Perennial Advantage Freedom (HMO) Formulary



Below is the 2023 Formulary, or prescription drug list, from Perennial Advantage Freedom (HMO) by Perennial Advantage Of Ohio, 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 Ohio 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 Perennial Advantage Freedom (HMO)(H8797-003) plan has a $505 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. Perennial Advantage Of Ohio, 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:Perennial Advantage Freedom (HMO)
Plan ID: H8797-003
Provider: Perennial Advantage Of Ohio, Inc
Plan Year:2023
Premium:$0.00
Deductible:$505
Initial Coverage Limit:$4660
Coverage Area:Ohio
Similar Plan:H8797-001


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
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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
2YNA$15NA30/30NN
Palynziq
5NA25%NAYN
Panretin
5NA25%NAYN
Panzyga
5NA25%NAYN
Paricalcitol
2YNA$15NANN
Paromomycin Sulfate
4YNA$95NANN
Paroxetine
2YNA$15NANN
Paroxetine Hydrochloride
2YNA$15NANN
Pediarix
3YNA$45NANN
Pedvaxhib
3YNA$45NANN
Peg-3350 And Electrolytes
1NNA$2NANN
Pegasys
5NA25%NANN
Pemazyre
5NA25%NA14/21YN
Penicillamine
2YNA$15NANN
Penicillin G Potassium
2YNA$15NANN
Penicillin G Procaine
3YNA$45NANN
Penicillin G Sodium
3YNA$45NANN
Penicillin V Potassium
1NNA$2NANN
Pentacel
3YNA$45NANN
Pentamidine Isethionate
2YNA$15NA1/28YN
Pentoxifylline
1NNA$2NANN
Perindopril Erbumine
1NNA$2NANN
Periogard Alcohol Free
1NNA$2NANN
Permethrin
1NNA$2NANN
Perphenazine
1NNA$2NANN
Perseris
5NA25%NA1/28NN
Phenelzine Sulfate
1NNA$2NANN
Phenobarbital
1NNA$2NANN
Phenoxybenzamine Hydrochloride
2YNA$15NANN
Phenytek
4YNA$95NANN
Phenytoin
2YNA$15NANN
Phoslyra
3YNA$45NANN
Pifeltro
5NA25%NANN
Pilocarpine Hydrochloride
1NNA$2NANN
Pimecrolimus
2YNA$15NA100/30NN
Pimozide
3YNA$45NANN
Pindolol
1NNA$2NANN
Piperacillin And Tazobactam
2YNA$15NANN
Piqray
5NA25%NA60/30YN
Pirmella 1/35
2YNA$15NANN
Piroxicam
2YNA$15NANN
Plegridy
5NA25%NANN
Plenamine
2YNA$15NAYN
Podofilox
2YNA$15NA7/30NN
Polyethylene Glycol 3350, Sodium Chloride, Sodium
1NNA$2NANN
Polymyxin B Sulfate And Trimethoprim
1NNA$2NA10/7NN
Portia
2YNA$15NANN
Potassium Chloride
1NNA$2NANN
Potassium Chloride In Dextrose
2YNA$15NANN
Potassium Chloride In Dextrose And Sodium Chloride
3YNA$45NANN
Potassium Chloride In Lactated Ringers And Dextros
3YNA$45NANN
Potassium Chloride In Sodium Chloride
2YNA$15NANN
Potassium Citrate
2YNA$15NANN
Pradaxa
4YNA$95NANN
Pramipexole Dihydrochloride
2YNA$15NANN
Prasugrel
1NNA$2NANN
Pravastatin Sodium
1NNA$2NANN
Praziquantel
2YNA$15NANN
Prazosin Hydrochloride
1NNA$2NANN
Pred Mild
3YNA$45NANN
Pred-g
3YNA$45NANN
Prednisolone Acetate
1NNA$2NANN
Prednisolone Sodium Phosphate
1NNA$2NAYN
Prednisolone Sodium Phosphate Oral Solution
4YNA$95NAYN
Prednisone
1NNA$2NAYN
Prefest
4YNA$95NANN
Pregabalin
2YNA$15NANN
Premarin
3YNA$45NANN
Premasol - Sulfite-free (amino Acid)
4YNA$95NAYN
Premphase
3YNA$45NANN
Prempro
3YNA$45NANN
Prevymis
5NA25%NA30/30YN
Prezcobix
5NA25%NANN
Prezista
5NA25%NANN
Priftin
3YNA$45NANN
Primaquine Phosphate
2YNA$15NANN
Primidone
1NNA$2NANN
Privigen
5NA25%NAYN
Probenecid
1NNA$2NANN
Probenecid And Colchicine
1NNA$2NANN
Procalamine
4YNA$95NAYN
Prochlorperazine Maleate
1NNA$2NANN
Procto-med Hc
1NNA$2NANN
Proctosol-hc
1NNA$2NANN
Proctozone-hc
1NNA$2NANN
Progesterone
1NNA$2NANN
Prograf
4YNA$95NAYN
Prolastin-c
5NA25%NAYN
Prolensa
3YNA$45NA12/365NN
Prolia
4YNA$95NA1/168YN
Promacta
5NA25%NAYN
Promethazine Hydrochloride
1NNA$2NANN
Propafenone Hydrochloride
2YNA$15NANN
Propranolol Hydrochloride
1NNA$2NANN
Propylthiouracil
1NNA$2NANN
Proquad
3YNA$45NANN
Prosol
4YNA$95NAYN
Protriptyline Hydrochloride
2YNA$15NANN
Pulmozyme
5NA25%NA150/30YN
Purixan
4YNA$95NANN
Pylera
4YNA$95NANN
Pyrazinamide
1NNA$2NANN
Pyridostigmine Bromide
2YNA$15NANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H8797-003

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $505. 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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