Great Plains Medicare Advantage Gold (HMO I-SNP) Formulary
Below is the 2022 Formulary, or prescription drug list, from Good Samaritan Insurance Plan Of Nebraska, Inc. for Great Plains Medicare Advantage Gold (HMO I-SNP)( H7511-002). A formulary is a list of prescription medications that are covered under Good Samaritan Insurance Plan Of Nebraska, Inc.'s
2022 Medicare Advantage Plan in Nebraska.
This Great Plains Medicare Advantage Gold (HMO I-SNP) plan has a $0 drug deductible.
The Initial Coverage Limit (ICL) for this plan is $4430.
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 $4430 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" be clicking the "Coverage Gap"
link on the left above the chart.
In 2022 if you have spent $7550 in expenditures you enter the Catastrophic Phase. During the Catastrophic Period you will begin to receive significant coverage. Great Plains Medicare Advantage Gold (HMO I-SNP) 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 on the left above the chart.
| Plan Name: | Great Plains Medicare Advantage Gold (HMO I-SNP) |
|---|---|
| Plan ID: | H7511-002 Formulary |
| Provider: | Good Samaritan Insurance Plan Of Nebraska, Inc. |
| Plan Year: | 2022 |
| Premium: | $45.00 |
| Deductible: | $0 |
| Initial Coverage Limit: | $4430 |
| Coverage Area: | Nebraska |
Change Table Options:
| Drugs Starting Letter: | |
|---|---|
| Coverage Phase: |
⇅ Click the Header to Sort
| Drug Name⇅ |
Tier Level |
Cost Preferred |
Cost Non Preferred |
Cost |
Limit Amt/Days |
Prior Auth Y/N |
Step Therapy |
|---|---|---|---|---|---|---|---|
| Bacitracin Zinc And Polymyxin B Sulfate |
2 | NA | $10 | NA | N | N | |
| Baclofen |
3 | NA | $45 | NA | N | N | |
| Bafiertam |
5 | NA | 33% | NA | 120/30 | Y | N |
| Balsalazide Disodium |
4 | NA | $95 | NA | N | N | |
| Balversa |
5 | NA | 33% | NA | Y | N | |
| Balziva |
3 | NA | $45 | NA | N | N | |
| Baqsimi |
3 | NA | $45 | NA | N | N | |
| Baraclude |
5 | NA | 33% | NA | 600/30 | N | N |
| Baxdela |
5 | NA | 33% | NA | N | N | |
| Bcg Vaccine |
3 | NA | $45 | NA | N | N | |
| Benazepril Hydrochloride And Hydrochlorothiazide |
1 | NA | $4 | NA | N | N | |
| Benznidazole |
3 | NA | $45 | NA | N | N | |
| Benztropine Mesylate |
2 | NA | $10 | NA | N | N | |
| Bepotastine Besilate |
4 | NA | $95 | NA | N | N | |
| Betamethasone Dipropionate |
3 | NA | $45 | NA | N | N | |
| Betamethasone Valerate |
3 | NA | $45 | NA | N | N | |
| Betaxolol Hydrochloride |
3 | NA | $45 | NA | N | N | |
| Bethanechol Chloride |
2 | NA | $10 | NA | N | N | |
| Bexarotene |
5 | NA | 33% | NA | Y | N | |
| Bexsero |
3 | NA | $45 | NA | N | N | |
| Bicillin L-a |
4 | NA | $95 | NA | N | N | |
| Biktarvy |
5 | NA | 33% | NA | 30/30 | N | N |
| Bisoprolol Fumarate |
2 | NA | $10 | NA | N | N | |
| Bisoprolol Fumarate And Hydrochlorothiazide |
2 | NA | $10 | NA | N | N | |
| Bivigam |
5 | NA | 33% | NA | Y | N | |
| Blisovi 24 Fe |
3 | NA | $45 | NA | N | N | |
| Blisovi Fe 1.5/30 |
3 | NA | $45 | NA | N | N | |
| Boostrix |
3 | NA | $45 | NA | N | N | |
| Bosulif |
5 | NA | 33% | NA | Y | N | |
| Braftovi |
5 | NA | 33% | NA | Y | N | |
| Breo Ellipta |
3 | NA | $45 | NA | 60/30 | N | N |
| Breztri |
3 | NA | $45 | NA | 23/28 | N | N |
| Briellyn |
3 | NA | $45 | NA | N | N | |
| Brilinta |
3 | NA | $45 | NA | N | N | |
| Brimonidine Tartrate |
4 | NA | $95 | NA | N | N | |
| Briviact |
5 | NA | 33% | NA | Y | N | |
| Budesonide |
4 | NA | $95 | NA | N | N | |
| Bumetanide |
1 | NA | $4 | NA | N | N | |
| Buprenorphine |
4 | NA | $95 | NA | 4/28 | N | N |
| Buprenorphine And Naloxone |
2 | NA | $10 | NA | 60/30 | N | N |
| Buprenorphine Hcl |
2 | NA | $10 | NA | N | N | |
| Buprenorphine Hydrochloride And Naloxone Hydrochlo |
2 | NA | $10 | NA | 90/30 | N | N |
| Bupropion Hydrochloride |
2 | NA | $10 | NA | 30/30 | N | N |
| Buspirone Hydrochloride |
4 | NA | $95 | NA | N | N |
* Drug Prices and Coverage is for a 30 Day Supply
Coverage Levels for H7511-002
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 $4430
3.Coverage Gap: (AKA Donut Hole) After you reach the plans ICL but before the Catastrophic of $7550 in 2022.
4.Catastrophic: Anything over $7550 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 2022 is $320. 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 in order 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 plans 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.
Source:CMS Formulary Data Q1 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.