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Cigna-HealthSpring Rx Secure (PDP) (S5617-220-0)
Tier 1 (188)
Tier 2 (725)
Tier 3 (444)
Tier 4 (1367)
Tier 5 (549)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
Yes No Show either
Cick on the first letter of your drug name to browse the formulary:

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2019 Medicare Part D Plan Formulary Information
Cigna-HealthSpring Rx Secure (PDP) (S5617-220-0)
Benefit Details           
The Cigna-HealthSpring Rx Secure (PDP) (S5617-220-0)
Formulary Drugs Starting with the Letter B

in CMS PDP Region 12 which includes: AL TN
Plan Monthly Premium: $53.50 Deductible: $415 Qualifies for LIS: No
Drugs Starting with Letter B

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Bacitracin 500 unit/gm Eye Ointment   4 Non-Preferred Drug 35%35%None
BACITRACIN/POLYMYXIN B OINT 500UNT/10000UNT   2 Generic $3.00$9.00None
BACLOFEN 10 MG TABLET   2 Generic $3.00$9.00None
BACLOFEN 20 MG TABLET   2 Generic $3.00$9.00None
BACLOFEN 5 MG TABLET   2 Generic $3.00$9.00None
BALSALAZIDE DISODIUM 750MG CAPSULE (280 CT)   4 Non-Preferred Drug 35%35%None
BALVERSA 3 MG TABLET   5 Specialty Tier 25%N/AP Q:90
/30Days
BALVERSA 4 MG TABLET   5 Specialty Tier 25%N/AP Q:60
/30Days
BALVERSA 5 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
Balziva 6 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK   4 Non-Preferred Drug 35%35%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Banzel 200mg/1   5 Specialty Tier 25%N/AP Q:60
/30Days
Banzel 40mg/mL   5 Specialty Tier 25%N/AP Q:2400
/30Days
BANZEL TABLET 400MG   5 Specialty Tier 25%N/AP Q:240
/30Days
BAXDELA 300 MG VIAL   4 Non-Preferred Drug 35%35%None
BAXDELA 450 MG TABLET   4 Non-Preferred Drug 35%35%None
BCG VACCINE 50mg/1 1 VIAL per CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL   4 Non-Preferred Drug 35%35%None
BENAZEPRIL HCL 10 MG TABLET   1 Preferred Generic $1.00$3.00Q:60
/30Days
BENAZEPRIL HCL 20 MG TABLET   1 Preferred Generic $1.00$3.00Q:60
/30Days
BENAZEPRIL HCL 40 MG TABLET   1 Preferred Generic $1.00$3.00Q:60
/30Days
BENAZEPRIL HCL 5 MG TABLET   1 Preferred Generic $1.00$3.00Q:60
/30Days
BENAZEPRIL HCL-HCTZ TABLET 10-12.5MG (100 CT)   2 Generic $3.00$9.00Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BENAZEPRIL HCL-HCTZ TABLET 20-12.5MG (100 CT)   2 Generic $3.00$9.00Q:60
/30Days
BENAZEPRIL HCL-HCTZ TABLET 20-25MG (100 CT)   2 Generic $3.00$9.00Q:30
/30Days
BENAZEPRIL HCL-HCTZ TABLET 5-6.25MG (100 CT)   2 Generic $3.00$9.00Q:30
/30Days
BENZTROPINE MES 0.5 MG Tablet [Cogentin]   2 Generic $3.00$9.00P
