Elevate Medicare Select (HMO) Formulary



Below is the 2023 Formulary, or prescription drug list, from Elevate Medicare Select (HMO) by Denver Health Medical Plan, 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 Colorado 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 Elevate Medicare Select (HMO)(H5608-002) 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. Denver Health Medical Plan, 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:Elevate Medicare Select
Plan ID: H5608-002
Provider: Denver Health Medical Plan, Inc
Plan Year:2023
Premium:$0.00
Deductible:$0
Initial Coverage Limit:$4660
Coverage Area:Colorado
Similar Plan:H5608-001


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
⇅ Click the Header to Sort
Drug
Name⇅
Tier
Level
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Edarbi
3NA$47NANN
Edarbyclor
3NA$47NANN
Edurant
5NA33%NANN
Efavirenz
2NA$9NANN
Efavirenz, Emtricitabine And Tenofovir Disoproxil
5NA33%NANN
Efavirenz, Lamivudine And Tenofovir Disoproxil Fum
5NA33%NANN
Egrifta Sv
5NA33%NA30/30YN
Eligard
4NA$95NAYN
Eliquis
3NA$47NANN
Elmiron
4NA$95NA90/30NN
Eluryng
2NA$9NA1/28NN
Emcyt
5NA33%NANN
Emend
4NA$95NA6/28YN
Emgality
3NA$47NA3/30YN
Emsam
5NA33%NA30/30NY
Emtricitabine
2NA$9NANN
Emtricitabine And Tenofovir Disoproxil Fumarate
5NA33%NANN
Emtriva
4NA$95NANN
Enalapril Maleate And Hydrochlorothiazide
6NA$0NANN
Enbrel
5NA33%NAYN
Endocet
2NA$9NA180/30NN
Engerix-b
6NA$0NAYN
Enoxaparin Sodium
2NA$9NA60/30NN
Enpresse
2NA$9NANN
Enskyce
2NA$9NANN
Entacapone
2NA$9NANN
Entecavir
2NA$9NANN
Entresto
3NA$47NA60/30NN
Enulose
2NA$9NANN
Epclusa
5NA33%NA28/28YN
Epidiolex
5NA33%NAYN
Epinastine Hydrochloride
2NA$9NANN
Epinephrine
2NA$9NA4/30NN
Epitol
2NA$9NANN
Epivir
4NA$95NANN
Eplerenone
2NA$9NANN
Eprontia
4NA$95NA480/30NY
Ergoloid Mesylates
2NA$9NANN
Erivedge
5NA33%NA28/28YN
Erleada
5NA33%NA120/30YN
Erlotinib
5NA33%NA60/30YN
Errin
1NA$0NANN
Ertapenem
2NA$9NANN
Ery
2NA$9NANN
Erythromycin
2NA$9NA180/30NN
Erythromycin Ethylsuccinate
2NA$9NANN
Esbriet
5NA33%NA270/30YN
Escitalopram
1NA$0NANN
Escitalopram Oxalate
2NA$9NANN
Estarylla
2NA$9NANN
Estradiol
1NA$0NAYN
Estradiol / Norethindrone Acetate
2NA$9NAYN
Estradiol Transdermal System
2NA$9NA4/28YN
Estradiol Valerate
2NA$9NANN
Eszopiclone
2NA$9NA30/30NN
Ethambutol Hydrochloride
2NA$9NANN
Ethosuximide
2NA$9NANN
Ethynodiol Diacetate And Ethinyl Estradiol
2NA$9NANN
Etodolac
2NA$9NANN
Etonogestrel/ethinyl Estradiol
2NA$9NA1/28NN
Etravirine
5NA33%NANN
Everolimus
5NA33%NA56/28YN
Evotaz
5NA33%NANN
Evrysdi
5NA33%NAYN
Exemestane
2NA$9NANN
Exkivity
5NA33%NA120/30YN
Eysuvis
3NA$47NA/14NN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H5608-002

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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