PacificSource Medicare Explorer Rx 17 (PPO) Formulary



Below is the 2023 Formulary, or prescription drug list, from PacificSource Medicare Explorer Rx 17 (PPO) by Pacificsource Community Health Plans. A formulary is a continually updated list of available medications and prescription drug cost information. Examining a plans formulary can help you find a Montana 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 PacificSource Medicare Explorer Rx 17 (PPO)(H4754-017) plan has a $225 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. Pacificsource Community Health Plans 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:PacificSource Medicare Explorer Rx 17
Plan ID: H4754-017
Provider: Pacificsource Community Health Plans
Plan Year:2023
Premium:$33.00
Deductible:$225
Initial Coverage Limit:$4660
Coverage Area:Montana
Similar Plan:H4754-004


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
Paliperidone
4Y31%32%31%NN
Palynziq
529%29%29%YN
Panretin
529%29%29%NN
Paricalcitol
2N$12$17$12NN
Paromomycin Sulfate
4Y31%32%31%NN
Paroxetine
4Y31%32%31%NY
Paroxetine Hydrochloride
2N$12$17$12NN
Paser
4Y31%32%31%NN
Pediarix
3Y$37$47$37NN
Pedvaxhib
3Y$37$47$37NN
Pegasys
529%29%29%YN
Pemazyre
529%29%29%14/21YN
Penicillamine
529%29%29%YN
Penicillin G Potassium
3Y$37$47$37NN
Penicillin G Procaine
3Y$37$47$37NN
Penicillin G Sodium
2N$12$17$12NN
Penicillin V Potassium
2N$12$17$12NN
Pentacel
3Y$37$47$37NN
Pentamidine Isethionate
2N$12$17$12YN
Pentoxifylline
2N$12$17$12NN
Perindopril Erbumine
6N$0$0$0NN
Periogard Alcohol Free
2N$12$17$12NN
Permethrin
2N$12$17$12NN
Perphenazine
2N$12$17$12NN
Perseris
529%29%29%YN
Pexeva
4Y31%32%31%NY
Phenelzine Sulfate
2N$12$17$12NN
Phenobarbital
2N$12$17$12NN
Phenoxybenzamine Hydrochloride
529%29%29%YN
Phenytoin
2N$12$17$12NN
Phospholine Iodide
4Y31%32%31%NN
Pifeltro
529%29%29%30/30NN
Pilocarpine Hydrochloride
2N$12$17$12NN
Pimecrolimus
4Y31%32%31%YN
Pimozide
2N$12$17$12NN
Pindolol
2N$12$17$12NN
Piperacillin And Tazobactam
2N$12$17$12NN
Piqray
529%29%29%YN
Pirmella 1/35
2N$12$17$12NN
Piroxicam
2N$12$17$12NN
Plenamine
2N$12$17$12YN
Podofilox
2N$12$17$12NN
Polyethylene Glycol 3350, Sodium Chloride, Sodium
2N$12$17$12NN
Polymyxin B Sulfate And Trimethoprim
2N$12$17$12NN
Portia
2N$12$17$12NN
Potassium Chloride
2N$12$17$12NN
Potassium Chloride In Dextrose
2N$12$17$12YN
Potassium Chloride In Dextrose And Sodium Chloride
3Y$37$47$37YN
Potassium Chloride In Lactated Ringers And Dextros
4Y31%32%31%YN
Potassium Chloride In Sodium Chloride
2N$12$17$12NN
Potassium Citrate
2N$12$17$12NN
Pradaxa
4Y31%32%31%60/30NN
Pramipexole Dihydrochloride
2N$12$17$12NY
Prasugrel
4Y31%32%31%NN
Pravastatin Sodium
6N$0$0$0NN
Praziquantel
4Y31%32%31%NN
Prazosin Hydrochloride
2N$12$17$12NN
Pred Mild
3Y$37$47$37NN
Prednisolone Acetate
2N$12$17$12NN
Prednisolone Sodium Phosphate
4Y31%32%31%NN
Prednisolone Sodium Phosphate Oral Solution
4Y31%32%31%NN
Prednisone
2N$12$17$12NN
Prednisone Intensol
3Y$37$47$37NN
Prefest
4Y31%32%31%NN
Pregabalin
2N$12$17$1260/30NN
Premarin
4Y31%32%31%NN
Premasol - Sulfite-free (amino Acid)
4Y31%32%31%YN
Premphase
4Y31%32%31%NN
Prempro
4Y31%32%31%NN
Pretomanid
4Y31%32%31%30/30YN
Prevymis
529%29%29%100/365NN
Prezcobix
529%29%29%NN
Prezista
529%29%29%NN
Priftin
3Y$37$47$37NN
Primaquine Phosphate
2N$12$17$12NN
Primidone
2N$12$17$12NN
Privigen
529%29%29%YN
Proair
2N$12$17$1217/30NN
Proair Respiclick
2N$12$17$122/30NN
Probenecid
2N$12$17$12NN
Probenecid And Colchicine
2N$12$17$12NN
Procalamine
4Y31%32%31%YN
Prochlorperazine Maleate
2N$12$17$12NN
Procrit
529%29%29%YN
Procto-med Hc
2N$12$17$12NN
Procysbi
529%29%29%YN
Progesterone
2N$12$17$12NN
Prograf
4Y31%32%31%YN
Prolastin-c
529%29%29%YN
Prolia
4Y31%32%31%NN
Promacta
529%29%29%YN
Promethazine Hydrochloride
2N$12$17$12NN
Propafenone Hydrochloride
2N$12$17$12NN
Propranolol Hydrochloride
2N$12$17$12NN
Propylthiouracil
2N$12$17$12NN
Proquad
3Y$37$47$37NN
Prosol
4Y31%32%31%YN
Protriptyline Hydrochloride
2N$12$17$12NN
Pulmicort
4Y31%32%31%4/30NN
Pulmozyme
529%29%29%YN
Purixan
529%29%29%NN
Pyrazinamide
2N$12$17$12NN
Pyridostigmine Bromide
2N$12$17$12NN
Pyrimethamine
529%29%29%YN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H4754-017

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $225. 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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