2018 Medicare Part D Plan Formulary Information |
Dean Advantage Balance (HMO) (H9096-002-0)
Benefit Details
|
The Dean Advantage Balance (HMO) (H9096-002-0) Formulary Drugs Starting with the Letter H in Columbia County, WI: CMS MA Region 14 which includes: WI Plan Monthly Premium: $82.00 Deductible: $200 |
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 |
HAEGARDA 2,000 UNIT VIAL |
5 |
Specialty Tier |
29% | N/A | P |
HAEGARDA 3,000 UNIT VIAL |
5 |
Specialty Tier |
29% | N/A | P |
Halaven 0.5mg/mL |
5 |
Specialty Tier |
29% | N/A | None |
HALOBETASOL PROP 0.05% CREAM |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
Halobetasol Propionate 0.5mg/g 1 TUBE per CARTON / 50 g in 1 TUBE |
4 |
Non-Preferred Brand |
$100.00 | N/A | None |
Halog 1mg/g 60 g in 1 TUBE |
4 |
Non-Preferred Brand |
$100.00 | N/A | P |
HALOG OINTMENT 1mg/g 60 g in 1 TUBE [HALOG] |
4 |
Non-Preferred Brand |
$100.00 | N/A | P |
HALOPERIDOL 0.5 MG TABLET |
2* |
Generic |
$10.00 | N/A | None |
HALOPERIDOL 1 MG TABLET |
2* |
Generic |
$10.00 | N/A | None |
HALOPERIDOL 10 MG TABLET |
2* |
Generic |
$10.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HALOPERIDOL 20MG TABLET (100 CT) |
2* |
Generic |
$10.00 | N/A | None |
HALOPERIDOL 2MG TABLET (100 CT) |
2* |
Generic |
$10.00 | N/A | None |
HALOPERIDOL 5 MG TABLET |
2* |
Generic |
$10.00 | N/A | None |
HALOPERIDOL DEC 100 MG/ML VIAL |
2* |
Generic |
$10.00 | N/A | None |
HALOPERIDOL DEC 100 MG/ML VIAL |
2* |
Generic |
$10.00 | N/A | None |
HALOPERIDOL DEC 50MG 10 X 1ML PKG |
2* |
Generic |
$10.00 | N/A | None |
HALOPERIDOL LAC 2 MG/ML CONC |
2* |
Generic |
$10.00 | N/A | None |
HALOPERIDOL LAC 5 MG/ML SYRING |
2* |
Generic |
$10.00 | N/A | None |
HALOPERIDOL LAC 5 MG/ML VIAL |
2* |
Generic |
$10.00 | N/A | None |
HAVRIX 1,440 UNITS/ML SYRINGE |
3 |
Preferred Brand |
$47.00 | N/A | None |
HAVRIX 720 UNITS/0.5 ML VIAL |
3 |
Preferred Brand |
$47.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 SOD 1,000 UNIT/ML VIAL |
2* |
Generic |
$10.00 | N/A | P |
HEPARIN SOD 5,000 UNIT/ML VIAL |
2* |
Generic |
$10.00 | N/A | P |
Heparin Sodium in Dextrose 5; 10000g/100mL; [USP'U]/100mL 24 CONTAINER in 1 CASE / 250 mL in 1 CONT |
2* |
Generic |
$10.00 | N/A | P |
Heparin Sodium in Dextrose 5; 4000g/100mL; [USP'U]/100mL 24 CONTAINER in 1 CASE / 500 mL in 1 CONTA |
2* |
Generic |
$10.00 | N/A | P |
Heparin Sodium in Dextrose 5; 5000g/100mL; [USP'U]/100mL 24 CONTAINER in 1 CASE / 500 mL in 1 CONTA |
2* |
Generic |
$10.00 | N/A | P |
HEPARIN SODIUM INJECTION |
2* |
Generic |
$10.00 | N/A | P |
HEPARIN SODIUM INJECTION |
2* |
Generic |
$10.00 | N/A | P |
HEPATAMINE INJECTION 8% |
2* |
Generic |
$10.00 | N/A | P |
Hepatitis B Surface Antigen Vaccine 0.01 MG/ML Prefilled 0.5 ML Syringe [Recombivax] |
3 |
Preferred Brand |
$47.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HEPATITIS B VACCINE RECOMBIANT ADULT FORMULATION INJECTION 10MCG 1ML VIALSD |
3 |
Preferred Brand |
$47.00 | N/A | P |
HERCEPTIN 150 MG VIAL |
5 |
Specialty Tier |
29% | N/A | None |
HERCEPTIN 440MG VIAL |
5 |
Specialty Tier |
29% | N/A | None |
HETLIOZ 20 MG CAPSULE |
5 |
Specialty Tier |
29% | N/A | P Q:30 /30Days |
HEXALEN 50MG CAPSULES |
5 |
Specialty Tier |
29% | N/A | None |
HIBERIX VACCINE WITH DILUENT |
3 |
Preferred Brand |
$47.00 | N/A | None |
