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2011 Medicare Part D Plan Formulary Information
CVS Caremark Plus (PDP) (S5601-003-0) Benefit Details
The CVS Caremark Plus (PDP) (S5601-003-0) Formulary Drugs Starting with the Letter I in CMS PDP Region 01 which includes: ME NH
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 100MG/5ML SUSP	1	Preferred Generic Tier	$2.00	$3.00	None
IBUPROFEN 600 MG ORAL TABLET	1	Preferred Generic Tier	$2.00	$3.00	None
IBUPROFEN 800 MG TABLET	1	Preferred Generic Tier	$2.00	$3.00	None
IBUPROFEN TABLETS	1	Preferred Generic Tier	$2.00	$3.00	None
IDARUBICIN HCL 1MG/ML VIAL	2	Non-Preferred Generic Tier	$5.00	$8.00	P
IFEX INJECTION 3GM/ML 3GM VIALSD	3	Preferred Brand Tier	$35.00	$79.00	P
IFOSFAMIDE FOR INFECTION 1 GM	5	Specialty Tier	33%	N/A	P
IFOSFAMIDE/MESNA KIT 1G/20ML / 1MG/	2	Non-Preferred Generic Tier	$5.00	$8.00	P
IFOSFAMIDE/MESNA KIT 1G/20ML / 1MG/	2	Non-Preferred Generic Tier	$5.00	$8.00	P
ILOPERIDONE 1 MG ORAL TABLET [FANAPT]	4	Non-Preferred Generic and Non-Preferred Brand Tier	$90.00	$248.00	S
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ILOPERIDONE 10 MG ORAL TABLET [FANAPT]	4	Non-Preferred Generic and Non-Preferred Brand Tier	$90.00	$248.00	S
ILOPERIDONE 12 MG ORAL TABLET [FANAPT]	4	Non-Preferred Generic and Non-Preferred Brand Tier	$90.00	$248.00	S
ILOPERIDONE 2 MG ORAL TABLET [FANAPT]	4	Non-Preferred Generic and Non-Preferred Brand Tier	$90.00	$248.00	S
ILOPERIDONE 4 MG ORAL TABLET [FANAPT]	4	Non-Preferred Generic and Non-Preferred Brand Tier	$90.00	$248.00	S
ILOPERIDONE 6 MG ORAL TABLET [FANAPT]	4	Non-Preferred Generic and Non-Preferred Brand Tier	$90.00	$248.00	S
ILOPERIDONE 8 MG ORAL TABLET [FANAPT]	4	Non-Preferred Generic and Non-Preferred Brand Tier	$90.00	$248.00	S
IMIPRAMINE HCL 10MG TABLET (100 CT)	2	Non-Preferred Generic Tier	$5.00	$8.00	None
IMIPRAMINE HCL 25MG TABLET (100 CT)	2	Non-Preferred Generic Tier	$5.00	$8.00	None
IMIPRAMINE HCL 50MG TABLET (100 CT)	2	Non-Preferred Generic Tier	$5.00	$8.00	None
IMIQUIMOD 5% CREAM	2	Non-Preferred Generic Tier	$5.00	$8.00	None
IMOVAX RABIES VACCINE 2.5UNT/ML	3	Preferred Brand Tier	$35.00	$79.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
INCRELEX 40MG/4ML VIAL	5	Specialty Tier	33%	N/A	P
INDAPAMIDE 1.25MG TABLET USP (1000 CT)	1	Preferred Generic Tier	$2.00	$3.00	None
INDAPAMIDE 2.5MG TABLET USP (1000 CT)	1	Preferred Generic Tier	$2.00	$3.00	None
INDOCIN ORAL SUSPENSION 25MG/5ML 237 ML BOT	3	Preferred Brand Tier	$35.00	$79.00	None
