2012 Medicare Part D Plan Formulary Information |
Health Net Orange Option 1 (PDP) (S5678-018-0)
Sanctioned Plan
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The Health Net Orange Option 1 (PDP) (S5678-018-0) Formulary Drugs Starting with the Letter I in CMS PDP Region 6 which includes: PA WV
|
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 ![Compare how all Medicare Part D PDP plans in PA cover IBANDRONATE SODIUM 150 MG TAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | P |
Ibuprofen 100mg/5mL 473 mL in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in PA cover Ibuprofen 100mg/5mL 473 mL in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
IBUPROFEN 600mg/1 500 TABLET in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in PA cover IBUPROFEN 600mg/1 500 TABLET in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
IBUPROFEN 800 MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover IBUPROFEN 800 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
IBUPROFEN TABLETS ![Compare how all Medicare Part D PDP plans in PA cover IBUPROFEN TABLETS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
IDAMYCIN PFS 1MG/ML VIAL ![Compare how all Medicare Part D PDP plans in PA cover IDAMYCIN PFS 1MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Injectable Drugs |
25% | 25% | None |
IDARUBICIN HCL 1MG/ML VIAL ![Compare how all Medicare Part D PDP plans in PA cover IDARUBICIN HCL 1MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Injectable Drugs |
25% | 25% | None |
IFEX INJECTION 3GM/ML 3GM VIALSD ![Compare how all Medicare Part D PDP plans in PA cover IFEX INJECTION 3GM/ML 3GM VIALSD.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Injectable Drugs |
25% | 25% | None |
IFOSFAMIDE FOR INFECTION 1 GM ![Compare how all Medicare Part D PDP plans in PA cover IFOSFAMIDE FOR INFECTION 1 GM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Injectable Drugs |
25% | 25% | None |
IFOSFAMIDE/MESNA KIT 1G/20ML / 1MG/ ![Compare how all Medicare Part D PDP plans in PA cover IFOSFAMIDE/MESNA KIT 1G/20ML / 1MG/.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Injectable Drugs |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IFOSFAMIDE/MESNA KIT 1G/20ML / 1MG/ ![Compare how all Medicare Part D PDP plans in PA cover IFOSFAMIDE/MESNA KIT 1G/20ML / 1MG/.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Injectable Drugs |
25% | 25% | None |
Ilaris 150mg/mL 1 VIAL, SINGLE-USE in 1 CARTON / 1 mL in 1 VIAL, SINGLE-USE ![Compare how all Medicare Part D PDP plans in PA cover Ilaris 150mg/mL 1 VIAL, SINGLE-USE in 1 CARTON / 1 mL in 1 VIAL, SINGLE-USE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier Drugs |
25% | 25% | None |
IMIPENEM-CILASTATIN 250 MG VL ![Compare how all Medicare Part D PDP plans in PA cover IMIPENEM-CILASTATIN 250 MG VL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
IMIPENEM-CILASTATIN 500 MG VL ![Compare how all Medicare Part D PDP plans in PA cover IMIPENEM-CILASTATIN 500 MG VL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
IMIPRAMINE HCL 10MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover IMIPRAMINE HCL 10MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
IMIPRAMINE HCL 25MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover IMIPRAMINE HCL 25MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
IMIPRAMINE HCL 50MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover IMIPRAMINE HCL 50MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
IMIPRAMINE PAMOATE CAPSULES ![Compare how all Medicare Part D PDP plans in PA cover IMIPRAMINE PAMOATE CAPSULES.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
IMIPRAMINE PAMOATE CAPSULES ![Compare how all Medicare Part D PDP plans in PA cover IMIPRAMINE PAMOATE CAPSULES.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
IMIPRAMINE PAMOATE CAPSULES ![Compare how all Medicare Part D PDP plans in PA cover IMIPRAMINE PAMOATE CAPSULES.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
IMIPRAMINE PAMOATE CAPSULES ![Compare how all Medicare Part D PDP plans in PA cover IMIPRAMINE PAMOATE CAPSULES.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IMIQUIMOD 5% CREAM ![Compare how all Medicare Part D PDP plans in PA cover IMIQUIMOD 5% CREAM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
