Pharmacy resources

Providence Health Plan is pleased to provide plan members with a comprehensive prescription drug formulary (list of covered drugs) designed to promote safe, effective, and affordable drug therapy.

Your formulary is easy to search, includes information about the drug, and includes special considerations about the prescription, if they apply.

Finding and searching your formulary

Find your pharmacy benefit formulary below by first selecting the type of health plan you have, then clicking on the link for the formulary that applies to your medical plan. Once selected, you can search your online formulary for the prescriptions you are inquiring about. The online search results will provide information about the tier the drug may be on and any associated restrictions (such as prior authorization or quantity limitations).

Formulary Exception: There may be times when you require a drug that is not on the formulary. If you currently take a prescription drug not on the formulary, contact customer service to make sure the drug is not covered. If the prescription drug is not covered, your provider may request an exception be made. There are two ways you, your representative or prescriber can initiate a prior authorization request: Complete the Providence Health Plan drug coverage prior authorization form or your provider may use the drug prior authorization form to submit the exception request.

Generic Alternatives: A generic alternative is a generic drug that is used to treat the same condition as a brand-name drug; it is not the exact same medication as the brand-name drug. According to clinical evidence, a generic alternative can be expected to treat the same condition as well as the brand-name alternative. A new prescription is needed to obtain a generic alternative drug. You may search the formulary by medical condition category and look for a medication classified as generic.

There are multiple formularies posted on the Providence Health Plan (PHP) website. If you need assistance determining which formulary applies to you, it can be found by logging in to your myProvidence.com account or by calling PHP Pharmacy Customer Service at 503-574-7400 or 877-216-3644.

Requesting authorization for your drugs

You can use the formulary information above to determine if your drug requires prior authorization or has any other restrictions. To request authorization or an exception to any restrictions, your doctor can complete one of the following forms or you can use the secure email link and submit to the health plan.

• Drug prior authorization form (PDF)
• Uniform prior authorization prescription request form (PDF)
• Providence Health Plan drug coverage prior authorization form (secure email)

For more information on what is a prior authorization and other limits see the Pharmacy FAQ.

Medical benefit drug authorization

The following list is intended to provide guidance regarding coverage of drugs that are typically administered by a healthcare professionals (such as your doctor) and is not all-inclusive. Additional exclusions may apply based on benefit and contract terms. For pharmacy benefit drug prior authorization information, please refer to your current formulary above.

• Medical Service Prior Authorization List (PDF)   This list includes medications that are injected, infused or otherwise administered by a health care professional that are covered under your medical benefit.

Infusion Therapy Site of Care Policy – Commercial Members (Individual, Small Group and Large Group Plans)

Infused drugs are covered under your medical benefit. Providence Health Plan (PHP) requires site of care prior authorization for the drugs listed below when given in an unapproved hospital outpatient setting. A separate prior authorization may be required for the drug.

Please Note: This policy only applies if you receive medical insurance through Providence Health Plan

• Infusion Therapy Site of Care Policy and Drug List  Effective 8/1/2022 - 12/31/2022
• 2023 Infusion Therapy Site of Care Policy and Drug List  Effective 1/1/2023
• Approved Site of Care Facility List
• Site of Care Prior Authorization Request Form (PDF)

Self-Administered Drug Exclusion Policy

Self-Administered Drug definition - Medications which have been identified as being medically appropriate for administration by a patient or caregiver, safely and effectively, without medical supervision.

Certain medications considered to be usually self-administered by the patient or their caregiver are excluded from coverage under the medical benefit without prior-authorization.

• Self-Administered Drug Exclusion Policy  Effective 8/1/2022 for Commercial and Medicaid members

Additional member resources

• Formulary updates (PDF)
  A summary of upcoming changes to your formulary
• Coverage of Affordable Care Act (ACA) preventive drugs (PDF)
  Information about which preventive drugs are covered without imposing a copayment, coinsurance or deductible.
• Emergency Prescription Fills (PDF) - Applies to Washington Commercial Members only
  Information for emergency prescription fills for Washington Commercial Members.
• Prescription Drug Reimbursement - Prescription drug reimbursement is subject to plan benefits, limitations and exclusions at the time the prescription was filled. Most plan benefits require use of a participating pharmacy. Services are eligible for reimbursement only if a Providence Health Plan participating pharmacy was not available or accessible (e.g., emergencies). To request reimbursement for prescription drugs, fill out the prescription drug reimbursement request form (PDF) and submit it, along with a copy of your itemized receipt, to the address indicated on the form. Keep a copy of the completed form and a copy of your receipt for your records.

Participating pharmacies

You have access to more than 36,000 participating pharmacy locations nationwide.

Retail pharmacy

A retail pharmacy can provide up to a 30-day supply of prescription drugs. Search the pharmacy directory for a pharmacy near you.

Preferred retail pharmacy

A preferred retail pharmacy can provide up to a 90-day supply of prescription drugs. Search the pharmacy directory for a pharmacy near you.

Mail-order pharmacy

A mail-order pharmacy can provide up to a 90-day supply of maintenance drugs and specializes in direct delivery to your home.

Specialty pharmacy

Specialty drugs are prescriptions that require special delivery, handling, administration and monitoring by a pharmacist. These drugs are listed on the Providence Health Plan formulary with a status of "specialty."

• Specialty drugs are available through Credena Health.
• Some specialty drugs are denoted as Limited Access (LA) on the formulary. Credena Health may not be able to provide some of these drugs since they are limited to only a few specialty pharmacies. For more information, call Customer Service at 877-216-3644 (TTY: 711), Monday – Friday, 8 a.m. to 6 p.m. (Pacific Time).

Fertility Pharmacy

Most fertility medications are highly specialized and require specific training from your clinic and specialty pharmacy staff. These are pharmacies with expertise in fertility medications.

• Freedom Fertility Pharmacy
• New Era Pharmacy
• OHSU Fertility Pharmacy Services
• SMP Pharmacy

Having trouble finding something?

Visit our pharmacy FAQ page for more answers to commonly asked questions or contact our customer service team and we will be happy to help you find the answers you need.