Guide to drug coverage under medical benefit
Prescription drugs are covered in two ways—through the Summit Community Care pharmacy benefit or via medical benefit. The method of coverage depends on whether the drug is self-administered or administered by a health care professional at home (such as home infusion therapy) or given in a clinical setting like a doctor’s office.
Drugs that are only administered to members by healthcare professionals are available under the medical benefit and can be obtained in several ways:
- Buy and bill: Physicians may purchase drugs directly through pharmaceutical wholesalers and distributors and submit a claim to Summit Community Care. To review the list of services and drugs that are billable on the medical benefit for Summit Community Care, please refer to the state fee schedule .
- Delivery: Physicians may request delivery of a member specific specialty medication that will be administered in their office by calling Summit Community Care’s contracted medical specialty pharmacy (MSP), CVS Specialty®.
- Referral: Physicians may refer their members to infusion suites and outpatient hospital services
For more information on self-administered prescription drugs and pharmacy benefit coverage, please visit the Summit Community Care pharmacy page.
Medical specialty pharmacy (MSP)
Summit Community Care is pleased to announce a drug delivery option that enhances medication accessibility to both members and providers. Summit Community Care is contracted with CVS Specialty® as the MSP. CVS Specialty® can deliver member specific medication that is covered under the Summit Community Care medical benefit to your office for administration to the member.
Delivery of medication
To set up delivery or check a prescription order status, please call 877-254-0015, and you will be transferred to a pharmacist for a verbal prescription order. Please plan to provide your member's Summit Community Care ID located on their ID card. Staff will obtain additional information necessary to support the delivery of the medication, including the need by date. Please allow up to 10 days for processing and shipping. The staff will then make an outbound call to your member to obtain consent as needed to support the delivery of the medication to your office. Once all of the necessary information is obtained for shipping, the staff will make an outbound call to your office to confirm delivery.
You may also fax prescription orders to 866-336-8479 and a staff member will call your office to obtain additional information necessary to support the delivery of the medication as described above.
Note: If it is an urgent medication request and the need by date is less than seven days from the order date, please indicate this so the order can be expedited.
Prior authorization
Some medications require prior authorization before they can be paid. Please review the Prior Authorization Look-up Tool for a listing of covered drugs and any associated requirements. If prior authorization is required, you may request a prior authorization by phone, fax, or electronically
How to request prior authorization
To ensure timely review of the prior authorization, please include the servicing medical specialty pharmacy and provider name during the prior authorization intake.
Request by phone
Phone: 844-462-0022
Hours: 8 a.m. – 8 p.m. ET Monday to Friday
10 a.m. – 2 p.m. ET Saturday
Request by fax
Medical injectables: 844-429-7762
Request electronically
Prior authorization requirements
Electronic prior authorizations (ePA)
Electronic prior authorization requests can be submitted through CoverMyMeds, an independent company providing medication prior authorization services on behalf of Summit Community Care.
Using CoverMyMeds for prior authorization requests
CoverMyMeds streamlines the medication prior authorization process, electronically connecting providers, pharmacists, and plan/pharmacy benefit managers (PBMs) to improve time to therapy and decrease prescription abandonment with electronic prior authorization. Prescribers can view real-time status of any medication PA request submitted via ePA, phone, or fax by logging into the CoverMyMeds website and entering the member’s information. Prescribers also have the option to contact CoverMyMeds directly by calling 866-452-5017 for questions, information, or website concerns, or via live chat on the CoverMyMeds website.
Home infusion therapy (HIT)
Home infusion therapy is the administration of prescription legend drugs through intravenous, intraspinal, epidural, or subcutaneous routes from the comfort of the member’s home. HIT is prescribed by a physician that both the physician and Summit Community Care have determined to be medically necessary and must be supervised by a qualified health care professional to the member in their residence.
To find an in-network HIT provider, please use our Find a Pharmacy tool.
Tools and medical coverage resources
Find a Pharmacy
Need to get a specialty prescription filled or find an in-network provider? Find a plan pharmacy nearby.
Prior Authorization Lookup Tool
To request or check the status of a prior authorization request or decision, access our Interactive Care Reviewer (ICR) tool via Availity.* Once logged in, select Patient Registration > Authorizations & Referrals, then select Authorizations or Auth/Referral Inquiry as appropriate.
Prior Authorization Lookup Tool