2019 Medicare Part D Plan Formulary Information |
Humana Gold Plus SNP-DE H4007-016 (HMO SNP) (H4007-016-0)
Benefit Details
|
The Humana Gold Plus SNP-DE H4007-016 (HMO SNP) (H4007-016-0) Formulary Drugs Starting with the Letter I in Trujillo Alto County, PR: CMS MA Region 30 which includes: PR Plan Monthly Premium: $0.00 Deductible: $415 |
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] |
2 |
Generic |
25% | 25% | 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 |
2 |
Generic |
25% | 25% | None |
IBUPROFEN 400 MG TABLET |
1 |
Preferred Generic |
25% | 25% | None |
IBUPROFEN 600 MG ORAL TABLET |
1 |
Preferred Generic |
25% | 25% | None |
IBUPROFEN 600mg/1 500 TABLET BOTTLE |
1 |
Preferred Generic |
25% | 25% | None |
IBUPROFEN 800 MG ORAL TABLET |
1 |
Preferred Generic |
25% | 25% | None |
IBUPROFEN 800 MG TABLET |
1 |
Preferred Generic |
25% | 25% | 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 |
25% | N/A | P Q:60 /30Days |
ICLUSIG 45 MG TABLET |
5* |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
IDHIFA 100 MG TABLET |
5* |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
IDHIFA 50 MG TABLET |
5* |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
ILEVRO 0.3% OPHTH DROPS |
3 |
Preferred Brand |
25% | 25% | None |
IMATINIB MESYLATE 100 MG TAB [Gleevec] |
2 |
Generic |
25% | 25% | P Q:180 /30Days |
IMATINIB MESYLATE 400 MG TAB [Gleevec] |
2 |
Generic |
25% | 25% | P Q:60 /30Days |
IMBRUVICA 140 MG CAPSULE |
5* |
Specialty Tier |
25% | N/A | P Q:90 /30Days |
IMBRUVICA 420 MG TABLET |
5* |
Specialty Tier |
25% | N/A | P Q:28 /28Days |
IMBRUVICA 560 MG TABLET |
5* |
Specialty Tier |
25% | N/A | P Q:28 /28Days |
IMBRUVICA 70 MG CAPSULE |
5* |
Specialty Tier |
25% | N/A | P Q:28 /28Days |
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 |
25% | 25% | P |
IMIPRAMINE HCL 25MG TABLET (100 CT) |
2 |
Generic |
25% | 25% | P |
IMIPRAMINE HCL 50 MG TABLET |
2 |
Generic |
25% | 25% | P |
IMIPRAMINE PAMOATE 100MG CAPSULES |
2 |
Generic |
25% | 25% | P |
IMIPRAMINE PAMOATE 125MG CAPSULES |
2 |
Generic |
25% | 25% | P |
IMIPRAMINE PAMOATE 150MG CAPSULES |
2 |
Generic |
25% | 25% | P |
IMIPRAMINE PAMOATE 75MG CAPSULES |
2 |
Generic |
25% | 25% | P |
IMIQUIMOD 5% CREAM PACKET |
2 |
Generic |
25% | 25% | Q:12 /30Days |
IMOVAX RABIES VACCINE |
3 |
Preferred Brand |
25% | 25% | P |
INCASSIA 0.35 MG TABLET [Sharobel 28-Day] |
2 |
Generic |
25% | 25% | None |
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 |
25% | 25% | Q:30 /30Days |
Indapamide 1.25mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
1 |
Preferred Generic |
25% | 25% | None |
INDAPAMIDE 2.5 MG TABLET |
1 |
Preferred Generic |
25% | 25% | None |
INDOMETHACIN 25 MG CAPSULE |
2 |
Generic |
25% | 25% | None |
INDOMETHACIN 50 MG CAPSULE |
2 |
Generic |
