PrimeTime Health Plan Aultimate (HMO-POS) Formulary



Below is the 2023 Formulary, or prescription drug list, from PrimeTime Health Plan Aultimate (HMO-POS) by Aultcare Health Insuring Corporation. A formulary is a continually updated list of available medications and prescription drug cost information. Examining a plans formulary can help you find a Ohio 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 PrimeTime Health Plan Aultimate (HMO-POS)(H3664-021) plan has a $150 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. Aultcare Health Insuring Corporation 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:PrimeTime Health Plan Aultimate
Plan ID: H3664-021
Provider: Aultcare Health Insuring Corporation
Plan Year:2023
Premium:$0.00
Deductible:$150
Initial Coverage Limit:$4660
Coverage Area:Ohio
Similar Plan:H3664-017


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
4Y$95$100NANN
Pancreaze
529%29%NANN
Panretin
529%29%NANN
Paricalcitol
4Y$95$100NANN
Paromomycin Sulfate
4Y$95$100NANN
Paroxetine
4Y$95$100NANN
Paroxetine Hydrochloride
3Y$42$47NANN
Paser
4Y$95$100NANN
Pediarix
3Y$42$47NANN
Pedvaxhib
3Y$42$47NANN
Peg-3350 And Electrolytes
2N$15$20NANN
Peg-3350, Electrolytes, And Ascorbate
2N$15$20NANN
Pegasys
529%29%NANN
Pemazyre
529%29%NA30/30YN
Penicillamine
529%29%NANN
Penicillin G Procaine
4Y$95$100NANN
Penicillin G Sodium
529%29%NANN
Penicillin V Potassium
2N$15$20NANN
Pentacel
3Y$42$47NANN
Pentamidine Isethionate
4Y$95$100NAYN
Pentasa
4Y$95$100NANN
Pentoxifylline
2N$15$20NANN
Perindopril Erbumine
2N$15$20NANN
Periogard Alcohol Free
2N$15$20NANN
Permethrin
3Y$42$47NANN
Perphenazine
4Y$95$100NANN
Perphenazine And Amitriptyline Hydrochloride
4Y$95$100NANN
Perseris
529%29%NANN
Pertzye
529%29%NANN
Pexeva
4Y$95$100NANN
Phenelzine Sulfate
3Y$42$47NANN
Phenobarbital
2N$15$20NANN
Phenoxybenzamine Hydrochloride
529%29%NANN
Phenytoin
2N$15$20NANN
Phospholine Iodide
4Y$95$100NANN
Pifeltro
529%29%NANN
Pilocarpine Hydrochloride
3Y$42$47NANN
Pimozide
4Y$95$100NANN
Pindolol
2N$15$20NANN
Piperacillin And Tazobactam
4Y$95$100NANN
Piqray
529%29%NAYN
Pirmella 1/35
3Y$42$47NANN
Piroxicam
2N$15$20NANN
Plegridy
529%29%NANN
Plenamine
4Y$95$100NAYN
Podofilox
4Y$95$100NANN
Polyethylene Glycol 3350, Sodium Chloride, Sodium
2N$15$20NANN
Polymyxin B Sulfate And Trimethoprim
2N$15$20NANN
Portia
3Y$42$47NANN
Potassium Chloride
2N$15$20NANN
Potassium Chloride In Dextrose
4Y$95$100NANN
Potassium Chloride In Dextrose And Sodium Chloride
4Y$95$100NANN
Potassium Chloride In Lactated Ringers And Dextros
3Y$42$47NANN
Potassium Chloride In Sodium Chloride
4Y$95$100NANN
Potassium Citrate
2N$15$20NANN
Prasugrel
2N$15$20NANN
Pravastatin Sodium
1N$0$10NANN
Praziquantel
4Y$95$100NANN
Prazosin Hydrochloride
2N$15$20NANN
Prednisolone Acetate
2N$15$20NANN
Prednisolone Sodium Phosphate
4Y$95$100NANN
Prednisolone Sodium Phosphate Oral Solution
2N$15$20NANN
Prednisone
3Y$42$47NANN
Prednisone Intensol
4Y$95$100NANN
Pregabalin
4Y$95$100NA60/30NN
Premarin
4Y$95$100NANN
Premasol - Sulfite-free (amino Acid)
4Y$95$100NAYN
Premphase
4Y$95$100NANN
Prempro
4Y$95$100NANN
Prevymis
529%29%NANN
Prezcobix
529%29%NANN
Prezista
529%29%NANN
Priftin
4Y$95$100NANN
Primaquine Phosphate
4Y$95$100NANN
Primidone
2N$15$20NANN
Privigen
529%29%NAYN
Proair
3Y$42$47NANN
Proair Digihaler
3Y$42$47NANN
Proair Respiclick
4Y$95$100NANN
Probenecid
2N$15$20NANN
Probenecid And Colchicine
2N$15$20NANN
Procalamine
4Y$95$100NAYN
Prochlorperazine Maleate
2N$15$20NANN
Procrit
529%29%NAYN
Procto-med Hc
2N$15$20NANN
Proctosol-hc
2N$15$20NANN
Proctozone-hc
2N$15$20NANN
Progesterone
2N$15$20NANN
Prograf
4Y$95$100NAYN
Prolastin-c
529%29%NAYN
Prolia
4Y$95$100NANN
Promacta
529%29%NAYN
Promethazine Hydrochloride
2N$15$20NANN
Propafenone Hydrochloride
4Y$95$100NANN
Propranolol Hydrochloride
2N$15$20NANN
Propylthiouracil
3Y$42$47NANN
Proquad
4Y$95$100NANN
Prosol
4Y$95$100NAYN
Protriptyline Hydrochloride
4Y$95$100NANN
Pulmozyme
529%29%NAYN
Purixan
529%29%NANN
Pylera
529%29%NANN
Pyrazinamide
4Y$95$100NANN
Pyridostigmine Bromide
4Y$95$100NANN
Pyrimethamine
529%29%NANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H3664-021

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $150. 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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