Amerivantage Comfort (HMO I-SNP) Formulary



Below is the 2023 Formulary, or prescription drug list, from Amerivantage Comfort (HMO I-SNP) by Amerigroup Texas, 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 Arizona 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 Amerivantage Comfort (HMO I-SNP)(H2593-019) plan has a $0 drug deductible. 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. Amerigroup Texas, 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:Amerivantage Comfort (HMO I-SNP)
Plan ID: H2593-019
Provider: Amerigroup Texas, Inc
Plan Year:2023
Premium:$0.00
Deductible:$0
Initial Coverage Limit:$4660
Coverage Area:Arizona
Similar Plan:H2593-021


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
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Drug
Name⇅
Tier
Level
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Abacavir
3NA$40NA960/30NN
Abacavir And Lamivudine
4NA$85NA30/30NN
Abelcet
4NA$85NAYN
Abilify Maintena
5NA33%NA1/28NN
Abiraterone
5NA33%NA120/30YN
Abiraterone Acetate
5NA33%NA60/30YN
Acarbose
2NA$7.5NA90/30NN
Accutane
4NA$85NANN
Acebutolol Hydrochloride
2NA$7.5NANN
Acetaminophen And Codeine Phosphate
2NA$7.5NA900/30NN
Acetazolamide
2NA$7.5NANN
Acetic Acid
2NA$7.5NANN
Acetylcysteine
2NA$7.5NAYN
Acitretin
4NA$85NANN
Acthib
3NA$40NANN
Actimmune
5NA33%NAYN
Acyclovir
2NA$7.5NANN
Acyclovir Sodium
2NA$7.5NAYN
Adapalene
2NA$7.5NANN
Adefovir Dipivoxil
4NA$85NAYN
Adempas
5NA33%NAYN
Advair
3NA$40NA60/30NN
Advair Hfa
3NA$40NA12/30NN
Aimovig
3NA$40NA1/28YN
Alacort
2NA$7.5NANN
Albendazole
5NA33%NANN
Albuterol Sulfate
2NA$7.5NANN
Alclometasone Dipropionate
2NA$7.5NANN
Alecensa
5NA33%NA240/30YN
Alendronate Sodium
2NA$7.5NA4/28NN
Aliskiren
3NA$40NANN
Alosetron Hydrochloride
5NA33%NA60/30YN
Alprazolam
2NA$7.5NA120/30NN
Altavera
2NA$7.5NANN
Alunbrig
5NA33%NA30/180YN
Alyacen 1/35
2NA$7.5NANN
Amantadine Hydrochloride
2NA$7.5NANN
Ambisome
5NA33%NAYN
Amikacin Sulfate
2NA$7.5NANN
Amiloride Hydrochloride And Hydrochlorothiazide
2NA$7.5NANN
Amiloride Hydrocloride
2NA$7.5NANN
Amiodarone Hydrochloride
2NA$7.5NANN
Amitriptyline Hydrochloride
2NA$7.5NANN
Amlodipine And Benazepril Hydrochloride
6NA$0NANN
Amlodipine And Olmesartan Medoxomil
2NA$7.5NANN
Amlodipine And Valsartan
6NA$0NANN
Amlodipine Besylate
1NA$0NANN
Amlodipine Besylate And Benazepril Hydrochloride
6NA$0NANN
Ammonium Lactate
2NA$7.5NANN
Amnesteem
4NA$85NANN
Amoxapine
2NA$7.5NAYN
Amoxicillin
2NA$7.5NANN
Amoxicillin And Clavulanate Potassium
2NA$7.5NANN
Amphotericin B
2NA$7.5NAYN
Ampicillin
2NA$7.5NANN
Ampicillin And Sulbactam
2NA$7.5NANN
Ampicillin Sodium And Sulbactam Sodium
2NA$7.5NANN
Anagrelide
2NA$7.5NANN
Anastrozole
2NA$7.5NA30/30NN
Apraclonidine Ophthalmic
2NA$7.5NANN
Aprepitant
4NA$85NA15/30YN
Apri
2NA$7.5NANN
Aptivus
5NA33%NA120/30NN
Aralast
5NA33%NAYN
Aranelle
2NA$7.5NANN
Aripiprazole
4NA$85NA90/30NN
Aristada
5NA33%NA/60NN
Aristada Initio
5NA33%NA/365NN
Armodafinil
3NA$40NA30/30YN
Arnuity Ellipta
3NA$40NA30/30NN
Asenapine
4NA$85NA60/30NN
Atenolol And Chlorthalidone
1NA$0NANN
Atomoxetine
4NA$85NA30/30NN
Atovaquone
4NA$85NAYN
Atrovent
3NA$40NA26/30NN
Aubra Eq
2NA$7.5NANN
Auryxia
5NA33%NAYN
Austedo
5NA33%NA120/30YN
Aviane
2NA$7.5NANN
Avita
2NA$7.5NA45/30YN
Avonex
5NA33%NA4/28YN
Ayvakit
5NA33%NA30/30YN
Azasan
3NA$40NAYN
Azathioprine
3NA$40NAYN
Azelastine Hcl Nasal
2NA$7.5NA30/25NN
Azelastine Hydrochloride
2NA$7.5NA30/25NN
Azithromycin
2NA$7.5NANN
Aztreonam
2NA$7.5NANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H2593-019

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $0. 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.

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