Advantage Care CHF by Ultimate (HMO C-SNP) Formulary



Below is the 2023 Formulary, or prescription drug list, from Advantage Care CHF by Ultimate (HMO C-SNP) by Ultimate Health Plans, 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 Florida 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 Advantage Care CHF by Ultimate (HMO C-SNP)(H2962-022) 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. Ultimate Health Plans, 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:Advantage Care CHF by Ultimate (HMO C-SNP)
Plan ID: H2962-022
Provider: Ultimate Health Plans, Inc
Plan Year:2023
Premium:$0.00
Deductible:$0
Initial Coverage Limit:$4660
Coverage Area:Florida
Similar Plan:H2962-023


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
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Abacavir
3NA$60NANN
Abacavir And Lamivudine
3NA$60NA30/30NN
Abelcet
3NA$60NAYN
Abilify Maintena
4NA33%NANN
Abiraterone
4NA33%NAYN
Abiraterone Acetate
4NA33%NAYN
Acarbose
1NA$0NANN
Accutane
3NA$60NAYN
Acebutolol Hydrochloride
1NA$0NANN
Acetaminophen And Codeine Phosphate
1NA$0NANN
Acetazolamide
1NA$0NANN
Acetic Acid
1NA$0NANN
Acetylcysteine
1NA$0NAYN
Acitretin
3NA$60NANN
Acthar
4NA33%NAYN
Acthib
2NA$20NANN
Actimmune
4NA33%NAYN
Acyclovir
3NA$60NANN
Acyclovir Sodium
3NA$60NAYN
Adapalene
1NA$0NANN
Adapalene And Benzoyl Peroxide
2NA$20NANN
Adefovir Dipivoxil
3NA$60NANN
Adempas
4NA33%NA90/30YN
Albendazole
4NA33%NANN
Albuterol Sulfate
1NA$0NA13/30NN
Alclometasone Dipropionate
1NA$0NANN
Alecensa
4NA33%NAYN
Alendronate Sodium
1NA$0NA4/28NN
Aliskiren
3NA$60NANN
Almotriptan
3NA$60NA12/30NN
Alocril
3NA$60NANN
Alomide
3NA$60NANN
Alosetron Hydrochloride
4NA33%NAYN
Alprazolam
1NA$0NA90/30NN
Altavera
1NA$0NANN
Alunbrig
4NA33%NA60/365YN
Alyacen 1/35
1NA$0NANN
Alyq
4NA33%NA60/30YN
Amabelz
1NA$0NANN
Amantadine Hydrochloride
1NA$0NANN
Ambisome
4NA33%NAYN
Amethia
1NA$0NA91/91NN
Amikacin Sulfate
1NA$0NANN
Amiloride Hydrochloride And Hydrochlorothiazide
1NA$0NANN
Amiloride Hydrocloride
1NA$0NANN
Amiodarone Hydrochloride
1NA$0NANN
Amitriptyline Hydrochloride
1NA$0NANN
Amlodipine And Benazepril Hydrochloride
1NA$0NANN
Amlodipine And Olmesartan Medoxomil
1NA$0NANN
Amlodipine And Valsartan
1NA$0NANN
Amlodipine Besylate
1NA$0NANN
Amlodipine Besylate And Benazepril Hydrochloride
1NA$0NANN
Ammonium Lactate
1NA$0NANN
Amnesteem
3NA$60NAYN
Amoxapine
1NA$0NANN
Amoxicillin
1NA$0NANN
Amoxicillin And Clavulanate Potassium
1NA$0NANN
Amphotericin B
3NA$60NAYN
Ampicillin
1NA$0NANN
Ampicillin And Sulbactam
1NA$0NANN
Ampicillin Sodium And Sulbactam Sodium
1NA$0NANN
Anagrelide
1NA$0NANN
Anastrozole
1NA$0NANN
Androderm
2NA$20NAYN
Apraclonidine Ophthalmic
1NA$0NANN
Aprepitant
1NA$0NA6/30YN
Apri
1NA$0NANN
Aptivus
4NA33%NANN
Aralast
4NA33%NAYN
Aranelle
1NA$0NANN
Aranesp
4NA33%NAYN
Aripiprazole
4NA33%NA60/30NN
Aristada
4NA33%NANN
Aristada Initio
4NA33%NANN
Armodafinil
1NA$0NA30/30YN
Arnuity Ellipta
5NA$10NA30/30NN
Ascomp With Codeine
1NA$0NANN
Asenapine
1NA$0NA60/30NN
Ashlyna
1NA$0NA91/91NN
Asmanex
3NA$60NA1/30NN
Asmanex Hfa
3NA$60NA13/30NN
Atenolol And Chlorthalidone
1NA$0NANN
Atomoxetine
2NA$20NA30/30NN
Atovaquone
4NA33%NANN
Atovaquone And Proguanil Hydrochloride Pediatric
1NA$0NANN
Atrovent
5NA$10NA25/30NN
Aubra Eq
1NA$0NANN
Austedo
4NA33%NA120/30YN
Aviane
1NA$0NANN
Avita
1NA$0NAYN
Avonex
4NA33%NA4/28YN
Avycaz
4NA33%NANN
Ayvakit
4NA33%NA30/30YN
Azathioprine
1NA$0NAYN
Azelaic Acid
2NA$20NANN
Azelastine Hcl Nasal
1NA$0NA60/30NN
Azelastine Hydrochloride
1NA$0NA60/30NN
Azithromycin
1NA$0NANN
Aztreonam
3NA$60NANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H2962-022

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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