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:
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.
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.
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.
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.
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.
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.