Medicare Pharmacy Questions

• What is a formulary?
• Can the Formulary change?
• How will I find out if my drug coverage has been changed?
• How to I find an in-network pharmacy in my area?
• Filling prescriptions outside of the network
• Medication Therapy Management (MTM) Program
• Who Qualifies for MTM in 2010?

Providence Medicare Advantage Plans uses a List of Covered Drugs (formulary or “Drug List”). The Drug List tells which Part D prescription drugs 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 will get a copy of the formulary. You may also review the most current version here (PDF).

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Yes, Providence Health Plan may make certain changes to our formulary during the year, Most changes in the formulary happen at the beginning of each year (January 1). However, during the year there may also be changes. For example, the plan might:

• Add or remove drugs from the Drug List. New drugs, including new generic drugs may become available or there is a new use for an existing drug. We may remove a drug because it has been found to be ineffective or there may be a drug recall.
• Add or remove restrictions on coverage for a drug. (for more information about restrictions on drug coverage, refer to your Member Handbook/Evidence of Coverage.
• Replace a brand-name drug with a generic drug

In most cases Providence Medicare Advantage Plans must get approval from Medicare for changes that we make to the plan’s Drug List. To get updated information about the drugs covered by Providence Health Plan, please call Customer Service at 1-800-603-2340, seven days a week, from 8 a.m. to 8 p.m. TTY/TDD users should call 1-888-244-6642.

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Providence Health Plan has approximately 20,000 participating pharmacies available for your use nationwide.

You may look in your Provider Directory, visit our website (link to provider directory), or call Customer Service, whichever is easiest for you. You may also contact Customer Service to request a revised list of in-network pharmacies by dialing 503-574-8000 or 1-800-603-2340, seven days a week from 8 a.m. to 8 p.m. (TTY/TDD Users should call 503-574-8702 or 1-888-244-6642.)

Note: Providence Health Plan has contracts with pharmacies that equals or exceeds the Centers for Medicare and Medicaid requirements for pharmacy access in your area.

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Providence Health Plan has approximately 20,000 participating pharmacies available for your use nationwide. Generally, we only cover drugs filled at an out-of-network pharmacy only when a network pharmacy is not available. Before you fill your prescription in these situations, call Customer Service to see if there is a network pharmacy in your area where you can fill your prescription. Below are some circumstances when we would cover prescriptions filled at an out-of-network pharmacy:

• Coverage for out-of-network access of emergency drugs and some routine drugs will be provided when the member cannot access a network pharmacy and one of the following conditions exists: You are traveling outside the service area and run out or lose your covered drugs or become ill and need a covered drug.
• You are unable to obtain a covered drug in a timely manner at a network pharmacy in your service area (e.g. no access to a 24 hour/7 day a week network pharmacy).
• You are unable to obtain a particular drug as it is not regularly stocked at an accessible network pharmacy or mail order pharmacy (e.g. orphan or specialty drug with limited distribution).
• The network mail-order pharmacy is unable to get the covered drug to you in a timely manner and you run out of your drug.
• Drug is dispensed to you by an out-of-network institution based pharmacy while you are in an emergency department, provider-based clinic, outpatient surgery, or other outpatient settings.

If you do go to an out-of-network pharmacy for the reasons listed above, you may have to pay the full cost (rather than paying just your copayment) when you fill your prescription. You can ask us to reimburse you for our share of the cost. Send us your request for payment, along with your documentation of any payment you have made., You may pay more for a drug purchased at an out-of-network pharmacy because the out-of-network pharmacy's price is higher than what a network pharmacy would have charged. You should submit a claim to us if you fill a prescription at an out-of-network pharmacy as any amount you pay, consistent with the circumstances listed above, will help you qualify for catastrophic coverage.

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The MTM program is designed to help us provide better coverage for our members.

• It helps make sure that our members are using appropriate drugs to treat their medical conditions and helps reduce the risk of adverse events and adverse drug interactions.
• The MTM program is offered to members who meet specific criteria.
• Once beneficiaries are identified as meeting the criteria they will be automatically enrolled into the MTM Program.
• There is no additional cost for members. Contact Providence Health Plan for more information.

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Medicare Part-D members must meet ALL three criteria to qualify for MTM:

• Members must have three or more chronic medical conditions.
• Members must have filled seven or more covered Part D drugs.
• Members must be likely to incur annual total costs of at least $3000 for all Part D drugs.

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