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2009 Medicare Part D Plan Formulary Information
MedicareBlue Rx Option 2 (S5743-003-0) Benefit Details
The MedicareBlue Rx Option 2 (S5743-003-0) Formulary Drugs Starting with the Letter I in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY
Drugs Starting with Letter I Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter I Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
IBU TABLET 600MG (500 CT)	1	Level 1: Covered Generic	$4.00	$8.00	None
IBU TABLET 800MG (500 CT)	1	Level 1: Covered Generic	$4.00	$8.00	None
IBUPROFEN 100MG/5ML SUSP	1	Level 1: Covered Generic	$4.00	$8.00	None
IBUPROFEN 400MG TABLET	1	Level 1: Covered Generic	$4.00	$8.00	None
IDAMYCIN PFS 1MG/ML VIAL	4	Covered Specialty	33%	33%	None
IDARUBICIN HCL 1MG/ML VIAL	4	Covered Specialty	33%	33%	None
IFEX 1GM VIAL	4	Covered Specialty	33%	33%	None
IFEX 3GM VIAL	4	Covered Specialty	33%	33%	None
IFEX/MESNEX KIT 1 GM/VIL 1 GM/	4	Covered Specialty	33%	33%	None
IFOSFAMIDE 1GM VIAL	4	Covered Specialty	33%	33%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
IFOSFAMIDE 1GM/ 20ML VIAL 20ML	4	Covered Specialty	33%	33%	None
IFOSFAMIDE 3GM VIAL	4	Covered Specialty	33%	33%	None
IFOSFAMIDE 3GM/ 60ML VIAL 60ML	4	Covered Specialty	33%	33%	None
IFOSFAMIDE/MESNA KIT 1G/20ML / 1MG/	4	Covered Specialty	33%	33%	None
IFOSFAMIDE/MESNA KIT 1G/20ML / 1MG/	4	Covered Specialty	33%	33%	None
IMIPRAMINE HCL 10MG TABLET (100 CT)	1	Level 1: Covered Generic	$4.00	$8.00	None
IMIPRAMINE HCL 25MG TABLET (100 CT)	1	Level 1: Covered Generic	$4.00	$8.00	None
IMIPRAMINE HCL 50MG TABLET (100 CT)	1	Level 1: Covered Generic	$4.00	$8.00	None
IMIPRAMINE PAMOATE 100MG CAPSULE	3	Level 3: Covered Brand	50%	50%	None
IMIPRAMINE PAMOATE 125MG CAPSULE	3	Level 3: Covered Brand	50%	50%	None
IMIPRAMINE PAMOATE 150MG CAPSULE	3	Level 3: Covered Brand	50%	50%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
IMIPRAMINE PAMOATE 75MG CAPSULE	3	Level 3: Covered Brand	50%	50%	None
IMITREX 100MG TABLET	3	Level 3: Covered Brand	50%	50%	Q:18 /30Days
IMITREX 20MG NASAL SPRAY	3	Level 3: Covered Brand	50%	50%	Q:12 /30Days
IMITREX 25MG TABLET	3	Level 3: Covered Brand	50%	50%	Q:18 /30Days
IMITREX 4MG/0.5ML KIT REFILL	3	Level 3: Covered Brand	50%	50%	Q:6 /30Days
IMITREX 4MG/0.5ML SYRNG KIT	3	Level 3: Covered Brand	50%	50%	Q:6 /30Days
IMITREX 50MG TABLET	3	Level 3: Covered Brand	50%	50%	Q:18 /30Days
IMITREX 5MG NASAL SPRAY	3	Level 3: Covered Brand	50%	50%	Q:12 /30Days
IMITREX 6MG/0.5ML SYRNG KIT	3	Level 3: Covered Brand	50%	50%	Q:6 /30Days
IMITREX 6MG/0.5ML SYRNG KIT	3	Level 3: Covered Brand	50%	50%	Q:6 /30Days
IMITREX 6MG/0.5ML VIAL	3	Level 3: Covered Brand	50%	50%	Q:5 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
IMOVAX RABIES VACCINE 2.5UNT/ML	3	Level 3: Covered Brand	50%	50%	None
INCRELEX 40MG/4ML VIAL	4	Covered Specialty	33%	33%	None
INDAPAMIDE 1.25MG TABLET USP (1000 CT)	1	Level 1: Covered Generic	$4.00	$8.00	None
INDAPAMIDE 2.5MG TABLET USP (1000 CT)	1	Level 1: Covered Generic	$4.00	$8.00	None
