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Cigna-HealthSpring Rx -Reg 15 (PDP) (S5932-014-0)
Tier 1 (3079)



Requires Prior Authorization:
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Uses Step Therapy:
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Has Quantity Limits:
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2014 Medicare Part D Plan Formulary Information
Cigna-HealthSpring Rx -Reg 15 (PDP) (S5932-014-0)
Benefit Details           
The Cigna-HealthSpring Rx -Reg 15 (PDP) (S5932-014-0)
Formulary Drugs Starting with the Letter A

in CMS PDP Region 15 which includes: IN KY
Plan Monthly Premium: $35.50 Deductible: $310 Qualifies for LIS: Yes
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-HYDROCORT 100MG VIAL   1 On Formulary 25%25%None
ABACAVIR 300 MG TABLET   1 On Formulary 25%25%None
Abacavir Sulfate-Lamivudine-Zidovudine tablets [Trizivir]   1 On Formulary 25%25%None
ABELCENT INJECTION SUSPENSION 5MG/ML   1 On Formulary 25%25%P
ABILIFY 10MG TABLET   1 On Formulary 25%25%Q:30
/30Days
ABILIFY 15MG TABLET   1 On Formulary 25%25%Q:30
/30Days
ABILIFY 1MG/ML SOLUTION   1 On Formulary 25%25%Q:900
/30Days
ABILIFY 20MG TABLET   1 On Formulary 25%25%Q:30
/30Days
ABILIFY 2MG TABLET   1 On Formulary 25%25%Q:30
/30Days
ABILIFY 30MG TABLET   1 On Formulary 25%25%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ABILIFY 5MG TABLET (OTSUKA)   1 On Formulary 25%25%Q:30
/30Days
ABILIFY DISCMELT 10MG TABLET   1 On Formulary 25%25%Q:60
/30Days
ABILIFY DISCMELT 15MG TABLET   1 On Formulary 25%25%Q:60
/30Days
ABILIFY INJ 9.75MG   1 On Formulary 25%25%None
ABILIFY MAINTENA ER 300 MG VL   1 On Formulary 25%25%Q:2
/30Days
ABRAXANE 100MG VIAL   1 On Formulary 25%25%P
ABSORICA 10 MG CAPSULE   1 On Formulary 25%25%None
ABSORICA 20 MG CAPSULE   1 On Formulary 25%25%None
Acamprosate Calcium DR 333 MG tablets [Campral]   1 On Formulary 25%25%P Q:180
/30Days
Acarbose 100mg/1 1000 TABLET BOTTLE, PLASTIC   1 On Formulary 25%25%Q:90
/30Days
ACARBOSE 25 MG TABLETS   1 On Formulary 25%25%Q:90
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Acarbose 50mg/1 100 TABLET BOTTLE   1 On Formulary 25%25%Q:90
/30Days
ACEBUTOLOL 200MG CAPSULE   1 On Formulary 25%25%None
ACEBUTOLOL 400MG CAPSULE   1 On Formulary 25%25%None
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE   1 On Formulary 25%25%None
Acetaminophen and Codeine Phosphate 300; 60mg/1; mg/1 500 TABLET BOTTLE   1 On Formulary 25%25%Q:240
/30Days
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD   1 On Formulary 25%25%Q:5000
/30Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT)   1 On Formulary 25%25%Q:360
/30Days
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)   1 On Formulary 25%25%Q:360
/30Days
ACETASOL HC SOLUTION 10ML 10 ML BOT   1 On Formulary 25%25%None
ACETAZOLAMIDE 125MG TABLET   1 On Formulary 25%25%None
ACETAZOLAMIDE 250MG TABLET (100 CT)   1 On Formulary 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT   1 On Formulary 25%25%None
ACETIC ACID 2% SOLUTION NON-ORAL   1 On Formulary 25%25%None
ACETYLCYSTEINE 10% VIAL   1 On Formulary 25%25%P
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN   1 On Formulary 25%25%P
ACITRETIN 10 MG CAPSULE [Soriatane]   1 On Formulary 25%25%P
