2017 Medicare Part D Plan Formulary Information |
Humana Gold Choice H8145-052 (PFFS) (H8145-052-0)
Benefit Details
|
The Humana Gold Choice H8145-052 (PFFS) (H8145-052-0) Formulary Drugs Starting with the Letter I in Clinton County, PA: CMS MA Region 6 which includes: PA Plan Monthly Premium: $60.00 Deductible: $360 |
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] |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:3 /90Days |
IBANDRONATE SODIUM 150 MG TABLET [Boniva] |
2* |
Generic |
$17.00 | $0.00 | Q:1 /28Days |
IBRANCE 100 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:21 /28Days |
IBRANCE 125 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:21 /28Days |
IBRANCE 75 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:21 /28Days |
Ibuprofen 100mg/5mL 473 mL in 1 BOTTLE |
1* |
Preferred Generic |
$7.00 | $0.00 | None |
IBUPROFEN 400MG TABLETS |
1* |
Preferred Generic |
$7.00 | $0.00 | None |
IBUPROFEN 600mg/1 500 TABLET BOTTLE |
1* |
Preferred Generic |
$7.00 | $0.00 | None |
Ibuprofen 800mg/1 100 TABLET BOTTLE |
1* |
Preferred Generic |
$7.00 | $0.00 | None |
ICLUSIG 15 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ICLUSIG 45 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
IDAMYCIN PFS 1MG/ML VIAL |
5 |
Specialty Tier |
25% | N/A | P |
IDARUBICIN HCL 1MG/ML VIAL |
5 |
Specialty Tier |
25% | N/A | P |
IFOSFAMIDE FOR INFECTION 1 GM |
3* |
Preferred Brand |
$47.00 | $131.00 | P |
ILEVRO 0.3% OPHTH DROPS |
3* |
Preferred Brand |
$47.00 | $131.00 | None |
IMBRUVICA 140 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
IMFINZI 120 MG/2.4 ML VIAL |
5 |
Specialty Tier |
25% | N/A | P |
IMFINZI 500 MG/10 ML VIAL |
5 |
Specialty Tier |
25% | N/A | P |
IMIPENEM-CILASTATIN 250 MG VL |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
IMIPENEM-CILASTATIN 500 MG VL |
3* |
Preferred Brand |
$47.00 | $131.00 | None |
IMIPRAMINE HCL 10MG TABLET (100 CT) |
2* |
Generic |
$17.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IMIPRAMINE HCL 25MG TABLET (100 CT) |
2* |
Generic |
$17.00 | $0.00 | None |
IMIPRAMINE HCL 50MG TABLET (100 CT) |
2* |
Generic |
$17.00 | $0.00 | None |
IMIPRAMINE PAMOATE 100MG CAPSULES |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
IMIPRAMINE PAMOATE 125MG CAPSULES |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
IMIPRAMINE PAMOATE 150MG CAPSULES |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
IMIPRAMINE PAMOATE 75MG CAPSULES |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
IMIQUIMOD 5% CREAM |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:12 /30Days |
IMOGAM RABIES-HT 150 UNIT/ML |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P |
IMOVAX RABIES VACCINE |
3* |
Preferred Brand |
$47.00 | $131.00 | P |
IMURAN 50MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P |
Increlex 40mg/4mL 1 VIAL, MULTI-DOSE per CARTON / 4 mL in 1 VIAL, MULTI-DOSE |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INCRUSE ELLIPTA 62.5 MCG INH |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days |
Indapamide 1.25mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1* |
Preferred Generic |
$7.00 | $0.00 | None |
INDAPAMIDE 2.5MG TABLET USP (1000 CT) |
1* |
Preferred Generic |
$7.00 | $0.00 | None |
Indomethacin 25 mg capsule |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
INDOMETHACIN 50 MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
INDOMETHACIN 75MG CAPSULE SA |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
INGREZZA 40 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
INLYTA 1 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:180 /30Days |
INLYTA 5 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
INTELENCE 100MG TABLET |
5 |
Specialty Tier |
25% | N/A | Q:120 /30Days |
Intelence 200mg/1 |
5 |
Specialty Tier |
25% | 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 Drug |
$100.00 | $290.00 | Q:120 /30Days |
INTRALIPID 20% IV FAT EMUL |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P |
INTRALIPID 30% IV FAT EMUL |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P |
INTRON A 10 MILLION UNITS VIAL |
5 |
Specialty Tier |
25% | N/A | P |
INTRON A 18 MILLION UNITS VIAL |
5 |
Specialty Tier |
25% | N/A | P |
INTRON A 25 MILLION UNIT/2.5ML |
5 |
Specialty Tier |
25% | N/A | P |
INTRON A 50 MILLION UNITS VIAL |
5 |
Specialty Tier |
25% | N/A | P |
INTRON A 6MMU/ML VIAL |
5 |
Specialty Tier |
25% | N/A | P |
Introvale 3 CARTON in 1 BOX / 1 KIT per CARTON |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
INVANZ 1GM VIAL |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
INVEGA 3MG TABLET SR OSMOTIC PUSH 24HR |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INVEGA 6MG TABLET SR OSMOTIC PUSH 24HR |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
INVEGA 9MG TABLET SR OSMOTIC PUSH 24HR |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
INVEGA ER 1.5mg/ 30 TABLET BOTTLE |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
Invega Sustenna 117 mg/0.75mL Prefilled Syringe |
5 |
Specialty Tier |
25% | N/A | Q:2 /28Days |
Invega Sustenna 156 mg/mL Prefilled Syringe |
5 |
Specialty Tier |
25% | N/A | Q:1 /28Days |
Invega Sustenna 234 mg/1.5mL Prefilled Syringe |
5 |
Specialty Tier |
25% | N/A | Q:2 /28Days |
Invega Sustenna 39 mg/0.25mL Prefilled Syringe |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:2 /28Days |
Invega Sustenna 78 mg/0.5mL Prefilled Syringe |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:2 /28Days |
INVEGA TRINZA 273 MG/0.875 ML |
5 |
Specialty Tier |
25% | N/A | Q:1 /90Days |
INVEGA TRINZA 410 MG/1.315 ML |
5 |
Specialty Tier |
25% | N/A | Q:1 /90Days |
INVEGA TRINZA 546 MG/1.75 ML |
5 |
Specialty Tier |
25% | N/A | Q:2 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INVEGA TRINZA 819 MG/2.625 ML |
5 |
Specialty Tier |
25% | N/A | Q:3 /90Days |
INVIRASE 200MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | Q:300 /30Days |
INVIRASE 500MG TABLET |
5 |
Specialty Tier |
25% | N/A | Q:120 /30Days |
INVOKAMET 150-1,000 MG TABLET |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
INVOKAMET 150-500 MG TABLET |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
INVOKAMET 50-1,000 MG TABLET |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
INVOKAMET 50-500 MG TABLET |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
INVOKAMET XR 150-1,000 MG TAB |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
INVOKAMET XR 150-500 MG TABLET |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
INVOKAMET XR 50-1,000 MG TAB |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
INVOKAMET XR 50-500 MG TABLET |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INVOKANA 100 MG TABLET |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days |
INVOKANA 300 MG TABLET |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days |
IONOSOL B-D5W IV SOLUTION |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
IONOSOL MB-D5W IV SOLUTION |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
IOPIDINE 1% EYE DROPS |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
IPOL VIAL 40;8;32; UNT |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
Ipratropium Bromide 0.5mg/2.5mL 1 POUCH per CARTON / 30 VIAL in 1 POUCH / 2.5 mL in 1 VIAL |
2* |
Generic |
$17.00 | $0.00 | P |
Ipratropium Bromide 42ug/1 1 BOTTLE, SPRAY per CARTON / 165 SPRAY, METERED in 1 BOTTLE, SPRAY |
2* |
Generic |
$17.00 | $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* |
Generic |
$17.00 | $0.00 | P |
IPRATROPIUM BROMIDE NASAL SPRAY |
2* |
Generic |
$17.00 | $0.00 | Q:30 /30Days |
IRBESARTAN 150 MG TABLET [Avapro] |
1* |
Preferred Generic |
$7.00 | $0.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IRBESARTAN 300 MG TABLET [Avapro] |
1* |
Preferred Generic |
$7.00 | $0.00 | Q:30 /30Days |
IRBESARTAN 75 MG TABLET [Avapro] |
1* |
Preferred Generic |
$7.00 | $0.00 | Q:30 /30Days |
IRBESARTAN-HCTZ 150-12.5 MG TB [Avalide] |
2* |
Generic |
$17.00 | $0.00 | Q:30 /30Days |
Irbesartan-hctz 300-12.5 mg tb [Avalide] |
2* |
Generic |
$17.00 | $0.00 | Q:30 /30Days |
IRESSA 250 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
irinotecan hcl 100 mg/5 ml vl |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P |
ISENTRESS 100 MG POWDER PACKET |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:300 /30Days |
ISENTRESS 100 MG TABLET CHEW |
5 |
Specialty Tier |
25% | N/A | Q:180 /30Days |
ISENTRESS 25 MG TABLET CHEW |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:180 /30Days |
ISENTRESS 400MG TABLET |
5 |
Specialty Tier |
25% | N/A | Q:120 /30Days |
ISOLYTE P IN 5% DEXTROSE INJECTION |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISOLYTE S IV SOLUTION-EXCEL |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
ISONIAZID 100 MG TABLET |
1* |
Preferred Generic |
$7.00 | $0.00 | None |
ISONIAZID 300 MG TABLET |
1* |
Preferred Generic |
$7.00 | $0.00 | None |
ISONIAZID 50MG/5ML SYRUP |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
ISONIAZID INJ 100MG/ML |
1* |
Preferred Generic |
$7.00 | $0.00 | None |
ISOPTO CARPINE 10mg/mL 15 mL in 1 BOTTLE |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
ISOPTO CARPINE 20mg/mL 15 mL in 1 BOTTLE |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
ISOPTO CARPINE 40mg/mL 15 mL in 1 BOTTLE |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
ISORDIL 40 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P |
ISORDIL TITRADOSE 5 MG TAB |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P |
ISOSORBIDE DINITRATE 40MG TABLETS EXTENDED RELEASE |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISOSORBIDE DN 10 MG TABLET |
2* |
Generic |
$17.00 | $0.00 | None |
ISOSORBIDE DN 20MG TABLET |
2* |
Generic |
$17.00 | $0.00 | None |
ISOSORBIDE DN 30MG TABLET |
2* |
Generic |
$17.00 | $0.00 | None |
ISOSORBIDE DN 5 MG TABLET |
2* |
Generic |
$17.00 | $0.00 | None |
ISOSORBIDE MN 10 MG TABLET |
2* |
Generic |
$17.00 | $0.00 | None |
ISOSORBIDE MONONITRATE 20MG TABLET |
2* |
Generic |
$17.00 | $0.00 | None |
ISOSORBIDE MONONITRATE ER TABLET 120MG (100 CT) |
2* |
Generic |
$17.00 | $0.00 | None |
ISOSORBIDE MONONITRATE ER TABLET 30MG (100 CT) |
2* |
Generic |
$17.00 | $0.00 | None |
ISOSORBIDE MONONITRATE TABLETS EXTENDED RELEASE 60MG 100 TABLETS BOT |
2* |
Generic |
$17.00 | $0.00 | None |
ISOTON GENTAMICIN 80MG/100ML |
3* |
Preferred Brand |
$47.00 | $131.00 | None |
ISOTONIC GENTAMICIN 100 MG/100 ML |
3* |
Preferred Brand |
$47.00 | $131.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISOTONIC GENTAMICIN 80 MG/50 ML |
3* |
Preferred Brand |
$47.00 | $131.00 | None |
ISRADIPINE CAPSULES 2.5MG (100 CT) |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
ISRADIPINE CAPSULES 5MG (100 CT) |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |
ISTODAX 10 MG VIAL |
5 |
Specialty Tier |
25% | N/A | P |
ITRACONAZOLE 100MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:120 /30Days |
IVERMECTIN 3 MG TABLET [Stromectol, Sklice] |
3* |
Preferred Brand |
$47.00 | $131.00 | None |
IXIARO JAPANESE ENCEPHALITIS VACCINE 6MCG/.5ML |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None |