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CCA Formulary Listings

One Care List of Covered Drugs—Formulary (2021)

A list of prescription drugs covered by your CCA One Care plan.

SCO List of Covered Drugs—Formulary (2021)

A list of medications covered by your CCA Senior Care Options plan.

Coverage Determination

Prior Authorization Requirements and Process

For some drugs, you will need to get approval (“prior authorization”) from Commonwealth Care Alliance before we can agree to cover a drug for your patient. The requirement for getting approval in advance may also help to guide appropriate use of certain drugs. If you do not get this approval, your patient’s drug might not be covered by the plan.

These documents provide lists of drugs that require prior authorization:

2021 One Care Prior Authorization Criteria

A list of certain drugs that require pre-approval by CCA before they are covered.
Download:

2021 Senior Care Options Prior Authorization Criteria

A list of certain drugs that require pre-approval by CCA before they are covered.
Download:

Submit Prior Authorization Form Online

Submit a prior authorization request for prescription drug coverage determination online, or through mail or fax using the form below.

Request for Medicare Prescription Drug Coverage Determination

Medicare Part B vs. D Forms

Prior authorization is required to determine appropriate coverage under Medicare Part B or Part D.

To initiate a Medicare Part B vs. D coverage determination request, please use the following method: 

Call Navitus MedicareRx Customer Care at 1-866-270-3877. The Customer Care Agent can complete the questions on Navitus’ internal Primary Billing Form and complete the Part B vs. Part D request, allowing for an immediate determination over the phone.

Navitus Health Solutions will review your request and make a determination as to whether the request meets the requirements for approval. The decisions for standard requests are made no later than 72 hours from when we received the request. If waiting 72 hours could potentially jeopardize a patient’s health, providers can send an expedited request for the patient, in which case a decision will be issued within 24 hours. For all expedited requests, providers must include a statement that they confirm that this request should be escalated.

If the request is denied, patients or their provider have the right to appeal our decision.

CCA Redetermination Form

If your request for coverage for a prescription drug was denied, you have the right to ask for an appeal of our decision within 60 days of the Notice of Denial.

Redetermination Form

Prescriber Portal

The Prescriber Portal allows providers to access claim status, member eligibility, and claim submission options.


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