Freedom Blue PPO Classic (PPO) Formulary



Below is the 2023 Formulary, or prescription drug list, from Freedom Blue PPO Classic (PPO) by Highmark Senior Health Company. 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 Freedom Blue PPO Classic (PPO)(H3916-002) 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. Highmark Senior Health Company 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:Freedom Blue PPO Classic
Plan ID: H3916-002
Provider: Highmark Senior Health Company
Plan Year:2023
Premium:$117.00
Deductible:$0
Initial Coverage Limit:$4660
Coverage Area:Pennsylvania
Similar Plan:H3916-005


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
Famciclovir
2$13$19NANN
Famotidine
1$0$5NANN
Fanapt
4$95$100NA16/365NN
Fasenra
533%33%33%1/56YN
Felbamate
4$95$100NANN
Felodipine
2$13$19NANN
Femring
4$95$100NANN
Femynor
2$13$19NANN
Fenofibrate
2$13$19NANN
Fentanyl
4$95$100NA10/30YN
Fentanyl Buccal
533%33%33%59/31YN
Fentanyl Citrate
533%33%33%30/31YN
Fentanyl Transdermal
2$13$19NA20/30YN
Fentora
533%33%33%59/31YN
Fetzima
4$95$100NA31/31YN
Fiasp
3$45$47NANN
Finacea Foam
4$95$100NA50/28NN
Firdapse
533%33%33%248/31YN
Firmagon
533%33%33%NN
Firvanq
4$95$100NANN
Flavoxate Hydrochloride
2$13$19NANN
Flebogamma Dif
533%33%33%YN
Flecainide Acetate
2$13$19NANN
Flovent
4$95$100NA24/30NN
Fluconazole
3$45$47NANN
Flucytosine
533%33%33%NN
Fludrocortisone Acetate
2$13$19NANN
Flunisolide
2$13$19NA50/25NN
Fluocinolone Acetonide
2$13$19NA11/28NN
Fluocinonide
2$13$19NA60/28NN
Fluorometholone
2$13$19NANN
Fluorouracil
2$13$19NANN
Fluorouracil Cream
533%33%33%NN
Fluoxetine
1$0$5NANN
Fluphenazine Decanoate
2$13$19NANN
Fluphenazine Hydrochloride
2$13$19NANN
Flurandrenolide
4$95$100NA120/28NN
Flurbiprofen
2$13$19NANN
Flurbiprofen Sodium
2$13$19NANN
Fluticasone Propionate
2$13$19NANN
Fluticasone Propionate And Salmeterol
3$45$47NA60/30NN
Fluvoxamine Maleate
2$13$19NANN
Fondaparinux Sodium
533%33%33%NN
Fosamprenavir Calcium
4$95$100NANN
Fosfomycin Tromethamine
4$95$100NANN
Fosinopril Sodium
1$0$5NANN
Fosinopril Sodium And Hydrochlorothiazide
1$0$5NANN
Fosrenol
533%33%33%NN
Fotivda
533%33%33%21/28YN
Fragmin
533%33%33%NN
Frovatriptan Succinate
4$95$100NA12/28NN
Fulphila
533%33%33%NN
Furosemide
2$13$19NANN
Fuzeon
533%33%33%NN
Fycompa
533%33%33%744/31NN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H3916-002

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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