Prescription coverage built to support your health
How it works, where to go, what’s covered, and how to get the medication you need with your CHPW Individual & Family Plan.
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Your Rx benefit
How it works | Costs | Express Scripts
CHPW Individual & Family Plans cover prescription drugs based on medical science and the needs of our members. We manage this benefit for you with the help of our pharmacy benefit partner, Express Scripts.
How it works
✔ To get the most out of your Prescription Drug Coverage benefit, fill your prescriptions at an in-network pharmacy.
✔ After you’ve paid your share of the cost, we pay the pharmacy the rest if:
- The pharmacy is in-network
- Covered by your plan
- Prescribed and medically necessary
- Prior authorization is approved if required*
*If you have an urgent medical need, based on what your pharmacy provider decides, an Emergency Fill up to one 30-day supply may be covered with cost-shares from an in-network pharmacy. See your plan’s Evidence of Coverage for details.
Reimbursement
If you paid full price for a prescription at an in-network pharmacy, you can ask to be paid back (reimbursement) if you find out it can be covered.
To request reimbursement, contact our benefit manager, Express Scripts online or by mail and submit a Prescription Reimbursement Claim Form.
How do I request reimbursement for OTC?
You will need to request reimbursement by fax or mail using different forms if you paid:
For more information about your plan’s benefits, review your Evidence of Coverage (EOC) and drug list (formulary). If you have questions or need a printed copy of a plan document, call us at 1-866-907-1906 (TTY:711), from 8 a.m. to 5 p.m., Monday through Friday, or email [email protected].
Costs
Your cost for prescription medication depends on your plan and the type of drug or tier (Generic, Preferred Brand, Non-Preferred Brand, Specialty). Find cost-share details in your plan’s Schedule of Benefits or the drug list (formulary).
To only see plan documents for your specific plan, login to your myCHPW member portal.
How do I find out how much a medication costs?
To know what you will pay for a medication you were prescribed, call your in-network pharmacy directly. They will need your CHPW Member ID number and the prescription from your provider.
If the medication has not been prescribed yet:
Prescription medications have a cost-share based on the tier and your plan.
- Know which plan you have, by checking your CHPW Member ID or login to your myCHPW account.
- To see the drug type (tier), search our online drug list (formulary) for your plan metal level. In this search tool, you can also see the cost for each tier.
- Select the drug and check the tier level. Then scroll down to see what the cost is for that tier under your plan type.
A member of our Customer Service Team can also help you find out what you will pay.
Express Scripts
We partner with Express Scripts to provide a large network of pharmacies and a range of covered prescriptions.
Creating an Express Scripts account helps you order refills, set up home-delivery for long-term medications, or check the status of a prior authorization. Log in or Register to create an account:
Log in to Express Scripts Register
Express scripts frequently asked questions ➔
Find a pharmacy in-network
Local pharmacies | Home delivery
We offer a large network of participating pharmacies across Washington State. Your Community Health Center (CHC) or health clinic might have a pharmacy too!
Local pharmacies
Find an in-network pharmacy close to you in our Pharmacy Directory or search pharmacies on Express Script’s website.
A 90-day supply of select medications is available at all participating Walgreens and CHC pharmacies. Ask you doctor or pharmacist about a 90-day supply of your prescription.
Home delivery
Get your prescriptions delivered to you by setting up home delivery. You have options:
Your CHC Pharmacy
Some CHCs offer delivery services. Ask your provider or CHC pharmacist for more information.
CHCs offering delivery
- King: Health Point Pharmacy
- Spokane, Asotin: CHAS Health Pharmacy
- Yakima, Kittitas: Community Health of Central Washington (CHCW) Pharmacy
This is not a complete list. Also ask your provider or CHC Pharmacy if you need help getting your prescriptions.
Express Scripts
If you need medication routinely for a chronic condition, ask your provider to send your prescription to Express Scripts Pharmacy, or create an account and transfer your prescription.
How to get started with Express Scripts
1. Register to create an account
Provide your basic information and your mailing address.
2. Link your health plan using one of the following:
Last 4 of your social, CHPW Member ID, or a prescription number (Rx#) from a medication you are currently taking.
3. After you’ve created your account, look for “Request an Rx” for new prescriptions, or check “My Medications” if you have any current prescriptions.
Note: CHPW covers 90-day refills of most long-term medications for chronic conditions. Save time and ask your doctor or pharmacist about it.