IMITREX 4MG/0.5ML KIT REFILL ![Compare how all Medicare Part D PDP plans in PA cover IMITREX 4MG/0.5ML KIT REFILL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Injectable Drugs |
25% | 25% | None |
IMITREX 6MG/0.5ML SYRNG KIT ![Compare how all Medicare Part D PDP plans in PA cover IMITREX 6MG/0.5ML SYRNG KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Injectable Drugs |
25% | 25% | None |
IMITREX 6MG/0.5ML VIAL ![Compare how all Medicare Part D PDP plans in PA cover IMITREX 6MG/0.5ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Injectable Drugs |
25% | 25% | None |
IMOVAX RABIES VACCINE 2.5UNT/ML ![Compare how all Medicare Part D PDP plans in PA cover IMOVAX RABIES VACCINE 2.5UNT/ML.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Injectable Drugs |
25% | 25% | P |
IMURAN 50MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover IMURAN 50MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Non-Preferred Brand Drugs |
$81.00 | $203.00 | P |
Incivek 375mg/1 4 BOX in 1 CARTON / 7 BLISTER PACK in 1 BOX / 6 TABLET, FILM COATED in 1 BLISTER PA ![Compare how all Medicare Part D PDP plans in PA cover Incivek 375mg/1 4 BOX in 1 CARTON / 7 BLISTER PACK in 1 BOX / 6 TABLET, FILM COATED in 1 BLISTER PA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier Drugs |
25% | 25% | P |
Increlex 40mg/4mL 1 VIAL, MULTI-DOSE in 1 CARTON / 4 mL in 1 VIAL, MULTI-DOSE ![Compare how all Medicare Part D PDP plans in PA cover Increlex 40mg/4mL 1 VIAL, MULTI-DOSE in 1 CARTON / 4 mL in 1 VIAL, MULTI-DOSE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Injectable Drugs |
25% | 25% | None |
Indapamide 1.25mg/1 100 TABLET, FILM COATED in 1 BOTTLE, PLASTIC ![Compare how all Medicare Part D PDP plans in PA cover Indapamide 1.25mg/1 100 TABLET, FILM COATED in 1 BOTTLE, PLASTIC.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
INDAPAMIDE 2.5MG TABLET USP (1000 CT) ![Compare how all Medicare Part D PDP plans in PA cover INDAPAMIDE 2.5MG TABLET USP (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
INDOCIN ORAL SUSPENSION 25MG/5ML 237 ML BOT ![Compare how all Medicare Part D PDP plans in PA cover INDOCIN ORAL SUSPENSION 25MG/5ML 237 ML BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Preferred Brand Drugs |
$44.00 | $88.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INDOMETHACIN 50MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover INDOMETHACIN 50MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
INDOMETHACIN 75MG CAPSULE SA ![Compare how all Medicare Part D PDP plans in PA cover INDOMETHACIN 75MG CAPSULE SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
INDOMETHACIN CAPSULES ![Compare how all Medicare Part D PDP plans in PA cover INDOMETHACIN CAPSULES.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
INFERGEN INJECTION ![Compare how all Medicare Part D PDP plans in PA cover INFERGEN INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier Drugs |
25% | 25% | P |
INFUMORPH 10MG/ML AMPUL P/F ![Compare how all Medicare Part D PDP plans in PA cover INFUMORPH 10MG/ML AMPUL P/F.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Injectable Drugs |
25% | 25% | None |
INFUMORPH 25MG/ML AMPUL P/F ![Compare how all Medicare Part D PDP plans in PA cover INFUMORPH 25MG/ML AMPUL P/F.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Injectable Drugs |
25% | 25% | None |
INLYTA 1 MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover INLYTA 1 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier Drugs |
25% | 25% | None |
INLYTA 5 MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover INLYTA 5 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier Drugs |
25% | 25% | None |
INNOHEP 20000[iU]/mL 1 VIAL, MULTI-DOSE in 1 CARTON / 2 mL in 1 VIAL, MULTI-DOSE ![Compare how all Medicare Part D PDP plans in PA cover INNOHEP 20000[iU]/mL 1 VIAL, MULTI-DOSE in 1 CARTON / 2 mL in 1 VIAL, MULTI-DOSE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Injectable Drugs |
25% | 25% | None |
INNOPRAN CAPSULES EXTENDED RELEASE 120 MG ![Compare how all Medicare Part D PDP plans in PA cover INNOPRAN CAPSULES EXTENDED RELEASE 120 MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Non-Preferred Brand Drugs |
