2012 Medicare Part D Plan Formulary Information |
Medica Prime Solution Basic with Part D Option 3 (Cost) (H2450-005-0)
Benefit Details
|
The Medica Prime Solution Basic with Part D Option 3 (Cost) (H2450-005-0) Formulary Drugs Starting with the Letter I in WALSH County, ND: CMS MA Region 19 which includes: ND
|
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 |
IBANDRONATE SODIUM 150 MG TAB |
1 |
Tier 1 |
$10.00 | $20.00 | Q:1 /28Days |
Ibuprofen 100mg/5mL 473 mL in 1 BOTTLE |
1 |
Tier 1 |
$10.00 | $20.00 | None |
IBUPROFEN 600mg/1 500 TABLET in 1 BOTTLE |
1 |
Tier 1 |
$10.00 | $20.00 | None |
IBUPROFEN 800 MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | None |
IBUPROFEN TABLETS |
1 |
Tier 1 |
$10.00 | $20.00 | None |
IDAMYCIN PFS 1MG/ML VIAL |
3 |
Tier 3 |
$74.00 | $148.00 | None |
IDARUBICIN HCL 1MG/ML VIAL |
1 |
Tier 1 |
$10.00 | $20.00 | None |
IFEX INJECTION 3GM/ML 3GM VIALSD |
3 |
Tier 3 |
$74.00 | $148.00 | P |
IFOSFAMIDE FOR INFECTION 1 GM |
1 |
Tier 1 |
$10.00 | $20.00 | P |
IFOSFAMIDE/MESNA KIT 1G/20ML / 1MG/ |
1 |
Tier 1 |
$10.00 | $20.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IFOSFAMIDE/MESNA KIT 1G/20ML / 1MG/ |
1 |
Tier 1 |
$10.00 | $20.00 | P |
Ilaris 150mg/mL 1 VIAL, SINGLE-USE in 1 CARTON / 1 mL in 1 VIAL, SINGLE-USE |
4 |
Tier 4 |
25% | 25% | None |
IMIPENEM-CILASTATIN 250 MG VL |
1 |
Tier 1 |
$10.00 | $20.00 | None |
IMIPENEM-CILASTATIN 500 MG VL |
1 |
Tier 1 |
$10.00 | $20.00 | None |
IMIPRAMINE HCL 10MG TABLET (100 CT) |
1 |
Tier 1 |
$10.00 | $20.00 | None |
IMIPRAMINE HCL 25MG TABLET (100 CT) |
1 |
Tier 1 |
$10.00 | $20.00 | None |
IMIPRAMINE HCL 50MG TABLET (100 CT) |
1 |
Tier 1 |
$10.00 | $20.00 | None |
IMIPRAMINE PAMOATE CAPSULES |
1 |
Tier 1 |
$10.00 | $20.00 | None |
IMIPRAMINE PAMOATE CAPSULES |
1 |
Tier 1 |
$10.00 | $20.00 | None |
IMIPRAMINE PAMOATE CAPSULES |
1 |
Tier 1 |
$10.00 | $20.00 | None |
IMIPRAMINE PAMOATE CAPSULES |
1 |
Tier 1 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IMIQUIMOD 5% CREAM |
1 |
Tier 1 |
$10.00 | $20.00 | P Q:24 /30Days |
IMITREX 100MG TABLET |
3 |
Tier 3 |
$74.00 | $148.00 | Q:9 /28Days |
IMITREX 20MG NASAL SPRAY |
3 |
Tier 3 |
$74.00 | $148.00 | Q:12 /28Days |
IMITREX 25MG TABLET |
3 |
Tier 3 |
$74.00 | $148.00 | Q:9 /28Days |
IMITREX 4MG/0.5ML KIT REFILL |
3 |
Tier 3 |
$74.00 | $148.00 | Q:4 /28Days |
IMITREX 50MG TABLET |
3 |
Tier 3 |
$74.00 | $148.00 | Q:9 /28Days |
IMITREX 5MG NASAL SPRAY |
3 |
Tier 3 |
$74.00 | $148.00 | Q:18 /28Days |
IMITREX 6MG/0.5ML SYRNG KIT |
3 |
Tier 3 |
$74.00 | $148.00 | Q:4 /28Days |
IMITREX 6MG/0.5ML VIAL |
3 |
Tier 3 |
$74.00 | $148.00 | Q:4 /28Days |
IMOVAX RABIES VACCINE 2.5UNT/ML |
2 |
Tier 2 |
$34.00 | $68.00 | P |
IMURAN 50MG TABLET |
3 |
Tier 3 |
$74.00 | $148.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Incivek 375mg/1 4 BOX in 1 CARTON / 7 BLISTER PACK in 1 BOX / 6 TABLET, FILM COATED in 1 BLISTER PA |
4 |
Tier 4 |