BENZTROPINE MES 1 MG TABLET [Cogentin]   2 Generic $3.00$9.00P
BENZTROPINE MES 2 MG TABLET [Cogentin]   2 Generic $3.00$9.00P
BESIVANCE BESIFLOACIN OPTHALMIC SUSPENSION 0.6% 5 ML BOTDR   4 Non-Preferred Drug 35%35%None
Betamethasone Dipropionate 0.64mg/g / 45 g TUBE   3 Preferred Brand $30.00$90.00None
BETAMETHASONE DP 0.05% LOT   3 Preferred Brand $30.00$90.00None
Betamethasone DP 0.05% ointment   3 Preferred Brand $30.00$90.00None
BETAMETHASONE DP AUG 0.05% CRM   2 Generic $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BETAMETHASONE DP AUG 0.05% GEL   3 Preferred Brand $30.00$90.00None
BETAMETHASONE DP AUG 0.05% LOT   4 Non-Preferred Drug 35%35%None
BETAMETHASONE DP AUG 0.05% OIN   4 Non-Preferred Drug 35%35%None
BETAMETHASONE VA 0.1% CREAM   3 Preferred Brand $30.00$90.00None
BETAMETHASONE VALERATE 0.1% LOTION   3 Preferred Brand $30.00$90.00None
BETAMETHASONE VALERATE 0.12% FOAM   4 Non-Preferred Drug 35%35%None
BETAMETHASONE VALERATE OINTMENT USP   3 Preferred Brand $30.00$90.00None
BETASERON 0.3 MG KIT   5 Specialty Tier 25%N/AP Q:14
/28Days
BETAXOLOL 10 MG TABLET   2 Generic $3.00$9.00None
BETAXOLOL 20 MG TABLET   2 Generic $3.00$9.00None
Betaxolol 5 MG/ML Ophthalmic Solution   4 Non-Preferred Drug 35%35%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BETHANECHOL 10 MG TABLET   3 Preferred Brand $30.00$90.00None
BETHANECHOL 25 MG TABLET   3 Preferred Brand $30.00$90.00None
BETHANECHOL 5 MG TABLET   3 Preferred Brand $30.00$90.00None
BETHANECHOL 50 MG TABLET   3 Preferred Brand $30.00$90.00None
BEXAROTENE 75 MG CAPSULE [Targretin]   5 Specialty Tier 25%N/ANone
BEXSERO PREFILLED SYRINGE   4 Non-Preferred Drug 35%35%None
BICALUTAMIDE 50 MG TABLET   3 Preferred Brand $30.00$90.00Q:30
/30Days
BICILL LA PFS 600MU 1ML PED   4 Non-Preferred Drug 35%35%None
BICILLIN LA PFS 1200MU 2ML   4 Non-Preferred Drug 35%35%None
BICILLIN LA. 600000UNIT/ML 1ML   4 Non-Preferred Drug 35%35%None
BIDIL TABLET   3 Preferred Brand $30.00$90.00Q:180
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BIKTARVY 50-200-25 MG TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
Biltricide 600mg/1 6 FILM COATED TABLETS in BOTTLE   4 Non-Preferred Drug 35%35%None
BINOSTO 70 MG TABLET EFF   4 Non-Preferred Drug 35%35%None
BISOPROLOL FUMARATE 10 MG TAB   2 Generic $3.00$9.00None
BISOPROLOL FUMARATE 5 MG TAB   2 Generic $3.00$9.00None
BISOPROLOL-HCTZ 10-6.25 MG TAB   1 Preferred Generic $1.00$3.00None
BISOPROLOL-HCTZ 2.5-6.25 MG TB   1 Preferred Generic $1.00$3.00None
BISOPROLOL-HCTZ 5-6.25 MG TAB   1 Preferred Generic $1.00$3.00None
BLEPHAMIDE 10-0.2% EYE OINT   4 Non-Preferred Drug 35%35%None
