Medicare Pharmacy Questions

• Can the Formulary change?
• How to I find an in-network pharmacy in my area?
• Filling prescriptions outside of the network
• Medication Therapy Management Program
• Who Qualifies for MTM?

Yes, Providence Health Plan may add or remove drugs from our formulary during the year. The enclosed formulary is current as of Jan. 1, 2006. 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. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, we must notify members who take the drug that it will be removed at least 60 days before the date that the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug's manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.

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Providence Health Plan has approximately 20,000 participating pharmacies available for your use nationwide. You may contact your Customer Service Team to find out if a particular pharmacy is within our network or 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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Generally, we only cover drugs filled at an out-of-network pharmacy in limited, non-routine circumstances when a network pharmacy is not available. Below are some circumstances when we would cover prescriptions filled at an out-of-network pharmacy. 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. If you do go to an out-of-network pharmacy for the reasons listed below, 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 by submitting a claim form. However, even after we reimburse you for our share of the cost, 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 help us to identify possible medication errors
• MTM benefits are offered to members who meet specific criteria
• Once beneficiaries are identified as meeting the criteria they will be automatically enrolled into the program
• There is no additional cost for beneficiaries. Contact plan for more information.

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

• Beneficiary must have three (3) or more multiple medical conditions
• Beneficiary must have filled six (6) or more covered Part D drugs
• Beneficiary must be likely to incur annual total costs of at least $4000 for all Part D drugs

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