Provider Pharmacy

Pharmacy Guide

Providers can access all Ohio Health Medical Plan Formulary lists, PA criteria, P&T updates and information about how to contact Navitus Prescriber Portal - home (navitus.com) 

Current drug policies

Providers and pharmacies can search our prescription drug Prior authorization criteria and drug policies. 

Login Provider portal: Prescriber Portal - home (navitus.com) 

Prescription drug Requests - Prior Authorizations, Exceptions, & Appeals

NavitusHealth solutions processes prior authorization & appeal requests for drugs obtained under the prescription drug benefit (i.e. pharmacy benefit), on behalf of OhioHealth Medical Plan, To request prior authorization or an appeal for a drug that will be obtained under the PHARMACY benefit, submit the request to Navitus Health Solutions.  

Drug coverage criteria require use in accordance with FDA-approved labeling, drug compendia (reference books) or substantially accepted peer-reviewed scientific literature. To demonstrate the medical necessity of a requested drug, medical records and relevant clinical information should be submitted with the coverage request. 

Providers, members or authorized representatives can submit a request for drug coverage. 

• Electronic requests: Submitting drug coverage requests online is convenient and allows you to track the status of your request. Refer to detail above for links to online portals to submit a drug coverage request electronically. 
• Mail or Fax requests: Drug coverage request forms can be found below. These forms can be used to submit a request by mail or fax. 
• Phone requests: Drug coverage requests can be initiated by phone. Call the applicable phone number listed to initiate a request. 

For electronic PA submission Ohio Health Medical Plan support ePA through Epic, Surescripts, CenterRx and Cover my meds.  

For Fax or mail use the below forms : 

Prior authorization and appeal requests can be submitted by  

PHONE: (844) 268-9789  

MAIL: Navitus Health Solutions LLC
Attn: Prior Authorizations
1025 West Navitus Dr.
Appleton, WI 54913  

FAX: (855) 668-8551 (toll free)

Electonic portal for Cover my meds Log In | CoverMyMeds, The Leader In Electronic Prior Authorization, 

Medical Drug Management

OhioHealth Medical Plan recognizes that a comprehensive approach to managing specialty drugs, including high cost oncology drugs, covered under the medical and pharmacy benefits is critical to all of our customers. Many new specialty drugs have been introduced to the marketplace and many of these specialty drugs are being administered to patients at their doctor’s office, a hospital outpatient facility, or stand-alone outpatient infusion center. These are not the types of drugs that could be obtained at a drug store. To help manage these drugs, Ohio Health Medical Plan has partnered with Archimedes for a Medical Drug Management (MDM) program.   

Components of our MDM program include: 

• Requiring a Prior Authorization for some medications 
• Requiring a National Drug Code (NDC) on medications that require prior authorization 
• Editing outpatient and professional claims to ensure a medication has been approved and the dose administered matches the approval 
• Application of maximum daily dose edits on a number of targeted medications 

Medical Drug Formularies

To access the list of medications that require prior authorization under the MEDICAL benefit click Medical-Benefit-Prior-Authorization-Specialty-Drug-List_8.24.23.pdf (ohiohealthyplans.com) 

Medical drug coverage criteria require use in accordance with FDA-approved labeling, drug compendia (reference books) or substantially accepted peer-reviewed scientific literature. To demonstrate the medical necessity of a requested drug, medical records and relevant clinical information should be submitted with the coverage request.  

Prior authorization requests for drugs obtained under the MEDICAL benefit are not processed by Navitus. For drugs that will be obtained under the MEDICAL benefit (e.g., drug will be billed on a medical claim by a provider), submit the request to Archimedes.  

For Fax or Mail use the forms below:  

Medical Drug Prior authorization and appeals form: Physician Fax Form (ohiohealthyplans.com) 

Prior authorization and appeal requests can be submitted by  

PHONE: 1 (888) 504-5563 

MAIL: Archimedes, LLC 278 Franklin Rd. Ste 245 Brentwood, TN 37027 

FAX: (866) 491-6971