2014 Medicare Part D Plan Formulary Information |
United American - Enhanced (PDP) (S5755-016-0)
Benefit Details
|
The United American - Enhanced (PDP) (S5755-016-0) Formulary Drugs Starting with the Letter H in CMS PDP Region 13 which includes: MI Plan Monthly Premium: $57.80 Deductible: $110 Qualifies for LIS: No |
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 GEL 80 UNIT/ML VIAL |
5 |
Specialty Tier |
30% | 30% | P |
Halaven 0.5mg/mL |
5 |
Specialty Tier |
30% | 30% | None |
HALDOL 5MG/ML INJECTION |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
HALDOL DECANOATE 100MG/ML INJECTION |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
HALDOL DECANOATE 50MG/ML INJECTION |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
HalfLytely and Bisacodyl Bowel Prep with Flavor Packs 1 KIT per CARTON |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Halobetasol Propionate 0.5mg/g 1 TUBE per CARTON / 50 g in 1 TUBE |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | None |
halobetasol propionate 0.5mg/g 50 g in 1 TUBE |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | None |
Halog 1mg/g 60 g in 1 TUBE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | S |
HALOG OINTMENT 1mg/g 60 g in 1 TUBE [HALOG] |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HALOPERIDOL 0.5MG TABLET |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
Haloperidol 10mg/1 100 TABLET BOTTLE, PLASTIC |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
HALOPERIDOL 1MG TABLET |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
HALOPERIDOL 20MG TABLET (100 CT) |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
HALOPERIDOL 2MG TABLET (100 CT) |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
HALOPERIDOL 5MG TABLET |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
HALOPERIDOL DEC 100MG/ML VL |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | None |
HALOPERIDOL DEC 50MG 10 X 1ML PKG |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | None |
HALOPERIDOL LAC 2MG/ML CONC |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | None |
HALOPERIDOL LAC 5MG/ML VIAL |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | None |
HAVRIX HEPATITIS A VACCINE INACTIVATED INJECTION SOLUTION 1440UNITS 10 X 1ML VIALSD |
3 |
Preferred Brand |
$37.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HAVRIX HEPATITIS A VACCINE INJECTION |
3 |
Preferred Brand |
$37.00 | $90.00 | None |
HECTOROL 0.5MCG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
HECTOROL 2.5MCG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Hectorol 4ug/2mL |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
HEPARIN 25000U-1/2NS 250ML |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | None |
HEPARIN 25000U-1/2NS 500ML |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | 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 |
$7.00 | $39.00 | None |
HEPARIN SODIUM INJECTION |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | None |
HEPARIN SODIUM INJECTION |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | None |
HEPARIN SODIUM INJECTION |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | None |
HEPARIN SODIUM INJECTION |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HEPARIN SODIUM INJECTION SOLUTION 200UNITS 12 X 1000ML CTR |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | None |
HEPATAMINE INJECTION 8% |
3 |
Preferred Brand |
$37.00 | $90.00 | None |
HEPATASOL INJECTION 8% 500ML BAG |
3 |
Preferred Brand |
$37.00 | $90.00 | None |
HEPATITIS B VACCINE RECOMBIANT ADULT FORMULATION INJECTION 10MCG 1ML VIALSD |
3 |
Preferred Brand |
$37.00 | $90.00 | P |
HEPSERA 10MG TABLET |
5 |
Specialty Tier |
30% | 30% | None |
HERCEPTIN 440MG VIAL |
5 |
Specialty Tier |
30% | 30% | None |
HETLIOZ 20 MG CAPSULE |
5 |
Specialty Tier |
30% | 30% | None |
HEXALEN 50MG CAPSULES |
5 |
Specialty Tier |
30% | 30% | None |
HIPREX 1GM TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
HORIZANT 600mg/1 30 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | P |
HORIZANT ER 300 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HUMALOG 100U/ML VIAL |
3 |
Preferred Brand |
$37.00 | $90.00 | None |
HUMALOG KWIKPEN INJECTION |
3 |
Preferred Brand |
$37.00 | $90.00 | None |
HUMALOG MIX 50/50 VIAL |
3 |
Preferred Brand |
$37.00 | $90.00 | None |
HUMALOG MIX 75/25 VIAL |
3 |
Preferred Brand |
$37.00 | $90.00 | None |
HUMALOG MIX KWIKPEN INJECTION |
3 |
Preferred Brand |
$37.00 | $90.00 | None |
HUMALOG MIX KWIKPEN INJECTION SUSPENSION |
3 |
Preferred Brand |
$37.00 | $90.00 | None |
HUMATROPE 12MG CARTRIDGE |
5 |
Specialty Tier |
30% | 30% | P |
HUMATROPE 24MG CARTRIDGE |
5 |
Specialty Tier |
30% | 30% | P |
HUMATROPE 5 MG VIAL |
5 |
Specialty Tier |
30% | 30% | P |
HUMATROPE 6MG CARTRIDGE |
5 |
Specialty Tier |
30% | 30% | P |
Humira 2 KIT per CARTON / 1 KIT in 1 KIT |
5 |
Specialty Tier |
30% | 30% | P Q:13 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HUMIRA PEN KIT 40MG-70% 1 PKGCOM |
5 |
Specialty Tier |
30% | 30% | P Q:6 /180Days |
Humulin 70/30 100[iU]/mL 5 SYRINGE per CARTON / 3 mL in 1 SYRINGE |
3 |
Preferred Brand |
$37.00 | $90.00 | None |
HUMULIN 70/30 VIAL |
3 |
Preferred Brand |
$37.00 | $90.00 | None |
Humulin N 100[iU]/mL 5 SYRINGE per CARTON / 3 mL in 1 SYRINGE |
3 |
Preferred Brand |
$37.00 | $90.00 | None |
HUMULIN N 100U/ML VIAL |
3 |
Preferred Brand |
$37.00 | $90.00 | None |
HUMULIN R 100U/ML VIAL |
3 |
Preferred Brand |
$37.00 | $90.00 | None |
HUMULIN R 500U/ML VIAL |
3 |
Preferred Brand |
$37.00 | $90.00 | None |
HYCAMTIN POWDER FOR INJECTION SOLUTION 4MG 1 VIAL |
5 |
Specialty Tier |
30% | 30% | None |
