WellSense Choice (HMO) Formulary



Below is the 2023 Formulary, or prescription drug list, from WellSense Choice (HMO) by Boston Medical Center 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 Hampshire 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 WellSense Choice (HMO)(H6851-003) 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. Boston Medical Center 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:WellSense Choice (HMO)
Plan ID: H6851-003
Provider: Boston Medical Center Health Plan, Inc
Plan Year:2023
Premium:$19.00
Deductible:$0
Initial Coverage Limit:$4660
Coverage Area:New Hampshire
Similar Plan:H6851-001


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
Labetalol Hcl
2NA$12NANN
Lamivudine
3NA$47NANN
Lamotrigine
2NA$12NANN
Lansoprazole
3NA$47NA30/30NN
Lantus
3NA$47NANN
Lapatinib
5NA33%NA180/30YN
Larissia
2NA$12NANN
Latanoprost
1NA$0NANN
Leflunomide
3NA$47NA30/30NN
Lenvima
5NA33%NAYN
Lessina
2NA$12NANN
Leucovorin Calcium
3NA$47NANN
Leukeran
5NA33%NANN
Leukine
5NA33%NAYN
Leuprolide Acetate
5NA33%NAYN
Levetiracetam
2NA$12NANN
Levo-t
1NA$0NANN
Levobunolol Hydrochloride
2NA$12NANN
Levocarnitine
4NA$100NANN
Levocetirizine Dihydrochloride
4NA$100NANN
Levofloxacin
4NA$100NAYN
Levonorgestrel And Ethinyl Estradiol
2NA$12NANN
Levonorgestrel And Ethinyl Estradiol And Ethinyl E
2NA$12NANN
Levora
2NA$12NANN
Levothyroxine Sodium
1NA$0NANN
Levoxyl
1NA$0NANN
Lexiva
4NA$100NANN
Lidocaine
4NA$100NA36/30NN
Lidocaine Hydrochloride
2NA$12NANN
Lindane
4NA$100NANN
Linezolid
5NA33%NANN
Lisinopril
1NA$0NANN
Lithium Carbonate
2NA$12NANN
Lokelma
3NA$47NANN
Lonsurf
5NA33%NAYN
Loperamide Hydrochloride
2NA$12NANN
Lopinavir And Ritonavir
3NA$47NANN
Lopinavir-ritonavir
4NA$100NANN
Lorazepam
2NA$12NA150/30YN
Lorbrena
5NA33%NA30/30YN
Loryna
2NA$12NANN
Loteprednol Etabonate
3NA$47NANN
Low-ogestrel
2NA$12NANN
Loxapine
2NA$12NANN
Lupron Depot
5NA33%NAYN
Lutera
2NA$12NANN
Lyleq
2NA$12NANN
Lyllana
3NA$47NA8/28YN
Lynparza
5NA33%NA120/30YN
Lysodren
5NA33%NANN
Lyumjev
3NA$47NANN
Lyza
2NA$12NANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H6851-003

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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