AARP Medicare Advantage Mosaic Choice (PPO) Formulary



Below is the 2023 Formulary, or prescription drug list, from AARP Medicare Advantage Mosaic Choice (PPO) by Care Improvement Plus South Central Insurance Co. 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 AARP Medicare Advantage Mosaic Choice (PPO)(H3418-001) plan has a $250 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. Care Improvement Plus South Central Insurance Co 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:AARP Medicare Advantage Mosaic Choice
Plan ID: H3418-001
Provider: Care Improvement Plus South Central Insurance Co
Plan Year:2023
Premium:$0.00
Deductible:$250
Initial Coverage Limit:$4660
Coverage Area:New York
Similar Plan:H3418-002


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
Deductible
Apply
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Abacavir
4YNA$100NA960/30NN
Abacavir And Lamivudine
4YNA$100NA30/30NN
Abelcet
4YNA$100NAYN
Abilify Maintena
5NA29%29%NN
Abiraterone
4YNA$100NA120/30YN
Abiraterone Acetate
5NA29%29%60/30YN
Acarbose
1NNA$0NA360/30NN
Accutane
4YNA$100NAYN
Acebutolol Hydrochloride
2NNA$12NANN
Acetaminophen And Codeine Phosphate
2NNA$12NA4500/30NN
Acetaminophen, Caffeine, Dihydrocodeine Bitartrate
4YNA$100NA300/30NN
Acetazolamide
3YNA$47NANN
Acetic Acid
2NNA$12NANN
Acetylcysteine
2NNA$12NAYN
Acitretin
4YNA$100NANN
Actemra
5NA29%29%3/28YN
Actemra Actpen
5NA29%29%3/28YN
Acthib
3YNA$47NA1/1NN
Actimmune
5NA29%29%NN
Acyclovir
3YNA$47NANN
Acyclovir Sodium
4YNA$100NAYN
Adapalene
3YNA$47NANN
Adefovir Dipivoxil
4YNA$100NANN
Adempas
5NA29%29%YN
Advair
3YNA$47NA60/30NN
Advair Hfa
3YNA$47NA12/30NN
Aimovig
4YNA$100NA1/30YN
Alacort
2NNA$12NANN
Albendazole
4YNA$100NA480/30NN
Albuterol Sulfate
2NNA$12NANN
Alclometasone Dipropionate
3YNA$47NANN
Alecensa
5NA29%29%240/30YN
Alendronate Sodium
1NNA$0NA4/28NN
Aliskiren
1NNA$0NA30/30NN
Alocril
4YNA$100NANN
Alomide
4YNA$100NANN
Alosetron Hydrochloride
5NA29%29%YN
Alprazolam
1NNA$0NA150/30NN
Altavera
4YNA$100NANN
Alunbrig
5NA29%29%60/365YN
Alyacen 1/35
4YNA$100NANN
Alyq
4YNA$100NA60/30YN
Amantadine Hydrochloride
3YNA$47NANN
Ambisome
5NA29%29%YN
Amethia
4YNA$100NANN
Amikacin Sulfate
4YNA$100NANN
Amiloride Hydrochloride And Hydrochlorothiazide
2NNA$12NANN
Amiloride Hydrocloride
2NNA$12NANN
Amitriptyline Hydrochloride
4YNA$100NANN
Amlodipine And Benazepril Hydrochloride
1NNA$0NA30/30NN
Amlodipine And Olmesartan Medoxomil
1NNA$0NA30/30NN
Amlodipine And Valsartan
1NNA$0NA30/30NN
Amlodipine Besylate
1NNA$0NANN
Amlodipine Besylate And Benazepril Hydrochloride
1NNA$0NA30/30NN
Ammonium Lactate
3YNA$47NANN
Amnesteem
4YNA$100NAYN
Amoxapine
3YNA$47NANN
Amoxicillin
1NNA$0NANN
Amoxicillin And Clavulanate Potassium
2NNA$12NANN
Amphotericin B
4YNA$100NAYN
Ampicillin
4YNA$100NANN
Ampicillin And Sulbactam
4YNA$100NANN
Ampicillin Sodium And Sulbactam Sodium
4YNA$100NANN
Anagrelide
3YNA$47NANN
Anastrozole
1NNA$0NANN
Androderm
3YNA$47NA30/30NN
Anzemet
4YNA$100NAYN
Apraclonidine Ophthalmic
3YNA$47NANN
Aprepitant
4YNA$100NA6/28YN
Apri
4YNA$100NANN
Aptivus
5NA29%29%120/30NN
Aralast
5NA29%29%YN
Aranelle
4YNA$100NANN
Aranesp
5NA29%29%YN
Aripiprazole
5NA29%29%60/30NN
Aristada
5NA29%29%NN
Aristada Initio
5NA29%29%NN
Armodafinil
4YNA$100NA30/30YN
Arnuity Ellipta
3YNA$47NA30/30NN
Asenapine
4YNA$100NA60/30NN
Ashlyna
4YNA$100NANN
Atenolol And Chlorthalidone
1NNA$0NANN
Atomoxetine
4YNA$100NA30/30NN
Atovaquone
5NA29%29%420/30NN
Atovaquone And Proguanil Hydrochloride Pediatric
3YNA$47NANN
Atrovent
4YNA$100NANN
Aubra Eq
4YNA$100NANN
Auryxia
5NA29%29%YN
Austedo
5NA29%29%120/30YN
Aviane
4YNA$100NANN
Avonex
5NA29%29%1/28NN
Ayvakit
5NA29%29%30/30YN
Azathioprine
2NNA$12NAYN
Azelaic Acid
4YNA$100NA50/30NN
Azelastine Hcl Nasal
3YNA$47NANN
Azelastine Hydrochloride
3YNA$47NANN
Azelastine Hydrochloride And Fluticasone Propionat
4YNA$100NANN
Azithromycin
4YNA$100NANN
Aztreonam
4YNA$100NANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H3418-001

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $250. 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.

      Site Search:

MedicareHelp.org is a privately-owned Non-governmental agency. The government website can be found at HealthCare.gov.

Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options. Enrollment depends on the plan’s contract renewal.

Every year, Medicare evaluates plans based on a 5-star rating system.