2013 Medicare Part D Plan Formulary Information |
Cigna Medicare Rx Plan One (PDP) (S5617-215-0)
Benefit Details
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The Cigna Medicare Rx Plan One (PDP) (S5617-215-0) Formulary Drugs Starting with the Letter H in CMS PDP Region 6 which includes: PA WV
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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 |
H.P. Acthar 80[USP'U]/mL |
5 |
Specialty Tier |
25% | 25% | P |
Halaven 0.5mg/mL |
5 |
Specialty Tier |
25% | 25% | None |
HalfLytely and Bisacodyl Bowel Prep with Flavor Packs 1 KIT in 1 CARTON |
3 |
Preferred Brand Drugs |
$34.00 | $85.00 | None |
Halobetasol Propionate 0.5mg/g 1 TUBE in 1 CARTON / 50 g in 1 TUBE |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
Halobetasol Propionate 0.5mg/g 1 TUBE in 1 CARTON / 50 g in 1 TUBE |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
HALOPERIDOL 0.5MG TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
Haloperidol 10mg/1 100 TABLET BOTTLE, PLASTIC |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
HALOPERIDOL 1MG TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
HALOPERIDOL 20MG TABLET (100 CT) |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
HALOPERIDOL 2MG TABLET (100 CT) |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HALOPERIDOL 5MG TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
HALOPERIDOL DEC 100MG/ML VL |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
HALOPERIDOL DEC 50MG 10 X 1ML PKG |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
HALOPERIDOL LAC 2MG/ML CONC |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
HALOPERIDOL LAC 5MG/ML VIAL |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
HAVRIX HEPATITIS A VACCINE INACTIVATED INJECTION SOLUTION 1440UNITS 10 X 1ML VIALSD |
3 |
Preferred Brand Drugs |
$34.00 | $85.00 | None |
HAVRIX HEPATITIS A VACCINE INJECTION |
3 |
Preferred Brand Drugs |
$34.00 | $85.00 | None |
HECTOROL 0.5MCG CAPSULE |
4 |
Non-Preferred Brand Drugs |
$83.00 | $207.50 | P S |
HECTOROL 2.5MCG CAPSULE |
4 |
Non-Preferred Brand Drugs |
$83.00 | $207.50 | P S |
Hectorol 4ug/2mL |
4 |
Non-Preferred Brand Drugs |
$83.00 | $207.50 | P S |
HEPARIN 25000U-1/2NS 250ML |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HEPARIN 25000U-1/2NS 500ML |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
Heparin Sodium in Dextrose 5; 4000g/100mL; [USP'U]/100mL 24 CONTAINER in 1 CASE / 500 mL in 1 CONTA |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
HEPARIN SODIUM INJECTION |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | P |
HEPARIN SODIUM INJECTION |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
HEPARIN SODIUM INJECTION |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
HEPARIN SODIUM INJECTION |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
HEPARIN SODIUM INJECTION SOLUTION 200UNITS 12 X 1000ML CTR |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
HEPATAMINE INJECTION 8% |
3 |
Preferred Brand Drugs |
$34.00 | $85.00 | P |
HEPATASOL INJECTION 8% 500ML BAG |
3 |
Preferred Brand Drugs |
$34.00 | $85.00 | P |
HEPATITIS B VACCINE RECOMBIANT ADULT FORMULATION INJECTION 10MCG 1ML VIALSD |
3 |
Preferred Brand Drugs |
$34.00 | $85.00 | P |
HEPSERA 10MG TABLET |
5 |
Specialty Tier |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HERCEPTIN 440MG VIAL |
5 |
Specialty Tier |
25% | 25% | P |
HEXALEN CAPSULES |
5 |
Specialty Tier |
25% | 25% | None |
HORIZANT 600mg/1 30 TABLET BOTTLE |
4 |
Non-Preferred Brand Drugs |
$83.00 | $207.50 | None |
HUMALOG 100U/ML VIAL |
3 |
Preferred Brand Drugs |
$34.00 | $85.00 | None |
HUMALOG KWIKPEN INJECTION |
3 |
Preferred Brand Drugs |
$34.00 | $85.00 | None |
HUMALOG MIX 50/50 VIAL |
3 |
Preferred Brand Drugs |
$34.00 | $85.00 | None |
HUMALOG MIX 75/25 VIAL |
3 |
Preferred Brand Drugs |
$34.00 | $85.00 | None |
HUMALOG MIX KWIKPEN INJECTION |
3 |
Preferred Brand Drugs |
$34.00 | $85.00 | None |
HUMALOG MIX KWIKPEN INJECTION SUSPENSION |
3 |
Preferred Brand Drugs |
$34.00 | $85.00 | None |
HUMATROPE 12MG CARTRIDGE |
5 |
Specialty Tier |
25% | 25% | P |
HUMATROPE 24MG CARTRIDGE |
5 |
Specialty Tier |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HUMATROPE 5 MG VIAL |
5 |
Specialty Tier |
25% | 25% | P |
HUMATROPE 6MG CARTRIDGE |
5 |
Specialty Tier |
25% | 25% | P |
Humira 2 KIT in 1 CARTON / 1 KIT in 1 KIT |
5 |
Specialty Tier |
25% | 25% | P |
HUMIRA PEN KIT 40MG-70% 1 PKGCOM |
5 |
Specialty Tier |
25% | 25% | P |
Humulin 70/30 100[iU]/mL 5 SYRINGE in 1 CARTON / 3 mL in 1 SYRINGE |
3 |
Preferred Brand Drugs |
$34.00 | $85.00 | None |
HUMULIN 70/30 VIAL |
3 |
Preferred Brand Drugs |
$34.00 | $85.00 | None |
Humulin N 100[iU]/mL 5 SYRINGE in 1 CARTON / 3 mL in 1 SYRINGE |
3 |
Preferred Brand Drugs |
$34.00 | $85.00 | None |
HUMULIN N 100U/ML VIAL |
3 |
Preferred Brand Drugs |
$34.00 | $85.00 | None |
HUMULIN R 100U/ML VIAL |
3 |
Preferred Brand Drugs |
$34.00 | $85.00 | None |
HUMULIN R 500U/ML VIAL |
3 |
Preferred Brand Drugs |
$34.00 | $85.00 | None |
HYCAMTIN POWDER FOR INJECTION SOLUTION 4MG 1 VIAL |
5 |
Specialty Tier |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDRALAZINE 100MG TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
HYDRALAZINE 10MG TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
