PriorityMedicare Select (PPO) Formulary



Below is the 2023 Formulary, or prescription drug list, from PriorityMedicare Select (PPO) by Priority Health. 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 PriorityMedicare Select (PPO)(H4875-017) 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. Priority Health 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:PriorityMedicare Select
Plan ID: H4875-017
Provider: Priority Health
Plan Year:2023
Premium:$69.50
Deductible:$0
Initial Coverage Limit:$4660
Coverage Area:Michigan
Similar Plan:H4875-018


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
⇅ Click the Header to Sort
Drug
Name⇅
Tier
Level
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Paliperidone
445%50%45%30/30NY
Panretin
533%33%33%60/30YN
Paricalcitol
445%50%45%NN
Paromomycin Sulfate
2$7$12$7NN
Paroxetine
445%50%45%NN
Paser
3$37$42$37NN
Pediarix
3$37$42$37NN
Pedvaxhib
3$37$42$37NN
Peg-3350 And Electrolytes
2$7$12$7NN
Pegasys
533%33%33%NN
Pemazyre
533%33%33%14/21YN
Penicillamine
445%50%45%YN
Penicillin G Potassium
445%50%45%NN
Penicillin G Procaine
445%50%45%NN
Penicillin G Sodium
445%50%45%NN
Penicillin V Potassium
2$7$12$7NN
Pentacel
3$37$42$37NN
Pentamidine Isethionate
3$37$42$37YN
Pentoxifylline
2$7$12$7NN
Perindopril Erbumine
1$1$6$1NN
Permethrin
2$7$12$7NN
Perphenazine
2$7$12$7NN
Perseris
533%33%33%1/28NN
Phenelzine Sulfate
2$7$12$7NN
Phenobarbital
2$7$12$7YN
Phenytoin
2$7$12$7NN
Pifeltro
533%33%33%30/30NN
Pilocarpine Hydrochloride
2$7$12$7NN
Pimecrolimus
3$37$42$3730/30NN
Pimozide
2$7$12$7NN
Pindolol
2$7$12$7NN
Pioglitazone And Glimepiride
2$7$12$7NN
Piperacillin And Tazobactam
2$7$12$7NN
Piqray
533%33%33%56/28YN
Pirmella 1/35
2$7$12$7NN
Piroxicam
2$7$12$7NN
Plegridy
533%33%33%1/28YN
Podofilox
2$7$12$7NN
Polyethylene Glycol 3350, Sodium Chloride, Sodium
2$7$12$7NN
Polymyxin B Sulfate And Trimethoprim
2$7$12$7NN
Portia
2$7$12$7NN
Potassium Chloride
2$7$12$7NN
Potassium Chloride In Dextrose
2$7$12$7NN
Potassium Chloride In Dextrose And Sodium Chloride
2$7$12$7NN
Potassium Chloride In Lactated Ringers And Dextros
2$7$12$7NN
Potassium Chloride In Sodium Chloride
2$7$12$7NN
Potassium Citrate
2$7$12$7NN
Pradaxa
445%50%45%60/30NN
Pramipexole Dihydrochloride
445%50%45%NN
Prasugrel
3$37$42$37NN
Pravastatin Sodium
1$1$6$1NN
Praziquantel
3$37$42$37NN
Prazosin Hydrochloride
2$7$12$7NN
Pred-g
3$37$42$37NN
Prednisolone Acetate
2$7$12$7NN
Prednisolone Sodium Phosphate
445%50%45%NN
Prednisone
2$7$12$7NN
Prednisone Intensol
445%50%45%NN
Pregabalin
2$7$12$7900/30NN
Premasol - Sulfite-free (amino Acid)
3$37$42$37YN
Pretomanid
445%50%45%30/30YN
Prevymis
533%33%33%YN
Prezcobix
533%33%33%30/30NN
Prezista
533%33%33%30/30NN
Priftin
445%50%45%NN
Primaquine Phosphate
2$7$12$7NN
Primidone
2$7$12$7NN
Probenecid
2$7$12$7NN
Probenecid And Colchicine
2$7$12$7NN
Procalamine
3$37$42$37YN
Prochlorperazine Maleate
2$7$12$7NN
Procrit
533%33%33%YN
Procto-med Hc
2$7$12$7NN
Proctosol-hc
2$7$12$7NN
Proctozone-hc
2$7$12$7NN
Progesterone
2$7$12$7NN
Prograf
445%50%45%YN
Prolastin-c
533%33%33%YN
Prolia
445%50%45%1/180YN
Promacta
533%33%33%30/30YN
Promethazine Hydrochloride
2$7$12$7NN
Propafenone Hydrochloride
445%50%45%NN
Propranolol Hydrochloride
2$7$12$7NN
Propylthiouracil
2$7$12$7NN
Proquad
3$37$42$37NN
Protriptyline Hydrochloride
445%50%45%NN
Pulmicort
3$37$42$372/30NN
Pulmozyme
533%33%33%YN
Purified Cortrophin Gel
533%33%33%YN
Purixan
533%33%33%NN
Pyrazinamide
2$7$12$7NN
Pyridostigmine Bromide
445%50%45%NN
Pyrimethamine
533%33%33%NN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H4875-017

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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