Amerivantage Dual Coordination (HMO D-SNP) Formulary



Below is the 2023 Formulary, or prescription drug list, from Amerivantage Dual Coordination (HMO D-SNP) by Amerigroup Texas, 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 Tennessee 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 Amerivantage Dual Coordination (HMO D-SNP)(H2593-021) plan has a $450 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. Amerigroup Texas, 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:Amerivantage Dual Coordination (HMO D-SNP)
Plan ID: H2593-021
Provider: Amerigroup Texas, Inc
Plan Year:2023
Premium:$0.00
Deductible:$450
Initial Coverage Limit:$4660
Coverage Area:Tennessee
Similar Plan:H2593-022


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
Abacavir
4Y$95$100NA960/30NN
Abacavir And Lamivudine
4Y$95$100NA30/30NN
Abelcet
4Y$95$100NAYN
Abilify Maintena
525%25%NA1/28NN
Abiraterone
525%25%NA120/30YN
Abiraterone Acetate
525%25%NA60/30YN
Acarbose
2Y$20$20NA90/30NN
Accutane
4Y$95$100NANN
Acebutolol Hydrochloride
2Y$20$20NANN
Acetaminophen And Codeine Phosphate
3Y$47$47NA900/30NN
Acetazolamide
3Y$47$47NANN
Acetic Acid
1Y$10$10NANN
Acetylcysteine
2Y$20$20NAYN
Acitretin
4Y$95$100NANN
Acthib
3Y$47$47NANN
Actimmune
525%25%NAYN
Acyclovir
4Y$95$100NANN
Acyclovir Sodium
4Y$95$100NAYN
Adapalene
4Y$95$100NANN
Adefovir Dipivoxil
4Y$95$100NAYN
Adempas
525%25%NAYN
Advair
3Y$47$47NA60/30NN
Advair Hfa
3Y$47$47NA12/30NN
Aimovig
3Y$47$47NA1/28YN
Alacort
1Y$10$10NANN
Albendazole
525%25%NANN
Albuterol Sulfate
2Y$20$20NANN
Alclometasone Dipropionate
3Y$47$47NANN
Alecensa
525%25%NA240/30YN
Alendronate Sodium
6Y$10$10NA4/28NN
Aliskiren
3Y$47$47NANN
Alosetron Hydrochloride
525%25%NA60/30YN
Alprazolam
3Y$47$47NA120/30NN
Altavera
3Y$47$47NANN
Alunbrig
525%25%NA30/180YN
Alyacen 1/35
4Y$95$100NANN
Amabelz
4Y$95$100NAYN
Amantadine Hydrochloride
3Y$47$47NANN
Ambisome
525%25%NAYN
Amethia
4Y$95$100NANN
Amikacin Sulfate
4Y$95$100NANN
Amiloride Hydrochloride And Hydrochlorothiazide
1Y$10$10NANN
Amiloride Hydrocloride
3Y$47$47NANN
Amiodarone Hydrochloride
4Y$95$100NANN
Amitriptyline Hydrochloride
2Y$20$20NANN
Amlodipine And Benazepril Hydrochloride
6Y$10$10NANN
Amlodipine And Olmesartan Medoxomil
3Y$47$47NANN
Amlodipine And Valsartan
6Y$10$10NANN
Amlodipine Besylate
1Y$10$10NANN
Amlodipine Besylate And Benazepril Hydrochloride
6Y$10$10NANN
Ammonium Lactate
2Y$20$20NANN
Amnesteem
4Y$95$100NANN
Amoxapine
2Y$20$20NAYN
Amoxicillin
1Y$10$10NANN
Amoxicillin And Clavulanate Potassium
3Y$47$47NANN
Amphotericin B
4Y$95$100NAYN
Ampicillin
4Y$95$100NANN
Ampicillin And Sulbactam
4Y$95$100NANN
Ampicillin Sodium And Sulbactam Sodium
4Y$95$100NANN
Anagrelide
3Y$47$47NANN
Anastrozole
2Y$20$20NA30/30NN
Apraclonidine Ophthalmic
3Y$47$47NANN
Aprepitant
3Y$47$47NA15/30YN
Apri
3Y$47$47NANN
Aptivus
525%25%NA120/30NN
Aralast
525%25%NAYN
Aranelle
3Y$47$47NANN
Aranesp
525%25%NAYN
Aripiprazole
4Y$95$100NA90/30NN
Aristada
525%25%NA/60NN
Aristada Initio
525%25%NA/365NN
Armodafinil
4Y$95$100NA30/30YN
Arnuity Ellipta
3Y$47$47NA30/30NN
Ascomp With Codeine
4Y$95$100NA180/30YN
Asenapine
4Y$95$100NA60/30NN
Ashlyna
4Y$95$100NANN
Asmanex
3Y$47$47NA1/30NN
Asmanex Hfa
3Y$47$47NA13/30NN
Atenolol And Chlorthalidone
1Y$10$10NANN
Atomoxetine
4Y$95$100NA30/30NN
Atovaquone
4Y$95$100NAYN
Atovaquone And Proguanil Hydrochloride Pediatric
4Y$95$100NANN
Atrovent
4Y$95$100NA26/30NN
Aubra Eq
3Y$47$47NANN
Auryxia
525%25%NAYN
Austedo
525%25%NA120/30YN
Aviane
3Y$47$47NANN
Avita
3Y$47$47NA45/30YN
Avonex
525%25%NA4/28YN
Ayvakit
525%25%NA30/30YN
Azathioprine
2Y$20$20NAYN
Azelastine Hcl Nasal
4Y$95$100NA30/25NN
Azelastine Hydrochloride
3Y$47$47NA30/25NN
Azithromycin
4Y$95$100NANN
Azopt
4Y$95$100NANN
Aztreonam
4Y$95$100NANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H2593-021

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $450. 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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