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2010 Medicare Part D Plan (PDP Only) Formulary Browser

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CIGNA Medicare Rx Plan Three (PDP) (S5617-185-0)
Tier 1 (1625)
Tier 2 (1172)
Tier 3 (667)
Tier 4 (384)

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Uses Step Therapy:
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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 Three (PDP) (S5617-185-0)
Benefit Details  
The CIGNA Medicare Rx Plan Three (PDP) (S5617-185-0)
Formulary Drugs Starting with the Letter A

in CMS PDP Region 15 which includes: IN KY
Drugs Starting with Letter A

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
A METHAPRED METHLYPREDNISOLONE SODIUM SUCCINATE FOR INJECTION 125 MG   1 Tier 1 $6.00$15.00P
A-HYDROCORT 100MG VIAL   1 Tier 1 $6.00$15.00P
A-METHAPRED 40MG UNIVIAL   1 Tier 1 $6.00$15.00P
ABELCENT INJECTION SUSPENSION 5MG/ML   4 Tier 4 33%33%P
ABILIFY 10MG TABLET   3 Tier 3 $60.00$150.00P Q:30
/30Days
ABILIFY 15MG TABLET   3 Tier 3 $60.00$150.00P Q:30
/30Days
ABILIFY 1MG/ML SOLUTION   3 Tier 3 $60.00$150.00P Q:900
/30Days
ABILIFY 20MG TABLET   3 Tier 3 $60.00$150.00P Q:30
/30Days
ABILIFY 2MG TABLET   3 Tier 3 $60.00$150.00P Q:30
/30Days
ABILIFY 30MG TABLET   3 Tier 3 $60.00$150.00P Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ABILIFY 5MG TABLET (OTSUKA)   3 Tier 3 $60.00$150.00P Q:30
/30Days
ABILIFY DISCMELT 10MG TABLET   3 Tier 3 $60.00$150.00P Q:60
/30Days
ABILIFY DISCMELT 15MG TABLET   3 Tier 3 $60.00$150.00P Q:60
/30Days
ABILIFY INJ 9.75MG   3 Tier 3 $60.00$150.00P
ABRAXANE 100MG VIAL   4 Tier 4 33%33%P
ACARBOSE 100MG TABLET S   1 Tier 1 $6.00$15.00None
ACARBOSE 25MG TABLET S   1 Tier 1 $6.00$15.00None
ACARBOSE 50MG TABLET S   1 Tier 1 $6.00$15.00None
ACCOLATE 10MG TABLET   3 Tier 3 $60.00$150.00None
ACCOLATE 20MG TABLET   3 Tier 3 $60.00$150.00None
ACEBUTOLOL 200MG CAPSULE   1 Tier 1 $6.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACEBUTOLOL 400MG CAPSULE   1 Tier 1 $6.00$15.00None
ACEON 2MG TABLET   2 Tier 2 $35.00$87.50None
ACEON 4MG TABLET   2 Tier 2 $35.00$87.50None
ACEON 8MG TABLET   2 Tier 2 $35.00$87.50None
ACETADOTE 200MG/ML VIAL   2 Tier 2 $35.00$87.50P
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD   1 Tier 1 $6.00$15.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT)   1 Tier 1 $6.00$15.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT)   1 Tier 1 $6.00$15.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)   1 Tier 1 $6.00$15.00None
ACETASOL HC OTIC SOLUTION   1 Tier 1 $6.00$15.00None
ACETASOL HC SOLUTION 10ML 10 ML BOT   1 Tier 1 $6.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETAZOLAMIDE 125MG TABLET   1 Tier 1 $6.00$15.00None
ACETAZOLAMIDE 250MG TABLET (100 CT)   1 Tier 1 $6.00$15.00None
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT   2 Tier 2 $35.00$87.50None
ACETAZOLAMIDE SOD 500MG VL   1 Tier 1 $6.00$15.00None
ACETIC ACID 2% SOLUTION NON-ORAL   1 Tier 1 $6.00$15.00None
ACETIC ACID IN AQUEOUS ALUMINUM ACETATE OTIC SOLUTION 2% 60 ML BOT   1 Tier 1 $6.00$15.00None
ACETYLCYSTEINE 10% VIAL   1 Tier 1 $6.00$15.00None
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN   1 Tier 1 $6.00$15.00None
ACIPHEX 20MG TABLET EC   3 Tier 3 $60.00$150.00S Q:30
/30Days
ACTHIB VACCINE VIAL 10-24UNT/5ML   2 Tier 2 $35.00$87.50None
