Update: The Agency for Health Care Administration (AHCA) has updated the preferred drug list (PDL) requirements and guidelines for opioid medications.
If you have Prestige Health Choice patients who take an opioid medication, there are changes to how they can get their prescriptions filled. This includes cough or cold prescriptions containing an opioid.
Members with opioid prescriptions
- Members must use 90 percent of all opioid prescription medication before they can get a refill.
- Members are limited to a seven-day supply of short-acting opioid medications at point of sale.
- Members are limited to only two seven-day supplies of short-acting opioid medications within a 30-day period. This can be increased when medically necessary.
- Members requiring a long-acting opioid medication are limited to only one opioid medication prescription at a time.
- Medicaid has adopted a minimum age limitation of 18 years on all prescription cough and cold medications containing codeine or hydrocodone.
Members with no history of opioid prescriptions during the last 60 days
- Members are limited to 90 morphine milligram equivalents (MME) a day. This is for all opioid medications, including tramadol.
Exondys 51™ and Spinraza® requests should be faxed to Magellan Rx Management, the Agency for Health Care Administration's (AHCA) pharmacy benefit manager, at 1-877-614-1078. You can also call the Magellan Clinical Help Desk at 1-800-603-1714. Physician “buy and bill” is not permitted.
- AHCA's clinical criteria for Exondys 51 and Spinraza
- Preferred drug list (formulary) and summary of drug limitations — printable
Use the preferred drug list to find a covered medicine. Refer to the summary of drug limitations to find important information regarding quantity and/or age limits for various drugs.
- AHCA prior authorization criteria and listing of non-preferred drugs
- Drug recall information
This information can be shared with members.
Pharmacy prior authorization
Providers are responsible for obtaining prior authorization. Providers may not bill members for services that require prior authorization for which authorization was not obtained.
Authorization is not a guarantee of payment. Other limitations or requirements may apply.
- Submit authorization requests to the PerformRx℠ Prior Authorization team by fax at 1-855-825-2717. For any questions, call PerformRx at 1-855-371-3963.
- To submit requests for medication with Healthcare Common Procedure Coding System (HCPCS) codes that require authorization, include the HCPCS code that corresponds to the medication in the request. If the HCPCS code is a miscellaneous code, the National Drug Code (NDC) number must also be included on the request.
- HCPCS codes requiring prior authorization (PDF)
- HCPCS/Common Procedural Terminology (CPT) prior authorization request form (PDF)
AHCA pharmacy prior authorization
You may use an AHCA form if there is no matching PerformRx form listed above. These forms should still be submitted to PerformRx.
Pharmacy contact information
PerformRx provides pharmacy benefit management services to Prestige Health Choice, with the exception of Exondys 51 and Spinraza. Requests for these drugs should be directed to Magellan, AHCA’s pharmacy benefit manager.
- You may fax prior authorization requests to PerformRx at 1-855-825-2717.
- You may call Provider Services at 1-800-617-5727 for assistance. For pharmacy questions, call the Pharmacy Help Desk at 1-855-371-3963, 24 hours a day, seven days a week.
Upon approval of a specialty authorization, you may forward the corresponding prescription to PerformSpecialty® via fax at 1-844-489-9565 for prompt service. You can contact them by phone at 1-855-287-7888.