Before you fill your prescription at an out-of-network pharmacy, 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 co-insurance or copayment when you fill your prescription). You may ask us to reimburse you for our share of the cost by submitting a paper claim. You should submit a claim to us if you fill a prescription at an out-of-network pharmacy, as any amount you pay for a covered Part D drug will help you qualify for catastrophic coverage. See below for information on how to submit a paper claim.

If we do pay for the drugs you get at an out-of-network pharmacy, you may still pay more for your drugs than what you would have paid if you had gone to an in-network pharmacy.

Please mail or fax in a copy of the itemized prescription receipt along with a copy of the register receipt if available. Please note the register receipt alone is not adequate as it doesn’t have all pertinent information needed for a Direct Member Reimbursement (DMR).

The itemized receipt should contain the following information:

• Pharmacy Name, Address, Phone Number;
• Prescription (Rx) Number;
• Date of Service;
• Drug Name;
• National Drug Code (NDC);
• Quantity and Day Supply;
• Provider Name; and
• Member Cost/Responsibility.

Mail to:
Providence Medicare Advantage Plans
Attn: Pharmacy Services
P.O. Box 3125
Portland, OR 97208-3125

Fax: 503-574-8646 or 1-800-249-7114

Most vaccines given in the provider’s office are considered out-of-network. Please use an in-network pharmacy to receive your vaccines. An in-network pharmacy can process your vaccines directly to PHIP Providence Medicare Advantage Plans. If you receive a vaccine at your provider’s office, you will have to pay full price and submit your receipts for reimbursement.

We will cover prescriptions that are filled at an out-of-network pharmacy for medical emergencies and in some routine situations for up to a 31-day supply. Drugs excluded by federal statute from the Medicare Part D formulary are not eligible for coverage even in emergency or urgent situations.

Coverage for out-of-network access of emergency drugs and some routine drugs will be provided when the member cannot access a network pharmacy and one of the following conditions exist:

• You are traveling outside the service area and run out or lose your covered Part D drugs or become ill and need a covered Part D drug.
• You are unable to obtain a covered drug in a timely manner at a network pharmacy in your service area (e.g. no access to 24 hour/7 days a week network pharmacy).
• You are unable to obtain a particular drug as it is not regularly stocked at an accessible network pharmacy or mail-order pharmacy (e.g. orphan or specialty drug with limited distribution).
• The network mail-order pharmacy is unable to get the covered Part D drug to you in a timely manner and you run out of your drug.
• Drug is dispensed to you by an out-of-network institution-based pharmacy while you are in an emergency department, provider-based clinic, outpatient surgery or other outpatient setting.
  
  

Providence Medicare Advantage Plans can choose not to renew its contract with a partner pharmacy and any pharmacy may also refuse to renew the contract resulting in a termination or non-renewal. This may result in termination of the beneficiary’s in-network coverage at the non-renewing pharmacy. If this happens, you have a transition period to find another in-network pharmacy.

If you have prescription drug coverage please refer to chapter 9 of your plan's Evidence of Coverage (EOC) for more information regarding grievance, determination and appeals processes.

Coverage determinations are the first decisions made by the plan that determine whether or not to provide or pay for a Part D drug and what your share of the cost is for the drug. Coverage determinations include exception requests.

"Standard" coverage determination: For a "standard" coverage determination, the decision will typically be made within a 72-hour timeframe.

"Fast" or "expedited" coverage determination: You can ask for a "fast" coverage determination ONLY if you or your doctor determine that waiting for a standard decision could seriously harm your health or your ability to function. "Fast" decisions only apply for Part D drugs that you have not yet received. A "fast" coverage determination is made typically within 24 hours.

To check status or to request a "standard," "fast" or "expedited" coverage determination: You, your appointed representative or your prescribing physician should contact us by telephone, fax or mail at the numbers or address below:

• Phone: 503-574-7400 or 1-877-216-3644
• Fax: 503-574-8646 or 1-800-249-7714
• Mail to:
  Providence Medicare Advantage Plans
  P.O. Box 3125
  Portland, OR 97208-3125

You, your prescriber or member representative may ask for a coverage decision via secure email by using the drug coverage determination form below:

• Option 1: Submit your application via secure online form.
• Option 2: Download, print and fill out a PDF form (PDF). You can then mail or fax the form to Providence Medicare Advantage Plans.

Please mail or fax in a copy of the itemized prescription receipt along with a copy of the register receipt if available. Please note the register receipt alone is not adequate as it doesn’t have all pertinent information needed for a Direct Member Reimbursement (DMR).

The itemized receipt should contain the following information:

• Pharmacy Name, Address, Phone Number;
• Prescription (Rx) Number;
• Date of Service;
• Drug Name;
• National Drug Code (NDC);
• Quantity and Day Supply;
• Provider Name; and
• Member Cost/Responsibility.

Mail to:

Providence Medicare Advantage Plans
Attn: Pharmacy Services
P.O. Box 3125
Portland, OR 97208-3125

Fax:

503-574-8646 or 1-800-249-7714

Appeals

An appeal is the process that deals with the review of an unfavorable coverage determination. You can file an appeal if you want us to reconsider a decision we have made regarding your Part D prescription drug benefits or cost sharing associated with your Part D drug coverage.

A "standard" appeal decision means we have up to 7 calendar days from the time we receive your request to make a decision on a "standard" appeal.

A "fast" appeal decision means an appeal decision for a Part D drug you have not received may take up to 72 hours from the time we receive your request.

Grievances

A grievance is any complaint or dispute (dissatisfaction) other than one involving a coverage determination. It is different from a coverage determination request; it usually will not involve coverage or payment for Part D drug benefits.