ACTICIN 5% CREAM   1 Tier 1 $6.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACTIMMUNE SOLUTION FOR INJECTION 100MCG   4 Tier 4 33%33%P
ACTIVELLA 0.5-0.1MG TABLET 28 DLPK   3 Tier 3 $60.00$150.00None
ACTIVELLA 1-0.5MG TABLET 28 DLPK   3 Tier 3 $60.00$150.00None
ACTONEL 30MG TABLET   3 Tier 3 $60.00$150.00S Q:30
/30Days
ACTONEL 35MG TABLET   3 Tier 3 $60.00$150.00S Q:4
/28Days
ACTONEL 5MG TABLET   3 Tier 3 $60.00$150.00S Q:30
/30Days
ACTONEL 75MG TABLET   3 Tier 3 $60.00$150.00S Q:2
/30Days
ACTONEL WITH CALCIUM TABLET   3 Tier 3 $60.00$150.00S Q:28
/28Days
ACTOPLUS MET 15MG/500MG TABLET   2 Tier 2 $35.00$87.50Q:90
/30Days
ACTOPLUS MET 15MG/850MG TABLET   2 Tier 2 $35.00$87.50Q:90
/30Days
ACTOS 15MG TABLET   2 Tier 2 $35.00$87.50Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACTOS 30MG TABLET (500 CT)   2 Tier 2 $35.00$87.50Q:30
/30Days
ACTOS 45MG TABLET   2 Tier 2 $35.00$87.50Q:30
/30Days
ACULAR 0.5% EYE DROPS   3 Tier 3 $60.00$150.00None
ACULAR LS 0.4% OPHTH SOL   3 Tier 3 $60.00$150.00None
ACYCLOVIR 200MG CAPSULE (1000 CT)   1 Tier 1 $6.00$15.00None
ACYCLOVIR 200MG/5ML SUSP   2 Tier 2 $35.00$87.50None
ACYCLOVIR 400MG TABLET (100 CT)   1 Tier 1 $6.00$15.00None
ACYCLOVIR SODIUM 500MG VIAL   2 Tier 2 $35.00$87.50P
ACYCLOVIR TABLET USP 800MG (100 CT)   1 Tier 1 $6.00$15.00None
ADACEL VIAL 2UNT/5UNT   2 Tier 2 $35.00$87.50None
ADAGEN 250U/ML VIAL   4 Tier 4 33%33%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADCIRCA TABLETS 20MG 60 BOT   4 Tier 4 33%33%P Q:60
/30Days
ADDERALL XR 10MG CAPSULE SA   3 Tier 3 $60.00$150.00Q:30
/30Days
ADDERALL XR 15MG CAPSULE SA   3 Tier 3 $60.00$150.00Q:30
/30Days
ADDERALL XR 20MG CAPSULE SA   3 Tier 3 $60.00$150.00Q:60
/30Days
ADDERALL XR 25MG CAPSULE SA   3 Tier 3 $60.00$150.00Q:60
/30Days
ADDERALL XR 30MG CAPSULE SA   3 Tier 3 $60.00$150.00Q:60
/30Days
ADDERALL XR 5MG CAPSULE SA   3 Tier 3 $60.00$150.00Q:30
/30Days
ADVAIR DISKU MIS 100/50   2 Tier 2 $35.00$87.50None
ADVAIR DISKU MIS 250/50   2 Tier 2 $35.00$87.50None
ADVAIR DISKU MIS 500/50   2 Tier 2 $35.00$87.50None
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL   2 Tier 2 $35.00$87.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADVAIR HFA INHALER 230;21MCG;MCG   2 Tier 2 $35.00$87.50None
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL   2 Tier 2 $35.00$87.50None
ADVICOR ER 20-750MG TABLET (90 CT)   3 Tier 3 $60.00$150.00Q:30
/30Days
ADVICOR EXTENDED RELEASE TABLETS 20;1000MG;MG 90 BOTPL   3 Tier 3 $60.00$150.00Q:30
/30Days
ADVICOR EXTENDED RELEASE TABLETS 20;500MG;MG 90 BOTPL   3 Tier 3 $60.00$150.00Q:30
/30Days
ADVICOR EXTENDED RELEASE TABLETS 40;1000MG;MG 90 BOTPL   3 Tier 3 $60.00$150.00Q:30
/30Days
AFEDITAB CR 30MG TABLET SA   1 Tier 1 $6.00$15.00None
AFEDITAB CR 60MG TABLET SA   1 Tier 1 $6.00$15.00None
AGGRENOX 25-200MG CAPSULE   3 Tier 3 $60.00$150.00Q:60
/30Days
AK-CON 0.1% EYE DROPS   1 Tier 1 $6.00$15.00None
AK-POLY-BAC EYE OINTMENT 500UNT/1000UNT   1 Tier 1 $6.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AKNE-MYCIN 2% OINTMENT   2 Tier 2 $35.00$87.50None
AKTOB 0.3% EYE DROPS   1 Tier 1 $6.00$15.00None
ALA-CORT 1% CREAM   1 Tier 1 $6.00$15.00None
ALA-CORT 1% LOTION   1 Tier 1 $6.00$15.00None
ALA-SCALP HP 2% LOTION   2 Tier 2 $35.00$87.50None
ALAMAST 0.1% DROPS   3 Tier 3 $60.00$150.00None
ALBENZA 200MG TABLET   2 Tier 2 $35.00$87.50None
