MVP Medicare WellSelect with Part D (PPO) Formulary



Below is the 2023 Formulary, or prescription drug list, from MVP Medicare WellSelect with Part D (PPO) by Mvp Health Plan, 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 New York 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 MVP Medicare WellSelect with Part D (PPO)(H9615-010) plan has a $250 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. Mvp Health Plan, 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:MVP Medicare WellSelect with Part D
Plan ID: H9615-010
Provider: Mvp Health Plan, Inc
Plan Year:2023
Premium:$0.00
Deductible:$250
Initial Coverage Limit:$4660
Coverage Area:New York
Similar Plan:H9615-012


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
M-m-r Ii
3YNA$47NANN
Magnesium Sulfate
3YNA$47NANN
Malathion
2NNA$12NANN
Marlissa
2NNA$12NANN
Marplan
4YNA25%NANN
Matulane
5NA27%NANN
Mavyret
5NA27%NAYN
Mayzent
5NA27%NANN
Meclizine Hydrochloride
2NNA$12NANN
Medroxyprogesterone Acetate
2NNA$12NANN
Mefloquine Hydrochloride
2NNA$12NANN
Megestrol Acetate
2NNA$12NAYN
Mekinist
5NA27%NAYN
Mektovi
5NA27%NAYN
Memantine
2NNA$12NANN
Memantine Hydrochloride
3YNA$47NANN
Menactra
3YNA$47NANN
Menquadfi
3YNA$47NANN
Menveo
3YNA$47NANN
Mercaptopurine
2NNA$12NANN
Meropenem
2NNA$12NANN
Merzee
2NNA$12NANN
Mesalamine
3YNA$47NANN
Mesnex
3YNA$47NANN
Metaxalone
3YNA$47NANN
Metformin Hydrochloride
1NNA$0NA60/30NN
Methazolamide
2NNA$12NANN
Methenamine Hippurate
2NNA$12NANN
Methimazole
2NNA$12NANN
Methitest
4YNA25%NANN
Methocarbamol
3YNA$47NANN
Methotrexate
3YNA$47NANN
Methoxsalen
5NA27%NANN
Methscopolamine Bromide
2NNA$12NANN
Methylphenidate Hydrochloride
2NNA$12NANN
Methylprednisolone
2NNA$12NANN
Methyltestosterone
4YNA25%NANN
Metoclopramide
2NNA$12NANN
Metolazone
2NNA$12NANN
Metoprolol Succinate
1NNA$0NANN
Metoprolol Tartrate
1NNA$0NANN
Metoprolol Tartrate And Hydrochlorothiazide
1NNA$0NANN
Metronidazole
2NNA$12NANN
Metyrosine
5NA27%NANN
Mexiletine Hydrochloride
3YNA$47NANN
Micafungin
5NA27%NANN
Miglitol
2NNA$12NANN
Miglustat
5NA27%NAYN
Minocycline
2NNA$12NANN
Minocycline Hydrochloride
2NNA$12NANN
Minoxidil
2NNA$12NANN
Mirtazapine
2NNA$12NANN
Moexipril Hydrochloride
1NNA$0NANN
Molindone Hydrochloride
4YNA25%NANN
Mometasone Furoate
2NNA$12NANN
Morphine Sulfate
2NNA$12NA60/30NN
Movantik
3YNA$47NANN
Moxifloxacin
2NNA$12NANN
Mulpleta
5NA27%NAYN
Mupirocin
2NNA$12NANN
Myalept
5NA27%NAYN
Mycapssa
5NA27%NANN
Mycophenolate Mofetil
2NNA$12NAYN
Mycophenolic Acid
3YNA$47NAYN
Myrbetriq
3YNA$47NANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H9615-010

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $250. 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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