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Cigna-HealthSpring Rx Secure-Essential (PDP) (S5617-291-0)
Tier 1 (171)
Tier 2 (751)
Tier 3 (445)
Tier 4 (1362)
Tier 5 (510)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
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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2019 Medicare Part D Plan Formulary Information
Cigna-HealthSpring Rx Secure-Essential (PDP) (S5617-291-0)
Benefit Details           
The Cigna-HealthSpring Rx Secure-Essential (PDP) (S5617-291-0)
Formulary Drugs Starting with the Letter S

in CMS PDP Region 12 which includes: AL TN
Plan Monthly Premium: $21.90 Deductible: $415 Qualifies for LIS: No
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
SANCUSO TRANSDERMAL SYSTEM 3.1MG/24HRS 1 PATCH CRTN   5 Specialty Tier 25%N/AQ:4
/28Days
SANDIMMUNE 100MG/ML TUBEX   4 Non-Preferred Drug 49%49%P
SANTYL OINTMENT   4 Non-Preferred Drug 49%49%None
SAPHRIS 10 MG TAB SL BLK CHERY   4 Non-Preferred Drug 49%49%Q:60
/30Days
SAPHRIS 2.5 MG TAB SL BLK CHRY   4 Non-Preferred Drug 49%49%Q:60
/30Days
SAPHRIS 5 MG TAB SL BLK CHERRY   4 Non-Preferred Drug 49%49%Q:60
/30Days
SCOPOLAMINE 1 MG/3 DAY PATCH [Transderm Scop]   4 Non-Preferred Drug 49%49%Q:10
/30Days
SELEGILINE HCL 5 MG TABLET   3 Preferred Brand 20%20%None
SELEGILINE HCL 5MG CAPSULE   3 Preferred Brand 20%20%None
SELENIUM SULFIDE 2.5mg/100mL 118 mL in 1 BOTTLE   2* Generic $3.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SELZENTRY 150mg/1 60 FILM COATED TABLETS in BOTTLE   5 Specialty Tier 25%N/AQ:60
/30Days
SELZENTRY 20 MG/ML ORAL SOLN   5 Specialty Tier 25%N/AQ:1610
/26Days
SELZENTRY 25 MG TABLET   4 Non-Preferred Drug 49%49%Q:240
/30Days
SELZENTRY 300mg/1 60 FILM COATED TABLETS in BOTTLE   5 Specialty Tier 25%N/AQ:120
/30Days
SELZENTRY 75 MG TABLET   5 Specialty Tier 25%N/AQ:60
/30Days
SENSIPAR 30MG TABLET   5 Specialty Tier 25%N/AQ:60
/30Days
SENSIPAR 60MG TABLET   5 Specialty Tier 25%N/AQ:60
/30Days
SENSIPAR 90MG TABLET   5 Specialty Tier 25%N/AQ:120
/30Days
SEREVENT DIS AER 50MCG   3 Preferred Brand 20%20%Q:60
/30Days
SERTRALINE 20 MG/ML ORAL CONC   3 Preferred Brand 20%20%Q:300
/30Days
SERTRALINE HCL 100 MG TABLET   2* Generic $3.00$6.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SERTRALINE HCL 25 MG TABLET   2* Generic $3.00$6.00Q:30
/30Days
SERTRALINE HCL 50 MG TABLET   2* Generic $3.00$6.00Q:120
/30Days
SETLAKIN 0.15 MG-0.03 MG TAB   4 Non-Preferred Drug 49%49%Q:91
/91Days
SEVELAMER 0.8 GM POWDER PACKET [RENVELA]   4 Non-Preferred Drug 49%49%Q:180
/30Days
SEVELAMER 2.4 GM POWDER PACKET POWD PACK [Renvela]   4 Non-Preferred Drug 49%49%Q:180
/30Days
SEVELAMER CARBONATE 26.7 MG/ML ORAL SUSPENSION [RENVELA]   3 Preferred Brand 20%20%Q:180
/30Days
SEVELAMER CARBONATE 40 MG/ML ORAL SUSPENSION [RENVELA]   3 Preferred Brand 20%20%Q:180
/30Days
SEVELAMER CARBONATE 800 MG TAB [RENVELA]   4 Non-Preferred Drug 49%49%Q:540
/30Days
SHAROBEL 0.35 MG TABLET   2* Generic $3.00$6.00None
