2018 Medicare Part D Plan Formulary Information |
Aetna Medicare Gold Plan (PPO) (H5521-122-0)
Benefit Details
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The Aetna Medicare Gold Plan (PPO) (H5521-122-0) Formulary Drugs Starting with the Letter H in Erie County, PA: CMS MA Region 6 which includes: PA Plan Monthly Premium: $156.00 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 |
Halaven 0.5mg/mL ![Compare how all Medicare Part D PDP plans in PA cover Halaven 0.5mg/mL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | P |
HALCION 0.25 MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover HALCION 0.25 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:60 /30Days |
HALDOL 5MG/ML INJECTION ![Compare how all Medicare Part D PDP plans in PA cover HALDOL 5MG/ML INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
HALDOL DECANOATE 100MG/ML INJECTION ![Compare how all Medicare Part D PDP plans in PA cover HALDOL DECANOATE 100MG/ML INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
HALDOL DECANOATE 50MG/ML INJECTION ![Compare how all Medicare Part D PDP plans in PA cover HALDOL DECANOATE 50MG/ML INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
HALOBETASOL PROP 0.05% CREAM ![Compare how all Medicare Part D PDP plans in PA cover HALOBETASOL PROP 0.05% CREAM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
Halobetasol Propionate 0.5mg/g 1 TUBE per CARTON / 50 g in 1 TUBE ![Compare how all Medicare Part D PDP plans in PA cover Halobetasol Propionate 0.5mg/g 1 TUBE per CARTON / 50 g in 1 TUBE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
Halog 1mg/g 60 g in 1 TUBE ![Compare how all Medicare Part D PDP plans in PA cover Halog 1mg/g 60 g in 1 TUBE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
HALOG OINTMENT 1mg/g 60 g in 1 TUBE [HALOG] ![Compare how all Medicare Part D PDP plans in PA cover HALOG OINTMENT 1mg/g 60 g in 1 TUBE [HALOG].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
HALOPERIDOL 0.5 MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover HALOPERIDOL 0.5 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$42.00 | $121.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HALOPERIDOL 1 MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover HALOPERIDOL 1 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$42.00 | $121.00 | None |
HALOPERIDOL 10 MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover HALOPERIDOL 10 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$42.00 | $121.00 | None |
HALOPERIDOL 20MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover HALOPERIDOL 20MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$42.00 | $121.00 | None |
HALOPERIDOL 2MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover HALOPERIDOL 2MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$42.00 | $121.00 | None |
HALOPERIDOL 5 MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover HALOPERIDOL 5 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$42.00 | $121.00 | None |
HALOPERIDOL DEC 100 MG/ML VIAL ![Compare how all Medicare Part D PDP plans in PA cover HALOPERIDOL DEC 100 MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
HALOPERIDOL DEC 100 MG/ML VIAL ![Compare how all Medicare Part D PDP plans in PA cover HALOPERIDOL DEC 100 MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
HALOPERIDOL DEC 50MG 10 X 1ML PKG ![Compare how all Medicare Part D PDP plans in PA cover HALOPERIDOL DEC 50MG 10 X 1ML PKG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
HALOPERIDOL LAC 2 MG/ML CONC ![Compare how all Medicare Part D PDP plans in PA cover HALOPERIDOL LAC 2 MG/ML CONC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$42.00 | $121.00 | None |
HALOPERIDOL LAC 5 MG/ML SYRING ![Compare how all Medicare Part D PDP plans in PA cover HALOPERIDOL LAC 5 MG/ML SYRING.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
HALOPERIDOL LAC 5 MG/ML VIAL ![Compare how all Medicare Part D PDP plans in PA cover HALOPERIDOL LAC 5 MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HARVONI 90-400 MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover HARVONI 90-400 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
