2022 Medicare Part D Plan Formulary Information |
Premera Blue Cross Medicare Advantage Charter + Rx (HMO) (H9302-003-0)
Benefit Details
This plan covers select insulin pay $35 copay.
See individual insulin cost-sharing below. |
The Premera Blue Cross Medicare Advantage Charter + Rx (HMO) (H9302-003-0) Formulary Drugs Starting with the Letter I in King County, WA: CMS MA Region 23 which includes: WA
|
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 |
$12.00 | $36.00 | P |
IBRANCE 100 MG CAPSULE |
5 |
Specialty Tier |
30% | N/A | P Q:21 /28Days |
IBRANCE 100 MG TABLET |
5 |
Specialty Tier |
30% | N/A | P Q:21 /28Days |
IBRANCE 125 MG CAPSULE |
5 |
Specialty Tier |
30% | N/A | P Q:21 /28Days |
IBRANCE 125 MG TABLET |
5 |
Specialty Tier |
30% | N/A | P Q:21 /28Days |
IBRANCE 75 MG CAPSULE |
5 |
Specialty Tier |
30% | N/A | P Q:21 /28Days |
IBRANCE 75 MG TABLET |
5 |
Specialty Tier |
30% | N/A | P Q:21 /28Days |
IBSRELA 50 MG TABLET |
5 |
Specialty Tier |
30% | N/A | P Q:60 /30Days |
IBU 600 MG TABLET [Toxicology Saliva Collection] |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
IBU 800 MG TABLET [Samson-8] |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [PediaCare Children's Pain Reliever/Fever Reducer IB] |
2* |
Generic |
$12.00 | $36.00 | None |
IBUPROFEN 400 MG TABLET [Motrin] |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
IBUPROFEN 600 MG TABLET [Toxicology Saliva Collection] |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
IBUPROFEN 800 MG TABLET [Samson-8] |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
ICATIBANT 30 MG/3 ML SYRINGE [FIRAZYR] |
5 |
Specialty Tier |
30% | N/A | P Q:27 /30Days |
ICLEVIA 0.15 MG-0.03 MG TABLET TBDSPK 3MO [Setlakin] |
2* |
Generic |
$12.00 | $36.00 | None |
ICLUSIG 10 MG TABLET |
5 |
Specialty Tier |
30% | N/A | P Q:60 /30Days |
ICLUSIG 15 MG TABLET |
5 |
Specialty Tier |
30% | N/A | P Q:30 /30Days |
ICLUSIG 30 MG TABLET |
5 |
Specialty Tier |
30% | N/A | P Q:30 /30Days |
ICLUSIG 45 MG TABLET |
5 |
Specialty Tier |
30% | N/A | P Q:30 /30Days |
IDHIFA 100 MG TABLET |
5 |
Specialty Tier |
30% | N/A | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IDHIFA 50 MG TABLET |
5 |
Specialty Tier |
30% | N/A | P Q:30 /30Days |
ILEVRO 0.3% OPHTH DROPS EYE DROPPER |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
IMATINIB MESYLATE 100 MG TABLET [Gleevec] |
5 |
Specialty Tier |
30% | N/A | P Q:90 /30Days |
IMATINIB MESYLATE 400 MG TABLET [Gleevec] |
5 |
Specialty Tier |
30% | N/A | P Q:60 /30Days |
IMBRUVICA 140 MG CAPSULE |
5 |
Specialty Tier |
30% | N/A | P Q:120 /30Days |
IMBRUVICA 140 MG TABLET |
5 |
Specialty Tier |
30% | N/A | P Q:30 /30Days |
IMBRUVICA 280 MG TABLET |
5 |
Specialty Tier |
30% | N/A | P Q:30 /30Days |
IMBRUVICA 420 MG TABLET |
5 |
Specialty Tier |
30% | N/A | P Q:30 /30Days |
IMBRUVICA 560 MG TABLET |
5 |
Specialty Tier |
30% | N/A | P Q:30 /30Days |
IMBRUVICA 70 MG CAPSULE |
5 |
Specialty Tier |
30% | N/A | P Q:30 /30Days |
IMIPRAMINE HCL 10MG TABLET (100 CT) |
2* |
Generic |
$12.00 | $36.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IMIPRAMINE HCL 25MG TABLET (100 CT) |
2* |
Generic |
$12.00 | $36.00 | None |
