Amerivantage ESRD Care (HMO C-SNP) Formulary



Below is the 2023 Formulary, or prescription drug list, from Amerivantage ESRD Care (HMO C-SNP) by Amerigroup Texas, 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 Arizona 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 Amerivantage ESRD Care (HMO C-SNP)(H2593-040) 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. Amerigroup Texas, 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:Amerivantage ESRD Care (HMO C-SNP)
Plan ID: H2593-040
Provider: Amerigroup Texas, Inc
Plan Year:2023
Premium:$0.00
Deductible:$0
Initial Coverage Limit:$4660
Coverage Area:Arizona
Similar Plan:H2593-041


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
3$40$45NA960/30NN
Abacavir And Lamivudine
4$85$95NA30/30NN
Abelcet
4$85$95NAYN
Abilify Maintena
533%33%NA1/28NN
Abiraterone
533%33%NA120/30YN
Abiraterone Acetate
533%33%NA60/30YN
Acarbose
2$7.5$12.5NA90/30NN
Accutane
4$85$95NANN
Acebutolol Hydrochloride
2$7.5$12.5NANN
Acetaminophen And Codeine Phosphate
2$7.5$12.5NA900/30NN
Acetazolamide
2$7.5$12.5NANN
Acetic Acid
2$7.5$12.5NANN
Acetylcysteine
2$7.5$12.5NAYN
Acitretin
4$85$95NANN
Acthib
3$40$45NANN
Actimmune
533%33%NAYN
Acyclovir
2$7.5$12.5NANN
Acyclovir Sodium
2$7.5$12.5NAYN
Adapalene
2$7.5$12.5NANN
Adefovir Dipivoxil
4$85$95NAYN
Adempas
533%33%NAYN
Advair
3$40$45NA60/30NN
Advair Hfa
3$40$45NA12/30NN
Aimovig
3$40$45NA1/28YN
Alacort
2$7.5$12.5NANN
Albendazole
533%33%NANN
Albuterol Sulfate
2$7.5$12.5NANN
Alclometasone Dipropionate
2$7.5$12.5NANN
Alecensa
533%33%NA240/30YN
Alendronate Sodium
2$7.5$12.5NA4/28NN
Aliskiren
3$40$45NANN
Alosetron Hydrochloride
533%33%NA60/30YN
Alprazolam
2$7.5$12.5NA120/30NN
Altavera
2$7.5$12.5NANN
Alunbrig
533%33%NA30/180YN
Alyacen 1/35
2$7.5$12.5NANN
Amantadine Hydrochloride
2$7.5$12.5NANN
Ambisome
533%33%NAYN
Amikacin Sulfate
2$7.5$12.5NANN
Amiloride Hydrochloride And Hydrochlorothiazide
2$7.5$12.5NANN
Amiloride Hydrocloride
2$7.5$12.5NANN
Amiodarone Hydrochloride
2$7.5$12.5NANN
Amitriptyline Hydrochloride
2$7.5$12.5NANN
Amlodipine And Benazepril Hydrochloride
6$0$0NANN
Amlodipine And Olmesartan Medoxomil
2$7.5$12.5NANN
Amlodipine And Valsartan
6$0$0NANN
Amlodipine Besylate
1$0$5NANN
Amlodipine Besylate And Benazepril Hydrochloride
6$0$0NANN
Ammonium Lactate
2$7.5$12.5NANN
Amnesteem
4$85$95NANN
Amoxapine
2$7.5$12.5NAYN
Amoxicillin
2$7.5$12.5NANN
Amoxicillin And Clavulanate Potassium
2$7.5$12.5NANN
Amphotericin B
2$7.5$12.5NAYN
Ampicillin
2$7.5$12.5NANN
Ampicillin And Sulbactam
2$7.5$12.5NANN
Ampicillin Sodium And Sulbactam Sodium
2$7.5$12.5NANN
Anagrelide
2$7.5$12.5NANN
Anastrozole
2$7.5$12.5NA30/30NN
Apraclonidine Ophthalmic
2$7.5$12.5NANN
Aprepitant
4$85$95NA15/30YN
Apri
2$7.5$12.5NANN
Aptivus
533%33%NA120/30NN
Aralast
533%33%NAYN
Aranelle
2$7.5$12.5NANN
Aripiprazole
4$85$95NA90/30NN
Aristada
533%33%NA/60NN
Aristada Initio
533%33%NA/365NN
Armodafinil
3$40$45NA30/30YN
Arnuity Ellipta
3$40$45NA30/30NN
Asenapine
4$85$95NA60/30NN
Atenolol And Chlorthalidone
1$0$5NANN
Atomoxetine
4$85$95NA30/30NN
Atovaquone
4$85$95NAYN
Atrovent
3$40$45NA26/30NN
Aubra Eq
2$7.5$12.5NANN
Auryxia
533%33%NAYN
Austedo
533%33%NA120/30YN
Aviane
2$7.5$12.5NANN
Avita
2$7.5$12.5NA45/30YN
Avonex
533%33%NA4/28YN
Ayvakit
533%33%NA30/30YN
Azasan
3$40$45NAYN
Azathioprine
3$40$45NAYN
Azelastine Hcl Nasal
2$7.5$12.5NA30/25NN
Azelastine Hydrochloride
2$7.5$12.5NA30/25NN
Azithromycin
2$7.5$12.5NANN
Aztreonam
2$7.5$12.5NANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H2593-040

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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