Q1Medicare.com 2009 Medicare Part D or Medicare Advantage Plan Formulary Browser

2009 Medicare Part D Plan Formulary Information
UPMC for Life Prescription Drug Plan (S3389-005-0) Benefit Details
The UPMC for Life Prescription Drug Plan (S3389-005-0) Formulary Drugs Starting with the Letter I in CMS PDP Region 6 which includes: PA WV
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	Generic	$5.00	$12.50	None
IBU TABLET 800MG (500 CT)	1	Generic	$5.00	$12.50	None
IBUPROFEN 100MG/5ML SUSP	1	Generic	$5.00	$12.50	None
IBUPROFEN 400MG TABLET	1	Generic	$5.00	$12.50	None
IDAMYCIN PFS 1MG/ML VIAL	3	Non-Preferred Brand	$80.00	$200.00	None
IDARUBICIN HCL 1MG/ML VIAL	1	Generic	$5.00	$12.50	None
IFOSFAMIDE 1GM VIAL	1	Generic	$5.00	$12.50	None
IFOSFAMIDE 1GM/ 20ML VIAL 20ML	1	Generic	$5.00	$12.50	None
IFOSFAMIDE 3GM VIAL	1	Generic	$5.00	$12.50	None
IFOSFAMIDE 3GM/ 60ML VIAL 60ML	1	Generic	$5.00	$12.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
IFOSFAMIDE/MESNA KIT 1G/20ML / 1MG/	1	Generic	$5.00	$12.50	None
IFOSFAMIDE/MESNA KIT 1G/20ML / 1MG/	1	Generic	$5.00	$12.50	None
IMIPRAMINE HCL 10MG TABLET (100 CT)	1	Generic	$5.00	$12.50	None
IMIPRAMINE HCL 25MG TABLET (100 CT)	1	Generic	$5.00	$12.50	None
IMIPRAMINE HCL 50MG TABLET (100 CT)	1	Generic	$5.00	$12.50	None
IMIPRAMINE PAMOATE 100MG CAPSULE	1	Generic	$5.00	$12.50	None
IMIPRAMINE PAMOATE 125MG CAPSULE	1	Generic	$5.00	$12.50	None
IMIPRAMINE PAMOATE 150MG CAPSULE	1	Generic	$5.00	$12.50	None
IMIPRAMINE PAMOATE 75MG CAPSULE	1	Generic	$5.00	$12.50	None
IMITREX 100MG TABLET	2	Preferred Brand	$32.00	$80.00	Q:9 /30Days
IMITREX 20MG NASAL SPRAY	2	Preferred Brand	$32.00	$80.00	Q:12 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
IMITREX 25MG TABLET	2	Preferred Brand	$32.00	$80.00	Q:9 /30Days
IMITREX 4MG/0.5ML KIT REFILL	2	Preferred Brand	$32.00	$80.00	Q:4 /30Days
IMITREX 50MG TABLET	2	Preferred Brand	$32.00	$80.00	Q:9 /30Days
IMITREX 5MG NASAL SPRAY	2	Preferred Brand	$32.00	$80.00	Q:32 /30Days
IMITREX 6MG/0.5ML SYRNG KIT	2	Preferred Brand	$32.00	$80.00	Q:4 /30Days
IMITREX 6MG/0.5ML VIAL	2	Preferred Brand	$32.00	$80.00	Q:4 /30Days
IMMU GLOBULIN GAMMA (IGG) 12G VIAL	4	Specialty	33%	N/A	P
IMMU GLOBULIN GAMMA (IGG) 6G VIAL	4	Specialty	33%	N/A	P
IMOVAX RABIES VACCINE 2.5UNT/ML	2	Preferred Brand	$32.00	$80.00	None
INCRELEX 40MG/4ML VIAL	4	Specialty	33%	N/A	P
INDAPAMIDE 1.25MG TABLET USP (1000 CT)	1	Generic	$5.00	$12.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
INDAPAMIDE 2.5MG TABLET USP (1000 CT)	1	Generic	$5.00	$12.50	None
INDOMETHACIN 25MG CAPSULE	1	Generic	$5.00	$12.50	None
INDOMETHACIN 50MG CAPSULE	1	Generic	$5.00	$12.50	None
