Pharmacy benefit plans

Many of your client's employees likely rely on prescription medications to maintain their everyday health and manage conditions, such as high blood pressure, diabetes and depression. Employers and employees alike are looking for options that will allow them to save money on crucial medications.

Providence offers several pharmacy benefit plans with different broad formulary options that supplement your client's Providence medical plans. Our different plan types and options enable your clients to configure the level of coverage and cost-sharing that works best for your client's business and employees.

Plan features

All pharmacy plans – five-tier plans and value-based plans – include:

  • Preventive prescription medications covered in full on ACA preventive prescription medication
  • Access to more than 26,000 participating pharmacies
  • A 90-day pharmacy transition period for most prescriptions that normally require prior authorization for newly enrolled members
  • No separate out-of-pocket maximum
  • Care management for members with chronic conditions, including support for medication adherence, help identifying harmful drug interactions and help
  • identifying opportunities to reduce health care costs

For more information on these products, formularies or participating pharmacies, see pharmacy resources.

To get a list of preventive medications Providence Health Plan covers without imposing a copayment, coinsurance or deductible, download the Affordable Care Act (ACA) list of preventive prescription medications (PDF).

Five-tier pharmacy plans

Five-tier pharmacy plans features

  • Prescription cost-shares do not apply to the medical deductible, but do go toward the medical plan out-of-pocket maximum
  • Coverage for preventive, preferred generic, generic, preferred brand-name and brand name, specialty and compound medication
  • 90-day supply of maintenance medication through the preferred retail or mail order service for two times the cost of a 30-day supply at a retail pharmacy

Five-tier pharmacy plans

Rx 0/10/15/20/50

   Retail Preferred retail/
Mail order
Preventive $0 $0
Preferred generic $10 $20
Generic $15 $30
Preferred brand $20 $40
Brand name 50% - $100 50% - $200
Specialty and compound drugs
(limited to a 30-day supply)*
50% - $100 ——

* Specialty prescription drugs are not available with the Mail Order/Maintenance benefit, are limited to a 30-day supply, and must be obtained through the Providence Health Plan participating specialty pharmacy. 90-day supplies of maintenance medication can only be obtained through a preferred retail pharmacy or the mail order service.


Rx 0/15/20/30/50

   Retail Preferred retail/
Mail order
Preventive $0 $0
Preferred generic $15 $30
Generic $20 $40
Preferred brand $30 $60
Brand name 50%-$100 50%-$200
Specialty and compound drugs
(limited to a 30-day supply)*
50%-$100 ——

* Specialty prescription drugs are not available with the Mail Order/Maintenance benefit, are limited to a 30-day supply, and must be obtained through the Providence Health Plan participating specialty pharmacy. 90-day supplies of maintenance medication can only be obtained through a preferred retail pharmacy or the mail order service.


Rx 0/15/20/45/50

   Retail Preferred retail/
Mail order
Preventive $0 $0
Preferred generic $15 $30
Generic $20 $40
Preferred brand $45 $90
Brand name 50%-$100 50%-$200
Specialty and compound drugs
(limited to a 30-day supply)*
50%-$100 ——

* Specialty prescription drugs are not available with the Mail Order/Maintenance benefit, are limited to a 30-day supply, and must be obtained through the Providence Health Plan participating specialty pharmacy. 90-day supplies of maintenance medication can only be obtained through a preferred retail pharmacy or the mail order service.


Rx 0/15/25/40/50

   Retail Preferred retail/
Mail order
Preventive $0 $0
Preferred generic $20 $40
Generic $25 $50
Preferred brand $40 $80
Brand name 50%-$100 50%-$200
Specialty and compound drugs
(limited to a 30-day supply)*
50%-$100 ——

* Specialty prescription drugs are not available with the Mail Order/Maintenance benefit, are limited to a 30-day supply, and must be obtained through the Providence Health Plan participating specialty pharmacy. 90-day supplies of maintenance medication can only be obtained through a preferred retail pharmacy or the mail order service.


Rx 0/25/30/50/50

   Retail Preferred retail/
Mail order
Preventive $0 $0
Preferred generic $25 $50
Generic $30 $60
Preferred brand $50 $100
Brand name 50%-$100 50%-$200
Specialty and compound drugs
(limited to a 30-day supply)*
50%-$100 ——

* Specialty prescription drugs are not available with the Mail Order/Maintenance benefit, are limited to a 30-day supply, and must be obtained through the Providence Health Plan participating specialty pharmacy. 90-day supplies of maintenance medication can only be obtained through a preferred retail pharmacy or the mail order service.

Value-based prescription drug plans

Value-based prescription drug plans

Providence's value-based prescription drug plans use a four-tier formulary and offer low copays on a large number of "value drugs" – which is the first tier and includes commonly prescribed, first-line treatments for common risk factors and conditions, such as asthma, diabetes, heart disease, high cholesterol,high blood pressure and depression.

The other tiers of these plans include generic drugs, brand-name drugs included in the Providence formulary and brand-name drugs not included in the formulary. These provide more ways to encourage employees to talk with their care providers and make cost-effective decisions about the medications they take.

 
 

 
Participating/Preferred
Retail 30-Day Supply
 Copays/Coinsurance
Value Generic Formulary
Brand Name
Non-Formulary
Brand Name
 Rx $5/$10/
$30/50%
 $5  $10  $30  50%
 Rx $5/$10/
$50/50%
 $5  $10  $50  50%
 Rx $5/$15/
$30/50%
 $5  $15  $30  50%
 Rx $5/$15/
$40/50%
 $5  $15  $40  50%


 
 

 
Mail Order/Preferred
Retail 90-Day Supply
Maintenance Prescriptions
 Copays/Coinsurance
 Value Generic Formulary
Brand Name
Non-Formulary Brand Name
 Rx $5/$10/
$30/50%
 $15  $30  $90  50%
 Rx $5/$10/
$50/50%
 $15  $30  $150  50%
 Rx $5/$15/
$30/50%
 $15  $45  $90  50%
 Rx $5/$15/
$40/50%
 $15  $45  $150  50%


View benefit summaries for all value-based prescription plans.