Amerivantage Select Plus (HMO) Formulary



Below is the 2023 Formulary, or prescription drug list, from Amerivantage Select Plus (HMO) by Amerigroup 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 Texas 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 Select Plus (HMO)(H8849-009) 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 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:Amerivantage Select Plus
Plan ID: H8849-009
Provider: Amerigroup Insurance Company
Plan Year:2023
Premium:$0.00
Deductible:$0
Initial Coverage Limit:$4660
Coverage Area:Texas
Similar Plan:H8849-010


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
Abacavir
4$95$100NA960/30NN
Abacavir And Lamivudine
4$95$100NA30/30NN
Abelcet
4$95$100NAYN
Abilify Maintena
533%33%NA1/28NN
Abiraterone
533%33%NA120/30YN
Abiraterone Acetate
533%33%NA60/30YN
Acarbose
2$10$15NA90/30NN
Accutane
4$95$100NANN
Acebutolol Hydrochloride
2$10$15NANN
Acetaminophen And Codeine Phosphate
3$42$47NA900/30NN
Acetazolamide
3$42$47NANN
Acetic Acid
1$3$8NANN
Acetylcysteine
2$10$15NAYN
Acitretin
4$95$100NANN
Acthib
3$42$47NANN
Actimmune
533%33%NAYN
Acyclovir
4$95$100NANN
Acyclovir Sodium
4$95$100NAYN
Adapalene
4$95$100NANN
Adefovir Dipivoxil
4$95$100NAYN
Adempas
533%33%NAYN
Advair
3$42$47NA60/30NN
Advair Hfa
3$42$47NA12/30NN
Aimovig
3$42$47NA1/28YN
Alacort
1$3$8NANN
Albendazole
533%33%NANN
Albuterol Sulfate
2$10$15NANN
Alclometasone Dipropionate
3$42$47NANN
Alecensa
533%33%NA240/30YN
Alendronate Sodium
6$0$0NA4/28NN
Aliskiren
3$42$47NANN
Alosetron Hydrochloride
533%33%NA60/30YN
Alprazolam
3$42$47NA120/30NN
Altavera
3$42$47NANN
Alunbrig
533%33%NA30/180YN
Alyacen 1/35
4$95$100NANN
Amabelz
4$95$100NAYN
Amantadine Hydrochloride
3$42$47NANN
Ambisome
533%33%NAYN
Amethia
4$95$100NANN
Amikacin Sulfate
4$95$100NANN
Amiloride Hydrochloride And Hydrochlorothiazide
1$3$8NANN
Amiloride Hydrocloride
3$42$47NANN
Amiodarone Hydrochloride
4$95$100NANN
Amitriptyline Hydrochloride
2$10$15NANN
Amlodipine And Benazepril Hydrochloride
6$0$0NANN
Amlodipine And Olmesartan Medoxomil
3$42$47NANN
Amlodipine And Valsartan
6$0$0NANN
Amlodipine Besylate
1$3$8NANN
Amlodipine Besylate And Benazepril Hydrochloride
6$0$0NANN
Ammonium Lactate
2$10$15NANN
Amnesteem
4$95$100NANN
Amoxapine
2$10$15NAYN
Amoxicillin
1$3$8NANN
Amoxicillin And Clavulanate Potassium
3$42$47NANN
Amphotericin B
4$95$100NAYN
Ampicillin
4$95$100NANN
Ampicillin And Sulbactam
4$95$100NANN
Ampicillin Sodium And Sulbactam Sodium
4$95$100NANN
Anagrelide
3$42$47NANN
Anastrozole
2$10$15NA30/30NN
Apraclonidine Ophthalmic
3$42$47NANN
Aprepitant
3$42$47NA15/30YN
Apri
3$42$47NANN
Aptivus
533%33%NA120/30NN
Aralast
533%33%NAYN
Aranelle
3$42$47NANN
Aranesp
533%33%NAYN
Aripiprazole
4$95$100NA90/30NN
Aristada
533%33%NA/60NN
Aristada Initio
533%33%NA/365NN
Armodafinil
4$95$100NA30/30YN
Arnuity Ellipta
3$42$47NA30/30NN
Ascomp With Codeine
4$95$100NA180/30YN
Asenapine
4$95$100NA60/30NN
Ashlyna
4$95$100NANN
Asmanex
3$42$47NA1/30NN
Asmanex Hfa
3$42$47NA13/30NN
Atenolol And Chlorthalidone
1$3$8NANN
Atomoxetine
4$95$100NA30/30NN
Atovaquone
4$95$100NAYN
Atovaquone And Proguanil Hydrochloride Pediatric
4$95$100NANN
Atrovent
4$95$100NA26/30NN
Aubra Eq
3$42$47NANN
Auryxia
533%33%NAYN
Austedo
533%33%NA120/30YN
Aviane
3$42$47NANN
Avita
3$42$47NA45/30YN
Avonex
533%33%NA4/28YN
Ayvakit
533%33%NA30/30YN
Azathioprine
2$10$15NAYN
Azelastine Hcl Nasal
4$95$100NA30/25NN
Azelastine Hydrochloride
3$42$47NA30/25NN
Azithromycin
4$95$100NANN
Azopt
4$95$100NANN
Aztreonam
4$95$100NANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H8849-009

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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