SHINGRIX VIAL KIT   4 Non-Preferred Drug 49%49%Q:2
/999Days
Signifor .3 mg/mL   5 Specialty Tier 25%N/AP Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Signifor .6 mg/mL   5 Specialty Tier 25%N/AP Q:60
/30Days
Signifor .9 mg/mL   5 Specialty Tier 25%N/AP Q:60
/30Days
SILDENAFIL 20 MG TABLET   3 Preferred Brand 20%20%P Q:90
/30Days
SILENOR 3 MG TABLET   3 Preferred Brand 20%20%Q:30
/30Days
SILENOR 6 MG TABLET   3 Preferred Brand 20%20%Q:30
/30Days
SILVER SULFADIAZINE 1% CREAM   4 Non-Preferred Drug 49%49%None
SIMBRINZA 1%-0.2% EYE DROPS   4 Non-Preferred Drug 49%49%None
SIMVASTATIN 10 MG TABLET   1* Preferred Generic $1.00$2.00Q:30
/30Days
SIMVASTATIN 20 MG TABLET   1* Preferred Generic $1.00$2.00Q:30
/30Days
SIMVASTATIN 40 MG TABLET   1* Preferred Generic $1.00$2.00Q:30
/30Days
SIMVASTATIN 5 MG TABLET [Zocor]   1* Preferred Generic $1.00$2.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SIMVASTATIN 80 MG TABLET   1* Preferred Generic $1.00$2.00Q:30
/30Days
Sirolimus 0.5 MG Tablet [Rapamune]   4 Non-Preferred Drug 49%49%P
SIROLIMUS 1 MG TABLET [Rapamune]   4 Non-Preferred Drug 49%49%P
SIROLIMUS 1 MG/ML SOLUTION [Rapamune]   5 Specialty Tier 25%N/AP
SIROLIMUS 2 MG TABLET [Rapamune]   4 Non-Preferred Drug 49%49%P
SIRTURO 100 MG TABLET   4 Non-Preferred Drug 49%49%P Q:188
/365Days
SIVEXTRO 200 MG TABLET   5 Specialty Tier 25%N/AQ:6
/30Days
SKYRIZI 150 MG DOSE KIT-2 SYRINGEKIT   5 Specialty Tier 25%N/AP Q:2
/28Days
SODIUM CHLORIDE 0.45% TUBEX   4 Non-Preferred Drug 49%49%None
SODIUM CHLORIDE 0.9% IRRIG.   4 Non-Preferred Drug 49%49%None
SODIUM CHLORIDE 0.9% IV SOLN   4 Non-Preferred Drug 49%49%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Sodium Chloride 3g/100mL   4 Non-Preferred Drug 49%49%None
SODIUM CHLORIDE INJECTION USP 5%   4 Non-Preferred Drug 49%49%None
SODIUM LACTATE 5 MEQ/ML VIAL   4 Non-Preferred Drug 49%49%P
SODIUM PHENYLBUTYRATE 500MG TB [Buphenyl]   5 Specialty Tier 25%N/AP
SODIUM PHENYLBUTYRATE POWDER [Buphenyl]   5 Specialty Tier 25%N/AP
SODIUM POLYSTYRENE SULF POWDER   3 Preferred Brand 20%20%None
SOLIQUA 100 UNIT-33 MCG/ML PEN   3 Preferred Brand 20%20%S Q:18
/30Days
SOLTAMOX 20 MG/10 ML SOLN Solution   5 Specialty Tier 25%N/ANone
SOMATULINE DEPOT 120 MG/0.5 ML   5 Specialty Tier 25%N/AP Q:1
/28Days
SOMATULINE DEPOT 60 MG/0.2 ML   5 Specialty Tier 25%N/AP
SOMATULINE DEPOT 90 MG/0.3 ML   5 Specialty Tier 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SOMAVERT 10 MG VIAL   5 Specialty Tier 25%N/AP Q:30
/30Days
SOMAVERT 15 MG VIAL   5 Specialty Tier 25%N/AP Q:30
/30Days
SOMAVERT 20 MG VIAL   5 Specialty Tier 25%N/AP Q:30
/30Days
SOMAVERT 25 MG VIAL   5 Specialty Tier 25%N/AP Q:30
/30Days
SOMAVERT 30 MG VIAL   5 Specialty Tier 25%N/AP Q:30
/30Days
SORINE SOLTALOL HCL TABLETS 240MG 100 BOXUD   2* Generic $3.00$6.00None
SORINE SOTALOL HCL TABLETS 120MG 100 BOXUD   2* Generic $3.00$6.00None
SORINE SOTALOL HCL TABLETS 160MG 100 BOXUD   2* Generic $3.00$6.00None
