Prescription drugs FAQ

Your pharmacy network includes more than 60,000 pharmacies across the nation. To find a network pharmacy near you, use our searchable provider directory or see our Pharmacy Directory booklet.

Customer Service can also help find a network pharmacy or send you a copy of the directory. Call us at 503-416-4279, toll-free at 888-712-3258 or TTY 711. You can also send us a secure message through our member portal. Our hours are 8 a.m. to 8 p.m. seven days a week, October 1 to March 31, and 8 a.m. to 8 p.m. Monday through Friday, April 1 to September 30.

Pharmacies listed in our network can change over time. CareOregon Advantage updates pharmacies listed in our searchable provider directory every month. Check it for current network pharmacies in your area. Or, call Customer Service at 503-416-4279, toll-free at 888-712-3258 or TTY 711. You can also send us a secure message through our member portal. Our hours are 8 a.m. to 8 p.m. seven days a week, October 1 to March 31, and 8 a.m. to 8 p.m. Monday through Friday, April 1 to September 30.

We will send you a letter if your pharmacy leaves our network.

Show your CareOregon Advantage ID card at the pharmacy counter. If you do not have your ID card with you when you fill your prescription, call us at 503-416-4279, toll-free at 888-712-3258 or TTY 711. Our hours are 8 a.m. to 8 p.m. seven days a week, October 1 to March 31, and 8 a.m. to 8 p.m. Monday through Friday, April 1 to September 30. You can also send us a secure message through our member portal. We'll provide you the information needed to get your prescription filled.

If you're unable to call us or it's after hours, you may have to pay the full cost of the prescription (rather than paying just your copayment). If this happens, you can ask us to reimburse you for our share of the cost by submitting a paper claim. Visit our Drug Cost Reimbursement page for more details and to find the form.

With more than 60,000 pharmacies in our national network, please use a network pharmacy whenever you are able. Our searchable provider directory lists network pharmacies near you.

As long as you don't use an out-of-network pharmacy on a regular basis, here are some situations when we will cover up to 30-day supplies for prescriptions:

• You are unable to obtain a covered drug in a timely manner from a network pharmacy that provides 24-hour service and is within a reasonable driving distance.
• You fill a prescription at an out-of-network institution-based pharmacy while you were a patient in an ER, provider-based clinic or outpatient surgery facility.
• You need a prescription drug that is not regularly stocked at an accessible network retail or mail-order pharmacy (including high cost and unique drugs).
• You are traveling outside of our service area (but within the United States or its territories), need a prescription drug and cannot access a network pharmacy.

In some unusual circumstances, you may have to pay full price for your prescription drugs up front, out of your own pocket.

To request reimbursement, start by downloading and completing a Direct Member Reimbursement form and mailing it back to the address that's listed on it. Or, you can call us and ask for the form to be mailed to you. Our number is 503-416-4279, toll-free at 888-712-3258 or TTY 711. Our hours are 8 a.m. to 8 p.m. seven days a week, October 1 to March 31, and 8 a.m. to 8 p.m. Monday through Friday, April 1 to September 30. You can also send us a secure message through our member portal.

Your Medicare Part D benefit includes coverage for an extensive list of prescription drugs, called our formulary.

The formulary is created by a team of practicing doctors and pharmacists who carefully evaluate the available scientific evidence. For some prescription drugs, the team has recommended additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs safely and effectively. For more information about limits on prescription drugs that we cover, please refer to the CareOregon Advantage Prior Authorization and Step Therapy criteria.

Click here to view or print our drug list (formulary) or to check coverage and restrictions for your medications.

• We may add new drugs or new dosage forms to the formulary.
• We may remove or reduce coverage restrictions (like quantity limits, prior authorization or step therapy).
• We may add new generics to the formulary.
• If a drug is withdrawn from the market or becomes excluded by Medicare, we will discontinue coverage.*
• If the Food and Drug Administration deems a drug to be unsafe or the manufacturer voluntarily withdraws the drug from the market, we will immediately remove the drug from our formulary.*
• If a new, less costly generic becomes available, we may discontinue coverage of the brand.*

* If you use these drugs, you will receive notification from us as quickly as possible after we have made the change.

If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions or move a drug to a higher cost-sharing tier, affected members will be notified of the change at least 30 days before the change takes effect.

It's always best to call us before you get a vaccine. You can check on coverage, any restrictions that may apply and explore whether you want to get it at your pharmacy or at your health care provider’s office.

You do not have copays for vaccines you get at a network pharmacy. Note: If you are given a Part D vaccine at your health care provider's office, the office may bill you for the entire cost of your vaccine; most will not bill us directly. If you receive a Part D vaccine at your provider's office and have paid for it, you can ask us to reimburse you up to our allowable cost by submitting a Direct Member Reimbursement form.

Vaccines at the pharmacy
We cover most vaccines given by a pharmacist at a network pharmacy. These include some Part B vaccines, like flu and pneumonia vaccines and some Part D vaccines, like the shingles vaccine. Some vaccines have coverage limits. Please see our drug list (formulary) to check if a vaccine is covered and if any limits apply.

Vaccines given by your health care provider's office
We cover vaccines given by your health care provider. These include Part B vaccines, such as flu and pneumonia. Your health care provider may provide you with Part D vaccines as well. It is likely that the provider's office may bill you for the entire cost of Part D vaccines. You may ask us to reimburse you for Part D vaccines given by your provider by submitting a Direct Member Reimbursement form.

You, your representative or your health care provider can request a coverage determination or a formulary exception. This is the first decision we make about your prescription benefit coverage.

• Call: 503-416-4279, toll-free at 888-712-3258 or TTY 711
• Fax: 503-416-8109 
• Write: CareOregon Advantage
  Attn: Pharmacy
  315 SW Fifth Ave
  Portland, OR 97204
• Email: partdparequests@careoregon.org
• Use our secure online coverage determination form

Generally, we will only approve your request for a formulary exception if the alternative drugs on our formulary or additional use restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. Your doctor must give us a statement supporting your request. This statement can be faxed or mailed to us, or your physician can call us and follow up in writing.

If we make a coverage decision and you are not satisfied with this decision, you can appeal the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made. Your appeal request must be filed within 60 calendar days from the date of notice of the coverage determination denial, unless you have requested and received an appeal filing extension.

You will find information about your appeal rights in Chapter 9 of your Evidence of Coverage.

There are several ways you, your representative or your doctor can request an appeal:

• Call: 503-416-4279, toll-free at 888-712-3258 or TTY 711
• Fill out a Request for Redetermination form and fax, mail or email the completed form to us
• Fax: 503-416-1428
• Write: CareOregon Advantage
  Attn: Pharmacy
  315 SW Fifth Ave
  Portland, OR 97204
• Email: partdparequests@careoregon.org
• Use our secure online appeal form to send us your appeal

Here are some common medications or uses of medication that Medicare Part D does not cover:

• Used for anorexia, weight loss or weight gain (even if used for a non-cosmetic purpose like morbid obesity)
• Used to promote fertility
• Used for cosmetic purposes or hair growth
• Used for symptomatic relief of cough and colds
• Used to treat sexual or erectile dysfunction (ED)
• Prescription vitamin or mineral products (except prenatal vitamins and fluoride preparations)
• Over-the-counter drugs that don't require prescription
• Used as a requirement from a drug manufacturer who requires you to purchase associated tests or monitoring exclusively from that manufacturer or its designated company