Q1Medicare.com 2019 Medicare Part D or Medicare Advantage Plan Formulary Browser

2019 Medicare Part D Plan Formulary Information
Aetna Medicare Rx Value Plus (PDP) (S5768-148-0) Benefit Details
The Aetna Medicare Rx Value Plus (PDP) (S5768-148-0) Formulary Drugs Starting with the Letter I in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY Plan Monthly Premium: $58.80 Deductible: $0 Qualifies for LIS: No
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 TABLET [Boniva]	4	Non-Preferred Drug	50%	50%	Q:1 /30Days
IBRANCE 100 MG CAPSULE	5	Specialty Tier	33%	N/A	P
IBRANCE 125 MG CAPSULE	5	Specialty Tier	33%	N/A	P
IBRANCE 75 MG CAPSULE	5	Specialty Tier	33%	N/A	P
Ibuprofen 100mg/5mL 473 mL in 1 BOTTLE	2	Generic	$2.00	$6.00	None
IBUPROFEN 400 MG TABLET	1	Preferred Generic	$1.00	$3.00	None
IBUPROFEN 600 MG ORAL TABLET	1	Preferred Generic	$1.00	$3.00	None
IBUPROFEN 600mg/1 500 TABLET BOTTLE	1	Preferred Generic	$1.00	$3.00	None
IBUPROFEN 800 MG ORAL TABLET	1	Preferred Generic	$1.00	$3.00	None
IBUPROFEN 800 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
ICLUSIG 15 MG TABLET	5	Specialty Tier	33%	N/A	P
ICLUSIG 45 MG TABLET	5	Specialty Tier	33%	N/A	P
IDHIFA 100 MG TABLET	5	Specialty Tier	33%	N/A	P
IDHIFA 50 MG TABLET	5	Specialty Tier	33%	N/A	P
ILEVRO 0.3% OPHTH DROPS	3	Preferred Brand	$47.00	$141.00	None
IMATINIB MESYLATE 100 MG TAB [Gleevec]	5	Specialty Tier	33%	N/A	P Q:90 /30Days
IMATINIB MESYLATE 400 MG TAB [Gleevec]	5	Specialty Tier	33%	N/A	P Q:60 /30Days
IMBRUVICA 140 MG CAPSULE	5	Specialty Tier	33%	N/A	P
IMBRUVICA 140 MG TABLET	5	Specialty Tier	33%	N/A	P
IMBRUVICA 280 MG TABLET	5	Specialty Tier	33%	N/A	P
IMBRUVICA 420 MG TABLET	5	Specialty Tier	33%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
IMBRUVICA 560 MG TABLET	5	Specialty Tier	33%	N/A	P
IMBRUVICA 70 MG CAPSULE	5	Specialty Tier	33%	N/A	P
IMIPRAMINE HCL 10MG TABLET (100 CT)	2	Generic	$2.00	$6.00	P
IMIPRAMINE HCL 25MG TABLET (100 CT)	2	Generic	$2.00	$6.00	P
IMIPRAMINE HCL 50 MG TABLET	2	Generic	$2.00	$6.00	P
IMIPRAMINE PAMOATE 100MG CAPSULES	4	Non-Preferred Drug	50%	50%	P
IMIPRAMINE PAMOATE 125MG CAPSULES	4	Non-Preferred Drug	50%	50%	P
IMIPRAMINE PAMOATE 150MG CAPSULES	4	Non-Preferred Drug	50%	50%	P
IMIPRAMINE PAMOATE 75MG CAPSULES	4	Non-Preferred Drug	50%	50%	P
IMIQUIMOD 3.75% CREAM PUMP CRM MD PMP [Zyclara]	5	Specialty Tier	33%	N/A	Q:8 /30Days
IMIQUIMOD 5% CREAM PACKET	3	Preferred Brand	$47.00	$141.00	Q:24 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
IMOVAX RABIES VACCINE	3	Preferred Brand	$47.00	$141.00	P
INCASSIA 0.35 MG TABLET [Sharobel 28-Day]	3	Preferred Brand	$47.00	$141.00	None
Increlex 40mg/4mL 1 VIAL, MULTI-DOSE per CARTON / 4 mL in 1 VIAL, MULTI-DOSE	5	Specialty Tier	33%	N/A	P
INCRUSE ELLIPTA 62.5 MCG INH	3	Preferred Brand	$47.00	$141.00	Q:30 /30Days
Indapamide 1.25mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC	2	Generic	$2.00	$6.00	None
