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EnvisionRxPlus Silver (PDP) (S7694-032-0)
Tier 1 (556)
Tier 2 (1128)
Tier 3 (355)
Tier 4 (327)
Tier 5 (252)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
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Has Quantity Limits:
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Cick on the first letter of your drug name to browse the formulary:

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M N O P Q R S T U V W X Y Z 0-9 
2012 Medicare Part D Plan Formulary Information
EnvisionRxPlus Silver (PDP) (S7694-032-0)
Benefit Details           
The EnvisionRxPlus Silver (PDP) (S7694-032-0)
Formulary Drugs Starting with the Letter I

in CMS PDP Region 32 which includes: CA
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 473 mL in 1 BOTTLE   1 Preferred Generic Drugs 25%N/ANone
IBUPROFEN 600mg/1 500 TABLET in 1 BOTTLE   1 Preferred Generic Drugs 25%N/ANone
IBUPROFEN 800 MG TABLET   1 Preferred Generic Drugs 25%N/ANone
IBUPROFEN TABLETS   1 Preferred Generic Drugs 25%N/ANone
IMIPRAMINE HCL 10MG TABLET (100 CT)   2 Non-Preferred Generic Drugs 25%N/ANone
IMIPRAMINE HCL 25MG TABLET (100 CT)   2 Non-Preferred Generic Drugs 25%N/ANone
IMIPRAMINE HCL 50MG TABLET (100 CT)   2 Non-Preferred Generic Drugs 25%N/ANone
IMIPRAMINE PAMOATE CAPSULES   2 Non-Preferred Generic Drugs 25%N/ANone
IMIPRAMINE PAMOATE CAPSULES   2 Non-Preferred Generic Drugs 25%N/ANone
IMIPRAMINE PAMOATE CAPSULES   2 Non-Preferred Generic Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
IMIPRAMINE PAMOATE CAPSULES   2 Non-Preferred Generic Drugs 25%N/ANone
IMIQUIMOD 5% CREAM   2 Non-Preferred Generic Drugs 25%N/ANone
IMOVAX RABIES VACCINE 2.5UNT/ML   4 Non-Preferred Brand Drugs 25%N/AP
Incivek 375mg/1 4 BOX in 1 CARTON / 7 BLISTER PACK in 1 BOX / 6 TABLET, FILM COATED in 1 BLISTER PA   5 Specialty Tier Drugs 25%N/AP
Increlex 40mg/4mL 1 VIAL, MULTI-DOSE in 1 CARTON / 4 mL in 1 VIAL, MULTI-DOSE   5 Specialty Tier Drugs 25%N/ANone
Indapamide 1.25mg/1 100 TABLET, FILM COATED in 1 BOTTLE, PLASTIC   1 Preferred Generic Drugs 25%N/ANone
INDAPAMIDE 2.5MG TABLET USP (1000 CT)   1 Preferred Generic Drugs 25%N/ANone
INDOMETHACIN 50MG CAPSULE   2 Non-Preferred Generic Drugs 25%N/ANone
INDOMETHACIN 75MG CAPSULE SA   2 Non-Preferred Generic Drugs 25%N/ANone
INDOMETHACIN CAPSULES   1 Preferred Generic Drugs 25%N/ANone
INLYTA 1 MG TABLET   5 Specialty Tier Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
INLYTA 5 MG TABLET   5 Specialty Tier Drugs 25%N/ANone
INSULIN, GLULISINE, HUMAN 100 UNT/ML PREFILLED SYRINGE [APIDRA] 3 ML   3 Preferred Brand Drugs 25%N/ANone
INTELENCE 100MG TABLET   5 Specialty Tier Drugs 25%N/ANone
Intelence 200mg/1   5 Specialty Tier Drugs 25%N/ANone
INTRALIPID 20% IV FAT EMUL   1 Preferred Generic Drugs 25%N/ANone
INTRON A 10MMU VIAL   4 Non-Preferred Brand Drugs 25%N/ANone
Intron A 11.6ug/0.2mL 1 VIAL, MULTI-DOSE in 1 CARTON / 1.5 mL in 1 VIAL, MULTI-DOSE   4 Non-Preferred Brand Drugs 25%N/ANone
Intron A 19.2ug/0.2mL 1 VIAL, MULTI-DOSE in 1 CARTON / 1.5 mL in 1 VIAL, MULTI-DOSE   5 Specialty Tier Drugs 25%N/ANone
Intron A 38.4ug/0.2mL 1 VIAL, MULTI-DOSE in 1 CARTON / 1.5 mL in 1 VIAL, MULTI-DOSE   5 Specialty Tier Drugs 25%N/ANone
INTRON A 6MMU/ML VIAL   4 Non-Preferred Brand Drugs 25%N/ANone
INVANZ 1GM VIAL   4 Non-Preferred Brand Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
INVEGA 3MG TABLET SR OSMOTIC PUSH 24HR   4 Non-Preferred Brand Drugs 25%N/ANone
INVEGA 6MG TABLET SR OSMOTIC PUSH 24HR   4 Non-Preferred Brand Drugs 25%N/ANone
INVEGA 9MG TABLET SR OSMOTIC PUSH 24HR   4 Non-Preferred Brand Drugs 25%N/ANone
INVEGA ER 1.5mg/ 30 TABLET BOTTLE   4 Non-Preferred Brand Drugs 25%N/ANone
Invega Sustenna 117 mg/0.75mL Prefilled Syringe   5 Specialty Tier Drugs 25%N/ANone
