Pharmacy

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 health conditions are covered. The PDL applies to drugs you receive at retail pharmacies. 

View the Coordinated Care (Apple Health) Preferred Drug List (PDF). 
View the Coordinated Care (Apple Health Expansion) 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)
• Spermicides
• Sponges
• 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.

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.

On January 1, 2024, Express Scripts^® Pharmacy will replace CVS Caremark Mail Service Pharmacy.

Express Scripts^® Pharmacy
Phone: 1-833-750-4300 (TTY: 1-800-899-2114)
Fax: 1-800-837-0959

How to use mail service

For new prescriptions on or after January 1, 2024, you may do one of the following beginning on or after January 1, 2024:

• Ask your doctor to electronically send or fax a new prescription to Express Scripts^® Pharmacy. Your doctor can fax Express Scripts^® Pharmacy at 1-800-837-0959. This number is for provider fax use only.
• Go online at express-scripts.com/rx. Register or sign in and have your member ID number ready. Follow the guided steps to request a prescription. Once Express Scripts has your information, they will contact the doctor for approval of the prescription.
• Call Express Scripts^® Pharmacy at 1-833-750-4300 (TTY: 1-800-899-2114). Express Scripts^® Pharmacy can contact your doctor for a new prescription to be filled at mail order.
• Mail a home delivery order form. To get a copy of the form: 
  •  
    • Register or log in at express-scripts.com/rx. 
    • Go to the Benefit Menu, click Forms, and download the Home Delivery Order Form. 
    • Complete the form and mail it with the paper prescription to Express Scripts^® Pharmacy.

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. 

For a list of covered flu shots and vaccines at local in-network pharmacies, please visit Coordinated Care’s Preferred Drug List (PDF). 

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.

Prior Authorization Fax: 1-833-645-2734

Prior Authorization Phone: 1-866-716-5099
Clinical Hours: Monday – Friday 7 a.m. - 5 p.m. (PST)
Help Desk: 1-877-250-6176

Pharmacy Services will respond via fax or phone within 24 hours of receipt of the prior authorization request.