Individual and Family Plans: Update to Pharmacy Benefit and Medical Benefit Drugs
Certain medications previously covered under the medical benefit have been moved to the pharmacy benefit, and some medications have been moved from the pharmacy benefit to the medical benefit.
What does this mean for you?
Effective January 1, 2019, your office may need to submit prior authorization requests for medications differently, depending on if the drug falls to the medical benefit or the pharmacy benefit.
The attached grid lists all the drugs that require prior authorization and indicates if that drug is considered a medical or pharmacy benefit.
Items that are now covered under the pharmacy benefit and require prior authorization must be completed by downloading an authorization form from togetherCCHP.org/pharmacy-prior-auth and fax it to CCHP Pharmacy Services at 1-844-201-4675. If you have questions regarding drugs that are covered under the pharmacy benefit please contact Pharmacy Services at 1-844-201-4677. After the authorization is received the provider needs to request the drug from Accredo Specialty Pharmacy.
Items that are covered under the medical benefit and require prior authorization must be completed through the CareWeb QI Authorization Tool which can be found in the CCHP Provider Portal.
Please review the medication list to see if the medication requires a prior authorization and if it will be processed through the pharmacy or medical benefit.
Medications that are moving from medical benefit to the pharmacy benefit
This means your patient must obtain their medication from a specialty pharmacy. If your patient was affected by this change, their authorization was transferred to the pharmacy benefit. The authorization expiration date did not change.
How do you submit prior authorization?
Download an authorization form from togetherCCHP.org/pharmacy-prior-auth and fax it to Together with CCHP Pharmacy Services at 1-844-201-4675
Please contact Pharmacy Services at 1-844-201-4677.
Medications moving from pharmacy benefit to medical benefit
This medication must now be medically billed through either the buy and bill process or medically billed through a specialty pharmacy (if they are able to).
If your patient was affected by this change, their authorization was transferred to the medical benefit.
The authorization expiration date did not change.
How do you submit for prior authorization?
These medications will need to be submitted through CareWeb Qi Authorization Tool which can be found in the Provider Portal.
Please visit CCHP's website or call 1-414-266-4522.