the following:

1. Drugs when indicated or used for erectile dysfunction
2. Drugs determined to be less-than-effective in Drug Efficacy Study Implementation (DESI) by the United States Food and Drug Administration (FDA) and drugs identified as identical, related, or similar to DESI drugs
3. Drugs that are limited or excluded by the state as allowed by Federal law
4. Drugs dispensed after their expiration date
5. The cost of shipping or delivering a drug
6. Drugs lost in shipping or delivery
7. Drugs, both legend and OTC, that are not prescribed by practitioners licensed to prescribe or that are not prescribed within their scope of practice
8. Herbal or homeopathic products
9. Medical cannabis in any form

Generic Mandate

Pharmacies are required to substitute a generic equivalent or lower-priced medication and inform the member of the substitution under applicable Minnesota State Pharmacy Laws. If the member objects to the substitution, the following codes may be tried. Use of these codes does not guarantee that the formulary exception process can be avoided.

0 = No product selection indicated
1 = Substitution not allowed by prescriber
2 = Substitution allowed – patient requesting product dispensed
3 = Substitution allowed – pharmacist selected product dispensed
4 = Substitution allowed – generic drug not in stock
5 = Substitution allowed – brand drug dispensed as a generic
6 = Override
7 = Substitution not allowed – brand drug mandated by law
8 = Substitution allowed – generic drug not available in marketplace
9 = Other

Dispense as Written – Brand Necessary

1. Prescribers must obtain authorization for any brand name multiple source drug that has an FDA “AB” rated generic equivalent.
2. Providers must continue to write, in their own handwriting, “DAW - brand medically necessary” on the prescription (a checked DAW box or a typed DAW is not acceptable) and obtain prior authorization from PrimeWest Health.
3. For prescriptions transmitted electronically, the prescriber may indicate the DAW 1 box using the e-prescribing software. However, the prescriber must enter “Brand Medically Necessary” in the “Prescriber note to Pharmacy” field. The pharmacy may not make any changes to the “Prescriber note to Pharmacy” field. If a DAW “1” appears and there is no brand necessary notation, the pharmacist must contact the prescriber for a new prescription.
4. List the specific drug being requested, including dosage form, strength, and directions.
5. Document when the generic was tried and the length of the trial period.
6. Specify the medical problem caused by the generic product. Describe the problem in detail (e.g., the medication caused hives or a rash).
7. Provide chart documentation of generic failure whenever possible.
8. Include the name and National Provider Identifier (NPI) of the prescribing physician, the NDC number, and the NPI number of the dispensing pharmacy.
9. When submitting claims, dispensing providers must use code 01: Substitution Not Allowed by Provider and include the authorization number.
10. If a brand name drug is required by the primary insurance, PrimeWest Health will enter authorization for the brand name drug. Contact the PrimeWest Health Provider Contact Center at 1-866-431-0802 (toll free) to facilitate this process.

An exception to this policy is when a generic drug has a higher net cost than the brand name drug. When this occurs, PrimeWest Health may prefer the brand name drug over the generic until the generic product is available at a reduced cost. When PrimeWest Health prefers the brand over the generic, the prescriber is not required to write “DAW – brand medically necessary” on the prescription or enter “Brand Medically Necessary” in the “Prescriber note to Pharmacy” field. When a new generic drug becomes available, use our online formulary search or call the PrimeWest Health Provider Contact Center to determine if the generic drug has prior authorization requirements.

Online Claim Submission

The pharmacy is required to submit all claims online to MedImpact all prescription drug services provided to a member, including situations where:

1. The copay equals the pharmacy payment
2. The pharmacy payment is less than the copay

The pharmacy must submit claims online using the National Council for Prescription Drug Programs (NCPDP) format. The pharmacy has 90 days from the date of service (DOS) to submit a claim online. The pharmacy is required to submit the U&C charge on each claim processed through the online adjudication system. If the claim is older than 90 days, the pharmacy must submit a paper claim to MedImpact. Claims exceeding 180 days may not be eligible for reimbursement.

Online Availability

The online system is available for claims processing 24 hours a day, 365 days a year.

In the rare event that the MedImpact claim system is unavailable, or if a problem occurs at the switch company, the pharmacy should provide the member with enough medication until the claim can be adjudicated online.

Claim Reversal

The pharmacy has 14 days from the DOS to reverse a claim. Any prescription that has not been delivered or received by a member must be reversed through the POS claim adjudication system within 14 days from DOS.

Coordination of Benefits (COB)

COB capabilities are available on a limited basis. Please call PrimeWest Health at 1-866-431-0802 (toll free) for assistance in processing secondary claims. Keep in mind that all secondary claims submitted to PrimeWest Health must be on our formulary lists in order to be processed for payment. Non-formulary items will deny at POS for secondary claims unless a Prior Authorization has been received. Secondary claims for greater than a 34-day supply will be granted on a limited basis only when the primary insurance requires that a larger supply be provided (i.e., mandatory mail order).

