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Cigna-HealthSpring Rx Secure (PDP) (S5617-220-0)
Tier 1 (188)
Tier 2 (725)
Tier 3 (444)
Tier 4 (1367)
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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 T

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

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
TABLOID 40 MG TABLET   4 Non-Preferred Drug 35%35%None
Tacrolimus 0.03% ointment   4 Non-Preferred Drug 35%35%Q:100
/90Days
Tacrolimus 0.1% ointment   4 Non-Preferred Drug 35%35%Q:100
/90Days
TACROLIMUS 0.5 MG CAPSULE   4 Non-Preferred Drug 35%35%P
TACROLIMUS 1 MG CAPSULE   4 Non-Preferred Drug 35%35%P
TACROLIMUS 5 MG CAPSULE   4 Non-Preferred Drug 35%35%P
TAFINLAR 50 MG CAPSULE   5 Specialty Tier 25%N/AP Q:120
/30Days
TAFINLAR 75 MG CAPSULE   5 Specialty Tier 25%N/AP Q:120
/30Days
TAGRISSO 40 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
TAGRISSO 80 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TALZENNA 0.25 MG CAPSULE   5 Specialty Tier 25%N/AP Q:90
/30Days
TALZENNA 1 MG CAPSULE   5 Specialty Tier 25%N/AP Q:90
/30Days
TAMOXIFEN 10 MG TABLET   2 Generic $3.00$9.00None
TAMOXIFEN CITRATE 20MG TABLET (30 CT)   2 Generic $3.00$9.00None
TAMSULOSIN HCL 0.4 MG CAPSULE   2 Generic $3.00$9.00Q:60
/30Days
TARCEVA 100MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
TARCEVA 150MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
TARCEVA 25MG TABLET   5 Specialty Tier 25%N/AP Q:60
/30Days
TARGRETIN 1% GEL   5 Specialty Tier 25%N/AQ:60
/30Days
Tarina Fe 1-20 tablet   3 Preferred Brand $30.00$90.00None
Tasigna 150mg/1 4 BLISTER PACK per CARTON / 28 CAPSULE per BLISTER PACK   5 Specialty Tier 25%N/AP Q:112
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TASIGNA 200 MG CAPSULE   5 Specialty Tier 25%N/AP Q:112
/28Days
TASIGNA 50 MG CAPSULE   5 Specialty Tier 25%N/AP Q:420
/30Days
TAZAROTENE 0.1% CREAM [Tazorac]   4 Non-Preferred Drug 35%35%None
TAZICEF 1GM VIAL   4 Non-Preferred Drug 35%35%None
TAZICEF 2 GRAM VIAL   4 Non-Preferred Drug 35%35%None
TAZICEF 6 GRAM VIAL   4 Non-Preferred Drug 35%35%None
TAZORAC 0.05% CREAM   4 Non-Preferred Drug 35%35%None
TAZORAC 0.05% GEL   4 Non-Preferred Drug 35%35%Q:100
/30Days
TAZORAC 0.1% GEL   4 Non-Preferred Drug 35%35%Q:100
/30Days
TAZTIA DILTIAZEM HYDROCHLORIDE 120MG ER CAPSULES   3 Preferred Brand $30.00$90.00None
TAZTIA XT 180 MG CAPSULE   3 Preferred Brand $30.00$90.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TAZTIA XT 240MG CAPSULE SA   3 Preferred Brand $30.00$90.00None
TAZTIA XT 300 MG CAPSULE   3 Preferred Brand $30.00$90.00None
TECFIDERA DR 120 MG CAPSULE   5 Specialty Tier 25%N/AP Q:14
/30Days
TECFIDERA DR 240 MG CAPSULE   5 Specialty Tier 25%N/AP Q:60
/30Days
