2019 Medicare Part D Plan Formulary Information |
AdvantraOne (PPO) (H5522-017-0)
Benefit Details
|
The AdvantraOne (PPO) (H5522-017-0) Formulary Drugs Starting with the Letter I in Monroe County, PA: CMS MA Region 6 which includes: PA Plan Monthly Premium: $0.00 Deductible: $395 |
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] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:1 /30Days |
IBRANCE 100 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P |
IBRANCE 125 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P |
IBRANCE 75 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P |
Ibuprofen 100mg/5mL 473 mL in 1 BOTTLE |
2* |
Generic |
$10.00 | $25.00 | None |
IBUPROFEN 400 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
IBUPROFEN 600 MG ORAL TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
IBUPROFEN 600mg/1 500 TABLET BOTTLE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
IBUPROFEN 800 MG ORAL TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
IBUPROFEN 800 MG TABLET |
1* |
Preferred Generic |
$0.00 | $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 |
25% | N/A | P |
ICLUSIG 45 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
IDHIFA 100 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
IDHIFA 50 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
ILEVRO 0.3% OPHTH DROPS |
3* |
Preferred Brand |
$47.00 | $136.00 | None |
IMATINIB MESYLATE 100 MG TAB [Gleevec] |
5 |
Specialty Tier |
25% | N/A | P Q:90 /30Days |
IMATINIB MESYLATE 400 MG TAB [Gleevec] |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
IMBRUVICA 140 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P |
IMBRUVICA 140 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
IMBRUVICA 280 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
IMBRUVICA 420 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IMBRUVICA 560 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
IMBRUVICA 70 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P |
IMIPRAMINE HCL 10MG TABLET (100 CT) |
2* |
Generic |
$10.00 | $25.00 | P |
IMIPRAMINE HCL 25MG TABLET (100 CT) |
2* |
Generic |
$10.00 | $25.00 | P |
IMIPRAMINE HCL 50 MG TABLET |
2* |
Generic |
$10.00 | $25.00 | P |
IMIPRAMINE PAMOATE 100MG CAPSULES |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
IMIPRAMINE PAMOATE 125MG CAPSULES |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
IMIPRAMINE PAMOATE 150MG CAPSULES |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
IMIPRAMINE PAMOATE 75MG CAPSULES |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
IMIQUIMOD 3.75% CREAM PUMP CRM MD PMP [Zyclara] |
5 |
Specialty Tier |
25% | N/A | Q:8 /30Days |
IMIQUIMOD 5% CREAM PACKET |
3* |
Preferred Brand |
$47.00 | $136.00 | Q:24 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IMOVAX RABIES VACCINE |
3* |
Preferred Brand |
$47.00 | $136.00 | P |
INCASSIA 0.35 MG TABLET [Sharobel 28-Day] |
3* |
Preferred Brand |
$47.00 | $136.00 | None |
Increlex 40mg/4mL 1 VIAL, MULTI-DOSE per CARTON / 4 mL in 1 VIAL, MULTI-DOSE |
5 |
Specialty Tier |
25% | N/A | P |
INCRUSE ELLIPTA 62.5 MCG INH |
3* |
Preferred Brand |
$47.00 | $136.00 | Q:30 /30Days |
Indapamide 1.25mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC |
2* |
Generic |
$10.00 | $25.00 | None |
INDAPAMIDE 2.5 MG TABLET |
2* |
Generic |
$10.00 | $25.00 | None |
INDOMETHACIN 25 MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
INDOMETHACIN 50 MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
INDOMETHACIN ER 75 MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
INFANRIX DTAP VIAL |
3* |
Preferred Brand |
$47.00 | $136.00 | None |
INLYTA 1 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:180 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INLYTA 5 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
INTELENCE 100MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
Intelence 200mg/1 |
5 |
Specialty Tier |
25% | N/A | None |
INTELENCE 25 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
INTRALIPID 20% IV FAT EMUL EMULSION |
3* |
Preferred Brand |
$47.00 | $136.00 | P |
INTRALIPID 30% IV FAT EMUL |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
INTRON A 10 MILLION UNITS VIAL |
5 |
Specialty Tier |
25% | N/A | None |
INTRON A 18 MILLION UNITS VIAL |
5 |
Specialty Tier |
25% | N/A | None |
INTRON A 25 MILLION UNIT/2.5ML VIAL |
5 |
Specialty Tier |
25% | N/A | None |
INTRON A 50 MILLION UNITS VIAL |
5 |
Specialty Tier |
25% | N/A | None |
