Pharmacy
Sunshine Health is committed to providing appropriate, high-quality, and cost-effective drug therapy to all Sunshine Health members. Sunshine Health covers prescription medications and certain over-the-counter medications with a written order from a Sunshine Health provider. The pharmacy program does not cover all medications. Some medications may require prior authorization (PA) and some may have limitations. Other medically necessary pharmacy services are covered as well.
For the most current information about the Sunshine Health Pharmacy Program, call Provider Services at 1-844-477-8313 or visit Sunshine Health Provider News.
Sunshine Health follows the Agency for Health Care Administration (AHCA) Preferred Drug List (PDL) guidelines. Every quarter, the PDL is revised according to the recommendations of the AHCA Pharmaceutical and Therapeutics (P&T) Committee. Providers should always consult the most current PDL and quarterly changes.
This guidance applies to the following products:
- Sunshine Health Medicaid (MMA)
- Comprehensive Long Term Care (LTC)
- Sunshine Health Pathway to Shine Child Welfare Specialty Plan (CWSP)
- Sunshine Health Mindful Pathways Serious Mental Illness Specialty Plan (SMI)
- Sunshine Health Power to Thrive HIV/AIDS Specialty Plan (HIV)
Drug Lists
- Florida Medicaid Preferred Drug List (PDL)
- Traditional Drugs – Therapeutic Interchange List (PDF)
- 100-Day Supply List
General Pharmacy Forms
- Informed Consent For Psychotherapeutic Form (PDF)
- Lock-in Referral Form (PDF)
- Request to Change Lock-In Pharmacies (PDF)
Prior Authorization
- Cover My Meds electronic prior authorization (ePA)
- AHCA Drug Specific Prior Authorization Criteria
- Compound over $300 Prior Authorization Request Form (PDF)
- Prior Authorization Form – Non-Specialty Medication (PDF)
- Prior Authorization Form for Specialty Medication or Buy and Bill (PDF)
- Abstral/Actiq/Fentora/Lazanda/Onsolis/Subsys PA Form (PDF)
- Adult Antipsychotic High Dose PA Form (PDF)
- Albumin PA Form (PDF)
- Antidepressants Under 6 Years PA Form (PDF)
- Antipsychotic 6 to Under 18 Years PA Form (PDF)
- Antipsychotic Less than 6 years of age PA Form (PDF)
- Colony Stimulating Factors PA Form (PDF)
- Cytogam PA Form (PDF)
- Erythropoeisis Stimulating Agents PA Form (PDF)
- Exondys 51 PA Form (PDF)
- Fuzeon® PA Form (PDF)
- Hepatitis C Agents PA Form (PDF)
- HIV Diagnosis Verification PA Form (PDF)
- Human Growth Hormone PA Form (PDF)
- Increlex PA Form (PDF)
- Miscellaneous Form (PDF)
- Multi Source Brand Drug PA Form (PDF)
- Nitisinone PA Form (PDF)
- Opioid PA Form (PDF)
- Oral Oncology PA Form (PDF)
- Panretin PA Form (PDF)
- Proleukin PA Form (PDF)
- Selzentry PA Form (PDF)
- Serostim PA Form (PDF)
- Soma PA Form (PDF)
- Spinraza PA Form (PDF)
- Stimulants and Strattera (<6 years of age) PA Form (PDF)
- Supprelin LA PA Form (PDF)
- Synagis - All Florida Regions Combined PA Form (PDF)
- Synagis - Weight Change PA Form (PDF)
- Vfend PA Form (PDF)
Sunshine Health works with Express Scripts to process all pharmacy claims for prescribed drugs. Some drugs on the Sunshine Health Preferred Drug List (PDL) require PA. Centene Pharmacy Services is responsible for administering this process. Express Scripts is our Pharmacy Benefit Manager (PBM).
Medications may be dispensed up to a maximum of 34-day supply for each new prescription refill or 100-day supply for select medications. A total of 80% of the days’ supply must have elapsed before the prescription can be refilled at a Sunshine Health network pharmacy.
Covered by the following health plan products:
- Sunshine Health Medicaid (MMA)
- Comprehensive Long Term Care (LTC)
- Sunshine Health Pathway to Shine Child Welfare Specialty Plan (CWSP)
- Sunshine Health Mindful Pathways Serious Mental Illness Specialty Plan (SMI)
- Sunshine Health Power to Thrive HIV/AIDS Specialty Plan (HIV)
Select spacers/aerosol-holding chambers for members are covered through the pharmacy benefit. Members may receive one select spacer/chamber per year without prior authorization.
- Centene Pharmacy Solutions: 1-866-399-0928; Fax: 1-833-546-1507
- Prior Authorizations: 1-866-399-0928; Fax: 1-833-546-1507
- Express Scripts Pharmacy Help Desk (members and pharmacists): 1-833-750-4392
Sunshine Health offers tailored clinical programs that are customized to drive medication adherence and reduce medication errors. These programs are designed to improve health outcomes by supporting members in managing chronic conditions and ensuring they receive the right medications at the right time to get and stay healthy.
Sunshine Health’s Preferred Specialty Pharmacy is AcariaHealth
AcariaHealth is a national specialty pharmacy dedicated to transforming lives through compassionate care. They focus on enhancing the health and outcomes of people with complex medical conditions. AcariaHealth takes a collaborative approach to care, working closely with providers to tailor treatment programs to meet members’ unique needs.
AcariaHealth provider services include:
- Single point of contact (Provider Experience Managers)
- Support with referral and prior authorization processes
- Web-based collaboration and enhanced communication
While AcariaHealth is Sunshine Health’s preferred specialty pharmacy provider, members have the option to request that prescriptions be filled by any willing in-network specialty pharmacy provider of their choosing.
How to Send a Prescription Referral
AcariaHealth
- E-prescribe: Find AcariaHealth in your electronic medical records (EMR) system.
- Phone: Dial 1-800-511-5144, ext 608.0033 to speak directly to our pharmacists.
- Fax: Send completed referral form via fax to 1-877-541-1503.
- Download referral forms.
Contact AcariaHealth
- Phone: 1-800-511-5144 (TTY 711)
- Fax: 1-877-541-1503
- Email: customercare@acariahealth.com
- Website: AcariaHealth
Pharmacies with staff authorized to administer Long-Acting Injectable Antipsychotics (LAIAs) are available. Please contact the pharmacy for location-specific requirements.
For the most current information about the Ambetter Health Pharmacy Program, call Provider Services at 1-877-687-1169 (Relay Florida 1-800-955-8770), visit Pharmacy or Ambetter Health Provider News.
Preferred Drug List
Prior Authorization Forms
Additional Pharmacy Information