2019 Medicare Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
Cigna-HealthSpring Rx Secure-Extra (PDP) (S5617-257-0) Benefit Details | ||||||
This plan is available in CMS PDP Region 12 which includes: AL TN Monthly Premium: $57.90 Rx Deductible: $100 Initial Coverage Limit: $3,820 Qualifies for LIS: No Click on a letter below to view the Cigna-HealthSpring Rx Secure-Extra (PDP) Formulary 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 0-9 | ||||||
This Plan Uses Lower Cost-Sharing for Preferred Pharmacies | ||||||
30-Day Supply Cost-Sharing |
90-Day Supply Cost-Sharing |
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Preferred Pharmacy | Standard Pharmacy | Mail- Order* | Preferred Pharmacy | Standard Pharmacy | Mail- Order* | |
Initial Deductible Phase Cost Sharing | ||||||
Tier 1: Preferred Generic: | $4.00(E) | $9.00(E) | $4.00(E) | $12.00(E) | $27.00(E) | $10.00(E) |
Tier 2: Generic: | $10.00(E) | $15.00(E) | $10.00(E) | $30.00(E) | $45.00(E) | $25.00(E) |
Tier 3: Preferred Brand: | $42.00(E) | $47.00(E) | $42.00(E) | $126.00(E) | $141.00(E) | $105.00(E) |
Tier 4: Non-Preferred Drug: | 100% | 100% | 100% | 100% | 100% | 100% |
Tier 5: Specialty Tier: | 100% | 100% | 100% | 100% | 100% | 100% |
Tier 6: Select Care Drugs: | $6.00(E) | $11.00(E) | $6.00(E) | $18.00(E) | $33.00(E) | $15.00(E) |
Initial Coverage Phase Cost-Sharing | ||||||
Tier 1: Preferred Generic: | $4.00 | $9.00 | $4.00 | $12.00 | $27.00 | $10.00 |
Tier 2: Generic: | $10.00 | $15.00 | $10.00 | $30.00 | $45.00 | $25.00 |
Tier 3: Preferred Brand: | $42.00 | $47.00 | $42.00 | $126.00 | $141.00 | $105.00 |
Tier 4: Non-Preferred Drug: | 50% | 50% | 50% | 50% | 50% | 50% |
Tier 5: Specialty Tier: | 31% | 31% | 31% | n/a | n/a | n/a |
Tier 6: Select Care Drugs: | $6.00 | $11.00 | $6.00 | $18.00 | $33.00 | $15.00 |
Coverage Gap (Donut Hole) Phase Cost Sharing 63% Generic and 75% Brand Donut Hole Discount applies to all drugs even those with coverage in the gap | ||||||
Tier 1: Preferred Generic: | $4.00(A) | $9.00(A) | $4.00(A) | $12.00(A) | $27.00(A) | $10.00(A) |
Tier 2: Generic: | $10.00(A) | $15.00(A) | $10.00(A) | $30.00(A) | $45.00(A) | $25.00(A) |
All Formulary Generic Drugs: | 37% | 37% | 37% | 37% | 37% | 37% |
All Formulary Brand-Name Drugs: | 25% | 25% | 25% | 25% | 25% | 25% |
Catastrophic Coverage Phase Cost Sharing | ||||||
Generic & Preferred Multi-Source Drugs: | The greater of 5% or $3.40 | The greater of 5% or $3.40 | ||||
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): | The greater of 5% or $8.50 | The greater of 5% or $8.50 | ||||
Notes: *The mail-order cost-sharing is the plan’s "preferred" mail-order cost-sharing. (E) Drugs on this tier are excluded from the Initial Deductible and do not count toward meeting the deductible. (A) Coverage Gap cost-sharing applies to all drugs on the designated tier. Drugs that are covered in the coverage gap also receive the donut hole discount. (P) Coverage Gap cost-sharing applies to only some of drugs on the designated drug tier. Drugs that are covered in the coverage gap also receive the donut hole discount. | ||||||
Go to the Cigna-HealthSpring Rx Secure-Extra (PDP) 2019 Formulary Browser by choosing a letter below: 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 0-9 |