Pharmacy Quality and Safety Program
Providence Medicare Advantage Plans is committed to keeping you safe and healthy. Our pharmacy team has programs in place to help make sure your prescription drugs are safe and right for you. These programs look for possible issues—like medication risks or concerns—and alert your pharmacist when needed. If we find a concern, we work with your provider and pharmacist to review your medications. This helps make sure you get the care that is right for you.
What you need to know:
- We review your medications for safety every time you fill a prescription
- We may limit some medications to keep you safe and help keep your prescription costs affordable
- Your provider can request exceptions if needed
- We work with your care team to resolve any issues
How we help keep your medications safe
We regularly review your medications to help make sure they are safe and effective—especially if you see more than one provider. Each time you fill a prescription, we check for problems such as unsafe drug combinations, duplicate medications, or dosing errors. If we find a problem, we work with your provider and pharmacist to resolve it. Our goal is to help make sure you get the medicine that is right for you.
Why do some drugs have rules or limits?
Medicare requires plans to follow certain safety and coverage rules. These rules are developed by doctors and pharmacists to protect your health and support effective, lower-cost treatment, and to:
- Help ensure medications are safe and effective
- Avoid unnecessary or duplicate treatments
- Help keep your drug costs more affordable
What types of medication rules or limits are there?
Some medications have different types of rules to help keep you safe and make sure your treatment works well. These may include using a lower-cost medication that works the same before trying another more expensive option, getting approval before certain medications are covered, or having limits on how much of a medication you can receive at one time. These rules are designed to support safe, effective, and affordable care for everyone.
Getting approval before certain medications
Some medication rules say your provider must ask for approval before the medication is covered. This is called a prior authorization. Prior authorizations help ensure the medication is safe and appropriate for your condition before you receive it. Your provider will request this approval for you.
Trying a lower-cost option first
Some medication rules may require you to try safe, lower-cost options (such as generic medications) first. This is because these medications work in a similar way and work just as well for your condition as a higher-cost medication. This is called step therapy. If it does not work for you, your provider can request a different option.
Limits on how much medication you can receive
For safety reasons, some medications have limits on how much you can get at one time—for example, one pill per day if that is the safe amount. This is called a quantity limit. These limits are based on doses that are known to be safe and effective and help prevent possible harm. You may see the same drug more than once on your covered drug list. This is because there may be different limits or costs that apply for different strengths (such as 10mg verse 100mg), different amounts, or different formulations (such as liquid vs. capsule).
Does the plan make exceptions to these rules or limits?
Medicare sets rules about when a plan can make an exception. If a medication has a rule or limit, you or your provider can ask us to make an exception. This is called a coverage decision. Your provider would need to send us information explaining why the other medications will not work for you. We will then review the request and let you know if we are able to make an exception.