Anthem MediBlue Dual Advantage (HMO D-SNP) Formulary



Below is the 2022 Formulary, or prescription drug list, from Blue Cross Of California for Anthem MediBlue Dual Advantage (HMO D-SNP)( H0544-130). A formulary is a list of prescription medications that are covered under Blue Cross Of California's 2022 Medicare Advantage Plan in California.

This Anthem MediBlue Dual Advantage (HMO D-SNP) plan has a $480 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 $4430. 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 $4430 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" be clicking the "Coverage Gap" link on the left above the chart.

In 2022 if you have spent $7550 in expenditures you enter the Catastrophic Phase. During the Catastrophic Period you will begin to receive significant coverage. Anthem MediBlue Dual Advantage (HMO D-SNP) 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 on the left above the chart.




Plan Name:Anthem MediBlue Dual Advantage (HMO D-SNP)
Plan ID: H0544-130
Formulary
Provider: Blue Cross Of California
Plan Year:2022
Premium:$0.00
Deductible:$480
Initial Coverage Limit:$4430
Coverage Area:California


Change Table Options:

Drugs Starting Letter:
Coverage Phase:

⇅ Click the Header to Sort
Drug
Name⇅
Tier
Level
Deductible
Apply
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Bacitracin Zinc And Polymyxin B Sulfate
2Y$15$15NANN
Baclofen
2Y$15$15NA90/30NN
Balsalazide Disodium
4Y$95$100NANN
Balversa
525%25%NA30/30YN
Balziva
2Y$15$15NANN
Baraclude
525%25%NAYN
Bcg Vaccine
4Y$95$100NANN
Benazepril Hydrochloride And Hydrochlorothiazide
1N$0$0NANN
Benicar
3Y$47$47NANN
Benztropine Mesylate
2Y$15$15NAYN
Betamethasone Dipropionate
2Y$15$15NANN
Betamethasone Valerate
2Y$15$15NANN
Betaxolol Hydrochloride
2Y$15$15NANN
Bethanechol Chloride
2Y$15$15NANN
Betimol
4Y$95$100NANN
Betoptic S
4Y$95$100NANN
Bexarotene
525%25%NA300/30YN
Bexsero
3Y$47$47NANN
Bicillin C-r 900/300
4Y$95$100NANN
Bicillin Cr
4Y$95$100NANN
Bicillin L-a
4Y$95$100NANN
Biktarvy
525%25%NA30/30NN
Bisoprolol Fumarate
2Y$15$15NANN
Bisoprolol Fumarate And Hydrochlorothiazide
2Y$15$15NANN
Blephamide
4Y$95$100NANN
Blisovi 24 Fe
4Y$95$100NANN
Blisovi Fe 1.5/30
3Y$47$47NANN
Boostrix
3Y$47$47NANN
Bosulif
525%25%NA30/30YN
Braftovi
525%25%NA180/30YN
Breo Ellipta
3Y$47$47NA60/30NN
Briellyn
2Y$15$15NANN
Brilinta
3Y$47$47NA60/30NN
Brimonidine Tartrate
2Y$15$15NANN
Briviact
525%25%NA600/30YN
Bromfenac Ophthalmic Solution 0.09%
4Y$95$100NANN
Bromsite
4Y$95$100NANN
Budesonide
4Y$95$100NANN
Bumetanide
2Y$15$15NANN
Buprenorphine
2Y$15$15NA240/30NN
Buprenorphine Hcl
2Y$15$15NA60/30NN
Buprenorphine Hydrochloride And Naloxone Hydrochlo
2Y$15$15NA90/30NN
Bupropion Hydrochloride
2Y$15$15NA30/30NN
Buspirone Hydrochloride
2Y$15$15NANN
Butalbital And Acetaminophen
4Y$95$100NA180/30YN
Butalbital, Acetaminophen And Caffeine
4Y$95$100NA180/30YN
Butalbital, Acetaminophen, And Caffeine
4Y$95$100NA180/30YN
Butalbital, Acetaminophen, Caffeine And Codeine Ph
4Y$95$100NA180/30YN
Butalbital, Acetaminophen, Caffeine, And Codeine P
4Y$95$100NA180/30YN
Butalbital, Aspirin, And Caffeine
4Y$95$100NA180/30YN
Butalbital, Aspirin, Caffeine And Codeine Phosphat
4Y$95$100NA180/30YN
Butorphanol Tartrate
4Y$95$100NA5/30NN
Bydureon Bcise
3Y$47$47NA4/28NN
Byetta
3Y$47$47NA/30NN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H0544-130

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1.Pre-Deductable: Before you reach the plans deductible of $480. 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 $4430
3.Coverage Gap: (AKA Donut Hole) After you reach the plans ICL but before the Catastrophic of $7550 in 2022.
4.Catastrophic: Anything over $7550 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 2022 is $320. 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 in order 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 plans 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.

Source:CMS Formulary Data Q1 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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*Licensed Agent Disclaimer: We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE (TTY users should call 1-877-486-2048) 24 hours a day/7 days a week to get information on all of your options.

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