Pharmacy Program
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Defines Peach State Health Plan's pharmacy program governance, utilization management, prior authorization, DUR, P&T committee roles, and pharmacist responsibilities for Medicaid Members and P4HB Enrollees.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Prior Authorization Criteria
Prior authorization is used to manage high‑risk, high‑cost, or abuse‑prone medications. Requests may be submitted by phone, fax, or via the electronic portal; Pharmacy Services will respond and resolve within specified timeframes.
Coverage Criteria and Operational Rules
Coverage of outpatient drugs follows Georgia Families contract requirements and program operational rules for the Preferred Drug List, transition coverage, specialty drugs, and emergency/exception handling.
Provider Submissions, Utilization Management, and Actions Required
Submit PAs via phone, fax, or CoverMyMeds; 24‑hour response and 72‑hour final disposition
Providers may submit prior authorization (PA) requests to Pharmacy Services by telephone, fax, or through the CoverMyMeds electronic PA portal. Pharmacy Services will respond by telephone or other telecommunication (including fax) within 24 hours of a PA request and will resolve requests within 24 hours unless additional information is required; if so, documented contact with the prescriber must be made every 24 hours up to a final disposition within 72 hours. Prior authorizations are reviewed by a Pharmacist licensed in the State of Georgia.
- Submission channels: telephone, fax, automated electronic Prior Authorization portal (CoverMyMeds).
- Initial response time: within 24 hours by telephone or other telecommunication (including fax).
- Resolution timeline: resolve within 24 hours unless additional prescriber information is needed.
- If additional information required: documented contact with the prescriber every 24 hours up to final disposition within 72 hours.
- PA reviewer: Pharmacist licensed in Georgia.
Utilization controls: PA, DUR and automated edits for dosing, refills, quantity, duplicates, etc.
The Pharmacy Program employs prior authorization and medical necessity criteria plus concurrent and retrospective DUR and automated edits to manage utilization. Edits include maximum dosing, early refill prevention, age/gender checks, quantity limits, maximum approved costs, duplicate therapy, adverse reaction flags, and prescriber restrictions.
- Utilization controls: PA and medical necessity criteria; concurrent and retrospective DUR.
- Automated edits: maximum dosing, early refills, age/gender, quantity limits, maximum approved costs, duplicate therapy, adverse reactions, prescriber restrictions.
- Program functions also include utilization analysis and provider feedback for inappropriate prescribing patterns.
Direct specialty drug PAs to Pharmacy Services/CoverMyMeds; denials notified with PDL alternatives
Prior authorization requests for specialty drugs should be directed to Peach State Pharmacy Department/Pharmacy Services or submitted via the CoverMyMeds electronic portal. Pharmacy Services provides daily member‑specific adverse coverage determinations and notifies prescribers of denials by fax with suggested PDL alternatives; Peach State issues member denial letters that include appeal rights and referral back to the prescriber for PDL alternatives.
- Specialty PA routing: Peach State Pharmacy Department, Pharmacy Services, or CoverMyMeds portal.
- Adverse determinations: Pharmacy Services sends member‑specific adverse coverage determinations to Peach State daily.
- Notifications: Prescribers are faxed denials with suggestions for PDL alternatives; Peach State sends member denial letters including appeal rights.
Allow interim 72‑hour supply during review and after‑hours; NurseWise approves after‑hours fills
A 72‑hour emergency drug supply policy permits an interim 72‑hour supply while a clinical review is completed, and also allows a 72‑hour supply for non‑PDL requests made after hours or on holidays. After‑hours interim supplies are approved by NurseWise until Pharmacy Services resumes normal business hours.
- Interim supply: 72‑hour emergency drug supply allowed during clinical review.
- After‑hours/holidays: 72‑hour supply allowed for non‑PDL requests made after hours or on holidays.
- After‑hours approvals: NurseWise is responsible for approving interim 72‑hour supplies.
Transition of Care and Continuation Therapy Rules
Transition of Care — Continuation Therapy
When members move between CMOs or from DCH to a new CMO, medications previously covered are continued temporarily to allow clinical review and transition.
Codes, Reporting, and Timelines
| NDC | Utilization reporting by National Drug Code for rebate submission |
Key Definitions
Step Therapy Program and Interim Supply
| Program component | Review / Approval |
|---|---|
| Use of step therapy as part of the Pharmacy Program to promote appropriate use of the pharmacy benefit | Step therapies are reviewed and approved through the Centene P&T and clinical/UM committees (Pharmacy Program governance) |
| Interim supply allowance | After‑hours approval |
|---|---|
| A 72-hour emergency drug supply is allowed as interim therapy while clinical review is completed | NurseWise handles after‑hours calls and is responsible for approving interim 72‑hour supplies |
Quantity Limits and Controlled Substance Edits
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