2018 Medicare Part D Plan Formulary Information |
First Health Part D Value Plus (PDP) (S5768-147-0)
Benefit Details
|
The First Health Part D Value Plus (PDP) (S5768-147-0) Formulary Drugs Starting with the Letter H in CMS PDP Region 24 which includes: KS Plan Monthly Premium: $56.20 Deductible: $0 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 |
Halaven 0.5mg/mL |
5 |
Specialty Tier |
33% | N/A | P |
HALOBETASOL PROP 0.05% CREAM |
4 |
Non-Preferred Drug |
46% | 46% | None |
Halobetasol Propionate 0.5mg/g 1 TUBE per CARTON / 50 g in 1 TUBE |
4 |
Non-Preferred Drug |
46% | 46% | None |
HALOPERIDOL 0.5 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
HALOPERIDOL 1 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
HALOPERIDOL 10 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
HALOPERIDOL 20MG TABLET (100 CT) |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
HALOPERIDOL 2MG TABLET (100 CT) |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
HALOPERIDOL 5 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
HALOPERIDOL DEC 100 MG/ML VIAL |
4 |
Non-Preferred Drug |
46% | 46% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HALOPERIDOL DEC 100 MG/ML VIAL |
4 |
Non-Preferred Drug |
46% | 46% | None |
HALOPERIDOL DEC 50MG 10 X 1ML PKG |
4 |
Non-Preferred Drug |
46% | 46% | None |
HALOPERIDOL LAC 2 MG/ML CONC |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
HALOPERIDOL LAC 5 MG/ML SYRING |
4 |
Non-Preferred Drug |
46% | 46% | None |
HALOPERIDOL LAC 5 MG/ML VIAL |
4 |
Non-Preferred Drug |
46% | 46% | None |
HARVONI 90-400 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
HAVRIX 1,440 UNITS/ML SYRINGE |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
HAVRIX 720 UNITS/0.5 ML VIAL |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
HAVRIX HEPATITIS A VACCINE INACTIVATED INJECTION SOLUTION 1440UNITS 10 X 1ML VIALSD |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
HAVRIX HEPATITIS A VACCINE INJECTION |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
HEPARIN SOD 1,000 UNIT/ML VIAL |
4 |
Non-Preferred Drug |
46% | 46% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HEPARIN SOD 5,000 UNIT/ML VIAL |
4 |
Non-Preferred Drug |
46% | 46% | None |
Heparin Sodium in Dextrose 5; 10000g/100mL; [USP'U]/100mL 24 CONTAINER in 1 CASE / 250 mL in 1 CONT |
4 |
Non-Preferred Drug |
46% | 46% | None |
Heparin Sodium in Dextrose 5; 4000g/100mL; [USP'U]/100mL 24 CONTAINER in 1 CASE / 500 mL in 1 CONTA |
4 |
Non-Preferred Drug |
46% | 46% | None |
Heparin Sodium in Dextrose 5; 5000g/100mL; [USP'U]/100mL 24 CONTAINER in 1 CASE / 500 mL in 1 CONTA |
4 |
Non-Preferred Drug |
46% | 46% | None |
HEPARIN SODIUM INJECTION |
4 |
Non-Preferred Drug |
46% | 46% | None |
HEPARIN SODIUM INJECTION |
4 |
Non-Preferred Drug |
46% | 46% | None |
HEPATAMINE INJECTION 8% |
4 |
Non-Preferred Drug |
46% | 46% | P |
Hepatitis B Surface Antigen Vaccine 0.01 MG/ML Prefilled 0.5 ML Syringe [Recombivax] |
3 |
Preferred Brand |
$47.00 | $141.00 | P |
HEPATITIS B VACCINE RECOMBIANT ADULT FORMULATION INJECTION 10MCG 1ML VIALSD |
3 |
Preferred Brand |
$47.00 | $141.00 | P |
HERCEPTIN 150 MG VIAL |
5 |
Specialty Tier |
33% | N/A | P |
HERCEPTIN 440MG VIAL |
5 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HETLIOZ 20 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P |
HEXALEN 50MG CAPSULES |
5 |
Specialty Tier |
33% | N/A | None |
