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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:
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Has Quantity Limits:
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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 I

in CMS PDP Region 32 which includes: CA
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
IBUPROFEN 100MG/5ML SUSP   1 Tier 1 $2.00$6.00None
IBUPROFEN 600 MG ORAL TABLET   1 Tier 1 $2.00$6.00None
IBUPROFEN 800 MG TABLET   1 Tier 1 $2.00$6.00None
IBUPROFEN TABLETS   1 Tier 1 $2.00$6.00None
ILOPERIDONE 1 MG ORAL TABLET [FANAPT]   4 Tier 4 $60.00$165.00S Q:2
/1Days
ILOPERIDONE 10 MG ORAL TABLET [FANAPT]   4 Tier 4 $60.00$165.00S Q:2
/1Days
ILOPERIDONE 12 MG ORAL TABLET [FANAPT]   4 Tier 4 $60.00$165.00S Q:2
/1Days
ILOPERIDONE 2 MG ORAL TABLET [FANAPT]   4 Tier 4 $60.00$165.00S Q:2
/1Days
ILOPERIDONE 4 MG ORAL TABLET [FANAPT]   4 Tier 4 $60.00$165.00S Q:2
/1Days
ILOPERIDONE 6 MG ORAL TABLET [FANAPT]   4 Tier 4 $60.00$165.00S Q:2
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ILOPERIDONE 8 MG ORAL TABLET [FANAPT]   4 Tier 4 $60.00$165.00S Q:2
/1Days
IMIPRAMINE HCL 10MG TABLET (100 CT)   1 Tier 1 $2.00$6.00None
IMIPRAMINE HCL 25MG TABLET (100 CT)   1 Tier 1 $2.00$6.00None
IMIPRAMINE HCL 50MG TABLET (100 CT)   1 Tier 1 $2.00$6.00None
IMIPRAMINE PAMOATE CAPSULES   1 Tier 1 $2.00$6.00None
IMIPRAMINE PAMOATE CAPSULES   1 Tier 1 $2.00$6.00None
IMIPRAMINE PAMOATE CAPSULES   1 Tier 1 $2.00$6.00None
IMIPRAMINE PAMOATE CAPSULES   1 Tier 1 $2.00$6.00None
IMIQUIMOD 5% CREAM   2 Tier 2 $20.00$45.00None
IMOVAX RABIES VACCINE 2.5UNT/ML   4 Tier 4 $60.00$165.00P
INCRELEX 40MG/4ML VIAL   5 Tier 5 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
INDAPAMIDE 1.25MG TABLET USP (1000 CT)   1 Tier 1 $2.00$6.00None
INDAPAMIDE 2.5MG TABLET USP (1000 CT)   1 Tier 1 $2.00$6.00None
INDOMETHACIN 50MG CAPSULE   1 Tier 1 $2.00$6.00None
INDOMETHACIN 75MG CAPSULE SA   2 Tier 2 $20.00$45.00None
INDOMETHACIN CAPSULES   1 Tier 1 $2.00$6.00None
INFERGEN INJECTION   5 Tier 5 25%25%P
INNOPRAN CAPSULES EXTENDED RELEASE 120 MG   4 Tier 4 $60.00$165.00None
INNOPRAN CAPSULES EXTENDED RELEASE 80 MG   4 Tier 4 $60.00$165.00None
INTELENCE 100MG TABLET   5 Tier 5 25%25%None
INTERFERON BETA-1B 0.25 MG/ML INJECTABLE SOLUTION [EXTAVIA]   5 Tier 5 25%25%P Q:15
/28Days
INTRALIPID 20% IV FAT EMUL   4 Tier 4 $60.00$165.00None
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 $60.00$165.00None
INTRON A 10MMU INJ PEN   5 Tier 5 25%25%P
INTRON A 10MMU VIAL   5 Tier 5 25%25%P
INTRON A 3MMU INJECTION PEN   5 Tier 5 25%25%P
INTRON A 5MMU MULTIDOSE PEN   5 Tier 5 25%25%P
INTRON A 6MMU/ML VIAL   5 Tier 5 25%25%P
