Prior Authorization - Community Health Plan of Washington - Medicare Advantage

Prior Authorization

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 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.

You can look up common services and treatments that require prior authorization by visiting our provider 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 7-1-1) from 8:00 a.m. to 5:00 p.m., Monday through Friday.

Review our Prior Authorization guidelines and examples of medical services that need approval.

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

Do I need to submit prior authorization requests?
No, for any services or medications that need approval, your provider knows how to submit a claim with us.
I have received a specific treatment in the past, but now it is not covered by my plan. What can I do?

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.

My doctor’s request for a treatment I need was denied. Is there anything I can do?

Yes, you can file an appeal. An appeal is a request to reconsider a decision that was made. Find out how to submit one.

 

DID YOU KNOW...?

Stay on Top of Your Prescriptions

Woman grabbing a prescriptionDid you know that certain prescription medicines are available as a 90-day supply? Medicine that you take on a long-term basis to manage your health is called a “maintenance drug.” A 90-day supply makes it easier to keep taking the medicine you need to feel your best. You may also be eligible to receive your long-term medications through free home delivery.

LEARN MORE

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