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2017 Medicare Part D Plan Formulary Information
Harvard Pilgrim Stride Value Rx (HMO) (H1660-009-0) Benefit Details
The Harvard Pilgrim Stride Value Rx (HMO) (H1660-009-0) Formulary Drugs Starting with the Letter I in Norfolk County, MA: CMS MA Region 2 which includes: MA Plan Monthly Premium: $57.00 Deductible: $320
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]	2*	Generic	$10.00	N/A	P
IBANDRONATE SODIUM 150 MG TABLET [Boniva]	2*	Generic	$10.00	N/A	Q:1 /28Days
IBRANCE 100 MG CAPSULE	5	Specialty Tier	26%	N/A	None
IBRANCE 125 MG CAPSULE	5	Specialty Tier	26%	N/A	None
IBRANCE 75 MG CAPSULE	5	Specialty Tier	26%	N/A	None
Ibuprofen 100mg/5mL 473 mL in 1 BOTTLE	2*	Generic	$10.00	N/A	None
IBUPROFEN 400MG TABLETS	2*	Generic	$10.00	N/A	None
IBUPROFEN 600mg/1 500 TABLET BOTTLE	2*	Generic	$10.00	N/A	None
Ibuprofen 800mg/1 100 TABLET BOTTLE	2*	Generic	$10.00	N/A	None
ICLUSIG 15 MG TABLET	5	Specialty Tier	26%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ICLUSIG 45 MG TABLET	5	Specialty Tier	26%	N/A	None
IDARUBICIN HCL 1MG/ML VIAL	2*	Generic	$10.00	N/A	None
IFOSFAMIDE FOR INFECTION 1 GM	2*	Generic	$10.00	N/A	P
Ilaris 150mg/mL 1 VIAL, SINGLE-USE per CARTON / 1 mL in 1 VIAL, SINGLE-USE	5	Specialty Tier	26%	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	26%	N/A	None
IMATINIB MESYLATE 400 MG TABLET [Gleevec]	5	Specialty Tier	26%	N/A	None
IMBRUVICA 140 MG CAPSULE	5	Specialty Tier	26%	N/A	None
IMFINZI 120 MG/2.4 ML VIAL	5	Specialty Tier	26%	N/A	P
IMFINZI 500 MG/10 ML VIAL	5	Specialty Tier	26%	N/A	P
IMIPENEM-CILASTATIN 250 MG VL	2*	Generic	$10.00	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	$10.00	N/A	None
IMIPRAMINE HCL 10MG TABLET (100 CT)	2*	Generic	$10.00	N/A	None
IMIPRAMINE HCL 25MG TABLET (100 CT)	2*	Generic	$10.00	N/A	None
IMIPRAMINE HCL 50MG TABLET (100 CT)	2*	Generic	$10.00	N/A	None
IMIPRAMINE PAMOATE 100MG CAPSULES	2*	Generic	$10.00	N/A	None
IMIPRAMINE PAMOATE 125MG CAPSULES	2*	Generic	$10.00	N/A	None
IMIPRAMINE PAMOATE 150MG CAPSULES	2*	Generic	$10.00	N/A	None
IMIPRAMINE PAMOATE 75MG CAPSULES	2*	Generic	$10.00	N/A	None
IMIQUIMOD 5% CREAM	2*	Generic	$10.00	N/A	None
IMOGAM RABIES-HT 150 UNIT/ML	4	Non-Preferred Brand	$100.00	N/A	None
IMOVAX RABIES VACCINE	4	Non-Preferred Brand	$100.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Increlex 40mg/4mL 1 VIAL, MULTI-DOSE per CARTON / 4 mL in 1 VIAL, MULTI-DOSE	5	Specialty Tier	26%	N/A	P
INCRUSE ELLIPTA 62.5 MCG INH	3	Preferred Brand	$47.00	N/A	None
Indapamide 1.25mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC	1*	Preferred Generic	$0.00	N/A	None
INDAPAMIDE 2.5MG TABLET USP (1000 CT)	1*	Preferred Generic	$0.00	N/A	None
INDOCIN ORAL SUSPENSION 25MG/5ML 237 ML BOT	4	Non-Preferred Brand	$100.00	N/A	P
Indomethacin 25 mg capsule	2*	Generic	$10.00	N/A	P
INDOMETHACIN 50 MG CAPSULE	2*	Generic	$10.00	N/A	P
INDOMETHACIN 75MG CAPSULE SA	2*	Generic	$10.00	N/A	P
