Prior Authorization Makes Sure You Are Getting Appropriate Care
Your insurance does not automatically cover all procedures, prescription drugs, medical equipment or other services you may need. Your health provider will need to submit a prior authorization for certain services, drugs, and equipment.
You do not need to submit a prior authorization request. Your doctor will work with our team at Community Health Plan of Washington (CHPW) to determine if a service will be covered. Your health provider is in charge of submitting prior authorization requests to CHPW. However, it is your responsibility to follow through on requests.
To explore common services and treatments that require prior authorization, please refer to the Prior Authorization Lists and Utilization Guidelines available on our Provider Prior Authorization page.
How does CHPW decide whether to approve or deny a request?
Community Health Plan of Washington and its providers use guidelines for care written by experts in the field of medicine and behavioral health. These guidelines help providers know when to use certain treatments and what problems to look out for. If your doctor’s prior authorization request was denied, you have a right to appeal the decision. Submitting an appeal means we will reconsider our decision. Find out more information about appeals process.
To request a copy of criteria used in making a decision, please contact Customer Service at 1-800-942-0247 (TTY Relay: Dial 711) 7 days a week from 8:00 a.m. to 8:00 p.m., Monday through Friday.
Prescription Drug Coverage
Your plan prescription drug benefit does not cover all medications. Some may require prior authorization before we will cover them. View a list of drugs that are covered with your prescription coverage. Any medications that do not appear in our formularies require prior authorization. Please refer to our prescription drug benefit page for more information.
If you are currently taking a medication that does not appear in the formulary, you can ask CHPW Medicare Advantage to make an exception to our coverage rules. Click to learn more about exceptions and coverage determinations.
Member Prior Authorization FAQs
For medically necessary services, a prior authorization acts as a guideline for what the insurance will and will not cover. There may be an alternative treatment, such as a similar prescription drug or service, that is covered by the plan. In that case, your doctor will switch you to this service. However, if you need a specific treatment that is not currently covered, you can ask us to make an exception to our coverage rules. We will take your health needs into account when we make our decision. Learn more about coverage exceptions.
Yes, you can file an appeal. An appeal is a request to reconsider a decision that was made. Find out how to submit one.