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Cigna-HealthSpring Rx Secure-Extra (PDP) (S5617-256-0)
Tier 1 (214)
Tier 2 (832)
Tier 3 (394)
Tier 4 (1370)
Tier 5 (564)
Tier 6 (24)
Requires Prior Authorization:
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Uses Step Therapy:
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-Extra (PDP) (S5617-256-0)
Benefit Details           
The Cigna-HealthSpring Rx Secure-Extra (PDP) (S5617-256-0)
Formulary Drugs Starting with the Letter E
in CMS PDP Region 11 which includes: FL
Plan Monthly Premium: $61.70 Deductible: $100 Qualifies for LIS: No
Drugs Starting with Letter E

Drug Name		 Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order
ECONAZOLE NITRATE 1% CREAM 85GM TUBE   4 Non-Preferred Drug 50%50%None
EDARBI 40 MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
EDARBI 80 MG TABLET   4 Non-Preferred Drug 50%50%S Q:30
/30Days
EDARBYCLOR 40-12.5 MG TABLET   4 Non-Preferred Drug 50%50%S
EDARBYCLOR 40-25 MG TABLET   4 Non-Preferred Drug 50%50%S
EDURANT 27.5mg/1   5 Specialty Tier 31%N/AQ:30
/30Days
EFAVIRENZ 200 MG CAPSULE [Sustiva]   3* Preferred Brand $42.00$105.00Q:60
/30Days
EFAVIRENZ 50 MG CAPSULE [Sustiva]   3* Preferred Brand $42.00$105.00Q:90
/30Days
EFAVIRENZ 600 MG TABLET [Sustiva]   5 Specialty Tier 31%N/AQ:30
/30Days
ELIDEL 1% CREAM   4 Non-Preferred Drug 50%50%Q:100
/90Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ELIGARD 22.5 MG SYRINGE   4 Non-Preferred Drug 50%50%P Q:1
/90Days
ELIGARD 30 MG SYRINGE KIT   4 Non-Preferred Drug 50%50%P Q:1
/120Days
ELIGARD 45 MG SYRINGE KIT   4 Non-Preferred Drug 50%50%P Q:1
/180Days
ELIGARD 7.5 MG SYRINGE KIT   4 Non-Preferred Drug 50%50%P Q:1
/30Days
ELIQUIS 2.5 MG TABLET   4 Non-Preferred Drug 50%50%Q:60
/30Days
ELIQUIS 5 MG STARTER PACK   4 Non-Preferred Drug 50%50%Q:74
/30Days
ELIQUIS 5 MG TABLET   4 Non-Preferred Drug 50%50%Q:74
/30Days
ELMIRON 100mg GELATIN COATED 100 CAPSULE BOTTLE   4 Non-Preferred Drug 50%50%None
EMCYT 140MG CAPSULE   4 Non-Preferred Drug 50%50%None
EMEND 125 MG POWDER PACKET   4 Non-Preferred Drug 50%50%P Q:6
/28Days
EMOQUETTE 28 DAY TABLET [Solia]   2* Generic $10.00$25.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Empagliflozin 5 MG / Metformin hydrochloride 500 MG Oral Tablet [Synjardy]   3* Preferred Brand $42.00$105.00Q:60
/30Days
EMSAM TRANSDERMAL SYSTEM PATCHES 12MG/24H   5 Specialty Tier 31%N/AQ:30
/30Days
EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H   5 Specialty Tier 31%N/AQ:30
/30Days
EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H   5 Specialty Tier 31%N/AQ:30
/30Days
EMTRIVA 10MG/ML SOLUTION   3* Preferred Brand $42.00$105.00Q:680
/28Days
EMTRIVA 200MG CAPSULE   3* Preferred Brand $42.00$105.00Q:30
/30Days
ENALAPRIL MALEATE 10 MG TAB   1* Preferred Generic $4.00$10.00Q:60
/30Days
ENALAPRIL MALEATE 2.5 MG TAB   1* Preferred Generic $4.00$10.00Q:60
/30Days
ENALAPRIL MALEATE 20 MG TAB   1* Preferred Generic $4.00$10.00Q:60
/30Days