INDAPAMIDE 2.5 MG TABLET	2	Generic	$2.00	$6.00	None
INDOMETHACIN 25 MG CAPSULE	4	Non-Preferred Drug	50%	50%	P
INDOMETHACIN 50 MG CAPSULE	4	Non-Preferred Drug	50%	50%	P
INDOMETHACIN ER 75 MG CAPSULE	4	Non-Preferred Drug	50%	50%	P
INFANRIX DTAP VIAL	3	Preferred Brand	$47.00	$141.00	None
INLYTA 1 MG TABLET	5	Specialty Tier	33%	N/A	P Q:180 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
INLYTA 5 MG TABLET	5	Specialty Tier	33%	N/A	P Q:120 /30Days
INTELENCE 100MG TABLET	5	Specialty Tier	33%	N/A	None
Intelence 200mg/1	5	Specialty Tier	33%	N/A	None
INTELENCE 25 MG TABLET	4	Non-Preferred Drug	50%	50%	None
INTRALIPID 20% IV FAT EMUL EMULSION	3	Preferred Brand	$47.00	$141.00	P
INTRALIPID 30% IV FAT EMUL	4	Non-Preferred Drug	50%	50%	P
INTRON A 10 MILLION UNITS VIAL	5	Specialty Tier	33%	N/A	None
INTRON A 18 MILLION UNITS VIAL	5	Specialty Tier	33%	N/A	None
INTRON A 25 MILLION UNIT/2.5ML VIAL	5	Specialty Tier	33%	N/A	None
INTRON A 50 MILLION UNITS VIAL	5	Specialty Tier	33%	N/A	None
INTRON A 6MMU/ML VIAL	5	Specialty Tier	33%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
INTROVALE 0.15-0.03 MG TABLET TBDSPK 3MO [Setlakin]	3	Preferred Brand	$47.00	$141.00	None
INVANZ 1GM VIAL	4	Non-Preferred Drug	50%	50%	None
Invega Sustenna 117 mg/0.75mL Prefilled Syringe	5	Specialty Tier	33%	N/A	Q:1 /28Days
Invega Sustenna 156 mg/mL Prefilled Syringe	5	Specialty Tier	33%	N/A	Q:1 /28Days
Invega Sustenna 234 mg/1.5mL Prefilled Syringe	5	Specialty Tier	33%	N/A	Q:2 /28Days
Invega Sustenna 39 mg/0.25mL Prefilled Syringe	4	Non-Preferred Drug	50%	50%	None
Invega Sustenna 78 mg/0.5mL Prefilled Syringe	5	Specialty Tier	33%	N/A	Q:1 /28Days
INVEGA TRINZA 273 MG/0.875 ML	5	Specialty Tier	33%	N/A	Q:1 /90Days
INVEGA TRINZA 410 MG/1.315 ML	5	Specialty Tier	33%	N/A	Q:1 /90Days
INVEGA TRINZA 546 MG/1.75 ML	5	Specialty Tier	33%	N/A	Q:2 /90Days
INVEGA TRINZA 819 MG/2.625 ML	5	Specialty Tier	33%	N/A	Q:3 /90Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
INVIRASE 500MG TABLET	5	Specialty Tier	33%	N/A	None
IONOSOL MB-D5W IV SOLUTION	4	Non-Preferred Drug	50%	50%	None
IPOL VIAL 40;8;32; UNT	3	Preferred Brand	$47.00	$141.00	None
IPRAT-ALBUT 0.5-3(2.5) MG/3 ML	2	Generic	$2.00	$6.00	P
IPRATROPIUM 0.06% SPRAY	2	Generic	$2.00	$6.00	Q:45 /30Days
IPRATROPIUM BR 0.02% SOLN	2	Generic	$2.00	$6.00	P
IPRATROPIUM BROMIDE NASAL SPRAY	2	Generic	$2.00	$6.00	Q:30 /30Days
IRBESARTAN 150 MG TABLET [Avapro]	1	Preferred Generic	$1.00	$3.00	Q:30 /30Days
IRBESARTAN 300 MG TABLET [Avapro]	1	Preferred Generic	$1.00	$3.00	Q:30 /30Days
IRBESARTAN 75 MG TABLET [Avapro]	1	Preferred Generic	$1.00	$3.00	Q:30 /30Days
IRBESARTAN-HCTZ 150-12.5 MG TABLET [Avalide]	2	Generic	$2.00	$6.00	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
IRBESARTAN-HCTZ 300-12.5 MG TABLET [Avalide]	2	Generic	$2.00	$6.00	Q:30 /30Days
