CCA Medicare Value (PPO) Formulary



Below is the 2023 Formulary, or prescription drug list, from CCA Medicare Value (PPO) by Commonwealth Care Alliance Rhode Island, Llc. A formulary is a continually updated list of available medications and prescription drug cost information. Examining a plans formulary can help you find a Rhode Island 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 CCA Medicare Value (PPO)(H9876-002) 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. Commonwealth Care Alliance Rhode Island, Llc 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:CCA Medicare Value (PPO)
Plan ID: H9876-002
Provider: Commonwealth Care Alliance Rhode Island, Llc
Plan Year:2023
Premium:$29.00
Deductible:$0
Initial Coverage Limit:$4660
Coverage Area:Rhode Island
Similar Plan:H9876-001


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
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Cabergoline
2NANNANN
Cablivi
5NA25%NA30/30YN
Cabometyx
5NA25%NA30/30YN
Calcipotriene
2NANNA120/30YN
Calcitriol
2NANNANN
Calcium Acetate
2NANNANN
Calquence
5NA25%NA60/30YN
Camila
2NANNANN
Camrese Lo
2NANNANN
Candesartan
1NA$0NANN
Caplyta
4NA$100NA30/30YN
Caprelsa
5NA25%NA30/30YN
Captopril
2NANNANN
Carbamazepine
2NANNANN
Carbidopa
2NANNANN
Carbidopa And Levodopa
1NA$0NANN
Carbidopa, Levodopa, And Entacapone
2NANNANN
Cardizem La
4NA$100NANN
Carglumic Acid
4NA$100NAYN
Carteolol Hydrochloride
2NANNANN
Cartia
2NANNANN
Caspofungin Acetate
2NANNANN
Cayston
5NA25%NA84/28YN
Caziant
2NANNANN
Cefaclor
4NA$100NANN
Cefadroxil
1NA$0NANN
Cefazolin
2NANNANN
Cefdinir
1NA$0NANN
Cefixime
2NANNANN
Cefotetan
2NANNANN
Cefoxitin
2NANNANN
Cefpodoxime Proxetil
2NANNANN
Cefprozil
1NA$0NANN
Ceftazidime
2NANNANN
Ceftriaxone Sodium
2NANNANN
Cefuroxime
2NANNANN
Celecoxib
2NANNA60/30NN
Cellcept
4NA$100NAYN
Celontin
3NA$47NANN
Cephalexin
1NA$0NANN
Cerdelga
5NA25%NA60/30YN
Cetraxal
3NA$47NANN
Cevimeline
2NANNANN
Chemet
3NA$47NANN
Chenodal
5NA25%NANN
Chlordiazepoxide And Amitriptyline Hydrochloride
1NA$0NANN
Chlordiazepoxide Hydrochloride
1NA$0NA120/30NN
Chlorpromazine Hydrochloride
4NA$100NANN
Chlorthalidone
1NA$0NANN
Chlorzoxazone
3NA$47NANN
Cholbam
5NA25%NAYN
Cholestyramine
2NANNANN
Ciclopirox
2NANNA120/30NN
Ciclopirox Olamine
2NANNA60/30NN
Cilostazol
1NA$0NANN
Ciloxan
4NA$100NA7/7NN
Cimduo
5NA25%NANN
Cimetidine
2NANNANN
Cimetidine Hydrochloride
2NANNANN
Cimzia
5NA25%NA2/28YN
Cinacalcet Hydrochloride
2NANNANN
Cinryze
5NA25%NAYN
Cipro
4NA$100NANN
Ciprofloxacin
1NA$0NANN
Ciprofloxacin And Dexamethasone
2NANNANN
Ciprofloxacin Otic
3NA$47NANN
Citalopram Hydrobromide
2NANNANN
Claravis
2NANNANN
Clarithromycin
3NA$47NANN
Clenpiq
3NA$47NANN
Cleocin
4NA$100NANN
Clindacin Etz
2NANNA120/30NN
Clindamycin
2NANNANN
Clindamycin Hydrochloride
1NA$0NANN
Clindamycin In 5 Percent Dextrose
2NANNANN
Clindamycin Palmitate Hydrochloride (pediatric)
2NANNANN
Clindamycin Phosphate
2NANNANN
Clindamycin Phosphate And Benzoyl Peroxide
2NANNA90/30NN
Clindesse
4NA$100NANN
Clinimix
3NA$47NAYN
Clinimix E
3NA$47NAYN
Clobazam
2NANNA480/30NN
Clobetasol Propionate
2NANNA125/30NN
Clodan
2NANNA236/30NN
Clomipramine Hydrochloride
2NANNANN
Clonazepam
2NANNA300/30NN
Clonidine Hydrochloride
1NA$0NANN
Clonidine Transdermal System
2NANNANN
Clorazepate Dipotassium
2NANNA180/30NN
Clotrimazole
2NANNANN
Clotrimazole And Betamethasone Dipropionate
2NANNA60/30NN
Clozapine
2NANNANN
Coartem
3NA$47NANN
Codeine Sulfate
3NA$47NA180/30NN
Colchicine
2NANNANN
Colesevelam Hydrochloride
2NANNANN
Colestipol Hydrochloride
2NANNANN
Collagenase Santyl
3NA$47NA90/30NN
Combipatch (estradiol/norethindrone Acetate Transd
4NA$100NANN
Combivent Respimat
3NA$47NANN
Complera
5NA25%NANN
Compro
2NANNANN
Condylox
4NA$100NA7/30NN
Corlanor
4NA$100NAYN
Cotellic
5NA25%NA63/28YN
Creon
3NA$47NANN
Crinone
3NA$47NAYN
Cromolyn Sodium
2NANNANN
Cryselle
2NANNANN
Cyclobenzaprine Hydrochloride
1NA$0NANN
Cyclophosphamide
3NA$47NAYN
Cycloset
4NA$100NANN
Cyclosporine
2NANNAYN
Cyproheptadine Hydrochloride
2NANNANN
Cyred Eq
2NANNANN
Cystadrops
5NA25%NA20/28YN
Cystagon
3NA$47NANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H9876-002

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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