SORINE SOTALOL HCL TABLETS 80MG 100 BOXUD   2* Generic $3.00$6.00None
SOTALOL 120 MG TABLET [Sorine]   2* Generic $3.00$6.00None
SOTALOL 160 MG TABLET [Sorine]   2* Generic $3.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SOTALOL 240 MG TABLET [Sorine]   2* Generic $3.00$6.00None
SOTALOL 80 MG TABLET [Sorine]   2* Generic $3.00$6.00None
SOTALOL AF 120 MG TABLET   2* Generic $3.00$6.00None
SPIRIVA 18 MCG CP-HANDIHALER   4 Non-Preferred Drug 49%49%S Q:30
/30Days
SPIRONOLACTONE 100 MG TABLET   2* Generic $3.00$6.00None
SPIRONOLACTONE 25 MG TABLET   2* Generic $3.00$6.00None
SPIRONOLACTONE 50 MG TABLET   2* Generic $3.00$6.00None
SPIRONOLACTONE-HCTZ 25-25 TAB   2* Generic $3.00$6.00None
SPORANOX 10MG/ML SOLUTION   5 Specialty Tier 25%N/AP
SPRINTEC 0.25-0.035 TABLET   2* Generic $3.00$6.00None
SPRITAM 1,000 MG TABLET   4 Non-Preferred Drug 49%49%Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SPRITAM 250 MG TABLET   4 Non-Preferred Drug 49%49%Q:60
/30Days
SPRITAM 500 MG TABLET   4 Non-Preferred Drug 49%49%Q:60
/30Days
SPRITAM 750 MG TABLET   4 Non-Preferred Drug 49%49%Q:120
/30Days
SPRYCEL 100mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE   5 Specialty Tier 25%N/AP Q:30
/30Days
SPRYCEL 140mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE   5 Specialty Tier 25%N/AP Q:30
/30Days
SPRYCEL 20MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
SPRYCEL 50MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
SPRYCEL 70MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
SPRYCEL 80mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE   5 Specialty Tier 25%N/AP Q:30
/30Days
SPS 15 GM/60 ML SUSPENSION   3 Preferred Brand 20%20%None
SRONYX 0.10-0.02 MG TABLET   2* Generic $3.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SSD 1% CREAM   4 Non-Preferred Drug 49%49%None
STAVUDINE 15 MG CAPSULE   4 Non-Preferred Drug 49%49%Q:60
/30Days
STAVUDINE 20 MG CAPSULE   4 Non-Preferred Drug 49%49%Q:60
/30Days
STAVUDINE CAPSULES 30MG 60 BOT   4 Non-Preferred Drug 49%49%Q:60
/30Days
STAVUDINE CAPSULES 40MG 60 BOT   4 Non-Preferred Drug 49%49%Q:60
/30Days
STIVARGA 40 MG TABLET   5 Specialty Tier 25%N/AP
STRATTERA 100MG CAPSULE   4 Non-Preferred Drug 49%49%S Q:30
/30Days
STRATTERA 10MG CAPSULE   4 Non-Preferred Drug 49%49%S Q:60
/30Days
STRATTERA 18MG CAPSULE   4 Non-Preferred Drug 49%49%S Q:60
/30Days
STRATTERA 25MG CAPSULE   4 Non-Preferred Drug 49%49%S Q:60
/30Days
STRATTERA 40MG CAPSULE   4 Non-Preferred Drug 49%49%S Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
STRATTERA 60MG CAPSULE   4 Non-Preferred Drug 49%49%S Q:30
/30Days
STRATTERA 80MG CAPSULE   4 Non-Preferred Drug 49%49%S Q:30
/30Days
STREPTOMYCIN FOR INJECTION 1GM/VIL   4 Non-Preferred Drug 49%49%None
STRIBILD TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
SUBOXONE 12 MG-3 MG SL FILM   3 Preferred Brand 20%20%Q:90
/30Days
Suboxone 2; 0.5mg/1; mg/1 30 POUCH per CARTON / 1 FILM, SOLUBLE in 1 POUCH   3 Preferred Brand 20%20%Q:90
