Dean Advantage Complete (HMO) Formulary



Below is the 2023 Formulary, or prescription drug list, from Dean Advantage Complete (HMO) by Dean 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 Wisconsin 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 Dean Advantage Complete (HMO)(H9096-005) 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. Dean 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:Dean Advantage Complete
Plan ID: H9096-005
Provider: Dean Health Plan, Inc
Plan Year:2023
Premium:$110.90
Deductible:$0
Initial Coverage Limit:$4660
Coverage Area:Wisconsin
Similar Plan:H9096-006


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
Daliresp
4$95$100NANN
Danazol
3$42$47NANN
Dantrolene Sodium
2$10$15NANN
Dapsone
1$2$7NANN
Daptomycin
533%33%NANN
Darifenacin
3$42$47NANN
Daurismo
533%33%NAYN
Deferasirox
3$42$47NANN
Deferasirox Oral
3$42$47NANN
Deferiprone
533%33%NAYN
Delestrogen
4$95$100NANN
Delstrigo
533%33%NANN
Demeclocycline Hydrochloride
3$42$47NANN
Depo-estradiol
4$95$100NANN
Descovy
533%33%NA30/30NN
Desipramine Hydrochloride
2$10$15NANN
Desloratadine
1$2$7NANN
Desmopressin Acetate
2$10$15NANN
Desogestrel And Ethinyl Estradiol And Ethinyl Estr
3$42$47NANN
Desonide
2$10$15NA120/30NN
Desvenlafaxine
1$2$7NANN
Dexamethasone
1$2$7NANN
Dexamethasone Sodium Phosphate
3$42$47NANN
Dexmethylphenidate Hydrochloride
3$42$47NANN
Dextroamphetamine Saccharate, Amphetamine Aspartat
3$42$47NANN
Dextroamphetamine Sulfate
3$42$47NANN
Dextrose And Sodium Chloride
3$42$47NANN
Diacomit
533%33%NAYN
Diastat
4$95$100NA10/30NN
Diazepam
3$42$47NA10/30NN
Diazoxide
3$42$47NANN
Diclofenac Epolamine
4$95$100NA60/30YN
Diclofenac Potassium
1$2$7NANN
Diclofenac Sodium
2$10$15NA1000/30NN
Diclofenac Sodium And Misoprostol
2$10$15NANN
Dicloxacillin Sodium
1$2$7NANN
Dicyclomine
1$2$7NANN
Dicyclomine Hydrochloride
2$10$15NANN
Dificid
3$42$47NA136/10YN
Difluprednate Ophthalmic
2$10$15NANN
Digitek
2$10$15NANN
Digox
1$2$7NANN
Digoxin
1$2$7NANN
Dihydroergotamine Mesylate Nasal
533%33%NA16/30YN
Dilantin
3$42$47NANN
Diltiazem Hydrochloride
2$10$15NANN
Dimethyl Fumarate
3$42$47NANN
Dipentum
533%33%NANN
Diphenoxylate Hydrochloride And Atropine Sulfate
2$10$15NANN
Diphtheria And Tetanus Toxoids Adsorbed
6$0$0NAYN
Dipyridamole
2$10$15NANN
Disopyramide Phosphate
3$42$47NANN
Disulfiram
1$2$7NANN
Donepezil Hydrochloride
2$10$15NA30/30NN
Doptelet
533%33%NA10/5YN
Dorzolamide Hydrochloride Ophthalmic Solution
2$10$15NANN
Dotti
2$10$15NANN
Dovato
533%33%NANN
Doxazosin
1$2$7NANN
Doxepin Hydrochloride
2$10$15NANN
Doxercalciferol
3$42$47NANN
Doxy 100
3$42$47NANN
Doxycycline
1$2$7NANN
Doxycycline Hyclate
1$2$7NANN
Dronabinol
2$10$15NA60/30YN
Drospirenone And Ethinyl Estradiol
2$10$15NANN
Droxia
3$42$47NANN
Droxidopa
2$10$15NAYN
Dulera
3$42$47NA13/30NN
Duloxetine
2$10$15NANN
Dupixent
533%33%NAYN
Dutasteride
2$10$15NANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H9096-005

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