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SilverScript SmartRx (PDP) (S5601-186-0)
Tier 1 (250)
Tier 2 (611)
Tier 3 (799)
Tier 4 (1370)
Tier 5 (599)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
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Cick on the first letter of your drug name to browse the formulary:

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2022 Medicare Part D Plan Formulary Information
SilverScript SmartRx (PDP) (S5601-186-0)
Benefit Details           
The SilverScript SmartRx (PDP) (S5601-186-0)
Formulary Drugs Starting with the Letter I

in CMS PDP Region 11 which includes: FL
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 $19.00$57.00Q:1
/30Days
IBRANCE 100 MG CAPSULE   5 Specialty Tier 25%N/AP Q:21
/28Days
IBRANCE 100 MG TABLET   5 Specialty Tier 25%N/AP Q:21
/28Days
IBRANCE 125 MG CAPSULE   5 Specialty Tier 25%N/AP Q:21
/28Days
IBRANCE 125 MG TABLET   5 Specialty Tier 25%N/AP Q:21
/28Days
IBRANCE 75 MG CAPSULE   5 Specialty Tier 25%N/AP Q:21
/28Days
IBRANCE 75 MG TABLET   5 Specialty Tier 25%N/AP Q:21
/28Days
IBU 600 MG TABLET [Toxicology Saliva Collection]   1* Preferred Generic $1.00$3.00None
IBU 800 MG TABLET [Samson-8]   1* Preferred Generic $1.00$3.00None
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [PediaCare Children's Pain Reliever/Fever Reducer IB]   2 Generic $19.00$57.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
IBUPROFEN 400 MG TABLET [Motrin]   1* Preferred Generic $1.00$3.00None
IBUPROFEN 600 MG TABLET [Toxicology Saliva Collection]   1* Preferred Generic $1.00$3.00None
IBUPROFEN 800 MG TABLET [Samson-8]   1* Preferred Generic $1.00$3.00None
IBUPROFEN-FAMOTIDIN 800-26.6MG TABLET [DUEXIS]   4 Non-Preferred Drug 49%49%P Q:90
/30Days
ICATIBANT 30 MG/3 ML SYRINGE [FIRAZYR]   5 Specialty Tier 25%N/AP Q:27
/30Days
ICLEVIA 0.15 MG-0.03 MG TABLET TBDSPK 3MO [Setlakin]   3 Preferred Brand $46.00$138.00None
ICLUSIG 10 MG TABLET   5 Specialty Tier 25%N/AP
ICLUSIG 15 MG TABLET   5 Specialty Tier 25%N/AP Q:60
/30Days
ICLUSIG 30 MG TABLET   5 Specialty Tier 25%N/AP
ICLUSIG 45 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
IDHIFA 100 MG TABLET   5 Specialty Tier 25%N/AP 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 25%N/AP Q:30
/30Days
ILEVRO 0.3% OPHTH DROPS EYE DROPPER   4 Non-Preferred Drug 49%49%None
IMATINIB MESYLATE 100 MG TABLET [Gleevec]   5 Specialty Tier 25%N/AP Q:90
/30Days
IMATINIB MESYLATE 400 MG TABLET [Gleevec]   5 Specialty Tier 25%N/AP Q:60
/30Days
IMBRUVICA 140 MG CAPSULE   5 Specialty Tier 25%N/AP Q:90
/30Days
IMBRUVICA 140 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
IMBRUVICA 280 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
IMBRUVICA 420 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
IMBRUVICA 560 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
IMBRUVICA 70 MG CAPSULE   5 Specialty Tier 25%N/AP Q:56
/28Days
IMIPRAMINE HCL 10MG TABLET (100 CT)   4 Non-Preferred Drug 49%49%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
IMIPRAMINE HCL 25MG TABLET (100 CT)   4 Non-Preferred Drug 49%49%P
IMIPRAMINE HCL 50 MG TABLET   4 Non-Preferred Drug 49%49%P
IMIQUIMOD 3.75% CREAM PACK [Zyclara]   5 Specialty Tier 25%N/AQ:28
/28Days
IMIQUIMOD 5% CREAM PACKET   4 Non-Preferred Drug 49%49%Q:24
/30Days
IMOVAX RABIES VACCINE VIAL   3 Preferred Brand $46.00$138.00P
INCASSIA 0.35 MG TABLET [Sharobel 28-Day]   3 Preferred Brand $46.00$138.00None
Increlex 40mg/4mL 1 VIAL, MULTI-DOSE per CARTON / 4 mL in 1 VIAL, MULTI-DOSE   5 Specialty Tier 25%N/AP
INCRUSE ELLIPTA 62.5 MCG INH   3 Preferred Brand $46.00$138.00Q:30
/30Days
INDAPAMIDE 1.25 MG TABLET [Lozol]   1* Preferred Generic $1.00$3.00None
INDAPAMIDE 2.5 MG TABLET [Lozol]   1* Preferred Generic $1.00$3.00None
INFANRIX DTAP SYRINGE   3 Preferred Brand $46.00$138.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
INLYTA 1 MG TABLET   5 Specialty Tier 25%N/AP Q:180
/30Days
INLYTA 5 MG TABLET   5 Specialty Tier 25%N/AP Q:120
/30Days
INQOVI 35 MG-100 MG TABLET   5 Specialty Tier 25%N/AP Q:5
/28Days
INREBIC 100 MG CAPSULE   5 Specialty Tier 25%N/AP Q:120
/30Days
INTELENCE 100MG TABLET   5 Specialty Tier 25%N/ANone
INTELENCE 200 MG TABLET   5 Specialty Tier 25%N/ANone
INTELENCE 25 MG TABLET   4 Non-Preferred Drug 49%49%None
INTRON A 10 MILLION UNITS VIAL   5 Specialty Tier 25%N/ANone
