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Aetna CVS/pharmacy Prescription Drug Plan (PDP) (S5810-041-0)
Tier 1 (1451)
Tier 2 (735)
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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 S

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

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
SANDOSTATIN LAR 10MG KIT   5 Specialty drugs 25%25%P S
SANDOSTATIN LAR 20MG KIT   5 Specialty drugs 25%25%P S
SANDOSTATIN LAR 30MG KIT   5 Specialty drugs 25%25%P S
SAPHRIS 10mg/1 6 CASE in 1 CARTON / 1 BLISTER PACK in 1 CASE / 10 TABLET in 1 BLISTER PACK   4 Non-preferred brand name drugs 40%40%Q:2
/1Days
SAPHRIS 5mg/1 6 CASE in 1 CARTON / 1 BLISTER PACK in 1 CASE / 10 TABLET in 1 BLISTER PACK   4 Non-preferred brand name drugs 40%40%Q:2
/1Days
SAVELLA TABLETS 100MG 60 COUNT BOT   3 Preferred brand name drugs $35.00$105.00Q:2
/1Days
SAVELLA TABLETS 12.5MG 60 COUNT BOT   3 Preferred brand name drugs $35.00$105.00Q:2
/1Days
SAVELLA TABLETS 25MG 60 COUNT BOT   3 Preferred brand name drugs $35.00$105.00Q:2
/1Days
SAVELLA TABLETS TITRATION PACK KIT 12.5;25;50MG;MG;MG 55 COUNT PKGCOM   3 Preferred brand name drugs $35.00$105.00Q:55
/365Days
SAVELLA TALBETS 50MG 60 COUNT BOT   3 Preferred brand name drugs $35.00$105.00Q:2
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SEASONALE 0.15-0.03 TABLET DOSE PACK 3 MONTHS   4 Non-preferred brand name drugs 40%40%None
SEASONIQUE 150-30(84) TABLET DOSE PACK 3 MONTHS   4 Non-preferred brand name drugs 40%40%None
SELEGILINE HCL 5MG CAPSULE   1* Preferred generic drugs $3.00$9.00None
Selegiline Hydrochloride 5mg/1 60 TABLET in 1 BOTTLE, PLASTIC   1* Preferred generic drugs $3.00$9.00None
SELENIUM SULFIDE 2.5mg/100mL 118 mL in 1 BOTTLE   1* Preferred generic drugs $3.00$9.00None
SELFEMRA CAPSULES 10MG 28 CAPSULE BLPK   2* Non-preferred generic drugs $16.00$48.00Q:1
/1Days
SELFEMRA CAPSULES 20MG 28 CAPSULE 4X7 BLPK   2* Non-preferred generic drugs $16.00$48.00Q:4
/1Days
SELZENTRY 150mg/1 60 TABLET, FILM COATED in 1 BOTTLE   5 Specialty drugs 25%25%None
SELZENTRY 300mg/1 60 TABLET, FILM COATED in 1 BOTTLE   5 Specialty drugs 25%25%None
SENSIPAR 30MG TABLET   3 Preferred brand name drugs $35.00$105.00Q:2
/1Days
SENSIPAR 60MG TABLET   5 Specialty drugs 25%25%Q:2
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SENSIPAR 90MG TABLET   5 Specialty drugs 25%25%Q:4
/1Days
SEREVENT DIS AER 50MCG   4 Non-preferred brand name drugs 40%40%S Q:2
/1Days
SEROMYCIN 250mg/250mg 40 CAPSULE in 1 BOTTLE / 250 mg in 1 CAPSULE   4 Non-preferred brand name drugs 40%40%None
SEROQUEL 100MG TABLET   4 Non-preferred brand name drugs 40%40%Q:3
/1Days
SEROQUEL 200MG TABLET   4 Non-preferred brand name drugs 40%40%Q:4