25% | 25% | P Q:168 /28Days |
Increlex 40mg/4mL 1 VIAL, MULTI-DOSE in 1 CARTON / 4 mL in 1 VIAL, MULTI-DOSE |
4 |
Tier 4 |
25% | 25% | None |
Indapamide 1.25mg/1 100 TABLET, FILM COATED in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
$10.00 | $20.00 | None |
INDAPAMIDE 2.5MG TABLET USP (1000 CT) |
1 |
Tier 1 |
$10.00 | $20.00 | None |
INDERAL LA LONG ACTING CAPSULES 120MG 100 BOT |
3 |
Tier 3 |
$74.00 | $148.00 | None |
INDERAL LA LONG ACTING CAPSULES 160MG 100 BOT |
3 |
Tier 3 |
$74.00 | $148.00 | None |
INDERAL LA LONG ACTING CAPSULES 60MG 100 BOT |
3 |
Tier 3 |
$74.00 | $148.00 | None |
INDERAL LA LONG ACTING CAPSULES 80MG 100 BOT |
3 |
Tier 3 |
$74.00 | $148.00 | None |
INDOCIN ORAL SUSPENSION 25MG/5ML 237 ML BOT |
2 |
Tier 2 |
$34.00 | $68.00 | None |
INDOMETHACIN 50MG CAPSULE |
1 |
Tier 1 |
$10.00 | $20.00 | None |
INDOMETHACIN 75MG CAPSULE SA |
1 |
Tier 1 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INDOMETHACIN CAPSULES |
1 |
Tier 1 |
$10.00 | $20.00 | None |
INFERGEN INJECTION |
4 |
Tier 4 |
25% | 25% | P |
INFUMORPH 10MG/ML AMPUL P/F |
3 |
Tier 3 |
$74.00 | $148.00 | None |
INFUMORPH 25MG/ML AMPUL P/F |
3 |
Tier 3 |
$74.00 | $148.00 | None |
INLYTA 1 MG TABLET |
4 |
Tier 4 |
25% | 25% | P Q:180 /30Days |
INLYTA 5 MG TABLET |
4 |
Tier 4 |
25% | 25% | P Q:60 /30Days |
INNOHEP 20000[iU]/mL 1 VIAL, MULTI-DOSE in 1 CARTON / 2 mL in 1 VIAL, MULTI-DOSE |
3 |
Tier 3 |
$74.00 | $148.00 | P Q:18 /30Days |
INNOPRAN CAPSULES EXTENDED RELEASE 120 MG |
3 |
Tier 3 |
$74.00 | $148.00 | None |
INNOPRAN CAPSULES EXTENDED RELEASE 80 MG |
3 |
Tier 3 |
$74.00 | $148.00 | None |
INSPRA 25MG TABLET |
3 |
Tier 3 |
$74.00 | $148.00 | None |
Inspra 50mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
3 |
Tier 3 |
$74.00 | $148.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INSULIN, GLULISINE, HUMAN 100 UNT/ML PREFILLED SYRINGE [APIDRA] 3 ML |
3 |
Tier 3 |
$74.00 | $148.00 | Q:30 /28Days |
INTELENCE 100MG TABLET |
4 |
Tier 4 |
25% | 25% | None |
Intelence 200mg/1 |
4 |
Tier 4 |
25% | 25% | None |
INTERMEZZO 1.75 MG TAB SUBLING |
3 |
Tier 3 |
$74.00 | $148.00 | None |
INTERMEZZO 3.5 MG TAB SUBLING |
3 |
Tier 3 |
$74.00 | $148.00 | None |
INTRALIPID 20% IV FAT EMUL |
2 |
Tier 2 |
$34.00 | $68.00 | P |
INTRALIPID PHARMACY BULK PACKAGE FAT EMULSION 1.7-1.2-30GM 500ML BAG |
2 |
Tier 2 |
$34.00 | $68.00 | P |
INTRON A 10MMU VIAL |
2 |
Tier 2 |
$34.00 | $68.00 | P |
Intron A 11.6ug/0.2mL 1 VIAL, MULTI-DOSE in 1 CARTON / 1.5 mL in 1 VIAL, MULTI-DOSE |
2 |
Tier 2 |
$34.00 | $68.00 | P |
Intron A 19.2ug/0.2mL 1 VIAL, MULTI-DOSE in 1 CARTON / 1.5 mL in 1 VIAL, MULTI-DOSE |
4 |
Tier 4 |
25% | 25% | P |
Intron A 38.4ug/0.2mL 1 VIAL, MULTI-DOSE in 1 CARTON / 1.5 mL in 1 VIAL, MULTI-DOSE |
4 |
Tier 4 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INTRON A 6MMU/ML VIAL |
4 |
Tier 4 |
25% | 25% | P |
Introvale 3 CARTON in 1 BOX / 1 KIT in 1 CARTON |
1 |
