Provider Partners Pennsylvania Advantage Plan (HMO I-SNP) Formulary



Below is the 2023 Formulary, or prescription drug list, from Provider Partners Pennsylvania Advantage Plan (HMO I-SNP) by Provider Partners Health Plan Of Pennsylvania, 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 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 Provider Partners Pennsylvania Advantage Plan (HMO I-SNP)(H4093-001) 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. Provider Partners Health Plan Of Pennsylvania, 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:Provider Partners Pennsylvania Advantage Plan (HMO I-SNP)
Plan ID: H4093-001
Provider: Provider Partners Health Plan Of Pennsylvania, Inc
Plan Year:2023
Premium:$41.10
Deductible:$505
Initial Coverage Limit:$4660
Coverage Area:Pennsylvania
Similar Plan:H4093-004


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
1YNA25%NA30/30YN
Panretin
1YNA25%NAYN
Pantoprazole Sodium
1YNA25%NANN
Panzyga
1YNA25%NAYN
Paricalcitol
1YNA25%NAYN
Paromomycin Sulfate
1YNA25%NANN
Paroxetine
1YNA25%NANN
Paroxetine Hydrochloride
1YNA25%NANN
Paser
1YNA25%NANN
Pediarix
1YNA25%NANN
Pedvaxhib
1YNA25%NANN
Peg-3350 And Electrolytes
1YNA25%NANN
Pegasys
1YNA25%NAYN
Pemazyre
1YNA25%NA14/21YN
Penicillamine
1YNA25%NAYN
Penicillin G Potassium
1YNA25%NANN
Penicillin G Sodium
1YNA25%NANN
Penicillin V Potassium
1YNA25%NANN
Pentacel
1YNA25%NANN
Pentamidine Isethionate
1YNA25%NAYN
Pentoxifylline
1YNA25%NANN
Perindopril Erbumine
1YNA25%NANN
Periogard Alcohol Free
1YNA25%NANN
Permethrin
1YNA25%NANN
Perphenazine
1YNA25%NAYN
Perphenazine And Amitriptyline Hydrochloride
1YNA25%NANN
Perseris
1YNA25%NA1/30NN
Phenelzine Sulfate
1YNA25%NANN
Phenobarbital
1YNA25%NANN
Phenytoin
1YNA25%NANN
Pifeltro
1YNA25%NANN
Pilocarpine Hydrochloride
1YNA25%NANN
Pimecrolimus
1YNA25%NANN
Pimozide
1YNA25%NANN
Pindolol
1YNA25%NANN
Pioglitazone And Glimepiride
1YNA25%NANN
Piperacillin And Tazobactam
1YNA25%NANN
Piqray
1YNA25%NA56/28YN
Pirmella 1/35
1YNA25%NANN
Piroxicam
1YNA25%NANN
Plenamine
1YNA25%NAYN
Podofilox
1YNA25%NANN
Polyethylene Glycol 3350, Sodium Chloride, Sodium
1YNA25%NANN
Polymyxin B Sulfate And Trimethoprim
1YNA25%NANN
Portia
1YNA25%NANN
Potassium Chloride
1YNA25%NANN
Potassium Chloride In Dextrose
1YNA25%NANN
Potassium Chloride In Dextrose And Sodium Chloride
1YNA25%NANN
Potassium Chloride In Lactated Ringers And Dextros
1YNA25%NANN
Potassium Chloride In Sodium Chloride
1YNA25%NANN
Potassium Citrate
1YNA25%NANN
Prasugrel
1YNA25%NANN
Pravastatin Sodium
1YNA25%NANN
Prazosin Hydrochloride
1YNA25%NANN
Pred-g
1YNA25%NANN
Prednisolone Acetate
1YNA25%NANN
Prednisolone Sodium Phosphate
1YNA25%NAYN
Prednisolone Sodium Phosphate Oral Solution
1YNA25%NAYN
Prednisone
1YNA25%NANN
Prednisone Intensol
1YNA25%NAYN
Pregabalin
1YNA25%NA900/30NN
Premarin
1YNA25%NANN
Premasol - Sulfite-free (amino Acid)
1YNA25%NAYN
Premphase
1YNA25%NANN
Prempro
1YNA25%NANN
Prevymis
1YNA25%NA28/28YN
Prezcobix
1YNA25%NANN
Prezista
1YNA25%NANN
Priftin
1YNA25%NANN
Primaquine Phosphate
1YNA25%NANN
Primidone
1YNA25%NANN
Privigen
1YNA25%NAYN
Proair
1YNA25%NANN
Proair Respiclick
1YNA25%NANN
Probenecid
1YNA25%NANN
Probenecid And Colchicine
1YNA25%NANN
Procalamine
1YNA25%NAYN
Prochlorperazine Maleate
1YNA25%NANN
Procto-med Hc
1YNA25%NANN
Proctosol-hc
1YNA25%NANN
Proctozone-hc
1YNA25%NANN
Progesterone
1YNA25%NANN
Prograf
1YNA25%NAYN
Prolastin-c
1YNA25%NAYN
Prolia
1YNA25%NANN
Promacta
1YNA25%NA360/30YN
Promethazine Hydrochloride
1YNA25%NANN
Propafenone Hydrochloride
1YNA25%NANN
Propranolol Hydrochloride
1YNA25%NANN
Propylthiouracil
1YNA25%NANN
Proquad
1YNA25%NANN
Prosol
1YNA25%NAYN
Protriptyline Hydrochloride
1YNA25%NANN
Pulmozyme
1YNA25%NAYN
Purixan
1YNA25%NANN
Pyrazinamide
1YNA25%NANN
Pyridostigmine Bromide
1YNA25%NANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H4093-001

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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