2019 Medicare Part D Plan Formulary Information |
Blue Medicare Advantage Plus (HMO) (H1352-002-0)
Benefit Details
|
The Blue Medicare Advantage Plus (HMO) (H1352-002-0) Formulary Drugs Starting with the Letter I in Clay County, MO: CMS MA Region 15 which includes: MO Plan Monthly Premium: $29.00 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 SODIUM 150 MG TABLET [Boniva] |
1 |
Preferred Generic |
$3.00 | $0.00 | Q:1 /28Days |
IBRANCE 100 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:21 /28Days |
IBRANCE 125 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:21 /28Days |
IBRANCE 75 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:21 /28Days |
Ibuprofen 100mg/5mL 473 mL in 1 BOTTLE |
1 |
Preferred Generic |
$3.00 | $0.00 | None |
IBUPROFEN 400 MG TABLET |
1 |
Preferred Generic |
$3.00 | $0.00 | None |
IBUPROFEN 600 MG ORAL TABLET |
1 |
Preferred Generic |
$3.00 | $0.00 | None |
IBUPROFEN 600mg/1 500 TABLET BOTTLE |
1 |
Preferred Generic |
$3.00 | $0.00 | None |
IBUPROFEN 800 MG ORAL TABLET |
1 |
Preferred Generic |
$3.00 | $0.00 | None |
IBUPROFEN 800 MG TABLET |
1 |
Preferred Generic |
$3.00 | $0.00 | 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 Q:60 /30Days |
ICLUSIG 45 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
IDHIFA 100 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
IDHIFA 50 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
ILEVRO 0.3% OPHTH DROPS |
3 |
Preferred Brand |
$47.00 | $117.50 | None |
ILUMYA 100 MG/ML SYRINGE |
5 |
Specialty Tier |
33% | N/A | P |
IMATINIB MESYLATE 100 MG TAB [Gleevec] |
5 |
Specialty Tier |
33% | N/A | P Q:90 /30Days |
IMATINIB MESYLATE 400 MG TAB [Gleevec] |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
IMBRUVICA 140 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:120 /30Days |
IMBRUVICA 140 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:28 /28Days |
IMBRUVICA 280 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:28 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IMBRUVICA 420 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:28 /28Days |
IMBRUVICA 560 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:28 /28Days |
IMBRUVICA 70 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:28 /28Days |
IMIPRAMINE HCL 10MG TABLET (100 CT) |
1 |
Preferred Generic |
$3.00 | $0.00 | P |
IMIPRAMINE HCL 25MG TABLET (100 CT) |
1 |
Preferred Generic |
$3.00 | $0.00 | P |
IMIPRAMINE HCL 50 MG TABLET |
1 |
Preferred Generic |
$3.00 | $0.00 | P |
IMIQUIMOD 5% CREAM PACKET |
2 |
Generic |
$12.00 | $0.00 | P Q:24 /30Days |
IMOVAX RABIES VACCINE |
3 |
Preferred Brand |
$47.00 | $117.50 | P |
INBRIJA 42 MG INHALATION CAP CAP W/DEV |
5 |
Specialty Tier |
33% | N/A | P Q:300 /30Days |
INCASSIA 0.35 MG TABLET [Sharobel 28-Day] |
1 |
Preferred Generic |
$3.00 | $0.00 | None |
Increlex 40mg/4mL 1 VIAL, MULTI-DOSE per CARTON / 4 mL in 1 VIAL, MULTI-DOSE |
5 |
Specialty Tier |
33% | N/A | None |
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 | $117.50 | None |
Indapamide 1.25mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Preferred Generic |