$81.00 | $203.00 | None |
INNOPRAN CAPSULES EXTENDED RELEASE 80 MG ![Compare how all Medicare Part D PDP plans in PA cover INNOPRAN CAPSULES EXTENDED RELEASE 80 MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Non-Preferred Brand Drugs |
$81.00 | $203.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INTELENCE 100MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover INTELENCE 100MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier Drugs |
25% | 25% | None |
Intelence 200mg/1 ![Compare how all Medicare Part D PDP plans in PA cover Intelence 200mg/1.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier Drugs |
25% | 25% | None |
INTERMEZZO 1.75 MG TAB SUBLING ![Compare how all Medicare Part D PDP plans in PA cover INTERMEZZO 1.75 MG TAB SUBLING.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Non-Preferred Brand Drugs |
$81.00 | $203.00 | P |
INTERMEZZO 3.5 MG TAB SUBLING ![Compare how all Medicare Part D PDP plans in PA cover INTERMEZZO 3.5 MG TAB SUBLING.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Non-Preferred Brand Drugs |
$81.00 | $203.00 | P |
INTRALIPID 20% IV FAT EMUL ![Compare how all Medicare Part D PDP plans in PA cover INTRALIPID 20% IV FAT EMUL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Injectable Drugs |
25% | 25% | P |
INTRALIPID PHARMACY BULK PACKAGE FAT EMULSION 1.7-1.2-30GM 500ML BAG ![Compare how all Medicare Part D PDP plans in PA cover INTRALIPID PHARMACY BULK PACKAGE FAT EMULSION 1.7-1.2-30GM 500ML BAG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Injectable Drugs |
25% | 25% | P |
INTRON A 10MMU VIAL ![Compare how all Medicare Part D PDP plans in PA cover INTRON A 10MMU VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Injectable Drugs |
25% | 25% | None |
Intron A 11.6ug/0.2mL 1 VIAL, MULTI-DOSE in 1 CARTON / 1.5 mL in 1 VIAL, MULTI-DOSE ![Compare how all Medicare Part D PDP plans in PA cover Intron A 11.6ug/0.2mL 1 VIAL, MULTI-DOSE in 1 CARTON / 1.5 mL in 1 VIAL, MULTI-DOSE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Injectable Drugs |
25% | 25% | None |
Intron A 19.2ug/0.2mL 1 VIAL, MULTI-DOSE in 1 CARTON / 1.5 mL in 1 VIAL, MULTI-DOSE ![Compare how all Medicare Part D PDP plans in PA cover Intron A 19.2ug/0.2mL 1 VIAL, MULTI-DOSE in 1 CARTON / 1.5 mL in 1 VIAL, MULTI-DOSE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier Drugs |
25% | 25% | None |
Intron A 38.4ug/0.2mL 1 VIAL, MULTI-DOSE in 1 CARTON / 1.5 mL in 1 VIAL, MULTI-DOSE ![Compare how all Medicare Part D PDP plans in PA cover Intron A 38.4ug/0.2mL 1 VIAL, MULTI-DOSE in 1 CARTON / 1.5 mL in 1 VIAL, MULTI-DOSE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier Drugs |
25% | 25% | None |
INTRON A 6MMU/ML VIAL ![Compare how all Medicare Part D PDP plans in PA cover INTRON A 6MMU/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Injectable Drugs |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Introvale 3 CARTON in 1 BOX / 1 KIT in 1 CARTON ![Compare how all Medicare Part D PDP plans in PA cover Introvale 3 CARTON in 1 BOX / 1 KIT in 1 CARTON.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
Intuniv 1mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in PA cover Intuniv 1mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Non-Preferred Brand Drugs |
$81.00 | $203.00 | None |
Intuniv 2mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in PA cover Intuniv 2mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Non-Preferred Brand Drugs |
$81.00 | $203.00 | None |
Intuniv 3mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in PA cover Intuniv 3mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Non-Preferred Brand Drugs |
$81.00 | $203.00 | None |
Intuniv 4mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in PA cover Intuniv 4mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Non-Preferred Brand Drugs |
$81.00 | $203.00 | None |
INVANZ 1GM VIAL ![Compare how all Medicare Part D PDP plans in PA cover INVANZ 1GM VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Injectable Drugs |
25% | 25% | None |
INVEGA 3MG TABLET SR OSMOTIC PUSH 24HR ![Compare how all Medicare Part D PDP plans in PA cover INVEGA 3MG TABLET SR OSMOTIC PUSH 24HR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Preferred Brand Drugs |
