Premier by Ultimate (HMO) Formulary



Below is the 2023 Formulary, or prescription drug list, from Premier by Ultimate (HMO) by Ultimate Health Plans, 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 Florida 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 Premier by Ultimate (HMO)(H2962-028) plan has a $0 drug deductible. 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. Ultimate Health Plans, 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:Premier by Ultimate
Plan ID: H2962-028
Provider: Ultimate Health Plans, Inc
Plan Year:2023
Premium:$0.00
Deductible:$0
Initial Coverage Limit:$4660
Coverage Area:Florida
Similar Plan:H2962-029


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
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Paliperidone
3NA$60NA30/30NN
Panretin
4NA33%NANN
Paricalcitol
1NA$0NANN
Paromomycin Sulfate
1NA$0NANN
Paroxetine
1NA$0NANN
Paroxetine Hydrochloride
1NA$0NANN
Paser
3NA$60NANN
Pediarix
3NA$60NANN
Pedvaxhib
2NA$30NANN
Peg-3350 And Electrolytes
1NA$0NANN
Pegasys
4NA33%NAYN
Pemazyre
4NA33%NA30/30YN
Penicillamine
4NA33%NAYN
Penicillin G Sodium
4NA33%NANN
Penicillin V Potassium
1NA$0NANN
Pentacel
2NA$30NANN
Pentamidine Isethionate
1NA$0NAYN
Pentasa
3NA$60NANN
Pentazocine And Naloxone
3NA$60NANN
Pentoxifylline
1NA$0NANN
Perindopril Erbumine
1NA$0NANN
Periogard Alcohol Free
1NA$0NANN
Permethrin
1NA$0NANN
Perphenazine
1NA$0NANN
Perphenazine And Amitriptyline Hydrochloride
1NA$0NANN
Perseris
4NA33%NANN
Phenelzine Sulfate
1NA$0NANN
Phenobarbital
1NA$0NANN
Phenoxybenzamine Hydrochloride
4NA33%NANN
Phenytek
1NA$0NANN
Phenytoin
1NA$0NANN
Phospholine Iodide
3NA$60NANN
Pifeltro
4NA33%NANN
Pilocarpine Hydrochloride
1NA$0NANN
Pimecrolimus
3NA$60NANN
Pimozide
3NA$60NANN
Pindolol
1NA$0NANN
Pioglitazone And Glimepiride
1NA$0NA45/30NN
Piperacillin And Tazobactam
1NA$0NANN
Piqray
4NA33%NAYN
Pirmella 1/35
1NA$0NANN
Piroxicam
1NA$0NANN
Plegridy
4NA33%NA1/28YN
Plenamine
3NA$60NAYN
Podofilox
1NA$0NANN
Polyethylene Glycol 3350, Sodium Chloride, Sodium
1NA$0NANN
Polymyxin B Sulfate And Trimethoprim
1NA$0NANN
Portia
1NA$0NANN
Potassium Chloride
1NA$0NANN
Potassium Chloride In Dextrose
1NA$0NANN
Potassium Chloride In Dextrose And Sodium Chloride
1NA$0NANN
Potassium Chloride In Lactated Ringers And Dextros
1NA$0NANN
Potassium Chloride In Sodium Chloride
1NA$0NANN
Potassium Citrate
1NA$0NANN
Pramipexole Dihydrochloride
3NA$60NANN
Prasugrel
2NA$30NANN
Pravastatin Sodium
1NA$0NANN
Praziquantel
2NA$30NANN
Prazosin Hydrochloride
1NA$0NANN
Prednisolone Acetate
2NA$30NANN
Prednisolone Sodium Phosphate
3NA$60NANN
Prednisolone Sodium Phosphate Oral Solution
1NA$0NANN
Prednisone
1NA$0NANN
Prednisone Intensol
1NA$0NANN
Pregabalin
1NA$0NA900/30NN
Premarin
2NA$30NANN
Premasol - Sulfite-free (amino Acid)
3NA$60NAYN
Premphase
3NA$60NANN
Prempro
2NA$30NANN
Prevymis
4NA33%NANN
Prezcobix
4NA33%NA30/30NN
Prezista
4NA33%NANN
Priftin
3NA$60NANN
Primaquine Phosphate
1NA$0NANN
Primidone
1NA$0NANN
Proair Digihaler
2NA$30NA2/30NN
Proair Respiclick
2NA$30NA2/30NN
Probenecid
1NA$0NANN
Probenecid And Colchicine
1NA$0NANN
Procalamine
3NA$60NAYN
Prochlorperazine Maleate
1NA$0NANN
Procrit
4NA33%NAYN
Procto-med Hc
1NA$0NANN
Proctosol-hc
1NA$0NANN
Proctozone-hc
1NA$0NANN
Progesterone
1NA$0NANN
Prograf
3NA$60NAYN
Prolastin-c
4NA33%NAYN
Prolensa
2NA$30NA12/365NN
Prolia
2NA$30NA2/365NN
Promacta
4NA33%NAYN
Promethazine Hydrochloride
1NA$0NANN
Promethazine Vc
1NA$0NANN
Propafenone Hydrochloride
3NA$60NANN
Propranolol Hydrochloride
1NA$0NANN
Propylthiouracil
1NA$0NANN
Proquad
2NA$30NANN
Prosol
3NA$60NAYN
Protriptyline Hydrochloride
1NA$0NANN
Pulmozyme
4NA33%NAYN
Purified Cortrophin Gel
4NA33%NAYN
Purixan
4NA33%NANN
Pyrazinamide
1NA$0NANN
Pyridostigmine Bromide
4NA33%NANN
Pyrimethamine
4NA33%NAYN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H2962-028

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