2011 Medicare Part D Plan Formulary Information |
Health Net Orange Option 2 (PDP) (S5678-059-0)
Sanctioned Plan
|
The Health Net Orange Option 2 (PDP) (S5678-059-0) Formulary Drugs Starting with the Letter I in CMS PDP Region 27 which includes: CO
|
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 |
$2.00 | $4.00 | None |
IBUPROFEN 400 MG ORAL TABLET |
1 |
Tier 1 Preferred Generic |
$2.00 | $4.00 | None |
IBUPROFEN 600 MG ORAL TABLET |
1 |
Tier 1 Preferred Generic |
$2.00 | $4.00 | None |
IBUPROFEN 800 MG TABLET |
1 |
Tier 1 Preferred Generic |
$2.00 | $4.00 | None |
IDAMYCIN PFS 1MG/ML VIAL |
4 |
Tier 4 Injectable |
33% | 33% | None |
IDARUBICIN HCL 1MG/ML VIAL |
4 |
Tier 4 Injectable |
33% | 33% | None |
IFEX INJECTION 3GM/ML 3GM VIALSD |
4 |
Tier 4 Injectable |
33% | 33% | None |
IFOSFAMIDE FOR INFECTION 1 GM |
4 |
Tier 4 Injectable |
33% | 33% | None |
IFOSFAMIDE/MESNA KIT 1G/20ML / 1MG/ |
4 |
Tier 4 Injectable |
33% | 33% | None |
IFOSFAMIDE/MESNA KIT 1G/20ML / 1MG/ |
4 |
Tier 4 Injectable |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ILOPERIDONE 1 MG ORAL TABLET [FANAPT] |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | P Q:2 /1Days |
ILOPERIDONE 10 MG ORAL TABLET [FANAPT] |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | P Q:2 /1Days |
ILOPERIDONE 12 MG ORAL TABLET [FANAPT] |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | P Q:2 /1Days |
ILOPERIDONE 2 MG ORAL TABLET [FANAPT] |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | P Q:2 /1Days |
ILOPERIDONE 4 MG ORAL TABLET [FANAPT] |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | P Q:2 /1Days |
ILOPERIDONE 6 MG ORAL TABLET [FANAPT] |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | P Q:2 /1Days |
ILOPERIDONE 8 MG ORAL TABLET [FANAPT] |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | P Q:2 /1Days |
IMDUR 120MG TABLET SA |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | None |
IMDUR 30MG TABLET SA |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | None |
IMDUR 60MG TABLET SA |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | None |
IMIPRAMINE HCL 10MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$2.00 | $4.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IMIPRAMINE HCL 25MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$2.00 | $4.00 | None |
IMIPRAMINE HCL 50MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$2.00 | $4.00 | None |
IMIPRAMINE PAMOATE 100MG CAPSULE |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | None |
IMIPRAMINE PAMOATE 125MG CAPSULE |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | None |
IMIPRAMINE PAMOATE 150MG CAPSULE |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | None |
IMIPRAMINE PAMOATE 75MG CAPSULE |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | None |
IMIQUIMOD 5% CREAM |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | P |
IMITREX 100MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | None |
IMITREX 20MG NASAL SPRAY |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | None |
IMITREX 25MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | None |
IMITREX 4MG/0.5ML KIT REFILL |
4 |
Tier 4 Injectable |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IMITREX 50MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | None |
IMITREX 5MG NASAL SPRAY |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | Q:1 /1Days |
IMITREX 6MG/0.5ML SYRNG KIT |
4 |
Tier 4 Injectable |
33% | 33% | None |
IMITREX 6MG/0.5ML VIAL |
4 |
Tier 4 Injectable |
33% | 33% | None |
IMOVAX RABIES VACCINE 2.5UNT/ML |
4 |
Tier 4 Injectable |
33% | 33% | P |
IMURAN 50MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | P |
INCRELEX 40MG/4ML VIAL |
4 |
Tier 4 Injectable |
33% | 33% | P |
INDAPAMIDE 1.25MG TABLET USP (1000 CT) |
1 |
Tier 1 Preferred Generic |
