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Georgia Medicaid Fee-for-Service Pharmacy Program

Georgia Medicaid Fee-for-Service Pharmacy Program 2025

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The document provides a comprehensive overview of the Georgia Medicaid Fee-for-Service Pharmacy Program, addressing frequently asked questions about enrollment, services provided by the Pharmacy Benefit Manager (PBM) Catamaran, drug file updates, preferred drug lists, prior authorization processes, and contact information for various stakeholders. It outlines the roles of NorthStar Healthcare Consulting and the Drug Utilization Review Board in managing drug evaluations and policies. Additionally, it details reimbursement methodologies, co-payment structures for recipients, and resources available for providers.

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Does Georgia Medicaid pay for prescriptions?

Medicaid and PeachCare for Kids cover all rebated outpatient drugs from participating manufacturers with some exceptions. Regular retail pharmacies and some specialty pharmacies are reimbursed for prescriptions at a rate set by the department.

Who runs Medicaid in Georgia?

The Department of Community Health is responsible for administering the Medicaid program and CHIP in the State of Georgia. The State refers to its CHIP as PeachCare for Kids. Both programs include fee-for-service and managed care components. The Department of Community Health is the single State agency for Medicaid.

Does Medicaid have a PBM?

Definitions. PBMs: Pharmacy benefit managers (PBMs) are third party administrators that can perform a variety of financial and clinical services for Medicaid programs and help states administer the pharmacy benefit.

What is fee for service pharmaceutical?

The FFS contract is the pharmaceutical industrys particular way of limiting investment buying and compensating the distributors. It is essentially a profit/revenue sharing contract between the manufacturer and the distributors.

Who is the PBM for GA Medicaid?

OptumRx is the Pharmacy Benefits Manager for the Georgia Medicaid Fee For Service Outpatient Pharmacy Program. It processes all Fee For Service outpatient pharmacy claims on-line through Point of Sale transmission utilizing the NCPDP 5.1 communications standard.

Who is Georgia Medicaid PBM?

What is the FFS Medicaid in Georgia?

Georgia Medicaid offers benefits on a Fee-for-Service (FFS) basis or through managed care plans. Under the FFS model, Georgia pays providers directly for each covered service received by a Medicaid beneficiary. Under managed care, Georgia pays a fee to a managed care plan for each person enrolled in the plan.

Who is the PBM for Peach State Health Plan?

Peach State Health Plan works with Express Scripts to pay for pharmacy claims. Express Scripts is our Pharmacy Benefit Manager (PBM). Some drugs are only paid for when you get them from a Peach State Health Plan specialty pharmacy.

Georgia Medicaid Fee-for-Service Pharmacy Program 2025

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