25% | 25% | None |
INDOMETHACIN ER 75 MG CAPSULE |
2 |
Generic |
25% | 25% | None |
INFANRIX DTAP VIAL |
4 |
Non-Preferred Drug |
25% | 25% | None |
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 |
25% | 25% | Q:120 /30Days |
INTRALIPID 20% IV FAT EMUL EMULSION |
4 |
Non-Preferred Drug |
25% | 25% | P |
INTRALIPID 30% IV FAT EMUL |
4 |
Non-Preferred Drug |
25% | 25% | 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 VIAL |
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 0.15-0.03 MG TABLET TBDSPK 3MO [Setlakin] |
2 |
Generic |
25% | 25% | Q:91 /90Days |
INVANZ 1GM VIAL |
5* |
Specialty Tier |
25% | N/A | None |
Invega Sustenna 117 mg/0.75mL Prefilled Syringe |
5* |
Specialty Tier |
25% | N/A | Q:2 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 |
25% | 25% | Q:2 /28Days |
Invega Sustenna 78 mg/0.5mL Prefilled Syringe |
4 |
Non-Preferred Drug |
25% | 25% | 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 |
INVEGA TRINZA 819 MG/2.625 ML |
5* |
Specialty Tier |
25% | N/A | Q:3 /90Days |
INVIRASE 500MG TABLET |
5* |
Specialty Tier |
25% | N/A | Q:120 /30Days |
INVOKAMET 150-1,000 MG TABLET |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days |
INVOKAMET 150-500 MG TABLET |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INVOKAMET 50-1,000 MG TABLET |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days |
INVOKAMET 50-500 MG TABLET |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days |
INVOKAMET XR 150-1,000 MG TAB |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days |
INVOKAMET XR 150-500 MG TABLET |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days |
INVOKAMET XR 50-1,000 MG TAB |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days |
INVOKAMET XR 50-500 MG TABLET |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days |
INVOKANA 100 MG TABLET |
3 |
Preferred Brand |
25% | 25% | Q:30 /30Days |
INVOKANA 300 MG TABLET |
3 |
Preferred Brand |
25% | 25% | Q:30 /30Days |
IONOSOL MB-D5W IV SOLUTION |
4 |
Non-Preferred Drug |
25% | 25% | None |
IPOL VIAL 40;8;32; UNT |
4 |
Non-Preferred Drug |
25% | 25% | None |
IPRAT-ALBUT 0.5-3(2.5) MG/3 ML |
2 |
Generic |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IPRATROPIUM 0.06% SPRAY |
2 |
Generic |
25% | 25% | Q:45 /30Days |
IPRATROPIUM BR 0.02% SOLN |
2 |
Generic |
25% | 25% | P |
IPRATROPIUM BROMIDE NASAL SPRAY |
2 |
Generic |
25% | 25% | Q:30 /30Days |
IRBESARTAN 150 MG TABLET [Avapro] |
1 |
Preferred Generic |
25% | 25% | Q:30 /30Days |
IRBESARTAN 300 MG TABLET [Avapro] |
1 |
Preferred Generic |
25% | 25% | Q:30 /30Days |
IRBESARTAN 75 MG TABLET [Avapro] |
1 |
Preferred Generic |
25% | 25% | Q:30 /30Days |
IRBESARTAN-HCTZ 150-12.5 MG TABLET [Avalide] |
1 |
Preferred Generic |
25% | 25% | Q:30 /30Days |
IRBESARTAN-HCTZ 300-12.5 MG TABLET [Avalide] |
