2009 Medicare Part D Plan Formulary Information |
Aetna Medicare Rx Essentials (S5810-040-0)
Benefit Details
|
The Aetna Medicare Rx Essentials (S5810-040-0) Formulary Drugs Starting with the Letter I in CMS PDP Region 6 which includes: PA WV
|
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 |
IBU TABLET 600MG (500 CT) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
IBU TABLET 800MG (500 CT) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
IBUPROFEN 100MG/5ML SUSP |
2 |
Tier 2 - Non-Preferred Generic |
$11.00 | $22.00 | None |
IBUPROFEN 400MG TABLET |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
IDAMYCIN PFS 1MG/ML VIAL |
5 |
Tier 5 - Specialty |
25% | 25% | None |
IDARUBICIN HCL 1MG/ML VIAL |
5 |
Tier 5 - Specialty |
25% | 25% | None |
IFEX 1GM VIAL |
5 |
Tier 5 - Specialty |
25% | 25% | None |
IFEX 3GM VIAL |
5 |
Tier 5 - Specialty |
25% | 25% | None |
IFEX/MESNEX KIT 1 GM/VIL 1 GM/ |
5 |
Tier 5 - Specialty |
25% | 25% | None |
IFOSFAMIDE 1GM VIAL |
2 |
Tier 2 - Non-Preferred Generic |
$11.00 | $22.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IFOSFAMIDE 1GM/ 20ML VIAL 20ML |
2 |
Tier 2 - Non-Preferred Generic |
$11.00 | $22.00 | None |
IFOSFAMIDE 3GM VIAL |
2 |
Tier 2 - Non-Preferred Generic |
$11.00 | $22.00 | None |
IFOSFAMIDE 3GM/ 60ML VIAL 60ML |
2 |
Tier 2 - Non-Preferred Generic |
$11.00 | $22.00 | None |
IFOSFAMIDE/MESNA KIT 1G/20ML / 1MG/ |
5 |
Tier 5 - Specialty |
25% | 25% | None |
IFOSFAMIDE/MESNA KIT 1G/20ML / 1MG/ |
5 |
Tier 5 - Specialty |
25% | 25% | None |
IMDUR 120MG TABLET SA |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | None |
IMDUR 30MG TABLET SA |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | None |
IMDUR 60MG TABLET SA |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | None |
IMIPRAMINE HCL 10MG TABLET (100 CT) |
2 |
Tier 2 - Non-Preferred Generic |
$11.00 | $22.00 | None |
IMIPRAMINE HCL 25MG TABLET (100 CT) |
2 |
Tier 2 - Non-Preferred Generic |
$11.00 | $22.00 | None |
IMIPRAMINE HCL 50MG TABLET (100 CT) |
2 |
Tier 2 - Non-Preferred Generic |
$11.00 | $22.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IMIPRAMINE PAMOATE 100MG CAPSULE |
2 |
Tier 2 - Non-Preferred Generic |
$11.00 | $22.00 | None |
IMIPRAMINE PAMOATE 125MG CAPSULE |
2 |
Tier 2 - Non-Preferred Generic |
$11.00 | $22.00 | None |
IMIPRAMINE PAMOATE 150MG CAPSULE |
2 |
Tier 2 - Non-Preferred Generic |
$11.00 | $22.00 | None |
IMIPRAMINE PAMOATE 75MG CAPSULE |
2 |
Tier 2 - Non-Preferred Generic |
$11.00 | $22.00 | None |
IMITREX 100MG TABLET |
3 |
Tier 3 - Preferred Brand |
$29.00 | $58.00 | Q:18 /30Days |
IMITREX 20MG NASAL SPRAY |
3 |
Tier 3 - Preferred Brand |
$29.00 | $58.00 | Q:4 /1Days |
IMITREX 25MG TABLET |
3 |
Tier 3 - Preferred Brand |
$29.00 | $58.00 | Q:18 /30Days |
IMITREX 4MG/0.5ML KIT REFILL |
3 |
Tier 3 - Preferred Brand |
$29.00 | $58.00 | Q:4 /30Days |
IMITREX 50MG TABLET |
3 |
Tier 3 - Preferred Brand |
$29.00 | $58.00 | Q:18 /30Days |
IMITREX 5MG NASAL SPRAY |
3 |
Tier 3 - Preferred Brand |
$29.00 | $58.00 | Q:1 /1Days |
IMITREX 6MG/0.5ML SYRNG KIT |
3 |
Tier 3 - Preferred Brand |
$29.00 | $58.00 | Q:4 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IMITREX 6MG/0.5ML VIAL |
3 |
Tier 3 - Preferred Brand |
$29.00 | $58.00 | Q:5 /30Days |
IMMU GLOBULIN GAMMA (IGG) 12G VIAL |
5 |
Tier 5 - Specialty |
25% | 25% | P |
IMMU GLOBULIN GAMMA (IGG) 6G VIAL |
5 |
Tier 5 - Specialty |
25% | 25% | P |
IMOVAX RABIES VACCINE 2.5UNT/ML |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | P |
IMURAN 50MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | P |
INCRELEX 40MG/4ML VIAL |
5 |
Tier 5 - Specialty |
25% | 25% | P |
INDAPAMIDE 1.25MG TABLET USP (1000 CT) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
INDAPAMIDE 2.5MG TABLET USP (1000 CT) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
INDERAL LA 120MG CAPSULE |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | S |
INDERAL LA 160MG CAPSULE |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | S |
INDERAL LA 60MG CAPSULE |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INDERAL LA 80MG CAPSULE |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | S |
