Prescription Drug Coverage

Our prescription drug coverage is accepted at more 1,000 Washington State pharmacies and more than 50,000 pharmacies nationwide.

Here you’ll find CHPW’s Medicare Advantage (MA) directory of in-network pharmacies, lists of covered prescriptions (formularies), and information about how to safely, reliably, and conveniently use your medication benefits.

Tip: For lowest copays and highest convenience, get 90 day refills and use preferred pharmacy and preferred mail order. Learn how below.

Get a Larger Supply of Medication

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 are available exclusively through select network pharmacies (preferred pharmacies and preferred mail order) and Community Health Center pharmacies. Ask your provider if your medication is eligible for a 90-day fill.

Get Started with Home Delivery

Have your medications delivered to your door for the same low prices you’d get at the pharmacy. Setting up mail order is simple. Here’s how:

• ePrescribe: Ask your doctor to send prescriptions electronically to Express Scripts Pharmacy
• Call: 1-844-605-8168 (TTY: 1-800-899-2114), 24 hours a day, 7 days a week
• Online or by Mobile App: Register at express-scripts.com with your member ID card, then follow the prompts to move your prescriptions to home delivery.

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

Find a Pharmacy

For lowest copays, use preferred pharmacies and preferred mail order. Look for those marked P in our pharmacy directory below.

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

Medication Formularies

Formularies are lists of covered prescriptions.

View Medication Formularies

✓ Dual Plan Prescription Drug Formulary (1 Tier):

• Tier 1 Online Searchable Formulary (MA Dual Plan)
• Tier 1 Formulary, updated 7/26/2022 English and Spanish combined (MA Dual Plan)

✓ Prescription Drug Formulary (5 Tier):

• Tier 5 Online Searchable Formulary (MA Plans 1, 2, 3, 4)
• Tier 5 Formulary, updated 7/26/2022 English and Spanish combined (MA Plans 1, 2, 3, 4)

Notice of Changes to Formularies

Our formulary PDFs are updated on a monthly basis. Click to see what has changed.

Tier 1 Formulary

• August 2022
• July 2022
• Jun 2022
• May 2022
• April 2022
• March 2022
• February 2022

Tier 5 Formulary

• August 2022
• July 2022
• Jun 2022
• May 2022
• April 2022
• March 2022
• February 2022

Prior Authorization & Step Therapy Criteria

• Pharmacy Prior Authorization Criteria

Do I Need Prior Authorization?

Some drugs require prior authorization. This means CHPW has to approve coverage before we can help you pay for them. To check if your medicine needs prior authorization or has coverage restrictions:

• Call Customer Service, or
• Check our Tier 1 formulary (MA Dual Plan) or Tier 5 formulary (MA Plans 1, 2, 3, 4)

Requesting an Exception

You can request a coverage determination review by mailing a completed Coverage Determination Request formCoverage Determination Request form 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. To request redetermination, mail your completed Coverage Redetermination Request form or fill 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 | Formulario de reclamación para medicamentos recetados
• 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.

Limits for Opioid Prescriptions from CMS

As of January 1, 2019, there are 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 effective 2020, please see the CMS Fact Sheet: Improving Drug Utilization Review Controls (Opioids).

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: 711). Prospective Members should call 1-800-944-1247  (TTY: 711).