BLEPHAMIDE EYE DROPS   4 Non-Preferred Drug 35%35%None
BLISOVI FE 1.5-30 TABLET   2 Generic $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BOOSTRIX TDAP VACCINE SYRINGE   4 Non-Preferred Drug 35%35%Q:1
/365Days
BOOSTRIX TDAP VACCINE VIAL   4 Non-Preferred Drug 35%35%Q:1
/365Days
BOSENTAN 125 MG TABLET [Tracleer]   5 Specialty Tier 25%N/AP Q:60
/30Days
BOSENTAN 62.5 MG TABLET [Tracleer]   5 Specialty Tier 25%N/AP Q:60
/30Days
BOSULIF 100 MG TABLET   5 Specialty Tier 25%N/AP Q:120
/30Days
BOSULIF 400 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
BOSULIF 500 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
BRAFTOVI 50 MG CAPSULE   5 Specialty Tier 25%N/AP Q:180
/30Days
BRAFTOVI 75 MG CAPSULE   5 Specialty Tier 25%N/AP Q:180
/30Days
BREO ELLIPTA 100-25 MCG INH   3 Preferred Brand $30.00$90.00Q:60
/30Days
BREO ELLIPTA 200-25 MCG INH   3 Preferred Brand $30.00$90.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BRIELLYN TABLET   2 Generic $3.00$9.00None
BRILINTA 60 MG TABLET   3 Preferred Brand $30.00$90.00Q:60
/30Days
BRILINTA 90mg/1 60 TABLET BOTTLE   3 Preferred Brand $30.00$90.00Q:60
/30Days
BRIMONIDINE 0.2% EYE DROP   2 Generic $3.00$9.00None
BRIMONIDINE TARTRATE 0.15% DRP   3 Preferred Brand $30.00$90.00None
BRIVIACT 10 MG TABLET   5 Specialty Tier 25%N/AQ:60
/30Days
BRIVIACT 10 MG/ML ORAL SOLN   5 Specialty Tier 25%N/AQ:1200
/30Days
BRIVIACT 100 MG TABLET   5 Specialty Tier 25%N/AQ:120
/30Days
BRIVIACT 25 MG TABLET   5 Specialty Tier 25%N/AQ:60
/30Days
BRIVIACT 50 MG TABLET   5 Specialty Tier 25%N/AQ:60
/30Days
BRIVIACT 75 MG TABLET   5 Specialty Tier 25%N/AQ:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BROMFENAC SODIUM 0.09% EYE DROPS [Xibrom]   4 Non-Preferred Drug 35%35%None
BROMOCRIPTINE 2.5 MG TABLET [Parlodel]   4 Non-Preferred Drug 35%35%None
BROMOCRIPTINE MESYLATE 5MG CAPSULE [Parlodel]   4 Non-Preferred Drug 35%35%None
BUDESONIDE 0.25 MG/2 ML SUSP AMPUL-NEB [Pulmicort]   4 Non-Preferred Drug 35%35%P Q:120
/30Days
BUDESONIDE 0.5 MG/2 ML SUSP AMPUL-NEB [Pulmicort]   4 Non-Preferred Drug 35%35%P Q:120
/30Days
BUDESONIDE 1 MG/2 ML INH SUSP AMPUL-NEB [Pulmicort]   4 Non-Preferred Drug 35%35%P Q:120
/30Days
BUDESONIDE EC 3 MG CAPSULE CAPDR - ER [Entocort EC]   4 Non-Preferred Drug 35%35%None
BUMETANIDE 0.25MG/ML VIAL   4 Non-Preferred Drug 35%35%None
BUMETANIDE 0.5 MG TABLET   2 Generic $3.00$9.00None
BUMETANIDE 1 MG TABLET   2 Generic $3.00$9.00None
BUMETANIDE 2 MG TABLET   3 Preferred Brand $30.00$90.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BUPRENORP-NALOX 12-3 MG SL FILM [Suboxone]   4 Non-Preferred Drug 35%35%Q:90
/30Days
