hydroxyzine pamoate 100 MG Oral Capsule
hydroxyzine pamoate
RxCUI: 995232
What the CMS Formulary Data Shows for hydroxyzine pamoate 100 MG Oral Capsule
Per the CMS 2026 Part D formulary file, hydroxyzine pamoate 100 MG Oral Capsule (RxNorm concept RXCUI 995232, generic name hydroxyzine pamoate) appears on 156 distinct formulary files spanning 3,446 Medicare Part D plan offerings - 68% of enrollable Part D products, mid-range placement; shopping across contracts changes access. Tier placement ranges from Tier 1 to Tier 4, with a cross-plan average of Tier 2.5.
Real-world access to hydroxyzine pamoate 100 MG Oral Capsule depends on utilization management as much as tier placement: 28.2% of covering formularies require prior authorization. 0% require step therapy. 0% apply quantity limits.
Historical spending context from the CMS Medicare Part D Drug Spending Dashboard shows 419,149 Part D beneficiaries filled hydroxyzine pamoate 100 MG Oral Capsule in 2023, with total plan-and-beneficiary spending of $20,653,891 and an average per-beneficiary annual cost of $49.28. The plan-by-plan detail below lists exactly which PDP and MA-PD contracts carry hydroxyzine pamoate 100 MG Oral Capsule today.
Coverage Details
- Formularies covering
- 156
- Plans covering
- 3,446
- Coverage rate
- 68%
- Tier range
- Tier 1 – Tier 4
- Average tier
- Tier 2, Generic
Restrictions
- Prior authorization required
- 28.2% of formularies
- Step therapy required
- 0% of formularies
- Quantity limits
- 0% of formularies
2023 Medicare Spending
- Beneficiaries
- 419,149
- Total spending
- $20,653,891
- Avg per beneficiary
- $49.28
Tier Distribution Across Plans
Medicare Advantage Plans (MA-PD) Covering hydroxyzine pamoate 100 MG Oral Capsule
100 Medicare Advantage plans with Part D drug coverage include this drug.
| Plan | Insurer | Tier | PA | Premium | States |
|---|---|---|---|---|---|
| CareAdvantage (HMO D-SNP) | SAN MATEO HEALTH COMMISSION | T1 | No | $0 | CA |
| DrMax (HMO) | DOCTORS HEALTHCARE PLANS, INC. | T1 | Yes | $0 | FL |
| DrExtraCare (HMO C-SNP) | DOCTORS HEALTHCARE PLANS, INC. | T1 | Yes | $0 | FL |
| DrSelect (HMO) | DOCTORS HEALTHCARE PLANS, INC. | T1 | Yes | $0 | FL |
| DrSelect-CFL (HMO) | DOCTORS HEALTHCARE PLANS, INC. | T1 | Yes | $0 | FL |
| DrPlatinum-CFL (HMO D-SNP) | DOCTORS HEALTHCARE PLANS, INC. | T1 | Yes | $0 | FL |
| DrTotalCare-CFL (HMO C-SNP) | DOCTORS HEALTHCARE PLANS, INC. | T1 | Yes | $0 | FL |
| DrElite-SFL (HMO) | DOCTORS HEALTHCARE PLANS, INC. | T1 | Yes | $0 | FL |
| Horizon NJ TotalCare (HMO D-SNP) | HORIZON HEALTHCARE OF NEW JERSEY, INC. | T1 | Yes | $0 | NJ |
| NaviCare (HMO D-SNP) | FALLON COMMUNITY HEALTH PLAN | T1 | No | $0 | MA |
| Hamaspik Medicare Choice (HMO D-SNP) | HAMASPIK, INC. | T1 | Yes | $0 | NY |
| SeniorCare Complete (HMO D-SNP) | SOUTH COUNTRY HEALTH ALLIANCE | T1 | Yes | $0 | MN |
| AbilityCare (HMO D-SNP) | SOUTH COUNTRY HEALTH ALLIANCE | T1 | Yes | $0 | MN |
| Alameda Alliance Wellness (HMO D-SNP) | ALAMEDA ALLIANCE FOR HEALTH | T1 | Yes | $0 | CA |
| PHP (HMO C-SNP) | AIDS HEALTHCARE FOUNDATION | T1 | No | $0 | CA |
| Astiva Health Savings Plan (HMO) | ASTIVA HEALTH, INC. | T1 | No | $0 | CA |
| Astiva Health C-SNP Deluxe (HMO C-SNP) | ASTIVA HEALTH, INC. | T1 | No | $0 | CA |
| Astiva Health Savings Plan - NorCal (HMO) | ASTIVA HEALTH, INC. | T1 | No | $0 | CA |
| Astiva Health Premier Plan - NorCal (HMO) | ASTIVA HEALTH, INC. | T1 | No | $0 | CA |
| Astiva Health Premier Plan (HMO) | ASTIVA HEALTH, INC. | T1 | No | $0 | CA |
