Formulary – Check our Prescription Drug List

If you sign up for our Medicare Advantage Plan with Pharmacy or Medicare Advantage Special Needs Plan, you will receive coverage for the prescription drugs on our Formulary and pay no deductible.  The Comprehensive Formulary document provides you with a list of drugs covered under the Community HealthFirst Medicare Advantage Plan with Pharmacy, along with their cost sharing tier and any additional requirements or limitations.

In the Comprehensive Formulary you will find the following information:

• What is the formulary and how do I use it?
• Can the formulary change?
• What are generic drugs?
• Are there any restrictions on my coverage?
• What if my drug is not on the formulary and how do I request an exception to the formulary?
• What do I do before I can talk to my doctor about changing my drugs or requesting an exception?

To search for a specific drug, simply open the Formulary Drug List PDF 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 Drug List
Notice of Changes to the Comprehensive Formulary Drug List

2008 Coverage for Vaccinations

Scroll down this page to get information on requesting exceptions to the Formulary drug list and coverage, along with, the Policies and Procedures for Appeals and Grievances, and Quality Assurance program related to the prescription drug benefit (Part D).

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.

• You can ask Customer Service for a list of similar drugs that are covered by Community HealthFirst. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Community HealthFirst.
• You can ask Community HealthFirst to make an exception and cover your drug. See the following information about how to request an exception.

You can ask Community HealthFirst to make an exception to our drug list or coverage rules. There are several types of exceptions that you can ask us to make.

• You can ask us to cover your drug even if it is not on our formulary.
• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Community HealthFirst limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.

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. 
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

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 Appeals and Grievances.

It is Community HealthFirst’s policy to emphasize the quality of your pharmaceutical care.  Our goal is to provide you with the most effective and affordable medications available to improve your health. 

We use the best research and evidence available in developing our formulary to ensure that you have access to cost-effective medications. 

We offer a medication therapy management program to qualified members.  This program is intended to optimize the drug therapy for our members who have the following chronic conditions:  Diabetes, Chronic Obstructive Pulmonary Disease (COPD), Hypertension, Asthma, and high blood cholesterol. These programs may have limited eligibility criteria.  If you have questions about the medication therapy management program, 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.