IMIPRAMINE HCL 50 MG TABLET |
2* |
Generic |
$12.00 | $36.00 | None |
IMIPRAMINE PAMOATE 100 MG CAPSULE [Tofranil-PM] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
IMIPRAMINE PAMOATE 125 MG CAPSULE [Tofranil-PM] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
IMIPRAMINE PAMOATE 150 MG CAPSULE [Tofranil-PM] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
IMIPRAMINE PAMOATE 75 MG CAPSULE [Tofranil-PM] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
IMIQUIMOD 5% CREAM PACKET |
2* |
Generic |
$12.00 | $36.00 | Q:24 /30Days |
IMOVAX RABIES VACCINE VIAL |
3 |
Preferred Brand |
$42.00 | $126.00 | P |
IMVEXXY 10 MCG MAINTENANCE PAK INSERT |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
IMVEXXY 10 MCG STARTER PACK INSR DS PK |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
IMVEXXY 4 MCG MAINTENANCE PACK INSERT |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IMVEXXY 4 MCG STARTER PACK INSR DS PK |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
INBRIJA 42 MG INHALATION CAPSULE W/DEV |
5 |
Specialty Tier |
30% | N/A | P Q:300 /30Days |
INCASSIA 0.35 MG TABLET [Sharobel 28-Day] |
2* |
Generic |
$12.00 | $36.00 | None |
Increlex 40mg/4mL 1 VIAL, MULTI-DOSE per CARTON / 4 mL in 1 VIAL, MULTI-DOSE |
5 |
Specialty Tier |
30% | N/A | P |
INCRUSE ELLIPTA 62.5 MCG INH |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:30 /30Days |
INDAPAMIDE 1.25 MG TABLET [Lozol] |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
INDAPAMIDE 2.5 MG TABLET [Lozol] |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
INFANRIX DTAP SYRINGE |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
INGREZZA 40 MG CAPSULE |
5 |
Specialty Tier |
30% | N/A | P Q:30 /30Days |
INGREZZA 60 MG CAPSULE |
5 |
Specialty Tier |
30% | N/A | P Q:30 /30Days |
INGREZZA 80 MG CAPSULE |
5 |
Specialty Tier |
30% | N/A | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INGREZZA INITIATION PACK CAPSULE DS PK |
5 |
Specialty Tier |
30% | N/A | P Q:28 /28Days |
INLYTA 1 MG TABLET |
5 |
Specialty Tier |
30% | N/A | P Q:180 /30Days |
INLYTA 5 MG TABLET |
5 |
Specialty Tier |
30% | N/A | P Q:120 /30Days |
INQOVI 35 MG-100 MG TABLET |
5 |
Specialty Tier |
30% | N/A | P |
INREBIC 100 MG CAPSULE |
5 |
Specialty Tier |
30% | N/A | P |
INSULIN ASPART 100 UNIT/ML CARTRIDGE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
INSULIN ASPART 100 UNIT/ML INSULIN PEN [NovoLog PenFill] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
INSULIN ASPART 100 UNIT/ML VIAL [NovoLog PenFill] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
INSULIN ASPART PROT-INSULN ASP INSULIN PEN [NovoLog Mix 70/30] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
INSULIN ASPART PROT-INSULN ASP VIAL [NovoLog Mix 70/30] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
INSULIN LISPRO 100 UNIT/ML INSULN PEN [LYUMJEV] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INSULIN LISPRO 100 UNIT/ML VIAL [LYUMJEV] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
INSULIN LISPRO JR 100 UNIT/ML INSULN PEN HF |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
INSULIN LISPRO MIX 75-25 KWIKPEN INSULN PEN [Humalog KwikPen Mix 75/25] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
