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2009 Medicare Part D Plan (PDP Only) Formulary Browser

This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.
Select your search style and criteria below or use this example to get started
Search Criteria
PDP Plans
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CIGNA Medicare Rx Plan One (S5617-058-0)
Tier 1 (1837)
Tier 2 (1190)
Tier 3 (543)
Tier 4 (483)

Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
Yes No Show either
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Cick on the first letter of your drug name to browse the formulary:

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2009 Medicare Part D Plan Formulary Information
CIGNA Medicare Rx Plan One (S5617-058-0)
Benefit Details  
The CIGNA Medicare Rx Plan One (S5617-058-0)
Formulary Drugs Starting with the Letter C

in CMS PDP Region 12 which includes: AL TN
Drugs Starting with Letter C

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
CABERGOLINE 0.5MG TABLET   2 Tier 2 $30.00$75.00Q:16
/28Days
CADUET 10MG/10MG TABLET   2 Tier 2 $30.00$75.00Q:30
/30Days
CADUET 10MG/20MG TABLET   2 Tier 2 $30.00$75.00Q:30
/30Days
CADUET 10MG/40MG TABLET   2 Tier 2 $30.00$75.00Q:30
/30Days
CADUET 10MG/80MG TABLET   2 Tier 2 $30.00$75.00Q:30
/30Days
CADUET 2.5MG/10MG TABLET   2 Tier 2 $30.00$75.00Q:30
/30Days
CADUET 2.5MG/20MG TABLET   2 Tier 2 $30.00$75.00Q:30
/30Days
CADUET 2.5MG/40MG TABLET   2 Tier 2 $30.00$75.00Q:30
/30Days
CADUET 5MG/10MG TABLET   2 Tier 2 $30.00$75.00Q:30
/30Days
CADUET 5MG/20MG TABLET   2 Tier 2 $30.00$75.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CADUET 5MG/40MG TABLET   2 Tier 2 $30.00$75.00Q:30
/30Days
CADUET 5MG/80MG TABLET   2 Tier 2 $30.00$75.00Q:30
/30Days
CAFERGOT 1-100MG TABLET   3 Tier 3 $79.00$197.50None
CALCIJEX 1 MCG/ML AMPUL   2 Tier 2 $30.00$75.00P
CALCIPOTRIENE TOPICAL SOLUTION   2 Tier 2 $30.00$75.00None
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY   1 Tier 1 $2.50$6.25None
CALCITRIOL 0.25MCG CAPSULE   1 Tier 1 $2.50$6.25None
CALCITRIOL 0.5MCG CAPSULE   1 Tier 1 $2.50$6.25None
CALCITRIOL 1MCG/ML SOLUTION ORAL   1 Tier 1 $2.50$6.25None
CALCITRIOL 2 MCG/ML VIAL   1 Tier 1 $2.50$6.25None
CALCITRIOL INJECTION SOLUTION 1MCG 50 X 01ML AMP   1 Tier 1 $2.50$6.25None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CALCIUM ACETATE CAPSULE 667 MG   2 Tier 2 $30.00$75.00None
CAMILA 0.35MG TABLET   1 Tier 1 $2.50$6.25None
CAMPATH 30MG/ML VIAL   4 Tier 4 25%25%P
CAMPRAL 333MG DOSE PAK   3 Tier 3 $79.00$197.50None
CAMPTOSAR 20MG/ML VIAL   4 Tier 4 25%25%P
CANASA RECTAL SUPPOSITORIES 1000MG 30 BOX   2 Tier 2 $30.00$75.00None
CANCIDAS IV 50MG VIAL   4 Tier 4 25%25%P
CANCIDAS IV 70MG VIAL   4 Tier 4 25%25%P
CAPASTAT SULFATE 1GM VIAL   2 Tier 2 $30.00$75.00None
CAPTOPRIL 100MG TABLET   1 Tier 1 $2.50$6.25None
CAPTOPRIL 12.5MG TABLET   1 Tier 1 $2.50$6.25None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CAPTOPRIL 25MG TABLET   1 Tier 1 $2.50$6.25None
CAPTOPRIL 50MG TABLET   1 Tier 1 $2.50$6.25None
CAPTOPRIL/HCTZ 25/15 TABLET   1 Tier 1 $2.50$6.25None
CAPTOPRIL/HCTZ 25/25 TABLET   1 Tier 1 $2.50$6.25None
CAPTOPRIL/HCTZ 50/15 TABLET   1 Tier 1 $2.50$6.25None
CAPTOPRIL/HCTZ 50/25 TABLET   1 Tier 1 $2.50$6.25None
CARAC CRE 0.5%   2 Tier 2 $30.00$75.00None
CARAFATE SUCRALFATE 1G TABLET ORAL   3 Tier 3 $79.00$197.50None
CARAFATE SUS 1GM/10ML   3 Tier 3 $79.00$197.50None
CARBAMAZEPINE 100MG/5ML SUSPENSION ORAL   1 Tier 1 $2.50$6.25None
CARBAMAZEPINE TABLET CHEWABLE 100MG (100 CT)   1 Tier 1 $2.50$6.25None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARBAMAZEPINE TABLET USP 200MG (1000 CT)   1 Tier 1 $2.50$6.25None
CARBATROL 100MG CAPSULE SA   3 Tier 3 $79.00$197.50None
