CareAdvantage (HMO D-SNP) Formulary



Below is the 2023 Formulary, or prescription drug list, from CareAdvantage (HMO D-SNP) by San Mateo Health Commission. A formulary is a continually updated list of available medications and prescription drug cost information. Examining a plans formulary can help you find a California 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 CareAdvantage (HMO D-SNP)(H6019-001) plan has a $505 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. San Mateo Health Commission 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:CareAdvantage (HMO D-SNP)
Plan ID: H6019-001
Provider: San Mateo Health Commission
Plan Year:2023
Premium:$0.00
Deductible:$505
Initial Coverage Limit:$4660
Coverage Area:California
Similar Plan:H6019-001


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
Deductible
Apply
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Cabergoline
1YNA$14NANN
Cabometyx
2YNA$32NA30/30YN
Calcipotriene
1YNA$14NANN
Calcitriol
1YNA$14NAYN
Calcium Acetate
1YNA$14NANN
Calquence
2YNA$32NA60/30YN
Camila
1YNA$14NANN
Camrese Lo
1YNA$14NANN
Candesartan
1YNA$14NANN
Candesartan Cilexetil And Hydrochlorothiazide
1YNA$14NANN
Caplyta
2YNA$32NA30/30YN
Caprelsa
2YNA$32NA30/30YN
Captopril
1YNA$14NANN
Carbamazepine
1YNA$14NANN
Carbidopa
1YNA$14NANY
Carbidopa And Levodopa
1YNA$14NANN
Carbinoxamine Maleate
1YNA$14NANN
Carglumic Acid
1YNA$14NANN
Carisoprodol
1YNA$14NA120/30NN
Carteolol Hydrochloride
1YNA$14NANN
Cartia
1YNA$14NANN
Caspofungin Acetate
1YNA$14NANN
Cayston
2YNA$32NANN
Caziant
1YNA$14NANN
Cefaclor
1YNA$14NANN
Cefadroxil
1YNA$14NANN
Cefazolin
1YNA$14NANN
Cefdinir
1YNA$14NANN
Cefixime
1YNA$14NANN
Cefotetan
1YNA$14NANN
Cefoxitin
1YNA$14NANN
Cefpodoxime Proxetil
1YNA$14NANN
Cefprozil
1YNA$14NANN
Ceftazidime
1YNA$14NANN
Ceftriaxone Sodium
1YNA$14NANN
Cefuroxime
1YNA$14NANN
Celecoxib
1YNA$14NA60/30NN
Celontin
2YNA$32NANN
Cephalexin
1YNA$14NANN
Cevimeline
1YNA$14NANN
Chlordiazepoxide And Amitriptyline Hydrochloride
1YNA$14NANN
Chlordiazepoxide Hydrochloride
1YNA$14NA120/30NN
Chlorpromazine Hydrochloride
1YNA$14NANN
Chlorthalidone
1YNA$14NANN
Chlorzoxazone
1YNA$14NANN
Cholestyramine
1YNA$14NANN
Ciclopirox
1YNA$14NANN
Ciclopirox Olamine
1YNA$14NANN
Cilostazol
1YNA$14NANN
Ciloxan
2YNA$32NANN
Cimduo
2YNA$32NA30/30NN
Cimetidine
1YNA$14NANN
Cimetidine Hydrochloride
1YNA$14NANN
Cinacalcet Hydrochloride
1YNA$14NA120/30YN
Cinryze
2YNA$32NAYN
Ciprofloxacin
1YNA$14NANN
Ciprofloxacin And Dexamethasone
1YNA$14NANN
Citalopram Hydrobromide
1YNA$14NANN
Claravis
1YNA$14NANN
Clarithromycin
1YNA$14NANN
Clemastine Fumarate
1YNA$14NANN
Cleocin
2YNA$32NANN
Climara Pro
2YNA$32NA4/30NN
Clindamycin
1YNA$14NANN
Clindamycin Hydrochloride
1YNA$14NANN
Clindamycin In 5 Percent Dextrose
1YNA$14NANN
Clindamycin Palmitate Hydrochloride (pediatric)
1YNA$14NANN
Clindamycin Phosphate
1YNA$14NANN
Clindamycin Phosphate And Benzoyl Peroxide
1YNA$14NANN
Clinimix
2YNA$32NAYN
Clinimix E
2YNA$32NAYN
Clobazam
1YNA$14NA480/30YN
Clobetasol Propionate
1YNA$14NANN
Clodan
1YNA$14NANN
Clomipramine Hydrochloride
1YNA$14NANN
Clonazepam
1YNA$14NA120/30NN
Clonidine Hydrochloride
1YNA$14NANN
Clonidine Transdermal System
1YNA$14NA4/30NN
Clorazepate Dipotassium
1YNA$14NA120/30NN
Clotrimazole
1YNA$14NANN
Clotrimazole Topical Solution Usp, 1%
1YNA$14NANN
Clozapine
1YNA$14NANN
Coartem
2YNA$32NANN
Colchicine
1YNA$14NA120/30NN
Colestipol Hydrochloride
1YNA$14NANN
Collagenase Santyl
2YNA$32NANN
Combipatch (estradiol/norethindrone Acetate Transd
2YNA$32NA/30NN
Combivent Respimat
2YNA$32NA/30NN
Complera
2YNA$32NA30/30NN
Compro
1YNA$14NANN
Condylox
2YNA$32NANN
Corlanor
2YNA$32NAYN
Cotellic
2YNA$32NA90/30YN
Creon
2YNA$32NANN
Cromolyn Sodium
1YNA$14NANN
Cryselle
1YNA$14NANN
Cyclobenzaprine Hydrochloride
1YNA$14NANN
Cyclophosphamide
1YNA$14NAYN
Cyclosporine
1YNA$14NAYN
Cyproheptadine Hydrochloride
1YNA$14NANN
Cyred Eq
1YNA$14NANN
Cystagon
2YNA$32NANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H6019-001

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $505. 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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