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 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.
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.
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: