PacificSource Medicare Essentials Rx 36 (HMO) Formulary



Below is the 2022 Formulary, or prescription drug list, from Pacificsource Community Health Plans for PacificSource Medicare Essentials Rx 36 (HMO)( H3864-036). A formulary is a list of prescription medications that are covered under Pacificsource Community Health Plans's 2022 Medicare Advantage Plan in Oregon.

This PacificSource Medicare Essentials Rx 36 (HMO) plan has a $200 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 $4430. 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 $4430 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" be clicking the "Coverage Gap" link on the left above the chart.

In 2022 if you have spent $7550 in expenditures you enter the Catastrophic Phase. During the Catastrophic Period you will begin to receive significant coverage. PacificSource Medicare Essentials Rx 36 (HMO) 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 on the left above the chart.




Plan Name:PacificSource Medicare Essentials Rx 36 (HMO)
Plan ID: H3864-036
Formulary
Provider: Pacificsource Community Health Plans
Plan Year:2022
Premium:$0.00
Deductible:$200
Initial Coverage Limit:$4430
Coverage Area:Oregon


Change Table Options:

Drugs Starting Letter:
Coverage Phase:

⇅ Click the Header to Sort
Drug
Name⇅
Tier
Level
Deductible
Apply
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Bacitracin Zinc And Polymyxin B Sulfate
2N$12$17$12NN
Baclofen
2N$12$17$12NN
Balsalazide Disodium
2N$12$17$12NN
Balversa
529%29%29%YN
Balziva
2N$12$17$12NN
Baraclude
3Y$37$47$37NN
Bcg Vaccine
3Y$37$47$37NN
Benazepril Hydrochloride And Hydrochlorothiazide
6N$0$0$0NN
Benznidazole
3Y$37$47$37NN
Benztropine Mesylate
1N$3$8$0NN
Bepotastine Besilate
2N$12$17$12NN
Berinert
529%29%29%YN
Betamethasone Dipropionate
2N$12$17$12NN
Betamethasone Valerate
2N$12$17$12NN
Betaxolol Hydrochloride
2N$12$17$12NN
Bethanechol Chloride
2N$12$17$12NN
Betoptic S
3Y$37$47$37NN
Bexarotene
529%29%29%YN
Bexsero
3Y$37$47$37NN
Bicillin C-r 900/300
4Y31%33%31%NN
Bicillin Cr
4Y31%33%31%NN
Bicillin L-a
4Y31%33%31%NN
Biktarvy
529%29%29%30/30NN
Bisoprolol Fumarate
2N$12$17$12NN
Bisoprolol Fumarate And Hydrochlorothiazide
2N$12$17$12NN
Blephamide
4Y31%33%31%NN
Blisovi 24 Fe
2N$12$17$12NN
Blisovi Fe 1.5/30
2N$12$17$12NN
Boostrix
3Y$37$47$37NN
Bosulif
529%29%29%30/30YN
Braftovi
529%29%29%YN
Breo Ellipta
3Y$37$47$37NN
Briellyn
2N$12$17$12NN
Brilinta
3Y$37$47$37NN
Brimonidine Tartrate
2N$12$17$12NN
Briviact
529%29%29%NY
Bromfenac Ophthalmic Solution 0.09%
2N$12$17$12NN
Budesonide
4Y31%33%31%NN
Budesonide And Formoterol Fumarate Dihydrate
2N$12$17$12NN
Bumetanide
2N$12$17$12NN
Buprenorphine
4Y31%33%31%4/28NN
Buprenorphine And Naloxone
2N$12$17$1260/30NN
Buprenorphine Hcl
2N$12$17$1290/30NN
Buprenorphine Hydrochloride And Naloxone Hydrochlo
2N$12$17$1290/30NN
Bupropion Hydrochloride
2N$12$17$12NN
Buspirone Hydrochloride
2N$12$17$12NN
Butorphanol Tartrate
2N$12$17$12/30NN
Bydureon Bcise
3Y$37$47$374/28NN
Byetta
4Y31%33%31%NN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H3864-036

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1.Pre-Deductable: Before you reach the plans deductible of $200. 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 $4430
3.Coverage Gap: (AKA Donut Hole) After you reach the plans ICL but before the Catastrophic of $7550 in 2022.
4.Catastrophic: Anything over $7550 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 2022 is $320. 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 in order 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 plans 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.

Source:CMS Formulary Data Q1 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.

      Site Search:

MedicareHelp.org is a privately-owned Non-governmental agency. The government website can be found at HealthCare.gov.

Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options. Enrollment depends on the plan’s contract renewal.

Every year, Medicare evaluates plans based on a 5-star rating system.