Drug Coverage Details

drug coverage forms

Learn About Your Drug Coverage

Prescription drugs can be an important part of getting and staying healthy.

Try our search tool to find your medications and network pharmacies.

A complete list of covered medications can be found on the Medicare Formulary. Formularies are updated throughout the year so continue to check for changes.

Is Your Drug Covered By Our Plan?

If your medication is not on our Medicare Formulary or if the drug is restricted in some way, you have options.

You may be able to get a temporary supply of the drug (only members in certain situations can get a temporary supply). If you are approved for a temporary supply, you should talk with your prescriber during that time to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan, or ask the plan to make an exception for you and cover your current drug.

How to Request a Formulary Exception

If you can’t switch to another drug, you and your prescriber can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered. If your prescriber says that you have medical reasons that justify asking us for an exception, your prescriber can help you request an exception to the rule. This is called a “coverage determination.”

You and your prescriber can complete the Coverage Determination Request Form and submit it to the CDPHP pharmacy department for consideration. You may also ask us for a coverage determination by phone at (518) 641-3950 or 1-888-248-6522 (TTY: 711).

If we approve your request for a Formulary exception, our approval usually is valid for at least one year. This is true as long as your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition.


How to Request a Formulary Redetermination

If we deny your request for a Formulary exception, you can ask for a review of our decision by making an appeal. This is called a “redetermination”.

You and your prescriber can complete the Redetermination Request Form and submit it to the CDPHP appeals department for consideration.

NOTE: These forms should be completed by you (or someone acting on your behalf) and your prescriber.

Pharmacy Guidelines

You can choose to have your prescription filled at a local pharmacy or mailed directly to your home or office using mail order service. Details can be found on our mail order page.

Pharmacy and Prescription Forms

Network Pharmacies

Prescriptions that are included in the Part D formulary must be filled at a network pharmacy.

We will fill prescriptions at non-network pharmacies under certain circumstances as described in the Evidence of Coverage.

If you’re a new Medicare Advantage member or an existing member whose plan includes a new formulary, you could be eligible for a transition fill for non-formulary drugs you’re currently prescribed. The transition process allows you to obtain coverage for non-formulary drugs during a medical review of your drug request, and when appropriate, switch to therapeutically appropriate formulary alternatives. Guidelines are outlined in the Transition Fill Policy.


Sign Up for Our Mail Order Service

Have your prescriptions filled and mailed directly to your home or office using one of our mail order pharmacy providers.


Out-Of-Network Pharmacy

Out-of-network pharmacies are those pharmacies not in the plan's network. If you use an out-of-network pharmacy, you may have to pay the full cost (rather than paying just your copayment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a claim form (coming soon). You may be responsible for paying the difference between what we would pay for a prescription filled at an in-network pharmacy and what the out-of-network pharmacy charged.

When to Use an Out-Of-Network Pharmacy

  • When you are traveling outside your plan’s service area.

  • If you lose or run out of your covered drugs or you become ill and need a covered drug immediately and cannot access a network pharmacy.

  • If you cannot obtain a covered drug within your service area in a timely manner due to lack of availability of a participating network pharmacy.

  • If your covered drug is provided by an out-of-network institution-based pharmacy while you are in an emergency department, provider-based clinic, outpatient surgery, or other outpatient setting.

  • If you are administered a vaccine covered by your plan in a physician’s office.

  • If you must fill a covered drug prescription and the drug is not regularly stocked at accessible network retail or mail-order pharmacies.

How to Submit a Paper Claim for an Out-of-Network Prescription

If you go to an out-of-network pharmacy for any of the reasons listed above, the pharmacy may not be able to submit the claim directly to us. When that happens, you will have to pay the full cost of your prescription and mail the completed claim form along with the receipt to:

Capital Rx- Attn. Claims Dept
9450 SW Gemini Dr., #87234
Beaverton, OR 97008

Upon receipt, an initial coverage determination will be made on the claim. For more information on initial coverage determinations, limits, and financial responsibilities, please refer to your Evidence of Coverage, or call CDPHP Pharmacy Customer Care Center at 1-866-289-2319. TTY users should call 711. A representative is available 24 hours a day, seven days a week.

Transition Policy

New members taking drugs that are not on our formulary or that are subject to certain restrictions, such as prior authorization or step therapy, should review the Transition Fill Policy or the plan's Evidence of Coverage (EOC) for details.


Part D Prescription Questions

Current CDPHP Medicare Advantage members with questions about their Part D coverage should contact CDPHP:

Medicare Advantage members call toll free 1-866-289-2319

The phone lines are open 24 hours a day, seven days a week. All TTY/TDD users should call 711.