HAVRIX 1,440 UNITS/ML SYRINGE ![Compare how all Medicare Part D PDP plans in PA cover HAVRIX 1,440 UNITS/ML SYRINGE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$42.00 | $121.00 | None |
HAVRIX 720 UNITS/0.5 ML VIAL ![Compare how all Medicare Part D PDP plans in PA cover HAVRIX 720 UNITS/0.5 ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$42.00 | $121.00 | None |
HAVRIX HEPATITIS A VACCINE INACTIVATED INJECTION SOLUTION 1440UNITS 10 X 1ML VIALSD ![Compare how all Medicare Part D PDP plans in PA cover HAVRIX HEPATITIS A VACCINE INACTIVATED INJECTION SOLUTION 1440UNITS 10 X 1ML VIALSD.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$42.00 | $121.00 | None |
HAVRIX HEPATITIS A VACCINE INJECTION ![Compare how all Medicare Part D PDP plans in PA cover HAVRIX HEPATITIS A VACCINE INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$42.00 | $121.00 | None |
Hectorol 4ug/2mL ![Compare how all Medicare Part D PDP plans in PA cover Hectorol 4ug/2mL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
HEPARIN SOD 1,000 UNIT/ML VIAL ![Compare how all Medicare Part D PDP plans in PA cover HEPARIN SOD 1,000 UNIT/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
HEPARIN SOD 5,000 UNIT/ML VIAL ![Compare how all Medicare Part D PDP plans in PA cover HEPARIN SOD 5,000 UNIT/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
Heparin Sodium in Dextrose 5; 10000g/100mL; [USP'U]/100mL 24 CONTAINER in 1 CASE / 250 mL in 1 CONT ![Compare how all Medicare Part D PDP plans in PA cover Heparin Sodium in Dextrose 5; 10000g/100mL; [USP'U]/100mL 24 CONTAINER in 1 CASE / 250 mL in 1 CONT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
Heparin Sodium in Dextrose 5; 4000g/100mL; [USP'U]/100mL 24 CONTAINER in 1 CASE / 500 mL in 1 CONTA ![Compare how all Medicare Part D PDP plans in PA cover Heparin Sodium in Dextrose 5; 4000g/100mL; [USP'U]/100mL 24 CONTAINER in 1 CASE / 500 mL in 1 CONTA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
Heparin Sodium in Dextrose 5; 5000g/100mL; [USP'U]/100mL 24 CONTAINER in 1 CASE / 500 mL in 1 CONTA ![Compare how all Medicare Part D PDP plans in PA cover Heparin Sodium in Dextrose 5; 5000g/100mL; [USP'U]/100mL 24 CONTAINER in 1 CASE / 500 mL in 1 CONTA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HEPARIN SODIUM INJECTION ![Compare how all Medicare Part D PDP plans in PA cover HEPARIN SODIUM INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
HEPARIN SODIUM INJECTION ![Compare how all Medicare Part D PDP plans in PA cover HEPARIN SODIUM INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
HEPATAMINE INJECTION 8% ![Compare how all Medicare Part D PDP plans in PA cover HEPATAMINE INJECTION 8%.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
Hepatitis B Surface Antigen Vaccine 0.01 MG/ML Prefilled 0.5 ML Syringe [Recombivax] ![Compare how all Medicare Part D PDP plans in PA cover Hepatitis B Surface Antigen Vaccine 0.01 MG/ML Prefilled 0.5 ML Syringe [Recombivax].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$42.00 | $121.00 | P |
HEPATITIS B VACCINE RECOMBIANT ADULT FORMULATION INJECTION 10MCG 1ML VIALSD ![Compare how all Medicare Part D PDP plans in PA cover HEPATITIS B VACCINE RECOMBIANT ADULT FORMULATION INJECTION 10MCG 1ML VIALSD.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$42.00 | $121.00 | P |
HERCEPTIN 150 MG VIAL ![Compare how all Medicare Part D PDP plans in PA cover HERCEPTIN 150 MG VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | P |
HERCEPTIN 440MG VIAL ![Compare how all Medicare Part D PDP plans in PA cover HERCEPTIN 440MG VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | P |
HETLIOZ 20 MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover HETLIOZ 20 MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | P |
HEXALEN 50MG CAPSULES ![Compare how all Medicare Part D PDP plans in PA cover HEXALEN 50MG CAPSULES.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | None |
