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Pharmacy

Pharmacy Claims Processing

Important Pharmacy Claims Processing Change, Effective January 1, 2024. Learn More

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 Resources & Forms

OTC COVID Tests

Coordinated Care will cover over-the-counter (OTC) COVID-19 tests with or without a prescription for members. An adjudicated pharmacy claim is required for reimbursement of an OTC COVID-19 test. Pharmacies may not bill for administration of an OTC COVID-19 test; these tests should be used by the member in the home setting.

To bill OTC COVID-19 tests, pharmacies must follow the NCPDP standard and use the national drug code (NDC) or universal product code (UPC) found on the package.

No prescription

When there is no prescription, pharmacies can submit using the following prescriber information:

  • Prescriber ID Qualifier 01 
  • Prescriber ID: 5123456787 
  • Prescriber Last Name: OTC PRODUCT

Pharmacies can also submit using:

  • Prescriber ID: Qualifier 01 
  • Prescriber ID: Dispensing Pharmacist NPI 
  • Prescriber Last Name: Dispensing Pharmacist Name

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.

Electronic Prior Authorization Submissions 

You can also submit a PA request electronically through our preferred solution CoverMyMeds. Electronic prior authorization (ePA) automates the PA process making it a quick and simple way to complete PA requests. The ePA process is HIPAA compliant and enables faster determinations. You may also use this link to track ePA requests.

Submit a Prior Auth Request

Pharmacy Services MAC appeals are being managed by Express Scripts®. All Pharmacy Services MAC appeals must be submitted using the MAC Appeal Form that can be accessed via Express Scripts Pharmacist Resource Center.

For instructions on how to submit MAC appeal, please click here (PDF).

Coordinated Care provides members with 90 day supplies through our preferred mail order pharmacy, Express Scripts® , or any contracted pharmacy that offers 90 day supplies. 

The products listed on our Preferred Drug List (PDF) with the "MP" indicator are considered maintenance medications. These are used to treat long-term conditions or illnesses. Please contact Coordinated Care if you have any questions regarding this benefit. 

The maintenance drug list is subject to change, may not be comprehensive and some of the medications on the list may be subject to additional plan coverage rules. 

We authorize pharmacies to provide up to a 30 day supply of medication for an emergency fill when a licensed pharmacist has used his or her professional judgment in identifying that there is an emergency medical condition for which lack of immediate access to pharmaceutical treatment would result in, (a) placing the health of the individual or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy; (b) serious impairment to bodily functions; or (c) serious dysfunction of any bodily organ or part.

Review our emergency fill policy (PDF) for full details.

What is an EA or PAMC code?

EA and PAMC codes are designed to eliminate the need to request authorization. The intent is to establish authorization criteria and associate these criteria with specific EA or PAMC codes, enabling pharmacies to enter the appropriate code when approval criteria is met.

How is an EA or PAMC code used?

To process a claim for drugs that meet the criteria listed in the table below, the pharmacy must enter the appropriate EA or PAMC code with the claim submission.

Expedited Authorization Criteria
CriteriaDrugCode
Member is in active cancer treatment, hospice care, palliative care, or other end-of-life care. This code will override the 18 or 42 dose limit and the chronic use (42 days in a 90 day period) limit, but NOT the 120 MME limit.

Opioid products (excludes injectable/IV) containing:

  • benzhydrocodone
  • buprenorphine (pain indications only)
  • butorphanol
  • codeine
  • dihydrocodeine
  • fentanyl
  • hydrocodone
  • hydromorphone
  • levorphanol
  • meperidine
  • morphine
  • oxycodone
  • oxymorphone
  • pentazocine
  • tapentadol
  • tramadol
85000000540
Prescriber has indicated “EXEMPT” on the prescription. This code will override the 18 or 42 dose limit, but NOT the chronic use (42 days in a 90 day period) limit or the 120 MME limit.

Opioid products (excludes injectable/IV) containing:

  • benzhydrocodone
  • buprenorphine (pain indications only)
  • butorphanol
  • codeine
  • dihydrocodeine
  • fentanyl
  • hydrocodone
  • hydromorphone
  • levorphanol
  • meperidine
  • morphine
  • oxycodone
  • oxymorphone
  • pentazocine
  • tapentadol
  • tramadol
85000000541

For members 18 years of age and older:

  • Testosterone therapy for the treatment of gender dysphoria.

