2020 Medicare Part D Plan Formulary Information |
Senior Advantage Medicare Medicaid (HMO D-SNP) (H0630-014-0)
Benefit Details
|
The Senior Advantage Medicare Medicaid (HMO D-SNP) (H0630-014-0) Formulary Drugs Starting with the Letter I in Adams County, CO: CMS MA Region 20 which includes: CO Plan Monthly Premium: $29.10 Deductible: $435 |
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 |
Tier 2 |
15% | 15% | P |
IBRANCE 100 MG CAPSULE |
5 |
Tier 5 |
15% | 15% | None |
IBRANCE 100 MG TABLET |
5 |
Tier 5 |
15% | 15% | None |
IBRANCE 125 MG CAPSULE |
5 |
Tier 5 |
15% | 15% | None |
IBRANCE 125 MG TABLET |
5 |
Tier 5 |
15% | 15% | None |
IBRANCE 75 MG CAPSULE |
5 |
Tier 5 |
15% | 15% | None |
IBRANCE 75 MG TABLET |
5 |
Tier 5 |
15% | 15% | None |
IBU 600 MG TABLET [Toxicology Saliva Collection] |
2 |
Tier 2 |
15% | 15% | None |
IBU 800 MG TABLET [Samson-8] |
2 |
Tier 2 |
15% | 15% | None |
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [PediaCare Children's Pain Reliever/Fever Reducer IB] |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IBUPROFEN 400 MG TABLET [Motrin] |
2 |
Tier 2 |
15% | 15% | None |
IBUPROFEN 600 MG TABLET [Toxicology Saliva Collection] |
2 |
Tier 2 |
15% | 15% | None |
IBUPROFEN 800 MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
ICATIBANT 30 MG/3 ML SYRINGE [FIRAZYR] |
5 |
Tier 5 |
15% | 15% | None |
ICLUSIG 15 MG TABLET |
5 |
Tier 5 |
15% | 15% | None |
ICLUSIG 45 MG TABLET |
5 |
Tier 5 |
15% | 15% | None |
IDHIFA 100 MG TABLET |
5 |
Tier 5 |
15% | 15% | None |
IDHIFA 50 MG TABLET |
5 |
Tier 5 |
15% | 15% | None |
ILEVRO 0.3% OPHTH DROPS |
4 |
Tier 4 |
15% | 15% | None |
ILUMYA 100 MG/ML SYRINGE |
5 |
Tier 5 |
15% | 15% | P |
IMATINIB MESYLATE 100 MG TABLET [Gleevec] |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IMATINIB MESYLATE 400 MG TABLET [Gleevec] |
2 |
Tier 2 |
15% | 15% | None |
IMBRUVICA 140 MG CAPSULE |
5 |
Tier 5 |
15% | 15% | None |
IMBRUVICA 140 MG TABLET |
5 |
Tier 5 |
15% | 15% | None |
IMBRUVICA 280 MG TABLET |
5 |
Tier 5 |
15% | 15% | None |
IMBRUVICA 420 MG TABLET |
5 |
Tier 5 |
15% | 15% | None |
IMBRUVICA 560 MG TABLET |
5 |
Tier 5 |
15% | 15% | None |
IMBRUVICA 70 MG CAPSULE |
5 |
Tier 5 |
15% | 15% | None |
IMIPRAMINE HCL 10MG TABLET (100 CT) |
2 |
Tier 2 |
15% | 15% | None |
IMIPRAMINE HCL 25MG TABLET (100 CT) |
2 |
Tier 2 |
15% | 15% | None |
IMIPRAMINE HCL 50 MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
IMIPRAMINE PAMOATE 100 MG CAPSULE [Tofranil-PM] |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IMIPRAMINE PAMOATE 125MG CAPSULES |
2 |
Tier 2 |
15% | 15% | None |
IMIPRAMINE PAMOATE 150 MG CAPSULE [Tofranil-PM] |
2 |
Tier 2 |
15% | 15% | None |
IMIPRAMINE PAMOATE 75 MG CAPSULE [Tofranil-PM] |
2 |
Tier 2 |
15% | 15% | None |
IMIQUIMOD 3.75% CREAM PUMP [Zyclara] |
2 |
Tier 2 |
15% | 15% | None |
IMIQUIMOD 5% CREAM PACKET |
