Pharmacy
Peach State Health Plan is committed to providing appropriate, high-quality, and cost-effective drug therapy to all Peach State Health Plan members. Peach State Health Plan covers prescription medications and certain over-the-counter medications with a written order from a Peach State Health Plan provider. The pharmacy program does not cover all medications. Some medications may require prior authorization and some may have limitations. Other medically necessary pharmacy services are covered as well.
Use our Preferred Drug List (PDL) to find more information on the drugs that are covered.
Prior Auth Criteria Search
Please use the search function or select View All to locate the drug specific Peach State Health Plan prior authorization form that should be used when submitting an authorization request.
Preferred Drug Lists
- Georgia Families® & PeachCare for Kids® Preferred Drug List (PDL) (PDF)
- Planning for Healthy Babies®: Family Planning Preferred Drug List (PDL) (PDF)
- Planning for Healthy Babies®: Inter-Pregnancy Care Preferred Drug List (PDL)(PDF)
- Appropriate Use and Safety Edits (last updated 04/2020) (PDF)
- PSHP GA 2020 Q3 PDL Update (effective 09/21/2020) (PDF)
- PSHP GA 2020 Q2 PDL Update (effective 06/22/2020) (PDF).
- PSHP GA 2020 Q1 PDL Update (effective 03/23/2020) (PDF)
- PSHP GA 2019 Q3 PDL Update (effective 9/23/2019) (PDF).
- PSHP GA 2019 Q2 PDL Update (effective 06/24/2019) (PDF)
- PSHP GA 2019 Q1 PDL Update (effective 03/25/2019) (PDF).
- PSHP GA 2019 Q4 PDL Update (effective 12/23/2019) (PDF).
- PSHP Preferred DIABETIC SUPPLIES: Alcohol and Lancets (effective 06/01/16) (PDF)
Quick Reference List
- Topical Corticosteroids (PDF)
- Antidepressants (PDF)
- Asthma-COPD Agents (PDF)
- Atypical Antipsychotics (PDF)
- Cholesterol Lowering Agents (PDF)
- Diuretics (PDF)
- Gastro Agents (PDF)
- Injectable Antidiabetic Agents (PDF)
- Oral Antidiabetic Agents (PDF)
- ADHD Agents (PDF).
JSON Preferred Drug Lists
- Preferred Drug List (PDL) (JSON)
- Family Planning Preferred Drug List (PDL) (JSON)
- Inter-Pregnancy Care Preferred Drug List (PDL) (JSON)
PDL Archive
- PSHP GA 2018 Q3 PDL Update (effective 09/24/2018) (PDF)
- PSHP GA 2018 Q2 PDL Update (effective 06/29/2018) (PDF)
- PSHP GA 2018 Q1 PDL Update (effective 03/30/18) (PDF)
- PSHP GA 2017 Q4 PDL Update (effective 12/26/17) (PDF)
- PSHP-GA Biopharmaceutical Pharmacy Program 2015 (PDF)
- PSHP GA 2017 Q3 PDL Changes (effective 9/25/17) (PDF)
- PSHP GA 2017-Q2 PDL Changes (effective 6/5/17) (PDF)
- PSHP GA 2017-Q2 PDL Changes (part 2 – effective 6/25/17) (PDF)
Pharmacy Forms
- 2019-2020 Synagis Season Prior Authorization Form (PDF)
- Medication Prior Authorization Request – Envolve Pharmacy Solutions (updated 10/01/2020) (PDF)
- Specialty Medication Prior Authorization Form 2015 (PDF)
- Axicabtagne ciloleucel (Yescarta) Prior Authorization Form (PDF)
- Brexucabtagene autoleucel (Tecartus) Prior Authorization Form (PDF)
- Eteplirsen (Exondys 51) Prior Authorization Form (PDF)
- Nuisnersen (Spinraza) Prior Authorization Form (PDF)
- Golodirsen (Vyondys 53) Prior Authorization Form (PDF)
- Onasemnogene abeparvovec (Zolgensma) Prior Authorization Form (PDF)
- Tisagenlecleucel (Kymriah) Prior Authorization Form (PDF)
- Viltolarsen (Viltepso) Prior Authorization Form (PDF)
- Voretigene neparvovec-rzyl (Luxturna) Prior Authorization Form (PDF)
Pharmacy Notifications
Pharmacy Notification Archive
- PSHP-USS OPR Provider Notice (effective 1/1/2014) (PDF)
- PSHP PHARM PHARMACY ImmunityConnect Notification (PDF)
- Intrauterine Devices (IUDs) No Longer Require Prior Notification (PDF)
- New Specialty Pharmacy: Acaria – Provider Notice (PDF)
Maximum Allowable Cost
Pharmacies access RxAdvance Login for MAC pricing information