Self-funded Pharmacy FAQ

Your benefit information, along with other applicable member materials, is available online through your My Collective® account.

Compounded drugs are prescriptions that are custom prepared by your pharmacist. These prescription drugs are subject to review, plan and benefit limits, and are not always covered. These prescription drugs must contain at least one FDA-approved drug to be eligible for coverage under your plan benefit.

Diabetic supplies may be covered under your pharmacy benefit. Limitations, coinsurance, or copayments may apply. Please log in to your My Collective® account to view your benefit summary for additional information.

Yes. Covered drugs are subject to plan limitations and exclusions. Some drugs may require prior authorization or step therapy. Other drugs may have a quantity limit which limits the amount of the drug covered for a specified time frame. The Providence Health Plan Powered by Collective Health formulary lists whether a drug requires prior authorization or has a specific quantity limit.

No. With the exception of insulin and FDA-approved contraceptives, your prescription drug benefit does not cover over-the-counter drugs.

Some prescription drugs in the market today that are not approved for safety and effectiveness by the FDA. Prescription drugs must be approved by the FDA to be eligible for coverage. Learn more about unapproved drugs by visiting the FDA website.

The pharmacy may submit claims electronically to Providence Health Plan Powered by Collective Health.

If your pharmacy needs assistance, they may call the Pharmacy Technical Help Desk at 888-445-5518.

If the pharmacy is not able to submit an electronic claim to Providence Health Plan Powered by Collective Health, you may have to pay for the prescription at the time of service and then submit a claim for reimbursement from Providence Health Plan Powered by Collective Health. To request reimbursement, please:

 

1. Fill out a prescription drug reimbursement request form;
   

    

2. Attach your itemized pharmacy receipt; and
   

    

3. Mail the completed form and the itemized receipt to the address indicated on the form. Keep a copy of the completed form and your receipt for your records.

   
   

Prescription drugs are evaluated for coverage by the health plan’s Pharmacy and Therapeutics Committee. This committee is made up of doctors, pharmacists, and nurses that review prescription drugs for their safety, effectiveness, and cost. The committee regularly reviews the latest evidence and makes formulary decisions to ensure safe, effective, and affordable drug therapy is available to our membership.

To view your copayment structure, please refer to your benefit summary which can be found at within your My Collective® account.

You may also use the pharmacy cost estimator tool to search specific drugs and receive a cost estimate based on your health plan. Log in to your My Collective account to access the cost estimator tool.

Your prescription drug benefit requires that you fill medication(s) at a participating pharmacy. You have access to more than 34,000 participating pharmacies and their services nationwide. To find a pharmacy:

• If you are a current Providence Health Plan Powered by Collective Health member, log into your My Collective® account and search using the Get Care tool.
• If you are not a current member, visit our online provider directory and "browse by provider networks" choose "coverage through my employer" and select the correct network.
  

You may purchase up to a 90-day supply of maintenance drugs using a participating mail-order pharmacy or a preferred retail pharmacy. Not all drugs are considered maintenance prescriptions, including compounded drugs, drugs from specialty pharmacies, and oncology drugs.

Yes. There are mail-order pharmacies available for you to use, including:

 

• Postal Prescription Services
• Costco Home Delivery
  
  

Eligible members and their qualified dependents have access to these mail-order pharmacies. Your network provisions may require the use of just one of these mail-order pharmacies for coverage. Have questions? Call a Member Advocate at 855-526-3824 Monday - Friday, 4 a.m. to 6 p.m., and Saturday, from 7 a.m. to 11 a.m. (Pacific Time).

Plan ahead. You may get a 90-day supply of your prescription drug(s) at a preferred participating pharmacy or a mail-order pharmacy.

If you need to fill a prescription drug while you are out of town, you have access to more than 34,000 participating pharmacies and their services nationwide.

To find a pharmacy:

 

• If you are a current Providence Health Plan Powered by Collective Health member, log into your My Collective® account and search using the Get Care tool.
• If you are not a current member, visit our online provider directory and "browse by provider networks" choose "coverage through my employer" and select the correct network.
  

