Premera Blue Cross Medicare Advantage Peak + Rx (HMO) Formulary



Below is the 2023 Formulary, or prescription drug list, from Premera Blue Cross Medicare Advantage Peak + Rx (HMO) by Premera Blue Cross. A formulary is a continually updated list of available medications and prescription drug cost information. Examining a plans formulary can help you find a Washington 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 Premera Blue Cross Medicare Advantage Peak + Rx (HMO)(H9302-011) plan has a $160 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. Premera Blue Cross 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:Premera Blue Cross Medicare Advantage Peak Rx
Plan ID: H9302-011
Provider: Premera Blue Cross
Plan Year:2023
Premium:$0.00
Deductible:$160
Initial Coverage Limit:$4660
Coverage Area:Washington
Similar Plan:H9302-007


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
Paliperidone
2NNA$12NA30/30NN
Palynziq
5NA30%NAYN
Pancreaze
4YNA$100NANN
Panretin
5NA30%NA60/30YN
Pantoprazole Sodium
2NNA$12NA30/30NY
Panzyga
5NA30%NAYN
Paricalcitol
2NNA$12NAYN
Paromomycin Sulfate
2NNA$12NANN
Paroxetine
4YNA$100NAYN
Paroxetine Hydrochloride
4YNA$100NA60/30NN
Paser
4YNA$100NANN
Pediarix
3YNA$42NANN
Pedvaxhib
3YNA$42NANN
Peg-3350 And Electrolytes
1NNA$3NANN
Pegasys
5NA30%NAYN
Pemazyre
5NA30%NAYN
Penicillamine
5NA30%NANN
Penicillin G Potassium
4YNA$100NANN
Penicillin G Procaine
4YNA$100NANN
Penicillin G Sodium
2NNA$12NANN
Penicillin V Potassium
1NNA$3NANN
Pentacel
3YNA$42NANN
Pentamidine Isethionate
2NNA$12NAYN
Pentasa
5NA30%NA240/30NN
Pentoxifylline
1NNA$3NANN
Perindopril Erbumine
1NNA$3NANN
Periogard Alcohol Free
1NNA$3NANN
Permethrin
2NNA$12NA60/30NN
Perphenazine
2NNA$12NANN
Perseris
5NA30%NA1/30NN
Pertzye
4YNA$100NANN
Pexeva
4YNA$100NA30/30NN
Phenelzine Sulfate
2NNA$12NANN
Phenobarbital
3YNA$42NAYN
Phenoxybenzamine Hydrochloride
5NA30%NAYN
Phenytek
4YNA$100NANN
Phenytoin
2NNA$12NANN
Phoslyra
4YNA$100NANN
Pifeltro
5NA30%NANN
Pilocarpine Hydrochloride
2NNA$12NANN
Pimozide
2NNA$12NANN
Pindolol
2NNA$12NANN
Pioglitazone And Glimepiride
2NNA$12NA30/30NN
Piperacillin And Tazobactam
2NNA$12NANN
Piqray
5NA30%NAYN
Pirmella 1/35
2NNA$12NANN
Piroxicam
2NNA$12NANN
Plenamine
2NNA$12NAYN
Plenvu
4YNA$100NANN
Podofilox
2NNA$12NA7/28NN
Polyethylene Glycol 3350, Sodium Chloride, Sodium
1NNA$3NANN
Polymyxin B Sulfate And Trimethoprim
1NNA$3NANN
Portia
2NNA$12NANN
Potassium Chloride
1NNA$3NANN
Potassium Chloride In Dextrose
2NNA$12NANN
Potassium Chloride In Dextrose And Sodium Chloride
4YNA$100NANN
Potassium Chloride In Lactated Ringers And Dextros
4YNA$100NANN
Potassium Chloride In Sodium Chloride
4YNA$100NANN
Potassium Citrate
2NNA$12NANN
Pradaxa
4YNA$100NA60/30NN
Pramipexole Dihydrochloride
2NNA$12NANN
Prasugrel
2NNA$12NANN
Pravastatin Sodium
1NNA$3NA30/30NN
Praziquantel
2NNA$12NANN
Prazosin Hydrochloride
2NNA$12NANN
Pred Mild
4YNA$100NANN
Pred-g
4YNA$100NANN
Prednisolone Acetate
2NNA$12NANN
Prednisolone Sodium Phosphate
2NNA$12NAYN
Prednisolone Sodium Phosphate Oral Solution
2NNA$12NAYN
Prednisone
2NNA$12NANN
Prednisone Intensol
4YNA$100NAYN
Pregabalin
2NNA$12NA60/30YN
Premasol - Sulfite-free (amino Acid)
5NA30%NAYN
Pretomanid
4YNA$100NANN
Prevymis
5NA30%NA28/28YN
Prezcobix
5NA30%NANN
Prezista
5NA30%NA30/30NN
Priftin
4YNA$100NANN
Prilosec
4YNA$100NAYN
Primaquine Phosphate
3YNA$42NANN
Primidone
1NNA$3NANN
Privigen
5NA30%NAYN
Probenecid
2NNA$12NANN
Probenecid And Colchicine
2NNA$12NANN
Procalamine
4YNA$100NAYN
Prochlorperazine Maleate
2NNA$12NANN
Procrit
5NA30%NAYN
Procto-med Hc
2NNA$12NANN
Proctosol-hc
2NNA$12NANN
Proctozone-hc
2NNA$12NANN
Procysbi
5NA30%NAYN
Progesterone
2NNA$12NANN
Prograf
4YNA$100NAYN
Prolastin-c
5NA30%NAYN
Prolensa
3YNA$42NANN
Prolia
4YNA$100NA1/180NN
Promacta
5NA30%NA360/30YN
Promethazine Hydrochloride
2NNA$12NAYN
Propafenone Hydrochloride
2NNA$12NANN
Propranolol Hydrochloride
2NNA$12NANN
Propylthiouracil
2NNA$12NANN
Proquad
3YNA$42NANN
Prosol
4YNA$100NAYN
Protriptyline Hydrochloride
4YNA$100NANN
Pulmicort
4YNA$100NA3/30NN
Pulmozyme
5NA30%NAYN
Purixan
5NA30%NANN
Pyrazinamide
2NNA$12NANN
Pyridostigmine Bromide
5NA30%NANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H9302-011

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $160. 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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