INTELENCE 25 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
INTRALIPID 20% IV FAT EMULSION |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
INTRALIPID 30% IV FAT EMULSION |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
INTRAROSA 6.5 MG VAG INSERT |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
INTRON A 10 MILLION UNITS VIAL |
3 |
Preferred Brand |
$42.00 | $126.00 | P |
INTRON A 18 MILLION UNITS VIAL |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
INTRON A 50 MILLION UNITS VIAL |
5 |
Specialty Tier |
30% | N/A | P |
INTROVALE 0.15-0.03 MG TABLET TBDSPK 3MO [Setlakin] |
2* |
Generic |
$12.00 | $36.00 | None |
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 |
30% | N/A | Q:1 /28Days |
Invega Sustenna 156 mg/mL Prefilled Syringe |
5 |
Specialty Tier |
30% | N/A | Q:1 /28Days |
Invega Sustenna 234 mg/1.5mL Prefilled Syringe |
5 |
Specialty Tier |
30% | 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 |
30% | N/A | Q:1 /28Days |
INVEGA TRINZA 273 MG/0.875 ML |
5 |
Specialty Tier |
30% | N/A | Q:1 /90Days |
INVEGA TRINZA 410 MG/1.315 ML |
5 |
Specialty Tier |
30% | N/A | Q:1 /90Days |
INVEGA TRINZA 546 MG/1.75 ML |
5 |
Specialty Tier |
30% | N/A | Q:2 /90Days |
INVEGA TRINZA 819 MG/2.625 ML |
5 |
Specialty Tier |
30% | N/A | Q:3 /90Days |
INVELTYS 1% EYE DROP EYE DROPPER |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
INVOKAMET 150-1,000 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:60 /30Days |
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 Drug |
$100.00 | $300.00 | Q:60 /30Days |
INVOKAMET 50-1,000 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:60 /30Days |
INVOKAMET 50-500 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:120 /30Days |
INVOKAMET XR 150-1,000 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:60 /30Days |
INVOKAMET XR 150-500 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:60 /30Days |
INVOKAMET XR 50-1,000 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:60 /30Days |
INVOKAMET XR 50-500 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:120 /30Days |
INVOKANA 100 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:60 /30Days |
INVOKANA 300 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
IPOL VIAL 40;8;32; UNT |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
IPRAT-ALBUT 0.5-3(2.5) MG/3 ML |
2* |
Generic |
$12.00 | $36.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IPRATROPIUM 0.06% SPRAY |
2* |
Generic |
$12.00 | $36.00 | None |
IPRATROPIUM BR 0.02% SOLUTION [Atrovent] |
2* |
Generic |
$12.00 | $36.00 | P |
IPRATROPIUM BROMIDE NASAL SPRAY |
2* |
Generic |
$12.00 | $36.00 | None |
IRBESARTAN 150 MG TABLET [Avapro] |
1* |
Preferred Generic |
$2.00 | $0.00 | Q:30 /30Days |
IRBESARTAN 300 MG TABLET [Avapro] |
1* |
Preferred Generic |
$2.00 | $0.00 | Q:30 /30Days |
IRBESARTAN 75 MG TABLET [Avapro] |
1* |
Preferred Generic |
$2.00 | $0.00 | Q:30 /30Days |
IRBESARTAN-HCTZ 150-12.5 MG TABLET [Avalide] |
1* |
Preferred Generic |
$2.00 | $0.00 | Q:30 /30Days |
IRBESARTAN-HCTZ 300-12.5 MG TABLET [Avalide] |
1* |
Preferred Generic |
