Devoted CORE San Antonio (HMO) Formulary



Below is the 2023 Formulary, or prescription drug list, from Devoted CORE San Antonio (HMO) by Devoted Health Plan Of Texas, 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 Texas 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 Devoted CORE San Antonio (HMO)(H7993-003) 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. Devoted Health Plan Of Texas, 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:Devoted CORE San Antonio
Plan ID: H7993-003
Provider: Devoted Health Plan Of Texas, Inc
Plan Year:2023
Premium:$0.00
Deductible:$0
Initial Coverage Limit:$4660
Coverage Area:Texas
Similar Plan:H7993-004


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
Daliresp
4NA$99NANN
Danazol
4NA$99NANN
Dantrolene Sodium
4NA$99NANN
Dapsone
3NA$40NANN
Daptomycin
5NA33%NANN
Darifenacin
4NA$99NA30/30NY
Daurismo
5NA33%NAYN
Deferasirox
5NA33%NAYN
Deferasirox Oral
5NA33%NAYN
Delestrogen
4NA$99NANN
Delstrigo
5NA33%NANN
Descovy
5NA33%NA30/30NN
Desipramine Hydrochloride
4NA$99NANN
Desloratadine
3NA$40NANN
Desmopressin Acetate
3NA$40NANN
Desogestrel And Ethinyl Estradiol And Ethinyl Estr
3NA$40NANN
Desvenlafaxine
4NA$99NA30/30YN
Dexamethasone
3NA$40NANN
Dexamethasone Sodium Phosphate
3NA$40NANN
Dexmethylphenidate Hydrochloride
3NA$40NA60/30YN
Dextroamphetamine Saccharate, Amphetamine Aspartat
3NA$40NA60/30YN
Dextrose And Sodium Chloride
3NA$40NANN
Diacomit
5NA33%NA180/30YN
Diazepam
4NA$99NANN
Diazepam Intensol
3NA$40NA240/30YN
Diazoxide
5NA33%NANN
Diclofenac Potassium
3NA$40NA120/30NN
Diclofenac Sodium
3NA$40NA1000/30NN
Diclofenac Sodium And Misoprostol
4NA$99NANN
Dicloxacillin Sodium
3NA$40NANN
Dicyclomine
3NA$40NANN
Dicyclomine Hydrochloride
4NA$99NANN
Dificid
5NA33%NANN
Difluprednate Ophthalmic
4NA$99NANN
Digox
2NANNA30/30NN
Digoxin
2NANNA30/30NN
Dihydroergotamine Mesylate Nasal
5NA33%NA8/30YN
Dilantin
4NA$99NANN
Dilantin Infatabs
4NA$99NANN
Dilantin-125
4NA$99NANN
Diltiazem Hydrochloride
4NA$99NANN
Diphenoxylate Hydrochloride And Atropine Sulfate
3NA$40NANN
Diphtheria And Tetanus Toxoids Adsorbed
1NA$0NAYN
Dipyridamole
3NA$40NAYN
Disopyramide Phosphate
4NA$99NANN
Disulfiram
3NA$40NANN
Doptelet
5NA33%NAYN
Dorzolamide Hydrochloride Ophthalmic Solution
2NANNANN
Dotti
3NA$40NANN
Dovato
5NA33%NANN
Doxazosin
2NANNANN
Doxepin
3NA$40NA30/30NN
Doxepin Hydrochloride
3NA$40NANN
Doxercalciferol
4NA$99NAYN
Doxy 100
4NA$99NANN
Doxycycline
2NANNANN
Doxycycline Hyclate
3NA$40NANN
Dronabinol
4NA$99NA60/30YN
Drospirenone And Ethinyl Estradiol
3NA$40NANN
Droxia
3NA$40NANN
Droxidopa
5NA33%NA180/30YN
Duloxetine
2NANNA60/30NN
Dupixent
5NA33%NAYN
Dutasteride
3NA$40NA30/30NN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H7993-003

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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