Claim Formats

1. POS claims must be submitted in the current NCPDP version as specified by MedImpact.
2. A Universal Claim Form (UCF) can be submitted for paper submissions

A MedImpact payer specification sheet can be found at www.medimpact.com for a complete list of required and/or situational processing requirements.

Copay Charge

The copay is the amount specified by PrimeWest Health that the member is required to pay to the pharmacy for prescription drug services. MedImpact passes back the appropriate copay to be collected from the member when the claim is adjudicated through the online system.

1. The pharmacy will only collect the copay adjudicated back from MedImpact on the claim. No additional costs will be requested for services.
2. If the member cannot pay the copay, service may not be denied at that time. Services cannot be withheld or refused if the member is unable to pay the copay or has other debts unpaid. Please refer to Title 42 Code of Federal Regulations (CFR) Part 447.53 for additional details.
3. PrimeWest Senior Health Complete and Prime Health Complete members entering a long-term care facility (LTCF) will be responsible for any copays on their prescriptions for at least the remainder of that month, sometimes longer. For stays in the LTCF anticipated to be less than a month, copays would still apply and be the responsibility of the member until enrollment is updated to reflect institutional status.

Accepting Cash Payments

A pharmacy may accept cash payment for a non-covered prescription drug provided that:

1. The patient is not enrolled in the Restricted Recipient Program (RRP)
2. All available covered alternatives have been reviewed with the member
3. The pharmacy obtains a patient signature acknowledging their understanding that the prescription is not covered and they will have to pay for it
4. The prescription is not for a controlled substance or gabapentin

Effective May 1, 2015, pharmacies can accept cash payment for phentermine.

A pharmacy may accept cash payment for a controlled substance or gabapentin only if the pharmacy has received an Advance Member Notice of Noncovered Prescription (DHS-3641) signed by the prescriber and all criteria have been met for a member who is not enrolled in the Restricted Recipient Program (RRP). PrimeWest Health will not authorize a pharmacy to accept cash if the medication requires prior authorization or is subject to a quantity limit and the prescriber has not attempted to obtain the prior authorization or authorization to exceed the quantity limit. PrimeWest Health will authorize cash payment if the pharmacy and member complete their sections of the Advance Member Notice of Noncovered Prescription (DHS-3641) and the prescriber also confirms the following:

1. Covered alternatives are not viable options for the member
2. The prescriber is aware that they are seeking authorization for the pharmacy to charge the member for the medication
3. The prescriber is aware of the last time the medication was filled for the member, if applicable 
4. The prescriber attests that allowing the member to purchase the medication is medically necessary

The prescriber must sign the Advance Member Notice of Noncovered Prescription (DHS-3641), send the completed form to the pharmacy, and retain a copy of the completed form in the member’s medical record. The pharmacy must also retain a copy of the completed form as documentation of approval from PrimeWest Health to accept cash payment on the date of service. The completed Advance Member Notice of Noncovered Prescription (DHS-3641) is authorization from PrimeWest Health to accept cash payment on the date of service; you do not need to submit a copy to PrimeWest Health, unless requested. The prescriber or pharmacy does not need to call PrimeWest Health or MedImpact for additional authorization. The form must be completed each time the prescription is filled.

If a member’s PrimeWest Health eligibility status is in question and the member offers cash payment for prescriptions, the pharmacy must verify eligibility through Minnesota Information Transfer System (MN–ITS) or the Eligibility Verification System (EVS). If the person does not have coverage through PrimeWest Health, you may charge that person and accept cash as payment. If the member is covered by PrimeWest Health, do not accept cash payment from the member for the prescription if they are enrolled in the RRP or the product requested is a controlled substance or gabapentin.

Eligible Providers and Prescribers

Eligible Dispensing Providers

1. A pharmacy that is licensed by the Minnesota Board of Pharmacy
2. A pharmacy enrolled into the MedImpact network of pharmacies
3. An out-of-network pharmacy, licensed by a state board of pharmacy, that applies for retroactive enrollment
4. The pharmacy must maintain a clean professional environment in accordance with all State pharmacy laws
5. The pharmacy must maintain all license requirements established by the Board of Pharmacy in its jurisdiction
6. A physician located in a local trade area where there is no PrimeWest Health-enrolled pharmacy
   1. The physician, to be eligible for payment, must personally dispense the prescribed drug according to applicable Minnesota Statutes, and must adhere to the labeling requirements of the Minnesota Board of Pharmacy
7. A physician or nurse practitioner (NP) employed by or under contract with a community health board for communicable disease control

Eligible Prescribers

A physician, osteopath, dentist, podiatrist, NP, mental health certified nurse specialist, optometrist, physician assistant (PA), or other health care professional licensed to prescribe drugs under Minnesota Statute or, the laws of another state or Canada may prescribe drugs within the scope of their profession. Pharmacists may prescribe OTC medications to PrimeWest Health members.

