2010 Medicare Part D Plan Formulary Information |
Health Net Value Orange Option 2 (PDP) (S5678-055-0)
Benefit Details
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The Health Net Value Orange Option 2 (PDP) (S5678-055-0) Formulary Drugs Starting with the Letter H in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY
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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 |
HALDOL 5MG/ML AMPUL |
4 |
Tier 4 Injectable |
33% | N/A | None |
HALDOL DECANOATE 100 AMPUL |
4 |
Tier 4 Injectable |
33% | N/A | None |
HALDOL DECANOATE 50 AMPUL |
4 |
Tier 4 Injectable |
33% | N/A | None |
HALFLYTELY AND BISACODYL TABLETS BOWEL PREP KIT 5.6;2.86;GM;GM;GM; 1 PKGCOM |
2 |
Tier 2 Preferred Brand |
$42.00 | $84.00 | None |
HALOBETASOL PROPIONATE 0.05% CREAM |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:1 /1Days |
HALOBETASOL PROPIONATE 0.05% OINTMENT |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:1 /1Days |
HALOG 0.1% OINTMENT |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:1 /1Days |
HALOG 0.10% 60 GM |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | Q:1 /1Days |
HALOPERIDOL 0.5MG TABLET |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
HALOPERIDOL 10MG TABLET (1000 CT) |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HALOPERIDOL 1MG TABLET |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
HALOPERIDOL 20MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
HALOPERIDOL 2MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
HALOPERIDOL 5MG TABLET |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
HALOPERIDOL DEC 100MG/ML VL |
4 |
Tier 4 Injectable |
33% | N/A | None |
HALOPERIDOL DEC 50MG 10 X 1ML PKG |
4 |
Tier 4 Injectable |
33% | N/A | None |
HALOPERIDOL LAC 2MG/ML CONC |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
HALOPERIDOL LAC 5MG/ML VIAL |
4 |
Tier 4 Injectable |
33% | N/A | None |
HAVRIX 720UNIT/0.5ML SYRINGE |
4 |
Tier 4 Injectable |
33% | N/A | None |
HAVRIX HEPATITIS A VACCINE INACTIVATED INJECTION SOLUTION 1440UNITS 10 X 1ML VIALSD |
4 |
Tier 4 Injectable |
33% | N/A | None |
HECTOROL 4 MCG/2ML AMPUL |
4 |
Tier 4 Injectable |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HEPARIN 25000U-1/2NS 250ML |
4 |
Tier 4 Injectable |
33% | N/A | None |
HEPARIN 25000U-1/2NS 500ML |
4 |
Tier 4 Injectable |
33% | N/A | None |
HEPARIN NA 2000UNITS/ML VIAL |
4 |
Tier 4 Injectable |
33% | N/A | None |
HEPARIN NA 2500UNITS/ML VIAL |
4 |
Tier 4 Injectable |
33% | N/A | None |
HEPARIN SODIUM 20MU/ML VIAL |
4 |
Tier 4 Injectable |
33% | N/A | None |
HEPARIN SODIUM IN 5% DEXTROSE INJECTION 25000UNITS 24 X 250ML BAG |
4 |
Tier 4 Injectable |
33% | N/A | None |
HEPARIN SODIUM IN 5% DEXTROSE INJECTION SOLUTION 4000UNITS 24 X 500ML CTR |
4 |
Tier 4 Injectable |
33% | N/A | None |
HEPARIN SODIUM IN 5% DEXTROSE INJECTION SOLUTION 5000UNITS 24 X 500ML CTR |
4 |
Tier 4 Injectable |
33% | N/A | None |
HEPARIN SODIUM IN SODIUM CHLORIDE INJECTION |
4 |
Tier 4 Injectable |
33% | N/A | None |
HEPARIN SODIUM INJECTION 10000UNITS 25 X 5ML VIALMD |
4 |
Tier 4 Injectable |
33% | N/A | None |
HEPARIN SODIUM INJECTION SOLUTION 200UNITS 12 X 1000ML CTR |
4 |
Tier 4 Injectable |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HEPARIN SODIUM INJECTION USP 1000UNITS 25 X 10ML VIALMD |
4 |
Tier 4 Injectable |
33% | N/A | None |
HEPARIN SODIUM INJECTION USP 5000UNITS 25 X 10ML VIALMD |
4 |
Tier 4 Injectable |
33% | N/A | None |
HEPATAMINE INJECTION 8% |
4 |
Tier 4 Injectable |
33% | N/A | P |
HEPATASOL INJECTION 8% 500ML BAG |
4 |
Tier 4 Injectable |
33% | N/A | P |
HEPATITIS B VACCINE RECOMBIANT ADULT FORMULATION INJECTION 10MCG 1ML VIALSD |
4 |
Tier 4 Injectable |
33% | N/A | P |
HEPSERA 10MG TABLET |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | P |
HERCEPTIN 440MG VIAL |
5 |
Tier 5 Specialty |
33% | N/A | None |
HEXALEN 50MG CAPSULE |
5 |
Tier 5 Specialty |
33% | N/A | None |
HIBTITER VACCINE VIAL |
4 |
Tier 4 Injectable |
33% | N/A | None |
HUMALOG 100U/ML VIAL |
2 |
Tier 2 Preferred Brand |
$42.00 | $84.00 | Q:2 /1Days |
HUMALOG 100UNITS/ML PEN |
2 |
Tier 2 Preferred Brand |
$42.00 | $84.00 | P Q:45 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HUMALOG MIX 50/50 PEN |
2 |
Tier 2 Preferred Brand |
$42.00 | $84.00 | P Q:45 /30Days |
HUMALOG MIX 50/50 VIAL |
2 |
Tier 2 Preferred Brand |
$42.00 | $84.00 | Q:2 /1Days |
HUMALOG MIX 75/25 PEN |
2 |
Tier 2 Preferred Brand |
$42.00 | $84.00 | P Q:45 /30Days |
HUMALOG MIX 75/25 VIAL |
2 |
Tier 2 Preferred Brand |
$42.00 | $84.00 | Q:2 /1Days |
HUMATROPE 12MG CARTRIDGE |
5 |
Tier 5 Specialty |
33% | N/A | P |
HUMATROPE 24MG CARTRIDGE |
5 |
Tier 5 Specialty |
33% | N/A | P |
HUMATROPE 6MG CARTRIDGE |
5 |
Tier 5 Specialty |
33% | N/A | P |
HUMATROPE FOR INJECTION 5MG 6 X 5ML VIAL |
5 |
Tier 5 Specialty |
33% | N/A | P |
HUMIRA 40MG/0.8ML SYRINGE |
5 |
Tier 5 Specialty |
33% | N/A | P |
HUMIRA PEN KIT 40MG-70% 1 PKGCOM |
5 |
Tier 5 Specialty |
33% | N/A | P |
HUMULIN 50/50 VIAL |
2 |
Tier 2 Preferred Brand |
$42.00 | $84.00 | Q:1 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HUMULIN 70/30 PEN INJECTION 100UNT 1 X 3.0ML(PEN) CTG |
2 |
Tier 2 Preferred Brand |
$42.00 | $84.00 | Q:45 /30Days |
HUMULIN 70/30 VIAL |
2 |
Tier 2 Preferred Brand |
$42.00 | $84.00 | Q:1 /1Days |
HUMULIN N 100U/ML VIAL |
2 |
Tier 2 Preferred Brand |
$42.00 | $84.00 | Q:1 /1Days |
HUMULIN N PEN INJECTION 100UNT 1 X 3.0ML (PEN) CTG |
2 |
Tier 2 Preferred Brand |
$42.00 | $84.00 | Q:45 /30Days |
HUMULIN R 100U/ML VIAL |
2 |
Tier 2 Preferred Brand |
$42.00 | $84.00 | Q:1 /1Days |
HUMULIN R 500U/ML VIAL |
2 |
Tier 2 Preferred Brand |
$42.00 | $84.00 | Q:1 /1Days |
HYCAMTIN POWDER FOR INJECTION SOLUTION 4MG 1 VIAL |
5 |
Tier 5 Specialty |
33% | N/A | None |
HYCET SOL 7.5-325 |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
HYDRALAZINE 100MG TABLET |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
HYDRALAZINE 10MG TABLET |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
HYDRALAZINE 25MG TABLET |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDRALAZINE 50MG TABLET |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
HYDRALAZINE HCL INJECTION 20MG 25 X 1ML VIALSD |
4 |
Tier 4 Injectable |
33% | N/A | None |
HYDROCHLORIDE 50MG TABLET (1000 CT) |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
HYDROCHLOROTHIAZIDE 12.5MG CAPSULE (100 CT) |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
HYDROCHLOROTHIAZIDE 12.5MG TABLET |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
HYDROCHLOROTHIAZIDE 25MG TABLET |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
HYDROCODONE BITARTRATE AND ACETAMINOPHEN ORAL SOLUTION 500;7;7.5MG/15ML;% 4 FLO BOT |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
HYDROCODONE BITARTRATE AND ACETAMINOPHEN TABLET 500-7.5MG (120 CT) |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
HYDROCODONE BITARTRATE AND ACETAMINOPHEN TABLET 7.5-650MG (500 CT) |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
HYDROCODONE BITARTRATE AND IBUPROFEN TABLET 7.5-200MG (100 CT) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | None |
HYDROCODONE-ACETAMINOPHEN 10-750MG TABLET |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDROCODONE-ACETAMINOPHEN 10MG-500MG TABLET |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
HYDROCODONE-ACETAMINOPHEN 10MG-650MG TABLET |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
HYDROCODONE-ACETAMINOPHEN 5MG-325MG TABLET |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
