Medicare Plus Blue PPO Vitality (PPO) Formulary



Below is the 2023 Formulary, or prescription drug list, from Medicare Plus Blue PPO Vitality (PPO) by Bcbs Of Michigan Mutual Insurance Company. 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 Medicare Plus Blue PPO Vitality (PPO)(H9572-002) 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. Bcbs Of Michigan Mutual Insurance Company 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:Medicare Plus Blue PPO Vitality
Plan ID: H9572-002
Provider: Bcbs Of Michigan Mutual Insurance Company
Plan Year:2023
Premium:$31.10
Deductible:$0
Initial Coverage Limit:$4660
Coverage Area:Michigan
Similar Plan:H9572-003


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
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
M-m-r Ii
3$42$47$42NN
Malathion
450%50%50%NN
Marplan
450%50%50%540/90NN
Matulane
533%33%33%NN
Meclizine Hydrochloride
2$11$20$11NN
Meclofenamate Sodium
450%50%50%NN
Medroxyprogesterone Acetate
3$42$47$42NN
Mefloquine Hydrochloride
2$11$20$11NN
Megestrol Acetate
450%50%50%NN
Mekinist
533%33%33%YN
Mektovi
533%33%33%YN
Memantine
2$11$20$111080/90YN
Memantine Hydrochloride
450%50%50%90/90YN
Menactra
3$42$47$42NN
Menest
450%50%50%NN
Menquadfi
3$42$47$42NN
Menveo
3$42$47$42NN
Mercaptopurine
2$11$20$11NN
Meropenem
3$42$47$42NN
Mesalamine
450%50%50%NN
Mesnex
3$42$47$42NN
Metformin Hydrochloride
1$0$5$0180/90NN
Methadone Hydrochloride
2$11$20$11NN
Methazolamide
450%50%50%NN
Methenamine Hippurate
2$11$20$11NN
Methimazole
2$11$20$11NN
Methitest
533%33%33%NN
Methocarbamol
2$11$20$11NN
Methotrexate
2$11$20$11NN
Methoxsalen
533%33%33%NN
Methscopolamine Bromide
2$11$20$11NN
Methylphenidate Hydrochloride
2$11$20$115400/90NN
Methylphenidate Hydrochloride Cd
2$11$20$1190/90NN
Methylprednisolone
1$0$5$0NN
Methyltestosterone
533%33%33%NN
Metoclopramide
2$11$20$11NN
Metolazone
1$0$5$0NN
Metoprolol Succinate
1$0$5$0180/90NN
Metoprolol Tartrate And Hydrochlorothiazide
1$0$5$0NN
Metronidazole
2$11$20$11NN
Metyrosine
533%33%33%NN
Mexiletine Hydrochloride
2$11$20$11NN
Miconazole Nitrate
2$11$20$11NN
Migergot
533%33%33%NN
Miglitol
1$0$5$0NN
Miglustat
533%33%33%YN
Minocycline
2$11$20$11NN
Minocycline Hydrochloride
2$11$20$11NN
Minoxidil
2$11$20$11NN
Mirtazapine
2$11$20$1190/90NN
Moexipril Hydrochloride
1$0$5$0360/90NN
Molindone Hydrochloride
2$11$20$11NN
Mometasone Furoate
2$11$20$11102/90NN
Montelukast Sodium
2$11$20$1190/90NN
Morphine Sulfate
450%50%50%90/90NN
Movantik
450%50%50%90/90YN
Moxifloxacin
2$11$20$11NN
Mupirocin
2$11$20$1190/90NN
Myalept
533%33%33%YN
Mycophenolate Mofetil
533%33%33%YN
Mycophenolic Acid
2$11$20$11YN
Myrbetriq
3$42$47$4290/90NN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H9572-002

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