PROVIDENCE MEDICARE ADVANTAGE PLANS 2023 FORMULARY

Welcome

Your Providence Medicare Advantage Plan covers both brand name drugs and generic drugs. Generic drugs have the same active-ingredient formula as a 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 effective as brand name drugs.

Important Message About What You Pay for Vaccines- Our plan covers most Part D vaccines at no cost to you (For Prime plan members: even if you haven’t paid your deductible). Call Customer Service for more information.

Important Message About What You Pay for Insulin - You won’t pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it’s on (For Prime plan members: even if you haven’t paid your deductible).

COVID-19 Vaccination

Vaccination is a safe, effective, and reliable way to prevent getting sick from COVID-19. Getting vaccinated is one of the best ways to protect you and your family.

COVID-19 vaccines are available at no cost
All FDA-authorized and FDA-approved COVID-19 vaccines are provided at no charge to you, no matter where you get the vaccine. This includes when multiple doses are required and recommended boosters.

Everyone 6 months of age and older is eligible to get a COVID-19 vaccine

The most current vaccine information, including recommendations for boosters and special populations, can be found on the CDC website.

For the most update to information on COVID-19 Vaccine, please visit our Frequently Asked Questions (FAQ) page.

Influenza

Influenza — also known as the flu — is a highly contagious respiratory virus. The effects of the flu vary from person to person and range from mild to severe. The best protection against the flu is to get a flu shot each year.

Did you know that you may be able to get a flu shot at an in-network pharmacy?

Flu vaccines are available at many retail pharmacy locations or through your in-network health care provider.

Going to the pharmacy is a convenient option as generally no appointment is needed and flu shots are covered at no cost to our members with proof of insurance.

To find an in-network pharmacy: You can call Customer Service at 503-574-7500 (TTY: 711), Pharmacy Services at 503-574-7400 (TTY: 711), or access the Pharmacy Directory.

What is a Formulary?

A formulary is a list of covered drugs which represents the prescription therapies believed to be a necessary part of a quality treatment program. We will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Printable Files

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How to Search For Drugs

Use the alphabetical list to search by the first letter of your medication.

Search by typing part of the generic (chemical) and brand (trade) names.

Search by selecting the therapeutic class of the medication you are looking for.

How to Request an Exception

You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make:

You can ask us to cover your drug even if it is not on our formulary.

You can ask us to waive coverage restrictions or limits on your drug.

You can ask us to provide a higher level of coverage for your drug.

Additional information

Can the formulary change?

Best Available Evidence- Centers for Medicare & Medicaid Services

The formulary and pharmacy network may change at any time. You will receive notice when necessary.

You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction exception. When you are requesting a formulary or utilization restriction exception you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescribing physician’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescribing physician’s supporting statement.

Providence Medicare Advantage Plans is an HMO, HMO-POS, and HMO SNP with Medicare and Oregon Health Plan contracts. Enrollment in Providence Medicare Advantage Plans depends on contract renewal.

For questions, please contact Providence Health Assurance Customer Service at 503-574-8000 or 1-800-603-2340 or, for TTY users, 711, seven days a week, between 8 a.m. and 8 p.m. (Pacific time).

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