PacificSource Medicare Explorer Rx 4 (PPO) Formulary



Below is the 2023 Formulary, or prescription drug list, from PacificSource Medicare Explorer Rx 4 (PPO) by Pacificsource Community Health Plans. A formulary is a continually updated list of available medications and prescription drug cost information. Examining a plans formulary can help you find a Oregon 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 PacificSource Medicare Explorer Rx 4 (PPO)(H4754-004) 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. Pacificsource Community Health Plans 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:PacificSource Medicare Explorer Rx 4
Plan ID: H4754-004
Provider: Pacificsource Community Health Plans
Plan Year:2023
Premium:$72.20
Deductible:$0
Initial Coverage Limit:$4660
Coverage Area:Oregon
Similar Plan:H4754-007


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
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Paliperidone
431%33%31%NN
Palynziq
533%33%33%YN
Panretin
533%33%33%NN
Paricalcitol
2$12$17$12NN
Paromomycin Sulfate
431%33%31%NN
Paroxetine
431%33%31%NY
Paroxetine Hydrochloride
2$12$17$12NN
Paser
431%33%31%NN
Pediarix
3$37$47$37NN
Pedvaxhib
3$37$47$37NN
Pegasys
533%33%33%YN
Pemazyre
533%33%33%14/21YN
Penicillamine
533%33%33%YN
Penicillin G Potassium
3$37$47$37NN
Penicillin G Procaine
3$37$47$37NN
Penicillin G Sodium
2$12$17$12NN
Penicillin V Potassium
2$12$17$12NN
Pentacel
3$37$47$37NN
Pentamidine Isethionate
2$12$17$12YN
Pentoxifylline
2$12$17$12NN
Perindopril Erbumine
6$0$0$0NN
Periogard Alcohol Free
2$12$17$12NN
Permethrin
2$12$17$12NN
Perphenazine
2$12$17$12NN
Perseris
533%33%33%YN
Pexeva
431%33%31%NY
Phenelzine Sulfate
2$12$17$12NN
Phenobarbital
2$12$17$12NN
Phenoxybenzamine Hydrochloride
533%33%33%YN
Phenytoin
2$12$17$12NN
Phospholine Iodide
431%33%31%NN
Pifeltro
533%33%33%30/30NN
Pilocarpine Hydrochloride
2$12$17$12NN
Pimecrolimus
431%33%31%YN
Pimozide
2$12$17$12NN
Pindolol
2$12$17$12NN
Piperacillin And Tazobactam
2$12$17$12NN
Piqray
533%33%33%YN
Pirmella 1/35
2$12$17$12NN
Piroxicam
2$12$17$12NN
Plenamine
2$12$17$12YN
Podofilox
2$12$17$12NN
Polyethylene Glycol 3350, Sodium Chloride, Sodium
2$12$17$12NN
Polymyxin B Sulfate And Trimethoprim
2$12$17$12NN
Portia
2$12$17$12NN
Potassium Chloride
2$12$17$12NN
Potassium Chloride In Dextrose
2$12$17$12YN
Potassium Chloride In Dextrose And Sodium Chloride
3$37$47$37YN
Potassium Chloride In Lactated Ringers And Dextros
431%33%31%YN
Potassium Chloride In Sodium Chloride
2$12$17$12NN
Potassium Citrate
2$12$17$12NN
Pradaxa
431%33%31%60/30NN
Pramipexole Dihydrochloride
2$12$17$12NY
Prasugrel
431%33%31%NN
Pravastatin Sodium
6$0$0$0NN
Praziquantel
431%33%31%NN
Prazosin Hydrochloride
2$12$17$12NN
Pred Mild
3$37$47$37NN
Prednisolone Acetate
2$12$17$12NN
Prednisolone Sodium Phosphate
431%33%31%NN
Prednisolone Sodium Phosphate Oral Solution
431%33%31%NN
Prednisone
2$12$17$12NN
Prednisone Intensol
3$37$47$37NN
Prefest
431%33%31%NN
Pregabalin
2$12$17$1260/30NN
Premarin
431%33%31%NN
Premasol - Sulfite-free (amino Acid)
431%33%31%YN
Premphase
431%33%31%NN
Prempro
431%33%31%NN
Pretomanid
431%33%31%30/30YN
Prevymis
533%33%33%100/365NN
Prezcobix
533%33%33%NN
Prezista
533%33%33%NN
Priftin
3$37$47$37NN
Primaquine Phosphate
2$12$17$12NN
Primidone
2$12$17$12NN
Privigen
533%33%33%YN
Proair
2$12$17$1217/30NN
Proair Respiclick
2$12$17$122/30NN
Probenecid
2$12$17$12NN
Probenecid And Colchicine
2$12$17$12NN
Procalamine
431%33%31%YN
Prochlorperazine Maleate
2$12$17$12NN
Procrit
533%33%33%YN
Procto-med Hc
2$12$17$12NN
Procysbi
533%33%33%YN
Progesterone
2$12$17$12NN
Prograf
431%33%31%YN
Prolastin-c
533%33%33%YN
Prolia
431%33%31%NN
Promacta
533%33%33%YN
Promethazine Hydrochloride
2$12$17$12NN
Propafenone Hydrochloride
2$12$17$12NN
Propranolol Hydrochloride
2$12$17$12NN
Propylthiouracil
2$12$17$12NN
Proquad
3$37$47$37NN
Prosol
431%33%31%YN
Protriptyline Hydrochloride
2$12$17$12NN
Pulmicort
431%33%31%4/30NN
Pulmozyme
533%33%33%YN
Purixan
533%33%33%NN
Pyrazinamide
2$12$17$12NN
Pyridostigmine Bromide
2$12$17$12NN
Pyrimethamine
533%33%33%YN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H4754-004

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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