2017 AARP MedicareRx Walgreens (PDP) Formulary



Below is the Formulary, or drug list, for AARP MedicareRx Walgreens (PDP) from Unitedhealthcare Ins. Co. And Unitedhealthcare Ny This formulary is a list of prescription medications that are covered under Unitedhealthcare Ins. Co. And Unitedhealthcare Ny's 2017 Part-D Plan. The AARP MedicareRx Walgreens (PDP) plan has a $400 drug deductible. This deductible is the amount of expenses that must be paid out of pocket before the Initial Coverage period begins. However some drugs do not require that the deductible is met before you receive coverage. You can see if the deductible is required below in the "Does the Deductible Apply" column. The Initial Coverage Limit (ICL) for this plan is $3700. The Initial Coverage Period is the period after the Deductible has been met but before the Coverage Gap phase. Once you and your plan provider have spent $3700 on covered drugs. (combined amount plus your deductible) You will enter the coverage gap. (AKA "donut hole") Once you reach the coverage gap you will be required to pay 45% of the plan's cost for covered brand-name prescription drugs unless your plan offers additional coverage. You can see if this plan offers coverage in the "donut hole" be clicking the "Coverage Gap" link on the left above the chart. In 2017 if you have spent $4700 in expenditures you enter the Catastrophic Phase. During the Catastrophic Period you will begin to receive significant coverage. AARP MedicareRx Walgreens (PDP) will begin paying approximately 95% of your covered medication expenses. You can see if this plan covers your drugs in the Catastrophic Phase by clicking the "Catastrophic" link on the left above the chart.

See More on AARP MedicareRx Walgreens (PDP)





Plan Name:
AARP MedicareRx Walgreens (PDP)
Plan ID:
S5921-383
Provider: Unitedhealthcare Ins. Co. And Unitedhealthcare Ny
Plan Year:2017
Premium:$22.50
Deductible:$400
Initial Coverage Limit:$3700
Coverage Area:Florida




Current Table info:


Coverage Level:
Initial Coverage
Days Supply:
30 Days
Drugs Starting With Letter: I

Change Table Options:


Drugs Starting Letter:
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 
Coverage Level:
Drug Days Pricing:60 Day
90 Day











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(Click the Drug Name to Compare every Plans Price)