Tier 1 |
$10.00 | $20.00 | Q:91 /84Days |
Intuniv 1mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
3 |
Tier 3 |
$74.00 | $148.00 | Q:30 /30Days |
Intuniv 2mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
3 |
Tier 3 |
$74.00 | $148.00 | Q:30 /30Days |
Intuniv 3mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
3 |
Tier 3 |
$74.00 | $148.00 | Q:30 /30Days |
Intuniv 4mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
3 |
Tier 3 |
$74.00 | $148.00 | Q:30 /30Days |
INVANZ 1GM VIAL |
2 |
Tier 2 |
$34.00 | $68.00 | None |
INVEGA 3MG TABLET SR OSMOTIC PUSH 24HR |
3 |
Tier 3 |
$74.00 | $148.00 | Q:31 /31Days |
INVEGA 6MG TABLET SR OSMOTIC PUSH 24HR |
3 |
Tier 3 |
$74.00 | $148.00 | Q:62 /31Days |
INVEGA 9MG TABLET SR OSMOTIC PUSH 24HR |
3 |
Tier 3 |
$74.00 | $148.00 | Q:31 /31Days |
INVEGA ER 1.5mg/ 30 TABLET BOTTLE |
3 |
Tier 3 |
$74.00 | $148.00 | Q:31 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Invega Sustenna 117 mg/0.75mL Prefilled Syringe |
4 |
Tier 4 |
25% | 25% | Q:1 /28Days |
Invega Sustenna 156 mg/mL Prefilled Syringe |
4 |
Tier 4 |
25% | 25% | Q:1 /28Days |
Invega Sustenna 234 mg/1.5mL Prefilled Syringe |
4 |
Tier 4 |
25% | 25% | Q:2 /28Days |
Invega Sustenna 39 mg/0.25mL Prefilled Syringe |
2 |
Tier 2 |
$34.00 | $68.00 | None |
Invega Sustenna 78 mg/0.5mL Prefilled Syringe |
2 |
Tier 2 |
$34.00 | $68.00 | Q:1 /28Days |
INVIRASE 200MG CAPSULE |
4 |
Tier 4 |
25% | 25% | None |
INVIRASE 500MG TABLET |
4 |
Tier 4 |
25% | 25% | None |
IONOSOL B-D5W IV SOLUTION |
2 |
Tier 2 |
$34.00 | $68.00 | None |
IONOSOL MB-D5W IV SOLUTION |
2 |
Tier 2 |
$34.00 | $68.00 | None |
IONOSOL T-D5W IV SOLUTION |
2 |
Tier 2 |
$34.00 | $68.00 | None |
IOPIDINE 0.5% EYE DROPS |
3 |
Tier 3 |
$74.00 | $148.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IOPIDINE 1% EYE DROPS |
3 |
Tier 3 |
$74.00 | $148.00 | None |
IPOL VIAL 40;8;32; UNT |
2 |
Tier 2 |
$34.00 | $68.00 | None |
Ipratropium Bromide 42ug/1 1 BOTTLE, SPRAY in 1 CARTON / 165 SPRAY, METERED in 1 BOTTLE, SPRAY |
1 |
Tier 1 |
$10.00 | $20.00 | Q:15 /10Days |
IPRATROPIUM BROMIDE NASAL SPRAY |
1 |
Tier 1 |
$10.00 | $20.00 | Q:30 /28Days |
IQUIX 1.5% DROPS |
3 |
Tier 3 |
$74.00 | $148.00 | None |
IRBESARTAN 150 MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | None |
IRBESARTAN 300 MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | None |
IRBESARTAN 75 MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | None |
IRBESARTAN-HCTZ 150-12.5 MG TB |
1 |
Tier 1 |
$10.00 | $20.00 | None |
IRBESARTAN-HCTZ 300-12.5 MG TB |
1 |
Tier 1 |
$10.00 | $20.00 | None |
IRESSA 250MG TABLET |
4 |
Tier 4 |
25% | 25% | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IRINOTECAN HCL INJECTION 20MG |
4 |
Tier 4 |
25% | 25% | None |
ISENTRESS 400MG TABLET |
4 |
Tier 4 |
25% | 25% | None |
ISOCHRON 40MG TABLET SA |
3 |
Tier 3 |
$74.00 | $148.00 | None |
ISOLYTE H IN 5% DEXTROSE |
2 |
Tier 2 |