Prescribers are required to comply with section 5042 of the Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act when prescribing controlled substances to PrimeWest Health members. Section 5042 of the SUPPORT for Patients and Communities Act requires prescribers to check the prescription drug monitoring program (PDMP), hosted by the Minnesota Board of Pharmacy, before prescribing a controlled substance to a PrimeWest Health member. If a prescriber is unable to check the PDMP prior to prescribing a controlled substance, then the prescriber must document the good faith effort, including the reason why they were unable to check the PDMP. Prescribers may be required to submit the documentation of the failure to check the PDMP prior to prescribing a controlled substance to a PrimeWest Health member to DHS upon request.

Provider Identifier

In accordance with State and Federal regulations, NPIs of the pharmacy and practitioners must be transmitted with all claims. Failure to use the pharmacy’s NPI will result in a denied claim. If reasonable efforts to obtain and send the NPI of the prescriber are tried, the pharmacy can use other identifiers in accordance with their current pharmacy benefits management (PBM) agreement. A pharmacy can use the NPI of an MHCP-enrolled supervising physician if the NPI of the prescribing provider is not available because the prescribing provider is an intern or resident. The Drug Enforcement Agency (DEA) number can also be submitted as identification (ID) for the prescribing provider. When a pharmacist has prescribed OTC medications, the NPI of the dispensing pharmacy may be used as the prescribing provider.

Physician-Administered Drugs

Drugs that are administered to a patient as part of a clinic or other outpatient visit should be billed to PrimeWest Health using the appropriate HCPCS code(s). Do not bill drugs administered during an outpatient visit through the pharmacy POS system. PrimeWest Health does not allow “brown-bagging” or “white-bagging” of prescription drugs administered in an office setting.

Pharmacies, including mail order pharmacies, that are providing the drugs for a clinic visit, should bill the clinic and not PrimeWest Health for the drugs dispensed. PrimeWest Health will make an exception only if a member has third-party liability and the third-party payer requires that the drugs be billed through the pharmacy benefit.

Pharmacies should not dispense drugs directly to a patient if the drugs are intended for use during a clinic or other outpatient visit.

Pharmacist Prescribing – Over-the-Counter (OTC) Medications

The following policies apply to pharmacists prescribing OTC medications:

1. OTC medication must be medically necessary, and the member must not need a referral to another health care professional
2. Drug therapy must be reviewed for potential adverse interactions
3. Drug counseling must be consistent with MN Rules part 6800.0910
4. Keep on file a prescription as defined in MN Stat. sec. 151.01, subd. 16. As with all other Medical Assistance (Medicaid) and Prescription Drug Plan (PDP) prescriptions, the prescription must be kept on file for the term applicable to Federal and State requirements. For the purposes of providing OTC drugs to members, the pharmacist is the prescriber who must sign the prescription. Prescriptions may be refilled for up to 12 months as specified in MN Rules part 6800.3510.
5. Prescription must be dispensed in accordance with all relevant sections of MN Stat. sec. 151 and MN Rules part 6800
6. The pharmacy’s NPI number should be used in conjunction with the evaluating pharmacist when sending through claims. Individual pharmacists will not be enrolled as providers.
7. For the original fill, document on the prescription information regarding medical necessity, drug therapy reviews, and drug counseling. For refills, document in the member’s profile any updated information regarding medical necessity, drug therapy reviews, and drug counseling.
8. The pharmacist is required to have the member sign for receipt of the prescription whenever possible.
9. The entire package of all OTC medications used on a maintenance or as-needed basis must be dispensed at each fill. Do not dispense a partial package of an OTC drug unless the drug is being used on a one-time basis and it is not anticipated that the patient will need a refill. All vitamin and mineral supplements should always be dispensed in the entire package quantity.
10. Pharmacies may repackage OTCs, but the entire package quantity must still be dispensed for all OTC medications used on a maintenance or as-needed basis. No additional or enhanced dispensing fee is available for the repackaging of OTC medications.
11. OTC drug products must be billed at the shelf price of the pharmacy. If a pharmacy is not accessible to, or frequented by the general public, or if the OTC drug is not on display for sale to the general public, then the U&C charge for the OTC drug will be the actual acquisition cost of the product plus a reasonable mark-up based on the actual acquisition cost. The MedImpact MAC list will supersede any submitted OTC drug prices.
12. The smallest quantity of OTC medication must be selected to fulfill the member’s needs for the 30/34 day supply. In the event an OTC product contains greater than the 30/34 day supply, it is acceptable to dispense the entire, unopened container and submit a day’s supply of 30/34 to allow the claim to be paid. Efforts should be taken by the pharmacy to document this and stock the smallest container size available to achieve the month’s supply.

Eligible Members

Member Eligibility

A member’s eligibility can be verified through the claim adjudication system or by calling the MedImpact Help Desk at 1-800-788-2949 (toll free). Under no circumstances should a member, whose eligibility has been verified, be denied a prescription drug service (subject to pharmacist’s professional judgment) or be asked to pay more than the transmitted copay.

