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Aetna CVS/pharmacy Prescription Drug Plan (PDP) (S5810-041-0)
Tier 1 (1451)
Tier 2 (735)
Tier 3 (314)
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Tier 5 (319)
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A B C D E F G H I J K L 
M N O P Q R S T U V W X Y Z 0-9 
2012 Medicare Part D Plan Formulary Information
Aetna CVS/pharmacy Prescription Drug Plan (PDP) (S5810-041-0)
Benefit Details           
The Aetna CVS/pharmacy Prescription Drug Plan (PDP) (S5810-041-0)
Formulary Drugs Starting with the Letter E

in CMS PDP Region 7 which includes: VA
Drugs Starting with Letter E

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
E.E.S. GRAN SUS 200/5ML   4 Non-preferred brand name drugs 40%40%None
ECONAZOLE NITRATE 1% CREAM 85GM TUBE   1* Preferred generic drugs $3.00$9.00None
ED K+10 TABLET   1* Preferred generic drugs $3.00$9.00None
EDURANT 27.5mg/1   5 Specialty drugs 25%25%None
EES 400 TABLET 400MG 100 BOT   1* Preferred generic drugs $3.00$9.00None
EFFEXOR 37.5MG CAPSULE ER (90 CT)   4 Non-preferred brand name drugs 40%40%Q:1
/1Days
EFFEXOR XR 150MG CAPSULE ER 15 CAPSULES BOT   4 Non-preferred brand name drugs 40%40%Q:2
/1Days
EFFEXOR XR 75MG CAPSULE ER 15 CAPSULES BOT   4 Non-preferred brand name drugs 40%40%Q:1
/1Days
EGG YOLK PHOSPHOLIPIDS 12 MG/ML / GLYCERIN 25 MG/ML / SAFFLOWER OIL 100 MG/ML / SOYBEAN OIL 100 MG/M   4 Non-preferred brand name drugs 40%40%None
Egrifta 1 KIT in 1 CARTON   5 Specialty drugs 25%25%P Q:2
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ELAPRASE 6mg/3mL 1 VIAL, GLASS in 1 BOX / 3 mL in 1 VIAL, GLASS   5 Specialty drugs 25%25%None
ELESTAT 0.5mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 5 mL in 1 BOTTLE, DROPPER   4 Non-preferred brand name drugs 40%40%None
ELIDEL 1% CREAM   4 Non-preferred brand name drugs 40%40%S Q:2
/1Days
ELIGARD 1 KIT in 1 CARTON   4 Non-preferred brand name drugs 40%40%P
ELIGARD 1 KIT in 1 CARTON   4 Non-preferred brand name drugs 40%40%P
ELIGARD 1 KIT in 1 CARTON   4 Non-preferred brand name drugs 40%40%P
ELIGARD 1 KIT in 1 CARTON   4 Non-preferred brand name drugs 40%40%P
ELIPHOS TABLETS CALCIUM ACETATE TABLETS 667MG 200 BOT   4 Non-preferred brand name drugs 40%40%None
Elitek 3 KIT in 1 CARTON / 1 KIT in 1 KIT   5 Specialty drugs 25%25%P
ELIXOPHYLLIN 80mg/15mL 473 mL in 1 BOTTLE   4 Non-preferred brand name drugs 40%40%None
ELMIRON 100mg/1 100 CAPSULE, GELATIN COATED in 1 BOTTLE   4 Non-preferred brand name drugs 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ELOXATIN 100MG/20ML VIAL   5 Specialty drugs 25%25%P
ELSPAR INJ 10000UNT   4 Non-preferred brand name drugs 40%40%P
EMCYT 140MG CAPSULE   4 Non-preferred brand name drugs 40%40%None
EMEND 40MG CAPSULE   4 Non-preferred brand name drugs 40%40%P Q:5
/30Days
EMEND CAPSULES 125MG 6 BLPK   4 Non-preferred brand name drugs 40%40%P Q:5
/30Days
EMEND CAPSULES 80MG 2 BLPK   4 Non-preferred brand name drugs 40%40%P Q:6
/30Days
EMEND TRIFOLD PACK   4 Non-preferred brand name drugs 40%40%P Q:6
/30Days
Emoquette 6 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK   1* Preferred generic drugs $3.00$9.00None
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H   4 Non-preferred brand name drugs 40%40%P S Q:1
