2024 Medicare Part D Plan Formulary Information |
Network Health PremierRx (PPO) (H5215-005-0)
Benefits & Contact Info
Insulin on a Medicare Part D plan's formulary will have a monthly copay of $35 or less. Call drug plan for more details. |
The Network Health PremierRx (PPO) (H5215-005-0) Formulary Drugs Starting with the Letter I in Waupaca County, WI: CMS MA Region 14 which includes: WI
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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 |
$8.00 | $0.00 | Q:1 /30Days |
IBRANCE 100 MG CAPSULE |
5 |
Tier 5 |
29% | N/A | P Q:21 /28Days |
IBRANCE 100 MG TABLET |
5 |
Tier 5 |
29% | N/A | P Q:21 /28Days |
IBRANCE 125 MG CAPSULE |
5 |
Tier 5 |
29% | N/A | P Q:21 /28Days |
IBRANCE 125 MG TABLET |
5 |
Tier 5 |
29% | N/A | P Q:21 /28Days |
IBRANCE 75 MG CAPSULE |
5 |
Tier 5 |
29% | N/A | P Q:21 /28Days |
IBRANCE 75 MG TABLET |
5 |
Tier 5 |
29% | N/A | P Q:21 /28Days |
IBU 600 MG TABLET [Toxicology Saliva Collection] |
2* |
Generic |
$8.00 | $0.00 | None |
IBU 800 MG TABLET [Samson-8] |
2* |
Generic |
$8.00 | $0.00 | None |
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [PediaCare Children's Pain Reliever/Fever Reducer IB] |
2* |
Generic |
$8.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IBUPROFEN 400 MG TABLET [Motrin] |
2* |
Generic |
$8.00 | $0.00 | None |
IBUPROFEN 600 MG TABLET [Toxicology Saliva Collection] |
2* |
Generic |
$8.00 | $0.00 | None |
IBUPROFEN 800 MG TABLET [Samson-8] |
2* |
Generic |
$8.00 | $0.00 | None |
ICATIBANT 30 MG/3 ML SYRINGE [FIRAZYR] |
5 |
Tier 5 |
29% | N/A | P Q:27 /30Days |
ICLUSIG 10 MG TABLET |
5 |
Tier 5 |
29% | N/A | P Q:30 /30Days |
ICLUSIG 15 MG TABLET |
5 |
Tier 5 |
29% | N/A | P Q:30 /30Days |
ICLUSIG 30 MG TABLET |
5 |
Tier 5 |
29% | N/A | P Q:30 /30Days |
ICLUSIG 45 MG TABLET |
5 |
Tier 5 |
29% | N/A | P Q:30 /30Days |
ICOSAPENT ETHYL 1 GRAM CAPSULE [VASCEPA] |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
ICOSAPENT ETHYL 500 MG CAPSULE [VASCEPA] |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
IDHIFA 100 MG TABLET |
5 |
Tier 5 |
29% | 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 |
Tier 5 |
29% | N/A | P Q:30 /30Days |
ILEVRO 0.3% OPHTH DROPS EYE DROPPER |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | None |
ILUMYA 100 MG/ML SYRINGE |
5 |
Tier 5 |
29% | N/A | P Q:2 /28Days |
IMATINIB MESYLATE 100 MG TABLET [Gleevec] |
5 |
Tier 5 |
29% | N/A | P Q:90 /30Days |
IMATINIB MESYLATE 400 MG TABLET [Gleevec] |
5 |
Tier 5 |
29% | N/A | P Q:90 /30Days |
IMBRUVICA 140 MG CAPSULE |
5 |
Tier 5 |
29% | N/A | P Q:120 /30Days |
IMBRUVICA 280 MG TABLET |
5 |
Tier 5 |
29% | N/A | P Q:60 /30Days |
IMBRUVICA 420 MG TABLET |
5 |
Tier 5 |
29% | N/A | P Q:30 /30Days |
IMBRUVICA 70 MG CAPSULE |
5 |
Tier 5 |
29% | N/A | P Q:240 /30Days |
IMBRUVICA 70 MG/ML ORAL SUSPENSION |
5 |
Tier 5 |
29% | N/A | P Q:324 /30Days |
IMIPRAMINE HCL 10 MG TABLET [Tofranil] |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IMIPRAMINE HCL 25 MG TABLET [Tofranil] |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
IMIPRAMINE HCL 50 MG TABLET [Tofranil] |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
IMIPRAMINE PAMOATE 100 MG CAPSULE [Tofranil-PM] |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | None |
IMIPRAMINE PAMOATE 125 MG CAPSULE [Tofranil-PM] |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | None |
