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Health Net Orange Option 1 (PDP) (S5678-056-0)
Tier 1 (1401)
Tier 2 (633)
Tier 3 (558)
Tier 4 (668)
Tier 5 (286)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
Yes No Show either
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Cick on the first letter of your drug name to browse the formulary:

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2011 Medicare Part D Plan Formulary Information
Health Net Orange Option 1 (PDP) (S5678-056-0)
Sanctioned Plan           
The Health Net Orange Option 1 (PDP) (S5678-056-0)
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
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
IBUPROFEN 100MG/5ML SUSP   1 Tier 1 Preferred Generic $4.00$8.00None
IBUPROFEN 400 MG ORAL TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
IBUPROFEN 600 MG ORAL TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
IBUPROFEN 800 MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
IDAMYCIN PFS 1MG/ML VIAL   4 Tier 4 Injectable 25%25%None
IDARUBICIN HCL 1MG/ML VIAL   4 Tier 4 Injectable 25%25%None
IFEX INJECTION 3GM/ML 3GM VIALSD   4 Tier 4 Injectable 25%25%None
IFOSFAMIDE FOR INFECTION 1 GM   4 Tier 4 Injectable 25%25%None
IFOSFAMIDE/MESNA KIT 1G/20ML / 1MG/   4 Tier 4 Injectable 25%25%None
IFOSFAMIDE/MESNA KIT 1G/20ML / 1MG/   4 Tier 4 Injectable 25%25%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 $75.00$188.00P Q:2
/1Days
ILOPERIDONE 10 MG ORAL TABLET [FANAPT]   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00P Q:2
/1Days
ILOPERIDONE 12 MG ORAL TABLET [FANAPT]   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00P Q:2
/1Days
ILOPERIDONE 2 MG ORAL TABLET [FANAPT]   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00P Q:2
/1Days
ILOPERIDONE 4 MG ORAL TABLET [FANAPT]   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00P Q:2
/1Days
ILOPERIDONE 6 MG ORAL TABLET [FANAPT]   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00P Q:2
/1Days
ILOPERIDONE 8 MG ORAL TABLET [FANAPT]   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00P Q:2
/1Days
IMIPRAMINE HCL 10MG TABLET (100 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
IMIPRAMINE HCL 25MG TABLET (100 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
IMIPRAMINE HCL 50MG TABLET (100 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
IMIQUIMOD 5% CREAM   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
IMITREX 4MG/0.5ML KIT REFILL   4 Tier 4 Injectable 25%25%None
IMITREX 6MG/0.5ML SYRNG KIT   4 Tier 4 Injectable 25%25%None
IMITREX 6MG/0.5ML VIAL   4 Tier 4 Injectable 25%25%None
IMOVAX RABIES VACCINE 2.5UNT/ML   4 Tier 4 Injectable 25%25%P
INCRELEX 40MG/4ML VIAL   4 Tier 4 Injectable 25%25%P
INDAPAMIDE 1.25MG TABLET USP (1000 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
INDAPAMIDE 2.5MG TABLET USP (1000 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
INDOCIN ORAL SUSPENSION 25MG/5ML 237 ML BOT   2 Tier 2 Preferred Brand $37.00$74.00None
INDOMETHACIN 25MG CAPSULE   1 Tier 1 Preferred Generic $4.00$8.00None
INDOMETHACIN 50MG CAPSULE   1 Tier 1 Preferred Generic $4.00$8.00None
INDOMETHACIN 75MG CAPSULE SA   1 Tier 1 Preferred Generic $4.00$8.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
INFERGEN SOLUTION FOR INJECTION 15MCG/0.5ML   5 Tier 5 Specialty 25%25%P
INFUMORPH 10MG/ML AMPUL P/F   4 Tier 4 Injectable 25%25%None
INFUMORPH 25MG/ML AMPUL P/F   4 Tier 4 Injectable 25%25%None
INNOHEP 20000UNIT/ML VIAL   4 Tier 4 Injectable 25%25%Q:6
/10Days
INNOPRAN CAPSULES EXTENDED RELEASE 120 MG   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
INNOPRAN CAPSULES EXTENDED RELEASE 80 MG   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
INTELENCE 100MG TABLET   5 Tier 5 Specialty 25%25%None
INTERFERON BETA-1B 0.25 MG/ML INJECTABLE SOLUTION [EXTAVIA]   5 Tier 5 Specialty 25%25%P
INTRALIPID 20% IV FAT EMUL   4 Tier 4 Injectable 25%25%P
INTRALIPID PHARMACY BULK PACKAGE FAT EMULSION 1.7-1.2-30GM 500ML BAG   4 Tier 4 Injectable 25%25%P
INTRON A 10MMU INJ PEN   5 Tier 5 Specialty 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
INTRON A 10MMU VIAL   4 Tier 4 Injectable 25%25%None
INTRON A 3MMU INJECTION PEN   4 Tier 4 Injectable 25%25%None
INTRON A 5MMU MULTIDOSE PEN   5 Tier 5 Specialty 25%25%None