/1Days
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H   4 Non-preferred brand name drugs 40%40%P S Q:1
/1Days
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H   4 Non-preferred brand name drugs 40%40%P S Q:1
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
EMTRIVA 10MG/ML SOLUTION   3 Preferred brand name drugs $35.00$105.00None
EMTRIVA 200MG CAPSULE   3 Preferred brand name drugs $35.00$105.00None
ENABLEX 15MG TABLET   3 Preferred brand name drugs $35.00$105.00Q:1
/1Days
Enablex 7.5mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE   3 Preferred brand name drugs $35.00$105.00Q:1
/1Days
ENALAPRIL MALEATE 10MG TABLET (100 CT)   1* Preferred generic drugs $3.00$9.00None
Enalapril Maleate 2.5mg/1 100 TABLET in 1 BOTTLE   1* Preferred generic drugs $3.00$9.00None
Enalapril Maleate 20mg/1 500 TABLET in 1 BOTTLE, PLASTIC   1* Preferred generic drugs $3.00$9.00None
Enalapril Maleate 5mg/1 1000 TABLET in 1 BOTTLE, PLASTIC   1* Preferred generic drugs $3.00$9.00None
ENALAPRIL MALEATE-HCTZ 10MG-25MG TABLET (100 CT)   1* Preferred generic drugs $3.00$9.00None
ENALAPRIL MALEATE-HCTZ 5-12.5MG TABLET (100 CT)   1* Preferred generic drugs $3.00$9.00None
ENBREL 25 MG/0.5 ML SYRINGE   5 Specialty drugs 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ENBREL 25MG KIT   5 Specialty drugs 25%25%P Q:14
/28Days
ENBREL 50mg/mL   5 Specialty drugs 25%25%P
ENDOCET 10/650MG TABLET   1* Preferred generic drugs $3.00$9.00Q:6
/1Days
ENDOCET 10MG-325MG TABLET   1* Preferred generic drugs $3.00$9.00Q:12
/1Days
ENDOCET 5/325 TABLET   1* Preferred generic drugs $3.00$9.00Q:12
/1Days
ENDOCET 7.5-325MG TABLET   1* Preferred generic drugs $3.00$9.00Q:12
/1Days
ENDOCET 7.5/500MG TABLET   1* Preferred generic drugs $3.00$9.00Q:8
/1Days
ENDODAN TABLETS 325;4.8355MG;MG 100 BOT   2* Non-preferred generic drugs $16.00$48.00Q:12
/1Days
ENGERIX B INJECTION   3 Preferred brand name drugs $35.00$105.00P
ENGERIX B INJECTION 20MCG/ML   3 Preferred brand name drugs $35.00$105.00P
ENGERIX-B 10MCG 10 X 0.5ML VIALSD   3 Preferred brand name drugs $35.00$105.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ENJUVIA 0.3MG TABLET   4 Non-preferred brand name drugs 40%40%P
ENJUVIA 0.45MG TABLET   4 Non-preferred brand name drugs 40%40%P
ENJUVIA 0.625MG TABLET   4 Non-preferred brand name drugs 40%40%P
ENJUVIA 0.9MG TABLET   4 Non-preferred brand name drugs 40%40%P
ENJUVIA 1.25MG TABLET   4 Non-preferred brand name drugs 40%40%P
ENOXAPARIN SODIUM INJECTION   2* Non-preferred generic drugs $16.00$48.00None
ENOXAPARIN SODIUM INJECTION   2* Non-preferred generic drugs $16.00$48.00None
ENOXAPARIN SODIUM INJECTION   2* Non-preferred generic drugs $16.00$48.00None
ENOXAPARIN SODIUM INJECTION   2* Non-preferred generic drugs $16.00$48.00None
ENOXAPARIN SODIUM INJECTION   2* Non-preferred generic drugs $16.00$48.00None
ENOXAPARIN SODIUM INJECTION   2* Non-preferred generic drugs $16.00$48.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ENOXAPARIN SODIUM INJECTION   2* Non-preferred generic drugs $16.00$48.00None
ENTOCORT EC 3MG CAPSULE   4 Non-preferred brand name drugs 40%40%None
ENULOSE SYRUP 10GM/15ML 1 PINT BOTPL   1* Preferred generic drugs $3.00$9.00None
EPIDUO GEL 0.1;2.5%;% 45 TRADE SIZE TUBE   4 Non-preferred brand name drugs 40%40%None
