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2018 Medicare Part D Plan Formulary Information
Aetna Medicare Rx Saver (PDP) (S5810-035-0) Benefit Details
The Aetna Medicare Rx Saver (PDP) (S5810-035-0) Formulary Drugs Starting with the Letter P in CMS PDP Region 01 which includes: ME NH Plan Monthly Premium: $28.80 Deductible: $300 Qualifies for LIS: Yes
Drugs Starting with Letter P Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter P Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PACERONE 100MG TABLET	2*	Generic	$2.00	$6.00	None
PACERONE 200 MG TABLET	2*	Generic	$2.00	$6.00	None
PACERONE 400MG TABLET	2*	Generic	$2.00	$6.00	None
PACLITAXEL 100 MG/16.7 ML VIAL	4	Non-Preferred Drug	35%	35%	None
PALIPERIDONE ER 1.5 MG TABLET [INVEGA]	5	Specialty Tier	27%	N/A	Q:30 /30Days
PALIPERIDONE ER 3 MG TABLET [INVEGA]	5	Specialty Tier	27%	N/A	Q:30 /30Days
PALIPERIDONE ER 6 MG TABLET [INVEGA]	5	Specialty Tier	27%	N/A	Q:60 /30Days
PALIPERIDONE ER 9 MG TABLET [INVEGA]	5	Specialty Tier	27%	N/A	Q:30 /30Days
PAMIDRONATE 30 MG/10 ML VIAL	4	Non-Preferred Drug	35%	35%	None
PAMIDRONATE 60MG/10ML VIAL	4	Non-Preferred Drug	35%	35%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PAMIDRONATE 90 MG/10 ML VIAL	4	Non-Preferred Drug	35%	35%	None
PANRETIN 0.1% GEL 60GM TUBE	5	Specialty Tier	27%	N/A	None
PANTOPRAZOLE SOD DR 20 MG TAB	1*	Preferred Generic	$1.00	$3.00	Q:30 /30Days
PANTOPRAZOLE SOD DR 40 MG TAB	1*	Preferred Generic	$1.00	$3.00	Q:60 /30Days
PANTOPRAZOLE SODIUM 40 MG VIAL	4	Non-Preferred Drug	35%	35%	None
PARICALCITOL 1 MCG CAPSULE [Zemplar]	4	Non-Preferred Drug	35%	35%	None
PARICALCITOL 10 MCG/2 ML VIAL [Zemplar]	4	Non-Preferred Drug	35%	35%	None
PARICALCITOL 2 MCG CAPSULE [Zemplar]	4	Non-Preferred Drug	35%	35%	None
PARICALCITOL 2 MCG/ML VIAL [Zemplar]	4	Non-Preferred Drug	35%	35%	None
PARICALCITOL 4 MCG CAPSULE [Zemplar]	4	Non-Preferred Drug	35%	35%	None
PAROMOMYCIN 250 MG CAPSULE	4	Non-Preferred Drug	35%	35%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PAROXETINE HCL 10 MG TABLET	2*	Generic	$2.00	$6.00	Q:30 /30Days
PAROXETINE HCL 20 MG TABLET	2*	Generic	$2.00	$6.00	Q:30 /30Days
PAROXETINE HCL 30 MG TABLET	2*	Generic	$2.00	$6.00	Q:60 /30Days
PAROXETINE HCL 40 MG TABLET	2*	Generic	$2.00	$6.00	Q:60 /30Days
PASER GRANULES 4GM PACKET	3	Preferred Brand	$30.00	$90.00	None
PATADAY 0.2% DROPS	3	Preferred Brand	$30.00	$90.00	None
PAXIL ORAL SUSPENSION 10 MG/5ML	4	Non-Preferred Drug	35%	35%	Q:900 /30Days
PAZEO 0.7% EYE DROPS	3	Preferred Brand	$30.00	$90.00	None
PEDVAXHIB VACCINE VIAL	3	Preferred Brand	$30.00	$90.00	None
