Wellcare Giveback (HMO) Formulary



Below is the 2022 Formulary, or prescription drug list, from Buckeye Community Health Plan, Inc. for Wellcare Giveback (HMO)( H0908-005). A formulary is a list of prescription medications that are covered under Buckeye Community Health Plan, Inc.'s 2022 Medicare Advantage Plan in Ohio.

This Wellcare Giveback (HMO) 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. Wellcare Giveback (HMO) 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:Wellcare Giveback (HMO)
Plan ID: H0908-005
Formulary
Provider: Buckeye Community Health Plan, Inc.
Plan Year:2022
Premium:$0.00
Deductible:$480
Initial Coverage Limit:$4430
Coverage Area:Ohio


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$20$15NN
Baclofen
3Y$37$47$37NN
Balsalazide Disodium
3Y$37$47$37NN
Balversa
525%25%25%YN
Balziva
3Y$37$47$37NN
Baraclude
525%25%25%NN
Basaglar
3Y$37$47$37NN
Bcg Vaccine
3Y$37$47$37NN
Benazepril Hydrochloride And Hydrochlorothiazide
6N$0$0$0NN
Benztropine Mesylate
4Y48%50%48%YN
Berinert
525%25%25%24/30YN
Betamethasone Dipropionate
3Y$37$47$37120/30NN
Betamethasone Valerate
3Y$37$47$37120/30NN
Betaxolol Hydrochloride
3Y$37$47$37NN
Bethanechol Chloride
3Y$37$47$37NN
Betoptic S
3Y$37$47$37NN
Bevespi Aerosphere
3Y$37$47$371/30NN
Bexarotene
525%25%25%YN
Bexsero
6N$0$0$0NN
Bicillin L-a
4Y48%50%48%NN
Biktarvy
525%25%25%NN
Bisoprolol Fumarate
2Y$15$20$15NN
Bisoprolol Fumarate And Hydrochlorothiazide
2Y$15$20$15NN
Bivigam
525%25%25%YN
Blephamide
4Y48%50%48%NN
Blisovi Fe 1.5/30
2Y$15$20$15NN
Boostrix
6N$0$0$0NN
Bosulif
525%25%25%YN
Braftovi
525%25%25%YN
Breo Ellipta
3Y$37$47$3760/30NN
Breztri
3Y$37$47$371/30NN
Briellyn
3Y$37$47$37NN
Brilinta
3Y$37$47$37NN
Brimonidine Tartrate
4Y48%50%48%NN
Briviact
525%25%25%600/30YN
Bromfenac Ophthalmic Solution 0.09%
4Y48%50%48%NN
Bromsite
4Y48%50%48%NN
Budesonide
4Y48%50%48%YN
Bumetanide
3Y$37$47$37NN
Buprenorphine
3Y$37$47$3790/30YN
Buprenorphine And Naloxone
4Y48%50%48%60/30NN
Buprenorphine Hcl
3Y$37$47$3790/30YN
Buprenorphine Hydrochloride And Naloxone Hydrochlo
2Y$15$20$1590/30NN
Bupropion Hydrochloride
2Y$15$20$15NN
Buspirone Hydrochloride
3Y$37$47$37NN
Bydureon Bcise
3Y$37$47$37/28NN
Byetta
4Y48%50%48%/30NN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H0908-005

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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