2010 Medicare Part D Plan Formulary Information |
AARP MedicareRx Preferred (PDP) (S5820-015-0)
Benefit Details
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The AARP MedicareRx Preferred (PDP) (S5820-015-0) Formulary Drugs Starting with the Letter I in CMS PDP Region 16 which includes: WI
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Drugs Starting with Letter I
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
IBUPROFEN 100MG/5ML SUSP |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
IBUPROFEN TABLET 400MG 1 BLPK |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
IBUPROFEN TABLETS 600MG 90 BOT |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
IBUPROFEN TABLETS USP 800MG 10 X 10 BOXUD |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
IDAMYCIN PFS 1MG/ML VIAL |
4 |
Tier 4 Specialty |
33% | 33% | None |
IDARUBICIN HCL 1MG/ML VIAL |
4 |
Tier 4 Specialty |
33% | 33% | None |
IFEX INJECTION 3GM/ML 3GM VIALSD |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
IFOSFAMIDE 1GM VIAL |
2 |
Tier 2 Generic Preferred Brand |
$44.00 | $117.00 | None |
IFOSFAMIDE/MESNA KIT 1G/20ML / 1MG/ |
4 |
Tier 4 Specialty |
33% | 33% | None |
IFOSFAMIDE/MESNA KIT 1G/20ML / 1MG/ |
4 |
Tier 4 Specialty |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IMDUR 120MG TABLET SA |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
IMDUR 30MG TABLET SA |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
IMDUR 60MG TABLET SA |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
IMIPRAMINE HCL 10MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
IMIPRAMINE HCL 25MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
IMIPRAMINE HCL 50MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
IMIPRAMINE PAMOATE 100MG CAPSULE |
2 |
Tier 2 Generic Preferred Brand |
$44.00 | $117.00 | None |
IMIPRAMINE PAMOATE 125MG CAPSULE |
2 |
Tier 2 Generic Preferred Brand |
$44.00 | $117.00 | None |
IMIPRAMINE PAMOATE 150MG CAPSULE |
2 |
Tier 2 Generic Preferred Brand |
$44.00 | $117.00 | None |
IMIPRAMINE PAMOATE 75MG CAPSULE |
2 |
Tier 2 Generic Preferred Brand |
$44.00 | $117.00 | None |
IMITREX 100MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | Q:9 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IMITREX 20MG NASAL SPRAY |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | Q:6 /30Days |
IMITREX 25MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | Q:9 /30Days |
IMITREX 4MG/0.5ML KIT REFILL |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | Q:4 /30Days |
IMITREX 50MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | Q:9 /30Days |
IMITREX 5MG NASAL SPRAY |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | Q:6 /30Days |
IMITREX 6MG/0.5ML SYRNG KIT |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | Q:4 /30Days |
IMITREX 6MG/0.5ML VIAL |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | Q:4 /30Days |
IMOVAX RABIES VACCINE 2.5UNT/ML |
2 |
Tier 2 Generic Preferred Brand |
$44.00 | $117.00 | None |
IMURAN 50MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
INCRELEX 40MG/4ML VIAL |
4 |
Tier 4 Specialty |
33% | 33% | P |
INDAPAMIDE 1.25MG TABLET USP (1000 CT) |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | 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 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
INDERAL LA LONG ACTING CAPSULES 120MG 100 BOT |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
INDERAL LA LONG ACTING CAPSULES 160MG 100 BOT |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
INDERAL LA LONG ACTING CAPSULES 60MG 100 BOT |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
INDERAL LA LONG ACTING CAPSULES 80MG 100 BOT |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
INDOCIN ORAL SUSPENSION 25MG/5ML 237 ML BOT |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
INDOCIN SR 75MG CAPSULE SA |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
INDOMETHACIN 25MG CAPSULE |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
INDOMETHACIN 50MG CAPSULE |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
INDOMETHACIN 75MG CAPSULE SA |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
INFANRIX VACCINE VIAL 25-10UNT/.5ML |
2 |
Tier 2 Generic Preferred Brand |
$44.00 | $117.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INFERGEN SOLUTION FOR INJECTION 15MCG/0.5ML |
4 |
Tier 4 Specialty |
33% | 33% | P |
INFUMORPH 10MG/ML AMPUL P/F |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
INFUMORPH 25MG/ML AMPUL P/F |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
INNOHEP 20000UNIT/ML VIAL |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
INNOPRAN XL (PROPRANOLOL HCL) 120MG CAPSULE SR 24 HR |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
INNOPRAN XL (PROPRANOLOL HCL) 80MG CAPSULE SR 24 HR |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
INSPRA 25MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
INSPRA 50MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
INTAL INH AER 800MCG |
2 |
Tier 2 Generic Preferred Brand |
$44.00 | $117.00 | None |
INTELENCE 100MG TABLET |
4 |
Tier 4 Specialty |
33% | 33% | None |
INTRALIPID 20% IV FAT EMUL |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INTRALIPID PHARMACY BULK PACKAGE FAT EMULSION 1.7-1.2-30GM 500ML BAG |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | P |