PEG 3350 ELECTROLYTE SOLN SOLN RECON [GaviLyte-C]	2*	Generic	$2.00	$6.00	None
PEG 3350-ELECTROLYTE SOLUTION SOLN RECON	2*	Generic	$2.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PEG-3350 AND ELECTROLYTES SOLN SOLN RECON	2*	Generic	$2.00	$6.00	None
PEGANONE 250 MG TABLET	4	Non-Preferred Drug	35%	35%	None
Pegasys 180ug/0.5mL 1 PACKET in 1 BOX / 4 SYRINGE, GLASS in 1 PACKET / 0.5 mL in 1 SYRINGE, GLASS	5	Specialty Tier	27%	N/A	P
PEGASYS INJECTION	5	Specialty Tier	27%	N/A	P
PEGASYS PROCLICK 135 MCG/0.5	5	Specialty Tier	27%	N/A	P
PEGASYS PROCLICK 180 MCG/0.5	5	Specialty Tier	27%	N/A	P
PENICILLIN G PROCAINE 1200000UNT 2ML CTG	4	Non-Preferred Drug	35%	35%	None
Penicillin G Sodium 5000000[iU]/1 10 VIAL per CARTON / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL	4	Non-Preferred Drug	35%	35%	None
PENICILLIN GK 20 MILLION UNIT	4	Non-Preferred Drug	35%	35%	None
PENICILLIN V POTASSIUM 250MG/5ML LIQUID	1*	Preferred Generic	$1.00	$3.00	None
PENICILLIN V POTASSIUM 500MG TABLET	1*	Preferred Generic	$1.00	$3.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PENICILLIN VK 125 MG/5 ML SOLN	1*	Preferred Generic	$1.00	$3.00	None
PENICILLIN VK 250 MG TABLET	1*	Preferred Generic	$1.00	$3.00	None
PENTAM 300 INJ 300MG	4	Non-Preferred Drug	35%	35%	None
PENTOXIFYLLINE 400MG TABLET SA	2*	Generic	$2.00	$6.00	None
PERINDOPRIL ERBUMINE 2 MG TAB	2*	Generic	$2.00	$6.00	None
PERINDOPRIL ERBUMINE 4 MG TAB	2*	Generic	$2.00	$6.00	None
PERINDOPRIL ERBUMINE 8 MG TAB	2*	Generic	$2.00	$6.00	None
PERIOGARD 0.12% ORAL RINSE	1*	Preferred Generic	$1.00	$3.00	None
PERJETA 420 MG/14 ML VIAL	5	Specialty Tier	27%	N/A	P
Permethrin 50mg/g 1 TUBE per CARTON / 60 g in 1 TUBE	4	Non-Preferred Drug	35%	35%	None
PERPHEN-AMITRIP 2 MG-10 MG TAB	4	Non-Preferred Drug	35%	35%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PERPHEN-AMITRIP 2 MG-25 MG TAB	4	Non-Preferred Drug	35%	35%	P
PERPHEN-AMITRIP 4 MG-25 MG TAB	4	Non-Preferred Drug	35%	35%	P
Perphenazine 16mg/1 100 FILM COATED TABLETS in BOTTLE	4	Non-Preferred Drug	35%	35%	None
PERPHENAZINE 4 MG TABLET	4	Non-Preferred Drug	35%	35%	None
PERPHENAZINE 8 MG TABLET	4	Non-Preferred Drug	35%	35%	None
PERPHENAZINE TABLETS USP 2MG 100 BOT	4	Non-Preferred Drug	35%	35%	None
PHENADOZ 12.5 MG SUPPOSITORY	4	Non-Preferred Drug	35%	35%	P
Phenelzine Sulfate 15mg/1 60 TABLET BOTTLE	3	Preferred Brand	$30.00	$90.00	None
Phenobarbital 100mg/1	3	Preferred Brand	$30.00	$90.00	P Q:120 /30Days
Phenobarbital 15mg/1	3	Preferred Brand	$30.00	$90.00	P Q:120 /30Days
