2014 Medicare Part D Plan Formulary Information |
Senior Advantage Medicare Medi-Cal Plan North (HMO SNP) (H0524-030-0)
Benefit Details
|
The Senior Advantage Medicare Medi-Cal Plan North (HMO SNP) (H0524-030-0) Formulary Drugs Starting with the Letter I in ALAMEDA County, CA: CMS MA Region 24 which includes: CA Plan Monthly Premium: $9.50 Deductible: $0 |
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 3 MG/3 ML VIAL [Boniva] |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
IBANDRONATE SODIUM 150 MG TABLET [Boniva] |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | P |
Ibuprofen 100mg/5mL 473 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
IBUPROFEN 400MG TABLETS |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
IBUPROFEN 600mg/1 500 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
Ibuprofen 800 mg tablet |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
IDAMYCIN PFS 1MG/ML VIAL |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
IDARUBICIN HCL 1MG/ML VIAL |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
IFEX INJECTION 3GM/ML 3GM VIALSD |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
IFOSFAMIDE FOR INFECTION 1 GM |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Ilaris 150mg/mL 1 VIAL, SINGLE-USE per CARTON / 1 mL in 1 VIAL, SINGLE-USE |
5 |
Specialty Tier |
25% | 25% | None |
ILEVRO 0.3% OPHTH DROPS |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
IMBRUVICA 140 MG CAPSULE |
5 |
Specialty Tier |
25% | 25% | None |
IMIPENEM-CILASTATIN 250 MG VL |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
IMIPENEM-CILASTATIN 500 MG VL |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
IMIPRAMINE HCL 10MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
IMIPRAMINE HCL 25MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
IMIPRAMINE HCL 50MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
IMIPRAMINE PAMOATE 100MG CAPSULES |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
IMIPRAMINE PAMOATE 125MG CAPSULES |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
IMIPRAMINE PAMOATE 150MG CAPSULES |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IMIPRAMINE PAMOATE 75MG CAPSULES |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
IMIQUIMOD 5% CREAM |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
IMITREX 100MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
IMITREX 20MG NASAL SPRAY |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
IMITREX 25MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
IMITREX 4MG/0.5ML KIT REFILL |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
IMITREX 50MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
IMITREX 5MG NASAL SPRAY |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
IMITREX 6MG/0.5ML SYRNG KIT |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
IMITREX 6MG/0.5ML VIAL |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
IMOVAX RABIES VACCINE |
6 |
Vaccines |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IMURAN 50MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | P |
Incivek 375mg/1 4 BOX per CARTON / 7 BLISTER PACK in 1 BOX / 6 FILM COATED TABLETS in BLISTER PA |
5 |
Specialty Tier |
25% | 25% | None |
Increlex 40mg/4mL 1 VIAL, MULTI-DOSE per CARTON / 4 mL in 1 VIAL, MULTI-DOSE |
5 |
Specialty Tier |
25% | 25% | None |
Indapamide 1.25mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Preferred Generic |
$8.00 | $16.00 | None |
INDAPAMIDE 2.5MG TABLET USP (1000 CT) |
1 |
Preferred Generic |
$8.00 | $16.00 | None |
INDERAL LA LONG ACTING CAPSULES 120MG 100 BOT |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
INDERAL LA LONG ACTING CAPSULES 160MG 100 BOT |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
INDERAL LA LONG ACTING CAPSULES 60MG 100 BOT |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
INDERAL LA LONG ACTING CAPSULES 80MG 100 BOT |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
INDOCIN ORAL SUSPENSION 25MG/5ML 237 ML BOT |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
INDOMETHACIN 25MG CAPSULES |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INDOMETHACIN 50 MG CAPSULE |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
INDOMETHACIN 75MG CAPSULE SA |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
INFERGEN INJECTION |
5 |
Specialty Tier |
25% | 25% | None |
INLYTA 1 MG TABLET |
5 |
Specialty Tier |
25% | 25% | None |
INLYTA 5 MG TABLET |
5 |
Specialty Tier |
25% | 25% | None |
INNOPRAN CAPSULES EXTENDED RELEASE 120 MG |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
INNOPRAN XL 80 MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
INSPRA 25MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Inspra 50mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
INTELENCE 100MG TABLET |
5 |
Specialty Tier |
25% | 25% | None |
Intelence 200mg/1 |
5 |
Specialty Tier |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INTELENCE 25 MG TABLET |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
INTERMEZZO 1.75 MG TAB SUBLING |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
INTERMEZZO 3.5 MG TAB SUBLING |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
INTRALIPID 20% IV FAT EMUL |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
INTRALIPID PHARMACY BULK PACKAGE FAT EMULSION 1.7-1.2-30GM 500ML BAG |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
INTRON A 10MMU VIAL |
5 |
Specialty Tier |
25% | 25% | None |
INTRON A 6MMU/ML VIAL |
5 |
Specialty Tier |
25% | 25% | None |
Introvale 3 CARTON in 1 BOX / 1 KIT per CARTON |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