ENALAPRIL MALEATE 5 MG TABLET   1* Preferred Generic $4.00$10.00Q:60
/30Days
Enalapril Maleate and Hydrochlorothiazide 10; 25mg/1; mg/1 100 TABLET BOTTLE, PLASTIC   1* Preferred Generic $4.00$10.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ENALAPRIL-HCTZ 5-12.5 MG TAB   1* Preferred Generic $4.00$10.00None
ENBREL 25 MG/0.5 ML SYRINGE   5 Specialty Tier 31%N/AP Q:4
/28Days
ENBREL 25MG KIT   5 Specialty Tier 31%N/AP Q:8
/28Days
ENBREL 50 MG/ML SURECLICK SYR   5 Specialty Tier 31%N/AP Q:8
/28Days
ENBREL 50mg/mL   5 Specialty Tier 31%N/AP Q:8
/28Days
ENDOCET 10MG-325MG TABLET   4 Non-Preferred Drug 50%50%Q:180
/30Days
ENDOCET 5/325 TABLET   4 Non-Preferred Drug 50%50%Q:360
/30Days
ENDOCET 7.5-325MG TABLET   4 Non-Preferred Drug 50%50%Q:240
/30Days
ENGERIX B INJECTION   4 Non-Preferred Drug 50%50%P Q:3
/365Days
ENGERIX-B 20 MCG/ML SYRN   4 Non-Preferred Drug 50%50%P Q:8
/365Days
ENOXAPARIN 100 MG/ML SYRINGE   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ENOXAPARIN 120 MG/0.8 ML SYRINGE   4 Non-Preferred Drug 50%50%None
ENOXAPARIN 150 MG/ML SYRINGE   4 Non-Preferred Drug 50%50%None
ENOXAPARIN 30 MG/0.3 ML SYR   4 Non-Preferred Drug 50%50%None
ENOXAPARIN 40 MG/0.4 ML SYR   4 Non-Preferred Drug 50%50%None
ENOXAPARIN 60 MG/0.6 ML SYRINGE   4 Non-Preferred Drug 50%50%None
ENOXAPARIN 80 MG/0.8 ML SYRINGE   4 Non-Preferred Drug 50%50%None
ENSKYCE 28 TABLET [Solia]   3* Preferred Brand $42.00$105.00None
ENTACAPONE 200 MG TABLET [Comtan Entacapone]   4 Non-Preferred Drug 50%50%Q:240
/30Days
ENTECAVIR 0.5 MG TABLET [Baraclude]   4 Non-Preferred Drug 50%50%Q:30
/30Days
ENTECAVIR 1 MG TABLET [Baraclude]   4 Non-Preferred Drug 50%50%Q:30
/30Days
ENTRESTO 24 MG-26 MG TABLET   3* Preferred Brand $42.00$105.00Q:60
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ENTRESTO 49 MG-51 MG TABLET   3* Preferred Brand $42.00$105.00Q:60
/30Days
ENTRESTO 97 MG-103 MG TABLET   3* Preferred Brand $42.00$105.00Q:60
/30Days
ENULOSE 10 GM/15 ML SOLUTION   2* Generic $10.00$25.00None
ENVARSUS XR 0.75 MG TABLET   4 Non-Preferred Drug 50%50%P
ENVARSUS XR 1 MG TABLET   4 Non-Preferred Drug 50%50%P
ENVARSUS XR 4 MG TABLET   5 Specialty Tier 31%N/AP
EPCLUSA 400 MG-100 MG TABLET   3* Preferred Brand $42.00$105.00P Q:28
/28Days
EPIDIOLEX 100 MG/ML SOLUTION   5 Specialty Tier 31%N/AP
EPINASTINE HCL 0.05% EYE DROPS   4 Non-Preferred Drug 50%50%None
EPINEPHRINE 0.15 MG AUTO-INJCT   2* Generic $10.00$25.00Q:2
/30Days
EPINEPHRINE 0.15 MG AUTO-INJECT   2* Generic $10.00$25.00Q:2
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
EPINEPHRINE 0.3 MG AUTO-INJECT   2* Generic $10.00$25.00Q:2
/30Days
EPINEPHRINE 0.3 MG AUTO-INJECT [Twinject]   2* Generic $10.00$25.00Q:2
/30Days
EPIPEN 0.3MG AUTO-INJECTOR   3* Preferred Brand $42.00$105.00Q:2
/30Days
EPIPEN JR 0.15MG AUTO-INJCT   3* Preferred Brand $42.00$105.00Q:2
/30Days
EPITOL 200MG TABLET   2* Generic $10.00$25.00None
EPIVIR HBV 25MG/5ML TUBEX   3* Preferred Brand $42.00$105.00None
