2017 AARP MedicareRx Walgreens (PDP) Formulary



Below is the Formulary, or drug list, for AARP MedicareRx Walgreens (PDP) from Unitedhealthcare Ins. Co. And Unitedhealthcare Ny This formulary is a list of prescription medications that are covered under Unitedhealthcare Ins. Co. And Unitedhealthcare Ny's 2017 Part-D Plan. The AARP MedicareRx Walgreens (PDP) plan has a $400 drug deductible. This deductible is the amount of expenses that must be paid out of pocket before the Initial Coverage period begins. However some drugs do not require that the deductible is met before you receive coverage. You can see if the deductible is required below in the "Does the Deductible Apply" column. The Initial Coverage Limit (ICL) for this plan is $3700. The Initial Coverage Period is the period after the Deductible has been met but before the Coverage Gap phase. Once you and your plan provider have spent $3700 on covered drugs. (combined amount plus your deductible) You will enter the coverage gap. (AKA "donut hole") Once you reach the coverage gap you will be required to pay 45% of the plan's cost for covered brand-name prescription drugs unless your plan offers additional coverage. You can see if this plan offers coverage in the "donut hole" be clicking the "Coverage Gap" link on the left above the chart. In 2017 if you have spent $4700 in expenditures you enter the Catastrophic Phase. During the Catastrophic Period you will begin to receive significant coverage. AARP MedicareRx Walgreens (PDP) will begin paying approximately 95% of your covered medication expenses. You can see if this plan covers your drugs in the Catastrophic Phase by clicking the "Catastrophic" link on the left above the chart.

See More on AARP MedicareRx Walgreens (PDP)





Plan Name:
AARP MedicareRx Walgreens (PDP)
Plan ID:
S5921-383
Provider: Unitedhealthcare Ins. Co. And Unitedhealthcare Ny
Plan Year:2017
Premium:$22.50
Deductible:$400
Initial Coverage Limit:$3700
Coverage Area:Florida




Current Table info:


Coverage Level:
Initial Coverage
Days Supply:
30 Days
Drugs Starting With Letter: H

Change Table Options:


Drugs Starting Letter:
A  B  C  D  E  F  G  H  I  J  K  L  M  N  O  P  Q  R  S T  U  V  W  X  Y  Z 
Coverage Level:
Drug Days Pricing:60 Day
90 Day











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(Click the Drug Name to Compare every Plans Price)

