- Pharmacy Lock-In Program
- Retail vs. Specialty Pharmacy
Pharmacy Lock-In Program
What is the Pharmacy Lock-In Program?
The Pharmacy Lock-In Program is designed to detect and prevent abuse or misuse of the pharmacy benefit, as defined by specific criteria, by restricting members to ONE specific pharmacy and, sometimes, ONE specific controlled substance prescriber for a defined period of time. Protecting the member’s safety is the ultimate reason for placement in Pharmacy Lock-In Program.
How is the Pharmacy Venue Selected for Pharmacy Lock-In Candidates?
The Pharmacy Venue is based on proximity of the member’s address (as noted by Georgia Health Partnership (GHP) Portal) and the drug dispensing history of the selected pharmacy.
How is a Grievance to Be Filed for Pharmacy Lock-In?
All grievances must be submitted in WRITING by the member or the member’s authorized representative and forwarded to the following address for review:
Peach State Health Plan
Appeals and Grievances Coordinator
1100 Circle 75 Parkway SE, Suite 1100
Atlanta, GA 30339
Can Drug Utilization Review (DUR) Profiles Be Requested for Pharmacy Lock-In Patients?
Providers can request DUR profiles for the patients they are treating via fax at (866) 374-1579 or phone at (800) 514-0083, Option 2.
What Should a Pharmacy Lock-In Member Do If Their Home Address Has Changed?
The member MUST contact Georgia Families at (888) 423-6765 to get their address updated with GHP. Reconsideration for venue change cannot be reviewed until the address has been updated in GHP’s web portal. Once the address has been updated, the member can contact Peach State’s Member Services Department at (800)704-1484 and notify of the Plan of the address correction. A pharmacy venue update and possible change will be reviewed based on the member’s new address.
Retail vs. Specialty Pharmacy
Are Compounded Medications Covered for PSHP Members?
Compounds are covered for children under six (6) years old. They do not require a Prior Authorization (PA) if the medications used in the compound are on the Preferred Drug List (PDL) and the cost of the compound is less than $50. A PA must be requested if the medications are NOT on the PDL. A PA form will need to be submitted to US Script for review. Any compound that costs $50 or greater will require an override from US Script. Please contact US Script at (866)399-0928 for assistance.
How Is Copay Determined for PSHP Members?
Co-pays are not required for family planning services, children under the age of 21, pregnant women, members with breast and cervical cancer, nursing home facility residents and hospice care members. If a member is being charged a co-pay in error at the pharmacy and needs assistance, please have them call Peach State Member Services at 800-704-1484.
How Can a Member Request Reimbursement On a Medication?
Reimbursement can NOT be provided for non-preferred drug list (PDL) medications, unless prior authorization was obtained for the drug in question. If a purchase was made within the last 7 days, the dispensing pharmacy can call US Script at 800-460-8988 for processing. Otherwise, the PRESCRIPTION CLAIM REIMBURSEMENT FORM found on the Peach State Health Plan website must be completed and submitted to US Script for review.
Are Retroactive Authorization Requests Allowed?
All medications must be approved PRIOR to dispensing or administering. Retroactive authorizations can NOT be reviewed or entered by the Pharmacy Department.
What Form(s) Should Be Used For Prior Authorization Requests?
US Script MEDICATION PRIOR AUTHORIZATION Form - Used for all retail requests (oral and topical). Fax to 866-399-0929.
Peach State Health Plan’s Specialty Medication Prior Authorization Form 2013 - Use for any medication that appears on the Biopharmaceutical Pharmacy Program list. This form is for Specialty medications, as well as Physician Injectables. Most of these medications will be injectables. However, specialty oral medications (ex. Tykerb or Xeloda) will also require this form to be filled out and submitted for review.
What is the Process for Prior Authorization?
Dependent upon type of drug requested (specialty vs. retail),
- Fax appropriate prior authorization request form (specialty vs. retail) to the fax number listed at the top of the form along with all documented clinical information relevant to request. Note: Lack of clinical information can cause a delay in processing and/or denial of prior authorization request for lack of information.
- Specialty and Physician Injectable prior authorization requests are handled in Peach State’s Pharmacy Department. These medications have a standard turn-around-time of 14 days from the receipt of a valid request.
- Certain injectable anticoagulants are the only medications that will be considered as an urgent request to include: Lovenox, Fragmin, Innohep and Arixtra. Requests for these drugs will be reviewed, and a determination will be provided to the requesting provider within 24 hours of the receipt of a valid request with supporting clinical information. Turn-around-time for requests sent to US Script’s Prior Authorization Department is 24 hours from the receipt of a prior authorization request that includes the necessary clinical information needed to process the request.
