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2009 Medicare Part D Plan Formulary Information
MedicareBlue Rx Option 3 (S5743-004-0) Benefit Details
The MedicareBlue Rx Option 3 (S5743-004-0) Formulary Drugs Starting with the Letter H in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY
Drugs Starting with Letter H Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter H Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
HALOBETASOL PROPIONATE 0.05% CREAM	1	Level 1: Covered Generic	$3.00	$6.00	None
HALOBETASOL PROPIONATE 0.05% OINTMENT	1	Level 1: Covered Generic	$3.00	$6.00	None
HALOPERIDOL 0.5MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
HALOPERIDOL 10MG TABLET (1000 CT)	1	Level 1: Covered Generic	$3.00	$6.00	None
HALOPERIDOL 1MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
HALOPERIDOL 20MG TABLET (100 CT)	1	Level 1: Covered Generic	$3.00	$6.00	None
HALOPERIDOL 2MG TABLET (100 CT)	1	Level 1: Covered Generic	$3.00	$6.00	None
HALOPERIDOL 5MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
HALOPERIDOL DEC 100MG/ML VL	1	Level 1: Covered Generic	$3.00	$6.00	None
HALOPERIDOL DEC 50MG 10 X 1ML PKG	1	Level 1: Covered Generic	$3.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
HALOPERIDOL LAC 2MG/ML CONC	1	Level 1: Covered Generic	$3.00	$6.00	None
HALOPERIDOL LAC 5MG/ML VIAL	1	Level 1: Covered Generic	$3.00	$6.00	None
HAVRIX 720UNIT/0.5ML SYRINGE	3	Level 3: Covered Brand	50%	50%	None
HAVRIX HEPATITIS A VACCINE INACTIVATED INJECTION SOLUTION 1440UNITS 10 X 1ML VIALSD	3	Level 3: Covered Brand	50%	50%	None
HECTOROL 0.5MCG CAPSULE	2	Level 2: Covered Preferred Brand	$37.00	$74.00	None
HECTOROL 2.5MCG CAPSULE	2	Level 2: Covered Preferred Brand	$37.00	$74.00	None
HEPARIN SODIUM INJECTION 10000UNITS 25 X 5ML VIALMD	1	Level 1: Covered Generic	$3.00	$6.00	None
HEPARIN SODIUM INJECTION USP 1000UNITS 25 X 10ML VIALMD	1	Level 1: Covered Generic	$3.00	$6.00	None
HEPARIN SODIUM INJECTION USP 5000UNITS 25 X 10ML VIALMD	1	Level 1: Covered Generic	$3.00	$6.00	None
HEPATAMINE INJECTION 8%	1	Level 1: Covered Generic	$3.00	$6.00	P
HEPATITIS B VACCINE ENGERIX B FOR ADULT USE ONLY 20MCG 10 X 1ML VIALSD	3	Level 3: Covered Brand	50%	50%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
HEPSERA 10MG TABLET	3	Level 3: Covered Brand	50%	50%	None
HERCEPTIN 440MG VIAL	4	Covered Specialty	33%	33%	None
HEXALEN 50MG CAPSULE	4	Covered Specialty	33%	33%	None
HIBTITER VACCINE VIAL	3	Level 3: Covered Brand	50%	50%	None
HUMALOG 100U/ML VIAL	2	Level 2: Covered Preferred Brand	$37.00	$74.00	None
HUMALOG 100UNITS/ML PEN	2	Level 2: Covered Preferred Brand	$37.00	$74.00	None
HUMALOG KWIKPEN INJECTION 100UNT/ML 5 X 3ML CTG	2	Level 2: Covered Preferred Brand	$37.00	$74.00	None
HUMALOG MIX 50/50 PEN	2	Level 2: Covered Preferred Brand	$37.00	$74.00	None
HUMALOG MIX 50/50 VIAL	2	Level 2: Covered Preferred Brand	$37.00	$74.00	None
HUMALOG MIX 75/25 PEN	2	Level 2: Covered Preferred Brand	$37.00	$74.00	None
HUMALOG MIX 75/25 VIAL	2	Level 2: Covered Preferred Brand	$37.00	$74.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
HUMALOG MIX KWIKPEN INJECTION 50;50UNT/ML;	2	Level 2: Covered Preferred Brand	$37.00	$74.00	None
HUMALOG MIX KWIKPEN INJECTION 75;25%;% 5 X 3ML CTG	2	Level 2: Covered Preferred Brand	$37.00	$74.00	None
HUMIRA 40MG/0.8ML PEN	4	Covered Specialty	33%	33%	S
HUMIRA 40MG/0.8ML SYRINGE	4	Covered Specialty	33%	33%	S
HUMIRA PEN KIT 40MG-70% 1 PKGCOM	4	Covered Specialty	33%	33%	S
HUMULIN 50/50 VIAL	2	Level 2: Covered Preferred Brand	$37.00	$74.00	None
HUMULIN 70/30 PEN INJECTION 100UNT 1 X 3.0ML(PEN) CTG	2	Level 2: Covered Preferred Brand	$37.00	$74.00	None
HUMULIN 70/30 VIAL	2	Level 2: Covered Preferred Brand	$37.00	$74.00	None
HUMULIN N 100U/ML VIAL	2	Level 2: Covered Preferred Brand	$37.00	$74.00	None
HUMULIN N PEN INJECTION 100UNT 1 X 3.0ML (PEN) CTG	2	Level 2: Covered Preferred Brand	$37.00	$74.00	None
HUMULIN R 100U/ML VIAL	2	Level 2: Covered Preferred Brand	$37.00	$74.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
HYCAMTIN POWDER FOR INJECTION SOLUTION 4MG 1 VIAL	4	Covered Specialty	33%	33%	None
HYDRALAZINE 100MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDRALAZINE 10MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDRALAZINE 25MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDRALAZINE 50MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROCHLORIDE 50MG TABLET (1000 CT)	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROCHLOROTHIAZIDE 12.5MG CAPSULE (100 CT)	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROCHLOROTHIAZIDE 25MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROCODONE BITARTRATE AND ACETAMINOPHEN ELIXIR 500-7.5 473ML BOT	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROCODONE BITARTRATE AND ACETAMINOPHEN TABLET 500-7.5MG (120 CT)	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROCODONE BITARTRATE AND ACETAMINOPHEN TABLET 7.5-650MG (500 CT)	1	Level 1: Covered Generic	$3.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
