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2010 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.
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CIGNA Medicare Rx Plan One (PDP) (S5617-148-0)
Tier 1 (1513)
Tier 2 (1117)
Tier 3 (445)
Tier 4 (383)

Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
Yes No Show either
  *required
 
Cick on the first letter of your drug name to browse the 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 
2010 Medicare Part D Plan Formulary Information
CIGNA Medicare Rx Plan One (PDP) (S5617-148-0)
Benefit Details  
The CIGNA Medicare Rx Plan One (PDP) (S5617-148-0)
Formulary Drugs Starting with the Letter I

in CMS PDP Region 30 which includes: OR WA
Drugs Starting with Letter I

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
IBUPROFEN 100MG/5ML SUSP   1 Tier 1 $3.00$7.50None
IBUPROFEN TABLET 400MG 1 BLPK   1 Tier 1 $3.00$7.50None
IBUPROFEN TABLETS 600MG 90 BOT   1 Tier 1 $3.00$7.50None
IBUPROFEN TABLETS USP 800MG 10 X 10 BOXUD   1 Tier 1 $3.00$7.50None
IDAMYCIN PFS 1MG/ML VIAL   4 Tier 4 25%25%P
IDARUBICIN HCL 1MG/ML VIAL   4 Tier 4 25%25%P
IFEX INJECTION 3GM/ML 3GM VIALSD   3 Tier 3 $78.00$195.00P
IFOSFAMIDE 1GM VIAL   1 Tier 1 $3.00$7.50P
IFOSFAMIDE/MESNA KIT 1G/20ML / 1MG/   4 Tier 4 25%25%P
IFOSFAMIDE/MESNA KIT 1G/20ML / 1MG/   4 Tier 4 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
IMIPRAMINE HCL 10MG TABLET (100 CT)   1 Tier 1 $3.00$7.50None
IMIPRAMINE HCL 25MG TABLET (100 CT)   1 Tier 1 $3.00$7.50None
IMIPRAMINE HCL 50MG TABLET (100 CT)   1 Tier 1 $3.00$7.50None
IMIPRAMINE PAMOATE 100MG CAPSULE   2 Tier 2 $31.00$77.50None
IMIPRAMINE PAMOATE 125MG CAPSULE   2 Tier 2 $31.00$77.50None
IMIPRAMINE PAMOATE 150MG CAPSULE   2 Tier 2 $31.00$77.50None
IMIPRAMINE PAMOATE 75MG CAPSULE   2 Tier 2 $31.00$77.50None
IMOVAX RABIES VACCINE 2.5UNT/ML   2 Tier 2 $31.00$77.50None
IMURAN 50MG TABLET   3 Tier 3 $78.00$195.00P
INCRELEX 40MG/4ML VIAL   4 Tier 4 25%25%P
INDAPAMIDE 1.25MG TABLET USP (1000 CT)   1 Tier 1 $3.00$7.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
INDAPAMIDE 2.5MG TABLET USP (1000 CT)   1 Tier 1 $3.00$7.50None
INDOMETHACIN 25MG CAPSULE   1 Tier 1 $3.00$7.50None
INDOMETHACIN 50MG CAPSULE   1 Tier 1 $3.00$7.50None
INDOMETHACIN 75MG CAPSULE SA   1 Tier 1 $3.00$7.50None
INFANRIX VACCINE VIAL 25-10UNT/.5ML   2 Tier 2 $31.00$77.50None
INFERGEN SOLUTION FOR INJECTION 15MCG/0.5ML   4 Tier 4 25%25%P
INFUMORPH 10MG/ML AMPUL P/F   3 Tier 3 $78.00$195.00P
INFUMORPH 25MG/ML AMPUL P/F   3 Tier 3 $78.00$195.00P
INNOHEP 20000UNIT/ML VIAL   3 Tier 3 $78.00$195.00Q:26
/365Days
INNOPRAN XL (PROPRANOLOL HCL) 120MG CAPSULE SR 24 HR   3 Tier 3 $78.00$195.00None
INNOPRAN XL (PROPRANOLOL HCL) 80MG CAPSULE SR 24 HR   3 Tier 3 $78.00$195.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
INSPRA 25MG TABLET   3 Tier 3 $78.00$195.00None
INSPRA 50MG TABLET   3 Tier 3 $78.00$195.00None
INTAL INH AER 800MCG   2 Tier 2 $31.00$77.50None
INTELENCE 100MG TABLET   4 Tier 4 25%25%None
INTRALIPID 20% IV FAT EMUL   2 Tier 2 $31.00$77.50P
INTRALIPID PHARMACY BULK PACKAGE FAT EMULSION 1.7-1.2-30GM 500ML BAG   2 Tier 2 $31.00$77.50P
INTRON A 10MMU INJ PEN   4 Tier 4 25%25%P
INTRON A 10MMU VIAL   4 Tier 4 25%25%P
INTRON A 3MMU INJECTION PEN   2 Tier 2 $31.00$77.50P
INTRON A 5MMU MULTIDOSE PEN   4 Tier 4 25%25%P
INTRON A 6MMU/ML VIAL   4 Tier 4 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
INVANZ 1GM VIAL   3 Tier 3 $78.00$195.00None
INVEGA 3MG TABLET SR OSMOTIC PUSH 24HR   3 Tier 3 $78.00$195.00S Q:30
