A drug formulary is a list of covered drugs that represents the prescription therapies believed to be a necessary part of a quality treatment program. The drug formulary is selected by Capital Health Plan in consultation with a team of health care providers. Your drug formulary lists all drugs your plan overs, plus any special rules you'll need to follow with certain medications.
- Important Message About What You Pay For Vaccines - Our plan covers most Medicare Part D vaccines at no cost to you. Call Member Services for more information.
- Important Message About What You Pay For Insulin - Medicare Members won’t pay more than $35 for a one month supply of each insulin product covered by your Part D Formulary, no matter what cost sharing tier it’s on.
Capital Health Plan utilizes Prime Therapeutics to administer our pharmacy benefits. You can register at the MyPrime.com website to help you manage your prescription drug benefit offered through Prime Therapeutics. After you register, you can check for drugs covered by your benefit, look up drug prices, search for a pharmacy near you, and view your pharmacy claim history and more.
- If you are enrolled in one of our current plans, please visit the Medicare, Employer, or Individual and Family pages for specific information about your plan.
The formulary publication is updated and posted monthly. All formularies apply to benefit plans with a pharmacy benefit.
Find Medications Online
Find medications online using this searchable online index to locate your prescriptions and your associated copayment. The copayment amount is determined by the type of prescription drug dispensed.
Our pharmacy network includes thousands of pharmacies nationwide. Search for pharmacies throughout the nation using our online pharmacy database.
Mail Order Service
Medicare members – Express Scripts Home Delivery and AllianceRx Walgreens Pharmacy are mail order pharmacy services offered through Capital Health Plan. If you take long-term medications, you can fill your prescriptions through Express Scripts Home Delivery or AllianceRx Walgreens Pharmacy.
Commercial and Marketplace members – Express Scripts Home Delivery is your new mail order pharmacy service offered through Capital Health Plan. If you take long-term medications, you can fill your prescriptions through Express Scripts Home Delivery.
Your Prescription Drug Benefit may be subject to limitations and exclusions. For a complete list, refer to your handbook and commercial formulary document.
- A prescription unit or refill is covered for up to a 30-day supply (or a 90-day supply of a generic drug at any participating retail pharmacy). Refills on prescriptions are not covered until at least 75% of the previous prescription is used based on the dosage schedule prescribed by the physician.
- Certain prescription drugs require prior authorization for coverage. For instructions on how to obtain prior authorization, please contact Member Services at (850) 383-3311 Monday through Friday, 8:00 a.m. to 5:00 p.m. Also, Commerical Criteria for those selected medications are available for download.
- CHP may limit quantities for medications prescribed to be taken on a p.r.n. (as needed) basis.
Please note: Medicare members have a different drug list, called the Medicare Advantage Formulary. If you are a Medicare member, please check our Medicare section for information on your prescription drug benefits.
How to Request an Exception to Our Prescription Drug Coverage Rules
You, your authorized representative, or your prescribing physician can request an exception to prescription drug coverage restrictions or quantity limits. For example, certain drugs on CHP's formulary have quantity limits. If your drug has a quantity limit, you can ask CHP to cover a quantity over the stated limit. You may need to meet certain clinical criteria to receive an approval for the higher quantity.
The exception request can be initiated by calling our Member Services department at (850) 383-3311 or toll-free at 1-877-247-6512, Monday through Friday from 8:00 am through 5:00 pm. The TDD number for the hearing impaired is (850) 383-3534. After hours or on a weekend, you can call (850) 383-3333 or toll-free (800) 390-1434. The after-hours number for the Florida State Relay, for the hearing impaired, is (800) 955-8771.
You can also submit a drug exception request by sending an email directly to Member Services.
A Member Services representative will contact you within one business day to let you know that the request has been submitted to our Pharmacy Services department for a decision by a Capital Health Plan Medical Director. Staff from the Pharmacy Services department may need to request additional information from you or your prescribing doctor. A request for an exception will be approved only when there is a medical reason for it. If the exception is denied, you will be notified of the decision and given information about your appeal rights. For additional information about the decision-making procedures for an exception request, review the Utilization Management section of the website.
ACA Preventive Drug Coverage
Under the Affordable Care Act (ACA), health plans must cover preventive services that are recommended by the U.S. Preventive Services Task Force (USPSTF), as a Grade ”A” or “B” Recommendation, without any out-of-pocket cost to members. In compliance with the ACA, Capital Health Plan offers this coverage to all Commercial members.
Please contact Member Services at 850-383-3311 for additional information.
You can access more information about Preventive Drug Coverage at anytime.
For up-to-date information on drug recalls, market withdrawals, and safety alerts, visit the U.S. Food and Drug Administration’s (FDA) website at https://www.fda.gov/Safety/Recalls/default.htm.