Check here for Information about CHP's Commercial and Medicare Formularies, Utilization Management Criteria, Pharmacy Network, and safe medication practices.
Medications Obtained Through the Pharmacy Benefit
For those drugs that process through the member's pharmacy benefit (e.g. the use of a retail, mail order, or specialty pharmacy), please refer to our Commercial (pdf 1.86 MB) and Medicare (Advantage Plus, Preferred Advantage or Retiree Advantage) formulary documents to determine if a prior authorization is needed. If prior authorization is needed, Commercial Criteria and Medicare Prior Authorization Criteria (Advantage Plus, Preferred Advantage, or Retiree Advantage) or Medicare Step Therapy Criteria (Advantage Plus, Preferred Advantage, or Retiree Advantage) are available for download.
When initiating a prior authorization request, the following forms may be used:
- Medication Prior Authorization Request Form (12 44.39 kB)
- Prime Specialty Enrollment Form (pdf 90.10 kB) - if the drug is marked as "specialty" on the Commercial criteria, this form should be utilized for all new Commercial prescriptions under the Pharmacy Benefit (in addition to the form above). "Specialty" medications must be obtained through the Prime Specialty Pharmacy Services in order for it to be covered. Upon completion, the enrollment form should be faxed to Prime and the Capital Health Plan Pharmacy Services Department (fax numbers are included at the top of the form).
Medicare members (although available, these forms are not required to be used):
- Request for Medicare Prescription Drug Coverage Determination Form (pdf 53.09 kB)
- Request for Redetermination of Medicare Prescription Drug Denial Form (pdf 43.62 kB)
For more information on prescription drug coverage for our Commercial members, visit the "About Your Medications" page of our Commercial member website.
For more information on prescription drug coverage for our Medicare members, including their rights to request a coverage determination or redetermination, make a complaint, file a grievance, or request an appeal, visit our Medicare website.
Note: the Formularies and Criteria are updated on a monthly basis. Please review these documents regularly for the most current information.
Medications Obtained Through the Medical Benefit
For those drugs that process through the Medical benefit, please refer to the attached table of drugs (pdf 23.00 kB) for a list of drugs which require prior authorization. If prior authorization is needed, the Commercial Criteria will be utilized for Commercial members, and Original Medicare guidelines will be utilized for Medicare members (National Coverage Determinations and Local Coverage Determinations can be found on the Centers for Medicare and Medicaid Services website.
The codes in the table are for informational purposes only and may be updated as new codes are identified for the drugs listed.
Note: the table is updated on a monthly basis. Please review this section regularly for the most current information.
Safe Practices for Medications
Below are some websites to the Food and Drug Administration and the Institute for Safe Medication Practices that contain important information on patient safety:
- List of Error Prone Abbreviations, Symbols, and Dose Designations
- List of Confused Drug Names
- List of High Alert Medications
- Food and Drug Administration (FDA) Drug Recalls, Market Withdrawals, and Safety Alerts
- USP-ISMP Medication Error Reporting Program
Capital Health Plan Pharmacy Network
Capital Health Plan contracts with over 50,000 pharmacies nationwide. To locate a pharmacy in our network, use our pharmacy locator. Capital Health Plan members may also contact Prime Therapeutics customer service department at 1-800-821-4795.