Can a Prior Authorization Be Requested Verbally?
Verbal requests cannot be accepted by Peach State Pharmacy Department as clinical documentation must accompany the prior authorization request for review and determination.
Can a Member Obtain an Early Refill for a Lost Prescription?
Members are allowed only ONE override per year for lost, spilled, or broken prescriptions. The pharmacy must call US Script to request this override.
Can a Member Obtain an Early Refill for Vacation?
Peach State does NOT cover a vacation supply. Member must make arrangements to get medication while on vacation.
Can a Member Obtain an Early Refill for a Stolen Prescription?
Any stolen prescription requires a police report to be filed. An override cannot be given unless a police report is presented. The pharmacy or member should call US Script directly to request this override.
How Can an Appeal Be Made?
Please refer to denial letter for complete instructions on how to appeal a denial decision.
Who is the Preferred Vendor for Specialty Medications?
ACARIA Health is the preferred Specialty Pharmacy vendor for Peach State. In some instances certain medications are only available at manufacturer approved pharmacies. For those medications, other pharmacies may be providing services. For shipping questions for ACARIA, please contact Acaria Health at (P) (855) 535-1815. NOTE: All PA requests must be submitted directly to Peach State Pharmacy department as instructed on the Specialty Medication Prior Authorization form.
How Should A Provider Request Prior Authorization For A Specialty Injection If A Provider Wants To Supply Medication Out Of Own Stock?
Providers should use the PEACH STATE SPECIALTY MEDICATION PRIOR AUTHORIZATION form, making sure to check the OFFICE STOCK box at the top of form. Please supply any pertinent clinical information, i.e., labs, office notes, clinicals, diagnostics, etc. Failure to provide this information can cause a delay in Peach State’s ability to review the request and provide a determination. This type of request should be faxed directly to Peach State Pharmacy Department at (866) 374-1579 for review. DO NOT SEND THIS REQUEST TO ACARIA or to US SCRIPT. Any requests sent to ACARIA or US Script will be returned to the provider as an invalid request.
Are Durable Medical Equipment (DME) Items Reviewed by Pharmacy Department?
Pharmacy does not review DME items. For authorizations related to home health, home infusion, durable medical equipment and supplies, call Peach State Health Plan at: 1-800-704-1483
What Diabetic Glucometer Devices/Machines and Supplies Are Covered?
True Results Meter and test strip products are covered by Peach State.
Can an Aerochamber Mask Be Provided by Retail Pharmacy?
An aerochamber mask CAN be provided by a retail pharmacy if the doctor writes a prescription for it. There is a limit of ONE (1) aero chamber mask per year per member. If a member/pharmacy has problems processing a claim for this item, please contact US Script at (800) 460-8988 for further instructions.
What Prenatal Vitamins are Covered?
Most generic prenatal vitamins are covered.
What Are The Pharmacy Department Hours?
Peach State Pharmacy Department’s hours of operation are from 8 a.m. to 6 p.m. EST, Monday-Friday.
What Should a Member Do if Possibly Exposed to Rabies?
The Rabies Injection is NOT reviewed by the Pharmacy Department. Members are to be directed to the emergency room for treatment.
Do Vaccinations Require Prior Authorization?
Any requests for vaccinations must be directed to Peach State’s Utilization Management Department via Phone: (800) 704-1483 or Fax: (866) 532-8834. These requests are NOT handled in Peach State’s Pharmacy Department.
What is the VFC Program?
Vaccine for Children (VFC) is a vaccine supply program, which is state operated and federally funded. VFC supplies federally purchased vaccines at no cost to VFC-enrolled providers to be administered to members between the ages of birth through 18 years of age. Peach State providers must enroll in VFC and must use VFC vaccines for members who are eligible. Members 19 years of age and older are not eligible to receive vaccine supplies through the VFC program. VFC provider enrollment is conducted directly by the VFC program. An enrollment package can be obtained by contacting VFC by phone at (404) 657-5013 or (800) 848-3868, or by fax at (404) 657- 5736 or (800) 372- 3627.
PHARMACY PROVIDER LIAISON
Providers may call the Pharmacy Provider Liaison at Peach State for any questions about Retail, Specialty, or Physician Injectables. This representative can help determine which clinicals are needed for PA requests as well as:
- Investigate claim questions related to HCPCS codes
- Assist with questions pertaining to member pharmacy benefits
If you have questions or would like to schedule an on-site visit, please call Peach State Health Plan’s Pharmacy Department at (800)514-0083, Option 2 and ask to speak with the Pharmacy Provider Liaison.