INVANZ 1GM VIAL   4 Tier 4 $60.00$165.00None
INVEGA 3MG TABLET SR OSMOTIC PUSH 24HR   4 Tier 4 $60.00$165.00P S Q:2
/1Days
INVEGA 6MG TABLET SR OSMOTIC PUSH 24HR   4 Tier 4 $60.00$165.00P S Q:2
/1Days
INVEGA 9MG TABLET SR OSMOTIC PUSH 24HR   4 Tier 4 $60.00$165.00P S Q:1
/1Days
INVIRASE 200MG CAPSULE   5 Tier 5 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
INVIRASE 500MG TABLET   5 Tier 5 25%25%None
IOPIDINE 0.5% EYE DROPS   4 Tier 4 $60.00$165.00None
IOPIDINE 1% EYE DROPS   4 Tier 4 $60.00$165.00None
IPOL VIAL 40;8;32; UNT   3 Tier 3 $25.00$60.00None
IPRATROPIUM BROMIDE 42MCG AEROSOL SPRAY   1 Tier 1 $2.00$6.00Q:30
/30Days
IPRATROPIUM BROMIDE INHALATION SOLUTION 0.02% 60 X 2.5ML VIALSD   1 Tier 1 $2.00$6.00P Q:13
/1Days
IPRATROPIUM BROMIDE NASAL SPRAY   1 Tier 1 $2.00$6.00Q:30
/30Days
IPRATROPIUM BROMIDE/ALBUTEROL SULFATE INHALATION SOLUTION 0.5MG/3ML 33 CRTN   2 Tier 2 $20.00$45.00P Q:22
/1Days
IRESSA 250MG TABLET   5 Tier 5 25%25%P Q:2
/1Days
ISENTRESS 400MG TABLET   5 Tier 5 25%25%None
ISOCHRON 40MG TABLET SA   1 Tier 1 $2.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ISOLYTE H IN 5% DEXTROSE   4 Tier 4 $60.00$165.00None
ISOLYTE M IN 5% DEXTROSE INJECTION   4 Tier 4 $60.00$165.00None
ISONARIF 300-150MG CAPSULE   2 Tier 2 $20.00$45.00None
ISONIAZID 100MG TABLET   1 Tier 1 $2.00$6.00None
ISONIAZID 50MG/5ML SYRUP   2 Tier 2 $20.00$45.00None
ISONIAZID INJ 100MG/ML   2 Tier 2 $20.00$45.00None
ISONIAZID TABLETS   1 Tier 1 $2.00$6.00None
ISOSORBIDE DINITRATE TABLETS   1 Tier 1 $2.00$6.00None
ISOSORBIDE DINITRATE TABLETS EXTENDED RELEASE   1 Tier 1 $2.00$6.00None
ISOSORBIDE DN 10MG TABLET   1 Tier 1 $2.00$6.00None
ISOSORBIDE DN 2.5 MG TAB SL   1 Tier 1 $2.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ISOSORBIDE DN 20MG TABLET   1 Tier 1 $2.00$6.00None
ISOSORBIDE DN 30MG TABLET   1 Tier 1 $2.00$6.00None
ISOSORBIDE DN 5MG TABLET SL   1 Tier 1 $2.00$6.00None
ISOSORBIDE MN 10MG TABLET   1 Tier 1 $2.00$6.00None
ISOSORBIDE MONONITRATE 20MG TABLET   1 Tier 1 $2.00$6.00None
ISOSORBIDE MONONITRATE ER TABLET 120MG (100 CT)   1 Tier 1 $2.00$6.00None
ISOSORBIDE MONONITRATE ER TABLET 30MG (100 CT)   1 Tier 1 $2.00$6.00None
ISOSORBIDE MONONITRATE TABLETS EXTENDED RELEASE 60MG 100 TABLETS BOT   1 Tier 1 $2.00$6.00None
ISOTON GENTAMICIN 60MG/100ML   1 Tier 1 $2.00$6.00None
ISOTON GENTAMICIN 80MG/100ML   1 Tier 1 $2.00$6.00None
ISRADIPINE CAPSULES 2.5MG (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
ISRADIPINE CAPSULES 5MG (100 CT)   2 Tier 2 $20.00$45.00None
ISTODAX KIT   5 Tier 5 25%25%P
ITRACONAZOLE 100MG CAPSULE   2 Tier 2 $20.00$45.00P
IXIARO JAPANESE ENCEPHALITIS VACCINE 6MCG/.5ML   4 Tier 4 $60.00$165.00None

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.