2020 Medicare Prescription Drug Plan Cost-Sharing Details

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2020 Medicare Prescription Drug
Formulary (Drug List) Cost-Sharing Details
Cigna-HealthSpring Rx Secure-Extra (PDP) (S5617-256-0)
Benefit Details        
This plan is available in CMS PDP Region 11
Monthly Premium: $65.30
Rx Deductible: $100
Initial Coverage Limit: $4,020 Qualifies for LIS: No


Click on a letter below to view the
Cigna-HealthSpring Rx Secure-Extra (PDP) Formulary
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This Plan Uses Lower Cost-Sharing for Preferred Pharmacies
  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: $4.00(E) $15.00(E) $4.00(E) $12.00(E) $45.00(E) $0.00(E)
Tier 2: Generic: $10.00(E) $20.00(E) $10.00(E) $30.00(E) $60.00(E) $20.00(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: $2.00(E) $11.00(E) $2.00(E) $6.00(E) $33.00(E) $4.00(E)
Initial Coverage Phase Cost-Sharing
Tier 1: Preferred Generic: $4.00 $15.00 $4.00 $12.00 $45.00 $0.00
Tier 2: Generic: $10.00 $20.00 $10.00 $30.00 $60.00 $20.00
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: $2.00 $11.00 $2.00 $6.00 $33.00 $4.00
Coverage Gap (Donut Hole) Phase Cost Sharing
75% 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) $15.00(A) $4.00(A) $12.00(A) $45.00(A) $0.00(A)
Tier 2: Generic: $10.00(A) $20.00(A) $10.00(A) $30.00(A) $60.00(A) $20.00(A)
All Formulary Generic Drugs: 25% 25% 25% 25% 25% 25%
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 $3.60 The greater of 5% or $3.60
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): The greater of 5% or $8.95 The greater of 5% or $8.95
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) 2020 Formulary Browser by choosing a letter below:
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