CARBATROL 200MG CAPSULE SA   3 Tier 3 $79.00$197.50None
CARBATROL 300MG CAPSULE SA   3 Tier 3 $79.00$197.50None
CARBIDOPA AND LEVEDOPA ORALLY DISINTEGRATING TABLETS 10;100MG;MG 100 BOT   1 Tier 1 $2.50$6.25None
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;100MG;MG 100 BOT   1 Tier 1 $2.50$6.25None
CARBIDOPA AND LEVODOPA ORALLY DISINTEGRATING TABLETS 25;250MG;MG 100 BOT   1 Tier 1 $2.50$6.25None
CARBIDOPA-LEVODOPA 25MG-100MG TABLET SA   1 Tier 1 $2.50$6.25None
CARBIDOPA-LEVODOPA 25MG-100MG TABLET SA   1 Tier 1 $2.50$6.25None
CARBIDOPA-LEVODOPA 25MG-100MG TABLET SA   1 Tier 1 $2.50$6.25None
CARBIDOPA-LEVODOPA 50MG-200MG TABLET SA   1 Tier 1 $2.50$6.25None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARBIDOPA-LEVODOPA 50MG-200MG TABLET SA   1 Tier 1 $2.50$6.25None
CARBIDOPA/LEVO 10/100 TABLET   1 Tier 1 $2.50$6.25None
CARBIDOPA/LEVO 25/100 TABLET   1 Tier 1 $2.50$6.25None
CARBIDOPA/LEVO 25/250 TABLET   1 Tier 1 $2.50$6.25None
CARBINOXAMINE MALEATE SOLUTION 4MG/5ML 16 OZ BOT   1 Tier 1 $2.50$6.25None
CARBINOXAMINE MALEATE TABLETS 4MG 100 BOT   1 Tier 1 $2.50$6.25None
CARBOPLATIN AQUEOUS SOLUTION INJECTION 150MG 15ML VIAL   2 Tier 2 $30.00$75.00P
CARBOPLATIN AQUEOUS SOLUTION INJECTION 50MG 5ML VIAL   2 Tier 2 $30.00$75.00P
CARBOPLATIN INJECTION 10MG 1 X 45ML VIAL   2 Tier 2 $30.00$75.00P
CARBOPLATIN INJECTION AQUEOUS SOLUTION 10MG 1 X 60ML VIAL   2 Tier 2 $30.00$75.00P
CARIMUNE NF 12GM VIAL   4 Tier 4 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARIMUNE NF 1GM VIAL   4 Tier 4 25%25%P
CARIMUNE NF 3GM VIAL   4 Tier 4 25%25%P
CARIMUNE NF 6GM VIAL   4 Tier 4 25%25%P
CARISOPRODOL COMPOUND (CARISOPRODOL/ASPIRIN) 200-325MG TABLET   1 Tier 1 $2.50$6.25None
CARISOPRODOL CPD/CODEINE TABLET   1 Tier 1 $2.50$6.25None
CARISOPRODOL TABLET USP 350MG (100 CT)   1 Tier 1 $2.50$6.25None
carteolol 2.5MG oral TABLET   3 Tier 3 $79.00$197.50None
carteolol 5MG oral TABLET   3 Tier 3 $79.00$197.50None
CARTEOLOL HCL OPHTHALMIC SOLUTION USP 1% 15ML BOT   1 Tier 1 $2.50$6.25None
CARTIA XT 120MG CAPSULE SA   1 Tier 1 $2.50$6.25None
CARTIA XT 180MG CAPSULE SA   1 Tier 1 $2.50$6.25None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CARTIA XT 240MG CAPSULE SA   1 Tier 1 $2.50$6.25None
CARTIA XT 300MG CAPSULE SR 24 HR   1 Tier 1 $2.50$6.25None
CARVEDILOL 12.5MG TABLET (100 CT)   1 Tier 1 $2.50$6.25None
CARVEDILOL 25MG TABLET (500 CT)   1 Tier 1 $2.50$6.25None
CARVEDILOL 3.125MG TABLET (100 CT)   1 Tier 1 $2.50$6.25None
CARVEDILOL 6.25MG TABLET (500 CT)   1 Tier 1 $2.50$6.25None
CASODEX 50MG TABLET   2 Tier 2 $30.00$75.00None
CEDAX 400MG CAPSULE   3 Tier 3 $79.00$197.50None
CEDAX 90MG/5ML SUSPENSION RECONSTITUTED ORAL   3 Tier 3 $79.00$197.50None
CEENU 100MG CAPSULE   2 Tier 2 $30.00$75.00None
CEENU 10MG CAPSULE   2 Tier 2 $30.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEENU 40MG CAPSULE   2 Tier 2 $30.00$75.00None
CEENU PAK DOSEPACK 1 KIT   2 Tier 2 $30.00$75.00None
CEFACLOR 250MG/5ML ORAL SUSP   1 Tier 1 $2.50$6.25None
CEFACLOR 375MG/5ML ORAL SUSP   1 Tier 1 $2.50$6.25None
CEFACLOR CAPSULES USP 250MG (100 CT)   1 Tier 1 $2.50$6.25None
CEFACLOR CAPSULES USP 500MG (100 CT)   1 Tier 1 $2.50$6.25None
CEFACLOR ER 500MG TABLET SR 12HR   1 Tier 1 $2.50$6.25None
CEFACLOR POWDER FOR ORAL SUSPENSION USP 125MG 75ML BOT   1 Tier 1 $2.50$6.25None
CEFADROXIL 1G TABLET   1 Tier 1 $2.50$6.25None
CEFADROXIL 500MG CAPSULE   1 Tier 1 $2.50$6.25None
CEFADROXIL 500MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Tier 1 $2.50$6.25None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFADROXIL FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   1 Tier 1 $2.50$6.25None
CEFAZOLIN 1GM ADD-VAN VIAL   2 Tier 2 $30.00$75.00None
