Pharmacy Programs

Frequently Asked Questions

Prior Authorization

To promote the most appropriate utilization, selected high risk or high-cost drugs require prior authorization to be eligible for coverage. The prior authorization criteria are approved by the Community Health Plan Pharmacy and Therapeutics Committee.

Current drugs that require prior authorization for all members are:

Amitiza

Coreg

Enbrel

Exjade

Genotropin

Gleevec

Humatrope

Increlex

Lamisil

Nexavar

Norditropin

Nutropin

Nutropin-AQ

Pegasys

Rebetron

Revatio

Saizen

Serostim

Sporanox

Sutent

Tarceva

Zelnorm

Age Restriction

Age restrictions apply to a few drugs. These drugs are covered without prior authorization for the specific age ranges noted, but are otherwise considered non-formulary.

Pulmicort Respules – covered for members under 7 years old.
Tretinoin & Retin A Micro – covered for members under 30 years old.

Step-Therapy

Step-therapy is a program that requires one or more “first line” drugs must be tried before the requested drug will be covered.
The “first line” drugs have been determined by Community Health Plan Pharmacy and Therapeutic Committee to be effective in treating the same medical condition as the requested drug.
If the doctor thinks the requested drug is medically necessary, the doctor must request an exception by contacting 1-888-256-6132. If the request is approved, the drug will then be covered.
Current drugs that require step–therapy for all members are:
Advair

Cozaar

Diovan

Effexor XR
Norvasc

Singulair

Strattera

Vytorin

There are some step-therapy programs designed specifically for members with an incentive formulary.

Current drugs that require step-therapy for members with an incentive formulary are:

Accolate

Aciphex

Adalat CC (Brand Name)

Atacand

Avapro

Benicar

Cardene (Brand Name)

Celexa (Brand Name)

Cymbalta

DynaCirc

Lexapro

Lunesta

Lyrica

Micardis

Nexium

Paxil (Brand Name)

Pexeva

Plendil (Brand Name)

Prevacid

Procardia (Brand Name)

Protonix

Prozac (Brand Name)

Sular

Symbicort

Teveten

Zegerid

Zoloft (Brand Name)

Zyflo

Half-Tablet

The following drugs are on the Community Health Plan half-tablet program. One tablet splitter is covered at $0.00 copay for members utilizing this program. The half-tablet program is a voluntary program. Members can decline the half-tablet program by having pharmacy call 1-888-256-6132.

Drug	Strength Required	Comments
citalopram	10 mg 20 mg	Use ½ of 20 mg Use ½ of 40 mg
Crestor (rosuvastatin)	5 mg 10 mg 20 mg	Use ½ of 10 mg Use ½ of 20 mg Use ½ of 40 mg
nefazodone	50 mg 100 mg	Use ½ of 100 mg Use ½ of 200 mg
paroxetine	10 mg 20 mg	Use ½ of 20 mg Use ½ of 40 mg
sertraline	25 mg 50 mg	Use ½ of 50 mg Use ½ of 100 mg
Valtrex (valacyclovir)	500 mg	Use ½ of 1000 mg
venlafaxine	25 mg 37.5 mg 50 mg	Use ½ of 50 mg Use ½ of 75 mg Use ½ of 100 mg