Sparrow Advantage (HMO-POS) Formulary



Below is the 2023 Formulary, or prescription drug list, from Sparrow Advantage (HMO-POS) by Php Medicare. 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 Sparrow Advantage (HMO-POS)(H7646-001) 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. Php Medicare 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:Sparrow Advantage
Plan ID: H7646-001
Provider: Php Medicare
Plan Year:2023
Premium:$0.00
Deductible:$0
Initial Coverage Limit:$4660
Coverage Area:Michigan
Similar Plan:H7646-002


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
Sancuso
533%33%NANN
Sandimmune
4$90$95NAYN
Sapropterin Dihydrochloride
533%33%NAYN
Savella
3$40$45NA60/30NN
Scemblix
533%33%NA300/30YN
Secuado
533%33%NA30/30NN
Segluromet
3$40$45NA60/30NN
Selegiline Hydrochloride
2$0$10NANN
Selenium Sulfide
2$0$10NANN
Selzentry
3$40$45NANN
Sertraline Hydrochloride
4$90$95NANN
Setlakin
2$0$10NANN
Shingrix
3$40$45NANN
Signifor
533%33%NAYN
Sildenafil
3$40$45NA90/30YN
Silodosin
4$90$95NANN
Simbrinza
4$90$95NANN
Sirolimus
4$90$95NAYN
Sirturo
533%33%NAYN
Skyrizi
533%33%NA2/28YN
Sodium Chloride
4$90$95NANN
Sodium Phenylbutyrate
533%33%NAYN
Sodium Polystyrene Sulfonate
3$40$45NANN
Somavert
533%33%NAYN
Sorine
2$0$10NANN
Sotalol Hydrochloride
2$0$10NANN
Spiriva
3$40$45NA90/90NN
Spironolactone
1$0$5NANN
Spironolactone And Hydrochlorothiazide
2$0$10NANN
Sprintec
2$0$10NANN
Spritam
4$90$95NANN
Sprycel
533%33%NA30/30YN
Sronyx
2$0$10NANN
Steglatro
3$40$45NA30/30NN
Stelara
533%33%NA1/28YN
Streptomycin
533%33%NA60/30YN
Stribild
533%33%NANN
Striverdi Respimat
3$40$45NA4/30NN
Sucraid
533%33%NAYN
Sucralfate
4$90$95NANN
Sulfacetamide Sodium
4$90$95NANN
Sulfacetamide Sodium And Prednisolone Sodium Phosp
2$0$10NANN
Sulfadiazine
4$90$95NANN
Sulfamethoxazole And Trimethoprim
1$0$5NANN
Sulfasalazine
2$0$10NANN
Sulindac
2$0$10NANN
Sumatriptan
4$90$95NA18/28NN
Sumatriptan Succinate
4$90$95NA8/28NN
Sunitinib Malate
533%33%NA30/30YN
Syeda
2$0$10NANN
Symbicort
3$40$45NA1/30NN
Symdeko
533%33%NA56/28YN
Symjepi
4$90$95NA2/30NN
Symlinpen
533%33%NA1/30YN
Sympazan
533%33%NA60/30YN
Symtuza
4$90$95NANN
Synarel
533%33%NAYN
Synribo
533%33%NAYN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H7646-001

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