Provider Pharmacy

Please refer to these formulary and drug coverage policies when prescribing for your OhioHealthy Medical Plan patients. These polices are not a substitute for the professional and clinical judgment of the prescriber.

Pharmacy guide and current drug policies

Providers can access all OhioHealth Medical Plan Formulary lists, P&T updates and information about how to contact N avitus as well as s earch our prescription drug prior authorization criteria and drug policies.

Prescription drug requests - Prior Authorizations, Exceptions, & Appeals

NavitusHealth solutions processes prior authorization & appeal requests for drugs obtained under the prescription drug benefit (i.e. pharmacy benefit), on behalf of OhioHealthy Medical Plan, To request prior authorization or an appeal for a drug that will be obtained under the PHARMACY benefit, submit the request to Navitus Health Solutions.

Drug coverage criteria require use in accordance with FDA-approved labeling, drug compendia (reference books) or substantially accepted peer-reviewed scientific literature. To demonstrate the medical necessity of a requested drug, medical records and relevant clinical information should be submitted with the coverage request .

Providers, members or authorized representatives can submit a request for drug coverage.

• Electronic requests: Submitting drug coverage requests online is convenient and allows you to track the status of your request. Refer to detail above for links to online portals to submit a drug coverage request electronically.
• Mail or Fax requests: Drug coverage request forms can be found below. These forms can be used to submit a request by mail or fax.
• Phone requests: Drug coverage requests can be initiated by phone. Call the applicable phone number listed to initiate a request.

For electronic PA submissions, OhioHealthy Medical Plans support ePA through Epic, Surescripts, CenterRx and CoverMyMeds.

For fax or mail, use the forms below:

Prior authorization and appeal requests can be submitted by

PHONE: (844) 268-9789

MAIL: Navitus Health Solutions LLC
Attn: Prior Authorizations
1025 West Navitus Dr.
Appleton, WI 54913

FAX: (855) 668-8551 (toll free)

Medical Drug Management

OhioHealthy Medical Plan recognizes that a comprehensive approach to managing specialty drugs, including high cost oncology drugs, covered under the medical and pharmacy benefits is critical to all of our customers. Many new specialty drugs have been introduced to the marketplace and many of these specialty drugs are being administered to patients at their doctor’s office, a hospital outpatient facility, or stand-alone outpatient infusion center. These are not the types of drugs that could be obtained at a drug store. To help manage these drugs, OhioHealthy Medical Plan has partnered with Archimedes for a Medical Drug Management (MDM) program.

Components of our MDM program include:

• Requiring a Prior Authorization for some medications
• Requiring a National Drug Code (NDC) on medications that require prior authorization
• Editing outpatient and professional claims to ensure a medication has been approved and the dose administered matches the approval
• Application of maximum daily dose edits on a number of targeted medications

Medical Drug Formularies

Access the list of medications that require prior authorization under the MEDICAL benefit: Medical Benefit Specialty Drug List Effective 7.1.2024 (PDF)

Medical drug coverage criteria require use in accordance with FDA-approved labeling, drug compendia (reference books) or substantially accepted peer-reviewed scientific literature. To demonstrate the medical necessity of a requested drug, medical records and relevant clinical information should be submitted with the coverage request.

Prior authorization requests for drugs obtained under the MEDICAL benefit are not processed by Navitus. For drugs that will be obtained under the MEDICAL benefit (e.g., drug will be billed on a medical claim by a provider), submit the request to Archimedes.

For Fax or Mail use the forms below:

Medical Drug Prior authorization and appeals form: Archimedes Specialty Drug Authorization Form (PDF)

Prior authorization and appeal requests can be submitted by

PHONE: ( 888) 504-5563

MAIL: Archimedes, LLC 278 Franklin Rd. Ste 245 Brentwood, TN 37027