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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
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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 O
in CMS PDP Region 32 which includes: CA
Drugs Starting with Letter O

Drug Name		 Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order
OCELLA TABLET   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
OCTREOTIDE ACETATE INJECTION 1000MCG 1X5ML VIALMD   5 Specialty Tier 33%33%P
OCTREOTIDE ACETATE INJECTION 100MCG 10 X1ML AMP   5 Specialty Tier 33%33%P
OCTREOTIDE ACETATE INJECTION 500MCG 10 X1ML AMP   5 Specialty Tier 33%33%P
OCTREOTIDE ACETATE INJECTION SOLUTION 200MCG 1 X 5ML VIALMD   5 Specialty Tier 33%33%P
OCTREOTIDE ACETATE INJECTION SOLUTION 50MCG 10X1ML AMP   5 Specialty Tier 33%33%P
OCUFEN 0.03% EYE DROPS   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
OCUTRICIN EYE OINTMENT 400UNT/3.5MG/10UNT   2 Preferred Generic/Preferred Brand $3.00$7.50None
OFLOXACIN 0.3% DROPS   2 Preferred Generic/Preferred Brand $3.00$7.50None
OFLOXACIN 200MG TABLET (50 CT)   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
OFLOXACIN 300MG TABLET (50 CT)   2 Preferred Generic/Preferred Brand $3.00$7.50None
OFLOXACIN 400MG TABLET (100 CT)   2 Preferred Generic/Preferred Brand $3.00$7.50None
OFLOXACIN OPHTHALMIC SOLUTION 0.3% 5ML BOT   2 Preferred Generic/Preferred Brand $3.00$7.50None
OGESTREL TABLET 0.05MG/0.5MG   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
OMEPRAZOLE 10MG CAPSULE DELAYED RELEASE (30 CT)   2 Preferred Generic/Preferred Brand $3.00$7.50Q:30
/30Days
OMEPRAZOLE CAPSULES DELAYED RELEASE   2 Preferred Generic/Preferred Brand $3.00$7.50Q:60
/30Days
OMEPRAZOLE CAPSULES DELAYED RELEASE 40 MG   2 Preferred Generic/Preferred Brand $3.00$7.50Q:30
/30Days
OMNARIS 50MCG SPRAY NON-AEROSOL   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
OMNITROPE FOR INJECTION KIT 5.8MG 1 BOX PKGCOM   5 Specialty Tier 33%33%P
OMNITROPE INJECTION 10MG/1.5ML 10MG X 1.5ML CTG   5 Specialty Tier 33%33%P
OMNITROPE INJECTION 5MG/1.5ML 1.5 ML CTG   5 Specialty Tier 33%33%P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ONCASPAR 750UNIT/ML VIAL   5 Specialty Tier 33%33%P
ONDANSETRON HCL 24MG TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50P Q:5
/30Days
ONDANSETRON HCL 4MG/5ML SOLUTION ORAL   2 Preferred Generic/Preferred Brand $3.00$7.50P Q:900
/30Days
ONDANSETRON HYDROCHLORIDE TABLETS   2 Preferred Generic/Preferred Brand $3.00$7.50P Q:60
/30Days
ONDANSETRON HYDROCHLORIDE TABLETS   2 Preferred Generic/Preferred Brand $3.00$7.50P Q:90
/30Days
ONDANSETRON INJECTION 2MG 5X2ML VIAL   2 Preferred Generic/Preferred Brand $3.00$7.50P
ONDANSETRON ODT 4MG TABLET (30 CT)   2 Preferred Generic/Preferred Brand $3.00$7.50P Q:60
/30Days
ONDANSETRON ODT 8MG (10 CT)   2 Preferred Generic/Preferred Brand $3.00$7.50P Q:90
/30Days
ONTAK INJECTION 300MCG/2ML VIALSU   5 Specialty Tier 33%33%P
OPRELVEKIN 5 MG/ML INJECTABLE SOLUTION [NEUMEGA]   5 Specialty Tier 33%33%P
OPTIPRANOLOL 0.3% EYE 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
OPTIVAR 0.05% DROPS   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
ORACEA CAPSULES 40MG 30 BOT   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
ORAP 1MG TABLET   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
ORAP 2MG TABLET   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
ORENCIA 250MG VIAL   5 Specialty Tier 33%33%P
ORFADIN 10MG CAPSULE   5 Specialty Tier 33%33%None
ORFADIN 2MG CAPSULE   5 Specialty Tier 33%33%None
ORFADIN 5MG CAPSULE   5 Specialty Tier 33%33%None
ORPHENADRINE CITRATE ER TABLET 100MG (100 CT)   2 Preferred Generic/Preferred Brand $3.00$7.50None
ORPHENADRINE CITRATE INJECTION 3030MG/ML 10ML VIAL   2 Preferred Generic/Preferred Brand $3.00$7.50P
ORPHENADRINE COMP FORTE TABLET   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
ORPHENADRINE COMPOUND 25-385-30 TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
ORTHO EVRA DIS WEEK .75MG / 6MG   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
