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CIGNA Medicare Rx Plan Two (PDP) (S5617-172-0)
Tier 1 (170)
Tier 2 (1309)
Tier 3 (1123)
Tier 4 (446)
Tier 5 (405)
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Cick on the first letter of your drug name to browse the formulary:

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M N O P Q R S T U V W X Y Z 0-9 
2011 Medicare Part D Plan Formulary Information
CIGNA Medicare Rx Plan Two (PDP) (S5617-172-0)
Benefit Details           
The CIGNA Medicare Rx Plan Two (PDP) (S5617-172-0)
Formulary Drugs Starting with the Letter S
in CMS PDP Region 2 which includes: CT MA RI VT
Drugs Starting with Letter S

Drug Name		 Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order
SAIZEN 5MG VIAL   5 Specialty Tier 33%33%P
SAIZEN 8.8MG CLICK.EASY CARTG   5 Specialty Tier 33%33%P
SANCUSO TRANSDERMAL SYSTEM 3.1MG/24HRS 1 PATCH CRTN   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00P Q:4
/30Days
SANDIMMUNE 100MG CAPSULE   3 Non-Preferred Generic/Preferred Brand $39.00$97.50P
SANDIMMUNE 100MG/ML TUBEX   3 Non-Preferred Generic/Preferred Brand $39.00$97.50P
SANDIMMUNE 25MG CAPSULE   3 Non-Preferred Generic/Preferred Brand $39.00$97.50P
SANDIMMUNE 50MG/ML AMPUL   3 Non-Preferred Generic/Preferred Brand $39.00$97.50P
SANDOSTATIN 0.05MG/ML AMPUL   5 Specialty Tier 33%33%P
SANDOSTATIN 0.1MG/ML AMPUL   5 Specialty Tier 33%33%P
SANDOSTATIN 0.2MG/ML VIAL   5 Specialty Tier 33%33%P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
SANDOSTATIN 0.5MG/ML AMPUL   5 Specialty Tier 33%33%P
SANDOSTATIN 1MG/ML VIAL   5 Specialty Tier 33%33%P
SANDOSTATIN LAR 10MG KIT   5 Specialty Tier 33%33%P
SANDOSTATIN LAR 20MG KIT   5 Specialty Tier 33%33%P
SANDOSTATIN LAR 30MG KIT   5 Specialty Tier 33%33%P
SAVELLA TABLETS 100MG 60 COUNT BOT   3 Non-Preferred Generic/Preferred Brand $39.00$97.50Q:60
/30Days
SAVELLA TABLETS 12.5MG 60 COUNT BOT   3 Non-Preferred Generic/Preferred Brand $39.00$97.50Q:60
/30Days
SAVELLA TABLETS 25MG 60 COUNT BOT   3 Non-Preferred Generic/Preferred Brand $39.00$97.50Q:60
/30Days
SAVELLA TABLETS TITRATION PACK KIT 12.5;25;50MG;MG;MG 55 COUNT PKGCOM   3 Non-Preferred Generic/Preferred Brand $39.00$97.50Q:55
/30Days
SAVELLA TALBETS 50MG 60 COUNT BOT   3 Non-Preferred Generic/Preferred Brand $39.00$97.50Q:60
/30Days
SAXAGLIPTIN 2.5 MG ORAL TABLET [ONGLYZA]   3 Non-Preferred Generic/Preferred Brand $39.00$97.50Q:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
SAXAGLIPTIN 5 MG ORAL TABLET [ONGLYZA]   3 Non-Preferred Generic/Preferred Brand $39.00$97.50Q:30
/30Days
SEASONIQUE 150-30(84) TABLET DOSE PACK 3 MONTHS   3 Non-Preferred Generic/Preferred Brand $39.00$97.50None
SELEGILINE HCL 5MG CAPSULE   2 Preferred Generic/Preferred Brand $3.00$7.50None
SELEGILINE HCL 5MG TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
SELENIUM SULFIDE LOTION USP 2.5% 4 FLOZ-118ML BOT   2 Preferred Generic/Preferred Brand $3.00$7.50None
SELFEMRA CAPSULES 10MG 28 CAPSULE BLPK   2 Preferred Generic/Preferred Brand $3.00$7.50None
SELFEMRA CAPSULES 20MG 28 CAPSULE 4X7 BLPK   2 Preferred Generic/Preferred Brand $3.00$7.50None
SELZENTRY 150MG TABLET   5 Specialty Tier 33%33%None
SELZENTRY 300MG TABLET   5 Specialty Tier 33%33%None
SENSIPAR 30MG TABLET   3 Non-Preferred Generic/Preferred Brand $39.00$97.50Q:60