CEFAZOLIN 1GM/D5W BAG   2 Tier 2 $30.00$75.00None
CEFAZOLIN 20GM BULK VIAL   2 Tier 2 $30.00$75.00None
CEFAZOLIN 500MG/D5W BAG   2 Tier 2 $30.00$75.00None
CEFAZOLIN FOR INJECTION   2 Tier 2 $30.00$75.00None
CEFAZOLIN FOR INJECTION 10GM 10 X 10 VIAL   2 Tier 2 $30.00$75.00None
CEFAZOLIN FOR INJECTION 1MG 25 VIALGL   2 Tier 2 $30.00$75.00None
CEFDINIR 250MG/5ML SUSPENSION RECONSTITUTED ORAL   2 Tier 2 $30.00$75.00None
CEFDINIR CAPSULES 300MG (60 CT)   2 Tier 2 $30.00$75.00None
CEFDINIR FOR ORAL SUSPENSION 125MG/5ML (100 CT)   2 Tier 2 $30.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFEPIME HCL 2 GRAM VIAL   2 Tier 2 $30.00$75.00None
CEFEPIME INJ 1GM 20ML APX 10x1G VIAL   2 Tier 2 $30.00$75.00None
CEFIZOX 1GM IN D5W 50ML   3 Tier 3 $79.00$197.50None
CEFIZOX 2GM IN D5W 50ML   4 Tier 4 25%25%None
CEFOTAXIME FOR INJECTION   1 Tier 1 $2.50$6.25None
CEFOTAXIME FOR INJECTION 1GM 50 BOX VIALGL   1 Tier 1 $2.50$6.25None
CEFOTAXIME FOR INJECTION 2GM 25 VIAL   1 Tier 1 $2.50$6.25None
CEFOTAXIME FOR INJECTION 500MG 10 VIAL   1 Tier 1 $2.50$6.25None
CEFOTAXIME SODIUM 20GM VIAL   1 Tier 1 $2.50$6.25None
CEFOTETAN 10 GM SOLR   2 Tier 2 $30.00$75.00None
CEFOTETAN 1GM VIAL 1EA x 10   2 Tier 2 $30.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFOTETAN 2GM VIAL 1EA x 10   2 Tier 2 $30.00$75.00None
CEFOXITIN FOR INJECTION 10GM 10 X 100ML VIAL   2 Tier 2 $30.00$75.00None
CEFOXITIN FOR INJECTION 1GM 25 X 20ML VIAL   2 Tier 2 $30.00$75.00None
CEFOXITIN FOR INJECTION 2GM 20ML VIAL   2 Tier 2 $30.00$75.00None
CEFPODOXIME PROXETIL 200MG TABLET   1 Tier 1 $2.50$6.25None
CEFPODOXIME PROXETIL FILM COATED TABLET 100MG (20 CT)   1 Tier 1 $2.50$6.25None
CEFPODOXIME PROXETIL FOR ORAL SUSPENSION 100MG 50ML BOT   1 Tier 1 $2.50$6.25None
CEFPODOXIME PROXETIL FOR ORAL SUSPENSION 50MG 50ML BOT   1 Tier 1 $2.50$6.25None
CEFPROZIL 250MG TABLET (100 CT)   1 Tier 1 $2.50$6.25None
CEFPROZIL 250MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Tier 1 $2.50$6.25None
CEFPROZIL 500MG TABLET   1 Tier 1 $2.50$6.25None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFPROZIL FOR ORAL SUSPENSION 125MG/5ML 75ML BOT   1 Tier 1 $2.50$6.25None
CEFTIN 125MG/5ML ORAL SUSP   3 Tier 3 $79.00$197.50None
CEFTIN 250MG TABLET   3 Tier 3 $79.00$197.50None
CEFTIN 250MG/5ML ORAL SUSP   3 Tier 3 $79.00$197.50None
CEFTIN 500MG TABLET (20 CT)   3 Tier 3 $79.00$197.50None
CEFTRIAXONE 10GM VIAL   2 Tier 2 $30.00$75.00None
CEFTRIAXONE 1GM PIGGYBACK   2 Tier 2 $30.00$75.00None
CEFTRIAXONE 2GM PIGGYBACK   2 Tier 2 $30.00$75.00None
CEFTRIAXONE FOR INJECTION 1GM 10 VIALSU   2 Tier 2 $30.00$75.00None
CEFTRIAXONE FOR INJECTION 250MG BOX OF 10 VIALGL   2 Tier 2 $30.00$75.00None
CEFTRIAXONE FOR INJECTION 2GM 10 VIALSU   2 Tier 2 $30.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFTRIAXONE FOR INJECTION 500MG BOX OF 10 VIALGL   2 Tier 2 $30.00$75.00None
CEFTRIAXONE FOR INJECTION AND DEXTROSE INJECTION 1 GM/50ML   2 Tier 2 $30.00$75.00None
CEFTRIAXONE FOR INJECTION AND DEXTROSE INJECTION 2 GM/50ML   2 Tier 2 $30.00$75.00None
CEFUROXIME 250MG TABLET   2 Tier 2 $30.00$75.00None
CEFUROXIME AXETIL 125MG/5ML SUSPENSION RECONSTITUTED ORAL   2 Tier 2 $30.00$75.00None
CEFUROXIME AXETIL 250MG/5ML SUSPENSION RECONSTITUTED ORAL   2 Tier 2 $30.00$75.00None
CEFUROXIME AXETIL 500MG TABLET (20 CT)   2 Tier 2 $30.00$75.00None
CEFUROXIME FOR INJECTION   2 Tier 2 $30.00$75.00None
CEFUROXIME FOR INJECTION   2 Tier 2 $30.00$75.00None
CEFUROXIME FOR INJECTION 7.5GM 10 X 7.5 VIALPHR   2 Tier 2 $30.00$75.00None
CEFUROXIME FOR INJECTION AND DEXTROSE INJECTION   2 Tier 2 $30.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEFUROXIME FOR INJECTION AND DEXTROSE INJECTION   2 Tier 2 $30.00$75.00None