Drug Name Drug Strength Units in Package Tier Level Amount Limit Days Limit Prior Authorization
Y/N
Step Therapy
Y/N
Does the Deduct Apply Cost Preferred Max Cost Non Preferred Max Cost Mail Max
Halaven .5mg/mL 1 Vial In 1 Carton > 2 Ml In 1 Vial
5
Y N Y 25%N25%NNAN
Halobetasol Propionate .5mg/g 50 G In 1 Tube
4
N N Y 32%N33%NNAN
Halobetasol Propionate .5mg/g 1 Tube In 1 Carton > 50 G In 1 Tube
4
N N Y 32%N33%NNAN
Haloperidol 2mg/mL 120 Ml In 1 Bottle, Dropper
2
N N N $3N$18NNAN
Haloperidol 2mg 100 Tablet In 1 Bottle, Plastic
2
N N N $3N$18NNAN
Haloperidol 10mg 100 Tablet In 1 Bottle, Plastic
2
N N N $3N$18NNAN
Haloperidol 5mg/mL 1 Vial, Multi-dose In 1 Carton > 10 Ml In 1 Vial, Multi-dose
4
N N Y 32%N33%NNAN
Haloperidol .5mg 100 Tablet In 1 Bottle
2
N N N $3N$18NNAN
Haloperidol 1mg 100 Tablet In 1 Bottle
2
N N N $3N$18NNAN
Haloperidol 5mg 100 Tablet In 1 Bottle
2
N N N $3N$18NNAN
Haloperidol 20mg 100 Tablet In 1 Bottle
2
N N N $3N$18NNAN
Haloperidol Decanoate 50mg/mL 10 Vial, Single-dose In 1 Tray
4
N N Y 32%N33%NNAN
Haloperidol Decanoate 100mg/mL 1 Vial, Multi-dose In 1 Carton > 5 Ml In 1 Vial, Multi-dose
4
N N Y 32%N33%NNAN
Havrix 720[iU]/.5mL 10 Syringe In 1 Carton
3
N N Y $27N$47NNAN
Havrix 1440[iU]/mL 10 Vial In 1 Carton
3
N N Y $27N$47NNAN
Heparin Sodium 1000[USP'U]/mL 25 Vial, Multi-dose In 1 Tray > 10 Ml In 1 Vial, Multi-dose
4
Y N Y 32%N33%NNAN
Heparin Sodium 10000[USP'U]/mL 25 Vial, Single-dose In 1 Tray > 1 Ml In 1 Vial, Single-dose
4
Y N Y 32%N33%NNAN
Heparin Sodium 5000[USP'U]/mL 25 Vial, Multi-dose In 1 Tray > 10 Ml In 1 Vial, Multi-dose
4
Y N Y 32%N33%NNAN
Heparin Sodium 20000[USP'U]/mL 25 Vial In 1 Carton > 1 Ml In 1 Vial
4
Y N Y 32%N33%NNAN
Heparin Sodium In Dextrose 5; 4000g/100mL; [USP'U]/100mL 24 Container In 1 Case > 500 Ml In 1 Container
4
Y N Y 32%N33%NNAN
Heparin Sodium In Dextrose 5; 5000g/100mL; [USP'U]/100mL 24 Container In 1 Case > 500 Ml In 1 Container
4
Y N Y 32%N33%NNAN
Heparin Sodium In Dextrose 5; 10000g/100mL; [USP'U]/100mL 24 Container In 1 Case > 250 Ml In 1 Container
4
Y N Y 32%N33%NNAN
Hepatamine .77; .6; .014; .9; .24; .9; 1.1; .61; .1; .1; .115g/100mL; g/100mL; g/100mL; g/100mL; g/100mL; g/100 6 Carton In 1 Case > 1 Container In 1 Carton > 500 Ml In 1 Container
4
Y N Y 32%N33%NNAN
Herceptin 1 Kit In 1 Carton * 20 Ml In 1 Vial, Multi-dose * 20 Ml In 1 Vial
5
Y N Y 25%N25%NNAN
Hetlioz 20mg 30 Capsule In 1 Bottle
5
30 30 Y N Y 25%N25%NNAN
Hexalen 50mg 100 Capsule In 1 Bottle
5
Y N Y 25%N25%NNAN
Humalog 100[iU]/mL 1 Vial In 1 Carton > 3 Ml In 1 Vial
3
N N Y $27N$47NNAN
Humalog 100[iU]/mL 1 Vial In 1 Carton > 10 Ml In 1 Vial
3
N N Y $27N$47NNAN
Humalog 100[iU]/mL 1 Vial In 1 Carton > 10 Ml In 1 Vial
3
N N Y $27N$47NNAN
Humalog 5 Cartridge In 1 Carton
3
N N Y $27N$47NNAN
Humalog 100[iU]/mL 5 Syringe In 1 Carton
3
N N Y $27N$47NNAN
Humalog 100[iU]/mL 5 Syringe In 1 Carton
3
N N Y $27N$47NNAN
Humalog 5 Syringe In 1 Carton
3
N N Y $27N$47NNAN
Humira 2 Kit In 1 Carton > 1 Kit In 1 Kit * 1 Syringe In 1 Tray > .8 Ml In 1 Syringe * 1 Swab In 1 Packet
5
Y N Y 25%N25%NNAN
Humira 3 Kit In 1 Carton > 1 Kit In 1 Kit * 1 Syringe In 1 Tray > .8 Ml In 1 Syringe * 1 Swab In 1 Packet
5
Y N Y 25%N25%NNAN
Humira 6 Kit In 1 Carton > 1 Kit In 1 Kit * 1 Syringe In 1 Tray > .8 Ml In 1 Syringe * 1 Swab In 1 Packet
5
Y N Y 25%N25%NNAN
Humira 2 Kit In 1 Carton > 1 Kit In 1 Kit * 1 Syringe In 1 Tray > .8 Ml In 1 Syringe * 1 Swab In 1 Packet
5
Y N Y 25%N25%NNAN
Humira 6 Kit In 1 Carton > 1 Kit In 1 Kit * 1 Syringe In 1 Tray > .8 Ml In 1 Syringe * 1 Swab In 1 Packet
5
Y N Y 25%N25%NNAN
Humira 2 Kit In 1 Carton > 1 Kit In 1 Kit * 1 Syringe In 1 Tray > .2 Ml In 1 Syringe * 1 Swab In 1 Packet
5
Y N Y 25%N25%NNAN
Humira 2 Kit In 1 Carton > 1 Kit In 1 Kit * 1 Syringe In 1 Tray > .4 Ml In 1 Syringe * 1 Swab In 1 Packet
5
Y N Y 25%N25%NNAN
Humulin 100[iU]/mL 1 Vial In 1 Carton > 10 Ml In 1 Vial
3
N N Y $27N$47NNAN
Humulin 100[iU]/mL 1 Vial In 1 Carton > 10 Ml In 1 Vial