TECFIDERA STARTER PACK   5 Specialty Tier 25%N/AP Q:120
/365Days
Teflaro 400mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE   5 Specialty Tier 25%N/ANone
Teflaro 600mg/20mL 10 VIAL, SINGLE-DOSE per CARTON / 20 mL in 1 VIAL, SINGLE-DOSE   5 Specialty Tier 25%N/ANone
TELMISARTAN 20 MG TABLET [Micardis]   2 Generic $3.00$9.00Q:30
/30Days
TELMISARTAN 40 MG TABLET [Micardis]   2 Generic $3.00$9.00Q:30
/30Days
TELMISARTAN 80 MG TABLET [Micardis]   2 Generic $3.00$9.00Q:60
/30Days
Telmisartan-Amlodipine 40-10 MG [Micardis]   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
Telmisartan-Amlodipine 40-5 MG [Micardis]   2 Generic $3.00$9.00Q:30
/30Days
Telmisartan-Amlodipine 80-10 MG [Micardis]   2 Generic $3.00$9.00Q:30
/30Days
Telmisartan-Amlodipine 80-5 MG [Micardis]   2 Generic $3.00$9.00Q:30
/30Days
TELMISARTAN-HCTZ 40-12.5 MG TB [Micardis]   2 Generic $3.00$9.00Q:30
/30Days
TELMISARTAN-HCTZ 80-12.5 MG TAB [Micardis HCT]   2 Generic $3.00$9.00Q:60
/30Days
TELMISARTAN-HCTZ 80-25 MG TAB [Micardis HCT]   2 Generic $3.00$9.00Q:30
/30Days
TEMAZEPAM 15 MG CAPSULE   2 Generic $3.00$9.00Q:60
/365Days
TEMAZEPAM 22.5 MG CAPSULE   4 Non-Preferred Drug 35%35%Q:60
/365Days
TEMAZEPAM 30 MG CAPSULE   2 Generic $3.00$9.00Q:60
/365Days
Temazepam 7.5mg/1 100 CAPSULE BOTTLE, PLASTIC   4 Non-Preferred Drug 35%35%Q:60
/365Days
TENIVAC SYRINGE   4 Non-Preferred Drug 35%35%Q:1
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TENOFOVIR DISOP FUM 300 MG TABLET [Viread]   5 Specialty Tier 25%N/AQ:30
/30Days
TERAZOSIN 1 MG CAPSULE   1 Preferred Generic $1.00$3.00None
TERAZOSIN 10 MG CAPSULE [Hytrin]   1 Preferred Generic $1.00$3.00Q:60
/30Days
TERAZOSIN 2 MG CAPSULE   1 Preferred Generic $1.00$3.00None
TERAZOSIN 5 MG CAPSULE [Hytrin]   1 Preferred Generic $1.00$3.00None
TERBINAFINE HCL 250 MG TABLET   2 Generic $3.00$9.00Q:90
/365Days
TERBUTALINE SULFATE 2.5 MG TAB   4 Non-Preferred Drug 35%35%None
TERBUTALINE SULFATE 5MG TABLET   4 Non-Preferred Drug 35%35%None
TERCONAZOLE 0.4% CREAM WITH APPLICATOR   4 Non-Preferred Drug 35%35%None
TERCONAZOLE 0.8% CREAM   4 Non-Preferred Drug 35%35%None
TERCONAZOLE 80MG SUPPOSITORY VAGINAL   4 Non-Preferred Drug 35%35%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TESTOSTERONE 12.5 MG/1.25 GRAM   4 Non-Preferred Drug 35%35%P Q:300
/30Days
Testosterone 2500 MG 0.01 MG/MG Topical Gel   4 Non-Preferred Drug 35%35%P Q:300
/30Days
Testosterone 5000 MG 0.01 MG/MG Topical Gel   4 Non-Preferred Drug 35%35%P Q:300
/30Days
Testosterone cyp 100 mg/ml   4 Non-Preferred Drug 35%35%None
TESTOSTERONE CYP 200 MG/ML   4 Non-Preferred Drug 35%35%None
TESTOSTERONE ENANTHATE 200MG/ML INJECTION   4 Non-Preferred Drug 35%35%Q:5
/30Days
TETRABENAZINE 12.5 MG TABLET [XENAZINE]   5 Specialty Tier 25%N/AP Q:90
