Covenant Advantage (HMO-POS) Formulary



Below is the 2023 Formulary, or prescription drug list, from Covenant Advantage (HMO-POS) by Php Medicare. A formulary is a continually updated list of available medications and prescription drug cost information. Examining a plans formulary can help you find a Michigan 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 Covenant Advantage (HMO-POS)(H7646-002) 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. Php Medicare 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:Covenant Advantage
Plan ID: H7646-002
Provider: Php Medicare
Plan Year:2023
Premium:$0.00
Deductible:$0
Initial Coverage Limit:$4660
Coverage Area:Michigan
Similar Plan:H7646-003


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
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Cabergoline
3$40$45NANN
Cablivi
533%33%NAYN
Cabometyx
533%33%NA30/30YN
Calcipotriene
4$90$95NA120/30NN
Calcitriol
4$90$95NANN
Calcium Acetate
3$40$45NA360/30NN
Calquence
533%33%NA60/30YN
Camila
2$0$10NANN
Candesartan
2$0$10NANN
Candesartan Cilexetil And Hydrochlorothiazide
2$0$10NANN
Caplyta
4$90$95NA30/30NN
Caprelsa
533%33%NA30/30YN
Captopril
2$0$10NANN
Carbamazepine
3$40$45NANN
Carbidopa
2$0$10NANN
Carbidopa And Levodopa
2$0$10NANN
Carbidopa, Levodopa, And Entacapone
4$90$95NANN
Carglumic Acid
533%33%NAYN
Carteolol Hydrochloride
2$0$10NANN
Cartia
2$0$10NANN
Caspofungin Acetate
4$90$95NANN
Cayston
533%33%NA84/56YN
Caziant
2$0$10NANN
Cefaclor
2$0$10NANN
Cefadroxil
2$0$10NANN
Cefazolin
4$90$95NANN
Cefdinir
2$0$10NANN
Cefixime
4$90$95NANN
Cefoxitin
4$90$95NAYN
Cefpodoxime Proxetil
4$90$95NANN
Cefprozil
2$0$10NANN
Ceftazidime
4$90$95NAYN
Ceftriaxone Sodium
4$90$95NANN
Cefuroxime
4$90$95NAYN
Celecoxib
2$0$10NANN
Celontin
4$90$95NANN
Cephalexin
2$0$10NANN
Cevimeline
4$90$95NANN
Chemet
3$40$45NAYN
Chenodal
533%33%NAYN
Chlorpromazine Hydrochloride
4$90$95NANN
Chlorthalidone
2$0$10NANN
Cholbam
533%33%NAYN
Cholestyramine
3$40$45NANN
Ciclopirox
3$40$45NA120/28NN
Ciclopirox Olamine
3$40$45NA60/28NN
Cilostazol
2$0$10NANN
Cimduo
533%33%NANN
Cimetidine
2$0$10NANN
Cimetidine Hydrochloride
2$0$10NANN
Cimzia
533%33%NA2/28YN
Cinacalcet Hydrochloride
4$90$95NAYN
Cinryze
533%33%NAYN
Ciprofloxacin
2$0$10NANN
Ciprofloxacin And Dexamethasone
3$40$45NANN
Ciprofloxacin Otic
4$90$95NANN
Citalopram Hydrobromide
3$40$45NANN
Claravis
4$90$95NANN
Clarithromycin
2$0$10NANN
Clindamycin
4$90$95NAYN
Clindamycin Hydrochloride
2$0$10NANN
Clindamycin In 5 Percent Dextrose
4$90$95NAYN
Clindamycin Palmitate Hydrochloride (pediatric)
4$90$95NANN
Clindamycin Phosphate
3$40$45NANN
Clinimix
4$90$95NAYN
Clobazam
4$90$95NA480/30YN
Clobetasol Propionate
4$90$95NA118/28NN
Clodan
4$90$95NA236/28NN
Clomipramine Hydrochloride
4$90$95NANN
Clonazepam
2$0$10NA300/30NN
Clonidine Hydrochloride
1$0$5NANN
Clonidine Transdermal System
4$90$95NA4/28NN
Clorazepate Dipotassium
3$40$45NA180/30YN
Clotrimazole
2$0$10NANN
Clotrimazole And Betamethasone Dipropionate
4$90$95NA60/28NN
Clotrimazole Topical Solution Usp, 1%
2$0$10NA30/28NN
Clozapine
3$40$45NANN
Coartem
4$90$95NANN
Colchicine
2$0$10NANN
Colesevelam Hydrochloride
4$90$95NANN
Colestipol Hydrochloride
4$90$95NANN
Collagenase Santyl
3$40$45NA180/30NN
Combivent Respimat
3$40$45NA8/30NN
Complera
4$90$95NANN
Compro
4$90$95NANN
Corlanor
3$40$45NA450/30NN
Cotellic
533%33%NA63/28YN
Creon
3$40$45NANN
Cresemba
4$90$95NAYN
Cromolyn Sodium
2$0$10NANN
Crotan
2$0$10NANN
Cryselle
2$0$10NANN
Cyclobenzaprine Hydrochloride
4$90$95NAYN
Cyclophosphamide
3$40$45NAYN
Cyclosporine
3$40$45NAYN
Cyred Eq
2$0$10NANN
Cystagon
4$90$95NAYN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H7646-002

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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