At Peach State Health Plan, we try to ensure that our providers are well informed about our processes, so that we can better work together to help our members grow healthy and stay healthy. One area that has been identified as an opportunity for improvement is our prior authorization process for drugs.

We have noticed a large number of prior authorization requests that are initially denied when there is not enough clinical information sent with the request. Many of these denials are overturned on appeal, because the appropriate clinical information is sent with the appeal. We know that our physician offices spend much of their time with prior authorization requests, and we want to provide some helpful information to make this process more efficient.

Each time that your office has to file an appeal due to lack of clinical information on the initial request, more of your valuable time is wasted. To partner with you in decreasing the administrative burden, we have some tips for a more efficient prior authorization process.

Many of the Centene/ Peach State Prior Authorization Guidelines require a trial and failure of or contraindication to at least two agents on the preferred drug list before authorization will be granted for a non-preferred drug.

1. If you are sending a request to US Script to ask for a non-preferred drug, please fill out the prior authorization form, but also include chart notes that specify which preferred drugs have been tried, the length of time that they were tried, and what the therapy failure was.
2. Providing as much clinical information as possible for all requests will ensure that the person reviewing the request will have enough information to make an accurate decision based on the Centene/ Peach State criteria.

Prior authorization requests sent to Caremark or directly to Peach State for dispensing out of office stock for Neupogen and Neulasta require specific information for processing.

• If your patient is undergoing chemotherapy and you want to use this drug to prevent neutropenia, please send us the names of the chemotherapy drugs being used for the patient so that we can determine medical necessity.
• If you are using these drugs for a patient who already has neutropenia, please send the most recent CBC’s to include the absolute neutrophil count (ANC).

Prior authorization requests for immunosuppressant drugs will be approved for transplant patients.

• If you are requesting an immunosuppressant for any indication other than a transplant, please send all pertinent clinical information to show how the diagnosis was made and all other therapies that have been tried by the patient.

All prior authorization requests for commonly used drugs (drugs that would not be considered specialty drugs) should be entered on the US Script prior authorization request form and faxed directly to US Script at 866-399-0929.

All prior authorization requests for specialty drugs that will be dispensed out of the physician’s office stock or facility stock should be entered on a Caremark specialty request form, but should NOT be faxed to Caremark. These requests should be faxed directly to the Peach State Health Plan Pharmacy Department at 866-374-1579. Please remember to specify the name of the facility providing the drug (physician office or outpatient facility) on the top of the form and include the phrase “Office Stock” to ensure that we know you will not need Caremark to ship the drug to your office.

All prior authorization requests for specialty drugs that will need to be shipped to the physician’s office or to the patient’s home should be entered on a Caremark specialty request form and faxed directly to Caremark. Faxing these requests directly to Caremark will speed the process and allow better shipping efficiency.

• If you receive notification of approval of your prior authorization request, but are not contacted by Caremark to set up delivery, please call CarePlus Pharmacy at 866-367-5201 to check the status of your shipment.

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