CELEBREX 100MG CAPSULE   2 Tier 2 $30.00$75.00Q:60
/30Days
CELEBREX 200MG CAPSULE   2 Tier 2 $30.00$75.00Q:60
/30Days
CELEBREX 400MG CAPSULE   2 Tier 2 $30.00$75.00Q:60
/30Days
CELEBREX 50MG CAPSULE   2 Tier 2 $30.00$75.00Q:60
/30Days
CELLCEPT 200MG/ML ORAL SUSP   4 Tier 4 25%25%P
CELLCEPT 500MG TABLET   4 Tier 4 25%25%P
CELLCEPT CAPSULES 250MG (500 CT)   3 Tier 3 $79.00$197.50P Q:180
/30Days
CELLCEPT IV INJ 500MG   4 Tier 4 25%25%P
CELONTIN 300MG KAPSEAL   2 Tier 2 $30.00$75.00None
CEPHALEXIN 250MG CAPSULE   1 Tier 1 $2.50$6.25None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CEPHALEXIN 250MG TABLET   1 Tier 1 $2.50$6.25None
CEPHALEXIN 250MG/5ML ORAL SUSP   1 Tier 1 $2.50$6.25None
CEPHALEXIN 500MG TABLET   1 Tier 1 $2.50$6.25None
CEPHALEXIN CAPSULES 500MG (500 CT)   1 Tier 1 $2.50$6.25None
CEPHALEXIN POWDER FOR SUSPENSION ORAL USP 125MG 200ML BOT   1 Tier 1 $2.50$6.25None
CEREBYX 50MG/ML INJECTION   2 Tier 2 $30.00$75.00None
CEREDASE 80UNITS/ML VIAL   4 Tier 4 25%25%P
CEREZYME INJ 200UNIT   4 Tier 4 25%25%P
CEREZYME INJ 400UNIT   4 Tier 4 25%25%P
CERUBIDINE 20MG VIAL   3 Tier 3 $79.00$197.50P
CESIA 7 DAYS X 3 TABLET   1 Tier 1 $2.50$6.25None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CHANTIX 0.5MG TABLET   3 Tier 3 $79.00$197.50S
CHANTIX 1MG TABLET   3 Tier 3 $79.00$197.50S
CHANTIX STARTING MONTH PAK   3 Tier 3 $79.00$197.50S
CHEMET 100MG CAPSULE   3 Tier 3 $79.00$197.50None
CHLORAMPHEN NA SUCC 1GM VL   1 Tier 1 $2.50$6.25None
CHLORDIAZEPOXIDE AND AMITRIPTYLINE HCL TABLET 12.5-5MG (500 CT)   1 Tier 1 $2.50$6.25None
CHLORHEXIDINE GLUCONATE 0.12% MOUTHWASH   1 Tier 1 $2.50$6.25None
CHLORHEXIDINE GLUCONATE 0.12% MOUTHWASH   1 Tier 1 $2.50$6.25None
CHLOROQUINE PH 500MG TABLET   1 Tier 1 $2.50$6.25None
CHLOROQUINE PHOSPHATE 250MG TABLET (50 CT)   1 Tier 1 $2.50$6.25None
CHLOROTHIAZIDE 250MG TABLET   1 Tier 1 $2.50$6.25None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CHLOROTHIAZIDE 500MG TABLET   1 Tier 1 $2.50$6.25None
CHLORPROMAZINE 100MG TABLET   1 Tier 1 $2.50$6.25None
CHLORPROMAZINE 10MG TABLET   1 Tier 1 $2.50$6.25P
CHLORPROMAZINE 25MG TABLET   1 Tier 1 $2.50$6.25P
CHLORPROMAZINE 25MG/ML AMP   1 Tier 1 $2.50$6.25None
CHLORPROMAZINE 50MG TABLET   1 Tier 1 $2.50$6.25None
CHLORPROMAZINE HCL 200MG TABLET   1 Tier 1 $2.50$6.25None
CHLORPROPAMIDE 100MG TABLET   1 Tier 1 $2.50$6.25None
CHLORPROPAMIDE 250MG TABLET (1000 CT)   1 Tier 1 $2.50$6.25None
CHLORTHALIDONE 25MG TABLET (100 CT)   1 Tier 1 $2.50$6.25None
CHLORTHALIDONE 50MG TABLET (1000 CT)   1 Tier 1 $2.50$6.25None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CHLORZOXAZONE 250MG TABLET   1 Tier 1 $2.50$6.25None
CHLORZOXAZONE 500MG TABLET   1 Tier 1 $2.50$6.25None
CHOLESTYRAMINE LIGHT ORAL SUSP USP POWDER 4GM 210GM CAN   1 Tier 1 $2.50$6.25None
CHOLESTYRAMINE LIGHT ORAL SUSP USP POWDER 4GM 60 X 5 SINGLE DOSE CRTN   1 Tier 1 $2.50$6.25None
CHOLESTYRAMINE POWDER FOR ORAL SUSPENSION USP 4GM 60 X 9GM SINGLE DOSE CRTN   1 Tier 1 $2.50$6.25None
CHOLESTYRAMINE POWDER FOR ORAL SUSPENSION USP 4GM 378GM CAN   1 Tier 1 $2.50$6.25None
CICLOPIROX 0.77% CREAM   1 Tier 1 $2.50$6.25None
CICLOPIROX 0.77% GEL   1 Tier 1 $2.50$6.25None
CICLOPIROX 0.77% TOPICAL SUSPENSION   1 Tier 1 $2.50$6.25None
CICLOPIROX 8% TOPICAL SOLUTION NAIL LACQUER 6.6ML BOT   1 Tier 1 $2.50$6.25P
CILOSTAZOL 50MG TABLET (60 CT)   1 Tier 1 $2.50$6.25None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CILOSTAZOL TABLET 100MG (60 CT)   1 Tier 1 $2.50$6.25None
CIMETIDINE 150MG/ML VIAL   1 Tier 1 $2.50$6.25None
CIMETIDINE 200MG TABLET   1 Tier 1 $2.50$6.25None
CIMETIDINE HCL 300MG/5ML SOL   1 Tier 1 $2.50$6.25None
CIMETIDINE TABLET USP 300MG (1000 CT)   1 Tier 1 $2.50$6.25None
CIMETIDINE TABLET USP 400MG (1000 CT)   1 Tier 1 $2.50$6.25None
CIMETIDINE TABLET USP 800MG (30 CT)   1 Tier 1 $2.50$6.25None
CIMZIA KIT   4 Tier 4 25%25%P
CIPRO IV 10MG/ML VIAL   3 Tier 3 $79.00$197.50None
CIPRO IV 10MG/ML VIAL   3 Tier 3 $79.00$197.50None
CIPRO IV INFUSION 200MG 100ML BAG   3 Tier 3 $79.00$197.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CIPRO IV INJECTION 400MG 200ML BAG   3 Tier 3 $79.00$197.50None
CIPRODEX OTIC SUSPENSION   2 Tier 2 $30.00$75.00None
CIPROFLOXACIN 10MG/ML VIAL   1 Tier 1 $2.50$6.25None
CIPROFLOXACIN 250MG TABLET (100 CT)   1 Tier 1 $2.50$6.25None
CIPROFLOXACIN 500MG TABLET   1 Tier 1 $2.50$6.25None
CIPROFLOXACIN 750MG TABLET (50 CT)   1 Tier 1 $2.50$6.25None
CIPROFLOXACIN ER 1000MG TABLET (30 CT)   2 Tier 2 $30.00$75.00None
CIPROFLOXACIN ER 500MG TABLET (30 CT)   2 Tier 2 $30.00$75.00None
CIPROFLOXACIN HCL 0.3% DROPS   1 Tier 1 $2.50$6.25None
CIPROFLOXACIN HCL 100MG TABLET   1 Tier 1 $2.50$6.25None
CIPROFLOXACIN INJECTION IN DEXTROSE INJECTION   1 Tier 1 $2.50$6.25None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CIPROFLOXACIN INJECTION IN DEXTROSE INJECTION   1 Tier 1 $2.50$6.25None
CISPLATIN INJECTION 1MG   1 Tier 1 $2.50$6.25P
CITALOPRAM HBR 20MG TABLET (100 CT)   1 Tier 1 $2.50$6.25Q:90
/30Days
CITALOPRAM HBR 40MG TABLET (100 CT)   1 Tier 1 $2.50$6.25Q:30
/30Days
CITALOPRAM HBR ORAL SOLUTION 10MG 240ML BOTPL   1 Tier 1 $2.50$6.25Q:900
/30Days
CITOLOPRAM HBR 10MG TABLET (100 CT)   1 Tier 1 $2.50$6.25Q:30
/30Days
CLADRIBINE 1MG/ML VIAL   4 Tier 4 25%25%P
CLAFORAN 10GM VIAL   2 Tier 2 $30.00$75.00None
CLAFORAN 1GM VIAL   2 Tier 2 $30.00$75.00None
CLAFORAN 1GM/50ML GALAXY   2 Tier 2 $30.00$75.00None
CLAFORAN 2GM ADD-VANTAGE VL   2 Tier 2 $30.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLAFORAN 2GM/50ML GALAXY   2 Tier 2 $30.00$75.00None
CLAFORAN 500MG VIAL   2 Tier 2 $30.00$75.00None
CLAFORAN INJECTION ADD VANTAGE SYSTEM 1GM 25 X 1GM VIAL   2 Tier 2 $30.00$75.00None
CLAFORAN INJECTION STERILE 2GM 10 X 2GM VIAL   2 Tier 2 $30.00$75.00None
CLARAVIS 10MG CAPSULE   2 Tier 2 $30.00$75.00None
CLARAVIS 20MG CAPSULE   2 Tier 2 $30.00$75.00None
CLARAVIS 30MG CAPSULE   2 Tier 2 $30.00$75.00None
CLARAVIS 40MG CAPSULE   2 Tier 2 $30.00$75.00None
CLARITHROMYCIN 250MG TABLET   1 Tier 1 $2.50$6.25None
CLARITHROMYCIN 250MG/5ML. SUS. 100ML   1 Tier 1 $2.50$6.25None
CLARITHROMYCIN 500MG TABLET   1 Tier 1 $2.50$6.25None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLARITHROMYCIN ER 500MG TABLET (60 CT)   1 Tier 1 $2.50$6.25None
CLARITHROMYCIN FOR ORAL SUSPENSION 125/5ML 125MG BOT   1 Tier 1 $2.50$6.25None
CLEMASTINE FUM 2.68MG TABLET   1 Tier 1 $2.50$6.25None
CLEMASTINE FUMARATE 0.67MG/5ML SYRUP   1 Tier 1 $2.50$6.25None
CLEOCIN 300MG/D5W/GALAXY   3 Tier 3 $79.00$197.50None
CLEOCIN 600MG/D5W/GALAXY   3 Tier 3 $79.00$197.50None
CLEOCIN 900MG/D5W/GALAXY   3 Tier 3 $79.00$197.50None
CLEOCIN PHOS 150MG/ML VIAL   3 Tier 3 $79.00$197.50None
CLEOCIN PHOS 150MG/ML VIAL   3 Tier 3 $79.00$197.50None
CLINDAMYCIN 150MG/ML ADDVAN   1 Tier 1 $2.50$6.25None
CLINDAMYCIN HCL 150MG CAPSULE   1 Tier 1 $2.50$6.25None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLINDAMYCIN HCL 300MG CAPS   1 Tier 1 $2.50$6.25None
CLINDAMYCIN INJECTION 150MG/60ML VIAL PHAR CRTN   1 Tier 1 $2.50$6.25None
CLINDAMYCIN PHOSP 1% LOTION   1 Tier 1 $2.50$6.25None
CLINDAMYCIN PHOSPHATE 1% SOLUTION NON-ORAL   1 Tier 1 $2.50$6.25None
CLINDAMYCIN PHOSPHATE 2% CREAM WITH APPLICATOR   1 Tier 1 $2.50$6.25None
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE   1 Tier 1 $2.50$6.25None
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX   1 Tier 1 $2.50$6.25None
CLINIMIX 2.75%/5% INJECTION 1000ML BAG   2 Tier 2 $30.00$75.00P
CLINIMIX 4.25/10 SOLUTION   2 Tier 2 $30.00$75.00P