Epinastine HCl 0.5mg/mL   2* Non-preferred generic drugs $16.00$48.00None
Epinephrine 0.1mg/mL   1* Preferred generic drugs $3.00$9.00None
EPIPEN 0.3MG AUTO-INJECTOR   4 Non-preferred brand name drugs 40%40%None
EPIPEN JR 0.15MG AUTO-INJCT   4 Non-preferred brand name drugs 40%40%None
EPIRUBICIN HCL INJECTION SOLUTION 2MG 1 X 25ML VIAL   2* Non-preferred generic drugs $16.00$48.00P
EPITOL 200MG TABLET   1* Preferred generic drugs $3.00$9.00None
EPIVIR 300mg/1 30 TABLET, FILM COATED in 1 BOTTLE   4 Non-preferred brand name drugs 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
EPIVIR HBV 100MG TABLET   4 Non-preferred brand name drugs 40%40%None
EPIVIR HBV 25MG/5ML TUBEX   4 Non-preferred brand name drugs 40%40%None
EPIVIR ORAL SOLUTION   4 Non-preferred brand name drugs 40%40%None
EPIVIR TABLETS   4 Non-preferred brand name drugs 40%40%None
Eplerenone 25mg/1 30 TABLET in 1 BOTTLE   2* Non-preferred generic drugs $16.00$48.00None
Eplerenone 50mg/1 30 TABLET in 1 BOTTLE   2* Non-preferred generic drugs $16.00$48.00None
EPROSARTAN MESYLATE 600 MG TABLET   2* Non-preferred generic drugs $16.00$48.00None
EPZICOM TABLETS   5 Specialty drugs 25%25%None
EQUETRO CAPSULES 200MG 120 BOT   4 Non-preferred brand name drugs 40%40%Q:8
/1Days
EQUETRO CAPSULES 300MG 120 BOT   4 Non-preferred brand name drugs 40%40%Q:5
/1Days
EQUETRO EXTENDED RELEASE CAPSULES 100MG 120 BOT   4 Non-preferred brand name drugs 40%40%Q:4
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ERAXIS 100mg/30mL 30 mL in 1 VIAL, SINGLE-USE   5 Specialty drugs 25%25%P
ERBITUX 100MG/50ML VIAL   5 Specialty drugs 25%25%P
ERGOLOID MESYLATES TABLETS 1MG 100 BOT   2* Non-preferred generic drugs $16.00$48.00None
ERGOMAR SUBLINGUAL TABLET 2MG   4 Non-preferred brand name drugs 40%40%None
ERGOTAMINE-CAFFEINE TABLET 100 CT Bottle   1* Preferred generic drugs $3.00$9.00None
ERIVEDGE 150 MG CAPSULE   5 Specialty drugs 25%25%P Q:1
/1Days
ERRIN 0.35MG TABLET   1* Preferred generic drugs $3.00$9.00None
ERY 2% PADS 2% 60 PADS JAR   1* Preferred generic drugs $3.00$9.00None
ERY-TAB 500mg/1 100 TABLET, DELAYED RELEASE in 1 BOTTLE   4 Non-preferred brand name drugs 40%40%None
ERY-TAB TAB 250MG EC   4 Non-preferred brand name drugs 40%40%None
ERY-TAB TAB 333MG EC   4 Non-preferred brand name drugs 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ERYPED 200MG/5ML 100 ML BOT   4 Non-preferred brand name drugs 40%40%None
ERYPED POWDER FOR ORAL SOLUTION 400MG/5ML 100 ML BOT   4 Non-preferred brand name drugs 40%40%None
ERYTHROCIN 500MG ADDVNT VL   4 Non-preferred brand name drugs 40%40%None
ERYTHROCIN TAB 250MG   4 Non-preferred brand name drugs 40%40%None
ERYTHROMYCIN 2% SOLUTION   1* Preferred generic drugs $3.00$9.00None
Erythromycin 20mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE   1* Preferred generic drugs $3.00$9.00None
ERYTHROMYCIN 500 MG FILMTAB   1* Preferred generic drugs $3.00$9.00None
ERYTHROMYCIN ETHYLSUCCINATE AND SULFISOXAZOLE ACETYL POWDER FOR ORAL SUSPENSION 200;600MG/5ML;MG/ 10   1* Preferred generic drugs $3.00$9.00None
ERYTHROMYCIN ETHYLSUCCINATE TABLETS 400 MG 100 BOT   1* Preferred generic drugs $3.00$9.00None
ERYTHROMYCIN OPHTHALMIC OINTMENT 0.5% 1 G BOX OF 50 TUBE   1* Preferred generic drugs $3.00$9.00None