/1Days
SEROQUEL 25MG TABLET   4 Non-preferred brand name drugs 40%40%Q:6
/1Days
SEROQUEL 300MG TABLET   4 Non-preferred brand name drugs 40%40%Q:2
/1Days
SEROQUEL 400MG TABLET   4 Non-preferred brand name drugs 40%40%Q:2
/1Days
SEROQUEL 50MG TABLET (100 CT)   4 Non-preferred brand name drugs 40%40%Q:3
/1Days
SEROQUEL TABLETS EXTENDED RELEASE 150MG 100 CRTN   3 Preferred brand name drugs $35.00$105.00Q:1
/1Days
SEROQUEL TABLETS EXTENDED RELEASE 200MG 100 X 200 MG CRTN   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
SEROQUEL TABLETS EXTENDED RELEASE 400MG 100 X 400 MG CRTN   3 Preferred brand name drugs $35.00$105.00Q:2
/1Days
SEROQUEL TABLETS EXTENDED RELEASE 50MG 100 TABS CRTN   3 Preferred brand name drugs $35.00$105.00Q:6
/1Days
SEROQUEL XR 300MG TABLET 60X300MG BOT   3 Preferred brand name drugs $35.00$105.00Q:2
/1Days
SERTRALINE HCL 100MG TABLET (30 CT)   1* Preferred generic drugs $3.00$9.00Q:2
/1Days
SERTRALINE HCL 25 MG TABLET   1* Preferred generic drugs $3.00$9.00Q:1
/1Days
SERTRALINE HCL 50MG TABLET (30 CT)   1* Preferred generic drugs $3.00$9.00Q:2
/1Days
SERTRALINE HYDROCHLORIDE ORAL CONCENTRATE   2* Non-preferred generic drugs $16.00$48.00Q:10
/1Days
SEVELAMER CARBONATE 26.7 MG/ML ORAL SUSPENSION [RENVELA]   3 Preferred brand name drugs $35.00$105.00None
SEVELAMER CARBONATE 40 MG/ML ORAL SUSPENSION [RENVELA]   3 Preferred brand name drugs $35.00$105.00None
SILVER SULFADIAZINE 1% CRM   1* Preferred generic drugs $3.00$9.00None
SIMCOR 500MG-20MG TABLET MULTIPHASIC RELEASE 24HR   3 Preferred brand name drugs $35.00$105.00Q:2
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SIMCOR 750MG-20MG TABLET MULTIPHASIC RELEASE 24HR   3 Preferred brand name drugs $35.00$105.00Q:2
/1Days
SIMCOR TABLETS EXTENDED RELEASE   3 Preferred brand name drugs $35.00$105.00Q:1
/1Days
SIMCOR TABLETS EXTENDED RELEASE   3 Preferred brand name drugs $35.00$105.00Q:1
/1Days
SIMPONI GOLIMUMAB INJECTION 50MG/0.5ML 1 50 MG SINGLE DOSE SYR SYR   5 Specialty drugs 25%25%P
SIMULECT 20MG VIAL   5 Specialty drugs 25%25%P
Simvastatin 10mg/1 30 TABLET, FILM COATED in 1 BOTTLE   1* Preferred generic drugs $3.00$9.00Q:1
/1Days
SIMVASTATIN 20MG TABLET 10000 BOT   1* Preferred generic drugs $3.00$9.00Q:1
/1Days
SIMVASTATIN 40MG TABLET (500 CT)   1* Preferred generic drugs $3.00$9.00Q:1
/1Days
Simvastatin 5mg/1   1* Preferred generic drugs $3.00$9.00Q:1
/1Days
SIMVASTATIN 80MG TABLET (1000 CT)   1* Preferred generic drugs $3.00$9.00Q:1
/1Days
SINGULAIR 10MG 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
SINGULAIR 4MG GRANULES   3 Preferred brand name drugs $35.00$105.00Q:1
/1Days
SINGULAIR 4MG TABLET CHEW   3 Preferred brand name drugs $35.00$105.00Q:1
