PriorityMedicare Ideal (PPO) Formulary



Below is the 2023 Formulary, or prescription drug list, from PriorityMedicare Ideal (PPO) by Priority Health. A formulary is a continually updated list of available medications and prescription drug cost information. Examining a plans formulary can help you find a Michigan 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 PriorityMedicare Ideal (PPO)(H4875-018) plan has a $125 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. Priority Health 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:PriorityMedicare Ideal
Plan ID: H4875-018
Provider: Priority Health
Plan Year:2023
Premium:$25.00
Deductible:$125
Initial Coverage Limit:$4660
Coverage Area:Michigan
Similar Plan:H4875-020


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
4Y50%50%50%30/30NY
Panretin
530%30%30%60/30YN
Paricalcitol
4Y50%50%50%NN
Paromomycin Sulfate
2N$13$18$13NN
Paroxetine
4Y50%50%50%NN
Paser
3Y$42$47$42NN
Pediarix
3Y$42$47$42NN
Pedvaxhib
3Y$42$47$42NN
Peg-3350 And Electrolytes
2N$13$18$13NN
Pegasys
530%30%30%NN
Pemazyre
530%30%30%14/21YN
Penicillamine
4Y50%50%50%YN
Penicillin G Potassium
4Y50%50%50%NN
Penicillin G Procaine
4Y50%50%50%NN
Penicillin G Sodium
4Y50%50%50%NN
Penicillin V Potassium
2N$13$18$13NN
Pentacel
3Y$42$47$42NN
Pentamidine Isethionate
3Y$42$47$42YN
Pentoxifylline
2N$13$18$13NN
Perindopril Erbumine
1N$4$9$4NN
Permethrin
2N$13$18$13NN
Perphenazine
2N$13$18$13NN
Perseris
530%30%30%1/28NN
Phenelzine Sulfate
2N$13$18$13NN
Phenobarbital
2N$13$18$13YN
Phenytoin
2N$13$18$13NN
Pifeltro
530%30%30%30/30NN
Pilocarpine Hydrochloride
2N$13$18$13NN
Pimecrolimus
3Y$42$47$4230/30NN
Pimozide
2N$13$18$13NN
Pindolol
2N$13$18$13NN
Pioglitazone And Glimepiride
2N$13$18$13NN
Piperacillin And Tazobactam
2N$13$18$13NN
Piqray
530%30%30%56/28YN
Pirmella 1/35
2N$13$18$13NN
Piroxicam
2N$13$18$13NN
Plegridy
530%30%30%1/28YN
Podofilox
2N$13$18$13NN
Polyethylene Glycol 3350, Sodium Chloride, Sodium
2N$13$18$13NN
Polymyxin B Sulfate And Trimethoprim
2N$13$18$13NN
Portia
2N$13$18$13NN
Potassium Chloride
2N$13$18$13NN
Potassium Chloride In Dextrose
2N$13$18$13NN
Potassium Chloride In Dextrose And Sodium Chloride
2N$13$18$13NN
Potassium Chloride In Lactated Ringers And Dextros
2N$13$18$13NN
Potassium Chloride In Sodium Chloride
2N$13$18$13NN
Potassium Citrate
2N$13$18$13NN
Pradaxa
4Y50%50%50%60/30NN
Pramipexole Dihydrochloride
4Y50%50%50%NN
Prasugrel
3Y$42$47$42NN
Pravastatin Sodium
1N$4$9$4NN
Praziquantel
3Y$42$47$42NN
Prazosin Hydrochloride
2N$13$18$13NN
Pred-g
3Y$42$47$42NN
Prednisolone Acetate
2N$13$18$13NN
Prednisolone Sodium Phosphate
4Y50%50%50%NN
Prednisone
2N$13$18$13NN
Prednisone Intensol
4Y50%50%50%NN
Pregabalin
2N$13$18$13900/30NN
Premasol - Sulfite-free (amino Acid)
3Y$42$47$42YN
Pretomanid
4Y50%50%50%30/30YN
Prevymis
530%30%30%YN
Prezcobix
530%30%30%30/30NN
Prezista
530%30%30%30/30NN
Priftin
4Y50%50%50%NN
Primaquine Phosphate
2N$13$18$13NN
Primidone
2N$13$18$13NN
Probenecid
2N$13$18$13NN
Probenecid And Colchicine
2N$13$18$13NN
Procalamine
3Y$42$47$42YN
Prochlorperazine Maleate
2N$13$18$13NN
Procrit
530%30%30%YN
Procto-med Hc
2N$13$18$13NN
Proctosol-hc
2N$13$18$13NN
Proctozone-hc
2N$13$18$13NN
Progesterone
2N$13$18$13NN
Prograf
4Y50%50%50%YN
Prolastin-c
530%30%30%YN
Prolia
4Y50%50%50%1/180YN
Promacta
530%30%30%30/30YN
Promethazine Hydrochloride
2N$13$18$13NN
Propafenone Hydrochloride
4Y50%50%50%NN
Propranolol Hydrochloride
2N$13$18$13NN
Propylthiouracil
2N$13$18$13NN
Proquad
3Y$42$47$42NN
Protriptyline Hydrochloride
4Y50%50%50%NN
Pulmicort
3Y$42$47$422/30NN
Pulmozyme
530%30%30%YN
Purified Cortrophin Gel
530%30%30%YN
Purixan
530%30%30%NN
Pyrazinamide
2N$13$18$13NN
Pyridostigmine Bromide
4Y50%50%50%NN
Pyrimethamine
530%30%30%NN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H4875-018

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $125. 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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