INDOMETHACIN 25MG CAPSULE	1	Level 1: Covered Generic	$4.00	$8.00	None
INDOMETHACIN 50MG CAPSULE	1	Level 1: Covered Generic	$4.00	$8.00	None
INDOMETHACIN 75MG CAPSULE SA	1	Level 1: Covered Generic	$4.00	$8.00	None
INFANRIX VACCINE VIAL 25-10UNT/.5ML	3	Level 3: Covered Brand	50%	50%	None
INTAL INH AER 800MCG	2	Level 2: Covered Preferred Brand	$32.00	$64.00	Q:42 /30Days
INTELENCE 100MG TABLET	3	Level 3: Covered Brand	50%	50%	None
INTERFERON ALFACON-1 VIAL 15MCG-0.5ML	4	Covered Specialty	33%	33%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
INTERFERON ALFACON-1 VIAL 9MCG-0.3ML	4	Covered Specialty	33%	33%	None
INTRALIPID 10% IV FAT EMUL	1	Level 1: Covered Generic	$4.00	$8.00	None
INTRALIPID 20% IV FAT EMUL	1	Level 1: Covered Generic	$4.00	$8.00	None
INTRALIPID IV FAT EMULSION	1	Level 1: Covered Generic	$4.00	$8.00	None
INTRON A 10MMU INJ PEN	4	Covered Specialty	33%	33%	None
INTRON A 10MMU VIAL	4	Covered Specialty	33%	33%	None
INTRON A 10MMU/ML VIAL	4	Covered Specialty	33%	33%	None
INTRON A 18MMU VIAL	4	Covered Specialty	33%	33%	None
INTRON A 3MMU INJECTION PEN	4	Covered Specialty	33%	33%	None
INTRON A 50MMU VIAL	4	Covered Specialty	33%	33%	None
INTRON A 5MMU MULTIDOSE PEN	4	Covered Specialty	33%	33%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
INTRON A 6MMU/ML VIAL	4	Covered Specialty	33%	33%	None
INVANZ 1GM VIAL	4	Covered Specialty	33%	33%	None
INVEGA 3MG TABLET SR OSMOTIC PUSH 24HR	3	Level 3: Covered Brand	50%	50%	S Q:30 /30Days
INVEGA 6MG TABLET SR OSMOTIC PUSH 24HR	3	Level 3: Covered Brand	50%	50%	S Q:60 /30Days
INVEGA 9MG TABLET SR OSMOTIC PUSH 24HR	3	Level 3: Covered Brand	50%	50%	S Q:30 /30Days
INVIRASE 200MG CAPSULE	3	Level 3: Covered Brand	50%	50%	None
INVIRASE 500MG TABLET	3	Level 3: Covered Brand	50%	50%	None
IPOL VIAL 40;8;32; UNT	3	Level 3: Covered Brand	50%	50%	None
IPRATROPIUM BROMIDE 21MCG AEROSOL SPRAY	1	Level 1: Covered Generic	$4.00	$8.00	Q:60 /30Days
IPRATROPIUM BROMIDE 42MCG AEROSOL SPRAY	1	Level 1: Covered Generic	$4.00	$8.00	Q:45 /30Days
IRESSA 250MG TABLET	4	Covered Specialty	33%	33%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
IRINOTECAN HCL INJECTION 20MG	4	Covered Specialty	33%	33%	None
ISENTRESS 400MG TABLET	2	Level 2: Covered Preferred Brand	$32.00	$64.00	None
ISO GENTAMICIN 100MG/100ML	1	Level 1: Covered Generic	$4.00	$8.00	None
ISO GENTAMICIN 120MG/100ML	1	Level 1: Covered Generic	$4.00	$8.00	None
ISOCHRON 40MG TABLET SA	1	Level 1: Covered Generic	$4.00	$8.00	None
ISOLYTE M IN 5% DEXTROSE INJECTION	1	Level 1: Covered Generic	$4.00	$8.00	None
ISONARIF 300-150MG CAPSULE	1	Level 1: Covered Generic	$4.00	$8.00	None
ISONIAZID 100MG TABLET	1	Level 1: Covered Generic	$4.00	$8.00	None
ISONIAZID 300MG TABLET	1	Level 1: Covered Generic	$4.00	$8.00	None
ISONIAZID INJ 100MG/ML	1	Level 1: Covered Generic	$4.00	$8.00	None
ISOSORBIDE DN 10MG TABLET	1	Level 1: Covered Generic	$4.00	$8.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ISOSORBIDE DN 2.5MG TABLET SL	1	Level 1: Covered Generic	$4.00	$8.00	None