/30Days
INVEGA 6MG TABLET SR OSMOTIC PUSH 24HR   3 Tier 3 $78.00$195.00S Q:60
/30Days
INVEGA 9MG TABLET SR OSMOTIC PUSH 24HR   3 Tier 3 $78.00$195.00S Q:30
/30Days
INVIRASE 200MG CAPSULE   4 Tier 4 25%25%None
INVIRASE 500MG TABLET   4 Tier 4 25%25%None
IONOSOL B-D5W IV SOLUTION   2 Tier 2 $31.00$77.50P
IONOSOL MB-D5W IV SOLUTION   2 Tier 2 $31.00$77.50P
IONOSOL T-D5W IV SOLUTION   2 Tier 2 $31.00$77.50P
IOPIDINE 0.5% EYE DROPS   2 Tier 2 $31.00$77.50None
IOPIDINE 1% EYE DROPS   2 Tier 2 $31.00$77.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
IPOL VIAL 40;8;32; UNT   2 Tier 2 $31.00$77.50None
IPRATROPIUM BROMIDE 21MCG AEROSOL SPRAY   1 Tier 1 $3.00$7.50None
IPRATROPIUM BROMIDE 42MCG AEROSOL SPRAY   1 Tier 1 $3.00$7.50None
IPRATROPIUM BROMIDE INHALATION SOLUTION 0.02% 60 X 2.5ML VIALSD   1 Tier 1 $3.00$7.50P
IQUIX 1.5% DROPS   2 Tier 2 $31.00$77.50None
IRESSA 250MG TABLET   4 Tier 4 25%25%P
IRINOTECAN HCL INJECTION 20MG   4 Tier 4 25%25%P
ISENTRESS 400MG TABLET   4 Tier 4 25%25%None
ISOLYTE H IN 5% DEXTROSE   2 Tier 2 $31.00$77.50P
ISOLYTE M IN 5% DEXTROSE INJECTION   2 Tier 2 $31.00$77.50P
ISOLYTE P IN 5% DEXTROSE INJECTION   2 Tier 2 $31.00$77.50P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ISOLYTE S IN 5% DEXTROSE INJECTION   2 Tier 2 $31.00$77.50P
ISOLYTE S SOLUTION FOR INJECTION   2 Tier 2 $31.00$77.50P
ISONARIF 300-150MG CAPSULE   1 Tier 1 $3.00$7.50None
ISONIAZID 100MG TABLET   1 Tier 1 $3.00$7.50None
ISONIAZID 300MG TABLET   1 Tier 1 $3.00$7.50None
ISONIAZID 50MG/5ML SYRUP   1 Tier 1 $3.00$7.50None
ISONIAZID INJ 100MG/ML   1 Tier 1 $3.00$7.50None
ISOSORBIDE DN 10MG TABLET   1 Tier 1 $3.00$7.50None
ISOSORBIDE DN 2.5MG TABLET SL   1 Tier 1 $3.00$7.50None
ISOSORBIDE DN 20MG TABLET   1 Tier 1 $3.00$7.50None
ISOSORBIDE DN 30MG TABLET   1 Tier 1 $3.00$7.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ISOSORBIDE DN 40MG TABLET SA   1 Tier 1 $3.00$7.50None
ISOSORBIDE DN 5MG TABLET   1 Tier 1 $3.00$7.50None
ISOSORBIDE DN 5MG TABLET SL   1 Tier 1 $3.00$7.50None
ISOSORBIDE MN 10MG TABLET   1 Tier 1 $3.00$7.50None
ISOSORBIDE MONONITRATE ER TABLET 120MG (100 CT)   1 Tier 1 $3.00$7.50None
ISOSORBIDE MONONITRATE ER TABLET 30MG (100 CT)   1 Tier 1 $3.00$7.50None
ISOSORBIDE MONONITRATE TABLETS 20MG 100 TABLETS BOT   1 Tier 1 $3.00$7.50None
ISOSORBIDE MONONITRATE TABLETS EXTENDED RELEASE 60MG 100 TABLETS BOT   1 Tier 1 $3.00$7.50None
ISOTON GENTAMICIN 60MG/100ML   2 Tier 2 $31.00$77.50None
ISOTON GENTAMICIN 80MG/100ML   2 Tier 2 $31.00$77.50None
ISRADIPINE CAPSULES 2.5MG (100 CT)   1 Tier 1 $3.00$7.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ISRADIPINE CAPSULES 5MG (100 CT)   1 Tier 1 $3.00$7.50None
ISTALOL 0.5% EYE DROPS   3 Tier 3 $78.00$195.00None
ITRACONAZOLE 100MG CAPSULE   3 Tier 3 $78.00$195.00P
IV BUSULFEX 6MG 1 X 10ML VIALGL   2 Tier 2 $31.00$77.50P
IXEMPRA KIT 45MG   4 Tier 4 25%25%P

Chart Legend:

Below are a few notes to help you understand the above 2010 Medicare Part D CIGNA Medicare Rx Plan One (PDP) 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 $310 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 $2830) 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 2010 )

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.







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  • 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.
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  • 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.