True Blue Special Needs Plan (HMO D-SNP) Formulary



Below is the 2023 Formulary, or prescription drug list, from True Blue Special Needs Plan (HMO D-SNP) by Blue Cross Of Idaho Care Plus, 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 Idaho 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 True Blue Special Needs Plan (HMO D-SNP)(H1350-009) plan has a $505 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. Blue Cross Of Idaho Care Plus, 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:True Blue Special Needs Plan (HMO D-SNP)
Plan ID: H1350-009
Provider: Blue Cross Of Idaho Care Plus, Inc
Plan Year:2023
Premium:$0.00
Deductible:$505
Initial Coverage Limit:$4660
Coverage Area:Idaho
Similar Plan:H1350-023


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
4YNA$0NANN
Tabrecta
5NA$0NA120/30YN
Tacrolimus
2YNANNA100/30YN
Tafinlar
5NA$0NA120/30YN
Tagrisso
5NA$0NA30/30YN
Talzenna
5NA$0NA30/30YN
Tamoxifen Citrate
1YNA$0NANN
Tamsulosin Hydrochloride
1YNA$0NANN
Targretin
5NA$0NA60/30YN
Tarina 24 Fe
1YNA$0NANN
Tarina Fe 1/20 Eq
1YNA$0NANN
Tasigna
5NA$0NA112/28YN
Tazarotene
2YNANNAYN
Tazicef
2YNANNANN
Tazorac
4YNA$0NAYN
Tazverik
5NA$0NA240/30YN
Tdvax
3YNA$0NANN
Tecfidera
5NA$0NAYN
Teflaro
5NA$0NANN
Tegretol
4YNA$0NANN
Telmisartan And Amlodipine
6YNA$0NANN
Temazepam
2YNANNA30/30NN
Tencon
1YNA$0NA180/30YN
Tenofovir Disproxil Fumarate
2YNANNA30/30NN
Terazosin
1YNA$0NANN
Terbutaline Sulfate
1YNA$0NANN
Terconazole
1YNA$0NANN
Teriparatide
5NA$0NA3/28YN
Testosterone
2YNANNA150/30YN
Testosterone Cypionate
2YNANNAYN
Testosterone Enanthate
2YNANNAYN
Tetracycline Hydrochloride
2YNANNANN
Theophylline
1YNA$0NANN
Thioridazine Hydrochloride
2YNANNANN
Thiothixene
1YNA$0NANN
Tiagabine Hydrochloride
2YNANNANN
Tibsovo
5NA$0NA60/30YN
Ticovac
3YNA$0NANN
Tigecycline
5NA$0NANN
Timolol Maleate
1YNA$0NANN
Timolol Maleate Ophthalmic Gel Forming Solution, 0
2YNANNANN
Tindazole
2YNANNANN
Tinidazole
2YNANNANN
Tivicay
5NA$0NA60/30NN
Tivicay Pd
5NA$0NA360/30NN
Tizanidine Hydrochloride
2YNANNANN
Tobi Podhaler
5NA$0NA224/28NN
Tobradex
3YNA$0NANN
Tobramycin
1YNA$0NANN
Tobramycin And Dexamethasone
2YNANNANN
Tobramycin Inhalation
5NA$0NA224/28YN
Tolcapone
5NA$0NA180/30YN
Tolterodine Tartrate
2YNANNA60/30NN
Topiramate
1YNA$0NANN
Toremifene Citrate
5NA$0NA30/30NN
Torsemide
1YNA$0NANN
Toviaz
4YNA$0NA30/30NN
Tradjenta
3YNA$0NA30/30NN
Tramadol Hydrochloride And Acetaminophen
1YNA$0NA40/5NN
Trandolapril
6YNA$0NANN
Trandolapril And Verapamil Hydrochloride
6YNA$0NANN
Tranexamic Acid
2YNANNANN
Tranylcypromine Sulfate
2YNANNANN
Travoprost Ophthalmic Solution
2YNANNANN
Trazodone Hydrochloride
1YNA$0NANN
Trecator
4YNA$0NANN
Trelegy Ellipta
3YNA$0NA60/30NN
Trelstar
5NA$0NAYN
Tresiba
3YNA$0NA30/30NN
Tretinoin
2YNANNA45/30YN
Trexall
4YNA$0NANN
Tri-estarylla
1YNA$0NANN
Tri-legest Fe
2YNANNANN
Tri-lo- Estarylla
1YNA$0NANN
Tri-lo-sprintec
1YNA$0NANN
Tri-sprintec
1YNA$0NANN
Tri-vylibra Lo
1YNA$0NANN
Triamcinolone Acetonide
1YNA$0NANN
Triamterene
2YNANNANN
Triazolam
1YNA$0NA30/30NN
Triderm
1YNA$0NANN
Trientine Hydrochloride
5NA$0NANN
Trifluoperazine Hydrochloride
1YNA$0NANN
Trifluridine
2YNANNANN
Trihexyphenidyl Hydrochloride
1YNA$0NANN
Trijardy Xr
3YNA$0NA60/30NN
Trimethobenzamide Hydrochloride
2YNANNANN
Trimethoprim
1YNA$0NANN
Trimipramine Maleate
2YNANNANN
Triumeq
5NA$0NA30/30NN
Trivora
1YNA$0NANN
Trizivir
5NA$0NA60/30NN
Trophamine
3YNA$0NAYN
Trospium Chloride
2YNANNA30/30NN
Truseltiq
5NA$0NA42/28YN
Tukysa
5NA$0NA120/30YN
Turalio
5NA$0NA120/30YN
Twinrix
3YNA$0NANN
Tybost
3YNA$0NA30/30NN
Tymlos
5NA$0NA1/28YN
Typhim Vi
3YNA$0NANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H1350-009

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $505. 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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