2012 Medicare Part D Plan Formulary Information |
BlueRx Complete (PDP) (S5593-003-0)
Benefit Details
|
The BlueRx Complete (PDP) (S5593-003-0) 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 |
1 |
Generic Drugs |
$7.00 | $17.50 | P |
Ibuprofen 100mg/5mL 473 mL in 1 BOTTLE |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
IBUPROFEN 600mg/1 500 TABLET in 1 BOTTLE |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
IBUPROFEN 800 MG TABLET |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
IBUPROFEN TABLETS |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
IDAMYCIN PFS 1MG/ML VIAL |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |
IDARUBICIN HCL 1MG/ML VIAL |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
IFEX INJECTION 3GM/ML 3GM VIALSD |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |
IFOSFAMIDE FOR INFECTION 1 GM |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
IFOSFAMIDE/MESNA KIT 1G/20ML / 1MG/ |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IFOSFAMIDE/MESNA KIT 1G/20ML / 1MG/ |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |
Ilaris 150mg/mL 1 VIAL, SINGLE-USE in 1 CARTON / 1 mL in 1 VIAL, SINGLE-USE |
4 |
Specialty Tier Drugs |
33% | 33% | P |
IMIPENEM-CILASTATIN 250 MG VL |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
IMIPENEM-CILASTATIN 500 MG VL |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
IMIPRAMINE HCL 10MG TABLET (100 CT) |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
IMIPRAMINE HCL 25MG TABLET (100 CT) |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
IMIPRAMINE HCL 50MG TABLET (100 CT) |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
IMIPRAMINE PAMOATE CAPSULES |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
IMIPRAMINE PAMOATE CAPSULES |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
IMIPRAMINE PAMOATE CAPSULES |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
IMIPRAMINE PAMOATE CAPSULES |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IMIQUIMOD 5% CREAM |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
IMITREX 100MG TABLET |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | Q:9 /25Days |
IMITREX 20MG NASAL SPRAY |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | Q:9 /25Days |
IMITREX 25MG TABLET |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | Q:9 /25Days |
IMITREX 4MG/0.5ML KIT REFILL |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | Q:12 /25Days |
IMITREX 50MG TABLET |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | Q:9 /25Days |
IMITREX 5MG NASAL SPRAY |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | Q:9 /25Days |
IMITREX 6MG/0.5ML SYRNG KIT |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | Q:12 /25Days |
IMITREX 6MG/0.5ML VIAL |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | Q:9 /25Days |
IMOVAX RABIES VACCINE 2.5UNT/ML |
2 |
Preferred Brand Drugs |
$40.00 | $100.00 | None |
IMURAN 50MG TABLET |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | 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 |
Specialty Tier Drugs |
33% | 33% | P |
Increlex 40mg/4mL 1 VIAL, MULTI-DOSE in 1 CARTON / 4 mL in 1 VIAL, MULTI-DOSE |
4 |
Specialty Tier Drugs |
33% | 33% | P |
Indapamide 1.25mg/1 100 TABLET, FILM COATED in 1 BOTTLE, PLASTIC |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
INDAPAMIDE 2.5MG TABLET USP (1000 CT) |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
INDERAL LA LONG ACTING CAPSULES 120MG 100 BOT |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |
INDERAL LA LONG ACTING CAPSULES 160MG 100 BOT |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |
INDERAL LA LONG ACTING CAPSULES 60MG 100 BOT |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |
INDERAL LA LONG ACTING CAPSULES 80MG 100 BOT |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |
INDOCIN ORAL SUSPENSION 25MG/5ML 237 ML BOT |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |
INDOMETHACIN 50MG CAPSULE |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
INDOMETHACIN 75MG CAPSULE SA |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INDOMETHACIN CAPSULES |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
INFERGEN INJECTION |
4 |
Specialty Tier Drugs |
33% | 33% | P |
INFUMORPH 10MG/ML AMPUL P/F |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |
INFUMORPH 25MG/ML AMPUL P/F |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |
INLYTA 1 MG TABLET |
4 |
Specialty Tier Drugs |
33% | 33% | P |
INLYTA 5 MG TABLET |
4 |
Specialty Tier Drugs |
33% | 33% | P |
INNOHEP 20000[iU]/mL 1 VIAL, MULTI-DOSE in 1 CARTON / 2 mL in 1 VIAL, MULTI-DOSE |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |
INNOPRAN CAPSULES EXTENDED RELEASE 120 MG |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |
INNOPRAN CAPSULES EXTENDED RELEASE 80 MG |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |
INSPRA 25MG TABLET |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |
Inspra 50mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | 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 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |
INTELENCE 100MG TABLET |
4 |
Specialty Tier Drugs |
33% | 33% | None |
Intelence 200mg/1 |
4 |
Specialty Tier Drugs |
33% | 33% | None |
INTERMEZZO 1.75 MG TAB SUBLING |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |
INTERMEZZO 3.5 MG TAB SUBLING |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |
INTRALIPID 20% IV FAT EMUL |
1 |
Generic Drugs |
$7.00 | $17.50 | P |
INTRALIPID PHARMACY BULK PACKAGE FAT EMULSION 1.7-1.2-30GM 500ML BAG |
2 |
Preferred Brand Drugs |
$40.00 | $100.00 | P |
INTRON A 10MMU VIAL |
2 |
Preferred Brand Drugs |
$40.00 | $100.00 | P |
Intron A 11.6ug/0.2mL 1 VIAL, MULTI-DOSE in 1 CARTON / 1.5 mL in 1 VIAL, MULTI-DOSE |
2 |
Preferred Brand Drugs |
$40.00 | $100.00 | P |
Intron A 19.2ug/0.2mL 1 VIAL, MULTI-DOSE in 1 CARTON / 1.5 mL in 1 VIAL, MULTI-DOSE |
4 |
Specialty Tier Drugs |
33% | 33% | P |
Intron A 38.4ug/0.2mL 1 VIAL, MULTI-DOSE in 1 CARTON / 1.5 mL in 1 VIAL, MULTI-DOSE |
2 |
Preferred Brand Drugs |
$40.00 | $100.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INTRON A 6MMU/ML VIAL |
2 |
Preferred Brand Drugs |
$40.00 | $100.00 | P |
Introvale 3 CARTON in 1 BOX / 1 KIT in 1 CARTON |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
Intuniv 1mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | P |
Intuniv 2mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | P |
Intuniv 3mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | P |
Intuniv 4mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | P |
INVANZ 1GM VIAL |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |
INVEGA 3MG TABLET SR OSMOTIC PUSH 24HR |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |
INVEGA 6MG TABLET SR OSMOTIC PUSH 24HR |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |
INVEGA 9MG TABLET SR OSMOTIC PUSH 24HR |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |
INVEGA ER 1.5mg/ 30 TABLET BOTTLE |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |
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 |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |
Invega Sustenna 156 mg/mL Prefilled Syringe |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |
Invega Sustenna 234 mg/1.5mL Prefilled Syringe |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |
Invega Sustenna 39 mg/0.25mL Prefilled Syringe |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |
Invega Sustenna 78 mg/0.5mL Prefilled Syringe |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |
INVIRASE 200MG CAPSULE |
4 |
Specialty Tier Drugs |
33% | 33% | None |
INVIRASE 500MG TABLET |
4 |
Specialty Tier Drugs |
33% | 33% | None |
IONOSOL B-D5W IV SOLUTION |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | P |
IONOSOL MB-D5W IV SOLUTION |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | P |
IONOSOL T-D5W IV SOLUTION |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | P |
IOPIDINE 0.5% EYE DROPS |
2 |
Preferred Brand Drugs |
$40.00 | $100.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IOPIDINE 1% EYE DROPS |
2 |
Preferred Brand Drugs |
$40.00 | $100.00 | None |
IPOL VIAL 40;8;32; UNT |
2 |
Preferred Brand Drugs |
$40.00 | $100.00 | None |
Ipratropium Bromide 42ug/1 1 BOTTLE, SPRAY in 1 CARTON / 165 SPRAY, METERED in 1 BOTTLE, SPRAY |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
Ipratropium Bromide 500ug/2.5mL 30 POUCH in 1 CARTON / 1 VIAL in 1 POUCH / 2.5 mL in 1 VIAL |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
IPRATROPIUM BROMIDE and ALBUTEROL SULFATE 2.5; 0.5mg/3mL; mg/3mL 12 POUCH in 1 CARTON / 5 VIAL, PLA |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