$2.00 | $0.00 | Q:30 /30Days |
IRESSA 250 MG TABLET |
5 |
Specialty Tier |
30% | N/A | P |
ISENTRESS 100 MG POWDER PACKET |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
ISENTRESS 100 MG TABLET CHEW |
5 |
Specialty Tier |
30% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISENTRESS 25 MG TABLET CHEW |
3 |
Preferred Brand |
$42.00 | $126.00 | None |
ISENTRESS 400MG TABLET |
5 |
Specialty Tier |
30% | N/A | None |
ISENTRESS HD 600 MG TABLET |
5 |
Specialty Tier |
30% | N/A | None |
ISIBLOOM 28 DAY TABLET [Solia] |
2* |
Generic |
$12.00 | $36.00 | None |
ISOLYTE P IN 5% DEXTROSE INJECTION |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
ISOLYTE S IV SOLUTION PH7.4 |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
ISONIAZID 100 MG TABLET |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
ISONIAZID 300 MG TABLET |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
ISONIAZID 50MG/5ML SYRUP |
2* |
Generic |
$12.00 | $36.00 | None |
ISOSORBIDE DINITRATE 10 MG TABLET [Wesorbide] |
2* |
Generic |
$12.00 | $36.00 | None |
ISOSORBIDE DINITRATE 20 MG TABLET [Wesorbide] |
2* |
Generic |
$12.00 | $36.00 | 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 |
$12.00 | $36.00 | None |
ISOSORBIDE DN 5 MG TABLET |
2* |
Generic |
$12.00 | $36.00 | None |
ISOSORBIDE MN ER 30 MG TABLET |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
ISOSORBIDE MONONIT 10 MG TABLET [Monoket] |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
ISOSORBIDE MONONIT 20 MG TABLET [Monoket] |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
ISOSORBIDE MONONIT ER 60 MG TABLET ER 24H [Isotrate ER] |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
ISOSORBIDE MONONITRATE ER TABLET 120MG (100 CT) |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
ISOSORBIDE-HYDRALAZINE 20-37.5 TABLET [BiDil] |
2* |
Generic |
$12.00 | $36.00 | None |
ISOTON GENTAMICIN 80MG/100ML |
2* |
Generic |
$12.00 | $36.00 | None |
ISOTONIC GENTAMICIN 100 MG/100 ML |
2* |
Generic |
$12.00 | $36.00 | None |
ISOTONIC GENTAMICIN 80 MG/50 ML |
2* |
Generic |
$12.00 | $36.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISOTRETINOIN 10 MG CAPSULE [ZENATANE] |
2* |
Generic |
$12.00 | $36.00 | P |
ISOTRETINOIN 20 MG CAPSULE [ZENATANE] |
2* |
Generic |
$12.00 | $36.00 | P |
ISOTRETINOIN 30 MG CAPSULE [ZENATANE] |
2* |
Generic |
$12.00 | $36.00 | P |
ISOTRETINOIN 40 MG CAPSULE [ZENATANE] |
2* |
Generic |
$12.00 | $36.00 | P |
ISRADIPINE 2.5 MG CAPSULE [DynaCirc] |
2* |
Generic |
$12.00 | $36.00 | None |
ISRADIPINE 5 MG CAPSULE [DynaCirc] |
2* |
Generic |
$12.00 | $36.00 | None |
ITRACONAZOLE 10 MG/ML SOLUTION [Sporanox] |
5 |
Specialty Tier |
30% | N/A | None |
ITRACONAZOLE 100 MG CAPSULE [Sporanox] |
2* |
Generic |
$12.00 | $36.00 | P |
IVERMECTIN 3 MG TABLET [Stromectol, Sklice] |
2* |
Generic |
$12.00 | $36.00 | P |
Ixekizumab 1ML 80 MG/ML Auto-Injector [Taltz] |
5 |
Specialty Tier |
30% | N/A | P Q:3 /28Days |
Ixekizumab 1ML 80 MG/ML Prefilled Syringe [Taltz] |
5 |
Specialty Tier |
30% | N/A | P Q:3 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IXIARO 6 UNIT(6 MCG)/0.5ML SYRINGE |
3 |
Preferred Brand |
$42.00 | $126.00 | None |