There is no substitute for safety when prescribing medication.
Get a current list of pharmacies in the network or find out which drugs are on the formulary:
Important: The formulary and search do not apply to Medicare Advantage Plan members. Please refer to the Community HealthFirst site for information on Medicare Plan coverage.
To request a prior authorization, step therapy, nonformulary, or quantity limit override, please call ESI at 1-844-605-8168, 24 hours a day, 7 days a week, and speak to a prior authorization service specialist. This specialist will review medical information and criteria with the provider or designee regarding the need for the requested drug.
Carved out drugs: Covered by Fee-for-Service
- Brineura (cerliponase alfa)
- Dental-related prescriptions
- Exondys 51
- Hepatitis C Therapy
- Hemophilia-related medications/factors
- Kymriah (tisagenlecleucel-t)
- Yescarta (axicabtage ciloleucel)
The Washington State HCA will be responsible for ALL pre-authorizations and approvals for therapy based on HCA clinical guidelines. HCA Policy is available here.
Medication Therapy Management
Coverage for Medication Therapy Management services is now available to Apple Health providers and members who meet certain eligibility requirements listed below.
- MTM Provider Credentialing Checklist
- MTM Provider and Member Requirements
- Sample MTM form (for assistance in guiding medication therapy review)
If you are a Medicare Advantage member, visit the Community HealthFirst website for information on Medicare HealthFirst Medication Therapy information.
Pharmacy and Therapeutics (P&T) Committee
Our P&T Committee meets to evaluate our formulary, prior authorization requirements, and safety measures to ensure quality. Read the most recent decisions:
- March 2, 2018: No Clinical Decisions
- November 17, 2017: No Clinical Decisions
- August 11, 2017: No Clinical Decisions
- March 3, 2017 P&T Decisions
- November 11, 2016 P&T Decisions
- June 17, 2016 P&T Decisions
- March 11, 2016 P&T Decisions
Be sure to read the latest Drug Recall Report for updates on medications that are recalled due to safety issues.