PHENOBARBITAL 16.2 MG TABLET	3	Preferred Brand	$30.00	$90.00	P Q:120 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PHENOBARBITAL 20 MG/5 ML ELIX	3	Preferred Brand	$30.00	$90.00	P Q:1500 /30Days
Phenobarbital 30mg/1	3	Preferred Brand	$30.00	$90.00	P Q:120 /30Days
PHENOBARBITAL 32.4 MG TABLET	3	Preferred Brand	$30.00	$90.00	P Q:120 /30Days
Phenobarbital 60mg/1	3	Preferred Brand	$30.00	$90.00	P Q:120 /30Days
PHENOBARBITAL 64.8 MG TABLET	3	Preferred Brand	$30.00	$90.00	P Q:120 /30Days
PHENOBARBITAL 97.2 MG TABLET	3	Preferred Brand	$30.00	$90.00	P Q:120 /30Days
PHENYTEK 200 MG CAPSULE	3	Preferred Brand	$30.00	$90.00	None
PHENYTEK 300 MG CAPSULE	3	Preferred Brand	$30.00	$90.00	None
Phenytoin 50 MG Chewable Tablet	3	Preferred Brand	$30.00	$90.00	None
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT	3	Preferred Brand	$30.00	$90.00	None
PHENYTOIN SOD EXT 100 MG CAP	3	Preferred Brand	$30.00	$90.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PHENYTOIN SOD EXT 200 MG CAP	3	Preferred Brand	$30.00	$90.00	None
PHENYTOIN SOD EXT 300 MG CAP	3	Preferred Brand	$30.00	$90.00	None
PHENYTOIN SODIUM 100MG /2ML INJECTION	4	Non-Preferred Drug	35%	35%	None
PHOSPHOLINE IODIDE 0.125% 6.25MG	4	Non-Preferred Drug	35%	35%	None
PHRENILIN FORTE 50-300-40 MG	4	Non-Preferred Drug	35%	35%	P Q:180 /30Days
PILOCARPINE 1% EYE DROPS [Pilocar]	4	Non-Preferred Drug	35%	35%	None
PILOCARPINE 2% EYE DROPS [Pilocar]	4	Non-Preferred Drug	35%	35%	None
PILOCARPINE 4% EYE DROPS [Pilocar]	4	Non-Preferred Drug	35%	35%	None
PILOCARPINE HCL 5 MG TABLET [Salagen]	4	Non-Preferred Drug	35%	35%	None
PILOCARPINE HCL 7.5 MG TABLET [Salagen]	4	Non-Preferred Drug	35%	35%	None
PIMOZIDE 1 MG TABLET [Orap]	4	Non-Preferred Drug	35%	35%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PIMOZIDE 2 MG TABLET [Orap]	4	Non-Preferred Drug	35%	35%	None
PIMTREA 28 DAY TABLET	3	Preferred Brand	$30.00	$90.00	None
PINDOLOL 10 MG TABLET	3	Preferred Brand	$30.00	$90.00	None
PINDOLOL 5 MG TABLET	3	Preferred Brand	$30.00	$90.00	None
pioglitaz-glimepir 30-2 mg tab	4	Non-Preferred Drug	35%	35%	Q:30 /30Days
PIOGLITAZONE HCL 15 MG TABLET [Actos]	1*	Preferred Generic	$1.00	$3.00	Q:30 /30Days
PIOGLITAZONE HCL 30 MG TABLET [Actos]	1*	Preferred Generic	$1.00	$3.00	Q:30 /30Days
PIOGLITAZONE HCL 45 MG TABLET [Actos]	1*	Preferred Generic	$1.00	$3.00	Q:30 /30Days
PIOGLITAZONE-GLIMEPIRIDE 30-4 Tablet [Duetact]	4	Non-Preferred Drug	35%	35%	Q:30 /30Days
PIOGLITAZONE-METFORMIN 15-500	3	Preferred Brand	$30.00	$90.00	Q:90 /30Days
PIOGLITAZONE-METFORMIN 15-850	3	Preferred Brand	$30.00	$90.00	Q:90 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PIPERACIL-TAZOBACT 2.25 GM VIAL	4	Non-Preferred Drug	35%	35%	None
