Amerivantage Rx Basic (PDP) Formulary



Below is the 2023 Formulary, or prescription drug list, from Amerivantage Rx Basic (PDP) by Amerigroup Insurance Company. A formulary is a continually updated list of available medications and prescription drug cost information. Examining a plans formulary can help you find a 2023 Medicare Part-D in Texas 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 Rx Basic (PDP)(S8182-001) 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. Amerigroup Insurance Company 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 Rx Basic (PDP)
Plan ID: S8182-001
Formulary
Provider: Amerigroup Insurance Company
Plan Year:2023
Premium:$79.30
Deductible:$505
Initial Coverage Limit:$4660
Coverage Area:Texas
Similar Plan:S8182-003


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
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Drug
Name⇅
Tier
Level
Deductible
Apply
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Abacavir
4Y40%41%NA960/30NN
Abacavir And Lamivudine
4Y40%41%NA30/30NN
Abelcet
4Y40%41%NAYN
Abilify Maintena
4Y40%41%NA1/28NN
Abiraterone
525%25%NA120/30YN
Abiraterone Acetate
525%25%NA60/30YN
Acarbose
3Y$40$41NA90/30NN
Accutane
4Y40%41%NANN
Acebutolol Hydrochloride
4Y40%41%NANN
Acetaminophen And Codeine Phosphate
3Y$40$41NA900/30NN
Acetazolamide
3Y$40$41NANN
Acetic Acid
3Y$40$41NANN
Acetylcysteine
4Y40%41%NAYN
Acitretin
4Y40%41%NANN
Acthib
3Y$40$41NANN
Actimmune
525%25%NAYN
Acyclovir
4Y40%41%NANN
Acyclovir Sodium
4Y40%41%NAYN
Adefovir Dipivoxil
4Y40%41%NAYN
Adempas
525%25%NAYN
Advair
3Y$40$41NA60/30NN
Advair Hfa
3Y$40$41NA12/30NN
Aimovig
3Y$40$41NA1/28YN
Alacort
2N$1$3NANN
Albendazole
4Y40%41%NANN
Albuterol Sulfate
3Y$40$41NANN
Alclometasone Dipropionate
3Y$40$41NANN
Alecensa
525%25%NA240/30YN
Alendronate Sodium
2N$1$3NA4/28NN
Aliskiren
4Y40%41%NANN
Alprazolam
3Y$40$41NA120/30NN
Altavera
3Y$40$41NANN
Alunbrig
525%25%NA30/180YN
Alyacen 1/35
3Y$40$41NANN
Amabelz
3Y$40$41NAYN
Amantadine Hydrochloride
3Y$40$41NANN
Ambisome
4Y40%41%NAYN
Amikacin Sulfate
4Y40%41%NANN
Amiloride Hydrochloride And Hydrochlorothiazide
2N$1$3NANN
Amiloride Hydrocloride
3Y$40$41NANN
Amiodarone Hydrochloride
3Y$40$41NANN
Amitriptyline Hydrochloride
3Y$40$41NANN
Amlodipine And Benazepril Hydrochloride
2N$1$3NANN
Amlodipine And Valsartan
3Y$40$41NANN
Amlodipine Besylate
1N$0$2NANN
Amlodipine Besylate And Benazepril Hydrochloride
2N$1$3NANN
Ammonium Lactate
3Y$40$41NANN
Amnesteem
4Y40%41%NANN
Amoxapine
3Y$40$41NAYN
Amoxicillin
2N$1$3NANN
Amoxicillin And Clavulanate Potassium
3Y$40$41NANN
Amphotericin B
4Y40%41%NAYN
Ampicillin
4Y40%41%NANN
Ampicillin And Sulbactam
4Y40%41%NANN
Ampicillin Sodium And Sulbactam Sodium
4Y40%41%NANN
Anagrelide
3Y$40$41NANN
Anastrozole
2N$1$3NA30/30NN
Apraclonidine Ophthalmic
3Y$40$41NANN
Aprepitant
4Y40%41%NA15/30YN
Apri
3Y$40$41NANN
Aptivus
525%25%NA120/30NN
Aranelle
3Y$40$41NANN
Aripiprazole
4Y40%41%NA90/30NN
Armodafinil
4Y40%41%NA30/30YN
Arnuity Ellipta
3Y$40$41NA30/30NN
Asenapine
4Y40%41%NA60/30NN
Atenolol And Chlorthalidone
2N$1$3NANN
Atomoxetine
3Y$40$41NA30/30NN
Atovaquone
4Y40%41%NAYN
Atovaquone And Proguanil Hydrochloride Pediatric
4Y40%41%NANN
Atrovent
4Y40%41%NA26/30NN
Aubra Eq
3Y$40$41NANN
Aviane
3Y$40$41NANN
Avita
4Y40%41%NA45/30YN
Ayvakit
525%25%NA30/30YN
Azathioprine
3Y$40$41NAYN
Azelastine Hcl Nasal
3Y$40$41NA30/25NN
Azelastine Hydrochloride
3Y$40$41NA30/25NN
Azithromycin
4Y40%41%NANN
Azopt
4Y40%41%NANN
Aztreonam
4Y40%41%NANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for S8182-001

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 2022 is $320. 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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