CDPHP Vital Rx (PPO) Formulary



Below is the 2023 Formulary, or prescription drug list, from CDPHP Vital Rx (PPO) by Cdphp Universal Benefits, 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 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 CDPHP Vital Rx (PPO)(H5042-009) plan has a $300 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. Cdphp Universal Benefits, 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:CDPHP Vital Rx
Plan ID: H5042-009
Provider: Cdphp Universal Benefits, Inc
Plan Year:2023
Premium:$0.00
Deductible:$300
Initial Coverage Limit:$4660
Coverage Area:New York
Similar Plan:H5042-011


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
3YNA$47$47NN
Cabometyx
5NA26%26%30/30YN
Calcipotriene
4YNA$100$100120/30NN
Calcitriol
2NNA$17$0YN
Calcium Acetate
2NNA$17$0360/30NN
Calquence
5NA26%26%60/30YN
Camila
2NNA$17$0NN
Candesartan
3YNA$47$47NN
Caplyta
4YNA$100$10030/30NN
Caprelsa
5NA26%26%YN
Captopril
1NNA$3$0NN
Carbamazepine
3YNA$47$47NN
Carbidopa And Levodopa
1NNA$3$0NN
Carbidopa, Levodopa, And Entacapone
3YNA$47$47NN
Carglumic Acid
5NA26%26%YN
Carteolol Hydrochloride
1NNA$3$0NN
Cartia
2NNA$17$0NN
Caspofungin Acetate
4YNA$100$100NN
Cayston
5NA26%26%NN
Caziant
2NNA$17$0NN
Cefaclor
4YNA$100$100NN
Cefadroxil
1NNA$3$0NN
Cefazolin
3YNA$47$47NN
Cefdinir
2NNA$17$0NN
Cefixime
3YNA$47$47NN
Cefoxitin
4YNA$100$100NN
Cefpodoxime Proxetil
3YNA$47$47NN
Cefprozil
2NNA$17$0NN
Ceftazidime
3YNA$47$47NN
Ceftriaxone Sodium
3YNA$47$47NN
Cefuroxime
3YNA$47$47NN
Celecoxib
3YNA$47$4760/30NN
Celontin
4YNA$100$100NN
Cephalexin
2NNA$17$0NN
Cerdelga
5NA26%26%YN
Cevimeline
4YNA$100$100NN
Chemet
4YNA$100$100NN
Chlorpromazine Hydrochloride
4YNA$100$100NN
Chlorthalidone
1NNA$3$0NN
Cholestyramine
2NNA$17$0NN
Ciclopirox
3YNA$47$47120/30NN
Ciclopirox Olamine
3YNA$47$4760/30NN
Cilostazol
1NNA$3$0NN
Ciloxan
3YNA$47$47NN
Cimduo
5NA26%26%NN
Cimetidine
2NNA$17$0NN
Cimetidine Hydrochloride
2NNA$17$0NN
Cinacalcet Hydrochloride
5NA26%26%120/30YN
Cipro
4YNA$100$100NN
Ciprofloxacin
2NNA$17$0NN
Ciprofloxacin And Dexamethasone
2NNA$17$0NN
Citalopram Hydrobromide
2NNA$17$0NN
Claravis
4YNA$100$100NN
Clarithromycin
4YNA$100$100NN
Clindacin Etz
2NNA$17$0NN
Clindamycin
3YNA$47$47NN
Clindamycin Hydrochloride
1NNA$3$0NN
Clindamycin In 5 Percent Dextrose
4YNA$100$100NN
Clindamycin Palmitate Hydrochloride (pediatric)
2NNA$17$0NN
Clindamycin Phosphate
2NNA$17$0NN
Clinimix
4YNA$100$100YN
Clobazam
3YNA$47$47480/30YN
Clomipramine Hydrochloride
4YNA$100$100YN
Clonazepam
2NNA$17$0300/30NN
Clonidine Hydrochloride
1NNA$3$0NN
Clonidine Transdermal System
4YNA$100$100NN
Clorazepate Dipotassium
3YNA$47$47180/30YN
Clotrimazole
3YNA$47$47150/30NN
Clotrimazole Topical Solution Usp, 1%
2NNA$17$030/30NN
Clozapine
2NNA$17$0135/30NN
Coartem
4YNA$100$100NN
Colchicine
2NNA$17$0120/30NN
Colesevelam Hydrochloride
3YNA$47$47NN
Colestipol Hydrochloride
3YNA$47$47NN
Collagenase Santyl
4YNA$100$100180/30NN
Combipatch (estradiol/norethindrone Acetate Transd
4YNA$100$100NN
Combivent Respimat
4YNA$100$1008/30NN
Complera
5NA26%26%NN
Compro
3YNA$47$47NN
Copaxone
5NA26%26%30/30NN
Corlanor
4YNA$100$100NN
Cosentyx
5NA26%26%YN
Cotellic
5NA26%26%YN
Creon
3YNA$47$47NN
Cromolyn Sodium
1NNA$3$0NN
Cryselle
2NNA$17$0NN
Cyclobenzaprine Hydrochloride
2NNA$17$0YN
Cyclophosphamide
3YNA$47$47YN
Cyclosporine
4YNA$100$100YN
Cyproheptadine Hydrochloride
3YNA$47$47YN
Cyred Eq
2NNA$17$0NN
Cystadrops
5NA26%26%NN
Cystagon
4YNA$100$100YN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H5042-009

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $300. 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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