Esteem Rx (HMO-POS) Formulary



Below is the 2023 Formulary, or prescription drug list, from Esteem Rx (HMO-POS) by Security Health Plan Of Wisconsin, 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 Wisconsin 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 Esteem Rx (HMO-POS)(H5211-012) plan has a $250 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. Security Health Plan Of Wisconsin, 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:Esteem Rx
Plan ID: H5211-012
Provider: Security Health Plan Of Wisconsin, Inc
Plan Year:2023
Premium:$0.00
Deductible:$250
Initial Coverage Limit:$4660
Coverage Area:Wisconsin
Similar Plan:H5211-013


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
Edurant
5NA28%NA30/30NN
Efavirenz
4YNA$100NA30/30NN
Efavirenz, Emtricitabine And Tenofovir Disoproxil
5NA28%NA30/30NN
Efavirenz, Lamivudine And Tenofovir Disoproxil Fum
5NA28%NA30/30NN
Eletriptan
4YNA$100NA12/30NN
Eletriptan Hydrobromide
4YNA$100NA12/30NN
Eliquis
3YNA$47NA74/30NN
Elmiron
4YNA$100NANN
Eluryng
4YNA$100NA1/28NN
Emcyt
4YNA$100NANN
Emsam
5NA28%NA30/30NN
Emtricitabine
4YNA$100NA30/30NN
Emtricitabine And Tenofovir Disoproxil Fumarate
5NA28%NA30/30NN
Emtriva
4YNA$100NA850/30NN
Enalapril Maleate And Hydrochlorothiazide
1NNA$4NANN
Enalapril Maleate Oral Solution
4YNA$100NANN
Enbrel
5NA28%NA8/28YN
Endocet
3YNA$47NA360/30NN
Engerix-b
6NNA$0NAYN
Enoxaparin Sodium
4YNA$100NA56/28NN
Enpresse
4YNA$100NANN
Enskyce
4YNA$100NANN
Entacapone
4YNA$100NA300/30NN
Entecavir
4YNA$100NA30/30NN
Entresto
3YNA$47NA60/30NN
Enulose
2NNA$16NANN
Epclusa
5NA28%NA30/30YN
Epidiolex
5NA28%NAYN
Epinastine Hydrochloride
2NNA$16NANN
Epinephrine
3YNA$47NA4/30NN
Epitol
2NNA$16NANN
Epivir
3YNA$47NANN
Eplerenone
4YNA$100NANN
Eprontia
4YNA$100NA480/30NN
Equetro
4YNA$100NANN
Eraxis
5NA28%NANN
Ergotamine Tartrate And Caffeine
3YNA$47NANN
Erivedge
5NA28%NA30/30YN
Erleada
5NA28%NA120/30YN
Erlotinib
5NA28%NA90/30YN
Errin
4YNA$100NANN
Ertapenem
4YNA$100NANN
Ery
2NNA$16NANN
Ery-tab
4YNA$100NANN
Erythrocin Lactobionate
4YNA$100NANN
Erythromycin
4YNA$100NANN
Erythromycin Ethylsuccinate
4YNA$100NANN
Escitalopram
1NNA$4NA45/30NN
Escitalopram Oxalate
4YNA$100NA600/30NN
Esomeprazole Magnesium
4YNA$100NA60/30NN
Estarylla
4YNA$100NANN
Estradiol
1NNA$4NANN
Estradiol / Norethindrone Acetate
3YNA$47NANN
Estradiol Transdermal System
2NNA$16NA4/28NN
Estradiol Valerate
4YNA$100NANN
Estring
4YNA$100NA1/90NN
Eszopiclone
2NNA$16NA30/30NN
Ethacrynic Acid
4YNA$100NANN
Ethambutol Hydrochloride
4YNA$100NANN
Ethosuximide
2NNA$16NANN
Ethynodiol Diacetate And Ethinyl Estradiol
4YNA$100NANN
Etodolac
2NNA$16NANN
Etonogestrel/ethinyl Estradiol
4YNA$100NA1/28NN
Etravirine
5NA28%NA60/30NN
Euthyrox
1NNA$4NANN
Everolimus
5NA28%NA30/30YN
Evotaz
5NA28%NA30/30NN
Exemestane
2NNA$16NA60/30NN
Exkivity
5NA28%NA120/30NN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H5211-012

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $250. 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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