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CIGNA Medicare Rx Plan Two (PDP) (S5617-202-0)
Tier 1 (170)
Tier 2 (1309)
Tier 3 (1123)
Tier 4 (446)
Tier 5 (405)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
Yes No Show either
Cick on the first letter of your drug name to browse the formulary:

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2011 Medicare Part D Plan Formulary Information
CIGNA Medicare Rx Plan Two (PDP) (S5617-202-0)
Benefit Details           
The CIGNA Medicare Rx Plan Two (PDP) (S5617-202-0)
Formulary Drugs Starting with the Letter I
in CMS PDP Region 32 which includes: CA
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 Preferred Generic $0.00$0.00None
IBUPROFEN 600 MG ORAL TABLET   1 Preferred Generic $0.00$0.00None
IBUPROFEN 800 MG TABLET   1 Preferred Generic $0.00$0.00None
IBUPROFEN TABLETS   1 Preferred Generic $0.00$0.00None
IDAMYCIN PFS 1MG/ML VIAL   5 Specialty Tier 33%33%P
IDARUBICIN HCL 1MG/ML VIAL   5 Specialty Tier 33%33%P
IFEX INJECTION 3GM/ML 3GM VIALSD   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00P
IFOSFAMIDE FOR INFECTION 1 GM   2 Preferred Generic/Preferred Brand $3.00$7.50P
IFOSFAMIDE/MESNA KIT 1G/20ML / 1MG/   5 Specialty Tier 33%33%P
IFOSFAMIDE/MESNA KIT 1G/20ML / 1MG/   5 Specialty Tier 33%33%P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ILOPERIDONE 1 MG ORAL TABLET [FANAPT]   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00P Q:60
/30Days
ILOPERIDONE 10 MG ORAL TABLET [FANAPT]   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00P Q:60
/30Days
ILOPERIDONE 12 MG ORAL TABLET [FANAPT]   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00P Q:60
/30Days
ILOPERIDONE 2 MG ORAL TABLET [FANAPT]   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00P Q:60
/30Days
ILOPERIDONE 4 MG ORAL TABLET [FANAPT]   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00P Q:60
/30Days
ILOPERIDONE 6 MG ORAL TABLET [FANAPT]   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00P Q:60
/30Days
ILOPERIDONE 8 MG ORAL TABLET [FANAPT]   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00P Q:60
/30Days
IMIPRAMINE HCL 10MG TABLET (100 CT)   2 Preferred Generic/Preferred Brand $3.00$7.50None
IMIPRAMINE HCL 25MG TABLET (100 CT)   2 Preferred Generic/Preferred Brand $3.00$7.50None
IMIPRAMINE HCL 50MG TABLET (100 CT)   2 Preferred Generic/Preferred Brand $3.00$7.50None
IMIPRAMINE PAMOATE CAPSULES   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
IMIPRAMINE PAMOATE CAPSULES   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
IMIPRAMINE PAMOATE CAPSULES   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
IMIPRAMINE PAMOATE CAPSULES   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
IMIQUIMOD 5% CREAM   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
IMOVAX RABIES VACCINE 2.5UNT/ML   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
IMURAN 50MG TABLET   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00P
INCRELEX 40MG/4ML VIAL   5 Specialty Tier 33%33%P
INDAPAMIDE 1.25MG TABLET USP (1000 CT)   1 Preferred Generic $0.00$0.00None
INDAPAMIDE 2.5MG TABLET USP (1000 CT)   1 Preferred Generic $0.00$0.00None
INDOMETHACIN 50MG CAPSULE   1 Preferred Generic $0.00$0.00None
INDOMETHACIN 75MG CAPSULE SA   1 Preferred Generic $0.00$0.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
INDOMETHACIN CAPSULES   1 Preferred Generic $0.00$0.00None
INFERGEN INJECTION   5 Specialty Tier 33%33%P
INFUMORPH 10MG/ML AMPUL P/F   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00P
INFUMORPH 25MG/ML AMPUL P/F   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00P
INNOPRAN CAPSULES EXTENDED RELEASE 120 MG   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
INNOPRAN CAPSULES EXTENDED RELEASE 80 MG   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
INSULIN, GLULISINE, HUMAN 100 UNT/ML PREFILLED SYRINGE [APIDRA] 3 ML   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
INTELENCE 100MG TABLET   5 Specialty Tier 33%33%None
INTERFERON BETA-1B 0.25 MG/ML INJECTABLE SOLUTION [EXTAVIA]   5 Specialty Tier 33%33%P
INTRALIPID 20% IV FAT EMUL   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
INTRALIPID PHARMACY BULK PACKAGE FAT EMULSION 1.7-1.2-30GM 500ML BAG   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
INTRON A 10MMU INJ PEN   5 Specialty Tier 33%33%P
INTRON A 10MMU VIAL   5 Specialty Tier 33%33%P
INTRON A 3MMU INJECTION PEN   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
INTRON A 5MMU MULTIDOSE PEN   5 Specialty Tier 33%33%P
INTRON A 6MMU/ML VIAL   5 Specialty Tier 33%33%P
INVANZ 1GM VIAL   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
INVEGA 3MG TABLET SR OSMOTIC PUSH 24HR   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00P Q:30
/30Days