/30Days
SUBOXONE 4 MG-1 MG SL FILM   3 Preferred Brand 20%20%Q:90
/30Days
Suboxone 8; 2mg/1; mg/1 30 POUCH per CARTON / 1 FILM, SOLUBLE in 1 POUCH   3 Preferred Brand 20%20%Q:90
/30Days
SUCRALFATE 1GM TABLET   2* Generic $3.00$6.00None
SULF-PRED 10-0.23% EYE DROPS   2* Generic $3.00$6.00None
SULFACETAMIDE SOD 10% TOP SUSP   4 Non-Preferred Drug 49%49%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SULFACETAMIDE SODIUM OPHTHALMIC SOLUTION USP 10% 15 ML BOT   2* Generic $3.00$6.00None
Sulfadiazine 500mg/1 100 TABLET BOTTLE   4 Non-Preferred Drug 49%49%None
SULFAMETHOXAZOLE-TMP DS TABLET [Septra DS]   1* Preferred Generic $1.00$2.00None
SULFAMETHOXAZOLE-TMP SS TABLET [Septra]   1* Preferred Generic $1.00$2.00None
SULFAMETHOXAZOLE-TMP SUSP Oral Suspension [Sultrex Pediatric]   4 Non-Preferred Drug 49%49%None
SULFAMYLON 50G PACKET   4 Non-Preferred Drug 49%49%None
SULFASALAZINE 500 MG TABLET   2* Generic $3.00$6.00None
SULFASALAZINE DR 500 MG TAB   2* Generic $3.00$6.00None
SULINDAC 150 MG TABLET   2* Generic $3.00$6.00None
SULINDAC 200 MG TABLET   2* Generic $3.00$6.00None
Sumatriptan 20 MG/ACTUAT Nasal Spray   4 Non-Preferred Drug 49%49%Q:12
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SUMATRIPTAN 4 MG/0.5 ML CART   4 Non-Preferred Drug 49%49%Q:8
/30Days
Sumatriptan 4 mg/0.5 ml inject   4 Non-Preferred Drug 49%49%Q:8
/30Days
Sumatriptan 5 MG/ACTUAT Nasal Spray   4 Non-Preferred Drug 49%49%Q:12
/30Days
SUMATRIPTAN 6 MG/0.5 ML INJECT   4 Non-Preferred Drug 49%49%Q:4
/30Days
SUMATRIPTAN 6 MG/0.5 ML INJECT   4 Non-Preferred Drug 49%49%Q:4
/30Days
SUMATRIPTAN 6 MG/0.5 ML SYRNG Syringe [Sumavel DosePro System]   4 Non-Preferred Drug 49%49%Q:4
/30Days
Sumatriptan 6 mg/0.5 ml vial   4 Non-Preferred Drug 49%49%Q:4
/30Days
SUMATRIPTAN SUCC 100 MG TABLET   2* Generic $3.00$6.00Q:9
/30Days
SUMATRIPTAN SUCC 50 MG TABLET   2* Generic $3.00$6.00Q:9
/30Days
Sumatriptan Succinate 25mg/1 9 BLISTER PACK per CARTON / 9 TABLET per BLISTER PACK   2* Generic $3.00$6.00Q:9
/30Days
SUPREP BOWEL PREP KIT SOLN RECON   4 Non-Preferred Drug 49%49%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SUTENT 12.5MG CAPSULE   5 Specialty Tier 25%N/AP Q:28
/28Days
SUTENT 25mg/1 28 CAPSULE BOTTLE   5 Specialty Tier 25%N/AP Q:28
/28Days
SUTENT 37.5 MG CAPSULE   5 Specialty Tier 25%N/AP Q:28
/28Days
SUTENT 50MG CAPSULE   5 Specialty Tier 25%N/AP Q:28
/28Days
SYLATRON 200 MCG KIT   5 Specialty Tier 25%N/AP Q:4
/28Days
SYLATRON 300 MCG KIT   5 Specialty Tier 25%N/AP Q:4
/28Days
SYLATRON 600 MCG KIT   5 Specialty Tier 25%N/AP Q:4
/28Days
SYMBICORT 160-4.5MCG HFA AEROSOL WITH ADAPTER   4 Non-Preferred Drug 49%49%S Q:12
/30Days
SYMBICORT 80; 4.5ug/1; ug/1 1 POUCH in 1 CARTON / 1 CANISTER in 1 POUCH / 120 AEROSOL in 1 CANISTER   4 Non-Preferred Drug 49%49%S Q:14
/30Days
SYMFI 600-300-300 MG TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