CLINIMIX 4.25/20 SOLUTION   2 Tier 2 $30.00$75.00P
CLINIMIX 4.25/25 SOLUTION   2 Tier 2 $30.00$75.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLINIMIX 4.25/5 SOLUTION   2 Tier 2 $30.00$75.00P
CLINIMIX 5/15 SOLUTION   2 Tier 2 $30.00$75.00P
CLINIMIX 5/20 SOLUTION   2 Tier 2 $30.00$75.00P
CLINIMIX 5/25 SULFITE FREE INJECTIONS 1035MG-420MEQ 1000ML BAG   2 Tier 2 $30.00$75.00P
CLINIMIX E 2.75/10 SOLUTION   2 Tier 2 $30.00$75.00P
CLINIMIX E 2.75/5 SOLUTION   2 Tier 2 $30.00$75.00P
CLINIMIX E 4.25/25 SOLUTION   2 Tier 2 $30.00$75.00P
CLINIMIX E 4.25/5 SOLUTION   2 Tier 2 $30.00$75.00P
CLINIMIX E 5/20 SOLUTION   2 Tier 2 $30.00$75.00P
CLINIMIX E 5/25 SOLUTION   2 Tier 2 $30.00$75.00P
CLINIMIX E 5/35 SOLUTION   2 Tier 2 $30.00$75.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLINIMIX E 5%/15% INJECTION 2000ML BAG   2 Tier 2 $30.00$75.00P
CLINISOL 15% SOLUTION   2 Tier 2 $30.00$75.00P
CLOBETASOL 0.05% CREAM   1 Tier 1 $2.50$6.25None
CLOBETASOL 0.05% CREAM   1 Tier 1 $2.50$6.25None
CLOBETASOL 0.05% GEL   1 Tier 1 $2.50$6.25None
CLOBETASOL 0.05% OINTMENT   1 Tier 1 $2.50$6.25None
CLOBETASOL 0.05% SOLUTION   1 Tier 1 $2.50$6.25None
CLOBETASOL E 0.05% CREAM   1 Tier 1 $2.50$6.25None
CLOBETASOL PROPIONATE 0.05% FOAM   2 Tier 2 $30.00$75.00None
CLOLAR 1MG/ML VIAL   4 Tier 4 25%25%P
CLOMIPRAMINE HCL 25MG CAPSULE   1 Tier 1 $2.50$6.25None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLOMIPRAMINE HCL 50MG CAPSULE   1 Tier 1 $2.50$6.25None
CLOMIPRAMINE HCL 75MG CAPSULE   1 Tier 1 $2.50$6.25None
CLONIDINE HCL 0.2MG TABLET (500 CT)   1 Tier 1 $2.50$6.25None
CLONIDINE HCL TABLET 0.1MG (500 CT)   1 Tier 1 $2.50$6.25None
CLONIDINE HCL TABLET 0.3MG (100 CT)   1 Tier 1 $2.50$6.25None
CLOTRIMAZOLE 1% CREAM   1 Tier 1 $2.50$6.25None
CLOTRIMAZOLE 10MG TROCHE   1 Tier 1 $2.50$6.25None
CLOTRIMAZOLE 10MG TROCHE   1 Tier 1 $2.50$6.25None
CLOTRIMAZOLE SOLUTION TOPICAL 1% 30ML BOTPL   1 Tier 1 $2.50$6.25None
CLOTRIMAZOLE-BETAMETHASONE 1-0.05% LOTION   1 Tier 1 $2.50$6.25None
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE CREAM USP .5MG-10GM 45GM TUBE   1 Tier 1 $2.50$6.25None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CLOZAPINE 100MG TABLET   2 Tier 2 $30.00$75.00None
CLOZAPINE 200MG TABLET (500 CT)   2 Tier 2 $30.00$75.00None
CLOZAPINE 25MG TABLET (100 CT)   2 Tier 2 $30.00$75.00None
CLOZAPINE 50MG TABLET (500 CT)   2 Tier 2 $30.00$75.00None
CO-GESIC 5/500 TABLET   1 Tier 1 $2.50$6.25None
COGENTIN 1MG/ML AMPUL   3 Tier 3 $79.00$197.50None
COGNEX 10MG CAPSULE   3 Tier 3 $79.00$197.50Q:120
/30Days
COGNEX 20MG CAPSULE   3 Tier 3 $79.00$197.50Q:120
/30Days
COGNEX 30MG CAPSULE   3 Tier 3 $79.00$197.50Q:120
/30Days
COGNEX 40MG CAPSULE   3 Tier 3 $79.00$197.50Q:120
/30Days
COLAZAL 750MG CAPSULE   2 Tier 2 $30.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COLCHICINE TABLET USP 0.6MG (100 CT)   1 Tier 1 $2.50$6.25None
COLESTIPOL HCL 1G TABLET   1 Tier 1 $2.50$6.25None
COLESTIPOL HCL 5G GRANULES   1 Tier 1 $2.50$6.25None
COLESTIPOL HYDROCHLORIDE GRANULE 5GM/SCP 90 PKT   1 Tier 1 $2.50$6.25None
COLISTIMETHATE 150MG VIAL   4 Tier 4 25%25%None
COLLAGENASE SANTYL OINTMENT 250UNT 30GM TUBE   2 Tier 2 $30.00$75.00None
COLOCORT 100MG ENEMA   1 Tier 1 $2.50$6.25None
COLY-MYCIN M 150MG VIAL   4 Tier 4 25%25%None
COLY-MYCIN S EAR DROPS   2 Tier 2 $30.00$75.00None
COMBIGAN 0.2%-0.5% DROPS   2 Tier 2 $30.00$75.00None
COMBIVENT INHALER   2 Tier 2 $30.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COMBIVIR TABLET   4 Tier 4 25%25%None
COMPRO 25MG SUPPOSITORY   1 Tier 1 $2.50$6.25None
COMTAN 200MG TABLET   3 Tier 3 $79.00$197.50None
COMVAX VACCINE VIAL   2 Tier 2 $30.00$75.00None
CONCERTA 18MG TABLET SA   3 Tier 3 $79.00$197.50Q:30
/30Days