INDOCIN 25MG/5ML SUSPENSION |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | None |
INDOCIN SR 75MG CAPSULE SA |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | None |
INDOMETHACIN 25MG CAPSULE |
2 |
Tier 2 - Non-Preferred Generic |
$11.00 | $22.00 | None |
INDOMETHACIN 50MG CAPSULE |
2 |
Tier 2 - Non-Preferred Generic |
$11.00 | $22.00 | None |
INDOMETHACIN 75MG CAPSULE SA |
2 |
Tier 2 - Non-Preferred Generic |
$11.00 | $22.00 | None |
INFANRIX VACCINE VIAL 25-10UNT/.5ML |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | None |
INFUMORPH 10MG/ML AMPUL P/F |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | P |
INFUMORPH 25MG/ML AMPUL P/F |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | P |
INNOHEP 20000UNIT/ML VIAL |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | None |
INNOPRAN XL (PROPRANOLOL HCL) 120MG CAPSULE SR 24 HR |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INNOPRAN XL (PROPRANOLOL HCL) 80MG CAPSULE SR 24 HR |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | S |
INSPRA 25MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | None |
INSPRA 50MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | None |
INTAL INH AER 800MCG |
3 |
Tier 3 - Preferred Brand |
$29.00 | $58.00 | None |
INTAL NEBULIZER SOLUTION |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | P |
INTELENCE 100MG TABLET |
5 |
Tier 5 - Specialty |
25% | 25% | None |
INTERFERON ALFACON-1 VIAL 15MCG-0.5ML |
5 |
Tier 5 - Specialty |
25% | 25% | None |
INTERFERON ALFACON-1 VIAL 9MCG-0.3ML |
5 |
Tier 5 - Specialty |
25% | 25% | None |
INTRALIPID 10% IV FAT EMUL |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | None |
INTRALIPID 20% IV FAT EMUL |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | None |
INTRALIPID IV FAT EMULSION |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INTRALIPID PHARMACY BULK PACKAGE FAT EMULSION 1.7-1.2-30GM 500ML BAG |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | None |
INTRON A 10MMU INJ PEN |
5 |
Tier 5 - Specialty |
25% | 25% | None |
INTRON A 10MMU VIAL |
5 |
Tier 5 - Specialty |
25% | 25% | None |
INTRON A 10MMU/ML VIAL |
5 |
Tier 5 - Specialty |
25% | 25% | None |
INTRON A 18MMU VIAL |
5 |
Tier 5 - Specialty |
25% | 25% | None |
INTRON A 3MMU INJECTION PEN |
5 |
Tier 5 - Specialty |
25% | 25% | None |
INTRON A 50MMU VIAL |
5 |
Tier 5 - Specialty |
25% | 25% | None |
INTRON A 5MMU MULTIDOSE PEN |
5 |
Tier 5 - Specialty |
25% | 25% | None |
INTRON A 6MMU/ML VIAL |
5 |
Tier 5 - Specialty |
25% | 25% | None |
INVANZ 1GM VIAL |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | None |
INVEGA 3MG TABLET SR OSMOTIC PUSH 24HR |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | S Q:2 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
INVEGA 6MG TABLET SR OSMOTIC PUSH 24HR |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | S Q:2 /1Days |
INVEGA 9MG TABLET SR OSMOTIC PUSH 24HR |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | S Q:1 /1Days |
INVERSINE 2.5MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | None |
INVIRASE 200MG CAPSULE |
5 |
Tier 5 - Specialty |
25% | 25% | None |
INVIRASE 500MG TABLET |
5 |
Tier 5 - Specialty |
25% | 25% | None |
IONOSOL B-D5W IV SOLUTION |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | None |
IONOSOL MB-D5W IV SOLUTION |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | None |
IONOSOL T-D5W IV SOLUTION |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | None |
IOPIDINE 0.5% EYE DROPS |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | None |
IOPIDINE 1% EYE DROPS |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | None |
IPLEX 36MG/0.6ML VIAL |
5 |
Tier 5 - Specialty |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
IPOL VIAL 40;8;32; UNT |
3 |
Tier 3 - Preferred Brand |
$29.00 | $58.00 | None |
IPRATROPIUM BROMIDE 21MCG AEROSOL SPRAY |
2 |
Tier 2 - Non-Preferred Generic |
$11.00 | $22.00 | None |
IPRATROPIUM BROMIDE 42MCG AEROSOL SPRAY |
2 |
Tier 2 - Non-Preferred Generic |
$11.00 | $22.00 | None |
IPRATROPIUM BROMIDE INHALATION SOLUTION 0.02% 60 X 2.5ML VIALSD |
