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2019 Medicare Part D Plan Formulary Information
Farm Bureau Select Rx (PDP) (S2668-006-0) Benefit Details
The Farm Bureau Select Rx (PDP) (S2668-006-0) Formulary Drugs Starting with the Letter H in CMS PDP Region 12 which includes: AL TN Plan Monthly Premium: $99.00 Deductible: $0 Qualifies for LIS: No
Drugs Starting with Letter H Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter H Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
H.P. ACTHAR GEL 80 UNIT/ML VIAL	5	Specialty Tier	33%	33%	P
HAEGARDA 2,000 UNIT VIAL	5	Specialty Tier	33%	33%	P
HAEGARDA 3,000 UNIT VIAL	5	Specialty Tier	33%	33%	P
HAILEY 24 FE 1 MG-20 MCG TABLET [Tarina Fe 1/20]	2	Generic	$8.00	$24.00	None
HALOBETASOL PROP 0.05% CREAM	2	Generic	$8.00	$24.00	None
HALOBETASOL PROP 0.05% FOAM [LEXETTE]	5	Specialty Tier	33%	33%	None
Halobetasol Propionate 0.5mg/g 1 TUBE per CARTON / 50 g in 1 TUBE	2	Generic	$8.00	$24.00	None
HALOPERIDOL 0.5 MG TABLET	2	Generic	$8.00	$24.00	None
HALOPERIDOL 1 MG TABLET	2	Generic	$8.00	$24.00	None
HALOPERIDOL 10 MG TABLET	2	Generic	$8.00	$24.00	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	$8.00	$24.00	None
HALOPERIDOL 2MG TABLET (100 CT)	2	Generic	$8.00	$24.00	None
HALOPERIDOL 5 MG TABLET	2	Generic	$8.00	$24.00	None
HALOPERIDOL DEC 100 MG/ML VIAL	2	Generic	$8.00	$24.00	None
HALOPERIDOL DEC 100 MG/ML VIAL	2	Generic	$8.00	$24.00	None
HALOPERIDOL DEC 50MG 10 X 1ML PKG	2	Generic	$8.00	$24.00	None
HALOPERIDOL LAC 2 MG/ML CONC	2	Generic	$8.00	$24.00	None
HALOPERIDOL LAC 5 MG/ML SYRING	2	Generic	$8.00	$24.00	None
HALOPERIDOL LAC 5 MG/ML VIAL	2	Generic	$8.00	$24.00	None
HARVONI 90-400 MG TABLET	5	Specialty Tier	33%	33%	P Q:168 /365Days
HAVRIX 1,440 UNITS/ML SYRINGE	3	Preferred Brand	$40.00	$120.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
HAVRIX 720 UNITS/0.5 ML VIAL	3	Preferred Brand	$40.00	$120.00	None
HAVRIX HEPATITIS A VACCINE INACTIVATED INJECTION SOLUTION 1440UNITS 10 X 1ML VIALSD	3	Preferred Brand	$40.00	$120.00	None
HAVRIX HEPATITIS A VACCINE INJECTION	3	Preferred Brand	$40.00	$120.00	None
HEPARIN 30,000 UNIT/30 ML VIAL	2	Generic	$8.00	$24.00	None
HEPARIN SOD 5,000 UNIT/ML VIAL	2	Generic	$8.00	$24.00	None
HEPARIN SODIUM INJECTION	2	Generic	$8.00	$24.00	None
HEPARIN SODIUM INJECTION	2	Generic	$8.00	$24.00	None
HEPATAMINE INJECTION 8%	4	Non-Preferred Drug	45%	45%	P
Hepatitis B Surface Antigen Vaccine 0.01 MG/ML Prefilled 0.5 ML Syringe [Recombivax]	3	Preferred Brand	$40.00	$120.00	P
HEPATITIS B VACCINE RECOMBIANT ADULT FORMULATION INJECTION 10MCG 1ML VIALSD	3	Preferred Brand	$40.00	$120.00	P
HETLIOZ 20 MG CAPSULE	5	Specialty Tier	33%	33%	P Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
HIBERIX VACCINE WITH DILUENT	3	Preferred Brand	$40.00	$120.00	None
HUMALOG 100 UNITS/ML CARTRIDGE	3	Preferred Brand	$40.00	$120.00	None
HUMALOG 100 UNITS/ML VIAL	3	Preferred Brand	$40.00	$120.00	None
HUMALOG 200 UNITS/ML KWIKPEN	3	Preferred Brand	$40.00	$120.00	None
HUMALOG JR 100 UNIT/ML KWIKPEN	3	Preferred Brand	$40.00	$120.00	None
HUMALOG KWIKPEN INJECTION	3	Preferred Brand	$40.00	$120.00	None
HUMALOG MIX 50/50 VIAL	3	Preferred Brand	$40.00	$120.00	None
HUMALOG MIX 75/25 VIAL	3	Preferred Brand	$40.00	$120.00	None
HUMALOG MIX KWIKPEN INJECTION	3	Preferred Brand	$40.00	$120.00	None
HUMALOG MIX KWIKPEN INJECTION SUSPENSION	3	Preferred Brand	$40.00	$120.00	None
