The Health Plan SecureChoice Capitol Plan (PPO) Formulary



Below is the 2023 Formulary, or prescription drug list, from The Health Plan SecureChoice Capitol Plan (PPO) by Thp Insurance 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 West Virginia 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 The Health Plan SecureChoice Capitol Plan (PPO)(H8604-013) plan has a $100 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. Thp Insurance 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:The Health Plan SecureChoice Capitol Plan
Plan ID: H8604-013
Provider: Thp Insurance Company
Plan Year:2023
Premium:$78.00
Deductible:$100
Initial Coverage Limit:$4660
Coverage Area:West Virginia
Similar Plan:H8604-010


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
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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
Tabloid
4Y$100$100$100NN
Tabrecta
531%31%31%YN
Tacrolimus
4Y$100$100$100100/30YN
Tafinlar
531%31%31%120/30YN
Tagrisso
531%31%31%30/30YN
Taltz
531%31%31%1/28YN
Talzenna
531%31%31%30/30YN
Tamoxifen Citrate
2N$10$20$10NN
Tamsulosin Hydrochloride
2N$10$20$10NN
Tarina Fe 1/20 Eq
2N$10$20$10NN
Tasigna
531%31%31%120/30YN
Tazarotene
4Y$100$100$100YN
Tazicef
4Y$100$100$100YN
Tazverik
531%31%31%YN
Tdvax
3Y$47$47$47NN
Teflaro
531%31%31%YN
Telmisartan And Amlodipine
2N$10$20$10NN
Tenofovir Disproxil Fumarate
4Y$100$100$100NN
Terazosin
1N$3$13$360/30NN
Terbutaline Sulfate
4Y$100$100$100NN
Terconazole
3Y$47$47$47NN
Teriparatide
531%31%31%2/28YN
Testosterone
4Y$100$100$100150/30YN
Testosterone Cypionate
3Y$47$47$47YN
Testosterone Enanthate
3Y$47$47$47YN
Tetracycline Hydrochloride
4Y$100$100$100NN
Theo-24
3Y$47$47$47NN
Theophylline
2N$10$20$10NN
Thioridazine Hydrochloride
3Y$47$47$47NN
Thiothixene
4Y$100$100$100NN
Tiagabine Hydrochloride
4Y$100$100$100NN
Tibsovo
531%31%31%YN
Ticovac
3Y$47$47$47NN
Tigecycline
531%31%31%YN
Timolol Maleate
4Y$100$100$100NN
Timolol Maleate Ophthalmic Gel Forming Solution, 0
4Y$100$100$100NN
Tindazole
3Y$47$47$47NN
Tinidazole
3Y$47$47$47NN
Tivicay
531%31%31%NN
Tivicay Pd
531%31%31%NN
Tobramycin
2N$10$20$1010/14NN
Tobramycin And Dexamethasone
3Y$47$47$4710/14NN
Tobramycin Inhalation
531%31%31%224/28YN
Tolterodine Tartrate
4Y$100$100$100NN
Topiramate
2N$10$20$10YN
Toremifene Citrate
531%31%31%NN
Torsemide
2N$10$20$10NN
Tramadol Hydrochloride And Acetaminophen
2N$10$20$10240/30NN
Trandolapril
1N$3$13$3NN
Tranexamic Acid
3Y$47$47$47NN
Tranylcypromine Sulfate
4Y$100$100$100NN
Travoprost Ophthalmic Solution
3Y$47$47$47NN
Trazodone Hydrochloride
1N$3$13$3NN
Trecator
4Y$100$100$100NN
Trelstar
531%31%31%YN
Tretinoin
3Y$47$47$47YN
Tri-estarylla
2N$10$20$10NN
Tri-legest Fe
4Y$100$100$100NN
Tri-lo- Estarylla
2N$10$20$10NN
Tri-lo-sprintec
2N$10$20$10NN
Tri-sprintec
2N$10$20$10NN
Triamcinolone Acetonide
2N$10$20$10NN
Triderm
2N$10$20$10NN
Trientine Hydrochloride
531%31%31%YN
Trifluoperazine Hydrochloride
3Y$47$47$47NN
Trifluridine
3Y$47$47$47NN
Trikafta
531%31%31%84/28YN
Trimethoprim
2N$10$20$10NN
Trimipramine Maleate
4Y$100$100$100NN
Triumeq
531%31%31%NN
Trivora
2N$10$20$10NN
Trizivir
531%31%31%NN
Trophamine
4Y$100$100$100YN
Truseltiq
531%31%31%42/28YN
Tukysa
531%31%31%120/30YN
Turalio
531%31%31%120/30YN
Twinrix
3Y$47$47$47NN
Typhim Vi
3Y$47$47$47NN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H8604-013

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $100. 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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