HIBERIX VACCINE WITH DILUENT ![Compare how all Medicare Part D PDP plans in PA cover HIBERIX VACCINE WITH DILUENT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$42.00 | $121.00 | None |
HIPREX 1 GM TABLET ![Compare how all Medicare Part D PDP plans in PA cover HIPREX 1 GM TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HUMIRA 10 MG/0.1 ML SYRINGEKIT ![Compare how all Medicare Part D PDP plans in PA cover HUMIRA 10 MG/0.1 ML SYRINGEKIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | P Q:2 /28Days |
HUMIRA 10 MG/0.2 ML SYRINGE ![Compare how all Medicare Part D PDP plans in PA cover HUMIRA 10 MG/0.2 ML SYRINGE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | P Q:2 /28Days |
Humira 2 KIT per CARTON / 1 KIT in 1 KIT ![Compare how all Medicare Part D PDP plans in PA cover Humira 2 KIT per CARTON / 1 KIT in 1 KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | P Q:6 /28Days |
HUMIRA 20 MG/0.2 ML SYRINGEKIT ![Compare how all Medicare Part D PDP plans in PA cover HUMIRA 20 MG/0.2 ML SYRINGEKIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | P Q:2 /28Days |
HUMIRA 40 MG/0.4 ML PEN IJ KIT ![Compare how all Medicare Part D PDP plans in PA cover HUMIRA 40 MG/0.4 ML PEN IJ KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | P Q:6 /28Days |
HUMIRA 40 MG/0.4 ML SYRINGEKIT ![Compare how all Medicare Part D PDP plans in PA cover HUMIRA 40 MG/0.4 ML SYRINGEKIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | P Q:6 /28Days |
HUMIRA 40 MG/0.8 ML PEN ![Compare how all Medicare Part D PDP plans in PA cover HUMIRA 40 MG/0.8 ML PEN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | P Q:6 /28Days |
HUMIRA PED CROHNS 80 MG/0.8 ML SYRINGEKIT ![Compare how all Medicare Part D PDP plans in PA cover HUMIRA PED CROHNS 80 MG/0.8 ML SYRINGEKIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | P |
HUMIRA PEDIATR CROHN'S 80-40MG SYRINGEKIT ![Compare how all Medicare Part D PDP plans in PA cover HUMIRA PEDIATR CROHN'S 80-40MG SYRINGEKIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | P |
HUMIRA PEDIATRIC CROHN'S START ![Compare how all Medicare Part D PDP plans in PA cover HUMIRA PEDIATRIC CROHN'S START.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | P |
HUMIRA PEDIATRIC CROHN'S START ![Compare how all Medicare Part D PDP plans in PA cover HUMIRA PEDIATRIC CROHN'S START.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
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 PEN KIT 40MG-70% 1 PKGCOM ![Compare how all Medicare Part D PDP plans in PA cover HUMIRA PEN KIT 40MG-70% 1 PKGCOM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | P |
HUMIRA PEN PSORIASIS-UVEITIS ![Compare how all Medicare Part D PDP plans in PA cover HUMIRA PEN PSORIASIS-UVEITIS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | P |
HUMULIN R 500 UNITS/ML KWIKPEN ![Compare how all Medicare Part D PDP plans in PA cover HUMULIN R 500 UNITS/ML KWIKPEN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | None |
HUMULIN R 500U/ML VIAL ![Compare how all Medicare Part D PDP plans in PA cover HUMULIN R 500U/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | P |
HYDRALAZINE 10 MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover HYDRALAZINE 10 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$5.00 | $10.00 | None |
HYDRALAZINE 100 MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover HYDRALAZINE 100 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$5.00 | $10.00 | None |
HYDRALAZINE 20 MG/ML VIAL ![Compare how all Medicare Part D PDP plans in PA cover HYDRALAZINE 20 MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
HYDRALAZINE 25 MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover HYDRALAZINE 25 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$5.00 | $10.00 | None |
HYDRALAZINE 50 MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover HYDRALAZINE 50 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$5.00 | $10.00 | None |
HYDREA 500MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover HYDREA 500MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
Hydrochlorothiazide 12.5 MG Oral Capsule ![Compare how all Medicare Part D PDP plans in PA cover Hydrochlorothiazide 12.5 MG Oral Capsule.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$2.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDROCHLOROTHIAZIDE 12.5 MG TB ![Compare how all Medicare Part D PDP plans in PA cover HYDROCHLOROTHIAZIDE 12.5 MG TB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$2.00 | $0.00 | None |
HYDROCHLOROTHIAZIDE 25 MG TAB ![Compare how all Medicare Part D PDP plans in PA cover HYDROCHLOROTHIAZIDE 25 MG TAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$2.00 | $0.00 | None |
HYDROCHLOROTHIAZIDE 50 MG TAB ![Compare how all Medicare Part D PDP plans in PA cover HYDROCHLOROTHIAZIDE 50 MG TAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$2.00 | $0.00 | None |
HYDROCODON-ACETAMINOPH 2.5-325 ![Compare how all Medicare Part D PDP plans in PA cover HYDROCODON-ACETAMINOPH 2.5-325.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$42.00 | $121.00 | Q:180 /30Days |
HYDROCODON-ACETAMINOPH 7.5-325 ![Compare how all Medicare Part D PDP plans in PA cover HYDROCODON-ACETAMINOPH 7.5-325.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$42.00 | $121.00 | Q:180 /30Days |
HYDROCODON-ACETAMINOPHEN 5-325 ![Compare how all Medicare Part D PDP plans in PA cover HYDROCODON-ACETAMINOPHEN 5-325.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$42.00 | $121.00 | Q:180 /30Days |
HYDROCODON-ACETAMINOPHN 10-325 ![Compare how all Medicare Part D PDP plans in PA cover HYDROCODON-ACETAMINOPHN 10-325.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$42.00 | $121.00 | Q:180 /30Days |
Hydrocodone Bitartrate and Acetaminophen 300; 10mg/1; mg/1 ![Compare how all Medicare Part D PDP plans in PA cover Hydrocodone Bitartrate and Acetaminophen 300; 10mg/1; mg/1.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$42.00 | $121.00 | Q:180 /30Days |
Hydrocodone Bitartrate and Acetaminophen 300; 5mg/1; mg/1 ![Compare how all Medicare Part D PDP plans in PA cover Hydrocodone Bitartrate and Acetaminophen 300; 5mg/1; mg/1.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$42.00 | $121.00 | Q:180 /30Days |
Hydrocodone Bitartrate and Acetaminophen 300; 7.5mg/1; mg/1 ![Compare how all Medicare Part D PDP plans in PA cover Hydrocodone Bitartrate and Acetaminophen 300; 7.5mg/1; mg/1.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$42.00 | $121.00 | Q:180 /30Days |
Hydrocodone Bitartrate and Acetaminophen 325; 7.5mg/15mL; mg/15mL ![Compare how all Medicare Part D PDP plans in PA cover Hydrocodone Bitartrate and Acetaminophen 325; 7.5mg/15mL; mg/15mL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$42.00 | $121.00 | Q:5550 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDROCODONE BITARTRATE AND IBUPROFEN TABLET 7.5-200MG (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover HYDROCODONE BITARTRATE AND IBUPROFEN TABLET 7.5-200MG (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$42.00 | $121.00 | Q:150 /30Days |
HYDROCODONE-IBUPROFEN 10-200 ![Compare how all Medicare Part D PDP plans in PA cover HYDROCODONE-IBUPROFEN 10-200.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:150 /30Days |
HYDROCODONE-IBUPROFEN 5-200 MG ![Compare how all Medicare Part D PDP plans in PA cover HYDROCODONE-IBUPROFEN 5-200 MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$42.00 | $121.00 | Q:150 /30Days |
HYDROCORTISONE 0.1% SOLN ![Compare how all Medicare Part D PDP plans in PA cover HYDROCORTISONE 0.1% SOLN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
HYDROCORTISONE 1% CREAM ![Compare how all Medicare Part D PDP plans in PA cover HYDROCORTISONE 1% CREAM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$2.00 | $0.00 | None |
HYDROCORTISONE 1% OINTMENT ![Compare how all Medicare Part D PDP plans in PA cover HYDROCORTISONE 1% OINTMENT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$2.00 | $0.00 | None |
Hydrocortisone 10 MG/ML Topical Cream [Ala-Cort] ![Compare how all Medicare Part D PDP plans in PA cover Hydrocortisone 10 MG/ML Topical Cream [Ala-Cort].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$2.00 | $0.00 | None |
