Pharmacy Management

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Drug Formulary and Medication Utilization

Healthy Options/CHIP, Disability Lifeline, and Basic Health

The Community Health Plan drug formulary is developed by the Community Health Plan Pharmacy and Therapeutics Committee. The formulary is available in book format, searchable on this web site, and also by downloading onto a PDA from epocrates.com.

For all Community Health Plan enrollees, submit prior authorization, step therapy, and nonformulary medication requests as well as requests for quantity overrides for review to Community Health Plan’s pharmacy benefit manager, Express Scripts Inc. (ESI). All requests will be resolved by ESI within 48 hours.

Note: ESI requires a Community Health Plan member number to process requests. You may obtain a member number from Community Health Plan Customer Service at 1-800-440-1561 or through One Health Port.

Medicare Advantage Plan

The Community HealthFirst drug formulary is developed by the ESI Pharmacy and Therapeutics Committee. The formulary is available in book format, on the HealthFirst web site, and also by downloading onto a PDA from epocrates.com.

For all Community HealthFirst Part D beneficiaries, submit prior authorization, step therapy, and nonformulary medication requests as well as requests for quantity overrides for review to ESI. All requests will be resolved by ESI within 72 hours.

Note: ESI requires a Community HealthFirst beneficiary number to process requests. You may obtain a member number from Community HealthFirst Customer Service at 1-800-942-0247.

Notification Regarding Formulary Changes: For updates regarding periodic changes to the formulary and other pharmaceutical management programs please see the enrollee pharmacy web page.

Prior Authorization, Step Therapy, Nonformulary, and Quantity Override Requests

Healthy Options/CHIP, Disability Lifeline, and Basic Health

To request a prior authorization, step therapy, nonformulary, or quantity limit override, please call ESI at 1-888-256-6132, 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.

If the drug is denied by ESI, you may appeal the decision by sending a letter and clinical documentation, including the date and reason for the denial given by ESI, to:
Community Health Plan
Attn: Appeals Coordinator
720 Olive Way, Suite 300
Seattle, WA 98101
Fax 206-613-8983

Expedited appeals are reserved for emergency situations only. Call 1-800-440-1561.

Medicare Advantage Plan

To request a prior authorization, step therapy, nonformulary, or quantity limit override, please call ESI at 1-800-417-8164, 24 hours a day, 7 days a week, and speak to a prior authorization service specialist. The specialist will review medical information and criteria with the provider or designee regarding the need for the requested drug.

If the drug is denied by ESI, you may appeal the decision by sending a letter and clinical documentation, including the date and reason for the denial given by Express Scripts, to:
Community Health Plan
Attn: Community HealthFirst Appeals
720 Olive Way, Suite 300
Seattle, WA 98101
Fax 206-613-8983

Expedited appeals are reserved for emergency situations only. Call 1-800-942-0247.

Pharmacy Benefit Exclusions

Healthy Options/CHIP, Disability Lifeline, and Basic Health

Certain medications are benefit exclusions and are not covered under any circumstances.

These include:

  • Non-FDA approved drug products
  • Experimental and investigational (E & I) drugs
  • Compounded drugs with non-FDA approved ingredients
  • Drugs for weight loss or appetite suppression
  • Drugs for impotence or sexual dysfunction
  • Drugs to treat cosmetic conditions
  • Infertility drugs

Prescriptions for Healthy Options, SCHIP, and Basic Health Plus enrollees written by Regional Support Network (RSN) providers are not covered if these enrollees meet RSN access standards: They are covered and billed through HRSA as a fee-for-service item. (The pharmacy help line for HRSA is 1-800-365-4944.)

Medicare Advantage Plan

Certain medications are not covered by Part D.

These include:

  • Benzodiazepines
  • Barbiturates
  • Drugs for anorexia, weight loss, or weight gain
  • Drugs used to promote fertility
  • Drugs used for cosmetic purposes or for hair growth
  • Drugs used for symptomatic relief of cough and colds
  • Drugs for erectile dysfunction
  • Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparation products
  • Nonprescription or over-the-counter (OTC) drugs
  • Drugs for which the manufacturer seeks to require as a condition of purchase that associated test and monitoring services be purchased exclusively from the manufacturer or its designee