/30Days
SENSIPAR 60MG TABLET   5 Specialty Tier 33%33%Q:60
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
SENSIPAR 90MG TABLET   5 Specialty Tier 33%33%Q:120
/30Days
SEREVENT DIS AER 50MCG   3 Non-Preferred Generic/Preferred Brand $39.00$97.50None
SEROMYCIN CAPSULES 250MG   3 Non-Preferred Generic/Preferred Brand $39.00$97.50None
SEROQUEL 100MG TABLET   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00Q:120
/30Days
SEROQUEL 200MG TABLET   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00Q:120
/30Days
SEROQUEL 25MG TABLET   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00Q:120
/30Days
SEROQUEL 300MG TABLET   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00Q:60
/30Days
SEROQUEL 400MG TABLET   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00Q:60
/30Days
SEROQUEL 50MG TABLET (100 CT)   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00Q:120
/30Days
SEROQUEL TABLETS EXTENDED RELEASE 150MG 100 CRTN   3 Non-Preferred Generic/Preferred Brand $39.00$97.50Q:30
/30Days
SEROQUEL TABLETS EXTENDED RELEASE 200MG 100 X 200 MG CRTN   3 Non-Preferred Generic/Preferred Brand $39.00$97.50Q:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
SEROQUEL TABLETS EXTENDED RELEASE 400MG 100 X 400 MG CRTN   3 Non-Preferred Generic/Preferred Brand $39.00$97.50Q:60
/30Days
SEROQUEL TABLETS EXTENDED RELEASE 50MG 100 TABS CRTN   3 Non-Preferred Generic/Preferred Brand $39.00$97.50Q:60
/30Days
SEROQUEL XR 300MG TABLET 60X300MG BOT   3 Non-Preferred Generic/Preferred Brand $39.00$97.50Q:60
/30Days
SEROSTIM 4MG VIAL   5 Specialty Tier 33%33%P
SEROSTIM 5MG VIAL   5 Specialty Tier 33%33%P
SEROSTIM 6MG VIAL   5 Specialty Tier 33%33%P
SERTRALINE HCL 100MG TABLET (30 CT)   2 Preferred Generic/Preferred Brand $3.00$7.50Q:60
/30Days
SERTRALINE HCL 25 MG TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50Q:30
/30Days
SERTRALINE HCL 50MG TABLET (30 CT)   2 Preferred Generic/Preferred Brand $3.00$7.50Q:30
/30Days
SERTRALINE HYDROCHLORIDE ORAL CONCENTRATE   2 Preferred Generic/Preferred Brand $3.00$7.50Q:300
/30Days
SEVELAMER CARBONATE 26.7 MG/ML ORAL SUSPENSION [RENVELA]   3 Non-Preferred Generic/Preferred Brand $39.00$97.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
SEVELAMER CARBONATE 40 MG/ML ORAL SUSPENSION [RENVELA]   3 Non-Preferred Generic/Preferred Brand $39.00$97.50None
SILVADENE 1% CREAM   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
SILVER SULFADIAZINE 1% CRM   2 Preferred Generic/Preferred Brand $3.00$7.50None
SIMCOR 1000-20MG TABLET MULTIPHASIC RELEASE 24HR   3 Non-Preferred Generic/Preferred Brand $39.00$97.50Q:60
/30Days
SIMCOR 500MG-20MG TABLET MULTIPHASIC RELEASE 24HR   3 Non-Preferred Generic/Preferred Brand $39.00$97.50Q:30
/30Days
SIMCOR 750MG-20MG TABLET MULTIPHASIC RELEASE 24HR   3 Non-Preferred Generic/Preferred Brand $39.00$97.50Q:60
/30Days
SIMCOR TABLETS EXTENDED RELEASE   3 Non-Preferred Generic/Preferred Brand $39.00$97.50Q:30
/30Days
SIMCOR TABLETS EXTENDED RELEASE   3 Non-Preferred Generic/Preferred Brand $39.00$97.50Q:30
/30Days
SIMPONI GOLIMUMAB INJECTION 50MG/0.5ML 1 50 MG SINGLE DOSE SYR SYR   5 Specialty Tier 33%33%P
SIMULECT 20MG VIAL   5 Specialty Tier 33%33%P
SIMVASTATIN 10MG TABLET (30 CT)   1 Preferred Generic $0.00$0.00Q:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
