Pharmacy

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
 

Recent Updates

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/

Beginning February 1, 2022, the following changes will be made to Outpatient Pharmacy Clinical Coverage Criteria and the accompanying prior authorization request forms:

  • Cystic Fibrosis
    • Minimum age for Trikafta changed from 12 years to 6 years, or greater. Updated criteria and form.
  • Hepatitis C
    • Clarified duration of therapy for Mavyret for treatment experienced genotype 1 & 3 patients, includes patients with liver and kidney transplant. Minimum age for Mavyret changed from 12 to 3 years of age; minimum weight requirement removed; added Mavyret pellet packs. Updated criteria and forms for Mavyret.
    • Minimum age for Epclusa changed from 6 to 3 years of age; minimum weight requirement removed; added Epclusa pellet packs. Updated criteria and forms for Epclusa and generic Epclusa, Sofosbuvir-Velpatasvir.
  • Opioid Analgesics
    • Added generic Hysingla ER. Updated criteria with no change to form.
  • PCSK9 Inhibitors
    • Added Homozygous Familial Hypercholesterolemia (HoFH) for Praluent. Updated criteria and form.
  • Zolgensma
    • Added exemption from providing (CHOP-INTEND) score or HINE score for infants initiating treatment based on Newborn Screening results indicating baby has SMA. Updated criteria and form.