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2017 Medicare Part D Plan Formulary Information
Humana Walmart Rx Plan (PDP) (S5884-157-0) Benefit Details
The Humana Walmart Rx Plan (PDP) (S5884-157-0) Formulary Drugs Starting with the Letter H in CMS PDP Region 11 which includes: FL Plan Monthly Premium: $17.00 Deductible: $400 Qualifies for LIS: No
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
H.P. ACTHAR GEL 80 UNIT/ML VIAL	5	Specialty Tier	25%	N/A	P
Halobetasol Propionate 0.5mg/g 1 TUBE per CARTON / 50 g in 1 TUBE	4	Non-Preferred Drug	35%	30%	None
halobetasol propionate 0.5mg/g 50 g in 1 TUBE	4	Non-Preferred Drug	35%	30%	None
HALOPERIDOL 0.5MG TABLET	1*	Preferred Generic	$1.00	$0.00	None
Haloperidol 10mg/1 100 TABLET BOTTLE, PLASTIC	2*	Generic	$4.00	$8.00	None
HALOPERIDOL 1MG TABLET	1*	Preferred Generic	$1.00	$0.00	None
HALOPERIDOL 20MG TABLET (100 CT)	2*	Generic	$4.00	$8.00	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	4	Non-Preferred Drug	35%	30%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
HALOPERIDOL DEC 50MG 10 X 1ML PKG	4	Non-Preferred Drug	35%	30%	None
HALOPERIDOL LAC 2MG/ML CONC	2*	Generic	$4.00	$8.00	None
HALOPERIDOL LAC 5 MG/ML VIAL	2*	Generic	$4.00	$8.00	None
HARVONI 90-400 MG TABLET	5	Specialty Tier	25%	N/A	P Q:28 /28Days
HAVRIX HEPATITIS A VACCINE INACTIVATED INJECTION SOLUTION 1440UNITS 10 X 1ML VIALSD	4	Non-Preferred Drug	35%	30%	None
HAVRIX HEPATITIS A VACCINE INJECTION	4	Non-Preferred Drug	35%	30%	None
Heparin Sodium in Dextrose 5; 10000g/100mL; [USP'U]/100mL 24 CONTAINER in 1 CASE / 250 mL in 1 CONT	2*	Generic	$4.00	$8.00	None
Heparin Sodium in Dextrose 5; 4000g/100mL; [USP'U]/100mL 24 CONTAINER in 1 CASE / 500 mL in 1 CONTA	2*	Generic	$4.00	$8.00	None
Heparin Sodium in Dextrose 5; 5000g/100mL; [USP'U]/100mL 24 CONTAINER in 1 CASE / 500 mL in 1 CONTA	2*	Generic	$4.00	$8.00	None
HEPARIN SODIUM INJECTION	3	Preferred Brand	20%	15%	None
HEPARIN SODIUM INJECTION	3	Preferred Brand	20%	15%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
HEPARIN SODIUM INJECTION	3	Preferred Brand	20%	15%	None
HEPARIN SODIUM INJECTION	3	Preferred Brand	20%	15%	None
HEPATAMINE INJECTION 8%	4	Non-Preferred Drug	35%	30%	P
HEPATITIS B VACCINE RECOMBIANT ADULT FORMULATION INJECTION 10MCG 1ML VIALSD	4	Non-Preferred Drug	35%	30%	P
HERCEPTIN 440MG VIAL	5	Specialty Tier	25%	N/A	P
HETLIOZ 20 MG CAPSULE	5	Specialty Tier	25%	N/A	P Q:30 /30Days
HEXALEN 50MG CAPSULES	5	Specialty Tier	25%	N/A	None
HIBERIX VACCINE WITH DILUENT	4	Non-Preferred Drug	35%	30%	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
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
HUMIRA PEDIATRIC CROHN'S START	5	Specialty Tier	25%	N/A	P Q:6 /28Days
HUMIRA PEDIATRIC CROHN'S START	5	Specialty Tier	25%	N/A	P Q:6 /28Days
HUMIRA PEN KIT 40MG-70% 1 PKGCOM	5	Specialty Tier	25%	N/A	P Q:6 /28Days
HUMIRA PEN PSORIASIS-UVEITIS	5	Specialty Tier	25%	N/A	P Q:6 /28Days
HUMULIN R 500 UNITS/ML KWIKPEN	5	Specialty Tier	25%	N/A	None
HUMULIN R 500U/ML VIAL	5	Specialty Tier	25%	N/A	None
HYCAMTIN 4 MG VIAL	5	Specialty Tier	25%	N/A	None
HYDRALAZINE 10 MG TABLET	1*	Preferred Generic	$1.00	$0.00	None
HYDRALAZINE 100 MG TABLET	2*	Generic	$4.00	$8.00	None
HYDRALAZINE 20 MG/ML VIAL	3	Preferred Brand	20%	15%	None
HYDRALAZINE 25 MG TABLET	1*	Preferred Generic	$1.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
HYDRALAZINE 50 MG TABLET	2*	Generic	$4.00	$8.00	None