CONCERTA 27MG TABLET SA   3 Tier 3 $79.00$197.50Q:30
/30Days
CONCERTA 36MG TABLET SA   3 Tier 3 $79.00$197.50Q:30
/30Days
CONCERTA 54MG TABLET SA   3 Tier 3 $79.00$197.50Q:30
/30Days
CONDYLOX 0.5% GEL   3 Tier 3 $79.00$197.50None
CONDYLOX 0.5% TOPICAL TUBEX   3 Tier 3 $79.00$197.50None
CONSTULOSE 10GM/15ML SYRUP   1 Tier 1 $2.50$6.25None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COPAXONE 20MG INJECTION KIT   4 Tier 4 25%25%P
COPEGUS 200MG TABLET   4 Tier 4 25%25%None
CORMAX 0.05% CREAM   1 Tier 1 $2.50$6.25None
CORMAX 0.05% OINTMENT   1 Tier 1 $2.50$6.25None
CORMAX 0.05% SOLUTION   1 Tier 1 $2.50$6.25None
CORTEF 10MG TABLET   2 Tier 2 $30.00$75.00None
CORTEF 20MG TABLET   2 Tier 2 $30.00$75.00P
CORTEF 5MG TABLET   2 Tier 2 $30.00$75.00P
CORTISONE ACETATE 25MG TABLET (100 CT)   1 Tier 1 $2.50$6.25None
CORTOMYCIN EAR SOLUTION   1 Tier 1 $2.50$6.25None
CORTOMYCIN EAR SUSPENSION   1 Tier 1 $2.50$6.25None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CORZIDE 40-5MG TABLET   3 Tier 3 $79.00$197.50None
CORZIDE 80-5MG TABLET   3 Tier 3 $79.00$197.50None
COSMEGEN 0.5MG VIAL   4 Tier 4 25%25%P
COSOPT PLUS EYE DROPS 22.3 MG/ML 6.8 MG/M   3 Tier 3 $79.00$197.50None
COUMADIN 10MG TABLET   3 Tier 3 $79.00$197.50None
COUMADIN 1MG TABLET   3 Tier 3 $79.00$197.50None
COUMADIN 2.5MG TABLET   3 Tier 3 $79.00$197.50None
COUMADIN 2MG TABLET   3 Tier 3 $79.00$197.50None
COUMADIN 3MG TABLET   3 Tier 3 $79.00$197.50None
COUMADIN 4MG TABLET   3 Tier 3 $79.00$197.50None
COUMADIN 5MG TABLET   3 Tier 3 $79.00$197.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
COUMADIN 5MG VIAL   3 Tier 3 $79.00$197.50None
COUMADIN 6MG TABLET   3 Tier 3 $79.00$197.50None
COUMADIN 7.5MG TABLET   3 Tier 3 $79.00$197.50None
COZAAR 100MG TABLET   2 Tier 2 $30.00$75.00Q:30
/30Days
COZAAR 25MG TABLET (1000 CT)   2 Tier 2 $30.00$75.00Q:30
/30Days
COZAAR 50MG TABLET 10000 BOT   2 Tier 2 $30.00$75.00Q:30
/30Days
CREON 10 CAPSULE EC   2 Tier 2 $30.00$75.00None
CREON 20 CAPSULE SA   2 Tier 2 $30.00$75.00None
CREON 5 CAPSULE EC   2 Tier 2 $30.00$75.00None
CRESTOR 10MG TABLET   2 Tier 2 $30.00$75.00Q:30
/30Days
CRESTOR 20MG TABLET   2 Tier 2 $30.00$75.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CRESTOR 40MG TABLET   2 Tier 2 $30.00$75.00Q:30
/30Days
CRESTOR 5MG TABLET   2 Tier 2 $30.00$75.00Q:30
/30Days
CRIXIVAN 100MG CAPSULE   2 Tier 2 $30.00$75.00None
CRIXIVAN 200MG CAPSULE   2 Tier 2 $30.00$75.00None
CRIXIVAN 333MG CAPSULE   2 Tier 2 $30.00$75.00None
CRIXIVAN 400MG CAPSULE (120 CT)   2 Tier 2 $30.00$75.00None
CROLOM 4% EYE DROPS   1 Tier 1 $2.50$6.25None
CROMOLYN SODIUM 4% 40MG 10ML BOT   1 Tier 1 $2.50$6.25None
CRYSELLE-28 TABLET 28 TABLET S   1 Tier 1 $2.50$6.25None
CUBICIN 500MG VIAL   4 Tier 4 25%25%None
CUPRIMINE 125MG CAPSULE   2 Tier 2 $30.00$75.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CUPRIMINE CAPSULES 250MG (100 CT)   2 Tier 2 $30.00$75.00None
CYCLESSA 28 DAY TABLET   3 Tier 3 $79.00$197.50None
CYCLOBENZAPRINE HCL 10MG TABLET (1000 CT)   1 Tier 1 $2.50$6.25None
CYCLOBENZAPRINE HCL 5MG TABLET (500 CT)   1 Tier 1 $2.50$6.25None
CYCLOPHOSPHAMIDE 1GM VIAL   2 Tier 2 $30.00$75.00P
CYCLOPHOSPHAMIDE 25MG TABLET   2 Tier 2 $30.00$75.00P
CYCLOPHOSPHAMIDE 2GM VIAL   2 Tier 2 $30.00$75.00P
CYCLOPHOSPHAMIDE 500MG VIAL   2 Tier 2 $30.00$75.00P
CYCLOPHOSPHAMIDE 50MG TABLET   2 Tier 2 $30.00$75.00P
CYCLOSPORINE 100MG CAPSULE   2 Tier 2 $30.00$75.00P
CYCLOSPORINE 100MG CAPSULE   2 Tier 2 $30.00$75.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CYCLOSPORINE 100MG/ML SOLUTION ORAL   2 Tier 2 $30.00$75.00P
CYCLOSPORINE 25MG CAPSULE   2 Tier 2 $30.00$75.00P
CYCLOSPORINE 25MG CAPSULE   2 Tier 2 $30.00$75.00P
CYCLOSPORINE 50MG CAPSULE   2 Tier 2 $30.00$75.00P