PIPERACIL-TAZOBACT 3.375 GM VIAL	4	Non-Preferred Drug	35%	35%	None
PIPERACIL-TAZOBACT 4.5 GM VIAL	4	Non-Preferred Drug	35%	35%	None
PIPERACIL-TAZOBACT 40.5 GM VIAL	4	Non-Preferred Drug	35%	35%	None
Pirmella 1-35-28 tablet	3	Preferred Brand	$30.00	$90.00	None
PIROXICAM 10 MG CAPSULE	3	Preferred Brand	$30.00	$90.00	None
PIROXICAM 20 MG CAPSULE	4	Non-Preferred Drug	35%	35%	None
PLASMA-LYTE 148 IV SOLUTION	4	Non-Preferred Drug	35%	35%	None
PLASMA-LYTE A PH 7.4 SOLUTION 37;368; MG/100ML;	4	Non-Preferred Drug	35%	35%	None
PODOFILOX 0.5% TOPICAL TUBEX	4	Non-Preferred Drug	35%	35%	None
POLYETHYLENE GLYCOL 3350 POWD	2*	Generic	$2.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
POLYMYXIN B-TMP EYE DROPS	1*	Preferred Generic	$1.00	$3.00	None
POMALYST 1 MG CAPSULE	5	Specialty Tier	27%	N/A	P
POMALYST 2 MG CAPSULE	5	Specialty Tier	27%	N/A	P
POMALYST 3 MG CAPSULE	5	Specialty Tier	27%	N/A	P
POMALYST 4 MG CAPSULE	5	Specialty Tier	27%	N/A	P
PORTIA 0.15-0.03 TABLET	3	Preferred Brand	$30.00	$90.00	None
POT CHL/SWFI P-B 40 MEQ 24X100 ML	3	Preferred Brand	$30.00	$90.00	None
Potassium Chloride 200 meq/1000mL 24 POUCH in 1 CASE	3	Preferred Brand	$30.00	$90.00	None
Potassium Chloride 8 MEQ Extended Release Oral Tablet	2*	Generic	$2.00	$6.00	None
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION	4	Non-Preferred Drug	35%	35%	None
Potassium Chloride in Dextrose 5; 150g/100mL; mg/100mL 1000 mL in 1 BAG	4	Non-Preferred Drug	35%	35%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Potassium Chloride in Dextrose and Sodium Chloride 5; 0.15; 0.33g/100mL; g/100mL; g/100mL 12 CONTAI	4	Non-Preferred Drug	35%	35%	None
Potassium Chloride in Dextrose and Sodium Chloride 5; 300; 900g/100mL; mg/100mL; mg/100mL 1000 mL i	4	Non-Preferred Drug	35%	35%	None
Potassium Chloride in Lactated Ringers and Dextrose 20; 5; 179; 600; 310mg/100mL; g/100mL; mg/100mL	3	Preferred Brand	$30.00	$90.00	None
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION	4	Non-Preferred Drug	35%	35%	None
POTASSIUM CHLORIDE INJECTION 10MEQ/100ML	3	Preferred Brand	$30.00	$90.00	None
POTASSIUM CITRATE ER 10 MEQ TB	4	Non-Preferred Drug	35%	35%	None
POTASSIUM CITRATE ER 15 MEQ TABLET	4	Non-Preferred Drug	35%	35%	None
POTASSIUM CITRATE ER 5 MEQ TAB	4	Non-Preferred Drug	35%	35%	None
Potassium cl 10% (20 meq/15 ml)	4	Non-Preferred Drug	35%	35%	None
Potassium cl 20% (40 meq/15 ml)	4	Non-Preferred Drug	35%	35%	None
POTASSIUM CL 40 MEQ/20 ML CONC	2*	Generic	$2.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
