2017 Medicare Part D Plan Formulary Information |
Fidelis Medicare $0 Premium (HMO) (H3328-020-1)
Benefit Details
|
The Fidelis Medicare $0 Premium (HMO) (H3328-020-1) Formulary Drugs Starting with the Letter I in Herkimer County, NY: CMS MA Region 3 which includes: NY Plan Monthly Premium: $0.00 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 |
Generic |
$20.00 | N/A | P Q:3 /90Days |
IBANDRONATE SODIUM 150 MG TABLET [Boniva] |
2 |
Generic |
$20.00 | N/A | P |
IBRANCE 100 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P |
IBRANCE 125 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P |
IBRANCE 75 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P |
IBUDONE 10; 200mg/1; mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
2 |
Generic |
$20.00 | N/A | Q:150 /30Days |
Ibuprofen 100mg/5mL 473 mL in 1 BOTTLE |
2 |
Generic |
$20.00 | N/A | None |
IBUPROFEN 400MG TABLETS |
1 |
Preferred Generic |
$0.00 | N/A | None |
IBUPROFEN 600mg/1 500 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | N/A | None |
Ibuprofen 800mg/1 100 TABLET BOTTLE |
1 |
Preferred Generic |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ICLUSIG 15 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
ICLUSIG 45 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
IDAMYCIN PFS 1MG/ML VIAL |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
IDARUBICIN HCL 1MG/ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
IFEX 1g/1 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, SINGLE-DOSE |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
IFOSFAMIDE FOR INFECTION 1 GM |
2 |
Generic |
$20.00 | N/A | P |
ILEVRO 0.3% OPHTH DROPS |
3 |
Preferred Brand |
$47.00 | N/A | None |
IMATINIB MESYLATE 100 MG TABLET [Gleevec] |
5 |
Specialty Tier |
33% | N/A | P Q:90 /30Days |
IMATINIB MESYLATE 400 MG TABLET [Gleevec] |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
IMBRUVICA 140 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P |
IMIPENEM-CILASTATIN 250 MG VL |
2 |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IMIPENEM-CILASTATIN 500 MG VL |
2 |
Generic |
$20.00 | N/A | None |
IMIPRAMINE HCL 10MG TABLET (100 CT) |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
IMIPRAMINE HCL 25MG TABLET (100 CT) |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
IMIPRAMINE HCL 50MG TABLET (100 CT) |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
IMIPRAMINE PAMOATE 100MG CAPSULES |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
IMIPRAMINE PAMOATE 125MG CAPSULES |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
IMIPRAMINE PAMOATE 150MG CAPSULES |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
IMIPRAMINE PAMOATE 75MG CAPSULES |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
IMIQUIMOD 5% CREAM |
2 |
Generic |
$20.00 | N/A | None |
IMITREX 100MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | Q:12 /30Days |
IMITREX 20MG NASAL SPRAY |
4 |
Non-Preferred Drug |
$100.00 | N/A | Q:12 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IMITREX 25MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | Q:12 /30Days |
IMITREX 4MG/0.5ML KIT REFILL |
5 |
Specialty Tier |
33% | N/A | Q:9 /30Days |
IMITREX 50MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | Q:12 /30Days |
IMITREX 5MG NASAL SPRAY |
4 |
Non-Preferred Drug |
$100.00 | N/A | Q:24 /30Days |
IMITREX 6MG/0.5ML SYRNG KIT |
5 |
Specialty Tier |
33% | N/A | Q:6 /30Days |
IMITREX 6MG/0.5ML VIAL |
5 |
Specialty Tier |
33% | N/A | Q:6 /30Days |
IMOVAX RABIES VACCINE |
3 |
Preferred Brand |
$47.00 | N/A | None |
IMURAN 50MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
Increlex 40mg/4mL 1 VIAL, MULTI-DOSE per CARTON / 4 mL in 1 VIAL, MULTI-DOSE |
5 |
Specialty Tier |
33% | N/A | P |
INCRUSE ELLIPTA 62.5 MCG INH |
3 |
Preferred Brand |
$47.00 | N/A | Q:30 /30Days |
Indapamide 1.25mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
2 |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INDAPAMIDE 2.5MG TABLET USP (1000 CT) |
2 |
Generic |
$20.00 | N/A | None |
INDERAL LA LONG ACTING CAPSULES 120MG 100 BOT |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
INDERAL LA LONG ACTING CAPSULES 160MG 100 BOT |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
INDERAL LA LONG ACTING CAPSULES 60MG 100 BOT |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
INDERAL LA LONG ACTING CAPSULES 80MG 100 BOT |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
INLYTA 1 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
INLYTA 5 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
INSPRA 25MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
INSPRA 50 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
INTELENCE 100MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
Intelence 200mg/1 |
5 |
Specialty Tier |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INTELENCE 25 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
INTRALIPID 20% IV FAT EMUL |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
INTRALIPID 30% IV FAT EMUL |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
INTRON A 10 MILLION UNITS VIAL |
5 |
Specialty Tier |
33% | N/A | P |
INTRON A 18 MILLION UNITS VIAL |
5 |
Specialty Tier |
33% | N/A | P |
INTRON A 25 MILLION UNIT/2.5ML |
5 |
Specialty Tier |
33% | N/A | P |
INTRON A 50 MILLION UNITS VIAL |
5 |
Specialty Tier |
33% | N/A | P |
INTRON A 6MMU/ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
Intuniv 1 MG ER 100 TABLET in BOTTLE |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
Intuniv 2 MG ER 100 TABLET in BOTTLE |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
Intuniv 3 MG ER 100 TABLET in BOTTLE |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Intuniv 4 MG ER 100 TABLET in BOTTLE |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
INVANZ 1GM VIAL |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
INVEGA 3MG TABLET SR OSMOTIC PUSH 24HR |
5 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
INVEGA 6MG TABLET SR OSMOTIC PUSH 24HR |
5 |
Specialty Tier |
33% | N/A | Q:60 /30Days |
INVEGA 9MG TABLET SR OSMOTIC PUSH 24HR |
5 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
INVEGA ER 1.5mg/ 30 TABLET BOTTLE |
5 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
Invega Sustenna 117 mg/0.75mL Prefilled Syringe |
5 |
Specialty Tier |
33% | N/A | Q:1 /28Days |
Invega Sustenna 156 mg/mL Prefilled Syringe |
5 |
Specialty Tier |
33% | N/A | Q:1 /28Days |
Invega Sustenna 234 mg/1.5mL Prefilled Syringe |
5 |
Specialty Tier |
33% | N/A | Q:2 /28Days |
Invega Sustenna 39 mg/0.25mL Prefilled Syringe |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
Invega Sustenna 78 mg/0.5mL Prefilled Syringe |
5 |
Specialty Tier |
33% | N/A | Q:1 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INVEGA TRINZA 273 MG/0.875 ML |
5 |
Specialty Tier |
33% | N/A | Q:1 /90Days |
INVEGA TRINZA 410 MG/1.315 ML |
5 |
Specialty Tier |
33% | N/A | Q:1 /90Days |
INVEGA TRINZA 546 MG/1.75 ML |
5 |
Specialty Tier |
33% | N/A | Q:2 /90Days |
INVEGA TRINZA 819 MG/2.625 ML |
5 |
Specialty Tier |
33% | N/A | Q:3 /90Days |
INVIRASE 200MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | None |
INVIRASE 500MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
INVOKAMET 150-1,000 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | Q:60 /30Days |
INVOKAMET 150-500 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | Q:60 /30Days |
INVOKAMET 50-1,000 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | Q:60 /30Days |
INVOKAMET 50-500 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | Q:120 /30Days |
INVOKAMET XR 150-1,000 MG TAB |
3 |
Preferred Brand |
$47.00 | N/A | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INVOKAMET XR 150-500 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | Q:60 /30Days |
INVOKAMET XR 50-1,000 MG TAB |
3 |
Preferred Brand |
$47.00 | N/A | Q:60 /30Days |
INVOKAMET XR 50-500 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | Q:120 /30Days |
INVOKANA 100 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | Q:90 /30Days |
INVOKANA 300 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | Q:30 /30Days |
IONOSOL B-D5W IV SOLUTION |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
IONOSOL MB-D5W IV SOLUTION |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
IPOL VIAL 40;8;32; UNT |
3 |
Preferred Brand |
$47.00 | N/A | None |
Ipratropium Bromide 0.5mg/2.5mL 1 POUCH per CARTON / 30 VIAL in 1 POUCH / 2.5 mL in 1 VIAL |
2 |
Generic |
$20.00 | N/A | P |
Ipratropium Bromide 42ug/1 1 BOTTLE, SPRAY per CARTON / 165 SPRAY, METERED in 1 BOTTLE, SPRAY |
2 |
Generic |
$20.00 | N/A | None |
IPRATROPIUM BROMIDE and ALBUTEROL SULFATE 2.5; 0.5mg/3mL; mg/3mL 6 POUCH per CARTON / 5 VIAL, PLAS |
2 |
Generic |
$20.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IPRATROPIUM BROMIDE NASAL SPRAY |
2 |
Generic |
$20.00 | N/A | None |
IRBESARTAN 150 MG TABLET [Avapro] |
1 |
Preferred Generic |
$0.00 | N/A | None |
IRBESARTAN 300 MG TABLET [Avapro] |
1 |
Preferred Generic |
$0.00 | N/A | None |
IRBESARTAN 75 MG TABLET [Avapro] |
1 |
Preferred Generic |
$0.00 | N/A | None |
IRBESARTAN-HCTZ 150-12.5 MG TB [Avalide] |
1 |
Preferred Generic |
$0.00 | N/A | None |
Irbesartan-hctz 300-12.5 mg tb [Avalide] |
1 |
Preferred Generic |
$0.00 | N/A | None |
IRESSA 250 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
irinotecan hcl 100 mg/5 ml vl |
2 |
Generic |
$20.00 | N/A | P |
ISENTRESS 100 MG POWDER PACKET |
5 |
Specialty Tier |
33% | N/A | None |
ISENTRESS 100 MG TABLET CHEW |
5 |
Specialty Tier |
33% | N/A | None |
ISENTRESS 25 MG TABLET CHEW |
3 |
Preferred Brand |
$47.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISENTRESS 400MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
ISOLYTE P IN 5% DEXTROSE INJECTION |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
ISOLYTE S IV SOLUTION-EXCEL |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
ISONIAZID 100 MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
ISONIAZID 300 MG TABLET |
1 |
Preferred Generic |
$0.00 | N/A | None |
ISONIAZID 50MG/5ML SYRUP |
2 |
Generic |
$20.00 | N/A | None |
ISONIAZID INJ 100MG/ML |
2 |
Generic |
$20.00 | N/A | None |
ISOPTO CARPINE 10mg/mL 15 mL in 1 BOTTLE |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
ISOPTO CARPINE 20mg/mL 15 mL in 1 BOTTLE |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
ISOPTO CARPINE 40mg/mL 15 mL in 1 BOTTLE |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
ISORDIL 40 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISORDIL TITRADOSE 5 MG TAB |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
ISOSORBIDE DINITRATE 40MG TABLETS EXTENDED RELEASE |
2 |
Generic |
$20.00 | N/A | None |
ISOSORBIDE DN 10 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
ISOSORBIDE DN 20MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
ISOSORBIDE DN 30MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
ISOSORBIDE DN 5 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
ISOSORBIDE MN 10 MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
ISOSORBIDE MONONITRATE 20MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
ISOSORBIDE MONONITRATE ER TABLET 120MG (100 CT) |
2 |
Generic |
$20.00 | N/A | None |
ISOSORBIDE MONONITRATE ER TABLET 30MG (100 CT) |
2 |
Generic |
$20.00 | N/A | None |
ISOSORBIDE MONONITRATE TABLETS EXTENDED RELEASE 60MG 100 TABLETS BOT |
2 |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISOTON GENTAMICIN 80MG/100ML |
2 |
Generic |
$20.00 | N/A | None |
ISOTONIC GENTAMICIN 100 MG/100 ML |
2 |
Generic |
$20.00 | N/A | None |
ISOTONIC GENTAMICIN 80 MG/50 ML |
2 |
Generic |
$20.00 | N/A | None |
ISRADIPINE CAPSULES 2.5MG (100 CT) |
2 |
Generic |
$20.00 | N/A | None |
ISRADIPINE CAPSULES 5MG (100 CT) |
2 |
Generic |
$20.00 | N/A | None |
ISTALOL 0.5% EYE DROPS |
3 |
Preferred Brand |
$47.00 | N/A | None |
ISTODAX 10 MG VIAL |
5 |
Specialty Tier |
33% | N/A | P |
ITRACONAZOLE 100MG CAPSULE |
2 |
Generic |
$20.00 | N/A | P |
IVERMECTIN 3 MG TABLET [Stromectol, Sklice] |
2 |
Generic |
$20.00 | N/A | None |
IXIARO JAPANESE ENCEPHALITIS VACCINE 6MCG/.5ML |
3 |
Preferred Brand |
$47.00 | N/A | None |