Pharmacy pre-authorization

Use CoverMyMeds to submit pre-authorization requests.

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Services provided

To be reimbursed directly for medications provided during a visit/stay

Ambulatory surgery center (ASC)

Include in medical claim

Emergency room

Include in medical claim

Home health

Include in medical claim

Hospital or other inpatient setting

Include in medical claim

Medical or dental provider/clinic

Include in medical claim if covered under medical benefits Submit claim to TransactRx if covered under Rx benefits

Pharmacy

Pharmacy submits claim through PBM

Skilled nursing facility (SNF)

Include in medical claim

Urgent care

Include in medical claim

Vaccines

  • Covered vaccines are usually eligible under medical benefits and can be included in the medical claim (for commercial and Medicare) except those that CMS has designated as Medicare Part D for Medicare patients.
  • For Washington members: Vaccines provided under the Washington Universal Vaccine Program should be billed to the health plan as directed by the program.

Infusion medications

  • Certain infusion medications are subject to the Site of Care Program (dru408) medication policy (PDF)

  • For other infusion medications, each medication policy states whether the drug is considered self-administered or not.

    • Self-administered medications are generally covered by the patient's pharmacy benefit.
    • Claims for those that are considered non-self-administered should be submitted as a medical claim.