Provider Pharmacy

Medical Benefit Specialty Drug Management

OhioHealthy 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, OhioHealthy 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
• Requiring chart documentation (progress notes) outlining diagnosis, previously tried therapies, and clinical outcomes on therapies.
• 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 Benefit Specialty Drug Formularies

Specialty Medications requiring PA available through OhioHealthy’s Medical Benefit: Medical Benefit Specialty Drug List Effective 4.1.2025 (PDF)

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

Prior authorization requests for drugs obtained under the MEDICAL benefit are reviewed by Archimedes. For drugs that will be obtained under the MEDICAL benefit (e.g., drug will be billed on a medical claim by a provider), use the forms and submit to the contact below.

For Fax or Mail use the forms below:
Medical Drug Prior authorization and appeals form: Archimedes Specialty Drug Authorization Form (PDF)  

Prior authorization and appeal requests can be submitted by
PHONE: (888) 504-5563
MAIL: Archimedes, LLC 278 Franklin Rd. Ste 245 Brentwood, TN 37027
FAX: (866) 491-6971

Questions on medical Benefit Drugs? Contact Archimedes Customer Service (888) 504-5563.

Prescription drug requests on the Pharmacy Benefit

Navitus Health solutions processes prior authorization & appeal requests for drugs obtained under the prescription drug benefit (i.e. pharmacy benefit), on behalf of OhioHealthy 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.

Pharmacy guide and current drug policies

Providers can access all OhioHealth Medical Plan Formulary lists, P&T updates and information about how to contact Navitus as well as search our prescription drug prior authorization criteria and drug policies.

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

OhioHealth Associate Plan Formulary

All other Employer Large Group and Level Funded Formulary

For electronic PA submissions, OhioHealthy Medical Plans support ePA through Epic, Surescripts, CenterRx and CoverMyMeds.

For fax or mail, use your NPI to sign into the Navitus Provider Portal for the appropriate PA form and information on coverage.

Prior authorization and appeal requests can be submitted by
PHONE: (844) 268-9789
FAX: (855) 668-8551 (toll free)
MAIL: Navitus Health Solutions LLC Attn: Prior Authorizations
1025 West Navitus Dr. Appleton, WI 54913

Questions? Contact Navitus Customer Care at (855) 673-6504.