Tribute Advantage (HMO-POS D-SNP) Formulary



Below is the 2023 Formulary, or prescription drug list, from Tribute Advantage (HMO-POS D-SNP) by Arkansas Superior Select, Inc. A formulary is a continually updated list of available medications and prescription drug cost information. Examining a plans formulary can help you find a Arkansas Medicare Part-C plan that covers your prescriptions. It also helps you compare costs among Medicare Part D and Medicare Advantage plans available to you. You’ll want to make sure the medicines you are currently taking are covered under any plans you are considering enrolling in.

This Tribute Advantage (HMO-POS D-SNP)(H1587-001) plan has a $505 drug deductible. A deductible is the amount of expenses that must be paid out of pocket before the Initial Coverage period begins. However, some drugs do not require that the deductible is met before you receive coverage. You can see if the deductible is required below in the "Does the Deductible Apply" column. The Initial Coverage Limit (ICL) for this plan is $4660. The Initial Coverage Period is the period after the Deductible has been met but before the Coverage Gap phase. Once you and your plan provider have spent $4660 on covered drugs. (Combined amount plus your deductible) You will enter the coverage gap. (AKA "donut hole") Once you reach the coverage gap you will be required to pay 25% of the plan's cost for covered brand-name prescription drugs unless your plan offers additional coverage. You can see if this plan offers coverage in the "donut hole" by clicking the "Coverage Gap" link above the chart.

In 2023 if you have spent $7400 in expenditures you enter the Catastrophic Phase. During the Catastrophic Period you will begin to receive significant coverage. Arkansas Superior Select, Inc will begin paying approximately 95% of your covered medication expenses. You can see if this plan covers your drugs in the Catastrophic Phase by clicking the "Catastrophic" link above the chart.



Plan Overview

Plan Name:Tribute Advantage (HMO-POS D-SNP)
Plan ID: H1587-001
Provider: Arkansas Superior Select, Inc
Plan Year:2023
Premium:$0.00
Deductible:$505
Initial Coverage Limit:$4660
Coverage Area:Arkansas
Similar Plan:H1587-003


Change Table Options:

Drugs Starting Letter:
Coverage Phase:

*Tip Click the Drug name to Compare Coverage and Retail Cost for Every Plan In Your Area
⇅ Click the Header to Sort
Drug
Name⇅
Tier
Level
Deductible
Apply
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Tabloid
1YNA$0NANN
Tabrecta
1YNA$0NA120/30YN
Tacrolimus
1YNA$0NANN
Tafinlar
1YNA$0NA120/30YN
Tagrisso
1YNA$0NA30/30YN
Takhzyro
1YNA$0NAYN
Talzenna
1YNA$0NA30/30YN
Tamoxifen Citrate
1YNA$0NANN
Tamsulosin Hydrochloride
1YNA$0NANN
Tarina Fe 1/20 Eq
1YNA$0NANN
Tasigna
1YNA$0NA120/30YN
Tavneos
1YNA$0NAYN
Tazarotene
1YNA$0NAYN
Tazorac
1YNA$0NAYN
Tazverik
1YNA$0NAYN
Tdvax
1YNA$0NAYN
Teflaro
1YNA$0NANN
Tegsedi
1YNA$0NAYN
Telmisartan And Amlodipine
1YNA$0NANN
Temazepam
1YNA$0NA30/30NN
Tenofovir Disproxil Fumarate
1YNA$0NANN
Terazosin
1YNA$0NANN
Terbutaline Sulfate
1YNA$0NANN
Terconazole
1YNA$0NANN
Teriparatide
1YNA$0NAYN
Testosterone
1YNA$0NAYN
Testosterone Cypionate
1YNA$0NAYN
Testosterone Enanthate
1YNA$0NAYN
Tetracycline Hydrochloride
1YNA$0NANN
Theophylline
1YNA$0NANN
Thioridazine Hydrochloride
1YNA$0NAYN
Thiothixene
1YNA$0NAYN
Tiagabine Hydrochloride
1YNA$0NANN
Tibsovo
1YNA$0NAYN
Ticovac
1YNA$0NANN
Tigecycline
1YNA$0NANN
Timolol Maleate
1YNA$0NANN
Timolol Maleate Ophthalmic Gel Forming Solution, 0
1YNA$0NANN
Tindazole
1YNA$0NANN
Tinidazole
1YNA$0NANN
Tivicay
1YNA$0NANN
Tivicay Pd
1YNA$0NANN
Tizanidine Hydrochloride
1YNA$0NANN
Tobramycin
1YNA$0NANN
Tobramycin And Dexamethasone
1YNA$0NANN
Tolterodine Tartrate
1YNA$0NANN
Topiramate
1YNA$0NANN
Toremifene Citrate
1YNA$0NAYN
Torsemide
1YNA$0NANN
Tpn Electrolytes
1YNA$0NAYN
Tramadol Hydrochloride And Acetaminophen
1YNA$0NA240/30NN
Trandolapril
1YNA$0NANN
Tranexamic Acid
1YNA$0NANN
Tranylcypromine Sulfate
1YNA$0NANN
Travoprost Ophthalmic Solution
1YNA$0NANN
Trazodone Hydrochloride
1YNA$0NANN
Trecator
1YNA$0NANN
Trelegy Ellipta
1YNA$0NANN
Trelstar
1YNA$0NAYN
Tresiba
1YNA$0NANN
Tretinoin
1YNA$0NANN
Trexall
1YNA$0NAYN
Tri-estarylla
1YNA$0NANN
Tri-sprintec
1YNA$0NANN
Triamcinolone Acetonide
1YNA$0NANN
Triazolam
1YNA$0NANN
Trientine Hydrochloride
1YNA$0NAYN
Trifluoperazine Hydrochloride
1YNA$0NAYN
Trifluridine
1YNA$0NANN
Trihexyphenidyl Hydrochloride
1YNA$0NANN
Trikafta
1YNA$0NA84/28YN
Trimethobenzamide Hydrochloride
1YNA$0NANN
Trimethoprim
1YNA$0NANN
Trimipramine Maleate
1YNA$0NANN
Triumeq
1YNA$0NANN
Trivora
1YNA$0NANN
Trizivir
1YNA$0NANN
Trophamine
1YNA$0NAYN
Trospium Chloride
1YNA$0NANN
Truseltiq
1YNA$0NA42/28YN
Tukysa
1YNA$0NA120/30YN
Turalio
1YNA$0NAYN
Twinrix
1YNA$0NANN
Tybost
1YNA$0NANN
Tymlos
1YNA$0NAYN
Typhim Vi
1YNA$0NANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H1587-001