INVEGA 6MG TABLET SR OSMOTIC PUSH 24HR   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00P Q:60
/30Days
INVEGA 9MG TABLET SR OSMOTIC PUSH 24HR   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00P Q:30
/30Days
INVIRASE 200MG CAPSULE   5 Specialty Tier 33%33%None
INVIRASE 500MG TABLET   5 Specialty Tier 33%33%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
IONOSOL B-D5W IV SOLUTION   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
IONOSOL MB-D5W IV SOLUTION   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
IONOSOL T-D5W IV SOLUTION   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
IOPIDINE 0.5% EYE DROPS   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
IOPIDINE 1% EYE DROPS   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
IPOL VIAL 40;8;32; UNT   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
IPRATROPIUM BROMIDE 42MCG AEROSOL SPRAY   2 Preferred Generic/Preferred Brand $3.00$7.50None
IPRATROPIUM BROMIDE INHALATION SOLUTION 0.02% 60 X 2.5ML VIALSD   2 Preferred Generic/Preferred Brand $3.00$7.50P
IPRATROPIUM BROMIDE NASAL SPRAY   2 Preferred Generic/Preferred Brand $3.00$7.50None
IPRATROPIUM BROMIDE/ALBUTEROL SULFATE INHALATION SOLUTION 0.5MG/3ML 33 CRTN   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
IQUIX 1.5% DROPS   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
IRESSA 250MG TABLET   5 Specialty Tier 33%33%P
IRINOTECAN HCL INJECTION 20MG   5 Specialty Tier 33%33%P
ISENTRESS 400MG TABLET   5 Specialty Tier 33%33%None
ISOLYTE H IN 5% DEXTROSE   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
ISOLYTE M IN 5% DEXTROSE INJECTION   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
ISOLYTE P IN 5% DEXTROSE INJECTION   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
ISOLYTE S IN 5% DEXTROSE INJECTION   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
ISOLYTE S SOLUTION FOR INJECTION   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
ISONARIF 300-150MG CAPSULE   2 Preferred Generic/Preferred Brand $3.00$7.50None
ISONIAZID 100MG TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
ISONIAZID 50MG/5ML SYRUP   2 Preferred Generic/Preferred Brand $3.00$7.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ISONIAZID INJ 100MG/ML   2 Preferred Generic/Preferred Brand $3.00$7.50None
ISONIAZID TABLETS   2 Preferred Generic/Preferred Brand $3.00$7.50None
ISOSORBIDE DINITRATE TABLETS   2 Preferred Generic/Preferred Brand $3.00$7.50None
ISOSORBIDE DINITRATE TABLETS EXTENDED RELEASE   2 Preferred Generic/Preferred Brand $3.00$7.50None
ISOSORBIDE DN 10MG TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
ISOSORBIDE DN 2.5 MG TAB SL   2 Preferred Generic/Preferred Brand $3.00$7.50None
ISOSORBIDE DN 20MG TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
ISOSORBIDE DN 30MG TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
ISOSORBIDE DN 5MG TABLET SL   2 Preferred Generic/Preferred Brand $3.00$7.50None
ISOSORBIDE MN 10MG TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
ISOSORBIDE MONONITRATE 20 MG ORAL TABLET [MONOKET]   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ISOSORBIDE MONONITRATE 20MG TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
ISOSORBIDE MONONITRATE ER TABLET 120MG (100 CT)   2 Preferred Generic/Preferred Brand $3.00$7.50None
ISOSORBIDE MONONITRATE ER TABLET 30MG (100 CT)   2 Preferred Generic/Preferred Brand $3.00$7.50None
ISOSORBIDE MONONITRATE TABLETS EXTENDED RELEASE 60MG 100 TABLETS BOT   2 Preferred Generic/Preferred Brand $3.00$7.50None
ISOTON GENTAMICIN 60MG/100ML   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
ISOTON GENTAMICIN 80MG/100ML   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
ISRADIPINE CAPSULES 2.5MG (100 CT)   2 Preferred Generic/Preferred Brand $3.00$7.50None
ISRADIPINE CAPSULES 5MG (100 CT)   2 Preferred Generic/Preferred Brand $3.00$7.50None
ISTALOL 0.5% EYE DROPS   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
ISTODAX KIT   5 Specialty Tier 33%33%P
ITRACONAZOLE 100MG CAPSULE   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
IV BUSULFEX 6MG 1 X 10ML VIALGL   3 Non-Preferred Generic/Preferred Brand $36.00$90.00P
IXEMPRA KIT 45MG   5 Specialty Tier 33%33%P
IXIARO JAPANESE ENCEPHALITIS VACCINE 6MCG/.5ML   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None

Chart Legend:

Below are a few notes to help you understand the above 2011 Medicare Part D CIGNA Medicare Rx Plan Two (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 intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $(2840)) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, on the 2011 Humana Walmart-Preferred Rx Plan the pricing 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 2011 )

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.