Carolina Complete Health covers certain prescription drugs and over-the-counter drugs when prescribed by an in-network provider. The pharmacy program does not cover all drugs. Some drugs require prior authorization and may have limitations on age, dosage or maximum quantities.
Outpatient Pharmacy:
Retail / Specialty / Home Infusion
Physician Administered
Drug Program (PDP)
Over-the-Counter:
Medications and Products
On April 1, 2024, the below PDL updates will go into effect. Trial and failure of two preferred drugs are required unless only one preferred option is listed or is otherwise indicated. Clinical criteria and prior authorization forms can be found at https://network.carolinacompletehealth.com/resources/pharmacy/outpatient-pharmacy-benefit.html.
Beginning March 1, 2024, the following updates will be made to Outpatient Pharmacy Clinical Coverage Criteria and the accompanying prior authorization request forms:
This FAQ provides additional information on the migration of our Pharmacy Benefit Manager (PBM) services from CVS® to Express Scripts®, effective January 1, 2024.
Express Scripts is a pharmacy benefit management (PBM) company serving more than 100 million Americans. Express Scripts Pharmacy delivers specialized care that puts patients first through a smarter approach to pharmacy services.
Express Scripts as our PBM will bring increased levels of transparency and value, positioning us to provide the highest level of quality at the lowest possible cost to our members.
Express Scripts will be the PBM of record providing pharmacy claims adjudication, pharmacy network administration and rebate administration on behalf of our health plan.
There will be no immediate change in service for our members, although they will receive new ID cards. We will continue to provide the same member-focused care and support as we do today.
Our highest priority continues to be serving all our members, and we remain committed to providing affordable quality healthcare services. Our team is working closely with both CVS and Express Scripts to ensure a seamless migration.
Yes, Amazon is part of the Express Scripts network.
No, CVS Caremark Mail Service Pharmacy will be out of network, effective January 1, 2024. If members wish to continue using mail order in 2024, they must switch to Express Scripts Pharmacy.
Members have a choice to use other pharmacies that offer home delivery but Express Scripts Pharmacy is the preferred mail order pharmacy for our health plan.
Yes. Impacted Medicaid members will receive a Mail Order Change notification letter.
For existing mail order users:
For new mail order prescriptions on or after January 1, 2024, members may do one of the following:
Yes, members will be able to download the Express Scripts Pharmacy app, available on the App Store and Google Play. Members with a mail order benefit can order medications, track delivery and more.
2023
October 1, 2023: Preferred Drug List (PDL) Updates
On October 1, 2023, the below PDL updates will go into effect. Trial and failure of two preferred drugs are required unless only one preferred option is listed or is otherwise indicated. Clinical criteria and prior authorization forms can be found at https://network.carolinacompletehealth.com/resources/pharmacy/outpatient-pharmacy-benefit.html.
October 1, 2023 - Prefered Drug List (PDL) Updates
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April 1, 2023: Preferred Drug List (PDL) Updates
On April 1, 2023, the attached PDL updates will go into effect. Trial and failure of two preferred drugs are required unless only one preferred option is listed or is otherwise indicated. Clinical criteria and prior authorization forms can be found on the Outpatient Pharmacy Benefits webpage.
April 1, 2023 - Prefered Drug List (PDL) Updates
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April 27, 2022: Recent Update to Outpatient Pharmacy Prior Authorization Request Fax Number
Beginning April 27, 2022, providers submitting outpatient pharmacy prior authorization requests will fax requests to our new fax number at (833) 404-2393, which is listed on the individual request forms. This will include retail, specialty and home infusion prior authorization requests. As a reminder, these requests may also be submitted online at https://www.covermymeds.com/main/prior-authorization-forms/
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February 1, 2022: Recent Updates to Outpatient Pharmacy Clinical Coverage Criteria and Revisions to Prior Authorization Request Forms
Beginning February 1, 2022, the following changes will be made to Outpatient Pharmacy Clinical Coverage Criteria and the accompanying prior authorization request forms: