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2013 Medicare Part D Plan Formulary Information
Aetna Medicare Rx Premier (PDP) (S5810-202-0) Benefit Details
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
Drugs Starting with Letter I Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
IBANDRONATE SODIUM 150 MG TAB	2	Non-preferred generic	$33.00	$99.00	P Q:1 /30Days
Ibuprofen 100mg/5mL 473 mL in 1 BOTTLE	1	Preferred generic	$5.00	$5.00	None
IBUPROFEN 600mg/1 500 TABLET BOTTLE	1	Preferred generic	$5.00	$5.00	None
IBUPROFEN 800 MG TABLET	1	Preferred generic	$5.00	$5.00	None
IBUPROFEN TABLETS	1	Preferred generic	$5.00	$5.00	None
ICLUSIG 15 MG TABLET	5	Specialty	33%	33%	P
ICLUSIG 45 MG TABLET	5	Specialty	33%	33%	P
IDARUBICIN HCL 1MG/ML VIAL	5	Specialty	33%	33%	None
IFOSFAMIDE FOR INFECTION 1 GM	2	Non-preferred generic	$33.00	$99.00	None
ILEVRO 0.3% OPHTH DROPS	4	Non-preferred brand	49%	49%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
IMIPENEM-CILASTATIN 250 MG VL	2	Non-preferred generic	$33.00	$99.00	None
IMIPENEM-CILASTATIN 500 MG VL	2	Non-preferred generic	$33.00	$99.00	None
IMIPRAMINE HCL 10MG TABLET (100 CT)	1	Preferred generic	$5.00	$5.00	None
IMIPRAMINE HCL 25MG TABLET (100 CT)	1	Preferred generic	$5.00	$5.00	None
IMIPRAMINE HCL 50MG TABLET (100 CT)	1	Preferred generic	$5.00	$5.00	None
IMIPRAMINE PAMOATE CAPSULES	1	Preferred generic	$5.00	$5.00	None
IMIPRAMINE PAMOATE CAPSULES	1	Preferred generic	$5.00	$5.00	None
IMIPRAMINE PAMOATE CAPSULES	1	Preferred generic	$5.00	$5.00	None
IMIPRAMINE PAMOATE CAPSULES	1	Preferred generic	$5.00	$5.00	None
IMIQUIMOD 5% CREAM	2	Non-preferred generic	$33.00	$99.00	None
IMOVAX RABIES VACCINE	4	Non-preferred brand	49%	49%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Incivek 375mg/1 4 BOX in 1 CARTON / 7 BLISTER PACK in 1 BOX / 6 FILM COATED TABLETS in BLISTER PA	5	Specialty	33%	33%	P Q:6 /1Days
Increlex 40mg/4mL 1 VIAL, MULTI-DOSE in 1 CARTON / 4 mL in 1 VIAL, MULTI-DOSE	5	Specialty	33%	33%	P
Indapamide 1.25mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC	1	Preferred generic	$5.00	$5.00	None
INDAPAMIDE 2.5MG TABLET USP (1000 CT)	1	Preferred generic	$5.00	$5.00	None
INDOMETHACIN 50 MG CAPSULE	1	Preferred generic	$5.00	$5.00	None
INDOMETHACIN 75MG CAPSULE SA	2	Non-preferred generic	$33.00	$99.00	None
INDOMETHACIN CAPSULES	1	Preferred generic	$5.00	$5.00	None
INLYTA 1 MG TABLET	5	Specialty	33%	33%	P Q:8 /1Days
INLYTA 5 MG TABLET	5	Specialty	33%	33%	P Q:4 /1Days
INTELENCE 100MG TABLET	5	Specialty	33%	33%	None
Intelence 200mg/1	5	Specialty	33%	33%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
INTRALIPID 20% IV FAT EMUL	2	Non-preferred generic	$33.00	$99.00	P
INTRALIPID PHARMACY BULK PACKAGE FAT EMULSION 1.7-1.2-30GM 500ML BAG	4	Non-preferred brand	49%	49%	P
INTRON A 10MMU VIAL	5	Specialty	33%	33%	P
INTRON A 6MMU/ML VIAL	4	Non-preferred brand	49%	49%	P
Introvale 3 CARTON in 1 BOX / 1 KIT in 1 CARTON	1	Preferred generic	$5.00	$5.00	None
Intuniv 1mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE	4	Non-preferred brand	49%	49%	P Q:1 /1Days
Intuniv 2mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE	4	Non-preferred brand	49%	49%	P Q:1 /1Days
Intuniv 3mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE	4	Non-preferred brand	49%	49%	P Q:1 /1Days
Intuniv 4mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE	4	Non-preferred brand	49%	49%	P Q:1 /1Days
INVANZ 1GM VIAL	4	Non-preferred brand	49%	49%	None
INVEGA 3MG TABLET SR OSMOTIC PUSH 24HR	4	Non-preferred brand	49%	49%	Q:2 /1Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
INVEGA 6MG TABLET SR OSMOTIC PUSH 24HR	4	Non-preferred brand	49%	49%	Q:2 /1Days
INVEGA 9MG TABLET SR OSMOTIC PUSH 24HR	4	Non-preferred brand	49%	49%	Q:1 /1Days
INVEGA ER 1.5mg/ 30 TABLET BOTTLE	4	Non-preferred brand	49%	49%	Q:1 /1Days
Invega Sustenna 117 mg/0.75mL Prefilled Syringe	5	Specialty	33%	33%	Q:1 /30Days
Invega Sustenna 156 mg/mL Prefilled Syringe	5	Specialty	33%	33%	Q:1 /30Days
Invega Sustenna 234 mg/1.5mL Prefilled Syringe	5	Specialty	33%	33%	Q:2 /30Days
Invega Sustenna 39 mg/0.25mL Prefilled Syringe	4	Non-preferred brand	49%	49%	None
Invega Sustenna 78 mg/0.5mL Prefilled Syringe	4	Non-preferred brand	49%	49%	Q:1 /30Days
INVIRASE 200MG CAPSULE	4	Non-preferred brand	49%	49%	None
INVIRASE 500MG TABLET	5	Specialty	33%	33%	None
IOPIDINE 0.5% EYE DROPS	4	Non-preferred brand	49%	49%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
IPOL VIAL 40;8;32; UNT	3	Preferred brand	$45.00	$135.00	None
Ipratropium Bromide 0.5mg/2.5mL 1 POUCH in 1 CARTON / 30 VIAL in 1 POUCH / 2.5 mL in 1 VIAL	1	Preferred generic	$5.00	$5.00	P Q:10 /1Days
Ipratropium Bromide 42ug/1 1 BOTTLE, SPRAY in 1 CARTON / 165 SPRAY, METERED in 1 BOTTLE, SPRAY	1	Preferred generic	$5.00	$5.00	Q:2 /1Days
IPRATROPIUM BROMIDE and ALBUTEROL SULFATE 2.5; 0.5mg/3mL; mg/3mL 6 POUCH in 1 CARTON / 5 VIAL, PLAS	2	Non-preferred generic	$33.00	$99.00	P Q:18 /1Days
IPRATROPIUM BROMIDE NASAL SPRAY	1	Preferred generic	$5.00	$5.00	Q:1 /1Days
IRBESARTAN 150 MG TABLET	1	Preferred generic	$5.00	$5.00	Q:1 /1Days
IRBESARTAN 300 MG TABLET	1	Preferred generic	$5.00	$5.00	None
IRBESARTAN 75 MG TABLET	1	Preferred generic	$5.00	$5.00	Q:1 /1Days
Irbesartan-Hctz 150-12.5 mg tb	1	Preferred generic	$5.00	$5.00	Q:1 /1Days
IRBESARTAN-HCTZ 300-12.5 MG TB	1	Preferred generic	$5.00	$5.00	None
