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Aetna Medicare Rx Premier (PDP) (S5810-202-0)
Tier 1 (1457)
Tier 2 (610)
Tier 3 (258)
Tier 4 (540)
Tier 5 (315)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
Yes No Show either
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Cick on the first letter of your drug name to browse the formulary:

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2011 Medicare Part D Plan Formulary Information
Aetna Medicare Rx Premier (PDP) (S5810-202-0)
Sanctioned Plan           
The Aetna Medicare Rx Premier (PDP) (S5810-202-0)
Formulary Drugs Starting with the Letter H

in CMS PDP Region 32 which includes: CA
Drugs Starting with Letter H

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
HALOBETASOL 0.5 MG/ML TOPICAL CREAM   1 Tier 1 $2.00$6.00None
HALOBETASOL PROPIONATE 0.05% OINTMENT   1 Tier 1 $2.00$6.00None
HALOPERIDOL 0.5MG TABLET   1 Tier 1 $2.00$6.00None
HALOPERIDOL 10MG TABLET (1000 CT)   1 Tier 1 $2.00$6.00None
HALOPERIDOL 1MG TABLET   1 Tier 1 $2.00$6.00None
HALOPERIDOL 20MG TABLET (100 CT)   1 Tier 1 $2.00$6.00None
HALOPERIDOL 2MG TABLET (100 CT)   1 Tier 1 $2.00$6.00None
HALOPERIDOL 5MG TABLET   1 Tier 1 $2.00$6.00None
HALOPERIDOL DEC 100MG/ML VL   2 Tier 2 $20.00$45.00None
HALOPERIDOL DEC 50MG 10 X 1ML PKG   2 Tier 2 $20.00$45.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
HALOPERIDOL LAC 2MG/ML CONC   1 Tier 1 $2.00$6.00None
HALOPERIDOL LAC 5MG/ML VIAL   1 Tier 1 $2.00$6.00None
HAVRIX HEPATITIS A VACCINE INACTIVATED INJECTION SOLUTION 1440UNITS 10 X 1ML VIALSD   4 Tier 4 $60.00$165.00P
HAVRIX HEPATITIS A VACCINE INJECTION   4 Tier 4 $60.00$165.00P
HECTOROL 0.5MCG CAPSULE   3 Tier 3 $25.00$60.00P
HECTOROL 2.5MCG CAPSULE   3 Tier 3 $25.00$60.00P
HECTOROL 4 MCG/2ML AMPUL   3 Tier 3 $25.00$60.00P
HEPARIN 25000U-1/2NS 250ML   4 Tier 4 $60.00$165.00None
HEPARIN 25000U-1/2NS 500ML   4 Tier 4 $60.00$165.00None
HEPARIN NA 2000UNITS/ML VIAL   2 Tier 2 $20.00$45.00None
HEPARIN NA 2500UNITS/ML VIAL   4 Tier 4 $60.00$165.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
HEPARIN SODIUM IN 5% DEXTROSE INJECTION SOLUTION 4000UNITS 24 X 500ML CTR   1 Tier 1 $2.00$6.00None
HEPARIN SODIUM INJECTION   2 Tier 2 $20.00$45.00P
HEPARIN SODIUM INJECTION   2 Tier 2 $20.00$45.00None
HEPARIN SODIUM INJECTION   4 Tier 4 $60.00$165.00None
HEPARIN SODIUM INJECTION   2 Tier 2 $20.00$45.00None
HEPARIN SODIUM INJECTION SOLUTION 200UNITS 12 X 1000ML CTR   1 Tier 1 $2.00$6.00None
HEPATITIS B VACCINE RECOMBIANT ADULT FORMULATION INJECTION 10MCG 1ML VIALSD   4 Tier 4 $60.00$165.00P
HEPSERA 10MG TABLET   5 Tier 5 25%25%P Q:1
/1Days
HEXALEN CAPSULES   5 Tier 5 25%25%P
HIZENTRA LIQUID   5 Tier 5 25%25%P