ACITRETIN 17.5 MG CAPSULE [Soriatane]   1 On Formulary 25%25%P
ACITRETIN 25 MG CAPSULE [Soriatane]   1 On Formulary 25%25%P
ACTHIB VACCINE VIAL 10-24UNT/5ML   1 On Formulary 25%25%None
ACTIMMUNE 100 MCG/0.5 ML VIAL   1 On Formulary 25%25%P
Actonel 150mg/1 36 DOSE PACK CASE / 1 TRAY DOSE PACK / 1 FILM COATED TABLETS in TRAY   1 On Formulary 25%25%Q:1
/28Days
Actonel 30mg/1 12 BOTTLE CASE / 30 FILM COATED TABLETS in BOTTLE   1 On Formulary 25%25%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Actonel 35mg/1 36 DOSE PACK CASE / 1 TRAY DOSE PACK / 4 FILM COATED TABLETS in TRAY   1 On Formulary 25%25%Q:4
/28Days
Actonel 5mg/1 12 BOTTLE CASE / 30 FILM COATED TABLETS in BOTTLE   1 On Formulary 25%25%Q:30
/30Days
ACYCLOVIR 200 MG CAPSULE   1 On Formulary 25%25%None
Acyclovir 200mg/5mL 473 mL in 1 BOTTLE   1 On Formulary 25%25%None
Acyclovir 400mg/1   1 On Formulary 25%25%None
Acyclovir 5% Ointment   1 On Formulary 25%25%None
ACYCLOVIR 800 MG TABLET   1 On Formulary 25%25%None
ACYCLOVIR SODIUM 500MG VIAL   1 On Formulary 25%25%None
ADACEL VIAL 2UNT/5UNT   1 On Formulary 25%25%None
ADAGEN 250U/ML VIAL   1 On Formulary 25%25%P
ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA]   1 On Formulary 25%25%P Q:2
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADEFOVIR DIPIVOXIL 10 MG TAB [Hepsera]   1 On Formulary 25%25%Q:30
/30Days
ADVAIR DISKUS MIS 100/50   1 On Formulary 25%25%Q:60
/30Days
ADVAIR DISKUS MIS 250/50   1 On Formulary 25%25%Q:60
/30Days
ADVAIR DISKUS MIS 500/50   1 On Formulary 25%25%Q:60
/30Days
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER   1 On Formulary 25%25%Q:24
/30Days
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL   1 On Formulary 25%25%Q:24
/30Days
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL   1 On Formulary 25%25%Q:24
/30Days
AFEDITAB CR 30MG TABLET SA   1 On Formulary 25%25%None
AFEDITAB CR 60MG TABLET SA   1 On Formulary 25%25%None
Afinitor 7.5mg/1 28 BLISTER PACK per CARTON / 1 TABLET per BLISTER PACK   1 On Formulary 25%25%P Q:30
/30Days
AFINITOR DISPERZ 2 MG TABLET   1 On Formulary 25%25%P Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AFINITOR DISPERZ 3 MG TABLET   1 On Formulary 25%25%P Q:60
/30Days
AFINITOR DISPERZ 5 MG TABLET   1 On Formulary 25%25%P Q:60
/30Days
AFINITOR TABLETS 10 MG   1 On Formulary 25%25%P Q:30
/30Days
AFINITOR TABLETS 2.5 MG   1 On Formulary 25%25%P Q:30
/30Days
AFINITOR TABLETS 5 MG   1 On Formulary 25%25%P Q:30
/30Days
AGGRENOX 25-200MG CAPSULE   1 On Formulary 25%25%Q:60
/30Days
AK-CON 0.1% EYE DROPS   1 On Formulary 25%25%None
ALA-CORT 1% CREAM   1 On Formulary 25%25%None
ALA-SCALP HP 2% LOTION   1 On Formulary 25%25%None
ALBENZA 200 MG TABLET   1 On Formulary 25%25%None
ALBUTEROL SULFATE 0.75mg/3mL 30 POUCH per CARTON / 1 VIAL, SINGLE-DOSE in 1 POUCH / 3 mL in 1 VIAL   1 On Formulary 25%25%P Q:375
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   1 On Formulary 25%25%P Q:375
/30Days
ALBUTEROL SULFATE 4MG TABLET SR 12HR   1 On Formulary 25%25%None
ALBUTEROL SULFATE 8MG TABLET SR 12HR   1 On Formulary 25%25%None
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   1 On Formulary 25%25%P Q:360
/30Days
