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2013 Medicare Prescription Drug Plan Cost-Sharing Details

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2013 Medicare Prescription Drug
Formulary (Drug List) Cost-Sharing Details
Cigna Medicare Rx Plan One (PDP) (S5617-003-0)
Benefit Details        
This plan is available in CMS PDP Region 01
which includes: ME NH

Click on a letter below to view the
Cigna Medicare Rx Plan One (PDP) Formulary
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  30-Day Supply
Cost-Sharing
90-Day Supply
Cost-Sharing
Preferred Pharmacy Standard Pharmacy Mail- Order* Preferred Pharmacy Standard Pharmacy Mail- Order*
Initial Deductible Phase Cost Sharing
Tier 1: Preferred Generic Drugs: $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
Tier 2: Non-Preferred Generic Drugs: $8.00 $8.00 $8.00 $24.00 $24.00 $20.00
Tier 3: Preferred Brand Drugs: 100% 100% 100% 100% 100% 100%
Tier 4: Non-Preferred Brand Drugs: 100% 100% 100% 100% 100% 100%
Tier 5: Specialty Tier: 100% 100% 100% 100% 100% 100%
Initial Coverage Phase Cost-Sharing
Tier 1: Preferred Generic Drugs: $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
Tier 2: Non-Preferred Generic Drugs: $8.00 $8.00 $8.00 $24.00 $24.00 $20.00
Tier 3: Preferred Brand Drugs: $25.00 $25.00 $25.00 $75.00 $75.00 $62.50
Tier 4: Non-Preferred Brand Drugs: $87.00 $87.00 $87.00 $261.00 $261.00 $217.50
Tier 5: Specialty Tier: 25% 25% 25% 25% 25% 25%
Coverage Gap (Donut Hole) Phase Cost Sharing
Plan offers no Gap Coverage -- 21% Generic and 52.5% Brand Donut Hole Discount applies
All Formulary Generic Drugs: 79% 79% 79% 79% 79% 79%
All Formulary Brand-Name Drugs: 47.5% 47.5% 47.5% 47.5% 47.5% 47.5%
Catastrophic Coverage Phase Cost Sharing
Generic & Preferred Multi-Source Drugs: The greater of 5% or $2.65 The greater of 5% or $2.65
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): The greater of 5% or $6.60 The greater of 5% or $6.60
Go to the Cigna Medicare Rx Plan One (PDP) 2013 Formulary Browser by choosing a letter below:
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