Pharmacy transition process

Providence Medicare Advantage Plans wants to make your prescription transition as safe and as easy as possible. Review the information below for help guiding you through any prescription drug transition(s). Please read about our transition policy (PDF) for more information.

What is a formulary?

Providence Medicare Advantage Plans uses a List of Covered Drugs (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. You may get a copy of the most current formulary. Providence Medicare Advantage Plans covers both brand name drugs and generic drugs. Generic drugs have the same active-ingredient as the brand-name drug. Generic drugs usually cost less than brand-name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and equally effective as brand-name drugs. When a generic drug is available for a brand name drug, the brand name drug will generally not be covered and is considered non-formulary. Some drugs may have additional requirements or limits on coverage. These requirements and limits may include:

  • Prior Authorization: For certain drugs, you or your provider need to get approval from Providence Medicare Advantage Plans before we agree to cover the drug for you. This is called “prior authorization.” This means that your provider will need to contact us before you fill your prescription. If you don't get approval, Providence Medicare Advantage Plans may not cover the drug.
  • Quantity Limits: For certain drugs, Providence Medicare Advantage Plans limits the amount of the drug that you can have per prescription or for a defined period of time. For example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day.
  • Step Therapy: In some cases, Providence Medicare Advantage Plans requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover drug B unless you try Drug A first. If Drug A does not work for you, then we will cover Drug B. This requirement encourages you to try safer or more effective drugs before the plan covers another drug.

You can access the Providence Medicare Advantage Plans formulary online or if you have questions regarding our formulary or our transition process you may contact the Providence Medicare Plans Customer Service Team at 503-574-8000 or 1-800-603-2340. If you are hearing impaired and use a Teletype (TTY) Device, please call our TTY line at 711.

Customer service is available between 8 a.m. and 8 p.m., seven days a week (Pacific time).

New member transition restrictions

The Centers for Medicare and Medicaid Services (CMS) restricts coverage of some drug categories. Providence Medicare Advantage Plans will not cover these drugs during your transition. The following are examples of commonly excluded categories not covered under Medicare Part D:

  • Non-prescription drugs (also called over-the counter)
  • Drugs when used to promote fertility
  • Drugs when used for the relief of cough and cold symptoms
  • Drugs when used for cosmetic purposes or to promote hair growth
  • Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations
  • Drugs when used for the treatment of sexual or erectile dysfunction, such as Viagra, Cialis, Levitra, and Caverject
  • Drugs when used for the treatment of anorexia, weight loss, or weight gain
  • Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale

Current members

If you are a current member of Providence Medicare Advantage Plans you may be affected by changes in our formulary from one year to the next. You may notice that the drug you are currently taking is no longer on the plan’s drug list (formulary) or the drug you are taking is now restricted in some way. If your drug is not on our drug list or is restricted in some way and you need help switching to a different drug that we cover or requesting a formulary exception, please contact your customer service team at 503-574-8000 or 1-800-603-2340 (TTY: 711). Service is available from 8 a.m. to 8 p.m. (Pactific time), seven days a week.

New member transition

As a new member to our plan, you may be taking a drug that is not on our Drug List (formulary) or has certain restrictions, such as prior authorization, step therapy or quantity limits. While you talk to your doctor to determine the right course of action for you, we will cover a temporary 30-day supply (if you have a prescription written for fewer days, we will allow multiple fills to provide up to a maximum of 30 days of medication) when you go to a network pharmacy. After your first 30-day supply of drugs that are not on our Drug List or drugs that are restricted in some way, we will require medical necessity review even if you have been a member of the plan less than 90 days.

For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that is on our formulary or request a formulary exception so that we will cover the drug you take.

New member transition as a long-term care resident

If you are a resident of a long-term care facility, we will cover a temporary 93-day transition supply (unless you have a prescription written for fewer days). If necessary, we will cover more than one refill of these drugs during the first 90 days you are a member of our plan. If you need a drug that is not on our Drug List or is subject to other restrictions, such as step therapy, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless the prescription is for fewer days) while you pursue a formulary exception.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits may change on January 1 of each year. The Formulary and pharmacy network may change at any time. You will receive notice when necessary.