Drug Name Drug Strength Units in Package Tier Level Amount Limit Days Limit Prior Authorization
Y/N
Step Therapy
Y/N
Does the Deduct Apply Cost Preferred Max Cost Non Preferred Max Cost Mail Max
Ibandronate Sodium 150mg 3 Blister Pack In 1 Package > 1 Tablet, Film Coated In 1 Blister Pack
3
1 28 N N Y $27N$47NNAN
Ibuprofen 400mg 100 Tablet, Film Coated In 1 Box, Unit-dose
2
N N N $3N$18NNAN
Ibuprofen 100mg/5mL 473 Ml In 1 Bottle
2
N N N $3N$18NNAN
Ibuprofen 600mg 500 Tablet In 1 Bottle
2
N N N $3N$18NNAN
Ibuprofen 800mg 100 Tablet In 1 Bottle
2
N N N $3N$18NNAN
Iclusig 30 Tablet, Film Coated In 1 Bottle
5
30 30 Y N Y 25%N25%NNAN
Iclusig 30 Tablet, Film Coated In 1 Bottle
5
60 30 Y N Y 25%N25%NNAN
Idarubicin Hydrochloride 1mg/mL 1 Vial, Single-dose In 1 Carton > 10 Ml In 1 Vial, Single-dose
5
N N Y 25%N25%NNAN
Ifosfamide 1g 1 Injection, Powder, Lyophilized, For Solution In 1 Box
4
N N Y 32%N33%NNAN
Ilaris 150mg/mL 1 Vial, Single-use In 1 Carton > 1 Ml In 1 Vial, Single-use
5
2 28 Y N Y 25%N25%NNAN
Ilevro 3mg/mL 1 Bottle, Dropper In 1 Carton > 1.7 Ml In 1 Bottle, Dropper
3
N N Y $27N$47NNAN
Imbruvica 140mg 90 Capsule In 1 Bottle, Plastic
5
120 30 Y N Y 25%N25%NNAN
Imipenem And Cilastatin 500; 500mg/100mL; mg/100mL 25 Vial In 1 Carton > 100 Ml In 1 Vial
4
N N Y 32%N33%NNAN
Imipenem And Cilastatin 250; 250mg/100mL; mg/100mL 25 Vial In 1 Carton > 100 Ml In 1 Vial
4
N N Y 32%N33%NNAN
Imipramine Hydrochloride 10mg 100 Tablet In 1 Bottle
4
N N Y 32%N33%NNAN
Imipramine Hydrochloride 25mg 100 Tablet In 1 Bottle
4
N N Y 32%N33%NNAN
Imipramine Hydrochloride 50mg 100 Tablet, Film Coated In 1 Bottle, Plastic
4
N N Y 32%N33%NNAN
Imipramine Pamoate 75mg 30 Capsule In 1 Bottle
4
N N Y 32%N33%NNAN
Imipramine Pamoate 100mg 30 Capsule In 1 Bottle
4
N N Y 32%N33%NNAN
Imipramine Pamoate 125mg 30 Capsule In 1 Bottle
4
N N Y 32%N33%NNAN
Imipramine Pamoate 150mg 30 Capsule In 1 Bottle
4
N N Y 32%N33%NNAN
Imiquimod 50mg/g 24 Packet In 1 Box
4
N N Y 32%N33%NNAN
Imovax Rabies 1 Kit In 1 Carton
3
Y N Y $27N$47NNAN
Increlex 40mg/4mL 1 Vial, Multi-dose In 1 Carton > 4 Ml In 1 Vial, Multi-dose
5
Y N Y 25%N25%NNAN
Indapamide 1.25mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N N $3N$18NNAN
Indapamide 2.5mg 1000 Tablet, Film Coated In 1 Bottle, Plastic
2
N N N $3N$18NNAN
Indomethacin 25mg 1000 Capsule In 1 Bottle
3
N N Y $27N$47NNAN
Indomethacin 50mg 12 Bottle In 1 Case > 100 Capsule In 1 Bottle
3
N N Y $27N$47NNAN
Infanrix 25; 8; 25; 10; 25ug/.5mL; ug/.5mL; ug/.5mL; [iU]/.5mL; [iU]/.5mL 10 Vial In 1 Carton
3
N N Y $27N$47NNAN
Inlyta 1mg 180 Tablet, Film Coated In 1 Bottle
5
120 30 Y N Y 25%N25%NNAN
Inlyta 5mg 60 Tablet, Film Coated In 1 Bottle
5
120 30 Y N Y 25%N25%NNAN
Intelence 100mg 120 Tablet In 1 Bottle, Plastic
5
60 30 N N Y 25%N25%NNAN
Intelence 200mg 60 Tablet In 1 Bottle, Plastic
5
90 30 N N Y 25%N25%NNAN
Intelence 25mg 120 Tablet In 1 Bottle, Plastic
5
180 30 N N Y 25%N25%NNAN
Intralipid 20g/100mL 250 Ml In 1 Bag
4
Y N Y 32%N33%NNAN
Intralipid 30g/100mL 500 Ml In 1 Bag
4
Y N Y 32%N33%NNAN
Intron A 1 Kit In 1 Carton * 1.25 Ml In 1 Vial * 1.25 Ml In 1 Vial
5
Y N Y 25%N25%NNAN
Intron A 11.6ug/.5mL 1 Vial, Multi-dose In 1 Carton > 3.8 Ml In 1 Vial, Multi-dose
5
Y N Y 25%N25%NNAN
Intron A 1 Kit In 1 Carton
5
Y N Y 25%N25%NNAN
Intron A 1 Kit In 1 Carton
5
Y N Y 25%N25%NNAN
Introvale 3 Carton In 1 Box > 1 Kit In 1 Carton
4
N N Y 32%N33%NNAN
Invanz 1g 10 Vial, Single-dose In 1 Tray > 1 Injection, Powder, Lyophilized, For Solution In 1 Vial, Single-dose
4
N N Y 32%N33%NNAN
Invega Sustenna 39mg/.25mL 1 Syringe In 1 Kit > .25 Ml In 1 Syringe
4
N N Y 32%N33%NNAN
