CDPHP Value Rx (HMO) Formulary



Below is the 2023 Formulary, or prescription drug list, from CDPHP Value Rx (HMO) by Capital District Physicians' Health 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 New York 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 CDPHP Value Rx (HMO)(H3388-004) 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. Capital District Physicians' Health 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:CDPHP Value Rx
Plan ID: H3388-004
Provider: Capital District Physicians' Health Plan, Inc
Plan Year:2023
Premium:$58.30
Deductible:$0
Initial Coverage Limit:$4660
Coverage Area:New York
Similar Plan:H3388-013


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
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Cabergoline
3NA$42$42NN
Cabometyx
5NA33%33%30/30YN
Calcipotriene
4NA$93$93120/30NN
Calcitriol
2NA$13$0YN
Calcium Acetate
2NA$13$0360/30NN
Calquence
5NA33%33%60/30YN
Camila
2NA$13$0NN
Candesartan
3NA$42$42NN
Caplyta
4NA$93$9330/30NN
Caprelsa
5NA33%33%YN
Captopril
1NA$2$0NN
Carbamazepine
3NA$42$42NN
Carbidopa And Levodopa
1NA$2$0NN
Carbidopa, Levodopa, And Entacapone
3NA$42$42NN
Carglumic Acid
5NA33%33%YN
Carteolol Hydrochloride
1NA$2$0NN
Cartia
2NA$13$0NN
Caspofungin Acetate
4NA$93$93NN
Cayston
5NA33%33%NN
Caziant
2NA$13$0NN
Cefaclor
4NA$93$93NN
Cefadroxil
1NA$2$0NN
Cefazolin
3NA$42$42NN
Cefdinir
2NA$13$0NN
Cefixime
3NA$42$42NN
Cefoxitin
4NA$93$93NN
Cefpodoxime Proxetil
3NA$42$42NN
Cefprozil
2NA$13$0NN
Ceftazidime
3NA$42$42NN
Ceftriaxone Sodium
3NA$42$42NN
Cefuroxime
3NA$42$42NN
Celecoxib
3NA$42$4260/30NN
Celontin
4NA$93$93NN
Cephalexin
2NA$13$0NN
Cerdelga
5NA33%33%YN
Cevimeline
4NA$93$93NN
Chemet
4NA$93$93NN
Chlorpromazine Hydrochloride
4NA$93$93NN
Chlorthalidone
1NA$2$0NN
Cholestyramine
2NA$13$0NN
Ciclopirox
3NA$42$42120/30NN
Ciclopirox Olamine
3NA$42$4260/30NN
Cilostazol
1NA$2$0NN
Ciloxan
3NA$42$42NN
Cimduo
5NA33%33%NN
Cimetidine
2NA$13$0NN
Cimetidine Hydrochloride
2NA$13$0NN
Cinacalcet Hydrochloride
5NA33%33%120/30YN
Cipro
4NA$93$93NN
Ciprofloxacin
2NA$13$0NN
Ciprofloxacin And Dexamethasone
2NA$13$0NN
Citalopram Hydrobromide
2NA$13$0NN
Claravis
4NA$93$93NN
Clarithromycin
4NA$93$93NN
Clindacin Etz
2NA$13$0NN
Clindamycin
3NA$42$42NN
Clindamycin Hydrochloride
1NA$2$0NN
Clindamycin In 5 Percent Dextrose
4NA$93$93NN
Clindamycin Palmitate Hydrochloride (pediatric)
2NA$13$0NN
Clindamycin Phosphate
2NA$13$0NN
Clinimix
4NA$93$93YN
Clobazam
3NA$42$42480/30YN
Clomipramine Hydrochloride
4NA$93$93YN
Clonazepam
2NA$13$0300/30NN
Clonidine Hydrochloride
1NA$2$0NN
Clonidine Transdermal System
4NA$93$93NN
Clorazepate Dipotassium
3NA$42$42180/30YN
Clotrimazole
3NA$42$42150/30NN
Clotrimazole Topical Solution Usp, 1%
2NA$13$030/30NN
Clozapine
2NA$13$0135/30NN
Coartem
4NA$93$93NN
Colchicine
2NA$13$0120/30NN
Colesevelam Hydrochloride
3NA$42$42NN
Colestipol Hydrochloride
3NA$42$42NN
Collagenase Santyl
4NA$93$93180/30NN
Combipatch (estradiol/norethindrone Acetate Transd
4NA$93$93NN
Combivent Respimat
4NA$93$938/30NN
Complera
5NA33%33%NN
Compro
3NA$42$42NN
Copaxone
5NA33%33%30/30NN
Corlanor
4NA$93$93NN
Cosentyx
5NA33%33%YN
Cotellic
5NA33%33%YN
Creon
3NA$42$42NN
Cromolyn Sodium
1NA$2$0NN
Cryselle
2NA$13$0NN
Cyclobenzaprine Hydrochloride
2NA$13$0YN
Cyclophosphamide
3NA$42$42YN
Cyclosporine
4NA$93$93YN
Cyproheptadine Hydrochloride
3NA$42$42YN
Cyred Eq
2NA$13$0NN
Cystadrops
5NA33%33%NN
Cystagon
4NA$93$93YN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H3388-004

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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