Part B (Medical Drug Coverage)

Refer to the medical policy information below to determine which medications need prior authorization as a condition of payment prior to the service being rendered. Prior authorization requests are reviewed and determined within the timeframe outlined by the CMS standards and must meet medical necessity criteria.

Part B (Medical Drug Coverage)/Appeal
 
If your doctor or pharmacist tells you that we will not cover a medical drug you should contact us and ask for a Part B (Medical Drug Coverage) request. 
 
The following are examples of when you may want to ask us for a Part B coverage review: 
 
· If there is a limit on the quantity (or dose) of the drug and you disagree with the requirement or dosage limitation
· If there is a requirement that you try another drug before we will pay for the drug you are requesting  
 
Part B (Medical Drug Coverage)/Appeal Forms
 
These forms can be used for Part B Coverage Requests/Appeals.  Have a physician complete the appropriate form below and fax it to 855-212-8110 or mail it to Prime Therapeutics LLC, Attention: Clinical Review Department, 2900 Ames Crossing Road, Suite 200, Eagan, Minnesota 55121. 
 
For additional assistance, please contact the Customer Service Number on the back of your insurance card.  Hours are 8a.m.-8p.m., local time, 7 days a week.  From February 15th-September 30th, alternate technologies (for example, voicemail) will be used on the weekends and holidays.  TTY/TTD users should call 711. 

Additional Addresses and Phone Numbers

Paper Claim Request Address
Clinical Review
P.O. Box 20970
Lehigh Valley, PA 18002-0970

Paper Claim Fax Number
855.212.8110

Return Address
Clinical Review
P.O. Box 64813
St. Paul, MN 55164-0813
 
Secure Online Submission Process
 
If you would like to submit your request by email instead of fax or mail, the following links will provide forms that can be used to request coverage of your medication. 
 
Part B (Medical Drug Request): use the following form if this is your first request for coverage of a drug.
Request for Medical Drug Organization Determination
 
Part B (Medical Drug Request) Appeal: use the following form if you are appealing a previously denied request. 
Request for Medical Drug Appeal
 
For Medicare members, Prime Therapeutics defers to Centers for Medicare and Medicaid Services (CMS) guidelines for coverage where they exist. The Medicare Coverage Database contains all National Coverage Determinations (NDCs), Local Coverage Determinations (LCDs), and articles. For a copy of the CMS guidelines please review the Medicare Coverage Database.

CMS Request Forms
 
Below are CMS model forms developed specifically for use by all Part B prescribing physicians or enrollees.  You may use these Model Part B Forms or the Part B (Medical Drug Request) forms listed above.  Either of these forms will be accepted.   
 
Medicare Reimbursement Claim Form
 
Providers click here to complete patient prior authorization electronically
 

Medicare Part B © Prime Therapeutics LLC