ConnectiCare Choice Plan 3 (HMO) Formulary



Below is the 2023 Formulary, or prescription drug list, from ConnectiCare Choice Plan 3 (HMO) by Connecticare, 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 Connecticut 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 ConnectiCare Choice Plan 3 (HMO)(H3528-014) 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. Connecticare, 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:ConnectiCare Choice Plan 3
Plan ID: H3528-014
Provider: Connecticare, Inc
Plan Year:2023
Premium:$0.00
Deductible:$0
Initial Coverage Limit:$4660
Coverage Area:Connecticut
Similar Plan:H3528-015


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
3$42$47$42NN
Cablivi
533%33%33%YN
Cabometyx
533%33%33%30/30YN
Calcipotriene
4$95$100$95120/30NN
Calcitriol
4$95$100$95NN
Calcium Acetate
3$42$47$42360/30NN
Calquence
533%33%33%60/30YN
Camila
2$10$20$0NN
Candesartan
2$10$20$0NN
Candesartan Cilexetil And Hydrochlorothiazide
2$10$20$0NN
Caplyta
4$95$100$9530/30NN
Caprelsa
533%33%33%30/30YN
Captopril
2$10$20$0NN
Carbamazepine
3$42$47$42NN
Carbidopa
2$10$20$0NN
Carbidopa And Levodopa
2$10$20$0NN
Carbidopa, Levodopa, And Entacapone
4$95$100$95NN
Carglumic Acid
533%33%33%YN
Carteolol Hydrochloride
2$10$20$0NN
Cartia
2$10$20$0NN
Caspofungin Acetate
4$95$100$95NN
Cayston
533%33%33%84/56YN
Caziant
2$10$20$0NN
Cefaclor
2$10$20$0NN
Cefadroxil
2$10$20$0NN
Cefazolin
4$95$100$95NN
Cefdinir
2$10$20$0NN
Cefixime
4$95$100$95NN
Cefoxitin
4$95$100$95YN
Cefpodoxime Proxetil
4$95$100$95NN
Cefprozil
2$10$20$0NN
Ceftazidime
4$95$100$95YN
Ceftriaxone Sodium
4$95$100$95NN
Cefuroxime
4$95$100$95YN
Celecoxib
2$10$20$0NN
Celontin
4$95$100$95NN
Cephalexin
2$10$20$0NN
Cevimeline
4$95$100$95NN
Chemet
3$42$47$42YN
Chenodal
533%33%33%YN
Chlorpromazine Hydrochloride
4$95$100$95NN
Chlorthalidone
2$10$20$0NN
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$20$0NN
Cimduo
533%33%33%NN
Cimetidine
2$10$20$0NN
Cimetidine Hydrochloride
2$10$20$0NN
Cimzia
533%33%33%2/28YN
Cinacalcet Hydrochloride
4$95$100$95YN
Cinryze
533%33%33%YN
Ciprofloxacin
2$10$20$0NN
Ciprofloxacin And Dexamethasone
3$42$47$42NN
Ciprofloxacin Otic
4$95$100$95NN
Citalopram Hydrobromide
3$42$47$42NN
Claravis
4$95$100$95NN
Clarithromycin
2$10$20$0NN
Clindamycin
4$95$100$95YN
Clindamycin Hydrochloride
2$10$20$0NN
Clindamycin In 5 Percent Dextrose
4$95$100$95YN
Clindamycin Palmitate Hydrochloride (pediatric)
4$95$100$95NN
Clindamycin Phosphate
3$42$47$42NN
Clinimix
4$95$100$95YN
Clobazam
4$95$100$95480/30YN
Clobetasol Propionate
4$95$100$95118/28NN
Clodan
4$95$100$95236/28NN
Clomipramine Hydrochloride
4$95$100$95NN
Clonazepam
2$10$20$0300/30NN
Clonidine Hydrochloride
1$2$9$0NN
Clonidine Transdermal System
4$95$100$954/28NN
Clorazepate Dipotassium
3$42$47$42180/30YN
Clotrimazole
2$10$20$0NN
Clotrimazole And Betamethasone Dipropionate
4$95$100$9560/28NN
Clotrimazole Topical Solution Usp, 1%
2$10$20$030/28NN
Clozapine
3$42$47$42NN
Coartem
4$95$100$95NN
Colchicine
2$10$20$0NN
Colesevelam Hydrochloride
4$95$100$95NN
Colestipol Hydrochloride
4$95$100$95NN
Collagenase Santyl
3$42$47$42180/30NN
Combivent Respimat
3$42$47$428/30NN
Complera
4$95$100$95NN
Compro
4$95$100$95NN
Corlanor
3$42$47$42450/30NN
Cotellic
533%33%33%63/28YN
Creon
3$42$47$42NN
Cresemba
4$95$100$95YN
Cromolyn Sodium
2$10$20$0NN
Crotan
2$10$20$0NN
Cryselle
2$10$20$0NN
Cyclobenzaprine Hydrochloride
4$95$100$95YN
Cyclophosphamide
3$42$47$42YN
Cyclosporine
3$42$47$42YN
Cyred Eq
2$10$20$0NN
Cystagon
4$95$100$95YN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H3528-014

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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