Eligibility Verification

1. Access member eligibility information by using the PrimeWest Health web portal, Provider Contact Center, or the automated DHS EVS, which includes a telephone service and a web portal within MN–ITS.
2. Verify member eligibility through:
   1. PrimeWest Health web portal. Prior registration is required using the Web Portal Registration Form.
   2. PrimeWest Health Provider Contact Center: 1-866-431-0802 (toll free)
   3. DHS MN–ITS web portal
   4. DHS EVS Line: 1-651-431-2700 or 1-800-657-3613 (toll free)

Standard Eligibility Format

The eligibility format used by the majority of PrimeWest Health members includes the following elements:

1. Member ID number
2. Date of birth (DOB)
3. Gender status
4. Prescriber identifier (NPI)

The pharmacy can require a person to produce a member ID card or other photo ID prior to providing a prescription drug service. The ID card does not ensure a member’s eligibility. If a member does not have a member ID card/valid photo ID and the pharmacy is unsure of eligibility, call the MedImpact Help Desk at 1‑800-788-2949 (toll free) or use MN–ITS to verify eligibility on the DOS to obtain accurate member information prior to processing a claim. The member’s Medical Assistance (Medicaid) number is the same as their PrimeWest Health ID number.

Responsibility of Pharmacy

All pharmacy claims for medications are processed by MedImpact. Pharmacies should follow their policies and procedures for proper submission of claims. In addition to MedImpact’s requirements, PrimeWest Health requires the following:

1. Provide prescription drug services to all members in accordance with the standard of practice of the communities in which the pharmacy provides services. Service should be provided without regard to race, religion, sex, color, national origin, age, or physical or mental health status, upon the written or verbal prescription order or refill from a prescribing provider
2. Submit all claims online to MedImpact for adjudication within 90 days from the date the prescription is dispensed
3. Submit no more than the U&C charge for all claims for prescription drug services
4. Submit the NDC from the original package size from which the prescription drug was dispensed
5. Comply with the Drug Formulary unless otherwise directed by the prescribing provider to dispense the prescription “Brand Necessary,” “DAW,” etc.
6. Collect all applicable copays from the member at time of service unless other arrangements have been made. If the member is unable to pay the copay, the pharmacy may not refuse service at that time. Future prescriptions may be denied if it is the pharmacy’s policy to not allow delinquent accounts. Under no circumstances shall the pharmacy collect or attempt to collect additional fees for prescription drug services provided.
7. Contacting the member’s prescriber in cases of claims rejection related to UM policies or non-formulary status is strongly recommended
8. Notification of members prior to dispensing of any rejected medications claims for any reason, especially those members residing in LTCFs, of the potential of non-coverage is expected of all pharmacies serving PrimeWest Health members
9. PrimeWest Health does not allow automatic refills. Prescription refills are not eligible for payment without an explicit request from a member or authorized caregiver. The pharmacy provider may not contact the member in an effort to initiate a refill unless it is part of a good faith clinical effort to assess the member’s medication regimen.

A nurse or other authorized agent of the facility may initiate a request for refill for a member residing in a skilled nursing facility, group home, or assisted living arrangement.

Summary of Pharmacy Requirements while Filling Prescriptions

1. Verify “AS DIRECTED” prescription orders by contacting the prescribing provider to verify directions. This allows the pharmacy to provide an accurate days’ supply on the claim. If the prescribing provider is unavailable, the pharmacy should ask the member how they were instructed to take the prescription drug. A pharmacy audit of files with inaccurate or unjustified quantities or direction may result in recoupment of payments.
2. Maintain a signature log that contains the signature of the member or designee, indicating receipt of the prescription drug. Mailed or delivered prescriptions should be noted on the signature log with the date of delivery. An electronic transaction log may be used in lieu of a signature log.

Limitations on Pharmacy Services

1. A prescribed drug must be dispensed in the quantity specified on the prescription unless the pharmacy is using unit dose dispensing or the specified quantity is not available in the pharmacy when the prescription is dispensed. Only one dispensing fee is allowed for dispensing the quantity specified on the prescription.
   1. OTC drugs must be dispensed in the manufacturer’s original, unopened container and can be dispensed in greater than 30/34-day supplies, if necessary, to meet that requirement. If dispensing under this provision, the smallest commercially made form must be used.
   2. Inhalers or units of use medications that cannot be dispensed in partial quantities are acceptable to dispense at the maximum monthly supply. If dispensing under this provision, the smallest commercially made form must be used.
   3. Two rescue inhalers such as albuterol and pirbuterol can be dispensed for members who need one for home and one for school or work even if the days’ supply is greater than 34.
2. Except as noted above, an initial or refill prescription for a maintenance drug must be dispensed in not less than the maximum monthly supply, unless the pharmacy is using unit dose dispensing or the drug is clozapine, the dispensing fee is limited to one per month, and no additional dispensing fee will be paid until that quantity is used by the member.
3. Except as described below or unless the drug is clozapine, the dispensing fee billed by or paid to a particular pharmacy or dispensing physician for a maintenance drug is limited to the fee per maximum monthly supply.
4. More than one dispensing fee per calendar month for a maintenance drug for a member is allowed if the record kept by the pharmacist or dispensing physician documents that there is a significant chance of overdose by the member if a larger quantity of drug is dispensed, and if the pharmacist or dispensing physician writes of this reason on the prescription. Short cycle dispensing of solid oral doses of brand name drugs to Medicare members in LTCFs in accordance with 42 CFR 423.154 will also receive more than one dispensing fee per the PBM agreement.
5. Refill prescriptions must be authorized and approved by the prescriber as consistent with accepted pharmacy practice. Refills must be documented in the prescription file and initialed by the pharmacist who refills the prescription.
6. Pharmacies may repackage OTCs, but the entire package quantity must still be dispensed at each fill for all OTC medications used on a maintenance or an as-needed basis. No additional or enhanced dispensing fee is available for the repackaging of OTC medications.

Compound Drugs

“Compound Prescription” means a prescription where two or more medications are mixed together. One of these drugs must be a Federal legend drug. The end product must not be available in an equivalent commercial form. A prescription will not be considered a compound prescription if it is reconstituted or if only water, alcohol, or sodium chloride solutions are added to the active ingredient. Compound drugs are reimbursed based off rates specified in the pharmacy provider agreement executed between the pharmacy and MedImpact. Compounds are driven by the compound code the pharmacist enters into the system. Once the claim is determined to be a compound, it will adjudicate off of how MedImpact has set up and the price/patient pay schedules. Compound drugs can be submitted through the online adjudication system following current NCPDP guidelines.

Accurate Quantity

The quantity dispensed must be entered exactly as written. Quantities should be submitted as metric quantity (including decimal points). The pharmacy must enter the exact quantity, no rounding up or down on claims.

OTC Products

Price will not exceed shelf price for customer purchase. A list of covered OTC items is included in the Formularies section.

Solutions Prescriptions

Solutions such as saline for nebulizers, intravenous (IV) solutions, irrigation solutions, and diluents are to be billed under medical supply items.

General Insulin Benefits

A valid prescription must be on file for any insulin dispensed to a member.

Insulin should be dispensed within the days’ supply limits set by PrimeWest Health.

Insulin Supplies

Unless indicated by the POS system, insulin syringes and needles are generally a covered benefit. For PrimeWest Senior Health Complete/Prime Health Complete members, these are considered Part D-covered items and should be sent to that specific BIN and PCN listed above.

A valid prescription is required for insulin syringes and needles that are dispensed to a member.

Complaints and Appeals

Please contact the PrimeWest Health Complaints/Appeals & Grievances Specialist at 1-866-431-0801 (toll free) for full information regarding complaints and Appeals.

Utilization Management (UM) Programs for Families & Children (F&C), MinnesotaCare, Minnesota Senior Care Plus (MSC+), Special Needs BasicCare (SNBC), and PrimeWest Senior Health Complete (HMO SNP)

Administrative Determinations
 

Maximum Allowable Cost (MAC) List

Multiple manufacturers of a given drug product create competition in the marketplace resulting in decreased acquisition costs. Typically, generic drugs are introduced at costs lower than those of the original brand name product. A number of elements support the idea of a MAC program rather than a specific percentage discount for reimbursement of multi-source products.

1. Generic drugs are sold to pharmacies over a very wide discount range off AWP, whereas brand drugs are typically sold at a very narrow discount off AWP. Thus, a single discount percent off AWP does not fit all generics.
2. A MAC program can select a reimbursement price that will cover most generics, but not the brand version. Reimbursement lower than the brand acquisition is a strong driver to generic dispensing.
3. A MAC program can selectively pick generic drug products that meet pre-determined criteria relating to clinical, marketing, and cost considerations.

PrimeWest Health has adopted the MedImpact’s MAC program, which includes a list of multi-source drugs that are reimbursed at an upper limit per unit price. Highly utilized products are reviewed quarterly. However, individual products can be adjusted on an as-needed basis. If availability of a drug becomes limited, the MAC may be temporarily suspended or the drug may be permanently removed from the MAC list. The drug may be re-added when market sources confirm adequate supply and distribution. For a copy of the MedImpact’s MAC list, please contact MedImpact per your pharmacy provider agreement.

Generic Drugs

Information about Generic Drugs

Health professionals and consumers can be assured that the FDA-approved generic drugs on the MAC list meet the same rigid standards as the brand name drugs. To gain FDA approval, a generic drug must:

1. Contain the same active ingredients as the brand name drug
2. Be identical in strength, dosage form, and route of administration
3. Have the same labeling
4. Be bioequivalent to the referenced brand
5. Meet the same batch requirements for identity, strength purity, and quality
6. Be manufactured under the same strict standards of the FDA’s good manufacturing practice regulations required for brand name products

Generic Drug Standards

1. The provider must dispense a generic drug whenever permitted and in accordance with applicable laws.
2. The pharmacy must contact the prescriber to encourage a change to a generic substitute when the prescription contains a “Dispense as Written” signature for a multi-source brand name medication.
3. The pharmacy must stock a sufficient amount of drugs under their generic name coinciding with the habits of local prescribers, the PrimeWest Health formulary(s) as indicated by the claims system response and other correspondence, or the generic formulary of the state in which the provider resides.

