HYDROXYZINE PAMOATE 50 mg Capsule
Coverage in Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming (CMS PDP Region 25).
10 of 11 stand-alone Part D plans in Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming 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.
190 Medicare Advantage plans in IA, MN, MT, NE, ND, SD, WY 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. IA: 51 plans · MN: 43 plans · MT: 22 plans · NE: 40 plans · ND: 14 plans · SD: 12 plans · WY: 8 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)$66.50/mo premium · $615.00 deductible | 3Preferred Brand | 17% | 17% | $0.1557 | — |
|
| Humana Premier Rx Plan (PDP)$103.70/mo premium · $0.00 deductible | 3Preferred Brand | $45.00 | $125.00 | $0.1127 | — | None |
| HealthSpring Assurance Rx (PDP)$125.90/mo premium · $615.00 deductible | 3Preferred Brand | 21% | 21% | $0.1694 | — |
|
| Humana Basic Rx Plan (PDP)$4.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 34% | — | $0.1133 | — | None |
| AARP Medicare Rx Saver from UHC (PDP)$5.30/mo premium · $615.00 deductible | 4Non-Preferred Drug | 35% | — | $0.1177 | — |
|
| Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible | 4Non-Preferred Drug | 40% | 40% | $0.2530 | — |
|
| Wellcare Classic (PDP)$12.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 27% | 27% | $0.2489 | — |
|
| Humana Value Rx Plan (PDP)$20.80/mo premium · $601.00 deductible | 4Non-Preferred Drug | 34% | — | $0.1145 | — | None |
| SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible | 4Non-Preferred Drug | 35% | 35% | $0.2082 | — |
|
| AARP Medicare Rx Preferred from UHC (PDP)$140.20/mo premium · $130.00 deductible | 4Non-Preferred Drug | 34% | — | $0.1176 | — |
|
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.