Aetna Medicare Advantra Silver (PPO) Formulary



Below is the 2023 Formulary, or prescription drug list, from Aetna Medicare Advantra Silver (PPO) by Healthassurance Pennsylvania, 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 Pennsylvania 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 Aetna Medicare Advantra Silver (PPO)(H5522-004) 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. Healthassurance Pennsylvania, 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:Aetna Medicare Advantra Silver
Plan ID: H5522-004
Provider: Healthassurance Pennsylvania, Inc
Plan Year:2023
Premium:$0.00
Deductible:$0
Initial Coverage Limit:$4660
Coverage Area:Pennsylvania
Similar Plan:H5522-005


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
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Abacavir
4$100$100$100NN
Abacavir And Lamivudine
4$100$100$100NN
Abelcet
4$100$100$100YN
Abilify Maintena
533%33%33%1/28NN
Abiraterone
533%33%33%YN
Abiraterone Acetate
533%33%33%YN
Acarbose
2$0$20$090/30NN
Accutane
4$100$100$100YN
Acebutolol Hydrochloride
2$0$20$0NN
Acetaminophen And Codeine Phosphate
2$0$20$02700/30NN
Acetazolamide
4$100$100$100NN
Acetic Acid
2$0$20$0NN
Acetylcysteine
2$0$20$0YN
Acitretin
4$100$100$100YN
Acthib
3$47$47$47NN
Actimmune
533%33%33%YN
Acyclovir
2$0$20$0NN
Acyclovir Sodium
4$100$100$100YN
Adefovir Dipivoxil
4$100$100$10030/30NN
Adempas
533%33%33%90/30YN
Advair
3$47$47$4760/30NN
Advair Hfa
3$47$47$4712/30NN
Aimovig
3$47$47$471/30YN
Alacort
2$0$20$0NN
Albendazole
533%33%33%NN
Albuterol Sulfate
2$0$20$013/30NN
Alclometasone Dipropionate
4$100$100$100NN
Alecensa
533%33%33%240/30YN
Alendronate Sodium
1$0$15$04/28NN
Aliskiren
4$100$100$100NN
Alosetron Hydrochloride
533%33%33%60/30YN
Alprazolam
4$100$100$100NN
Altavera
2$0$20$0NN
Alunbrig
533%33%33%YN
Alyacen 1/35
2$0$20$0NN
Alyq
533%33%33%YN
Amabelz
4$100$100$100NN
Amantadine Hydrochloride
2$0$20$0120/30NN
Amethia
2$0$20$0NN
Amikacin Sulfate
4$100$100$100NN
Amiloride Hydrochloride And Hydrochlorothiazide
2$0$20$0NN
Amiloride Hydrocloride
2$0$20$0NN
Amiodarone Hydrochloride
2$0$20$0NN
Amitriptyline Hydrochloride
3$47$47$47YN
Amlodipine And Benazepril Hydrochloride
1$0$15$030/30NN
Amlodipine And Olmesartan Medoxomil
1$0$15$030/30NN
Amlodipine And Valsartan
1$0$15$030/30NN
Amlodipine Besylate
1$0$15$0NN
Amlodipine Besylate And Benazepril Hydrochloride
1$0$15$030/30NN
Ammonium Lactate
2$0$20$0NN
Amnesteem
4$100$100$100YN
Amoxapine
3$47$47$47NN
Amoxicillin
1$0$15$0NN
Amoxicillin And Clavulanate Potassium
2$0$20$0NN
Amphotericin B
4$100$100$100YN
Ampicillin
4$100$100$100NN
Ampicillin And Sulbactam
4$100$100$100NN
Ampicillin Sodium And Sulbactam Sodium
4$100$100$100NN
Anagrelide
2$0$20$0NN
Anastrozole
2$0$20$0NN
Aprepitant
4$100$100$100YN
Apri
2$0$20$0NN
Aptivus
533%33%33%NN
Aranelle
2$0$20$0NN
Aripiprazole
533%33%33%60/30NN
Aristada
533%33%33%3/56NN
Aristada Initio
533%33%33%NN
Armodafinil
4$100$100$10030/30YN
Arnuity Ellipta
3$47$47$4730/30NN
Asenapine
4$100$100$10060/30NN
Ashlyna
2$0$20$0NN
Atenolol And Chlorthalidone
2$0$20$0NN
Atomoxetine
4$100$100$10030/30NN
Atovaquone
533%33%33%YN
Atovaquone And Proguanil Hydrochloride Pediatric
4$100$100$100NN
Atrovent
4$100$100$10025/30NN
Aubra Eq
2$0$20$0NN
Austedo
533%33%33%120/30YN
Aviane
2$0$20$0NN
Avonex
533%33%33%1/28YN
Ayvakit
533%33%33%30/30YN
Azathioprine
2$0$20$0YN
Azelaic Acid
4$100$100$10050/30NN
Azelastine Hcl Nasal
2$0$20$030/25NN
Azelastine Hydrochloride
2$0$20$030/25NN
Azithromycin
4$100$100$100NN
Aztreonam
4$100$100$100NN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H5522-004

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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*Licensed Agent Disclaimer: We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE (TTY users should call 1-877-486-2048) 24 hours a day/7 days a week to get information on all of your options.

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