Get the Answers You Need
Whether you are a new member or you have been with us for a while, you may have questions about your coverage with CHPW Medicare Advantage. Use this page as a resource to find answers to common questions.
Members Frequently Asked Questions
If you are not feeling well and unsure of what kind of care you need, you can talk to the experts. Our Nurse Advice Line is available 24 hours a day, 7 days a week. This is an added benefit for our members. They can help you decide whether to seek emergency care or wait to see you primary care provider.
Our Nurse Advice Line number is 1-866-418-2920 (TTY Relay: Dial 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 at 1-800-440-1561 (TTY Relay: Dial 711), 8:00 a.m. to 5:00 p.m., Monday through Friday.
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 formulary page, or call Customer Service at 1-800-942-0247 (TTY Relay: Dial 7-1-1) from 8:00 a.m. to 8:00 p.m., seven days a week.
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 this address:
Community Health Plan of Washington Medicare Advantage – Claims
P.O. Box 269002
Plano, TX 75026-9002
Prescription Drug Frequently Asked Questions
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.” You should review this list to determine what tier your drug is on and if there are any restrictions on it.
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).
For more detailed information, please see your plan’s Evidence of Coverage (EOC)
If you still have questions, please contact Customer Service for assistance at 1-800-942-0247 (TTY Relay: Dial 7-1-1). Our local, friendly team is available from 8:00 a.m. to 8:00 p.m., seven days a week.