Central Health San Mateo Medicare Plan (HMO) Formulary



Below is the 2023 Formulary, or prescription drug list, from Central Health San Mateo Medicare Plan (HMO) by Central Health Plan Of California, 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 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 Central Health San Mateo Medicare Plan (HMO)(H5649-018) 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. Central Health Plan Of California, 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:Central Health San Mateo Medicare Plan
Plan ID: H5649-018
Provider: Central Health Plan Of California, Inc
Plan Year:2023
Premium:$0.00
Deductible:$0
Initial Coverage Limit:$4660
Coverage Area:California
Similar Plan:H5649-019


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
3NA$35NANN
Cablivi
5NA33%NAYN
Cabometyx
5NA33%NA30/30YN
Calcipotriene
4NA$75NA120/30NN
Calcitriol
4NA$75NANN
Calcium Acetate
3NA$35NA360/30NN
Calquence
5NA33%NA60/30YN
Camila
2NANNANN
Candesartan
2NANNANN
Candesartan Cilexetil And Hydrochlorothiazide
2NANNANN
Caplyta
4NA$75NA30/30NN
Caprelsa
5NA33%NA30/30YN
Captopril
2NANNANN
Carbamazepine
3NA$35NANN
Carbidopa
2NANNANN
Carbidopa And Levodopa
2NANNANN
Carbidopa, Levodopa, And Entacapone
4NA$75NANN
Carglumic Acid
5NA33%NAYN
Carteolol Hydrochloride
2NANNANN
Cartia
2NANNANN
Caspofungin Acetate
4NA$75NANN
Cayston
5NA33%NA84/56YN
Caziant
2NANNANN
Cefaclor
2NANNANN
Cefadroxil
2NANNANN
Cefazolin
4NA$75NANN
Cefdinir
2NANNANN
Cefixime
4NA$75NANN
Cefoxitin
4NA$75NAYN
Cefpodoxime Proxetil
4NA$75NANN
Cefprozil
2NANNANN
Ceftazidime
4NA$75NAYN
Ceftriaxone Sodium
4NA$75NANN
Cefuroxime
4NA$75NAYN
Celecoxib
2NANNANN
Celontin
4NA$75NANN
Cephalexin
2NANNANN
Cevimeline
4NA$75NANN
Chemet
3NA$35NAYN
Chenodal
5NA33%NAYN
Chlorpromazine Hydrochloride
4NA$75NANN
Chlorthalidone
2NANNANN
Cholbam
5NA33%NAYN
Cholestyramine
3NA$35NANN
Ciclopirox
3NA$35NA120/28NN
Ciclopirox Olamine
3NA$35NA60/28NN
Cilostazol
2NANNANN
Cimduo
5NA33%NANN
Cimetidine
2NANNANN
Cimetidine Hydrochloride
2NANNANN
Cimzia
5NA33%NA2/28YN
Cinacalcet Hydrochloride
4NA$75NAYN
Cinryze
5NA33%NAYN
Ciprofloxacin
2NANNANN
Ciprofloxacin And Dexamethasone
3NA$35NANN
Ciprofloxacin Otic
4NA$75NANN
Citalopram Hydrobromide
3NA$35NANN
Claravis
4NA$75NANN
Clarithromycin
2NANNANN
Clindamycin
4NA$75NAYN
Clindamycin Hydrochloride
2NANNANN
Clindamycin In 5 Percent Dextrose
4NA$75NAYN
Clindamycin Palmitate Hydrochloride (pediatric)
4NA$75NANN
Clindamycin Phosphate
3NA$35NANN
Clinimix
4NA$75NAYN
Clobazam
4NA$75NA480/30YN
Clobetasol Propionate
4NA$75NA118/28NN
Clodan
4NA$75NA236/28NN
Clomipramine Hydrochloride
4NA$75NANN
Clonazepam
2NANNA300/30NN
Clonidine Hydrochloride
1NA$0NANN
Clonidine Transdermal System
4NA$75NA4/28NN
Clorazepate Dipotassium
3NA$35NA180/30YN
Clotrimazole
2NANNANN
Clotrimazole And Betamethasone Dipropionate
4NA$75NA60/28NN
Clotrimazole Topical Solution Usp, 1%
2NANNA30/28NN
Clozapine
3NA$35NANN
Coartem
4NA$75NANN
Colchicine
2NANNANN
Colesevelam Hydrochloride
4NA$75NANN
Colestipol Hydrochloride
4NA$75NANN
Collagenase Santyl
3NA$35NA180/30NN
Combivent Respimat
3NA$35NA8/30NN
Complera
4NA$75NANN
Compro
4NA$75NANN
Corlanor
3NA$35NA450/30NN
Cotellic
5NA33%NA63/28YN
Creon
3NA$35NANN
Cresemba
4NA$75NAYN
Cromolyn Sodium
2NANNANN
Crotan
2NANNANN
Cryselle
2NANNANN
Cyclobenzaprine Hydrochloride
4NA$75NAYN
Cyclophosphamide
3NA$35NAYN
Cyclosporine
3NA$35NAYN
Cyred Eq
2NANNANN
Cystagon
4NA$75NAYN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H5649-018

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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