2019 Medicare Part D Plan Formulary Information |
Anthem MediBlue Dual Advantage (HMO SNP) (H3655-033-0)
Benefit Details
|
The Anthem MediBlue Dual Advantage (HMO SNP) (H3655-033-0) Formulary Drugs Starting with the Letter H in Coshocton County, OH: CMS MA Region 12 which includes: OH Plan Monthly Premium: $32.90 Deductible: $415 |
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 |
H.P. ACTHAR GEL 80 UNIT/ML VIAL |
5 |
Specialty Tier |
25% | N/A | P |
HALOBETASOL PROP 0.05% CREAM |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
Halobetasol Propionate 0.5mg/g 1 TUBE per CARTON / 50 g in 1 TUBE |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
Halog 1mg/g 60 g in 1 TUBE |
5 |
Specialty Tier |
25% | N/A | None |
HALOG OINTMENT 1mg/g 60 g in 1 TUBE [HALOG] |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
HALOPERIDOL 0.5 MG TABLET |
2 |
Generic |
$4.00 | $12.00 | None |
HALOPERIDOL 1 MG TABLET |
2 |
Generic |
$4.00 | $12.00 | None |
HALOPERIDOL 10 MG TABLET |
2 |
Generic |
$4.00 | $12.00 | None |
HALOPERIDOL 20MG TABLET (100 CT) |
2 |
Generic |
$4.00 | $12.00 | None |
HALOPERIDOL 2MG TABLET (100 CT) |
2 |
Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HALOPERIDOL 5 MG TABLET |
2 |
Generic |
$4.00 | $12.00 | None |
HALOPERIDOL DEC 100 MG/ML VIAL |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
HALOPERIDOL DEC 100 MG/ML VIAL |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
HALOPERIDOL DEC 50MG 10 X 1ML PKG |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
HALOPERIDOL LAC 2 MG/ML CONC |
2 |
Generic |
$4.00 | $12.00 | None |
HALOPERIDOL LAC 5 MG/ML SYRING |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
HALOPERIDOL LAC 5 MG/ML VIAL |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
HARVONI 90-400 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:28 /28Days |
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 |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HAVRIX HEPATITIS A VACCINE INJECTION |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
HEPARIN 30,000 UNIT/30 ML VIAL |
3 |
Preferred Brand |
$47.00 | $141.00 | P |
HEPARIN SOD 5,000 UNIT/ML VIAL |
3 |
Preferred Brand |
$47.00 | $141.00 | P |
HEPARIN SODIUM INJECTION |
3 |
Preferred Brand |
$47.00 | $141.00 | P |
HEPARIN SODIUM INJECTION |
3 |
Preferred Brand |
$47.00 | $141.00 | P |
HEPATAMINE INJECTION 8% |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | 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 |
HETLIOZ 20 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
HIBERIX VACCINE WITH DILUENT |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
HUMALOG 100 UNITS/ML CARTRIDGE |
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 |
HUMALOG 100 UNITS/ML VIAL |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
HUMALOG 200 UNITS/ML KWIKPEN |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
HUMALOG JR 100 UNIT/ML KWIKPEN |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
HUMALOG KWIKPEN INJECTION |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
HUMALOG MIX 50/50 VIAL |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
HUMALOG MIX 75/25 VIAL |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
HUMALOG MIX KWIKPEN INJECTION |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
HUMALOG MIX KWIKPEN INJECTION SUSPENSION |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
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:4 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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:4 /28Days |
HUMIRA 40 MG/0.4 ML SYRINGEKIT |
5 |
Specialty Tier |
25% | N/A | P Q:4 /28Days |
HUMIRA 40 MG/0.8 ML PEN |
5 |
Specialty Tier |
25% | N/A | P Q:4 /28Days |
HUMIRA PED CROHNS 80 MG/0.8 ML SYRINGEKIT |
5 |
Specialty Tier |
25% | N/A | P Q:6 /365Days |
HUMIRA PEDIATR CROHN'S 80-40MG SYRINGEKIT |
5 |
Specialty Tier |
25% | N/A | P Q:4 /365Days |
HUMIRA PEDIATRIC CROHN'S START |
5 |
Specialty Tier |
25% | N/A | P Q:6 /365Days |
HUMIRA PEDIATRIC CROHN'S START |
5 |
Specialty Tier |
25% | N/A | P Q:12 /365Days |
HUMIRA PEN KIT 40MG-70% 1 PKGCOM |
5 |
Specialty Tier |
25% | N/A | P Q:12 /365Days |
HUMIRA PEN PSORIASIS-UVEITIS |
5 |
Specialty Tier |
25% | N/A | P Q:8 /365Days |
HUMIRA(CF) PEN CRHN-UC-HS 80MG PEN IJ KIT |
5 |
Specialty Tier |
25% | N/A | P Q:6 /365Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HUMIRA(CF) PEN PS-UV-AHS 80-40 PEN IJ KIT |
