2015 Medicare Part D Plan Formulary Information |
Freedom Blue PPO ValueRx (PPO) (H3916-033-0)
Benefit Details
|
The Freedom Blue PPO ValueRx (PPO) (H3916-033-0) Formulary Drugs Starting with the Letter H in BEDFORD County, PA: CMS MA Region 6 which includes: PA Plan Monthly Premium: $105.00 Deductible: $0 |
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 |
33% | 33% | P |
Halaven 0.5mg/mL |
5 |
Specialty Tier |
33% | 33% | None |
HALDOL 5MG/ML INJECTION |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
HALDOL DECANOATE 100MG/ML INJECTION |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
HALDOL DECANOATE 50MG/ML INJECTION |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
Halobetasol Propionate 0.5mg/g 1 TUBE per CARTON / 50 g in 1 TUBE |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | None |
halobetasol propionate 0.5mg/g 50 g in 1 TUBE |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | None |
Halog 1mg/g 60 g in 1 TUBE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
HALOG OINTMENT 1mg/g 60 g in 1 TUBE [HALOG] |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
HALOPERIDOL 0.5MG TABLET |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Haloperidol 10mg/1 100 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
HALOPERIDOL 1MG TABLET |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
HALOPERIDOL 20MG TABLET (100 CT) |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
HALOPERIDOL 2MG TABLET (100 CT) |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
HALOPERIDOL 5MG TABLET |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
HALOPERIDOL DEC 100MG/ML VL |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | None |
HALOPERIDOL DEC 50MG 10 X 1ML PKG |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | None |
HALOPERIDOL LAC 2MG/ML CONC |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
HALOPERIDOL LAC 5MG/ML VIAL |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | None |
HARVONI 90-400 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P Q:28 /28Days |
HAVRIX HEPATITIS A VACCINE INACTIVATED INJECTION SOLUTION 1440UNITS 10 X 1ML VIALSD |
3 |
Preferred Brand |
$45.00 | $112.50 | 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 |
$45.00 | $112.50 | None |
HECTOROL 0.5MCG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P |
HECTOROL 2.5MCG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P |
Hectorol 4ug/2mL |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P |
Heparin Sodium in Dextrose 5; 10000g/100mL; [USP'U]/100mL 24 CONTAINER in 1 CASE / 250 mL in 1 CONT |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | 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 |
$15.00 | $37.50 | None |
Heparin Sodium in Dextrose 5; 5000g/100mL; [USP'U]/100mL 24 CONTAINER in 1 CASE / 500 mL in 1 CONTA |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | None |
HEPARIN SODIUM INJECTION |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | None |
HEPARIN SODIUM INJECTION |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | None |
HEPARIN SODIUM INJECTION |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | None |
HEPARIN SODIUM INJECTION |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HEPATAMINE INJECTION 8% |
3 |
Preferred Brand |
$45.00 | $112.50 | P |
HEPATITIS B VACCINE RECOMBIANT ADULT FORMULATION INJECTION 10MCG 1ML VIALSD |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P |
HEPSERA 10MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
HERCEPTIN 440MG VIAL |
5 |
Specialty Tier |
33% | 33% | None |
HETLIOZ 20 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | P |
HEXALEN 50MG CAPSULES |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
HIPREX 1GM TABLET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
HORIZANT ER 300 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P |
HORIZANT ER 600 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P |
HUMALOG 100 UNITS/ML CARTRIDGE |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
HUMALOG 100 UNITS/ML KWIKPEN |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Humalog 100[iU]/mL 1 VIAL in 1 CARTON / 3 mL in 1 VIAL |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
HUMALOG 200 UNITS/ML KWIKPEN |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
HUMALOG KWIKPEN INJECTION |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
HUMALOG MIX 50/50 VIAL |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
HUMALOG MIX 75/25 VIAL |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
HUMALOG MIX KWIKPEN INJECTION |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
HUMALOG MIX KWIKPEN INJECTION SUSPENSION |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
HUMATROPE 12MG CARTRIDGE |
5 |
Specialty Tier |
33% | 33% | P |
HUMATROPE 24MG CARTRIDGE |
5 |
Specialty Tier |
33% | 33% | P |
HUMATROPE 5 MG VIAL |
5 |
Specialty Tier |
33% | 33% | P |
HUMATROPE 6MG CARTRIDGE |
5 |
Specialty Tier |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HUMIRA 10 MG/0.2 ML SYRINGE |
5 |
Specialty Tier |
33% | 33% | P |
Humira 2 KIT per CARTON / 1 KIT in 1 KIT |
5 |
Specialty Tier |
33% | 33% | P |
HUMIRA PEN KIT 40MG-70% 1 PKGCOM |
5 |
Specialty Tier |
33% | 33% | P |
HUMULIN 70/30 KWIKPEN |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
HUMULIN 70/30 VIAL |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
HUMULIN N 100 UNITS/ML KWIKPEN |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
HUMULIN N 100U/ML VIAL |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
HUMULIN R 100U/ML VIAL |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
HUMULIN R 500U/ML VIAL |