HYDROCODONE BITARTRATE AND IBUPROFEN TABLET 7.5-200MG (100 CT)	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROCODONE-ACETAMINOPHEN 10-750MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROCODONE-ACETAMINOPHEN 10MG-500MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROCODONE-ACETAMINOPHEN 10MG-650MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROCODONE-ACETAMINOPHEN 5MG-325MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROCODONE-ACETAMINOPHEN 7.5-325MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROCODONE/APAP 10/325 TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROCODONE/APAP 10/325 TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROCODONE/APAP 10/500 TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROCODONE/APAP 10/660 TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROCODONE/APAP 2.5/500 TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
HYDROCODONE/APAP 5/500 TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROCODONE/APAP 7.5/750 TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROCORTISONE 0.2% CREAM	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROCORTISONE 0.2% OINTMENT	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROCORTISONE 1% LOTION	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROCORTISONE 1% OINTMENT	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROCORTISONE 100MG ENEMA	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROCORTISONE 10MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROCORTISONE 20MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROCORTISONE 5MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROCORTISONE BUTYRATE 0.1% CREAM	1	Level 1: Covered Generic	$3.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
HYDROCORTISONE BUTYRATE 0.1% OINTMENT	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROCORTISONE BUTYRATE 0.1% SOLUTION NON-ORAL	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROCORTISONE CREAM 1% 1 LB JAR	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROCORTISONE CREAM USP 2.5% 20GM TUBE	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROCORTISONE LOTION 2.5% 2 OZ BOT	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROCORTISONE OINTMENT 1% 1 LB JAR	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROCORTISONE OINTMENT USP 2.5% 20GM TUBE BOX	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROMORPHON INJ 10MG/ML	1	Level 1: Covered Generic	$3.00	$6.00	P
HYDROMORPHON INJ 50MG/5ML	1	Level 1: Covered Generic	$3.00	$6.00	P
HYDROMORPHONE HCL 2MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROMORPHONE HCL 4MG TABLET (100 CT)	1	Level 1: Covered Generic	$3.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
HYDROMORPHONE HCL 8MG TABLET (100 CT)	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROXYCHLOROQUINE 200MG TABLET (500 CT)	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROXYUREA 500MG CAPSULE	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROXYZINE HCL 10MG TABLET (500 CT)	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROXYZINE HCL 10MG/5ML ORAL SOLUTION 1 PT BOT	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROXYZINE HCL 25MG TABLET	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROXYZINE HCL 50MG TABLET (500 CT)	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROXYZINE PAM 100MG CAPSULE	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROXYZINE PAM 50MG CAPSULE	1	Level 1: Covered Generic	$3.00	$6.00	None
HYDROXYZINE PAMOATE 25MG CAPSULE	1	Level 1: Covered Generic	$3.00	$6.00	None
HYZAAR 100-12.5MG TABLET (90 CT)	2	Level 2: Covered Preferred Brand	$37.00	$74.00	S
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
HYZAAR 100-25MG TABLET (90 CT)	2	Level 2: Covered Preferred Brand	$37.00	$74.00	S
HYZAAR 50-12.5MG TABLET (5000 CT)	2	Level 2: Covered Preferred Brand	$37.00	$74.00	S

Chart Legend:

Below are a few notes to help you understand the above 2009 Medicare Part D MedicareBlue Rx Option 3 Plan Formulary.

Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region).
Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.
Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $295 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.
Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
- Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.
- No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.
Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
- Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
- Drug Description - This is the Medicare Part D plan’s description of this particular drug tier.
Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
- Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the initial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $2700) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2013 Humana Walmart-Preferred Rx Plan the cost-sharing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
- Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
- None - This drug does not fall under any drug utilization management controls.
- P - Prior Authorization -This drug is subject to prior authorization.
- S - Step Therapy -This drug is subject to step therapy.
- Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.

(Chart Source: Centers for Medicare and Medicaid files: CMS Data October 2009 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.