ALBUTEROL SULFATE 0.63MG/3ML VIAL NEBULIZER   1 Tier 1 $6.00$15.00P
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   1 Tier 1 $6.00$15.00P
ALBUTEROL SULFATE 2.5MG/3ML VIAL NEBULIZER   1 Tier 1 $6.00$15.00P
ALBUTEROL SULFATE 4MG TABLET SR 12HR   1 Tier 1 $6.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALBUTEROL SULFATE 8MG TABLET SR 12HR   1 Tier 1 $6.00$15.00None
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   1 Tier 1 $6.00$15.00P
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT   1 Tier 1 $6.00$15.00None
ALBUTEROL SULFATE TABLET 2MG (500 CT)   1 Tier 1 $6.00$15.00None
ALBUTEROL TABLET 4MG (500 CT)   1 Tier 1 $6.00$15.00None
ALCLOMETASONE DIPROPIONATE 0.05% CREAM   1 Tier 1 $6.00$15.00None
ALCLOMETASONE DIPROPIONATE 0.05% OINTMENT   1 Tier 1 $6.00$15.00None
ALCOHOL 5%/DEXTROSE 5%   2 Tier 2 $35.00$87.50P
ALDARA IMIQUIMOD CREAM 5% 24 PKT X 250 MG CRTN   2 Tier 2 $35.00$87.50None
ALDURAZYME 2.9MG/5ML VIAL   4 Tier 4 33%33%P
ALENDRONATE SODIUM 10MG TABLET   1 Tier 1 $6.00$15.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALENDRONATE SODIUM 40MG TABLET   1 Tier 1 $6.00$15.00Q:30
/30Days
ALENDRONATE SODIUM 5MG TABLET   1 Tier 1 $6.00$15.00Q:30
/30Days
ALENDRONATE SODIUM 70MG TABLET 4 BLPK   1 Tier 1 $6.00$15.00Q:4
/28Days
ALENDRONATE SODIUM TABLET 35MG 20 CRTN   1 Tier 1 $6.00$15.00Q:4
/28Days
ALFERON N INJ 5MU/ML   4 Tier 4 33%33%P
ALIMTA 500MG VIAL   4 Tier 4 33%33%P
ALINIA 100MG/5ML SUSPENSION   3 Tier 3 $60.00$150.00None
ALINIA 500MG TABLET   3 Tier 3 $60.00$150.00None
ALKERAN FOR INJECTION 50MG/VIAL 1 VIALSU   4 Tier 4 33%33%P
ALLEGRA-D 12 HOUR TABLET 60-120MG (500 CT)   3 Tier 3 $60.00$150.00S Q:60
/30Days
ALLEGRA-D 24 HOUR TABLET   3 Tier 3 $60.00$150.00S Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALLOPURINOL SODIUM 500MG VIAL   2 Tier 2 $35.00$87.50None
ALLOPURINOL TABLET 300MG (1000 CT)   1 Tier 1 $6.00$15.00None
ALLOPURINOL TABLET USP 100MG (1000 CT)   1 Tier 1 $6.00$15.00None
ALOCRIL 2% EYE DROPS   3 Tier 3 $60.00$150.00None
ALOMIDE 0.1% EYE DROPS   3 Tier 3 $60.00$150.00None
ALOPRIM SOLUTION FOR INJECTION 500MG/VIAL 30 ML VIALGL   2 Tier 2 $35.00$87.50P
ALORA 0.025MG PATCH   2 Tier 2 $35.00$87.50Q:8
/28Days
ALORA 0.05MG PATCH   2 Tier 2 $35.00$87.50Q:8
/28Days
ALORA 0.075MG PATCH   2 Tier 2 $35.00$87.50Q:8
/28Days
ALORA 0.1MG PATCH   2 Tier 2 $35.00$87.50Q:8
/28Days
ALOXI 0.25MG/5ML   4 Tier 4 33%33%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALPHAGAN P 0.1% DROPS   2 Tier 2 $35.00$87.50None
ALPHAGAN P 0.15% EYE DROPS   2 Tier 2 $35.00$87.50None
ALREX 0.2% EYE DROPS   3 Tier 3 $60.00$150.00None
ALTABAX 1% OINTMENT   3 Tier 3 $60.00$150.00None
AMANTADINE 100MG CAPSULE   1 Tier 1 $6.00$15.00None
AMANTADINE 100MG TABLET   1 Tier 1 $6.00$15.00None
AMBIEN CR 12.5MG TABLET   3 Tier 3 $60.00$150.00S Q:30
/30Days
AMBIEN CR 6.25MG TABLET   3 Tier 3 $60.00$150.00S Q:30
/30Days
AMBISOME 50MG VIAL   4 Tier 4 33%33%P
AMCINONIDE 0.1% CREAM   1 Tier 1 $6.00$15.00None
AMCINONIDE 0.1% LOTION   1 Tier 1 $6.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMCINONIDE 0.1% OINTMENT 60GM TUBE   1 Tier 1 $6.00$15.00None
AMERGE 1MG TABLET   3 Tier 3 $60.00$150.00S Q:18
/30Days
AMERGE 2.5MG TABLET   3 Tier 3 $60.00$150.00S Q:9
/30Days
AMEVIVE ADMISTRATION PACK FOR INTRAMUSCULAR ADMINISTRATION KIT 15MG 1 X 4 PKGCOM   4 Tier 4 33%33%P