Vacation Supply and Lost Medications

A pharmacy may obtain Prior Authorization for a dosage change or vacation request by calling the MedImpact Help Desk at 1-800-788-2949 (toll free). Controlled substances are not eligible for vacation supply requests. The following are situations that would be covered under this provision:

Drugs

Refer to Formularies for medications that require authorization.

The following do not require Service Authorization through the medical benefit (this list is subject to change):

• Infliximab biosimilars – Preferred
  • Inflectra (infliximab-dyyb) – Q5103
  • Renflexis (infliximab-abda) – Q5104
  • Avsola (infliximab-axxq) – Q5121
  • Ixifi (infliximab-qbtx) – Q5109
• Trastuzumab – biosimilars are preferred
  • Ontruzant (trastuzumab-dttb) – Q5112
  • Herzuma (trastuzumab-pkrb) – Q5113
  • Ogivri (trastuzumab-dkst) – Q5114 - Preferred
  • Trazimera (trastuzumab-qyyp) – Q5116
  • Kanjinti (trastuzumab-anns) – Q5117
• Ritixuimab biosimilars
  • Truxima (rituximab-abbs) – Q5115 - Preferred
  • Riabni (rituximab-arrx) – Q5123
  • Ruxience (rituximab-pvvr) – Q5119
• Onabotulinum toxin (subject to retrospective review)
  • Botox (onabotulinumtoxina) – J0585
  • Dysport (Abobotulinumtoxina) – J0586
  • Myobloc  (rimabotulinumtoxinb) – J0587
• Colony Stimulating Factor
  • Udenyca – Q5111 – Preferred

Effective January 1, 2023, reference/brand name versions of biosimilar drugs listed above are subject to Part B Step Therapy requirements.

Part B Step Therapy

• IV Iron
• Herceptin
• Remicade
• Rituxan

The following require Service Authorization when dispensed during a medical office visit or in the member’s home. Please be aware that this list is subject to change. These drugs may also be part of our Part B Step Therapy program. Call the Provider Contact Center at 1-866-431-0802 for the most current drug coverage information. 

PrimeWest Health has an open medical drug formulary. Review the list of covered codes for medical drugs. The drugs in this list may require Service Authorization.

Medicare determinations are reviewed using LCD/NCD when available or Part B Step Therapy as identified above.