irinotecan hcl 100 mg/5 ml vl	2	Non-preferred generic	$33.00	$99.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ISENTRESS 100 MG TABLET CHEW	4	Non-preferred brand	49%	49%	None
ISENTRESS 25 MG TABLET CHEW	4	Non-preferred brand	49%	49%	None
ISENTRESS 400MG TABLET	5	Specialty	33%	33%	None
ISOLYTE H IN 5% DEXTROSE	4	Non-preferred brand	49%	49%	None
ISOLYTE M IN 5% DEXTROSE INJECTION	2	Non-preferred generic	$33.00	$99.00	None
ISONIAZID 100MG TABLET	2	Non-preferred generic	$33.00	$99.00	None
ISONIAZID 50MG/5ML SYRUP	2	Non-preferred generic	$33.00	$99.00	None
ISONIAZID INJ 100MG/ML	2	Non-preferred generic	$33.00	$99.00	None
ISONIAZID TABLETS	2	Non-preferred generic	$33.00	$99.00	None
ISOPTO CARPINE 10mg/mL 15 mL in 1 BOTTLE	4	Non-preferred brand	49%	49%	None
ISOPTO CARPINE 20mg/mL 15 mL in 1 BOTTLE	4	Non-preferred brand	49%	49%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ISOPTO CARPINE 40mg/mL 15 mL in 1 BOTTLE	4	Non-preferred brand	49%	49%	None
Isosorbide Dinitrate 5mg/1 100 TABLET BOTTLE	1	Preferred generic	$5.00	$5.00	None
ISOSORBIDE DINITRATE TABLETS	1	Preferred generic	$5.00	$5.00	None
ISOSORBIDE DINITRATE TABLETS EXTENDED RELEASE	1	Preferred generic	$5.00	$5.00	None
ISOSORBIDE DN 10MG TABLET	1	Preferred generic	$5.00	$5.00	None
ISOSORBIDE DN 2.5 MG TAB SL	1	Preferred generic	$5.00	$5.00	None
ISOSORBIDE DN 20MG TABLET	1	Preferred generic	$5.00	$5.00	None
ISOSORBIDE DN 30MG TABLET	1	Preferred generic	$5.00	$5.00	None
ISOSORBIDE MN 10 MG TABLET	1	Preferred generic	$5.00	$5.00	None
ISOSORBIDE MONONITRATE 20MG TABLET	1	Preferred generic	$5.00	$5.00	None
ISOSORBIDE MONONITRATE ER TABLET 120MG (100 CT)	1	Preferred generic	$5.00	$5.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ISOSORBIDE MONONITRATE ER TABLET 30MG (100 CT)	1	Preferred generic	$5.00	$5.00	None
ISOSORBIDE MONONITRATE TABLETS EXTENDED RELEASE 60MG 100 TABLETS BOT	1	Preferred generic	$5.00	$5.00	None
ISOTON GENTAMICIN 80MG/100ML	1	Preferred generic	$5.00	$5.00	None
ISRADIPINE CAPSULES 2.5MG (100 CT)	2	Non-preferred generic	$33.00	$99.00	None
ISRADIPINE CAPSULES 5MG (100 CT)	2	Non-preferred generic	$33.00	$99.00	None
ISTODAX KIT	5	Specialty	33%	33%	P
ITRACONAZOLE 100MG CAPSULE	2	Non-preferred generic	$33.00	$99.00	P
IXEMPRA 45 MG KIT	5	Specialty	33%	33%	None
IXIARO JAPANESE ENCEPHALITIS VACCINE 6MCG/.5ML	4	Non-preferred brand	49%	49%	None

Chart Legend:

Below are a few notes to help you understand the above 2013 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 $325 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 $2970) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2013 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 October 2013 )

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.