HUMALOG MIX 50/50 VIAL   4 Tier 4 $60.00$165.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
HUMALOG MIX KWIKPEN INJECTION   4 Tier 4 $60.00$165.00None
HUMIRA 40MG/0.8ML SYRINGE   5 Tier 5 25%25%P Q:6
/28Days
HUMIRA PEN KIT 40MG-70% 1 PKGCOM   5 Tier 5 25%25%P Q:6
/28Days
HUMULIN R 500U/ML VIAL   4 Tier 4 $60.00$165.00None
HYCET SOL 7.5-325   2 Tier 2 $20.00$45.00Q:185
/1Days
HYDRALAZINE 100MG TABLET   1 Tier 1 $2.00$6.00None
HYDRALAZINE 10MG TABLET   1 Tier 1 $2.00$6.00None
HYDRALAZINE 25MG TABLET   1 Tier 1 $2.00$6.00None
HYDRALAZINE 50MG TABLET   1 Tier 1 $2.00$6.00None
HYDRALAZINE HCL INJECTION 20MG 25 X 1ML VIALSD   1 Tier 1 $2.00$6.00None
HYDROCHLORIDE 50MG TABLET (1000 CT)   1 Tier 1 $2.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
HYDROCHLOROTHIAZIDE 12.5MG CAPSULE (100 CT)   1 Tier 1 $2.00$6.00None
HYDROCHLOROTHIAZIDE 12.5MG TABLET   1 Tier 1 $2.00$6.00None
HYDROCHLOROTHIAZIDE 25 MG / TRIAMTERENE 50 MG ORAL CAPSULE   1 Tier 1 $2.00$6.00None
HYDROCHLOROTHIAZIDE TABLETS 25MG   1 Tier 1 $2.00$6.00None
HYDROCODONE BITARTRATE AND ACETAMINOPHEN ORAL SOLUTION 10;325MG/15ML 7.5 ML CUPUD   2 Tier 2 $20.00$45.00Q:185
/1Days
HYDROCODONE BITARTRATE AND ACETAMINOPHEN ORAL SOLUTION 500;7;7.5MG/15ML;% 4 FLO BOT   1 Tier 1 $2.00$6.00Q:120
/1Days
HYDROCODONE BITARTRATE AND ACETAMINOPHEN TABLET 500-7.5MG (120 CT)   1 Tier 1 $2.00$6.00Q:8
/1Days
HYDROCODONE BITARTRATE AND ACETAMINOPHEN TABLET 7.5-650MG (500 CT)   1 Tier 1 $2.00$6.00Q:6
/1Days
HYDROCODONE BITARTRATE AND IBUPROFEN TABLET 7.5-200MG (100 CT)   1 Tier 1 $2.00$6.00Q:5
/1Days
HYDROCODONE-ACETAMINOPHEN 10-750MG TABLET   2 Tier 2 $20.00$45.00Q:5
/1Days
HYDROCODONE-ACETAMINOPHEN 10MG-500MG TABLET   1 Tier 1 $2.00$6.00Q:8
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
HYDROCODONE-ACETAMINOPHEN 10MG-650MG TABLET   1 Tier 1 $2.00$6.00Q:6
/1Days
HYDROCODONE-ACETAMINOPHEN 5MG-325MG TABLET   1 Tier 1 $2.00$6.00Q:12
/1Days
HYDROCODONE-ACETAMINOPHEN 7.5-325MG TABLET   1 Tier 1 $2.00$6.00Q:12
/1Days
HYDROCODONE/APAP 10/325 TABLET   1 Tier 1 $2.00$6.00Q:12
/1Days
HYDROCODONE/APAP 10/660 TABLET   1 Tier 1 $2.00$6.00Q:6
/1Days
HYDROCODONE/APAP 2.5/500 TABLET   1 Tier 1 $2.00$6.00Q:8
/1Days
HYDROCODONE/APAP 5/500 TABLET   1 Tier 1 $2.00$6.00Q:8
/1Days
HYDROCODONE/APAP 7.5/750 TABLET   1 Tier 1 $2.00$6.00Q:5
/1Days
HYDROCORTISONE 0.2% CREAM   1 Tier 1 $2.00$6.00None
HYDROCORTISONE 0.2% OINTMENT   1 Tier 1 $2.00$6.00None
HYDROCORTISONE 1% LOTION 118ML   1 Tier 1 $2.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
HYDROCORTISONE 100MG ENEMA   2 Tier 2 $20.00$45.00None
HYDROCORTISONE 10MG TABLET   1 Tier 1 $2.00$6.00None
HYDROCORTISONE 20MG TABLET   1 Tier 1 $2.00$6.00None
