Erickson Advantage Champion (HMO-POS C-SNP) Formulary



Below is the 2023 Formulary, or prescription drug list, from Erickson Advantage Champion (HMO-POS C-SNP) by Sierra Health And Life Insurance Company, 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 Colorado 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 Erickson Advantage Champion (HMO-POS C-SNP)(H5652-004) 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. Sierra Health And Life Insurance Company, 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:Erickson Advantage Champion (HMO-POS C-SNP)
Plan ID: H5652-004
Provider: Sierra Health And Life Insurance Company, Inc
Plan Year:2023
Premium:$28.80
Deductible:$0
Initial Coverage Limit:$4660
Coverage Area:Colorado
Similar Plan:H5652-006


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
Edarbi
4NA$85NA30/30NN
Edarbyclor
4NA$85NA30/30NN
Edurant
5NA33%33%30/30NN
Efavirenz
4NA$85NA30/30NN
Efavirenz, Emtricitabine And Tenofovir Disoproxil
5NA33%33%30/30NN
Efavirenz, Lamivudine And Tenofovir Disoproxil Fum
5NA33%33%30/30NN
Egrifta Sv
5NA33%33%YN
Elestrin
4NA$85NANN
Eliquis
3NA$45NA148/365NN
Elmiron
5NA33%33%NN
Eluryng
4NA$85NANN
Emcyt
4NA$85NANN
Emgality
4NA$85NA3/30YN
Emsam
5NA33%33%30/30NN
Emtricitabine
4NA$85NA30/30NN
Emtricitabine And Tenofovir Disoproxil Fumarate
5NA33%33%30/30NN
Emtriva
4NA$85NA850/30NN
Enalapril Maleate And Hydrochlorothiazide
1NA$0NA60/30NN
Enalapril Maleate Oral Solution
4NA$85NANN
Enbrel
5NA33%33%8/28YN
Endocet
3NA$45NA360/30NN
Engerix-b
3NA$45NA0/1YN
Enoxaparin Sodium
4NA$85NA60/30NN
Enpresse
4NA$85NANN
Enskyce
4NA$85NANN
Entacapone
4NA$85NANN
Entecavir
4NA$85NANN
Entresto
3NA$45NA60/30NN
Enulose
2NA$5NANN
Envarsus
4NA$85NAYN
Epclusa
5NA33%33%28/28YN
Epidiolex
5NA33%33%YN
Epinastine Hydrochloride
3NA$45NANN
Epinephrine
3NA$45NA4/30NN
Epitol
3NA$45NANN
Epivir
4NA$85NANN
Eplerenone
2NA$5NANN
Eprontia
4NA$85NANN
Ergotamine Tartrate And Caffeine
3NA$45NANN
Erivedge
5NA33%33%YN
Erleada
5NA33%33%120/30YN
Erlotinib
5NA33%33%90/30YN
Errin
4NA$85NANN
Ertapenem
4NA$85NANN
Ery
3NA$45NANN
Erythrocin Lactobionate
4NA$85NANN
Erythromycin
4NA$85NANN
Erythromycin Ethylsuccinate
4NA$85NANN
Esbriet
5NA33%33%90/30YN
Escitalopram
1NA$0NANN
Escitalopram Oxalate
2NA$5NANN
Esomeprazole Magnesium
3NA$45NANN
Estarylla
4NA$85NANN
Estradiol
1NA$0NANN
Estradiol Transdermal System
3NA$45NA4/28NN
Estradiol Valerate
4NA$85NANN
Estring
4NA$85NANN
Eszopiclone
3NA$45NA90/365NN
Ethacrynic Acid
4NA$85NANN
Ethambutol Hydrochloride
3NA$45NANN
Ethosuximide
3NA$45NANN
Ethynodiol Diacetate And Ethinyl Estradiol
4NA$85NANN
Etodolac
4NA$85NANN
Etonogestrel/ethinyl Estradiol
4NA$85NANN
Etravirine
5NA33%33%60/30NN
Euthyrox
3NA$45NANN
Everolimus
5NA33%33%YN
Evotaz
5NA33%33%30/30NN
Exemestane
4NA$85NANN
Exkivity
5NA33%33%120/30YN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H5652-004

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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