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.
Envolve Pharmacy Solutions, de Coordinated Care PBM, processes pharmacy claims and administers the medication prior authorization process.
Telephonic Prior Authorization: 1-855-757-6565 (available 5 a.m. - 5 p.m. PST)
Pharmacy Maximum Allowance cost (MAC) Appeal
As of 5/1/2017, Envolve Pharmacy Solution MAC appeals are being managed by CVS Caremark®. All Envolve Pharmacy Solution MAC appeals must be submitted using the MAC Appeal Form that can be accessed via the CVS Caremark Pharmacy Portal.
Coordinated Care provides members with 90 day supplies through our preferred mail order pharmacy, Homescripts, or any contracted pharmacy. To transfer a current prescription or phone a prescription directly Homescripts call 1-800-785-4197.
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. Once a brand name medication on the maintenance drug list becomes generically available, only the generic drug will be covered as a maintenance medication.
We authorize pharmacies to provide a 30-day supply of medication while awaiting a prior authorization or medical necessity (MN) determination for drug coverage.
AcariaHealth, de Coordinated Care preferred specialty pharmacy vendor, can supply a number of products. Some of these products can be delivered directly to the provider’s location for office administration by de Coordinated Care preferred specially pharmacy provider, AcariaHealth.
For a complete listing of products that AcariaHealth can supply, please see the Coordinated Care Specialty Pharmacy Program (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.
Chronic Opioid Attestation Form (PDF): Use this form to attest that criteria for chronic use of opioids for the treatment of non-cancer pain are met, or there is documentation in the patient’s chart for why one or more are not applicable, and that the requested treatment is medically necessary, does not exceed the medical needs of the members, and is clinically supported in the member’s medical record.
For more information regarding the Washington State Health Care Authority (HCA) Clinical Opioid policy, go to https://www.hca.wa.gov/billers-providers/programs-and-services/opioids.
All 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
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.