ALBUTEROL SULFATE SOLUTION FOR INHALATION   1 On Formulary 25%25%P Q:375
/30Days
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT   1 On Formulary 25%25%None
ALBUTEROL SULFATE TABLET 2MG (500 CT)   1 On Formulary 25%25%None
ALBUTEROL TABLET 4MG (500 CT)   1 On Formulary 25%25%None
ALCLOMETASONE DIPROPIONATE 0.05% CREAM   1 On Formulary 25%25%None
Alclometasone Dipropionate 0.5mg/g 1 TUBE per CARTON / 60 g in 1 TUBE   1 On Formulary 25%25%None
ALDURAZYME 2.9MG/5ML VIAL   1 On Formulary 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALENDRONATE SODIUM 10MG TABLET   1 On Formulary 25%25%Q:30
/30Days
Alendronate Sodium 35mg, 4 BLISTER PACK in 1 BOX / 1 TABLET per BLISTER PACK   1 On Formulary 25%25%Q:4
/28Days
ALENDRONATE SODIUM 40MG TABLET   1 On Formulary 25%25%Q:30
/30Days
ALENDRONATE SODIUM 5MG TABLET   1 On Formulary 25%25%Q:30
/30Days
Alendronate Sodium 70 mg tab   1 On Formulary 25%25%Q:4
/28Days
ALIMTA 500MG VIAL   1 On Formulary 25%25%P
ALINIA 100MG/5ML SUSPENSION   1 On Formulary 25%25%None
ALINIA 500 MG TABLET   1 On Formulary 25%25%None
ALLOPURINOL 100 MG TABLETS   1 On Formulary 25%25%None
Allopurinol 300mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET per BLISTER PACK   1 On Formulary 25%25%None
ALOCRIL 2% EYE DROPS   1 On Formulary 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALOPRIM SOLUTION FOR INJECTION 500MG/VIAL 30 ML VIALGL   1 On Formulary 25%25%None
ALORA 0.025 MG PATCH   1 On Formulary 25%25%P
ALORA 0.05 MG PATCH   1 On Formulary 25%25%P
ALORA 0.075 MG PATCH   1 On Formulary 25%25%P
ALORA 0.1 MG PATCH   1 On Formulary 25%25%P
ALOXI 0.25 MG/5 ML   1 On Formulary 25%25%P
ALPRAZOLAM 0.25 MG TABLET   1 On Formulary 25%25%Q:90
/30Days
Alprazolam 0.25mg/1 10 BLISTER PACK per CARTON / 10 TABLET, ORALLY DISINTEGRATING in 1 BLISTER PAC   1 On Formulary 25%25%Q:90
/30Days
ALPRAZOLAM 0.5 MG TABLET   1 On Formulary 25%25%Q:90
/30Days
Alprazolam 0.5mg/1 10 BLISTER PACK per CARTON / 10 TABLET, ORALLY DISINTEGRATING per BLISTER PACK   1 On Formulary 25%25%Q:90
/30Days
ALPRAZOLAM 1 MG TABLET   1 On Formulary 25%25%Q:300
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Alprazolam 1mg/1 10 BLISTER PACK per CARTON / 10 TABLET, ORALLY DISINTEGRATING per BLISTER PACK   1 On Formulary 25%25%Q:300
/30Days
ALPRAZOLAM 2 MG TABLET   1 On Formulary 25%25%Q:150
/30Days
Alprazolam 2mg/1 10 BLISTER PACK per CARTON / 10 TABLET, ORALLY DISINTEGRATING per BLISTER PACK   1 On Formulary 25%25%Q:150
/30Days
AMANTADINE 100MG CAPSULE   1 On Formulary 25%25%None
AMANTADINE 100MG TABLET   1 On Formulary 25%25%None
Amantadine Hydrochloride 50mg/5mL 473 mL in 1 BOTTLE   1 On Formulary 25%25%None
AMBISOME 50MG VIAL   1 On Formulary 25%25%P
AMCINONIDE 0.1% CREAM   1 On Formulary 25%25%None
AMCINONIDE 0.1% LOTION   1 On Formulary 25%25%None
AMCINONIDE 0.1% OINTMENT 60GM TUBE   1 On Formulary 25%25%None
AMIFOSTINE 50mg/mL 3 VIAL, SINGLE-USE per CARTON / 10 mL in 1 VIAL, SINGLE-USE   1 On Formulary 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMIKACIN SULFATE 500 MG/2 ML VIAL   1 On Formulary 25%25%None
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET   1 On Formulary 25%25%None
AMILORIDE HYDROCHLORIDE TABLETS 5MG 100 BOT   1 On Formulary 25%25%None
