Anthem MediBlue Rx Plus (PDP) Formulary



Below is the 2023 Formulary, or prescription drug list, from Anthem MediBlue Rx Plus (PDP) by Anthem Insurance Companies, 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 In Indiana, Kentucky. 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 Anthem MediBlue Rx Plus (PDP)(S5596-018) 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. Anthem Insurance Companies, 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:Anthem MediBlue Rx Plus (PDP)
Plan ID: S5596-018
Formulary
Provider: Anthem Insurance Companies, Inc
Plan Year:2023
Premium:$58.20
Deductible:$0
Initial Coverage Limit:$4660
Coverage Area:Indiana, Kentucky
Similar Plan:S5596-043


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
Abacavir
450%50%NA960/30NN
Abacavir And Lamivudine
450%50%NA30/30NN
Abelcet
450%50%NAYN
Abilify Maintena
450%50%NA1/28NN
Abiraterone
533%33%NA120/30YN
Abiraterone Acetate
533%33%NA60/30YN
Acarbose
3$47$47NA90/30NN
Accutane
450%50%NANN
Acebutolol Hydrochloride
2$4$20NANN
Acetaminophen And Codeine Phosphate
3$47$47NA900/30NN
Acetazolamide
3$47$47NANN
Acetic Acid
3$47$47NANN
Acetylcysteine
450%50%NAYN
Acitretin
450%50%NANN
Acthib
3$47$47NANN
Actimmune
533%33%NAYN
Acyclovir
450%50%NANN
Acyclovir Sodium
450%50%NAYN
Adefovir Dipivoxil
450%50%NAYN
Adempas
533%33%NAYN
Advair
3$47$47NA60/30NN
Advair Hfa
3$47$47NA12/30NN
Aimovig
3$47$47NA1/28YN
Alacort
2$4$20NANN
Albendazole
450%50%NANN
Albuterol Sulfate
3$47$47NANN
Alclometasone Dipropionate
3$47$47NANN
Alecensa
533%33%NA240/30YN
Alendronate Sodium
1$1$19NA4/28NN
Aliskiren
450%50%NANN
Alosetron Hydrochloride
450%50%NA60/30YN
Alprazolam
2$4$20NA120/30NN
Altavera
3$47$47NANN
Alunbrig
533%33%NA30/180YN
Alyacen 1/35
3$47$47NANN
Amabelz
3$47$47NAYN
Amantadine Hydrochloride
3$47$47NANN
Ambisome
450%50%NAYN
Amikacin Sulfate
450%50%NANN
Amiloride Hydrochloride And Hydrochlorothiazide
2$4$20NANN
Amiloride Hydrocloride
2$4$20NANN
Amiodarone Hydrochloride
3$47$47NANN
Amitriptyline Hydrochloride
3$47$47NANN
Amlodipine And Benazepril Hydrochloride
2$4$20NANN
Amlodipine And Olmesartan Medoxomil
450%50%NANN
Amlodipine And Valsartan
3$47$47NANN
Amlodipine Besylate
1$1$19NANN
Amlodipine Besylate And Benazepril Hydrochloride
2$4$20NANN
Ammonium Lactate
3$47$47NANN
Amnesteem
450%50%NANN
Amoxapine
3$47$47NAYN
Amoxicillin
2$4$20NANN
Amoxicillin And Clavulanate Potassium
3$47$47NANN
Amphotericin B
450%50%NAYN
Ampicillin
450%50%NANN
Ampicillin And Sulbactam
450%50%NANN
Ampicillin Sodium And Sulbactam Sodium
450%50%NANN
Anagrelide
3$47$47NANN
Anastrozole
2$4$20NA30/30NN
Apraclonidine Ophthalmic
3$47$47NANN
Aprepitant
450%50%NA15/30YN
Apri
3$47$47NANN
Aptivus
533%33%NA120/30NN
Aranelle
3$47$47NANN
Aripiprazole
450%50%NA90/30NN
Aristada
533%33%NA/60NN
Aristada Initio
533%33%NA/365NN
Armodafinil
450%50%NA30/30YN
Arnuity Ellipta
3$47$47NA30/30NN
Asenapine
450%50%NA60/30NN
Atenolol And Chlorthalidone
2$4$20NANN
Atomoxetine
3$47$47NA30/30NN
Atovaquone
450%50%NAYN
Atovaquone And Proguanil Hydrochloride Pediatric
450%50%NANN
Atrovent
450%50%NA26/30NN
Aubra Eq
3$47$47NANN
Austedo
533%33%NA120/30YN
Aviane
3$47$47NANN
Avita
450%50%NA45/30YN
Ayvakit
533%33%NA30/30YN
Azathioprine
3$47$47NAYN
Azelaic Acid
450%50%NANN
Azelastine Hcl Nasal
3$47$47NA30/25NN
Azelastine Hydrochloride
3$47$47NA30/25NN
Azelastine Hydrochloride And Fluticasone Propionat
450%50%NA23/28NN
Azithromycin
450%50%NANN
Azopt
450%50%NANN
Aztreonam
450%50%NANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for S5596-018

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