$34.00 | $68.00 | None |
ISOLYTE M IN 5% DEXTROSE INJECTION |
2 |
Tier 2 |
$34.00 | $68.00 | None |
ISOLYTE P IN 5% DEXTROSE INJECTION |
2 |
Tier 2 |
$34.00 | $68.00 | None |
ISOLYTE S IN 5% DEXTROSE INJECTION |
2 |
Tier 2 |
$34.00 | $68.00 | None |
ISOLYTE S IV SOLUTION-EXCEL |
2 |
Tier 2 |
$34.00 | $68.00 | None |
ISONARIF 300-150MG CAPSULE |
1 |
Tier 1 |
$10.00 | $20.00 | None |
ISONIAZID 100MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | None |
ISONIAZID 50MG/5ML SYRUP |
1 |
Tier 1 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISONIAZID INJ 100MG/ML |
1 |
Tier 1 |
$10.00 | $20.00 | None |
ISONIAZID TABLETS |
1 |
Tier 1 |
$10.00 | $20.00 | None |
ISOPTIN SR 120MG |
3 |
Tier 3 |
$74.00 | $148.00 | None |
ISOPTIN SR 180MG |
3 |
Tier 3 |
$74.00 | $148.00 | None |
ISOPTIN SR 240MG (500 Count) |
3 |
Tier 3 |
$74.00 | $148.00 | None |
ISOPTO CARPINE 10mg/mL 15 mL in 1 BOTTLE |
3 |
Tier 3 |
$74.00 | $148.00 | None |
ISOPTO CARPINE 20mg/mL 15 mL in 1 BOTTLE |
3 |
Tier 3 |
$74.00 | $148.00 | None |
ISOPTO CARPINE 40mg/mL 15 mL in 1 BOTTLE |
3 |
Tier 3 |
$74.00 | $148.00 | None |
ISORDIL 40MG TABLET |
3 |
Tier 3 |
$74.00 | $148.00 | None |
ISORDIL TABLETS 5MG 100 BOT |
3 |
Tier 3 |
$74.00 | $148.00 | None |
Isosorbide Dinitrate 5mg/1 100 TABLET in 1 BOTTLE |
1 |
Tier 1 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISOSORBIDE DINITRATE TABLETS |
1 |
Tier 1 |
$10.00 | $20.00 | None |
ISOSORBIDE DINITRATE TABLETS EXTENDED RELEASE |
1 |
Tier 1 |
$10.00 | $20.00 | None |
ISOSORBIDE DN 10MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | None |
ISOSORBIDE DN 2.5 MG TAB SL |
1 |
Tier 1 |
$10.00 | $20.00 | None |
ISOSORBIDE DN 20MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | None |
ISOSORBIDE DN 30MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | None |
ISOSORBIDE MN 10MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | None |
ISOSORBIDE MONONITRATE 20 MG ORAL TABLET [MONOKET] |
3 |
Tier 3 |
$74.00 | $148.00 | None |
ISOSORBIDE MONONITRATE 20MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | None |
ISOSORBIDE MONONITRATE ER TABLET 120MG (100 CT) |
1 |
Tier 1 |
$10.00 | $20.00 | None |
ISOSORBIDE MONONITRATE ER TABLET 30MG (100 CT) |
1 |
Tier 1 |
$10.00 | $20.00 | 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 |
$10.00 | $20.00 | None |
ISOTON GENTAMICIN 60MG/100ML |
1 |
Tier 1 |
$10.00 | $20.00 | None |
ISOTON GENTAMICIN 80MG/100ML |
1 |
Tier 1 |
$10.00 | $20.00 | None |
ISRADIPINE CAPSULES 2.5MG (100 CT) |
1 |
Tier 1 |
$10.00 | $20.00 | None |
ISRADIPINE CAPSULES 5MG (100 CT) |
1 |
Tier 1 |
$10.00 | $20.00 | None |
ISTALOL 0.5% EYE DROPS |
2 |
Tier 2 |
$34.00 | $68.00 | None |
ISTODAX KIT |
4 |
Tier 4 |
25% | 25% | P |
ITRACONAZOLE 100MG CAPSULE |
1 |
Tier 1 |
$10.00 | $20.00 | None |
IXEMPRA 45 MG KIT |
4 |
Tier 4 |
25% | 25% | None |
IXIARO JAPANESE ENCEPHALITIS VACCINE 6MCG/.5ML |
2 |
Tier 2 |
$34.00 | $68.00 | None |