INTRON A 6MMU/ML VIAL   5 Tier 5 Specialty 25%25%None
INVANZ 1GM VIAL   4 Tier 4 Injectable 25%25%None
INVEGA 3MG TABLET SR OSMOTIC PUSH 24HR   2 Tier 2 Preferred Brand $37.00$74.00Q:1
/1Days
INVEGA 6MG TABLET SR OSMOTIC PUSH 24HR   2 Tier 2 Preferred Brand $37.00$74.00Q:2
/1Days
INVEGA 9MG TABLET SR OSMOTIC PUSH 24HR   2 Tier 2 Preferred Brand $37.00$74.00Q:1
/1Days
INVIRASE 200MG CAPSULE   5 Tier 5 Specialty 25%25%None
INVIRASE 500MG TABLET   5 Tier 5 Specialty 25%25%None
IONOSOL B-D5W IV SOLUTION   4 Tier 4 Injectable 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
IONOSOL MB-D5W IV SOLUTION   4 Tier 4 Injectable 25%25%P
IONOSOL T-D5W IV SOLUTION   4 Tier 4 Injectable 25%25%P
IOPIDINE 1% EYE DROPS   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
IPOL VIAL 40;8;32; UNT   4 Tier 4 Injectable 25%25%None
IPRATROPIUM BROMIDE 21MCG AEROSOL SPRAY   1 Tier 1 Preferred Generic $4.00$8.00Q:2
/1Days
IPRATROPIUM BROMIDE 42MCG AEROSOL SPRAY   1 Tier 1 Preferred Generic $4.00$8.00Q:1
/1Days
IPRATROPIUM BROMIDE INHALATION SOLUTION 0.02% 60 X 2.5ML VIALSD   1 Tier 1 Preferred Generic $4.00$8.00P
IQUIX 1.5% DROPS   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00Q:1
/1Days
IRESSA 250MG TABLET   5 Tier 5 Specialty 25%25%None
IRINOTECAN HCL INJECTION 20MG   4 Tier 4 Injectable 25%25%None
ISENTRESS 400MG TABLET   5 Tier 5 Specialty 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ISOCHRON 40MG TABLET SA   1 Tier 1 Preferred Generic $4.00$8.00None
ISOLYTE H IN 5% DEXTROSE   4 Tier 4 Injectable 25%25%P
ISOLYTE M IN 5% DEXTROSE INJECTION   4 Tier 4 Injectable 25%25%P
ISOLYTE P IN 5% DEXTROSE INJECTION   4 Tier 4 Injectable 25%25%P
ISOLYTE S IN 5% DEXTROSE INJECTION   4 Tier 4 Injectable 25%25%P
ISOLYTE S SOLUTION FOR INJECTION   4 Tier 4 Injectable 25%25%P
ISONIAZID 100MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
ISONIAZID 300MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
ISONIAZID 50MG/5ML SYRUP   1 Tier 1 Preferred Generic $4.00$8.00None
ISONIAZID INJ 100MG/ML   4 Tier 4 Injectable 25%25%None
ISORDIL 40MG TABLET   2 Tier 2 Preferred Brand $37.00$74.00None
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 $4.00$8.00None
ISOSORBIDE DN 2.5 MG TAB SL   1 Tier 1 Preferred Generic $4.00$8.00None
ISOSORBIDE DN 20MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
ISOSORBIDE DN 30MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
ISOSORBIDE DN 40MG TABLET SA   1 Tier 1 Preferred Generic $4.00$8.00None
ISOSORBIDE DN 5MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
ISOSORBIDE DN 5MG TABLET SL   1 Tier 1 Preferred Generic $4.00$8.00None
ISOSORBIDE MN 10MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
ISOSORBIDE MONONITRATE 20MG TABLET   1 Tier 1 Preferred Generic $4.00$8.00None
ISOSORBIDE MONONITRATE ER TABLET 120MG (100 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
ISOSORBIDE MONONITRATE ER TABLET 30MG (100 CT)   1 Tier 1 Preferred Generic $4.00$8.00None
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 $4.00$8.00None
ISOTON GENTAMICIN 60MG/100ML   4 Tier 4 Injectable 25%25%None
ISOTON GENTAMICIN 80MG/100ML   4 Tier 4 Injectable 25%25%None
ISRADIPINE CAPSULES 2.5MG (100 CT)   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
ISRADIPINE CAPSULES 5MG (100 CT)   3 Tier 3 Non-Preferred Generic Non-Preferred Brand $75.00$188.00None
ISTALOL 0.5% EYE DROPS   2 Tier 2 Preferred Brand $37.00$74.00None
ISTODAX KIT 10MG/2ML   5 Tier 5 Specialty 25%25%P
ITRACONAZOLE 100MG CAPSULE   1 Tier 1 Preferred Generic $4.00$8.00P
IV BUSULFEX 6MG 1 X 10ML VIALGL   4 Tier 4 Injectable 25%25%None
IXEMPRA KIT 45MG   5 Tier 5 Specialty 25%25%P
IXIARO JAPANESE ENCEPHALITIS VACCINE 6MCG/.5ML   4 Tier 4 Injectable 25%25%None

Chart Legend:

Below are a few notes to help you understand the above 2011 Medicare Part D Health Net Orange Option 1 (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 intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $(2840)) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, on the 2011 Humana Walmart-Preferred Rx Plan the pricing 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 2011 )

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.







Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.