CCA Medicare Ultima (HMO) Formulary



Below is the 2023 Formulary, or prescription drug list, from CCA Medicare Ultima (HMO) by Cca Health Michigan, 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 CCA Medicare Ultima (HMO)(H9861-002) 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. Cca Health Michigan, 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:CCA Medicare Ultima (HMO)
Plan ID: H9861-002
Provider: Cca Health Michigan, Inc
Plan Year:2023
Premium:$40.00
Deductible:$0
Initial Coverage Limit:$4660
Coverage Area:Michigan
Similar Plan:H9861-003


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
⇅ Click the Header to Sort
Drug
Name⇅
Tier
Level
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Cabergoline
3$47$47$47NN
Cablivi
530%30%30%30/30YN
Cabometyx
530%30%30%YN
Calcipotriene
4$100$100$100120/30NN
Calcium Acetate
3$47$47$47NN
Calquence
530%30%30%YN
Camila
3$47$47$47NN
Camrese Lo
4$100$100$10091/91NN
Candesartan
1$0$6$0NN
Candesartan Cilexetil And Hydrochlorothiazide
1$0$6$0NN
Caplyta
530%30%30%30/30YN
Caprelsa
530%30%30%YN
Captopril
2$0$15$0NN
Carbamazepine
4$100$100$100NN
Carbidopa
4$100$100$100NN
Carbidopa And Levodopa
2$0$15$0NN
Carglumic Acid
530%30%30%NN
Carteolol Hydrochloride
2$0$15$0NN
Cartia
2$0$15$0NN
Carvedilol Phosphate
4$100$100$100NN
Caspofungin Acetate
4$100$100$100NN
Cayston
530%30%30%YN
Cefaclor
4$100$100$100NN
Cefadroxil
2$0$15$0NN
Cefazolin
4$100$100$100NN
Cefdinir
2$0$15$0NN
Cefotetan
3$47$47$47NN
Cefoxitin
3$47$47$47NN
Cefpodoxime Proxetil
3$47$47$47NN
Cefprozil
3$47$47$47NN
Ceftazidime
3$47$47$47NN
Ceftriaxone Sodium
3$47$47$47NN
Cefuroxime
3$47$47$47NN
Celecoxib
2$0$15$060/30NN
Celontin
4$100$100$100NN
Cephalexin
2$0$15$0NN
Cerdelga
530%30%30%YN
Chemet
530%30%30%NN
Chlordiazepoxide Hydrochloride
2$0$15$0360/30NN
Chlorpromazine Hydrochloride
4$100$100$100NN
Chlorthalidone
2$0$15$0NN
Cholbam
530%30%30%YN
Cholestyramine
3$47$47$47NN
Ciclopirox
3$47$47$47NN
Ciclopirox Olamine
3$47$47$47NN
Cilostazol
2$0$15$0NN
Cimduo
530%30%30%30/30NN
Cimzia
530%30%30%YN
Cinacalcet Hydrochloride
530%30%30%NN
Cinryze
530%30%30%YN
Cipro
4$100$100$100NN
Ciprofloxacin
1$0$6$0NN
Ciprofloxacin And Dexamethasone
4$100$100$100NN
Ciprofloxacin Otic
4$100$100$100NN
Citalopram Hydrobromide
4$100$100$100NN
Claravis
4$100$100$100YN
Clarithromycin
4$100$100$100NN
Clenpiq
3$47$47$47NN
Climara Pro
4$100$100$100NN
Clindacin Etz
2$0$15$0NN
Clindamycin
3$47$47$47NN
Clindamycin Hydrochloride
2$0$15$0NN
Clindamycin Palmitate Hydrochloride (pediatric)
4$100$100$100NN
Clindamycin Phosphate
4$100$100$100NN
Clindamycin Phosphate And Benzoyl Peroxide
3$47$47$47NN
Clobazam
4$100$100$100NN
Clobetasol Propionate
4$100$100$100NN
Clomipramine Hydrochloride
4$100$100$100NN
Clonazepam
3$47$47$47300/30NN
Clonidine Hydrochloride
1$0$6$0NN
Clonidine Transdermal System
4$100$100$100NN
Clorazepate Dipotassium
4$100$100$100180/30NN
Clotrimazole
3$47$47$47NN
Clozapine
4$100$100$100120/30NN
Coartem
4$100$100$100NN
Codeine Sulfate
4$100$100$100NN
Colchicine
3$47$47$47NN
Colestipol Hydrochloride
3$47$47$47NN
Collagenase Santyl
4$100$100$100NN
Combivent Respimat
3$47$47$478/30NN
Complera
530%30%30%30/30NN
Compro
4$100$100$100NN
Corlanor
4$100$100$100450/30YN
Cosentyx
530%30%30%YN
Cotellic
530%30%30%YN
Creon
3$47$47$47NN
Cromolyn Sodium
2$0$15$0NN
Cryselle
3$47$47$47NN
Cyclobenzaprine Hydrochloride
3$47$47$47NN
Cyclophosphamide
3$47$47$47YN
Cycloset
4$100$100$100NN
Cyclosporine
4$100$100$100YN
Cystagon
4$100$100$100NN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H9861-002

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 $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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