/30Days
TETRABENAZINE 25 MG TABLET [XENAZINE]   5 Specialty Tier 25%N/AP Q:120
/30Days
TETRACYCLINE 250 MG CAPSULE   4 Non-Preferred Drug 35%35%None
TETRACYCLINE 500 MG CAPSULE   4 Non-Preferred Drug 35%35%None
TEXACORT 2.5% SOLUTION   3 Preferred Brand $30.00$90.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
THALOMID 100 MG CAPSULE   5 Specialty Tier 25%N/AP Q:28
/28Days
THALOMID 150 MG CAPSULE   5 Specialty Tier 25%N/AP Q:28
/28Days
THALOMID 200 MG CAPSULE   5 Specialty Tier 25%N/AP Q:56
/28Days
THALOMID 50 MG CAPSULE   5 Specialty Tier 25%N/AP Q:28
/28Days
THEOPHYLLINE ER 100 MG TABLET   2 Generic $3.00$9.00None
THEOPHYLLINE ER 200 MG TABLET   2 Generic $3.00$9.00None
THEOPHYLLINE ER 300 MG TAB   2 Generic $3.00$9.00None
THEOPHYLLINE ER 400 MG TABLET   2 Generic $3.00$9.00None
THEOPHYLLINE ER 600 MG TABLET   2 Generic $3.00$9.00None
THIORIDAZINE 10 MG TABLET   4 Non-Preferred Drug 35%35%None
THIORIDAZINE 100MG TABLET   4 Non-Preferred Drug 35%35%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
THIORIDAZINE 25 MG TABLET   4 Non-Preferred Drug 35%35%None
THIORIDAZINE 50 MG TABLET   4 Non-Preferred Drug 35%35%None
THIOTHIXENE 1 MG CAPSULE   4 Non-Preferred Drug 35%35%None
THIOTHIXENE 10MG CAPSULE   4 Non-Preferred Drug 35%35%None
THIOTHIXENE 2MG CAPSULE   4 Non-Preferred Drug 35%35%None
THIOTHIXENE 5MG CAPSULE   4 Non-Preferred Drug 35%35%None
THYROLAR-1 TABLETS   3 Preferred Brand $30.00$90.00None
THYROLAR-1/2 TABLETS   3 Preferred Brand $30.00$90.00None
THYROLAR-1/4 TABLETS   3 Preferred Brand $30.00$90.00None
THYROLAR-2 TABLETS   3 Preferred Brand $30.00$90.00None
THYROLAR-3 TABLETS   3 Preferred Brand $30.00$90.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TIAGABINE HCL 12 MG TABLET [Gabitril]   4 Non-Preferred Drug 35%35%S
TIAGABINE HCL 16 MG TABLET [Gabitril]   4 Non-Preferred Drug 35%35%S
tiagabine hcl 2 mg tablet [Gabitril]   4 Non-Preferred Drug 35%35%S
tiagabine hcl 4 mg tablet [Gabitril]   4 Non-Preferred Drug 35%35%S
TIBSOVO 250 MG TABLET   5 Specialty Tier 25%N/AP Q:60
/30Days
TIGECYCLINE 50 MG VIAL [Tygacil]   5 Specialty Tier 25%N/ANone
TIMOLOL 0.25% EYE DROPS   1 Preferred Generic $1.00$3.00None
TIMOLOL 0.25% GFS GEL-SOLUTION   4 Non-Preferred Drug 35%35%None
TIMOLOL 0.5% EYE DROPS   1 Preferred Generic $1.00$3.00None
TIMOLOL 0.5% GFS GEL-SOLUTION   4 Non-Preferred Drug 35%35%None
TIMOLOL MALEATE 10MG TABLET   4 Non-Preferred Drug 35%35%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TIMOLOL MALEATE 20MG TABLET   4 Non-Preferred Drug 35%35%None
TIMOLOL MALEATE 5MG TABLET   4 Non-Preferred Drug 35%35%None
TIVICAY 10 MG TABLET   4 Non-Preferred Drug 35%35%Q:60
/30Days
TIVICAY 25 MG TABLET   5 Specialty Tier 25%N/AQ:60
/30Days
