Member Pharmacy Transition Process

If you are a current member of Providence Medicare Plans you may notice that a formulary medication, which you are currently taking, is either not on our new 2007 Formulary or coverage is limited. If this is the case, please contact your Customer Service team for assistance at 503-574-8000 or 1-800-603-2340.

Please note: If you had an approved exception request for a formulary or a non-formulary medication in 2006 it will continue to be covered in 2007 according to the limitations and coverage under which it was approved.

As a new member to our plan, you may be taking a drug that is not on our formulary or has a quantity limit, step therapy or requires prior authorization. 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 (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 90-day supply of drugs that are not on our formulary, that require prior authorization, step therapy or exceed our plan quantity limits, we will require medical necessity review even if you have been a member of the plan less than 90-days.

For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that is on our formulary or request a formulary exception so that we will cover the drug you take.

If you are a resident of a long-term care facility, we will cover a temporary 34-day transition supply (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90-days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited; but you are past the first 90-days of membership in our plan, we will cover a 34-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

Providence Medicare Plans uses a “formulary”. Formulary drugs are usually the safest and least expensive first choice drug that effectively treats a medical condition. Providence Medicare Plans generally covers the drugs listed on our formulary when plan rules are followed. Drugs not listed on our formulary are considered non-formulary and are generally not covered.

Providence Medicare Plans covers both brand name drugs and generic drugs. Generic drugs have the same active-ingredient as the brand-name drug. Generic drugs usually cost less than brand-name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and equally effective as brand-name drugs. When a generic drug is available for a brand name drug, the brand name drug will generally not be covered and is considered non-formulary. Some drugs may have additional requirements or limits on coverage. These requirements and limits may include:

• Prior Authorization: Providence Medicare Plans requires you, your appointed representative or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Providence Medicare Plans before you fill your prescriptions. If you don't get approval, Providence Medicare Plans may not cover the drug.
• Quantity Limits: For certain drugs, Providence Medicare Plans limits the amount of the drug that Providence Medicare Plans will cover. For example, Providence Medicare Plans provides 2 packages per prescription for Imitrex. This may be in addition to a standard one month or three month supply.
• Step Therapy: In some cases, Providence Medicare Plans requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Providence Medicare Plans may not cover drug B unless you try Drug A first. If Drug A does not work for you, Providence Medicare Plans will then cover Drug B.

You can access our formulary online (PDF 1.9MB) or if you have questions regarding our formulary or our transition process you may contact the Providence Medicare Plans Customer Service Team at 503-574-8000 or 1-800-603-2340. If you are hearing impaired and use a Teletype (TTY) Device, please call our TTY line at 503-574-8702 or 1-888-244-6642. Customer Service assistance is available to answer Part D (prescription) questions, seven days a week, between 8 a.m. and 8 p.m. For Medical Benefit questions Customer Service assistance is available Monday through Friday, between 8 a.m. and 5 p.m.

The Centers for Medicare and Medicaid Services (CMS) restricts coverage of some drug categories. Providence Medicare Plans will not cover these drugs during your transition. The following are examples of commonly excluded categories not covered under Medicare Part D:

• benzodiazepines (examples: clonazepan, diazepam, lorazepam, temazepam)
• barbiturates (example: phenobarbital and others)
• cough and cold preparations
• erectile dysfunction (ED) drugs (Viagra, Cialis, Levitra, and Caverject)
• vitamins
• over-the-counter (OTC) drugs (OTC exceptions: Prilosec OTC and Claritin OTC)