3
N N Y $27N$47NNAN
Humulin 500[iU]/mL 1 Vial In 1 Carton > 20 Ml In 1 Vial
3
N N Y $27N$47NNAN
Humulin 100[iU]/mL 1 Vial In 1 Carton > 10 Ml In 1 Vial
3
N N Y $27N$47NNAN
Hydralazine Hydrochloride 25mg 1000 Tablet In 1 Bottle
2
N N N $3N$18NNAN
Hydralazine Hydrochloride 50mg 1000 Tablet In 1 Bottle
2
N N N $3N$18NNAN
Hydralazine Hydrochloride 10mg 1000 Tablet In 1 Bottle
2
N N N $3N$18NNAN
Hydralazine Hydrochloride 100mg 100 Tablet In 1 Bottle
2
N N N $3N$18NNAN
Hydralazine Hydrochloride 25 Vial, Single-dose In 1 Tray > 1 Ml In 1 Vial, Single-dose
4
N N Y 32%N33%NNAN
Hydrochlorothiazide 12.5mg 100 Tablet In 1 Bottle
1
N N N $0N$15NNAN
Hydrochlorothiazide 25mg 1000 Tablet In 1 Bottle, Plastic
1
N N N $0N$15NNAN
Hydrochlorothiazide 50mg 1000 Tablet In 1 Bottle
1
N N N $0N$15NNAN
Hydrochlorothiazide 500 Capsule In 1 Bottle, Plastic
1
N N N $0N$15NNAN
Hydrocodone Bitartrate And Acetaminophen 325; 5mg/1; mg 100 Tablet In 1 Bottle, Plastic
3
360 30 N N Y $27N$47NNAN
Hydrocodone Bitartrate And Acetaminophen 325; 7.5mg/1; mg 100 Tablet In 1 Bottle, Plastic
3
360 30 N N Y $27N$47NNAN
Hydrocodone Bitartrate And Acetaminophen 100 Tablet In 1 Bottle, Plastic
3
360 30 N N Y $27N$47NNAN
Hydrocodone Bitartrate And Acetaminophen 500 Tablet In 1 Bottle
3
360 30 N N Y $27N$47NNAN
Hydrocodone Bitartrate And Acetaminophen 325; 7.5mg/15mL; mg/15mL 473 Ml In 1 Bottle
3
5400 30 N N Y $27N$47NNAN
Hydrocodone Bitartrate And Ibuprofen 7.5; 200mg/1; mg 100 Tablet In 1 Bottle
3
150 30 N N Y $27N$47NNAN
Hydrocortisone 10mg/g 453.6 G In 1 Jar
2
N N N $3N$18NNAN
Hydrocortisone 10mg/g 453.6 G In 1 Jar
2
N N N $3N$18NNAN
Hydrocortisone 5mg 50 Tablet In 1 Bottle, Plastic
3
N N Y $27N$47NNAN
Hydrocortisone 10mg 100 Tablet In 1 Bottle, Plastic
3
N N Y $27N$47NNAN
Hydrocortisone 20mg 100 Tablet In 1 Bottle, Plastic
3
N N Y $27N$47NNAN
Hydrocortisone 25mg/g 1 Tube In 1 Carton > 30 G In 1 Tube
2
N N N $3N$18NNAN
Hydrocortisone 25mg/mL 1 Bottle, Plastic In 1 Carton > 59 Ml In 1 Bottle, Plastic
3
N N Y $27N$47NNAN
Hydrocortisone 25mg/g 1 Tube In 1 Carton > 20 G In 1 Tube
2
N N N $3N$18NNAN
Hydrocortisone 100mg/60mL 7 Bottle, With Applicator In 1 Box
3
N N Y $27N$47NNAN
Hydrocortisone And Acetic Acid 2.41; 3.15g/100mL; g/100mL 1 Bottle In 1 Carton > 10 Ml In 1 Bottle
3
N N Y $27N$47NNAN
Hydrocortisone Butyrate 1mg/g 1 Tube In 1 Carton > 45 G In 1 Tube
3
N N Y $27N$47NNAN
Hydrocortisone Valerate 2mg/g 1 Tube In 1 Carton > 60 G In 1 Tube
4
N N Y 32%N33%NNAN
Hydrocortisone Valerate 2mg/g 1 Tube In 1 Carton > 60 G In 1 Tube
4
N N Y 32%N33%NNAN
Hydromorphone Hydrochloride 1mg/mL 473 Ml In 1 Bottle
4
2700 30 N N Y 32%N33%NNAN
Hydromorphone Hydrochloride 8mg 100 Tablet In 1 Bottle
2
330 30 N N N $3N$18NNAN
Hydromorphone Hydrochloride 10 Syringe In 1 Box > 1 Ml In 1 Syringe
4
N N Y 32%N33%NNAN
Hydromorphone Hydrochloride 2mg 100 Tablet In 1 Bottle, Plastic
2
240 30 N N N $3N$18NNAN
Hydromorphone Hydrochloride 4mg 100 Tablet In 1 Bottle, Plastic
2
240 30 N N N $3N$18NNAN
Hydromorphone Hydrochloride 10 Vial In 1 Carton
4
N N Y 32%N33%NNAN
Hydroxychloroquine Sulfate 200mg 500 Tablet, Film Coated In 1 Bottle
2
N N N $3N$18NNAN
Hydroxyurea 500mg 100 Blister Pack In 1 Box, Unit-dose
2
N N N $3N$18NNAN
Hydroxyzine Hydrochloride 500 Tablet, Film Coated In 1 Bottle
3
N N Y $27N$47NNAN
Hydroxyzine Hydrochloride 1000 Tablet, Film Coated In 1 Bottle
3
N N Y $27N$47NNAN
Hydroxyzine Hydrochloride 25mg/mL 25 Vial, Single-dose In 1 Tray > 1 Ml In 1 Vial, Single-dose
4
N N Y 32%N33%NNAN
Hydroxyzine Hydrochloride 50mg/mL 25 Vial, Single-dose In 1 Tray > 1 Ml In 1 Vial, Single-dose
4
N N Y 32%N33%NNAN
Hydroxyzine Hydrochloride 473 Ml In 1 Bottle, Plastic
3
N N Y $27N$47NNAN
Hydroxyzine Pamoate 100mg 100 Capsule In 1 Bottle
3
N N Y $27N$47NNAN
Hydroxyzine Pamoate 25mg 500 Capsule In 1 Bottle, Plastic
3
N N Y $27N$47NNAN
Hydroxyzine Pamoate 50mg 100 Capsule In 1 Bottle, Plastic
3
N N Y $27N$47NNAN