For members 17 years of age and under:

  • Testosterone therapy for the treatment of gender dysphoria; AND
  • A pediatric endocrinologist or other clinician experienced in pubertal assessment has determined hormone treatment to be appropriate.

This code will not override prior authorization for brands with generic equivalents or non-preferred products unless member has met tried and failed criteria.

Testosterone Therapy

Aveed (testosterone undecanoate)

AndroDerm (testosterone transdermal patch)

testosterone cypionate IM testosterone transdermal gel 1.62%

Xyosted (testosterone enanthate)

85000000102


 

GnRH therapy for puberty suppression in adolescents diagnosed with gender dysphoria AND a pediatric endocrinologist or other clinician experienced in pubertal assessment has determined hormone treatment to be appropriate.

This code will not override prior authorization for brands with generic equivalents or non-preferred products unless member has met tried and failed criteria.

Gonadotropin-releasing Hormone (GnRH) Agonists85000000103

For members 18 years of age and older:

  • GnRH therapy for the treatment of gender dysphoria.

For members 17 years of age and under:

  • GnRH therapy for  the treatment of gender dysphoria AND
  • A pediatric endocrinologist or other clinician experienced in pubertal assessment has determined hormone treatment to be appropriate.

This code will not override prior authorization for brands with generic equivalents or non-preferred products unless member has met tried and failed criteria.

Gonadotropin-releasing Hormone (GnRH) Agonists85000000104
Used as a contraceptive, dispense one yearContraceptives85000000131

Used as a contraceptive, dispensed less than a twelve month supply due to ONE of the following:

  • The prescriber is unwilling to change dispensed quantity to twelve-month supply
  • The member does not want twelve-month supply
  • The pharmacy does not have adequate stock
Contraceptives85000000132
Used for other diagnosis, not related to contraception up to a 91-day supply.Contraceptives85000000133

PAMC Code Criteria
CriteriaDrugCode

Fill Limits Exceeded

Medication may be dispensed for more than the allowable fill limit per month under the following circumstances:

  • The prescription is written for a short days-supply because the prescriber is monitoring the member’s supply.
  • The member needs a take-home supply of medication for school, camp, or skilled nursing facility.
  • For any other circumstance, the provider must acknowledge monitoring and provide justification that it is medically necessary for needing more than the allowable fill limit per month.
     
MultiplePA override type 8 with PAMC code 28011004444

AcariaHealth, Coordinated Care's preferred specialty pharmacy vendor, can supply a number of products. Some products can be delivered directly to the provider’s location for office administration. 

Visit AcariaHealth's website for a list of products AcariaHealth can provide to Coordinated Care members.

Providers can submit requests for specialty medications to Coordinated Care by filling out the General Specialty Medication PA Form and fax to Pharmacy Services.

AcariaHealth General Customer Care
Phone: 1-800-511-5144
Fax: 1-877-541-1503

Prescriber can submit requests to use their own stock of biopharmaceutical products by filling out the Buy and Bill Prior Authorization Form (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.

Opioid Attestation Form (PDF): Effective 05/01/2020, this form is required when patients begin chronic use of opioids, when daily opioid doses exceed 120 MME, or when both occur.

Expedited Authorization (EA) codes: Expedited Authorization codes provide immediate overrides when patients or prescriptions meet certain criteria. For other situations, please contact our pharmacy help desk. Below are EA codes that can be used for certain situations and contacts for additional information.

Patient or prescription criteriaExpedited Authorization Code
Patient is in active cancer treatment, hospice care, palliative care, or other end-of-life care.PA Number: 85000000540
Prescriber has indicated “EXEMPT” on the prescription (acute use only).PA Number: 85000000541
  • Prior Authorization Phone:
  • Prior Authorization Fax:
    • 1-833-645-2734

For more information regarding the Washington State Health Care Authority (HCA) Clinical Opioid policy, visit the HCA website.

OTC Contraceptives

All over-the-counter (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  

EA Codes for Contraceptives

Effective 6/1/2022, an expedited authorization (EA) code will be required on all claims for contraceptives. The EA code will allow pharmacies to submit a claim for contraceptives based on the following criteria.

