2009 Medicare Part D Plan Formulary Information |
AdvantraRx Premier (S5674-009-0)
Benefit Details
|
The AdvantraRx Premier (S5674-009-0) Formulary Drugs Starting with the Letter H in CMS PDP Region 2 which includes: CT MA RI VT
|
Drugs Starting with Letter H
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
HALFLYTELY AND BISACODYL TABLETS 210;2.86;GM;GM;GM; 2 L BOT |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$68.00 | $204.00 | None |
HALOBETASOL PROPIONATE 0.05% CREAM |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HALOBETASOL PROPIONATE 0.05% OINTMENT |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HALOG 0.1% CREAM |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$68.00 | $204.00 | None |
HALOG 0.1% OINTMENT 30GM TUBE |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$68.00 | $204.00 | None |
HALOG 0.1% SOLUTION |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$68.00 | $204.00 | None |
HALOPERIDOL 0.5MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HALOPERIDOL 10MG TABLET (1000 CT) |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HALOPERIDOL 1MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HALOPERIDOL 20MG TABLET (100 CT) |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HALOPERIDOL 2MG TABLET (100 CT) |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HALOPERIDOL 5MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HALOPERIDOL DEC 100MG/ML VL |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HALOPERIDOL DEC 50MG 10 X 1ML PKG |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HALOPERIDOL LAC 2MG/ML CONC |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HALOPERIDOL LAC 5MG/ML VIAL |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HAVRIX 720UNIT/0.5ML SYRINGE |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$68.00 | $204.00 | None |
HAVRIX HEPATITIS A VACCINE INACTIVATED INJECTION SOLUTION 1440UNITS 10 X 1ML VIALSD |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$68.00 | $204.00 | None |
HECTOROL 0.5MCG CAPSULE |
2 |
Preferred Brand |
$27.00 | $54.00 | None |
HECTOROL 2.5MCG CAPSULE |
2 |
Preferred Brand |
$27.00 | $54.00 | None |
HELIDAC THERAPY |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$68.00 | $204.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HEPARIN NA 2000UNITS/ML VIAL |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HEPARIN NA 2500UNITS/ML VIAL |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HEPARIN SODIUM 20MU/ML VIAL |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HEPARIN SODIUM IN 5% DEXTROSE INJECTION 25000UNITS 24 X 250ML BAG |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HEPARIN SODIUM IN 5% DEXTROSE INJECTION SOLUTION 4000UNITS 24 X 500ML CTR |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HEPARIN SODIUM IN 5% DEXTROSE INJECTION SOLUTION 5000UNITS 24 X 500ML CTR |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HEPARIN SODIUM IN SODIUM CHLORIDE INJECTION |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HEPARIN SODIUM INJECTION 10000UNITS 25 X 5ML VIALMD |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HEPARIN SODIUM INJECTION USP 1000UNITS 25 X 10ML VIALMD |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HEPARIN SODIUM INJECTION USP 5000UNITS 25 X 10ML VIALMD |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HEPATITIS B VACCINE ENGERIX B FOR ADULT USE ONLY 20MCG 10 X 1ML VIALSD |
2 |
Preferred Brand |
$27.00 | $54.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HEPATITIS B VACCINE RECOMBIANT ADULT FORMULATION INJECTION 10MCG 1ML VIALSD |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$68.00 | $204.00 | P |
HEPSERA 10MG TABLET |
4 |
Specialty-Generic and Brand |
33% | N/A | Q:30 /30Days |
HERCEPTIN 440MG VIAL |
4 |
Specialty-Generic and Brand |
33% | N/A | P |
HEXALEN 50MG CAPSULE |
4 |
Specialty-Generic and Brand |
33% | N/A | None |
HIBTITER VACCINE VIAL |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$68.00 | $204.00 | None |
HUMALOG 100U/ML VIAL |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$68.00 | $204.00 | None |
HUMALOG 100UNITS/ML PEN |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$68.00 | $204.00 | P |
HUMALOG KWIKPEN INJECTION 100UNT/ML 5 X 3ML CTG |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$68.00 | $204.00 | P |
HUMALOG MIX 50/50 PEN |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$68.00 | $204.00 | P |
HUMALOG MIX 50/50 VIAL |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$68.00 | $204.00 | None |
HUMALOG MIX 75/25 PEN |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$68.00 | $204.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HUMALOG MIX 75/25 VIAL |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$68.00 | $204.00 | None |
HUMALOG MIX KWIKPEN INJECTION 50;50UNT/ML; |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$68.00 | $204.00 | P |
HUMALOG MIX KWIKPEN INJECTION 75;25%;% 5 X 3ML CTG |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$68.00 | $204.00 | P |
HUMIRA 40MG/0.8ML PEN |
4 |
Specialty-Generic and Brand |
33% | N/A | P Q:6 /30Days |
HUMIRA 40MG/0.8ML SYRINGE |
4 |
Specialty-Generic and Brand |
33% | N/A | P Q:6 /30Days |
HUMULIN 50/50 VIAL |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$68.00 | $204.00 | None |
HUMULIN 70/30 PEN INJECTION 100UNT 1 X 3.0ML(PEN) CTG |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$68.00 | $204.00 | P |