BUPRENORP-NALOX 2-0.5 MG SL FILM [Suboxone]   4 Non-Preferred Drug 35%35%Q:90
/30Days
BUPRENORP-NALOX 4-1 MG SL FILM [Suboxone]   4 Non-Preferred Drug 35%35%Q:90
/30Days
BUPRENORP-NALOX 8-2 MG SL FILM [Suboxone]   4 Non-Preferred Drug 35%35%Q:90
/30Days
BUPRENORPHIN-NALOXON 2-0.5 MG SL [Suboxone]   4 Non-Preferred Drug 35%35%Q:90
/30Days
BUPRENORPHIN-NALOXON 8-2 MG SL [Suboxone]   4 Non-Preferred Drug 35%35%Q:90
/30Days
BUPRENORPHINE 2 MG TABLET Subligual [Subutex]   4 Non-Preferred Drug 35%35%P Q:90
/30Days
BUPRENORPHINE 8 MG TABLET Subligual [Subutex]   4 Non-Preferred Drug 35%35%P Q:90
/30Days
BUPROPION HCL 100 MG TABLET   3 Preferred Brand $30.00$90.00Q:120
/30Days
BUPROPION HCL 75 MG TABLET   3 Preferred Brand $30.00$90.00Q:180
/30Days
BUPROPION HCL SR 100 MG TABLET   3 Preferred Brand $30.00$90.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BUPROPION HCL SR 150 MG TABLET   3 Preferred Brand $30.00$90.00Q:60
/30Days
BUPROPION HCL SR 150 MG TABLET   3 Preferred Brand $30.00$90.00Q:60
/30Days
BUPROPION HCL SR 200 MG TABLET   3 Preferred Brand $30.00$90.00Q:60
/30Days
BUPROPION HCL XL 150 MG TABLET   3 Preferred Brand $30.00$90.00Q:30
/30Days
BUPROPION HCL XL 300 MG TABLET   3 Preferred Brand $30.00$90.00Q:30
/30Days
BUSPIRONE HCL 15 MG TABLET   2 Generic $3.00$9.00None
BUSPIRONE HCL 30 MG TABLET   2 Generic $3.00$9.00None
BUSPIRONE HCL 5 MG TABLET   2 Generic $3.00$9.00None
BUSPIRONE HCL 7.5 MG TABLET   2 Generic $3.00$9.00None
BUSPIRONE HYDROCHLORIDE 10 MG TABLETS   2 Generic $3.00$9.00None
BUTALB-ACETAMIN-CAFF 50-325-40   4 Non-Preferred Drug 35%35%P Q:180
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
BUTALBITAL COMP-CODEINE #3 CAP   4 Non-Preferred Drug 35%35%P Q:180
/30Days
BUTALBITAL-ASA-CAFFEINE CAPSULE   4 Non-Preferred Drug 35%35%P Q:180
/30Days
BUTALBITAL/ACETAMINOPHEN/CAFFEINE 50-300-40   4 Non-Preferred Drug 35%35%P Q:180
/30Days
BUTALBITAL/ACETAMINOPHEN/CAFFEINE CP   4 Non-Preferred Drug 35%35%P Q:180
/30Days
BUTORPHANOL 10MG/ML SPRAY   4 Non-Preferred Drug 35%35%Q:5
/30Days
BYDUREON 2 MG PEN INJECT   4 Non-Preferred Drug 35%35%Q:4
/28Days
BYDUREON BCISE 2 MG AUTOINJECT   4 Non-Preferred Drug 35%35%Q:4
/28Days
Bystolic 10mg/1 30 TABLET BOTTLE   4 Non-Preferred Drug 35%35%Q:30
/30Days
Bystolic 2.5mg/1 30 TABLET BOTTLE   4 Non-Preferred Drug 35%35%Q:30
/30Days
BYSTOLIC 20 MG TABLET   4 Non-Preferred Drug 35%35%Q:60
/30Days
Bystolic 5mg 30 TABLET BOTTLE   4 Non-Preferred Drug 35%35%Q:30
/30Days

Chart Legend:

Below are a few notes to help you understand the above 2019 Medicare Part D Cigna-HealthSpring Rx Secure (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.