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2017 Medicare Part D Plan Formulary Information
Fidelis Dual Advantage (HMO SNP) (H3328-002-0) Benefit Details
The Fidelis Dual Advantage (HMO SNP) (H3328-002-0) Formulary Drugs Starting with the Letter H in Saratoga County, NY: CMS MA Region 3 which includes: NY Plan Monthly Premium: $34.60 Deductible: $400
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 0.5mg/g 1 TUBE per CARTON / 50 g in 1 TUBE	2	Generic	$20.00	N/A	None
halobetasol propionate 0.5mg/g 50 g in 1 TUBE	2	Generic	$20.00	N/A	None
HALOPERIDOL 0.5MG TABLET	2	Generic	$20.00	N/A	None
Haloperidol 10mg/1 100 TABLET BOTTLE, PLASTIC	2	Generic	$20.00	N/A	None
HALOPERIDOL 1MG TABLET	2	Generic	$20.00	N/A	None
HALOPERIDOL 20MG TABLET (100 CT)	2	Generic	$20.00	N/A	None
HALOPERIDOL 2MG TABLET (100 CT)	2	Generic	$20.00	N/A	None
HALOPERIDOL 5MG TABLET	2	Generic	$20.00	N/A	None
HALOPERIDOL DEC 100MG/ML VL	2	Generic	$20.00	N/A	None
HALOPERIDOL DEC 50MG 10 X 1ML PKG	2	Generic	$20.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
HALOPERIDOL LAC 2MG/ML CONC	2	Generic	$20.00	N/A	None
HALOPERIDOL LAC 5 MG/ML VIAL	2	Generic	$20.00	N/A	None
HAVRIX HEPATITIS A VACCINE INACTIVATED INJECTION SOLUTION 1440UNITS 10 X 1ML VIALSD	3	Preferred Brand	$47.00	N/A	None
HAVRIX HEPATITIS A VACCINE INJECTION	3	Preferred Brand	$47.00	N/A	None
Heparin Sodium in Dextrose 5; 10000g/100mL; [USP'U]/100mL 24 CONTAINER in 1 CASE / 250 mL in 1 CONT	3	Preferred Brand	$47.00	N/A	None
Heparin Sodium in Dextrose 5; 4000g/100mL; [USP'U]/100mL 24 CONTAINER in 1 CASE / 500 mL in 1 CONTA	3	Preferred Brand	$47.00	N/A	None
Heparin Sodium in Dextrose 5; 5000g/100mL; [USP'U]/100mL 24 CONTAINER in 1 CASE / 500 mL in 1 CONTA	3	Preferred Brand	$47.00	N/A	None
HEPARIN SODIUM INJECTION	2	Generic	$20.00	N/A	P
HEPARIN SODIUM INJECTION	2	Generic	$20.00	N/A	P
HEPARIN SODIUM INJECTION	2	Generic	$20.00	N/A	P
HEPARIN SODIUM INJECTION	2	Generic	$20.00	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
HEPATAMINE INJECTION 8%	4	Non-Preferred Drug	$100.00	N/A	P
HEPATITIS B VACCINE RECOMBIANT ADULT FORMULATION INJECTION 10MCG 1ML VIALSD	3	Preferred Brand	$47.00	N/A	P
HERCEPTIN 440MG VIAL	5	Specialty Tier	25%	N/A	P
HETLIOZ 20 MG CAPSULE	5	Specialty Tier	25%	N/A	P
HEXALEN 50MG CAPSULES	5	Specialty Tier	25%	N/A	None
HIBERIX VACCINE WITH DILUENT	3	Preferred Brand	$47.00	N/A	None
HUMIRA 10 MG/0.2 ML SYRINGE	5	Specialty Tier	25%	N/A	P Q:2 /28Days
Humira 2 KIT per CARTON / 1 KIT in 1 KIT	5	Specialty Tier	25%	N/A	P Q:6 /28Days
HUMIRA 40 MG/0.8 ML PEN	5	Specialty Tier	25%	N/A	P Q:6 /28Days
HUMIRA PEDIATRIC CROHN'S START	5	Specialty Tier	25%	N/A	P
HUMIRA PEDIATRIC CROHN'S START	5	Specialty Tier	25%	N/A	P
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	25%	N/A	P
HUMIRA PEN PSORIASIS-UVEITIS	5	Specialty Tier	25%	N/A	P
HUMULIN R 500 UNITS/ML KWIKPEN	5	Specialty Tier	25%	N/A	None
HUMULIN R 500U/ML VIAL	5	Specialty Tier	25%	N/A	P
HYDRALAZINE 10 MG TABLET	2	Generic	$20.00	N/A	None
HYDRALAZINE 100 MG TABLET	2	Generic	$20.00	N/A	None
HYDRALAZINE 20 MG/ML VIAL	2	Generic	$20.00	N/A	None
HYDRALAZINE 25 MG TABLET	2	Generic	$20.00	N/A	None
HYDRALAZINE 50 MG TABLET	2	Generic	$20.00	N/A	None
HYDROCHLOROTHIAZIDE 12.5 MG CP	1*	Preferred Generic	$0.00	N/A	None
