Personal Choice 65 Prime Rx (PPO) Formulary



Below is the 2023 Formulary, or prescription drug list, from Personal Choice 65 Prime Rx (PPO) by Qcc 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 Pennsylvania 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 Personal Choice 65 Prime Rx (PPO)(H3909-015) 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. Qcc 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:Personal Choice 65 Prime Rx
Plan ID: H3909-015
Provider: Qcc Insurance Company
Plan Year:2023
Premium:$0.00
Deductible:$0
Initial Coverage Limit:$4660
Coverage Area:Pennsylvania
Similar Plan:H3909-016


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
3$47$47NANN
Palynziq
533%33%NAYN
Pancreaze
533%33%NANN
Panretin
533%33%NANN
Pantoprazole Sodium
2$8$20NA60/30NN
Panzyga
533%33%NAYN
Paricalcitol
2$8$20NANN
Paromomycin Sulfate
2$8$20NANN
Paroxetine
4$100$100NANN
Paroxetine Hydrochloride
4$100$100NANN
Paser
4$100$100NANN
Pediarix
3$47$47NANN
Pedvaxhib
3$47$47NANN
Peg-3350 And Electrolytes
2$8$20NANN
Peg-3350, Electrolytes, And Ascorbate
2$8$20NANN
Pegasys
533%33%NANN
Pemazyre
533%33%NAYN
Penicillamine
533%33%NANN
Penicillin G Potassium
2$8$20NANN
Penicillin G Procaine
2$8$20NANN
Penicillin G Sodium
533%33%NANN
Penicillin V Potassium
2$8$20NANN
Pennsaid
533%33%NANN
Pentacel
3$47$47NANN
Pentamidine Isethionate
2$8$20NAYN
Pentasa
4$100$100NANN
Pentoxifylline
2$8$20NANN
Perindopril Erbumine
1$0$9NANN
Periogard Alcohol Free
1$0$9NANN
Permethrin
2$8$20NANN
Perphenazine
2$8$20NANN
Perphenazine And Amitriptyline Hydrochloride
2$8$20NANN
Perseris
533%33%NANN
Pertzye
533%33%NANN
Phenelzine Sulfate
2$8$20NANN
Phenobarbital
2$8$20NA90/30NN
Phenoxybenzamine Hydrochloride
533%33%NANN
Phenytek
4$100$100NANN
Phenytoin
2$8$20NANN
Phoslyra
4$100$100NANN
Phospholine Iodide
4$100$100NANN
Pifeltro
533%33%NANN
Pilocarpine Hydrochloride
2$8$20NANN
Pimecrolimus
4$100$100NANN
Pimozide
2$8$20NANN
Pindolol
2$8$20NANN
Pioglitazone And Glimepiride
1$0$9NA30/30NN
Piperacillin And Tazobactam
4$100$100NANN
Piqray
533%33%NAYN
Pirmella 1/35
2$8$20NANN
Piroxicam
2$8$20NANN
Plegridy
533%33%NA1/28NN
Plenamine
4$100$100NAYN
Podofilox
2$8$20NANN
Polyethylene Glycol 3350, Sodium Chloride, Sodium
2$8$20NANN
Polymyxin B Sulfate And Trimethoprim
2$8$20NANN
Ponvory
533%33%NA30/30NY
Portia
2$8$20NANN
Potassium Chloride
2$8$20NANN
Potassium Chloride In Dextrose
2$8$20NANN
Potassium Chloride In Dextrose And Sodium Chloride
2$8$20NANN
Potassium Chloride In Lactated Ringers And Dextros
2$8$20NANN
Potassium Chloride In Sodium Chloride
2$8$20NANN
Potassium Citrate
2$8$20NANN
Pramipexole Dihydrochloride
2$8$20NANN
Prasugrel
3$47$47NANN
Pravastatin Sodium
1$0$9NA30/30NN
Praziquantel
2$8$20NANN
Prazosin Hydrochloride
2$8$20NANN
Pred-g
4$100$100NANN
Prednisolone Acetate
3$47$47NANN
Prednisolone Sodium Phosphate
2$8$20NANN
Prednisolone Sodium Phosphate Oral Solution
2$8$20NANN
Prednisone
2$8$20NANN
Prednisone Intensol
2$8$20NAYN
Prefest
4$100$100NAYN
Pregabalin
2$8$20NA900/30NN
Premarin
3$47$47NAYN
Premasol - Sulfite-free (amino Acid)
4$100$100NAYN
Premphase
3$47$47NANN
Prempro
3$47$47NANN
Pretomanid
4$100$100NAYN
Prevymis
533%33%NANN
Prezcobix
533%33%NA30/30NN
Prezista
533%33%NA30/30NN
Priftin
4$100$100NANN
Primaquine Phosphate
2$8$20NANN
Primidone
2$8$20NANN
Privigen
533%33%NAYN
Proair
3$47$47NA17/30NN
Proair Digihaler
4$100$100NA2/30NY
Proair Respiclick
3$47$47NA2/30NN
Probenecid
2$8$20NANN
Probenecid And Colchicine
2$8$20NANN
Procalamine
4$100$100NAYN
Prochlorperazine Maleate
2$8$20NANN
Procrit
533%33%NAYN
Procto-med Hc
2$8$20NANN
Proctosol-hc
2$8$20NANN
Proctozone-hc
2$8$20NANN
Procysbi
533%33%NAYN
Progesterone
2$8$20NANN
Prograf
4$100$100NAYN
Prolastin-c
533%33%NAYN
Prolia
4$100$100NAYN
Promacta
533%33%NA360/30YN
Promethazine Hydrochloride
2$8$20NAYN
Propafenone Hydrochloride
4$100$100NANN
Propranolol Hydrochloride
3$47$47NANN
Propylthiouracil
2$8$20NANN
Proquad
3$47$47NANN
Prosol
4$100$100NAYN
Protriptyline Hydrochloride
2$8$20NANN
Provigil
533%33%NA60/30YN
Pulmozyme
533%33%NAYN
Purified Cortrophin Gel
533%33%NAYN
Purixan
533%33%NANN
Pyrazinamide
2$8$20NANN
Pyridostigmine Bromide
533%33%NANN
Pyrimethamine
533%33%NANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H3909-015

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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