2 |
Tier 2 |
15% | 15% | None |
IMOVAX RABIES VACCINE |
6 |
Tier 6 |
15% | 15% | None |
IMPOYZ 0.025% CREAM (G) |
4 |
Tier 4 |
15% | 15% | None |
IMVEXXY 10 MCG MAINTENANCE PAK INSERT |
4 |
Tier 4 |
15% | 15% | None |
IMVEXXY 10 MCG STARTER PACK INSR DS PK |
4 |
Tier 4 |
15% | 15% | None |
IMVEXXY 4 MCG MAINTENANCE PACK INSERT |
4 |
Tier 4 |
15% | 15% | None |
IMVEXXY 4 MCG STARTER PACK INSR DS PK |
4 |
Tier 4 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INBRIJA 42 MG INHALATION CAPSULE W/DEV |
5 |
Tier 5 |
15% | 15% | None |
INCASSIA 0.35 MG TABLET [Sharobel 28-Day] |
2 |
Tier 2 |
15% | 15% | None |
Increlex 40mg/4mL 1 VIAL, MULTI-DOSE per CARTON / 4 mL in 1 VIAL, MULTI-DOSE |
5 |
Tier 5 |
15% | 15% | None |
INCRUSE ELLIPTA 62.5 MCG INH |
4 |
Tier 4 |
15% | 15% | None |
INDAPAMIDE 1.25 MG TABLET [Lozol] |
1 |
Tier 1 |
15% | 15% | None |
INDAPAMIDE 2.5 MG TABLET [Lozol] |
1 |
Tier 1 |
15% | 15% | None |
INDOCIN 25 MG/5 ML ORAL SUSPENSION |
4 |
Tier 4 |
15% | 15% | None |
INDOCIN 50 MG SUPPOSITORY SUPP.RECT |
2 |
Tier 2 |
15% | 15% | None |
INDOMETHACIN 25 MG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
INDOMETHACIN 50 MG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
INDOMETHACIN ER 75 MG CAPSULE ER [Indocin SR] |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INFANRIX DTAP VIAL |
6 |
Tier 6 |
15% | 15% | None |
INGREZZA 40 MG CAPSULE |
5 |
Tier 5 |
15% | 15% | None |
INGREZZA 80 MG CAPSULE |
5 |
Tier 5 |
15% | 15% | None |
INGREZZA INITIATION PACK CAPSULE DS PK |
5 |
Tier 5 |
15% | 15% | None |
INLYTA 1 MG TABLET |
5 |
Tier 5 |
15% | 15% | None |
INLYTA 5 MG TABLET |
5 |
Tier 5 |
15% | 15% | None |
INNOPRAN XL 120 MG CAPSULE ER 24H |
4 |
Tier 4 |
15% | 15% | None |
INNOPRAN XL 80 MG CAPSULE ER 24H |
4 |
Tier 4 |
15% | 15% | None |
INREBIC 100 MG CAPSULE |
5 |
Tier 5 |
15% | 15% | None |
INSULIN ASPART 100 UNIT/ML CARTRIDGE |
2 |
Tier 2 |
15% | 15% | None |
INSULIN ASPART 100 UNIT/ML INSULIN PEN [NovoLog PenFill] |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INSULIN ASPART 100 UNIT/ML VIAL [NovoLog PenFill] |
2 |
Tier 2 |
15% | 15% | P |
INSULIN ASPART PROT-INSULN ASP INSULIN PEN [NovoLog Mix 70/30] |
2 |
Tier 2 |
15% | 15% | None |
INSULIN ASPART PROT-INSULN ASP VIAL [NovoLog Mix 70/30] |
2 |
Tier 2 |
15% | 15% | None |
INSULIN LISPRO 100 UNIT/ML INSULN PEN [Humalog KwikPen] |
4 |
Tier 4 |
15% | 15% | None |
INSULIN LISPRO 100 UNIT/ML VIAL [Humalog KwikPen] |
4 |
Tier 4 |
15% | 15% | None |
INSULIN LISPRO JR 100 UNIT/ML INSULN PEN HF |
2 |
Tier 2 |
15% | 15% | None |
INSULIN LISPRO MIX 75-25 KWIKPEN INSULN PEN [Humalog KwikPen Mix 75/25] |
2 |
Tier 2 |
15% | 15% | None |
INTELENCE 100MG TABLET |
3 |
Tier 3 |
15% | 15% | None |
INTELENCE 200 MG TABLET |
3 |
Tier 3 |
15% | 15% | None |
INTELENCE 25 MG TABLET |
3 |
Tier 3 |
15% | 15% | None |