IMIPRAMINE PAMOATE 150 MG CAPSULE [Tofranil-PM] |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | None |
IMIPRAMINE PAMOATE 75 MG CAPSULE [Tofranil-PM] |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | None |
IMIQUIMOD 5% CREAM PACKET |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
IMOVAX RABIES VACCINE VIAL |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
IMPAVIDO 50 MG CAPSULE |
5 |
Tier 5 |
29% | N/A | P |
IMVEXXY 10 MCG MAINTENANCE PAK INSERT |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | None |
IMVEXXY 10 MCG STARTER PACK INSR DS PK |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IMVEXXY 4 MCG MAINTENANCE PACK INSERT |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | None |
IMVEXXY 4 MCG STARTER PACK INSR DS PK |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | None |
INCASSIA 0.35 MG TABLET [Sharobel 28-Day] |
2* |
Generic |
$8.00 | $0.00 | None |
Increlex 40mg/4mL 1 VIAL, MULTI-DOSE per CARTON / 4 mL in 1 VIAL, MULTI-DOSE |
5 |
Tier 5 |
29% | N/A | None |
INCRUSE ELLIPTA 62.5 MCG INH |
3* |
Preferred Brand |
$42.00 | $105.00 | Q:30 /30Days |
INDAPAMIDE 1.25 MG TABLET [Lozol] |
2* |
Generic |
$8.00 | $0.00 | None |
INDAPAMIDE 2.5 MG TABLET [Lozol] |
2* |
Generic |
$8.00 | $0.00 | None |
INDOMETHACIN 25 MG CAPSULE [Indocin] |
3* |
Preferred Brand |
$42.00 | $105.00 | P |
INDOMETHACIN 50 MG CAPSULE [Indocin] |
3* |
Preferred Brand |
$42.00 | $105.00 | P |
INDOMETHACIN ER 75 MG CAPSULE ER [Indocin SR] |
3* |
Preferred Brand |
$42.00 | $105.00 | P |
INFANRIX DTAP SYRINGE |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INGREZZA 40 MG CAPSULE |
5 |
Tier 5 |
29% | N/A | P Q:30 /30Days |
INGREZZA 40 MG SPRINKLE CAPSULE |
5 |
Tier 5 |
29% | N/A | P Q:30 /30Days |
INGREZZA 60 MG CAPSULE |
5 |
Tier 5 |
29% | N/A | P Q:30 /30Days |
INGREZZA 60 MG SPRINKLE CAPSULE |
5 |
Tier 5 |
29% | N/A | P Q:30 /30Days |
INGREZZA 80 MG CAPSULE |
5 |
Tier 5 |
29% | N/A | P Q:30 /30Days |
INGREZZA 80 MG SPRINKLE CAPSULE |
5 |
Tier 5 |
29% | N/A | P Q:30 /30Days |
INGREZZA INITIATION PACK CAPSULE DS PK |
5 |
Tier 5 |
29% | N/A | P Q:28 /28Days |
INLYTA 1 MG TABLET |
5 |
Tier 5 |
29% | N/A | P Q:120 /30Days |
INLYTA 5 MG TABLET |
5 |
Tier 5 |
29% | N/A | P Q:120 /30Days |
INQOVI 35 MG-100 MG TABLET |
5 |
Tier 5 |
29% | N/A | P Q:5 /28Days |
INREBIC 100 MG CAPSULE |
5 |
Tier 5 |
29% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INSULIN ASPART 100 UNIT/ML CARTRIDGE |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
INSULIN ASPART 100 UNIT/ML INSULIN PEN [NovoLog PenFill] |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
INSULIN ASPART 100 UNIT/ML VIAL [NovoLog PenFill] |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
INSULIN ASPART PROT-INSULN ASP INSULIN PEN [NovoLog Mix 70/30] |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
INSULIN ASPART PROT-INSULN ASP VIAL [NovoLog Mix 70/30] |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
INSULIN DEGLUDEC 100 UNIT/ML VIAL [Tresiba] |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | P |
INSULIN DEGLUDEC PEN (U-100) INSULN PEN [Tresiba] |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | P |
INSULIN DEGLUDEC PEN (U-200) INSULN PEN [Tresiba] |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | P |
INSULIN GLARGINE MAX SOLO U300 INSULN PEN [Toujeo SoloStar] |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | P |
INSULIN GLARGINE SOLOSTAR U300 INSULN PEN [Toujeo SoloStar] |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | P |
