Medicare Blue Choice Extra (HMO) Formulary



Below is the 2023 Formulary, or prescription drug list, from Medicare Blue Choice Extra (HMO) by Excellus Health Plan, 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 Medicare Blue Choice Extra (HMO)(H3351-021) plan has a $400 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. Excellus Health Plan, 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:Medicare Blue Choice Extra
Plan ID: H3351-021
Provider: Excellus Health Plan, Inc
Plan Year:2023
Premium:$0.00
Deductible:$400
Initial Coverage Limit:$4660
Coverage Area:New York
Similar Plan:H3351-002


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
M-m-r Ii
1N$0$5$0NN
Magnesium Sulfate
2N$15$20$15NN
Malathion
3Y$42$47$42NN
Marlissa
2N$15$20$15NN
Marplan
4Y28%28%28%NN
Matulane
526%26%26%NN
Mavyret
526%26%26%150/30YN
Mayzent
526%26%26%NN
Meclizine Hydrochloride
2N$15$20$15NN
Meclofenamate Sodium
2N$15$20$15NN
Medrol
4Y28%28%28%YN
Medroxyprogesterone Acetate
2N$15$20$15NN
Mefloquine Hydrochloride
2N$15$20$15NN
Megestrol Acetate
2N$15$20$15NN
Mekinist
526%26%26%30/30YN
Mektovi
526%26%26%180/30YN
Memantine
3Y$42$47$42300/30NN
Memantine Hydrochloride
3Y$42$47$4230/30NN
Menactra
4Y28%28%28%NN
Menest
4Y28%28%28%NN
Menquadfi
4Y28%28%28%NN
Menveo
3Y$42$47$42NN
Mercaptopurine
2N$15$20$15NN
Meropenem
3Y$42$47$42NN
Merzee
4Y28%28%28%NN
Mesalamine
4Y28%28%28%NN
Mesnex
526%26%26%NN
Metaxalone
4Y28%28%28%NN
Metformin Hydrochloride
4Y28%28%28%YN
Methadone Hydrochloride
2N$15$20$15NN
Methamphetamine Hydrochloride
4Y28%28%28%YN
Methazolamide
3Y$42$47$42NN
Methenamine Hippurate
2N$15$20$15NN
Methimazole
2N$15$20$15NN
Methitest
4Y28%28%28%NN
Methocarbamol
2N$15$20$15NN
Methotrexate
2N$15$20$15NN
Methoxsalen
526%26%26%NN
Methscopolamine Bromide
2N$15$20$15NN
Methylphenidate Hydrochloride
2N$15$20$15NN
Methylphenidate Hydrochloride (la)
3Y$42$47$4230/30NN
Methylphenidate Hydrochloride Cd
3Y$42$47$4230/30NN
Methylprednisolone
2N$15$20$15YN
Methyltestosterone
3Y$42$47$42NN
Metoclopramide
2N$15$20$15NN
Metolazone
2N$15$20$15NN
Metoprolol Succinate
1N$0$5$0NN
Metoprolol Tartrate
1N$0$5$0NN
Metoprolol Tartrate And Hydrochlorothiazide
2N$15$20$15NN
Metronidazole
2N$15$20$15NN
Metyrosine
526%26%26%NN
Mexiletine Hydrochloride
2N$15$20$15NN
Miconazole Nitrate
2N$15$20$15NN
Migergot
4Y28%28%28%20/28NN
Miglitol
2N$15$20$15NN
Miglustat
526%26%26%YN
Minocycline
3Y$42$47$42NN
Minocycline Hydrochloride
3Y$42$47$42NN
Minoxidil
2N$15$20$15NN
Mirtazapine
2N$15$20$15NN
Moexipril Hydrochloride
2N$15$20$15NN
Molindone Hydrochloride
4Y28%28%28%NN
Mometasone Furoate
2N$15$20$1534/30NN
Montelukast Sodium
2N$15$20$15NN
Morphine Sulfate
4Y28%28%28%NN
Movantik
3Y$42$47$4230/30NN
Moviprep
4Y28%28%28%NN
Moxifloxacin
3Y$42$47$4212/28NN
Moxifloxacin Hydrochloride
4Y28%28%28%NN
Mulpleta
526%26%26%7/30YN
Mupirocin
2N$15$20$15NN
Myalept
526%26%26%YN
Mycophenolate Mofetil
4Y28%28%28%YN
Mycophenolic Acid
4Y28%28%28%YN
Myfortic
526%26%26%YN
Myrbetriq
3Y$42$47$4230/30NN
Mytesi
4Y28%28%28%YN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H3351-021

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $400. 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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