HYDROCORTISONE 100 MG/60 ML ![Compare how all Medicare Part D PDP plans in PA cover HYDROCORTISONE 100 MG/60 ML.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$5.00 | $10.00 | None |
HYDROCORTISONE 10MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover HYDROCORTISONE 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$42.00 | $121.00 | None |
HYDROCORTISONE 2.5% CREAM ![Compare how all Medicare Part D PDP plans in PA cover HYDROCORTISONE 2.5% CREAM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$2.00 | $0.00 | None |
HYDROCORTISONE 2.5% LOTION ![Compare how all Medicare Part D PDP plans in PA cover HYDROCORTISONE 2.5% LOTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDROCORTISONE 2.5% OINTMENT ![Compare how all Medicare Part D PDP plans in PA cover HYDROCORTISONE 2.5% OINTMENT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic |
$2.00 | $0.00 | None |
Hydrocortisone 20mg 100 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in PA cover Hydrocortisone 20mg 100 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$42.00 | $121.00 | None |
HYDROCORTISONE 5MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover HYDROCORTISONE 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$42.00 | $121.00 | None |
HYDROCORTISONE BUTY 0.1% CREAM ![Compare how all Medicare Part D PDP plans in PA cover HYDROCORTISONE BUTY 0.1% CREAM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
HYDROCORTISONE BUTYR 0.1% OINT ![Compare how all Medicare Part D PDP plans in PA cover HYDROCORTISONE BUTYR 0.1% OINT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
HYDROCORTISONE VAL 0.2% CREAM ![Compare how all Medicare Part D PDP plans in PA cover HYDROCORTISONE VAL 0.2% CREAM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
HYDROCORTISONE VAL 0.2% OINTMT ![Compare how all Medicare Part D PDP plans in PA cover HYDROCORTISONE VAL 0.2% OINTMT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
HYDROCORTISONE-ACETIC ACID SOLN ![Compare how all Medicare Part D PDP plans in PA cover HYDROCORTISONE-ACETIC ACID SOLN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
HYDROMORPHONE 1 MG/ML SOLUTION [Dilaudid] ![Compare how all Medicare Part D PDP plans in PA cover HYDROMORPHONE 1 MG/ML SOLUTION [Dilaudid].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:2400 /30Days |
HYDROMORPHONE 10 MG/ML VIAL [Dilaudid-HP] ![Compare how all Medicare Part D PDP plans in PA cover HYDROMORPHONE 10 MG/ML VIAL [Dilaudid-HP].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
HYDROMORPHONE 2 MG TABLET [Dilaudid] ![Compare how all Medicare Part D PDP plans in PA cover HYDROMORPHONE 2 MG TABLET [Dilaudid].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$42.00 | $121.00 | Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDROMORPHONE 2 MG/ML ISECURE Syringe [Simplist Dilaudid] ![Compare how all Medicare Part D PDP plans in PA cover HYDROMORPHONE 2 MG/ML ISECURE Syringe [Simplist Dilaudid].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
HYDROMORPHONE 4 MG TABLET [Dilaudid] ![Compare how all Medicare Part D PDP plans in PA cover HYDROMORPHONE 4 MG TABLET [Dilaudid].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$42.00 | $121.00 | Q:180 /30Days |
HYDROMORPHONE 50 MG/5 ML VIAL [Dilaudid-HP] ![Compare how all Medicare Part D PDP plans in PA cover HYDROMORPHONE 50 MG/5 ML VIAL [Dilaudid-HP].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
HYDROMORPHONE 8 MG TABLET [Dilaudid] ![Compare how all Medicare Part D PDP plans in PA cover HYDROMORPHONE 8 MG TABLET [Dilaudid].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$42.00 | $121.00 | Q:180 /30Days |
HYDROMORPHONE HCL ER 12 MG Tablet 24H [Exalgo] ![Compare how all Medicare Part D PDP plans in PA cover HYDROMORPHONE HCL ER 12 MG Tablet 24H [Exalgo].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
HYDROMORPHONE HCL ER 16 MG Tablet 24H [Exalgo] ![Compare how all Medicare Part D PDP plans in PA cover HYDROMORPHONE HCL ER 16 MG Tablet 24H [Exalgo].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
