AgeRight Advantage Premier Health Plan (HMO C-SNP) Formulary



Below is the 2023 Formulary, or prescription drug list, from AgeRight Advantage Premier Health Plan (HMO C-SNP) by Marquis Advantage, 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 Oregon 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 AgeRight Advantage Premier Health Plan (HMO C-SNP)(H1372-003) plan has a $300 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. Marquis Advantage, 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:AgeRight Advantage Premier Health Plan (HMO C-SNP)
Plan ID: H1372-003
Provider: Marquis Advantage, Inc
Plan Year:2023
Premium:$37.00
Deductible:$300
Initial Coverage Limit:$4660
Coverage Area:Oregon
Similar Plan:H1372-001


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
2YNA$15NANN
Abacavir And Lamivudine
2YNA$15NANN
Abelcet
4YNA$95NAYN
Abilify Maintena
5NA28%NA1/28YN
Abiraterone
1NNA$0NA120/30NN
Acarbose
1NNA$0NANN
Accutane
2YNA$15NANN
Acebutolol Hydrochloride
1NNA$0NANN
Acetaminophen And Codeine Phosphate
2YNA$15NA4980/30NN
Acetazolamide
1NNA$0NANN
Acetic Acid
1NNA$0NANN
Acetylcysteine
1NNA$0NAYN
Acitretin
2YNA$15NANN
Actemra
5NA28%NA/28YN
Actemra Actpen
5NA28%NA/28YN
Acthib
3YNA$45NANN
Actimmune
5NA28%NAYN
Acyclovir
1NNA$0NANN
Acyclovir Sodium
2YNA$15NAYN
Adapalene
2YNA$15NA45/30YN
Adapalene And Benzoyl Peroxide
2YNA$15NA45/30YN
Adefovir Dipivoxil
2YNA$15NANN
Adempas
5NA28%NA90/30YN
Advair
2YNA$15NA60/30NN
Advair Hfa
3YNA$45NA12/30NN
Aimovig
3YNA$45NAYN
Alacort
1NNA$0NA240/30NN
Albendazole
2YNA$15NANN
Albuterol Sulfate
1NNA$0NAYN
Alclometasone Dipropionate
2YNA$15NA120/30NN
Alecensa
5NA28%NA240/30YN
Alendronate Sodium
1NNA$0NANN
Aliskiren
2YNA$15NANN
Alocril
3YNA$45NANN
Alomide
3YNA$45NANN
Alosetron Hydrochloride
2YNA$15NANN
Alprazolam
2YNA$15NA90/30NN
Altavera
2YNA$15NANN
Alunbrig
5NA28%NA30/30YN
Alyacen 1/35
2YNA$15NANN
Alyq
1NNA$0NAYN
Amabelz
1NNA$0NANN
Amantadine Hydrochloride
1NNA$0NANN
Amethia
2YNA$15NANN
Amikacin Sulfate
2YNA$15NANN
Amiloride Hydrochloride And Hydrochlorothiazide
1NNA$0NANN
Amiloride Hydrocloride
1NNA$0NANN
Amiodarone Hydrochloride
1NNA$0NANN
Amitriptyline Hydrochloride
1NNA$0NANN
Amlodipine And Benazepril Hydrochloride
1NNA$0NANN
Amlodipine And Olmesartan Medoxomil
2YNA$15NANN
Amlodipine And Valsartan
2YNA$15NANN
Amlodipine Besylate
1NNA$0NANN
Amlodipine Besylate And Benazepril Hydrochloride
1NNA$0NANN
Ammonium Lactate
1NNA$0NANN
Amnesteem
2YNA$15NANN
Amoxapine
1NNA$0NANN
Amoxicillin
1NNA$0NANN
Amoxicillin And Clavulanate Potassium
1NNA$0NANN
Amphotericin B
4YNA$95NAYN
Ampicillin
2YNA$15NANN
Ampicillin And Sulbactam
2YNA$15NANN
Ampicillin Sodium And Sulbactam Sodium
2YNA$15NANN
Anagrelide
1NNA$0NANN
Anastrozole
1NNA$0NANN
Androderm
3YNA$45NA30/30YN
Annovera
4YNA$95NA1/365NN
Anzemet
4YNA$95NAYN
Apraclonidine Ophthalmic
2YNA$15NANN
Aprepitant
2YNA$15NA6/4YN
Apri
2YNA$15NANN
Aptivus
5NA28%NANN
Aralast
5NA28%NAYN
Aranelle
2YNA$15NANN
Arikayce
5NA28%NA252/30YN
Aripiprazole
2YNA$15NA60/30NN
Aristada
5NA28%NA/56NN
Aristada Initio
5NA28%NA/42NN
Armodafinil
1NNA$0NA30/30YN
Arnuity Ellipta
3YNA$45NA30/30NN
Asenapine
2YNA$15NA60/30NN
Ashlyna
2YNA$15NANN
Asmanex
3YNA$45NA1/30NN
Asmanex Hfa
3YNA$45NA13/30NN
Atenolol And Chlorthalidone
1NNA$0NANN
Atomoxetine
2YNA$15NA60/30NN
Atovaquone
2YNA$15NANN
Atovaquone And Proguanil Hydrochloride Pediatric
1NNA$0NANN
Atrovent
1NNA$0NANN
Aubra Eq
2YNA$15NANN
Auryxia
4YNA$95NAYN
Austedo
5NA28%NA120/30YN
Aviane
2YNA$15NANN
Avita
2YNA$15NA45/30YN
Avonex
5NA28%NANN
Ayvakit
5NA28%NA30/30YN
Azasan
2YNA$15NAYN
Azathioprine
2YNA$15NAYN
Azelaic Acid
2YNA$15NA50/30NN
Azelastine Hcl Nasal
2YNA$15NANN
Azelastine Hydrochloride
1NNA$0NANN
Azithromycin
2YNA$15NANN
Aztreonam
2YNA$15NANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H1372-003

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $300. 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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