 

Product EA CodeCode Criteria
Contraceptives 85000000131Used as a contraceptive, dispense 1 year
Contraceptives85000000132

Used as a contraceptive, dispensed less than a twelve month supply due to ONE of the following:

  • The prescriber is unwilling to change dispensed quantity to twelve-month supply
  • The member does not want twelve-month supply
  • The pharmacy does not have adequate stock
Contraceptives85000000133Used for other diagnosis, not related to contraception up to a 91-day supply.

 

As mandated by the legislature in RCW 74.09.490, the Health Care Authority (HCA) developed the second opinion program to improve prescribing practices in children.

In collaboration with The Pediatric Mental Health Advisory Group and the Drug Utilization Review Board, HCA established pediatric mental health guidelines to identify children who may be at high risk due to off-label use of prescription medication, use of multiple medications, duplicated therapy, high medication dosage, or lack of coordination among multiple prescribing providers.

The HCA requires a review by an agency-designated mental health specialist from the Second Opinion Network when drugs used to treat mental health conditions are prescribed outside of the established guidelines set by the pediatric children’s mental health workgroup.

Payment for time spent engaging in SON review

Providers can submit procedure code 99441 on the claim to receive payment for the time spent engaging in medication review process with the SON.

Partnership Access Line (PAL)

To assist prescribers in meeting the needs of children with a mental health diagnosis, and to minimize the need for required SON review, providers can contact the Partnership Access Line (PAL). PAL is a telephone based child mental health consultation system funded by the state legislature, being implemented in Washington State. PAL employs child psychiatrists, child psychologists, and social workers affiliated with Seattle Children’s Hospital to deliver consultation services. The PAL team is available to any primary care provider throughout Washington State.  PCPs may call 1‐866‐599‐7257 between 8am and 5pm for any type of mental health issue that arises with any child, not just Coordinated Care members. For additional information on the PAL visit Seattle Children's web site. 

The 21st Century Cures Act mandates that states shall not make payment for services to anyone who provides services, orders, prescribes or refers services to those eligible for the Apple Health (Medicaid) program unless they are screened and enrolled with the state Apple Health (Medicaid) agency providing benefits to the member.

Effective January 1, 2020, all pharmacies must be enrolled with ProviderOne. Failure for pharmacies to enroll prior to this date will result in prescriptions rejecting at the pharmacy. Members will be unable to obtain prescriptions at pharmacies that are not registered with ProviderOne.

Pharmacies can enroll on the Washington State Health Care Authority web site. Providers who have questions about the enrollment process or require assistance may contact the Apple Health (Medicaid) Provider Enrollment Help Desk at 1-800-562-3022 Ext. 16137.

After January 1, 2020 providers and members can use the Find a Provider tool to find a pharmacy that is in the Coordinated Care network and also enrolled with ProviderOne.
 

Mail Order Service  

If a member takes medications on a regular basis, mail service pharmacy may be the right choice. Home delivery is a convenient and safe way to order the medications a member takes every day. Medications will be shipped to member’s home at no cost.  The member can receive up to a 90-day supply of maintenance medications or up to a month of non-maintenance medications.

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, members may do one of the following beginning on or after January 1, 2024:

  • Ask the doctor to electronically send or fax a new prescription to Express Scripts® Pharmacy. The 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 the member ID number ready. Follow the guided steps to request a prescription. Once Express Scripts has the member’s 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 the 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
      • Download the Home Delivery Order Form
      • Complete the form and mail it with the paper prescription to Express Scripts® Pharmacy.

Pharmacies may bill the following vaccines with national drug codes (NDCs) through the point- of- Sale (POS) pharmacy system:

  • Abrysvo
  • Anthrax
  • Arexvy for ages 60 and older
  • Cholera
  • Covid-19 for ages 19 and older*
  • Dengue
  • Hepatitis A for ages 18 and older
  • Hepatitis B for ages 18 and older
  • Influenza for ages 19 and older*
  • Japanese Encephalitis
  • Pneumonia
  • Shingles for ages 50 and older
  • Typhoid
  • Yellow Fever

*  For members aged 18 and younger these vaccines are only covered through the Vaccines for Children (VFC) Program.  For more information on the Vaccine for Children program please see link below:

Vaccines for Children Program.