INDOMETHACIN 50MG CAPSULE	2	Non-Preferred Generic Tier	$5.00	$8.00	None
INDOMETHACIN 75MG CAPSULE SA	2	Non-Preferred Generic Tier	$5.00	$8.00	None
INDOMETHACIN CAPSULES	2	Non-Preferred Generic Tier	$5.00	$8.00	None
INFERGEN INJECTION	5	Specialty Tier	33%	N/A	P
INSULIN, GLULISINE, HUMAN 100 UNT/ML PREFILLED SYRINGE [APIDRA] 3 ML	3	Preferred Brand Tier	$35.00	$79.00	None
INTELENCE 100MG TABLET	3	Preferred Brand Tier	$35.00	$79.00	None
INTERFERON BETA-1B 0.25 MG/ML INJECTABLE SOLUTION [EXTAVIA]	5	Specialty Tier	33%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
INTRALIPID 20% IV FAT EMUL	2	Non-Preferred Generic Tier	$5.00	$8.00	P
INTRALIPID PHARMACY BULK PACKAGE FAT EMULSION 1.7-1.2-30GM 500ML BAG	3	Preferred Brand Tier	$35.00	$79.00	P
INTRON A 10MMU INJ PEN	5	Specialty Tier	33%	N/A	P
INTRON A 10MMU VIAL	3	Preferred Brand Tier	$35.00	$79.00	P
INTRON A 3MMU INJECTION PEN	5	Specialty Tier	33%	N/A	P
INTRON A 5MMU MULTIDOSE PEN	5	Specialty Tier	33%	N/A	P
INTRON A 6MMU/ML VIAL	5	Specialty Tier	33%	N/A	P
INVANZ 1GM VIAL	3	Preferred Brand Tier	$35.00	$79.00	P
INVEGA 3MG TABLET SR OSMOTIC PUSH 24HR	4	Non-Preferred Generic and Non-Preferred Brand Tier	$90.00	$248.00	S Q:30 /30Days
INVEGA 6MG TABLET SR OSMOTIC PUSH 24HR	4	Non-Preferred Generic and Non-Preferred Brand Tier	$90.00	$248.00	S
INVEGA 9MG TABLET SR OSMOTIC PUSH 24HR	4	Non-Preferred Generic and Non-Preferred Brand Tier	$90.00	$248.00	S
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
INVIRASE 200MG CAPSULE	3	Preferred Brand Tier	$35.00	$79.00	None
INVIRASE 500MG TABLET	3	Preferred Brand Tier	$35.00	$79.00	None
IONOSOL B-D5W IV SOLUTION	3	Preferred Brand Tier	$35.00	$79.00	None
IONOSOL MB-D5W IV SOLUTION	3	Preferred Brand Tier	$35.00	$79.00	None
IONOSOL T-D5W IV SOLUTION	3	Preferred Brand Tier	$35.00	$79.00	None
IPOL VIAL 40;8;32; UNT	3	Preferred Brand Tier	$35.00	$79.00	None
IPRATROPIUM BROMIDE 42MCG AEROSOL SPRAY	2	Non-Preferred Generic Tier	$5.00	$8.00	None
IPRATROPIUM BROMIDE INHALATION SOLUTION 0.02% 60 X 2.5ML VIALSD	2	Non-Preferred Generic Tier	$5.00	$8.00	P Q:315 /30Days
IPRATROPIUM BROMIDE NASAL SPRAY	2	Non-Preferred Generic Tier	$5.00	$8.00	None
IPRATROPIUM BROMIDE/ALBUTEROL SULFATE INHALATION SOLUTION 0.5MG/3ML 33 CRTN	2	Non-Preferred Generic Tier	$5.00	$8.00	P Q:540 /30Days
IRINOTECAN HCL INJECTION 20MG	5	Specialty Tier	33%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ISENTRESS 400MG TABLET	5	Specialty Tier	33%	N/A	None
ISOCHRON 40MG TABLET SA	2	Non-Preferred Generic Tier	$5.00	$8.00	None