$3.00 | $0.00 | None |
INDAPAMIDE 2.5 MG TABLET |
1 |
Preferred Generic |
$3.00 | $0.00 | None |
INDOMETHACIN 25 MG CAPSULE |
1 |
Preferred Generic |
$3.00 | $0.00 | P Q:240 /30Days |
INDOMETHACIN 50 MG CAPSULE |
1 |
Preferred Generic |
$3.00 | $0.00 | P Q:120 /30Days |
INFANRIX DTAP VIAL |
3 |
Preferred Brand |
$47.00 | $117.50 | None |
INGREZZA 40 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
INGREZZA 80 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
INGREZZA INITIATION PACK CAPSULE DS PK |
5 |
Specialty Tier |
33% | N/A | P |
INLYTA 1 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:180 /30Days |
INLYTA 5 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INTELENCE 100MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
Intelence 200mg/1 |
5 |
Specialty Tier |
33% | N/A | None |
INTELENCE 25 MG TABLET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
INTRALIPID 20% IV FAT EMUL EMULSION |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | P |
INTRALIPID 30% IV FAT EMUL |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | 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 VIAL |
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 |
INTROVALE 0.15-0.03 MG TABLET TBDSPK 3MO [Setlakin] |
1 |
Preferred Generic |
$3.00 | $0.00 | Q:91 /84Days |
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 |
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 Brand |
$100.00 | $250.00 | None |
Invega Sustenna 78 mg/0.5mL Prefilled Syringe |
5 |
Specialty Tier |
33% | N/A | Q:1 /28Days |
INVEGA TRINZA 273 MG/0.875 ML |
5 |
Specialty Tier |
33% | N/A | Q:1 /84Days |
INVEGA TRINZA 410 MG/1.315 ML |
5 |
Specialty Tier |
33% | N/A | Q:1 /84Days |
INVEGA TRINZA 546 MG/1.75 ML |
5 |
Specialty Tier |
33% | N/A | Q:2 /84Days |
INVEGA TRINZA 819 MG/2.625 ML |
5 |
Specialty Tier |
33% | N/A | Q:3 /84Days |
INVELTYS 1% EYE DROP Eye Dropper |
3 |
Preferred Brand |
$47.00 | $117.50 | None |
INVIRASE 500MG 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 |
INVOKAMET 150-1,000 MG TABLET |
3 |
Preferred Brand |
$47.00 | $117.50 | S Q:60 /30Days |
INVOKAMET 150-500 MG TABLET |
3 |
Preferred Brand |
$47.00 | $117.50 | S Q:60 /30Days |
INVOKAMET 50-1,000 MG TABLET |
3 |
Preferred Brand |
$47.00 | $117.50 | S Q:60 /30Days |
INVOKAMET 50-500 MG TABLET |
3 |
Preferred Brand |
$47.00 | $117.50 | S Q:120 /30Days |
INVOKAMET XR 150-1,000 MG TAB |
3 |
Preferred Brand |
$47.00 | $117.50 | S Q:60 /30Days |
INVOKAMET XR 150-500 MG TABLET |
3 |
Preferred Brand |
$47.00 | $117.50 | S Q:60 /30Days |
INVOKAMET XR 50-1,000 MG TAB |
3 |
Preferred Brand |
$47.00 | $117.50 | S Q:60 /30Days |
INVOKAMET XR 50-500 MG TABLET |
3 |
Preferred Brand |
$47.00 | $117.50 | S Q:60 /30Days |
INVOKANA 100 MG TABLET |
3 |
Preferred Brand |
$47.00 | $117.50 | S Q:60 /30Days |
INVOKANA 300 MG TABLET |
3 |
Preferred Brand |
$47.00 | $117.50 | S Q:30 /30Days |
IONOSOL MB-D5W IV SOLUTION |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IPOL VIAL 40;8;32; UNT |
3 |
Preferred Brand |
$47.00 | $117.50 | None |