AMIFOSTINE FOR INJECTION 500MG/VIAL   4 Tier 4 33%33%P
AMIKACIN 250MG/ML VIAL   1 Tier 1 $6.00$15.00None
AMIKACIN 50MG/ML VIAL   1 Tier 1 $6.00$15.00None
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET   1 Tier 1 $6.00$15.00None
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT   1 Tier 1 $6.00$15.00None
AMINESS 5.2% IV SOLUTION   2 Tier 2 $35.00$87.50P
AMINOPHYLLINE 100MG TABLET   1 Tier 1 $6.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOPHYLLINE 200MG TABLET (1000 CT)   1 Tier 1 $6.00$15.00None
AMINOPHYLLINE INJECTION 250MG 10ML X 25 VIALSD   1 Tier 1 $6.00$15.00None
AMINOSYN 10% IV SOLUTION   2 Tier 2 $35.00$87.50P
AMINOSYN 3.5% IV SOLUTION   2 Tier 2 $35.00$87.50P
AMINOSYN 5% IV SOLUTION   2 Tier 2 $35.00$87.50P
AMINOSYN 7% IV SOLUTION   2 Tier 2 $35.00$87.50P
AMINOSYN 7%-ELECTROLYTE SOL   2 Tier 2 $35.00$87.50P
AMINOSYN 8.5% IV SOLUTION   2 Tier 2 $35.00$87.50P
AMINOSYN II 10% IV SOLUTION   2 Tier 2 $35.00$87.50P
AMINOSYN II 15% IV SOLUTION   2 Tier 2 $35.00$87.50P
AMINOSYN II 3.5% IN D25W IV   2 Tier 2 $35.00$87.50P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN II 3.5% M/D5W IV   2 Tier 2 $35.00$87.50P
AMINOSYN II 3.5% W/ELEC DEX   2 Tier 2 $35.00$87.50P
AMINOSYN II 4.25% IN D10W   2 Tier 2 $35.00$87.50P
AMINOSYN II 4.25% IN D20W   2 Tier 2 $35.00$87.50P
AMINOSYN II 4.25% W/ELEC DW   2 Tier 2 $35.00$87.50P
AMINOSYN II 4.25%-D25W IV   2 Tier 2 $35.00$87.50P
AMINOSYN II 5% IN D25W IV   2 Tier 2 $35.00$87.50P
AMINOSYN II 7% IV SOLUTION   2 Tier 2 $35.00$87.50P
AMINOSYN II 8.5% ELECTROLYT   2 Tier 2 $35.00$87.50P
AMINOSYN II 8.5% IV SOLUTION   2 Tier 2 $35.00$87.50P
AMINOSYN M 3.5% IV SOLUTION   2 Tier 2 $35.00$87.50P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN PF INJECTION   2 Tier 2 $35.00$87.50P
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5%   2 Tier 2 $35.00$87.50P
AMINOSYN-HBC 7% IV SOLUTION   2 Tier 2 $35.00$87.50P
AMINOSYN-HF 8% IV SOLUTION   2 Tier 2 $35.00$87.50P
AMINOSYN-PF 7% IV SOLUTION   2 Tier 2 $35.00$87.50P
AMIODARONE HCL 200MG TABLET (60 CT)   1 Tier 1 $6.00$15.00None
AMIODARONE HCL 400MG TABLET   1 Tier 1 $6.00$15.00None
AMIODARONE HCL INJECTION   1 Tier 1 $6.00$15.00None
AMITIZA 8MCG CAPSULE   3 Tier 3 $60.00$150.00Q:60
/30Days
AMITIZA CAPSULES 24MCG 60 CAP BOT   3 Tier 3 $60.00$150.00Q:60
/30Days
AMITRIP/CDP 25-10 TABLET   1 Tier 1 $6.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIP/PERPHEN 10-2 TABLET   1 Tier 1 $6.00$15.00None
AMITRIP/PERPHEN 10-4 TABLET   1 Tier 1 $6.00$15.00None
AMITRIP/PERPHEN 25-2 TABLET   1 Tier 1 $6.00$15.00None
AMITRIP/PERPHEN 25-4 TABLET   1 Tier 1 $6.00$15.00None
AMITRIP/PERPHEN 50-4 TABLET   1 Tier 1 $6.00$15.00None
AMITRIPTYLINE HCL 100MG TABLET   1 Tier 1 $6.00$15.00None
AMITRIPTYLINE HCL 10MG TABLET   1 Tier 1 $6.00$15.00None
AMITRIPTYLINE HCL 150MG TABLET (100 CT)   1 Tier 1 $6.00$15.00None
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)   1 Tier 1 $6.00$15.00None
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)   1 Tier 1 $6.00$15.00None
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT   1 Tier 1 $6.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE BESYLATE 10MG TABLET (90 CT)   1 Tier 1 $6.00$15.00None
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)   1 Tier 1 $6.00$15.00None
AMLODIPINE BESYLATE 5MG TABLET (90 CT)   1 Tier 1 $6.00$15.00None
