The following are answers to commonly asked questions about pharmacy coverage. Please review them as well as your Prescription Drug Plan Benefit Summary for additional information.
What is a formulary?
A formulary is a list of Food and Drug Administration-approved prescription drugs developed by physicians and pharmacies. Formularies are designed to offer drug-treatment choices for covered medical conditions. Formularies can be a useful resource in helping you and your physician choose effective medications that minimize your out-of-pocket expense.
What if my drug is not on the formulary?
Non-formulary drugs may be eligible for coverage. However, the drug may require prior-authorization. If your drug is not included on the formulary, you can identify similar drugs on the formulary by searching for the medical condition category. You may also contact Providence Health Plan Customer Service to confirm whether your drug is covered, if it requires prior authorization and/or to ask for a list of similar drugs that are covered.
How does my doctor know which medications are on my formulary?
Your formulary is available to your doctor via the Providence Health Plan website, as well as through other electronic and online resources frequently used by your doctor's office.
How do drugs get selected for the formulary?
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.
Does the formulary change?
Yes. The formulary is updated every two months. Generally, formulary status for a formulary drug you are taking with your Providence Health Plan pharmacy benefit will not change during the year unless:
- The same medication is now available in generic form (the generic form will be covered), or
- 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 individuals are always notified in writing at least 60 days before any change.
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What is prior authorization?
Prior authorization is a process to review a prescription drug for coverage before it is dispensed. This process is usually initiated by your doctor or other prescriber of the medication.
Why does Providence Health Plan prior authorize certain drugs?
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 medications require prior authorization review. Prescriptions that require a prior authorization will include "PA" in the comment section of the formulary.
What is step therapy?
The purpose of step therapy is to confirm if a member has tried a drug that is considered to be "first-line" therapy based on clinical evidence first, before the drug requiring step therapy is generally considered. Step therapy uses Providence Health Plan pharmacy claims history to confirm if certain drugs have been tried first and if they have, the drug requiring prior authorization will automatically be approved. In the event these drugs are not tried first, cannot be tried first or the drug history is not part of Providence Health Plan claims, prior authorization is required. Drugs that require step therapy are indicated with a "ST" in the online formulary.
Why do some drugs have quantity limits?
Quantity limits or "QL" in the comment section of the formulary are in place to ensure safe and appropriate use of a drug.
My prescription is for a drug that requires prior authorization. What do I need to do?
Talk to your doctor or other health care provider. You may wish to consider changing your prescription to an effective formulary alternative. Otherwise, you'll need to ask your doctor or other health care provider to submit a prior authorization request.
How does my doctor know which drugs require prior authorization?
Your health care provider has access to your formulary and the prior authorization request form through the Providence Health Plan website. Although most providers are familiar with the process, if you're seeking care from an out-of-network provider, let him/her know that some drugs require prior authorization and ask them to call Providence's pharmacy team with questions. The direct number is 877-216-3644.
If you encounter a denial at the pharmacy because your provider did not contact us to initiate a prior authorization, call our pharmacy team and we will contact the provider on your behalf to begin the prior authorization process.
How will I know if a request for prior authorization was approved?
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.
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What are specialty drugs?
Specialty drugs are prescriptions that require special delivery, handling, administration and monitoring by your pharmacist. These drugs are often for certain chronic and/or long-term conditions, such as MS, cancer, and rheumatoid arthritis. Specialty drugs are available through Credena Health.
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What is a generic drug?
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.
Are brand-name and generic drugs equivalent?
A generic prescription drug is equivalent to the brand-name prescription 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, Zocor® is available from multiple manufacturers under the generic name simvastatin. Zocor® and simvastatin are identical drugs - the only difference is one is a brand-name, the other is generic and costs much less.
My drug does not have a generic equivalent. Is there a generic alternative?
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. For example, for high cholesterol, simvastatin (the generic form of Zocor®) may be prescribed instead of Lipitor®. A new prescription is needed to obtain a generic alternative drug.
Where can I find more information about generics?
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New member transition
If you are a new member to our plan, you may be notified about a drug you are taking that is not on our 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 90-day supply or up to three 30-day supplies when you go to a network pharmacy (unless you have a prescription written for fewer days or there is a quantity limit). After your first 90-day supply of these medications, we will require medical necessity review even if you have been a member of the plan less than 90 days.