Intuniv 1mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Intuniv 2mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Intuniv 3mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Intuniv 4mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
INVANZ 1GM VIAL |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
INVEGA 3MG TABLET SR OSMOTIC PUSH 24HR |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
INVEGA 6MG TABLET SR OSMOTIC PUSH 24HR |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
INVEGA 9MG TABLET SR OSMOTIC PUSH 24HR |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
INVEGA ER 1.5mg/ 30 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Invega Sustenna 117 mg/0.75mL Prefilled Syringe |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Invega Sustenna 156 mg/mL Prefilled Syringe |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Invega Sustenna 234 mg/1.5mL Prefilled Syringe |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Invega Sustenna 39 mg/0.25mL Prefilled Syringe |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Invega Sustenna 78 mg/0.5mL Prefilled Syringe |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INVIRASE 200MG CAPSULE |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
INVIRASE 500MG TABLET |
5 |
Specialty Tier |
25% | 25% | None |
INVOKANA 100 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
INVOKANA 300 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
IONOSOL B-D5W IV SOLUTION |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
IONOSOL MB-D5W IV SOLUTION |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
IOPIDINE 0.5% EYE DROPS |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
IOPIDINE 1% EYE DROPS |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
IPOL VIAL 40;8;32; UNT |
6 |
Vaccines |
$0.00 | N/A | None |
Ipratropium Bromide 0.5mg/2.5mL 1 POUCH per CARTON / 30 VIAL in 1 POUCH / 2.5 mL in 1 VIAL |
1 |
Preferred Generic |
$8.00 | $16.00 | None |
Ipratropium Bromide 42ug/1 1 BOTTLE, SPRAY per CARTON / 165 SPRAY, METERED in 1 BOTTLE, SPRAY |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IPRATROPIUM BROMIDE and ALBUTEROL SULFATE 2.5; 0.5mg/3mL; mg/3mL 6 POUCH per CARTON / 5 VIAL, PLAS |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
IPRATROPIUM BROMIDE NASAL SPRAY |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
IRBESARTAN 150 MG TABLET [Avapro] |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
IRBESARTAN 300 MG TABLET [Avapro] |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
IRBESARTAN 75 MG TABLET [Avapro] |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
IRBESARTAN-HCTZ 150-12.5 MG TABLET [Avalide] |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
IRBESARTAN-HCTZ 300-12.5 MG TABLET [Avalide] |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
irinotecan hcl 100 mg/5 ml vl |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
ISENTRESS 100 MG TABLET CHEW |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
ISENTRESS 25 MG TABLET CHEW |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
ISENTRESS 400MG TABLET |
5 |
Specialty Tier |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISOLYTE P IN 5% DEXTROSE INJECTION |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ISOLYTE S IV SOLUTION-EXCEL |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
ISONIAZID 100 MG TABLET |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
ISONIAZID 300 MG TABLET |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
ISONIAZID 50MG/5ML SYRUP |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
ISONIAZID INJ 100MG/ML |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
ISOPTO CARPINE 10mg/mL 15 mL in 1 BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ISOPTO CARPINE 20mg/mL 15 mL in 1 BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ISOPTO CARPINE 40mg/mL 15 mL in 1 BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ISORDIL 40 MG TABLET |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
ISORDIL TITRADOSE 5 MG TAB |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISOSORBIDE DINITRATE 40MG TABLETS EXTENDED RELEASE |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
ISOSORBIDE DN 10 MG TABLET |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
ISOSORBIDE DN 2.5 MG TAB SL |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
ISOSORBIDE DN 20MG TABLET |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
ISOSORBIDE DN 30MG TABLET |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
ISOSORBIDE DN 5 MG TABLET |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
ISOSORBIDE MN 10 MG TABLET |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
ISOSORBIDE MONONITRATE 20MG TABLET |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
ISOSORBIDE MONONITRATE ER TABLET 120MG (100 CT) |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
ISOSORBIDE MONONITRATE ER TABLET 30MG (100 CT) |
1 |
Preferred Generic |
$8.00 | $16.00 | None |
ISOSORBIDE MONONITRATE TABLETS EXTENDED RELEASE 60MG 100 TABLETS BOT |
1 |
Preferred Generic |
$8.00 | $16.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISOTON GENTAMICIN 80MG/100ML |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
ISRADIPINE CAPSULES 2.5MG (100 CT) |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
ISRADIPINE CAPSULES 5MG (100 CT) |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
ISTALOL 0.5% EYE DROPS |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
ISTODAX KIT 10MG/VIAL |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
ITRACONAZOLE 100MG CAPSULE |
2 |
Non-Preferred Generic |
$13.00 | $26.00 | None |
IXEMPRA 45 MG KIT |
5 |
Specialty Tier |
25% | 25% | None |
IXIARO JAPANESE ENCEPHALITIS VACCINE 6MCG/.5ML |
6 |
Vaccines |
$0.00 | N/A | None |