SIMVASTATIN 20MG TABLET 10000 BOT   1 Preferred Generic $0.00$0.00Q:30
/30Days
SIMVASTATIN 40MG TABLET (500 CT)   1 Preferred Generic $0.00$0.00Q:30
/30Days
SIMVASTATIN 5MG TABLET (90 CT)   1 Preferred Generic $0.00$0.00Q:30
/30Days
SIMVASTATIN 80MG TABLET (1000 CT)   1 Preferred Generic $0.00$0.00Q:30
/30Days
SINGULAIR 10MG TABLET   3 Non-Preferred Generic/Preferred Brand $39.00$97.50None
SINGULAIR 4MG GRANULES   3 Non-Preferred Generic/Preferred Brand $39.00$97.50None
SINGULAIR 4MG TABLET CHEW   3 Non-Preferred Generic/Preferred Brand $39.00$97.50None
SINGULAIR 5MG TABLET CHEW   3 Non-Preferred Generic/Preferred Brand $39.00$97.50None
SODIUM BICARB INJ 7.5%   2 Preferred Generic/Preferred Brand $3.00$7.50P
SODIUM BICARB INJ 8.4%   2 Preferred Generic/Preferred Brand $3.00$7.50P
SODIUM CHLORIDE 0.45% TUBEX   2 Preferred Generic/Preferred Brand $3.00$7.50P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
SODIUM CHLORIDE INJECTION 3% 24X500ML BAG   2 Preferred Generic/Preferred Brand $3.00$7.50P
SODIUM CHLORIDE INJECTION USP .9 4X100ML CTR   2 Preferred Generic/Preferred Brand $3.00$7.50P
SODIUM CHLORIDE INJECTION USP 5%   2 Preferred Generic/Preferred Brand $3.00$7.50P
SODIUM CHLORIDE IRRIGATION 0.9% 1000ML CASE   2 Preferred Generic/Preferred Brand $3.00$7.50None
SODIUM CL 2.5 MEQ/ML VIAL   2 Preferred Generic/Preferred Brand $3.00$7.50P
SODIUM FLUORIDE 1MG TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
SODIUM LACTATE 1/6MOLAR INJ   3 Non-Preferred Generic/Preferred Brand $39.00$97.50P
SODIUM LACTATE 5 MEQ/ML VIAL   3 Non-Preferred Generic/Preferred Brand $39.00$97.50P
SODIUM POLYSTYRENE SULFONATE POWDER   2 Preferred Generic/Preferred Brand $3.00$7.50None
SOLARAZE 3% GEL   3 Non-Preferred Generic/Preferred Brand $39.00$97.50None
SOLIA 0.15-0.03 TABLET   3 Non-Preferred Generic/Preferred Brand $39.00$97.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
SOLU CORTEF INJECTION   3 Non-Preferred Generic/Preferred Brand $39.00$97.50P
SOLU CORTEF INJECTION 100 MG/VIAL   3 Non-Preferred Generic/Preferred Brand $39.00$97.50P
SOLU MEDROL 125 MG AOV 25, 125MG/2ML   3 Non-Preferred Generic/Preferred Brand $39.00$97.50P
SOLU MEDROL FOR INJECTION 40 MG/ML   3 Non-Preferred Generic/Preferred Brand $39.00$97.50P
SOLU MEDROL FOR INJECTION 500 MG/ML   3 Non-Preferred Generic/Preferred Brand $39.00$97.50P
SOLU-MEDROL 2000MG VIAL   3 Non-Preferred Generic/Preferred Brand $39.00$97.50P
SOMATROPIN INJECTION KIT 5.8MG/1.14ML 1 PKGCOM   5 Specialty Tier 33%33%P
SOMATULINE 60 MG/0.2 ML SYRING   5 Specialty Tier 33%33%P
SOMAVERT 10MG VIAL   5 Specialty Tier 33%33%P
SOMAVERT 15MG VIAL   5 Specialty Tier 33%33%P
SOMAVERT 20MG VIAL   5 Specialty Tier 33%33%P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
SORIATANE 17.5 MG CAPSULE   5 Specialty Tier 33%33%None
SORIATANE 22.5 MG CAPSULE   5 Specialty Tier 33%33%None
SORIATANE CAPSULES   5 Specialty Tier 33%33%None
SORIATANE CAPSULES   5 Specialty Tier 33%33%None
SORINE SOLTALOL HCL TABLETS 240MG 100 BOXUD   2 Preferred Generic/Preferred Brand $3.00$7.50None
SORINE SOTALOL HCL TABLETS 120MG 100 BOXUD   2 Preferred Generic/Preferred Brand $3.00$7.50None
SORINE SOTALOL HCL TABLETS 160MG 100 BOXUD   2 Preferred Generic/Preferred Brand $3.00$7.50None
SORINE SOTALOL HCL TABLETS 80MG 100 BOXUD   2 Preferred Generic/Preferred Brand $3.00$7.50None
SOTALOL HCL 120MG TABLET 100 BOT   2 Preferred Generic/Preferred Brand $3.00$7.50None
SOTALOL HCL 160MG TABLET (100 CT)   2 Preferred Generic/Preferred Brand $3.00$7.50None
SOTALOL HCL 80MG 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
SOTALOL HCL TABLET 240MG   2 Preferred Generic/Preferred Brand $3.00$7.50None
SOTRET 10MG CAPSULE   3 Non-Preferred Generic/Preferred Brand $39.00$97.50None
SOTRET 20MG CAPSULE   3 Non-Preferred Generic/Preferred Brand $39.00$97.50None
SOTRET 30MG CAPSULE   3 Non-Preferred Generic/Preferred Brand $39.00$97.50None
SOTRET 40MG CAPSULE   3 Non-Preferred Generic/Preferred Brand $39.00$97.50None
SPECTRACEF 400 MG DOSE PACK TB   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
SPECTRACEF TABLETS 200 MG   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
SPIRIVA 18MCG CP-HANDIHALER 90 (9 X 10) BLPK   3 Non-Preferred Generic/Preferred Brand $39.00$97.50None
SPIRONOLACTONE 100MG TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
SPIRONOLACTONE 25MG TABLET (100 CT)   2 Preferred Generic/Preferred Brand $3.00$7.50None
SPIRONOLACTONE 50MG TABLET (100 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
SPIRONOLACTONE/HCTZ TABLET 25-25MG (500 CT)   2 Preferred Generic/Preferred Brand $3.00$7.50None
SPORANOX 100MG CAPSULE   5 Specialty Tier 33%33%P
SPORANOX 10MG/ML SOLUTION   5 Specialty Tier 33%33%P
SPRINTEC 0.25-0.035 TABLET   3 Non-Preferred Generic/Preferred Brand $39.00$97.50None
SPRYCEL 20MG TABLET   5 Specialty Tier 33%33%P
SPRYCEL 50MG TABLET   5 Specialty Tier 33%33%P
SPRYCEL 70MG TABLET   5 Specialty Tier 33%33%P
SPRYCEL TABLETS   5 Specialty Tier 33%33%P
SRONYX 0.1-0.02 TABLET   3 Non-Preferred Generic/Preferred Brand $39.00$97.50None
SSD 1% CREAM   2 Preferred Generic/Preferred Brand $3.00$7.50None
STAGESIC 5MG-500MG CAPSULE   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
STALEVO 100 TABLET   3 Non-Preferred Generic/Preferred Brand $39.00$97.50None
STALEVO 125/200 MG/MG TABLETS   3 Non-Preferred Generic/Preferred Brand $39.00$97.50None
STALEVO 150 TABLET   3 Non-Preferred Generic/Preferred Brand $39.00$97.50None
STALEVO 18.75/75 MG/MG TABLETS   3 Non-Preferred Generic/Preferred Brand $39.00$97.50None
STALEVO 200 50-200-200 TABLET   3 Non-Preferred Generic/Preferred Brand $39.00$97.50None
STALEVO 50 TABLET   3 Non-Preferred Generic/Preferred Brand $39.00$97.50None
STAVUDINE CAPSULES 15MG 60 BOT   3 Non-Preferred Generic/Preferred Brand $39.00$97.50None
STAVUDINE CAPSULES 20MG 60 BOT   3 Non-Preferred Generic/Preferred Brand $39.00$97.50None
STAVUDINE CAPSULES 30MG 60 BOT   3 Non-Preferred Generic/Preferred Brand $39.00$97.50None
STAVUDINE CAPSULES 40MG 60 BOT   3 Non-Preferred Generic/Preferred Brand $39.00$97.50None
STAVUDINE FOR ORAL SOLUTION 1MG/ML 200 ML BOT   3 Non-Preferred Generic/Preferred Brand $39.00$97.50None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
STELARA 45 MG/0.5 ML SYRINGE   5 Specialty Tier 33%33%P
STELARA 45 MG/0.5 ML VIAL   5 Specialty Tier 33%33%P
STELARA 90 MG/ML SYRINGE   5 Specialty Tier 33%33%P
STERILE VANCOMYCIN HCL INJECTION 10 X 1GM VIAL   3 Non-Preferred Generic/Preferred Brand $39.00$97.50None
STERILE VANCOMYCIN HYDROCHLORIDE INJECTION   3 Non-Preferred Generic/Preferred Brand $39.00$97.50None
STERILE WATER FOR IRRIGATION 100 24 X 500ML BAG   2 Preferred Generic/Preferred Brand $3.00$7.50None
STRATTERA 100MG CAPSULE   3 Non-Preferred Generic/Preferred Brand $39.00$97.50Q:30
/30Days
STRATTERA 10MG CAPSULE   3 Non-Preferred Generic/Preferred Brand $39.00$97.50Q:60
/30Days
STRATTERA 18MG CAPSULE   3 Non-Preferred Generic/Preferred Brand $39.00$97.50Q:60
/30Days
STRATTERA 25MG CAPSULE   3 Non-Preferred Generic/Preferred Brand $39.00$97.50Q:60
/30Days
STRATTERA 40MG CAPSULE   3 Non-Preferred Generic/Preferred Brand $39.00$97.50Q:60
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
STRATTERA 60MG CAPSULE   3 Non-Preferred Generic/Preferred Brand $39.00$97.50Q:30
/30Days
STRATTERA 80MG CAPSULE   3 Non-Preferred Generic/Preferred Brand $39.00$97.50Q:30
/30Days
STREPTOMYCIN FOR INJECTION 1GM/VIL   3 Non-Preferred Generic/Preferred Brand $39.00$97.50None
STROMECTOL 3MG TABLET   3 Non-Preferred Generic/Preferred Brand $39.00$97.50None
SUBOXONE 2MG-0.5MG TABLET   3 Non-Preferred Generic/Preferred Brand $39.00$97.50None
SUBOXONE 8MG-2MG TABLET   3 Non-Preferred Generic/Preferred Brand $39.00$97.50None
SUCRALFATE 1GM TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
SULAR 17MG TABLET SR 24HR   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00Q:30
/30Days
SULAR 25.5MG TABLET SR 24HR   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00Q:30
/30Days
SULAR 34MG TABLET SR 24HR   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00Q:30
/30Days
SULAR 8.5MG TABLET SR 24HR   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00Q:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
SULFACETAMIDE SODIUM 10% SUSPENSION TOPICAL   2 Preferred Generic/Preferred Brand $3.00$7.50None
SULFACETAMIDE SODIUM OPHTHALMIC SOLUTION USP 10% 15 ML BOT   2 Preferred Generic/Preferred Brand $3.00$7.50None
SULFACETAMIDE-PREDNISOLONE 10-0.25% DROPS   2 Preferred Generic/Preferred Brand $3.00$7.50None
SULFADIAZINE 500MG TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
SULFAMETHOXAZOLE W/TMP 800-160MG TABLET (100 CT)   2 Preferred Generic/Preferred Brand $3.00$7.50None
SULFAMETHOXAZOLE W/TMP VIAL 80MG-16ML 10 X 10ML VIAL   2 Preferred Generic/Preferred Brand $3.00$7.50None
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40MG ORAL SUSPENSION 473ML BOT   2 Preferred Generic/Preferred Brand $3.00$7.50None
SULFAMETHOXAZOLE-TRIMETHOPRIM TABLET 400-80MG (500 CT)   2 Preferred Generic/Preferred Brand $3.00$7.50None
SULFASALAZINE 500MG TABLET   2 Preferred Generic/Preferred Brand $3.00$7.50None
SULFATRIM PEDIATRIC SUSP   2 Preferred Generic/Preferred Brand $3.00$7.50None
SULFAZINE EC 500MG TABLET DELAYED RELEASE   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
SULINDAC 150MG TABLET (100 CT)   1 Preferred Generic $0.00$0.00None
SULINDAC 200MG TABLET   1 Preferred Generic $0.00$0.00None
SUMATRIPTAN   3 Non-Preferred Generic/Preferred Brand $39.00$97.50Q:4
/30Days
SUMATRIPTAN SUCCINATE INJECTION 4MG/0.5ML 0.5 ML VIALSD   3 Non-Preferred Generic/Preferred Brand $39.00$97.50Q:4
/30Days
SUMATRIPTAN SUCCINATE TABLETS 100MG 9 BOXUD   3 Non-Preferred Generic/Preferred Brand $39.00$97.50Q:9
/30Days
SUMATRIPTAN SUCCINATE TABLETS 25MG 9 BOX   3 Non-Preferred Generic/Preferred Brand $39.00$97.50Q:36
