Network PlatinumPremier Pharmacy (PPO) Formulary



Below is the 2023 Formulary, or prescription drug list, from Network PlatinumPremier Pharmacy (PPO) by Network Health Insurance Corporation. A formulary is a continually updated list of available medications and prescription drug cost information. Examining a plans formulary can help you find a Wisconsin 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 Network PlatinumPremier Pharmacy (PPO)(H5215-005) plan has a $260 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. Network Health Insurance Corporation 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:Network PlatinumPremier Pharmacy
Plan ID: H5215-005
Provider: Network Health Insurance Corporation
Plan Year:2023
Premium:$126.70
Deductible:$260
Initial Coverage Limit:$4660
Coverage Area:Wisconsin
Similar Plan:H5215-007


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
Nabumetone
2N$8$15$8NN
Nafcillin
4Y$95$100$95NN
Naftin
4Y$95$100$95NN
Naloxone Hydrochloride
2N$8$15$8NN
Namenda
4Y$95$100$95YN
Namzaric
4Y$95$100$95YN
Naprelan
4Y$95$100$95NN
Naproxen
2N$8$15$8NN
Naproxen Sodium
2N$8$15$8NN
Narcan
4Y$95$100$95NN
Nardil
4Y$95$100$95NN
Natacyn
3N$42$47$42NN
Natesto
4Y$95$100$95YN
Natpara (parathyroid Hormone)
529%29%29%YN
Natroba
4Y$95$100$95NN
Nayzilam
529%29%29%NN
Nebivolol
1N$2$5$2NN
Nebupent
4Y$95$100$95YN
Nefazodone Hydrochloride
2N$8$15$8NN
Neo-synalar
4Y$95$100$95NN
Neomycin And Polymyxin B Sulfates And Bacitracin Z
2N$8$15$8NN
Neomycin And Polymyxin B Sulfates And Dexamethason
2N$8$15$8NN
Neomycin And Polymyxin B Sulfates And Gramicidin
2N$8$15$8NN
Neomycin And Polymyxin B Sulfates And Hydrocortiso
2N$8$15$8NN
Neomycin And Polymyxin B Sulfates, Bacitracin Zinc
2N$8$15$8NN
Neomycin Polymyxin B Sulfates And Dexamethasone
2N$8$15$8NN
Neomycin Sulfate
2N$8$15$8NN
Neoral
4Y$95$100$95YN
Nerlynx
529%29%29%240/30YN
Nesina
4Y$95$100$9530/30YN
Neuac
2N$8$15$8NN
Neulasta
529%29%29%NN
Neupogen
529%29%29%NN
Neupro
4Y$95$100$95NN
Neurontin
4Y$95$100$95YN
Nevanac
4Y$95$100$95NN
Nevirapine
4Y$95$100$95NN
Nexavar
529%29%29%YN
Nexium
4Y$95$100$95NN
Nexletol
4Y$95$100$9530/30YN
Nexlizet
4Y$95$100$9530/30YN
Nicotrol
3N$42$47$42NN
Nifedipine
2N$8$15$8NN
Nikki
2N$8$15$8NN
Nilandron
529%29%29%NN
Nilutamide
529%29%29%NN
Nimodipine
4Y$95$100$95NN
Ninlaro
529%29%29%3/28YN
Nisoldipine
2N$8$15$8NN
Nitisinone
529%29%29%NN
Nitro-dur
4Y$95$100$95NN
Nitrofurantoin
3N$42$47$42NN
Nitrofurantoin Macrocrystals
2N$8$15$8NN
Nitrofurantoin Monohydrate/ Macrocrystalline
2N$8$15$8NN
Nitroglycerin
2N$8$15$8NN
Nitroglycerin Lingual
2N$8$15$8NN
Nitrolingual
4Y$95$100$95NN
Nitrostat
4Y$95$100$95NN
Nityr
529%29%29%NN
Nivestym
529%29%29%NN
Nizatidine
2N$8$15$8NN
Nocdurna
4Y$95$100$9530/30NN
Nora Be
2N$8$15$8NN
Norditropin
529%29%29%YN
Norethindrone
2N$8$15$8NN
Norethindrone Acetate And Ethinyl Estradiol
2N$8$15$8NN
Norethindrone And Ethinyl Estradiol And Ferrous Fu
2N$8$15$8NN
Norgestimate And Ethinyl Estradiol
2N$8$15$8NN
Noritate
4Y$95$100$95NN
Norpace
4Y$95$100$95NN
Norpace Cr
4Y$95$100$95NN
Norpramin
4Y$95$100$95NN
Nortrel
2N$8$15$8NN
Nortrel 7/7/7
2N$8$15$8NN
Nortriptyline Hydrochloride
1N$2$5$2NN
Norvasc
4Y$95$100$95NN
Norvir
4Y$95$100$95NN
Novolin
3N$42$47$42NN
Novolog
3N$42$47$42NN
Novolog Mix 70/30
3N$42$47$42NN
Noxafil
529%29%29%240/30NN
Nubeqa
529%29%29%YN
Nucala
529%29%29%3/28YN
Nurtec Odt
529%29%29%16/30YN
Nutropin Aq Nuspin 10
529%29%29%YN
Nutropin Aq Nuspin 20
529%29%29%YN
Nutropin Aq Nuspin 5
529%29%29%YN
Nuvaring
4Y$95$100$95NN
Nuvigil
4Y$95$100$95YN
Nuzyra
529%29%29%NN
Nylia 1/35
2N$8$15$8NN
Nylia 7/7/7
2N$8$15$8NN
Nystatin
2N$8$15$8NN
Nystatin And Triamcinolone Acetonide
2N$8$15$8NN
Nystop
2N$8$15$8NN
Nyvepria
529%29%29%NN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H5215-005

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $260. 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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