Prescription Drug Coverage

Our prescription drug coverage is accepted at more 1,000 Washington State pharmacies and more than 50,000 pharmacies nationwide. Search our list of covered drugs, browse our pharmacy directory, and more. Formulary Tier 1 is for Dual Plan (HMO SNP) members. Tier 5 is for members of Plan 1 (HMO), Plan 2 (HMO), Plan 3 (HMO), and Plan 4 (HMO). Please note: the formularies may change at any time. You will receive notice when necessary.

COVID-19 Vaccines: The Pfizer BioNTech, Moderna, and Johnson & Johnson COVID-19 vaccines are covered as part of the medication benefit on Plans 1, 2, 3, 4 and Dual Plan (SNP) at any location they are offered.

➔ Learn more about COVID-19 vaccines, eligibility and locations

Get a Larger Supply of Select Medications

Our members can get a 90-day supply of select medications used to treat chronic conditions (known as maintenance medications) such as high blood pressure, diabetes, and depression. Larger supplies of prescriptions are available exclusively through Community Health Center pharmacies and select network pharmacies (preferred pharmacies). Ask your provider if any of the medications you are taking are eligible for a 90-day fill. You may also be eligible for free home delivery of your long-term medications. Read the documents below for more information.

How to get started with home delivery?

Here are 3 simple ways to get started with home delivery.

• ePrescribe: Ask your doctor to send your prescriptions electronically to Express Scripts Pharmacy.
• Phone: Call 1-844-605-8168  24 hours a day (including holidays), 7 days a week to talk with us about getting your long-term medicine delivered. TTY users: 1-800-899-2114 
• Online:  Visit express-scripts.com or download our mobile app for free. You need to register with your member ID card. Follow the prompts to move your prescriptions to home delivery.

Read the documents below for more information.

Free Home Delivery for Prescriptions | Entrega gratuita a domicilio para medicamentos recetados

Medication Formularies for 2021 Plans

• Tier 1 Online Searchable Formulary (MA Dual Plan)
• Tier 1 Formulary English and Spanish combined (MA Dual Plan)
• Tier 5 Online Searchable Formulary (MA Plans 1, 2, 3, 4)
• Tier 5 Formulary English and Spanish combined (MA Plans 1, 2, 3, 4)

2021 – Find a Pharmacy

• Pharmacy Directory (MA Plans 1, 2, 3, 4)
• Pharmacy Directory (MA Dual Plan)

Notice of Changes to Formularies

Our formulary PDFs are updated on a monthly basis. If you want to see what has changed about our formularies throughout the past year, refer to the list below.

*Click the + below to see what has changed from past months.

Tier 1 Formulary

2021

Tier 5 Formulary

2021

Prior Authorization & Step Therapy Criteria

• 2021 Prior Authorization Criteria
• No Step Therapy Criteria applicable at this time

Prior Authorization

Some drugs require prior authorization. This means CHPW has to approve coverage before we can help you pay for them. Check whether your medicine needs prior authorization or has any coverage restrictions by calling Customer Service or checking our Tier 1 formulary (MA Dual Plan) or Tier 5 formulary (MA Plans 1, 2, 3, 4).

Requesting an Exception

You can submit a request for a coverage determination review by sending in a Coverage Determination Request form by mail or filling out the online form.

Requesting a Redetermination

If coverage for a specific drug has been denied, you can ask us to reconsider our decision. Please submit a request for redetermination by sending in a Coverage Redetermination Request form by mail or filling out the online form.

We must make our decision within 72 hours of getting your prescribing provider’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescribing provider’s supporting statement.

Pharmacy Forms, Programs, and Policies

• Medication Therapy Management Program
• How to Request Coverage Exceptions, Determinations, and Redeterminations
• Prescription Drug Claims Form
• Prescription Drug Plan Transition Policy |  Política Transición de Plan por Medicamentos Recetados

Medication Safety

Be sure to read our Drug Recall Report for updates on medications that are recalled due to safety issues.

New Limits for Opioid Prescriptions from CMS

As of January 1, 2019, there are new limits on opioid prescriptions for members who have Medicare Part D. This change follows guidance from the Centers for Medicare & Medicaid Services (CMS).

• Members who are filling a first-time prescription for opioids to treat acute pain won’t be able to get more than a seven-day supply at one time.
• Pharmacists will be required to consult with the prescriber for opioid prescriptions greater than 90 morphine equivalent dose (MME) per day.

These limits don’t apply to members who:

• Live in a long-term care facility.
• Are in hospice and receiving end-of-life care.
• Are being treated for active cancer-related pain.
• Are prescribed buprenorphine products for medically assisted treatment (MAT).

More oversight

CMS recommends more oversight and monitoring of opioid prescription to address current trends and safety concerns. Medication reviews may result in a member being assigned to a single pharmacy and a single subscriber for controlled substances in order to better coordinate care and case management.

To read more about changes to opioid prescriptions for Medicare Part D members in 2020, please see the CMS Factsheet: 2020 CMS Fact Sheet

Questions about Prescription Drug Coverage?

If you have any questions about our formulary drug list, tiering, copay levels or policies, please call Customer Service between the hours of 8:00 a.m. to 8:00 p.m., seven days a week. Current Members should call 1-800-942-0247 (TTY Relay: 711). Prospective Members should call 1-800-944-1247  (TTY Relay: 7-1-1).