Invega Sustenna 156 mg/mL Prefilled Syringe   5 Specialty Tier Drugs 25%N/ANone
Invega Sustenna 234 mg/1.5mL Prefilled Syringe   4 Non-Preferred Brand Drugs 25%N/ANone
Invega Sustenna 39 mg/0.25mL Prefilled Syringe   4 Non-Preferred Brand Drugs 25%N/ANone
Invega Sustenna 78 mg/0.5mL Prefilled Syringe   4 Non-Preferred Brand Drugs 25%N/ANone
INVIRASE 200MG CAPSULE   4 Non-Preferred Brand Drugs 25%N/ANone
INVIRASE 500MG TABLET   5 Specialty Tier Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
IPOL VIAL 40;8;32; UNT   4 Non-Preferred Brand Drugs 25%N/ANone
Ipratropium Bromide 42ug/1 1 BOTTLE, SPRAY in 1 CARTON / 165 SPRAY, METERED in 1 BOTTLE, SPRAY   2 Non-Preferred Generic Drugs 25%N/ANone
Ipratropium Bromide 500ug/2.5mL 30 POUCH in 1 CARTON / 1 VIAL in 1 POUCH / 2.5 mL in 1 VIAL   1 Preferred Generic Drugs 25%N/AP
IPRATROPIUM BROMIDE and ALBUTEROL SULFATE 2.5; 0.5mg/3mL; mg/3mL 12 POUCH in 1 CARTON / 5 VIAL, PLA   2 Non-Preferred Generic Drugs 25%N/AP
IPRATROPIUM BROMIDE NASAL SPRAY   2 Non-Preferred Generic Drugs 25%N/ANone
IRESSA 250MG TABLET   5 Specialty Tier Drugs 25%N/ANone
ISENTRESS 400MG TABLET   5 Specialty Tier Drugs 25%N/ANone
ISOCHRON 40MG TABLET SA   2 Non-Preferred Generic Drugs 25%N/ANone
ISOLYTE H IN 5% DEXTROSE   2 Non-Preferred Generic Drugs 25%N/ANone
ISOLYTE M IN 5% DEXTROSE INJECTION   2 Non-Preferred Generic Drugs 25%N/ANone
ISOLYTE P IN 5% DEXTROSE INJECTION   4 Non-Preferred Brand Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ISOLYTE S IN 5% DEXTROSE INJECTION   4 Non-Preferred Brand Drugs 25%N/ANone
ISOLYTE S IV SOLUTION-EXCEL   4 Non-Preferred Brand Drugs 25%N/ANone
ISONARIF 300-150MG CAPSULE   1 Preferred Generic Drugs 25%N/ANone
ISONIAZID 100MG TABLET   1 Preferred Generic Drugs 25%N/ANone
ISONIAZID 50MG/5ML SYRUP   1 Preferred Generic Drugs 25%N/ANone
ISONIAZID INJ 100MG/ML   1 Preferred Generic Drugs 25%N/ANone
ISONIAZID TABLETS   1 Preferred Generic Drugs 25%N/ANone
Isosorbide Dinitrate 5mg/1 100 TABLET in 1 BOTTLE   1 Preferred Generic Drugs 25%N/ANone
ISOSORBIDE DINITRATE TABLETS   2 Non-Preferred Generic Drugs 25%N/ANone
ISOSORBIDE DINITRATE TABLETS EXTENDED RELEASE   2 Non-Preferred Generic Drugs 25%N/ANone
ISOSORBIDE DN 10MG TABLET   2 Non-Preferred Generic Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ISOSORBIDE DN 2.5 MG TAB SL   2 Non-Preferred Generic Drugs 25%N/ANone
ISOSORBIDE DN 20MG TABLET   2 Non-Preferred Generic Drugs 25%N/ANone
ISOSORBIDE DN 30MG TABLET   2 Non-Preferred Generic Drugs 25%N/ANone
ISOSORBIDE MN 10MG TABLET   2 Non-Preferred Generic Drugs 25%N/ANone
ISOSORBIDE MONONITRATE 20MG TABLET   2 Non-Preferred Generic Drugs 25%N/ANone
ISOSORBIDE MONONITRATE ER TABLET 120MG (100 CT)   2 Non-Preferred Generic Drugs 25%N/ANone
ISOSORBIDE MONONITRATE ER TABLET 30MG (100 CT)   1 Preferred Generic Drugs 25%N/ANone
ISOSORBIDE MONONITRATE TABLETS EXTENDED RELEASE 60MG 100 TABLETS BOT   1 Preferred Generic Drugs 25%N/ANone
ISRADIPINE CAPSULES 2.5MG (100 CT)   1 Preferred Generic Drugs 25%N/ANone
ISRADIPINE CAPSULES 5MG (100 CT)   1 Preferred Generic Drugs 25%N/ANone
ISTODAX KIT   5 Specialty Tier Drugs 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ITRACONAZOLE 100MG CAPSULE   2 Non-Preferred Generic Drugs 25%N/ANone
IXIARO JAPANESE ENCEPHALITIS VACCINE 6MCG/.5ML   4 Non-Preferred Brand Drugs 25%N/ANone

Chart Legend:

Below are a few notes to help you understand the above 2012 Medicare Part D EnvisionRxPlus Silver (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 $320 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 $2930) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2012 Humana Walmart-Preferred Rx Plan the cost-sharing 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 September 2012 )

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.