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2014 Medicare Part D Plan Formulary Information
HumanaChoice H4408-001 (PPO) (H4408-001-0) Benefit Details
The HumanaChoice H4408-001 (PPO) (H4408-001-0) Formulary Drugs Starting with the Letter I in BENTON County, MS: CMS MA Region 16 which includes: MS Plan Monthly Premium: $55.00 Deductible: $100
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 3 MG/3 ML VIAL [Boniva]	4	Non-Preferred Brand	$90.00	$260.00	P Q:3 /90Days
IBANDRONATE SODIUM 150 MG TABLET [Boniva]	4	Non-Preferred Brand	$90.00	$260.00	Q:1 /28Days
Ibuprofen 100mg/5mL 473 mL in 1 BOTTLE	1*	Preferred Generic	$6.00	$0.00	None
IBUPROFEN 400MG TABLETS	1*	Preferred Generic	$6.00	$0.00	None
IBUPROFEN 600mg/1 500 TABLET BOTTLE	1*	Preferred Generic	$6.00	$0.00	None
Ibuprofen 800 mg tablet	1*	Preferred Generic	$6.00	$0.00	None
IDAMYCIN PFS 1MG/ML VIAL	5	Specialty Tier	30%	N/A	P
IDARUBICIN HCL 1MG/ML VIAL	5	Specialty Tier	30%	N/A	P
IFEX INJECTION 3GM/ML 3GM VIALSD	4	Non-Preferred Brand	$90.00	$260.00	P
IFOSFAMIDE FOR INFECTION 1 GM	3*	Preferred Brand	$45.00	$125.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ILEVRO 0.3% OPHTH DROPS	4	Non-Preferred Brand	$90.00	$260.00	None
IMBRUVICA 140 MG CAPSULE	5	Specialty Tier	30%	N/A	P Q:120 /30Days
IMIPENEM-CILASTATIN 250 MG VL	4	Non-Preferred Brand	$90.00	$260.00	None
IMIPENEM-CILASTATIN 500 MG VL	4	Non-Preferred Brand	$90.00	$260.00	None
IMIPRAMINE HCL 10MG TABLET (100 CT)	2*	Non-Preferred Generic	$12.00	$0.00	P
IMIPRAMINE HCL 25MG TABLET (100 CT)	2*	Non-Preferred Generic	$12.00	$0.00	P
IMIPRAMINE HCL 50MG TABLET (100 CT)	2*	Non-Preferred Generic	$12.00	$0.00	P
IMIPRAMINE PAMOATE 100MG CAPSULES	4	Non-Preferred Brand	$90.00	$260.00	P
IMIPRAMINE PAMOATE 125MG CAPSULES	4	Non-Preferred Brand	$90.00	$260.00	P
IMIPRAMINE PAMOATE 150MG CAPSULES	4	Non-Preferred Brand	$90.00	$260.00	P
IMIPRAMINE PAMOATE 75MG CAPSULES	4	Non-Preferred Brand	$90.00	$260.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
IMIQUIMOD 5% CREAM	4	Non-Preferred Brand	$90.00	$260.00	Q:12 /30Days
IMOVAX RABIES VACCINE	3*	Preferred Brand	$45.00	$125.00	P
Incivek 375mg/1 4 BOX per CARTON / 7 BLISTER PACK in 1 BOX / 6 FILM COATED TABLETS in BLISTER PA	5	Specialty Tier	30%	N/A	P Q:168 /28Days
Increlex 40mg/4mL 1 VIAL, MULTI-DOSE per CARTON / 4 mL in 1 VIAL, MULTI-DOSE	5	Specialty Tier	30%	N/A	P
Indapamide 1.25mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC	1*	Preferred Generic	$6.00	$0.00	None
INDAPAMIDE 2.5MG TABLET USP (1000 CT)	1*	Preferred Generic	$6.00	$0.00	None
INFERGEN INJECTION	5	Specialty Tier	30%	N/A	P Q:30 /30Days
INLYTA 1 MG TABLET	5	Specialty Tier	30%	N/A	P Q:180 /30Days
INLYTA 5 MG TABLET	5	Specialty Tier	30%	N/A	P Q:60 /30Days
INTELENCE 100MG TABLET	5	Specialty Tier	30%	N/A	Q:120 /30Days
Intelence 200mg/1	5	Specialty Tier	30%	N/A	Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
INTELENCE 25 MG TABLET	4	Non-Preferred Brand	$90.00	$260.00	Q:120 /30Days
INTRALIPID 20% IV FAT EMUL	4	Non-Preferred Brand	$90.00	$260.00	P
INTRALIPID PHARMACY BULK PACKAGE FAT EMULSION 1.7-1.2-30GM 500ML BAG	4	Non-Preferred Brand	$90.00	$260.00	P
INTRON A 10MMU VIAL	5	Specialty Tier	30%	N/A	P
INTRON A 6MMU/ML VIAL	5	Specialty Tier	30%	N/A	P
Introvale 3 CARTON in 1 BOX / 1 KIT per CARTON	4	Non-Preferred Brand	$90.00	$260.00	Q:91 /90Days
INVANZ 1GM VIAL	4	Non-Preferred Brand	$90.00	$260.00	None
INVEGA 3MG TABLET SR OSMOTIC PUSH 24HR	4	Non-Preferred Brand	$90.00	$260.00	S Q:30 /30Days
INVEGA 6MG TABLET SR OSMOTIC PUSH 24HR	4	Non-Preferred Brand	$90.00	$260.00	S Q:60 /30Days
INVEGA 9MG TABLET SR OSMOTIC PUSH 24HR	4	Non-Preferred Brand	$90.00	$260.00	S Q:30 /30Days
INVEGA ER 1.5mg/ 30 TABLET BOTTLE	4	Non-Preferred Brand	$90.00	$260.00	S 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	5	Specialty Tier	30%	N/A	Q:2 /30Days
Invega Sustenna 156 mg/mL Prefilled Syringe	5	Specialty Tier	30%	N/A	Q:2 /30Days
Invega Sustenna 234 mg/1.5mL Prefilled Syringe	5	Specialty Tier	30%	N/A	Q:2 /30Days
Invega Sustenna 39 mg/0.25mL Prefilled Syringe	4	Non-Preferred Brand	$90.00	$260.00	Q:2 /30Days
Invega Sustenna 78 mg/0.5mL Prefilled Syringe	4	Non-Preferred Brand	$90.00	$260.00	Q:2 /30Days
INVIRASE 200MG CAPSULE	5	Specialty Tier	30%	N/A	Q:300 /30Days
INVIRASE 500MG TABLET	5	Specialty Tier	30%	N/A	Q:120 /30Days
INVOKANA 100 MG TABLET	4	Non-Preferred Brand	$90.00	$260.00	S Q:30 /30Days
INVOKANA 300 MG TABLET	4	Non-Preferred Brand	$90.00	$260.00	S Q:30 /30Days
IONOSOL B-D5W IV SOLUTION	4	Non-Preferred Brand	$90.00	$260.00	None
IONOSOL MB-D5W IV SOLUTION	4	Non-Preferred Brand	$90.00	$260.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
IOPIDINE 0.5% EYE DROPS	4	Non-Preferred Brand	$90.00	$260.00	P
IOPIDINE 1% EYE DROPS	4	Non-Preferred Brand	$90.00	$260.00	None
IPOL VIAL 40;8;32; UNT	4	Non-Preferred Brand	$90.00	$260.00	None
Ipratropium Bromide 0.5mg/2.5mL 1 POUCH per CARTON / 30 VIAL in 1 POUCH / 2.5 mL in 1 VIAL	2*	Non-Preferred Generic	$12.00	$0.00	P
Ipratropium Bromide 42ug/1 1 BOTTLE, SPRAY per CARTON / 165 SPRAY, METERED in 1 BOTTLE, SPRAY	2*	Non-Preferred Generic	$12.00	$0.00	Q:45 /30Days
IPRATROPIUM BROMIDE and ALBUTEROL SULFATE 2.5; 0.5mg/3mL; mg/3mL 6 POUCH per CARTON / 5 VIAL, PLAS	2*	Non-Preferred Generic	$12.00	$0.00	P
IPRATROPIUM BROMIDE NASAL SPRAY	2*	Non-Preferred Generic	$12.00	$0.00	Q:30 /30Days
IRBESARTAN 150 MG TABLET [Avapro]	2*	Non-Preferred Generic	$12.00	$0.00	Q:30 /30Days
IRBESARTAN 300 MG TABLET [Avapro]	2*	Non-Preferred Generic	$12.00	$0.00	Q:30 /30Days
IRBESARTAN 75 MG TABLET [Avapro]	2*	Non-Preferred Generic	$12.00	$0.00	Q:30 /30Days
