A formulary (also called a covered drug list) shows which prescription drugs your Part D plan pays for. It also notes if any drugs have rules or limits, like prior authorization, step therapy, or quantity limits. The list is developed with doctors and pharmacists and meets requirements set by the Centers for Medicare & Medicaid Services (CMS). Have questions about coverage rules or limits?

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Yes. Providence Medicare Advantage plans may make changes to our covered drug list during the year. Most changes happen at the beginning of each year (January 1), but changes may also occur during the year. For example, we may:

• Add new drugs (including newly approved medications by the Food and Drug Administration, or FDA)
• Remove drugs due to safety concerns, lack of effectiveness, or if they are taken off the market 
• Move drugs to a different cost-sharing tier (This does not apply to non-formulary drugs or specialty drugs.)
• Add or remove coverage rules, such as prior authorization, step therapy, or quantity limits (See your Member Handbook/Evidence of Coverage for more details.) 
• Replace a brand-name drug with a generic or biosimilar

Most changes to the covered drug list must be approved by the Centers for Medicare & Medicaid Services (CMS). To get the most up-to-date information, call Customer Service at 1-800-603-2340 (TTY 711). Hours are 8 a.m. to 8 p.m. (Pacific Time), 7 days a week from October 1 through March 31, and Monday through Friday from April 1 through September 30.

If we remove drugs from our covered drug list, or add restrictions (such as prior authorization, quantity limits, and/or step therapy), we will send you a notice. In most cases, we will let you know at least 30 days in advance. However, in certain situations, you may receive notice later:

• If a drug is recalled for safety reasons, we will remove it from the covered drug list right away. We will notify members who are taking the drug as soon as possible.
• If a generic becomes available, we will add the generic to the covered drug list and remove the brand-name drug at the same time. We will notify members who are taking the drug as soon as possible.
  

Providence Medicare Advantage Plans has over 34,000 participating pharmacies available for your use nationwide.

You may look in your Provider and Pharmacy Directory, visit our online 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, (TTY 711) 8 a.m. to 8 p.m. (Pacific Time) 7 days a week, October 1st through March 31st and Monday - Friday, April 1st through September 30th.

Note: Providence Medicare Advantage Plans has contracts with pharmacies that equal or exceed the Centers for Medicare and Medicaid Services (CMS) requirements for pharmacy access in your area.

Providence Medicare Advantage Plans has over 34,000 participating pharmacies available for your use nationwide. Generally, we only cover drugs filled at an out-of-network pharmacy when an in-network pharmacy is not available.

Before filling a prescription at an out-of-network pharmacy, call Customer Service to check if there is a network pharmacy nearby. Out-of-network fills are generally limited to a 30-day supply.

Below are some circumstances when we would cover prescriptions filled at an out-of-network pharmacy.

We may cover prescriptions filled at an out-of-network pharmacy in situations like these:

• You are traveling outside the service area and run out of, lose, or need a covered Part D drug
• You cannot get a covered drug in a timely way from a network pharmacy in your service area (for example, no 24-hour network pharmacy is available)
• A covered drug is not regularly stocked at an accessible network or mail-order pharmacy (for example, a specialty drug with limited distribution)
• The network mail-order pharmacy cannot deliver your covered drug before you run out
• You receive a drug from an out-of-network, facility-based pharmacy (such as in an emergency department, outpatient surgery, or clinic)

If you use an out-of-network pharmacy for these reasons, you may have to pay the full cost at the time of purchase rather than just your copayment. You can then ask us to reimburse you for our share of the cost by submitting a request with your itemized receipt(s).

Please note: Out-of-network pharmacies may charge higher prices than network pharmacies, so you may pay more. Any amount you pay for covered drugs in these approved situations will count toward your maximum out-of-pocket costs.

The Providence Medicare Advantage Plans has preferred testing supplies that may be obtained through any participating network pharmacy.

• Traditional blood glucose meters and supplies: Preferred products are Accu-Chek Guide (made by Roche) and Freestyle (made by Abbott).
• Continuous glucose monitors (CGMs) and supplies: CGMs are subject to prior authorization for coverage. Preferred CGMs are Dexcom and Freestyle Libre when used with a receiver/reader.

Non-preferred testing supplies will require prior authorization for coverage. Diabetic testing supplies are paid under your Part B benefit. Please refer to your Benefit Summary for additional information.