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.

START THE PROCESS

Formularies and Pharmacies

• Online Searchable Formulary (Dual Complete and Dual Select)
• Dual Complete and Dual Select Formulary, English and Spanish Combined – Updated 01/20/2026 
• Pharmacy Directory – Dual Plans (Dual Complete and Dual Select)

* If you need these documents in another format, please fill out a request form.

Notice of Changes to Formularies

Our Medicare formularies are updated on a monthly basis. Please click the pdf to see what has changed.

COVID-19 Vaccines: The Pfizer BioNTech, Moderna, and Johnson & Johnson COVID-19 vaccines are covered as part of the medication benefit on Plans 1, 2, 3, 4 and Dual Plan (SNP) at any location they are offered.

Prior Authorization & Step Therapy Criteria

• Pharmacy Prior Authorization Criteria
• Step Therapy Clinical Criteria

Pharmacy Forms, Programs, and Policies

• Medication Therapy Management Program
• How to Request Coverage Exceptions, Determinations, and Redeterminations
• Prescription Drug Claim Form
• Plan Transition Policy |  Español

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.

Limits for Opioid Prescriptions from CMS

Effective January 1, 2019, there are additional 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 opioid prescription updates for Medicare Part D members effective 2019, please see the CMS Factsheet: Improving Drug Utilization Review Controls.