hydroxyzine pamoate 50 MG Oral Capsule
hydroxyzine pamoate
RxCUI: 995278
What the CMS Formulary Data Shows for hydroxyzine pamoate 50 MG Oral Capsule
Per the CMS 2026 Part D formulary file, hydroxyzine pamoate 50 MG Oral Capsule (RxNorm concept RXCUI 995278, generic name hydroxyzine pamoate) appears on 272 distinct formulary files spanning 4,743 Medicare Part D plan offerings - 93.6% of enrollable Part D products, near-universal placement. Tier placement ranges from Tier 1 to Tier 4, with a cross-plan average of Tier 2.3.
Real-world access to hydroxyzine pamoate 50 MG Oral Capsule depends on utilization management as much as tier placement: 43.8% 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 50 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 50 MG Oral Capsule today.
Coverage Details
- Formularies covering
- 272
- Plans covering
- 4,743
- Coverage rate
- 93.6%
- Tier range
- Tier 1 – Tier 4
- Average tier
- Tier 2, Generic
Restrictions
- Prior authorization required
- 43.8% 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 50 MG Oral Capsule
100 Medicare Advantage plans with Part D drug coverage include this drug.
| Plan | Insurer | Tier | PA | Premium | States |
|---|---|---|---|---|---|
| Sentara Community Complete Select (HMO D-SNP) | SENTARA HEALTH PLANS | T1 | No | $0 | VA |
| Sentara Community Complete (HMO D-SNP) | SENTARA HEALTH PLANS | T1 | No | $0 | VA |
| Florida Complete Care-Duals VIP (HMO-POS D-SNP) | HPMP OF FLORIDA, INC. | T1 | Yes | $0 | FL |
| Mercy Care Advantage (HMO D-SNP) | MERCY CARE | T1 | Yes | $0 | AZ |
| Mercy Care Advantage (HMO D-SNP) | MERCY CARE | T1 | Yes | $0 | AZ |
| Mercy Care Advantage (HMO D-SNP) | MERCY CARE | T1 | Yes | $0 | AZ |
| Elderplan Plus Long-Term Care (HMO-POS D-SNP) | ELDERPLAN, INC. | T1 | Yes | $0 | NY |
| Health Choice Pathway (HMO D-SNP) | HEALTH CHOICE ARIZONA, INC. | T1 | Yes | $0 | AZ |
| Healthfirst CompleteCare (HMO D-SNP) | HEALTHFIRST HEALTH PLAN, INC. | T1 | Yes | $0 | NY |
| IMCare Classic (HMO D-SNP) | ITASCA MEDICAL CARE | T1 | Yes | $0 | MN |
| Johns Hopkins Advantage MD D-SNP (HMO D-SNP) | HOPKINS HEALTH ADVANTAGE, INC. | T1 | Yes | $0 | MD |
| MetroPlus UltraCare (HMO D-SNP) | METROPLUS HEALTH PLAN, INC. | T1 | Yes | $0 | NY |
| Senior Whole Health SCO (HMO D-SNP) | SENIOR WHOLE HEALTH, LLC | T1 | Yes | $0 | MA |
| Senior Whole Health SCO NHC (HMO D-SNP) | SENIOR WHOLE HEALTH, LLC | T1 | Yes | $0 | MA |
| Molina One Care (HMO D-SNP) | SENIOR WHOLE HEALTH, LLC | T1 | Yes | $0 | MA |
| PruittHealth Premier D-SNP (HMO D-SNP) | PRUITTHEALTH PREMIER, INC. | T1 | No | $0 | GA |
| KeyCare Advantage Plus (HMO C-SNP) | ISNP VENTURES, LLC | T1 | No | $0 | MD |
| Premier Care (HMO-POS I-SNP) | LIFEWORKS ADVANTAGE, LLC | T1 | No | $0 | VA |
| Premier Care (HMO I-SNP) | ALIGN SENIOR CARE CALIFORNIA INC. | T1 | No | $0 | CA |
| Advantage Care (HMO) | ALIGN SENIOR CARE CALIFORNIA INC. | T1 | No | $0 | CA |
| Premier Care (HMO-POS I-SNP) | ALIGN SENIOR CARE MI, LLC | T1 | No | $0 | MI |
