Q1Medicare.com 2010 Medicare Part D or Medicare Advantage Plan Formulary Browser

2010 Medicare Part D Plan Formulary Information
AdvantraRx Value (PDP) (S5674-026-0) Benefit Details
The AdvantraRx Value (PDP) (S5674-026-0) Formulary Drugs Starting with the Letter I in CMS PDP Region 15 which includes: IN KY
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
IBUPROFEN TABLET 400MG 1 BLPK	1	Preferred Generic	$6.00	$15.00	None
IBUPROFEN TABLETS 600MG 90 BOT	1	Preferred Generic	$6.00	$15.00	None
IBUPROFEN TABLETS USP 800MG 10 X 10 BOXUD	1	Preferred Generic	$6.00	$15.00	None
IMIPRAMINE HCL 10MG TABLET (100 CT)	1	Preferred Generic	$6.00	$15.00	None
IMIPRAMINE HCL 25MG TABLET (100 CT)	1	Preferred Generic	$6.00	$15.00	None
IMIPRAMINE HCL 50MG TABLET (100 CT)	1	Preferred Generic	$6.00	$15.00	None
IMOVAX RABIES VACCINE 2.5UNT/ML	3	Non-Preferred Generic and Non-Preferred Brand	64%	64%	None
INCRELEX 40MG/4ML VIAL	3	Non-Preferred Generic and Non-Preferred Brand	64%	64%	P
INDAPAMIDE 1.25MG TABLET USP (1000 CT)	1	Preferred Generic	$6.00	$15.00	None
INDAPAMIDE 2.5MG TABLET USP (1000 CT)	1	Preferred Generic	$6.00	$15.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
INDOMETHACIN 25MG CAPSULE	1	Preferred Generic	$6.00	$15.00	None
INDOMETHACIN 50MG CAPSULE	1	Preferred Generic	$6.00	$15.00	None
INDOMETHACIN 75MG CAPSULE SA	1	Preferred Generic	$6.00	$15.00	None
INFANRIX VACCINE VIAL 25-10UNT/.5ML	3	Non-Preferred Generic and Non-Preferred Brand	64%	64%	None
INFERGEN SOLUTION FOR INJECTION 15MCG/0.5ML	4	Specialty - Generic and Brand	30%	N/A	P
INNOHEP 20000UNIT/ML VIAL	4	Specialty - Generic and Brand	30%	N/A	P
INNOPRAN XL (PROPRANOLOL HCL) 120MG CAPSULE SR 24 HR	3	Non-Preferred Generic and Non-Preferred Brand	64%	64%	Q:30 /30Days
INNOPRAN XL (PROPRANOLOL HCL) 80MG CAPSULE SR 24 HR	3	Non-Preferred Generic and Non-Preferred Brand	64%	64%	Q:60 /30Days
INTAL INH AER 800MCG	2	Preferred Brand	20%	18%	Q:28 /30Days
INTELENCE 100MG TABLET	4	Specialty - Generic and Brand	30%	N/A	Q:120 /30Days
INTRALIPID 20% IV FAT EMUL	3	Non-Preferred Generic and Non-Preferred Brand	64%	64%	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	Non-Preferred Generic and Non-Preferred Brand	64%	64%	P
INTRON A 10MMU INJ PEN	4	Specialty - Generic and Brand	30%	N/A	P
INTRON A 10MMU VIAL	4	Specialty - Generic and Brand	30%	N/A	P
INTRON A 3MMU INJECTION PEN	3	Non-Preferred Generic and Non-Preferred Brand	64%	64%	P
INTRON A 5MMU MULTIDOSE PEN	4	Specialty - Generic and Brand	30%	N/A	P
INTRON A 6MMU/ML VIAL	4	Specialty - Generic and Brand	30%	N/A	P
INVANZ 1GM VIAL	3	Non-Preferred Generic and Non-Preferred Brand	64%	64%	None
INVEGA 3MG TABLET SR OSMOTIC PUSH 24HR	3	Non-Preferred Generic and Non-Preferred Brand	64%	64%	P Q:30 /30Days
INVEGA 6MG TABLET SR OSMOTIC PUSH 24HR	3	Non-Preferred Generic and Non-Preferred Brand	64%	64%	P Q:60 /30Days
INVEGA 9MG TABLET SR OSMOTIC PUSH 24HR	3	Non-Preferred Generic and Non-Preferred Brand	64%	64%	P Q:30 /30Days