POTASSIUM CL ER 10 MEQ CAPSULE	2*	Generic	$2.00	$6.00	None
POTASSIUM CL ER 10 MEQ TABLET	2*	Generic	$2.00	$6.00	None
POTASSIUM CL ER 10 MEQ TABLET	2*	Generic	$2.00	$6.00	None
POTASSIUM CL ER 20 MEQ TABLET	2*	Generic	$2.00	$6.00	None
Potassium cl er 20 meq tablet	2*	Generic	$2.00	$6.00	None
POTASSIUM CL ER 8 MEQ CAPSULE	2*	Generic	$2.00	$6.00	None
PRADAXA 110 MG CAPSULE	4	Non-Preferred Drug	35%	35%	None
PRADAXA 150 MG CAPSULE	4	Non-Preferred Drug	35%	35%	None
PRADAXA 75 MG CAPSULE	4	Non-Preferred Drug	35%	35%	None
PRALUENT 150 MG/ML PEN	5	Specialty Tier	27%	N/A	P
PRALUENT 75 MG/ML PEN	5	Specialty Tier	27%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PRAMIPEXOLE 0.125 MG TABLET	2*	Generic	$2.00	$6.00	None
PRAMIPEXOLE 0.25 MG TABLET	2*	Generic	$2.00	$6.00	None
PRAMIPEXOLE 0.5 MG TABLET	2*	Generic	$2.00	$6.00	None
PRAMIPEXOLE 0.75 MG TABLET	2*	Generic	$2.00	$6.00	None
PRAMIPEXOLE 1 MG TABLET	2*	Generic	$2.00	$6.00	None
PRAMIPEXOLE 1.5 MG TABLET	2*	Generic	$2.00	$6.00	None
PRASUGREL 10 MG TABLET	4	Non-Preferred Drug	35%	35%	None
PRASUGREL 5 MG TABLET	4	Non-Preferred Drug	35%	35%	None
PRAVASTATIN SODIUM 10 MG TAB	1*	Preferred Generic	$1.00	$3.00	Q:30 /30Days
PRAVASTATIN SODIUM 20 MG TAB	1*	Preferred Generic	$1.00	$3.00	Q:30 /30Days
PRAVASTATIN SODIUM 40 MG TAB	1*	Preferred Generic	$1.00	$3.00	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PRAVASTATIN SODIUM 80 MG TAB	1*	Preferred Generic	$1.00	$3.00	Q:30 /30Days
PRAZOSIN 1 MG CAPSULE	3	Preferred Brand	$30.00	$90.00	None
PRAZOSIN 2 MG CAPSULE	3	Preferred Brand	$30.00	$90.00	None
PRAZOSIN 5MG CAPSULE	3	Preferred Brand	$30.00	$90.00	None
Prednicarbate 0.1% cream	4	Non-Preferred Drug	35%	35%	None
PREDNICARBATE 0.1% OINTMENT	4	Non-Preferred Drug	35%	35%	None
Prednisolone 10 mg/5 ml soln	3	Preferred Brand	$30.00	$90.00	None
PREDNISOLONE 15 MG/5 ML SOLN	2*	Generic	$2.00	$6.00	None
PREDNISOLONE 20 MG/5 ML SOLN	3	Preferred Brand	$30.00	$90.00	None
PREDNISOLONE AC 1% EYE DROP	2*	Generic	$2.00	$6.00	None
PREDNISOLONE SOD 1% EYE DROP	3	Preferred Brand	$30.00	$90.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PREDNISOLONE SOD PH 25 MG/5 ML	2*	Generic	$2.00	$6.00	None
PREDNISOLONE SODIUM PHOSPHATE 5MG /5ML ORAL SOLUTION	3	Preferred Brand	$30.00	$90.00	None
PREDNISONE 1 MG TABLET	1*	Preferred Generic	$1.00	$3.00	None
Prednisone 10 MG Oral Tablet	1*	Preferred Generic	$1.00	$3.00	None
PREDNISONE 10 MG TAB DOSE PACK	1*	Preferred Generic	$1.00	$3.00	None
PREDNISONE 10 MG TAB DOSE PACK	1*	Preferred Generic	$1.00	$3.00	None
PREDNISONE 2.5 MG TABLET	1*	Preferred Generic	$1.00	$3.00	None
