Essential Rx (PPO) Formulary



Below is the 2023 Formulary, or prescription drug list, from Essential Rx (PPO) by Aspirus 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 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 Essential Rx (PPO)(H6874-001) plan has a $245 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. Aspirus 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:Essential Rx (PPO)
Plan ID: H6874-001
Provider: Aspirus Health Plan, Inc
Plan Year:2023
Premium:$0.00
Deductible:$245
Initial Coverage Limit:$4660
Coverage Area:Wisconsin
Similar Plan:H6874-002


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
E.e.s
4Y50%50%50%NN
Edurant
529%29%29%NN
Efavirenz
4Y50%50%50%NN
Efavirenz, Emtricitabine And Tenofovir Disoproxil
529%29%29%NN
Efavirenz, Lamivudine And Tenofovir Disoproxil Fum
529%29%29%NN
Eletriptan
4Y50%50%50%18/28NN
Eletriptan Hydrobromide
4Y50%50%50%18/28NN
Eligard
4Y50%50%50%YN
Eliquis
3Y$47$47$47NN
Elmiron
3Y$47$47$47NN
Eluryng
4Y50%50%50%NN
Emcyt
529%29%29%NN
Emend
4Y50%50%50%YN
Emgality
3Y$47$47$473/30YN
Emsam
529%29%29%NN
Emtricitabine
4Y50%50%50%NN
Emtricitabine And Tenofovir Disoproxil Fumarate
529%29%29%NN
Emtriva
3Y$47$47$47NN
Enalapril Maleate And Hydrochlorothiazide
1N$3$8$3NN
Enbrel
529%29%29%16/28YN
Endocet
3Y$47$47$47360/30NN
Engerix-b
3Y$47$47$47YN
Enoxaparin Sodium
4Y50%50%50%28/28NN
Enpresse
2N$12$18$12NN
Enskyce
2N$12$18$12NN
Entacapone
4Y50%50%50%NN
Entecavir
4Y50%50%50%NN
Entresto
3Y$47$47$4760/30NN
Enulose
2N$12$18$12NN
Epidiolex
4Y50%50%50%YN
Epinastine Hydrochloride
4Y50%50%50%NN
Epinephrine
2N$12$18$122/30NN
Epitol
2N$12$18$12NN
Epivir
3Y$47$47$47NN
Eplerenone
2N$12$18$12NN
Eprontia
4Y50%50%50%YN
Ergotamine Tartrate And Caffeine
2N$12$18$12NN
Erivedge
529%29%29%30/30YN
Erleada
529%29%29%120/30YN
Erlotinib
529%29%29%60/30YN
Errin
2N$12$18$12NN
Ertapenem
4Y50%50%50%14/14NN
Ery
3Y$47$47$47NN
Ery-tab
4Y50%50%50%NN
Erythrocin Stearate
4Y50%50%50%NN
Erythromycin
4Y50%50%50%NN
Erythromycin Ethylsuccinate
4Y50%50%50%NN
Esbriet
529%29%29%270/30YN
Escitalopram
1N$3$8$330/30NN
Escitalopram Oxalate
2N$12$18$12NN
Estarylla
2N$12$18$12NN
Estradiol
3Y$47$47$47NN
Estradiol / Norethindrone Acetate
4Y50%50%50%NN
Estradiol Transdermal System
4Y50%50%50%4/28NN
Estradiol Valerate
4Y50%50%50%NN
Estring
4Y50%50%50%NN
Eszopiclone
4Y50%50%50%30/30NN
Ethacrynic Acid
4Y50%50%50%NN
Ethambutol Hydrochloride
2N$12$18$12NN
Ethosuximide
2N$12$18$12NN
Ethynodiol Diacetate And Ethinyl Estradiol
2N$12$18$12NN
Etodolac
2N$12$18$12NN
Etonogestrel/ethinyl Estradiol
4Y50%50%50%NN
Etravirine
529%29%29%NN
Euthyrox
1N$3$8$3NN
Everolimus
529%29%29%30/30YN
Evotaz
529%29%29%NN
Exemestane
4Y50%50%50%NN
Exkivity
529%29%29%120/30YN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H6874-001

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $245. 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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