INSULIN GLARGINE-YFGN U100 INSULIN PEN [Semglee] |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INSULIN GLARGINE-YFGN U100 VIAL [Semglee] |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | P |
INSULIN LISPRO 100 UNIT/ML INSULN PEN [LYUMJEV] |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | P |
INSULIN LISPRO 100 UNIT/ML VIAL [LYUMJEV] |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | P |
INSULIN LISPRO JR 100 UNIT/ML INSULN PEN HF |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | P |
INSULIN LISPRO MIX 75-25 KWIKPEN INSULN PEN [Humalog KwikPen Mix 75/25] |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | P |
INTELENCE 25 MG TABLET |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
INTRALIPID 20% IV FAT EMULSION |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | P |
INTRALIPID 30% IV FAT EMULSION |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | P |
INTRAROSA 6.5 MG VAG INSERT |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | P |
INVEGA HAFYERA 1,092 MG/3.5 ML SYRINGE |
5 |
Tier 5 |
29% | N/A | None |
INVEGA HAFYERA 1,560 MG/5 ML SYRINGE |
5 |
Tier 5 |
29% | N/A | 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 |
Tier 5 |
29% | N/A | None |
Invega Sustenna 156 mg/mL Prefilled Syringe |
5 |
Tier 5 |
29% | N/A | None |
Invega Sustenna 234 mg/1.5mL Prefilled Syringe |
5 |
Tier 5 |
29% | N/A | None |
Invega Sustenna 39 mg/0.25mL Prefilled Syringe |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | None |
Invega Sustenna 78 mg/0.5mL Prefilled Syringe |
5 |
Tier 5 |
29% | N/A | None |
INVEGA TRINZA 273 MG/0.875 ML |
5 |
Tier 5 |
29% | N/A | None |
INVEGA TRINZA 410 MG/1.315 ML |
5 |
Tier 5 |
29% | N/A | None |
INVEGA TRINZA 546 MG/1.75 ML |
5 |
Tier 5 |
29% | N/A | None |
INVEGA TRINZA 819 MG/2.625 ML |
5 |
Tier 5 |
29% | N/A | None |
INVELTYS 1% EYE DROP EYE DROPPER |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | None |
INVOKAMET 150-1,000 MG TABLET |
3* |
Preferred Brand |
$42.00 | $105.00 | 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 |
3* |
Preferred Brand |
$42.00 | $105.00 | Q:60 /30Days |
INVOKAMET 50-1,000 MG TABLET |
3* |
Preferred Brand |
$42.00 | $105.00 | Q:60 /30Days |
INVOKAMET 50-500 MG TABLET |
3* |
Preferred Brand |
$42.00 | $105.00 | Q:120 /30Days |
INVOKAMET XR 150-1,000 MG TABLET |
3* |
Preferred Brand |
$42.00 | $105.00 | Q:60 /30Days |
INVOKAMET XR 150-500 MG TABLET |
3* |
Preferred Brand |
$42.00 | $105.00 | Q:60 /30Days |
INVOKAMET XR 50-1,000 MG TABLET |
3* |
Preferred Brand |
$42.00 | $105.00 | Q:60 /30Days |
INVOKAMET XR 50-500 MG TABLET |
3* |
Preferred Brand |
$42.00 | $105.00 | Q:120 /30Days |
INVOKANA 100 MG TABLET |
3* |
Preferred Brand |
$42.00 | $105.00 | Q:90 /30Days |
INVOKANA 300 MG TABLET |
3* |
Preferred Brand |
$42.00 | $105.00 | Q:30 /30Days |
IOPIDINE 1% EYE DROPS |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | None |
IPOL VIAL 40;8;32; UNT |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IPRAT-ALBUT 0.5-3(2.5) MG/3 ML AMPUL-NEB [DuoNeb] |
2* |
Generic |
$8.00 | $0.00 | P |
IPRATROPIUM 0.03% SPRAY [Atrovent] |
2* |
Generic |
$8.00 | $0.00 | Q:60 /30Days |
IPRATROPIUM 0.06% SPRAY [Atrovent] |
2* |
Generic |
$8.00 | $0.00 | Q:45 /30Days |
IPRATROPIUM BR 0.02% SOLUTION [Atrovent] |
2* |
Generic |
$8.00 | $0.00 | P |
IRBESARTAN 150 MG TABLET [Avapro] |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