Check if a medication is covered
Rx drug list | Pre-approval | OTC
Find out what’s covered, what to do if you need prior authorization, or if your medication is not in the drug list (formulary). Also see your coverage for contraception, vaccines, and other over-the-counter (OTC) items.
Rx drug list (formulary)
Look up your medication using our formulary search tool:
Bronze & Gold Formulary Silver Formulary
View the full Rx drug list with benefit details in the 2026 Prescription Drug (Formulary) ➔
The formulary is updated throughout the year and may change.
Need medication that isn’t listed on our formulary? You or your provider can request a Formulary Exception.
Pre-approval
For certain medications, you will need pre-approval also known as prior authorization before you can fill the prescription.
Most authorizations are good for one year. If a medication you need is not in the formulary, a different type of approval called a formulary exception can be requested.
How do I request Prior Authorization or a Formulary Exception?
You or your provider can send prior authorizations and formulary exceptions through Express Script’s website, by phone, fax, or mail.
Phone: 1-800-753-2851
Fax: 1- 877-328-9660
Mail: Express Scripts
Attn: Benefit Coverage Review Department
PO Box 66587
St Louis, MO 63166-6587
Before requesting a formulary exception or prior authorization, you can also search the Clinical Review Criteria* for Prescription Drugs to confirm what’s needed for approval and check coverage restrictions.
*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, review your plan documents and formulary.
Which medications require Prior Authorization?
To check if your medication needs prior authorization or has any coverage restrictions:
- Ask your provider or pharmacist, or contact us.
- Check your Prescription Drug Formulary to see if a specific prescription is covered.
- Review your Evidence of Coverage, for full details about prior authorization.
Over-the-counter (OTC)
Preventive OTC drugs are covered at no cost*. That includes OTC contraceptives (birth control, condoms, and more), immunizations (vaccines) at a pharmacy, and certain OTC drugs when prescribed.
OTC contraceptives
CHPW Individual & Family members can get reimbursed, with no cost shares, when purchasing any FDA-approved over-the-counter contraceptives from an in-network pharmacy or provider.
This benefit is available to everyone, for any medical purpose, inclusive of all sexual orientations. There is also no age limit.
What is covered?
When purchased in-network, you can get reimbursed for FDA-approved over-the-counter contraceptives including:
- Oral contraceptives (birth control pills)
- Emergency contraceptives (morning after pill)
- Birth control barrier methods, like condoms and dental dams
- Sponges and more
How does it work?
Make your purchase in-network from a pharmacy, online provider, or clinic and your CHPW Individual & Family Plan will pay you back (reimburse you) for covered products.
If you purchase OTC contraceptives from a store that is not in your plan’s network, like a convenience store or vending machine, you will not be able to get reimbursed
To get reimbursed, let us know you made the purchase and provide receipts, by submitting a claim in writing by mail.
How do I get reimbursed for OTC contraceptives?
- Make your purchase from an in-network pharmacy or provider.
- Save your receipts.
- Submit your claim within 90 days, by mailing your reimbursement request.
- Send your request in writing by mail including your receipts from the in-network pharmacy or provider directly to:
CHP Claims
PO Box 269002
Plano, TX 75026-9002
Immunizations
Select preventive immunizations (vaccines) are covered with no out-of-pocket cost when you get them at an in-network pharmacy.
Recommended preventive vaccines are also covered at your doctor’s office, clinic, or CHC for children and adults at no cost when you get them from an in-network provider with all Individual & Family Plans.
If you paid out-of-pocket or were charged cost-shares at an in-network pharmacy for a preventive over-the-counter medicine, you may be able to request reimbursement.
Which vaccines can I get at the pharmacy at no cost?
Under the Affordable Care Act, when the pharmacy is in-network, preventive immunizations include:
- Flu
- COVID-19 vaccines: Pfizer BioNTech, Moderna, and Novavax
- Tdap/Td (Diphtheria, tetanus, pertussis)
- Shingles
- Pneumonia
- Travel vaccines
- Hepatitis
- HPV (Human papillomavirus)
- MMR (Childhood measles, mumps, rubella)
- Meningitis
- Rabies
For more details, review your Evidence of Coverage, the drug list (formulary) for your plan, or call our Customer Service Team.
Prescribed OTC
Certain over-the-counter medications are covered when prescribed at zero cost* to you under the Affordable Care Act (ACA).
For certain medications, you may be charged a cost-share up front, and will need to request a cost-share review to get paid back (reimbursement).