CYCLOSPORINE 50MG/ML AMP   2 Tier 2 $30.00$75.00P
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT   2 Tier 2 $30.00$75.00P
CYKLOKAPRON 100MG/ML AMPUL   2 Tier 2 $30.00$75.00P
CYMBALTA 20MG CAPSULE   3 Tier 3 $79.00$197.50S Q:60
/30Days
CYMBALTA 60MG CAPSULE   3 Tier 3 $79.00$197.50S Q:30
/30Days
CYMBALTA CAPSULES DELAYED RELEASE 30MG (30 CT)   3 Tier 3 $79.00$197.50S Q:60
/30Days
CYPROHEPTADINE 2MG/5ML SYRUP   1 Tier 1 $2.50$6.25None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CYPROHEPTADINE 4MG TABLET   1 Tier 1 $2.50$6.25None
CYSTADANE POWDER FOR ORAL SOLUTION 180GM   2 Tier 2 $30.00$75.00None
CYSTAGON 150MG CAPSULE   2 Tier 2 $30.00$75.00None
CYSTAGON 50MG CAPSULE   2 Tier 2 $30.00$75.00None
CYTARABINE 100MG VIAL   1 Tier 1 $2.50$6.25P
CYTARABINE 1GM VIAL   1 Tier 1 $2.50$6.25P
CYTARABINE 20MG/ML VIAL   1 Tier 1 $2.50$6.25P
CYTARABINE 2GM VIAL   1 Tier 1 $2.50$6.25P
CYTARABINE 500MG VIAL   1 Tier 1 $2.50$6.25P
CYTARABINE SOLUTION INJECTION 100MG 20ML VIALSD   1 Tier 1 $2.50$6.25P
CYTOMEL 25MCG TABLET   3 Tier 3 $79.00$197.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
CYTOMEL 50MCG TABLET   3 Tier 3 $79.00$197.50None
CYTOMEL 5MCG TABLET   3 Tier 3 $79.00$197.50None
CYTOVENE 500MG VIAL   4 Tier 4 25%25%P
CYTOXAN 1GM VIAL   3 Tier 3 $79.00$197.50P
CYTOXAN 25MG TABLET   3 Tier 3 $79.00$197.50P
CYTOXAN 2GM VIAL   3 Tier 3 $79.00$197.50P
CYTOXAN 500MG VIAL   3 Tier 3 $79.00$197.50P
CYTOXAN 50MG TABLET   3 Tier 3 $79.00$197.50P

Chart Legend:

Below are a few notes to help you understand the above 2009 Medicare Part D CIGNA Medicare Rx Plan One Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region).

  • Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.

  • Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $295 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.

  • Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
    • Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.

    • No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.

  • Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
  • Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
    • Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
    • Drug Description - This is the Medicare Part D plan’s description of this particular drug tier.
  • Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
    • Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the initial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $2700) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2013 Humana Walmart-Preferred Rx Plan the cost-sharing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
    • Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
  • Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
    • None - This drug does not fall under any drug utilization management controls.
    • P - Prior Authorization -This drug is subject to prior authorization.
    • S - Step Therapy -This drug is subject to step therapy.
    • Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.




(Chart Source: Centers for Medicare and Medicaid files: CMS Data October 2009 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.







Tips & Disclaimers
  • Q1Medicare®, Q1Rx®, and Q1Group® are registered Service Marks of Q1Group LLC and may not be used in any advertising, publicity, or for commercial purposes without the express authorization of Q1Group.
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDPCompare.com and MACompare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
    Statement required by Medicare:
    "We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options."
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.