SUMMARY OF BENEFITS
If you have any questions about this plan’s benefits or costs, please contact Providence Health Plan.
Benefit Category 29 - Prescription Drugs
See page 27-28 for additional information about Prescription Drugs.
Most drugs are not covered under Original Medicare. You can add prescription drug coverage to Original Medicare by joining a Medicare Prescription Drug Plan, or you can get all your Medicare coverage, including prescription drug coverage, by joining a Medicare Advantage Plan or a Medicare Cost Plan that offers prescription drug coverage.
Providence Medicare Extra + RX
Drugs covered under Medicare Part B
10% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs.
Drugs Covered under Medicare Part D
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at
www.providence.org/healthplans on the web.
Different out-of-pocket costs may apply for people who
have limited incomes, live in long term care facilities, or have access to Indian/Tribal/Urban (Indian Health Service).
The plan offers national in-network prescription coverage (i.e., this would include 50 states and DC). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel).
Total yearly drug costs are the total drug costs paid by both you and the plan.