/30Days
SUMATRIPTAN SUCCINATE TABLETS 50MG 9 (3 CARDS OF 3) BOX   3 Non-Preferred Generic/Preferred Brand $39.00$97.50Q:18
/30Days
SUPRAX 100MG/5ML SUSPENSION RECONSTITUTED ORAL 50ML BOT   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
SUPRAX 200MG/5ML SUSPENSION RECONSTITUTED ORAL   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
SURMONTIL 100MG CAPSULE   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
SURMONTIL 25MG CAPSULE   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
SURMONTIL 50MG CAPSULE   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
SUSTIVA 200MG CAPSULE   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
SUSTIVA 50MG CAPSULE   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
SUSTIVA 600MG TABLET   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
SUTENT 12.5MG CAPSULE   5 Specialty Tier 33%33%P
SUTENT 25MG CAPSULE   5 Specialty Tier 33%33%P
SUTENT 50MG CAPSULE   5 Specialty Tier 33%33%P
SYMBICORT 160-4.5MCG HFA AEROSOL WITH ADAPTER   3 Non-Preferred Generic/Preferred Brand $39.00$97.50None
SYMBICORT 80-4.5MCG HFA AEROSOL WITH ADAPTER 60 INHL   3 Non-Preferred Generic/Preferred Brand $39.00$97.50None
SYMBYAX 12-25MG CAPSULE   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00P Q:30
/30Days
SYMBYAX 12-50MG CAPSULE   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00P Q:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
SYMBYAX 3MG-25MG CAPSULE   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00P Q:30
/30Days
SYMBYAX 6-25MG CAPSULE   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00P Q:30
/30Days
SYMBYAX 6-50MG CAPSULE   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00P Q:30
/30Days
SYMLIN 0.6MG/ML VIAL   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00P Q:20
/30Days
SYMLINPEN 120 1000MCG/ML PEN INJECTOR   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00P Q:11
/30Days
SYMLINPEN 60 1000MCG/ML PEN INJECTOR   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00P Q:12
/30Days
SYNAGIS 50MG/0.5ML VIAL   5 Specialty Tier 33%33%P
SYNAREL 2MG/ML NASAL SPRAY   5 Specialty Tier 33%33%P
SYNERCID 500MG VIAL   5 Specialty Tier 33%33%None
SYNTHROID 100MCG TABLET   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
SYNTHROID 112 MCG TABLET   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
SYNTHROID 125MCG TABLET   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
SYNTHROID 137MCG TABLET   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
SYNTHROID 150MCG TABLET   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
SYNTHROID 175MCG TABLET   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
SYNTHROID 200MCG TABLET   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
SYNTHROID 25MCG TABLET   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
SYNTHROID 300MCG TABLET   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
SYNTHROID 50MCG TABLET   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
SYNTHROID 75MCG TABLET   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
SYNTHROID 88 MCG TABLET   4 Non-Preferred Generic/Non-Preferred Brand $78.00$195.00None
SYPRINE 250MG CAPSULE (100 CT)   3 Non-Preferred Generic/Preferred Brand $39.00$97.50None

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.