SelectHealth Medicare Classic (HMO) Formulary



Below is the 2023 Formulary, or prescription drug list, from SelectHealth Medicare Classic (HMO) by Selecthealth, 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 Utah 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 SelectHealth Medicare Classic (HMO)(H1994-002) plan has a $200 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. Selecthealth, 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:SelectHealth Medicare Classic
Plan ID: H1994-002
Provider: Selecthealth, Inc
Plan Year:2023
Premium:$38.00
Deductible:$200
Initial Coverage Limit:$4660
Coverage Area:Utah
Similar Plan:H1994-003


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
Sandimmune
3YNA$47NAYN
Sapropterin Dihydrochloride
2NNA$10NAYN
Savella
4YNA$100NA60/30NY
Scemblix
5NA29%NA300/30YN
Secuado
5NA29%NA30/30NY
Segluromet
4YNA$100NA60/30NY
Selegiline Hydrochloride
2NNA$10NANN
Selzentry
5NA29%NA1800/30NN
Serevent
3YNA$47NA60/30NN
Sertraline Hydrochloride
1NNA$0NA300/30NN
Sevelamer Hydrochloride
2NNA$10NANN
Shingrix
1NNA$0NANN
Signifor
5NA29%NA60/30YN
Sildenafil
2NNA$10NA180/30YN
Silodosin
1NNA$0NA30/30NN
Simbrinza
4YNA$100NA16/30NN
Sirolimus
4YNA$100NAYN
Sirturo
5NA29%NA1050/30YN
Sitavig
5NA29%NA30/30YN
Sivextro
4YNA$100NA6/30YN
Skyrizi
5NA29%NA1/84YN
Sodium Chloride
2NNA$10NANN
Sodium Phenylbutyrate
2NNA$10NANN
Sodium Polystyrene Sulfonate
2NNA$10NANN
Sofosbuvir And Velpatasvir
5NA29%NA30/30YN
Solifenacin Succinate
1NNA$0NA30/30NN
Somavert
5NA29%NA60/30YN
Sorine
1NNA$0NANN
Sotalol Hydrochloride
1NNA$0NANN
Spinosad
4YNA$100NANN
Spiriva
3YNA$47NA30/30NN
Spironolactone
1NNA$0NANN
Spironolactone And Hydrochlorothiazide
1NNA$0NANN
Sprintec
1NNA$0NANN
Spritam
4YNA$100NA90/30NY
Sprycel
5NA29%NA60/30YN
Sronyx
2NNA$10NANN
Steglatro
4YNA$100NA30/30NY
Stelara
5NA29%NA2/84YN
Streptomycin
2NNA$10NAYN
Stribild
5NA29%NA30/30NN
Striverdi Respimat
3YNA$47NA4/30NN
Sucraid
5NA29%NA354/30YN
Sucralfate
2NNA$10NANN
Sulfacetamide Sodium
3YNA$47NANN
Sulfacetamide Sodium And Prednisolone Sodium Phosp
2NNA$10NANN
Sulfadiazine
2NNA$10NANN
Sulfamethoxazole And Trimethoprim
1NNA$0NANN
Sulfasalazine
2NNA$10NANN
Sulindac
1NNA$0NANN
Sumatriptan
2NNA$10NA12/30NY
Sumatriptan Succinate
2NNA$10NA4/30NN
Sunitinib Malate
5NA29%NA30/30YN
Sunosi
4YNA$100NA30/30NY
Suprax
4YNA$100NANN
Suprep Bowel Prep
3YNA$47NANN
Symbicort
1NNA$0NA2/30NN
Symdeko
5NA29%NA60/30YN
Symjepi
3YNA$47NANN
Symlinpen
5NA29%NA1/30NY
Sympazan
5NA29%NA60/30YN
Symtuza
5NA29%NA30/30NN
Synarel
4YNA$100NAYN
Synribo
5NA29%NAYN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H1994-002

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $200. 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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