HIBERIX VACCINE WITH DILUENT |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
HUMIRA 10 MG/0.1 ML SYRINGEKIT |
5 |
Specialty Tier |
33% | N/A | P Q:2 /28Days |
HUMIRA 10 MG/0.2 ML SYRINGE |
5 |
Specialty Tier |
33% | N/A | P Q:2 /28Days |
Humira 2 KIT per CARTON / 1 KIT in 1 KIT |
5 |
Specialty Tier |
33% | N/A | P Q:6 /28Days |
HUMIRA 20 MG/0.2 ML SYRINGEKIT |
5 |
Specialty Tier |
33% | N/A | P Q:2 /28Days |
HUMIRA 40 MG/0.4 ML PEN IJ KIT |
5 |
Specialty Tier |
33% | N/A | P Q:6 /28Days |
HUMIRA 40 MG/0.4 ML SYRINGEKIT |
5 |
Specialty Tier |
33% | N/A | P Q:6 /28Days |
HUMIRA 40 MG/0.8 ML PEN |
5 |
Specialty Tier |
33% | N/A | P Q:6 /28Days |
HUMIRA PED CROHNS 80 MG/0.8 ML SYRINGEKIT |
5 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HUMIRA PEDIATR CROHN'S 80-40MG SYRINGEKIT |
5 |
Specialty Tier |
33% | N/A | P |
HUMIRA PEDIATRIC CROHN'S START |
5 |
Specialty Tier |
33% | N/A | P |
HUMIRA PEDIATRIC CROHN'S START |
5 |
Specialty Tier |
33% | N/A | P |
HUMIRA PEN KIT 40MG-70% 1 PKGCOM |
5 |
Specialty Tier |
33% | N/A | P |
HUMIRA PEN PSORIASIS-UVEITIS |
5 |
Specialty Tier |
33% | N/A | P |
HUMULIN R 500 UNITS/ML KWIKPEN |
5 |
Specialty Tier |
33% | N/A | None |
HUMULIN R 500U/ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
HYDRALAZINE 10 MG TABLET |
2 |
Generic |
$5.00 | $15.00 | None |
HYDRALAZINE 100 MG TABLET |
2 |
Generic |
$5.00 | $15.00 | None |
HYDRALAZINE 20 MG/ML VIAL |
4 |
Non-Preferred Drug |
46% | 46% | None |
HYDRALAZINE 25 MG TABLET |
2 |
Generic |
$5.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDRALAZINE 50 MG TABLET |
2 |
Generic |
$5.00 | $15.00 | None |
Hydrochlorothiazide 12.5 MG Oral Capsule |
1 |
Preferred Generic |
$2.00 | $6.00 | None |
HYDROCHLOROTHIAZIDE 12.5 MG TB |
1 |
Preferred Generic |
$2.00 | $6.00 | None |
HYDROCHLOROTHIAZIDE 25 MG TAB |
1 |
Preferred Generic |
$2.00 | $6.00 | None |
HYDROCHLOROTHIAZIDE 50 MG TAB |
1 |
Preferred Generic |
$2.00 | $6.00 | None |
HYDROCODON-ACETAMINOPH 2.5-325 |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days |
HYDROCODON-ACETAMINOPH 7.5-325 |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days |
HYDROCODON-ACETAMINOPHEN 5-325 |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days |
HYDROCODON-ACETAMINOPHN 10-325 |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days |
Hydrocodone Bitartrate and Acetaminophen 300; 10mg/1; mg/1 |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days |
Hydrocodone Bitartrate and Acetaminophen 300; 5mg/1; mg/1 |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Hydrocodone Bitartrate and Acetaminophen 300; 7.5mg/1; mg/1 |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days |
Hydrocodone Bitartrate and Acetaminophen 325; 7.5mg/15mL; mg/15mL |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:5550 /30Days |
HYDROCODONE BITARTRATE AND IBUPROFEN TABLET 7.5-200MG (100 CT) |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:150 /30Days |
HYDROCODONE-IBUPROFEN 10-200 |
4 |
Non-Preferred Drug |
46% | 46% | Q:150 /30Days |
HYDROCODONE-IBUPROFEN 5-200 MG |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:150 /30Days |
HYDROCORTISONE 0.1% SOLN |
4 |
Non-Preferred Drug |
46% | 46% | None |
HYDROCORTISONE 1% CREAM |
1 |
Preferred Generic |
$2.00 | $6.00 | None |
HYDROCORTISONE 1% OINTMENT |
1 |
Preferred Generic |
$2.00 | $6.00 | None |
Hydrocortisone 10 MG/ML Topical Cream [Ala-Cort] |
1 |
Preferred Generic |
$2.00 | $6.00 | None |
HYDROCORTISONE 100 MG/60 ML |