HYDROCODONE-ACETAMINOPHEN 7.5-325MG TABLET |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
HYDROCODONE/APAP 10/325 TABLET |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
HYDROCODONE/APAP 10/660 TABLET |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
HYDROCODONE/APAP 2.5/500 TABLET |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
HYDROCODONE/APAP 5/500 TABLET |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
HYDROCODONE/APAP 7.5/750 TABLET |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
HYDROCORTISONE 0.2% CREAM |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | Q:2 /1Days |
HYDROCORTISONE 0.2% OINTMENT |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | Q:2 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDROCORTISONE 1% LOTION 118ML |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | Q:4 /1Days |
HYDROCORTISONE 1% OINTMENT |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | Q:2 /1Days |
HYDROCORTISONE 100MG ENEMA |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
HYDROCORTISONE 10MG TABLET |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
HYDROCORTISONE 20MG TABLET |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
HYDROCORTISONE 5MG TABLET |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
HYDROCORTISONE BUTYRATE 0.1% CREAM |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | Q:2 /1Days |
HYDROCORTISONE BUTYRATE 0.1% OINTMENT |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | Q:2 /1Days |
HYDROCORTISONE BUTYRATE 0.1% SOLUTION NON-ORAL |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | Q:4 /1Days |
HYDROCORTISONE CREAM 1% 1 LB JAR |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | Q:3 /1Days |
HYDROCORTISONE CREAM USP 2.5% 20GM TUBE |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | Q:2 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDROCORTISONE LOTION 2.5% 2 OZ BOT |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | Q:4 /1Days |
HYDROCORTISONE OINTMENT 1% 1 LB JAR |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | Q:2 /1Days |
HYDROCORTISONE OINTMENT USP 2.5% 20GM TUBE BOX |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | Q:2 /1Days |
HYDROMORPHON INJ 10MG/ML |
4 |
Tier 4 Injectable |
33% | N/A | None |
HYDROMORPHONE HCL 8MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
HYDROMORPHONE HYDROCHLORIDE TABLETS USP 2MG 100 BOT |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
HYDROMORPHONE HYDROCHLORIDE TABLETS USP 4MG 100 BOT |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
HYDROXYCHLOROQUINE 200MG TABLET (500 CT) |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
HYDROXYUREA 500MG CAPSULE |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
HYDROXYZINE 25MG/ML VIAL |
4 |
Tier 4 Injectable |
33% | N/A | None |
HYDROXYZINE 50MG/ML VIAL |
4 |
Tier 4 Injectable |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDROXYZINE HCL 10MG TABLET (500 CT) |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
HYDROXYZINE HCL 10MG/5ML ORAL SOLUTION 1 PT BOT |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
HYDROXYZINE HCL 25MG TABLET |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
HYDROXYZINE HCL TABLETS 50MG 100 BOT |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
HYDROXYZINE PAM 100MG CAPSULE |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
HYDROXYZINE PAM 50MG CAPSULE |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
HYDROXYZINE PAMOATE 25MG CAPSULE |
1 |
Tier 1 Preferred Generic |
$0.00 | $0.00 | None |
HYZAAR 100-12.5MG TABLET (90 CT) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | S Q:1 /1Days |
HYZAAR 100-25MG TABLET (90 CT) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | S Q:1 /1Days |
HYZAAR 50-12.5MG TABLET (5000 CT) |
3 |
Tier 3 Non-Preferred |
$95.00 | $238.00 | S Q:1 /1Days |