ConnectiCare Choice Dual (HMO D-SNP) Formulary



Below is the 2023 Formulary, or prescription drug list, from ConnectiCare Choice Dual (HMO D-SNP) by Connecticare Insurance Company, 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 Connecticut 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 ConnectiCare Choice Dual (HMO D-SNP)(H3276-001) 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. Connecticare Insurance Company, 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:ConnectiCare Choice Dual (HMO D-SNP)
Plan ID: H3276-001
Provider: Connecticare Insurance Company, Inc
Plan Year:2023
Premium:$0.00
Deductible:$505
Initial Coverage Limit:$4660
Coverage Area:Connecticut
Similar Plan:H3276-002


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$47NANN
Cablivi
5NA25%NAYN
Cabometyx
5NA25%NA30/30YN
Calcipotriene
4YNA$100NA120/30NN
Calcitriol
4YNA$100NANN
Calcium Acetate
3YNA$47NA360/30NN
Calquence
5NA25%NA60/30YN
Camila
2NNA$16NANN
Candesartan
2NNA$16NANN
Candesartan Cilexetil And Hydrochlorothiazide
2NNA$16NANN
Caplyta
4YNA$100NA30/30NN
Caprelsa
5NA25%NA30/30YN
Captopril
2NNA$16NANN
Carbamazepine
3YNA$47NANN
Carbidopa
2NNA$16NANN
Carbidopa And Levodopa
2NNA$16NANN
Carbidopa, Levodopa, And Entacapone
4YNA$100NANN
Carglumic Acid
5NA25%NAYN
Carteolol Hydrochloride
2NNA$16NANN
Cartia
2NNA$16NANN
Caspofungin Acetate
4YNA$100NANN
Cayston
5NA25%NA84/56YN
Caziant
2NNA$16NANN
Cefaclor
2NNA$16NANN
Cefadroxil
2NNA$16NANN
Cefazolin
4YNA$100NANN
Cefdinir
2NNA$16NANN
Cefixime
4YNA$100NANN
Cefoxitin
4YNA$100NAYN
Cefpodoxime Proxetil
4YNA$100NANN
Cefprozil
2NNA$16NANN
Ceftazidime
4YNA$100NAYN
Ceftriaxone Sodium
4YNA$100NANN
Cefuroxime
4YNA$100NAYN
Celecoxib
2NNA$16NANN
Celontin
4YNA$100NANN
Cephalexin
2NNA$16NANN
Cevimeline
4YNA$100NANN
Chemet
3YNA$47NAYN
Chenodal
5NA25%NAYN
Chlorpromazine Hydrochloride
4YNA$100NANN
Chlorthalidone
2NNA$16NANN
Cholbam
5NA25%NAYN
Cholestyramine
3YNA$47NANN
Ciclopirox
3YNA$47NA120/28NN
Ciclopirox Olamine
3YNA$47NA60/28NN
Cilostazol
2NNA$16NANN
Cimduo
5NA25%NANN
Cimetidine
2NNA$16NANN
Cimetidine Hydrochloride
2NNA$16NANN
Cimzia
5NA25%NA2/28YN
Cinacalcet Hydrochloride
4YNA$100NAYN
Cinryze
5NA25%NAYN
Ciprofloxacin
2NNA$16NANN
Ciprofloxacin And Dexamethasone
3YNA$47NANN
Ciprofloxacin Otic
4YNA$100NANN
Citalopram Hydrobromide
3YNA$47NANN
Claravis
4YNA$100NANN
Clarithromycin
2NNA$16NANN
Clindamycin
4YNA$100NAYN
Clindamycin Hydrochloride
2NNA$16NANN
Clindamycin In 5 Percent Dextrose
4YNA$100NAYN
Clindamycin Palmitate Hydrochloride (pediatric)
4YNA$100NANN
Clindamycin Phosphate
3YNA$47NANN
Clinimix
4YNA$100NAYN
Clobazam
4YNA$100NA480/30YN
Clobetasol Propionate
4YNA$100NA118/28NN
Clodan
4YNA$100NA236/28NN
Clomipramine Hydrochloride
4YNA$100NANN
Clonazepam
2NNA$16NA300/30NN
Clonidine Hydrochloride
1NNA$6NANN
Clonidine Transdermal System
4YNA$100NA4/28NN
Clorazepate Dipotassium
3YNA$47NA180/30YN
Clotrimazole
2NNA$16NANN
Clotrimazole And Betamethasone Dipropionate
4YNA$100NA60/28NN
Clotrimazole Topical Solution Usp, 1%
2NNA$16NA30/28NN
Clozapine
3YNA$47NANN
Coartem
4YNA$100NANN
Colchicine
2NNA$16NANN
Colesevelam Hydrochloride
4YNA$100NANN
Colestipol Hydrochloride
4YNA$100NANN
Collagenase Santyl
3YNA$47NA180/30NN
Combivent Respimat
3YNA$47NA8/30NN
Complera
4YNA$100NANN
Compro
4YNA$100NANN
Corlanor
3YNA$47NA450/30NN
Cotellic
5NA25%NA63/28YN
Creon
3YNA$47NANN
Cresemba
4YNA$100NAYN
Cromolyn Sodium
2NNA$16NANN
Crotan
2NNA$16NANN
Cryselle
2NNA$16NANN
Cyclobenzaprine Hydrochloride
4YNA$100NAYN
Cyclophosphamide
3YNA$47NAYN
Cyclosporine
3YNA$47NAYN
Cyred Eq
2NNA$16NANN
Cystagon
4YNA$100NAYN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H3276-001

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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