UVM Health Advantage Preferred (PPO) Formulary



Below is the 2023 Formulary, or prescription drug list, from UVM Health Advantage Preferred (PPO) by Mvp Health Plan, 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 New York 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 UVM Health Advantage Preferred (PPO)(H9615-017) 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. Mvp Health Plan, 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:UVM Health Advantage Preferred
Plan ID: H9615-017
Provider: Mvp Health Plan, Inc
Plan Year:2023
Premium:$75.90
Deductible:$0
Initial Coverage Limit:$4660
Coverage Area:New York
Similar Plan:H9615-018


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
Labetalol Hcl
2NA$10NANN
Lamivudine
2NA$10NANN
Lamotrigine
2NA$10NANN
Lansoprazole
2NA$10NA60/30NN
Lansoprazole, Amoxicillin And Clarithromycin
4NA$100NANN
Lanthanum Carbonate
3NA$40NANN
Lantus
3NA$40NANN
Lapatinib
5NA27%NANN
Larissia
2NA$10NANN
Latanoprost
2NA$10NANN
Layolis Fe
2NA$10NANN
Leena
3NA$40NANN
Leflunomide
3NA$40NANN
Lenvima
5NA27%NAYN
Lessina
2NA$10NANN
Leucovorin Calcium
4NA$100NANN
Leukeran
3NA$40NANN
Leuprolide Acetate
2NA$10NANN
Levalbuterol
2NA$10NAYN
Levalbuterol Hydrochloride
2NA$10NAYN
Levalbuterol Tartrate Hfa Inhalation
3NA$40NANN
Levemir
3NA$40NANN
Levetiracetam
2NA$10NANN
Levo-t
1NA$0NANN
Levobunolol Hydrochloride
2NA$10NANN
Levocarnitine
3NA$40NANN
Levocetirizine Dihydrochloride
2NA$10NANN
Levofloxacin
2NA$10NANN
Levonorgestrel And Ethinyl Estradiol
2NA$10NANN
Levonorgestrel And Ethinyl Estradiol And Ethinyl E
2NA$10NANN
Levora
2NA$10NANN
Levothyroxine Sodium
1NA$0NANN
Levoxyl
3NA$40NANN
Lexiva
4NA$100NANN
Lidocaine
3NA$40NAYN
Lidocaine Hydrochloride
2NA$10NANN
Lindane
2NA$10NANN
Linezolid
5NA27%NANN
Lisinopril
1NA$0NANN
Lithium Carbonate
2NA$10NANN
Livalo
4NA$100NANN
Livtencity
5NA27%NANN
Lokelma
4NA$100NANN
Lonsurf
5NA27%NAYN
Loperamide Hydrochloride
2NA$10NANN
Lopinavir And Ritonavir
3NA$40NANN
Lopinavir-ritonavir
3NA$40NANN
Lorazepam
2NA$10NANN
Lorbrena
5NA27%NAYN
Loreev Xr
4NA$100NANN
Loryna
2NA$10NANN
Loteprednol Etabonate
3NA$40NANN
Low-ogestrel
2NA$10NANN
Loxapine
2NA$10NANN
Lubiprostone
3NA$40NA60/30NN
Luliconazole
2NA$10NANN
Lupkynis
5NA27%NA180/30YN
Lupron Depot
5NA27%NANN
Lutera
2NA$10NANN
Lyleq
2NA$10NANN
Lyllana
3NA$40NANN
Lynparza
5NA27%NAYN
Lysodren
3NA$40NANN
Lyumjev
3NA$40NANN
Lyza
2NA$10NANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H9615-017

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