ATRIO Special Needs Plan (Willamette) (HMO D-SNP) Formulary



Below is the 2023 Formulary, or prescription drug list, from ATRIO Special Needs Plan (Willamette) (HMO D-SNP) by Atrio Health Plans. A formulary is a continually updated list of available medications and prescription drug cost information. Examining a plans formulary can help you find a Oregon 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 ATRIO Special Needs Plan (Willamette) (HMO D-SNP)(H5995-001) plan has a $505 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. Atrio Health Plans 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:ATRIO Special Needs Plan (Willamette) (HMO D-SNP)
Plan ID: H5995-001
Provider: Atrio Health Plans
Plan Year:2023
Premium:$41.00
Deductible:$505
Initial Coverage Limit:$4660
Coverage Area:Oregon
Similar Plan:H5995-001


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
Deductible
Apply
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Abacavir
1YNA15%NANN
Abacavir And Lamivudine
1YNA15%NANN
Abelcet
1YNA15%NAYN
Abiraterone
1YNA15%NA120/30YN
Abiraterone Acetate
1YNA15%NA120/30YN
Acarbose
1YNA15%NA90/30NN
Accutane
1YNA15%NANN
Acebutolol Hydrochloride
1YNA15%NANN
Acetaminophen And Codeine Phosphate
1YNA15%NA4500/30NN
Acetazolamide
1YNA15%NANN
Acetic Acid
1YNA15%NANN
Acetylcysteine
1YNA15%NAYN
Acitretin
1YNA15%NANN
Actemra
1YNA15%NAYN
Actemra Actpen
1YNA15%NAYN
Acthar
1YNA15%NA35/28YN
Acthib
1YNA15%NANN
Actimmune
1YNA15%NAYN
Acyclovir
1YNA15%NANN
Acyclovir Sodium
1YNA15%NAYN
Adapalene
1YNA15%NANN
Adefovir Dipivoxil
1YNA15%NANN
Adempas
1YNA15%NA90/30YN
Advair
1YNA15%NA60/30NN
Advair Hfa
1YNA15%NA12/30NN
Ajovy
1YNA15%NA/30YN
Alacort
1YNA15%NANN
Albendazole
1YNA15%NANN
Albuterol Sulfate
1YNA15%NA1/30NN
Alclometasone Dipropionate
1YNA15%NANN
Alecensa
1YNA15%NA240/30YN
Alendronate Sodium
1YNA15%NA4/28NN
Aliskiren
1YNA15%NANN
Alosetron Hydrochloride
1YNA15%NANN
Alprazolam
1YNA15%NA150/30NN
Altavera
1YNA15%NANN
Alunbrig
1YNA15%NAYN
Alyacen 1/35
1YNA15%NANN
Alyq
1YNA15%NA60/30YN
Amabelz
1YNA15%NANN
Amantadine Hydrochloride
1YNA15%NANN
Ambisome
1YNA15%NAYN
Amethia
1YNA15%NA91/84NN
Amiloride Hydrochloride And Hydrochlorothiazide
1YNA15%NANN
Amiloride Hydrocloride
1YNA15%NANN
Amiodarone Hydrochloride
1YNA15%NANN
Amitriptyline Hydrochloride
1YNA15%NANN
Amlodipine And Benazepril Hydrochloride
1YNA15%NANN
Amlodipine And Olmesartan Medoxomil
1YNA15%NANN
Amlodipine And Valsartan
1YNA15%NANN
Amlodipine Besylate
1YNA15%NANN
Amlodipine Besylate And Benazepril Hydrochloride
1YNA15%NANN
Ammonium Lactate
1YNA15%NANN
Amoxapine
1YNA15%NANN
Amoxicillin
1YNA15%NANN
Amoxicillin And Clavulanate Potassium
1YNA15%NANN
Amphotericin B
1YNA15%NAYN
Ampicillin
1YNA15%NANN
Ampicillin And Sulbactam
1YNA15%NANN
Ampicillin Sodium And Sulbactam Sodium
1YNA15%NANN
Anagrelide
1YNA15%NANN
Anastrozole
1YNA15%NANN
Apraclonidine Ophthalmic
1YNA15%NANN
Aprepitant
1YNA15%NAYN
Apri
1YNA15%NANN
Aptivus
1YNA15%NANN
Aranelle
1YNA15%NANN
Aripiprazole
1YNA15%NA90/30NY
Aristada
1YNA15%NA/56NN
Aristada Initio
1YNA15%NA/365NN
Armodafinil
1YNA15%NA30/30YN
Arnuity Ellipta
1YNA15%NA30/30NN
Ascomp With Codeine
1YNA15%NA180/30NN
Asenapine
1YNA15%NA60/30NN
Ashlyna
1YNA15%NA91/84NN
Atenolol And Chlorthalidone
1YNA15%NANN
Atomoxetine
1YNA15%NA30/30NN
Atovaquone
1YNA15%NANN
Atovaquone And Proguanil Hydrochloride Pediatric
1YNA15%NANN
Atrovent
1YNA15%NA2/28NN
Aubra Eq
1YNA15%NANN
Austedo
1YNA15%NA120/30YN
Aviane
1YNA15%NANN
Avonex
1YNA15%NA1/28YN
Ayvakit
1YNA15%NA30/30YN
Azathioprine
1YNA15%NAYN
Azelastine Hcl Nasal
1YNA15%NA30/25NN
Azelastine Hydrochloride
1YNA15%NA30/25NN
Azithromycin
1YNA15%NANN
Azopt
1YNA15%NANN
Aztreonam
1YNA15%NANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H5995-001

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $505. 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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