It's almost time for Open Enrollment! Learn about how far your health coverage can go - learn more

It's almost time for Open Enrollment! Learn about how far your health coverage can go - learn more

Pharmacy benefits & coverage


Fill your prescriptions with ease. Find out what's covered, to what extent, and how you could save money on your medicine.

For details on your pharmacy coverage, log in to your Member account.
Man at pharmacy with medicine Man at pharmacy with medicine

Manage medications
the easy way

GoodRx & Price Assure

Price Assure automatically guarantees the lowest possible price on generic medications when you take your prescriptions to in-network pharmacies that also accept GoodRx

Medication Synchronization Program

Through our Medication Synchronization Program, our Pharmacy team works directly with those who are prescribed three or more maintenance medications to coordinate refills to be picked up at the same time—eliminating multiple trips to the pharmacy.

ScriptSaver Program

With ScriptSaver, our Pharmacy team works with you, your provider and the pharmacy to find cost-saving opportunities.

Special Insulin Provision

Members won't pay more than $35 for up to a 30-day supply of covered insulins on all plans.

Specialty Pharmacy via Accredo

We partner with Accredo to manage specialty medication needs. Accredo benefit specialists help Members navigate insurance coverage, approvals and eligibility. We know specialty medications are expensive. Accredo helps Members save by working with drug manufacturers and community organizations that offer financial assistance programs. 

Pharmacist and customer looking at medicine Pharmacist and customer looking at medicine
Get many common generic prescriptions for just $5

DRUG FORMULARY

Look up medications

Our drug formulary helps Members and providers find cost-effective medications. Use this ACA-version of the formulary to check if your prescriptions are covered and keep your out-of-pocket costs low.

For pricing specific to your plan, log in to your Member portal.

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
woman reading on cell phone woman reading on cell phone

Using Express Scripts

We work closely with Express Scripts, a leading pharmacy benefit manager (known as a PBM).

Create an Express Scripts account to easily access your prescription drug information. You can also search for covered medications, place mail order refill requests and compare costs — all entirely online or via app.

Resources you can rely on

Paying for your prescriptions can be stressful, but there are ways you can reduce your costs. From our Chronic Illness Support Program to meeting with our care team, see how you can save.

Woman looking at her medications

Chronic Illness Support Program (CISP)

All non-HSA plans include our CISP program — designed to improve the health and well-being with additional benefits and coverage for our Members with asthma, coronary artery disease, COPD, diabetes and hypertension.

Man at home smiling at cell phone

Care Management is here to help

Think of our Care Managers as a case manager assigned to help coordinate your care. From finding resources like a ride home from the hospital to organizing your continuity of care paperwork, they can help you navigate difficult health care issues.

Finding ways for a Member to get the medicine they need at a cost they can afford is at the heart of my role here.

Sarah J.
Care Manager since 2021

Questions? We have answers.

What is a formulary? Where can I find one for my plan?

A formulary is a list of prescription medications covered by your health insurance plan. You can search the ACA version right here. It includes:

  • Medication names: Generic and brand-name versions of drugs
  • Dosage forms: Tablets, capsules, injections, vials, etc.
  • Tier status: the cost and coverage of the medication

Your specific plan may have a custom formulary as some plans differ. For the most accurate and up-to-date version of your formulary, we recommend signing into your Member portal.

Haven’t set up a Member portal account yet? The portal gives you secure, 24/7 access to your plan and benefits information: create account.

What if I need access to medications not listed on my plan’s formulary?

If a medication isn’t listed on the plan’s formulary (drug list), first ask your provider about whether there are alternatives available that are just as effective—and may cost you less.

If you have a medical reason that requires a specific brand name, for instance, you and your provider may ask for an exception. To do so, your provider may submit this Medication Prior Authorization Form by faxing it to (877) 251-5896. Community Health Options will consider your prescription through the formulary exception review process. For urgent requests, please call (800) 417-8164.

You have the right to appeal if the request is denied. You also have the right to an external review. You may ask us to submit the case for an external review by an impartial, third-party reviewer known as an Independent Review Organization (IRO). Note that we must follow the IRO’s decision even if they uphold the denial. An IRO review may be requested by a Member, Member’s representative or prescribing provider by mailing, calling or electronically submitting the request to:

Maine Bureau of Insurance,
34 State House Station,
Augusta, ME 04333,
Phone: 1-800-300-5000,
TTY: 1-888-577-6690,
Web site at: www.maine.gov/pfr/insurance

A standard exception review takes up to 72 hours or two business days, whichever is less, from when we receive the request. An expedited exception review takes up to 24 hours from when we receive the request.

How can I save money on my prescription medication?

You may be able to save money on your prescription medications. Our Member Services team is here to help explore your options: (855) 624-6463.

MEMBER PORTAL

Looking for plan details?
Visit your Member account for benefits & coverage