AbilityCare (HMO D-SNP) Formulary



Below is the 2023 Formulary, or prescription drug list, from AbilityCare (HMO D-SNP) by South Country Health Alliance. A formulary is a continually updated list of available medications and prescription drug cost information. Examining a plans formulary can help you find a Minnesota 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 AbilityCare (HMO D-SNP)(H5703-001) plan has a $505 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. South Country Health Alliance 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:AbilityCare (HMO D-SNP)
Plan ID: H5703-001
Provider: South Country Health Alliance
Plan Year:2023
Premium:$0.00
Deductible:$505
Initial Coverage Limit:$4660
Coverage Area:Minnesota
Similar Plan:H5703-001


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
1YNA$0NANN
Abacavir And Lamivudine
1YNA$0NA30/30NN
Abelcet
1YNA$0NAYN
Abilify Maintena
1YNA$0NA1/28NN
Abiraterone
1YNA$0NAYN
Abiraterone Acetate
1YNA$0NAYN
Acarbose
1YNA$0NA90/30NN
Acebutolol Hydrochloride
1YNA$0NANN
Acetaminophen And Codeine Phosphate
1YNA$0NANN
Acetazolamide
1YNA$0NANN
Acetic Acid
1YNA$0NANN
Acetylcysteine
1YNA$0NAYN
Acitretin
1YNA$0NAYN
Actemra
1YNA$0NAYN
Actemra Actpen
1YNA$0NAYN
Acthar
1YNA$0NAYN
Acthib
1YNA$0NANN
Actimmune
1YNA$0NAYN
Acyclovir
1YNA$0NANN
Acyclovir Sodium
1YNA$0NAYN
Adapalene And Benzoyl Peroxide
1YNA$0NANN
Adefovir Dipivoxil
1YNA$0NAYN
Adempas
1YNA$0NAYN
Advair Hfa
1YNA$0NANN
Aimovig
1YNA$0NAYN
Albendazole
1YNA$0NANN
Albuterol Sulfate
1YNA$0NANN
Alclometasone Dipropionate
1YNA$0NANN
Alecensa
1YNA$0NAYN
Alendronate Sodium
1YNA$0NANN
Aliskiren
1YNA$0NANN
Alosetron Hydrochloride
1YNA$0NA60/30NN
Alprazolam
1YNA$0NA150/30NN
Altavera
1YNA$0NANN
Alunbrig
1YNA$0NAYN
Alyacen 1/35
1YNA$0NANN
Amabelz
1YNA$0NANN
Amantadine Hydrochloride
1YNA$0NANN
Ambisome
1YNA$0NAYN
Amikacin Sulfate
1YNA$0NANN
Amiloride Hydrochloride And Hydrochlorothiazide
1YNA$0NANN
Amiloride Hydrocloride
1YNA$0NANN
Amiodarone Hydrochloride
1YNA$0NANN
Amitriptyline Hydrochloride
1YNA$0NAYN
Amlodipine And Benazepril Hydrochloride
1YNA$0NANN
Amlodipine And Olmesartan Medoxomil
1YNA$0NANN
Amlodipine And Valsartan
1YNA$0NANN
Amlodipine Besylate
1YNA$0NANN
Amlodipine Besylate And Benazepril Hydrochloride
1YNA$0NANN
Ammonium Lactate
1YNA$0NANN
Amnesteem
1YNA$0NANN
Amoxapine
1YNA$0NAYN
Amoxicillin
1YNA$0NANN
Amoxicillin And Clavulanate Potassium
1YNA$0NANN
Amphotericin B
1YNA$0NAYN
Ampicillin
1YNA$0NANN
Ampicillin And Sulbactam
1YNA$0NANN
Ampicillin Sodium And Sulbactam Sodium
1YNA$0NANN
Anagrelide
1YNA$0NANN
Anastrozole
1YNA$0NANN
Aprepitant
1YNA$0NAYN
Apri
1YNA$0NANN
Aptivus
1YNA$0NA120/30NN
Aralast
1YNA$0NAYN
Aranelle
1YNA$0NANN
Aranesp
1YNA$0NAYN
Aripiprazole
1YNA$0NA60/30NN
Aristada
1YNA$0NA/56YN
Aristada Initio
1YNA$0NAYN
Armodafinil
1YNA$0NAYN
Arnuity Ellipta
1YNA$0NANN
Ascomp With Codeine
1YNA$0NAYN
Asenapine
1YNA$0NA60/30NN
Atenolol And Chlorthalidone
1YNA$0NANN
Atomoxetine
1YNA$0NANN
Atovaquone
1YNA$0NANN
Atovaquone And Proguanil Hydrochloride Pediatric
1YNA$0NANN
Atrovent
1YNA$0NANN
Aubra Eq
1YNA$0NANN
Austedo
1YNA$0NAYN
Aviane
1YNA$0NANN
Ayvakit
1YNA$0NAYN
Azathioprine
1YNA$0NAYN
Azelastine Hcl Nasal
1YNA$0NANN
Azelastine Hydrochloride
1YNA$0NANN
Azithromycin
1YNA$0NANN
Aztreonam
1YNA$0NANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H5703-001

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $505. 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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