TIVICAY 50 MG TABLET   5 Specialty Tier 25%N/AQ:60
/30Days
TIZANIDINE HCL 2 MG TABLET   2 Generic $3.00$9.00None
TIZANIDINE HCL 4 MG TABLET   2 Generic $3.00$9.00None
TOBI PODHALER 28 MG INHALE CAP   5 Specialty Tier 25%N/AQ:1568
/365Days
TOBRADEX EYE OINTMENT   3 Preferred Brand $30.00$90.00None
TOBRAMYCIN 0.3% EYE DROPS [Tobrex]   2 Generic $3.00$9.00None
TOBRAMYCIN 10 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate]   4 Non-Preferred Drug 35%35%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TOBRAMYCIN 300 MG/5 ML AMPULE [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate]   5 Specialty Tier 25%N/AP
TOBRAMYCIN 40 MG/ML VIAL [Bethkis, Tobi, Tobi Podhaler, Tobramycin Sulfate]   4 Non-Preferred Drug 35%35%None
TOBRAMYCIN-DEXAMETH OPTH SUSP   3 Preferred Brand $30.00$90.00None
TOLAK 4% CREAM   4 Non-Preferred Drug 35%35%None
TOLTERODINE TARTRATE 1 MG TAB [Detrol LA]   4 Non-Preferred Drug 35%35%Q:60
/30Days
TOLTERODINE TARTRATE 2 MG TABLET [Detrol]   4 Non-Preferred Drug 35%35%Q:60
/30Days
TOLVAPTAN 15 MG ORAL TABLET [SAMSCA]   5 Specialty Tier 25%N/AP Q:30
/30Days
TOLVAPTAN 30 MG ORAL TABLET [SAMSCA]   5 Specialty Tier 25%N/AP Q:60
/30Days
TOPIRAMATE 100 MG TABLET   2 Generic $3.00$9.00None
TOPIRAMATE 15 MG SPRINKLE CAP   2 Generic $3.00$9.00None
TOPIRAMATE 200 MG TABLET   2 Generic $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TOPIRAMATE 25 MG TABLET   2 Generic $3.00$9.00None
Topiramate 25mg/1   2 Generic $3.00$9.00None
TOPIRAMATE 50 MG TABLET   2 Generic $3.00$9.00None
TOREMIFENE CITRATE 60 MG TABLET [Fareston]   5 Specialty Tier 25%N/AQ:30
/30Days
TORSEMIDE 10 MG TABLET   2 Generic $3.00$9.00None
TORSEMIDE 100 MG TABLET   2 Generic $3.00$9.00None
TORSEMIDE 20 MG TABLET   2 Generic $3.00$9.00None
TORSEMIDE 5 MG TABLET   2 Generic $3.00$9.00None
TOUJEO MAX SOLOSTAR 300UNIT/ML INSULN PEN   3 Preferred Brand $30.00$90.00None
TOUJEO SOLOSTAR 300 UNITS/ML   3 Preferred Brand $30.00$90.00None
TPN ELECTROLYTES16.5/25.4 VIAL   4 Non-Preferred Drug 35%35%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRACLEER 125MG TABLET   5 Specialty Tier 25%N/AP Q:60
/30Days
TRACLEER 32 MG TABLET FOR SUSP   5 Specialty Tier 25%N/AP
TRACLEER 62.5MG TABLET   5 Specialty Tier 25%N/AP Q:60
/30Days
TRADJENTA 5 MG TABLET   3 Preferred Brand $30.00$90.00Q:30
/30Days
TRAMADOL HCL 50 MG TABLET   2 Generic $3.00$9.00Q:240
/30Days
TRAMADOL-ACETAMINOPHN 37.5-325   4 Non-Preferred Drug 35%35%Q:240
/30Days
TRANDOLAPRIL 1 MG TABLET   2 Generic $3.00$9.00Q:30
/30Days
TRANDOLAPRIL 2 MG TABLET   2 Generic $3.00$9.00Q:60
/30Days
TRANDOLAPRIL 4 MG TABLET   2 Generic $3.00$9.00Q:60
/30Days
tranexamic acid 650 mg tablet   3 Preferred Brand $30.00$90.00Q:30
/28Days
TRANSDERM-SCOP 1.5 MG/3 DAY   4 Non-Preferred Drug 35%35%Q:10
