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Providence Health Plan is a health plan with a Medicare contract. - page 15 / 32

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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.

Original Medicare

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

General

10% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs.

Drugs Covered under Medicare Part D

General

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.

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