INDOMETHACIN 75MG CAPSULE SA	1	Generic	$5.00	$12.50	None
INFANRIX VACCINE VIAL 25-10UNT/.5ML	2	Preferred Brand	$32.00	$80.00	None
INNOHEP 20000UNIT/ML VIAL	3	Non-Preferred Brand	$80.00	$200.00	Q:60 /365Days
INSPRA 25MG TABLET	3	Non-Preferred Brand	$80.00	$200.00	None
INSPRA 50MG TABLET	3	Non-Preferred Brand	$80.00	$200.00	None
INTAL INH AER 800MCG	2	Preferred Brand	$32.00	$80.00	None
INTELENCE 100MG TABLET	4	Specialty	33%	N/A	None
INTERFERON ALFACON-1 VIAL 15MCG-0.5ML	4	Specialty	33%	N/A	P Q:12 /30Days
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	Specialty	33%	N/A	P Q:12 /30Days
INTRALIPID 10% IV FAT EMUL	2	Preferred Brand	$32.00	$80.00	None
INTRALIPID 20% IV FAT EMUL	2	Preferred Brand	$32.00	$80.00	None
INTRALIPID IV FAT EMULSION	2	Preferred Brand	$32.00	$80.00	None
INTRALIPID PHARMACY BULK PACKAGE FAT EMULSION 1.7-1.2-30GM 500ML BAG	2	Preferred Brand	$32.00	$80.00	None
INTRON A 10MMU INJ PEN	4	Specialty	33%	N/A	None
INTRON A 10MMU VIAL	4	Specialty	33%	N/A	None
INTRON A 10MMU/ML VIAL	4	Specialty	33%	N/A	None
INTRON A 18MMU VIAL	4	Specialty	33%	N/A	None
INTRON A 3MMU INJECTION PEN	2	Preferred Brand	$32.00	$80.00	None
INTRON A 50MMU VIAL	4	Specialty	33%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
INTRON A 5MMU MULTIDOSE PEN	4	Specialty	33%	N/A	None
INTRON A 6MMU/ML VIAL	4	Specialty	33%	N/A	None
INVANZ 1GM VIAL	4	Specialty	33%	N/A	None
INVEGA 3MG TABLET SR OSMOTIC PUSH 24HR	3	Non-Preferred Brand	$80.00	$200.00	P Q:31 /31Days
INVEGA 6MG TABLET SR OSMOTIC PUSH 24HR	3	Non-Preferred Brand	$80.00	$200.00	P Q:62 /31Days
INVEGA 9MG TABLET SR OSMOTIC PUSH 24HR	3	Non-Preferred Brand	$80.00	$200.00	P Q:31 /31Days
INVERSINE 2.5MG TABLET	2	Preferred Brand	$32.00	$80.00	None
INVIRASE 200MG CAPSULE	4	Specialty	33%	N/A	None
INVIRASE 500MG TABLET	4	Specialty	33%	N/A	None
IONOSOL B-D5W IV SOLUTION	3	Non-Preferred Brand	$80.00	$200.00	None
IONOSOL MB-D5W IV SOLUTION	3	Non-Preferred Brand	$80.00	$200.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
IONOSOL T-D5W IV SOLUTION	3	Non-Preferred Brand	$80.00	$200.00	None
IOPIDINE 0.5% EYE DROPS	3	Non-Preferred Brand	$80.00	$200.00	None
IOPIDINE 1% EYE DROPS	3	Non-Preferred Brand	$80.00	$200.00	None
IPLEX 36MG/0.6ML VIAL	4	Specialty	33%	N/A	P
IPOL VIAL 40;8;32; UNT	2	Preferred Brand	$32.00	$80.00	None
IPRATROPIUM BROMIDE 21MCG AEROSOL SPRAY	1	Generic	$5.00	$12.50	None
IPRATROPIUM BROMIDE 42MCG AEROSOL SPRAY	1	Generic	$5.00	$12.50	None
IPRATROPIUM BROMIDE INHALATION SOLUTION 0.02% 60 X 2.5ML VIALSD	1	Generic	$5.00	$12.50	None
IPRATROPIUM BROMIDE/ALBUTEROL SULFATE INHALATION SOLUTION 0.5MG/3ML 33 CRTN	1	Generic	$5.00	$12.50	None
IRESSA 250MG TABLET	4	Specialty	33%	N/A	P
