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.
Changes Coming to 2018 Formulary
On October 1, 2018, all managed care plans and Apple Health fee-for-service programs will continue to phase in a Single Preferred Drug List (PDL).
This change is mandated by the Washington State Legislature.
The Health Care Authority is working with managed care plans that serve Apple Health clients to create the Apple Health PDL. On October 1, 2018, the PDL will be adding an additional 66 drug classes. Managed care plans will continue to use their own preferred drug lists for drugs not included in the Apple Health PDL.
We will continue to provide more information to ensure a smooth transition for providers and patients to the Single Preferred Drug List. Please contact firstname.lastname@example.org with any questions.
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.
Pharmacy Reimbursement Issues
If you are having an issue with reimbursement, please submit an inquiry to ESI through their Pharmacist Resource Center.
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)
- Luxturna (voretigene neparvovec-rzyl)
- 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:
- July 13, 2018: No Clinical 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
Be sure to read the latest Drug Recall Report for updates on medications that are recalled due to safety issues.