HUMULIN 70/30 VIAL |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$68.00 | $204.00 | None |
HUMULIN N 100U/ML VIAL |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$68.00 | $204.00 | None |
HUMULIN N PEN INJECTION 100UNT 1 X 3.0ML (PEN) CTG |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$68.00 | $204.00 | P |
HUMULIN R 100U/ML VIAL |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$68.00 | $204.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HUMULIN R 500U/ML VIAL |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$68.00 | $204.00 | None |
HYCAMTIN POWDER FOR INJECTION SOLUTION 4MG 1 VIAL |
4 |
Specialty-Generic and Brand |
33% | N/A | P |
HYDRALAZINE 100MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDRALAZINE 10MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDRALAZINE 25MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDRALAZINE 50MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDRALAZINE HCL INJECTION 20MG 25 X 1ML VIALSD |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROCHLORIDE 50MG TABLET (1000 CT) |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROCHLOROTHIAZIDE 12.5MG CAPSULE (100 CT) |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROCHLOROTHIAZIDE 12.5MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROCHLOROTHIAZIDE 25MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDROCODONE BITARTRATE AND ACETAMINOPHEN ELIXIR 500-7.5 473ML BOT |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROCODONE BITARTRATE AND ACETAMINOPHEN TABLET 500-7.5MG (120 CT) |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROCODONE BITARTRATE AND ACETAMINOPHEN TABLET 7.5-650MG (500 CT) |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROCODONE BITARTRATE AND IBUPROFEN TABLET 7.5-200MG (100 CT) |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$68.00 | $204.00 | None |
HYDROCODONE-ACETAMINOPHEN 10-750MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROCODONE-ACETAMINOPHEN 10MG-500MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROCODONE-ACETAMINOPHEN 10MG-650MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROCODONE-ACETAMINOPHEN 5MG-325MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROCODONE-ACETAMINOPHEN 7.5-325MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROCODONE/APAP 10/325 TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROCODONE/APAP 10/660 TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDROCODONE/APAP 2.5/500 TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROCODONE/APAP 5/500 TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROCODONE/APAP 7.5/750 TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROCORTISONE 0.2% CREAM |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROCORTISONE 0.2% OINTMENT |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROCORTISONE 1% OINTMENT |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROCORTISONE 100MG ENEMA |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROCORTISONE 10MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROCORTISONE 20MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROCORTISONE 5MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROCORTISONE BUTYRATE 0.1% CREAM |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDROCORTISONE BUTYRATE 0.1% OINTMENT |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROCORTISONE BUTYRATE 0.1% SOLUTION NON-ORAL |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROCORTISONE CREAM 1% 1 LB JAR |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROCORTISONE CREAM USP 2.5% 20GM TUBE |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROCORTISONE LOTION 2.5% 2 OZ BOT |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROCORTISONE OINTMENT USP 2.5% 20GM TUBE BOX |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROMORPHON INJ 10MG/ML |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROMORPHONE HCL 2MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROMORPHONE HCL 4MG TABLET (100 CT) |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROMORPHONE HCL 8MG TABLET (100 CT) |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROXYCHLOROQUINE 200MG TABLET (500 CT) |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDROXYUREA 500MG CAPSULE |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROXYZINE 25MG/ML VIAL |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROXYZINE 50MG/ML VIAL |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROXYZINE HCL 10MG TABLET (500 CT) |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROXYZINE HCL 10MG/5ML ORAL SOLUTION 1 PT BOT |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROXYZINE HCL 25MG TABLET |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROXYZINE HCL 50MG TABLET (500 CT) |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROXYZINE PAM 100MG CAPSULE |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROXYZINE PAM 50MG CAPSULE |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYDROXYZINE PAMOATE 25MG CAPSULE |
1 |
Preferred Generic |
$5.00 | $10.00 | None |
HYZAAR 100-12.5MG TABLET (90 CT) |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$68.00 | $204.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYZAAR 100-25MG TABLET (90 CT) |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$68.00 | $204.00 | Q:30 /30Days |
HYZAAR 50-12.5MG TABLET (5000 CT) |
3 |
Non-Preferred Generic/Non-Preferred Brand |
$68.00 | $204.00 | Q:30 /30Days |