Aminophylline 25mg/mL 5 TRAY per CARTON / 5 AMPULE in 1 TRAY / 10 mL in 1 AMPULE   1 On Formulary 25%25%None
AMINOSYN HBC INJECTION SULFITE FREE 7%   1 On Formulary 25%25%P
AMINOSYN II 10% IV SOLUTION   1 On Formulary 25%25%P
AMINOSYN II 7% IV SOLUTION   1 On Formulary 25%25%P
AMINOSYN II 8.5% ELECTROLYT   1 On Formulary 25%25%P
AMINOSYN II 8.5% IV SOLUTION   1 On Formulary 25%25%P
Aminosyn II Sulfite-Free 1490; 1527; 1050; 1107; 750; 450; 990; 1500; 1575; 258; 405; 447; 1083; 79   1 On Formulary 25%25%P
AMINOSYN M 3.5% IV SOLUTION   1 On Formulary 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN PF INJECTION   1 On Formulary 25%25%P
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5%   1 On Formulary 25%25%P
AMINOSYN-PF 7% IV SOLUTION   1 On Formulary 25%25%P
AMIODARONE HCL 200MG 60 TABLET BOTTLE   1 On Formulary 25%25%None
AMIODARONE HCL 400MG TABLET   1 On Formulary 25%25%None
AMIODARONE HCL 50 MG INJECTION   1 On Formulary 25%25%None
AMITIZA 8MCG CAPSULE   1 On Formulary 25%25%Q:60
/30Days
AMITIZA CAPSULES 24MCG 60 CAP BOT   1 On Formulary 25%25%Q:60
/30Days
AMITRIP/PERPHEN 10-2 TABLET   1 On Formulary 25%25%P
AMITRIP/PERPHEN 10-4 TABLET   1 On Formulary 25%25%P
AMITRIP/PERPHEN 25-2 TABLET   1 On Formulary 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIP/PERPHEN 25-4 TABLET   1 On Formulary 25%25%P
AMITRIP/PERPHEN 50-4 TABLET   1 On Formulary 25%25%P
AMITRIPTYLINE HCL 100MG TABLET   1 On Formulary 25%25%P
AMITRIPTYLINE HCL 10MG TABLET   1 On Formulary 25%25%P
AMITRIPTYLINE HCL 150 MG TAB   1 On Formulary 25%25%P
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)   1 On Formulary 25%25%P
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)   1 On Formulary 25%25%P
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT   1 On Formulary 25%25%P
AMLODIPINE BESYLATE 10MG TABLET (90 CT)   1 On Formulary 25%25%None
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)   1 On Formulary 25%25%None
AMLODIPINE BESYLATE 5MG TABLET (90 CT)   1 On Formulary 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE   1 On Formulary 25%25%None
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE   1 On Formulary 25%25%None
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE   1 On Formulary 25%25%None
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE   1 On Formulary 25%25%None
AMLODIPINE-BENAZEPRIL 10-40 MG   1 On Formulary 25%25%None
AMLODIPINE-BENAZEPRIL 5-40 MG   1 On Formulary 25%25%None
ammonium lactate 12% cream   1 On Formulary 25%25%None
AMMONIUM LACTATE 12% LOTION   1 On Formulary 25%25%None
Amnesteem 10mg/1 3 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK   1 On Formulary 25%25%None
Amnesteem 20mg/1 3 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK   1 On Formulary 25%25%None
Amnesteem 40mg/1 3 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK   1 On Formulary 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
amox tr-k clv 200-28.5/5 susp   1 On Formulary 25%25%None
AMOX TR-K CLV 500-125 MG TAB   1 On Formulary 25%25%None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE   1 On Formulary 25%25%None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET   1 On Formulary 25%25%None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE   1 On Formulary 25%25%None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   1 On Formulary 25%25%None