IPRATROPIUM BROMIDE NASAL SPRAY |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
IQUIX 1.5% DROPS |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |
IRBESARTAN 150 MG TABLET |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
IRBESARTAN 300 MG TABLET |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
IRBESARTAN 75 MG TABLET |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
IRBESARTAN-HCTZ 150-12.5 MG TB |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IRBESARTAN-HCTZ 300-12.5 MG TB |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
IRESSA 250MG TABLET |
4 |
Specialty Tier Drugs |
33% | 33% | P |
IRINOTECAN HCL INJECTION 20MG |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
ISENTRESS 400MG TABLET |
4 |
Specialty Tier Drugs |
33% | 33% | None |
ISOCHRON 40MG TABLET SA |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |
ISOLYTE H IN 5% DEXTROSE |
2 |
Preferred Brand Drugs |
$40.00 | $100.00 | P |
ISOLYTE M IN 5% DEXTROSE INJECTION |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | P |
ISOLYTE P IN 5% DEXTROSE INJECTION |
2 |
Preferred Brand Drugs |
$40.00 | $100.00 | P |
ISOLYTE S IN 5% DEXTROSE INJECTION |
2 |
Preferred Brand Drugs |
$40.00 | $100.00 | P |
ISOLYTE S IV SOLUTION-EXCEL |
2 |
Preferred Brand Drugs |
$40.00 | $100.00 | P |
ISONARIF 300-150MG CAPSULE |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISONIAZID 100MG TABLET |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
ISONIAZID 50MG/5ML SYRUP |
2 |
Preferred Brand Drugs |
$40.00 | $100.00 | None |
ISONIAZID INJ 100MG/ML |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
ISONIAZID TABLETS |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
ISOPTIN SR 120MG |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |
ISOPTIN SR 180MG |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |
ISOPTIN SR 240MG (500 Count) |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |
ISOPTO CARPINE 10mg/mL 15 mL in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |
ISOPTO CARPINE 20mg/mL 15 mL in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |
ISOPTO CARPINE 40mg/mL 15 mL in 1 BOTTLE |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |
ISORDIL 40MG TABLET |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISORDIL TABLETS 5MG 100 BOT |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |
Isosorbide Dinitrate 5mg/1 100 TABLET in 1 BOTTLE |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
ISOSORBIDE DINITRATE TABLETS |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
ISOSORBIDE DINITRATE TABLETS EXTENDED RELEASE |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
ISOSORBIDE DN 10MG TABLET |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
ISOSORBIDE DN 2.5 MG TAB SL |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
ISOSORBIDE DN 20MG TABLET |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
ISOSORBIDE DN 30MG TABLET |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
ISOSORBIDE MN 10MG TABLET |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
ISOSORBIDE MONONITRATE 20 MG ORAL TABLET [MONOKET] |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |
ISOSORBIDE MONONITRATE 20MG TABLET |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISOSORBIDE MONONITRATE ER TABLET 120MG (100 CT) |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
ISOSORBIDE MONONITRATE ER TABLET 30MG (100 CT) |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
ISOSORBIDE MONONITRATE TABLETS EXTENDED RELEASE 60MG 100 TABLETS BOT |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
ISOTON GENTAMICIN 60MG/100ML |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
ISOTON GENTAMICIN 80MG/100ML |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
ISRADIPINE CAPSULES 2.5MG (100 CT) |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
ISRADIPINE CAPSULES 5MG (100 CT) |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
ISTALOL 0.5% EYE DROPS |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |
ISTODAX KIT |
4 |
Specialty Tier Drugs |
33% | 33% | None |
ITRACONAZOLE 100MG CAPSULE |
1 |
Generic Drugs |
$7.00 | $17.50 | None |
IXEMPRA 45 MG KIT |
4 |
Specialty Tier Drugs |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IXIARO JAPANESE ENCEPHALITIS VACCINE 6MCG/.5ML |
3 |
Non-Preferred Brand Drugs |
$70.00 | $175.00 | None |