Ergotamine-caffeine 1-100mg tb   3* Preferred Brand $42.00$105.00Q:40
/28Days
ERIVEDGE 150 MG CAPSULE   5 Specialty Tier 31%N/AP Q:28
/28Days
ERLEADA 60 MG TABLET   5 Specialty Tier 31%N/AP Q:120
/30Days
ERLOTINIB HCL 100 MG TABLET [Tarceva]   5 Specialty Tier 31%N/AP Q:30
/30Days
ERLOTINIB HCL 150 MG TABLET [Tarceva]   5 Specialty Tier 31%N/AP Q:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ERLOTINIB HCL 25 MG TABLET [Tarceva]   5 Specialty Tier 31%N/AP Q:60
/30Days
Errin 0.35 mg tablet   2* Generic $10.00$25.00None
ERTAPENEM 1 GRAM VIAL [Invanz]   4 Non-Preferred Drug 50%50%None
ERY 2% PADS 2% 60 PADS JAR   4 Non-Preferred Drug 50%50%None
ERY-TAB 500mg/1 100 TABLET, DELAYED RELEASE in 1 BOTTLE   4 Non-Preferred Drug 50%50%None
ERY-TAB TAB 250MG EC   4 Non-Preferred Drug 50%50%None
ERY-TAB TAB 333MG EC   4 Non-Preferred Drug 50%50%None
ERYPED 400 MG/5 ML SUSPENSION   5 Specialty Tier 31%N/ANone
ERYTHROCIN 500MG ADDVNT VL   4 Non-Preferred Drug 50%50%None
ERYTHROCIN TAB 250MG   4 Non-Preferred Drug 50%50%None
ERYTHROMYCIN 0.5% EYE OINTMENT   2* Generic $10.00$25.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ERYTHROMYCIN 2% GEL   4 Non-Preferred Drug 50%50%None
ERYTHROMYCIN 2% SOLUTION   2* Generic $10.00$25.00None
ERYTHROMYCIN 200 MG/5 ML GRAN Oral Suspension [EryPed]   4 Non-Preferred Drug 50%50%None
ERYTHROMYCIN 400 MG/5 ML SUSP Oral Suspension [EryPed]   5 Specialty Tier 31%N/ANone
ERYTHROMYCIN 500 MG FILMTAB   4 Non-Preferred Drug 50%50%None
ERYTHROMYCIN ES 400 MG TAB   4 Non-Preferred Drug 50%50%None
ERYTHROMYCIN TAB 250MG BS   4 Non-Preferred Drug 50%50%None
ERYTHROMYCIN-BENZOYL GEL   4 Non-Preferred Drug 50%50%None
ESBRIET 267 MG CAPSULE   5 Specialty Tier 31%N/AP Q:270
/30Days
ESBRIET 267 MG TABLET   5 Specialty Tier 31%N/AP Q:270
/30Days
ESBRIET 801 MG TABLET   5 Specialty Tier 31%N/AP Q:90
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ESCITALOPRAM 10 MG TABLET [Lexapro]   2* Generic $10.00$25.00Q:60
/30Days
ESCITALOPRAM 20 MG TABLET [Lexapro]   2* Generic $10.00$25.00Q:90
/30Days
ESCITALOPRAM 5 MG TABLET [Lexapro]   2* Generic $10.00$25.00Q:30
/30Days
ESCITALOPRAM OXALATE 5 MG/5 ML [Lexapro]   4 Non-Preferred Drug 50%50%Q:600
/30Days
ESOMEPRAZOLE MAG DR 20 MG CAP [Nexium]   4 Non-Preferred Drug 50%50%Q:60
/30Days
ESOMEPRAZOLE MAG DR 40 MG CAP [Nexium]   4 Non-Preferred Drug 50%50%Q:60
/30Days
ESTARYLLA 0.25-0.035 MG TABLET [VyLibra]   2* Generic $10.00$25.00None
ESTRADIOL 0.01% CREAM   4 Non-Preferred Drug 50%50%None
Estradiol 0.025 mg patch   4 Non-Preferred Drug 50%50%P Q:8
/28Days
Estradiol 0.0375 mg patch   4 Non-Preferred Drug 50%50%P Q:8
/28Days
Estradiol 0.05 mg patch   4 Non-Preferred Drug 50%50%P Q:8
/28Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Estradiol 0.075 mg patch   4 Non-Preferred Drug 50%50%P Q:8
/28Days
Estradiol 0.1 mg patch   4 Non-Preferred Drug 50%50%P Q:8
/28Days
ESTRADIOL 0.5 MG TABLET   2* Generic $10.00$25.00P
ESTRADIOL 1 MG TABLET   2* Generic $10.00$25.00P
