Medicare Advantage Plan with Pharmacy (Part D)
Printer Friendly PageThis plan includes coverage for prescription drugs along with important health care benefits beyond that of Original Medicare, all for a low $30.00 monthly premium.
On this page you will find the following information for our Medicare Advantage Plan with Pharmacy
- Plan Benefit Information
- Provider Directories
- Pharmacy Directory
- Formulary Drug List
- Easy Enrollment Instructions and Forms
- Low Income Subsidy Program - extra help to pay for prescription drug costs
- Policies and Procedures for Member Privacy, Rights, Appeals and Grievances
The Community HealthFirst Medicare Advantage Plan with Pharmacy (Part D) is offered by Community Health Plan, which contracts with the Federal Government as a Medicare HMO.
To see specific plan benefits, cost shares and how it compares to your Original Medicare benefits, simply click on the plan benefit information link for the county in which you live.
Medicare Advantage Plan with Pharmacy (H5826 008) applies if you live in any of the following counties: Island, King, Kitsap, Pierce, Snohomish, Spokane, Thurston.
Benefit Highlights – an easy to understand overview of Plan Benefits and how they compare to Original Medicare.
Summary of Benefits provides important details about the plan benefits, premiums, cost sharing and requirements for receiving care.
Evidence of Coverage (EOC) document is sent to members after they enroll and provides details about your Medicare Advantage Plan coverage. See full description of the EOC below on this page.
Medicare Advantage Plan with Pharmacy (H5826 009) applies if you live in any of the following counties: Adams, Benton, Chelan, Cowlitz, Douglas, Ferry, Franklin, Grant, Grays Harbor, Lewis, Lincoln, Mason, Okanogan, Pend Oreille, Skagit, Stevens, Walla Walla, Whatcom & Yakima
Benefit Highlights – an easy to understand overview of Plan Benefits and how they compare to Original Medicare.
Summary of Benefits provides important details about the plan benefits, premiums, cost sharing and requirements for receiving care.
Evidence of Coverage (EOC) document is sent to members after they enroll and provides details about your Medicare Advantage Plan coverage. See full description of the EOC below on this page.
Evidence of Coverage - The Evidence of Coverage (EOC) document is sent to members after they enroll and provides details about your Medicare Advantage Plan coverage. This booklet is an important legal document. It will be helpful to you after you have enrolled in the plan. The Evidence of Coverage document provides you with the following information:
- The Plan’s service area
- The Plan’s benefits, including annual deductible amount of initial coverage limit, and cost sharing
- How to access Part D benefits, including how to fill a prescription through retail pharmacy and mail order service
- How to access drugs at out-of-network pharmacies and submit a claim
- Major exclusions and limitations
- Network pharmacy information
- Exception process
- Quality assurance policies and procedures, including drug utilization management and medication therapy management programs
- Formulary tier structure and drug information
- Grievance, coverage determinations, exceptions process, and appeals rights and procedures
- Disenrollment rights, responsibilities, and procedures
Patient Navigator Services - The Patients Navigator program is a service that is provided FREE to all Community HealthFirst members. The Patient Navigator is your advocate and will guide you in exploring and understanding your new health benefits under the Community HealthFirst. Patient Navigator services include:
- Answering your questions about your Community HealthFirst, Medicare or Medicaid benefits.
- Helping you schedule appointments with your Primary care Provider (PCP).
- Helping you schedule appointments with specialty care providers when needed.
- Helping you find and schedule appointments with dentists who accept Medicare reimbursement.
- Assisting you with non-emergency transportation arrangements.
- Assistance in using translation services when appropriate.
- Assistance in maintaining Social Security Administration and Medicaid Dual Eligibility paperwork.
- Connecting you with community and social service resources in your area.
For more information on the Patient Navigator program, please contact us Monday - Friday, 8 a.m. - 5 p.m. at 1-866-717-2479 (TTY/TTD for the hearing impaired call 1-866-816-2479).
Community HealthFirst and your Primary Care Provider (PCP) work as partners to be sure you get the right care, at the right time, at the right place. Your PCP takes care of most of your health needs and writes you a referral when you need to see a specialist. Ultimately, you and your PCP decide the best course of action for your health care.
In the provider directories you will find the following information:
- Obtaining health care services
- Choosing a Primary Care Provider (PCP)
- Changing your PCP
- Specialist referrals
- Prior Authorizations
- Coverage for Urgent Care and Emergencies
- Billing from out of network providers
- Who to call if you have questions
To search for a specific Provider, simply click on the proper link below to open the Directory PDF, find the Directory listing for the county you live in, then check the network providers listed for your county.