$2.00 | $4.00 | None |
INDAPAMIDE 2.5MG TABLET USP (1000 CT) |
1 |
Tier 1 Preferred Generic |
$2.00 | $4.00 | None |
INDERAL LA LONG ACTING CAPSULES 120MG 100 BOT |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | None |
INDERAL LA LONG ACTING CAPSULES 160MG 100 BOT |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INDERAL LA LONG ACTING CAPSULES 60MG 100 BOT |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | None |
INDERAL LA LONG ACTING CAPSULES 80MG 100 BOT |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | None |
INDOCIN ORAL SUSPENSION 25MG/5ML 237 ML BOT |
2 |
Tier 2 Preferred Brand |
$34.00 | $68.00 | None |
INDOMETHACIN 25MG CAPSULE |
1 |
Tier 1 Preferred Generic |
$2.00 | $4.00 | None |
INDOMETHACIN 50MG CAPSULE |
1 |
Tier 1 Preferred Generic |
$2.00 | $4.00 | None |
INDOMETHACIN 75MG CAPSULE SA |
1 |
Tier 1 Preferred Generic |
$2.00 | $4.00 | None |
INFERGEN SOLUTION FOR INJECTION 15MCG/0.5ML |
5 |
Tier 5 Specialty |
33% | 33% | P |
INFUMORPH 10MG/ML AMPUL P/F |
4 |
Tier 4 Injectable |
33% | 33% | None |
INFUMORPH 25MG/ML AMPUL P/F |
4 |
Tier 4 Injectable |
33% | 33% | None |
INNOHEP 20000UNIT/ML VIAL |
4 |
Tier 4 Injectable |
33% | 33% | Q:6 /10Days |
INNOPRAN CAPSULES EXTENDED RELEASE 120 MG |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INNOPRAN CAPSULES EXTENDED RELEASE 80 MG |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | None |
INSPRA 25MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | None |
INSPRA 50MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | None |
INSULIN, GLULISINE, HUMAN 100 UNT/ML PREFILLED SYRINGE [APIDRA] 3 ML |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | Q:2 /1Days |
INTELENCE 100MG TABLET |
5 |
Tier 5 Specialty |
33% | 33% | None |
INTERFERON BETA-1B 0.25 MG/ML INJECTABLE SOLUTION [EXTAVIA] |
5 |
Tier 5 Specialty |
33% | 33% | P |
INTRALIPID 20% IV FAT EMUL |
4 |
Tier 4 Injectable |
33% | 33% | P |
INTRALIPID PHARMACY BULK PACKAGE FAT EMULSION 1.7-1.2-30GM 500ML BAG |
4 |
Tier 4 Injectable |
33% | 33% | P |
INTRON A 10MMU INJ PEN |
5 |
Tier 5 Specialty |
33% | 33% | None |
INTRON A 10MMU VIAL |
4 |
Tier 4 Injectable |
33% | 33% | None |
INTRON A 3MMU INJECTION PEN |
4 |
Tier 4 Injectable |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INTRON A 5MMU MULTIDOSE PEN |
5 |
Tier 5 Specialty |
33% | 33% | None |
INTRON A 6MMU/ML VIAL |
5 |
Tier 5 Specialty |
33% | 33% | None |
INVANZ 1GM VIAL |
4 |
Tier 4 Injectable |
33% | 33% | None |
INVEGA 3MG TABLET SR OSMOTIC PUSH 24HR |
2 |
Tier 2 Preferred Brand |
$34.00 | $68.00 | Q:1 /1Days |
INVEGA 6MG TABLET SR OSMOTIC PUSH 24HR |
2 |
Tier 2 Preferred Brand |
$34.00 | $68.00 | Q:2 /1Days |
INVEGA 9MG TABLET SR OSMOTIC PUSH 24HR |
2 |
Tier 2 Preferred Brand |
$34.00 | $68.00 | Q:1 /1Days |
INVIRASE 200MG CAPSULE |
5 |
Tier 5 Specialty |
33% | 33% | None |
INVIRASE 500MG TABLET |
5 |
Tier 5 Specialty |
33% | 33% | None |
IONOSOL B-D5W IV SOLUTION |
4 |
Tier 4 Injectable |
33% | 33% | P |
IONOSOL MB-D5W IV SOLUTION |
4 |
Tier 4 Injectable |
33% | 33% | P |
IONOSOL T-D5W IV SOLUTION |
4 |
Tier 4 Injectable |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IOPIDINE 0.5% EYE DROPS |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | Q:10 /30Days |
IOPIDINE 1% EYE DROPS |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | None |
IPOL VIAL 40;8;32; UNT |
4 |
Tier 4 Injectable |
33% | 33% | None |
IPRATROPIUM BROMIDE 21MCG AEROSOL SPRAY |
1 |
Tier 1 Preferred Generic |
$2.00 | $4.00 | Q:2 /1Days |
IPRATROPIUM BROMIDE 42MCG AEROSOL SPRAY |
1 |
Tier 1 Preferred Generic |
$2.00 | $4.00 | Q:1 /1Days |
IPRATROPIUM BROMIDE INHALATION SOLUTION 0.02% 60 X 2.5ML VIALSD |
1 |
Tier 1 Preferred Generic |
$2.00 | $4.00 | P |
IPRATROPIUM BROMIDE/ALBUTEROL SULFATE INHALATION SOLUTION 0.5MG/3ML 33 CRTN |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | P |