2 |
Generic |
$5.00 | $15.00 | None |
HYDROCORTISONE 10MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDROCORTISONE 2.5% CREAM |
1 |
Preferred Generic |
$2.00 | $6.00 | None |
HYDROCORTISONE 2.5% LOTION |
2 |
Generic |
$5.00 | $15.00 | None |
HYDROCORTISONE 2.5% OINTMENT |
1 |
Preferred Generic |
$2.00 | $6.00 | None |
Hydrocortisone 20mg 100 TABLET BOTTLE |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
HYDROCORTISONE 5MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
HYDROCORTISONE BUTY 0.1% CREAM |
4 |
Non-Preferred Drug |
46% | 46% | None |
HYDROCORTISONE BUTYR 0.1% OINT |
4 |
Non-Preferred Drug |
46% | 46% | None |
HYDROCORTISONE VAL 0.2% CREAM |
4 |
Non-Preferred Drug |
46% | 46% | None |
HYDROCORTISONE VAL 0.2% OINTMT |
4 |
Non-Preferred Drug |
46% | 46% | None |
HYDROCORTISONE-ACETIC ACID SOLN |
4 |
Non-Preferred Drug |
46% | 46% | None |
HYDROMORPHONE 1 MG/ML SOLUTION [Dilaudid] |
4 |
Non-Preferred Drug |
46% | 46% | Q:2400 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDROMORPHONE 10 MG/ML VIAL [Dilaudid-HP] |
4 |
Non-Preferred Drug |
46% | 46% | P |
HYDROMORPHONE 2 MG TABLET [Dilaudid] |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days |
HYDROMORPHONE 2 MG/ML ISECURE Syringe [Simplist Dilaudid] |
4 |
Non-Preferred Drug |
46% | 46% | P |
HYDROMORPHONE 4 MG TABLET [Dilaudid] |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days |
HYDROMORPHONE 50 MG/5 ML VIAL [Dilaudid-HP] |
4 |
Non-Preferred Drug |
46% | 46% | P |
HYDROMORPHONE 8 MG TABLET [Dilaudid] |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days |
HYDROMORPHONE HCL ER 12 MG Tablet 24H [Exalgo] |
4 |
Non-Preferred Drug |
46% | 46% | Q:30 /30Days |
HYDROMORPHONE HCL ER 16 MG Tablet 24H [Exalgo] |
4 |
Non-Preferred Drug |
46% | 46% | Q:30 /30Days |
HYDROMORPHONE HCL ER 32 MG Tablet 24H [Exalgo] |
4 |
Non-Preferred Drug |
46% | 46% | Q:30 /30Days |
HYDROMORPHONE HCL ER 8 MG Tablet 24H [Exalgo] |
4 |
Non-Preferred Drug |
46% | 46% | Q:30 /30Days |
HYDROXYCHLOROQUINE 200 MG TAB |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDROXYPROGESTERONE 1.25 G/5ML [MAKENA] |
5 |
Specialty Tier |
33% | N/A | P |
HYDROXYUREA 500 MG CAPSULE |
2 |
Generic |
$5.00 | $15.00 | None |
HYDROXYZINE 10 MG/5 ML SOLN |
4 |
Non-Preferred Drug |
46% | 46% | P |
HYDROXYZINE 25MG/ML VIAL |
4 |
Non-Preferred Drug |
46% | 46% | P |
HYDROXYZINE 50MG/ML VIAL |
4 |
Non-Preferred Drug |
46% | 46% | P |
HYDROXYZINE HCL 10 MG TABLET |
4 |
Non-Preferred Drug |
46% | 46% | P |
HYDROXYZINE HCL 25 MG TABLET |
4 |
Non-Preferred Drug |
46% | 46% | P |
HYDROXYZINE HCL 50 MG TABLET |
4 |
Non-Preferred Drug |
46% | 46% | P |
HYDROXYZINE PAM 100MG CAPSULE |
4 |
Non-Preferred Drug |
46% | 46% | P |
HYDROXYZINE PAM 25 MG CAP |
4 |
Non-Preferred Drug |
46% | 46% | P |
HYDROXYZINE PAM 50 MG CAP |
4 |
Non-Preferred Drug |
46% | 46% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYSINGLA ER 100 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days |
HYSINGLA ER 120 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days |
HYSINGLA ER 20 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days |
HYSINGLA ER 30 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days |
HYSINGLA ER 40 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days |
HYSINGLA ER 60 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days |
HYSINGLA ER 80 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days |