INTRALIPID 20% IV FAT EMULSION |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INTRALIPID 30% IV FAT EMULSION |
4 |
Tier 4 |
15% | 15% | None |
INTRAROSA 6.5 MG VAGINAL INSERT |
4 |
Tier 4 |
15% | 15% | None |
INTRON A 10 MILLION UNITS VIAL |
5 |
Tier 5 |
15% | 15% | None |
INTRON A 18 MILLION UNITS VIAL |
5 |
Tier 5 |
15% | 15% | None |
INTRON A 25 MILLION UNIT/2.5ML VIAL |
5 |
Tier 5 |
15% | 15% | None |
INTRON A 50 MILLION UNITS VIAL |
5 |
Tier 5 |
15% | 15% | None |
INTRON A 6MMU/ML VIAL |
5 |
Tier 5 |
15% | 15% | None |
INTROVALE 0.15-0.03 MG TABLET TBDSPK 3MO [Setlakin] |
2 |
Tier 2 |
15% | 15% | None |
Invega Sustenna 117 mg/0.75mL Prefilled Syringe |
5 |
Tier 5 |
15% | 15% | None |
Invega Sustenna 156 mg/mL Prefilled Syringe |
5 |
Tier 5 |
15% | 15% | None |
Invega Sustenna 234 mg/1.5mL Prefilled Syringe |
5 |
Tier 5 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Invega Sustenna 39 mg/0.25mL Prefilled Syringe |
4 |
Tier 4 |
15% | 15% | None |
Invega Sustenna 78 mg/0.5mL Prefilled Syringe |
5 |
Tier 5 |
15% | 15% | None |
INVEGA TRINZA 273 MG/0.875 ML |
5 |
Tier 5 |
15% | 15% | None |
INVEGA TRINZA 410 MG/1.315 ML |
5 |
Tier 5 |
15% | 15% | None |
INVEGA TRINZA 546 MG/1.75 ML |
5 |
Tier 5 |
15% | 15% | None |
INVEGA TRINZA 819 MG/2.625 ML |
5 |
Tier 5 |
15% | 15% | None |
INVELTYS 1% EYE DROP EYE DROPPER |
4 |
Tier 4 |
15% | 15% | None |
INVIRASE 500MG TABLET |
3 |
Tier 3 |
15% | 15% | None |
INVOKAMET 150-1,000 MG TABLET |
4 |
Tier 4 |
15% | 15% | None |
INVOKAMET 150-500 MG TABLET |
4 |
Tier 4 |
15% | 15% | None |
INVOKAMET 50-1,000 MG TABLET |
4 |
Tier 4 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INVOKAMET 50-500 MG TABLET |
4 |
Tier 4 |
15% | 15% | None |
INVOKAMET XR 150-1,000 MG TABLET |
4 |
Tier 4 |
15% | 15% | None |
INVOKAMET XR 150-500 MG TABLET |
4 |
Tier 4 |
15% | 15% | None |
INVOKAMET XR 50-1,000 MG TABLET |
4 |
Tier 4 |
15% | 15% | None |
INVOKAMET XR 50-500 MG TABLET |
4 |
Tier 4 |
15% | 15% | None |
INVOKANA 100 MG TABLET |
4 |
Tier 4 |
15% | 15% | None |
INVOKANA 300 MG TABLET |
4 |
Tier 4 |
15% | 15% | None |
IOPIDINE 1% EYE DROPS |
3 |
Tier 3 |
15% | 15% | None |
IPOL VIAL 40;8;32; UNT |
6 |
Tier 6 |
15% | 15% | None |
IPRAT-ALBUT 0.5-3(2.5) MG/3 ML |
2 |
Tier 2 |
15% | 15% | P |
IPRATROPIUM 0.06% SPRAY |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IPRATROPIUM BR 0.02% SOLN |
1 |
Tier 1 |
15% | 15% | P |
IPRATROPIUM BROMIDE NASAL SPRAY |
2 |
Tier 2 |
15% | 15% | None |
IRBESARTAN 150 MG TABLET [Avapro] |
2 |
Tier 2 |
15% | 15% | None |
IRBESARTAN 300 MG TABLET [Avapro] |
2 |
Tier 2 |
15% | 15% | None |
IRBESARTAN 75 MG TABLET [Avapro] |
2 |
Tier 2 |
15% | 15% | None |
IRBESARTAN-HCTZ 150-12.5 MG TABLET [Avalide] |
2 |
Tier 2 |
15% | 15% | None |
IRBESARTAN-HCTZ 300-12.5 MG TABLET [Avalide] |
2 |
Tier 2 |
15% | 15% | None |
IRESSA 250 MG TABLET |
5 |
Tier 5 |
15% | 15% | None |