| ATRIO Prime Rx (HMO) | ATRIO HEALTH PLANS | T1 | No | $0 | OR |
| ATRIO Choice Rx (PPO) | ATRIO HEALTH PLANS | T1 | No | $0 | OR |
| ATRIO Choice Rx (PPO) | ATRIO HEALTH PLANS | T1 | No | $0 | OR |
| ATRIO Prime Rx (PPO) | ATRIO HEALTH PLANS | T1 | No | $0 | OR |
| ATRIO Prime Rx (PPO) | ATRIO HEALTH PLANS | T1 | No | $0 | OR |
| ATRIO Prime Rx (PPO) | ATRIO HEALTH PLANS | T1 | No | $0 | OR |
| ATRIO Choice Rx (PPO) | ATRIO HEALTH PLANS | T1 | No | $0 | OR |
| ATRIO Choice Rx (PPO) | ATRIO HEALTH PLANS | T1 | No | $0 | OR |
| ATRIO Support Rx (PPO C-SNP) | ATRIO HEALTH PLANS | T1 | No | $0 | OR |
| TotalCare (HMO D-SNP) | SANTA CRUZ MONTEREY MERCED SAN BENITO MARIPOSA MANAGED MEDIC | T1 | No | $0 | CA |
| Elevate Medicare Choice (HMO D-SNP) | DENVER HEALTH MEDICAL PLAN, INC. | T1 | No | $0 | CO |
| McLaren Medicare Inspire (HMO) | MCLAREN HEALTH PLAN, INC. | T1 | No | $0 | MI |
| McLaren Medicare Inspire Select (HMO) | MCLAREN HEALTH PLAN, INC. | T1 | No | $0 | MI |
| AllCare Advantage Redwood Rx (HMO D-SNP) | ALLCARE HEALTH PLAN, INC. | T1 | No | $0 | OR |
| PrimeWest Senior Health Complete (HMO D-SNP) | PRIMEWEST RURAL MN HEALTH CARE ACCESS INITIATIVE | T1 | No | $0 | MN |
| Prime Health Complete (HMO D-SNP) | PRIMEWEST RURAL MN HEALTH CARE ACCESS INITIATIVE | T1 | No | $0 | MN |
| DualConnect (HMO D-SNP) | SANTA CLARA COUNTY HEALTH AUTHORITY | T1 | No | $0 | CA |
| VNS Health Total (HMO D-SNP) | VNS CHOICE | T1 | No | $0 | NY |
| Alterwood Advantage Dual Secure (HMO D-SNP) | ALTERWOOD ADVANTAGE, INC. | T1 | No | $0 | MD |
| CommuniCare Advantage CSNP (HMO C-SNP) | OH CHS SNP INC. | T1 | No | $0 | MD, OH |
| Generations Classic Rewards (HMO) | GLOBALHEALTH, INC. | T1 | No | $0 | OK |
| Generations Classic Plus (HMO) | GLOBALHEALTH, INC. | T1 | No | $0 | OK |
| Generations Chronic Care (HMO C-SNP) | GLOBALHEALTH, INC. | T1 | No | $0 | OK |
| Generations Chronic Care Savings (HMO C-SNP) | GLOBALHEALTH, INC. | T1 | No | $0 | OK |
| Generations Dual Support (HMO D-SNP) | GLOBALHEALTH, INC. | T1 | No | $0 | OK |
| Generations Dual Premier (HMO D-SNP) | GLOBALHEALTH, INC. | T1 | No | $0 | OK |
| Nascentia Dual Advantage (HMO D-SNP) | VISITING NURSE ASSOCIATION OF CENTRAL NEW YORK | T1 | No | $0 | NY |
| Provider Partners Pennsylvania Community Plan (HMO I-SNP) | PROVIDER PARTNERS HEALTH PLAN OF PENNSYLVANIA, INC | T1 | No | $0 | PA |
| Provider Partners North Carolina Community Plan (HMO I-SNP) | PROVIDER PARTNERS HEALTH PLAN OF NORTH CAROLINA | T1 | No | $0 | NC |
| Provider Partners Indiana Community Plan (HMO I-SNP) | PROVIDER PARTNERS HEALTH PLAN OF INDIANA | T1 | No | $0 | IN |
Frequently Asked Questions
Is hydroxyzine pamoate 100 MG Oral Capsule covered by Medicare Part D?
Yes, hydroxyzine pamoate 100 MG Oral Capsule is covered by 3,446 Medicare Part D plans (68% of all Part D formularies).
What tier is hydroxyzine pamoate 100 MG Oral Capsule on Medicare Part D plans?
hydroxyzine pamoate 100 MG Oral Capsule averages Tier 2.5 across Part D plans, ranging from Tier 1 to Tier 4.
Does hydroxyzine pamoate 100 MG Oral Capsule require prior authorization?
28.2% of Part D formularies require prior authorization for hydroxyzine pamoate 100 MG Oral Capsule. Step therapy: 0%. Quantity limits: 0%.
How much does Medicare spend on hydroxyzine pamoate 100 MG Oral Capsule?
In 2023, total Medicare Part D spending on hydroxyzine pamoate 100 MG Oral Capsule was $20,653,891, covering 419,149 beneficiaries. The average spend per beneficiary was $49.28.
Read our methodology - how this data is sourced, computed, and verified.