Pharmacy FAQ

The following addresses many common questions about prescription drug coverage and provides information to help you make the most of your plan benefits.

Pharmacy benefits and prescription drug coverage

Participating pharmacies

Formulary

Prior authorization

Generic drugs

Additional articles and information

Pharmacy benefits and prescription drug coverage

Where can I find information about my prescription drug benefits?

Your benefit information, along with other applicable member materials, is available online through myProvidence.

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What is a specialty drug?

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 formulary with a status of "specialty."

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Where can I fill a prescription for a specialty drug?

Specialty drugs are available through designated pharmacies including Providence Specialty Pharmacy Services. For more information, please call customer service at 503-574-7500 or 800-878-4445.

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What are compounded medications? Are they covered?

Compounded medications are prescriptions that are custom prepared by your pharmacist. These medications must contain at least one FDA-approved drug to be eligible for coverage under your plan benefit.

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Are diabetes supplies covered?

Yes. Diabetes supplies may be ordered through Providence Home Medical Equipment Services and will be delivered directly to you. In addition, diabetes supplies are available through any participating pharmacy. Benefits for diabetes supplies are paid under your group medical supplies and devices benefits; limitations and coinsurance may apply. Please refer to your Benefit Summary for additional information.

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Are there any limitations on covered drugs?

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 formulary lists whether a drug requires prior authorization or has a specific quantity limit.

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Are over-the-counter medications covered?

No. With the exception of insulin, your prescription drug benefit does not cover over-the-counter medications.

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Is my medication approved by the Food and Drug Administration (FDA)?

You may be surprised to learn that there are prescription drugs on 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.

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I have secondary prescription drug coverage through Providence Health Plans. How do I get reimbursed for copays?

  • The pharmacy may submit claims electronically to Providence Health Plan.
  • 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, you may have to pay for the prescription at the time of service and then submit a claim for reimbursement from Providence Health Plan. To request reimbursement, please:
    1. Fill out a prescription drug reimbursement request form (PDF);
    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.

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Participating pharmacies

Where can I fill my prescription?

Your prescription drug benefit requires that you fill prescriptions at a participating pharmacy. You have access to more than 26,000 participating pharmacies and their services nationwide. Search the pharmacy directory to locate a pharmacy near you.

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Can I get a 90-day supply of medication at any pharmacy?

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.

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Can I obtain prescriptions through the mail?

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

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I am going to be out of town; where can I get my prescriptions filled?

  • Plan ahead. You may get a 90-day supply of your prescription at a preferred participating pharmacy or a mail-order pharmacy.
  • Ask your pharmacy if they can mail your prescription medication to you.
  • You have access to more than 26,000 participating pharmacies and their services nationwide. Search the pharmacy directory or call Customer Service to locate a pharmacy near you.

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My pharmacy is unable to bill Providence Health Plan. What should I do?

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

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I paid out-of-pocket for my prescription. Can I get reimbursed?

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.

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What if the pharmacy I want to use is not a participating pharmacy?

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 Providence Health Plan customer service for assistance in locating a participating pharmacy near you. Pharmacies wishing to participate may contact us at 503-574-7400 or 877-216-3644.

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Formulary

What is a formulary?

A formulary is a list of Food and Drug Administration-approved prescription generic, brand-name and specialty medications. The formulary can be a useful resource in helping you and your physician choose effective medications 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 chose a generic drug.

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Where can I find my formulary?

Your formulary is available in the Pharmacy Resources section of this site (www.ProvidenceHealthPlan.com, choose "Members" then "Pharmacy Resources").

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Which formulary applies to me?

There are multiple formularies posted on the Providence Health Plan website. If you need assistance determining which formulary applies to you, please call customer service at 503-574-7500 or 800-878-4445.

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How do I search the formulary?

There are three ways to search the formulary:

  1. By medical condition category: The first section of the formulary lists prescription drugs by the medical condition category that the drug treats (e.g., drugs used to treat heart conditions are listed under the category, Cardiovascular Agents).
  2. By searching the index: The index provides an alphabetical listing of the drugs included in the formulary.
  3. By using the "find" feature: When seeking a specific drug by name, you may use the "find" box at the top of the page.

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What if my drug is not on the formulary?

Nonformulary 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 for the medical condition category. You may also contact Customer Service to confirm whether your drug is covered and/or to ask for a list of similar drugs that are covered.

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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.

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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.

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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:

  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 individuals are always notified in writing at least 60 days before any change.

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Prior authorization

What is prior authorization?

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 medication.

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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.

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What is step therapy?

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 Plans claims history, prior authorization is required.

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Why do some drugs have quantity limits?

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

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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, your doctor or other health care provider can submit a prior authorization request.

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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 (PDF) through the Providence Health Plan website. Your doctor or other health care provider may call us with questions about medication coverage including prior authorization.

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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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Generic drugs

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.

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Are brand-name and generic drugs equivalent?

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.

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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. A new prescription is needed to obtain a generic alternative drug.

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How do I find a generic alternative for my brand-name medication?

  • Search the formulary by medical condition category and look for a medication classified as generic.
  • Visit the Consumer Reports Best Buy Drug website, which has information regarding safe and effective drug use by medical condition.

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Where can I find more information about generics?

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