About Your Medications
CHP works with a national pharmacy network to provide pharmacy benefits. When you purchase a covered prescription drug from a participating pharmacy, you will be required to pay a copayment. It’s important to note that not every plan offers prescription drug coverage; therefore, it’s advisable to consult your benefit documents for further information.
Medication Formulary
A medication formulary, also known as 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 covers, plus any special rules you’ll need to follow with certain medications. View your plan’s specific drug coverage information which is updated and posted monthly. All formularies apply to benefit plans with a pharmacy benefit.
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.
A formulary can help you understand:
- Important Messages About What You Pay For Vaccines – Our plan covers most Medicare Part D vaccines at no cost to you.
- Important Messages 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.
- The Copayment Structure for Restricted Pharmaceuticals – Members can find information on copayments for specialized drugs.
- The Policy for Exceptions – Regarding coverage of nonformulary pharmaceuticals; if there is a closed formulary.
- How to Access or Review Restrictions on Prescribing or Accessing Pharmaceuticals
- How to Access or Review Pharmaceutical Lists – Members and providers can view the Medication Code list here.
- Procedures That Impact Pharmaceutical Coverage
Medication Resources
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.
Pharmacy Services
Members can learn about available pharmacy services and explore over 5,000 nationwide pharmacies in-network.
Drug Recalls
For up-to-date information on drug recalls, market withdrawals, and safety alerts, visit the U.S. Food and Drug Administration’s (FDA) website.
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.
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 any time.
Medication Therapy Management Program (MTMP)
If you take eight or more Medicare Part D-covered maintenance drugs, have three or more long-term health conditions, and spend more than $5,330 a year on your drugs, you qualify for CHP’s MTMP.
Medicare Prescription Payment Plan
The Medicare Prescription Payment Plan is a new payment option in the prescription drug law that works with your current drug coverage to help you manage your out-of-pocket Medicare Part D drug costs by spreading them across the calendar year (January-December). Starting in 2025, anyone with a Medicare drug plan or Medicare health plan with drug coverage (like a Medicare Advantage Plan with drug coverage) can use this payment option. All plans offer this payment option and participation is voluntary. Click here for more information.
To learn more about the Medicare Prescription Payment Plan, contact Capital Health Plan at 1(833) 696-2087 (TTY – 711). You can also find additional information on the MyPrime webpage.