Pharmacy information

Resources for providers including preferred drug list (PDL), formulary, prior authorization information, and other related resources.

Pharmacy benefits manager

Healthy Blue administers pharmacy benefits for enrolled members, and CarelonRx, Inc. is the pharmacy benefits manager. Most medications are covered without prior authorization, but a few require you to contact our pharmacy department for prior approval.

CarelonRx

Pharmacy and physician-administered drug (PAD) resources

Healthy Blue follows the Kansas Department of Health and Environment (KDHE) Preferred Drug List (PDL), formulary, and prior authorization criteria.

The KDHE PDL does not contain a complete list of covered drugs; rather, it lists the preferred and non-preferred drugs within the most prescribed therapeutic categories. The PDL applies to drugs billed on the medical benefit and the pharmacy benefit. Generic drugs and interchangeable biologic products are required when available on the market for both preferred and non-preferred agents, unless a Brand Medical Necessity prior authorization request is approved. Members needing non-preferred drugs must meet the non-preferred prior authorization criteria. Additionally, some PDL drugs also have clinical prior authorization requirements.

The Healthy Blue Kansas formulary is a list of all brand-name and generic drugs. It will show preferred and non-preferred drugs, prior authorization requirements and drug limitations.

Please use these resources when prescribing for our members:

Kansas Department of Health and Environment (KDHE) Preferred Drug List (PDL)

Healthy Blue Formulary Searchable Tool (Pharmacy Benefit)

KDHE Clinical Prior Authorization Criteria and Forms

Kansas Medicaid (FFS & MCO) Pharmaceutical Program

KDHE Provider Interactive Tools

Note: When using the KDHE provider interactive tools, use the Search by NDC function to determine pharmacy benefit. Use the Search by Procedure function to locate physician-administered drugs.