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRANYLCYPROMINE SULF 10 MG TABLET [Parnate]   4 Non-Preferred Drug 35%35%None
TRAVASOL 10% SOLUTION VIAFLEX   4 Non-Preferred Drug 35%35%P
TRAVATAN Z 0.04MG DROPS 2.5ML BOT   3 Preferred Brand $30.00$90.00Q:5
/30Days
TRAZODONE 100 MG TABLET   2 Generic $3.00$9.00None
TRAZODONE 300 MG TABLET   2 Generic $3.00$9.00None
TRAZODONE 50 MG TABLET   2 Generic $3.00$9.00None
TRAZODONE HCL TABLET USP 150MG (100 CT)   2 Generic $3.00$9.00None
TRECATOR 250MG TABLET   3 Preferred Brand $30.00$90.00None
TRELEGY ELLIPTA 100-62.5-25   3 Preferred Brand $30.00$90.00Q:60
/30Days
TRELSTAR 11.25 MG SYRINGE   5 Specialty Tier 25%N/AP Q:1
/84Days
TRELSTAR 3.75 MG SYRINGE   5 Specialty Tier 25%N/AP Q:1
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRESIBA 100 UNIT/ML VIAL   3 Preferred Brand $30.00$90.00None
TRESIBA FLEXTOUCH 100 UNITS/ML   3 Preferred Brand $30.00$90.00None
TRESIBA FLEXTOUCH 200 UNITS/ML   3 Preferred Brand $30.00$90.00None
Tretinoin 0.0004 MG/MG Topical Gel   4 Non-Preferred Drug 35%35%P
Tretinoin 0.001 MG/MG Topical Gel   4 Non-Preferred Drug 35%35%P
TRETINOIN 0.01% GEL   3 Preferred Brand $30.00$90.00P Q:45
/30Days
TRETINOIN 0.025% CREAM   4 Non-Preferred Drug 35%35%P Q:45
/30Days
TRETINOIN 0.025% GEL   4 Non-Preferred Drug 35%35%P
TRETINOIN 0.05% CREAM   4 Non-Preferred Drug 35%35%P Q:45
/30Days
TRETINOIN 0.05% GEL [Atralin]   4 Non-Preferred Drug 35%35%P Q:45
/30Days
TRETINOIN 0.1% CREAM   4 Non-Preferred Drug 35%35%P Q:45
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRETINOIN 10MG CAPSULE   5 Specialty Tier 25%N/ANone
TRI-ESTARYLLA TABLET [Trinessa]   3 Preferred Brand $30.00$90.00None
TRI-LEGEST FE 5-7-9-7 TABLET   3 Preferred Brand $30.00$90.00None
TRI-MILI 28 TABLET [Trinessa]   2 Generic $3.00$9.00None
TRI-PREVIFEM TABLET [Trinessa]   2 Generic $3.00$9.00None
TRI-SPRINTEC 7DAYSX3 28 TABLET   2 Generic $3.00$9.00None
TRI-VYLIBRA 28 TABLET [Trinessa]   2 Generic $3.00$9.00None
TRIAMCINOLONE 0.025% CREAM   2 Generic $3.00$9.00None
TRIAMCINOLONE 0.025% LOTION   3 Preferred Brand $30.00$90.00None
TRIAMCINOLONE 0.025% OINT   2 Generic $3.00$9.00None
TRIAMCINOLONE 0.1% CREAM   2 Generic $3.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRIAMCINOLONE 0.1% LOTION [Kenalog]   3 Preferred Brand $30.00$90.00None
TRIAMCINOLONE 0.1% OINTMENT   2 Generic $3.00$9.00None
TRIAMCINOLONE 0.1% PASTE   4 Non-Preferred Drug 35%35%None
TRIAMCINOLONE ACETONIDE 0.05% OINTMENT 15GM TUBE   2 Generic $3.00$9.00None
Triamcinolone Acetonide 1 MG/ML Topical Cream [Triderm]   2 Generic $3.00$9.00None
Triamcinolone Acetonide 5mg/g 1 TUBE per CARTON / 15 g in 1 TUBE   2 Generic $3.00$9.00None
TRIAMTERENE-HCTZ 37.5-25 MG CP   1 Preferred Generic $1.00$3.00None