5 |
Specialty Tier |
25% | N/A | P Q:6 /365Days |
HUMULIN 70/30 KWIKPEN |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
HUMULIN 70/30 VIAL |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
HUMULIN N 100 UNITS/ML KWIKPEN |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
HUMULIN N 100U/ML VIAL |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
HUMULIN R 100U/ML VIAL |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
HUMULIN R 500 UNITS/ML KWIKPEN |
5 |
Specialty Tier |
25% | N/A | P |
HUMULIN R 500U/ML VIAL |
5 |
Specialty Tier |
25% | N/A | P |
HYDRALAZINE 10 MG TABLET |
2 |
Generic |
$4.00 | $12.00 | None |
HYDRALAZINE 100 MG TABLET |
2 |
Generic |
$4.00 | $12.00 | None |
HYDRALAZINE 25 MG TABLET |
2 |
Generic |
$4.00 | $12.00 | 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 | $12.00 | None |
Hydrochlorothiazide 12.5 MG Oral Capsule |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
HYDROCHLOROTHIAZIDE 12.5 MG TB |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
HYDROCHLOROTHIAZIDE 25 MG TAB |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
HYDROCHLOROTHIAZIDE 50 MG TAB |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
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 |
HYDROCODONE BITARTRATE AND IBUPROFEN TABLET 7.5-200MG (100 CT) |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:50 /10Days |
HYDROCODONE-ACETAMIN 10-325 MG Tablet [Norco] |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days |
HYDROCODONE-ACETAMIN 7.5-325/15 Solution [Hycet] |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:2700 /30Days |
HYDROCODONE-IBUPROFEN 10-200 |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:50 /10Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDROCODONE-IBUPROFEN 5-200 MG |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:50 /10Days |
HYDROCORTISONE 0.1% SOLN |
2 |
Generic |
$4.00 | $12.00 | None |
HYDROCORTISONE 1% CREAM |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
HYDROCORTISONE 1% OINTMENT |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
HYDROCORTISONE 10 MG TABLET [Hydrocortone] |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
HYDROCORTISONE 100 MG/60 ML |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
HYDROCORTISONE 2.5% CREAM |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
HYDROCORTISONE 2.5% LOTION |
3 |
Preferred Brand |
$47.00 | $141.00 | None |
HYDROCORTISONE 2.5% OINTMENT |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
HYDROCORTISONE 20 MG TABLET [Cortef] |
2 |
Generic |
$4.00 | $12.00 | None |
HYDROCORTISONE 5 MG TABLET [Cortef] |
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 BUTY 0.1% CREAM |
2 |
Generic |
$4.00 | $12.00 | None |
HYDROCORTISONE BUTYR 0.1% OINT |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
HYDROCORTISONE VAL 0.2% CREAM |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
HYDROCORTISONE VAL 0.2% OINTMT |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
HYDROCORTISONE-ACETIC ACID SOLN |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
HYDROMORPHONE 10 MG/ML VIAL [Dilaudid-HP] |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
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 |
$95.00 | $285.00 | Q:180 /30Days |
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 |
$95.00 | $285.00 | None |
HYDROMORPHONE 8 MG TABLET [Dilaudid] |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDROXYCHLOROQUINE 200 MG TAB |
2 |
Generic |
$4.00 | $12.00 | None |
HYDROXYUREA 500 MG CAPSULE |
2 |
Generic |
$4.00 | $12.00 | None |
HYDROXYZINE 10 MG/5 ML SOLN |
3 |
Preferred Brand |
$47.00 | $141.00 | P |
HYDROXYZINE HCL 10 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | P |
HYDROXYZINE HCL 25 MG TABLET |
2 |
Generic |
$4.00 | $12.00 | P |
HYDROXYZINE HCL 50 MG TABLET |
3 |
Preferred Brand |
$47.00 | $141.00 | P |
HYDROXYZINE PAM 100MG CAPSULE |
3 |
Preferred Brand |
$47.00 | $141.00 | P |
HYDROXYZINE PAM 25 MG CAP |
3 |
Preferred Brand |
$47.00 | $141.00 | P |
HYDROXYZINE PAM 50 MG CAP |
3 |
Preferred Brand |
$47.00 | $141.00 | P |
HYZAAR 100-12.5 TABLET |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
HYZAAR 100-25 TABLET |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYZAAR 50-12.5 TABLET |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None |