HYDROCHLOROTHIAZIDE 12.5MG TABLET	1*	Preferred Generic	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Hydrochlorothiazide 25 mg tab	1*	Preferred Generic	$0.00	N/A	None
Hydrochlorothiazide 50mg/1 1000 TABLET BOTTLE	1*	Preferred Generic	$0.00	N/A	None
Hydrocodone Acetaminophen 325; 10mg/1; mg/1 500 TABLET BOTTLE	2	Generic	$20.00	N/A	Q:360 /30Days
Hydrocodone Bitartrate and Acetaminophen 325; 7.5mg/15mL; mg/15mL	2	Generic	$20.00	N/A	Q:5400 /30Days
HYDROCODONE BITARTRATE AND IBUPROFEN TABLET 7.5-200MG (100 CT)	2	Generic	$20.00	N/A	Q:150 /30Days
HYDROCODONE-ACETAMINOPHEN 5MG-325MG TABLET	2	Generic	$20.00	N/A	Q:360 /30Days
HYDROCODONE-ACETAMINOPHEN 7.5-325MG TABLET	2	Generic	$20.00	N/A	Q:360 /30Days
HYDROCORTISONE 0.1% SOLN	2	Generic	$20.00	N/A	None
HYDROCORTISONE 0.2% CREAM	2	Generic	$20.00	N/A	None
HYDROCORTISONE 0.2% OINTMENT	2	Generic	$20.00	N/A	None
HYDROCORTISONE 100 MG/60 ML	2	Generic	$20.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
HYDROCORTISONE 10MG TABLET	2	Generic	$20.00	N/A	None
HYDROCORTISONE 2.5% LOTION	2	Generic	$20.00	N/A	None
Hydrocortisone 20mg 100 TABLET BOTTLE	2	Generic	$20.00	N/A	None
Hydrocortisone 25mg/g 1 TUBE in 1 TUBE / 30 g in 1 TUBE	1*	Preferred Generic	$0.00	N/A	None
HYDROCORTISONE 5MG TABLET	2	Generic	$20.00	N/A	None
HYDROCORTISONE BUTYR 0.1% OINT	2	Generic	$20.00	N/A	None
HYDROCORTISONE CREAM 1% 1 LB JAR	1*	Preferred Generic	$0.00	N/A	None
HYDROCORTISONE OINTMENT 1% 1 LB JAR	1*	Preferred Generic	$0.00	N/A	None
HYDROCORTISONE OINTMENT USP 2.5% 20GM TUBE BOX	1*	Preferred Generic	$0.00	N/A	None
HYDROMORPHONE 1 MG/ML SOLUTION	2	Generic	$20.00	N/A	None
HYDROMORPHONE 10 MG/ML 5ML	2	Generic	$20.00	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
HYDROMORPHONE 10 MG/ML VIAL	2	Generic	$20.00	N/A	P
HYDROMORPHONE HCL 8MG TABLET (100 CT)	2	Generic	$20.00	N/A	Q:270 /30Days
HYDROMORPHONE HYDROCHLORIDE 2MG TABLETS	2	Generic	$20.00	N/A	Q:270 /30Days
HYDROMORPHONE HYDROCHLORIDE 4MG TABLETS	2	Generic	$20.00	N/A	Q:270 /30Days
HYDROXYCHLOROQUINE 200MG TABLET (500 CT)	2	Generic	$20.00	N/A	None
Hydroxyprogesterone 1.25 g/5ml [MAKENA]	4	Non-Preferred Drug	$100.00	N/A	P
Hydroxyurea 500 mg capsule	2	Generic	$20.00	N/A	None
HYDROXYZINE 10 MG/5 ML SOLN	4	Non-Preferred Drug	$100.00	N/A	P
HYDROXYZINE 25MG/ML VIAL	4	Non-Preferred Drug	$100.00	N/A	P
HYDROXYZINE 50MG/ML VIAL	4	Non-Preferred Drug	$100.00	N/A	P
HYDROXYZINE HCL 10 MG TABLET	4	Non-Preferred Drug	$100.00	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
HYDROXYZINE HCL 25 MG TABLET	4	Non-Preferred Drug	$100.00	N/A	P
Hydroxyzine hcl 50 mg tablet	4	Non-Preferred Drug	$100.00	N/A	P
HYDROXYZINE PAM 100MG CAPSULE	4	Non-Preferred Drug	$100.00	N/A	P
Hydroxyzine pam 25 mg cap	4	Non-Preferred Drug	$100.00	N/A	P
Hydroxyzine pam 50 mg cap	4	Non-Preferred Drug	$100.00	N/A	P

Chart Legend:

Below are a few notes to help you understand the above 2017 Medicare Part D Fidelis Dual Advantage (HMO SNP) 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 $400 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 intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $3700) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2017 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 September 2017 )

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.