Prednisone 20 MG Oral Tablet	1*	Preferred Generic	$1.00	$3.00	None
PREDNISONE 5 MG TABLET	1*	Preferred Generic	$1.00	$3.00	None
PREDNISONE 5 MG TABLET	1*	Preferred Generic	$1.00	$3.00	None
PREDNISONE 5 MG TABLET	1*	Preferred Generic	$1.00	$3.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PREDNISONE 5 MG/5 ML SOLUTION	1*	Preferred Generic	$1.00	$3.00	None
PREDNISONE 50MG TABLET	1*	Preferred Generic	$1.00	$3.00	None
PREDNISONE 5MG/ML SOLUTION	3	Preferred Brand	$30.00	$90.00	P
PREMASOL 10% IV SOLUTION	4	Non-Preferred Drug	35%	35%	P
PREMASOL 6% IV SOLUTION	4	Non-Preferred Drug	35%	35%	P
PREVALITE PACKET	4	Non-Preferred Drug	35%	35%	None
Previfem 6 BLISTER PACK per BLISTER PACK / 1 KIT per BLISTER PACK	3	Preferred Brand	$30.00	$90.00	None
PREZCOBIX 800 MG-150 MG TABLET	5	Specialty Tier	27%	N/A	None
PREZISTA 100 MG/ML SUSPENSION	5	Specialty Tier	27%	N/A	None
PREZISTA 150MG TABLETS	3	Preferred Brand	$30.00	$90.00	None
PREZISTA 800 MG TABLET	5	Specialty Tier	27%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PREZISTA TABLET 600MG	5	Specialty Tier	27%	N/A	None
PREZISTA TABLET 75MG	3	Preferred Brand	$30.00	$90.00	None
PRIFTIN 150 MG TABLET	4	Non-Preferred Drug	35%	35%	None
Primaquine Phosphate 26.3 MG Oral Tablet	3	Preferred Brand	$30.00	$90.00	None
PRIMIDONE 250 MG TABLET	2*	Generic	$2.00	$6.00	None
PRIMIDONE 50 MG TABLET	2*	Generic	$2.00	$6.00	None
PRISTIQ 100MG TABLET SR 24HR	3	Preferred Brand	$30.00	$90.00	Q:30 /30Days
PRISTIQ ER 25 MG TABLET	3	Preferred Brand	$30.00	$90.00	Q:30 /30Days
PRISTIQ ER 50 MG TABLET ER 24H	3	Preferred Brand	$30.00	$90.00	Q:30 /30Days
PRIVIGEN 10% VIAL	5	Specialty Tier	27%	N/A	P
PROBENECID 500 MG TABLET	3	Preferred Brand	$30.00	$90.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PROBENECID/COLCHICINE 0.5MG/500MG TABLET	3	Preferred Brand	$30.00	$90.00	None
ProcalAmine 0.21; 0.29; 0.026; 0.014; 3; 0.42; 0.085; 0.21; 0.27; 0.22; 0.054; 0.16; 0.17; 0.041; 0	4	Non-Preferred Drug	35%	35%	P
PROCHLORPERAZINE 10 MG TAB	2*	Generic	$2.00	$6.00	None
Prochlorperazine 10 mg/2 ml vl	4	Non-Preferred Drug	35%	35%	None
PROCHLORPERAZINE 5 MG TABLET	2*	Generic	$2.00	$6.00	None
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX	2*	Generic	$2.00	$6.00	None
PROCRIT 10000U/ML VIAL	3	Preferred Brand	$30.00	$90.00	P
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL	3	Preferred Brand	$30.00	$90.00	P
PROCRIT 3,000 UNITS/ML VIAL	3	Preferred Brand	$30.00	$90.00	P
PROCRIT 4,000 UNITS/ML VIAL	3	Preferred Brand	$30.00	$90.00	P
PROCRIT 40000U/ML VIAL PR	5	Specialty Tier	27%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY	5	Specialty Tier	27%	N/A	P