INTRON A 6MMU/ML VIAL |
5 |
Specialty Tier |
25% | N/A | 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 |
$10.00 | $25.00 | None |
INVANZ 1GM VIAL |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
Invega Sustenna 117 mg/0.75mL Prefilled Syringe |
5 |
Specialty Tier |
25% | N/A | Q:1 /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 | $300.00 | None |
Invega Sustenna 78 mg/0.5mL Prefilled Syringe |
5 |
Specialty Tier |
25% | N/A | Q:1 /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 |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INVIRASE 500MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
IONOSOL MB-D5W IV SOLUTION |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
IPOL VIAL 40;8;32; UNT |
3* |
Preferred Brand |
$47.00 | $136.00 | None |
IPRAT-ALBUT 0.5-3(2.5) MG/3 ML |
2* |
Generic |
$10.00 | $25.00 | P |
IPRATROPIUM 0.06% SPRAY |
2* |
Generic |
$10.00 | $25.00 | Q:45 /30Days |
IPRATROPIUM BR 0.02% SOLN |
2* |
Generic |
$10.00 | $25.00 | P |
IPRATROPIUM BROMIDE NASAL SPRAY |
2* |
Generic |
$10.00 | $25.00 | Q:30 /30Days |
IRBESARTAN 150 MG TABLET [Avapro] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
IRBESARTAN 300 MG TABLET [Avapro] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
IRBESARTAN 75 MG TABLET [Avapro] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
IRBESARTAN-HCTZ 150-12.5 MG TABLET [Avalide] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IRBESARTAN-HCTZ 300-12.5 MG TABLET [Avalide] |
1* |
Preferred Generic |
$0.00 | $0.00 | Q:30 /30Days |
IRESSA 250 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
ISENTRESS 100 MG POWDER PACKET |
3* |
Preferred Brand |
$47.00 | $136.00 | None |
ISENTRESS 100 MG TABLET CHEW |
5 |
Specialty Tier |
25% | N/A | None |
ISENTRESS 25 MG TABLET CHEW |
3* |
Preferred Brand |
$47.00 | $136.00 | None |
ISENTRESS 400MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
ISENTRESS HD 600 MG TABLET |
5 |
Specialty Tier |
25% | N/A | None |
ISIBLOOM 28 DAY TABLET [Solia] |
2* |
Generic |
$10.00 | $25.00 | None |
ISOLYTE P IN 5% DEXTROSE INJECTION |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
ISOLYTE S IV SOLUTION-EXCEL |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
ISONIAZID 100 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISONIAZID 300 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ISONIAZID 50MG/5ML SYRUP |
2* |
Generic |
$10.00 | $25.00 | None |
ISORDIL 40 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
ISORDIL TITRADOSE 5 MG TAB |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
ISOSORBIDE DINITRATE 40MG TABLETS ER |
2* |
Generic |
$10.00 | $25.00 | None |
ISOSORBIDE DN 10 MG TABLET |
3* |
Preferred Brand |
$47.00 | $136.00 | None |
ISOSORBIDE DN 20 MG TABLET |
3* |
Preferred Brand |
$47.00 | $136.00 | None |
ISOSORBIDE DN 30 MG TABLET |
3* |
Preferred Brand |
$47.00 | $136.00 | None |
ISOSORBIDE DN 5 MG TABLET |
3* |
Preferred Brand |
$47.00 | $136.00 | None |
ISOSORBIDE MN 10 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ISOSORBIDE MN ER 30 MG TABLET |
2* |
Generic |
$10.00 | $25.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISOSORBIDE MN ER 60 MG TABLET |
2* |
Generic |
$10.00 | $25.00 | None |
ISOSORBIDE MONONITRATE 20MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
ISOSORBIDE MONONITRATE ER TABLET 120MG (100 CT) |
2* |
Generic |
$10.00 | $25.00 | None |
ISOTON GENTAMICIN 80MG/100ML |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
ISOTONIC GENTAMICIN 100 MG/100 ML |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
ISOTONIC GENTAMICIN 80 MG/50 ML |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
ISOTRETINOIN 10 MG CAPSULE [ZENATANE] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
ISOTRETINOIN 20 MG CAPSULE [ZENATANE] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
ISOTRETINOIN 30 MG CAPSULE [ZENATANE] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
ISOTRETINOIN 40 MG CAPSULE [ZENATANE] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
ISRADIPINE CAPSULES 2.5MG (100 CT) |
2* |
Generic |
$10.00 | $25.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISRADIPINE CAPSULES 5MG (100 CT) |
2* |
Generic |
$10.00 | $25.00 | None |
ITRACONAZOLE 100 MG CAPSULE [Sporanox] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
IVERMECTIN 3 MG TABLET [Stromectol, Sklice] |
3* |
Preferred Brand |
$47.00 | $136.00 | None |
IXIARO JAPANESE ENCEPHALITIS VACCINE 6MCG/.5ML |
3* |
Preferred Brand |
$47.00 | $136.00 | None |