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE   2 Tier 2 $35.00$87.50None
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE   2 Tier 2 $35.00$87.50None
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE   2 Tier 2 $35.00$87.50None
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE   2 Tier 2 $35.00$87.50None
AMMONIUM CHLORIDE 5 MEQ/ML   2 Tier 2 $35.00$87.50P
AMMONIUM LACTATE 12% CREAM   1 Tier 1 $6.00$15.00None
AMMONIUM LACTATE 12% LOTION   1 Tier 1 $6.00$15.00None
AMNESTEEM 10MG CAPSULE   2 Tier 2 $35.00$87.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMNESTEEM 20MG CAPSULE   2 Tier 2 $35.00$87.50None
AMNESTEEM 40MG CAPSULE   2 Tier 2 $35.00$87.50None
AMOCLAN 200-28.5/5 SUSPENSION RECONSTITUTED ORAL   1 Tier 1 $6.00$15.00None
AMOCLAN 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   1 Tier 1 $6.00$15.00None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL   1 Tier 1 $6.00$15.00None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE   1 Tier 1 $6.00$15.00None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET   1 Tier 1 $6.00$15.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE   1 Tier 1 $6.00$15.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   1 Tier 1 $6.00$15.00None
AMOX TR-POTASSIUM CLAVULANATE 500-125MG TABLET   1 Tier 1 $6.00$15.00None
AMOXAPINE 100MG TABLET   1 Tier 1 $6.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXAPINE 150MG TABLET   1 Tier 1 $6.00$15.00None
AMOXAPINE 25MG TABLET   1 Tier 1 $6.00$15.00None
AMOXAPINE 50MG TABLET   1 Tier 1 $6.00$15.00None
AMOXICILLIN 125MG TABLET CHEW   1 Tier 1 $6.00$15.00None
AMOXICILLIN 200MG TABLET CHEW   1 Tier 1 $6.00$15.00None
AMOXICILLIN 250MG CAPSULE   1 Tier 1 $6.00$15.00None
AMOXICILLIN 400MG TABLET CHEW   1 Tier 1 $6.00$15.00None
AMOXICILLIN 500MG CAPSULE   1 Tier 1 $6.00$15.00None
AMOXICILLIN 500MG TABLET (100 CT)   1 Tier 1 $6.00$15.00None
AMOXICILLIN 875MG TABLET   1 Tier 1 $6.00$15.00None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT   1 Tier 1 $6.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT   1 Tier 1 $6.00$15.00None
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT   1 Tier 1 $6.00$15.00None
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL   1 Tier 1 $6.00$15.00None
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   1 Tier 1 $6.00$15.00None
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL   1 Tier 1 $6.00$15.00None
AMOXICILLIN TABLET USP CHEWABLE 250MG (250 CT)   1 Tier 1 $6.00$15.00None
AMOXIL 250MG/5ML SUSPENSION   1 Tier 1 $6.00$15.00None
AMOXIL 400MG/5ML SUSPENSION   1 Tier 1 $6.00$15.00None
AMOXIL CAPSULES 500MG   1 Tier 1 $6.00$15.00None
AMPHET ASP/ AMPHET/ D-AMPHET 5MG TABLET   1 Tier 1 $6.00$15.00None
AMPHETAMINE SALT COMBO 12.5MG TABLET   1 Tier 1 $6.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPHETAMINE SALT COMBO 15MG TABLET   1 Tier 1 $6.00$15.00None
AMPHETAMINE SALT COMBO 30MG TABLET   1 Tier 1 $6.00$15.00None
AMPHETAMINE SALT COMBO 7.5MG TABLET   1 Tier 1 $6.00$15.00None
AMPHETAMINE SALTS 20MG TABLET   1 Tier 1 $6.00$15.00None
AMPHOTEC INJ 50MG   3 Tier 3 $60.00$150.00P
AMPHOTERICIN B FOR INJECTION 50 MG   2 Tier 2 $35.00$87.50P
AMPICILLIN AND SULBACTAM FOR INJECTION 10-5 1 VIAL   2 Tier 2 $35.00$87.50None
AMPICILLIN AND SULBACTAM FOR INJECTION 2-1 10 VIAL   2 Tier 2 $35.00$87.50None