ORTHO TRI-CYCLEN LO TABLET   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
ORTHO-EST 0.625 TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
ORTHO-EST 1.25 TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
ORTHOCLONE OKT-3 5MG/5ML   5 Specialty Tier 33%33%P
OVIDE 0.5% LOTION   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
OXACILLIN 1GM/50ML INJ   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
OXACILLIN 2GM/50ML INJ   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
OXACILLIN FOR INJECTION 1 GM   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
OXACILLIN INJECTION   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
OXALIPLATIN 5 MG/ML INJECTABLE SOLUTION   5 Specialty Tier 33%33%P
OXANDRIN 10MG TABLET   5 Specialty Tier 33%33%None
OXANDRIN 2.5MG TABLET   5 Specialty Tier 33%33%None
OXANDROLONE 10MG TABLET   5 Specialty Tier 33%33%None
OXANDROLONE TABLETS   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
OXAPROZIN 600MG TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
OXCARBAZEPINE 150MG TABLET   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
OXCARBAZEPINE 300MG TABLET 500 NCRC BOT   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
OXCARBAZEPINE 60 MG/ML ORAL SUSPENSION   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
OXCARBAZEPINE 600MG TABLET 500 NCRC BOT   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
OXSORALEN 1% LOTION   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
OXSORALEN-ULTRA 10MG CAP   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
OXYBUTYNIN 5MG TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
OXYBUTYNIN CHLORIDE ER 10MG TABLET (100 CT)   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:60
/30Days
OXYBUTYNIN CHLORIDE ER 5MG TABLET (100 CT)   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:30
/30Days
OXYBUTYNIN CHLORIDE SYRUP USP 5MG/5ML 5 ML UNIT DOSE CUP   2 Preferred Generic/Preferred Brand $3.00$7.50None
OXYBUTYNIN CHLORIDE TABLET ER 15MG (100 CT)   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:60
/30Days
OXYCODONE AND ACETAMINOPHEN 325-5MG TABLET USP (500 CT)   2 Preferred Generic/Preferred Brand $3.00$7.50None
OXYCODONE AND ACETAMINOPHEN CAPSULES 500;5MG;MG 500 BOT   2 Preferred Generic/Preferred Brand $3.00$7.50None
OXYCODONE AND ACETAMINOPHEN TABLETS 2.5;325MG;MG 100 BOT   2 Preferred Generic/Preferred Brand $3.00$7.50None
OXYCODONE HCL 30MG TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
OXYCODONE HCL 5MG TABLET   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
OXYCODONE HCL-ACETAMINOPHEN 10MG-325MG TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
OXYCODONE HCL-ACETAMINOPHEN 500-7.5MG TABLET (100 CT)   2 Preferred Generic/Preferred Brand $3.00$7.50None
OXYCODONE HCL-IBUPROFEN 400MG-5MG TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
OXYCODONE HYDROCHLORIDE AND ACETAMINOPHEN TABLETS 650;10MG;MG 100 BOT   3 Non-Preferred Generic/Preferred Brand $36.00$90.00None
OXYCODONE HYDROCHLORIDE TABLETS 15MG 100 TABLETS BOTPL   2 Preferred Generic/Preferred Brand $3.00$7.50None
OXYCODONE-ACETAMINOPHEN 7.5-325MG TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
OXYCODONE/ASA 4.88/325 TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
OXYCONTIN 10MG TABLET SA   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:60
/30Days
OXYCONTIN 15MG TABLET SR 12HR   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:60
/30Days
OXYCONTIN 20MG TABLET SA   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:60
/30Days
OXYCONTIN 30MG TABLET SR 12HR   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:60
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
OXYCONTIN 40MG TABLET SA   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:60
/30Days
OXYCONTIN 60MG TABLET SR 12HR   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:60
/30Days
OXYCONTIN 80MG TABLET SA   3 Non-Preferred Generic/Preferred Brand $36.00$90.00Q:120
/30Days
OXYTROL 3.9MG/24HR PATCH   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.