PROCTO-MED HC 2.5% CREAM	4	Non-Preferred Drug	35%	35%	None
procto-pak 1% cream	4	Non-Preferred Drug	35%	35%	None
PROCTOSOL-HC 2.5% CREAM	4	Non-Preferred Drug	35%	35%	None
PROCTOZONE-HC 2.5% CREAM	4	Non-Preferred Drug	35%	35%	None
PROGESTERONE 100 MG CAPSULE	3	Preferred Brand	$30.00	$90.00	None
PROGESTERONE 200 MG CAPSULE	3	Preferred Brand	$30.00	$90.00	None
PROGLYCEM 50 MG/ML ORAL SUSP	4	Non-Preferred Drug	35%	35%	None
PROGRAF 0.5MG CAPSULE	4	Non-Preferred Drug	35%	35%	P
PROGRAF 1MG CAPSULE	4	Non-Preferred Drug	35%	35%	P
PROGRAF 5 MG 1 BOTTLE per CARTON / 100 CAPSULE, GELATIN COATED in 1 BOTTLE	5	Specialty Tier	27%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PROLASTIN C 1,000 MG VIAL	5	Specialty Tier	27%	N/A	P
PROLENSA 0.07% EYE DROPS	3	Preferred Brand	$30.00	$90.00	None
PROLEUKIN 22 MILLION UNIT VIAL	5	Specialty Tier	27%	N/A	P
PROLIA 60MG/ML INJECTION	4	Non-Preferred Drug	35%	35%	Q:1 /166Days
PROMACTA 12.5 MG TABLET	5	Specialty Tier	27%	N/A	P Q:360 /30Days
PROMACTA 25 MG TABLET	5	Specialty Tier	27%	N/A	P Q:180 /30Days
PROMACTA 50 MG TABLET	5	Specialty Tier	27%	N/A	P Q:90 /30Days
PROMACTA 75 MG TABLET	5	Specialty Tier	27%	N/A	P Q:60 /30Days
PROMETHAZINE 12.5 MG TABLET	2*	Generic	$2.00	$6.00	P
PROMETHAZINE 25 MG TABLET	2*	Generic	$2.00	$6.00	P
PROMETHAZINE 50 MG SUPPOSITORY	4	Non-Preferred Drug	35%	35%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PROMETHAZINE 50 MG TABLET	2*	Generic	$2.00	$6.00	P
PROMETHAZINE 6.25 MG/5 ML SYRUP [Prometh Plain]	4	Non-Preferred Drug	35%	35%	P
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 12.5MG 12 BOX	4	Non-Preferred Drug	35%	35%	P
PROMETHAZINE HYDROCHLORIDE SUPPOSITORIES 25MG 12 BOX	4	Non-Preferred Drug	35%	35%	P
PROMETHEGAN 25MG SUPP	4	Non-Preferred Drug	35%	35%	P
PROMETHEGAN 50MG SUPPOS	4	Non-Preferred Drug	35%	35%	P
PROPAFENONE HCL 150 MG TABLET	3	Preferred Brand	$30.00	$90.00	None
PROPAFENONE HCL 225MG TABLET	3	Preferred Brand	$30.00	$90.00	None
PROPAFENONE HCL 300 MG TAB	3	Preferred Brand	$30.00	$90.00	None
PROPAFENONE HCL ER 225 MG CAP	4	Non-Preferred Drug	35%	35%	None
PROPAFENONE HYDROCHLORIDE 325MG CAPSULES EXTENDED RELEASE	4	Non-Preferred Drug	35%	35%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PROPAFENONE HYDROCHLORIDE 425MG CAPSULES EXTENDED RELEASE	4	Non-Preferred Drug	35%	35%	None
Proparacaine hydrochloride 5 MG/ML Ophthalmic Solution	3	Preferred Brand	$30.00	$90.00	None
PROPRANOLOL 1 MG/ML VIAL	4	Non-Preferred Drug	35%	35%	None
PROPRANOLOL 10 MG TABLET	2*	Generic	$2.00	$6.00	None
PROPRANOLOL 20 MG TABLET	2*	Generic	$2.00	$6.00	None
