Pharmacy Prior Authorization - Community Health Plan of Washington - Medicare Advantage

Pharmacy Prior Authorization

Any pharmaceutical not listed on our formulary requires prior authorization. For self-administered drugs requiring prior authorization, please contact Express Scripts at 1-844-605-8168 or use visit their website to start the prior authorization process.


Formularies and Pharmacies for 2020 Plans

Step Therapy Criteria

Pharmacy Forms, Programs, and Policies

Professionally Administered Drugs

CHPW requires prior authorization for certain professionally administered medications. MCG guidelines are used to determine medical necessity in the absence of CHPW Clinical Coverage Criteria. You can review our utilization management guidelines and policies for medical drug benefits by visiting our Prior Authorization page.

New Limits for Opioid Prescriptions from CMS

Starting on January 1, 2019, there will be 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.


Provider Education and Training

Laughing Female Doctor at Desk in OfficeCHPW provides the resources you need to best care for members and stay compliant with local and federal regulations. Some training programs are optional and others are mandatory.

All CHPW contracted providers and clinic staff must complete the following: Model of Care Training, Patient Rights and Responsibilities & Advance Directives Training, and CMS Fraud, Waste, and Abuse Training.

Learn more about required training in the provider manual.


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