2018 Medicare Part D Plan Formulary Information |
Aetna Medicare Rx Select (PDP) (S5810-292-0)
Benefit Details
 |
The Aetna Medicare Rx Select (PDP) (S5810-292-0) Formulary Drugs Starting with the Letter H in CMS PDP Region 21 which includes: LA Plan Monthly Premium: $17.70 Deductible: $405 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 |
25% | N/A | P |
HALCION 0.25 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | Q:60 /30Days |
HALDOL 5MG/ML INJECTION  |
4 |
Non-Preferred Drug |
37% | N/A | None |
HALDOL DECANOATE 100MG/ML INJECTION  |
4 |
Non-Preferred Drug |
37% | N/A | None |
HALDOL DECANOATE 50MG/ML INJECTION  |
4 |
Non-Preferred Drug |
37% | N/A | None |
HALOBETASOL PROP 0.05% CREAM  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Halobetasol Propionate 0.5mg/g 1 TUBE per CARTON / 50 g in 1 TUBE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Halog 1mg/g 60 g in 1 TUBE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
HALOG OINTMENT 1mg/g 60 g in 1 TUBE [HALOG] ![Compare how all Medicare Part D PDP plans in LA 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 |
37% | N/A | None |
HALOPERIDOL 0.5 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HALOPERIDOL 1 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
HALOPERIDOL 10 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
HALOPERIDOL 20MG TABLET (100 CT)  |
3 |
Preferred Brand |
$46.00 | N/A | None |
HALOPERIDOL 2MG TABLET (100 CT)  |
3 |
Preferred Brand |
$46.00 | N/A | None |
HALOPERIDOL 5 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
HALOPERIDOL DEC 100 MG/ML VIAL  |
4 |
Non-Preferred Drug |
37% | N/A | None |
HALOPERIDOL DEC 100 MG/ML VIAL  |
4 |
Non-Preferred Drug |
37% | N/A | None |
HALOPERIDOL DEC 50MG 10 X 1ML PKG  |
4 |
Non-Preferred Drug |
37% | N/A | None |
HALOPERIDOL LAC 2 MG/ML CONC  |
3 |
Preferred Brand |
$46.00 | N/A | None |
HALOPERIDOL LAC 5 MG/ML SYRING  |
4 |
Non-Preferred Drug |
37% | N/A | None |
HALOPERIDOL LAC 5 MG/ML VIAL  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HARVONI 90-400 MG TABLET  |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
HAVRIX 1,440 UNITS/ML SYRINGE  |
3 |
Preferred Brand |
$46.00 | N/A | None |
HAVRIX 720 UNITS/0.5 ML VIAL  |
3 |
Preferred Brand |
$46.00 | N/A | None |
HAVRIX HEPATITIS A VACCINE INACTIVATED INJECTION SOLUTION 1440UNITS 10 X 1ML VIALSD  |
3 |
Preferred Brand |
$46.00 | N/A | None |
HAVRIX HEPATITIS A VACCINE INJECTION  |
3 |
Preferred Brand |
$46.00 | N/A | None |
Hectorol 4ug/2mL  |
4 |
Non-Preferred Drug |
37% | N/A | None |
HEPARIN SOD 1,000 UNIT/ML VIAL  |
4 |
Non-Preferred Drug |
37% | N/A | None |
HEPARIN SOD 5,000 UNIT/ML VIAL  |
4 |
Non-Preferred Drug |
37% | N/A | 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 LA 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 |
37% | N/A | 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 LA 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 |
37% | N/A | 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 LA 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 |
37% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HEPARIN SODIUM INJECTION  |
4 |
Non-Preferred Drug |
37% | N/A | None |
HEPARIN SODIUM INJECTION  |
4 |
Non-Preferred Drug |
37% | N/A | None |
HEPATAMINE INJECTION 8%  |
4 |
Non-Preferred Drug |
37% | N/A | 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 LA 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 |
$46.00 | N/A | P |
HEPATITIS B VACCINE RECOMBIANT ADULT FORMULATION INJECTION 10MCG 1ML VIALSD  |
3 |
Preferred Brand |
$46.00 | N/A | P |
HERCEPTIN 150 MG VIAL  |
5 |
Specialty Tier |
25% | 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 |
$46.00 | N/A | None |
HIPREX 1 GM TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | 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  |
5 |
Specialty Tier |
25% | N/A | P Q:2 /28Days |
