Community Blue Medicare PPO Distinct (PPO) Formulary



Below is the 2023 Formulary, or prescription drug list, from Community Blue Medicare PPO Distinct (PPO) by Highmark Senior Health Company. A formulary is a continually updated list of available medications and prescription drug cost information. Examining a plans formulary can help you find a Pennsylvania 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 Community Blue Medicare PPO Distinct (PPO)(H3916-034) 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. Highmark Senior Health Company 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:Community Blue Medicare PPO Distinct
Plan ID: H3916-034
Provider: Highmark Senior Health Company
Plan Year:2023
Premium:$25.00
Deductible:$0
Initial Coverage Limit:$4660
Coverage Area:Pennsylvania
Similar Plan:H3916-035


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$42$47NANN
Cablivi
533%33%33%31/31YN
Cabometyx
533%33%33%31/31YN
Calcipotriene
3$42$47NA60/28NN
Calcitriol
4$100$100NANY
Calcium Acetate
3$42$47NANN
Calquence
533%33%33%62/31YN
Camila
2$0$15NANN
Candesartan
1$0$7NANN
Candesartan Cilexetil And Hydrochlorothiazide
1$0$7NANN
Caplyta
533%33%33%31/31YN
Caprelsa
533%33%33%31/31YN
Captopril
1$0$7NANN
Carbamazepine
3$42$47NANN
Carbidopa And Levodopa
2$0$15NANN
Carbidopa, Levodopa, And Entacapone
4$100$100NANN
Carglumic Acid
533%33%33%YN
Carteolol Hydrochloride
2$0$15NANN
Cartia
2$0$15NANN
Carvedilol Phosphate
4$100$100NANN
Caspofungin Acetate
4$100$100NANN
Cayston
533%33%33%YN
Caziant
2$0$15NANN
Cefadroxil
2$0$15NANN
Cefazolin
4$100$100NANN
Cefdinir
2$0$15NANN
Cefoxitin
4$100$100NANN
Cefpodoxime Proxetil
4$100$100NANN
Cefprozil
2$0$15NANN
Ceftazidime
4$100$100NANN
Ceftriaxone Sodium
2$0$15NANN
Cefuroxime
3$42$47NANN
Celecoxib
2$0$15NA62/31NY
Celontin
4$100$100NANN
Cephalexin
2$0$15NANN
Cerdelga
533%33%33%62/31YN
Cevimeline
4$100$100NANN
Chemet
4$100$100NANN
Chlorpromazine Hydrochloride
4$100$100NANN
Chlorthalidone
1$0$7NANN
Cholbam
533%33%33%YN
Cholestyramine
2$0$15NANN
Cialis
4$100$100NA62/31YN
Ciclopirox
3$42$47NA120/28NN
Ciclopirox Olamine
3$42$47NA60/28NN
Cilostazol
2$0$15NANN
Ciloxan
4$100$100NANN
Cimduo
533%33%33%31/31NN
Cimzia
533%33%33%2/28YN
Cinacalcet Hydrochloride
4$100$100NA124/31YN
Cinryze
533%33%33%20/28YN
Ciprofloxacin
1$0$7NANN
Ciprofloxacin And Dexamethasone
4$100$100NANN
Citalopram Hydrobromide
3$42$47NANN
Claravis
4$100$100NANN
Clarithromycin
4$100$100NANN
Clenpiq
4$100$100NANN
Clindamycin
2$0$15NANN
Clindamycin Hydrochloride
2$0$15NANN
Clindamycin In 5 Percent Dextrose
2$0$15NANN
Clindamycin Palmitate Hydrochloride (pediatric)
4$100$100NANN
Clindamycin Phosphate
2$0$15NANN
Clinimix
4$100$100NAYN
Clobazam
4$100$100NA496/31YN
Clomipramine Hydrochloride
4$100$100NAYN
Clonazepam
2$0$15NA310/31NN
Clonidine Hydrochloride
1$0$7NANN
Clonidine Transdermal System
3$42$47NANN
Clorazepate Dipotassium
3$42$47NA186/31NN
Clotrimazole
2$0$15NANN
Clotrimazole And Betamethasone Dipropionate
2$0$15NA60/28NN
Clotrimazole Topical Solution Usp, 1%
3$42$47NA30/28NN
Clozapine
3$42$47NA124/31NN
Coartem
4$100$100NANN
Colesevelam Hydrochloride
4$100$100NANN
Colestipol Hydrochloride
3$42$47NANN
Collagenase Santyl
4$100$100NA180/30NN
Combivent Respimat
3$42$47NA4/30NN
Complera
533%33%33%NN
Compro
4$100$100NANN
Copaxone
533%33%33%31/31NN
Corlanor
4$100$100NA420/28YN
Cosentyx
533%33%33%/28YN
Cotellic
533%33%33%63/28YN
Creon
533%33%33%NN
Cromolyn Sodium
2$0$15NANN
Crotan
4$100$100NANN
Cryselle
2$0$15NANN
Cyclobenzaprine Hydrochloride
2$0$15NA93/31YN
Cyclophosphamide
3$42$47NAYN
Cyclosporine
2$0$15NAYN
Cyproheptadine Hydrochloride
2$0$15NAYN
Cyred Eq
2$0$15NANN
Cystagon
4$100$100NANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H3916-034

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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