/1Days
SINGULAIR 5MG TABLET CHEW   3 Preferred brand name drugs $35.00$105.00Q:1
/1Days
SOD POLY SUL SUS 15GM/60   2* Non-preferred generic drugs $16.00$48.00None
SODIUM BICARB INJ 7.5%   1* Preferred generic drugs $3.00$9.00None
SODIUM BICARB INJ 8.4%   1* Preferred generic drugs $3.00$9.00None
SODIUM CHLORIDE 0.45% TUBEX   1* Preferred generic drugs $3.00$9.00None
Sodium Chloride 3g/100mL   1* Preferred generic drugs $3.00$9.00None
Sodium Chloride 900mg/100mL 9 BOTTLE, PLASTIC in 1 CASE / 1500 mL in 1 BOTTLE, PLASTIC   1* Preferred generic drugs $3.00$9.00None
Sodium Chloride 9g/1000mL 4 BAG in 1 PACKAGE / 100 mL in 1 BAG   1* Preferred generic drugs $3.00$9.00None
SODIUM CHLORIDE INJECTION USP 5%   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
SODIUM CL 2.5 MEQ/ML VIAL   1* Preferred generic drugs $3.00$9.00None
SODIUM LACTATE 1/6MOLAR INJ   1* Preferred generic drugs $3.00$9.00None
SODIUM LACTATE 5 MEQ/ML VIAL   1* Preferred generic drugs $3.00$9.00None
SOLARAZE 3% GEL   4 Non-preferred brand name drugs 40%40%None
SOLIA 0.15-0.03 TABLET   1* Preferred generic drugs $3.00$9.00None
SOMATULINE 60 MG/0.2 ML SYRING   5 Specialty drugs 25%25%P
Somatuline Depot 90mg/0.3mL 1 POUCH in 1 CARTON / 1 SYRINGE in 1 POUCH / 0.3 mL in 1 SYRINGE   5 Specialty drugs 25%25%P S
SOMAVERT 10MG VIAL   5 Specialty drugs 25%25%P S
SOMAVERT 15MG VIAL   5 Specialty drugs 25%25%P S
SOMAVERT 20MG VIAL   5 Specialty drugs 25%25%P S
SORIATANE 17.5 MG CAPSULE   5 Specialty drugs 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SORIATANE CAPSULES   5 Specialty drugs 25%25%None
SORIATANE CAPSULES   5 Specialty drugs 25%25%None
SORINE SOLTALOL HCL TABLETS 240MG 100 BOXUD   1* Preferred generic drugs $3.00$9.00None
SORINE SOTALOL HCL TABLETS 120MG 100 BOXUD   1* Preferred generic drugs $3.00$9.00None
SORINE SOTALOL HCL TABLETS 160MG 100 BOXUD   1* Preferred generic drugs $3.00$9.00None
SORINE SOTALOL HCL TABLETS 80MG 100 BOXUD   1* Preferred generic drugs $3.00$9.00None
SOTALOL HCL 120MG TABLET 100 BOT   1* Preferred generic drugs $3.00$9.00None
SOTALOL HCL 160MG TABLET (100 CT)   1* Preferred generic drugs $3.00$9.00None
SOTALOL HCL 80MG TABLET   1* Preferred generic drugs $3.00$9.00None
SOTALOL HCL TABLET 240MG   1* Preferred generic drugs $3.00$9.00None
SOTALOL HYDROCHLORIDE INJECTION 15MG/ML   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
SOTRET 10MG CAPSULE   2* Non-preferred generic drugs $16.00$48.00P
SOTRET 20MG CAPSULE   2* Non-preferred generic drugs $16.00$48.00P
SOTRET 30MG CAPSULE   2* Non-preferred generic drugs $16.00$48.00P
SOTRET 40MG CAPSULE   2* Non-preferred generic drugs $16.00$48.00P
SPECTRACEF 400 MG DOSE PACK TB   4 Non-preferred brand name drugs 40%40%None
