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Aetna Medicare Rx Essentials (PDP) (S5810-066-0)
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
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 Essentials (PDP) (S5810-066-0)
Sanctioned Plan           
The Aetna Medicare Rx Essentials (PDP) (S5810-066-0)
Formulary Drugs Starting with the Letter G

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

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
GABAPENTIN 400 MG CAPSULE   1 Tier 1 $5.00$15.00Q:9
/1Days
GABAPENTIN 600MG TABLET   2 Tier 2 $20.00$45.00Q:6
/1Days
GABAPENTIN CAPSULES 100MG 100 BOT   1 Tier 1 $5.00$15.00Q:6
/1Days
GABAPENTIN CAPSULES 300MG   1 Tier 1 $5.00$15.00Q:6
/1Days
GABAPENTIN TABLET 800MG   2 Tier 2 $20.00$45.00Q:6
/1Days
GABITRIL 12MG FILMTAB   4 Tier 4 $70.00$195.00P S Q:4
/1Days
GABITRIL 16MG FILMTAB   4 Tier 4 $70.00$195.00P S Q:4
/1Days
GABITRIL 2MG FILMTAB   4 Tier 4 $70.00$195.00P S Q:2
/1Days
GABITRIL 4MG FILMTAB   4 Tier 4 $70.00$195.00P S
GALANTAMINE HBR 12MG TABLET   2 Tier 2 $20.00$45.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
GALANTAMINE HBR 4MG TABLET   2 Tier 2 $20.00$45.00None
GALANTAMINE HBR 8MG TABLET   2 Tier 2 $20.00$45.00None
GALANTAMINE HYDROBROMIDE 4 MG/ML ORAL SOLUTION   2 Tier 2 $20.00$45.00None
GALANTAMINE HYDROBROMIDE CAPSULES EXTENDED RELEASE 16MG 30 BOT   2 Tier 2 $20.00$45.00None
GALANTAMINE HYDROBROMIDE CAPSULES EXTENDED RELEASE 24MG 30 BOT   2 Tier 2 $20.00$45.00None
GALANTAMINE HYDROBROMIDE CAPSULES EXTENDED RELEASE 8MG 30 BOT   2 Tier 2 $20.00$45.00None
GAMASTAN S/D INJECTION 16.5GM/2ML VIALGL   3 Tier 3 $26.00$63.00P
GAMMAGARD LIQUID 10% VIAL   5 Tier 5 25%25%P
GAMUNEX FOR SOLUTION 10GM/25ML VIALGL   5 Tier 5 25%25%P
GANCICLOVIR 250MG CAPSULE   2 Tier 2 $20.00$45.00None
GANCICLOVIR 500MG CAPSULE   5 Tier 5 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
GANCICLOVIR FOR INJECTION   2 Tier 2 $20.00$45.00None
GARDASIL VIAL   4 Tier 4 $70.00$195.00P
GASTROCROM 100MG/5ML CONC   5 Tier 5 25%25%P
GELNIQUE GEL 100MG/ML 30 PACKET IN 1 CRTN   3 Tier 3 $26.00$63.00Q:1
/1Days
GEMFIBROZIL TABLET 600MG (500 CT)   1 Tier 1 $5.00$15.00None
GENERLAC SOLUTION 10G/15 ML 473 ML BOTPL   1 Tier 1 $5.00$15.00None
GENGRAF 100MG CAPSULE U.D.   2 Tier 2 $20.00$45.00P
GENGRAF 100MG/ML SOLUTION   2 Tier 2 $20.00$45.00P
GENGRAF 25MG CAPSULE U.D.   2 Tier 2 $20.00$45.00P
GENTAK 3MG/GM EYE OINTMENT   1 Tier 1 $5.00$15.00None
GENTAK 3MG/ML EYE DROPS   1 Tier 1 $5.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
GENTAMICIN 100MG/NS 100ML   1 Tier 1 $5.00$15.00None
GENTAMICIN 10MG/ML VIAL   1 Tier 1 $5.00$15.00None
GENTAMICIN 60MG/NS 50ML PB   1 Tier 1 $5.00$15.00None
GENTAMICIN 70MG/NS 50ML PB   1 Tier 1 $5.00$15.00None
GENTAMICIN 80MG/NS 50ML PB   1 Tier 1 $5.00$15.00None
GENTAMICIN 90MG/NS 100ML PB   1 Tier 1 $5.00$15.00None
GENTAMICIN INJECTION USP 40MG 25 X 20ML VIALMD   1 Tier 1 $5.00$15.00None
GENTAMICIN SULFATE CREAM USP 0.1% 15GM TUBE   1 Tier 1 $5.00$15.00None
GENTAMICIN SULFATE OINTMENT USP 0.1% 15GM TUBE   1 Tier 1 $5.00$15.00None
GENTAMICIN SULFATE OPHTHALMIC SOLUTION 0.3% 5ML BOT   1 Tier 1 $5.00$15.00None
GENTASOL 3MG/ML EYE DROPS   1 Tier 1 $5.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
GEODON 20MG CAPSULE   4 Tier 4 $70.00$195.00P S Q:2
/1Days
GEODON 20MG VIAL   4 Tier 4 $70.00$195.00P S Q:2
/1Days
GEODON 40MG CAPSULE   4 Tier 4 $70.00$195.00P S Q:2
/1Days
GEODON 60MG CAPSULE   4 Tier 4 $70.00$195.00P S Q:2
/1Days
GEODON 80MG CAPSULE   4 Tier 4 $70.00$195.00P S Q:2