ESTRADIOL 10 MCG VAGINAL INSRT   4 Non-Preferred Drug 50%50%Q:18
/28Days
ESTRADIOL 2MG TABLET   2* Generic $10.00$25.00P
ESTRADIOL TDS 0.025 MG/DAY   4 Non-Preferred Drug 50%50%P Q:4
/28Days
ESTRADIOL TDS 0.0375 MG/DAY   4 Non-Preferred Drug 50%50%P Q:4
/28Days
ESTRADIOL TDS 0.05 MG/DAY   4 Non-Preferred Drug 50%50%P Q:4
/28Days
ESTRADIOL TDS 0.06 MG/DAY   4 Non-Preferred Drug 50%50%P Q:4
/28Days
ESTRADIOL TDS 0.075 MG/DAY   4 Non-Preferred Drug 50%50%P Q:4
/28Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ESTRADIOL TDS 0.1 MG/DAY   4 Non-Preferred Drug 50%50%P Q:4
/28Days
ESTRADIOL VALERATE 20mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE   4 Non-Preferred Drug 50%50%None
ESTRADIOL VALERATE 40mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE   4 Non-Preferred Drug 50%50%None
ESTRING 2MG VAGINAL RING   4 Non-Preferred Drug 50%50%Q:1
/90Days
ETHAMBUTOL HCL 400 MG TABLET   4 Non-Preferred Drug 50%50%None
Ethambutol Hydrochloride 100mg/1   4 Non-Preferred Drug 50%50%None
Ethinyl Estradiol 0.0025 MG / norethindrone acetate 0.5 MG Oral Tablet [Fyavolv]   4 Non-Preferred Drug 50%50%P
ETHINYL ESTRADIOL 0.03 MG / LEVONORGESTREL 0.05 MG ORAL TABLET) / 10 (ETHINYL ESTRADIOL 0.03 MG 6   2* Generic $10.00$25.00None
ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TAB 21   2* Generic $10.00$25.00None
ETHOSUXIMIDE 250 MG CAPSULE   4 Non-Preferred Drug 50%50%None
ETHOSUXIMIDE 250 MG/5 ML SOLN   4 Non-Preferred Drug 50%50%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
ethynodiol-eth estra 1mg-50mcg [ZOVIA]   4 Non-Preferred Drug 50%50%None
ETIDRONATE DISODIUM 400MG TABLET (60 CT)   2* Generic $10.00$25.00None
ETIDRONATE DISODIUM TABLETS 200MG 60 BOT   2* Generic $10.00$25.00None
ETODOLAC 200 MG CAPSULE [LODINE]   4 Non-Preferred Drug 50%50%None
ETODOLAC 300 MG CAPSULE [LODINE]   4 Non-Preferred Drug 50%50%None
ETODOLAC 400 MG TABLET [LODINE]   4 Non-Preferred Drug 50%50%None
ETODOLAC 500 MG TABLET [LODINE]   4 Non-Preferred Drug 50%50%None
ETODOLAC ER 400 MG TABLET [LODINE]   4 Non-Preferred Drug 50%50%None
ETODOLAC ER 500 MG TABLET [LODINE]   4 Non-Preferred Drug 50%50%None
ETODOLAC ER 600 MG TABLET [LODINE]   4 Non-Preferred Drug 50%50%None
EVOTAZ 300 MG-150 MG TABLET   5 Specialty Tier 31%N/AQ:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
EXEMESTANE 25 MG TABLET   4 Non-Preferred Drug 50%50%Q:60
/30Days
EXJADE 125MG TABLET   5 Specialty Tier 31%N/AS
EXJADE 250MG TABLET   5 Specialty Tier 31%N/AS
EXJADE 500MG TABLET   5 Specialty Tier 31%N/AS
EZETIMIBE 10 MG TABLET [Zetia]   3* Preferred Brand $42.00$105.00Q:30
/30Days
Ezetimibe-Simvastatin 10-10 MG [Vytorin]   4 Non-Preferred Drug 50%50%Q:30
/30Days
Ezetimibe-Simvastatin 10-20 MG [Vytorin]   4 Non-Preferred Drug 50%50%Q:30
/30Days
Ezetimibe-Simvastatin 10-40 MG [Vytorin]   4 Non-Preferred Drug 50%50%Q:30
/30Days
Ezetimibe-Simvastatin 10-80 MG [Vytorin]   4 Non-Preferred Drug 50%50%Q:30
/30Days

Chart Legend:

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