AMOXAPINE 100MG TABLET   1 On Formulary 25%25%None
AMOXAPINE 150MG TABLET   1 On Formulary 25%25%None
AMOXAPINE 25MG TABLET   1 On Formulary 25%25%None
AMOXAPINE 50MG TABLET   1 On Formulary 25%25%None
AMOXICILLIN 125MG TABLET CHEW   1 On Formulary 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN 250MG CAPSULE   1 On Formulary 25%25%None
Amoxicillin 250mg/1 500 TABLET, CHEWABLE in 1 BOTTLE   1 On Formulary 25%25%None
AMOXICILLIN 50 MG/ML / CLAVULANATE 12.5 MG/ML ORAL SUSPENSION   1 On Formulary 25%25%None
AMOXICILLIN 500MG TABLET (100 CT)   1 On Formulary 25%25%None
Amoxicillin 500mg/1 500 CAPSULE BOTTLE, PLASTIC   1 On Formulary 25%25%None
AMOXICILLIN 875MG TABLET   1 On Formulary 25%25%None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT   1 On Formulary 25%25%None
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS EXTENDED RELEASE 1000;62.5MG;MG   1 On Formulary 25%25%None
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT   1 On Formulary 25%25%None
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT   1 On Formulary 25%25%None
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL   1 On Formulary 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   1 On Formulary 25%25%None
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL   1 On Formulary 25%25%None
AMPHETAMINE SALT COMBO 12.5MG TABLET   1 On Formulary 25%25%Q:90
/30Days
AMPHETAMINE SALT COMBO 15MG TABLET   1 On Formulary 25%25%Q:90
/30Days
AMPHETAMINE SALT COMBO 30MG TABLET   1 On Formulary 25%25%Q:90
/30Days
AMPHETAMINE SALT COMBO 7.5MG TABLET   1 On Formulary 25%25%Q:90
/30Days
AMPHETAMINE SALTS 20MG TABLET   1 On Formulary 25%25%Q:90
/30Days
AMPHETAMINE SALTS 5 MG TAB   1 On Formulary 25%25%Q:90
/30Days
amphotericin b 50mg/10mL 10 mL in 1 VIAL   1 On Formulary 25%25%P
Ampicillin 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS   1 On Formulary 25%25%None
AMPICILLIN CAPSULES 250MG 100 BOT   1 On Formulary 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPICILLIN CAPSULES 500MG 100 BOT   1 On Formulary 25%25%None
AMPICILLIN FOR INJECTION POWDER   1 On Formulary 25%25%None
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT   1 On Formulary 25%25%None
AMPICILLIN POWDER FOR INJECTION 1 GM/ML   1 On Formulary 25%25%None
ampicillin-sulbactam 15 gm vl   1 On Formulary 25%25%None
ampicillin-sulbactam 3 gm vial   1 On Formulary 25%25%None
AMPYRA ER 10 MG TABLET   1 On Formulary 25%25%P Q:60
/30Days
Amturnide 150; 5; 12.5mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE   1 On Formulary 25%25%S
Amturnide 300; 10; 12.5mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE   1 On Formulary 25%25%S
Amturnide 300; 10; 25mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE   1 On Formulary 25%25%S
Amturnide 300; 5; 12.5mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE   1 On Formulary 25%25%S
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Amturnide 300; 5; 25mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE   1 On Formulary 25%25%S
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE BOTTLE   1 On Formulary 25%25%None
