PacificSource Medicare Explorer Rx 17 (PPO) Formulary
Below is the 2023 Formulary, or prescription drug list, from PacificSource Medicare Explorer Rx 17 (PPO) by Pacificsource Community Health Plans. A formulary is a continually updated list of available medications and prescription drug cost information. Examining a plans formulary can help you find a Montana 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 PacificSource Medicare Explorer Rx 17 (PPO)(H4754-017) plan has a $225 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. Pacificsource Community Health Plans 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: | PacificSource Medicare Explorer Rx 17 |
|---|---|
| Plan ID: | H4754-017 |
| Provider: | Pacificsource Community Health Plans |
| Plan Year: | 2023 |
| Premium: | $33.00 |
| Deductible: | $225 |
| Initial Coverage Limit: | $4660 |
| Coverage Area: | Montana |
| Similar Plan: | H4754-004 |
Change Table Options:
| Drugs Starting Letter: | |
|---|---|
| Coverage Phase: |
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| Drug Name⇅ |
Tier Level |
Deductible Apply | Cost Preferred |
Cost Non Preferred |
Cost |
Limit Amt/Days |
Prior Auth Y/N |
Step Therapy |
|---|---|---|---|---|---|---|---|---|
| Paliperidone |
4 | Y | 31% | 32% | 31% | N | N | |
| Palynziq |
5 | 29% | 29% | 29% | Y | N | ||
| Panretin |
5 | 29% | 29% | 29% | N | N | ||
| Paricalcitol |
2 | N | $12 | $17 | $12 | N | N | |
| Paromomycin Sulfate |
4 | Y | 31% | 32% | 31% | N | N | |
| Paroxetine |
4 | Y | 31% | 32% | 31% | N | Y | |
| Paroxetine Hydrochloride |
2 | N | $12 | $17 | $12 | N | N | |
| Paser |
4 | Y | 31% | 32% | 31% | N | N | |
| Pediarix |
3 | Y | $37 | $47 | $37 | N | N | |
| Pedvaxhib |
3 | Y | $37 | $47 | $37 | N | N | |
| Pegasys |
5 | 29% | 29% | 29% | Y | N | ||
| Pemazyre |
5 | 29% | 29% | 29% | 14/21 | Y | N | |
| Penicillamine |
5 | 29% | 29% | 29% | Y | N | ||
| Penicillin G Potassium |
3 | Y | $37 | $47 | $37 | N | N | |
| Penicillin G Procaine |
3 | Y | $37 | $47 | $37 | N | N | |
| Penicillin G Sodium |
2 | N | $12 | $17 | $12 | N | N | |
| Penicillin V Potassium |
2 | N | $12 | $17 | $12 | N | N | |
| Pentacel |
3 | Y | $37 | $47 | $37 | N | N | |
| Pentamidine Isethionate |
2 | N | $12 | $17 | $12 | Y | N | |
| Pentoxifylline |
2 | N | $12 | $17 | $12 | N | N | |
| Perindopril Erbumine |
6 | N | $0 | $0 | $0 | N | N | |
| Periogard Alcohol Free |
2 | N | $12 | $17 | $12 | N | N | |
| Permethrin |
2 | N | $12 | $17 | $12 | N | N | |
| Perphenazine |
2 | N | $12 | $17 | $12 | N | N | |
| Perseris |
5 | 29% | 29% | 29% | Y | N | ||
| Pexeva |
4 | Y | 31% | 32% | 31% | N | Y | |
| Phenelzine Sulfate |
2 | N | $12 | $17 | $12 | N | N | |
| Phenobarbital |
2 | N | $12 | $17 | $12 | N | N | |
| Phenoxybenzamine Hydrochloride |
5 | 29% | 29% | 29% | Y | N | ||
| Phenytoin |
2 | N | $12 | $17 | $12 | N | N | |
| Phospholine Iodide |
4 | Y | 31% | 32% | 31% | N | N | |
| Pifeltro |
5 | 29% | 29% | 29% | 30/30 | N | N | |
| Pilocarpine Hydrochloride |
2 | N | $12 | $17 | $12 | N | N | |
| Pimecrolimus |
4 | Y | 31% | 32% | 31% | Y | N | |
| Pimozide |
2 | N | $12 | $17 | $12 | N | N | |
| Pindolol |
2 | N | $12 | $17 | $12 | N | N | |
| Piperacillin And Tazobactam |
2 | N | $12 | $17 | $12 | N | N | |
| Piqray |
5 | 29% | 29% | 29% | Y | N | ||
| Pirmella 1/35 |
2 | N | $12 | $17 | $12 | N | N | |
| Piroxicam |
2 | N | $12 | $17 | $12 | N | N | |
| Plenamine |
2 | N | $12 | $17 | $12 | Y | N | |
| Podofilox |
2 | N | $12 | $17 | $12 | N | N | |
| Polyethylene Glycol 3350, Sodium Chloride, Sodium |
2 | N | $12 | $17 | $12 | N | N | |
| Polymyxin B Sulfate And Trimethoprim |
2 | N | $12 | $17 | $12 | N | N | |
