True Blue Rx St. Lukes Health Partners (HMO) Formulary



Below is the 2023 Formulary, or prescription drug list, from True Blue Rx St. Lukes Health Partners (HMO) by Blue Cross Of Idaho Care Plus, 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 Idaho 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 True Blue Rx St. Lukes Health Partners (HMO)(H1350-023) plan has a $125 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. Blue Cross Of Idaho Care Plus, 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:True Blue Rx St Lukes Health Partners
Plan ID: H1350-023
Provider: Blue Cross Of Idaho Care Plus, Inc
Plan Year:2023
Premium:$0.00
Deductible:$125
Initial Coverage Limit:$4660
Coverage Area:Idaho
Similar Plan:H1350-024


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
Tabloid
4Y$90$100$90NN
Tabrecta
531%31%31%120/30YN
Tacrolimus
2N$6$15$6100/30YN
Tafinlar
531%31%31%120/30YN
Tagrisso
531%31%31%30/30YN
Talzenna
531%31%31%30/30YN
Tamoxifen Citrate
1N$0$5$0NN
Tamsulosin Hydrochloride
1N$0$5$0NN
Targretin
531%31%31%60/30YN
Tarina 24 Fe
1N$0$5$0NN
Tarina Fe 1/20 Eq
1N$0$5$0NN
Tasigna
531%31%31%112/28YN
Tazarotene
2N$6$15$6YN
Tazicef
2N$6$15$6NN
Tazorac
4Y$90$100$90YN
Tazverik
531%31%31%240/30YN
Tdvax
3Y$37$47$37NN
Tecfidera
531%31%31%YN
Teflaro
531%31%31%NN
Tegretol
4Y$90$100$90NN
Telmisartan And Amlodipine
6N$0$5$0NN
Temazepam
2N$6$15$630/30NN
Tencon
1N$0$5$0180/30YN
Tenofovir Disproxil Fumarate
2N$6$15$630/30NN
Terazosin
1N$0$5$0NN
Terbutaline Sulfate
1N$0$5$0NN
Terconazole
1N$0$5$0NN
Teriparatide
531%31%31%3/28YN
Testosterone
2N$6$15$6150/30YN
Testosterone Cypionate
2N$6$15$6YN
Testosterone Enanthate
2N$6$15$6YN
Tetracycline Hydrochloride
2N$6$15$6NN
Theophylline
1N$0$5$0NN
Thioridazine Hydrochloride
2N$6$15$6NN
Thiothixene
1N$0$5$0NN
Tiagabine Hydrochloride
2N$6$15$6NN
Tibsovo
531%31%31%60/30YN
Ticovac
3Y$37$47$37NN
Tigecycline
531%31%31%NN
Timolol Maleate
1N$0$5$0NN
Timolol Maleate Ophthalmic Gel Forming Solution, 0
2N$6$15$6NN
Tindazole
2N$6$15$6NN
Tinidazole
2N$6$15$6NN
Tivicay
531%31%31%60/30NN
Tivicay Pd
531%31%31%360/30NN
Tizanidine Hydrochloride
2N$6$15$6NN
Tobi Podhaler
531%31%31%224/28NN
Tobradex
3Y$37$47$37NN
Tobramycin
1N$0$5$0NN
Tobramycin And Dexamethasone
2N$6$15$6NN
Tobramycin Inhalation
531%31%31%224/28YN
Tolcapone
531%31%31%180/30YN
Tolterodine Tartrate
2N$6$15$660/30NN
Topiramate
1N$0$5$0NN
Toremifene Citrate
531%31%31%30/30NN
Torsemide
1N$0$5$0NN
Toviaz
4Y$90$100$9030/30NN
Tradjenta
3Y$37$47$3730/30NN
Tramadol Hydrochloride And Acetaminophen
1N$0$5$040/5NN
Trandolapril
6N$0$5$0NN
Trandolapril And Verapamil Hydrochloride
6N$0$5$0NN
Tranexamic Acid
2N$6$15$6NN
Tranylcypromine Sulfate
2N$6$15$6NN
Travoprost Ophthalmic Solution
2N$6$15$6NN
Trazodone Hydrochloride
1N$0$5$0NN
Trecator
4Y$90$100$90NN
Trelegy Ellipta
3Y$37$47$3760/30NN
Trelstar
531%31%31%YN
Tresiba
3Y$37$47$3730/30NN
Tretinoin
2N$6$15$645/30YN
Trexall
4Y$90$100$90NN
Tri-estarylla
1N$0$5$0NN
Tri-legest Fe
2N$6$15$6NN
Tri-lo- Estarylla
1N$0$5$0NN
Tri-lo-sprintec
1N$0$5$0NN
Tri-sprintec
1N$0$5$0NN
Tri-vylibra Lo
1N$0$5$0NN
Triamcinolone Acetonide
1N$0$5$0NN
Triamterene
2N$6$15$6NN
Triazolam
1N$0$5$030/30NN
Triderm
1N$0$5$0NN
Trientine Hydrochloride
531%31%31%NN
Trifluoperazine Hydrochloride
1N$0$5$0NN
Trifluridine
2N$6$15$6NN
Trihexyphenidyl Hydrochloride
1N$0$5$0NN
Trijardy Xr
3Y$37$47$3760/30NN
Trimethobenzamide Hydrochloride
2N$6$15$6NN
Trimethoprim
1N$0$5$0NN
Trimipramine Maleate
2N$6$15$6NN
Triumeq
531%31%31%30/30NN
Trivora
1N$0$5$0NN
Trizivir
531%31%31%60/30NN
Trophamine
3Y$37$47$37YN
Trospium Chloride
2N$6$15$630/30NN
Truseltiq
531%31%31%42/28YN
Tukysa
531%31%31%120/30YN
Turalio
531%31%31%120/30YN
Twinrix
3Y$37$47$37NN
Tybost
3Y$37$47$3730/30NN
Tymlos
531%31%31%1/28YN
Typhim Vi
3Y$37$47$37NN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H1350-023

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $125. 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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