SPECTRACEF TABLETS 200 MG   4 Non-preferred brand name drugs 40%40%None
SPIRIVA 18MCG CP-HANDIHALER 90 (9 X 10) BLPK   3 Preferred brand name drugs $35.00$105.00Q:1
/1Days
SPIRONOLACTONE 100MG TABLET   1* Preferred generic drugs $3.00$9.00None
SPIRONOLACTONE 25MG TABLET (100 CT)   1* Preferred generic drugs $3.00$9.00None
SPIRONOLACTONE 50MG TABLET (100 CT)   1* Preferred generic drugs $3.00$9.00None
SPIRONOLACTONE/HCTZ TABLET 25-25MG (500 CT)   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
SPORANOX 10MG/ML SOLUTION   5 Specialty drugs 25%25%P
SPRINTEC 0.25-0.035 TABLET   1* Preferred generic drugs $3.00$9.00None
SPRYCEL 100mg/1 1 BOTTLE in 1 CARTON / 30 TABLET in 1 BOTTLE   5 Specialty drugs 25%25%P Q:1
/1Days
SPRYCEL 140mg/1 1 BOTTLE in 1 CARTON / 30 TABLET in 1 BOTTLE   5 Specialty drugs 25%25%P Q:1
/1Days
SPRYCEL 20MG TABLET   5 Specialty drugs 25%25%P Q:2
/1Days
SPRYCEL 50MG TABLET   5 Specialty drugs 25%25%P Q:2
/1Days
SPRYCEL 70MG TABLET   5 Specialty drugs 25%25%P Q:2
/1Days
SPRYCEL 80mg/1 1 BOTTLE in 1 CARTON / 30 TABLET in 1 BOTTLE   5 Specialty drugs 25%25%P Q:2
/1Days
SRONYX 0.1-0.02 TABLET   1* Preferred generic drugs $3.00$9.00None
SSD Cream 10g/1000g 85 g in 1 TUBE   1* Preferred generic drugs $3.00$9.00None
STAGESIC 5MG-500MG CAPSULE   1* Preferred generic drugs $3.00$9.00Q:8
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
STALEVO 100 TABLET   3 Preferred brand name drugs $35.00$105.00None
STALEVO 125/200 MG/MG TABLETS   3 Preferred brand name drugs $35.00$105.00None
STALEVO 150 TABLET   3 Preferred brand name drugs $35.00$105.00None
STALEVO 18.75/75 MG/MG TABLETS   3 Preferred brand name drugs $35.00$105.00None
STALEVO 200 50-200-200 TABLET   3 Preferred brand name drugs $35.00$105.00None
STALEVO 50 TABLET   3 Preferred brand name drugs $35.00$105.00None
STAVUDINE CAPSULES 15MG 60 BOT   2* Non-preferred generic drugs $16.00$48.00None
STAVUDINE CAPSULES 20MG 60 BOT   2* Non-preferred generic drugs $16.00$48.00None
STAVUDINE CAPSULES 30MG 60 BOT   2* Non-preferred generic drugs $16.00$48.00None
STAVUDINE CAPSULES 40MG 60 BOT   2* Non-preferred generic drugs $16.00$48.00None
STAVUDINE SOL 1MG/ML   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
STERILE WATER FOR IRRIGATION   1* Preferred generic drugs $3.00$9.00None
STRATTERA 100MG CAPSULE   4 Non-preferred brand name drugs 40%40%Q:1
/1Days
STRATTERA 10MG CAPSULE   4 Non-preferred brand name drugs 40%40%Q:2
/1Days
STRATTERA 18MG CAPSULE   4 Non-preferred brand name drugs 40%40%Q:2
/1Days
STRATTERA 25MG CAPSULE   4 Non-preferred brand name drugs 40%40%Q:2
/1Days
STRATTERA 40MG CAPSULE   4 Non-preferred brand name drugs 40%40%Q:2
/1Days
