Pharmacy Benefits
Capital Health Plan works to provide its members with comprehensive pharmacy services for those who are at-home, traveling, or in a long-term care facility. Search our nationwide pharmacy network to find convenient locations to fill a prescription, even when you’re on the road.
About Retail Pharmacies
Capital Health Plan members have access to over 50,000 retail pharmacies nationwide.
Medicare members can rest easy knowing that our pharmacy access meets or exceeds standards set by the Centers for Medicare and Medicaid Services (CMS):
- At least 90% of Medicare beneficiaries, on average, in urban areas served by Capital Health Plan Medicare Advantage (HMO) plans live within two miles of a network retail pharmacy.
- At least 90% of Medicare beneficiaries, on average, in suburban areas served by Capital Health Plan Medicare Advantage (HMO) plans live within five miles of a network retail pharmacy.
- At least 70% of Medicare beneficiaries, on average, in rural areas served Capital Health Plan Medicare Advantage (HMO) plans live within 15 miles of a network retail pharmacy.
Mail-Order & Home Delivery Pharmacy Services
Capital Health Plan will cover certain kinds of drugs through the plan’s network mail-order and home-delivery service. Express Scripts Home Delivery and Walgreens Mail Service are mail order pharmacy services offered through Capital Health Plan, even if you take long-term medications.
Generally, the drugs available through mail order are drugs that you take on a regular basis for a chronic or long-term medical condition. Drugs that are not available through the plan’s mail-order service are Tier 5 Specialty medications.
Our plan’s mail-order service allows you to order up to a 90-day supply. CHP Members can expect to receive their drugs within 14 business days of ordering. Call CHP Member Services with questions or if your drugs do not arrive within this time frame.
To get order forms and information about filling your prescriptions by mail, please contact our Member Services team, or fill out and print the online form found at http://www.primetherapeutics.com/.
Home Infusion Pharmacies
Capital Health Plan Medicare Advantage (HMO) plans will cover home infusion therapy when:
- Your prescription drug is covered by your Capital Health Plan Medicare Advantage plan
- Your prescription is written by a doctor
- You get your home infusion services from a Capital Health Plan Medicare Advantage network pharmacy
You can find participating Home Infusion Pharmacies in CHP’s Pharmacy Directory.
Long-Term Care Pharmacies
In some cases, residents of a long-term care facility may access their prescription drugs through the facility’s long-term care pharmacy.
You may find participating long-term care pharmacies in CHP’s Pharmacy Directory.
Find more information about your Medicare plan’s prescription drug coverage and pharmacy benefits by reviewing your specific plan details:
Out of Network Pharmacies
If you are traveling within the United States and territories and become ill, or lose your prescription, or run out of your prescription drugs, remember that Capital Health Plan has over 50,000 retail pharmacies in our pharmacy network.
Getting coverage when you travel or are away from the Plan’s service area.
Generally, CHP covers drugs filled at an out of network pharmacy in limited circumstances when a network pharmacy is not available. CHP will not pay for any prescriptions that are filled by pharmacies outside of the United States and territories, even for a medical emergency.
If you need a prescription because of a medical emergency or for urgent care.
CHP will cover prescriptions that are filled at an out-of-network pharmacy if the prescriptions are related to care for a medical emergency or urgent care. In either of these situations, you will have to pay the full cost (rather than paying just your copayment) when you fill your prescription. Complete the Non-Medicare Prescription Drug for Reimbursement Form or a Medicare Prescription Drug Reimbursement Form or contact Member Services to request reimbursement for CHP’s share of the costs.
CHP will cover your prescription at an out-of-network pharmacy if at least one of the following applies:
- If you are unable to obtain a covered drug in a timely manner within our service area because there is no network pharmacy within a reasonable driving distance that provides 24-hour service.
- If you are trying to fill a prescription drug that is not regularly stocked at an accessible network retail pharmacy (including high cost and unique drugs).
- If you are getting a vaccine that is medically necessary but not covered by Medicare Part B and some covered drugs that are administered in your doctor’s office.
- For more detailed information about your prescription drug coverage, please review your specific plan details.
For any questions about pharmacy benefits and services, please contact:
Member Services Team at (850) 383-3311 from 8:00 a.m. – 5:00 p.m., Monday – Friday.
Medicare Member Services Team at (850) 523-7441 – available October 1 – March 31, 8:00 a.m. – 8:00 p.m., seven days a week; and April 1 – September 30, 8:00 a.m. – 8:00 p.m., Monday – Friday.
State of Florida Member Services Team at 1 (877) 392-1532 from 7:00 a.m. – 7:00 p.m., Monday – Friday.