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2015 Medicare Part D and Medicare Advantage Plan Formulary Browser
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.
Select your search style and criteria below or use this example to get started

Search by:
State & Plan   ZIP & Plan   PlanID   FormularyID

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PDP     MAPD
Scroll down to see formulary results.

Aetna Medicare Rx Saver (PDP) (S5810-043-0)
Tier 1 (51)
Tier 2 (1047)
Tier 3 (362)
Tier 4 (1226)
Tier 5 (376)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
Yes No Show either
  *required
 
Cick on the first letter of your drug name to browse the formulary:

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 
2015 Medicare Part D Plan Formulary Information
Aetna Medicare Rx Saver (PDP) (S5810-043-0)
Benefit Details           
The Aetna Medicare Rx Saver (PDP) (S5810-043-0)
Formulary Drugs Starting with the Letter V
in CMS PDP Region 9 which includes: SC
Plan Monthly Premium: $25.40 Deductible: $295 Qualifies for LIS: Yes
Drugs Starting with Letter V

Drug Name		 Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order
VAGIFEM 10 MCG VAGINAL TAB   3 Preferred Brand $41.00$123.00None
VALACYCLOVIR 1000 MG ORAL TABLET   4 Non-Preferred Brand 39%39%None
VALACYCLOVIR 500 MG ORAL TABLET   4 Non-Preferred Brand 39%39%None
VALCHLOR 0.016% GEL   5 Specialty Tier 25%N/AP
VALCYTE 450MG TABLET   5 Specialty Tier 25%N/ANone
VALCYTE FOR ORAL SOLUTION 50MG/ML   5 Specialty Tier 25%N/ANone
VALGANCICLOVIR 450 MG TABLET [Valcyte]   5 Specialty Tier 25%N/ANone
VALPROATE SODIUM 500 mg/5 ml vl   4 Non-Preferred Brand 39%39%None
Valproic 250mg/1 100 CAPSULE, LIQUID FILLED in 1 BOTTLE   2 Non-Preferred Generic $7.00$21.00None
Valproic Acid 250mg/5mL 473 mL in 1 BOTTLE   2 Non-Preferred Generic $7.00$21.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
VALSARTAN 160 MG TABLET [Diovan]   2 Non-Preferred Generic $7.00$21.00None
VALSARTAN 320 MG TABLET [Diovan]   2 Non-Preferred Generic $7.00$21.00None
VALSARTAN 40 MG TABLET [Diovan]   2 Non-Preferred Generic $7.00$21.00None
VALSARTAN 80 MG TABLET [Diovan]   2 Non-Preferred Generic $7.00$21.00None
VALSARTAN-HCTZ 160-12.5 MG TABLET [Diovan HCT]   2 Non-Preferred Generic $7.00$21.00Q:30
/30Days
VALSARTAN-HCTZ 160-25 MG TABLET [Diovan HCT]   2 Non-Preferred Generic $7.00$21.00Q:30
/30Days
VALSARTAN-HCTZ 320-12.5 MG TABLET [Diovan HCT]   2 Non-Preferred Generic $7.00$21.00Q:30
/30Days
VALSARTAN-HCTZ 320-25 MG TABLET [Diovan HCT]   2 Non-Preferred Generic $7.00$21.00Q:30
/30Days
VALSARTAN-HCTZ 80-12.5 MG TABLET [Diovan HCT]   2 Non-Preferred Generic $7.00$21.00Q:30
/30Days
VANCOMYCIN HCL 125 MG CAPSULE   5 Specialty Tier 25%N/AP
VANCOMYCIN HCL 250 MG CAPSULE   5 Specialty Tier 25%N/AP
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
VANCOMYCIN HCL INJECTION 10 X 1GM VIAL (STERILE )   4 Non-Preferred Brand 39%39%None
VANCOMYCIN HYDROCHLORIDE 100mg/mL 1 VIAL, PHARMACY BULK PACKAGE in 1 CASE / 95 mL in 1 VIAL, PHARMA   4 Non-Preferred Brand 39%39%None
VANCOMYCIN HYDROCHLORIDE 500MG/100ML INJECTION (STERILE)   4 Non-Preferred Brand 39%39%None
VANDAZOLE 0.75% GEL WITH APPLICATOR   2 Non-Preferred Generic $7.00$21.00None
VAQTA 25 UNITS/0.5ML VIAL   4 Non-Preferred Brand 39%39%None
VAQTA 50 UNITS/ML SYRINGE   4 Non-Preferred Brand 39%39%None
VARIVAX VACCINE W/DILUENT   3 Preferred Brand $41.00$123.00None
