Anthem MediBlue Select Plus (HMO) Formulary



Below is the 2023 Formulary, or prescription drug list, from Anthem MediBlue Select Plus (HMO) by Matthew Thornton Health Plan, 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 New Hampshire 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 Anthem MediBlue Select Plus (HMO)(H3536-006) plan has a $350 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. Matthew Thornton Health Plan, 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:Anthem MediBlue Select Plus
Plan ID: H3536-006
Provider: Matthew Thornton Health Plan, Inc
Plan Year:2023
Premium:$0.00
Deductible:$350
Initial Coverage Limit:$4660
Coverage Area:New Hampshire
Similar Plan:H3536-002


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
4Y$94$99NA960/30NN
Abacavir And Lamivudine
4Y$94$99NA30/30NN
Abelcet
4Y$94$99NAYN
Abilify Maintena
527%27%NA1/28NN
Abiraterone
527%27%NA120/30YN
Abiraterone Acetate
527%27%NA60/30YN
Acarbose
2N$15$20NA90/30NN
Accutane
4Y$94$99NANN
Acebutolol Hydrochloride
2N$15$20NANN
Acetaminophen And Codeine Phosphate
3N$35$35NA900/30NN
Acetazolamide
3N$35$35NANN
Acetic Acid
1N$0$5NANN
Acetylcysteine
2N$15$20NAYN
Acitretin
4Y$94$99NANN
Acthib
3N$35$35NANN
Actimmune
527%27%NAYN
Acyclovir
4Y$94$99NANN
Acyclovir Sodium
4Y$94$99NAYN
Adapalene
4Y$94$99NANN
Adefovir Dipivoxil
4Y$94$99NAYN
Adempas
527%27%NAYN
Advair
3N$35$35NA60/30NN
Advair Hfa
3N$35$35NA12/30NN
Aimovig
3N$35$35NA1/28YN
Alacort
1N$0$5NANN
Albendazole
527%27%NANN
Albuterol Sulfate
2N$15$20NANN
Alclometasone Dipropionate
3N$35$35NANN
Alecensa
527%27%NA240/30YN
Alendronate Sodium
6N$0$0NA4/28NN
Aliskiren
3N$35$35NANN
Alosetron Hydrochloride
527%27%NA60/30YN
Alprazolam
3N$35$35NA120/30NN
Altavera
3N$35$35NANN
Alunbrig
527%27%NA30/180YN
Alyacen 1/35
4Y$94$99NANN
Amabelz
4Y$94$99NAYN
Amantadine Hydrochloride
3N$35$35NANN
Ambisome
527%27%NAYN
Amethia
4Y$94$99NANN
Amikacin Sulfate
4Y$94$99NANN
Amiloride Hydrochloride And Hydrochlorothiazide
1N$0$5NANN
Amiloride Hydrocloride
3N$35$35NANN
Amiodarone Hydrochloride
4Y$94$99NANN
Amitriptyline Hydrochloride
2N$15$20NANN
Amlodipine And Benazepril Hydrochloride
6N$0$0NANN
Amlodipine And Olmesartan Medoxomil
3N$35$35NANN
Amlodipine And Valsartan
6N$0$0NANN
Amlodipine Besylate
1N$0$5NANN
Amlodipine Besylate And Benazepril Hydrochloride
6N$0$0NANN
Ammonium Lactate
2N$15$20NANN
Amnesteem
4Y$94$99NANN
Amoxapine
2N$15$20NAYN
Amoxicillin
1N$0$5NANN
Amoxicillin And Clavulanate Potassium
3N$35$35NANN
Amphotericin B
4Y$94$99NAYN
Ampicillin
4Y$94$99NANN
Ampicillin And Sulbactam
4Y$94$99NANN
Ampicillin Sodium And Sulbactam Sodium
4Y$94$99NANN
Anagrelide
3N$35$35NANN
Anastrozole
2N$15$20NA30/30NN
Apraclonidine Ophthalmic
3N$35$35NANN
Aprepitant
3N$35$35NA15/30YN
Apri
3N$35$35NANN
Aptivus
527%27%NA120/30NN
Aralast
527%27%NAYN
Aranelle
3N$35$35NANN
Aranesp
527%27%NAYN
Aripiprazole
4Y$94$99NA90/30NN
Aristada
527%27%NA/60NN
Aristada Initio
527%27%NA/365NN
Armodafinil
4Y$94$99NA30/30YN
Arnuity Ellipta
3N$35$35NA30/30NN
Ascomp With Codeine
4Y$94$99NA180/30YN
Asenapine
4Y$94$99NA60/30NN
Ashlyna
4Y$94$99NANN
Asmanex
3N$35$35NA1/30NN
Asmanex Hfa
3N$35$35NA13/30NN
Atenolol And Chlorthalidone
1N$0$5NANN
Atomoxetine
4Y$94$99NA30/30NN
Atovaquone
4Y$94$99NAYN
Atovaquone And Proguanil Hydrochloride Pediatric
4Y$94$99NANN
Atrovent
4Y$94$99NA26/30NN
Aubra Eq
3N$35$35NANN
Auryxia
527%27%NAYN
Austedo
527%27%NA120/30YN
Aviane
3N$35$35NANN
Avita
3N$35$35NA45/30YN
Avonex
527%27%NA4/28YN
Ayvakit
527%27%NA30/30YN
Azathioprine
2N$15$20NAYN
Azelastine Hcl Nasal
4Y$94$99NA30/25NN
Azelastine Hydrochloride
3N$35$35NA30/25NN
Azithromycin
4Y$94$99NANN
Azopt
4Y$94$99NANN
Aztreonam
4Y$94$99NANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H3536-006

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $350. 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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