INVIRASE 200MG CAPSULE	4	Specialty - Generic and Brand	30%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
INVIRASE 500MG TABLET	4	Specialty - Generic and Brand	30%	N/A	None
IPOL VIAL 40;8;32; UNT	2	Preferred Brand	20%	18%	None
IPRATROPIUM BROMIDE 21MCG AEROSOL SPRAY	1	Preferred Generic	$6.00	$15.00	None
IPRATROPIUM BROMIDE 42MCG AEROSOL SPRAY	1	Preferred Generic	$6.00	$15.00	None
IPRATROPIUM BROMIDE INHALATION SOLUTION 0.02% 60 X 2.5ML VIALSD	1	Preferred Generic	$6.00	$15.00	P
IPRATROPIUM BROMIDE/ALBUTEROL SULFATE INHALATION SOLUTION 0.5MG/3ML 33 CRTN	3	Non-Preferred Generic and Non-Preferred Brand	64%	64%	P
IRESSA 250MG TABLET	4	Specialty - Generic and Brand	30%	N/A	Q:30 /30Days
ISENTRESS 400MG TABLET	4	Specialty - Generic and Brand	30%	N/A	Q:60 /30Days
ISONARIF 300-150MG CAPSULE	1	Preferred Generic	$6.00	$15.00	None
ISONIAZID 100MG TABLET	1	Preferred Generic	$6.00	$15.00	None
ISONIAZID 300MG TABLET	1	Preferred Generic	$6.00	$15.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ISONIAZID 50MG/5ML SYRUP	1	Preferred Generic	$6.00	$15.00	None
ISOSORBIDE DN 10MG TABLET	1	Preferred Generic	$6.00	$15.00	None
ISOSORBIDE DN 2.5MG TABLET SL	1	Preferred Generic	$6.00	$15.00	None
ISOSORBIDE DN 20MG TABLET	1	Preferred Generic	$6.00	$15.00	None
ISOSORBIDE DN 30MG TABLET	1	Preferred Generic	$6.00	$15.00	None
ISOSORBIDE DN 40MG TABLET SA	1	Preferred Generic	$6.00	$15.00	None
ISOSORBIDE DN 5MG TABLET	1	Preferred Generic	$6.00	$15.00	None
ISOSORBIDE DN 5MG TABLET SL	1	Preferred Generic	$6.00	$15.00	None
ISOSORBIDE MN 10MG TABLET	1	Preferred Generic	$6.00	$15.00	None
ISOSORBIDE MONONITRATE ER TABLET 120MG (100 CT)	1	Preferred Generic	$6.00	$15.00	None
ISOSORBIDE MONONITRATE ER TABLET 30MG (100 CT)	1	Preferred Generic	$6.00	$15.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ISOSORBIDE MONONITRATE TABLETS 20MG 100 TABLETS BOT	1	Preferred Generic	$6.00	$15.00	None
ISOSORBIDE MONONITRATE TABLETS EXTENDED RELEASE 60MG 100 TABLETS BOT	1	Preferred Generic	$6.00	$15.00	None
ISOTON GENTAMICIN 60MG/100ML	1	Preferred Generic	$6.00	$15.00	None
ISOTON GENTAMICIN 80MG/100ML	1	Preferred Generic	$6.00	$15.00	None
ISRADIPINE CAPSULES 2.5MG (100 CT)	3	Non-Preferred Generic and Non-Preferred Brand	64%	64%	None
ISRADIPINE CAPSULES 5MG (100 CT)	3	Non-Preferred Generic and Non-Preferred Brand	64%	64%	None
ISTALOL 0.5% EYE DROPS	2	Preferred Brand	20%	18%	Q:5 /30Days
ITRACONAZOLE 100MG CAPSULE	1	Preferred Generic	$6.00	$15.00	P
IXEMPRA KIT 45MG	4	Specialty - Generic and Brand	30%	N/A	P

Chart Legend:

Below are a few notes to help you understand the above 2010 Medicare Part D AdvantraRx Value (PDP) 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 $310 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 $2830) 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 2010 )

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.