Advantage U Signature (PPO) Formulary



Below is the 2023 Formulary, or prescription drug list, from Advantage U Signature (PPO) by University Of Utah Health Insurance 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 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 Advantage U Signature (PPO)(H4304-001) plan has a $125 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. University Of Utah Health Insurance 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:Advantage U Signature
Plan ID: H4304-001
Provider: University Of Utah Health Insurance Plans
Plan Year:2023
Premium:$0.00
Deductible:$125
Initial Coverage Limit:$4660
Coverage Area:Utah
Similar Plan:H4304-002


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
Abacavir
2NNA$10NANN
Abacavir And Lamivudine
2NNA$10NANN
Abelcet
4YNA$100NAYN
Abilify Maintena
5NA31%NA1/28NN
Abiraterone
5NA31%NAYN
Abiraterone Acetate
5NA31%NAYN
Acarbose
2NNA$10NANN
Accutane
2NNA$10NAYN
Acebutolol Hydrochloride
2NNA$10NANN
Acetaminophen And Codeine Phosphate
2NNA$10NA2700/30NN
Acetazolamide
2NNA$10NANN
Acetic Acid
2NNA$10NANN
Acetylcysteine
2NNA$10NAYN
Acitretin
2NNA$10NAYN
Acthib
3YNA$47NANN
Actimmune
5NA31%NAYN
Acyclovir
2NNA$10NANN
Acyclovir Sodium
2NNA$10NAYN
Adefovir Dipivoxil
5NA31%NANN
Adempas
5NA31%NA90/30YN
Advair
3YNA$47NA60/30NN
Advair Hfa
3YNA$47NA12/30NN
Aimovig
3YNA$47NA1/30YN
Alacort
1NNA$3NANN
Albendazole
5NA31%NANN
Albuterol Sulfate
2NNA$10NA1/30NN
Alclometasone Dipropionate
2NNA$10NA60/30NN
Alecensa
5NA31%NAYN
Alendronate Sodium
1NNA$3NANN
Aliskiren
2NNA$10NANN
Alosetron Hydrochloride
5NA31%NA60/30YN
Alprazolam
2NNA$10NA150/30NN
Altavera
2NNA$10NANN
Altoprev
5NA31%NA30/30NY
Alunbrig
5NA31%NAYN
Alyacen 1/35
2NNA$10NANN
Amabelz
3YNA$47NANN
Amantadine Hydrochloride
2NNA$10NA120/30NN
Amikacin Sulfate
2NNA$10NANN
Amiloride Hydrochloride And Hydrochlorothiazide
1NNA$3NANN
Amiloride Hydrocloride
1NNA$3NANN
Amiodarone Hydrochloride
2NNA$10NANN
Amitriptyline Hydrochloride
3YNA$47NANN
Amlodipine And Benazepril Hydrochloride
1NNA$3NA30/30NN
Amlodipine And Olmesartan Medoxomil
1NNA$3NA30/30NN
Amlodipine And Valsartan
1NNA$3NA30/30NN
Amlodipine Besylate
1NNA$3NANN
Amlodipine Besylate And Benazepril Hydrochloride
1NNA$3NA30/30NN
Ammonium Lactate
2NNA$10NANN
Amnesteem
2NNA$10NAYN
Amoxapine
3YNA$47NANN
Amoxicillin
1NNA$3NANN
Amoxicillin And Clavulanate Potassium
2NNA$10NANN
Amphotericin B
2NNA$10NAYN
Ampicillin
2NNA$10NANN
Ampicillin And Sulbactam
2NNA$10NANN
Ampicillin Sodium And Sulbactam Sodium
2NNA$10NANN
Anagrelide
2NNA$10NANN
Anastrozole
1NNA$3NANN
Aprepitant
2NNA$10NAYN
Apri
2NNA$10NANN
Aptivus
5NA31%NANN
Aralast
5NA31%NAYN
Aranelle
2NNA$10NANN
Aripiprazole
5NA31%NA60/30NN
Aristada
5NA31%NA/56NN
Aristada Initio
5NA31%NANN
Armodafinil
2NNA$10NA30/30YN
Arnuity Ellipta
3YNA$47NA30/30NN
Asenapine
2NNA$10NA60/30NN
Atenolol And Chlorthalidone
1NNA$3NANN
Atomoxetine
2NNA$10NA30/30NN
Atovaquone
2NNA$10NANN
Atovaquone And Proguanil Hydrochloride Pediatric
2NNA$10NANN
Atrovent
4YNA$100NA2/30NN
Aubra Eq
2NNA$10NANN
Austedo
5NA31%NA120/30YN
Aviane
2NNA$10NANN
Avita
2NNA$10NA45/30YN
Ayvakit
5NA31%NA30/30YN
Azathioprine
2NNA$10NAYN
Azelaic Acid
2NNA$10NA50/30NN
Azelastine Hcl Nasal
2NNA$10NANN
Azelastine Hydrochloride
2NNA$10NANN
Azithromycin
2NNA$10NANN
Aztreonam
2NNA$10NANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H4304-001

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $125. 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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