A formulary is a list of covered drugs (also known as a “Drug List”). The Providence Medicare Advantage Plans’ Drug List includes prescription drugs that are covered under Part D and outlines any restrictions on coverage (such as prior authorization, step therapy, or quantity limits). The Drug List is developed with the help of a team of doctors and pharmacists and meets the requirements set by the Centers for Medicare & Medicaid Services (CMS).

Yes, Providence Medicare Advantage Plans may make certain changes to our Drug List during the year. Most changes in the Drug List happen at the beginning of each year (January 1). However, during the year there may also be changes. For example, the plan might:

• Add new drugs to the Drug List (such as new drugs approved by the Food & Drug Administration, or FDA).
• Remove a drug from the Drug List because it has been found to be ineffective, has new safety concerns, or it was taken off the market (known as a drug recall).
• Move a drug to a higher or lower cost-sharing tier. This does not apply to our D-SNP plans, non-formulary drugs, or Specialty drugs.
• Add or remove restrictions on coverage for a drug (such as prior authorization, step therapy, or quantity limits). For more information about restrictions on drug coverage, refer to your Member Handbook/Evidence of Coverage.
• Replace a brand-name drug with a generic drug or biosimilar product.

In most cases Providence Medicare Advantage Plans must get approval from Centers for Medicare and Medicaid Services (CMS) for changes that we make to the plan’s Drug List. To get updated information about the drugs covered by Providence Medicare Advantage Plans, please call customer service at 1-800-603-2340, (TTY 711) 8 a.m. to 8 p.m. (Pacific Time) 7 days a week, October 1st through March 31st and Monday - Friday, April 1st through September 30th.

If we remove drugs from our drug list, or add restrictions (such as prior authorization, quantity limits, and/or step therapy), we will send you a notice. Normally, we will let you know at least 30 days in advance, but there are certain circumstances that you may receive notification at a later time:

1. If a drug is suddenly recalled because it has been found to be unsafe, we will remove the drug from the Drug List immediately. We will notify members taking the drug about the change as soon as possible.

2. If a generic version becomes available, we will add the generic to the Drug List and remove the brand name version at the same time. We will notify members taking the drug about the change as soon as possible. 

Providence Medicare Advantage Plans has over 34,000 participating pharmacies available for your use nationwide.

You may look in your Provider and Pharmacy Directory, visit our online directory, or call customer service, whichever is easiest for you. You may also contact customer service to request a revised list of in-network pharmacies by dialing 503-574-8000 or 1-800-603-2340, (TTY 711) 8 a.m. to 8 p.m. (Pacific Time) 7 days a week, October 1st through March 31st and Monday - Friday, April 1st through September 30th.

Note: Providence Medicare Advantage Plans has contracts with pharmacies that equal or exceed the Centers for Medicare and Medicaid Services (CMS) requirements for pharmacy access in your area.

Providence Medicare Advantage Plans has over 34,000 participating pharmacies available for your use nationwide. Generally, we only cover drugs filled at an out-of-network pharmacy when an in-network pharmacy is not available.

Before you fill your prescription in these situations, call customer service to see if there is an in-network pharmacy in your area where you can fill your prescription. Fills are limited to 30 days for out-of-network claims.

Below are some circumstances when we would cover prescriptions filled at an out-of-network pharmacy.

Coverage for out-of-network access of emergency drugs and some routine drugs will be provided when the member cannot access a network pharmacy and one of the following conditions exists:

• You are traveling outside the service area and run out, lose your covered drugs, or become ill and need a covered Part D drug.
• You are unable to obtain a covered drug in a timely manner at an in-network pharmacy in your service area (such as there is no access to a 24 hours/7 days a week network pharmacy).
• You are unable to obtain a particular drug as it is not regularly stocked at an accessible in-network pharmacy or mail order pharmacy (such as specialty drug with limited distribution).
• The network mail-order pharmacy is unable to get the covered Part D drug to you in a timely manner and you run out of your drug.
• Drug is dispensed to you by an out-of-network institution-based pharmacy while you are in an emergency department, provider-based clinic, outpatient surgery, or other outpatient settings.

If you do go to an out-of-network pharmacy for the reasons listed above, 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. Send us your request for payment along with your itemized receipt(s). You may pay more for a drug purchased at an out-of-network pharmacy because the out-of-network pharmacy’s price is higher than what a network pharmacy would have charged. You should submit to us if you fill a prescription at an out-of-network pharmacy as any amount you pay, consistent with the circumstances listed above, will count towards your maximum out-of-pocket costs.

The Providence Medicare Advantage Plans has preferred testing supplies that may be obtained through any participating pharmacy.

• Traditional blood glucose meters and supplies: Preferred products are Roche branded products (Accu-Chek) and Abbott branded products (Freestyle).
• Continuous glucose monitors (CGMs) and supplies: Preferred products are Dexcom G6, Dexcom G7 when used with a Dexcom Receiver, and Abbott Freestyle Libre and Freestyle Libre 2 products, Freestyle Libre 2 Plus and Freestyle Libre 3, Freestyle Libre 3 Plus when used with a Freestyle Libre receiver. These products are subject to Prior Authorization for coverage. 

Non-preferred testing supplies will require prior authorization for coverage. Diabetic testing supplies are paid under your Part B benefit. Please refer to your Benefit Summary for additional information.