Pharmacy

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File claims, get prior authorizations, check eligibility and benefits and more.

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Prior Authorizations:

CarelonRx

CarelonRx Inc. is an independent company providing pharmacy benefit management services on behalf of Healthy Blue.

You can reach CarelonRx at 844-410-6890 from 8 a.m. to 8 p.m. Eastern time Monday through Friday, and 10 a.m. to 2 p.m. Eastern time on Saturdays.

You can also fax your request to the following numbers:

NovoLogix will manage prior authorizations for medical injectables and specialty medication drugs.

CoverMyMeds®

CoverMyMeds is an independent company providing medication prior authorization services on behalf of Healthy Blue.

Prescribers can view real-time status of any medication prior authorization (PA) request submitted via ePA, phone, or fax by logging into the CoverMyMeds website and entering the member’s information.

Prescribers also have the option to contact CoverMyMeds directly by calling 866-452-5017 for questions, information or website concerns, or via live chat on the CoverMyMeds website.

Prior Authorization Forms:

Note: For Synagis authorizations, please contact Utilization Management at 866-757-8286.
 

Grievances and Appeals:

If for any reason you want a decision reconsidered or to file a complaint, please complete the form and send using one of the following:

Mail to Address:  
        CarelonRx Grievances and Appeals
        P.O. Box 775370
        St. Louis, MO 63177

Fax: 844-430-6802
Email: RxGrievanceandAppeals@carelon.com 
 

Specialty Medications 

Specialty medications often are covered under the medical benefit. They can be costly for our members, and not all plans cover them the same way. That’s why it’s important to review whether the use of these medications meets coverage criteria before a specialty drug is provided. Review the medical specialty drug list to see which medications require prior authorization.

Quarterly Pharmacy Formulary Changes

Related Pharmacy Information

Review policies for clinical criteria.

Drug Medical Policies

Review policies for clinical criteria for all injectable, infused or implanted prescription drugs or therapies which are covered under the medical benefit.

Search for medications included in the Healthy Blue formulary.

Healthy Blue Formulary

Use the Healthy Blue formulary to see which medications are included.

Review preferred medications available under the pharmacy benefit.

Preferred Drug List

Healthy Blue has a Preferred Drug List (PDL). Please refer to the PDL when prescribing for our members. This guide does not contain a complete list of drugs; rather, it lists the preferred drugs within the most commonly prescribed therapeutic categories.

PDL - Spanish Version

Review drugs which are available at a $0 copay under the pharmacy benefit.

Zero Dollar Copay List

Healthy Blue covers certain drugs that are available at a $0 copay under the pharmacy benefit. Always refer to the latest $0 copay list and refer to the PDL for coverage.

Find the common over-the-counter medications available under the pharmacy benefit.

Over-the-Counter Medication

Healthy Blue covers certain over-the-counter (OTC) medications. Be sure to review the latest OTC list and refer to the PDL for coverage.

OTC - Spanish Version

Drugs administered by health care professionals are available under the medical benefit.

Drugs Covered Under the Medical Benefit

Prescription drugs are covered in two ways — through the Healthy Blue pharmacy benefit or medical benefit. The method of coverage depends on whether the drug is self-administered or administered by a health care professional in a clinical setting like a doctor’s office.

Drugs that are only administered to members by health care professionals are available under the medical benefit and can be obtained in several ways:

  • Buy and bill: Physicians may purchase drugs directly through pharmaceutical wholesalers and distributors and submit a claim to Healthy Blue. To review the list of services and drugs that are billable on the medical benefit for Healthy Blue, please refer to the State Fee Schedule.*
  • Delivery: Physicians may request delivery of a member specific specialty medication that will be administered in their office by calling Healthy Blue’s contracted medical specialty pharmacy (MSP), CVS Specialty®.
  • Referral: Physicians may refer their members to infusion suites and outpatient hospital services.

Prior authorizations will be handled by NovoLogix, an independent company, on behalf of BlueChoice HealthPlan. To access NovoLogix, sign into My Insurance Manager.  Learn more on NovoLogix by exploring the presentation they have for you.

*This link leads to a third-party website. That party is solely responsible for the contents and privacy policy of its site.