INGREZZA 40 MG CAPSULE	5	Specialty Tier	26%	N/A	P Q:60 /30Days
INLYTA 1 MG TABLET	5	Specialty Tier	26%	N/A	None
INLYTA 5 MG TABLET	5	Specialty Tier	26%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
INNOPRAN XL 120 MG CAPSULE	4	Non-Preferred Brand	$100.00	N/A	None
INNOPRAN XL 80 MG CAPSULE	4	Non-Preferred Brand	$100.00	N/A	None
INTELENCE 100MG TABLET	5	Specialty Tier	26%	N/A	None
Intelence 200mg/1	5	Specialty Tier	26%	N/A	None
INTELENCE 25 MG TABLET	4	Non-Preferred Brand	$100.00	N/A	None
INTERMEZZO 1.75 MG TAB SUBLING	4	Non-Preferred Brand	$100.00	N/A	S Q:30 /30Days
INTERMEZZO 3.5 MG TAB SUBLING	4	Non-Preferred Brand	$100.00	N/A	S Q:30 /30Days
INTRALIPID 20% IV FAT EMUL	4	Non-Preferred Brand	$100.00	N/A	P
INTRALIPID 30% IV FAT EMUL	4	Non-Preferred Brand	$100.00	N/A	P
INTRON A 10 MILLION UNITS VIAL	4	Non-Preferred Brand	$100.00	N/A	None
INTRON A 18 MILLION UNITS VIAL	4	Non-Preferred Brand	$100.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
INTRON A 25 MILLION UNIT/2.5ML	4	Non-Preferred Brand	$100.00	N/A	None
INTRON A 50 MILLION UNITS VIAL	4	Non-Preferred Brand	$100.00	N/A	None
INTRON A 6MMU/ML VIAL	4	Non-Preferred Brand	$100.00	N/A	None
Introvale 3 CARTON in 1 BOX / 1 KIT per CARTON	2*	Generic	$10.00	N/A	None
INVANZ 1GM VIAL	4	Non-Preferred Brand	$100.00	N/A	P
Invega Sustenna 117 mg/0.75mL Prefilled Syringe	5	Specialty Tier	26%	N/A	None
Invega Sustenna 156 mg/mL Prefilled Syringe	5	Specialty Tier	26%	N/A	None
Invega Sustenna 234 mg/1.5mL Prefilled Syringe	5	Specialty Tier	26%	N/A	None
Invega Sustenna 39 mg/0.25mL Prefilled Syringe	4	Non-Preferred Brand	$100.00	N/A	None
Invega Sustenna 78 mg/0.5mL Prefilled Syringe	5	Specialty Tier	26%	N/A	None
INVEGA TRINZA 273 MG/0.875 ML	5	Specialty Tier	26%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
INVEGA TRINZA 410 MG/1.315 ML	5	Specialty Tier	26%	N/A	None
INVEGA TRINZA 546 MG/1.75 ML	5	Specialty Tier	26%	N/A	None
INVEGA TRINZA 819 MG/2.625 ML	5	Specialty Tier	26%	N/A	None
INVIRASE 200MG CAPSULE	5	Specialty Tier	26%	N/A	None
INVIRASE 500MG TABLET	5	Specialty Tier	26%	N/A	None
INVOKAMET 150-1,000 MG TABLET	3	Preferred Brand	$47.00	N/A	None
INVOKAMET 150-500 MG TABLET	3	Preferred Brand	$47.00	N/A	None
INVOKAMET 50-1,000 MG TABLET	3	Preferred Brand	$47.00	N/A	None
INVOKAMET 50-500 MG TABLET	3	Preferred Brand	$47.00	N/A	None
INVOKAMET XR 150-1,000 MG TAB	3	Preferred Brand	$47.00	N/A	None
INVOKAMET XR 150-500 MG TABLET	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
INVOKAMET XR 50-1,000 MG TAB	3	Preferred Brand	$47.00	N/A	None
INVOKAMET XR 50-500 MG TABLET	3	Preferred Brand	$47.00	N/A	None
INVOKANA 100 MG TABLET	3	Preferred Brand	$47.00	N/A	None
INVOKANA 300 MG TABLET	3	Preferred Brand	$47.00	N/A	None
IONOSOL B-D5W IV SOLUTION	4	Non-Preferred Brand	$100.00	N/A	None
IONOSOL MB-D5W IV SOLUTION	4	Non-Preferred Brand	$100.00	N/A	None