PROPRANOLOL 20MG/5ML TUBEX	3	Preferred Brand	$30.00	$90.00	None
PROPRANOLOL 40 MG TABLET	2*	Generic	$2.00	$6.00	None
PROPRANOLOL 40MG/5ML TUBEX	3	Preferred Brand	$30.00	$90.00	None
PROPRANOLOL 60 MG TABLET	2*	Generic	$2.00	$6.00	None
PROPRANOLOL 80 MG TABLET	2*	Generic	$2.00	$6.00	None
PROPRANOLOL ER 120 MG CAPSULE	4	Non-Preferred Drug	35%	35%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PROPRANOLOL ER 160 MG CAPSULE	4	Non-Preferred Drug	35%	35%	None
PROPRANOLOL ER 60 MG CAPSULE	4	Non-Preferred Drug	35%	35%	None
PROPRANOLOL ER 80 MG CAPSULE	4	Non-Preferred Drug	35%	35%	None
PROPRANOLOL/HCTZ 40/25 TABLET	2*	Generic	$2.00	$6.00	None
PROPRANOLOL/HCTZ 80/25 TABLET	2*	Generic	$2.00	$6.00	None
PROPYLTHIOURACIL 50MG TABLET	3	Preferred Brand	$30.00	$90.00	None
PROQUAD VIAL	3	Preferred Brand	$30.00	$90.00	None
PROSOL 20% INJECTION	4	Non-Preferred Drug	35%	35%	P
PROTRIPTYLINE HCL 10 MG TABLET	4	Non-Preferred Drug	35%	35%	None
PROTRIPTYLINE HCL 5 MG TABLET	4	Non-Preferred Drug	35%	35%	None
PULMICORT FLEXHALER 180MCG AEROSOL POWDER BREATH ACTIVATED	3	Preferred Brand	$30.00	$90.00	Q:2 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
PULMICORT FLEXHALER 90MCG AEROSOL POWDER BREATH ACTIVATED	3	Preferred Brand	$30.00	$90.00	Q:2 /30Days
PULMOZYME 1MG/ML AMPUL	5	Specialty Tier	27%	N/A	P
PURIXAN 20 MG/ML ORAL SUSP	5	Specialty Tier	27%	N/A	None
PYRAZINAMIDE 500 MG TABLET	4	Non-Preferred Drug	35%	35%	None
PYRIDOSTIGMINE BR 60 MG TABLET	3	Preferred Brand	$30.00	$90.00	None
PYRIDOSTIGMINE BR ER 180 MG TAB	3	Preferred Brand	$30.00	$90.00	None

Chart Legend:

Below are a few notes to help you understand the above 2018 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). The plan name is followed by the plan type (PDP, HMO, HMO-POS, PPO, PFFS, etc.)
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 $405 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 five (5) tiers 1=Preferred Generics, 2=Generics, 3=Preferred Brands, 4=Non-preferred Brands, 5=Specialty Drugs. *Some Part D plans exclude one or more drug tiers from the deductible. If the drug tier field above is followed by * (example: 2*), then this drug tier is excluded from the plan’s deductible.
- Tier 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 $3750) at a "Preferred" network pharmacy. In most cases, the "Preferred" network network pharmacy cost-sharing is lower than the standard (non-preferred) network pharmacy cost-sharing.
- 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 2018 )

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.