INTRON A 10MMU INJ PEN |
4 |
Tier 4 Specialty |
33% | 33% | P |
INTRON A 10MMU VIAL |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | P |
INTRON A 3MMU INJECTION PEN |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | P Q:6 /28Days |
INTRON A 5MMU MULTIDOSE PEN |
4 |
Tier 4 Specialty |
33% | 33% | P |
INTRON A 6MMU/ML VIAL |
4 |
Tier 4 Specialty |
33% | 33% | P |
INVANZ 1GM VIAL |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
INVEGA 3MG TABLET SR OSMOTIC PUSH 24HR |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | S |
INVEGA 6MG TABLET SR OSMOTIC PUSH 24HR |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | S |
INVEGA 9MG TABLET SR OSMOTIC PUSH 24HR |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | S |
INVERSINE 2.5MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INVIRASE 200MG CAPSULE |
4 |
Tier 4 Specialty |
33% | 33% | None |
INVIRASE 500MG TABLET |
4 |
Tier 4 Specialty |
33% | 33% | None |
IONOSOL B-D5W IV SOLUTION |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
IONOSOL MB-D5W IV SOLUTION |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
IONOSOL T-D5W IV SOLUTION |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
IOPIDINE 0.5% EYE DROPS |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
IOPIDINE 1% EYE DROPS |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
IPOL VIAL 40;8;32; UNT |
2 |
Tier 2 Generic Preferred Brand |
$44.00 | $117.00 | None |
IPRATROPIUM BROMIDE 21MCG AEROSOL SPRAY |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
IPRATROPIUM BROMIDE 42MCG AEROSOL SPRAY |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
IPRATROPIUM BROMIDE INHALATION SOLUTION 0.02% 60 X 2.5ML VIALSD |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IPRATROPIUM BROMIDE/ALBUTEROL SULFATE INHALATION SOLUTION 0.5MG/3ML 33 CRTN |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | P |
IQUIX 1.5% DROPS |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
IRESSA 250MG TABLET |
4 |
Tier 4 Specialty |
33% | 33% | None |
IRINOTECAN HCL INJECTION 20MG |
2 |
Tier 2 Generic Preferred Brand |
$44.00 | $117.00 | None |
ISENTRESS 400MG TABLET |
4 |
Tier 4 Specialty |
33% | 33% | None |
ISMO 20MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
ISOCHRON 40MG TABLET SA |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
ISOLYTE H IN 5% DEXTROSE |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
ISOLYTE M IN 5% DEXTROSE INJECTION |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
ISOLYTE P IN 5% DEXTROSE INJECTION |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
ISOLYTE S IN 5% DEXTROSE INJECTION |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISOLYTE S SOLUTION FOR INJECTION |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
ISONARIF 300-150MG CAPSULE |
2 |
Tier 2 Generic Preferred Brand |
$44.00 | $117.00 | None |
ISONIAZID 100MG TABLET |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
ISONIAZID 300MG TABLET |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
ISONIAZID 50MG/5ML SYRUP |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
ISONIAZID INJ 100MG/ML |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
ISOPTIN SR 120MG |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
ISOPTIN SR 180MG |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
ISOPTIN SR 240MG (500 Count) |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
ISORDIL 40MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
ISORDIL TABLETS 5MG 100 BOT |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISOSORBIDE DN 10MG TABLET |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
ISOSORBIDE DN 2.5MG TABLET SL |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
ISOSORBIDE DN 20MG TABLET |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
ISOSORBIDE DN 30MG TABLET |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
ISOSORBIDE DN 40MG TABLET SA |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
ISOSORBIDE DN 5MG TABLET |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
ISOSORBIDE DN 5MG TABLET SL |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
ISOSORBIDE MN 10MG TABLET |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
ISOSORBIDE MONONITRATE ER TABLET 120MG (100 CT) |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
ISOSORBIDE MONONITRATE ER TABLET 30MG (100 CT) |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
ISOSORBIDE MONONITRATE TABLETS 20MG 100 TABLETS BOT |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISOSORBIDE MONONITRATE TABLETS EXTENDED RELEASE 60MG 100 TABLETS BOT |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
ISOTON GENTAMICIN 60MG/100ML |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
ISOTON GENTAMICIN 80MG/100ML |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
ISRADIPINE CAPSULES 2.5MG (100 CT) |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
ISRADIPINE CAPSULES 5MG (100 CT) |
1 |
Tier 1 Preferred Generic Brand |
$7.00 | $4.00 | None |
ISTALOL 0.5% EYE DROPS |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None |
ITRACONAZOLE 100MG CAPSULE |
2 |
Tier 2 Generic Preferred Brand |
$44.00 | $117.00 | None |
IV BUSULFEX 6MG 1 X 10ML VIALGL |
4 |
Tier 4 Specialty |
33% | 33% | None |
IXEMPRA KIT 45MG |
4 |
Tier 4 Specialty |
33% | 33% | None |