Any pharmaceutical not listed on our formulary requires prior authorization. For self-administered drugs requiring prior authorization, please contact Express Scripts at 1-844-605-8168 or use visit their website to start the prior authorization process.
Formularies and Pharmacies for 2020 Plans
- Tier 1 Online Searchable Formulary (Special Needs Plan 014)
- Tier 1 Formulary English and Spanish combined (Special Needs Plan 014)
- Tier 5 Online Searchable Formulary (Plans 008, 009, 010, 016)
- Tier 5 Formulary English and Spanish combined (Plans 008, 009, 010, 016)
- Pharmacy Directory (Plans 008, 009, 010, 016)
- Pharmacy Directory (Special Needs Plan 014)
Step Therapy Criteria
Pharmacy Forms, Programs, and Policies
- Medication Therapy Management Program
- How to Request Coverage Exceptions, Determinations, and Redeterminations
- Prescription Drug Claim Form
- Plan Transition Policy | Español
Professionally Administered Drugs
CHPW requires prior authorization for certain professionally administered medications. MCG guidelines are used to determine medical necessity in the absence of CHPW Clinical Coverage Criteria. You can review our utilization management guidelines and policies for medical drug benefits by visiting our Prior Authorization page.
New Limits for Opioid Prescriptions from CMS
Starting on January 1, 2019, there will be new limits on opioid prescriptions for members who have Medicare Part D. This change follows guidance from the Centers for Medicare & Medicaid Services (CMS).
- Members who are filling a first-time prescription for opioids to treat acute pain won’t be able to get more than a seven-day supply at one time.
- Pharmacists will be required to consult with the prescriber for opioid prescriptions greater than 90 morphine equivalent dose (MME) per day.
These limits don’t apply to members who:
- Live in a long-term care facility.
- Are in hospice and receiving end-of-life care.
- Are being treated for active cancer-related pain.
- Are prescribed buprenorphine products for medically assisted treatment (MAT).
CMS recommends more oversight and monitoring of opioid prescription to address current trends and safety concerns. Medication reviews may result in a member being assigned to a single pharmacy and a single subscriber for controlled substances in order to better coordinate care and case management.
To read more about changes to opioid prescriptions for Medicare Part D members in 2019, please see the CMS Factsheet.