Pharmacy

As a Qualified Health Plan in the Health Insurance Marketplace^® (Exchange), CGHC provides prescription drug coverage to both On-Exchange and Commercial (Off-Exchange) members. This benefit provides coverage for prescriptions obtained from an in-network retail pharmacy, mail-order pharmacy or specialty pharmacy; and those that are administered in the patient’s home, including drugs administered through an in-network home health agency.

CGHC uses evidence-based guidelines to ensure health care services and medications meet the standards of excellent medical practice and are the lowest cost alternative for the member. These requirements ensure appropriate use of these medications.

Cost-Share

Members may be required to pay a cost-share amount (copayment, deductible and/or coinsurance) when receiving a prescription drug. Cost-share amounts vary based on plan and medication. View the Provider Manual for more information or call us at 1-877-514-2442.

Drug Formulary

CGHC updates the formulary regularly. Visit the current Drug Formulary for more information.

Generic Substitution

A pharmacy will provide a generic drug if available in place of a brand name drug. This is called generic substitution. Members and providers can expect the generic drug to produce the same effect and have the same safety profile as the brand name drug. If a brand name drug is requested when an equivalent generic drug is available, you may need to request prior authorization. Also, members may pay additional costs for brand name drugs when an equivalent generic drug is available.

Prior Authorization

Common Ground Healthcare Cooperative (CGHC) partners with CareSource to evaluate pharmacy prior authorization requests based on medical necessity, medical appropriateness, and benefit limits.

Effective December 1, 2024

Physician administered medications may also require prior authorization before they will be covered. Please check the Procedure Code Lookup Tool to view authorization requirements for medications administered under the outpatient Medical Benefit. For review criteria, Pharmacy policies can be found on the Policies page.

Prior authorization requests for medications covered under outpatient Medical Benefit may be submitted online through the Provider Portal or by fax.

• Medical Benefit Fax: 1-888-399-0271

Note: All oncology medication treatment regimen requests must be submitted and reviewed through the EVITI Connect Portal.

For all prior authorization decisions (standard or urgent), CGHC provides notice to the provider and member as expeditiously as the member’s health condition requires. Please specify if you believe the request is urgent.

Prior Authorization Forms

• Navigate Pharmacy Operations Specialty Prior Authorization Form
• Navigate Pharmacy Operations Facility Change Request Form

Effective January 1, 2025

Prescription drugs (administered under the Pharmacy Benefit) may require prior authorization before they will be covered. Opioid drugs always require prior authorization in the following circumstances:

• More than 90 days of therapy in the last 365 days
• More than 90 morphine milligram equivalents per day
• No concurrent therapy with benzodiazepines
• All extended-release opioids require prior authorization

Refer to the drug formulary to review prior authorization requirements and criteria for prescription drugs.

Prior Authorization requests for medications covered under the Pharmacy Benefit may be submitted electronically via the CoverMyMeds or SureScripts prior authorization portals or by fax. In emergent situations, requests may be accepted via phone.

• Pharmacy Benefit Fax: 1-866-930-0019
• Pharmacy Benefit Phone: 1-877-514-2442

Policies

CGHC’s pharmacy and medical policies include drug-specific and therapy class policies to be used as a guide when determining health care coverage for our members with benefit plans covering prescription drugs.

The policies are written for those prescription drugs that are non-formulary, formulary with prior authorization or require step therapy. The policy is a tool to be interpreted in conjunction with the member’s specific benefit plan. You can access pharmacy policies by selecting Policies from the Quick Links for more information.

Formulary Exceptions

CGHC has an exception process that allows the member or the member’s representative to make a request for an exception. Reasons for exceptions may include intolerance to drugs, allergies to drugs, or inadequate/inappropriate response to drugs listed on the formulary. The member or member’s representative can call Member Services to make the request or complete the online Member Exception Request for Non-Formulary Medication.

CGHC may reach out to the provider to obtain the appropriate documentation if necessary. CGHC will provide a decision no later than 72 hours after the request is received, or within 24 hours if the member is suffering from a serious health condition. Providers may be asked to provide written clinical documentation as to why a member needs an exception. In determining whether an exception will be given, CGHC will consider whether the requested drug is clinically appropriate.

Quantity Limits

Some drugs have limits on how much can be given to a member at one time. Quantity limits may be based on several factors such as drug makers’ recommended dosing, patient safety, applicable state and federal laws, or the Food & Drug Administration (FDA) recommendations.

Step Therapy

Sometimes, CGHC will require a member to try a less expensive drug used to treat the same condition before “stepping up” to a medication that costs more. This is called step therapy. Certain drugs may only be covered if step therapy is met in accordance with applicable state and federal law.

Therapeutic Interchange

A member might have a drug allergy or intolerance, or a certain drug might not be effective. If a non-formulary agent is requested, the provider will need to submit a prior authorization request. This is called therapeutic interchange.

Home Infusion Therapy

CGHC offers home infusion services to members who require treatment with certain injectable drugs. These services allow members to schedule and receive therapy safely and effectively in the comfort of their own home at a time that works best for their schedule. An infusion-trained nurse will administer the drug and remain with the member during the entire infusion. In most cases, home infusion services will be a lower cost to members through their plan benefits. Members can contact Member Services for more information about transitioning to home infusion therapy.

For most home infusion therapy services, CGHC does not require participating preferred provider to submit prior authorization requests. If you are not a participating preferred provider, you must submit a prior authorization request before rendering home infusion therapy services.

Pharmaceutical Management Procedures

To learn more about how to use our pharmaceutical management procedures, look in the drug formulary.  CGHC provides pharmaceutical management procedures annually and after updates. Changes are made in writing by mail, fax or email or via the web. If you have any questions regarding our pharmaceutical management procedures, please call Clinical Pharmacy Services at 1-877-514-2442.

Drug Safety Recalls

Sometimes, a drug manufacturer or the federal government issues drug recalls. If a CGHC member is impacted by a drug recall, CGHC will send a letter to the impacted member and prescriber notifying them of the recall. You can also  find out if a drug you have prescribed to a patient is being recalled by checking the listings on the FDA website.