Drug List - I

I
Drug Name Tier Restrictions
IBANDRONATE 1
IBRANCE CAP 125MG 3 Prior Authorization
IBUPROFEN 1
ILARIS INJ 180MG 3 Prior authorization
IMBRUVICA CAP 140MG 3 Prior Authorization
IMDUR 3 Prior authorization
IMIPRAMINE 1
IMIQUIMOD 1 Quantity limit
IMITREX 3 Prior authorization, Quantity limit, Step therapy
IMURAN $0
INCIVEK 2 Prior authorization
INCRUSE ELPT INH 62.5MCG 3 Prior authorizaton
INDAPAMIDE 1
INDERAL LA 3 Prior authorization
INDOMETHACIN 1
INDOMETHACIN ER 1
INNOHEP INJ 20000/ML 3
INOVA PAD 3 Quantity limit, Step therapy
INSPRA TAB 3 Prior authorization
INTAL INHALER 2 Quantity limit
INTERMEZZO 3 Prior authorization
INTRON-A INJ 2 Prior authorization, Quantity limit
INTUNIV 3 Prior authorization, Step therapy
INVEGA 3 Prior authorization, Step therapy
INVOKAMET 2 Step therapy
INVOKANA 2 Step therapy
IOPHEN C-NR LIQ 100-10/5 1
IPRATROPIUM 1 Quantity limit
IPRATROPIUM BROMIDE SPR 1 Quantity limit
IPRATROPIUM/ALBUTER 1 Quantity limit
IRBESARTAN 1
IRBESARTAN/HCTZ 1
IRESSA 2 Prior authorization, Quantity limit
ISENTRESS 2
ISOMETHEPTENE/DICHLORALPHEN 1
ISONIAZID $0
ISOPTIN SR 3 Prior authorization
ISOPTO HOMATROPINE 1
ISOPTO HYOSCINE 1
ISORDIL TITRADOSE 3 Prior authorization
ISOSORBIDE DINITRATE TA 1
ISOSORBIDE MONONITRATE ER 1
ISRADIPINE 1
ISTALOL 3
ITRACONAZOLE 1