Member FAQs

Yes. When you enroll in a CHPW Medicare Advantage plan, you will receive your ID card by mail within 30 days.

You can also download or print your ID card at anytime by logging into your myCHPW account.

You will need to show your ID card each time you get medical care. That includes medical visits, specialist visits, mental health visits, hospital visits, and pharmacy prescriptions.

If you need a new ID card sent to you, please call Customer Service at 1-800-942-0247 (TTY: 711), 8:00 a.m. to 8:00 p.m., 7 days a week.

If you’re not feeling well and unsure of what kind of care you need, speak with an expert who can help you decide whether to seek emergency care or wait to see you primary care provider.

CHPW members can contact our Nurse Advice Line 24 hours a day, 7 days a week: 1-866-418-2920 (TTY: 711).

With the CHPW Medicare Advantage Plan, you’re always covered for emergencies anywhere in the world. If you become ill or injured, or you have an emergency medical condition: call 9-1-1 or go to the nearest hospital emergency room or urgent care center for assistance.

When you move, you may need to change primary care providers (PCP). Our Customer Service representatives can help you choose a new PCP and inform you of any other actions you should take. Call Customer Service aat 1-800-942-0247 (TTY: 711), 8:00 a.m. to 8:00 p.m., 7 days a week.

Your Medigap policy can’t be used to pay your Medicare Advantage Plan copayments, deductibles, and premiums. A Medigap policy is a way for you to pay your Original Medicare costs. An Advantage Plan is a different way to receive your Medicare benefits, that gives you more coverage.

To get updated information about the drugs covered by CHPW Medicare Advantage, please visit our at formulary page, or call Customer Service at at 1-800-942-0247 (TTY: 711), 8:00 a.m. to 8:00 p.m., 7 days a week.

You can change your doctor because you’ve moved, or if you would feel more comfortable with another doctor. Whatever the reason, you can change from one in-network CHPW provider to another at any time:

• Online: log into the Member Center to change your doctor in your account
• Call us: 1-800-942-0247 (TTY: 711), 8:00 a.m. to 8:00 p.m., 7 days a week.
• Email us: [email protected]

Most providers will submit their bills to us directly. Sometimes when you get medical care or a prescription drug, you may pay directly. Other times, you may find that you have paid more than you expected under the coverage rules of your plan. In either case, you can ask your plan to pay you back.

To be paid back for covered services or drugs, please mail your request along with your bill and documentation of the payment you made to:
Community Health Plan of Washington Medicare Advantage – Claims
P.O. Box 269002
Plano, TX 75026-9002

Medicare is the Federal health insurance program for people 65 years of age or older, some people under age 65 with certain disabilities, and people with end-stage renal disease (kidney failure).

Medicare Part D is insurance for your prescription drug costs. Instead of paying full price for most medications, you will pay a copay (a set dollar amount) or coinsurance (a set percentage) of the drug’s cost.

Each year, we will publish a formulary, also known as “List of Covered Drugs” or “Drug List.” Review this list to determine what tier your drug is on and if there are any restrictions on it. [/expand]

For certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and pharmacists developed these rules to help our members use drugs in the most effective ways. These special rules also help control overall drug costs, which keeps your drug coverage more affordable.

In general, our rules encourage you to get a drug that works for your medical condition and is safe and effective. Whenever a safe, lower-cost drug will work just as well medically as a higher-cost drug, the plan’s rules are designed to encourage you and your provider to use that lower-cost option. We also need to comply with Medicare’s rules and regulations for drug coverage and cost-sharing.

Our plan uses different types of restrictions to help our members use drugs in the most effective ways. The sections below tell you more about the types of restrictions we use for certain drugs. These types of restrictions include:

Prior Authorization (PA): For certain drugs, you or your provider need to get approval from the plan before we will agree to cover the drug for you. This is called “prior authorization.” Sometimes the requirement for getting approval in advance helps guide the appropriate use of certain drugs. If you do not get this approval, your drug might not be covered by the plan.

Step Therapy (ST): This requirement encourages you to try a less costly but just as effective drug before the plan will cover another drug. For example, if Drug A and Drug B treat the same medical condition and Drug A is less costly, the plan may require you to try Drug A first. If Drug A does not work for you, the plan will then cover Drug B.

