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Providence Health Plan is a health plan with a Medicare contract. - page 16 / 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

Original Medicare

Providence Medicare Extra + RX

29 - Prescription Drugs (continued)

The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition.

Some drugs have quantity limits.

Your provider must get prior authorization from Providence Medicare Extra + RX for certain drugs.

You must go to certain pharmacies for a very limited number of drugs, due to special handling, provider coordination, or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website, formulary, printed materials, as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov.

If the actual cost of a drug is less than the normal cost-sharing amount for that drug, you will pay the actual cost, not the higher cost- sharing amount.

You pay $0 the first time you fill a prescription for certain drugs. These drugs will be listed as "free first fill" on the plan's website, formulary, printed materials, and on the Medicare Prescription Drug Plan Finder on Medicare.gov.

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