INTRON A 18 MILLION UNITS VIAL   5 Specialty Tier 25%N/ANone
INTRON A 50 MILLION UNITS VIAL   5 Specialty Tier 25%N/ANone
INTROVALE 0.15-0.03 MG TABLET TBDSPK 3MO [Setlakin]   3 Preferred Brand $46.00$138.00None
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   4 Non-Preferred Drug 49%49%Q:1
/28Days
Invega Sustenna 156 mg/mL Prefilled Syringe   4 Non-Preferred Drug 49%49%Q:1
/28Days
Invega Sustenna 234 mg/1.5mL Prefilled Syringe   4 Non-Preferred Drug 49%49%Q:2
/28Days
Invega Sustenna 39 mg/0.25mL Prefilled Syringe   4 Non-Preferred Drug 49%49%None
Invega Sustenna 78 mg/0.5mL Prefilled Syringe   4 Non-Preferred Drug 49%49%Q:1
/28Days
INVEGA TRINZA 273 MG/0.875 ML   4 Non-Preferred Drug 49%49%Q:1
/90Days
INVEGA TRINZA 410 MG/1.315 ML   4 Non-Preferred Drug 49%49%Q:1
/90Days
INVEGA TRINZA 546 MG/1.75 ML   4 Non-Preferred Drug 49%49%Q:2
/90Days
INVEGA TRINZA 819 MG/2.625 ML   4 Non-Preferred Drug 49%49%Q:3
/90Days
IPOL VIAL 40;8;32; UNT   3 Preferred Brand $46.00$138.00None
IPRAT-ALBUT 0.5-3(2.5) MG/3 ML   2 Generic $19.00$57.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
IPRATROPIUM 0.06% SPRAY   2 Generic $19.00$57.00Q:45
/30Days
IPRATROPIUM BR 0.02% SOLUTION [Atrovent]   2 Generic $19.00$57.00P
IPRATROPIUM BROMIDE NASAL SPRAY   2 Generic $19.00$57.00Q:30
/30Days
IRBESARTAN 150 MG TABLET [Avapro]   1* Preferred Generic $1.00$3.00Q:30
/30Days
IRBESARTAN 300 MG TABLET [Avapro]   1* Preferred Generic $1.00$3.00Q:30
/30Days
IRBESARTAN 75 MG TABLET [Avapro]   1* Preferred Generic $1.00$3.00Q:30
/30Days
IRBESARTAN-HCTZ 150-12.5 MG TABLET [Avalide]   1* Preferred Generic $1.00$3.00Q:30
/30Days
IRBESARTAN-HCTZ 300-12.5 MG TABLET [Avalide]   1* Preferred Generic $1.00$3.00Q:30
/30Days
IRESSA 250 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
ISENTRESS 100 MG POWDER PACKET   4 Non-Preferred Drug 49%49%None
ISENTRESS 100 MG TABLET CHEW   5 Specialty Tier 25%N/ANone
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 49%49%None
ISENTRESS 400MG TABLET   5 Specialty Tier 25%N/ANone
ISENTRESS HD 600 MG TABLET   5 Specialty Tier 25%N/ANone
ISIBLOOM 28 DAY TABLET [Solia]   2 Generic $19.00$57.00None
ISOLYTE P IN 5% DEXTROSE INJECTION   4 Non-Preferred Drug 49%49%None
ISOLYTE S IV SOLUTION PH7.4   4 Non-Preferred Drug 49%49%P
ISONIAZID 100 MG TABLET   1* Preferred Generic $1.00$3.00None
ISONIAZID 300 MG TABLET   1* Preferred Generic $1.00$3.00None
ISONIAZID 50MG/5ML SYRUP   4 Non-Preferred Drug 49%49%None
ISOSORBIDE DINITRATE 10 MG TABLET [Wesorbide]   2 Generic $19.00$57.00None
ISOSORBIDE DINITRATE 20 MG TABLET [Wesorbide]   2 Generic $19.00$57.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ISOSORBIDE DN 30 MG TABLET   2 Generic $19.00$57.00None
ISOSORBIDE DN 5 MG TABLET   2 Generic $19.00$57.00None
ISOSORBIDE MN ER 30 MG TABLET   2 Generic $19.00$57.00None
ISOSORBIDE MONONIT 10 MG TABLET [Monoket]   2 Generic $19.00$57.00None
ISOSORBIDE MONONIT 20 MG TABLET [Monoket]   2 Generic $19.00$57.00None
ISOSORBIDE MONONIT ER 60 MG TABLET ER 24H [Isotrate ER]   2 Generic $19.00$57.00None
ISOSORBIDE MONONITRATE ER TABLET 120MG (100 CT)   2 Generic $19.00$57.00None
ISOTON GENTAMICIN 80MG/100ML   4 Non-Preferred Drug 49%49%None
ISOTONIC GENTAMICIN 100 MG/100 ML   4 Non-Preferred Drug 49%49%None
ISOTONIC GENTAMICIN 80 MG/50 ML   4 Non-Preferred Drug 49%49%None
ISOTRETINOIN 10 MG CAPSULE [ZENATANE]   4 Non-Preferred Drug 49%49%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ISOTRETINOIN 20 MG CAPSULE [ZENATANE]   4 Non-Preferred Drug 49%49%P
ISOTRETINOIN 25 MG CAPSULE [Absorica]   4 Non-Preferred Drug 49%49%P
ISOTRETINOIN 30 MG CAPSULE [ZENATANE]   4 Non-Preferred Drug 49%49%P
ISOTRETINOIN 35 MG CAPSULE [Absorica]   4 Non-Preferred Drug 49%49%P
ISOTRETINOIN 40 MG CAPSULE [ZENATANE]   4 Non-Preferred Drug 49%49%P
ISRADIPINE 2.5 MG CAPSULE [DynaCirc]   3 Preferred Brand $46.00$138.00None
ISRADIPINE 5 MG CAPSULE [DynaCirc]   3 Preferred Brand $46.00$138.00None
ITRACONAZOLE 100 MG CAPSULE [Sporanox]   4 Non-Preferred Drug 49%49%P
IVERMECTIN 3 MG TABLET [Stromectol, Sklice]   3 Preferred Brand $46.00$138.00P
Ixekizumab 1ML 80 MG/ML Auto-Injector [Taltz]   5 Specialty Tier 25%N/AP Q:3
/28Days
Ixekizumab 1ML 80 MG/ML Prefilled Syringe [Taltz]   5 Specialty Tier 25%N/AP 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 $46.00$138.00None