HUMIRA 10 MG/0.1 ML SYRINGEKIT	5	Specialty Tier	33%	33%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
HUMIRA 10 MG/0.2 ML SYRINGE	5	Specialty Tier	33%	33%	P
Humira 2 KIT per CARTON / 1 KIT in 1 KIT	5	Specialty Tier	33%	33%	P
HUMIRA 20 MG/0.2 ML SYRINGEKIT	5	Specialty Tier	33%	33%	P
HUMIRA 40 MG/0.4 ML PEN IJ KIT	5	Specialty Tier	33%	33%	P
HUMIRA 40 MG/0.4 ML SYRINGEKIT	5	Specialty Tier	33%	33%	P
HUMIRA 40 MG/0.8 ML PEN	5	Specialty Tier	33%	33%	P
HUMIRA PED CROHNS 80 MG/0.8 ML SYRINGEKIT	5	Specialty Tier	33%	33%	P
HUMIRA PEDIATR CROHN'S 80-40MG SYRINGEKIT	5	Specialty Tier	33%	33%	P
HUMIRA PEDIATRIC CROHN'S START	5	Specialty Tier	33%	33%	P
HUMIRA PEDIATRIC CROHN'S START	5	Specialty Tier	33%	33%	P
HUMIRA PEN KIT 40MG-70% 1 PKGCOM	5	Specialty Tier	33%	33%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
HUMIRA PEN PSORIASIS-UVEITIS	5	Specialty Tier	33%	33%	P
HUMIRA(CF) PEN CRHN-UC-HS 80MG PEN IJ KIT	5	Specialty Tier	33%	33%	P
HUMIRA(CF) PEN PS-UV-AHS 80-40 PEN IJ KIT	5	Specialty Tier	33%	33%	P
HUMULIN 70/30 KWIKPEN	3	Preferred Brand	$40.00	$120.00	None
HUMULIN 70/30 VIAL	3	Preferred Brand	$40.00	$120.00	None
HUMULIN N 100 UNITS/ML KWIKPEN	3	Preferred Brand	$40.00	$120.00	None
HUMULIN N 100U/ML VIAL	3	Preferred Brand	$40.00	$120.00	None
HUMULIN R 100U/ML VIAL	3	Preferred Brand	$40.00	$120.00	None
HUMULIN R 500 UNITS/ML KWIKPEN	3	Preferred Brand	$40.00	$120.00	None
HUMULIN R 500U/ML VIAL	3	Preferred Brand	$40.00	$120.00	None
HYDRALAZINE 10 MG TABLET	2	Generic	$8.00	$24.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
HYDRALAZINE 100 MG TABLET	2	Generic	$8.00	$24.00	None
HYDRALAZINE 25 MG TABLET	2	Generic	$8.00	$24.00	None
HYDRALAZINE 50 MG TABLET	2	Generic	$8.00	$24.00	None
Hydrochlorothiazide 12.5 MG Oral Capsule	1	Preferred Generic	$3.00	$9.00	None
HYDROCHLOROTHIAZIDE 12.5 MG TB	1	Preferred Generic	$3.00	$9.00	None
HYDROCHLOROTHIAZIDE 25 MG TAB	1	Preferred Generic	$3.00	$9.00	None
HYDROCHLOROTHIAZIDE 50 MG TAB	1	Preferred Generic	$3.00	$9.00	None
HYDROCODON-ACETAMINOPH 7.5-325	2	Generic	$8.00	$24.00	None
HYDROCODON-ACETAMINOPHEN 5-325	2	Generic	$8.00	$24.00	None
Hydrocodone Bitartrate and Acetaminophen 300; 10mg/1; mg/1	2	Generic	$8.00	$24.00	None
Hydrocodone Bitartrate and Acetaminophen 300; 5mg/1; mg/1	2	Generic	$8.00	$24.00	None
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	2	Generic	$8.00	$24.00	None
HYDROCODONE-ACETAMIN 10-325 MG Tablet [Norco]	2	Generic	$8.00	$24.00	None
HYDROCODONE-ACETAMIN 7.5-325/15 Solution [Hycet]	2	Generic	$8.00	$24.00	None
HYDROCORT-PRAMOXINE 1%-1% CREAM/APPL [Zone A]	4	Non-Preferred Drug	45%	45%	None
HYDROCORTISONE 0.1% SOLN	2	Generic	$8.00	$24.00	None
HYDROCORTISONE 10 MG TABLET [Hydrocortone]	2	Generic	$8.00	$24.00	None
HYDROCORTISONE 100 MG/60 ML	2	Generic	$8.00	$24.00	None
HYDROCORTISONE 2.5% CREAM	1	Preferred Generic	$3.00	$9.00	None
HYDROCORTISONE 2.5% LOTION	2	Generic	$8.00	$24.00	None
HYDROCORTISONE 2.5% OINTMENT	1	Preferred Generic	$3.00	$9.00	None
HYDROCORTISONE 20 MG TABLET [Cortef]	2	Generic	$8.00	$24.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
HYDROCORTISONE 5 MG TABLET [Cortef]	2	Generic	$8.00	$24.00	None
HYDROCORTISONE BUTY 0.1% CREAM	2	Generic	$8.00	$24.00	None
HYDROCORTISONE BUTYR 0.1% LOTION [Locoid]	2	Generic	$8.00	$24.00	None
HYDROCORTISONE BUTYR 0.1% OINT	2	Generic	$8.00	$24.00	None
