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 Special Needs Plan 014 members. Tier 5 is for members of plans 008, 009, 010 and 016. Please note: the formularies may change at any time. You will receive notice when necessary.

Formularies and Pharmacies for 2019 Plans

• Tier 1 Online Searchable Formulary (Special Needs Plan 014)
• Tier 1 Formulary English and Spanish combined (Special Needs Plan 014)
• Tier 5 Online Searchable Formulary (Plans 008, 009, 010, 016)
• Tier 5 Formulary English and Spanish combined (Plans 008, 009, 010, 016)
• Pharmacy Directory (Plans 008, 009, 010, 016)
• Pharmacy Directory (Special Needs Plan 014)

Convenient 90-day Prescription Fills

Going to the pharmacy every month to refill your prescriptions can be a hassle. For prescription drugs that you take on an everyday basis, you could be getting a 90 day supply – saving you time and money. Ask your provider if any of the medications you are taking are eligible for a 90-day fill.

Your provider will need to write you a prescription for a 90 day fill. Certain medications, like antidepressants, require an initial 30-day fill.  All Community Health Center pharmacies and some select ESI pharmacy can fulfill a 90 day request. You may also be eligible for free home delivery of your long-term medications. Ask your pharmacy for more information.

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

2019 2018

Tier 5 Formulary

2019 2018

Step Therapy Criteria

• 2019 Step Therapy Criteria
• 2019 Prior Authorization Criteria

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 2019, please see the CMS Factsheet: https://www.cms.gov/newsroom/fact-sheets/2019-medicare-advantage-and-part-d-rate-announcement-and-call-letter

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: 7-1-1). Prospective Members should call 1-800-944-1247  (TTY Relay: 7-1-1).