IPRATROPIUM 0.06% SPRAY |
1 |
Preferred Generic |
$3.00 | $0.00 | Q:15 /10Days |
IPRATROPIUM BR 0.02% SOLN |
1 |
Preferred Generic |
$3.00 | $0.00 | P |
IPRATROPIUM BROMIDE NASAL SPRAY |
1 |
Preferred Generic |
$3.00 | $0.00 | Q:30 /28Days |
IRBESARTAN 150 MG TABLET [Avapro] |
1 |
Preferred Generic |
$3.00 | $0.00 | None |
IRBESARTAN 300 MG TABLET [Avapro] |
1 |
Preferred Generic |
$3.00 | $0.00 | None |
IRBESARTAN 75 MG TABLET [Avapro] |
1 |
Preferred Generic |
$3.00 | $0.00 | None |
IRBESARTAN-HCTZ 150-12.5 MG TABLET [Avalide] |
1 |
Preferred Generic |
$3.00 | $0.00 | None |
IRBESARTAN-HCTZ 300-12.5 MG TABLET [Avalide] |
1 |
Preferred Generic |
$3.00 | $0.00 | None |
IRESSA 250 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P Q:60 /30Days |
ISENTRESS 100 MG POWDER PACKET |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISENTRESS 100 MG TABLET CHEW |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
ISENTRESS 25 MG TABLET CHEW |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
ISENTRESS 400MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
ISENTRESS HD 600 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
ISIBLOOM 28 DAY TABLET [Solia] |
1 |
Preferred Generic |
$3.00 | $0.00 | None |
ISOLYTE P IN 5% DEXTROSE INJECTION |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
ISOLYTE S IV SOLUTION-EXCEL |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None |
ISONIAZID 100 MG TABLET |
1 |
Preferred Generic |
$3.00 | $0.00 | None |
ISONIAZID 300 MG TABLET |
1 |
Preferred Generic |
$3.00 | $0.00 | None |
ISONIAZID 50MG/5ML SYRUP |
2 |
Generic |
$12.00 | $0.00 | None |
ISOSORBIDE DINITRATE 40MG TABLETS ER |
2 |
Generic |
$12.00 | $0.00 | 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 |
$12.00 | $0.00 | None |
ISOSORBIDE DN 20 MG TABLET |
2 |
Generic |
$12.00 | $0.00 | None |
ISOSORBIDE DN 30 MG TABLET |
2 |
Generic |
$12.00 | $0.00 | None |
ISOSORBIDE DN 5 MG TABLET |
2 |
Generic |
$12.00 | $0.00 | None |
ISOSORBIDE MN 10 MG TABLET |
1 |
Preferred Generic |
$3.00 | $0.00 | None |
ISOSORBIDE MN ER 30 MG TABLET |
1 |
Preferred Generic |
$3.00 | $0.00 | None |
ISOSORBIDE MN ER 60 MG TABLET |
1 |
Preferred Generic |
$3.00 | $0.00 | None |
ISOSORBIDE MONONITRATE 20MG TABLET |
1 |
Preferred Generic |
$3.00 | $0.00 | None |
ISOSORBIDE MONONITRATE ER TABLET 120MG (100 CT) |
1 |
Preferred Generic |
$3.00 | $0.00 | None |
ISOTON GENTAMICIN 80MG/100ML |
2 |
Generic |
$12.00 | $0.00 | None |
ISOTONIC GENTAMICIN 100 MG/100 ML |
2 |
Generic |
$12.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISOTONIC GENTAMICIN 80 MG/50 ML |
2 |
Generic |
$12.00 | $0.00 | None |
ITRACONAZOLE 100 MG CAPSULE [Sporanox] |
2 |
Generic |
$12.00 | $0.00 | None |
IVERMECTIN 3 MG TABLET [Stromectol, Sklice] |
2 |
Generic |
$12.00 | $0.00 | None |
Ixekizumab 1ML 80 MG/ML Auto-Injector [Taltz] |
5 |
Specialty Tier |
33% | N/A | P |
Ixekizumab 1ML 80 MG/ML Prefilled Syringe [Taltz] |
5 |
Specialty Tier |
33% | N/A | P |
IXIARO JAPANESE ENCEPHALITIS VACCINE 6MCG/.5ML |
3 |
Preferred Brand |
$47.00 | $117.50 | None |