Quantity Limit (QL): For certain drugs, we limit the amount of the drug that you can have by limiting how much of a drug you can get each time you fill your prescription. For example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day.

B versus D Determination (BVD): This is simply a coverage determination to see which part of Medicare will cover your drug. There are certain criteria that some drugs must meet to be covered under Part D. (For example, chemotherapy and the drugs prescribed along with it to treat nausea and vomiting are subject to a B vs D determination).

When a drug is excluded from coverage, this means that Medicare does not pay for the drug. There are three general rules about drugs that Medicare drug plans will not cover under Part D: Part D drug coverage cannot cover a drug that would be covered under Part A or Part B; we cannot cover a drug purchased outside of the United States and its territories; usually we cannot cover off-label use. “Off-label use” is defined as the use of the drug other than those indicated on a drug’s label as approved by the Food and Drug Administration.

Additionally, by law, Medicare Part D cannot cover the following categories of drugs:

• Over-the-Counter, or non-prescription drugs
• Drugs used to promote fertility
• Drugs used for cough and cold symptoms
• Drugs used for cosmetic purposes or to promote hair growth
• Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations
• Drugs when used for the treatment of sexual or erectile dysfunction
• Drugs when used for the treatment of anorexia, weight loss, or weight gain
• Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale

Typically, a standard request must have a decision made within 72 hours (including weekends and holidays), unless we need additional information from your provider. You will be notified via phone and mail once a decision is made. In some instances, your provider may determine that coverage of a certain medication should be decided urgently. In these cases, a decision will be made within 24 hours (including weekends and holidays).

Prior authorization is a way for health plans to ensure that certain services, medical procedures, items, supplies, and medications are used safely and are covered in your benefit plan before you receive them.

At CHPW, we use prior authorizations to make sure that our members receive safe, appropriate, and cost effective care.

There are two ways to check the status of your authorization:

1. You can check the status of your prior authorization and send or receive secure messages through your myCHPW Member Portal. To access the portal, go to Member Center, scroll down to myCHPW Member Portal, and click the “Get started” button.
2. Another way to check the status is by calling our Customer Service at the number listed on the back of your plan ID card.

To access the portal, go to the Member Center, and scroll down to select myCHPW Member Portal.

If you have any questions getting started with your portal and need any other support, you can call Customer Service at the number listed on the back of your plan ID card. We’re here to help!

If you haven’t heard about the status on your prior authorization request, please login to your myCHPW Member portal to check the status.

You also can send and receive secure messages to get the status and receive an update.

Another way to check the status is by calling our Customer Service team at the number listed on the back of your plan ID card.

Prior authorizations usually take between 24 to 72 hours. The time it takes to process depends on several factors, and in some days it can take up to 30 days.

By going to your myCHPW Member portal you can check the status of your prior authorization.

You also can send and receive secure messages to get the status and receive an update. Another way to check the status is by calling our Customer Service team at the number listed on the back of your plan ID card.

We know how important your prior authorization request is. If your request is urgent, please let your doctor know. An Urgent request is one that could have serious impacts to your health or life.

Please consider how urgent your request is. If it’s not urgent, it will be treated as a standard or routine request, and we will make sure to process your request as quickly as possible. All requests are closely monitored by our team to ensure we process them in a timely manner.

You can check the status of your prior authorization by going to your myCHPW Member portal.

You also can send and receive secure messages to get the status and receive an update. If you can’t find your prior authorization this way, please call our Customer Service team at the number listed on the back of your plan ID card. We’re here to help!

You can check the status of your prior authorization by going to your myCHPW Member portal. You also can send and receive secure messages to get the status and receive an update.

If you can’t find your prior authorization this way, please call our Customer Service team at the number listed on the back of your plan ID card. We’re here to help!

If your prior authorization request is denied, CHPW will explain why. You will receive a notification by mail detailing the reason for the denial.

If the request was denied due to not meeting medical necessity or treatment appropriateness, your provider has two options: they can request a Peer-to-Peer review within 10 calendar days of the denial or submit an appeal. This usually means providing additional information or documentation to support the treatment’s necessity.

A Peer-to-Peer review is a conversation between your provider and a CHPW provider, where they can discuss your specific request and explore the need for the treatment.

See your benefit booklet or call Customer Service at the number listed on the back of your plan ID card. We’re here to help!