Pharmacy pre-authorization

Use CoverMyMeds to submit pre-authorization requests.

Need help? View user guides and training videos.

Pharmacy benefits manager

Prime Therapeutics (Prime) is our pharmacy benefits manager (PBM) for our group, Individual and Medicare members. Prime administers our pharmacy benefits, provides customer service and manages an extensive retail network.

BlueCross and BlueShield Federal Employee Program® (BCBS FEP®), BlueCard® members and members on administrative services only (ASO) groups or joint administration groups may use different PBMs.

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

Medicare Prescription Payment Plan

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.