IQUIX 1.5% DROPS |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | Q:1 /1Days |
IRESSA 250MG TABLET |
5 |
Tier 5 Specialty |
33% | 33% | None |
IRINOTECAN HCL INJECTION 20MG |
4 |
Tier 4 Injectable |
33% | 33% | None |
ISENTRESS 400MG TABLET |
5 |
Tier 5 Specialty |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISMO 20MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | None |
ISOCHRON 40MG TABLET SA |
1 |
Tier 1 Preferred Generic |
$2.00 | $4.00 | None |
ISOLYTE H IN 5% DEXTROSE |
4 |
Tier 4 Injectable |
33% | 33% | P |
ISOLYTE M IN 5% DEXTROSE INJECTION |
4 |
Tier 4 Injectable |
33% | 33% | P |
ISOLYTE P IN 5% DEXTROSE INJECTION |
4 |
Tier 4 Injectable |
33% | 33% | P |
ISOLYTE S IN 5% DEXTROSE INJECTION |
4 |
Tier 4 Injectable |
33% | 33% | P |
ISOLYTE S SOLUTION FOR INJECTION |
4 |
Tier 4 Injectable |
33% | 33% | P |
ISONARIF 300-150MG CAPSULE |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | None |
ISONIAZID 100MG TABLET |
1 |
Tier 1 Preferred Generic |
$2.00 | $4.00 | None |
ISONIAZID 300MG TABLET |
1 |
Tier 1 Preferred Generic |
$2.00 | $4.00 | None |
ISONIAZID 50MG/5ML SYRUP |
1 |
Tier 1 Preferred Generic |
$2.00 | $4.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISONIAZID INJ 100MG/ML |
4 |
Tier 4 Injectable |
33% | 33% | None |
ISOPTIN SR 120MG |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | None |
ISOPTIN SR 180MG |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | None |
ISOPTIN SR 240MG (500 Count) |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | None |
ISORDIL 40MG TABLET |
2 |
Tier 2 Preferred Brand |
$34.00 | $68.00 | None |
ISORDIL TABLETS 5MG 100 BOT |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | None |
ISOSORBIDE DN 10MG TABLET |
1 |
Tier 1 Preferred Generic |
$2.00 | $4.00 | None |
ISOSORBIDE DN 2.5 MG TAB SL |
1 |
Tier 1 Preferred Generic |
$2.00 | $4.00 | None |
ISOSORBIDE DN 20MG TABLET |
1 |
Tier 1 Preferred Generic |
$2.00 | $4.00 | None |
ISOSORBIDE DN 30MG TABLET |
1 |
Tier 1 Preferred Generic |
$2.00 | $4.00 | None |
ISOSORBIDE DN 40MG TABLET SA |
1 |
Tier 1 Preferred Generic |
$2.00 | $4.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISOSORBIDE DN 5MG TABLET |
1 |
Tier 1 Preferred Generic |
$2.00 | $4.00 | None |
ISOSORBIDE DN 5MG TABLET SL |
1 |
Tier 1 Preferred Generic |
$2.00 | $4.00 | None |
ISOSORBIDE MN 10MG TABLET |
1 |
Tier 1 Preferred Generic |
$2.00 | $4.00 | None |
ISOSORBIDE MONONITRATE 20 MG ORAL TABLET [MONOKET] |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | None |
ISOSORBIDE MONONITRATE 20MG TABLET |
1 |
Tier 1 Preferred Generic |
$2.00 | $4.00 | None |
ISOSORBIDE MONONITRATE ER TABLET 120MG (100 CT) |
1 |
Tier 1 Preferred Generic |
$2.00 | $4.00 | None |
ISOSORBIDE MONONITRATE ER TABLET 30MG (100 CT) |
1 |
Tier 1 Preferred Generic |
$2.00 | $4.00 | None |
ISOSORBIDE MONONITRATE TABLETS EXTENDED RELEASE 60MG 100 TABLETS BOT |
1 |
Tier 1 Preferred Generic |
$2.00 | $4.00 | None |
ISOTON GENTAMICIN 60MG/100ML |
4 |
Tier 4 Injectable |
33% | 33% | None |
ISOTON GENTAMICIN 80MG/100ML |
4 |
Tier 4 Injectable |
33% | 33% | None |
ISRADIPINE CAPSULES 2.5MG (100 CT) |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISRADIPINE CAPSULES 5MG (100 CT) |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$68.00 | $170.00 | None |
ISTALOL 0.5% EYE DROPS |
2 |
Tier 2 Preferred Brand |
$34.00 | $68.00 | None |
ISTODAX KIT 10MG/2ML |
5 |
Tier 5 Specialty |
33% | 33% | P |
ITRACONAZOLE 100MG CAPSULE |
1 |
Tier 1 Preferred Generic |
$2.00 | $4.00 | P |
IV BUSULFEX 6MG 1 X 10ML VIALGL |
4 |
Tier 4 Injectable |
33% | 33% | None |
IXEMPRA KIT 45MG |
5 |
Tier 5 Specialty |
33% | 33% | P |
IXIARO JAPANESE ENCEPHALITIS VACCINE 6MCG/.5ML |
4 |
Tier 4 Injectable |
33% | 33% | None |