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Paramount Elite Standard (HMO) Formulary



Below is the 2023 Formulary, or prescription drug list, from Paramount Elite Standard (HMO) by Paramount Care, 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 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 Paramount Elite Standard (HMO)(H3653-015) 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. Paramount Care, 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:Paramount Elite Standard
Plan ID: H3653-015
Provider: Paramount Care, Inc
Plan Year:2023
Premium:$0.00
Deductible:$0
Initial Coverage Limit:$4660
Coverage Area:Michigan
Similar Plan:H3653-022


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
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Paliperidone
4NA$100NA30/30NN
Panretin
5NA33%NA60/30YN
Panzyga
5NA33%NAYN
Paricalcitol
4NA$100NAYN
Paromomycin Sulfate
4NA$100NANN
Paroxetine
4NA$100NA900/30YN
Paser
4NA$100NANN
Pediarix
3NA$45NANN
Pedvaxhib
3NA$45NANN
Peg-3350 And Electrolytes
2NA$8NANN
Pegasys
5NA33%NAYN
Pemazyre
5NA33%NAYN
Penicillamine
5NA33%NANN
Penicillin G Potassium
4NA$100NANN
Penicillin G Procaine
4NA$100NANN
Penicillin G Sodium
4NA$100NANN
Penicillin V Potassium
1NA$0NANN
Pentacel
3NA$45NANN
Pentamidine Isethionate
4NA$100NAYN
Pentoxifylline
2NA$8NANN
Perindopril Erbumine
1NA$0NANN
Periogard Alcohol Free
1NA$0NANN
Permethrin
3NA$45NA60/30NN
Perphenazine
3NA$45NANN
Perseris
5NA33%NA1/30NN
Phenelzine Sulfate
3NA$45NANN
Phenobarbital
3NA$45NAYN
Phenytek
4NA$100NANN
Phenytoin
3NA$45NANN
Pifeltro
5NA33%NANN
Pilocarpine Hydrochloride
3NA$45NANN
Pimozide
4NA$100NANN
Pindolol
3NA$45NANN
Piperacillin And Tazobactam
4NA$100NANN
Piqray
5NA33%NAYN
Pirmella 1/35
3NA$45NANN
Piroxicam
3NA$45NANN
Plenamine
4NA$100NAYN
Plenvu
4NA$100NANN
Podofilox
3NA$45NA7/28NN
Polyethylene Glycol 3350, Sodium Chloride, Sodium
2NA$8NANN
Polymyxin B Sulfate And Trimethoprim
1NA$0NANN
Portia
3NA$45NANN
Potassium Chloride
2NA$8NANN
Potassium Chloride In Dextrose
3NA$45NANN
Potassium Chloride In Dextrose And Sodium Chloride
4NA$100NANN
Potassium Chloride In Sodium Chloride
4NA$100NANN
Potassium Citrate
4NA$100NANN
Pradaxa
4NA$100NA60/30NN
Prasugrel
3NA$45NANN
Pravastatin Sodium
1NA$0NA30/30NN
Praziquantel
4NA$100NANN
Prazosin Hydrochloride
3NA$45NANN
Prednisolone Acetate
3NA$45NANN
Prednisolone Sodium Phosphate
3NA$45NANN
Prednisolone Sodium Phosphate Oral Solution
3NA$45NAYN
Prednisone
3NA$45NANN
Prednisone Intensol
4NA$100NAYN
Pregabalin
4NA$100NA900/30YN
Premasol - Sulfite-free (amino Acid)
5NA33%NAYN
Prevymis
5NA33%NA28/28YN
Prezcobix
5NA33%NANN
Prezista
5NA33%NA30/30NN
Priftin
4NA$100NANN
Primaquine Phosphate
3NA$45NANN
Primidone
2NA$8NANN
Privigen
5NA33%NAYN
Probenecid
3NA$45NANN
Probenecid And Colchicine
3NA$45NANN
Procalamine
4NA$100NAYN
Prochlorperazine Maleate
2NA$8NANN
Procrit
5NA33%NAYN
Procto-med Hc
3NA$45NANN
Proctosol-hc
3NA$45NANN
Proctozone-hc
3NA$45NANN
Prograf
4NA$100NAYN
Prolastin-c
5NA33%NAYN
Prolensa
3NA$45NANN
Prolia
4NA$100NA1/180NN
Promacta
5NA33%NA360/30YN
Promethazine Hydrochloride
3NA$45NAYN
Propafenone Hydrochloride
4NA$100NANN
Propranolol Hydrochloride
3NA$45NANN
Propylthiouracil
3NA$45NANN
Proquad
3NA$45NANN
Prosol
4NA$100NAYN
Protriptyline Hydrochloride
4NA$100NANN
Pulmicort
4NA$100NA3/30NN
Pulmozyme
5NA33%NAYN
Purixan
5NA33%NANN
Pyrazinamide
4NA$100NANN
Pyridostigmine Bromide
3NA$45NANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H3653-015

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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