| Premier Care (HMO I-SNP) | ALIGN SENIOR CARE FLORIDA, INC. | T1 | No | $0 | FL |
| Perennial Advantage Freedom (HMO-POS) | PERENNIAL ADVANTAGE OF COLORADO, INC. | T1 | No | $0 | CO |
| Perennial Advantage Premier (HMO-POS I-SNP) | PERENNIAL ADVANTAGE OF COLORADO, INC. | T1 | No | $0 | CO |
| Perennial Advantage Freedom (HMO) | PERENNIAL ADVANTAGE OF COLORADO, INC. | T1 | No | $0 | PA |
| Perennial Advantage Premier (HMO I-SNP) | PERENNIAL ADVANTAGE OF COLORADO, INC. | T1 | No | $0 | PA |
| Perennial Advantage Freedom (HMO-POS) | PERENNIAL ADVANTAGE OF OHIO, INC. | T1 | No | $0 | OH |
| Perennial Advantage Premier (HMO-POS I-SNP) | PERENNIAL ADVANTAGE OF OHIO, INC. | T1 | No | $0 | OH |
| ProCare Advantage - Diabetes Care Management (HMO-POS C-SNP) | PROCARE ADVANTAGE, LLC | T1 | No | $0 | TX |
| PruittHealth Premier Advantage (HMO I-SNP) | PRUITTHEALTH PREMIER, INC. | T1 | No | $0 | GA |
| Senior Health Plan Silver Plus (HMO) | COMMUNITYCARE GOVERNMENT PROGRAMS, INC. | T1 | No | $0 | OK |
| Senior Health Plan Oklahoma Dual Complete (HMO D-SNP) | COMMUNITYCARE GOVERNMENT PROGRAMS, INC. | T1 | No | $0 | OK |
| Community First Medicare Advantage Alamo Plan (HMO) | COMMUNITY FIRST HEALTH PLANS, INC. | T1 | No | $0 | TX |
| Community First Medicare Advantage D-SNP (HMO D-SNP) | COMMUNITY FIRST HEALTH PLANS, INC. | T1 | No | $0 | TX |
| Community DualCare Aligned (HMO D-SNP) | COMMUNITY HEALTH CHOICE TEXAS, INC. | T1 | No | $0 | TX |
| Community DualCare Access (HMO D-SNP) | COMMUNITY HEALTH CHOICE TEXAS, INC. | T1 | No | $0 | TX |
| El Paso Health Medicare Advantage Dual (HMO D-SNP) | EL PASO FIRST HEALTH PLANS, INC. | T1 | No | $0 | TX |
| El Paso Health Total (HMO) | EL PASO FIRST HEALTH PLANS, INC. | T1 | No | $0 | TX |
| El Paso Health Giveback (HMO) | EL PASO FIRST HEALTH PLANS, INC. | T1 | No | $0 | TX |
| Liberty Medicare Advantage (HMO C-SNP) | LIBERTY ADVANTAGE, LLC | T1 | No | $0 | NC |
| Peak Advantage Vista (PPO) | PEAK HEALTH INSURANCE CORPORATION | T1 | No | $0 | PA, WV |
| SECUR Edge (HMO I-SNP) | SECUR INC | T1 | No | $0 | FL |
| Simpra Advantage Dual Care (PPO D-SNP) | SIMPRA ADVANTAGE, INC. | T1 | No | $0 | AL |
| 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 |
Frequently Asked Questions
Is hydroxyzine pamoate 50 MG Oral Capsule covered by Medicare Part D?
Yes, hydroxyzine pamoate 50 MG Oral Capsule is covered by 4,743 Medicare Part D plans (93.6% of all Part D formularies).
What tier is hydroxyzine pamoate 50 MG Oral Capsule on Medicare Part D plans?
hydroxyzine pamoate 50 MG Oral Capsule averages Tier 2.3 across Part D plans, ranging from Tier 1 to Tier 4.
Does hydroxyzine pamoate 50 MG Oral Capsule require prior authorization?
43.8% of Part D formularies require prior authorization for hydroxyzine pamoate 50 MG Oral Capsule. Step therapy: 0%. Quantity limits: 0%.
How much does Medicare spend on hydroxyzine pamoate 50 MG Oral Capsule?
In 2023, total Medicare Part D spending on hydroxyzine pamoate 50 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.