IRBESARTAN-HCTZ 150-12.5 MG TABLET [Avalide]	2*	Non-Preferred Generic	$12.00	$0.00	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
IRBESARTAN-HCTZ 300-12.5 MG TABLET [Avalide]	2*	Non-Preferred Generic	$12.00	$0.00	Q:30 /30Days
irinotecan hcl 100 mg/5 ml vl	4	Non-Preferred Brand	$90.00	$260.00	P
ISENTRESS 100 MG TABLET CHEW	3*	Preferred Brand	$45.00	$125.00	Q:180 /30Days
ISENTRESS 25 MG TABLET CHEW	4	Non-Preferred Brand	$90.00	$260.00	Q:180 /30Days
ISENTRESS 400MG TABLET	5	Specialty Tier	30%	N/A	Q:120 /30Days
ISOLYTE P IN 5% DEXTROSE INJECTION	4	Non-Preferred Brand	$90.00	$260.00	None
ISOLYTE S IV SOLUTION-EXCEL	4	Non-Preferred Brand	$90.00	$260.00	None
ISONIAZID 100 MG TABLET	1*	Preferred Generic	$6.00	$0.00	None
ISONIAZID 300 MG TABLET	1*	Preferred Generic	$6.00	$0.00	None
ISONIAZID 50MG/5ML SYRUP	1*	Preferred Generic	$6.00	$0.00	None
ISONIAZID INJ 100MG/ML	1*	Preferred Generic	$6.00	$0.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ISORDIL 40 MG TABLET	4	Non-Preferred Brand	$90.00	$260.00	None
ISORDIL TITRADOSE 5 MG TAB	4	Non-Preferred Brand	$90.00	$260.00	None
ISOSORBIDE DINITRATE 40MG TABLETS EXTENDED RELEASE	3*	Preferred Brand	$45.00	$125.00	None
ISOSORBIDE DN 10 MG TABLET	2*	Non-Preferred Generic	$12.00	$0.00	None
ISOSORBIDE DN 2.5 MG TAB SL	1*	Preferred Generic	$6.00	$0.00	None
ISOSORBIDE DN 20MG TABLET	2*	Non-Preferred Generic	$12.00	$0.00	None
ISOSORBIDE DN 30MG TABLET	2*	Non-Preferred Generic	$12.00	$0.00	None
ISOSORBIDE DN 5 MG TABLET	2*	Non-Preferred Generic	$12.00	$0.00	None
ISOSORBIDE MN 10 MG TABLET	2*	Non-Preferred Generic	$12.00	$0.00	None
ISOSORBIDE MONONITRATE 20MG TABLET	2*	Non-Preferred Generic	$12.00	$0.00	None
ISOSORBIDE MONONITRATE ER TABLET 120MG (100 CT)	2*	Non-Preferred Generic	$12.00	$0.00	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)	2*	Non-Preferred Generic	$12.00	$0.00	None
ISOSORBIDE MONONITRATE TABLETS EXTENDED RELEASE 60MG 100 TABLETS BOT	2*	Non-Preferred Generic	$12.00	$0.00	None
ISOTON GENTAMICIN 80MG/100ML	3*	Preferred Brand	$45.00	$125.00	None
ISRADIPINE CAPSULES 2.5MG (100 CT)	4	Non-Preferred Brand	$90.00	$260.00	None
ISRADIPINE CAPSULES 5MG (100 CT)	4	Non-Preferred Brand	$90.00	$260.00	None
ISTODAX KIT 10MG/VIAL	5	Specialty Tier	30%	N/A	P
ITRACONAZOLE 100MG CAPSULE	4	Non-Preferred Brand	$90.00	$260.00	Q:120 /30Days
IXEMPRA 45 MG KIT	5	Specialty Tier	30%	N/A	P Q:47 /21Days
IXIARO JAPANESE ENCEPHALITIS VACCINE 6MCG/.5ML	4	Non-Preferred Brand	$90.00	$260.00	None

Chart Legend:

Below are a few notes to help you understand the above 2014 Medicare Part D HumanaChoice H4408-001 (PPO) 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 $310 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 $2850) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2014 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 2014 )

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.