Need help? Call a Member Advocate at 855-526-3824 to locate a pharmacy near you.

For processing assistance, ask your pharmacy to call the Pharmacy Technical Help Desk at 888-445-5518.

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 Powered by Collective Health participating pharmacy was not available or accessible (e.g., emergencies). To request reimbursement for prescription drugs, fill out the prescription drug reimbursement request form and submit it, along with a copy of your itemized receipt, to the address indicated on the form. We recommend keeping a copy of the completed form and a copy of your receipt for your records.

Please note: This form may also be used to request reimbursement for FDA-approved over-the-counter contraceptives.

Most plan benefits require that you use a participating pharmacy. You can search the provider directory to locate a participating pharmacy. You may also call a Member Advocate for help finding a participating pharmacy near you.

Pharmacies wishing to participate may contact us at 503-574-7400 or 877-216-3644 (TTY: 711), Monday through Friday, 8 a.m. to 5 p.m. (Pacific Time).

A formulary is a list of Food and Drug Administration-approved prescription generic, brand-name, and specialty drugs. The formulary can be a useful resource in helping you and your provider choose effective prescription drugs that minimize your out-of-pocket expense. The formulary contains more than 2,500 drug-strength-dosage combinations and is externally audited every year to assure completeness. Once doctors become familiar with the formulary, more than 95 percent of the time they treat medical conditions with a formulary drug, and more than 80 percent of the time they choose a generic drug.

Log in to your My Collective® account to review your plan's formulary. You can also find a list of Providence Health Plan Powered by Collective Health formularies by visiting our Self-funded Pharmacy Resources page.

If you need help determining which plan formulary applies to you, call a Member Advocate at 855-526-3824, Monday - Friday, 4 a.m. to 6 p.m., and Saturday, from 7 a.m. to 11 a.m. (Pacific Time).

There are three ways to search the formulary:

 

1. Use the alphabetical list to search by the first letter of your prescription drug. 
   

    

2. Search by typing part of the generic (chemical) or brand (trade) names.
   

    

3. Search by selecting the therapeutic class of the prescription drug you are looking for.

Non-formulary drugs may be eligible for coverage. If your drug is not included on the formulary, you can identify similar drugs on the formulary by searching the medical condition category or you can call a Member Advocate for help finding a therapeutically interchangeable formulary alternative at 855-526-3824. If there are no appropriate formulary alternatives, your prescribing provider can request an exception by submitting supporting documentation via a prior authorization request.

Your formulary is available to your doctor via the Providence Health Plan Powered by Collective Health Self-funded Pharmacy Resources page as well as through other electronic and online resources frequently used by your doctor's office.

The formulary is developed by the Pharmacy and Therapeutics Committee, which is composed of doctors and pharmacists who review prescription drugs based on safety, effectiveness, cost and Food and Drug Administration approval. The committee reviews the latest evidence to identify opportunities to promote safe, effective and affordable drug therapy.

Yes. The formulary is updated every two months. Generally, formulary status for a formulary drug you are taking with your Providence Health Plan Powered by Collective Health pharmacy benefit will not change during the year unless:

 

1. The same medication is now available in generic form (the generic form will be covered), or
   

    

2. Safety or effectiveness concerns are raised about the prescription drug.

 

If a formulary change results in a reduction of benefits or an increase in copayment, impacted members are always notified in writing at least 60 days before any change.

Prior authorization is a process to review a prescription drug for coverage before it is dispensed. This process is initiated by your doctor or other prescriber of the prescription drug.

Many factors – including serious risks, Food and Drug Administration approved indications and cost-effectiveness – are considered before making the decision to require prior authorization of a prescription medication. A limited number of prescription drugs require prior authorization review.