Medicare Help's Additional Notes:

Coverage Levels for S5921-383

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1.Pre-Deductable: Before you reach the plans deductible of $400. Some plans offer select Pre-deductible drug Coverage
2.Initial Coverage: (ICL) After you reach the plans deductible but before the Initial Coverage limit of $3700
3.Coverage Gap: (AKA Donut Hole) After you reach the plans ICL but before the Catastrophic of $4950 in 2017.
4.Catastrophic: Anything over $4950 you will receive a significant increase in coverage.

Definitions:

Premium: A monthly flat fee that varies by plan.
Deductible: The amount you must pay each year for your prescriptions before your plan begins to pay its share of your covered drugs. The max in 2017 is $320. Some plans have a $0 Deductible.
Tier Level: Medicare drug plans place drugs into different "tiers" on their formularies. Drugs in each tier have a different cost. A drug in a lower tier will generally cost you less.
Quantity Limit Amount/Days: Certain drugs have a Quantity Limit. That means the plan will only cover the drug up to a designated quantity or amount. If your prescribing doctor feels it is necessary to exceed the set limit, he or she must get prior approval before the higher quantity will be covered.
Prior Authorization: Certain Drugs require you or your doctor to get prior authorization in order to be covered. Usually just an additional form. If you dont get approval, the plan may not cover the drug.
Does the Deduct Apply: Some drugs do not require that the deductible is met before you receive coverage.
Step Therapy: Means you must first try one drug to treat your medical condition before the plan will cover another drug for the same condition. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.
Cost Prefered: Your Cost for the Drug at the Providers In Network Prefered Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Non Pref: Your Cost for the Prescription Drug at a Non-Prefered Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Mail: Your Cost for Prescription Drugs through a Mail Order Pharmacy. As a Percent of the total drug cost or a flat rate.


What if a drug I need is not listed?

Please check the formulary for different brand and generic names. If you still cannot locate your drugs, your plan may not offer coverage. Talk to your doctor first about changing your prescription to a drug on your plans formulary. If this is not an option, you can request an exception to have the plan review its coverage decision based on your individual circumstances.

Source:CMS Formulary Data Oct. 2016
Source:NDC Directory by FDA.gov

**We make every attempt to keep our information accurate. But please check with the plan providers to verify all information.