Chart Legend:

Below are a few notes to help you understand the above 2022 Medicare Part D SilverScript SmartRx (PDP) Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug or Medicare Advantage plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region). The plan name is followed by the plan type (PDP, HMO, HMO-POS, PPO, PFFS, etc.)

  • Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.

  • Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $480 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.

  • Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
    • Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.
    • No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.

  • Plan ID: This is the Medicare Part D prescription drug plan's unique ID.

  • Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
    • Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have five (5) tiers 1=Preferred Generics, 2=Generics, 3=Preferred Brands, 4=Non-preferred Brands, 5=Specialty Drugs.
    • Tier Number* - Some Part D drug plans exclude one or more drug tiers from the plan’s deductible. If the drug tier field above is followed by * (example: 2*), then this drug tier is excluded from the plan’s deductible.
    • Tier Description - This is the Medicare Part D plan’s description of this particular drug tier.

  • Cost Sharing - Copay / Coinsurance - This is what you will pay for formulary drugs in the Initial Coverage Phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
    • Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the initial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $4,430) at a "Preferred" network pharmacy. In most cases, the "Preferred" network pharmacy cost-sharing is lower than the standard (non-preferred) network pharmacy cost-sharing.

      * When the insulin copay is in green, example: $35.00, this Part D plan may offer particular forms of insulin as part of the Senior Savings Model.  The Senior Savings Model stipulates that some insulin will cost no more than $35 in the deductible, initial coverage, and coverage gap phases of your Part D plan. Please contact the drug plan for more details.

    • Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).

  • Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
    • None - This drug does not fall under any drug utilization management controls.
    • P - Prior Authorization -This drug is subject to prior authorization.
    • S - Step Therapy -This drug is subject to step therapy.
    • Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.




(Chart Source: Centers for Medicare and Medicaid files: CMS Data September 2022 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Medicare plan provider.