Coordinated Care is committed to providing appropriate, high-quality, and cost-effective drug therapy to all Coordinated Care members. Coordinated Care covers prescription medications and certain over-the-counter medications with a written order from a Coordinated Care provider. The pharmacy program does not cover all medications. Some medications may require prior authorization and some may have limitations. Other medically necessary pharmacy services are covered as well.
Pharmacy Maximum Allowance cost (MAC) Appeal
As of 5/1/2017, Envolve Pharmacy Solution MAC appeals are being managed by CVS Caremark®. All Envolve Pharmacy Solution MAC appeals must be submitted using the MAC Appeal Form that can be accessed via the CVS Caremark Pharmacy Portal at https://rxservices.cvscaremark.com.
- Preferred Drug List (PDL)/Non-Formulary Prior Auth Request Form (PDF)
- Preferred Drug List (PDL) Change Request Form (PDF)
Envolve Pharmacy Solution Telephonic Prior Authorizations (non-specialty pharmacy): 1-855-757-6565 (5 a.m. to 5 p.m. PST)
Envolve Pharmacy Solutions, Coordinated Care's PBM, processes pharmacy claims and administers the medication prior authorization process.
Telephonic Prior Authorization: 1-855-757-6565 (available 5 a.m. - 5 p.m. PST)
Coordinated Care provides members with 90 day supplies through our preferred mail order pharmacy, Homescripts, or other participating retail maintenance drug pharmacies (PDF). The Maintenance Drug Program (PDF) provides details of the products that can be dispensed as part of this benefit.
To transfer a current prescription or phone a prescription directly Homescripts call 1-800-785-4197.
Members can also obtain a 90 day supply (3 month supply) of their maintenance medications from participating retail maintenance drug pharmacies (PDF).
AcariaHealth, Coordinated Care's preferred specialty pharmacy vendor, can supply a number of products. Some of these products can be delivered directly to the provider’s location for office administration by Coordinated Care's preferred specially pharmacy provider, AcariaHealth.
For a complete listing of products that AcariaHealth can supply, please see the Coordinated Care Specialty Pharmacy Program (PDF).
To find a pharmacy that is in the Coordinated Care network, you can use the Find a Provider tool. Click on the Provider Directory then enter the city or zip code and click Update. Choose Other and type the name of the pharmacy or select the pharmacy type in the Select Specialty area. Only the network pharmacies are listed.
Chronic Opioid Attestation Form (PDF): Use this form to attest that criteria for chronic use of opioids for the treatment of non-cancer pain are met, or there is documentation in the patient’s chart for why one or more are not applicable, and that the requested treatment is medically necessary, does not exceed the medical needs of the members, and is clinically supported in the member’s medical record.
For more information regarding the Washington State Health Care Authority (HCA) Clinical Opioid policy, go to https://www.hca.wa.gov/billers-providers/programs-and-services/opioids.
Policy (effective 1/18/2016)
- Clinical Guidelines and Coverage Limitations for Medication Assisted Treatment (MAT) (PDF)
- Prescribing Medication Assisted Treatment (PDF)
All OTC contraceptives are covered drug products and do not require a prescription to obtain a successful adjudication via prescription benefits. This includes but is not limited to condoms, spermicides, sponges and any emergency contraceptive drug that is FDA-approved to be dispensed over-the-counter.
To adjudicate a paid claim the pharmacy can process using:
Provider Name: Contraceptive DSHS
NPI #: 5123456787