Directory of Primary Care Providers and Hospitals
Addendums to this directory
Directory of Specialists
Addendums to this directory
Community HealthFirst has contracts with pharmacies that meet or exceed CMS requirements for pharmacy access in your area. The network Pharmacy information provided on the following links is updated quarterly. As of the most current period, the Community HealthFirst Pharmacy network contains over 1,200 contracted pharmacies in Washington and over 58,000 contracted pharmacies nationwide, which meets or exceeds the CMS requirements for pharmacy access in our service area.
In the Pharmacy Directory you will find the following information:
- Finding a network pharmacy in your area
- Filling your prescription at a network Pharmacy
- Filling your prescription outside the Pharmacy network
- How to find a Network Pharmacy in my area
- How to fill a prescription by mail order
- How to submit a paper claim
To search for a specific Pharmacy, simply click on the proper link below to open the Directory PDF, find the Directory listing for the type of Pharmacy you are seeking (Retail, Long Term Care, etc), then look for county you live in, then check the network pharmacies listed for your county.
Pharmacy Directory
Addendums to the Pharmacy Directory
A formulary is a list of covered drugs selected by Community HealthFirst in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Community HealthFirst will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Community HealthFirst network pharmacy, and other plan rules are followed.
To search for a specific drug, simply click on the Formulary link below, click on the Search Function in the tool bar at top represented by the binocular icon
, type the name of the drug you wish to search for in the box that appears on the top right hand side of the page and click Search.
Comprehensive Formulary of prescription drugs covered by Community HealthFirst.
The Community HealthFirst Formulary is updated monthly. Click here to view the Notice of Formulary Changes which contains the most recent changes to the Community HealthFirst Formulary, including removing a drug, adding prior authorization, quantity limits, step therapy or any other restrictions.
Requesting exceptions to the Formulary Drug List and coverage policies / procedures.
If your drug is not listed in the formulary, you should first contact Customer Service and ask if your drug is covered. If you learn that Community HealthFirst does not cover your drug, you may request an exception be made for coverage of that drug. You may also ask us to waive coverage restrictions or limits on a drug.
Generally, Community HealthFirst will only approve your request for an exception if the alternative drugs included on the plan’s formulary, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. Click here to get more information and details on the policies, procedures and forms for requesting formulary exceptions and coverage determinations.
We realize that situation may arise where you may need to access drugs that are not on the formulary or cases in which you need a refill sooner than expected. We call this a Plan Transition Process and have taken into account these special circumstances.
Click here to get complete information on our Plan Transition Process.
Questions about Prescription Drug coverage?
If you have any questions about our Formulary Drug List, tiering, copay levels or policies, please call Customer Service, 8 a.m. to 8 p.m., 7 days a week. Current Members should call 1-800-942-0247, Prospective Members should call 1-800-944-1247 and all TTY/TDD hearing impaired users should call 1-866-816-2479. Or you can send questions to Community HealthFirst, PO Box 960, Seattle, WA 98111-0960
Enrolling in a Community HealthFirst Plan is easy as 1, 2, 3
Click here for our handy Enrollment Check List, Instructions and Forms
If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly premium will be lower than what it would be if you did not get extra help from medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our Plan.
The table shows you what your monthly plan premium will be if you get extra help.
| Your level of extra help | Monthly Premium for Community HealthFirst MA w/Pharmacy (Urban)* | Monthly Premium for Community HealthFirst MA w/Pharmacy (Rural)* | Monthly Premium for Community HealthFirst MA Special Needs Plan* |
| 100% | $0 | $0 | $0 |
| 75% | $7.50 | $7.50 | $7.50 |
| 50% | $15.00 | $15.00 | $15.00 |
| 25% | $22.50 | $22.50 | $22.50 |
*This does not unclude any Medicare Part B premium you may have to pay.
Community HealthFirst premium includes coverage for both medical services and prescription drug coverage.
If you aren't getting extra help, you can see if you qualify by calling:
- 1-800-Medicare or TTY/TDD users call 1-877-486-2048 (24 hours a day/7 days a week),
- Your state Medicaid Office, or
- The Social Security Administration at 1-800-772-1213. TTY/TDD users should call 1-800-325-0778 between 7 a.m. and 7 p.m., Monday through Friday.
If you have any questions, please call our Customer Service Department, 7 days a week, from 8:00 a.m. to 8:00 p.m. Pacific Time, at 1-800-942-0247. TTY/TDD users should call 1-866-816-2479.
We take your rights and concerns very seriously. We want to ensure you receive the right care, at the right time, in the right place and that it is delivered with the respect and service you deserved. When you do not agree with our benefit determinations or have issues with the treatment you receive, we want to know about it. We consider them opportunities to improve care and service to our members.
Policies and Procedures for Member Privacy, Rights, Appeals and Grievances.