IRBESARTAN 300 MG TABLET [Avapro] |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
IRBESARTAN 75 MG TABLET [Avapro] |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
IRBESARTAN-HCTZ 150-12.5 MG TABLET [Avalide] |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
IRBESARTAN-HCTZ 300-12.5 MG TABLET [Avalide] |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
ISENTRESS 100 MG POWDER PACKET |
5 |
Tier 5 |
29% | N/A | None |
ISENTRESS 100 MG TABLET CHEWABLE |
5 |
Tier 5 |
29% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISENTRESS 25 MG TABLET CHEWABLE |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
ISENTRESS 400MG TABLET |
5 |
Tier 5 |
29% | N/A | None |
ISENTRESS HD 600 MG TABLET |
5 |
Tier 5 |
29% | N/A | None |
ISIBLOOM 28 DAY TABLET [Solia] |
2* |
Generic |
$8.00 | $0.00 | None |
ISOLYTE P IN 5% DEXTROSE INJECTION |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | None |
ISOLYTE S IV SOLUTION PH7.4 |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | None |
ISONIAZID 100 MG TABLET |
2* |
Generic |
$8.00 | $0.00 | None |
ISONIAZID 300 MG TABLET |
2* |
Generic |
$8.00 | $0.00 | None |
ISONIAZID 50MG/5ML SYRUP |
2* |
Generic |
$8.00 | $0.00 | None |
ISOSORBIDE DINITRATE 10 MG TABLET [Wesorbide] |
2* |
Generic |
$8.00 | $0.00 | None |
ISOSORBIDE DINITRATE 20 MG TABLET [Wesorbide] |
2* |
Generic |
$8.00 | $0.00 | 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 |
$8.00 | $0.00 | None |
ISOSORBIDE DN 5 MG TABLET |
2* |
Generic |
$8.00 | $0.00 | None |
ISOSORBIDE MN ER 30 MG TABLET |
2* |
Generic |
$8.00 | $0.00 | None |
ISOSORBIDE MONONIT 10 MG TABLET [Monoket] |
2* |
Generic |
$8.00 | $0.00 | None |
ISOSORBIDE MONONIT 20 MG TABLET [Monoket] |
2* |
Generic |
$8.00 | $0.00 | None |
ISOSORBIDE MONONIT ER 120 MG TABLET 24H [Imdur] |
2* |
Generic |
$8.00 | $0.00 | None |
ISOSORBIDE MONONIT ER 60 MG TABLET 24H [Isotrate ER] |
2* |
Generic |
$8.00 | $0.00 | None |
ISOSORBIDE-HYDRALAZINE 20-37.5 TABLET [BiDil] |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
ISOTON GENTAMICIN 80MG/100ML |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
ISOTONIC GENTAMICIN 100 MG/100 ML |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
ISOTONIC GENTAMICIN 80 MG/50 ML |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISRADIPINE 2.5 MG CAPSULE [DynaCirc] |
2* |
Generic |
$8.00 | $0.00 | None |
ISRADIPINE 5 MG CAPSULE [DynaCirc] |
2* |
Generic |
$8.00 | $0.00 | None |
ISTURISA 1 MG TABLET |
5 |
Tier 5 |
29% | N/A | P |
ISTURISA 5 MG TABLET |
5 |
Tier 5 |
29% | N/A | P |
ITRACONAZOLE 10 MG/ML SOLUTION [Sporanox] |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | P |
ITRACONAZOLE 100 MG CAPSULE [Sporanox] |
2* |
Generic |
$8.00 | $0.00 | P |
IVERMECTIN 1% CREAM (G) [Soolantra] |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
IVERMECTIN 3 MG TABLET [Stromectol, Sklice] |
3* |
Preferred Brand |
$42.00 | $105.00 | P |
IWILFIN 192 MG TABLET |
5 |
Tier 5 |
29% | N/A | P |
IXCHIQ Chikungunya 18 Years + Injectable 0.5mL Live SDV Ea |
3* |
Preferred Brand |
$42.00 | $105.00 | None |
Ixekizumab 1ML 80 MG/ML Auto-Injector [Taltz] |
5 |
Tier 5 |
29% | N/A | P Q:2 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Ixekizumab 1ML 80 MG/ML Prefilled Syringe [Taltz] |
5 |
Tier 5 |
29% | N/A | P Q:2 /28Days |
IXIARO 6 UNIT(6 MCG)/0.5ML SYRINGE |
3* |
Preferred Brand |
$42.00 | $105.00 | None |