Capital Blue Cross Select (PPO) Formulary



Below is the 2023 Formulary, or prescription drug list, from Capital Blue Cross Select (PPO) by Capital Advantage Insurance Company. A formulary is a continually updated list of available medications and prescription drug cost information. Examining a plans formulary can help you find a Pennsylvania 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 Capital Blue Cross Select (PPO)(H3923-028) 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 Advantage Insurance Company 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:Capital Blue Cross Select
Plan ID: H3923-028
Provider: Capital Advantage Insurance Company
Plan Year:2023
Premium:$0.00
Deductible:$0
Initial Coverage Limit:$4660
Coverage Area:Pennsylvania
Similar Plan:H3923-029


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
3$40$47NANN
Cablivi
533%33%NANN
Cabometyx
533%33%NA30/30YN
Calcipotriene
2$5$20NA120/30NN
Calcitriol
4$93$100NANN
Calcium Acetate
2$5$20NANN
Calquence
533%33%NA60/30YN
Camila
3$40$47NANN
Camrese Lo
3$40$47NANN
Candesartan
2$5$20NA30/30NN
Candesartan Cilexetil And Hydrochlorothiazide
2$5$20NA30/30NN
Caplyta
533%33%NA30/30YN
Caprelsa
533%33%NA30/30YN
Captopril
2$5$20NANN
Carac
533%33%NANN
Carbamazepine
3$40$47NANN
Carbidopa
4$93$100NANN
Carbidopa And Levodopa
2$5$20NANN
Carbidopa, Levodopa, And Entacapone
4$93$100NANN
Carglumic Acid
533%33%NAYN
Carteolol Hydrochloride
4$93$100NANN
Cartia
2$5$20NANN
Caspofungin Acetate
4$93$100NANN
Caziant
3$40$47NANN
Cefadroxil
2$5$20NANN
Cefazolin
4$93$100NANN
Cefdinir
2$5$20NANN
Cefoxitin
4$93$100NANN
Cefpodoxime Proxetil
4$93$100NANN
Cefprozil
2$5$20NANN
Ceftazidime
4$93$100NANN
Ceftriaxone Sodium
4$93$100NANN
Cefuroxime
4$93$100NANN
Celecoxib
2$5$20NA60/30NN
Celontin
4$93$100NANN
Cephalexin
2$5$20NANN
Cevimeline
4$93$100NANN
Chemet
533%33%NANN
Chenodal
533%33%NAYN
Chlorpromazine Hydrochloride
4$93$100NAYN
Chlorthalidone
2$5$20NANN
Cholestyramine
2$5$20NANN
Ciclopirox
2$5$20NANN
Ciclopirox Olamine
2$5$20NANN
Cilostazol
2$5$20NANN
Cimduo
533%33%NA30/30NN
Cimetidine Hydrochloride
4$93$100NANN
Cinacalcet Hydrochloride
533%33%NAYN
Ciprofloxacin
4$93$100NANN
Citalopram Hydrobromide
4$93$100NA600/30NN
Claravis
4$93$100NANN
Clarithromycin
4$93$100NANN
Clemastine Fumarate
4$93$100NAYN
Clindacin Etz
4$93$100NANN
Clindamycin
4$93$100NANN
Clindamycin Hydrochloride
2$5$20NANN
Clindamycin Phosphate
2$5$20NANN
Clobazam
4$93$100NA480/30YN
Clomipramine Hydrochloride
4$93$100NANN
Clonazepam
4$93$100NA300/30NN
Clonidine Hydrochloride
1$0$12NANN
Clonidine Transdermal System
3$40$47NANN
Clorazepate Dipotassium
3$40$47NA180/30YN
Clotrimazole
2$5$20NANN
Clotrimazole And Betamethasone Dipropionate
3$40$47NANN
Clozapine
3$40$47NA120/30YN
Coartem
4$93$100NANN
Codeine Sulfate
4$93$100NA180/30NN
Colchicine
3$40$47NANN
Colestipol Hydrochloride
2$5$20NANN
Collagenase Santyl
4$93$100NA180/30NN
Combivent Respimat
4$93$100NA8/30NN
Complera
533%33%NA30/30NN
Compro
3$40$47NANN
Copaxone
533%33%NA30/30YN
Corlanor
3$40$47NA600/30YN
Cosentyx
533%33%NAYN
Cotellic
533%33%NA63/28YN
Creon
3$40$47NANN
Cresemba
533%33%NAYN
Cromolyn Sodium
2$5$20NANN
Cryselle
3$40$47NANN
Cyclobenzaprine Hydrochloride
2$5$20NANN
Cyclophosphamide
3$40$47NAYN
Cyclosporine
4$93$100NAYN
Cyred Eq
3$40$47NANN
Cystadrops
533%33%NAYN
Cystagon
4$93$100NAYN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H3923-028

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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