| Portia |
2 | N | $12 | $17 | $12 | N | N | |
| Potassium Chloride |
2 | N | $12 | $17 | $12 | N | N | |
| Potassium Chloride In Dextrose |
2 | N | $12 | $17 | $12 | Y | N | |
| Potassium Chloride In Dextrose And Sodium Chloride |
3 | Y | $37 | $47 | $37 | Y | N | |
| Potassium Chloride In Lactated Ringers And Dextros |
4 | Y | 31% | 32% | 31% | Y | N | |
| Potassium Chloride In Sodium Chloride |
2 | N | $12 | $17 | $12 | N | N | |
| Potassium Citrate |
2 | N | $12 | $17 | $12 | N | N | |
| Pradaxa |
4 | Y | 31% | 32% | 31% | 60/30 | N | N |
| Pramipexole Dihydrochloride |
2 | N | $12 | $17 | $12 | N | Y | |
| Prasugrel |
4 | Y | 31% | 32% | 31% | N | N | |
| Pravastatin Sodium |
6 | N | $0 | $0 | $0 | N | N | |
| Praziquantel |
4 | Y | 31% | 32% | 31% | N | N | |
| Prazosin Hydrochloride |
2 | N | $12 | $17 | $12 | N | N | |
| Pred Mild |
3 | Y | $37 | $47 | $37 | N | N | |
| Prednisolone Acetate |
2 | N | $12 | $17 | $12 | N | N | |
| Prednisolone Sodium Phosphate |
4 | Y | 31% | 32% | 31% | N | N | |
| Prednisolone Sodium Phosphate Oral Solution |
4 | Y | 31% | 32% | 31% | N | N | |
| Prednisone |
2 | N | $12 | $17 | $12 | N | N | |
| Prednisone Intensol |
3 | Y | $37 | $47 | $37 | N | N | |
| Prefest |
4 | Y | 31% | 32% | 31% | N | N | |
| Pregabalin |
2 | N | $12 | $17 | $12 | 60/30 | N | N |
| Premarin |
4 | Y | 31% | 32% | 31% | N | N | |
| Premasol - Sulfite-free (amino Acid) |
4 | Y | 31% | 32% | 31% | Y | N | |
| Premphase |
4 | Y | 31% | 32% | 31% | N | N | |
| Prempro |
4 | Y | 31% | 32% | 31% | N | N | |
| Pretomanid |
4 | Y | 31% | 32% | 31% | 30/30 | Y | N |
| Prevymis |
5 | 29% | 29% | 29% | 100/365 | N | N | |
| Prezcobix |
5 | 29% | 29% | 29% | N | N | ||
| Prezista |
5 | 29% | 29% | 29% | N | N | ||
| Priftin |
3 | Y | $37 | $47 | $37 | N | N | |
| Primaquine Phosphate |
2 | N | $12 | $17 | $12 | N | N | |
| Primidone |
2 | N | $12 | $17 | $12 | N | N | |
| Privigen |
5 | 29% | 29% | 29% | Y | N | ||
| Proair |
2 | N | $12 | $17 | $12 | 17/30 | N | N |
| Proair Respiclick |
2 | N | $12 | $17 | $12 | 2/30 | N | N |
| Probenecid |
2 | N | $12 | $17 | $12 | N | N | |
| Probenecid And Colchicine |
2 | N | $12 | $17 | $12 | N | N | |
| Procalamine |
4 | Y | 31% | 32% | 31% | Y | N | |
| Prochlorperazine Maleate |
2 | N | $12 | $17 | $12 | N | N | |
| Procrit |
5 | 29% | 29% | 29% | Y | N | ||
| Procto-med Hc |
2 | N | $12 | $17 | $12 | N | N | |
| Procysbi |
5 | 29% | 29% | 29% | Y | N | ||
| Progesterone |
2 | N | $12 | $17 | $12 | N | N | |
| Prograf |
4 | Y | 31% | 32% | 31% | Y | N | |
| Prolastin-c |
5 | 29% | 29% | 29% | Y | N | ||
| Prolia |
4 | Y | 31% | 32% | 31% | N | N | |
| Promacta |
5 | 29% | 29% | 29% | Y | N | ||
| Promethazine Hydrochloride |
2 | N | $12 | $17 | $12 | N | N | |
| Propafenone Hydrochloride |
2 | N | $12 | $17 | $12 | N | N | |
| Propranolol Hydrochloride |
2 | N | $12 | $17 | $12 | N | N | |
| Propylthiouracil |
2 | N | $12 | $17 | $12 | N | N | |
| Proquad |
3 | Y | $37 | $47 | $37 | N | N | |
| Prosol |
4 | Y | 31% | 32% | 31% | Y | N | |
| Protriptyline Hydrochloride |
2 | N | $12 | $17 | $12 | N | N | |
| Pulmicort |
4 | Y | 31% | 32% | 31% | 4/30 | N | N |
| Pulmozyme |
5 | 29% | 29% | 29% | Y | N | ||
| Purixan |
5 | 29% | 29% | 29% | N | N | ||
| Pyrazinamide |
2 | N | $12 | $17 | $12 | N | N | |
| Pyridostigmine Bromide |
2 | N | $12 | $17 | $12 | N | N | |
| Pyrimethamine |
5 | 29% | 29% | 29% | Y | N |
* Drug Prices and Coverage is for a 30 Day Supply
Coverage Levels for H4754-017
Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $225. 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 2022Source: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.