Community Health Plan of WA MA Plan 4 (HMO) Formulary



Below is the 2023 Formulary, or prescription drug list, from Community Health Plan of WA MA Plan 4 (HMO) by Community Health Plan Of Washington. A formulary is a continually updated list of available medications and prescription drug cost information. Examining a plans formulary can help you find a Washington 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 Health Plan of WA MA Plan 4 (HMO)(H5826-009) 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. Community Health Plan Of Washington 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 Health Plan of WA MA Plan 4
Plan ID: H5826-009
Provider: Community Health Plan Of Washington
Plan Year:2023
Premium:$55.50
Deductible:$0
Initial Coverage Limit:$4660
Coverage Area:Washington
Similar Plan:H5826-010


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$47$42NN
Cablivi
533%33%33%YN
Cabometyx
533%33%33%30/30YN
Calcipotriene
450%50%50%120/30NN
Calcitriol
450%50%50%NN
Calcium Acetate
3$42$47$42360/30NN
Calquence
533%33%33%60/30YN
Camila
2$10$15$10NN
Candesartan
2$10$15$10NN
Candesartan Cilexetil And Hydrochlorothiazide
2$10$15$10NN
Caplyta
450%50%50%30/30NN
Caprelsa
533%33%33%30/30YN
Captopril
2$10$15$10NN
Carbamazepine
450%50%50%NN
Carbidopa
450%50%50%NN
Carbidopa And Levodopa
2$10$15$10NN
Carbidopa, Levodopa, And Entacapone
450%50%50%NN
Carglumic Acid
533%33%33%YN
Carteolol Hydrochloride
2$10$15$10NN
Cartia
2$10$15$10NN
Caspofungin Acetate
450%50%50%NN
Cayston
533%33%33%84/56YN
Caziant
2$10$15$10NN
Cefaclor
450%50%50%NN
Cefadroxil
2$10$15$10NN
Cefazolin
450%50%50%NN
Cefdinir
2$10$15$10NN
Cefixime
450%50%50%NN
Cefoxitin
450%50%50%YN
Cefpodoxime Proxetil
450%50%50%NN
Cefprozil
3$42$47$42NN
Ceftazidime
450%50%50%YN
Ceftriaxone Sodium
450%50%50%NN
Cefuroxime
450%50%50%YN
Celecoxib
3$42$47$42NN
Celontin
450%50%50%NN
Cephalexin
2$10$15$10NN
Chemet
3$42$47$42YN
Chenodal
533%33%33%YN
Chlorpromazine Hydrochloride
450%50%50%NN
Chlorthalidone
2$10$15$10NN
Cholbam
533%33%33%YN
Cholestyramine
3$42$47$42NN
Ciclopirox
3$42$47$42120/28NN
Ciclopirox Olamine
3$42$47$4260/28NN
Cilostazol
2$10$15$10NN
Cimduo
533%33%33%NN
Cinacalcet Hydrochloride
450%50%50%YN
Cinryze
533%33%33%YN
Ciprofloxacin
450%50%50%NN
Ciprofloxacin And Dexamethasone
3$42$47$42NN
Ciprofloxacin Otic
450%50%50%NN
Citalopram Hydrobromide
3$42$47$42NN
Claravis
450%50%50%NN
Clarithromycin
450%50%50%NN
Clindamycin
450%50%50%YN
Clindamycin Hydrochloride
2$10$15$10NN
Clindamycin In 5 Percent Dextrose
450%50%50%YN
Clindamycin Palmitate Hydrochloride (pediatric)
450%50%50%NN
Clindamycin Phosphate
450%50%50%NN
Clinimix
450%50%50%YN
Clobazam
450%50%50%480/30YN
Clobetasol Propionate
450%50%50%118/28NN
Clodan
450%50%50%236/28NN
Clomipramine Hydrochloride
450%50%50%NN
Clonazepam
450%50%50%300/30NN
Clonidine Hydrochloride
1$0$5$0NN
Clonidine Transdermal System
450%50%50%4/28NN
Clorazepate Dipotassium
450%50%50%180/30YN
Clotrimazole
2$10$15$10NN
Clotrimazole And Betamethasone Dipropionate
450%50%50%60/28NN
Clotrimazole Topical Solution Usp, 1%
2$10$15$1030/28NN
Clozapine
3$42$47$42NN
Coartem
450%50%50%NN
Colchicine
3$42$47$42NN
Colesevelam Hydrochloride
450%50%50%NN
Colestipol Hydrochloride
450%50%50%NN
Collagenase Santyl
3$42$47$42180/30NN
Combivent Respimat
3$42$47$428/30NN
Complera
450%50%50%NN
Compro
450%50%50%NN
Corlanor
3$42$47$42450/30NN
Cotellic
533%33%33%63/28YN
Creon
3$42$47$42NN
Cresemba
450%50%50%YN
Cromolyn Sodium
2$10$15$10NN
Crotan
2$10$15$10NN
Cryselle
2$10$15$10NN
Cyclobenzaprine Hydrochloride
450%50%50%YN
Cyclophosphamide
3$42$47$42YN
Cyclosporine
450%50%50%YN
Cyred Eq
2$10$15$10NN
Cystagon
450%50%50%YN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H5826-009

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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