HUMIRA 10 MG/0.1 ML SYRINGEKIT |
5 |
Specialty Tier |
29% | N/A | P |
HUMIRA 10 MG/0.2 ML SYRINGE |
5 |
Specialty Tier |
29% | N/A | P |
Humira 2 KIT per CARTON / 1 KIT in 1 KIT |
5 |
Specialty Tier |
29% | N/A | P |
HUMIRA 20 MG/0.2 ML SYRINGEKIT |
5 |
Specialty Tier |
29% | N/A | P |
HUMIRA 40 MG/0.4 ML PEN IJ KIT |
5 |
Specialty Tier |
29% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HUMIRA 40 MG/0.4 ML SYRINGEKIT |
5 |
Specialty Tier |
29% | N/A | P |
HUMIRA 40 MG/0.8 ML PEN |
5 |
Specialty Tier |
29% | N/A | P |
HUMIRA PED CROHNS 80 MG/0.8 ML SYRINGEKIT |
5 |
Specialty Tier |
29% | N/A | P |
HUMIRA PEDIATR CROHN'S 80-40MG SYRINGEKIT |
5 |
Specialty Tier |
29% | N/A | P |
HUMIRA PEDIATRIC CROHN'S START |
5 |
Specialty Tier |
29% | N/A | P |
HUMIRA PEDIATRIC CROHN'S START |
5 |
Specialty Tier |
29% | N/A | P |
HUMIRA PEN KIT 40MG-70% 1 PKGCOM |
5 |
Specialty Tier |
29% | N/A | P |
HUMIRA PEN PSORIASIS-UVEITIS |
5 |
Specialty Tier |
29% | N/A | P |
HUMULIN R 500 UNITS/ML KWIKPEN |
3 |
Preferred Brand |
$47.00 | N/A | None |
HUMULIN R 500U/ML VIAL |
3 |
Preferred Brand |
$47.00 | N/A | None |
HYDRALAZINE 10 MG TABLET |
2* |
Generic |
$10.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDRALAZINE 100 MG TABLET |
2* |
Generic |
$10.00 | N/A | None |
HYDRALAZINE 20 MG/ML VIAL |
2* |
Generic |
$10.00 | N/A | None |
HYDRALAZINE 25 MG TABLET |
2* |
Generic |
$10.00 | N/A | None |
HYDRALAZINE 50 MG TABLET |
2* |
Generic |
$10.00 | N/A | None |
Hydrochlorothiazide 12.5 MG Oral Capsule |
1* |
Preferred Generic |
$3.00 | N/A | None |
HYDROCHLOROTHIAZIDE 12.5 MG TB |
1* |
Preferred Generic |
$3.00 | N/A | None |
HYDROCHLOROTHIAZIDE 25 MG TAB |
1* |
Preferred Generic |
$3.00 | N/A | None |
HYDROCHLOROTHIAZIDE 50 MG TAB |
1* |
Preferred Generic |
$3.00 | N/A | None |
HYDROCODON-ACETAMINOPH 2.5-325 |
3 |
Preferred Brand |
$47.00 | N/A | Q:360 /30Days |
HYDROCODON-ACETAMINOPH 7.5-325 |
3 |
Preferred Brand |
$47.00 | N/A | Q:360 /30Days |
HYDROCODON-ACETAMINOPHEN 5-325 |
3 |
Preferred Brand |
$47.00 | N/A | Q:360 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDROCODON-ACETAMINOPHN 10-325 |
3 |
Preferred Brand |
$47.00 | N/A | Q:360 /30Days |
Hydrocodone Bitartrate and Acetaminophen 300; 10mg/1; mg/1 |
3 |
Preferred Brand |
$47.00 | N/A | Q:390 /30Days |
Hydrocodone Bitartrate and Acetaminophen 300; 5mg/1; mg/1 |
3 |
Preferred Brand |
$47.00 | N/A | Q:390 /30Days |
Hydrocodone Bitartrate and Acetaminophen 300; 7.5mg/1; mg/1 |
3 |
Preferred Brand |
$47.00 | N/A | Q:390 /30Days |
Hydrocodone Bitartrate and Acetaminophen 325; 7.5mg/15mL; mg/15mL |
3 |
Preferred Brand |
$47.00 | N/A | Q:5400 /30Days |
HYDROCODONE BITARTRATE AND IBUPROFEN TABLET 7.5-200MG (100 CT) |
3 |
Preferred Brand |
$47.00 | N/A | Q:480 /30Days |
HYDROCODONE-IBUPROFEN 10-200 |
3 |
Preferred Brand |
$47.00 | N/A | Q:480 /30Days |
HYDROCODONE-IBUPROFEN 5-200 MG |
3 |
Preferred Brand |
$47.00 | N/A | Q:480 /30Days |
HYDROCORT-PRAMOXINE 1%-1% CREAM/APPL [Zone A] |
2* |
Generic |
$10.00 | N/A | None |
HYDROCORTISONE 1% CREAM |
2* |
Generic |
$10.00 | N/A | None |
HYDROCORTISONE 1% OINTMENT |
2* |
Generic |
$10.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Hydrocortisone 10 MG/ML Topical Cream [Ala-Cort] |
2* |
Generic |
$10.00 | N/A | None |
HYDROCORTISONE 100 MG/60 ML |
2* |
Generic |