VASCEPA 1 GM CAPSULE   3 Preferred Brand $41.00$123.00None
Vectibix 100mg/5mL 1 VIAL, SINGLE-USE per CARTON / 5 mL in 1 VIAL, SINGLE-USE   5 Specialty Tier 25%N/AP
VELCADE 3.5MG VIAL   5 Specialty Tier 25%N/AP
Velivet Triphasic Regimen 3 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK   4 Non-Preferred Brand 39%39%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
VELPHORO 500 MG CHEWABLE TAB   4 Non-Preferred Brand 39%39%None
VENLAFAXINE HCL 100MG TABLET   2 Non-Preferred Generic $7.00$21.00None
VENLAFAXINE HCL 25MG TABLET   2 Non-Preferred Generic $7.00$21.00None
VENLAFAXINE HCL 37.5MG TABLET   2 Non-Preferred Generic $7.00$21.00None
VENLAFAXINE HCL 50MG TABLET   2 Non-Preferred Generic $7.00$21.00None
VENLAFAXINE HCL 75MG TABLET   2 Non-Preferred Generic $7.00$21.00None
VENLAFAXINE HCL ER TAB 225 MG   4 Non-Preferred Brand 39%39%Q:30
/30Days
VENLAFAXINE HYDROCHLORIDE 150MG CAPSULES EXTENDED RELEASE   2 Non-Preferred Generic $7.00$21.00Q:60
/30Days
VENLAFAXINE HYDROCHLORIDE 150MG TABLETS EXTENDED RELEASE   4 Non-Preferred Brand 39%39%Q:60
/30Days
VENLAFAXINE HYDROCHLORIDE 37.5MG CAPSULES EXTENDED RELEASE   2 Non-Preferred Generic $7.00$21.00Q:30
/30Days
VENLAFAXINE HYDROCHLORIDE 37.5MG TABLETS EXTENDED RELEASE   4 Non-Preferred Brand 39%39%Q:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
VENLAFAXINE HYDROCHLORIDE 75MG CAPSULES EXTENDED RELEASE   2 Non-Preferred Generic $7.00$21.00Q:30
/30Days
VENLAFAXINE HYDROCHLORIDE 75MG TABLETS EXTENDED RELEASE   4 Non-Preferred Brand 39%39%Q:30
/30Days
Ventavis 0.01mg/mL   5 Specialty Tier 25%N/AP
Ventavis 0.02mg/mL   5 Specialty Tier 25%N/AP
VENTOLIN HFA 90MCG INHALER   3 Preferred Brand $41.00$123.00Q:36
/30Days
VERAPAMIL 120MG CAP PELLET   2 Non-Preferred Generic $7.00$21.00None
VERAPAMIL 180MG CAP PELLET   2 Non-Preferred Generic $7.00$21.00None
VERAPAMIL 2.5MG/ML AMPUL   2 Non-Preferred Generic $7.00$21.00None
VERAPAMIL 240MG CAP PELLET   2 Non-Preferred Generic $7.00$21.00None
VERAPAMIL 40MG TABLET   2 Non-Preferred Generic $7.00$21.00None
VERAPAMIL ER 100MG CAPSULE 24HR SR PELLETS   2 Non-Preferred Generic $7.00$21.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
VERAPAMIL ER 120 MG TABLET   2 Non-Preferred Generic $7.00$21.00None
VERAPAMIL ER 180 MG TABLET   2 Non-Preferred Generic $7.00$21.00None
VERAPAMIL ER 200MG CAPSULE 24HR SR PELLETS (100 CT)   2 Non-Preferred Generic $7.00$21.00None
VERAPAMIL ER 300MG CAPSULE 24HR SR PELLETS   2 Non-Preferred Generic $7.00$21.00None
VERAPAMIL HCL 120MG TABLET   2 Non-Preferred Generic $7.00$21.00None
VERAPAMIL HCL 360MG CAPSULES SUSTAINED RELEASE   2 Non-Preferred Generic $7.00$21.00None
VERAPAMIL HCL 80MG TABLET   2 Non-Preferred Generic $7.00$21.00None
Verapamil Hydrochloride 240mg/1 500 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC   2 Non-Preferred Generic $7.00$21.00None
VERSACLOZ 50 MG/ML SUSPENSION   5 Specialty Tier 25%N/AS
VESICARE 10MG TABLET   3 Preferred Brand $41.00$123.00Q:30
/30Days
VESICARE 5MG TABLET (90 CT)   3 Preferred Brand $41.00$123.00Q:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Vestura 3 mg-0.02 mg tablet   4 Non-Preferred Brand 39%39%None
VICODIN 5-300 MG TABLET   4 Non-Preferred Brand 39%39%Q:390
/30Days
VICODIN ES 7.5-300 MG TABLET   4 Non-Preferred Brand 39%39%Q:390
/30Days
VICODIN HP 10-300 MG TABLET   4 Non-Preferred Brand 39%39%Q:390
/30Days
VICTOZA 3-PAK 18 MG/3 ML PEN   3 Preferred Brand $41.00$123.00Q:9
/30Days