HYDROCORTISONE 5MG TABLET   1 Tier 1 $2.00$6.00None
HYDROCORTISONE AND ACETIC ACID OTIC SOLUTION   1 Tier 1 $2.00$6.00None
HYDROCORTISONE BUTYRATE 0.1% CREAM   1 Tier 1 $2.00$6.00None
HYDROCORTISONE BUTYRATE 0.1% OINTMENT   2 Tier 2 $20.00$45.00None
HYDROCORTISONE BUTYRATE 0.1% SOLUTION NON-ORAL   1 Tier 1 $2.00$6.00None
HYDROCORTISONE CREAM 1% 1 LB JAR   1 Tier 1 $2.00$6.00None
HYDROCORTISONE CREAM USP 2.5% 20GM TUBE   1 Tier 1 $2.00$6.00None
HYDROCORTISONE LOTION 2.5% 2 OZ BOT   1 Tier 1 $2.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
HYDROCORTISONE OINTMENT 1% 1 LB JAR   1 Tier 1 $2.00$6.00None
HYDROCORTISONE OINTMENT USP 2.5% 20GM TUBE BOX   1 Tier 1 $2.00$6.00None
HYDROMORPHON INJ 10MG/ML   1 Tier 1 $2.00$6.00None
HYDROMORPHONE HCL 8MG TABLET (100 CT)   1 Tier 1 $2.00$6.00Q:8
/1Days
HYDROMORPHONE HYDROCHLORIDE TABLETS   1 Tier 1 $2.00$6.00Q:16
/1Days
HYDROMORPHONE HYDROCHLORIDE TABLETS   1 Tier 1 $2.00$6.00Q:8
/1Days
HYDROXYCHLOROQUINE 200MG TABLET (500 CT)   1 Tier 1 $2.00$6.00None
HYDROXYUREA 500MG CAPSULE   1 Tier 1 $2.00$6.00None
HYDROXYZINE 25MG/ML VIAL   1 Tier 1 $2.00$6.00P
HYDROXYZINE 50MG/ML VIAL   1 Tier 1 $2.00$6.00None
HYDROXYZINE HCL 10MG TABLET (500 CT)   1 Tier 1 $2.00$6.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
HYDROXYZINE HCL 10MG/5ML ORAL SOLUTION 1 PT BOT   1 Tier 1 $2.00$6.00P
HYDROXYZINE HCL 25MG TABLET   1 Tier 1 $2.00$6.00P
HYDROXYZINE HCL TABLETS 50MG 100 BOT   1 Tier 1 $2.00$6.00P
HYDROXYZINE PAM 100MG CAPSULE   1 Tier 1 $2.00$6.00P
HYDROXYZINE PAM 50MG CAPSULE   1 Tier 1 $2.00$6.00P
HYDROXYZINE PAMOATE 25MG CAPSULE   1 Tier 1 $2.00$6.00P

Chart Legend:

Below are a few notes to help you understand the above 2011 Medicare Part D Aetna Medicare Rx Premier (PDP) Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug 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).

  • 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 $310 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 four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
    • Drug Description - This is the Medicare Part D plan’s description of this particular drug tier.
  • Cost Sharing - Copay / Coinsurance - These figures apply to 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 intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $(2840)) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, on the 2011 Humana Walmart-Preferred Rx Plan the pricing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
    • 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 October 2011 )

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 Part D plan provider.







Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.