IRINOTECAN HCL INJECTION 20MG	4	Specialty	33%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ISENTRESS 400MG TABLET	4	Specialty	33%	N/A	None
ISO GENTAMICIN 100MG/100ML	3	Non-Preferred Brand	$80.00	$200.00	None
ISO GENTAMICIN 120MG/100ML	3	Non-Preferred Brand	$80.00	$200.00	None
ISOLYTE H IN 5% DEXTROSE	3	Non-Preferred Brand	$80.00	$200.00	None
ISOLYTE M IN 5% DEXTROSE INJECTION	3	Non-Preferred Brand	$80.00	$200.00	None
ISOLYTE P IN 5% DEXTROSE INJECTION	3	Non-Preferred Brand	$80.00	$200.00	None
ISOLYTE S PH 7.4 SOLUTION FOR INJECTION	3	Non-Preferred Brand	$80.00	$200.00	None
ISOLYTE S IN 5% DEXTROSE INJECTION	3	Non-Preferred Brand	$80.00	$200.00	None
ISOLYTE S SOLUTION FOR INJECTION	3	Non-Preferred Brand	$80.00	$200.00	None
ISONARIF 300-150MG CAPSULE	1	Generic	$5.00	$12.50	None
ISONIAZID 100MG TABLET	1	Generic	$5.00	$12.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ISONIAZID 300MG TABLET	1	Generic	$5.00	$12.50	None
ISONIAZID 50MG/5ML SYRUP	1	Generic	$5.00	$12.50	None
ISONIAZID INJ 100MG/ML	1	Generic	$5.00	$12.50	None
ISORDIL 40MG TABLET	2	Preferred Brand	$32.00	$80.00	None
ISOSORBIDE DN 10MG TABLET	1	Generic	$5.00	$12.50	None
ISOSORBIDE DN 2.5MG TABLET SL	1	Generic	$5.00	$12.50	None
ISOSORBIDE DN 20MG TABLET	1	Generic	$5.00	$12.50	None
ISOSORBIDE DN 30MG TABLET	1	Generic	$5.00	$12.50	None
ISOSORBIDE DN 40MG TABLET SA	1	Generic	$5.00	$12.50	None
ISOSORBIDE DN 5MG TABLET	1	Generic	$5.00	$12.50	None
ISOSORBIDE DN 5MG TABLET SL	1	Generic	$5.00	$12.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ISOSORBIDE MN 10MG TABLET	1	Generic	$5.00	$12.50	None
ISOSORBIDE MONONITRATE 20MG TABLET (500 CT)	1	Generic	$5.00	$12.50	None
ISOSORBIDE MONONITRATE ER TABLET 120MG (100 CT)	1	Generic	$5.00	$12.50	None
ISOSORBIDE MONONITRATE ER TABLET 30MG (100 CT)	1	Generic	$5.00	$12.50	None
ISOSORBIDE MONONITRATE TABLET ER 60MG (100 CT)	1	Generic	$5.00	$12.50	None
ISOTON GENTAMICIN 60MG/100ML	3	Non-Preferred Brand	$80.00	$200.00	None
ISOTON GENTAMICIN 80MG/100ML	3	Non-Preferred Brand	$80.00	$200.00	None
ISOTON GENTAMICIN 80MG/50ML	3	Non-Preferred Brand	$80.00	$200.00	None
ISRADIPINE CAPSULES 2.5MG (100 CT)	1	Generic	$5.00	$12.50	None
ISRADIPINE CAPSULES 5MG (100 CT)	1	Generic	$5.00	$12.50	None
ITRACONAZOLE 100MG CAPSULE	1	Generic	$5.00	$12.50	P Q:366 /90Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
IVEEGAM EN INJ 5GM HU	4	Specialty	33%	N/A	P
IXEMPRA KIT 15MG	4	Specialty	33%	N/A	None
IXEMPRA KIT 45MG	4	Specialty	33%	N/A	None

Chart Legend:

Below are a few notes to help you understand the above 2009 Medicare Part D UPMC for Life Prescription Drug Plan 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.