$44.00 | $88.00 | None |
INVEGA 6MG TABLET SR OSMOTIC PUSH 24HR ![Compare how all Medicare Part D PDP plans in PA cover INVEGA 6MG TABLET SR OSMOTIC PUSH 24HR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Preferred Brand Drugs |
$44.00 | $88.00 | None |
INVEGA 9MG TABLET SR OSMOTIC PUSH 24HR ![Compare how all Medicare Part D PDP plans in PA cover INVEGA 9MG TABLET SR OSMOTIC PUSH 24HR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Preferred Brand Drugs |
$44.00 | $88.00 | None |
INVEGA ER 1.5mg/ 30 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in PA cover INVEGA ER 1.5mg/ 30 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Preferred Brand Drugs |
$44.00 | $88.00 | None |
Invega Sustenna 117 mg/0.75mL Prefilled Syringe ![Compare how all Medicare Part D PDP plans in PA cover Invega Sustenna 117 mg/0.75mL Prefilled Syringe.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Injectable Drugs |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Invega Sustenna 156 mg/mL Prefilled Syringe ![Compare how all Medicare Part D PDP plans in PA cover Invega Sustenna 156 mg/mL Prefilled Syringe.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Injectable Drugs |
25% | 25% | None |
Invega Sustenna 234 mg/1.5mL Prefilled Syringe ![Compare how all Medicare Part D PDP plans in PA cover Invega Sustenna 234 mg/1.5mL Prefilled Syringe.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Injectable Drugs |
25% | 25% | None |
Invega Sustenna 39 mg/0.25mL Prefilled Syringe ![Compare how all Medicare Part D PDP plans in PA cover Invega Sustenna 39 mg/0.25mL Prefilled Syringe.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Injectable Drugs |
25% | 25% | None |
Invega Sustenna 78 mg/0.5mL Prefilled Syringe ![Compare how all Medicare Part D PDP plans in PA cover Invega Sustenna 78 mg/0.5mL Prefilled Syringe.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Injectable Drugs |
25% | 25% | None |
INVIRASE 200MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover INVIRASE 200MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Non-Preferred Brand Drugs |
$81.00 | $203.00 | None |
INVIRASE 500MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover INVIRASE 500MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier Drugs |
25% | 25% | None |
IONOSOL B-D5W IV SOLUTION ![Compare how all Medicare Part D PDP plans in PA cover IONOSOL B-D5W IV SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Injectable Drugs |
25% | 25% | None |
IONOSOL MB-D5W IV SOLUTION ![Compare how all Medicare Part D PDP plans in PA cover IONOSOL MB-D5W IV SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Injectable Drugs |
25% | 25% | None |
IONOSOL T-D5W IV SOLUTION ![Compare how all Medicare Part D PDP plans in PA cover IONOSOL T-D5W IV SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Injectable Drugs |
25% | 25% | None |
IOPIDINE 0.5% EYE DROPS ![Compare how all Medicare Part D PDP plans in PA cover IOPIDINE 0.5% EYE DROPS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Non-Preferred Brand Drugs |
$81.00 | $203.00 | None |
IOPIDINE 1% EYE DROPS ![Compare how all Medicare Part D PDP plans in PA cover IOPIDINE 1% EYE DROPS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Non-Preferred Brand Drugs |
$81.00 | $203.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IPOL VIAL 40;8;32; UNT ![Compare how all Medicare Part D PDP plans in PA cover IPOL VIAL 40;8;32; UNT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Injectable Drugs |
25% | 25% | None |
Ipratropium Bromide 42ug/1 1 BOTTLE, SPRAY in 1 CARTON / 165 SPRAY, METERED in 1 BOTTLE, SPRAY ![Compare how all Medicare Part D PDP plans in PA cover Ipratropium Bromide 42ug/1 1 BOTTLE, SPRAY in 1 CARTON / 165 SPRAY, METERED in 1 BOTTLE, SPRAY.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
Ipratropium Bromide 500ug/2.5mL 30 POUCH in 1 CARTON / 1 VIAL in 1 POUCH / 2.5 mL in 1 VIAL ![Compare how all Medicare Part D PDP plans in PA cover Ipratropium Bromide 500ug/2.5mL 30 POUCH in 1 CARTON / 1 VIAL in 1 POUCH / 2.5 mL in 1 VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | P |
