Platino Ultra (HMO D-SNP) Formulary



Below is the 2023 Formulary, or prescription drug list, from Platino Ultra (HMO D-SNP) by Triple S Advantage, 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 Puerto Rico 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 Platino Ultra (HMO D-SNP)(H5774-025) plan has a $505 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. Triple S Advantage, 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:Platino Ultra (HMO D-SNP)
Plan ID: H5774-025
Provider: Triple S Advantage, Inc
Plan Year:2023
Premium:$0.00
Deductible:$505
Initial Coverage Limit:$4660
Coverage Area:Puerto Rico
Similar Plan:H5774-026


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
Paliperidone
2Y$15$20NANY
Panretin
525%25%NAYN
Paricalcitol
2Y$15$20NAYN
Paromomycin Sulfate
2Y$15$20NANN
Paroxetine Hydrochloride
2Y$15$20NAYN
Paser
4Y$95$100NANN
Paxil
4Y$95$100NAYN
Pediarix
3Y$42$47NANN
Pedvaxhib
3Y$42$47NANN
Peg-3350 And Electrolytes
2Y$15$20NANN
Pegasys
525%25%NAYN
Pemazyre
525%25%NAYN
Penicillamine
2Y$15$20NANN
Penicillin G Potassium
2Y$15$20NAYN
Penicillin G Procaine
2Y$15$20NANN
Penicillin G Sodium
525%25%NAYN
Penicillin V Potassium
1Y$14$19NANN
Pentacel
3Y$42$47NANN
Pentamidine Isethionate
2Y$15$20NAYN
Pentoxifylline
1Y$14$19NANN
Perindopril Erbumine
6Y$10$11NANN
Permethrin
2Y$15$20NANN
Perphenazine
2Y$15$20NANN
Phenelzine Sulfate
2Y$15$20NANN
Phenobarbital
2Y$15$20NAYN
Phenytoin
2Y$15$20NANN
Phoslyra
4Y$95$100NANN
Pifeltro
525%25%NANN
Pilocarpine Hydrochloride
2Y$15$20NANN
Pimozide
2Y$15$20NANN
Pindolol
2Y$15$20NANN
Pioglitazone And Glimepiride
6Y$10$11NANN
Piperacillin And Tazobactam
2Y$15$20NANN
Piqray
525%25%NAYN
Plegridy
525%25%NAYN
Podofilox
2Y$15$20NANN
Polyethylene Glycol 3350, Sodium Chloride, Sodium
2Y$15$20NANN
Polymyxin B Sulfate And Trimethoprim
1Y$14$19NANN
Potassium Chloride
2Y$15$20NANN
Potassium Chloride In Dextrose
2Y$15$20NAYN
Potassium Chloride In Dextrose And Sodium Chloride
2Y$15$20NAYN
Potassium Chloride In Sodium Chloride
2Y$15$20NAYN
Potassium Citrate
2Y$15$20NANN
Pravastatin Sodium
6Y$10$11NANN
Praziquantel
2Y$15$20NANN
Prazosin Hydrochloride
2Y$15$20NANN
Prednisolone Acetate
2Y$15$20NANN
Prednisone
2Y$15$20NANN
Pregabalin
2Y$15$20NANN
Premarin
3Y$42$47NAYN
Premasol - Sulfite-free (amino Acid)
4Y$95$100NAYN
Pretomanid
2Y$15$20NAYN
Prevymis
525%25%NAYN
Prezcobix
525%25%NANN
Prezista
525%25%NANN
Priftin
4Y$95$100NANN
Primaquine Phosphate
2Y$15$20NANN
Primidone
2Y$15$20NANN
Privigen
525%25%NAYN
Probenecid
2Y$15$20NANN
Probenecid And Colchicine
2Y$15$20NANN
Procalamine
4Y$95$100NAYN
Prochlorperazine Maleate
1Y$14$19NANN
Procrit
525%25%NAYN
Prograf
4Y$95$100NAYN
Prolastin-c
525%25%NAYN
Prolia
4Y$95$100NA1/180YN
Promacta
525%25%NAYN
Promethazine Hydrochloride
2Y$15$20NAYN
Propafenone Hydrochloride
2Y$15$20NANN
Propranolol Hydrochloride
2Y$15$20NANN
Propylthiouracil
2Y$15$20NANN
Proquad
3Y$42$47NANN
Protriptyline Hydrochloride
2Y$15$20NANN
Pulmozyme
525%25%NAYN
Purixan
525%25%NANN
Pyrazinamide
2Y$15$20NANN
Pyridostigmine Bromide
2Y$15$20NANN
Pyrimethamine
525%25%NANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H5774-025

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $505. 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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