AMPICILLIN CAPSULES 250MG 100 BOT   1 Tier 1 $6.00$15.00None
AMPICILLIN CAPSULES 500MG 100 BOT   1 Tier 1 $6.00$15.00None
AMPICILLIN FOR INJECTION POWDER   2 Tier 2 $35.00$87.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPICILLIN FOR INJECTION USP 125MG/ML 1 VIAL   2 Tier 2 $35.00$87.50None
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT   1 Tier 1 $6.00$15.00None
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT   1 Tier 1 $6.00$15.00None
AMPICILLIN POWDER FOR INJECTION 1 GM/ML   2 Tier 2 $35.00$87.50None
ANADROL-50 50MG TABLET (100 CT)   2 Tier 2 $35.00$87.50None
ANAGRELIDE HCL 0.5MG CAPSULE   1 Tier 1 $6.00$15.00P
ANAGRELIDE HCL 1MG CAPSULE   1 Tier 1 $6.00$15.00P
ANCOBON 250MG CAPSULE   4 Tier 4 33%33%None
ANCOBON 500MG CAPSULE   4 Tier 4 33%33%None
ANDRODERM 2.5MG/24HR PATCH   2 Tier 2 $35.00$87.50None
ANDRODERM 5MG/24HR PATCH   2 Tier 2 $35.00$87.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANDROGEL 1%(50MG) GEL PACKET   2 Tier 2 $35.00$87.50None
ANGELIQ 1-0.5MG TABLET   3 Tier 3 $60.00$150.00None
ANTABUSE 250MG TABLET   2 Tier 2 $35.00$87.50None
ANTABUSE 500MG TABLET   2 Tier 2 $35.00$87.50None
ANTIZOL INJECTION 1GM 4 X 1.5ML VIAL CRTN   4 Tier 4 33%33%P
ANZEMET 100MG TABLET   3 Tier 3 $60.00$150.00P Q:5
/30Days
ANZEMET 20MG/ML VIAL   3 Tier 3 $60.00$150.00P
ANZEMET 50MG TABLET   3 Tier 3 $60.00$150.00P Q:5
/30Days
APHTHASOL 5% PASTE   3 Tier 3 $60.00$150.00None
APIDRA 100UNITS/ML VIAL   2 Tier 2 $35.00$87.50None
APLENZIN TABLETS EXTENDED RELEASE 348 MG   3 Tier 3 $60.00$150.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
APLENZIN TABLETS EXTENDED RELEASE 522 MG   3 Tier 3 $60.00$150.00Q:30
/30Days
APOKYN FOR INJECTION 30MG 5 CTG   4 Tier 4 33%33%P
APRI 0.15-0.03 TABLET   1 Tier 1 $6.00$15.00None
APTIVUS 250MG CAPSULE   4 Tier 4 33%33%None
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT   4 Tier 4 33%33%None
ARALAST 500MG VIAL   4 Tier 4 33%33%P
ARANELLE 7-9-5 TABLET   1 Tier 1 $6.00$15.00None
ARANESP 100MCG/ML VIAL   4 Tier 4 33%33%P
ARANESP 200MCG/0.4ML SYRINGE   4 Tier 4 33%33%P
ARANESP 200MCG/ML VIAL   4 Tier 4 33%33%P
ARANESP 25MCG/ML VIAL   2 Tier 2 $35.00$87.50P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP 300MCG/ML VIAL   4 Tier 4 33%33%P
ARANESP 500MCG/1ML SYRINGE   4 Tier 4 33%33%P
ARANESP 60MCG/ML VIAL   4 Tier 4 33%33%P
ARANESP PREFILLED SYRINGE SINGLE USE 100MCG/0.5ML 1 SYR   4 Tier 4 33%33%P
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR   4 Tier 4 33%33%P
ARANESP PREFILLED SYRINGE SINGLE USE 25MCG/0.42ML SYR   2 Tier 2 $35.00$87.50P
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR   4 Tier 4 33%33%P
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR   4 Tier 4 33%33%P
ARANESP PREFILLED SYRINGE SINGLE USE 60MCG/0.3ML 60MCG/ 0.3ML SYR   4 Tier 4 33%33%P
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD   4 Tier 4 33%33%P
ARAVA 10MG TABLET   3 Tier 3 $60.00$150.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARAVA 20MG TABLET   3 Tier 3 $60.00$150.00P
ARCALYST INJECTION 220MG/VIAL   4 Tier 4 33%33%P
ARICEPT 10MG TABLET   2 Tier 2 $35.00$87.50Q:30
/30Days
ARICEPT 5MG TABLET   2 Tier 2 $35.00$87.50Q:30
/30Days
ARICEPT ODT 10MG TABLET   2 Tier 2 $35.00$87.50Q:30
/30Days
ARICEPT ODT 5MG TABLET   2 Tier 2 $35.00$87.50Q:30
/30Days
ARIMIDEX 1MG TABLET   2 Tier 2 $35.00$87.50Q:30
/30Days
