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 2019 Formulary
On January 1, 2019, 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 January 1, 2019, the PDL will be adding an additional 74 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 email@example.com 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.
Pharmacy Emergency Fills
Emergency fills may be covered to prevent interruptions in therapy during an emergency. View our policy on emergency fills on our Policies and Procedures page.
Carved out drugs: Covered by Fee-for-Service
- Axicabtagene ciloleucel (Yescarta)
- Burosumab-twza (Crysvita) – effective 1/1/19
- Cerliponase alfa (Brineura)
- Edavarone (Radicava)
- Elapegademase (Revcovi) – effective 7/1/2019
- Emapalumab-lzsg (Gamifant) – effective 7/1/19
- Eterplirsen (Exondys 51)
- Lutetium Lu 177 dotatate (Lutathera) – effective 7/1/2019
- Nusinersen (Spinraza)
- Onasemnogene abeparvovec (Zolgensma) – effective 7/1/2019
- Pegvaliase-pgpz (Palynziq) – effective 1/1/19
- Tisagenlecleucel-t (Kymriah)
- Voretigene neparvovec-rzyl (Luxterna)
- Dental Prescriptions
- Hepatitis C medication
- Hemophilia medication
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.
Medications available for 90-day fills
CHPW members can get a 90-day supply of select generic oral medication for asthma, hypertension, diabetes, heart failure, and hyperlipidemia, as well as generic antidepressants and antipsychotics. Larger supplies of prescriptions are only available through Community Health Center pharmacies and select network pharmacies. Click below to see the full list of medication available for larger fills.
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.
Patient Review and Coordination Program
Our Patient Review and Coordination (PRC) Program helps members use their medical services safely and appropriately.
Members who are selected for PRC must choose one primary care provider, pharmacy, and hospital. One primary care provider makes sure medical care and prescriptions are coordinated for the health and safety of the member.
To refer a patient to the PRC program or learn more, call us at 1-866-907-1902.
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 25, 2019: No Clinical Decisions
- November 14, 2018: No Clinical Decisions
- July 13, 2018: No Clinical Decisions
- March 2, 2018: No Clinical Decisions
Be sure to read the latest Drug Recall Report for updates on medications that are recalled due to safety issues.