Grievance decisions will be made as quickly as your case requires but no later than 30 calendar days after receiving your complaint.

If you disagree with our decision not to give you a fast decision, you may file an expedited grievance with us. We will respond to your expedited grievance within 24 hours.

To check status or to request a "standard," "fast" or "expedited" appeal or a grievance: You, your appointed representative or your prescribing physician should contact us by telephone, fax, mail or hand deliver using the contact information below:

Phone:

503-574-8000 or 1-800-603-2340

Fax:

503-574-8757 or 1-800-396-4778

Mail to:

Providence Medicare Advantage Plans
Attn: Appeals and Grievance Department
P.O. Box 4158
Portland, OR 97208-4158

Hand deliver to:

Providence Medicare Advantage Plans
3601 SW Murray Blvd., Suite 10
Beaverton, OR 97005

You, your prescriber or member representative may ask for a redetermination (appeal) by completing the following request form:

• Option 1: Submit your application via secure online form.
• Option 2: Download, print and fill out a PDF form, Request for Redetermination of Medicare Prescription Drug Denial. You can then mail or fax the form to Providence Medicare Advantage Plans.

You may name a relative, friend, lawyer, advocate, doctor or anyone else to act for you. Other persons may already be authorized by the Court or in accordance with State law to act for you. If you want someone to act for you who is not already authorized by the Court or under State law, then you and that person must sign and date a statement that gives the person legal permission to be your representative. To learn how to name your representative, you may call customer service.

If you would prefer that someone else act on your behalf, please fill out the CMS' appointment of representative form (PDF), sign and return in one of the following ways:

Mail to:

Providence Medicare Advantage Plans
Attn: Appeals and Grievance Department
P.O. Box 4158
Portland, OR 97208-4158

Fax:

503-574-8757 or 1-800-396-4778

Call – if it is a fast appeal:

503-574-8000 or 1-800-603-2340

Visit us at:

Providence Medicare Advantage Plans
Appeals and Grievance Department
3601 SW Murray Blvd., Suite 10
Beaverton, OR 97005

If you have complaints or concerns about Providence Medicare Advantage Plans and would like to contact Medicare directly please use the CMS' complaint form.

The Office of the Medicare Ombudsman (OMO) helps you with complaints, grievances, and information requests.

Call 1-800-603-2340 or 503-574-8000, TTY: 711, Monday through Sunday, 8 a.m. to 8 p.m. (Pacific Time).

Other resources

Medicare Rights Center
Toll free: 1-888-HMO-9050 (1-888-466-9050)

Elder Care Locater
Toll-free: 1-800-677-1116

1-800-Medicare
(1-800-633-4227)
TTY: 1-877-486-2048

Providence Medicare Advantage Plans uses a List of Covered Drugs (formulary or “Drug List”). The Drug List includes Part D prescription drugs that are covered by Providence Medicare Advantage Plans. The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. The list must meet requirements set by Medicare. You may get a copy of the most current formulary. Providence Medicare Advantage 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: For certain drugs, you or your provider need to get approval from Providence Medicare Advantage Plans before we agree to cover the drug for you. This is called “prior authorization.” This means that your provider will need to contact us before you fill your prescription. If you don't get approval, Providence Medicare Advantage Plans may not cover the drug.
• Quantity Limits: For certain drugs, Providence Medicare Advantage Plans limits the amount of the drug that you can have per prescription or for a defined period of time. For example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day.
• Step Therapy: In some cases, Providence Medicare Advantage 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, we may not cover drug B unless you try Drug A first. If Drug A does not work for you, then we will cover Drug B. This requirement encourages you to try safer or more effective drugs before the plan covers another drug.

You can access the Providence Medicare Advantage Plans formulary online 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 711.

Customer service is available between 8 a.m. and 8 p.m., seven days a week (Pacific Time).

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

• Non-prescription drugs (also called over-the counter);
• Drugs when used to promote fertility;
• Drugs when used for the relief of cough and cold symptoms;
• Drugs when used for cosmetic purposes or to promote hair growth;
• Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations;
• Drugs when used for the treatment of sexual or erectile dysfunction, such as Viagra, Cialis, Levitra, and Caverject;
• Drugs when used for the treatment of anorexia, weight loss, or weight gain; and
• Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale.

If you are a current member of Providence Medicare Advantage Plans you may be affected by changes in our formulary from one year to the next. You may notice that the drug you are currently taking is no longer on the plan’s drug list (formulary) or the drug you are taking is now restricted in some way. If your drug is not on our drug list or is restricted in some way and you need help switching to a different drug that we cover or requesting a formulary exception, please contact your customer service team at 503-574-8000 or 1-800-603-2340 (TTY: 711). Service is available from 8 a.m. to 8 p.m. (Pacific Time), seven days a week.

As a new member to our plan, you may be taking a drug that is not on our Drug List (formulary) or has certain restrictions, such as prior authorization, step therapy or quantity limits. While you talk to your doctor to determine the right course of action for you, we will cover a temporary 30-day supply (if you have a prescription written for fewer days, we will allow multiple fills to provide up to a maximum of 30 days of medication) when you go to a network pharmacy. After your first 30-day supply of drugs that are not on our Drug List or drugs that are restricted in some way, 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 31-day transition supply (unless you have a prescription written for fewer days). If necessary, we will cover more than one refill of these drugs during the first 90 days you are a member of our plan. If you need a drug that is not on our Drug List or is subject to other restrictions, such as step therapy, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless the prescription is for fewer days) while you pursue a formulary exception.