• Abecma (idecabtagene vicleucel) – Q2055
• Adakveo (crizanlizumab-tmca) – J0791
• Aduhelm (aducanumab-avwa) – J0172
• Ajovy (fremanezumab-vfrm) – J3031
• Aliqopa (copanlisib) – J9057
• Antiemetics for chemotherapy – Q0161, Q0162, Q0163, Q0164, Q0166, Q0167, Q0169, Q0173, Q0174, Q0175, Q0177, Q0180, Q0181, S0091, J1454 (fosnetupitant and palonosetron [Akynzeo])
• Asparlas (calaspargase) – J9118
• Bavencio (avelumab) – J9023
• BENLYSTA (belimumab) – J0490
• Beovu (brolucizumab) – J0179
• Berinert (injection, c-1 esterase inhibitor [human], 10 units) – J0597
• Besponsa (inotuzumab ozogamicin; inj.) – J9229
• Blenrep (belantamab mafodotin-blmf) – J9037
• Breyanzi (lisocabtagene maraleucel) – Q2054
• BRINEURA (cerliponase alfa) – J0567
• Cabenuva (cabotegravir/rilpivirine) – J0741
• Camcevi (leuprolide) – J1952
• Carvykti (ciltacabtagene autoleucel) – Q2056
• CIMZIA (certolizumab pegol) – J0717
• CINQAIR (reslizumab) – J2786
• Cinryze (c-1 esterase inhibitor [human]) – J0598
• Cosela (trilaciclib) – J1448
• CRESEMBA (isavuconazonium sulfate) – J1833
• CRYSVITA (burosumab-twza) – J0584
• CYRAMZA (ramucirumab) – J9308
• Danyelza (naxitamab-gqgk) – J9348
• DARZALEX (daratumumab) – J9145
• Darzalex Faspro (daratumumab and hyaluronidase) – J9144
• Diacomit (stiripentol) – J3490
• Elahere (mirvetuximab soravtansine-gynx) – J9063
• Elzonris (tagraxofusp-erzs) – J9269
• ENBREL (etanercept) – J1438
• Enjaymo (sutimlimab-jome) – J1302
• ENTYVIO (vedolizumab) – J3380
• Ervebo (Ebola Zaire Vaccine) – 90758
• Evenity (romosozumab-aqqg) – J3111
• Evkeeza (evinacumab-dgnb) – J1305
• EXONDYS 51 (eteplirsen) – J1428
• EXTAVIA (interferon beta-1b) – Q3027, Q3028
• Factor VIII products – J7182, J7185, J7186, J7187, J7188, J7190, J7192, J7202, J7205, J7207, J7209, J7210, J7211, J7208, J7170
• FASENRA (benralizumab) – J0517
• FERAHEME (Ferumoxytol) – Q0138, Q0139
• Fensolvi (leuprolide acetate) – J1951
• Fertility drugs – Not covered by PrimeWest Health or DHS except under specific circumstances. Call the PrimeWest Health Provider Contact Center at 1-866-431-0802 for more information.
• Fibryga (human fibrinogen concentrate) – J7177
• Firazyr (injection, icatibant, 1 mg) – J1744
• Furoscix (furosemide) – J1941
• Fyarro (sirolimus) – J9331
• Gamifant (emapalumab-lzsg) – J3490, J3590, J9210
• General pharmacy criteria – J3490, J8999
• Givlaari (givosiran) – J0223
• Growth hormones – J2170 (INCRELEX [mecasermin]), J2940 (PROTROPIN [somatrem]), J2941 (SEROSTIM [somatropin])
• Haegarda (c-1 esterase inhibitor [human]) – J0599
• Hemgenix (etranacogene dezaparvovec-drlb iv susp) – J1411
• Hemlibra (emicizumab-kxwh) – J7170
• Herceptin (trastuzumab) – J9355, J9356
• HUMIRA (adalimumab) – J0135
• IGG (immunoglobulin G) – J1459, J1460, J1559, J1560, J1561, J1562, J1566, J1568, J1569, J1572, J1557, J1554, J1555
• Ilumya (tildrakizumab) – J3245
• Imfinzi (durvalumab) – J9173
• Implantable/insertable device for device-intensive procedure, not otherwise classified – C1889
• Infugem (gemcitabine premix) – J9198
• INJECTAFER (ferric caboxymaltose) – J1439
• Interferon – J9214, J9215, J9216
• Istodax (romidepsin) – J9318, J9319
• Ixinity (factor IX recombinant) – K9213
• Jelmyto (mitomycin pyelocaliceal) – J9281
• Jemperli (dostarlimab-gxly) – J9272
• JETREA (ocriplasmin) – J7316
• KADCYLA (ado-trastuzumab emtansine) – J9354
• KALBITOR (ecallantide) – J1290
• Kimmtrak (tebentafusp-tebn) – J9274
• KINERET (anakinra) – J3590
• KRYSTEXXA (pegloticase) – J2507
• KYMRIAH (tisagenlecleucel) – Q2042, J3490
• LEMTRADA (alemtuzmab) – J0202
• Leqvio (inclisiran) – J1306
• Levoleucovorin (Khapzory), Levoleucovorin calcium (Fusilev) – J0642, J0641
• Libtayo (cemiplimab-rwlc) – J9119
• Lumoxiti (Moxetumomab pasudotox-tdfk) – J9313
• Lutathera (lutetium Lu 177 Dotatate) – A9513
• Luxturna (voretigene neparvovec; 1 billion vector genome) – J3398
• Margenza (margetuximab-cmkb) – J9353
• Mepsevii (vestronidase alfa-vjbk) – J3397
• Monjuvi (tafasitamab-cxix) – J9349
• Monoferric (ferric derisomaltose) – J1437
• Mylotarg (gemtuzumab ozogamicin) – J9203
• Nexviazyme (avalglucosidase alfa-ngpt) – J0219
• NUCALA (mepolizumab) – J2182
• OCREVUS (ocrelizumab) – J2350
• OnPattro (patisiran) – J0222
• OPDIVO (nivolumab) – J9299
• Opdualag (nivolumab/relatlimab-rmbw) – J9298
• ORENCIA (abatacept) – J0129
• Oxlumo (lumasiran) – J0224
• Pepaxto (melphalan flufenamide) – J9247
• PERJETA (pertuzumab) – J9306
• POLIVY (polatuzumab vedotin) – J9309
• POTELIGEO (mogamulizumab-kpkc) – J9204
• PROLIA (denosumab) – J0897
• PROVENGE (siuleucel-T) – Q2043
• Radicava (edaravone) – J1301
• Rebyota (fecal microbiota, live) – J1440
• REMICADE (infliximab) – J1745
• RITUXAN (rituximab) – J9312, J9311 (with hyaluronidase)
• Ruconest (c-1 esterase inhibitor [recombinant]) – J0596
• Rybrevant (amivantamab-vmjw) – J9061
• Rylaze (asparaginase erwinia chrysanthemi recombinant-rywn) – J9021
• Saphnelo (anifrolumab-fnia) – J0491
• Sarclisa (isatuximab-irfc) – J9227
• SCULPTRA – Q2028
• SIMPONI (golimumab) – J1602
• SIVEXTRO (tedizolid phosphate) – J3090
• SOLIRIS (eculizumab) – J1300
• Spinraza (nusinersen) – J2326
• Spravato (esketamine) – S0013
• STELARA (ustekinumab) – J3357,  J3358
• Svfovre (pegcetacoplan) – C9151
• Takhzyro (lanadelumab-flyo) – J0593
• Tecvayli (teclistamab-cqyv) – Q0138
• Tremfya (guselkumab) – J1628
• Triferic-avnu (ferric pyrophosphate citrate) – J1445
• Trodelvy (sacituzumab govitecan-hziy) – J1746
• TROGARZO (ibalizumab-uiyk) – J1746
• TYSABRI (natalizumab) – J2323
• Ultomiris (ravulizumab-cwvz) – J1303
• Unclassified drug codes if billed amount is greater than $700 – J3490, J3590, J3535, J7599, J7699, J7799, J7999, J8498, J8499, J8597, J8999, J9999, Q4082, C9399
• Vabysmo (faricimab-svoa) – J2777
• Viltepso (viltolarsen) – J1427
• Vyepti (eptinezumab-jjmr) – J3032
• XGEVA (denosumab) – J0897
• XOLAIR (omalizumab) – J2357
• YERVOY (ipilimumab) – J9228
• YESCARTA (axicabtagene ciloleucel) – Q2041
• YONDELIS (trabectedin) – J9352
• ZALTRAP (ziv-aflibercept) – J9400
• ZILRETTA (triamcinolone extended-release) – J3304
• Zinplava (bezlotoxumab) – J0565
• Zolgensma (onasemnogene abeparvovec-xioi) – J3399
• Zulresso (brexanolone) – J1632
• Zynlonta (loncastuximab tesirine-lpyl) – J9359
• Zynteglo (betibeglogene autotemcel) – J3490, J3590

