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 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?
Venue is based on proximity of the member’s address (as noted by Georgia Health Partnership (GHP) Portal) and the history of drug dispensing activity of pharmacy.

How is a Grievance to Be Filed for Pharmacy Lock-In?
All grievances must be submitted in WRITING and forwarded to the following address for review:

Peach State Health Plan
Appeals and Grievances Coordinator
3200 Highlands Parkway SE, Suite 300
Smyrna, GA 30082

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 (866) 374-1579 or phone (800) 514-0083, option 2.

What Should a Pharmacy Lock-In Member Do If Home Address Has Changed?
Member MUST contact Georgia Families (888) 423-6765 to get address updated with GHP. Reconsideration for venue change can not be reviewed unless there is proof of residency. If information has not been updated with GHP, some other proof of residency must be submitted for review (i.e. driver license or utility bill showing current address).

Retail vs. Specialty Pharmacy

Are Compounded Medications Covered for PSHP Members?
Compounds are covered for children under 6. All compounds that cost less than $50 do not require authorization to process. Any compound $50 or greater will require an override from US Script.

How Is Copay Determined for PSHP Members?
Cost of Prescribed Drug is: Member Pays:

• Less than $ 10.01 $ 0.50
• Between $ 10.01 – $ 25.00 $ 1.00
• Between $ 25.01 – $ 50.00 $ 2.00
• More than $ 50.01 $ 3.00

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.

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 purchase was made within last 7 days, dispensing pharmacy can call US Script 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. 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
  Used for all retail requests (oral and topical).

• Caremark Specialty Pharmacy Services Enrollment
  Used for all specialty medication requests. This form is mostly for injectable drugs, but there are some specialty drugs that may be oral (ex. Prograf).

What is the Process for Prior Authorization?
Dependent upon type of drug requested (specialty vs. retail), fax appropriate prior authorization request form to the fax number listed at the top of the form. Supply all documented clinical information relevant to request. Lack of clinical information can cause a delay in processing or denial for lack of information. Prior authorization requests are handled in Peach State Pharmacy Department or the US Script Prior Authorization Department within 24 hours of receipt, as long as all clinical information is sent with initial request.

Can a Prior Authorization Be Requested Verbally?
Clinical documentation must be provided in order for prior authorization request to be reviewed. Verbal requests can not be accepted by Peach State Pharmacy Department.

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.

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 can not be given unless police report is presented.

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?
Caremark is the preferred Specialty Pharmacy vendor for Peach State. CarePlus Phone: (866) 367-5201 Fax: (800) 778-4518 is the local Caremark facility that provides medications to Peach State physicians and members.

How Should Provider Request Prior Authorization For A Specialty Injection If A Provider Wants To Supply Medication Out Of Own Stock?
Provider should use the CAREMARK SPECIALTY PHARMACY SERVICES ENROLLMENT form and manually write “OUT OF OFFICE/OUT PATIENT CENTER/HOSPITAL (whatever the case) STOCK” across the top of the request. Please supply any pertinent clinical information (labs, office notes, clinicals, etc). Lack of this information can cause delay of a decision. This type of request should be faxed directly to Peach State Pharmacy Department, (866) 374-1579, for review. DO NOT SEND THIS REQUEST TO CAREMARK/CAREPLUS.

Miscellaneous

Are Durable Medical Equipment (DME) Items Reviewed by Pharmacy Department?
Pharmacy does not review DME items. These items should be submitted to CareCentrix Phone: (877) 877-9899 Fax: (800) 218-4219 for review.

What Diabetic Glucometer Devices/Machines and Supplies Are Covered?
True Track and One Touch 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 aerochamber mask per year.

If member/pharmacy has problems processing claim for this item, please contact US Script (800) 460-8988 for further instructions.

What Prenatal Vitamins are Covered?
Most generic prenatal vitamins are covered.

What Are The Pharmacy Department Hours?
The hours of operation are 8 a.m. – 6 p.m., Monday-Friday.

What Should a Member Do if Possibly Exposed to Rabies?
The Rabies Injection is NOT reviewed by the Pharmacy Department. Member is to be directed to emergency room for treatment.

Do Vaccinations Require Prior Authorization?
Any requests for vaccinations must be directed to Peach State Utilization Management Department Phone: (800) 704-1483 Fax: (866) 532-8834. These requests are NOT handled in Peach State Pharmacy Department.

What is the VFC Program?
A 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 ages birth through 18 years of age. Peach State providers must enroll in VFC and must use VFC vaccines for members who are eligible for them. 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 and 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. http://www.cdc.gov/vaccines/programs/vfc/default.htm