TRIAMTERENE-HCTZ 37.5-25 MG TB   1 Preferred Generic $1.00$3.00None
TRIAMTERENE-HCTZ 75-50 MG TAB   1 Preferred Generic $1.00$3.00None
TRIENTINE HCL 250 MG CAPSULE [Syprine]   5 Specialty Tier 25%N/ANone
TRIFLUOPERAZINE 1 MG TABLET   4 Non-Preferred Drug 35%35%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRIFLUOPERAZINE HCL 2MG TABLET   4 Non-Preferred Drug 35%35%None
TRIFLUOPERAZINE HCL 5MG TABLET   4 Non-Preferred Drug 35%35%None
TRIFLUOPERAZINE HCL USP 10MG TABLET (100 CT)   4 Non-Preferred Drug 35%35%None
TRIFLURIDINE 1% OPTH SOLUTION 7.5ML BOT   4 Non-Preferred Drug 35%35%None
TRIHEXYPHENIDYL 2 MG TABLET   2 Generic $3.00$9.00P
TRIHEXYPHENIDYL 5 MG TABLET   2 Generic $3.00$9.00P
Trihexyphenidyl Hydrochloride 2mg/5mL 473 mL in 1 BOTTLE   2 Generic $3.00$9.00P
TRILYTE WITH FLAVOR PACKETS   2 Generic $3.00$9.00None
TRIMETHOPRIM 100 MG TABLET   2 Generic $3.00$9.00None
TRIMIPRAMINE MALEATE 100 MG CP   4 Non-Preferred Drug 35%35%P
TRIMIPRAMINE MALEATE 25 MG CAP   4 Non-Preferred Drug 35%35%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRIMIPRAMINE MALEATE 50 MG CAP   4 Non-Preferred Drug 35%35%P
TRINTELLIX 10 MG TABLET   4 Non-Preferred Drug 35%35%S Q:30
/30Days
TRINTELLIX 20 MG TABLET   4 Non-Preferred Drug 35%35%S Q:30
/30Days
TRINTELLIX 5 MG TABLET   4 Non-Preferred Drug 35%35%S Q:30
/30Days
Triptorelin 11.3 MG/ML Injectable Suspension [Trelstar]   5 Specialty Tier 25%N/AP Q:1
/168Days
TRIUMEQ TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
TRIVORA-28 TABLET   2 Generic $3.00$9.00None
TROPHAMINE INJECTION SOLUTION   4 Non-Preferred Drug 35%35%P
TROPHAMINE INJECTION SOLUTION 6%   4 Non-Preferred Drug 35%35%P
TRULANCE 3 MG TABLET   4 Non-Preferred Drug 35%35%Q:30
/30Days
TRULICITY 0.75 MG/0.5 ML PEN   3 Preferred Brand $30.00$90.00Q:2
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TRULICITY 1.5 MG/0.5 ML PEN   3 Preferred Brand $30.00$90.00Q:2
/28Days
TRUMENBA 120 MCG/0.5 ML VACCIN Syringe   4 Non-Preferred Drug 35%35%None
TRUVADA 100 MG-150 MG TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
TRUVADA 133 MG-200 MG TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
TRUVADA 167 MG-250 MG TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
TRUVADA 200/300MG TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
TWINRIX VACCINE SYRINGE   4 Non-Preferred Drug 35%35%None
TYBOST 150 MG TABLET   3 Preferred Brand $30.00$90.00Q:30
/30Days
TYDEMY TABLET   2 Generic $3.00$9.00None
TYKERB 250 MG TABLET   5 Specialty Tier 25%N/AP Q:180
/30Days
TYPHIM VI 25 MCG/0.5 ML SYRINGE   4 Non-Preferred Drug 35%35%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
TYPHIM VI 25MCG/0.5ML VIAL   4 Non-Preferred Drug 35%35%None

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.