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), notice of changes to 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 Directories
Medication Formularies
Formularies are lists of covered prescriptions.
✓ Dual Complete and Dual Select (D-SNP) Prescription Drug Formulary (1 Tier):
- Dual Complete and Dual Select Online Searchable Formulary
- Dual Complete and Dual Select Formulary, English and Spanish Combined – Updated 3/19/2024
✓ MA Plans Prescription Drug Formulary (5 Tier):
- MA Plans Online Searchable Formulary (Plans 1, 2, 3, 4)
- MA Plans Formulary, English and Spanish Combined (Plans 1, 2, 3, 4) – Updated 3/19/2024
Important Messages:
What You Pay for Insulin – You won’t pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it’s on, even if you haven’t paid your deductible.
What You Pay for Vaccines – Our plan covers most Part D vaccines at no cost to you, even if you haven’t paid your deductible. Call Customer Service for more information.
Notice of Changes to Formularies
Our Medicare formularies are updated on a monthly basis. Please click the pdf to see what has changed.
- Tier 1 Formulary
- Tier 5 Formulary
Prior Authorization & Step Therapy 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 (Dual Complete and Dual Select Plans) 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 form or filling out the online form.
Part B Drug Coverage
Medicare Part B covers a limited number of prescription drugs. Generally, Part B covers drugs that are not usually self-administered. These drugs may be provided in places like a doctor’s office, hospital outpatient setting, infusion center, etc. Some of these drugs require prior authorization, step therapy, or both. Step therapy is the requirement to try less costly but usually just as effective drugs before the plan covers another drug. The requirement for step therapy will only apply if you are starting a new drug. The guidelines we use to review prior authorizations and step therapy are available for reference below.
- Clinical Coverage Criteria (including last approval date and summary of change)
- MCG Criteria
- Local Coverage Determination/National Coverage Determination (LCD/NCD)
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).
Did 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.
