Pharmacy Frequently Asked Questions

Does Community Health Plan use a preferred drug list (formulary)?

Yes, Community Health Plan uses what is called a formulary system. This means it uses a certain list of covered drugs (formulary). The Community Health Plan Pharmacy and Therapeutics Committee, composed of providers and pharmacists, develops this formulary. The committee uses medical studies and research to choose FDA-approved drugs based on safety, effectiveness, and value.

Sometimes an exception may be made for a drug not on the formulary, if your provider believes it would be more beneficial for you. See below for the procedure to follow.

Please note: If your medical plan does not cover a specific medical condition, then a drug for that condition will not be approved. Please refer to your health program member book for these conditions.

How often does Community Health Plan change the formulary?

The formulary changes several times per year to make sure it meets member and provider needs. The Community Health Plan Pharmacy and Therapeutics Committee meets regularly to review new drugs and make sure there are appropriate drugs on the formulary to best meet our member’s medical conditions.

Please note: As brand name drugs become generic, the brand name drug will be replaced by the equivalent generic drug.

What if my drug is removed from the formulary?

If one of your chronic prescription drugs is removed from the formulary, we will send a letter to you. We will give you a 60-day "grace period" during which time your prescriptions for that drug will be covered and to allow you to meet with your provider and talk about other drugs on the formulary that may be suitable for you.

What should I do if I need a nonformulary drug?

Your PCP should call Community Health Plan's pharmacy benefit manager, Express Script, Inc., (ESI) at 1‑888‑256‑6132, 24 hours a day, seven days a week, to ask for nonformulary drugs. A decision might be made during the call for both normal circumstances and emergency medical conditions. The decision may take up to three business days. In general, information needed by your provider for a nonformulary drug is support that:

Two formulary drugs have been tried without a positive response; or
Contraindications or intolerance to formulary drugs exists; or
No formulary drug exists to treat the condition

What should I do if I need prior authorization for a drug?

Your PCP should call Community Health Plan's pharmacy benefit manager, Express Script, Inc., (ESI) at 1‑888‑256‑6132, 24 hours a day, seven days a week, to review prior authorization for a drug. A decision might be made during the call for both normal circumstances and emergency medical conditions. The decision may take up to three business days. For a list of drugs that require prior authorization please see Pharmacy Programs.

What should I do to ask for a drug excluded by my medical plan?

If your drug won’t be paid for when you try to fill the prescription at a pharmacy, you have the right to appeal.

If you want to appeal, please call the Community Health Plan customer service team at 1‑800‑440‑1561 (toll free). If you are hearing or speech impaired, please call TTY 1‑866‑816‑2479 (toll free) or local 206‑613‑8875.

What is the difference between brand name and generic drugs?

The Food and Drug Administration (FDA) determines which generic drugs are equivalents of brand name drugs and therefore are equally safe and effective.
Generic drugs usually cost much less than brand name drugs and therefore may help lower your prescription expense.
Many generic drugs, though highly effective, are forgotten because generic drugs are not advertised.
Some generic drugs are still the best-known treatment for certain conditions.
Generic drugs have been around longer than many new brand name drugs, so there is more known about the possible risks and side effects.

Does Community Health Plan prefer generic drugs?

For certain brand name drugs where the FDA has deemed a generic equivalent, Community Health Plan prefers the generic agent. If you have a pharmacy co-pay, it will be lower for a generic drug.

Please note: For Healthy Options, Children’s Health Insurance Program (CHIP), and General Assistance Unemployable (GA-U), there is no copay for any type of drug.

How many days supply of a drug can I get at one time?

Community Health Plan allows for a 30-day supply of a drug when the prescription is filled at your local pharmacy.

Once a year all Community Health Plan members may order an additional 30-day supply to cover vacations and trips. Your provider must approve this additional supply.

Mail order service is not available to Basic Health, Healthy Options, Children’s Health Insurance Program (CHIP), or General Assistance Unemployable (GA-U) members.

Do I have a copayment for prescriptions?

The amount of your copay depends on your health program coverage and the specific drugs prescribed. It may also depend on whether a generic substitution is available and if the drug is on Community Health Plan’s formulary.

Basic Health members: Please refer to your member handbook for information on your copays. Healthy Options, Children’s Health Insurance Program (CHIP), and General Assistance Unemployable (GA-U) members do not have a pharmacy copay.

Where do I fill my prescriptions?

Community Health Plan contracts with more than 1,000 pharmacies in Washington State.

To get a current list of pharmacies in the Healthy Options, SCHIP, Basic Health, or GA-U network:

Open or download the list (updated July 2009) of participating network pharmacies.
Contact the Community Health Plan customer service team at 1-800-440-1561 (toll free). If you are hearing or speech impaired, please call TTY 1-866-816-2479 (toll free) or local 206-613-8875.
Search for a participating pharmacy. Community Health Plan members use the ESI Access Your Account tool. If you are a first-time user, please use the ESI Activate Your Account tool.

What other pharmacy services does my health program offer?

Improved safety by checking and alerting your pharmacist of known allergies and drug interactions when you have your prescription filled. We automatically alert your physician in situations where the FDA requires a drug that you are taking to be removed from the market.

What antiviral agents are covered by Community Health Plan?

The formulary agents are amantadine, rimantadine, Tamiflu, and Relenza. There are quantity limits for Tamiflu and Relenza:

20 capsules/prescription for Tamiflu 30mg
10 capsules/prescription for Tamiflu 45mg
10 capsules/prescription for Tamiflu 75mg
75mL/prescription for Tamiflu suspension
1 inhaler of Relenza/prescriptions

Important! For questions related to Medicare Advantage, please go to www.healthfirst.chpw.org.