Community Health Plan of WA MA Plan 1 (HMO) Formulary



Below is the 2023 Formulary, or prescription drug list, from Community Health Plan of WA MA Plan 1 (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 1 (HMO)(H5826-016) plan has a $230 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. 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 1
Plan ID: H5826-016
Provider: Community Health Plan Of Washington
Plan Year:2023
Premium:$0.00
Deductible:$230
Initial Coverage Limit:$4660
Coverage Area:Washington
Similar Plan:H5826-008


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
Cabergoline
3N$42$47$42NN
Cablivi
529%29%29%YN
Cabometyx
529%29%29%30/30YN
Calcipotriene
4N50%50%50%120/30NN
Calcitriol
4N50%50%50%NN
Calcium Acetate
3N$42$47$42360/30NN
Calquence
529%29%29%60/30YN
Camila
2N$10$15$10NN
Candesartan
2N$10$15$10NN
Candesartan Cilexetil And Hydrochlorothiazide
2N$10$15$10NN
Caplyta
4N50%50%50%30/30NN
Caprelsa
529%29%29%30/30YN
Captopril
2N$10$15$10NN
Carbamazepine
4N50%50%50%NN
Carbidopa
4N50%50%50%NN
Carbidopa And Levodopa
2N$10$15$10NN
Carbidopa, Levodopa, And Entacapone
4N50%50%50%NN
Carglumic Acid
529%29%29%YN
Carteolol Hydrochloride
2N$10$15$10NN
Cartia
2N$10$15$10NN
Caspofungin Acetate
4N50%50%50%NN
Cayston
529%29%29%84/56YN
Caziant
2N$10$15$10NN
Cefaclor
4N50%50%50%NN
Cefadroxil
2N$10$15$10NN
Cefazolin
4N50%50%50%NN
Cefdinir
2N$10$15$10NN
Cefixime
4N50%50%50%NN
Cefoxitin
4N50%50%50%YN
Cefpodoxime Proxetil
4N50%50%50%NN
Cefprozil
3N$42$47$42NN
Ceftazidime
4N50%50%50%YN
Ceftriaxone Sodium
4N50%50%50%NN
Cefuroxime
4N50%50%50%YN
Celecoxib
3N$42$47$42NN
Celontin
4N50%50%50%NN
Cephalexin
2N$10$15$10NN
Chemet
3N$42$47$42YN
Chenodal
529%29%29%YN
Chlorpromazine Hydrochloride
4N50%50%50%NN
Chlorthalidone
2N$10$15$10NN
Cholbam
529%29%29%YN
Cholestyramine
3N$42$47$42NN
Ciclopirox
3N$42$47$42120/28NN
Ciclopirox Olamine
3N$42$47$4260/28NN
Cilostazol
2N$10$15$10NN
Cimduo
529%29%29%NN
Cinacalcet Hydrochloride
4N50%50%50%YN
Cinryze
529%29%29%YN
Ciprofloxacin
4N50%50%50%NN
Ciprofloxacin And Dexamethasone
3N$42$47$42NN
Ciprofloxacin Otic
4N50%50%50%NN
Citalopram Hydrobromide
3N$42$47$42NN
Claravis
4N50%50%50%NN
Clarithromycin
4N50%50%50%NN
Clindamycin
4N50%50%50%YN
Clindamycin Hydrochloride
2N$10$15$10NN
Clindamycin In 5 Percent Dextrose
4N50%50%50%YN
Clindamycin Palmitate Hydrochloride (pediatric)
4N50%50%50%NN
Clindamycin Phosphate
4N50%50%50%NN
Clinimix
4N50%50%50%YN
Clobazam
4N50%50%50%480/30YN
Clobetasol Propionate
4N50%50%50%118/28NN
Clodan
4N50%50%50%236/28NN
Clomipramine Hydrochloride
4N50%50%50%NN
Clonazepam
4N50%50%50%300/30NN
Clonidine Hydrochloride
1N$0$5$0NN
Clonidine Transdermal System
4N50%50%50%4/28NN
Clorazepate Dipotassium
4N50%50%50%180/30YN
Clotrimazole
2N$10$15$10NN
Clotrimazole And Betamethasone Dipropionate
4N50%50%50%60/28NN
Clotrimazole Topical Solution Usp, 1%
2N$10$15$1030/28NN
Clozapine
3N$42$47$42NN
Coartem
4N50%50%50%NN
Colchicine
3N$42$47$42NN
Colesevelam Hydrochloride
4N50%50%50%NN
Colestipol Hydrochloride
4N50%50%50%NN
Collagenase Santyl
3N$42$47$42180/30NN
Combivent Respimat
3N$42$47$428/30NN
Complera
4N50%50%50%NN
Compro
4N50%50%50%NN
Corlanor
3N$42$47$42450/30NN
Cotellic
529%29%29%63/28YN
Creon
3N$42$47$42NN
Cresemba
4N50%50%50%YN
Cromolyn Sodium
2N$10$15$10NN
Crotan
2N$10$15$10NN
Cryselle
2N$10$15$10NN
Cyclobenzaprine Hydrochloride
4N50%50%50%YN
Cyclophosphamide
3N$42$47$42YN
Cyclosporine
4N50%50%50%YN
Cyred Eq
2N$10$15$10NN
Cystagon
4N50%50%50%YN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H5826-016

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $230. 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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