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 20 MG/0.2 ML SYRINGEKIT  |
5 |
Specialty Tier |
25% | N/A | P Q:2 /28Days |
HUMIRA 40 MG/0.4 ML PEN IJ KIT  |
5 |
Specialty Tier |
25% | N/A | P Q:6 /28Days |
HUMIRA 40 MG/0.4 ML SYRINGEKIT  |
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 PED CROHNS 80 MG/0.8 ML SYRINGEKIT  |
5 |
Specialty Tier |
25% | N/A | P |
HUMIRA PEDIATR CROHN'S 80-40MG SYRINGEKIT  |
5 |
Specialty Tier |
25% | N/A | P |
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 |
$3.00 | N/A | None |
HYDRALAZINE 100 MG TABLET  |
2* |
Generic |
$3.00 | N/A | None |
HYDRALAZINE 20 MG/ML VIAL  |
4 |
Non-Preferred Drug |
37% | N/A | None |
HYDRALAZINE 25 MG TABLET  |
2* |
Generic |
$3.00 | N/A | None |
HYDRALAZINE 50 MG TABLET  |
2* |
Generic |
$3.00 | N/A | None |
HYDREA 500MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | None |
Hydrochlorothiazide 12.5 MG Oral Capsule  |
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 12.5 MG TB  |
1* |
Preferred Generic |
$0.00 | N/A | None |
HYDROCHLOROTHIAZIDE 25 MG TAB  |
1* |
Preferred Generic |
$0.00 | N/A | None |
HYDROCHLOROTHIAZIDE 50 MG TAB  |
1* |
Preferred Generic |
$0.00 | N/A | None |
HYDROCODON-ACETAMINOPH 2.5-325  |
3 |
Preferred Brand |
$46.00 | N/A | Q:180 /30Days |
HYDROCODON-ACETAMINOPH 7.5-325  |
3 |
Preferred Brand |
$46.00 | N/A | Q:180 /30Days |
HYDROCODON-ACETAMINOPHEN 5-325  |
3 |
Preferred Brand |
$46.00 | N/A | Q:180 /30Days |
HYDROCODON-ACETAMINOPHN 10-325  |
3 |
Preferred Brand |
$46.00 | N/A | Q:180 /30Days |
Hydrocodone Bitartrate and Acetaminophen 300; 10mg/1; mg/1  |
3 |
Preferred Brand |
$46.00 | N/A | Q:180 /30Days |
Hydrocodone Bitartrate and Acetaminophen 300; 5mg/1; mg/1  |
3 |
Preferred Brand |
$46.00 | N/A | Q:180 /30Days |
Hydrocodone Bitartrate and Acetaminophen 300; 7.5mg/1; mg/1  |
3 |
Preferred Brand |
$46.00 | N/A | Q:180 /30Days |
Hydrocodone Bitartrate and Acetaminophen 325; 7.5mg/15mL; mg/15mL  |
3 |
Preferred Brand |
$46.00 | N/A | 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)  |
3 |
Preferred Brand |
$46.00 | N/A | Q:150 /30Days |
HYDROCODONE-IBUPROFEN 10-200  |
4 |
Non-Preferred Drug |
37% | N/A | Q:150 /30Days |
HYDROCODONE-IBUPROFEN 5-200 MG  |
3 |
Preferred Brand |
$46.00 | N/A | Q:150 /30Days |
HYDROCORTISONE 0.1% SOLN  |
4 |
Non-Preferred Drug |
37% | N/A | None |
HYDROCORTISONE 1% CREAM  |
1* |
Preferred Generic |
$0.00 | N/A | None |
HYDROCORTISONE 1% OINTMENT  |
1* |
Preferred Generic |
$0.00 | N/A | None |
Hydrocortisone 10 MG/ML Topical Cream [Ala-Cort] ![Compare how all Medicare Part D PDP plans in LA cover Hydrocortisone 10 MG/ML Topical Cream [Ala-Cort].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1* |
Preferred Generic |
$0.00 | N/A | None |
HYDROCORTISONE 100 MG/60 ML  |
2* |
Generic |
$3.00 | N/A | None |
HYDROCORTISONE 10MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
HYDROCORTISONE 2.5% CREAM  |
1* |
Preferred Generic |
$0.00 | N/A | None |
HYDROCORTISONE 2.5% LOTION  |
2* |
Generic |
$3.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDROCORTISONE 2.5% OINTMENT  |
1* |
Preferred Generic |
$0.00 | N/A | None |
Hydrocortisone 20mg 100 TABLET BOTTLE  |
3 |
Preferred Brand |
$46.00 | N/A | None |
HYDROCORTISONE 5MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | None |
HYDROCORTISONE BUTY 0.1% CREAM  |
4 |
Non-Preferred Drug |
37% | N/A | None |
HYDROCORTISONE BUTYR 0.1% OINT  |
4 |
Non-Preferred Drug |
37% | N/A | None |
HYDROCORTISONE VAL 0.2% CREAM  |
4 |
Non-Preferred Drug |
37% | N/A | None |
HYDROCORTISONE VAL 0.2% OINTMT  |
4 |
Non-Preferred Drug |
37% | N/A | None |
HYDROCORTISONE-ACETIC ACID SOLN  |
4 |
Non-Preferred Drug |
37% | N/A | None |
HYDROMORPHONE 1 MG/ML SOLUTION [Dilaudid] ![Compare how all Medicare Part D PDP plans in LA cover HYDROMORPHONE 1 MG/ML SOLUTION [Dilaudid].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | Q:2400 /30Days |