ERYTHROMYCIN TAB 250MG BS   1* Preferred generic drugs $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ERYTHROMYCIN-BENZOYL PEROXIDE 3-5% GEL   1* Preferred generic drugs $3.00$9.00None
ESCITALOPRAM 10 MG TABLET   2* Non-preferred generic drugs $16.00$48.00Q:1
/1Days
ESCITALOPRAM 20 MG TABLET   2* Non-preferred generic drugs $16.00$48.00Q:1
/1Days
ESCITALOPRAM 5 MG TABLET   2* Non-preferred generic drugs $16.00$48.00Q:1
/1Days
ESCITALOPRAM OXALATE 5 MG/5 ML   2* Non-preferred generic drugs $16.00$48.00Q:20
/1Days
ESTRACE 0.5MG TABLET   4 Non-preferred brand name drugs 40%40%None
ESTRACE 2MG TABLET   4 Non-preferred brand name drugs 40%40%None
ESTRACE TABLET 1MG (100 CT)   4 Non-preferred brand name drugs 40%40%None
ESTRACE VAG CREAM 0.1MG/GM   4 Non-preferred brand name drugs 40%40%None
ESTRADIOL .025MG/24H PATCH TRANSDERMAL WEEKLY   1* Preferred generic drugs $3.00$9.00Q:4
/28Days
ESTRADIOL .0375MG/24 PATCH TRANSDERMAL WEEKLY   1* Preferred generic drugs $3.00$9.00Q:4
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ESTRADIOL .075MG/24H PATCH TRANSDERMAL WEEKLY   1* Preferred generic drugs $3.00$9.00Q:4
/28Days
ESTRADIOL 0.05MG/DAY PATCH   1* Preferred generic drugs $3.00$9.00Q:4
/28Days
ESTRADIOL 0.06MG/24H PATCH TRANSDERMAL WEEKLY   1* Preferred generic drugs $3.00$9.00Q:4
/28Days
ESTRADIOL 0.1MG/DAY PATCH   1* Preferred generic drugs $3.00$9.00Q:4
/28Days
ESTRADIOL 0.5MG TABLET   1* Preferred generic drugs $3.00$9.00None
ESTRADIOL 2MG TABLET   1* Preferred generic drugs $3.00$9.00None
ESTRADIOL TABLET 1MG (500 CT)   1* Preferred generic drugs $3.00$9.00None
ESTRADIOL VALERATE INJECTION   1* Preferred generic drugs $3.00$9.00None
ESTRADIOL VALERATE INJECTION   1* Preferred generic drugs $3.00$9.00None
ESTRADIOL VALERATE INJECTION   2* Non-preferred generic drugs $16.00$48.00None
ESTRADIOL-NORETH 1.0-0.5MG TABLET   1* Preferred generic drugs $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ESTROPIPATE 0.625 TABLET   1* Preferred generic drugs $3.00$9.00P
ESTROPIPATE 1.25 TABLET   1* Preferred generic drugs $3.00$9.00P
ESTROPIPATE 2.5 TABLET   1* Preferred generic drugs $3.00$9.00P
ETHAMBUTOL HCL 400MG TABLET (100 CT)   2* Non-preferred generic drugs $16.00$48.00None
Ethambutol Hydrochloride 100mg/1   2* Non-preferred generic drugs $16.00$48.00None
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6   1* Preferred generic drugs $3.00$9.00None
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TAB 21   1* Preferred generic drugs $3.00$9.00None
Ethosuximide 250mg/1 100 CAPSULE in 1 BOTTLE, PLASTIC   2* Non-preferred generic drugs $16.00$48.00None
ETHOSUXIMIDE 250MG/5ML SYRP   2* Non-preferred generic drugs $16.00$48.00None
ETIDRONATE DISODIUM 400MG TABLET (60 CT)   2* Non-preferred generic drugs $16.00$48.00None
ETIDRONATE DISODIUM TABLETS 200MG 60 BOT   2* Non-preferred generic drugs $16.00$48.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ETODOLAC 200MG CAPSULE   1* Preferred generic drugs $3.00$9.00None
ETODOLAC 300 MG CAPSULE   1* Preferred generic drugs $3.00$9.00None
ETODOLAC 400MG TABLET (500 CT)   1* Preferred generic drugs $3.00$9.00None
ETODOLAC 400MG TABLET SR 24HR   1* Preferred generic drugs $3.00$9.00None