HYDROCHLOROTHIAZIDE 12.5 MG CP	1*	Preferred Generic	$1.00	$0.00	None
HYDROCHLOROTHIAZIDE 12.5MG TABLET	2*	Generic	$4.00	$8.00	None
Hydrochlorothiazide 25 mg tab	1*	Preferred Generic	$1.00	$0.00	None
Hydrochlorothiazide 50mg/1 1000 TABLET BOTTLE	1*	Preferred Generic	$1.00	$0.00	None
Hydrocodone Acetaminophen 2.5-325	3	Preferred Brand	20%	15%	Q:360 /30Days
Hydrocodone Acetaminophen 325; 10mg/1; mg/1 500 TABLET BOTTLE	3	Preferred Brand	20%	15%	Q:360 /30Days
HYDROCODONE BITARTRATE AND IBUPROFEN TABLET 7.5-200MG (100 CT)	3	Preferred Brand	20%	15%	Q:150 /30Days
HYDROCODONE-ACETAMINOPHEN 5MG-325MG TABLET	3	Preferred Brand	20%	15%	Q:360 /30Days
HYDROCODONE-ACETAMINOPHEN 7.5-325MG TABLET	3	Preferred Brand	20%	15%	Q:360 /30Days
HYDROCODONE-IBUPROFEN 10-200	4	Non-Preferred Drug	35%	30%	Q:150 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
HYDROCODONE-IBUPROFEN 5-200 MG	4	Non-Preferred Drug	35%	30%	Q:150 /30Days
HYDROCORTISONE 0.1% SOLN	4	Non-Preferred Drug	35%	30%	None
HYDROCORTISONE 0.2% CREAM	4	Non-Preferred Drug	35%	30%	None
HYDROCORTISONE 0.2% OINTMENT	4	Non-Preferred Drug	35%	30%	None
HYDROCORTISONE 100 MG/60 ML	3	Preferred Brand	20%	15%	None
HYDROCORTISONE 10MG TABLET	2*	Generic	$4.00	$8.00	None
HYDROCORTISONE 2.5% LOTION	2*	Generic	$4.00	$8.00	None
Hydrocortisone 20mg 100 TABLET BOTTLE	2*	Generic	$4.00	$8.00	None
Hydrocortisone 25mg/g 1 TUBE in 1 TUBE / 30 g in 1 TUBE	1*	Preferred Generic	$1.00	$0.00	None
HYDROCORTISONE 5MG TABLET	2*	Generic	$4.00	$8.00	None
Hydrocortisone and Acetic Acid 2.41; 3.15g/100mL; g/100mL 1 BOTTLE per CARTON / 10 mL in 1 BOTTLE	4	Non-Preferred Drug	35%	30%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
HYDROCORTISONE BUTYR 0.1% OINT	4	Non-Preferred Drug	35%	30%	None
HYDROCORTISONE CREAM 1% 1 LB JAR	1*	Preferred Generic	$1.00	$0.00	None
HYDROCORTISONE OINTMENT 1% 1 LB JAR	2*	Generic	$4.00	$8.00	None
HYDROCORTISONE OINTMENT USP 2.5% 20GM TUBE BOX	2*	Generic	$4.00	$8.00	None
HYDROMORPHONE 10 MG/ML 5ML	4	Non-Preferred Drug	35%	30%	Q:144 /30Days
HYDROMORPHONE 10 MG/ML VIAL	4	Non-Preferred Drug	35%	30%	Q:144 /30Days
Hydromorphone 2 mg/ml Syringe	4	Non-Preferred Drug	35%	30%	Q:360 /30Days
HYDROMORPHONE HCL 8MG TABLET (100 CT)	3	Preferred Brand	20%	15%	Q:240 /30Days
HYDROMORPHONE HYDROCHLORIDE 2MG TABLETS	3	Preferred Brand	20%	15%	Q:360 /30Days
HYDROMORPHONE HYDROCHLORIDE 4MG TABLETS	3	Preferred Brand	20%	15%	Q:360 /30Days
HYDROXYCHLOROQUINE 200MG TABLET (500 CT)	4	Non-Preferred Drug	35%	30%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Hydroxyurea 500 mg capsule	2*	Generic	$4.00	$8.00	None
HYDROXYZINE 10 MG/5 ML SOLN	3	Preferred Brand	20%	15%	None
HYDROXYZINE 25MG/ML VIAL	3	Preferred Brand	20%	15%	None
HYDROXYZINE 50MG/ML VIAL	3	Preferred Brand	20%	15%	None
HYDROXYZINE HCL 10 MG TABLET	3	Preferred Brand	20%	15%	None
HYDROXYZINE HCL 25 MG TABLET	3	Preferred Brand	20%	15%	None
Hydroxyzine hcl 50 mg tablet	3	Preferred Brand	20%	15%	None
HYDROXYZINE PAM 100MG CAPSULE	3	Preferred Brand	20%	15%	None
Hydroxyzine pam 25 mg cap	3	Preferred Brand	20%	15%	None
Hydroxyzine pam 50 mg cap	3	Preferred Brand	20%	15%	None
HYPERRAB S-D 150 UNITS/ML VIAL	5	Specialty Tier	25%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
HYPERRAB S-D 150 UNITS/ML VIAL	5	Specialty Tier	25%	N/A	P

Chart Legend:

Below are a few notes to help you understand the above 2017 Medicare Part D Humana Walmart Rx Plan (PDP) 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.