It's important to Coordinated Care that our members receive drug therapy that is appropriate, high quality and cost effective. We work hard to ensure you have access to safe and effective medications that are medically proven to help you get healthy and stay healthy.
Coordinated Care covers certain prescription drugs and over-the-counter drugs when prescribed by a Coordinated Care provider. The pharmacy program does not cover all drugs. Some require prior authorization. Some drugs have limitations on age, dosage or maximum quantities.
The Preferred Drug List (PDL) is the list of drugs covered by Coordinated Care. Coordinated Care works with providers and pharmacists to ensure that medications used to treat a variety of conditions and diseases are covered. The PDL applies to drugs you receive at retail pharmacies. Coordinated Care's PDL is continually evaluated by the Pharmacy and Therapeutics Committee to promote the appropriate and cost-effective use of medications.
View the Preferred Drug List (PDF). To request paper copy of the PDL without charge, contact Coordinated Care and we will provide a copy within five business days.
To see the latest quarterly changes to the PDL, please review Coordinated Care’s Drug List updates (PDF).
Specialty Drugs: A specialty drug is a prescription drug that requires special handling, administration or monitoring. These are usually only ordered through a specialty pharmacy.
If you are unsure whether your current medication is a specialty drug, please review our Specialty Pharmacy Program list. It has a list of specialty drugs, plus more information about them.
Click to view a list of specialty drugs excluded from this program (PDF).
Your specialty pharmacy is AcariaHealth. They can be reached at 1-855-535-1815.
Over-the-counter contraceptives are covered products that may be dispensed at the pharmacy without a prescription. Covered products include:
- Condoms (including female)
- Emergency Contraceptive drug (plan B) that is FDA approved to be dispensed over-the-counter
You can have your prescriptions filled at a network pharmacy. At the pharmacy, you will need to give the pharmacist your prescription and your Coordinated Care ID Card. If you need help finding a pharmacy near you, call us or check online.
Coordinated Care members can get a 90 day supply of certain maintenance medications with our preferred mail order pharmacy, CVS Caremark. Register or sign up at Caremark.com. If you have questions, contact CVS Caremark at 1-888-624-1139 or visit the CVS Caremark web site.
The products listed on our Preferred Drug List (PDF) with the "MP" marker are maintenance medications. These treat long-term conditions or illnesses. Please reach out to us if you have questions about this.
The maintenance drug list is subject to change. It may not be comprehensive and some of the medications on the list may be subject to additional plan coverage rules. Once a brand name medication on the maintenance drug list has a generic offered, only the generic drug will be covered as a maintenance medication.
To find a pharmacy that is in the Coordinated Care network, you can use the Find a Provider tool. Type in your city or zip code. Then click Update. Choose Other and type the name of your pharmacy. You can also select the pharmacy type in the Select Specialty area. Only those pharmacies in the Coordinated Care network are listed.
Coordinated Care covers vaccines at local in-network pharmacies.
- Varicella Zoster (Shingles) vaccine for member’s age 50 and over are covered at a pharmacy.
- TDAP is only covered for pregnant women at a pharmacy.
- Covered Vaccines for ages 9 and up: Chickenpox, Hep A, Hep B, HPV, Meningococcal, MMR, Pneumococcal, & Td
- Flu Vaccines are covered for ages 7 and up.
All over the counter (OTC) contraceptives, or birth control, are covered drug products. They do not require a prescription to obtain.
This includes but is not limited to condoms, spermicides, sponges and any emergency contraceptive drug that is FDA-approved to be provided over-the-counter.
To adjudicate a paid claim the pharmacy can process using:
Provider Name: Contraceptive DSHS
NPI #: 5123456787
The Washington State Health Care Authority’s opioid clinical policy (PDF) is an addiction prevention and patient safety tool. It is meant to protect patients and combat the opioid crisis.
When patients are prescribed more pills than they need for pain relief, extra pills can be misused or sold. The policy limits the number of pills in a prescription for short-term use:
- For children and adolescents age 20 or younger: About a three-day supply (18 pills or liquid doses)
- For adults age 21 or older: About a seven-day supply (42 pills or liquid doses)
What is changing?
Effective November 1, 2019, Apple Health will apply a safety limit to the total daily dose of opioids. The dose of different opioids is measured in units called morphine milligram equivalents (MME). Opioid prescriptions or combinations of opioid prescriptions that exceed a daily dose equal to 120 MME will require your prescriber to complete and sign an opioid attestation form. This safety limit helps us ensure your prescriber is following best practices related to your care.
Envolve Pharmacy Solutions, Coordinated Care's pharmacy benefit manager (PBM), processes pharmacy claims and administers the medication prior authorization process.
Envolve Pharmacy Solutions will respond via fax or phone within 24 hours of receipt of the prior authorization request.