ARIXTRA 10MG SYRINGE   2 Tier 2 $35.00$87.50Q:24
/365Days
ARIXTRA 2.5MG SYRINGE   2 Tier 2 $35.00$87.50Q:32
/365Days
ARIXTRA 5MG SYRINGE   2 Tier 2 $35.00$87.50Q:12
/365Days
ARIXTRA 7.5MG SYRINGE   2 Tier 2 $35.00$87.50Q:18
/365Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AROMASIN 25MG TABLET   3 Tier 3 $60.00$150.00None
ARRANON 250MG VIAL   4 Tier 4 33%33%P
ARTHROTEC 50 50MG TABLET -200MCG (60 CT)   3 Tier 3 $60.00$150.00None
ARTHROTEC 75 TABLET EC   3 Tier 3 $60.00$150.00None
ASACOL 400MG TABLET EC   3 Tier 3 $60.00$150.00S
ASACOL HD DELAYED RELEASE TABLETS 800MG 180 BOT   3 Tier 3 $60.00$150.00S
ASCOMP W/CODEINE 30-50-325 CAPSULE   1 Tier 1 $6.00$15.00None
ASMANEX 220MCG(14) AEROSOL POWDER BREATH ACTIVATED   2 Tier 2 $35.00$87.50None
ASMANEX TWISTHALER 220MCG #120   2 Tier 2 $35.00$87.50None
ASMANEX TWISTHALER 220MCG #30   2 Tier 2 $35.00$87.50None
ASMANEX TWISTHALER 220MCG #60   2 Tier 2 $35.00$87.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ASTELIN 137MCG AEROSOL SPRAY W/PUMP   2 Tier 2 $35.00$87.50None
ASTEPRO NASAL SPRAY 137 MCG/SPRY   2 Tier 2 $35.00$87.50None
ASTRAMORPH-PF 0.5MG/ML VIAL   2 Tier 2 $35.00$87.50P
ASTRAMORPH-PF 1MG/ML VIAL   2 Tier 2 $35.00$87.50P
ATACAND 16MG TABLET   3 Tier 3 $60.00$150.00S Q:30
/30Days
ATACAND 32MG TABLET   3 Tier 3 $60.00$150.00S Q:30
/30Days
ATACAND 4MG TABLET   3 Tier 3 $60.00$150.00S Q:30
/30Days
ATACAND 8MG TABLET   3 Tier 3 $60.00$150.00S Q:30
/30Days
ATACAND HCT 16/12.5MG TABLET   3 Tier 3 $60.00$150.00S Q:30
/30Days
ATACAND HCT 32/12.5MG TABLET   3 Tier 3 $60.00$150.00S Q:30
/30Days
ATACAND HCT TABLETS 32;25MG;MG 90 TABLETS BOT   3 Tier 3 $60.00$150.00S Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATAMET   1 Tier 1 $6.00$15.00None
ATENOLOL 25MG TABLET (100 CT)   1 Tier 1 $6.00$15.00None
ATENOLOL TABLET USP 50MG (100 CT)   1 Tier 1 $6.00$15.00None
ATENOLOL TABLETS USP 100MG 1 BLPK   1 Tier 1 $6.00$15.00None
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT)   1 Tier 1 $6.00$15.00None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   1 Tier 1 $6.00$15.00None
ATGAM 50MG/ML AMPUL   4 Tier 4 33%33%P
ATRIPLA TABLET 600MG/200MG   4 Tier 4 33%33%None
ATROPINE 0.05MG/ML SYRINGE   1 Tier 1 $6.00$15.00None
ATROPINE 0.1MG/ML SYRINGE   1 Tier 1 $6.00$15.00None
ATROVENT HFA AER 17MCG   2 Tier 2 $35.00$87.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATROVENT NASAL SPRAY 0.03%   2 Tier 2 $35.00$87.50None
ATROVENT NASAL SPRAY 0.06%   2 Tier 2 $35.00$87.50None
ATTENUVAX VACCINE W/DILUENT 1 DOSE/0.5ML   2 Tier 2 $35.00$87.50None
AVALIDE 150-12.5MG TABLET   3 Tier 3 $60.00$150.00S Q:30
/30Days
AVALIDE 300-12.5MG TABLET   3 Tier 3 $60.00$150.00S Q:30
/30Days
AVALIDE 300-25MG TABLET   3 Tier 3 $60.00$150.00S Q:30
/30Days
AVANDAMET 2MG/1000MG TABLET   2 Tier 2 $35.00$87.50Q:60
/30Days
AVANDAMET 2MG/500MG TABLET   2 Tier 2 $35.00$87.50Q:60
/30Days
AVANDAMET 4MG/500MG TABLET   2 Tier 2 $35.00$87.50Q:60
/30Days
AVANDAMET TABLET 4-1000MG   2 Tier 2 $35.00$87.50Q:60
/30Days
AVANDARYL 4MG/1MG TABLET   2 Tier 2 $35.00$87.50Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVANDARYL 4MG/2MG TABLET   2 Tier 2 $35.00$87.50Q:60
/30Days
AVANDARYL 4MG/4MG TABLET   2 Tier 2 $35.00$87.50Q:60
/30Days
AVANDARYL 8MG-2MG TABLET   2 Tier 2 $35.00$87.50Q:30
/30Days
AVANDARYL 8MG-4MG TABLET   2 Tier 2 $35.00$87.50Q:30
/30Days
