Ascend Rx (HMO-POS) Formulary



Below is the 2023 Formulary, or prescription drug list, from Ascend Rx (HMO-POS) by Security Health Plan Of Wisconsin, 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 Wisconsin 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 Ascend Rx (HMO-POS)(H5211-013) plan has a $330 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. Security Health Plan Of Wisconsin, 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:Ascend Rx
Plan ID: H5211-013
Provider: Security Health Plan Of Wisconsin, Inc
Plan Year:2023
Premium:$44.00
Deductible:$330
Initial Coverage Limit:$4660
Coverage Area:Wisconsin
Similar Plan:H5211-002


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
4YNA$100NA960/30NN
Abacavir And Lamivudine
4YNA$100NA30/30NN
Abelcet
4YNA$100NAYN
Abiraterone
3YNA$47NA120/30YN
Acarbose
2NNA$9NA360/30NN
Accutane
4YNA$100NANN
Acebutolol Hydrochloride
2NNA$9NANN
Acetaminophen And Codeine Phosphate
2NNA$9NA4500/30NN
Acetazolamide
2NNA$9NANN
Acetic Acid
2NNA$9NANN
Acetylcysteine
4YNA$100NAYN
Acitretin
4YNA$100NANN
Actemra
5NA26%NA/28YN
Actemra Actpen
5NA26%NA/28YN
Acthib
6NNA$0NANN
Actimmune
5NA26%NANN
Acyclovir
4YNA$100NANN
Acyclovir Sodium
4YNA$100NAYN
Adapalene
3YNA$47NAYN
Adefovir Dipivoxil
4YNA$100NA30/30NN
Adempas
5NA26%NA90/30YN
Advair
2NNA$9NA60/30NN
Advair Hfa
3YNA$47NA12/30NN
Afinitor
5NA26%NAYN
Aimovig
3YNA$47NA1/28YN
Ajovy
3YNA$47NA/28YN
Alacort
2NNA$9NANN
Albendazole
4YNA$100NANN
Albuterol Sulfate
1NNA$2NA1/30NN
Alclometasone Dipropionate
2NNA$9NANN
Alecensa
5NA26%NA240/30YN
Alendronate Sodium
1NNA$2NA4/28NN
Aliskiren
4YNA$100NA30/30NN
Alosetron Hydrochloride
5NA26%NA60/30NN
Alprazolam
3YNA$47NA60/30NN
Altavera
4YNA$100NANN
Alunbrig
5NA26%NA30/30YN
Alyacen 1/35
4YNA$100NANN
Alyq
2NNA$9NA60/30YN
Amabelz
3YNA$47NANN
Amantadine Hydrochloride
2NNA$9NANN
Ambisome
5NA26%NAYN
Amethia
4YNA$100NA91/90NN
Amikacin Sulfate
4YNA$100NANN
Amiloride Hydrochloride And Hydrochlorothiazide
2NNA$9NANN
Amiloride Hydrocloride
2NNA$9NANN
Amiodarone Hydrochloride
4YNA$100NANN
Amitriptyline Hydrochloride
2NNA$9NANN
Amlodipine And Benazepril Hydrochloride
1NNA$2NA30/30NN
Amlodipine And Olmesartan Medoxomil
3YNA$47NA30/30NN
Amlodipine And Valsartan
2NNA$9NA30/30NN
Amlodipine Besylate
1NNA$2NANN
Amlodipine Besylate And Benazepril Hydrochloride
1NNA$2NA30/30NN
Ammonium Lactate
2NNA$9NANN
Amnesteem
4YNA$100NANN
Amoxapine
4YNA$100NANN
Amoxicillin
1NNA$2NANN
Amoxicillin And Clavulanate Potassium
3YNA$47NANN
Amphotericin B
4YNA$100NAYN
Ampicillin
4YNA$100NANN
Ampicillin And Sulbactam
4YNA$100NANN
Ampicillin Sodium And Sulbactam Sodium
4YNA$100NANN
Anagrelide
2NNA$9NANN
Anastrozole
1NNA$2NA30/30NN
Anzemet
4YNA$100NAYN
Apraclonidine Ophthalmic
3YNA$47NANN
Aprepitant
4YNA$100NA12/28YN
Apri
4YNA$100NANN
Aptivus
5NA26%NA120/30NN
Aralast
5NA26%NAYN
Aranelle
4YNA$100NANN
Aranesp
5NA26%NAYN
Aripiprazole
4YNA$100NA60/30NN
Aristada
5NA26%NA/56NN
Aristada Initio
5NA26%NA/28NN
Armodafinil
2NNA$9NA30/30YN
Arnuity Ellipta
3YNA$47NA30/30NN
Ascomp With Codeine
4YNA$100NA360/30NN
Asenapine
4YNA$100NA60/30NN
Ashlyna
4YNA$100NANN
Atenolol And Chlorthalidone
1NNA$2NANN
Atomoxetine
2NNA$9NA30/30NN
Atovaquone
5NA26%NANN
Atovaquone And Proguanil Hydrochloride Pediatric
4YNA$100NANN
Atrovent
4YNA$100NA2/30NN
Aubra Eq
4YNA$100NANN
Auryxia
5NA26%NA360/30YN
Austedo
5NA26%NA120/30YN
Aviane
4YNA$100NANN
Avita
3YNA$47NAYN
Avonex
5NA26%NA1/28YN
Ayvakit
5NA26%NA30/30YN
Azathioprine
2NNA$9NAYN
Azelaic Acid
2NNA$9NANN
Azelastine Hcl Nasal
2NNA$9NA30/25NN
Azelastine Hydrochloride
2NNA$9NA30/25NN
Azelastine Hydrochloride And Fluticasone Propionat
3YNA$47NANN
Azithromycin
4YNA$100NANN
Azopt
3YNA$47NANN
Aztreonam
4YNA$100NANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H5211-013

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $330. 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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