SYMFI LO 400-300-300 MG TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SYMLINPEN 120 PEN INJECTOR   4 Non-Preferred Drug 49%49%P Q:11
/28Days
SYMLINPEN 60 PEN INJECTOR   4 Non-Preferred Drug 49%49%P Q:6
/30Days
SYMPAZAN 10 MG FILM   5 Specialty Tier 25%N/AP Q:60
/30Days
SYMPAZAN 20 MG FILM   5 Specialty Tier 25%N/AP Q:60
/30Days
SYMPAZAN 5 MG FILM   5 Specialty Tier 25%N/AP Q:60
/30Days
SYMTUZA 800-150-200-10 MG TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
SYNAREL 2MG/ML NASAL SPRAY   5 Specialty Tier 25%N/AP
SYNJARDY 12.5-1,000 MG TABLET   3 Preferred Brand 20%20%Q:60
/30Days
SYNJARDY 12.5-500 MG TABLET   3 Preferred Brand 20%20%Q:60
/30Days
SYNJARDY 5-1,000 MG TABLET   3 Preferred Brand 20%20%Q:60
/30Days
SYNJARDY XR 10-1,000 MG TABLET BP 24H   3 Preferred Brand 20%20%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SYNJARDY XR 12.5-1,000 MG TABLET BP 24H   3 Preferred Brand 20%20%Q:60
/30Days
SYNJARDY XR 25-1,000 MG TABLET BP 24H   3 Preferred Brand 20%20%Q:30
/30Days
SYNJARDY XR 5-1,000 MG TABLET BP 24H   3 Preferred Brand 20%20%Q:60
/30Days
SYNRIBO 3.5 MG/ML VIAL   5 Specialty Tier 25%N/AP Q:28
/28Days
SYNTHROID 100 MCG TABLET   4 Non-Preferred Drug 49%49%None
SYNTHROID 112 MCG TABLET   4 Non-Preferred Drug 49%49%None
SYNTHROID 125 MCG TABLET   4 Non-Preferred Drug 49%49%None
Synthroid 137ug/1 90 TABLET BOTTLE   4 Non-Preferred Drug 49%49%None
SYNTHROID 150 MCG TABLET   4 Non-Preferred Drug 49%49%None
SYNTHROID 175 MCG TABLET   4 Non-Preferred Drug 49%49%None
SYNTHROID 200 MCG TABLET   4 Non-Preferred Drug 49%49%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
SYNTHROID 25 MCG TABLET   4 Non-Preferred Drug 49%49%None
SYNTHROID 300 MCG TABLET   4 Non-Preferred Drug 49%49%None
SYNTHROID 50 MCG TABLET   4 Non-Preferred Drug 49%49%None
SYNTHROID 75 MCG TABLET   4 Non-Preferred Drug 49%49%None
SYNTHROID 88 MCG TABLET   4 Non-Preferred Drug 49%49%None
SYPRINE 250 MG CAPSULE   5 Specialty Tier 25%N/ANone

Chart Legend:

Below are a few notes to help you understand the above 2019 Medicare Part D Cigna-HealthSpring Rx Secure-Essential (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). The plan name is followed by the plan type (PDP, HMO, HMO-POS, PPO, PFFS, etc.)

  • 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 $415 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 five (5) tiers 1=Preferred Generics, 2=Generics, 3=Preferred Brands, 4=Non-preferred Brands, 5=Specialty Drugs. *Some Part D plans exclude one or more drug tiers from the deductible. If the drug tier field above is followed by * (example: 2*), then this drug tier is excluded from the plan’s deductible.
    • Tier 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 $3820) at a "Preferred" network pharmacy. In most cases, the "Preferred" network pharmacy cost-sharing is lower than the standard (non-preferred) network pharmacy cost-sharing.
    • 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 2019 )

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.