VIDEX 2GM PEDIATRIC TUBEX   4 Non-Preferred Brand 39%39%None
VIGABATRIN 50 MG/ML ORAL SOLUTION [SABRIL]   5 Specialty Tier 25%N/AP
VIGABATRIN 500 MG ORAL TABLET [SABRIL]   5 Specialty Tier 25%N/AP
VIIBRYD 1 KIT per BLISTER PACK   4 Non-Preferred Brand 39%39%Q:30
/365Days
VIIBRYD 10mg/1 30 FILM COATED TABLETS in BOTTLE   4 Non-Preferred Brand 39%39%Q:30
/30Days
VIIBRYD 20mg/1 30 FILM COATED TABLETS in BOTTLE   4 Non-Preferred Brand 39%39%Q:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
VIIBRYD 40mg/1 30 FILM COATED TABLETS in BOTTLE   4 Non-Preferred Brand 39%39%Q:30
/30Days
VIMPAT 10 MG/ML SOLUTION   4 Non-Preferred Brand 39%39%None
Vimpat 100mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC   4 Non-Preferred Brand 39%39%Q:60
/30Days
Vimpat 10mg/mL 10 VIAL, GLASS per CARTON / 20 mL in 1 VIAL, GLASS   4 Non-Preferred Brand 39%39%None
Vimpat 150mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC   4 Non-Preferred Brand 39%39%Q:60
/30Days
Vimpat 200mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC   4 Non-Preferred Brand 39%39%Q:60
/30Days
Vimpat 50mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC   4 Non-Preferred Brand 39%39%Q:180
/30Days
VINBLASTINE 1 MG/ML VIAL   2 Non-Preferred Generic $7.00$21.00P
VINCRISTINE 1MG/ML VIAL   4 Non-Preferred Brand 39%39%P
VINCRISTINE 1MG/ML VIAL   4 Non-Preferred Brand 39%39%P
VINORELBINE 10MG/ML VIAL 5ML VIAL   4 Non-Preferred Brand 39%39%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
VIRACEPT 250MG TABLET   5 Specialty Tier 25%N/ANone
VIRACEPT 625MG TABLET   5 Specialty Tier 25%N/ANone
VIRAMUNE 50MG/5ML SUSP   4 Non-Preferred Brand 39%39%None
VIRAMUNE XR 100 MG TABLET   4 Non-Preferred Brand 39%39%None
VIRAZOLE 6 GM VIAL   5 Specialty Tier 25%N/ANone
VIREAD 150 MG TABLET   4 Non-Preferred Brand 39%39%None
VIREAD 200 MG TABLET   4 Non-Preferred Brand 39%39%None
VIREAD 250 MG TABLET   4 Non-Preferred Brand 39%39%None
VIREAD 300MG TABLET   4 Non-Preferred Brand 39%39%None
VIREAD POWDER   4 Non-Preferred Brand 39%39%None
VITEKTA 150 MG TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
VITEKTA 85 MG TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
VOLTAREN 1% GEL   3 Preferred Brand $41.00$123.00Q:1020
/30Days
VORICONAZOLE 200 MG VIAL   4 Non-Preferred Brand 39%39%None
Voriconazole 200mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC   5 Specialty Tier 25%N/ANone
Voriconazole 40 mg/ml susp   5 Specialty Tier 25%N/ANone
Voriconazole 50mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC   5 Specialty Tier 25%N/ANone
VOTRIENT 200mg/1 120 FILM COATED TABLETS in BOTTLE   5 Specialty Tier 25%N/AP Q:120
/30Days
VPRIV INJECTION SOLUTION 2.5 MG/ML   5 Specialty Tier 25%N/AP
Vyfemla 28 tablet   4 Non-Preferred Brand 39%39%None

Chart Legend:

Below are a few notes to help you understand the above 2015 Medicare Part D Aetna Medicare Rx Saver (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 $2960) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2016 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 2015 )

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.





 
 


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  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDPCompare.com and MACompare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
    Statement required by Medicare:
    "We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options."
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.
.