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Pharmacy
Delaware First Health (DFH) is committed to providing appropriate, high-quality, and cost-effective drug therapy to all of our members. DFH covers prescription medications and certain over-the-counter medications with a written order from a DFH provider. The pharmacy program does not cover all medications. Some medications may require prior authorization or have limitations on age, doseage and maximum quantities.
DFH uses the Preferred Drug List (PDL)/Formulary as developed by the Delaware Medicaid Program. Please use the PDL/Formulary to find more information on the drugs that are covered.
All Delaware First Health Members must use a pharmacy within network, including mail-order pharmacies. You can find an in-network pharmacy by using the Find a Provider tool.
Members can also obtain a 3 month supply of their maintenance medications through Express Scripts® Pharmacy mail order program by visiting the Express Scripts® Pharmacy portal and following the guided steps or completing the mail-order form. The prescriber may also electronically send or fax the prescription to 1-800-837-0959.
Please contact Express Scripts® Pharmacy at 1-833-750-4300 (TTY: 711) with any questions.
Express Scripts is the Pharmacy Benefit Manager (PBM) for Delaware First Health. Express Scripts processes pharmacy claims. Centene Pharmacy Services administers the pharmacy prior authorization process.
Retail Prior Authorization Fax: 1-844-233-6130 (Pharmacy Services)
Medical Pharmacy Prior Authorization Fax: 1-833-938-0826 (Pharmacy Services)
Clinical Hours: Monday-Friday: 6:00 AM - 12:00 AM EST
Saturday-Sunday: 8:00 AM – 8:00 PM EST
CoverMyMeds is the preferred way to receive prior authorization requests. Our electronic prior authorization (ePA) solution provides a safety net to ensure the right information needed for a determination gets to patients' health plans as fast as possible. The ePA process is HIPAA compliant and enables faster determinations.
Submit your prior authorization requests electronically through CoverMyMeds Prior Authorization Requests.
You may also use the alternative forms below.
- CoverMyMeds Electronic Prior Authorization Website
- Prior Authorization Request Form for Prescription Drugs (PDF)
- Specialty Medication Prior Authorization Form (PDF)
- Medical Pharmacy Prior Authorization Form (PDF)
For more information about CoverMyMeds, please review the CoverMyMeds Information Document.
Maximum Allowable Cost (MAC) pricing is available through the Express Scripts Pharmacy Benefit Manager (PBM) website. Participating pharmacies can visit the Express Scripts Pharmacist Resource Center. To access, log in is required.
Prior authorization and medical necessity criteria are developed to promote clinically appropriate utilization of selected high risk and/or high-cost medications and include consideration of program exception requests for medications not included on the Preferred Drug List (PDL)/Formulary.
The purpose of the DFH clinical policies is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. Please access the Clinical and Payment Policies page to review pharmacy medical necessity guidelines.