IPRATROPIUM BROMIDE and ALBUTEROL SULFATE 2.5; 0.5mg/3mL; mg/3mL 12 POUCH in 1 CARTON / 5 VIAL, PLA ![Compare how all Medicare Part D PDP plans in PA cover IPRATROPIUM BROMIDE and ALBUTEROL SULFATE 2.5; 0.5mg/3mL; mg/3mL 12 POUCH in 1 CARTON / 5 VIAL, PLA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | P |
IPRATROPIUM BROMIDE NASAL SPRAY ![Compare how all Medicare Part D PDP plans in PA cover IPRATROPIUM BROMIDE NASAL SPRAY.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
IQUIX 1.5% DROPS ![Compare how all Medicare Part D PDP plans in PA cover IQUIX 1.5% DROPS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Non-Preferred Brand Drugs |
$81.00 | $203.00 | None |
IRBESARTAN 150 MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover IRBESARTAN 150 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
IRBESARTAN 300 MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover IRBESARTAN 300 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
IRBESARTAN 75 MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover IRBESARTAN 75 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
IRBESARTAN-HCTZ 150-12.5 MG TB ![Compare how all Medicare Part D PDP plans in PA cover IRBESARTAN-HCTZ 150-12.5 MG TB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
IRBESARTAN-HCTZ 300-12.5 MG TB ![Compare how all Medicare Part D PDP plans in PA cover IRBESARTAN-HCTZ 300-12.5 MG TB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IRESSA 250MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover IRESSA 250MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier Drugs |
25% | 25% | None |
IRINOTECAN HCL INJECTION 20MG ![Compare how all Medicare Part D PDP plans in PA cover IRINOTECAN HCL INJECTION 20MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Injectable Drugs |
25% | 25% | None |
ISENTRESS 400MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover ISENTRESS 400MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier Drugs |
25% | 25% | None |
ISOCHRON 40MG TABLET SA ![Compare how all Medicare Part D PDP plans in PA cover ISOCHRON 40MG TABLET SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
ISOLYTE H IN 5% DEXTROSE ![Compare how all Medicare Part D PDP plans in PA cover ISOLYTE H IN 5% DEXTROSE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Injectable Drugs |
25% | 25% | None |
ISOLYTE M IN 5% DEXTROSE INJECTION ![Compare how all Medicare Part D PDP plans in PA cover ISOLYTE M IN 5% DEXTROSE INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Injectable Drugs |
25% | 25% | None |
ISOLYTE P IN 5% DEXTROSE INJECTION ![Compare how all Medicare Part D PDP plans in PA cover ISOLYTE P IN 5% DEXTROSE INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Injectable Drugs |
25% | 25% | None |
ISOLYTE S IN 5% DEXTROSE INJECTION ![Compare how all Medicare Part D PDP plans in PA cover ISOLYTE S IN 5% DEXTROSE INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Injectable Drugs |
25% | 25% | None |
ISOLYTE S IV SOLUTION-EXCEL ![Compare how all Medicare Part D PDP plans in PA cover ISOLYTE S IV SOLUTION-EXCEL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Injectable Drugs |
25% | 25% | None |
ISONIAZID 100MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover ISONIAZID 100MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
ISONIAZID 50MG/5ML SYRUP ![Compare how all Medicare Part D PDP plans in PA cover ISONIAZID 50MG/5ML SYRUP.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISONIAZID INJ 100MG/ML ![Compare how all Medicare Part D PDP plans in PA cover ISONIAZID INJ 100MG/ML.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Injectable Drugs |
25% | 25% | None |
ISONIAZID TABLETS ![Compare how all Medicare Part D PDP plans in PA cover ISONIAZID TABLETS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
ISOPTO CARPINE 10mg/mL 15 mL in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in PA cover ISOPTO CARPINE 10mg/mL 15 mL in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Preferred Brand Drugs |
$44.00 | $88.00 | None |
ISOPTO CARPINE 20mg/mL 15 mL in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in PA cover ISOPTO CARPINE 20mg/mL 15 mL in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Preferred Brand Drugs |
$44.00 | $88.00 | None |
