Ascension Complete Saint Thomas Reward (HMO) Formulary



Below is the 2023 Formulary, or prescription drug list, from Ascension Complete Saint Thomas Reward (HMO) by Centene Venture Company Tennessee. A formulary is a continually updated list of available medications and prescription drug cost information. Examining a plans formulary can help you find a Tennessee 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 Ascension Complete Saint Thomas Reward (HMO)(H2853-001) plan has a $480 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. Centene Venture Company Tennessee 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:Ascension Complete Saint Thomas Reward (HMO)
Plan ID: H2853-001
Provider: Centene Venture Company Tennessee
Plan Year:2023
Premium:$0.00
Deductible:$480
Initial Coverage Limit:$4660
Coverage Area:Tennessee
Similar Plan:H2853-002


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$90$100$90NN
Abacavir And Lamivudine
3Y$37$47$37NN
Abelcet
4Y$90$100$90YN
Abilify Maintena
525%25%25%1/28NN
Abiraterone
525%25%25%YN
Abiraterone Acetate
525%25%25%YN
Acarbose
6N$0$0$0NN
Accutane
4Y$90$100$90YN
Acebutolol Hydrochloride
3Y$37$47$37NN
Acetaminophen And Codeine Phosphate
3Y$37$47$372700/30NN
Acetazolamide
3Y$37$47$37NN
Acetic Acid
3Y$37$47$37NN
Acetylcysteine
4Y$90$100$90YN
Acitretin
4Y$90$100$90YN
Acthib
6N$0$0$0NN
Actimmune
525%25%25%YN
Acyclovir
4Y$90$100$90NN
Acyclovir Sodium
4Y$90$100$90YN
Adcirca
525%25%25%60/30YN
Adefovir Dipivoxil
525%25%25%NN
Adempas
525%25%25%90/30YN
Advair
3Y$37$47$3760/30NN
Advair Hfa
3Y$37$47$3712/30NN
Aimovig
3Y$37$47$371/30YN
Alacort
1N$0$5$0NN
Albendazole
525%25%25%NN
Albuterol Sulfate
3Y$37$47$371/30NN
Alclometasone Dipropionate
3Y$37$47$3760/30NN
Alecensa
525%25%25%YN
Alendronate Sodium
1N$0$5$0NN
Aliskiren
4Y$90$100$90NN
Alosetron Hydrochloride
525%25%25%60/30YN
Alprazolam
2N$5$15$5150/30NN
Altavera
3Y$37$47$37NN
Altoprev
525%25%25%30/30NY
Alunbrig
525%25%25%YN
Alyacen 1/35
3Y$37$47$37NN
Alyq
525%25%25%60/30YN
Amabelz
3Y$37$47$37NN
Amantadine Hydrochloride
3Y$37$47$37120/30NN
Amikacin Sulfate
4Y$90$100$90NN
Amiloride Hydrochloride And Hydrochlorothiazide
2N$5$15$5NN
Amiloride Hydrocloride
2N$5$15$5NN
Amiodarone Hydrochloride
4Y$90$100$90NN
Amitriptyline Hydrochloride
4Y$90$100$90NN
Amlodipine And Benazepril Hydrochloride
6N$0$0$030/30NN
Amlodipine And Olmesartan Medoxomil
6N$0$0$030/30NN
Amlodipine And Valsartan
6N$0$0$030/30NN
Amlodipine Besylate
1N$0$5$0NN
Amlodipine Besylate And Benazepril Hydrochloride
6N$0$0$030/30NN
Ammonium Lactate
2N$5$15$5NN
Amnesteem
4Y$90$100$90YN
Amoxapine
3Y$37$47$37NN
Amoxicillin
1N$0$5$0NN
Amoxicillin And Clavulanate Potassium
3Y$37$47$37NN
Amphotericin B
4Y$90$100$90YN
Ampicillin
4Y$90$100$90NN
Ampicillin And Sulbactam
4Y$90$100$90NN
Ampicillin Sodium And Sulbactam Sodium
4Y$90$100$90NN
Anagrelide
4Y$90$100$90NN
Anastrozole
2N$5$15$5NN
Apokyn
525%25%25%60/30YN
Aprepitant
4Y$90$100$90YN
Apri
2N$5$15$5NN
Aptivus
525%25%25%NN
Aralast
525%25%25%YN
Aranelle
3Y$37$47$37NN
Aripiprazole
525%25%25%60/30NN
Aristada
525%25%25%/56NN
Aristada Initio
525%25%25%NN
Armodafinil
3Y$37$47$3730/30YN
Arnuity Ellipta
3Y$37$47$3730/30NN
Asenapine
4Y$90$100$9060/30NN
Atenolol And Chlorthalidone
1N$0$5$0NN
Atomoxetine
4Y$90$100$9030/30NN
Atovaquone
4Y$90$100$90NN
Atovaquone And Proguanil Hydrochloride Pediatric
4Y$90$100$90NN
Atrovent
4Y$90$100$902/30NN
Aubra Eq
2N$5$15$5NN
Austedo
525%25%25%120/30YN
Aviane
2N$5$15$5NN
Avita
4Y$90$100$9045/30YN
Ayvakit
525%25%25%30/30YN
Azathioprine
3Y$37$47$37YN
Azelaic Acid
4Y$90$100$9050/30NN
Azelastine Hcl Nasal
3Y$37$47$37NN
Azelastine Hydrochloride
3Y$37$47$37NN
Azithromycin
3Y$37$47$37NN
Aztreonam
4Y$90$100$90NN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H2853-001

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $480. 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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