Anagrelide Hydrochloride 1mg/1 100 CAPSULE BOTTLE   1 On Formulary 25%25%None
Anastrozole 1mg/1 90 FILM COATED TABLETS in BOTTLE, PLASTIC   1 On Formulary 25%25%Q:30
/30Days
ANDROGEL 1%(50MG) GEL PACKET   1 On Formulary 25%25%P
Androgel 16.2mg/g 1 BOTTLE, PUMP per CARTON / 88 g in 1 BOTTLE, PUMP   1 On Formulary 25%25%P
APOKYN 30 MG/3 ML CARTRIDGE   1 On Formulary 25%25%P Q:60
/30Days
Apraclonidine Ophthalmic 5mg/mL 1 BOTTLE, DROPPER per CARTON / 10 mL in 1 BOTTLE, DROPPER   1 On Formulary 25%25%None
APRI 0.15-0.03 TABLET   1 On Formulary 25%25%None
APRISO CP24   1 On Formulary 25%25%None
APTIOM 200 MG TABLET   1 On Formulary 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
APTIOM 400 MG TABLET   1 On Formulary 25%25%None
APTIOM 600 MG TABLET   1 On Formulary 25%25%None
APTIOM 800 MG TABLET   1 On Formulary 25%25%None
APTIVUS 250MG CAPSULE   1 On Formulary 25%25%None
APTIVUS ORAL SOLUTION 100MG/ML 95 ML BOT   1 On Formulary 25%25%None
ARANELLE 7-9-5 TABLET   1 On Formulary 25%25%None
ARANESP 100ug/0.5mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.5 mL in 1 SYRINGE   1 On Formulary 25%25%P
ARANESP 100ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE   1 On Formulary 25%25%P
ARANESP 200MCG/0.4ML SYRINGE   1 On Formulary 25%25%P
ARANESP 200MCG/ML VIAL   1 On Formulary 25%25%P
ARANESP 25ug/0.42mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.42 mL in 1 SYRING   1 On Formulary 25%25%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP 25ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE   1 On Formulary 25%25%P
ARANESP 300MCG/ML VIAL   1 On Formulary 25%25%P
ARANESP 500MCG/1ML SYRINGE   1 On Formulary 25%25%P
ARANESP 60MCG/ML VIAL   1 On Formulary 25%25%P
ARANESP 60ug/0.3mL 1 BLISTER PACK in 1 PACKAGE / 4 SYRINGE per BLISTER PACK / 0.3 mL in 1 SYRINGE   1 On Formulary 25%25%P
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR   1 On Formulary 25%25%P
ARANESP PREFILLED SYRINGE SINGLE USE 300MCG/0.6ML 300MCG /0.6ML SYR   1 On Formulary 25%25%P
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR   1 On Formulary 25%25%P
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD   1 On Formulary 25%25%P
ARCALYST INJECTION 220MG/VIAL   1 On Formulary 25%25%P
ARRANON 250MG VIAL   1 On Formulary 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARZERRA 20mg/mL 3 VIAL per CARTON / 5 mL in 1 VIAL   1 On Formulary 25%25%P
Ascomp with Codeine 325; 50; 40; 30mg/1; mg/1; mg/1; mg/1 500 CAPSULE BOTTLE, PLASTIC   1 On Formulary 25%25%P Q:360
/30Days
ASTAGRAF XL 0.5 MG CAPSULE   1 On Formulary 25%25%P
ASTAGRAF XL 1 MG CAPSULE   1 On Formulary 25%25%P
ASTAGRAF XL 5 MG CAPSULE   1 On Formulary 25%25%P
Atelvia 35mg/1 36 DOSE PACK CASE / 4 TABLET, DELAYED RELEASE in 1 DOSE PACK   1 On Formulary 25%25%Q:4
/28Days
ATENOLOL 100 MG TABLET   1 On Formulary 25%25%None
Atenolol 25mg 100 TABLET BOTTLE   1 On Formulary 25%25%None
ATENOLOL TABLET USP 50MG (100 CT)   1 On Formulary 25%25%None
ATENOLOL-CHLORTHALIDONE 100-25   1 On Formulary 25%25%None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   1 On Formulary 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATGAM 50MG/ML AMPUL   1 On Formulary 25%25%P
