PHP Care Complete FIDA-IDD Plan (Medicare-Medicaid Plan) Formulary



Below is the 2023 Formulary, or prescription drug list, from PHP Care Complete FIDA-IDD Plan (Medicare-Medicaid Plan) by Partners 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 PHP Care Complete FIDA-IDD Plan (Medicare-Medicaid Plan)(H9869-001) plan has a $0 drug deductible. The Initial Coverage Limit (ICL) for this plan is $NA. 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 $NA 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. Partners 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:PHP Care Complete FIDA-IDD Plan (Medicare-Medicaid Plan)
Plan ID: H9869-001
Provider: Partners Health Plan, Inc
Plan Year:2023
Premium:$0.00
Deductible:$0
Initial Coverage Limit:$NA
Coverage Area:New York
Similar Plan:H9869-001


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
Paliperidone
1NA$0NA30/30NN
Palynziq
2NA$0NAYN
Panretin
2NA$0NA180/30NN
Paricalcitol
1NA$0NANN
Paromomycin Sulfate
1NA$0NANN
Paroxetine
1NA$0NAYN
Paroxetine Hydrochloride
1NA$0NAYN
Pediarix
2NA$0NANN
Pedvaxhib
2NA$0NANN
Pegasys
2NA$0NANN
Pemazyre
2NA$0NA14/21YN
Penicillamine
1NA$0NAYN
Penicillin G Procaine
1NA$0NANN
Penicillin V Potassium
1NA$0NANN
Pentacel
2NA$0NANN
Pentamidine Isethionate
1NA$0NAYN
Pentoxifylline
1NA$0NANN
Perindopril Erbumine
1NA$0NANN
Periogard Alcohol Free
1NA$0NANN
Permethrin
1NA$0NANN
Perphenazine
1NA$0NANN
Perphenazine And Amitriptyline Hydrochloride
1NA$0NANN
Perseris
2NA$0NA1/30NN
Phenelzine Sulfate
1NA$0NANN
Phenobarbital
1NA$0NAYN
Phenytoin
1NA$0NANN
Phoslyra
2NA$0NANN
Pifeltro
2NA$0NANN
Pilocarpine Hydrochloride
1NA$0NANN
Pimecrolimus
1NA$0NA100/30NN
Pimozide
1NA$0NANN
Pindolol
1NA$0NANN
Piperacillin And Tazobactam
1NA$0NANN
Piqray
2NA$0NA56/28YN
Pirmella 1/35
1NA$0NANN
Piroxicam
1NA$0NANN
Plegridy
2NA$0NA1/28YN
Podofilox
1NA$0NANN
Polyethylene Glycol 3350, Sodium Chloride, Sodium
1NA$0NANN
Polymyxin B Sulfate And Trimethoprim
1NA$0NANN
Portia
1NA$0NANN
Potassium Chloride
1NA$0NANN
Potassium Chloride In Sodium Chloride
1NA$0NANN
Potassium Citrate
1NA$0NANN
Prasugrel
1NA$0NA30/30NN
Pravastatin Sodium
1NA$0NA30/30NN
Prazosin Hydrochloride
1NA$0NANN
Prednisolone Acetate
2NA$0NANN
Prednisolone Sodium Phosphate
1NA$0NANN
Prednisolone Sodium Phosphate Oral Solution
1NA$0NAYN
Prednisone
1NA$0NANN
Pregabalin
1NA$0NA900/30NN
Premarin
2NA$0NAYN
Premphase
2NA$0NAYN
Prempro
2NA$0NAYN
Pretomanid
2NA$0NA30/30NN
Prevymis
2NA$0NA28/28YN
Prezcobix
2NA$0NANN
Prezista
2NA$0NANN
Priftin
2NA$0NANN
Primaquine Phosphate
2NA$0NANN
Primidone
1NA$0NANN
Privigen
2NA$0NAYN
Proair Respiclick
2NA$0NA2/30NN
Probenecid
1NA$0NANN
Probenecid And Colchicine
1NA$0NANN
Procalamine
2NA$0NAYN
Prochlorperazine Maleate
1NA$0NANN
Proctosol-hc
1NA$0NANN
Proctozone-hc
1NA$0NANN
Progesterone
1NA$0NANN
Prograf
2NA$0NAYY
Prolastin-c
2NA$0NAYN
Prolensa
2NA$0NANN
Prolia
2NA$0NA1/180NN
Promacta
2NA$0NA90/30YN
Promethazine Hydrochloride
1NA$0NAYN
Propafenone Hydrochloride
1NA$0NANN
Propranolol Hydrochloride
1NA$0NANN
Propylthiouracil
1NA$0NANN
Proquad
2NA$0NANN
Prosol
2NA$0NAYN
Protriptyline Hydrochloride
1NA$0NANN
Pulmozyme
2NA$0NAYN
Purified Cortrophin Gel
2NA$0NA35/28YN
Purixan
2NA$0NANN
Pyrazinamide
1NA$0NANN
Pyridostigmine Bromide
1NA$0NANN
Pyrimethamine
1NA$0NAYN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H9869-001

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