ETODOLAC 500MG TABLET SR 24HR   1* Preferred generic drugs $3.00$9.00None
ETODOLAC 500mg/1   1* Preferred generic drugs $3.00$9.00None
ETODOLAC 600MG TABLET SR 24HR   1* Preferred generic drugs $3.00$9.00None
Etoposide 20mg/mL 1 VIAL in 1 BOX, UNIT-DOSE / 50 mL in 1 VIAL   1* Preferred generic drugs $3.00$9.00P
Eurax Lotion and Cream 100mg/g 454 g in 1 BOTTLE   4 Non-preferred brand name drugs 40%40%None
Eurax Lotion and Cream 100mg/g 60 g in 1 TUBE   4 Non-preferred brand name drugs 40%40%None
EVAMIST 1.53/SPRAY SPRAY NON-AEROSOL   3 Preferred brand name drugs $35.00$105.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Evista 60mg/1 100 TABLET in 1 BOTTLE   3 Preferred brand name drugs $35.00$105.00Q:1
/1Days
EXELON 1.5MG CAPSULE   4 Non-preferred brand name drugs 40%40%None
EXELON 2MG/ML ORAL SOLUTION   4 Non-preferred brand name drugs 40%40%None
EXELON 3MG CAPSULE   4 Non-preferred brand name drugs 40%40%None
EXELON 4.5MG CAPSULE   4 Non-preferred brand name drugs 40%40%None
EXELON 4.6MG/24HR PATCH TRANSDERMAL 24 HOURS   3 Preferred brand name drugs $35.00$105.00None
EXELON 6MG CAPSULE   4 Non-preferred brand name drugs 40%40%None
EXELON 9.5MG/24HR PATCH TRANSDERMAL 24 HOURS   3 Preferred brand name drugs $35.00$105.00None
Exemestane 25mg/1 30 TABLET, FILM COATED in 1 BOTTLE   2* Non-preferred generic drugs $16.00$48.00None
EXFORGE 10MG-160MG TABLET   3 Preferred brand name drugs $35.00$105.00Q:1
/1Days
EXFORGE 10MG-320MG TABLET   3 Preferred brand name drugs $35.00$105.00Q:1
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
EXFORGE 5MG-160MG TABLET   3 Preferred brand name drugs $35.00$105.00Q:1
/1Days
EXFORGE 5MG-320MG TABLET   3 Preferred brand name drugs $35.00$105.00Q:1
/1Days
Exforge HCT 10; 12.5; 160mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   3 Preferred brand name drugs $35.00$105.00Q:1
/1Days
Exforge HCT 10; 25; 160mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   3 Preferred brand name drugs $35.00$105.00Q:1
/1Days
Exforge HCT 10; 25; 320mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   3 Preferred brand name drugs $35.00$105.00None
Exforge HCT 5; 12.5; 160mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   3 Preferred brand name drugs $35.00$105.00Q:1
/1Days
Exforge HCT 5; 25; 160mg/1; mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE   3 Preferred brand name drugs $35.00$105.00Q:1
/1Days
EXJADE 125MG TABLET   4 Non-preferred brand name drugs 40%40%P
EXJADE 250MG TABLET   5 Specialty drugs 25%25%P
EXJADE 500MG TABLET   5 Specialty drugs 25%25%P
EXTAVIA 15 BLISTER PACK in 1 CARTON / 1 KIT in 1 BLISTER PACK   5 Specialty drugs 25%25%P Q:1
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
EXTENDED PHENYTOIN SODIUM CAPSULES 300 MG   2* Non-preferred generic drugs $16.00$48.00None

Chart Legend:

Below are a few notes to help you understand the above 2012 Medicare Part D Aetna CVS/pharmacy Prescription Drug Plan (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 $320 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 $2930) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2012 Humana Walmart-Preferred Rx Plan the cost-sharing 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 September 2012 )

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.