EnvisionRxOptions pharmacy staff are available 24 hours a day at 1-844-222-5584

Prior Authorizations

Prior authorization forms are appropriate for both Commercial and Medicaid lines and must be completed by the prescribing physician.

Medications

Please check the formularies listed below to see if a medication requires prior authorization. A medication marked with “PA“ will require a prior authorization. If you cannot locate your medication in the formulary, please contact us.

• Pharmacy Prior Authorization Form
• Qualified Health Plan Authorization Form
• Medical Drug Prior Authorization Form

Specialty Drugs

Total Health Care works with Diplomat Specialty Pharmacy to provide Specialty Drugs to our members. A list of specialty drugs requiring prior authorization are listed in the document below.

• Specialty Drugs Requiring Prior Authorization
• Specialty Drugs Prior Authorization Form
• Synagis Prior Authorization Form

EnvisionRxOptions pharmacy staff are available 24 hours a day at 1-844-222-5584

Formularies – Updated as of 12/04/2018

A formulary is a list of guidelines for coverage of drugs and other products through Total Health Care.

Commercial

• 2-Tier Commercial Approved Drug List
• 3-Tier Commercial Approved Drug List
• 4-Tier Commercial Approved Drug List
• 4-Tier Commercial High Deductible Health Plan Approved Drug List
• 2-Tier Alternative List ofr Non-covered Drugs
• 2-Tier Search By Drug Name
• 3-Tier Search By Drug Name
• 4-Tier Search By Drug Name
• 4-Tier High Deductible Health Plan Search by Drug Name

Qualified Health Plan – Includes healthcare.gov, Individuals & Families, and SHOP

• Qualified Health Plan Approved Drug List – 2018
• Qualified Health Plan Approved Drug List – 2019
• Qualified Health Plan Search By Drug Name

Healthy Michigan Plan

Note: Effective 7/01/2016, THC has transitioned to Michigan’s Common Drug Formulary. For further information, click here

• Healthy Michigan Plan Approved Drug List
• Healthy Michigan Search By Drug Name
• Healthy Michigan Alternative List for Non-covered Drugs

Medicaid

Note: Effective 7/01/2016, THC has transitioned to Michigan’s Common Drug Formulary. For further information, click here

• Medicaid Approved Drug List
• Medicaid Alternative List for Non-covered Drugs
• Medicaid Children’s Special Health Care Services (CSHCS) Approved Drug List
• Medicaid Search By Drug Name

Approved Drug List Changes

• Changes Effective September 2018
• Changes Effective July 2018
• Changes Effective April 2018

Electronic Prescribing

Make the switch from handwritten to electronic prescriptions here. You will save time, money and improve patient safety.

Drug Codes

• Physician Administered Drug NDC Codes
• NDC/HCPCS Crosswalk
• NDC/HCPCS Additional Information
• MSA Policy Bulletin 10-26 National Drug Code Reporting