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $505. Some plans offer select Pre-deductible drug Coverage
2. Initial Coverage: (ICL) After you reach the plans deductible but before the Initial Coverage limit of $4660
3. Coverage Gap: (AKA Donut Hole) After you reach the plans ICL but before the Catastrophic of $7400 in 2023.
4. Catastrophic: Anything over $7400 you will receive a significant increase in coverage.

Definitions:

Premium: A monthly flat fee that varies by plan.
Deductible: The amount you must pay each year for your prescriptions before your plan begins to pay its share of your covered drugs. The max in 2023 is $505. Some plans have a $0 Deductible.
Tier Level: Medicare drug plans place drugs into different "tiers" on their formularies. Drugs in each tier have a different cost. A drug in a lower tier will generally cost you less.
Quantity Limit Amount/Days: Certain drugs have a Quantity Limit. That means the plan will only cover the drug up to a designated quantity or amount. If your prescribing doctor feels it is necessary to exceed the set limit, he or she must get prior approval before the higher quantity will be covered.
Prior Authorization: Certain Drugs require you or your doctor to get prior authorization to be covered. Usually just an additional form. If you dont get approval, the plan may not cover the drug.
Does the Deduct Apply: Some drugs do not require that the deductible is met before you receive coverage.
Step Therapy: Means you must first try one drug to treat your medical condition before the plan will cover another drug for the same condition. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.
Cost Preferred: Your Cost for the Drug at the Providers In-Network Preferred Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Non-Preferred: Your Cost for the Prescription Drug at a Non-Preferred Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Mail: Your Cost for Prescription Drugs through a Mail Order Pharmacy. As a Percent of the total drug cost or a flat rate.


What if a drug I need is not listed?

Please check the formulary for different brand and generic names. If you still cannot locate your drugs, your plan may not offer coverage. Talk to your doctor first about changing your prescription to a drug on your plan's formulary. If this is not an option, you can request an exception to have the plan review its coverage decision based on your individual circumstances.

Last updated on

Source:CMS Formulary Data Q4 2022
Source:NDC Directory by FDA.gov

**We make every attempt to keep our information accurate. But please check with the plan providers to verify all information.

      Site Search:

MedicareHelp.org is a privately-owned Non-governmental agency. The government website can be found at HealthCare.gov.

Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options. Enrollment depends on the plan’s contract renewal.

Every year, Medicare evaluates plans based on a 5-star rating system.