2018 Medicare Part D Plan Formulary Information |
Kaiser Permanente Medicare Plus High w/Part D (AB) (Cost) (H2150-002-0)
Benefit Details
|
The Kaiser Permanente Medicare Plus High w/Part D (AB) (Cost) (H2150-002-0) Formulary Drugs Starting with the Letter I in Howard County, MD: CMS MA Region 5 which includes: MD Plan Monthly Premium: $142.00 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 |
$15.00 | $30.00 | None |
IBANDRONATE SODIUM 150 MG TABLET [Boniva] |
2 |
Generic |
$15.00 | $30.00 | P |
IBRANCE 100 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |
IBRANCE 125 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |
IBRANCE 75 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |
IBUDONE 10; 200mg/1; mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
2 |
Generic |
$15.00 | $30.00 | None |
Ibuprofen 100mg/5mL 473 mL in 1 BOTTLE |
2 |
Generic |
$15.00 | $30.00 | None |
IBUPROFEN 400 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
IBUPROFEN 600 MG ORAL TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
IBUPROFEN 600mg/1 500 TABLET BOTTLE |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IBUPROFEN 800 MG ORAL TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
IBUPROFEN 800 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
ICLUSIG 15 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
ICLUSIG 45 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
IDAMYCIN PFS 1MG/ML VIAL |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
IDARUBICIN HCL 1MG/ML VIAL |
2 |
Generic |
$15.00 | $30.00 | None |
IDHIFA 100 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
IDHIFA 50 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
IFEX 1g/1 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, SINGLE-DOSE |
3 |
Preferred Brand |
$42.00 | $84.00 | None |
IFOSFAMIDE FOR INFECTION 1 GM |
2 |
Generic |
$15.00 | $30.00 | None |
ILARIS 150 MG/ML VIAL |
5 |
Specialty Tier |
33% | 33% | None |
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 |
$80.00 | $160.00 | None |
IMATINIB MESYLATE 100 MG TAB [Gleevec] |
2 |
Generic |
$15.00 | $30.00 | None |
IMATINIB MESYLATE 400 MG TAB [Gleevec] |
2 |
Generic |
$15.00 | $30.00 | None |
IMBRUVICA 140 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |
IMBRUVICA 140 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
IMBRUVICA 280 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
IMBRUVICA 420 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
IMBRUVICA 560 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
IMBRUVICA 70 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |
IMFINZI 120 MG/2.4 ML VIAL |
5 |
Specialty Tier |
33% | 33% | None |
IMFINZI 500 MG/10 ML VIAL |
5 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IMIPRAMINE HCL 10MG TABLET (100 CT) |
2 |
Generic |
$15.00 | $30.00 | None |
IMIPRAMINE HCL 25MG TABLET (100 CT) |
2 |
Generic |
$15.00 | $30.00 | None |
IMIPRAMINE HCL 50 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
IMIPRAMINE PAMOATE 100MG CAPSULES |
2 |
Generic |
$15.00 | $30.00 | None |
IMIPRAMINE PAMOATE 125MG CAPSULES |
2 |
Generic |
$15.00 | $30.00 | None |
IMIPRAMINE PAMOATE 150MG CAPSULES |
2 |
Generic |
$15.00 | $30.00 | None |
IMIPRAMINE PAMOATE 75MG CAPSULES |
2 |
Generic |
$15.00 | $30.00 | None |
IMIQUIMOD 5% CREAM PACKET |
2 |
Generic |
$15.00 | $30.00 | None |
IMITREX 100MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
IMITREX 20MG NASAL SPRAY |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
IMITREX 25MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IMITREX 4 MG/0.5 ML PEN INJECT |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
IMITREX 50MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
IMITREX 5MG NASAL SPRAY |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
IMITREX 6MG/0.5ML SYRNG KIT |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
IMITREX 6MG/0.5ML VIAL |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
IMOGAM RABIES-HT 150 UNIT/ML VIAL [KEDRAB] |
3 |
Preferred Brand |
$42.00 | $84.00 | None |
IMOVAX RABIES VACCINE |
6 |
Vaccines |
$0.00 | N/A | None |
IMPOYZ 0.025% CREAM (g) |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
IMURAN 50 MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | P |
Increlex 40mg/4mL 1 VIAL, MULTI-DOSE per CARTON / 4 mL in 1 VIAL, MULTI-DOSE |
5 |
Specialty Tier |
33% | 33% | None |
INCRUSE ELLIPTA 62.5 MCG INH |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Indapamide 1.25mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Preferred Generic |
$5.00 | $0.00 | None |
INDAPAMIDE 2.5 MG TABLET |
1 |
Preferred Generic |
$5.00 | $0.00 | None |
INDERAL LA 120 MG CAPSULE |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
