Q1Medicare.com 2013 Medicare Part D or Medicare Advantage Plan Formulary Browser

2013 Medicare Part D Plan Formulary Information
First Health Part D Essentials (PDP) (S5569-007-0) Benefit Details
The First Health Part D Essentials (PDP) (S5569-007-0) Formulary Drugs Starting with the Letter I in CMS PDP Region 3 which includes: NY
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
IBANDRONATE SODIUM 150 MG TAB	3	Non-Preferred Brand Drugs	30%	30%	Q:1 /30Days
IBUPROFEN 600mg/1 500 TABLET BOTTLE	1	Preferred Generic Drugs	$1.15	$3.45	None
IBUPROFEN 800 MG TABLET	1	Preferred Generic Drugs	$1.15	$3.45	None
IBUPROFEN TABLETS	1	Preferred Generic Drugs	$1.15	$3.45	None
ICLUSIG 15 MG TABLET	3	Non-Preferred Brand Drugs	30%	30%	P Q:60 /30Days
ICLUSIG 45 MG TABLET	3	Non-Preferred Brand Drugs	30%	30%	P Q:30 /30Days
Ilaris 150mg/mL 1 VIAL, SINGLE-USE in 1 CARTON / 1 mL in 1 VIAL, SINGLE-USE	3	Non-Preferred Brand Drugs	30%	30%	P Q:1 /56Days
ILEVRO 0.3% OPHTH DROPS	3	Non-Preferred Brand Drugs	30%	30%	Q:2 /30Days
IMIPENEM-CILASTATIN 250 MG VL	3	Non-Preferred Brand Drugs	30%	30%	None
IMIPENEM-CILASTATIN 500 MG VL	3	Non-Preferred Brand Drugs	30%	30%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
IMIPRAMINE HCL 10MG TABLET (100 CT)	1	Preferred Generic Drugs	$1.15	$3.45	None
IMIPRAMINE HCL 25MG TABLET (100 CT)	1	Preferred Generic Drugs	$1.15	$3.45	None
IMIPRAMINE HCL 50MG TABLET (100 CT)	1	Preferred Generic Drugs	$1.15	$3.45	None
IMIQUIMOD 5% CREAM	3	Non-Preferred Brand Drugs	30%	30%	Q:12 /30Days
IMOVAX RABIES VACCINE	3	Non-Preferred Brand Drugs	30%	30%	None
Incivek 375mg/1 4 BOX in 1 CARTON / 7 BLISTER PACK in 1 BOX / 6 FILM COATED TABLETS in BLISTER PA	3	Non-Preferred Brand Drugs	30%	30%	P Q:180 /30Days
Increlex 40mg/4mL 1 VIAL, MULTI-DOSE in 1 CARTON / 4 mL in 1 VIAL, MULTI-DOSE	3	Non-Preferred Brand Drugs	30%	30%	P
Indapamide 1.25mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC	1	Preferred Generic Drugs	$1.15	$3.45	None
INDAPAMIDE 2.5MG TABLET USP (1000 CT)	1	Preferred Generic Drugs	$1.15	$3.45	None
INDOCIN ORAL SUSPENSION 25MG/5ML 237 ML BOT	3	Non-Preferred Brand Drugs	30%	30%	None
INDOMETHACIN 50 MG CAPSULE	1	Preferred Generic Drugs	$1.15	$3.45	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
INDOMETHACIN 75MG CAPSULE SA	3	Non-Preferred Brand Drugs	30%	30%	None
INDOMETHACIN CAPSULES	1	Preferred Generic Drugs	$1.15	$3.45	None
INLYTA 1 MG TABLET	3	Non-Preferred Brand Drugs	30%	30%	P Q:240 /30Days
INLYTA 5 MG TABLET	3	Non-Preferred Brand Drugs	30%	30%	P Q:120 /30Days
INNOPRAN CAPSULES EXTENDED RELEASE 120 MG	3	Non-Preferred Brand Drugs	30%	30%	Q:60 /30Days
INNOPRAN CAPSULES EXTENDED RELEASE 80 MG	3	Non-Preferred Brand Drugs	30%	30%	Q:30 /30Days
INTELENCE 100MG TABLET	3	Non-Preferred Brand Drugs	30%	30%	Q:120 /30Days
Intelence 200mg/1	3	Non-Preferred Brand Drugs	30%	30%	Q:60 /30Days
INTRALIPID 20% IV FAT EMUL	3	Non-Preferred Brand Drugs	30%	30%	P
INTRALIPID PHARMACY BULK PACKAGE FAT EMULSION 1.7-1.2-30GM 500ML BAG	3	Non-Preferred Brand Drugs	30%	30%	P
INTRON A 10MMU VIAL	3	Non-Preferred Brand Drugs	30%	30%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
INTRON A 6MMU/ML VIAL	3	Non-Preferred Brand Drugs	30%	30%	P
Introvale 3 CARTON in 1 BOX / 1 KIT in 1 CARTON	3	Non-Preferred Brand Drugs	30%	30%	None
Intuniv 1mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE	3	Non-Preferred Brand Drugs	30%	30%	P Q:30 /30Days
Intuniv 2mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE	3	Non-Preferred Brand Drugs	30%	30%	P Q:30 /30Days
Intuniv 3mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE	3	Non-Preferred Brand Drugs	30%	30%	P Q:30 /30Days
Intuniv 4mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE	3	Non-Preferred Brand Drugs	30%	30%	P Q:30 /30Days
INVANZ 1GM VIAL	3	Non-Preferred Brand Drugs	30%	30%	None
INVEGA 3MG TABLET SR OSMOTIC PUSH 24HR	3	Non-Preferred Brand Drugs	30%	30%	P Q:30 /30Days
INVEGA 6MG TABLET SR OSMOTIC PUSH 24HR	3	Non-Preferred Brand Drugs	30%	30%	P Q:60 /30Days
INVEGA 9MG TABLET SR OSMOTIC PUSH 24HR	3	Non-Preferred Brand Drugs	30%	30%	P Q:30 /30Days
INVEGA ER 1.5mg/ 30 TABLET BOTTLE	3	Non-Preferred Brand Drugs	30%	30%	P Q:30 /30Days
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	30%	30%	Q:1 /28Days
Invega Sustenna 156 mg/mL Prefilled Syringe	3	Non-Preferred Brand Drugs	30%	30%	Q:1 /28Days
Invega Sustenna 234 mg/1.5mL Prefilled Syringe	3	Non-Preferred Brand Drugs	30%	30%	Q:2 /28Days
Invega Sustenna 39 mg/0.25mL Prefilled Syringe	3	Non-Preferred Brand Drugs	30%	30%	None
Invega Sustenna 78 mg/0.5mL Prefilled Syringe	3	Non-Preferred Brand Drugs	30%	30%	Q:1 /28Days
INVIRASE 200MG CAPSULE	3	Non-Preferred Brand Drugs	30%	30%	None
INVIRASE 500MG TABLET	3	Non-Preferred Brand Drugs	30%	30%	None
IPOL VIAL 40;8;32; UNT	2	Preferred Brand Drugs	20%	20%	None
Ipratropium Bromide 0.5mg/2.5mL 1 POUCH in 1 CARTON / 30 VIAL in 1 POUCH / 2.5 mL in 1 VIAL	1	Preferred Generic Drugs	$1.15	$3.45	P
Ipratropium Bromide 42ug/1 1 BOTTLE, SPRAY in 1 CARTON / 165 SPRAY, METERED in 1 BOTTLE, SPRAY	1	Preferred Generic Drugs	$1.15	$3.45	None
IPRATROPIUM BROMIDE and ALBUTEROL SULFATE 2.5; 0.5mg/3mL; mg/3mL 6 POUCH in 1 CARTON / 5 VIAL, PLAS	3	Non-Preferred Brand Drugs	30%	30%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
IPRATROPIUM BROMIDE NASAL SPRAY	1	Preferred Generic Drugs	$1.15	$3.45	None
IRBESARTAN 150 MG TABLET	1	Preferred Generic Drugs	$1.15	$3.45	Q:30 /30Days