Invega Sustenna 78mg/.5mL 1 Syringe In 1 Kit > .5 Ml In 1 Syringe
5
N N Y 25%N25%NNAN
Invega Sustenna 117mg/.75mL 1 Syringe In 1 Kit > .75 Ml In 1 Syringe
5
N N Y 25%N25%NNAN
Invega Sustenna 156mg/mL 1 Syringe In 1 Kit > 1 Ml In 1 Syringe
5
N N Y 25%N25%NNAN
Invega Sustenna 234mg/1.5mL 1 Syringe In 1 Kit > 1.5 Ml In 1 Syringe
5
N N Y 25%N25%NNAN
Invirase 500mg 120 Tablet, Film Coated In 1 Bottle, Plastic
5
180 30 N N Y 25%N25%NNAN
Invirase 200mg 270 Capsule In 1 Bottle, Plastic
5
450 30 N N Y 25%N25%NNAN
Ionosol And Dextrose 5; 53; 100; 100; 180; 280; 16g/100mL; mg/100mL; mg/100mL; mg/100mL; mg/100mL; m 12 Pouch In 1 Case > 1 Bag In 1 Pouch > 1000 Ml In 1 Bag
4
N N Y 32%N33%NNAN
Ionosol And Dextrose 5; 30; 141; 15; 260; 25g/100mL; mg/100mL; mg/100mL; mg/100mL; mg/100mL; m 24 Pouch In 1 Case > 1 Bag In 1 Pouch > 500 Ml In 1 Bag
4
N N Y 32%N33%NNAN
Ipol 40; 8; 32[D'ag'U]/.5mL; [D'ag'U]/.5mL; [D'ag'U]/.5mL 1 Vial, Multi-dose In 1 Package
3
N N Y $27N$47NNAN
Ipratropium Bromide 21ug 1 Bottle, Spray In 1 Carton > 345 Spray In 1 Bottle, Spray
2
N N N $3N$18NNAN
Ipratropium Bromide .5mg/2.5mL 1 Pouch In 1 Carton > 30 Vial In 1 Pouch > 2.5 Ml In 1 Vial
2
Y N N $3N$18NNAN
Ipratropium Bromide 42ug 1 Bottle, Spray In 1 Carton > 165 Spray, Metered In 1 Bottle, Spray
2
N N N $3N$18NNAN
Ipratropium Bromide And Albuterol Sulfate 2.5; .5mg/3mL; mg/3mL 6 Pouch In 1 Carton > 3 Ml In 1 Vial, Single-dose
2
Y N N $3N$18NNAN
Irbesartan 30 Tablet In 1 Bottle
2
90 30 N N N $3N$18NNAN
Irbesartan 150mg 500 Tablet In 1 Bottle
2
30 30 N N N $3N$18NNAN
Irbesartan 300mg 90 Tablet In 1 Bottle
2
30 30 N N N $3N$18NNAN
Iressa 30 Tablet, Coated In 1 Bottle
5
60 30 Y N Y 25%N25%NNAN
Irinotecan Hydrochloride 20mg/mL 1 Vial In 1 Box > 5 Ml In 1 Vial
4
N N Y 32%N33%NNAN
Isentress 400mg 60 Tablet, Film Coated In 1 Bottle
5
180 30 N N Y 25%N25%NNAN
Isentress 25mg 60 Tablet, Chewable In 1 Bottle
3
270 30 N N Y $27N$47NNAN
Isentress 100mg 60 Tablet, Chewable In 1 Bottle
5
270 30 N N Y 25%N25%NNAN
Isentress 100mg 60 Packet In 1 Carton
5
120 30 N N Y 25%N25%NNAN
Isolyte P In Dextrose 5; .031; .13; .026; .32g/100mL; g/100mL; g/100mL; g/100mL; g/100mL 24 Container In 1 Case > 500 Ml In 1 Container
4
N N Y 32%N33%NNAN
Isolyte S .03; .037; .37; .53; .5g/100mL; g/100mL; g/100mL; g/100mL; g/100mL 12 Container In 1 Case > 1000 Ml In 1 Container
4
N N Y 32%N33%NNAN
Isoniazid 300mg 1000 Tablet In 1 Bottle
2
N N N $3N$18NNAN
Isoniazid 100mg 100 Tablet In 1 Bottle
2
N N N $3N$18NNAN
Isoniazid 100mg/mL 1 Vial, Multi-dose In 1 Carton > 10 Ml In 1 Vial, Multi-dose
4
N N Y 32%N33%NNAN
Isoniazid 50mg/5mL 473 Ml In 1 Bottle
4
N N Y 32%N33%NNAN
Isosorbide 30mg 100 Tablet, Film Coated, Extended Release In 1 Bottle, Plastic
2
N N N $3N$18NNAN
Isosorbide Dinitrate 5mg 100 Tablet In 1 Bottle, Plastic
2
N N N $3N$18NNAN
Isosorbide Dinitrate 20mg 100 Tablet In 1 Bottle, Plastic
2
N N N $3N$18NNAN
Isosorbide Dinitrate 10mg 1000 Tablet In 1 Bottle
2
N N N $3N$18NNAN
Isosorbide Dinitrate 30mg 1000 Tablet In 1 Bottle
2
N N N $3N$18NNAN
Isosorbide Dinitrate 40mg 100 Tablet, Extended Release In 1 Bottle
2
N N N $3N$18NNAN
Isosorbide Mononitrate 20mg 100 Tablet, Coated In 1 Bottle
2
N N N $3N$18NNAN
Isosorbide Mononitrate 10mg 100 Tablet In 1 Bottle
2
N N N $3N$18NNAN
Isosorbide Mononitrate 60mg 100 Tablet, Extended Release In 1 Bottle
2
N N N $3N$18NNAN
Isosorbide Mononitrate 120mg 100 Tablet, Extended Release In 1 Bottle
2
N N N $3N$18NNAN
Istodax 1 Kit In 1 Carton
5
Y N Y 25%N25%NNAN
Itraconazole 100mg 30 Capsule In 1 Bottle
4
120 30 Y N Y 32%N33%NNAN
Ixiaro 6ug/.5mL 1 Syringe In 1 Package
3
N N Y $27N$47NNAN



