Medications Obtained Through the Pharmacy Benefit
For those drugs that process through the member's pharmacy benefit (e.g. the use of a retail, mail order, specialty, or other pharmacy), please refer to the formulary documents below to determine if a prior authorization is needed and, if so, submit the request directly to Prime.
Members and their health care doctors/providers have the right to request a step therapy protocol exemption by contacting CHP’s Pharmacy Benefits Manager (PBM), Prime Therapeutics. If the exemption request is denied, members and their doctor(s)/provider(s) have the right to appeal that denial.
For Prior Authorization Forms, Formularies, and Criteria for Medications obtained through the pharmacy benefit, choose the appropriate plan below:
Medicare Prescription Payment Plan
The Medicare Prescription Payment Plan is a new payment option in the prescription drug law that works with your current drug coverage to help you manage your out of-pocket Medicare Part D drug costs by spreading them across the calendar year (January-December). Starting in 2025, anyone with a Medicare drug plan or Medicare health plan with drug coverage (like a Medicare Advantage Plan with drug coverage) can use this payment option. All plans offer this payment option and participation is voluntary. For more information click "here".
To learn more about the Medicare Prescription Payment Plan, contact Capital Health Plan at (877) 247-6512. You can also find additional information on the MyPrime webpage.
Medications Obtained Through the Medical Benefit
For those drugs that process through the Medical benefit, (prescriber office or facility will supply the drug, administer it to the member, and then bill CHP), please refer to the documents below for a list of drugs that require prior authorization, criteria and prior authorization form, and submit request directly to CHP.
Medications that require a Prior Authorization
Note: The table is not all-inclusive and is updated on a regular basis, please review for the most current information. The codes in the table are for informational purposes only.
Clinical Criteria
A medical guideline, also called clinical criteria, is a document with the aim of guiding medical decisions regarding diagnosis, management, and treatment in specific areas of health care. Below you will find information about Capital Health Plan's clinical criteria for our Commercial and Medicare plans.
Commercial Criteria
All non-Medicare plans, also known as Commercial plans, require that you follow certain developed criteria that require prior authorization. You can read "What's New" regarding the latest updates for Florida Blue coverage guidelines at any time.
Site of Care Guidelines for Select Medications
Requests for select medications to be administered in a hospital-affiliated outpatient setting will be redirected to the CHP Infusion Center unless criteria for medical necessity are met. Refer to the Site of Care guideline on the Florida Blue Medical coverage guidelines page for specific criteria. The list of medications that will need to be provided at the CHP Infusion Clinic can be found here. These medications will also need a prior authorization.
Medicare Criteria
All Medicare plans require that you follow certain developed criteria that require prior authorization. You can access and read "What's New" regarding the latest updates for Original Medicare coverage guidelines for National Coverage Decisions (NCD) and Local Coverage Decisions (LCD) at any time.
In coverage situations where there is no Medicare NCD, LCD, Article or Coverage Rule, services will be reviewed using the applicable Blue Cross Blue Shield of Florida medical coverage guideline.
Reference-Medicare Manage Manual - Chapter 4, Section 90.5
Request form for medications obtained through the medical benefit.
- This form is to be used for requests when the prescriber office or facility will supply the drug, administer it to the member, and then bill CHP and for Medicare and Commercial members using J&B Medical for Diabetic Testing supplies.
Blood Glucose Monitor and Testing Supplies Using the Medical Benefit
Patient Headache Diary REQUIRED - A current headache diary (not more than 120 days old) with at least 3 months of data on all requests for coverage determinations of medical drugs with the diagnosis of Headache or Migraine.
Please note Capital Health Plan does not administer the pharmacy benefits for most State of Florida Commercial members, which has been in place since January 1, 2012.