CCHP Senior Program (HMO) Formulary



Below is the 2023 Formulary, or prescription drug list, from CCHP Senior Program (HMO) by Chinese Community Health Plan. A formulary is a continually updated list of available medications and prescription drug cost information. Examining a plans formulary can help you find a California 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 CCHP Senior Program (HMO)(H0571-001) 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. Chinese Community Health Plan 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:CCHP Senior Program
Plan ID: H0571-001
Provider: Chinese Community Health Plan
Plan Year:2023
Premium:$42.00
Deductible:$0
Initial Coverage Limit:$4660
Coverage Area:California
Similar Plan:H0571-005


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
Cabergoline
2$7$7NANN
Cablivi
533%33%NA30/30YN
Cabometyx
533%33%NA60/30YN
Calcipotriene
2$7$7NA120/30NN
Calcitriol
2$7$7NANN
Calcium Acetate
2$7$7NANN
Calquence
533%33%NA60/30YN
Camila
1$0$3NANN
Candesartan
2$7$7NANN
Candesartan Cilexetil And Hydrochlorothiazide
2$7$7NANN
Caplyta
533%33%NA30/30NY
Caprelsa
533%33%NA30/30YN
Captopril
2$7$7NANN
Carbamazepine
2$7$7NANN
Carbidopa And Levodopa
2$7$7NANN
Carbidopa, Levodopa, And Entacapone
4$60$60NANN
Carglumic Acid
533%33%NAYN
Carteolol Hydrochloride
2$7$7NANN
Cartia
2$7$7NANN
Caspofungin Acetate
2$7$7NANN
Cayston
533%33%NAYN
Caziant
2$7$7NANN
Cefaclor
4$60$60NANN
Cefadroxil
2$7$7NANN
Cefazolin
2$7$7NANN
Cefdinir
2$7$7NANN
Cefoxitin
4$60$60NANN
Cefpodoxime Proxetil
4$60$60NANN
Cefprozil
2$7$7NANN
Ceftazidime
2$7$7NANN
Ceftriaxone Sodium
2$7$7NANN
Cefuroxime
2$7$7NANN
Celecoxib
2$7$7NA60/30NN
Celontin
4$60$60NANN
Cephalexin
2$7$7NANN
Cerdelga
533%33%NAYN
Cevimeline
2$7$7NANN
Chlordiazepoxide Hydrochloride
1$0$3NA120/30NN
Chlorpromazine Hydrochloride
4$60$60NANN
Chlorthalidone
2$7$7NANN
Chlorzoxazone
2$7$7NANN
Cholestyramine
2$7$7NANN
Ciclopirox
2$7$7NA1/30NN
Ciclopirox Olamine
2$7$7NA180/30NN
Cilostazol
2$7$7NANN
Cimduo
533%33%NANN
Cimetidine Hydrochloride
2$7$7NANN
Cimzia
533%33%NAYN
Cinacalcet Hydrochloride
533%33%NA120/30NN
Cinryze
533%33%NAYN
Ciprofloxacin
1$0$3NANN
Ciprofloxacin And Dexamethasone
2$7$7NA/7NN
Citalopram Hydrobromide
2$7$7NA600/30NN
Clarithromycin
2$7$7NANN
Clenpiq
3$40$40NANN
Clindamycin
2$7$7NANN
Clindamycin Hydrochloride
2$7$7NANN
Clindamycin In 5 Percent Dextrose
2$7$7NANN
Clindamycin Palmitate Hydrochloride (pediatric)
2$7$7NANN
Clindamycin Phosphate
4$60$60NANN
Clindamycin Phosphate And Benzoyl Peroxide
2$7$7NANN
Clinimix
4$60$60NAYN
Clinimix E
4$60$60NAYN
Clobazam
2$7$7NA480/30NN
Clobetasol Propionate
2$7$7NANN
Clomipramine Hydrochloride
4$60$60NANN
Clonazepam
2$7$7NA300/30NN
Clonidine Hydrochloride
1$0$3NANN
Clonidine Transdermal System
2$7$7NA8/28NN
Clorazepate Dipotassium
2$7$7NA180/30NN
Clotrimazole
2$7$7NANN
Clozapine
2$7$7NA135/30NN
Coartem
4$60$60NANN
Codeine Sulfate
2$7$7NA180/30NN
Colchicine
4$60$60NA120/30YN
Colesevelam Hydrochloride
2$7$7NANN
Colestipol Hydrochloride
2$7$7NANN
Collagenase Santyl
4$60$60NA180/30NN
Combivent Respimat
3$40$40NA8/30NN
Complera
533%33%NANN
Compro
2$7$7NANN
Copaxone
533%33%NA30/30YN
Corlanor
3$40$40NA600/30NN
Cosentyx
533%33%NAYN
Cotellic
533%33%NA63/28YN
Creon
3$40$40NANN
Cromolyn Sodium
2$7$7NANN
Cryselle
2$7$7NANN
Cyclobenzaprine Hydrochloride
1$0$3NANN
Cyclophosphamide
4$60$60NAYY
Cyclosporine
2$7$7NAYN
Cyproheptadine Hydrochloride
2$7$7NANN
Cyred Eq
2$7$7NANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H0571-001

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