eternalHealth Give Back (PPO) Formulary



Below is the 2023 Formulary, or prescription drug list, from eternalHealth Give Back (PPO) by Eternalhealth, 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 Massachusetts 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 eternalHealth Give Back (PPO)(H2694-002) plan has a $300 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. Eternalhealth, 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:eternalHealth Give Back (PPO)
Plan ID: H2694-002
Provider: Eternalhealth, Inc
Plan Year:2023
Premium:$0.00
Deductible:$300
Initial Coverage Limit:$4660
Coverage Area:Massachusetts
Similar Plan:H2694-001


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
Deductible
Apply
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Edarbi
4YNA$100NANN
Edarbyclor
4YNA$100NANN
Edurant
5NA28%NANN
Efavirenz
4YNA$100NANN
Efavirenz, Emtricitabine And Tenofovir Disoproxil
5NA28%NA30/30NN
Efavirenz, Lamivudine And Tenofovir Disoproxil Fum
5NA28%NA30/30NN
Eliquis
3YNA$47NA148/365NN
Elmiron
4YNA$100NANN
Emcyt
5NA28%NANN
Emgality
4YNA$100NA3/30YN
Emsam
5NA28%NA30/30NY
Emtricitabine
2NNA$5NANN
Emtricitabine And Tenofovir Disoproxil Fumarate
5NA28%NA30/30NN
Emtriva
4YNA$100NANN
Enalapril Maleate And Hydrochlorothiazide
1NNA$0NANN
Enbrel
5NA28%NAYN
Endocet
3YNA$47NANN
Engerix-b
3YNA$47NAYN
Enoxaparin Sodium
4YNA$100NA35/90NN
Enpresse
3YNA$47NANN
Entacapone
3YNA$47NANN
Entecavir
4YNA$100NA30/30NN
Entresto
3YNA$47NA60/30NN
Enulose
2NNA$5NANN
Envarsus
4YNA$100NAYN
Epidiolex
5NA28%NAYN
Epinastine Hydrochloride
3YNA$47NANN
Epinephrine
3YNA$47NANN
Epitol
3YNA$47NANN
Epivir
4YNA$100NANN
Eplerenone
3YNA$47NANN
Eprontia
4YNA$100NANN
Ergoloid Mesylates
4YNA$100NANN
Ergotamine Tartrate And Caffeine
3YNA$47NA24/28NN
Erivedge
5NA28%NAYN
Erleada
5NA28%NAYN
Erlotinib
5NA28%NAYN
Errin
3YNA$47NANN
Ertapenem
4YNA$100NANN
Ery
3YNA$47NANN
Erythromycin
4YNA$100NANN
Erythromycin Ethylsuccinate
4YNA$100NANN
Esbriet
5NA28%NAYN
Escitalopram
1NNA$0NANN
Escitalopram Oxalate
2NNA$5NANN
Estarylla
3YNA$47NANN
Estradiol
2NNA$5NANN
Estradiol / Norethindrone Acetate
4YNA$100NANN
Estradiol Transdermal System
4YNA$100NANN
Estring
4YNA$100NA1/90NN
Eszopiclone
4YNA$100NA30/30NN
Ethambutol Hydrochloride
2NNA$5NANN
Ethosuximide
3YNA$47NANN
Ethynodiol Diacetate And Ethinyl Estradiol
3YNA$47NANN
Etodolac
3YNA$47NANN
Etravirine
5NA28%NANN
Euthyrox
3YNA$47NANN
Everolimus
5NA28%NA30/30YN
Evotaz
5NA28%NA30/30NN
Evrysdi
5NA28%NA240/30YN
Exemestane
4YNA$100NANN
Exkivity
5NA28%NAYN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H2694-002

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $300. 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.

      Site Search:

MedicareHelp.org is a privately-owned Non-governmental agency. The government website can be found at HealthCare.gov.

Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options. Enrollment depends on the plan’s contract renewal.

Every year, Medicare evaluates plans based on a 5-star rating system.