ATORVASTATIN 10 MG TABLET [Lipitor]   1 On Formulary 25%25%Q:30
/30Days
ATORVASTATIN 20 MG TABLET [Lipitor]   1 On Formulary 25%25%Q:30
/30Days
ATORVASTATIN 40 MG TABLET [Lipitor]   1 On Formulary 25%25%Q:30
/30Days
ATORVASTATIN 80 MG TABLET [Lipitor]   1 On Formulary 25%25%Q:30
/30Days
ATOVAQUONE 750 MG/5 ML SUSP [Mepron]   1 On Formulary 25%25%None
Atripla 600; 200; 300mg/1; mg/1; mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC   1 On Formulary 25%25%None
ATROPINE 0.05MG/ML SYRINGE   1 On Formulary 25%25%None
ATROPINE 0.1MG/ML SYRINGE   1 On Formulary 25%25%None
ATROVENT HFA AER 17MCG   1 On Formulary 25%25%Q:26
/30Days
AUGMENTED BETAMETHASONE DIPROPIONATE OINTMENT   1 On Formulary 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVASTIN 100MG/4ML VIAL   1 On Formulary 25%25%P
AVELOX 400MG TABLET   1 On Formulary 25%25%None
AVELOX ABC PACK 400MG TABLET   1 On Formulary 25%25%None
AVELOX IV 400MG/250ML   1 On Formulary 25%25%None
AVIANE 0.1-0.02 TABLET   1 On Formulary 25%25%None
AVODART 0.5MG SOFTGEL   1 On Formulary 25%25%None
AVONEX ADMIN PACK 30MCG SYR   1 On Formulary 25%25%P Q:4
/28Days
AVONEX ADMIN PACK 30MCG VL   1 On Formulary 25%25%P Q:4
/28Days
Azacitidine 100 mg vial [Vidaza]   1 On Formulary 25%25%P
AZACTAM INJECTION 1GM/50ML   1 On Formulary 25%25%None
AZACTAM INJECTION 2GM/50ML   1 On Formulary 25%25%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZASAN 100MG TABLET   1 On Formulary 25%25%P
AZASAN 75MG TABLET   1 On Formulary 25%25%P
AZASITE 1% DROPS   1 On Formulary 25%25%None
AZATHIOPRINE 50MG TABLET   1 On Formulary 25%25%None
AZELASTINE 137 MCG NASAL SPRAY   1 On Formulary 25%25%Q:60
/30Days
AZELASTINE HYDROCHLORIDE OPHTHALMIC SOLUTION   1 On Formulary 25%25%None
AZILECT 0.5MG TABLET   1 On Formulary 25%25%None
AZILECT 1MG TABLET   1 On Formulary 25%25%None
AZITHROMYCIN 1 GM PWD PACKET   1 On Formulary 25%25%Q:3
/30Days
Azithromycin 100mg/5mL 15 mL in 1 BOTTLE   1 On Formulary 25%25%Q:150
/30Days
Azithromycin 200mg/5mL 22.5 mL in 1 BOTTLE   1 On Formulary 25%25%Q:75
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZITHROMYCIN 250 MG TABLET   1 On Formulary 25%25%Q:12
/28Days
Azithromycin 500mg/1 10 VIAL, SINGLE-USE in 1 TRAY / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION   1 On Formulary 25%25%None
Azithromycin 500mg/1 30 FILM COATED TABLETS in BOTTLE   1 On Formulary 25%25%Q:12
/28Days
Azithromycin 600mg/1 30 FILM COATED TABLETS in BOTTLE   1 On Formulary 25%25%Q:12
/28Days
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT   1 On Formulary 25%25%None
AZTREONAM FOR INJECTION   1 On Formulary 25%25%None

Chart Legend:

Below are a few notes to help you understand the above 2014 Medicare Part D Cigna-HealthSpring Rx -Reg 15 (PDP) Plan Formulary.
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  • 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 intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $2850) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2014 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 September 2014 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.





 
 

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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.