Requesting Exceptions and Coverage Determination - Washington State Local Health Insurance - CHPW
Community Health Plan of Washington Apple Health Medicaid Plan Community Health Plan of Washington Apple Health Medicaid Plan

Requesting Exceptions and Coverage Determination

If the drug you’re taking isn’t covered, you can ask us to cover it anyway

Our formulary provides a list of prescription drugs we cover. If you’re taking a medication that is not on the list, you can ask us to make an exception. You can also ask us to waive restrictions or limitations on your drug. (For example, quantity limits or step therapy restrictions.)

You can use our online formulary search tool to see if a drug has any restrictions.

Requesting an exception

If you need medicine that isn’t listed on our formulary, you can request a coverage determination review by sending in a Coverage Determination Request form, filling out the online form, or by calling Customer Service at 1-800-440-1561 (TTY Relay: Dial 711), from 8 a.m. to 5 p.m., Monday through Friday.

If your coverage is denied by Express Scripts, you may appeal the decision with CHPW. Read about how to appeal or file a grievance.

If you paid full price for a prescription at a retail pharmacy, you can ask for a reimbursement. Check the formulary to make sure there were no restrictions on your medication before you ask to be reimbursed. Fill out a reimbursement form and either fax or mail it to Express Scripts.

Who to Contact

You can fax your completed Coverage Determination Request form to 1-877-251-5896.

You can fax your completed Prescription Drug Reimbursement / Coordination of Benefits Claim form to 1-608-741-5475.

Send written requests or mail your completed forms to:

Express Scripts
ATTN: Commercial Claims
P.O. Box 14711
Lexington, KY 40512-4711


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