ISOSORBIDE DN 20MG TABLET	1	Level 1: Covered Generic	$4.00	$8.00	None
ISOSORBIDE DN 30MG TABLET	1	Level 1: Covered Generic	$4.00	$8.00	None
ISOSORBIDE DN 40MG TABLET SA	1	Level 1: Covered Generic	$4.00	$8.00	None
ISOSORBIDE DN 5MG TABLET	1	Level 1: Covered Generic	$4.00	$8.00	None
ISOSORBIDE DN 5MG TABLET SL	1	Level 1: Covered Generic	$4.00	$8.00	None
ISOSORBIDE MN 10MG TABLET	1	Level 1: Covered Generic	$4.00	$8.00	None
ISOSORBIDE MONONITRATE 20MG TABLET (500 CT)	1	Level 1: Covered Generic	$4.00	$8.00	None
ISOSORBIDE MONONITRATE ER TABLET 120MG (100 CT)	1	Level 1: Covered Generic	$4.00	$8.00	None
ISOSORBIDE MONONITRATE ER TABLET 30MG (100 CT)	1	Level 1: Covered Generic	$4.00	$8.00	None
ISOSORBIDE MONONITRATE TABLET ER 60MG (100 CT)	1	Level 1: Covered Generic	$4.00	$8.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ISOTON GENTAMICIN 60MG/100ML	1	Level 1: Covered Generic	$4.00	$8.00	None
ISOTON GENTAMICIN 80MG/100ML	1	Level 1: Covered Generic	$4.00	$8.00	None
ISOTON GENTAMICIN 80MG/50ML	1	Level 1: Covered Generic	$4.00	$8.00	None
ISRADIPINE CAPSULES 2.5MG (100 CT)	1	Level 1: Covered Generic	$4.00	$8.00	None
ISRADIPINE CAPSULES 5MG (100 CT)	1	Level 1: Covered Generic	$4.00	$8.00	None
ISTALOL 0.5% EYE DROPS	3	Level 3: Covered Brand	50%	50%	None
ITRACONAZOLE 100MG CAPSULE	1	Level 1: Covered Generic	$4.00	$8.00	None
IXEMPRA KIT 15MG	4	Covered Specialty	33%	33%	None
IXEMPRA KIT 45MG	4	Covered Specialty	33%	33%	None

Chart Legend:

Below are a few notes to help you understand the above 2009 Medicare Part D MedicareBlue Rx Option 2 Plan Formulary.

Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region).
Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.
Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $295 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.
Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
- Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.
- No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.
Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
- Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
- Drug Description - This is the Medicare Part D plan’s description of this particular drug tier.
Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
- Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the initial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $2700) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2013 Humana Walmart-Preferred Rx Plan the cost-sharing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
- Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
- None - This drug does not fall under any drug utilization management controls.
- P - Prior Authorization -This drug is subject to prior authorization.
- S - Step Therapy -This drug is subject to step therapy.
- Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.

(Chart Source: Centers for Medicare and Medicaid files: CMS Data October 2009 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.