INDERAL LA 160 MG CAPSULE |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
INDERAL LA 60 MG CAPSULE |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
INDERAL LA 80 MG CAPSULE |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
INDOCIN ORAL SUSPENSION 25MG/5ML 237 ML BOT |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
INDOMETHACIN 25 MG CAPSULE |
2 |
Generic |
$15.00 | $30.00 | None |
INDOMETHACIN 50 MG CAPSULE |
2 |
Generic |
$15.00 | $30.00 | None |
INDOMETHACIN ER 75 MG CAPSULE |
2 |
Generic |
$15.00 | $30.00 | None |
INFANRIX DTAP VIAL |
6 |
Vaccines |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INFLECTRA 100 MG VIAL |
5 |
Specialty Tier |
33% | 33% | None |
INGREZZA 40 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |
INGREZZA 80 MG CAPSULE |
5 |
Specialty Tier |
33% | 33% | None |
INLYTA 1 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
INLYTA 5 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
INNOPRAN XL 120 MG CAPSULE |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
INNOPRAN XL 80 MG CAPSULE |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
INSPRA 25 MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
INSPRA 50 MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
INTELENCE 100MG TABLET |
3 |
Preferred Brand |
$42.00 | $84.00 | None |
Intelence 200mg/1 |
3 |
Preferred Brand |
$42.00 | $84.00 | 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 |
$42.00 | $84.00 | None |
INTERMEZZO 1.75 MG TAB SUBLING |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
INTERMEZZO 3.5 MG TAB SUBLING |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
INTRALIPID 20% IV FAT EMUL EMULSION |
2 |
Generic |
$15.00 | $30.00 | None |
INTRALIPID 30% IV FAT EMUL |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
INTRAROSA 6.5 MG VAG INSERT |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
INTRON A 10 MILLION UNITS VIAL |
5 |
Specialty Tier |
33% | 33% | None |
INTRON A 18 MILLION UNITS VIAL |
5 |
Specialty Tier |
33% | 33% | None |
INTRON A 25 MILLION UNIT/2.5ML VIAL |
5 |
Specialty Tier |
33% | 33% | None |
INTRON A 50 MILLION UNITS VIAL |
5 |
Specialty Tier |
33% | 33% | None |
INTRON A 6MMU/ML VIAL |
5 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INTROVALE 0.15-0.03 MG TABLET TBDSPK 3MO [Setlakin] |
2 |
Generic |
$15.00 | $30.00 | None |
Intuniv 1 MG ER 100 TABLET in BOTTLE |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
Intuniv 2 MG ER 100 TABLET in BOTTLE |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
Intuniv 3 MG ER 100 TABLET in BOTTLE |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
Intuniv 4 MG ER 100 TABLET in BOTTLE |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
INVANZ 1GM VIAL |
3 |
Preferred Brand |
$42.00 | $84.00 | None |
INVEGA 3MG TABLET SR OSMOTIC PUSH 24HR |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
INVEGA 6MG TABLET SR OSMOTIC PUSH 24HR |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
INVEGA 9MG TABLET SR OSMOTIC PUSH 24HR |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
INVEGA ER 1.5mg/ 30 TABLET BOTTLE |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
Invega Sustenna 117 mg/0.75mL Prefilled Syringe |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Invega Sustenna 156 mg/mL Prefilled Syringe |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
Invega Sustenna 234 mg/1.5mL Prefilled Syringe |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
Invega Sustenna 39 mg/0.25mL Prefilled Syringe |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
Invega Sustenna 78 mg/0.5mL Prefilled Syringe |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
INVEGA TRINZA 273 MG/0.875 ML |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
INVEGA TRINZA 410 MG/1.315 ML |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
INVEGA TRINZA 546 MG/1.75 ML |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
INVEGA TRINZA 819 MG/2.625 ML |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
INVIRASE 200MG CAPSULE |
3 |
Preferred Brand |
$42.00 | $84.00 | None |
INVIRASE 500MG TABLET |
3 |
Preferred Brand |
$42.00 | $84.00 | None |
INVOKAMET 150-1,000 MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INVOKAMET 150-500 MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
INVOKAMET 50-1,000 MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
INVOKAMET 50-500 MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
INVOKAMET XR 150-1,000 MG TAB |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
INVOKAMET XR 150-500 MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
INVOKAMET XR 50-1,000 MG TAB |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