/1Days
GIANVI TABLETS   1 Tier 1 $5.00$15.00None
GLEEVEC 100MG TABLET (90 CT)   5 Tier 5 25%25%P Q:3
/1Days
GLEEVEC 400MG TABLET   5 Tier 5 25%25%P Q:2
/1Days
GLIMEPIRIDE 1MG TABLET (100 CT)   1 Tier 1 $5.00$15.00Q:1
/1Days
GLIMEPIRIDE 2MG TABLET (100 CT)   1 Tier 1 $5.00$15.00Q:1
/1Days
GLIMEPIRIDE 4MG TABLET (100 CT)   1 Tier 1 $5.00$15.00Q:2
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
GLIPIZIDE 10MG TABLET (100 CT)   1 Tier 1 $5.00$15.00Q:4
/1Days
GLIPIZIDE 5MG TABLET   1 Tier 1 $5.00$15.00Q:8
/1Days
GLIPIZIDE AND METFORMIN HCL 2.5-250MG TABLET (100 CT)   1 Tier 1 $5.00$15.00Q:8
/1Days
GLIPIZIDE AND METFORMIN HCL 5-500MG TABLET (100 CT)   1 Tier 1 $5.00$15.00Q:4
/1Days
GLIPIZIDE ER 2.5MG TABLET SR OSMOTIC PUSH 24HR   1 Tier 1 $5.00$15.00Q:1
/1Days
GLIPIZIDE TABLETS EXTENDED RELEASE   1 Tier 1 $5.00$15.00Q:2
/1Days
GLIPIZIDE TABLETS EXTENDED RELEASE   1 Tier 1 $5.00$15.00Q:1
/1Days
GLIPIZIDE-METFORMIN 2.5-500MG TABLET   1 Tier 1 $5.00$15.00Q:4
/1Days
GLUCAGEN 1MG HYPOKIT   4 Tier 4 $70.00$195.00Q:1
/1Days
GLUCAGON 1MG EMERGENCY KIT   3 Tier 3 $26.00$63.00Q:1
/1Days
GLYBURIDE 2.5MG TABLET (100 CT)   1 Tier 1 $5.00$15.00Q:3
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
GLYBURIDE AND METFORMIN HCL 1.25-250MG TABLET (100 CT)   1 Tier 1 $5.00$15.00Q:8
/1Days
GLYBURIDE MICRO 3MG TABLET (100 CT)   1 Tier 1 $5.00$15.00Q:1
/1Days
GLYBURIDE MICRONIZED 1.5MG TABLET (100 CT)   1 Tier 1 $5.00$15.00Q:1
/1Days
GLYBURIDE TABLET MICRONIZED 6MG (500 CT)   1 Tier 1 $5.00$15.00Q:2
/1Days
GLYBURIDE TABLETS   1 Tier 1 $5.00$15.00Q:3
/1Days
GLYBURIDE TABLETS   1 Tier 1 $5.00$15.00Q:4
/1Days
GLYBURIDE-METFORMIN HCL 2.5-500MG TABLET   1 Tier 1 $5.00$15.00Q:4
/1Days
GLYBURIDE-METFORMIN HCL 5MG-500MG TABLET   1 Tier 1 $5.00$15.00Q:4
/1Days
GLYCOPYRROLATE 0.2MG/ML VL   1 Tier 1 $5.00$15.00None
GLYCOPYRROLATE TABLET 1MG (100 CT)   2 Tier 2 $20.00$45.00None
GLYCOPYRROLATE TABLET 2MG (100 CT)   2 Tier 2 $20.00$45.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
GLYCRON 1.5MG TABLET   1 Tier 1 $5.00$15.00Q:1
/1Days
GLYCRON 3MG TABLET   1 Tier 1 $5.00$15.00Q:1
/1Days
GLYCRON 4.5MG TABLET   1 Tier 1 $5.00$15.00Q:2
/1Days
GLYCRON 6MG TABLET   1 Tier 1 $5.00$15.00Q:2
/1Days
GLYSET 100MG TABLET   4 Tier 4 $70.00$195.00Q:3
/1Days
GLYSET 25MG TABLET   4 Tier 4 $70.00$195.00Q:3
/1Days
GLYSET 50MG TABLET   4 Tier 4 $70.00$195.00Q:3
/1Days
GOLYTELY PACKET 227.1 GM/2.82 GM   4 Tier 4 $70.00$195.00None
GRANISETRON 1 MG/ML INJECTABLE SOLUTION   2 Tier 2 $20.00$45.00P
GRANISETRON HCL 1MG TABLET (20 CT)   2 Tier 2 $20.00$45.00P Q:2
/1Days
GRANISETRON HYDROCHLORIDE INJECTION   2 Tier 2 $20.00$45.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
GRANISOL 1MG/5ML SOLUTION ORAL   2 Tier 2 $20.00$45.00P Q:10
/1Days
GRIFULVIN V 500MG TABLET   2 Tier 2 $20.00$45.00None
GRIS-PEG 125MG TABLET   4 Tier 4 $70.00$195.00None
GRIS-PEG 250 MG TABLET   4 Tier 4 $70.00$195.00None
GRISEOFULVIN ORAL SUSPENSION 125MG/5ML 4 FLOZ CTR   1 Tier 1 $5.00$15.00None
GUANABENZ ACETATE 4MG TABLET   1 Tier 1 $5.00$15.00None
GUANABENZ ACETATE 8MG TABLET   1 Tier 1 $5.00$15.00None
GUANFACINE 1MG TABLET   1 Tier 1 $5.00$15.00None
GUANFACINE 2MG TABLET (100 CT)   1 Tier 1 $5.00$15.00None
GUANIDINE HCL 125MG TABLET   1 Tier 1 $5.00$15.00None
GYNODIOL 1.5MG TABLET   1 Tier 1 $5.00$15.00None

Chart Legend:

Below are a few notes to help you understand the above 2011 Medicare Part D Aetna Medicare Rx Essentials (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.