HYDROXYZINE PAMOATE 25 mg Capsule
Coverage in Pennsylvania and West Virginia (CMS PDP Region 06).
10 of 12 stand-alone Part D plans in Pennsylvania and West Virginia cover this drug on tier 3–4.
Lowest 30-day cost $45.00 at a preferred pharmacy. 7 of 10 plans apply a prior authorization, step therapy or quantity limit.
278 Medicare Advantage plans in PA, WV do cover it
Medicare Advantage plans carry their own formularies, separate from stand-alone Part D. A patient on an MA-PD plan may have coverage even where no PDP lists the drug. PA: 236 plans · WV: 42 plans.
Every plan that covers it
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $0.0925 | — |
|
| HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible | 3Preferred Brand | 21% | 21% | $0.1353 | — |
|
| Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible | 3Preferred Brand | $45.00 | $125.00 | $0.0923 | — | None |
| Humana Basic Rx Plan (PDP)$6.60/mo premium · $615.00 deductible | 4Non-Preferred Drug | 33% | — | $0.0929 | — | None |
| Wellcare Value Script (PDP)$8.20/mo premium · $615.00 deductible | 4Non-Preferred Drug | 40% | 40% | $0.1906 | — |
|
| Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 28% | 28% | $0.1878 | — |
|
| Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible | 4Non-Preferred Drug | 33% | — | $0.0939 | — | None |
| SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 35% | 35% | $0.1130 | — |
|
| AARP Medicare Rx Saver from UHC (PDP)$43.50/mo premium · $615.00 deductible | 4Non-Preferred Drug | 41% | — | $0.0876 | — |
|
| AARP Medicare Rx Preferred from UHC (PDP)$121.90/mo premium · $130.00 deductible | 4Non-Preferred Drug | 33% | — | $0.0874 | — |
|
Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity.