Trinity Health Plan Of New England No Premium (HMO) Formulary



Below is the 2023 Formulary, or prescription drug list, from Trinity Health Plan Of New England No Premium (HMO) by Mount Carmel Health Plan Of Connecticut 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 Trinity Health Plan Of New England No Premium (HMO)(H6408-001) 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. Mount Carmel Health Plan Of Connecticut 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:Trinity Health Plan Of New England No Premium (HMO)
Plan ID: H6408-001
Provider: Mount Carmel Health Plan Of Connecticut Inc
Plan Year:2023
Premium:$0.00
Deductible:$0
Initial Coverage Limit:$4660
Coverage Area:Connecticut
Similar Plan:H6408-002


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
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Tabloid
4$100$100NANN
Tabrecta
533%33%NAYN
Tacrolimus
4$100$100NA100/30NN
Tafinlar
533%33%NAYN
Tagrisso
533%33%NA30/30YN
Taltz
533%33%NA3/28YN
Talzenna
533%33%NA30/30YN
Tamoxifen Citrate
2$0$20NANN
Tamsulosin Hydrochloride
1$0$10NANN
Tarina Fe 1/20 Eq
2$0$20NANN
Tasigna
533%33%NAYN
Tazarotene
3$47$47NA60/30YN
Tazicef
4$100$100NANN
Tazorac
4$100$100NA60/30YN
Tazverik
533%33%NAYN
Tdvax
3$47$47NAYN
Teflaro
533%33%NANN
Telmisartan And Amlodipine
1$0$10NA30/30NN
Temazepam
4$100$100NA30/30YN
Tenofovir Disproxil Fumarate
3$47$47NANN
Terazosin
2$0$20NANN
Terbutaline Sulfate
4$100$100NANN
Terconazole
3$47$47NANN
Teriparatide
533%33%NAYN
Testosterone
4$100$100NA150/30YN
Testosterone Cypionate
3$47$47NAYN
Testosterone Enanthate
3$47$47NAYN
Tetracycline Hydrochloride
4$100$100NAYN
Theo-24
4$100$100NANN
Theophylline
3$47$47NANN
Thioridazine Hydrochloride
3$47$47NANN
Thiothixene
4$100$100NANN
Tiagabine Hydrochloride
4$100$100NANN
Tibsovo
533%33%NAYN
Ticovac
3$47$47NANN
Tigecycline
533%33%NANN
Timolol Maleate
4$100$100NANN
Timolol Maleate Ophthalmic Gel Forming Solution, 0
4$100$100NANN
Tindazole
3$47$47NANN
Tinidazole
3$47$47NANN
Tivicay
533%33%NANN
Tivicay Pd
533%33%NANN
Tobradex
3$47$47NANN
Tobramycin
1$0$10NANN
Tobramycin And Dexamethasone
4$100$100NANN
Tolterodine Tartrate
4$100$100NA60/30NN
Topiramate
2$0$20NANN
Toremifene Citrate
533%33%NANN
Torsemide
2$0$20NANN
Tpn Electrolytes
4$100$100NAYN
Tradjenta
3$47$47NA30/30NN
Tramadol Hydrochloride And Acetaminophen
3$47$47NA240/30NN
Trandolapril
1$0$10NANN
Tranexamic Acid
3$47$47NANN
Tranylcypromine Sulfate
4$100$100NANN
Travoprost Ophthalmic Solution
4$100$100NANN
Trazodone Hydrochloride
1$0$10NANN
Trecator
4$100$100NANN
Trelegy Ellipta
3$47$47NA60/30NN
Tresiba
3$47$47NANN
Tretinoin
533%33%NANN
Trexall
4$100$100NAYN
Tri-estarylla
3$47$47NANN
Tri-legest Fe
4$100$100NANN
Tri-lo- Estarylla
3$47$47NANN
Tri-lo-sprintec
3$47$47NANN
Tri-sprintec
3$47$47NANN
Tri-vylibra Lo
3$47$47NANN
Triamcinolone Acetonide
3$47$47NANN
Trientine Hydrochloride
533%33%NAYN
Trifluoperazine Hydrochloride
3$47$47NANN
Trifluridine
4$100$100NANN
Trihexyphenidyl Hydrochloride
3$47$47NAYN
Trijardy Xr
3$47$47NA60/30NN
Trikafta
533%33%NA84/28YN
Trimethoprim
3$47$47NANN
Trimipramine Maleate
4$100$100NA60/30NN
Triumeq
533%33%NANN
Trivora
2$0$20NANN
Trizivir
533%33%NANN
Trophamine
4$100$100NAYN
Trospium Chloride
4$100$100NA30/30NN
Truseltiq
533%33%NAYN
Tukysa
533%33%NAYN
Turalio
533%33%NAYN
Twinrix
3$47$47NANN
Tybost
3$47$47NANN
Typhim Vi
3$47$47NANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H6408-001

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 $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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