HYDROCORTISONE VAL 0.2% CREAM	2	Generic	$8.00	$24.00	None
HYDROCORTISONE VAL 0.2% OINTMT	2	Generic	$8.00	$24.00	None
HYDROCORTISONE-ACETIC ACID SOLN	2	Generic	$8.00	$24.00	None
HYDROMORPHONE 1 MG/ML SOLUTION [Dilaudid]	2	Generic	$8.00	$24.00	None
HYDROMORPHONE 10 MG/ML VIAL [Dilaudid-HP]	2	Generic	$8.00	$24.00	None
HYDROMORPHONE 2 MG TABLET [Dilaudid]	2	Generic	$8.00	$24.00	None
HYDROMORPHONE 2 MG/ML ISECURE Syringe [Simplist Dilaudid]	2	Generic	$8.00	$24.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
HYDROMORPHONE 4 MG TABLET [Dilaudid]	2	Generic	$8.00	$24.00	None
HYDROMORPHONE 50 MG/5 ML VIAL [Dilaudid-HP]	2	Generic	$8.00	$24.00	None
HYDROMORPHONE 8 MG TABLET [Dilaudid]	2	Generic	$8.00	$24.00	None
HYDROMORPHONE HCL ER 16 MG TABLET ER 24H [Exalgo]	5	Specialty Tier	33%	33%	None
HYDROMORPHONE HCL ER 32 MG Tablet 24H [Exalgo]	5	Specialty Tier	33%	33%	None
HYDROXYCHLOROQUINE 200 MG TAB	2	Generic	$8.00	$24.00	None
HYDROXYUREA 500 MG CAPSULE	2	Generic	$8.00	$24.00	None
HYDROXYZINE 10 MG/5 ML SOLN	4	Non-Preferred Drug	45%	45%	P
HYDROXYZINE HCL 10 MG TABLET	4	Non-Preferred Drug	45%	45%	P
HYDROXYZINE HCL 25 MG TABLET	4	Non-Preferred Drug	45%	45%	P
HYDROXYZINE HCL 50 MG TABLET	4	Non-Preferred Drug	45%	45%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
HYDROXYZINE PAM 100MG CAPSULE	4	Non-Preferred Drug	45%	45%	P
HYDROXYZINE PAM 25 MG CAP	4	Non-Preferred Drug	45%	45%	P
HYDROXYZINE PAM 50 MG CAP	4	Non-Preferred Drug	45%	45%	P

Chart Legend:

Below are a few notes to help you understand the above 2019 Medicare Part D Farm Bureau Select Rx (PDP) Plan Formulary.

Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region). The plan name is followed by the plan type (PDP, HMO, HMO-POS, PPO, PFFS, etc.)
Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.
Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $415 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.
Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
- Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.
- No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.
Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
- Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have five (5) tiers 1=Preferred Generics, 2=Generics, 3=Preferred Brands, 4=Non-preferred Brands, 5=Specialty Drugs. *Some Part D plans exclude one or more drug tiers from the deductible. If the drug tier field above is followed by * (example: 2*), then this drug tier is excluded from the plan’s deductible.
- Tier Description - This is the Medicare Part D plan’s description of this particular drug tier.
Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
- Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $3820) at a "Preferred" network pharmacy. In most cases, the "Preferred" network pharmacy cost-sharing is lower than the standard (non-preferred) network pharmacy cost-sharing.
- Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
- None - This drug does not fall under any drug utilization management controls.
- P - Prior Authorization -This drug is subject to prior authorization.
- S - Step Therapy -This drug is subject to step therapy.
- Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.

(Chart Source: Centers for Medicare and Medicaid files: CMS Data September 2019 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.