Peach State Provider Office Manual - Peach State Health Plan ...

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• Drug Efficacy Study Implementation (DESI) and Identical, Related and Similar (IRS) drugs that areclassified as ineffective• Infusion therapy and supplies• Oral vitamins and minerals (except those listed in the PDL)• Drugs and other agents used for cosmetic purposes or for hair growth• Erectile dysfunction drugs prescribed to treat impotence• Over-the-Counter (OTC) drugs (except those listed in the PDL)• Medical supplies and DME (except those listed in the PDL)• Injectables (except those listed in the PDL)• Biologicals• Blood and blood plasma• Nutritional and dietary supplements• Diagnostic products (except those listed in the PDL)• Smoking cessation drug products• Drugs not FDA approved for the requested condition unless there is compelling clinical evidence tosupport the experimental useNewly Approved ProductsWe review new drugs for safety and effectiveness before adding them to the Peach State PDL. During thisperiod, access to these medications will be considered through the PA review process. If Peach State doesnot grant PA we will notify you and your provider and provide information regarding the appeal process.Over-the-Counter MedicationsThe Peach State PDL covers a variety of OTC medications. Peach State PDL OTCs are covered when youhave a prescription from a licensed clinician that meets all the legal requirements for a prescription.You can find a list of covered OTC medications in the Over-the-Counter Pharmacy Program documentlocated on the Peach State website at www.pshpgeorgia.com.Generic DrugsWhen generic drugs are available, the brand-name drug will not be covered without prior Peach Stateauthorization. Generic drugs have the same active ingredient, work the same as brand-name drugs, andhave lower co-payments. If you and your provider feel a brand-name drug is medically necessary, yourprovider can ask for PA. We will cover the brand-name drug according to our clinical guidelines if there isa medical reason you need the particular brand-name drug. If Peach State does not grant PA we will notifyyou and your provider and provide information regarding the appeal process.The provision is waived for the following products due to their narrow therapeutic index (NTI) asrecognized by current medical and pharmaceutical literature: Aminophylline, Carbamazepine,4 of 70
Cyclosporine, Digoxin, Disopyramide, Ethosuximide, Flecainide, L-thyroxine, Lithium, Phenytoin,Procainamide, Theophylline, Thyroid, Valproic Acid, and Warfarin.Drug Efficacy Study and Implementation DrugsDrug Efficacy Study and Implementation (DESI) products and known related drug products are definedas less than effective by the Food and Drug Administration because there is a lack of substantial evidenceof effectiveness for all labeling indications and because a compelling justification for their medical needhas not been established. Any DESI products that are covered by Peach State are listed in the PDL.Filling a PrescriptionYou can have your prescriptions filled at a Peach State network pharmacy. If you decide to have yourprescription filled at a network pharmacy you can locate a pharmacy near you by using your ProviderDirectory. You may also call a Peach State Member Services Representative to help you find a pharmacy.At the pharmacy you will need to provide the pharmacist with your prescription and your Peach State IDcard.CopaymentsThe table below lists the copayment for the drugs according to the actual cost of the prescription.Copayments are not required for family planning services, children under the age of 21, pregnant women,members with breast or cervical cancer, nursing home residents, or hospice care members.Actual Cost of PrescriptionMember CopaymentLess than $10.01 $0.50Between $10.01 and $25.00 $1.00Between $25.01 and $50.00 $2.00More than $50.01 $3.00Contact InformationPeach State Health Plan Member Services: 1-800-704-1484 Fax: 1-800-659-7518Peach State Health Plan Member Services TTY/TDD: 1-800-659-7487US Script Prior Authorizations: 1-866-399-0928 Fax: 1-866-399-0929US Script Help Desk: 1-800-460-8988CVS Caremark Specialty Pharmacy Prior Authorization: 1-800-237-2767 Fax: 1-800-323-24455 of 70
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CHRONIC AND COMPLEX CONDITIONS.....
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Description of GeorgiaFamiliesGeorg
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have any questions about Peach Stat
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Provider ResponsibilitiesPRIMARY CA
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Planning for Healthy BabiesWaiver P
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Tubal Ligation(Sterilization)• St
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Additional InformationProviders see
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83655 Lead Effective: 11/2010 Submi
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PROVIDER VISIT - WAITING TIMES• S
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Medical Management/Case Management1
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• Notification of all newborn del
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PROVIDER ASSISTANCE WITH PUBLIC HEA
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competency begins with self-awarene
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• Unresolved problems from previo
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• Member’s name, ID number• P
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Peach State may shorten the period
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Provider Services1-866-874-063302/2
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Notification is required to track i
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Members, a member’s representativ
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• HIV / AIDS• Children with Spe
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the member. The Peach State Medical
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Provider Services1-866-874-063302/2
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• A plan physician with privilege
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• In order to reimburse providers
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• Influence a member to choose on
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Covered Services andBenefits for Pe
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If you have any questions about the
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HEALTH CHECKGEORGIA HEALTH CHECK SE
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Health Check (EPSDT) Billing Requir
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Vaccine Codes must be billed with m
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Interperiodic Vision Only and Heari
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BLOOD LEAD SCREENINGPhysicians are
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General BillingInformation and Guid
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Peach State dental claims should be
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IMAGING REQUIREMENTSPeach State use
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PROCEDURES FOR FILING A CLAIM/ENCOU
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medical necessity. Peach State may
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Example: CPT 42820 submitted for a
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Page 83 and 84: BILLING CODESIt is important that p
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Page 87 and 88: UB 04 CLAIM INSTRUCTIONSPeach State
Page 89 and 90: EMERGENCY DEPARTMENT HOSPITAL CLAIM
Page 91 and 92: Peach State Health PlanATTN: Peach
Page 93 and 94: Inquiry, Claims Adjustmentsand Prov
Page 95 and 96: selected, unless the plan and the p
Page 97 and 98: As accountable and fiscally respons
Page 99 and 100: CredentialingCREDENTIALING REQUIREM
Page 101 and 102: CREDENTIALING OF HEALTH DELIVERY OR
Page 103 and 104: Quality ImprovementTHE PEACH STATE
Page 105 and 106: PROVIDER REVIEWThe Peach State Qual
Page 107 and 108: AUTHORITY AND RESPONSIBILITYThe Pea
Page 109 and 110: Provider Services1-866-874-063302/2
Page 111 and 112: Member ServicesPeach State is commi
Page 113 and 114: • Income• Health Status• Arre
Page 115 and 116: • To keep all your appointments.
Page 117 and 118: • An Administrative Law Hearing d
Page 119 and 120: The staff often answers questions a
Page 121 and 122: PharmacyThe Peach State preferred d
Page 123 and 124: • Experimental drugs• Nutrition
Page 125 and 126: The member or provider, acting with
Page 127 and 128: Pharmacy ProgramPeach State Health
Page 129: Gender LimitsSome medications on th
Page 133 and 134: SPECIALTY MEDICATIONPRIOR AUTHORIZA
Page 135 and 136: Common Brand Name(s) Product Descri
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Common Brand Name(s) Product Descri
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