IRBESARTAN 300 MG TABLET	1	Preferred Generic Drugs	$1.15	$3.45	Q:30 /30Days
IRBESARTAN 75 MG TABLET	1	Preferred Generic Drugs	$1.15	$3.45	Q:30 /30Days
Irbesartan-Hctz 150-12.5 mg tb	1	Preferred Generic Drugs	$1.15	$3.45	Q:30 /30Days
IRBESARTAN-HCTZ 300-12.5 MG TB	1	Preferred Generic Drugs	$1.15	$3.45	Q:30 /30Days
ISENTRESS 100 MG TABLET CHEW	3	Non-Preferred Brand Drugs	30%	30%	Q:180 /30Days
ISENTRESS 25 MG TABLET CHEW	3	Non-Preferred Brand Drugs	30%	30%	Q:660 /30Days
ISENTRESS 400MG TABLET	3	Non-Preferred Brand Drugs	30%	30%	Q:120 /30Days
ISONIAZID 100MG TABLET	1	Preferred Generic Drugs	$1.15	$3.45	None
ISONIAZID 50MG/5ML SYRUP	1	Preferred Generic Drugs	$1.15	$3.45	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ISONIAZID TABLETS	1	Preferred Generic Drugs	$1.15	$3.45	None
Isosorbide Dinitrate 5mg/1 100 TABLET BOTTLE	1	Preferred Generic Drugs	$1.15	$3.45	None
ISOSORBIDE DINITRATE TABLETS	1	Preferred Generic Drugs	$1.15	$3.45	None
ISOSORBIDE DINITRATE TABLETS EXTENDED RELEASE	1	Preferred Generic Drugs	$1.15	$3.45	None
ISOSORBIDE DN 10MG TABLET	1	Preferred Generic Drugs	$1.15	$3.45	None
ISOSORBIDE DN 2.5 MG TAB SL	1	Preferred Generic Drugs	$1.15	$3.45	None
ISOSORBIDE DN 20MG TABLET	1	Preferred Generic Drugs	$1.15	$3.45	None
ISOSORBIDE DN 30MG TABLET	1	Preferred Generic Drugs	$1.15	$3.45	None
ISOSORBIDE MN 10 MG TABLET	1	Preferred Generic Drugs	$1.15	$3.45	None
ISOSORBIDE MONONITRATE 20MG TABLET	1	Preferred Generic Drugs	$1.15	$3.45	None
ISOSORBIDE MONONITRATE ER TABLET 120MG (100 CT)	1	Preferred Generic Drugs	$1.15	$3.45	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)	1	Preferred Generic Drugs	$1.15	$3.45	None
ISOSORBIDE MONONITRATE TABLETS EXTENDED RELEASE 60MG 100 TABLETS BOT	1	Preferred Generic Drugs	$1.15	$3.45	None
ISOTON GENTAMICIN 80MG/100ML	1	Preferred Generic Drugs	$1.15	$3.45	None
ISRADIPINE CAPSULES 2.5MG (100 CT)	3	Non-Preferred Brand Drugs	30%	30%	None
ISRADIPINE CAPSULES 5MG (100 CT)	3	Non-Preferred Brand Drugs	30%	30%	None
ISTALOL 0.5% EYE DROPS	3	Non-Preferred Brand Drugs	30%	30%	None
ITRACONAZOLE 100MG CAPSULE	3	Non-Preferred Brand Drugs	30%	30%	P
IXEMPRA 45 MG KIT	3	Non-Preferred Brand Drugs	30%	30%	P
IXIARO JAPANESE ENCEPHALITIS VACCINE 6MCG/.5ML	3	Non-Preferred Brand Drugs	30%	30%	None

Chart Legend:

Below are a few notes to help you understand the above 2013 Medicare Part D First Health Part D Essentials (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 $325 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 $2970) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2013 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 October 2013 )

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.