Aetna Medicare Value (PPO) Formulary



Below is the 2023 Formulary, or prescription drug list, from Aetna Medicare Value (PPO) by Aetna Life Insurance Company. A formulary is a continually updated list of available medications and prescription drug cost information. Examining a plans formulary can help you find a Wisconsin Medicare Part-C plan that covers your prescriptions. It also helps you compare costs among Medicare Part D and Medicare Advantage plans available to you. You’ll want to make sure the medicines you are currently taking are covered under any plans you are considering enrolling in.

This Aetna Medicare Value (PPO)(H5521-387) plan has a $200 drug deductible. A 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 $4660. 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 $4660 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 25% 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" by clicking the "Coverage Gap" link above the chart.

In 2023 if you have spent $7400 in expenditures you enter the Catastrophic Phase. During the Catastrophic Period you will begin to receive significant coverage. Aetna Life Insurance Company 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 above the chart.



Plan Overview

Plan Name:Aetna Medicare Value
Plan ID: H5521-387
Provider: Aetna Life Insurance Company
Plan Year:2023
Premium:$0.00
Deductible:$200
Initial Coverage Limit:$4660
Coverage Area:Wisconsin
Similar Plan:H5521-388


Change Table Options:

Drugs Starting Letter:
Coverage Phase:

*Tip Click the Drug name to Compare Coverage and Retail Cost for Every Plan In Your Area
⇅ Click the Header to Sort
Drug
Name⇅
Tier
Level
Deductible
Apply
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Abacavir
4Y$100$100$100NN
Abacavir And Lamivudine
4Y$100$100$100NN
Abelcet
4Y$100$100$100YN
Abilify Maintena
529%29%29%1/28NN
Abiraterone
529%29%29%YN
Abiraterone Acetate
529%29%29%YN
Acarbose
2N$10$20$1090/30NN
Accutane
4Y$100$100$100YN
Acebutolol Hydrochloride
2N$10$20$10NN
Acetaminophen And Codeine Phosphate
2N$10$20$102700/30NN
Acetazolamide
4Y$100$100$100NN
Acetic Acid
2N$10$20$10NN
Acetylcysteine
2N$10$20$10YN
Acitretin
4Y$100$100$100YN
Acthib
3N$47$47$47NN
Actimmune
529%29%29%YN
Acyclovir
2N$10$20$10NN
Acyclovir Sodium
4Y$100$100$100YN
Adefovir Dipivoxil
4Y$100$100$10030/30NN
Adempas
529%29%29%90/30YN
Advair
3N$47$47$4760/30NN
Advair Hfa
3N$47$47$4712/30NN
Aimovig
3N$47$47$471/30YN
Alacort
2N$10$20$10NN
Albendazole
529%29%29%NN
Albuterol Sulfate
2N$10$20$1013/30NN
Alclometasone Dipropionate
4Y$100$100$100NN
Alecensa
529%29%29%240/30YN
Alendronate Sodium
1N$0$15$04/28NN
Aliskiren
4Y$100$100$100NN
Alosetron Hydrochloride
529%29%29%60/30YN
Alprazolam
4Y$100$100$100NN
Altavera
2N$10$20$10NN
Alunbrig
529%29%29%YN
Alyacen 1/35
2N$10$20$10NN
Alyq
529%29%29%YN
Amabelz
4Y$100$100$100NN
Amantadine Hydrochloride
2N$10$20$10120/30NN
Amethia
2N$10$20$10NN
Amikacin Sulfate
4Y$100$100$100NN
Amiloride Hydrochloride And Hydrochlorothiazide
2N$10$20$10NN
Amiloride Hydrocloride
2N$10$20$10NN
Amiodarone Hydrochloride
2N$10$20$10NN
Amitriptyline Hydrochloride
3N$47$47$47YN
Amlodipine And Benazepril Hydrochloride
1N$0$15$030/30NN
Amlodipine And Olmesartan Medoxomil
1N$0$15$030/30NN
Amlodipine And Valsartan
1N$0$15$030/30NN
Amlodipine Besylate
1N$0$15$0NN
Amlodipine Besylate And Benazepril Hydrochloride
1N$0$15$030/30NN
Ammonium Lactate
2N$10$20$10NN
Amnesteem
4Y$100$100$100YN
Amoxapine
3N$47$47$47NN
Amoxicillin
1N$0$15$0NN
Amoxicillin And Clavulanate Potassium
2N$10$20$10NN
Amphotericin B
4Y$100$100$100YN
Ampicillin
4Y$100$100$100NN
Ampicillin And Sulbactam
4Y$100$100$100NN
Ampicillin Sodium And Sulbactam Sodium
4Y$100$100$100NN
Anagrelide
2N$10$20$10NN
Anastrozole
2N$10$20$10NN
Aprepitant
4Y$100$100$100YN
Apri
2N$10$20$10NN
Aptivus
529%29%29%NN
Aranelle
2N$10$20$10NN
Aripiprazole
529%29%29%60/30NN
Aristada
529%29%29%3/56NN
Aristada Initio
529%29%29%NN
Armodafinil
4Y$100$100$10030/30YN
Arnuity Ellipta
3N$47$47$4730/30NN
Asenapine
4Y$100$100$10060/30NN
Ashlyna
2N$10$20$10NN
Atenolol And Chlorthalidone
2N$10$20$10NN
Atomoxetine
4Y$100$100$10030/30NN
Atovaquone
529%29%29%YN
Atovaquone And Proguanil Hydrochloride Pediatric
4Y$100$100$100NN
Atrovent
4Y$100$100$10025/30NN
Aubra Eq
2N$10$20$10NN
Austedo
529%29%29%120/30YN
Aviane
2N$10$20$10NN
Avonex
529%29%29%1/28YN
Ayvakit
529%29%29%30/30YN
Azathioprine
2N$10$20$10YN
Azelaic Acid
4Y$100$100$10050/30NN
Azelastine Hcl Nasal
2N$10$20$1030/25NN
Azelastine Hydrochloride
2N$10$20$1030/25NN
Azithromycin
4Y$100$100$100NN
Aztreonam
4Y$100$100$100NN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H5521-387

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $200. 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 $4660
3. Coverage Gap: (AKA Donut Hole) After you reach the plans ICL but before the Catastrophic of $7400 in 2023.
4. Catastrophic: Anything over $7400 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 2023 is $505. 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 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 Preferred: Your Cost for the Drug at the Providers In-Network Preferred Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Non-Preferred: Your Cost for the Prescription Drug at a Non-Preferred 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 plan's 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.

Last updated on

Source:CMS Formulary Data Q4 2022
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.

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