AVANDIA 2MG TABLET   2 Tier 2 $35.00$87.50Q:60
/30Days
AVANDIA 4MG TABLET (90 CT)   2 Tier 2 $35.00$87.50Q:60
/30Days
AVANDIA 8MG TABLET (90 CT)   2 Tier 2 $35.00$87.50Q:30
/30Days
AVAPRO 150MG TABLET   3 Tier 3 $60.00$150.00S Q:30
/30Days
AVAPRO 300MG TABLET   3 Tier 3 $60.00$150.00S Q:30
/30Days
AVAPRO 75MG TABLET (30 CT)   3 Tier 3 $60.00$150.00S Q:30
/30Days
AVASTIN 100MG/4ML VIAL   4 Tier 4 33%33%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVELOX 400MG TABLET   3 Tier 3 $60.00$150.00Q:30
/30Days
AVELOX ABC PACK 400MG TABLET   3 Tier 3 $60.00$150.00Q:30
/30Days
AVELOX IV 400MG/250ML   3 Tier 3 $60.00$150.00None
AVIANE 0.1-0.02 TABLET   1 Tier 1 $6.00$15.00None
AVINZA 120MG CAPSULE MULTIPHASIC RELEASE 24 HR   3 Tier 3 $60.00$150.00S Q:60
/30Days
AVINZA 30MG CAPSULE MULTIPHASIC RELEASE 24 HR   3 Tier 3 $60.00$150.00S Q:60
/30Days
AVINZA 60MG CAPSULE MULTIPHASIC RELEASE 24 HR   3 Tier 3 $60.00$150.00S Q:60
/30Days
AVINZA 90MG CAPSULE MULTIPHASIC RELEASE 24 HR   3 Tier 3 $60.00$150.00S Q:60
/30Days
AVINZA CAPSULES EXTENDED RELEASE 45MG 100 BOTPL   3 Tier 3 $60.00$150.00S Q:60
/30Days
AVINZA CAPSULES EXTENDED RELEASE 75MG 100 BOTPL   3 Tier 3 $60.00$150.00S Q:60
/30Days
AVITA 0.025% CREAM   3 Tier 3 $60.00$150.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVODART 0.5MG SOFTGEL   2 Tier 2 $35.00$87.50Q:30
/30Days
AVONEX ADMIN PACK 30MCG SYR   4 Tier 4 33%33%P
AVONEX ADMIN PACK 30MCG VL   4 Tier 4 33%33%P
AXERT 12.5MG TABLET   3 Tier 3 $60.00$150.00S Q:12
/30Days
AXERT 6.25MG TABLET   3 Tier 3 $60.00$150.00S Q:18
/30Days
AZACTAM 2GM VIAL   4 Tier 4 33%33%None
AZACTAM INJECTION 1GM 50ML BAG   3 Tier 3 $60.00$150.00None
AZACTAM/ISO-OSMOT 2GM/50ML   4 Tier 4 33%33%None
AZASAN 100MG TABLET   2 Tier 2 $35.00$87.50P
AZASAN 75MG TABLET   2 Tier 2 $35.00$87.50P
AZASITE 1% DROPS   2 Tier 2 $35.00$87.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZATHIOPRINE 50MG TABLET   1 Tier 1 $6.00$15.00P
AZATHIOPRINE SOD 100MG VIAL   1 Tier 1 $6.00$15.00P
AZELEX 20% CREAM 30GM TUBE   2 Tier 2 $35.00$87.50None
AZILECT 0.5MG TABLET   2 Tier 2 $35.00$87.50None
AZILECT 1MG TABLET   2 Tier 2 $35.00$87.50None
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Tier 1 $6.00$15.00None
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Tier 1 $6.00$15.00None
AZITHROMYCIN 250MG TABLET (30 CT)   1 Tier 1 $6.00$15.00Q:12
/30Days
AZITHROMYCIN 500MG TABLET (30 CT)   1 Tier 1 $6.00$15.00None
AZITHROMYCIN FOR INJECTION 500MG 10 VIALSD   1 Tier 1 $6.00$15.00None
AZITHROMYCIN TABLET 600MG (30 CT)   1 Tier 1 $6.00$15.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZMACORT INHALATION AEROSOL .1MG/1IHL 20 GM CSTR   3 Tier 3 $60.00$150.00None
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT   2 Tier 2 $35.00$87.50None

Chart Legend:

Below are a few notes to help you understand the above 2010 Medicare Part D CIGNA Medicare Rx Plan Three (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 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 wit 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 which tier the drug is in. 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.







Tips & Disclaimers
  • 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 PDP-Compare.com and MA-Compare.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.
  • 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.