HYDROMORPHONE 10 MG/ML VIAL [Dilaudid-HP] ![Compare how all Medicare Part D PDP plans in LA cover HYDROMORPHONE 10 MG/ML VIAL [Dilaudid-HP].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | P |
HYDROMORPHONE 2 MG TABLET [Dilaudid] ![Compare how all Medicare Part D PDP plans in LA cover HYDROMORPHONE 2 MG TABLET [Dilaudid].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$46.00 | N/A | 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 LA cover HYDROMORPHONE 2 MG/ML ISECURE Syringe [Simplist Dilaudid].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | P |
HYDROMORPHONE 4 MG TABLET [Dilaudid] ![Compare how all Medicare Part D PDP plans in LA cover HYDROMORPHONE 4 MG TABLET [Dilaudid].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$46.00 | N/A | Q:180 /30Days |
HYDROMORPHONE 50 MG/5 ML VIAL [Dilaudid-HP] ![Compare how all Medicare Part D PDP plans in LA cover HYDROMORPHONE 50 MG/5 ML VIAL [Dilaudid-HP].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | P |
HYDROMORPHONE 8 MG TABLET [Dilaudid] ![Compare how all Medicare Part D PDP plans in LA cover HYDROMORPHONE 8 MG TABLET [Dilaudid].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$46.00 | N/A | Q:180 /30Days |
HYDROMORPHONE HCL ER 12 MG Tablet 24H [Exalgo] ![Compare how all Medicare Part D PDP plans in LA cover HYDROMORPHONE HCL ER 12 MG Tablet 24H [Exalgo].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
HYDROMORPHONE HCL ER 16 MG Tablet 24H [Exalgo] ![Compare how all Medicare Part D PDP plans in LA cover HYDROMORPHONE HCL ER 16 MG Tablet 24H [Exalgo].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
HYDROMORPHONE HCL ER 32 MG Tablet 24H [Exalgo] ![Compare how all Medicare Part D PDP plans in LA cover HYDROMORPHONE HCL ER 32 MG Tablet 24H [Exalgo].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
HYDROMORPHONE HCL ER 8 MG Tablet 24H [Exalgo] ![Compare how all Medicare Part D PDP plans in LA cover HYDROMORPHONE HCL ER 8 MG Tablet 24H [Exalgo].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Drug |
37% | N/A | Q:30 /30Days |
HYDROXYCHLOROQUINE 200 MG TAB  |
3 |
Preferred Brand |
$46.00 | N/A | None |
HYDROXYPROGESTERONE 1.25 G/5ML [MAKENA] ![Compare how all Medicare Part D PDP plans in LA cover HYDROXYPROGESTERONE 1.25 G/5ML [MAKENA].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
25% | N/A | P |
HYDROXYUREA 500 MG CAPSULE  |
2* |
Generic |
$3.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDROXYZINE 10 MG/5 ML SOLN  |
4 |
Non-Preferred Drug |
37% | N/A | P |
HYDROXYZINE 25MG/ML VIAL  |
4 |
Non-Preferred Drug |
37% | N/A | P |
HYDROXYZINE 50MG/ML VIAL  |
4 |
Non-Preferred Drug |
37% | N/A | P |
HYDROXYZINE HCL 10 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | P |
HYDROXYZINE HCL 25 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | P |
HYDROXYZINE HCL 50 MG TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | P |
HYDROXYZINE PAM 100MG CAPSULE  |
4 |
Non-Preferred Drug |
37% | N/A | P |
HYDROXYZINE PAM 25 MG CAP  |
4 |
Non-Preferred Drug |
37% | N/A | P |
HYDROXYZINE PAM 50 MG CAP  |
4 |
Non-Preferred Drug |
37% | N/A | P |
HYSINGLA ER 100 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | Q:60 /30Days |
HYSINGLA ER 120 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | 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  |
3 |
Preferred Brand |
$46.00 | N/A | Q:30 /30Days |
HYSINGLA ER 30 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | Q:30 /30Days |
HYSINGLA ER 40 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | Q:60 /30Days |
HYSINGLA ER 60 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | Q:60 /30Days |
HYSINGLA ER 80 MG TABLET  |
3 |
Preferred Brand |
$46.00 | N/A | Q:60 /30Days |
HYZAAR 100-12.5 TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:30 /30Days |
HYZAAR 100-25 TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:30 /30Days |
HYZAAR 50-12.5 TABLET  |
4 |
Non-Preferred Drug |
37% | N/A | S Q:30 /30Days |