STRATTERA 60MG CAPSULE   4 Non-preferred brand name drugs 40%40%Q:2
/1Days
STRATTERA 80MG CAPSULE   4 Non-preferred brand name drugs 40%40%Q:1
/1Days
STREPTOMYCIN FOR INJECTION 1GM/VIL   1* Preferred generic drugs $3.00$9.00None
STROMECTOL 3MG TABLET   4 Non-preferred brand name drugs 40%40%None
Suboxone 2; 0.5mg/1; mg/1 30 POUCH in 1 CARTON / 1 FILM, SOLUBLE in 1 POUCH   4 Non-preferred brand name drugs 40%40%P Q:3
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SUBOXONE 2MG-0.5MG TABLET   4 Non-preferred brand name drugs 40%40%P Q:3
/1Days
Suboxone 8; 2mg/1; mg/1 30 POUCH in 1 CARTON / 1 FILM, SOLUBLE in 1 POUCH   4 Non-preferred brand name drugs 40%40%P Q:3
/1Days
SUBOXONE 8MG-2MG TABLET   4 Non-preferred brand name drugs 40%40%P Q:3
/1Days
SUCRALFATE 1GM TABLET   1* Preferred generic drugs $3.00$9.00None
SULFACETAMIDE 10% EYE OINTMENT   1* Preferred generic drugs $3.00$9.00None
Sulfacetamide Sodium 100mg/mL 118 mL in 1 BOTTLE   1* Preferred generic drugs $3.00$9.00None
SULFACETAMIDE SODIUM OPHTHALMIC SOLUTION USP 10% 15 ML BOT   1* Preferred generic drugs $3.00$9.00None
SULFACETAMIDE-PREDNISOLONE 10-0.25% DROPS   1* Preferred generic drugs $3.00$9.00None
SULFADIAZINE 500MG TABLET   2* Non-preferred generic drugs $16.00$48.00None
Sulfamethoxazole and Trimethoprim 200; 40mg/5mL; mg/5mL 473 mL in 1 BOTTLE   1* Preferred generic drugs $3.00$9.00None
SULFAMETHOXAZOLE W/TMP 800-160MG TABLET (100 CT)   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
SULFAMETHOXAZOLE W/TMP VIAL 80MG-16ML 10 X 10ML VIAL   2* Non-preferred generic drugs $16.00$48.00None
SULFAMETHOXAZOLE-TRIMETHOPRIM TABLET 400-80MG (500 CT)   1* Preferred generic drugs $3.00$9.00None
SULFAMYLON 50G PACKET   4 Non-preferred brand name drugs 40%40%None
SULFAMYLON CREAM 85GM 4 OZ TUBE   4 Non-preferred brand name drugs 40%40%None
SULFASALAZINE 500MG TABLET   1* Preferred generic drugs $3.00$9.00None
SULFAZINE EC 500MG TABLET DELAYED RELEASE   1* Preferred generic drugs $3.00$9.00None
SULINDAC 150MG TABLET (100 CT)   1* Preferred generic drugs $3.00$9.00None
SULINDAC 200MG TABLET   1* Preferred generic drugs $3.00$9.00None
SUMATRIPTAN   2* Non-preferred generic drugs $16.00$48.00Q:5
/30Days
SUMATRIPTAN SUCCINATE INJECTION 4MG/0.5ML 0.5 ML VIALSD   2* Non-preferred generic drugs $16.00$48.00Q:4
/30Days
SUMATRIPTAN SUCCINATE TABLETS 100MG 9 BOXUD   2* Non-preferred generic drugs $16.00$48.00Q:9
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SUMATRIPTAN SUCCINATE TABLETS 25MG 9 BOX   2* Non-preferred generic drugs $16.00$48.00Q:9
/30Days
SUMATRIPTAN SUCCINATE TABLETS 50MG 9 (3 CARDS OF 3) BOX   2* Non-preferred generic drugs $16.00$48.00Q:9
/30Days