HYCET 7.5 MG-325 MG/15 ML SOL |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | Q:5550 /30Days |
HYDRALAZINE 100MG TABLET |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | None |
HYDRALAZINE 10MG TABLET |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDRALAZINE 25MG TABLET |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | None |
HYDRALAZINE 50MG TABLET |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | None |
HYDRALAZINE HYDROCHLORIDE 20MG/ML INJECTION USP |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | None |
HYDREA 500MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
HYDROCHLOROTHIAZIDE 12.5MG CAPSULE (100 CT) |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
HYDROCHLOROTHIAZIDE 12.5MG TABLET |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
HYDROCHLOROTHIAZIDE 50 MG TAB |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
HYDROCHLOROTHIAZIDE TABLETS 25MG |
1* |
Preferred Generic |
$1.00 | $0.00 | None |
Hydrocodone Bitartrate and Acetaminophen 300; 10mg/1; mg/1 |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | Q:1080 /90Days |
Hydrocodone Bitartrate and Acetaminophen 300; 5mg/1; mg/1 |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | Q:1080 /90Days |
Hydrocodone Bitartrate and Acetaminophen 300; 7.5mg/1; mg/1 |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | Q:1080 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Hydrocodone Bitartrate and Acetaminophen 325; 7.5mg/15mL; mg/15mL |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | Q:5550 /30Days |
HYDROCODONE BITARTRATE AND IBUPROFEN TABLET 7.5-200MG (100 CT) |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | Q:150 /90Days |
HYDROCODONE-ACETAMINOPHEN 5MG-325MG TABLET |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | Q:1080 /90Days |
HYDROCODONE-ACETAMINOPHEN 7.5-325MG TABLET |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | Q:1080 /90Days |
HYDROCODONE/APAP 10/325 TABLET |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | Q:1080 /90Days |
HYDROCORTISONE 0.1% SOLN |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | None |
HYDROCORTISONE 0.2% CREAM |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | None |
HYDROCORTISONE 0.2% OINTMENT |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | None |
Hydrocortisone 100mg/60mL 7 BOTTLE, WITH APPLICATOR in 1 BOX / 60 mL in 1 BOTTLE, WITH APPLICATOR |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | None |
HYDROCORTISONE 10MG TABLET |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | None |
Hydrocortisone 20mg 100 TABLET BOTTLE |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Hydrocortisone 25mg/g 1 TUBE in 1 TUBE / 30 g in 1 TUBE |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | None |
HYDROCORTISONE 5MG TABLET |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | None |
Hydrocortisone and Acetic Acid 2.41; 3.15g/100mL; g/100mL 1 BOTTLE per CARTON / 10 mL in 1 BOTTLE |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | None |
HYDROCORTISONE BUTY 0.1% CREAM |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | None |
HYDROCORTISONE BUTYR 0.1% OINT |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | None |
HYDROCORTISONE BUTYRATE 0.1% lipo cream |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | None |
HYDROCORTISONE CREAM 1% 1 LB JAR |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | None |
HYDROCORTISONE LOTION 2.5% 2 OZ BOT |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | None |
HYDROCORTISONE OINTMENT 1% 1 LB JAR |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | None |
HYDROCORTISONE OINTMENT USP 2.5% 20GM TUBE BOX |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | None |
HYDROMORPHONE 1 MG/ML SOLUTION |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | Q:4500 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDROMORPHONE HCL 8MG TABLET (100 CT) |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | Q:540 /90Days |
Hydromorphone Hydrochloride 10mg/mL 1 VIAL per CARTON / 50 mL in 1 VIAL |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | None |
HYDROMORPHONE HYDROCHLORIDE 2MG TABLETS |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | Q:540 /90Days |
HYDROMORPHONE HYDROCHLORIDE 4MG TABLETS |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | Q:540 /90Days |
HYDROXYCHLOROQUINE 200MG TABLET (500 CT) |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | None |
HYDROXYUREA 500MG CAPSULE |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | None |
HYDROXYZINE 25MG/ML VIAL |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | None |
HYDROXYZINE 50MG/ML VIAL |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | None |
HYDROXYZINE HCL TABLETS 50MG 100 BOT |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | P |
Hydroxyzine Hydrochloride 10mg/1 |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | P |
HydrOXYzine Hydrochloride 10mg/5mL 473 mL in 1 BOTTLE, PLASTIC |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Hydroxyzine Hydrochloride 25mg/1 500 FILM COATED TABLETS in BOTTLE, PLASTIC |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | P |
HYDROXYZINE PAM 100MG CAPSULE |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | P |
HYDROXYZINE PAM 50MG CAPSULE |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | P |
HYDROXYZINE PAMOATE 25MG CAPSULE |
2* |
Non-Preferred Generic |
$7.00 | $39.00 | P |
HYZAAR 100-12.5MG TABLET (90 CT) |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | S |
HYZAAR 100-25MG TABLET (90 CT) |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | S |
HYZAAR 12.5; 50mg/1; mg/1 1000 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | S |