Step therapy is a form of prior authorization. Its purpose is to confirm if drugs generally considered "first-line" therapy based on clinical evidence have been tried first. If they have, the drug requiring step therapy will automatically be approved. In the event these drugs are not tried first, cannot be tried first or the drug is not part of Providence Health Plan Powered by Collective Health's claims history, prior authorization is required.

Quantity limits are in place to ensure safe and appropriate use of a drug.

Talk to your doctor or other health care provider. You may wish to consider changing your prescription to an effective formulary alternative. Otherwise, your doctor or other health care provider can submit a prior authorization request.

Your health care provider has access to your formulary and the prior authorization request form through the Providence Health Plan Powered by Collective Health Self-funded Pharmacy Resources page. Your doctor or other health care provider may call us with questions about medication coverage including prior authorization.

Your doctor's office will be contacted and your pharmacy, if known to us, will be notified. If the prior authorization is not approved, we will contact your doctor's office, and you and your doctor will receive a letter.

To check status or to request a "standard," "fast" or "expedited" coverage determination, you, your appointed representative or your prescribing physician should contact us by telephone or mail at the numbers or address below:

 

Phone: 503-574-7400 or 877-216-3644 (TTY: 711)

 

Mail to:

ATTN: Pharmacy Department 
Providence Health Plan
P.O. Box 4327
Portland, OR 97208-4327

 

There are two ways you, your representative or prescriber can initiate a prior authorization request:

 

1. Click on the secure email link below and initiate a prior authorization (secure email); or
   

    

2. Make a copy of Providence Health Plan Powered by Collective Health's prescription drug prior authorization request form and have it completed by your provider

 

Drug Coverage Prior Authorization Form (secure email)

 

Prescription Drug Prior Authorization Request Form (PDF)

Generic drugs have the same active ingredient as equivalent brand-name drugs. Generic drugs are determined by the Food and Drug Administration to be as safe and as effective as brand-name drugs. Generic drugs are only available after the brand-name patent expires. The bonus: They save you money.

A generic drug is equivalent to the brand-name drug with the same active ingredient, dosage form, and strength. The FDA assures equivalence between the brand-name and generic products. Generic drugs cost less than brand-name products. For example, for high cholesterol, Lipitor® is now available in generic form from multiple manufacturers under the generic name atorvastatin. Lipitor® and atorvastatin are identical drugs — the only difference is one is a brand-name, the other is generic and costs much less.

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 prescription drug 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.

Search the formulary by medical condition category and look for a prescription drug classified as generic.

• Learn more about generic drugs by visiting the FDA website.
• Visit the Consumer Reports Best Buy Drug website, which has information regarding safe and effective drug use.

Specialty drugs are injectable, infused, oral, or inhaled therapies that often require special delivery, handling, administration and monitoring. These drugs are listed on the Providence Health Plan Powered by Collective Health formulary with a status of "specialty."

Specialty drugs are available through Credena Health, located at 6348 NE Halsey Street, Suite A, Portland, OR 97213. For more information, please call a Member Advocate at 855-526-3824.

Credena Health is Providence Health Plan’s designated specialty pharmacy. Drugs identified on Providence Health Plan Powered by Collective Health's formularies as “specialty” are limited to a 30-day supply and are available through Credena Health.

Credena Health can assist with getting your prescription transferred from your previous pharmacy to avoid any disruptions in care. For more information, please call a Member Advocate at 855-526-3824.

Specialty drugs are available through Credena Health, located at 6348 NE Halsey Street, Portland, OR 97213. To reach Credena Health by phone, call 503-962-1700 or 855-360-5476.

If you have questions about specialty drugs, call a Member Advocate at 855-526-3824.

Limited access drugs are prescription drugs that may have special dosing or monitoring requirements or used in specific patient populations. Because of this, the manufacturer sometimes chooses to limit the distribution of their drug to only a few pharmacies. In some cases, Credena Health may not have access to these prescription drugs, and Providence Health Plan Powered by Collective Health will work with you and your physician to obtain this through an alternative pharmacy to assure you receive your prescription drug.