A prescription drug coverage determination is used to request a drug formulary exception for medications that are not on CommunityCare's formulary list or drugs that are on CommunityCare's formulary list but require a utilization management decision (prior authorization, quantity limit or step therapy).

• Commercial Prescription Coverage Determination Form (Large Group, Grandfathered and Traditional Plans)
• QHP Coverage Determination Form (Small Group and Individual ACA Plans)
• Navitus Prior Authorization Forms

Electronic Prescription Drug Prior Authorization

Electronic Prescription Drug Prior Authorization (ePA) helps prescribers and pharmacies quickly find, complete, and submit Prior Authorization (PA) requests for all plans and medications. Providers can use various web-based portals to send prescription drug PA requests to CommunityCare.

CommujnityCare ePA’s can be accessed from the following ePA vendors through Navitus and Banjo Health:

• Surescripts – a leader in healthcare information exchange, Surescripts connects providers and payers for real-time PA processing.
• CoverMyMeds – widely adopted by healthcare providers, CoverMyMeds offers robust tools for streamlined prior authorization workflows.
• CenterX – formerly AmerisourceBergen, Cencora enhances the medication access process with advanced ePA solutions.
• Arrive Health – known for simplifying prescription access, Arrive Health integrates cost transparency and clinical decision support into the ePA workflow.

It’s easy to start an ePA! Start taking advantage of fast, reliable electronic prior authorizations today!

What is ePA? Find more information about ePA’s.

Have more questions about ePA? Please contact our Pharmacy Help Desk at (918) 594-5211 or 1-877-293-8628for more information, or you can access the American Medical Association’s dedicated ePA website.

If you have additional questions, please contact your provider relations representative or the Pharmacy Help Desk at (918) 594-5211 or 1-877-293-8628.