1 |
Preferred Generic |
25% | 25% | Q:30 /30Days |
IRESSA 250 MG TABLET |
5* |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
ISENTRESS 100 MG POWDER PACKET |
3 |
Preferred Brand |
25% | 25% | Q:300 /30Days |
ISENTRESS 100 MG TABLET CHEW |
5* |
Specialty Tier |
25% | N/A | Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISENTRESS 25 MG TABLET CHEW |
4 |
Non-Preferred Drug |
25% | 25% | Q:180 /30Days |
ISENTRESS 400MG TABLET |
5* |
Specialty Tier |
25% | N/A | Q:120 /30Days |
ISENTRESS HD 600 MG TABLET |
5* |
Specialty Tier |
25% | N/A | Q:60 /30Days |
ISIBLOOM 28 DAY TABLET [Solia] |
2 |
Generic |
25% | 25% | None |
ISOLYTE P IN 5% DEXTROSE INJECTION |
4 |
Non-Preferred Drug |
25% | 25% | None |
ISOLYTE S IV SOLUTION-EXCEL |
4 |
Non-Preferred Drug |
25% | 25% | None |
ISONIAZID 100 MG TABLET |
1 |
Preferred Generic |
25% | 25% | None |
ISONIAZID 300 MG TABLET |
1 |
Preferred Generic |
25% | 25% | None |
ISONIAZID 50MG/5ML SYRUP |
2 |
Generic |
25% | 25% | None |
ISORDIL 40 MG TABLET |
4 |
Non-Preferred Drug |
25% | 25% | None |
ISORDIL TITRADOSE 5 MG TAB |
4 |
Non-Preferred Drug |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISOSORBIDE DINITRATE 40MG TABLETS ER |
2 |
Generic |
25% | 25% | None |
ISOSORBIDE DN 10 MG TABLET |
2 |
Generic |
25% | 25% | None |
ISOSORBIDE DN 20 MG TABLET |
2 |
Generic |
25% | 25% | None |
ISOSORBIDE DN 30 MG TABLET |
2 |
Generic |
25% | 25% | None |
ISOSORBIDE DN 5 MG TABLET |
2 |
Generic |
25% | 25% | None |
ISOSORBIDE MN 10 MG TABLET |
1 |
Preferred Generic |
25% | 25% | None |
ISOSORBIDE MN ER 30 MG TABLET |
2 |
Generic |
25% | 25% | None |
ISOSORBIDE MN ER 60 MG TABLET |
2 |
Generic |
25% | 25% | None |
ISOSORBIDE MONONITRATE 20MG TABLET |
1 |
Preferred Generic |
25% | 25% | None |
ISOSORBIDE MONONITRATE ER TABLET 120MG (100 CT) |
2 |
Generic |
25% | 25% | None |
ISOTON GENTAMICIN 80MG/100ML |
2 |
Generic |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISOTONIC GENTAMICIN 100 MG/100 ML |
2 |
Generic |
25% | 25% | None |
ISOTONIC GENTAMICIN 80 MG/50 ML |
2 |
Generic |
25% | 25% | None |
ISOTRETINOIN 10 MG CAPSULE [ZENATANE] |
2 |
Generic |
25% | 25% | Q:60 /30Days |
ISOTRETINOIN 20 MG CAPSULE [ZENATANE] |
2 |
Generic |
25% | 25% | Q:60 /30Days |
ISOTRETINOIN 30 MG CAPSULE [ZENATANE] |
2 |
Generic |
25% | 25% | Q:60 /30Days |
ISOTRETINOIN 40 MG CAPSULE [ZENATANE] |
2 |
Generic |
25% | 25% | Q:120 /30Days |
ISRADIPINE CAPSULES 2.5MG (100 CT) |
2 |
Generic |
25% | 25% | None |
ISRADIPINE CAPSULES 5MG (100 CT) |
2 |
Generic |
25% | 25% | None |
ITRACONAZOLE 100 MG CAPSULE [Sporanox] |
2 |
Generic |
25% | 25% | Q:120 /30Days |
IVERMECTIN 3 MG TABLET [Stromectol, Sklice] |
2 |
Generic |
25% | 25% | None |
IXIARO JAPANESE ENCEPHALITIS VACCINE 6MCG/.5ML |
4 |
Non-Preferred Drug |
25% | 25% | None |