Which preventive medications are covered?*
- Aspirin
- Bowel Preparation Agents
- Breast Cancer Prevention:
- Tamoxifen
- Raloxifene
- Anastrozole
- Exemestane
- Contraceptives
- Fluoride
- Folic acid
HIV Pre-exposure prophylaxis (PrEP):
- Combined tenofovir disoproxil fumarate emtricitabine (Truvada)
- Tenofovir disoproxil fumarate
- Immunizations when administered by a pharmacist
Smoking Cessation:
- Bupropion SR
- Varenicline
- Nicotine Replacement
Cardiovascular disease prevention:
- Atorvastatin
- Fluvastatin
- Lovastatin
- Pravastatin
- Rosuvastatin
*This list may change over time. For the most up to date information, please review the formulary for your plan.
I paid a cost-share for a preventive medication. Can I get reimbursed?
If you were charged a cost-share for a preventive medication that was prescribed, you can request a cost-share review and request reimbursement.
To request a cost-share review, you or your authorized representative must submit a Benefit Coverage Request Form and fax or mail it to:
Express Scripts
Attn: Benefit Coverage Review Department
Fax: 877- 328- 9660
Mail:
PO Box 66588
St Louis, MO 63166- 6588
Fax: 877-328-9660
*These medications are covered under the Affordable Care Act (ACA). See your Evidence of Coverage and Schedule of Benefits for cost sharing information.
Frequently asked questions
What can I do if I need my medication right away, but the pharmacy says it needs approval first?
If you have an urgent medical need and can’t wait for pre-approval or prior authorization, ask your in-network pharmacy for an Emergency Fill. This will allow you to get a one-time fill of your prescription without waiting for prior authorization from your health plan.
The pharmacist will use their best judgment to decide if you have an urgent medical need and if you should get a short supply right away.
CHPW covers Emergency Fills for the drugs on our formulary with the following limitations:
- Emergency Fills are not available for certain Specialty Drugs: Oncology drugs, hepatitis C, biologics, multiple sclerosis treatments, and enzyme replacements, which do not meet the criteria for “urgent therapeutic need”
- Not covered at pharmacies that are not in-network, or non-participating.
Only one Emergency Fill, up to a 30-day supply, is covered for a Prescription Drug. If you need another refill of the same medication, you will need to get prior authorization first (or pay full price out of pocket) and follow any other requirements based on your plan.
You will still pay your cost share for the Emergency Fill supply, including applicable deductibles, coinsurance, and copays.
Please refer to your plan’s Schedule of Benefits for details. The cost share is based on the tier, shown in your plan’s drug list (formulary).
My Prior Authorization request was not approved. What now?
Talk to your provider about prescribing you a similar drug that is covered, or about providing us with additional information to show you need it.
You or your provider can also appeal the decision. If you appeal, you are asking us to review our decision to cover the medication again.
How to appeal a coverage decision ➔
You can also get the original prescription filled at your pharmacy, but will be paying the full price if it’s not approved to be covered.
How do I change pharmacies or transfer a prescription?
There’s a few ways to do it:
- Ask your new pharmacy to contact your old pharmacy to get the prescription transferred. You’ll need your old pharmacy’s contact information, your prescription details, name of the medication, and the dosage.
- Ask your doctor for a new prescription, and give them your new pharmacy’s name and address. Call your clinic or send a message through your patient portal.
We’re here to help too. We can walk you through the steps, and help you get this done, contact us.
Safety guidelines and support
We follow federal laws that set standards to guarantee safe and effective pharmacy services. Take these steps to keep yourself and your community safe.
Know your rights
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, check your plan documents or contact us.
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.
View or download our medication list template ➔
If your prescription is recalled
Contact the pharmacy and prescriber right away.
For recent recalls, see CHPW’s Drug Recall Report ➔
Search by drug name using the U.S. Food & Drug Administration’s Drug Recall Search ➔
Help us stop fraud
We participate in monitoring for pharmacy fraud and abuse. If you suspect misuse or overuse of pharmaceuticals, contact us.
Understand your prescriptions
Express Scripts offers safety information about your prescriptions, including possible side effects and harmful drug interactions.
Questions?
If you have any questions about covered medications, costs, policies, or need help getting your medication, call a member of our Customer Service Team at 1-866-907-1906 (TTY: 711), from 8 a.m. to 5 p.m., Monday through Friday or email [email protected].
Interested in becoming a CHPW member? Find out more about our health plans and how we work together to support your whole health.