ISENTRESS 100 MG POWDER PACKET |
3 |
Tier 3 |
15% | 15% | None |
ISENTRESS 100 MG TABLET CHEW |
3 |
Tier 3 |
15% | 15% | None |
ISENTRESS 25 MG TABLET CHEW |
3 |
Tier 3 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISENTRESS 400MG TABLET |
3 |
Tier 3 |
15% | 15% | None |
ISENTRESS HD 600 MG TABLET |
3 |
Tier 3 |
15% | 15% | None |
ISIBLOOM 28 DAY TABLET [Solia] |
2 |
Tier 2 |
15% | 15% | None |
ISOLYTE P IN 5% DEXTROSE INJECTION |
4 |
Tier 4 |
15% | 15% | None |
ISOLYTE S IV SOLUTION-EXCEL |
4 |
Tier 4 |
15% | 15% | None |
ISONIAZID 100 MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
ISONIAZID 300 MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
ISONIAZID 50MG/5ML SYRUP |
2 |
Tier 2 |
15% | 15% | None |
ISORDIL 40 MG TABLET |
4 |
Tier 4 |
15% | 15% | None |
ISOSORBIDE DINITRATE 20 MG TABLET [Wesorbide] |
2 |
Tier 2 |
15% | 15% | None |
ISOSORBIDE DINITRATE 40 MG TABLET [Sorbitrate] |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISOSORBIDE DN 10 MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
ISOSORBIDE DN 30 MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
ISOSORBIDE DN 5 MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
ISOSORBIDE MN ER 30 MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
ISOSORBIDE MN ER 60 MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
ISOSORBIDE MONONIT 10 MG TABLET [Monoket] |
2 |
Tier 2 |
15% | 15% | None |
ISOSORBIDE MONONIT 20 MG TABLET [Monoket] |
2 |
Tier 2 |
15% | 15% | None |
ISOSORBIDE MONONITRATE ER TABLET 120MG (100 CT) |
2 |
Tier 2 |
15% | 15% | None |
ISOTON GENTAMICIN 80MG/100ML |
2 |
Tier 2 |
15% | 15% | None |
ISOTONIC GENTAMICIN 100 MG/100 ML |
2 |
Tier 2 |
15% | 15% | None |
ISOTONIC GENTAMICIN 80 MG/50 ML |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISOTRETINOIN 10 MG CAPSULE [ZENATANE] |
2 |
Tier 2 |
15% | 15% | None |
ISOTRETINOIN 20 MG CAPSULE [ZENATANE] |
2 |
Tier 2 |
15% | 15% | None |
ISOTRETINOIN 30 MG CAPSULE [ZENATANE] |
2 |
Tier 2 |
15% | 15% | None |
ISOTRETINOIN 40 MG CAPSULE [ZENATANE] |
2 |
Tier 2 |
15% | 15% | None |
ISRADIPINE 2.5 MG CAPSULE [DynaCirc] |
2 |
Tier 2 |
15% | 15% | None |
ISRADIPINE CAPSULES 5MG (100 CT) |
2 |
Tier 2 |
15% | 15% | None |
ISTURISA 1 MG TABLET |
5 |
Tier 5 |
15% | 15% | None |
ISTURISA 10 MG TABLET |
5 |
Tier 5 |
15% | 15% | None |
ISTURISA 5 MG TABLET |
5 |
Tier 5 |
15% | 15% | None |
ITRACONAZOLE 10 MG/ML SOLUTION [Sporanox] |
2 |
Tier 2 |
15% | 15% | None |
ITRACONAZOLE 100 MG CAPSULE [Sporanox] |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IVERMECTIN 3 MG TABLET [Stromectol, Sklice] |
2 |
Tier 2 |
15% | 15% | None |
Ixekizumab 1ML 80 MG/ML Auto-Injector [Taltz] |
5 |
Tier 5 |
15% | 15% | None |
Ixekizumab 1ML 80 MG/ML Prefilled Syringe [Taltz] |
5 |
Tier 5 |
15% | 15% | None |
IXIARO 6 UNIT(6 MCG)/0.5ML SYRINGE |
6 |
Tier 6 |
15% | 15% | None |