$10.00 | N/A | None |
HYDROCORTISONE 10MG TABLET |
2* |
Generic |
$10.00 | N/A | None |
HYDROCORTISONE 2.5% CREAM |
2* |
Generic |
$10.00 | N/A | None |
HYDROCORTISONE 2.5% LOTION |
2* |
Generic |
$10.00 | N/A | None |
HYDROCORTISONE 2.5% OINTMENT |
2* |
Generic |
$10.00 | N/A | None |
Hydrocortisone 20mg 100 TABLET BOTTLE |
2* |
Generic |
$10.00 | N/A | None |
HYDROCORTISONE 5MG TABLET |
2* |
Generic |
$10.00 | N/A | None |
HYDROCORTISONE VAL 0.2% CREAM |
2* |
Generic |
$10.00 | N/A | None |
HYDROCORTISONE VAL 0.2% OINTMT |
2* |
Generic |
$10.00 | N/A | None |
HYDROCORTISONE-ACETIC ACID SOLN |
2* |
Generic |
$10.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDROMORPHONE 1 MG/ML SOLUTION [Dilaudid] |
2* |
Generic |
$10.00 | N/A | Q:2400 /30Days |
HYDROMORPHONE 10 MG/ML VIAL [Dilaudid-HP] |
2* |
Generic |
$10.00 | N/A | None |
HYDROMORPHONE 2 MG TABLET [Dilaudid] |
2* |
Generic |
$10.00 | N/A | Q:450 /30Days |
HYDROMORPHONE 2 MG/ML ISECURE Syringe [Simplist Dilaudid] |
2* |
Generic |
$10.00 | N/A | None |
HYDROMORPHONE 4 MG TABLET [Dilaudid] |
2* |
Generic |
$10.00 | N/A | Q:240 /30Days |
HYDROMORPHONE 50 MG/5 ML VIAL [Dilaudid-HP] |
2* |
Generic |
$10.00 | N/A | None |
HYDROMORPHONE 8 MG TABLET [Dilaudid] |
2* |
Generic |
$10.00 | N/A | Q:120 /30Days |
HYDROMORPHONE HCL ER 12 MG Tablet 24H [Exalgo] |
2* |
Generic |
$10.00 | N/A | Q:60 /30Days |
HYDROMORPHONE HCL ER 16 MG Tablet 24H [Exalgo] |
2* |
Generic |
$10.00 | N/A | Q:60 /30Days |
HYDROMORPHONE HCL ER 32 MG Tablet 24H [Exalgo] |
2* |
Generic |
$10.00 | N/A | Q:60 /30Days |
HYDROMORPHONE HCL ER 8 MG Tablet 24H [Exalgo] |
2* |
Generic |
$10.00 | N/A | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDROXYCHLOROQUINE 200 MG TAB |
2* |
Generic |
$10.00 | N/A | None |
HYDROXYPROGESTERONE 1.25 G/5ML [MAKENA] |
5 |
Specialty Tier |
29% | N/A | P |
HYDROXYUREA 500 MG CAPSULE |
2* |
Generic |
$10.00 | N/A | None |
HYDROXYZINE 10 MG/5 ML SOLN |
2* |
Generic |
$10.00 | N/A | None |
HYDROXYZINE 25MG/ML VIAL |
2* |
Generic |
$10.00 | N/A | None |
HYDROXYZINE 50MG/ML VIAL |
2* |
Generic |
$10.00 | N/A | None |
HYDROXYZINE HCL 10 MG TABLET |
2* |
Generic |
$10.00 | N/A | None |
HYDROXYZINE HCL 25 MG TABLET |
2* |
Generic |
$10.00 | N/A | None |
HYDROXYZINE HCL 50 MG TABLET |
2* |
Generic |
$10.00 | N/A | None |
HYDROXYZINE PAM 100MG CAPSULE |
2* |
Generic |
$10.00 | N/A | None |
HYDROXYZINE PAM 25 MG CAP |
1* |
Preferred Generic |
$3.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDROXYZINE PAM 50 MG CAP |
1* |
Preferred Generic |
$3.00 | N/A | None |
HYPERRAB S-D 150 UNITS/ML VIAL |
4 |
Non-Preferred Brand |
$100.00 | N/A | P |
HYPERRAB S-D 150 UNITS/ML VIAL |
4 |
Non-Preferred Brand |
$100.00 | N/A | P |
HYSINGLA ER 100 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | Q:30 /30Days |
HYSINGLA ER 120 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | Q:30 /30Days |
HYSINGLA ER 20 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | Q:30 /30Days |
HYSINGLA ER 30 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | Q:30 /30Days |
HYSINGLA ER 40 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | Q:30 /30Days |
HYSINGLA ER 60 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | Q:30 /30Days |
HYSINGLA ER 80 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | Q:30 /30Days |