Medicare Help's Additional Notes:

Coverage Levels for S5921-383

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1.Pre-Deductable: Before you reach the plans deductible of $400. Some plans offer select Pre-deductible drug Coverage
2.Initial Coverage: (ICL) After you reach the plans deductible but before the Initial Coverage limit of $3700
3.Coverage Gap: (AKA Donut Hole) After you reach the plans ICL but before the Catastrophic of $4950 in 2017.
4.Catastrophic: Anything over $4950 you will receive a significant increase in coverage.

Definitions:

Premium: A monthly flat fee that varies by plan.
Deductible: The amount you must pay each year for your prescriptions before your plan begins to pay its share of your covered drugs. The max in 2017 is $320. Some plans have a $0 Deductible.
Tier Level: Medicare drug plans place drugs into different "tiers" on their formularies. Drugs in each tier have a different cost. A drug in a lower tier will generally cost you less.
Quantity Limit Amount/Days: Certain drugs have a Quantity Limit. That means the plan will only cover the drug up to a designated quantity or amount. If your prescribing doctor feels it is necessary to exceed the set limit, he or she must get prior approval before the higher quantity will be covered.
Prior Authorization: Certain Drugs require you or your doctor to get prior authorization in order to be covered. Usually just an additional form. If you dont get approval, the plan may not cover the drug.
Does the Deduct Apply: Some drugs do not require that the deductible is met before you receive coverage.
Step Therapy: Means you must first try one drug to treat your medical condition before the plan will cover another drug for the same condition. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.
Cost Prefered: Your Cost for the Drug at the Providers In Network Prefered Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Non Pref: Your Cost for the Prescription Drug at a Non-Prefered Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Mail: Your Cost for Prescription Drugs through a Mail Order Pharmacy. As a Percent of the total drug cost or a flat rate.


What if a drug I need is not listed?

Please check the formulary for different brand and generic names. If you still cannot locate your drugs, your plan may not offer coverage. Talk to your doctor first about changing your prescription to a drug on your plans formulary. If this is not an option, you can request an exception to have the plan review its coverage decision based on your individual circumstances.

Source:CMS Formulary Data Oct. 2016
Source:NDC Directory by FDA.gov

**We make every attempt to keep our information accurate. But please check with the plan providers to verify all information.