HYDROMORPHONE HCL ER 32 MG Tablet 24H [Exalgo] ![Compare how all Medicare Part D PDP plans in PA cover HYDROMORPHONE HCL ER 32 MG Tablet 24H [Exalgo].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
HYDROMORPHONE HCL ER 8 MG Tablet 24H [Exalgo] ![Compare how all Medicare Part D PDP plans in PA cover HYDROMORPHONE HCL ER 8 MG Tablet 24H [Exalgo].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
HYDROXYCHLOROQUINE 200 MG TAB ![Compare how all Medicare Part D PDP plans in PA cover HYDROXYCHLOROQUINE 200 MG TAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$42.00 | $121.00 | None |
HYDROXYPROGESTERONE 1.25 G/5ML [MAKENA] ![Compare how all Medicare Part D PDP plans in PA cover HYDROXYPROGESTERONE 1.25 G/5ML [MAKENA].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | P |
HYDROXYUREA 500 MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover HYDROXYUREA 500 MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDROXYZINE 10 MG/5 ML SOLN ![Compare how all Medicare Part D PDP plans in PA cover HYDROXYZINE 10 MG/5 ML SOLN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
HYDROXYZINE 25MG/ML VIAL ![Compare how all Medicare Part D PDP plans in PA cover HYDROXYZINE 25MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
HYDROXYZINE 50MG/ML VIAL ![Compare how all Medicare Part D PDP plans in PA cover HYDROXYZINE 50MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
HYDROXYZINE HCL 10 MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover HYDROXYZINE HCL 10 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
HYDROXYZINE HCL 25 MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover HYDROXYZINE HCL 25 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
HYDROXYZINE HCL 50 MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover HYDROXYZINE HCL 50 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
HYDROXYZINE PAM 100MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover HYDROXYZINE PAM 100MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
HYDROXYZINE PAM 25 MG CAP ![Compare how all Medicare Part D PDP plans in PA cover HYDROXYZINE PAM 25 MG CAP.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
HYDROXYZINE PAM 50 MG CAP ![Compare how all Medicare Part D PDP plans in PA cover HYDROXYZINE PAM 50 MG CAP.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
HYSINGLA ER 100 MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover HYSINGLA ER 100 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$42.00 | $121.00 | Q:60 /30Days |
HYSINGLA ER 120 MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover HYSINGLA ER 120 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$42.00 | $121.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYSINGLA ER 20 MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover HYSINGLA ER 20 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$42.00 | $121.00 | Q:30 /30Days |
HYSINGLA ER 30 MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover HYSINGLA ER 30 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$42.00 | $121.00 | Q:30 /30Days |
HYSINGLA ER 40 MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover HYSINGLA ER 40 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$42.00 | $121.00 | Q:60 /30Days |
HYSINGLA ER 60 MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover HYSINGLA ER 60 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$42.00 | $121.00 | Q:60 /30Days |
HYSINGLA ER 80 MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover HYSINGLA ER 80 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$42.00 | $121.00 | Q:60 /30Days |
HYZAAR 100-12.5 TABLET ![Compare how all Medicare Part D PDP plans in PA cover HYZAAR 100-12.5 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:30 /30Days |
HYZAAR 100-25 TABLET ![Compare how all Medicare Part D PDP plans in PA cover HYZAAR 100-25 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:30 /30Days |
HYZAAR 50-12.5 TABLET ![Compare how all Medicare Part D PDP plans in PA cover HYZAAR 50-12.5 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:30 /30Days |