Prescription Drug Coverage

Prescription Coverage That Works for You

Get your medicine when you need it. We provide information to help you safely, reliably, and conveniently use your medication benefits, including:

• List of covered prescriptions (formulary)
• Directory of participating (in-network) pharmacies
• Home delivery and 90-day refill options

Jump to: Formulary | Pharmacies | 90-Day Refills and/or Delivery

Prescription Medication Coverage

CHPW Individual & Family Plans cover prescription drugs based on medical science and the needs of our members. Your share of the cost for prescription drugs depends on your plan and the type of drug (Generic, Preferred Brand, Non-Preferred Brand, and Specialty).

Explore our formulary for a list of the prescriptions we cover:

• 2023 Gold, Silver, and Bronze Formulary

Search our online formularies:

• Gold and Bronze Plan Formulary
• Silver Plan Formulary

To request a free hard copy of the formulary, please call Customer Service at 1-866-907-1906 (TTY Relay: Dial 711), from 8 a.m. to 5 p.m., Monday through Friday.

COVID-19 Vaccines

The Pfizer BioNTech, Moderna, and Johnson & Johnson COVID-19 vaccines are covered on all CHPW Individual & Family Plans at any location where they are offered.

Preventive Medications under the Affordable Care Act (ACA)

Certain medications are covered under the Affordable Care Act (ACA) without any cost sharing when prescribed in accordance with recommendations by the U.S. Preventive Services Task Force. Please note that age, dose, quantity and clinical restrictions may apply.

Learn more about medications covered under the ACA

Find a Pharmacy

To help you find a pharmacy that works for you, we offer:

• An extensive network of participating pharmacies across Washington State
• Access to onsite pharmacies at participating Community Health Centers
• Convenient, affordable options near you

➔ 2023 Pharmacy Directory

Contact your local Community Health Center to learn about onsite pharmacies.

Don’t forget: Bring your CHPW ID card when you pick up your prescription.

Get a 90-Day Supply of Medication

A 90-day supply of select medications is available at all participating network pharmacies. Ask your doctor or pharmacist about a 90-day supply for your prescription.

Set Up Home Delivery

To get started with home delivery:

• Ask your doctor: request that your doctor send your prescriptions electronically to Express Scripts Pharmacy.
• Call: 1-888-637-8383 or TTY users: 1-800-759-1089 (24 hours a day, 7 days a week)
• Online: at express-scripts.com or download the free mobile app. Use your member ID card to register, then follow the prompts to move your prescriptions to home delivery.

Prior Authorization, Formulary Exception, and Emergency Fill

What Requires Prior Authorization?

Some drugs require prior authorization. To check whether your medicine needs prior authorization or has any coverage restrictions:

• Ask your doctor or pharmacist
• Consult your plan information in the:
  • 2023 Formulary and 2023 Evidence of Coverage (EOC)
• Refer to the Clinical Review Criteria for Prescription Drugs online search tool*

*Note: Not all medications listed in the Clinical Review Criteria will be covered on the formulary. Non-formulary medications are subject to the Medical Necessity for Non-Formulary Medications policy. To verify coverage, please ask your doctor or pharmacist, or consult the formulary and Evidence of Coverage (EOC) linked above.

How To Request Prior Authorization

To request prior authorization, ask your doctor to complete the Prior Authorization Form and submit via:

• Fax: 1-877-251-5896
• Mail:
  Express Scripts
  Attn: Pharmacy Coverage Determinations
  P.O. Box 66588
  St. Louis, MO 63166-6588

Please register or log into express-scripts.com to get your plan details including Prior Authorization status.

If your prior authorization request is denied by Express Scripts, you may appeal the decision with CHPW. Read about how to appeal or file a grievance.

Formulary Exception

Check whether your medicine needs formulary exception or has any coverage restrictions by referring to the Clinical Review Criteria for Prescription Drugs.

Note: Not all medications listed in the Clinical Review Criteria link will be covered on the formulary. Non-formulary medications are subject to the Medical Necessity for Non-Formulary Medications policy. To verify coverage, please consult the 2023 Evidence of Coverage (EOC) and 2023 Formulary. 

How To Request a Formulary Exception

Need medicine that isn’t listed on our formulary? You or your provider can call 1-800-753-2851 or submit your request in writing to:
Express Scripts
Attn: Pharmacy Coverage Determinations
P.O. Box 66588
St. Louis, MO 63166-6588

If your formulary exception request is denied by Express Scripts, you may appeal the decision with CHPW. Read about how to appeal or file a grievance.

Emergency Fill

Emergency Fill is when a participating pharmacy dispenses to a Member a prescription drug that is subject to Prior Authorization under their plan, without first obtaining that authorization. The participating pharmacy provider uses their professional judgment to identify that the Member has an “urgent medical need” requiring immediate fill of the prescription medication.

CHPW covers Emergency Fills for the drugs on our formulary with the following limitations:

• Emergency Fills are not available for certain Specialty Drugs, such as oncology drugs, hepatitis C, biologics, multiple sclerosis treatments, and enzyme replacements, which do not meet the criteria for “urgent therapeutic need”
• Emergency Fills are not covered at Non-Participating Pharmacies

Only the Emergency Fill dosage of the Prescription Drug is covered. In the event that the Prescription Drug is continued for treatment beyond the approved Emergency Fill, standard formulary restrictions and utilization management procedures will apply.

You will be responsible for your Cost Share of the Emergency Fill supply, including applicable Deductibles, Coinsurance, and Copayments. Please refer to the Schedule of Benefits for details. The cost share is based on the tier in which the Prescription Drug is included in the 2023 Formulary.

Staying Safe

We follow federal laws that set standards to guarantee safe and effective pharmacy services.

You have the right to know what pharmacy services are covered by your plan. For more information or a copy of our pharmacy coverage policies or benefits, you can check your 2023 Evidence of Coverage (EOC), or contact Community Health Plan of Washington at 1-866-907-1906 (TTY Relay: Dial 711), from 8 a.m. to 5 p.m., Monday through Friday, or [email protected].

Make a list to keep track of your medications . Write down your medication, supplements, and over-the-counter products. Bring the list with you to all your appointments.

If your prescription is recalled, discontinue use of that medication and contact the provider who prescribed it to you right away.

Help stop fraud. We participate in monitoring for pharmacy fraud and abuse. If you suspect misuse or overuse of pharmaceuticals, contact Customer Service.

Understand your prescriptions. Express Scripts offers safety information about your prescriptions, including possible side effects and harmful drug interactions.

Questions about Prescription Drug Coverage?

If you have any questions about our formulary drug list, copay levels, or policies, please call Customer Service between 8 a.m. and 5 p.m., Monday through Friday. Current members should call 1-866-907-1906 (TTY Relay: 711). Prospective members should call 1-833-993-0181 (TTY Relay: 711).