2 |
Tier 2 - Non-Preferred Generic |
$11.00 | $22.00 | P |
IPRATROPIUM BROMIDE/ALBUTEROL SULFATE INHALATION SOLUTION 0.5MG/3ML 33 CRTN |
2 |
Tier 2 - Non-Preferred Generic |
$11.00 | $22.00 | P |
IQUIX 1.5% DROPS |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | None |
IRESSA 250MG TABLET |
5 |
Tier 5 - Specialty |
25% | 25% | None |
IRINOTECAN HCL INJECTION 20MG |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
ISENTRESS 400MG TABLET |
5 |
Tier 5 - Specialty |
25% | 25% | None |
ISMO 20MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | None |
ISO GENTAMICIN 100MG/100ML |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISO GENTAMICIN 120MG/100ML |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
ISOCHRON 40MG TABLET SA |
2 |
Tier 2 - Non-Preferred Generic |
$11.00 | $22.00 | None |
ISOLYTE H IN 5% DEXTROSE |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | None |
ISOLYTE M IN 5% DEXTROSE INJECTION |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | None |
ISOLYTE P IN 5% DEXTROSE INJECTION |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | None |
ISOLYTE S PH 7.4 SOLUTION FOR INJECTION |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | None |
ISOLYTE S IN 5% DEXTROSE INJECTION |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | None |
ISOLYTE S SOLUTION FOR INJECTION |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | None |
ISONARIF 300-150MG CAPSULE |
2 |
Tier 2 - Non-Preferred Generic |
$11.00 | $22.00 | None |
ISONIAZID 100MG TABLET |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
ISONIAZID 300MG TABLET |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISONIAZID 50MG/5ML SYRUP |
2 |
Tier 2 - Non-Preferred Generic |
$11.00 | $22.00 | None |
ISONIAZID INJ 100MG/ML |
2 |
Tier 2 - Non-Preferred Generic |
$11.00 | $22.00 | None |
ISOPTIN SR 120MG |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | S Q:1 /1Days |
ISOPTIN SR 180MG |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | S Q:2 /1Days |
ISOPTIN SR 240MG (500 Count) |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | S |
ISORDIL 40MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | None |
ISORDIL 5MG TABLET |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | None |
ISOSORBIDE DN 10MG TABLET |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
ISOSORBIDE DN 2.5MG TABLET SL |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
ISOSORBIDE DN 20MG TABLET |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
ISOSORBIDE DN 30MG TABLET |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISOSORBIDE DN 40MG TABLET SA |
2 |
Tier 2 - Non-Preferred Generic |
$11.00 | $22.00 | None |
ISOSORBIDE DN 5MG TABLET |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
ISOSORBIDE DN 5MG TABLET SL |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
ISOSORBIDE MN 10MG TABLET |
2 |
Tier 2 - Non-Preferred Generic |
$11.00 | $22.00 | None |
ISOSORBIDE MONONITRATE 20MG TABLET (500 CT) |
2 |
Tier 2 - Non-Preferred Generic |
$11.00 | $22.00 | None |
ISOSORBIDE MONONITRATE ER TABLET 120MG (100 CT) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
ISOSORBIDE MONONITRATE ER TABLET 30MG (100 CT) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
ISOSORBIDE MONONITRATE TABLET ER 60MG (100 CT) |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
ISOTON GENTAMICIN 60MG/100ML |
1 |
Tier 1 - Preferred Generic |
$0.00 | $0.00 | None |
ISOTON GENTAMICIN 80MG/100ML |
2 |
Tier 2 - Non-Preferred Generic |
$11.00 | $22.00 | None |
ISOTON GENTAMICIN 80MG/50ML |
2 |
Tier 2 - Non-Preferred Generic |
$11.00 | $22.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ISRADIPINE CAPSULES 2.5MG (100 CT) |
2 |
Tier 2 - Non-Preferred Generic |
$11.00 | $22.00 | Q:4 /1Days |
ISRADIPINE CAPSULES 5MG (100 CT) |
2 |
Tier 2 - Non-Preferred Generic |
$11.00 | $22.00 | Q:4 /1Days |
ISTALOL 0.5% EYE DROPS |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $138.00 | None |
ITRACONAZOLE 100MG CAPSULE |
2 |
Tier 2 - Non-Preferred Generic |
$11.00 | $22.00 | P |
IVEEGAM EN INJ 5GM HU |
5 |
Tier 5 - Specialty |
25% | 25% | P |