INVOKAMET XR 50-500 MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
INVOKANA 100 MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
INVOKANA 300 MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
IONOSOL MB-D5W IV SOLUTION |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
IOPIDINE 0.5% EYE DROPS |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IOPIDINE 1% EYE DROPS |
3 |
Preferred Brand |
$42.00 | $84.00 | None |
IPOL VIAL 40;8;32; UNT |
6 |
Vaccines |
$0.00 | N/A | None |
IPRAT-ALBUT 0.5-3(2.5) MG/3 ML |
2 |
Generic |
$15.00 | $30.00 | P |
IPRATROPIUM 0.06% SPRAY |
2 |
Generic |
$15.00 | $30.00 | None |
IPRATROPIUM BR 0.02% SOLN |
1 |
Preferred Generic |
$5.00 | $0.00 | P |
IPRATROPIUM BROMIDE NASAL SPRAY |
2 |
Generic |
$15.00 | $30.00 | None |
IRBESARTAN 150 MG TABLET [Avapro] |
2 |
Generic |
$15.00 | $30.00 | None |
IRBESARTAN 300 MG TABLET [Avapro] |
2 |
Generic |
$15.00 | $30.00 | None |
IRBESARTAN 75 MG TABLET [Avapro] |
2 |
Generic |
$15.00 | $30.00 | None |
IRBESARTAN-HCTZ 150-12.5 MG TB [Avalide] |
2 |
Generic |
$15.00 | $30.00 | None |
IRBESARTAN-HCTZ 300-12.5 MG TB [Avalide] |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IRESSA 250 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
IRINOTECAN HCL 100 MG/5 ML VL |
2 |
Generic |
$15.00 | $30.00 | None |
ISENTRESS 100 MG POWDER PACKET |
3 |
Preferred Brand |
$42.00 | $84.00 | None |
ISENTRESS 100 MG TABLET CHEW |
3 |
Preferred Brand |
$42.00 | $84.00 | None |
ISENTRESS 25 MG TABLET CHEW |
3 |
Preferred Brand |
$42.00 | $84.00 | None |
ISENTRESS 400MG TABLET |
3 |
Preferred Brand |
$42.00 | $84.00 | None |
ISENTRESS HD 600 MG TABLET |
3 |
Preferred Brand |
$42.00 | $84.00 | None |
ISIBLOOM 28 DAY TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
ISOLYTE P IN 5% DEXTROSE INJECTION |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
ISOLYTE S IV SOLUTION-EXCEL |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
ISONIAZID 100 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISONIAZID 300 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
ISONIAZID 50MG/5ML SYRUP |
2 |
Generic |
$15.00 | $30.00 | None |
ISONIAZID INJ 100MG/ML |
2 |
Generic |
$15.00 | $30.00 | None |
ISOPTO CARPINE 10mg/mL 15 mL in 1 BOTTLE |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
ISOPTO CARPINE 20mg/mL 15 mL in 1 BOTTLE |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
ISOPTO CARPINE 40mg/mL 15 mL in 1 BOTTLE |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
ISORDIL 40 MG TABLET |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
ISORDIL TITRADOSE 5 MG TAB |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
ISOSORBIDE DINITRATE 40MG TABLETS ER |
2 |
Generic |
$15.00 | $30.00 | None |
ISOSORBIDE DN 10 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
ISOSORBIDE DN 20 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISOSORBIDE DN 30 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
ISOSORBIDE DN 5 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
ISOSORBIDE MN 10 MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
ISOSORBIDE MN ER 30 MG TABLET |
1 |
Preferred Generic |
$5.00 | $0.00 | None |
ISOSORBIDE MN ER 60 MG TABLET |
1 |
Preferred Generic |
$5.00 | $0.00 | None |
ISOSORBIDE MONONITRATE 20MG TABLET |
2 |
Generic |
$15.00 | $30.00 | None |
ISOSORBIDE MONONITRATE ER TABLET 120MG (100 CT) |
2 |
Generic |
$15.00 | $30.00 | None |
ISOTON GENTAMICIN 80MG/100ML |
2 |
Generic |
$15.00 | $30.00 | None |
ISOTONIC GENTAMICIN 100 MG/100 ML |
2 |
Generic |
$15.00 | $30.00 | None |
ISOTONIC GENTAMICIN 80 MG/50 ML |
2 |
Generic |
$15.00 | $30.00 | None |
ISOTRETINOIN 10 MG CAPSULE [ZENATANE] |
2 |
Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISOTRETINOIN 20 MG CAPSULE [ZENATANE] |
2 |
Generic |
$15.00 | $30.00 | None |
ISOTRETINOIN 30 MG CAPSULE [ZENATANE] |
2 |
Generic |
$15.00 | $30.00 | None |
ISOTRETINOIN 40 MG CAPSULE [ZENATANE] |
2 |
Generic |
$15.00 | $30.00 | None |
ISRADIPINE CAPSULES 2.5MG (100 CT) |
2 |
Generic |
$15.00 | $30.00 | None |
ISRADIPINE CAPSULES 5MG (100 CT) |
2 |
Generic |
$15.00 | $30.00 | None |
ISTALOL 0.5% EYE DROPS |
4 |
Non-Preferred Brand |
$80.00 | $160.00 | None |
ISTODAX 10 MG VIAL |
3 |
Preferred Brand |
$42.00 | $84.00 | None |
ITRACONAZOLE 100MG CAPSULE |
2 |
Generic |
$15.00 | $30.00 | None |
IVERMECTIN 3 MG TABLET [Stromectol, Sklice] |
2 |
Generic |
$15.00 | $30.00 | None |
Ixekizumab 1ML 80 MG/ML Auto-Injector [Taltz] |
5 |
Specialty Tier |
33% | 33% | None |
Ixekizumab 1ML 80 MG/ML Prefilled Syringe [Taltz] |
5 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IXIARO JAPANESE ENCEPHALITIS VACCINE 6MCG/.5ML |
6 |
Vaccines |
$0.00 | N/A | None |