SUPRAX 100MG/5ML SUSPENSION RECONSTITUTED ORAL 50ML BOT   4 Non-preferred brand name drugs 40%40%None
SUPRAX 200MG/5ML SUSPENSION RECONSTITUTED ORAL   4 Non-preferred brand name drugs 40%40%None
SUPRAX 400 MG TABLET   4 Non-preferred brand name drugs 40%40%None
SURMONTIL 100MG CAPSULE   4 Non-preferred brand name drugs 40%40%None
SURMONTIL 25MG CAPSULE   4 Non-preferred brand name drugs 40%40%None
Surmontil 50mg/1 100 CAPSULE in 1 BOTTLE   4 Non-preferred brand name drugs 40%40%None
SUSTIVA 200MG CAPSULE   4 Non-preferred brand name drugs 40%40%None
SUSTIVA 50MG CAPSULE   4 Non-preferred brand name drugs 40%40%None
SUSTIVA 600MG TABLET   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
SUTENT 12.5MG CAPSULE   5 Specialty drugs 25%25%P Q:3
/1Days
SUTENT 25mg/1 28 CAPSULE in 1 BOTTLE   5 Specialty drugs 25%25%P Q:2
/1Days
SUTENT 50MG CAPSULE   5 Specialty drugs 25%25%P Q:1
/1Days
SYLATRON 296 MCG KIT 1 KIT in 1 CARTON   5 Specialty drugs 25%25%P
SYLATRON 444 MCG KIT 1 KIT in 1 CARTON   5 Specialty drugs 25%25%P
SYLATRON 888 MCG KIT 1 KIT in 1 CARTON   5 Specialty drugs 25%25%P
SYMBICORT 160-4.5MCG HFA AEROSOL WITH ADAPTER   3 Preferred brand name drugs $35.00$105.00None
SYMBICORT 80-4.5MCG HFA AEROSOL WITH ADAPTER 60 INHL   3 Preferred brand name drugs $35.00$105.00Q:1
/1Days
SYMLIN 0.6MG/ML VIAL   4 Non-preferred brand name drugs 40%40%Q:1
/1Days
SYMLINPEN 120 1000MCG/ML PEN INJECTOR   4 Non-preferred brand name drugs 40%40%Q:1
/1Days
SYMLINPEN 60 1000MCG/ML PEN INJECTOR   4 Non-preferred brand name drugs 40%40%Q:1
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SYNAGIS 50MG/0.5ML VIAL   5 Specialty drugs 25%25%P
SYNAREL 2MG/ML NASAL SPRAY   5 Specialty drugs 25%25%None
SYNTHROID 100MCG TABLET   3 Preferred brand name drugs $35.00$105.00None
SYNTHROID 112 MCG TABLET   3 Preferred brand name drugs $35.00$105.00None
SYNTHROID 125MCG TABLET   3 Preferred brand name drugs $35.00$105.00None
Synthroid 137ug/1 90 TABLET in 1 BOTTLE   3 Preferred brand name drugs $35.00$105.00None
SYNTHROID 150MCG TABLET   3 Preferred brand name drugs $35.00$105.00None
SYNTHROID 175MCG TABLET   3 Preferred brand name drugs $35.00$105.00None
SYNTHROID 200MCG TABLET   3 Preferred brand name drugs $35.00$105.00None
SYNTHROID 25MCG TABLET   3 Preferred brand name drugs $35.00$105.00None
SYNTHROID 300MCG TABLET   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
SYNTHROID 50MCG TABLET   3 Preferred brand name drugs $35.00$105.00None
SYNTHROID 75MCG TABLET   3 Preferred brand name drugs $35.00$105.00None
SYNTHROID 88 MCG TABLET   3 Preferred brand name drugs $35.00$105.00None
SYPRINE 250MG CAPSULE (100 CT)   4 Non-preferred brand name drugs 40%40%None

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.