UnitedHealthcare Dual Complete Choice (PPO D-SNP) Formulary



Below is the 2023 Formulary, or prescription drug list, from UnitedHealthcare Dual Complete Choice (PPO D-SNP) by Care Improvement Plus South Central Insurance Co. A formulary is a continually updated list of available medications and prescription drug cost information. Examining a plans formulary can help you find a West Virginia 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 UnitedHealthcare Dual Complete Choice (PPO D-SNP)(H0271-013) plan has a $505 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. Care Improvement Plus South Central Insurance Co 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:UnitedHealthcare Dual Complete Choice (PPO D-SNP)
Plan ID: H0271-013
Provider: Care Improvement Plus South Central Insurance Co
Plan Year:2023
Premium:$0.00
Deductible:$505
Initial Coverage Limit:$4660
Coverage Area:West Virginia
Similar Plan:H0271-014


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
Labetalol Hcl
1YNA$0NANN
Lamivudine
3YNA$0NA30/30NN
Lamotrigine
3YNA$0NANN
Lanoxin
4YNA$0NANN
Lansoprazole
2YNANNA60/30NN
Lanthanum Carbonate
5NA$0NANN
Lantus
3YNA$0NANN
Lapatinib
5NA$0NAYN
Larissia
4YNA$0NANN
Latanoprost
1YNA$0NANN
Layolis Fe
4YNA$0NANN
Leena
4YNA$0NANN
Leflunomide
2YNANNANN
Lenvima
5NA$0NAYN
Lessina
4YNA$0NANN
Leucovorin Calcium
4YNA$0NANN
Leukeran
5NA$0NANN
Leukine
5NA$0NAYN
Leuprolide Acetate
4YNA$0NAYN
Levalbuterol
4YNA$0NAYN
Levalbuterol Hydrochloride
4YNA$0NAYN
Levalbuterol Tartrate Hfa Inhalation
3YNA$0NANN
Levemir
3YNA$0NANN
Levetiracetam
2YNANNANN
Levo-t
3YNA$0NANN
Levobunolol Hydrochloride
2YNANNANN
Levocarnitine
3YNA$0NANN
Levofloxacin
4YNA$0NANN
Levonorgestrel And Ethinyl Estradiol
4YNA$0NANN
Levonorgestrel And Ethinyl Estradiol And Ethinyl E
4YNA$0NANN
Levora
4YNA$0NANN
Levorphanol Tartrate
5NA$0NA180/30NN
Levothyroxine Sodium
1YNA$0NANN
Levoxyl
3YNA$0NANN
Lexiva
4YNA$0NA1800/30NN
Lidocaine
3YNA$0NA152/30NN
Lidocaine Hydrochloride
1YNA$0NANN
Linezolid
5NA$0NA1800/30NN
Lisinopril
1YNA$0NA60/30NN
Lithium Carbonate
2YNANNANN
Lithostat
5NA$0NANN
Livalo
3YNA$0NA30/30NN
Lokelma
4YNA$0NA90/30NN
Lonhala Magnair
5NA$0NA60/30NN
Lonsurf
5NA$0NA300/30YN
Loperamide Hydrochloride
2YNANNANN
Lopinavir And Ritonavir
4YNA$0NA120/30NN
Lopinavir-ritonavir
4YNA$0NA480/30NN
Lorazepam
1YNA$0NA150/30NN
Lorbrena
5NA$0NA30/30YN
Loryna
4YNA$0NANN
Lotemax
4YNA$0NANN
Loteprednol Etabonate
4YNA$0NANN
Low-ogestrel
4YNA$0NANN
Loxapine
2YNANNANN
Lubiprostone
3YNA$0NA60/30NN
Lupron Depot
5NA$0NAYN
Lutera
4YNA$0NANN
Lyleq
4YNA$0NANN
Lynparza
5NA$0NA120/30YN
Lysodren
5NA$0NANN
Lyumjev
3YNA$0NANN
Lyza
4YNA$0NANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H0271-013

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $505. 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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