Summary of Pharmacy Services
Pharmaceutical services provide First Choice members with needed pharmaceuticals as ordered through valid prescriptions from licensed prescribers for the purpose of saving lives in emergency situations or during short term illness, sustaining life in chronic or long-term illness or limiting the need for hospitalization. Members have access to most national chains and many independent pharmacies.
- All members are covered for prescription and certain over-the-counter (OTC) drugs/items with a prescription written by a doctor
- Medications are generally prescribed to cover a maximum 31-day supply, except for allowable 90-day supply medication (PDF)
- Pharmacy benefits are managed through PerformRx
- Direct pharmacy claims questions (technical online processing) to Argus at 1-800-522-7487
- Prior authorization and other pharmacy services related questions should be directed to Select Health/AmeriHealth Caritas Pharmacy Services at 1-866-610-2773 or faxed to 1-866-610-2775.
Monthly prescription limits
All First Choice members are eligible for unlimited prescriptions or refills.
Coverage of generic products
Select Health does not cover brand name products for which there are "A" rated, therapeutically equivalent, less costly generics available unless prior authorization is secured. Prescribers who wish to prescribe brand name products must furnish documentation of generic treatment failure prior to dispensing. The treatment failure must be directly attributed to the patient’s use of a generic of the brand name product.
Exceptions to the generic requirement include brand name products of: digoxin, warfarin, theophylline (controlled release), levothyroxine, pancrelipase, phenytoin, carbamazepine and continued treatment utilizing clozapine.
Over-the-counter drugs
All members are covered for certain over-the-counter (OTC) drugs with a prescription written by a doctor. Products will be dispensed generically when available as outlined above.
Co-payments
Members 19 years of age and older are subject to a $3.40 co-payment per prescription. The following members are exempt from a co-payment:
- 18 years of age or younger
- Pregnant
- Live in a nursing home or group home
- Receiving hospice, emergency or family planning services
- Receiving home- and community-based waiver services
Prior authorization
In a continuing effort to improve patient care and pharmaceutical utilization, Select Health, in conjunction with its pharmacy benefit manager, PerformRx℠, has implemented a prior authorization program for the initial prescription of certain medications. Requests for medications that require prior authorization should be directed to Pharmacy Services at 1-866-610-2773 or faxed to 1-866-610-2775.
Note: For medications that require prior authorization, members may receive an emergency supply of medicine that will cover them for 72 hours while a prior authorization request is pending. A member is permitted one temporary supply per prescription number. Inhalers, diabetic test strip and supplies, and creams or lotions are exceptions to the supply limit because of how they are packaged. For those medicines, the member may receive the smallest package size available.
Preferred drug list
Select Health maintains a Preferred Drug List (PDL). The PDL represents therapeutic recommendations based on documented clinical efficacy, safety and cost-effectiveness. All non-preferred medications will require prior authorization. Select Health’s criteria require a trial and failure or intolerance of one to three preferred medications, depending on the class. Requests for prior authorization medications should be directed to Select Health/AmeriHealth Caritas Pharmacy Services at 1-866-610-2773 or faxed to 1-866-610-2775.
Download a copy of our PDL (PDF).
Providers may request the addition of a medication to the list. Requests must include the drug name, rationale for inclusion on the list, role in therapy and medications that may be replaced by the addition. Please direct such requests to the Pharmacy and Therapeutics Committee at Select Health, PO Box 40849, Charleston, SC 29423.
Appeal of prior authorization denials
Prior authorization denials may be appealed. Please see the section of our provider manual entitled "Medical Review Determination" to review the appeal process.