Pharmacy guidelines and FAQs
Explore the topics below for more pharmacy and formulary information:
What is a formulary?
Providence Medicare Advantage Plans uses a List of Covered Drugs (also known as a formulary or “Drug List”). The Drug List includes Part D prescription drugs that are covered by Providence Medicare Advantage Plans. The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. The list must meet requirements set by Medicare.
Can the formulary change?
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 or remove drugs from the Drug List. New drugs, including new generic drugs may become available or there may be a new use for an existing drug. We may remove a drug because it has been found to be ineffective or there may be 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. 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.
In most cases Providence Medicare Advantage Plans must get approval from Medicare 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, seven days a week, from 8 a.m. to 8 p.m. (Pacific Time). TTY users should call 711.
How will I find out if my drug coverage has been changed?
If we remove drugs from our drug list, or add prior authorization, quantity limits, and/or step therapy restrictions on a drug, we will send you a notice. Normally, we will let you know at least 30 days in advance. 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.
How do I find an in-network pharmacy in my area?
Providence Medicare Advantage Plans has over 36,000 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, seven days a week, from 8 a.m. to 8 p.m. (Pacific Time). (TTY users should call 711)
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.
How do I fill prescriptions outside of the network?
Providence Medicare Advantage Plans has over 36,000 participating pharmacies available for your use nationwide. Generally, we only cover drugs filled at an out-of-network pharmacy when a network pharmacy is not available.
Before you fill your prescription in these situations, call customer service to see if there is a 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 a network pharmacy in your service area (e.g. 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 network pharmacy or mail order pharmacy (e.g. orphan or 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 documentation of any payment you have made. 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 a claim 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 help you qualify for catastrophic coverage.
How can I get diabetic meters and supplies?
The Providence Medicare Advantage Plans preferred traditional blood glucose meters and supplies are Accu-Chek Guide Meters/Strips or LifeScan (OneTouch) Meters/Strips. The co-preferred continuous glucose monitors are Dexcom and Freestyle Libre. Diabetes supplies are available through any participating pharmacy. Benefits for diabetes supplies are paid under your Part B benefit. Please refer to your Benefit Summary for additional information.
Webpage current as of: 7/05/2023