ISOPTO CARPINE 40mg/mL 15 mL in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in PA cover ISOPTO CARPINE 40mg/mL 15 mL in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Preferred Brand Drugs |
$44.00 | $88.00 | None |
ISORDIL 40MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover ISORDIL 40MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Preferred Brand Drugs |
$44.00 | $88.00 | None |
Isosorbide Dinitrate 5mg/1 100 TABLET in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in PA cover Isosorbide Dinitrate 5mg/1 100 TABLET in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
ISOSORBIDE DINITRATE TABLETS ![Compare how all Medicare Part D PDP plans in PA cover ISOSORBIDE DINITRATE TABLETS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
ISOSORBIDE DINITRATE TABLETS EXTENDED RELEASE ![Compare how all Medicare Part D PDP plans in PA cover ISOSORBIDE DINITRATE TABLETS EXTENDED RELEASE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
ISOSORBIDE DN 10MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover ISOSORBIDE DN 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
ISOSORBIDE DN 2.5 MG TAB SL ![Compare how all Medicare Part D PDP plans in PA cover ISOSORBIDE DN 2.5 MG TAB SL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISOSORBIDE DN 20MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover ISOSORBIDE DN 20MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
ISOSORBIDE DN 30MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover ISOSORBIDE DN 30MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
ISOSORBIDE MN 10MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover ISOSORBIDE MN 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
ISOSORBIDE MONONITRATE 20MG TABLET ![Compare how all Medicare Part D PDP plans in PA cover ISOSORBIDE MONONITRATE 20MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
ISOSORBIDE MONONITRATE ER TABLET 120MG (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover ISOSORBIDE MONONITRATE ER TABLET 120MG (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
ISOSORBIDE MONONITRATE ER TABLET 30MG (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover ISOSORBIDE MONONITRATE ER TABLET 30MG (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
ISOSORBIDE MONONITRATE TABLETS EXTENDED RELEASE 60MG 100 TABLETS BOT ![Compare how all Medicare Part D PDP plans in PA cover ISOSORBIDE MONONITRATE TABLETS EXTENDED RELEASE 60MG 100 TABLETS BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
ISOTON GENTAMICIN 60MG/100ML ![Compare how all Medicare Part D PDP plans in PA cover ISOTON GENTAMICIN 60MG/100ML.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Injectable Drugs |
25% | 25% | None |
ISOTON GENTAMICIN 80MG/100ML ![Compare how all Medicare Part D PDP plans in PA cover ISOTON GENTAMICIN 80MG/100ML.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Injectable Drugs |
25% | 25% | None |
ISRADIPINE CAPSULES 2.5MG (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover ISRADIPINE CAPSULES 2.5MG (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
ISRADIPINE CAPSULES 5MG (100 CT) ![Compare how all Medicare Part D PDP plans in PA cover ISRADIPINE CAPSULES 5MG (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISTALOL 0.5% EYE DROPS ![Compare how all Medicare Part D PDP plans in PA cover ISTALOL 0.5% EYE DROPS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Preferred Brand Drugs |
$44.00 | $88.00 | None |
ISTODAX KIT ![Compare how all Medicare Part D PDP plans in PA cover ISTODAX KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier Drugs |
25% | 25% | None |
ITRACONAZOLE 100MG CAPSULE ![Compare how all Medicare Part D PDP plans in PA cover ITRACONAZOLE 100MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Preferred Generic Drugs |
$4.00 | $8.00 | None |
IXEMPRA 45 MG KIT ![Compare how all Medicare Part D PDP plans in PA cover IXEMPRA 45 MG KIT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier Drugs |
25% | 25% | None |
IXIARO JAPANESE ENCEPHALITIS VACCINE 6MCG/.5ML ![Compare how all Medicare Part D PDP plans in PA cover IXIARO JAPANESE ENCEPHALITIS VACCINE 6MCG/.5ML.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Injectable Drugs |
25% | 25% | None |