IPOL VIAL 40;8;32; UNT	4	Non-Preferred Brand	$100.00	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	$10.00	N/A	P
Ipratropium Bromide 42ug/1 1 BOTTLE, SPRAY per CARTON / 165 SPRAY, METERED in 1 BOTTLE, SPRAY	2*	Generic	$10.00	N/A	None
IPRATROPIUM BROMIDE and ALBUTEROL SULFATE 2.5; 0.5mg/3mL; mg/3mL 6 POUCH per CARTON / 5 VIAL, PLAS	2*	Generic	$10.00	N/A	P
IPRATROPIUM BROMIDE NASAL SPRAY	2*	Generic	$10.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
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	26%	N/A	None
irinotecan hcl 100 mg/5 ml vl	2*	Generic	$10.00	N/A	None
ISENTRESS 100 MG POWDER PACKET	3	Preferred Brand	$47.00	N/A	None
ISENTRESS 100 MG TABLET CHEW	3	Preferred Brand	$47.00	N/A	None
ISENTRESS 25 MG TABLET CHEW	3	Preferred Brand	$47.00	N/A	None
ISENTRESS 400MG TABLET	5	Specialty Tier	26%	N/A	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	$100.00	N/A	None
ISOLYTE S IV SOLUTION-EXCEL	4	Non-Preferred Brand	$100.00	N/A	None
ISONIAZID 100 MG TABLET	2*	Generic	$10.00	N/A	None
ISONIAZID 300 MG TABLET	2*	Generic	$10.00	N/A	None
ISONIAZID 50MG/5ML SYRUP	2*	Generic	$10.00	N/A	None
ISONIAZID INJ 100MG/ML	2*	Generic	$10.00	N/A	None
ISOSORBIDE DINITRATE 40MG TABLETS EXTENDED RELEASE	2*	Generic	$10.00	N/A	None
ISOSORBIDE DN 10 MG TABLET	2*	Generic	$10.00	N/A	None
ISOSORBIDE DN 20MG TABLET	2*	Generic	$10.00	N/A	None
ISOSORBIDE DN 30MG TABLET	2*	Generic	$10.00	N/A	None
ISOSORBIDE DN 5 MG TABLET	2*	Generic	$10.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ISOSORBIDE MN 10 MG TABLET	2*	Generic	$10.00	N/A	None
ISOSORBIDE MONONITRATE 20MG TABLET	2*	Generic	$10.00	N/A	None
ISOSORBIDE MONONITRATE ER TABLET 120MG (100 CT)	2*	Generic	$10.00	N/A	None
ISOSORBIDE MONONITRATE ER TABLET 30MG (100 CT)	2*	Generic	$10.00	N/A	None
ISOSORBIDE MONONITRATE TABLETS EXTENDED RELEASE 60MG 100 TABLETS BOT	2*	Generic	$10.00	N/A	None
ISOTON GENTAMICIN 80MG/100ML	2*	Generic	$10.00	N/A	None
ISOTONIC GENTAMICIN 100 MG/100 ML	2*	Generic	$10.00	N/A	None
ISOTONIC GENTAMICIN 80 MG/50 ML	2*	Generic	$10.00	N/A	None
ISRADIPINE CAPSULES 2.5MG (100 CT)	2*	Generic	$10.00	N/A	None
ISRADIPINE CAPSULES 5MG (100 CT)	2*	Generic	$10.00	N/A	None
ISTALOL 0.5% EYE DROPS	4	Non-Preferred Brand	$100.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ISTODAX 10 MG VIAL	5	Specialty Tier	26%	N/A	None
ITRACONAZOLE 100MG CAPSULE	2*	Generic	$10.00	N/A	None
IVERMECTIN 3 MG TABLET [Stromectol, Sklice]	2*	Generic	$10.00	N/A	None
IXIARO JAPANESE ENCEPHALITIS VACCINE 6MCG/.5ML	4	Non-Preferred Brand	$100.00	N/A	None

Chart Legend:

Below are a few notes to help you understand the above 2017 Medicare Part D Harvard Pilgrim Stride Value Rx (HMO) 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 $400 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 $3700) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2017 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 2017 )

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.