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, develop this formulary. The committee uses medical studies and research to choose FDA-approved medications based on safety, effectiveness, and value.

Sometimes an exception may be made for a medication 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 medication 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 medications 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 medication is removed from the formulary?

If one of your chronic prescription medications 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 medications on the formulary that may be suitable for you.

What should I do if I need an exception for a medication?

Talk to your health care provider about your medications. If your provider wants to request an exception he/she must contact Express Scripts, our pharmacy vendor at 1-888-256-6132. Community Health Plan does consider special circumstances such as drug intolerance, allergy, etc.

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 and Children’s Health Program (CHIP) there is no co-pay for any type of drug.

How much medication can I get at one time?

Community Health Plan allows for a 30-day supply of medication 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 or CHIP members.

Do I have a co-payment for prescriptions?

The amount of your co-pay depends on your health program coverage and the specific medications prescribed. It may also depend on whether a generic substitution is available and if the medication is on Community Health Plan’s formulary.

Basic Health members please refer to your member handbook for information on your co-pays. Healthy Option members do not have a pharmacy co-pay.

Where do I fill my prescriptions?

Community Health Plan contracts with over 2,000 pharmacies in Washington State. Please see the list of pharmacies included in Community Health Plan Provider and Pharmacy Directory. You can also call Community Health Plan customer service at 1-800-440-1561 for help in finding a pharmacy near you.

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.

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