ISOLYTE H IN 5% DEXTROSE	3	Preferred Brand Tier	$35.00	$79.00	None
ISOLYTE M IN 5% DEXTROSE INJECTION	2	Non-Preferred Generic Tier	$5.00	$8.00	None
ISOLYTE P IN 5% DEXTROSE INJECTION	3	Preferred Brand Tier	$35.00	$79.00	None
ISOLYTE S IN 5% DEXTROSE INJECTION	3	Preferred Brand Tier	$35.00	$79.00	None
ISOLYTE S SOLUTION FOR INJECTION	3	Preferred Brand Tier	$35.00	$79.00	None
ISONIAZID 100MG TABLET	1	Preferred Generic Tier	$2.00	$3.00	None
ISONIAZID 50MG/5ML SYRUP	2	Non-Preferred Generic Tier	$5.00	$8.00	None
ISONIAZID INJ 100MG/ML	2	Non-Preferred Generic Tier	$5.00	$8.00	None
ISONIAZID TABLETS	1	Preferred Generic Tier	$2.00	$3.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ISORDIL 40MG TABLET	3	Preferred Brand Tier	$35.00	$79.00	None
ISOSORBIDE DINITRATE TABLETS	1	Preferred Generic Tier	$2.00	$3.00	None
ISOSORBIDE DINITRATE TABLETS EXTENDED RELEASE	2	Non-Preferred Generic Tier	$5.00	$8.00	None
ISOSORBIDE DN 10MG TABLET	1	Preferred Generic Tier	$2.00	$3.00	None
ISOSORBIDE DN 2.5 MG TAB SL	1	Preferred Generic Tier	$2.00	$3.00	None
ISOSORBIDE DN 20MG TABLET	1	Preferred Generic Tier	$2.00	$3.00	None
ISOSORBIDE DN 30MG TABLET	1	Preferred Generic Tier	$2.00	$3.00	None
ISOSORBIDE DN 5MG TABLET SL	1	Preferred Generic Tier	$2.00	$3.00	None
ISOSORBIDE MN 10MG TABLET	2	Non-Preferred Generic Tier	$5.00	$8.00	None
ISOSORBIDE MONONITRATE 20MG TABLET	2	Non-Preferred Generic Tier	$5.00	$8.00	None
ISOSORBIDE MONONITRATE ER TABLET 120MG (100 CT)	2	Non-Preferred Generic Tier	$5.00	$8.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ISOSORBIDE MONONITRATE ER TABLET 30MG (100 CT)	2	Non-Preferred Generic Tier	$5.00	$8.00	None
ISOSORBIDE MONONITRATE TABLETS EXTENDED RELEASE 60MG 100 TABLETS BOT	2	Non-Preferred Generic Tier	$5.00	$8.00	None
ISOTON GENTAMICIN 60MG/100ML	2	Non-Preferred Generic Tier	$5.00	$8.00	P
ISOTON GENTAMICIN 80MG/100ML	2	Non-Preferred Generic Tier	$5.00	$8.00	P
ISRADIPINE CAPSULES 2.5MG (100 CT)	2	Non-Preferred Generic Tier	$5.00	$8.00	None
ISRADIPINE CAPSULES 5MG (100 CT)	2	Non-Preferred Generic Tier	$5.00	$8.00	None
ISTODAX KIT	5	Specialty Tier	33%	N/A	P
ITRACONAZOLE 100MG CAPSULE	2	Non-Preferred Generic Tier	$5.00	$8.00	P
IV BUSULFEX 6MG 1 X 10ML VIALGL	3	Preferred Brand Tier	$35.00	$79.00	P
IXIARO JAPANESE ENCEPHALITIS VACCINE 6MCG/.5ML	3	Preferred Brand Tier	$35.00	$79.00	None

Chart Legend:

Below are a few notes to help you understand the above 2011 Medicare Part D CVS Caremark Plus (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.