PriorityMedicare Edge (PPO) Formulary



Below is the 2023 Formulary, or prescription drug list, from PriorityMedicare Edge (PPO) by Priority Health. A formulary is a continually updated list of available medications and prescription drug cost information. Examining a plans formulary can help you find a Michigan 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 PriorityMedicare Edge (PPO)(H4875-020) 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. Priority Health 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:PriorityMedicare Edge
Plan ID: H4875-020
Provider: Priority Health
Plan Year:2023
Premium:$0.00
Deductible:$0
Initial Coverage Limit:$4660
Coverage Area:Michigan
Similar Plan:H4875-021


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
440%45%40%30/30NY
Panretin
533%33%33%60/30YN
Paricalcitol
440%45%40%NN
Paromomycin Sulfate
2$8$15$8NN
Paroxetine
440%45%40%NN
Paser
3$38$47$38NN
Pediarix
3$38$47$38NN
Pedvaxhib
3$38$47$38NN
Peg-3350 And Electrolytes
2$8$15$8NN
Pegasys
533%33%33%NN
Pemazyre
533%33%33%14/21YN
Penicillamine
440%45%40%YN
Penicillin G Potassium
440%45%40%NN
Penicillin G Procaine
440%45%40%NN
Penicillin G Sodium
440%45%40%NN
Penicillin V Potassium
2$8$15$8NN
Pentacel
3$38$47$38NN
Pentamidine Isethionate
3$38$47$38YN
Pentoxifylline
2$8$15$8NN
Perindopril Erbumine
1$2$7$2NN
Permethrin
2$8$15$8NN
Perphenazine
2$8$15$8NN
Perseris
533%33%33%1/28NN
Phenelzine Sulfate
2$8$15$8NN
Phenobarbital
2$8$15$8YN
Phenytoin
2$8$15$8NN
Pifeltro
533%33%33%30/30NN
Pilocarpine Hydrochloride
2$8$15$8NN
Pimecrolimus
3$38$47$3830/30NN
Pimozide
2$8$15$8NN
Pindolol
2$8$15$8NN
Pioglitazone And Glimepiride
2$8$15$8NN
Piperacillin And Tazobactam
2$8$15$8NN
Piqray
533%33%33%56/28YN
Pirmella 1/35
2$8$15$8NN
Piroxicam
2$8$15$8NN
Plegridy
533%33%33%1/28YN
Podofilox
2$8$15$8NN
Polyethylene Glycol 3350, Sodium Chloride, Sodium
2$8$15$8NN
Polymyxin B Sulfate And Trimethoprim
2$8$15$8NN
Portia
2$8$15$8NN
Potassium Chloride
2$8$15$8NN
Potassium Chloride In Dextrose
2$8$15$8NN
Potassium Chloride In Dextrose And Sodium Chloride
2$8$15$8NN
Potassium Chloride In Lactated Ringers And Dextros
2$8$15$8NN
Potassium Chloride In Sodium Chloride
2$8$15$8NN
Potassium Citrate
2$8$15$8NN
Pradaxa
440%45%40%60/30NN
Pramipexole Dihydrochloride
440%45%40%NN
Prasugrel
3$38$47$38NN
Pravastatin Sodium
1$2$7$2NN
Praziquantel
3$38$47$38NN
Prazosin Hydrochloride
2$8$15$8NN
Pred-g
3$38$47$38NN
Prednisolone Acetate
2$8$15$8NN
Prednisolone Sodium Phosphate
440%45%40%NN
Prednisone
2$8$15$8NN
Prednisone Intensol
440%45%40%NN
Pregabalin
2$8$15$8900/30NN
Premasol - Sulfite-free (amino Acid)
3$38$47$38YN
Pretomanid
440%45%40%30/30YN
Prevymis
533%33%33%YN
Prezcobix
533%33%33%30/30NN
Prezista
533%33%33%30/30NN
Priftin
440%45%40%NN
Primaquine Phosphate
2$8$15$8NN
Primidone
2$8$15$8NN
Probenecid
2$8$15$8NN
Probenecid And Colchicine
2$8$15$8NN
Procalamine
3$38$47$38YN
Prochlorperazine Maleate
2$8$15$8NN
Procrit
533%33%33%YN
Procto-med Hc
2$8$15$8NN
Proctosol-hc
2$8$15$8NN
Proctozone-hc
2$8$15$8NN
Progesterone
2$8$15$8NN
Prograf
440%45%40%YN
Prolastin-c
533%33%33%YN
Prolia
440%45%40%1/180YN
Promacta
533%33%33%30/30YN
Promethazine Hydrochloride
2$8$15$8NN
Propafenone Hydrochloride
440%45%40%NN
Propranolol Hydrochloride
2$8$15$8NN
Propylthiouracil
2$8$15$8NN
Proquad
3$38$47$38NN
Protriptyline Hydrochloride
440%45%40%NN
Pulmicort
3$38$47$382/30NN
Pulmozyme
533%33%33%YN
Purified Cortrophin Gel
533%33%33%YN
Purixan
533%33%33%NN
Pyrazinamide
2$8$15$8NN
Pyridostigmine Bromide
440%45%40%NN
Pyrimethamine
533%33%33%NN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H4875-020

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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