IRESSA 250 MG TABLET	5	Specialty Tier	33%	N/A	P
ISENTRESS 100 MG POWDER PACKET	3	Preferred Brand	$47.00	$141.00	None
ISENTRESS 100 MG TABLET CHEW	5	Specialty Tier	33%	N/A	None
ISENTRESS 25 MG TABLET CHEW	3	Preferred Brand	$47.00	$141.00	None
ISENTRESS 400MG TABLET	5	Specialty Tier	33%	N/A	None
ISENTRESS HD 600 MG TABLET	5	Specialty Tier	33%	N/A	None
ISIBLOOM 28 DAY TABLET [Solia]	3	Preferred Brand	$47.00	$141.00	None
ISOLYTE P IN 5% DEXTROSE INJECTION	4	Non-Preferred Drug	50%	50%	None
ISOLYTE S IV SOLUTION-EXCEL	4	Non-Preferred Drug	50%	50%	None
ISONIAZID 100 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
ISONIAZID 300 MG TABLET	1	Preferred Generic	$1.00	$3.00	None
ISONIAZID 50MG/5ML SYRUP	2	Generic	$2.00	$6.00	None
ISORDIL 40 MG TABLET	4	Non-Preferred Drug	50%	50%	None
ISORDIL TITRADOSE 5 MG TAB	4	Non-Preferred Drug	50%	50%	None
ISOSORBIDE DINITRATE 40MG TABLETS ER	2	Generic	$2.00	$6.00	None
ISOSORBIDE DN 10 MG TABLET	3	Preferred Brand	$47.00	$141.00	None
ISOSORBIDE DN 20 MG TABLET	3	Preferred Brand	$47.00	$141.00	None
ISOSORBIDE DN 30 MG TABLET	3	Preferred Brand	$47.00	$141.00	None
ISOSORBIDE DN 5 MG TABLET	3	Preferred Brand	$47.00	$141.00	None
ISOSORBIDE MN 10 MG TABLET	1	Preferred Generic	$1.00	$3.00	None
ISOSORBIDE MN ER 30 MG TABLET	2	Generic	$2.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ISOSORBIDE MN ER 60 MG TABLET	2	Generic	$2.00	$6.00	None
ISOSORBIDE MONONITRATE 20MG TABLET	1	Preferred Generic	$1.00	$3.00	None
ISOSORBIDE MONONITRATE ER TABLET 120MG (100 CT)	2	Generic	$2.00	$6.00	None
ISOTON GENTAMICIN 80MG/100ML	4	Non-Preferred Drug	50%	50%	None
ISOTONIC GENTAMICIN 100 MG/100 ML	4	Non-Preferred Drug	50%	50%	None
ISOTONIC GENTAMICIN 80 MG/50 ML	4	Non-Preferred Drug	50%	50%	None
ISOTRETINOIN 10 MG CAPSULE [ZENATANE]	4	Non-Preferred Drug	50%	50%	None
ISOTRETINOIN 20 MG CAPSULE [ZENATANE]	4	Non-Preferred Drug	50%	50%	None
ISOTRETINOIN 30 MG CAPSULE [ZENATANE]	4	Non-Preferred Drug	50%	50%	None
ISOTRETINOIN 40 MG CAPSULE [ZENATANE]	4	Non-Preferred Drug	50%	50%	None
ISRADIPINE CAPSULES 2.5MG (100 CT)	2	Generic	$2.00	$6.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
ISRADIPINE CAPSULES 5MG (100 CT)	2	Generic	$2.00	$6.00	None
ITRACONAZOLE 100 MG CAPSULE [Sporanox]	4	Non-Preferred Drug	50%	50%	P
IVERMECTIN 3 MG TABLET [Stromectol, Sklice]	3	Preferred Brand	$47.00	$141.00	None
IXIARO JAPANESE ENCEPHALITIS VACCINE 6MCG/.5ML	3	Preferred Brand	$47.00	$141.00	None

Chart Legend:

Below are a few notes to help you understand the above 2019 Medicare Part D Aetna Medicare Rx Value Plus (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 $415 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 $3820) at a "Preferred" network pharmacy. In most cases, the "Preferred" 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 2019 )

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.