HYDRALAZINE 25MG TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
HYDRALAZINE 50MG TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
HYDRALAZINE HYDROCHLORIDE INJECTION USP |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
HYDROCHLOROTHIAZIDE 12.5MG CAPSULE (100 CT) |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
HYDROCHLOROTHIAZIDE 12.5MG TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
Hydrochlorothiazide 50mg/1 |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
HYDROCHLOROTHIAZIDE TABLETS 25MG |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
Hydrocodone Bitartrate and Acetaminophen 325; 7.5mg/15mL; mg/15mL |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | Q:5400 /30Days |
Hydrocodone Bitartrate and Acetaminophen 500; 7.5mg/1; mg/1 500 TABLET BOTTLE, PLASTIC |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | Q:240 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDROCODONE BITARTRATE AND ACETAMINOPHEN ORAL SOLUTION 500;7;7.5MG/15ML;% 4 FLO BOT |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | Q:3600 /30Days |
HYDROCODONE BITARTRATE AND ACETAMINOPHEN TABLET 7.5-650MG (500 CT) |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | Q:180 /30Days |
HYDROCODONE BITARTRATE AND IBUPROFEN TABLET 7.5-200MG (100 CT) |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | Q:180 /30Days |
HYDROCODONE-ACETAMINOPHEN 10-750MG TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | Q:150 /30Days |
HYDROCODONE-ACETAMINOPHEN 10MG-500MG TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | Q:240 /30Days |
HYDROCODONE-ACETAMINOPHEN 10MG-650MG TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | Q:180 /30Days |
HYDROCODONE-ACETAMINOPHEN 5MG-325MG TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | Q:360 /30Days |
HYDROCODONE-ACETAMINOPHEN 7.5-325MG TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | Q:360 /30Days |
HYDROCODONE/APAP 10/325 TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | Q:360 /30Days |
HYDROCODONE/APAP 10/660 TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | Q:180 /30Days |
HYDROCODONE/APAP 2.5/500 TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | Q:240 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDROCODONE/APAP 5/500 TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | Q:240 /30Days |
HYDROCODONE/APAP 7.5/750 TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | Q:150 /30Days |
HYDROCORTISONE 0.1% SOLN |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
HYDROCORTISONE 0.2% CREAM |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
HYDROCORTISONE 0.2% OINTMENT |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
Hydrocortisone 100mg/60mL 7 BOTTLE, WITH APPLICATOR in 1 BOX / 60 mL in 1 BOTTLE, WITH APPLICATOR |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
HYDROCORTISONE 10MG TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
Hydrocortisone 20mg 100 TABLET BOTTLE |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
Hydrocortisone 25mg/g 1 TUBE in 1 TUBE / 30 g in 1 TUBE |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
HYDROCORTISONE 5MG TABLET |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
Hydrocortisone and Acetic Acid 2.41; 3.15g/100mL; g/100mL 1 BOTTLE in 1 CARTON / 10 mL in 1 BOTTLE |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDROCORTISONE BUTY 0.1% CREAM |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
HYDROCORTISONE BUTYR 0.1% OINT |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
HYDROCORTISONE CREAM 1% 1 LB JAR |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
HYDROCORTISONE LOTION 2.5% 2 OZ BOT |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
HYDROCORTISONE OINTMENT 1% 1 LB JAR |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
HYDROCORTISONE OINTMENT USP 2.5% 20GM TUBE BOX |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
HYDROMORPHONE HCL 8MG TABLET (100 CT) |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | Q:240 /30Days |
Hydromorphone Hydrochloride 10mg/mL 1 VIAL in 1 CARTON / 50 mL in 1 VIAL |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
HYDROMORPHONE HYDROCHLORIDE TABLETS |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | Q:240 /30Days |
HYDROMORPHONE HYDROCHLORIDE TABLETS |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | Q:240 /30Days |
HYDROXYCHLOROQUINE 200MG TABLET (500 CT) |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDROXYUREA 500MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | None |
HYDROXYZINE 25MG/ML VIAL |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | P |
HYDROXYZINE 50MG/ML VIAL |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | P |
HYDROXYZINE HCL TABLETS 50MG 100 BOT |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | P |
Hydroxyzine Hydrochloride 10mg/1 |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | P |
HydrOXYzine Hydrochloride 10mg/5mL 473 mL in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | P |
Hydroxyzine Hydrochloride 25mg/1 500 FILM COATED TABLETS in BOTTLE, PLASTIC |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | P |
HYDROXYZINE PAM 100MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | P |
HYDROXYZINE PAM 50MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | P |
HYDROXYZINE PAMOATE 25MG CAPSULE |
2 |
Non-Preferred Generic Drugs |
$8.00 | $20.00 | P |