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.

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 2020 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)

Find a Pharmacy

• Pharmacy Directory (Plans 008, 009, 010, 016)
• Pharmacy Directory (Special Needs Plan 014)

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

Tier 5 Formulary

2019 2018

Step Therapy Criteria

• 2020 Step Therapy Criteria
• 2020 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 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).