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.
Submit a secure electronic Prior Authorization request through Cover My Meds at https://oidc.covermymeds.com/login.
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)
- 25Q2 PDL Change Notice (PDF)
- 25Q1 PDL Change Notice (PDF)
- 24Q4 PDL Change Notice (PDF)
- 24Q3 PDL Change Notice (PDF)
- 24Q2 PDL Change Notice (PDF)
- 24Q1 PDL Change Notice (PDF)
Quick Reference List
- Topical Corticosteroids (PDF)
- Antidepressants (PDF)
- Asthma-COPD Agents (PDF)
- Atypical Antipsychotics (PDF)
- Cholesterol Lowering Agents (PDF)
- Diuretics (PDF)
- Injectable Antidiabetic Agents (PDF)
- Oral Antidiabetic Agents (PDF)
- ADHD Agents (PDF).
- Acid Suppressant 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)
Pharmacy Forms
- Synagis Season Prior Authorization Form (PDF)
- Medication Prior Authorization Request (PDF)
- Afamitresgene Autoleucel (Tecelra) Prior Authorization Form (PDF)
- Atidarsagene Autotemcel (Lenmeldy) Prior Authorization Form (PDF)
- Axicabtagne ciloleucel (Yescarta) Prior Authorization Form (PDF)
- Betibeglogene Autotemcel (Zynteglo) Prior Authorization Form (PDF)
- Brexucabtagene autoleucel (Tecartus) Prior Authorization Form (PDF)
- Casimersen (Amondys 45) Prior Authorization Form (PDF)
- Ciltacabtagene Autoleucel Prior Authorization Form (PDF)
- Delandistrogene Moxeparvovec-rokl (Elevidys) (PDF)
- Eladocagene Exuparvovec (Upstaza) Prior Authorization Form (PDF)
- Elivaldogene autotemcel (Skysona) Prior Authorization Form (PDF)
- Eteplirsen (Exondys 51) Prior Authorization Form (PDF)
- Etranacogene dezaparvovec-drlb (Hemgenix) Prior Authorization Form (PDF)
- Exagamglogene Autotemcel (Casgevy) Prior Authorization Form (PDF)
- Fidanacogene Elaparvovec (Beqvez) Prior Authorization Form (PDF)
- Golodirsen (Vyondys 53) Prior Authorization Form (PDF)
- Idecabtagene Vicleucel (Abecma) Prior Authorization Form (PDF)
- Lifileucel (Amtagvi) Prior Authorization Form (PDF)
- Lisocabtagene maraleucel (Breyanzi) Prior Authorization Form (PDF)
- Lovotibeglogene Autotemcel (Lyfgenia) Prior Authorization Form (PDF)
- Nuisnersen (Spinraza) Prior Authorization Form (PDF)
- Onasemnogene abeparvovec (Zolgensma) Prior Authorization Form (PDF)
- Tisagenlecleucel (Kymriah) Prior Authorization Form (PDF)
- Valoctocogene Roxaparvovec-rvox (Roctavian) (PDF)
- Viltolarsen (Viltepso) Prior Authorization Form (PDF)
- Voretigene neparvovec-rzyl (Luxturna) Prior Authorization Form (PDF)
Pharmacy Notifications
- 24Q1 Preferred Formulary Medication (PDF)
- Synagis Season Provider Notification (PDF)
- Pharmacy: Did You Know (PDF)
- Pharmacy Tip Sheet (PDF)
Other
Maximum Allowable Cost
Pharmacies access Express Scripts Pharmacy Portal Login for MAC pricing information