Pharmacy Policies

MetroPlusHealth utilizes clinical review criteria for based upon a review of currently available clinical information (including FDA labeling, clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, and other relevant factors).

MetroPlusHealth expressly reserves the right to revise these conclusions as clinical information changes and welcomes further relevant information. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by MetroPlusHealth, as some programs exclude coverage for services or supplies. If there is a discrepancy between our internal established guidelines and a member’s benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members

Click here to View our Provider Pharmacy Policy.

Click here to view billing guidance for Duchenne Muscular Dystrophy Agents.

Practitioner Dispenser Policy

Click here to view billing guidance for Practitioner Dispensing.

COVID-19 Pharmacy Updates

COVID-19 Oral Antivirals Pharmacy Billing Guide

COVID-19 Vaccine Pharmacy Billing Guide

COVID-19 Vaccine Counseling Billing Guidance for Medicaid

COVID-19 Therapeutics Locator (arcgis.com)

• Refer to Provider Tools for our list of Physician Administered Medical Benefit Drugs Requiring Prior Authorization or Step Therapy