Intra-articular hyaluronic acid injections, Euflexxa, Synvisc, and Synvisc One are preferred

• ORTHOVISC – J7324
• MONOVISC – J7327
• GEL-ONE – J7326
• Preferred: SYNVISC ONE – J7325
• Preferred: EUFLEXXA – J7323
• SUPARTZ FX – J7321
• HYALGAN – J7321
• HYALGAN – J7321
• GENVISC 850 – J7320
• SODIUM HYALURONATE – J3490
• GELSYN-3 – J7328
• Preferred: SYNVISC – J7325
• HYMOVIS – J7322
• TRILURON – J7332
• DUROLANE – J7318
• VISCO-3 – J7321
• HYLENEX – J3473

Process for Handling “Refill-Too-Soon” Override and Authorization Requests

PrimeWest Health follows Chapter 22, Pharmacy, of the DHS MHCP Manual.

Criteria

1. Members will be allowed only one override in 12 months for lost, stolen, damaged, or destroyed non-controlled medications.
2. Members will be allowed only one vacation supply override per 12 months.
3. Vacation overrides will be allowed only after 50 percent of the last submitted days’ supply has passed (e.g., if the last submitted days’ supply was 34, a vacation override will not be granted until at least 17 days have passed since the last fill).
4. A leave of absence override maybe allowed in certain circumstances. The intent is that an authorization may be granted for a member who lives in an LTCF and receives a pass to leave the facility for a weekend or other short stay away from the facility. Authorization will not be granted for regularly scheduled absences such as for work and school supplies.
5. If the member increased the dose without prescriber consent, no override will be granted.

Pharmacy Non-Controlled Substance Overrides

Pharmacy Controlled Substance Overrides

Transition Medication Allowances

1. Newly enrolled PrimeWest Health members will be granted a supply of non-formulary medication upon request if they were taking the medication prior to enrollment. This transition period will not exceed 90 days.
   1. F&C, MinnesotaCare, MSC+, SNBC process: The PrimeWest Health Pharmacy Manager, or designated individual, enters an authorization into MedImpact’s claim processing system after the member or authorized representative notifies Member Services that a Formulary exception is needed. At the time the initial fill is allowed, it is expected that the dispensing pharmacy will request that a pharmacy determination be submitted by the prescribing health care provider.
   2. PrimeWest Senior Health Complete/Prime Health Complete process: Automated at POS to allow non-formulary or UM edits be overridden for the first fill. Subsequent fills are on case-by-case basis for approval. Contact Member Services 1-866-431-0801 (toll free) to initiate this process. At the time the initial fill is allowed, it is expected that the dispensing pharmacy will request that a pharmacy determination be submitted by the prescribing health care provider. The member also receives a formal letter notifying them of the transition process and to contact their provider for assistance.
2. Medications excluded by the DHS or CMS contract, State and Federal Statutes, or medications excluded from the formulary for safety reasons may not be granted approval.
3. Subject to conditions specified in MN Stat. sec. 62Q.527, PrimeWest Health will allow a member to continue to receive a prescribed drug to treat a diagnosed mental illness or emotional disturbance for up to one year, upon certification by the prescribing health care provider that the drug will best treat the member’s condition. This continuing care benefit is allowed if PrimeWest Health changes its Drug Formulary or when a member changes Managed Care Organizations (MCOs), and it will be extended annually if certification is provided to PrimeWest Health by the prescribing provider.
4. PrimeWest Health will not cover the prescribed drug if it has been removed from the formulary for safety reasons.
5. 72-hour emergency supply: Providers or pharmacies may request an emergency supply of medication by calling the PBM Pharmacy Help Desk at 1-800-788-2949 and requesting the emergency supply. This would be expected in rare instances. An appropriate use would be requesting opioids after surgery or fracture. Approval of a 72-hour emergency supply does not replace the need for prior authorization or guarantee approval. If a provider seeks an emergency supply, it is still at the discretion of the pharmacy to fill the supply.

PW_11-19_608
Updated_01/06/2025