3 |
Preferred Brand |
$45.00 | $112.50 | None |
HYCAMTIN POWDER FOR INJECTION SOLUTION 4MG 1 VIAL |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
HYCET 7.5 MG-325 MG/15 ML SOLN |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:5723 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDRALAZINE 100MG TABLET |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
HYDRALAZINE 10MG TABLET |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
HYDRALAZINE 20 MG/ML VIAL |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
HYDRALAZINE 25MG TABLET |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
HYDRALAZINE 50MG TABLET |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
HYDREA 500MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None |
HYDROCHLOROTHIAZIDE 12.5MG CAPSULE (100 CT) |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
HYDROCHLOROTHIAZIDE 12.5MG TABLET |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
Hydrochlorothiazide 50mg/1 1000 TABLET BOTTLE |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
HYDROCHLOROTHIAZIDE TABLETS 25MG |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
Hydrocodone Acetaminophen 2.5-325 |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | P Q:372 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Hydrocodone Acetaminophen 325; 10mg/1; mg/1 500 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | P Q:372 /31Days |
Hydrocodone Bitartrate and Acetaminophen 300; 10mg/1; mg/1 |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | P Q:403 /31Days |
Hydrocodone Bitartrate and Acetaminophen 300; 5mg/1; mg/1 |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | P Q:403 /31Days |
Hydrocodone Bitartrate and Acetaminophen 300; 7.5mg/1; mg/1 |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | P Q:403 /31Days |
Hydrocodone Bitartrate and Acetaminophen 325; 7.5mg/15mL; mg/15mL |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | P Q:5723 /31Days |
HYDROCODONE BITARTRATE AND IBUPROFEN TABLET 7.5-200MG (100 CT) |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | P |
HYDROCODONE-ACETAMINOPHEN 5MG-325MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | P Q:372 /31Days |
HYDROCODONE-ACETAMINOPHEN 7.5-325MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | P Q:372 /31Days |
HYDROCORTISONE 0.1% SOLN |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | None |
HYDROCORTISONE 0.2% CREAM |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | None |
HYDROCORTISONE 0.2% OINTMENT |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Hydrocortisone 100mg/60mL 7 BOTTLE, WITH APPLICATOR in 1 BOX / 60 mL in 1 BOTTLE, WITH APPLICATOR |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
HYDROCORTISONE 10MG TABLET |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
Hydrocortisone 20mg 100 TABLET BOTTLE |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
Hydrocortisone 25mg/g 1 TUBE in 1 TUBE / 30 g in 1 TUBE |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
HYDROCORTISONE 5MG TABLET |
1 |
Preferred Generic |
$4.00 | $10.00 | 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 |
$15.00 | $37.50 | None |
HYDROCORTISONE BUTYR 0.1% OINT |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | None |
HYDROCORTISONE BUTYRATE 0.1% lipo cream |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | None |
HYDROCORTISONE CREAM 1% 1 LB JAR |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
HYDROCORTISONE LOTION 2.5% 2 OZ BOT |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
HYDROCORTISONE OINTMENT 1% 1 LB JAR |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDROCORTISONE OINTMENT USP 2.5% 20GM TUBE BOX |
1 |
Preferred Generic |
$4.00 | $10.00 | None |
HYDROMORPHONE 1 MG/ML SOLUTION |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | P Q:2480 /31Days |
HYDROMORPHONE HCL 8MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | P Q:186 /31Days |
Hydromorphone hcl er 12 mg tab |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | P Q:62 /31Days |
Hydromorphone hcl er 16 mg tab |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | P Q:62 /31Days |
HYDROMORPHONE HCL ER 32 MG TAB |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | P Q:62 /31Days |
Hydromorphone hcl er 8 mg tab |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | P Q:62 /31Days |
Hydromorphone Hydrochloride 10mg/mL 1 VIAL per CARTON / 50 mL in 1 VIAL |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | P |
HYDROMORPHONE HYDROCHLORIDE 2MG TABLETS |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | P Q:186 /31Days |
HYDROMORPHONE HYDROCHLORIDE 4MG TABLETS |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | P Q:186 /31Days |
HYDROXYCHLOROQUINE 200MG TABLET (500 CT) |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Hydroxyurea 500 mg capsule |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | None |
HYPERRAB S-D 150 UNITS/ML VIAL |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P |
HYPERRAB S-D 150 UNITS/ML VIAL |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P |
HYSINGLA ER 100 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:31 /31Days |
HYSINGLA ER 120 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:31 /31Days |
HYSINGLA ER 20 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:31 /31Days |
HYSINGLA ER 30 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:31 /31Days |
HYSINGLA ER 40 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:31 /31Days |
HYSINGLA ER 60 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:31 /31Days |
HYSINGLA ER 80 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P Q:31 /31Days |