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Cigna-HealthSpring Rx Secure (PDP) (S5617-088-0)
Tier 1 (82)
Tier 2 (653)
Tier 3 (600)
Tier 4 (1356)
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M N O P Q R S T U V W X Y Z 0-9 
2020 Medicare Part D Plan Formulary Information
Cigna-HealthSpring Rx Secure (PDP) (S5617-088-0)
Benefit Details           
The Cigna-HealthSpring Rx Secure (PDP) (S5617-088-0)
Formulary Drugs Starting with the Letter C
in CMS PDP Region 18 which includes: MO
Plan Monthly Premium: $29.00 Deductible: $435 Qualifies for LIS: Yes
Drugs Starting with Letter C

Drug Name		 Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order
CABERGOLINE 0.5 MG TABLET   4 Non-Preferred Drug 37%37%None
CABOMETYX 20 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
CABOMETYX 40 MG TABLET   5 Specialty Tier 25%N/AP Q:60
/30Days
CABOMETYX 60 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
CALCIPOTRIENE 0.005% CREAM (g) [Dovonex]   4 Non-Preferred Drug 37%37%Q:120
/30Days
CALCIPOTRIENE 0.005% OINTMENT [Dovonex]   4 Non-Preferred Drug 37%37%Q:120
/30Days
CALCIPOTRIENE 0.005% SOLUTION [Dovonex Scalp]   3 Preferred Brand $30.00$90.00None
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY   3 Preferred Brand $30.00$90.00None
CALCITRIOL 0.25 MCG CAPSULE [Rocaltrol]   2 Generic $2.00$6.00None
CALCITRIOL 0.5 MCG CAPSULE [Rocaltrol]   2 Generic $2.00$6.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CALCITRIOL 1 MCG/ML SOLUTION ORAL   2 Generic $2.00$6.00None
CALCIUM ACETATE 667 MG GELCAPSULE [PhosLo]   6 Select Care Drugs $0.00$0.00None
CALCIUM ACETATE 667 MG TABLET [PhosLo]   6 Select Care Drugs $0.00$0.00None
CALQUENCE 100 MG CAPSULE   5 Specialty Tier 25%N/AP Q:60
/30Days
CAMILA 0.35 MG TABLET [Sharobel 28-Day]   3 Preferred Brand $30.00$90.00None
CAMRESE LO TABLET   4 Non-Preferred Drug 37%37%None
CANDESARTAN CILEXETIL 16 MG TABLET [Atacand]   2 Generic $2.00$6.00Q:60
/30Days
CANDESARTAN CILEXETIL 32 MG TABLET [Atacand]   2 Generic $2.00$6.00Q:30
/30Days
CANDESARTAN CILEXETIL 4 MG TABLET [Atacand]   2 Generic $2.00$6.00Q:60
/30Days
CANDESARTAN CILEXETIL 8 MG TABLET [Atacand]   2 Generic $2.00$6.00Q:60
/30Days
CANDESARTAN-HCTZ 16-12.5 MG TABLET [Atacand HCT]   2 Generic $2.00$6.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CANDESARTAN-HCTZ 32-12.5 MG TABLET [Atacand HCT]   2 Generic $2.00$6.00None
CANDESARTAN-HCTZ 32-25 MG TABLET [Atacand HCT]   2 Generic $2.00$6.00None
CAPLYTA 42 MG CAPSULE   4 Non-Preferred Drug 37%37%S Q:30
/30Days
CAPRELSA 100 MG TABLET   5 Specialty Tier 25%N/AP Q:60
/30Days
CAPRELSA 300 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
CAPTOPRIL 100MG TABLET   4 Non-Preferred Drug 37%37%None
CAPTOPRIL 12.5MG TABLET   4 Non-Preferred Drug 37%37%None
CAPTOPRIL 25 MG TABLET   4 Non-Preferred Drug 37%37%None
CAPTOPRIL 50MG TABLET   4 Non-Preferred Drug 37%37%None
Captopril and Hydrochlorothiazide 25; 15mg 100 TABLET BOTTLE   4 Non-Preferred Drug 37%37%None
Captopril and Hydrochlorothiazide 25; 25mg 100 TABLET BOTTLE   4 Non-Preferred Drug 37%37%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Captopril and Hydrochlorothiazide 50; 15mg 100 TABLET BOTTLE   4 Non-Preferred Drug 37%37%None
Captopril and Hydrochlorothiazide 50; 25mg 100 TABLET BOTTLE   4 Non-Preferred Drug 37%37%None
CARAFATE SUS 1GM/10ML   4 Non-Preferred Drug 37%37%None
CARBAGLU 200 MG DISPER TABLET   5 Specialty Tier 25%N/AP
CARBAMAZEPINE 100 MG TABLET CHEW   3 Preferred Brand $30.00$90.00None
CARBAMAZEPINE 100 MG/5 ML SUSP   4 Non-Preferred Drug 37%37%None
CARBAMAZEPINE 200 MG TABLET [Tegretol]   3 Preferred Brand $30.00$90.00None
CARBAMAZEPINE ER 100 MG CAPSULE CPMP 12HR [Carbatrol]   4 Non-Preferred Drug 37%37%None
CARBAMAZEPINE ER 100 MG TABLET   4 Non-Preferred Drug 37%37%None
CARBAMAZEPINE ER 200 MG CAPSULE CPMP 12HR [Carbatrol]   4 Non-Preferred Drug 37%37%None
CARBAMAZEPINE ER 300 MG CAPSULE CPMP 12HR [Carbatrol]   4 Non-Preferred Drug 37%37%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CARBAMAZEPINE XR 200 MG TABLET   4 Non-Preferred Drug 37%37%None
CARBAMAZEPINE XR 400 MG TABLET   4 Non-Preferred Drug 37%37%None
CARBIDOPA 25 MG TABLET [Lodosyn]   5 Specialty Tier 25%N/ANone
CARBIDOPA AND LEVEDOPA ORALLY DISINTEGRATING TABLETS 10;100MG;MG 100 BOT   4 Non-Preferred Drug 37%37%None
CARBIDOPA AND LEVODOPA ODT 25;100MG;MG 100 BOT   4 Non-Preferred Drug 37%37%None
CARBIDOPA AND LEVODOPA ODT 25;250MG;MG 100 BOT   4 Non-Preferred Drug 37%37%None
CARBIDOPA-LEVO ER 25-100 TABLET [SINEMET CR]   3 Preferred Brand $30.00$90.00None
CARBIDOPA-LEVO ER 50-200 TABLET [SINEMET CR]   3 Preferred Brand $30.00$90.00None
CARBIDOPA-LEVODOPA 10-100 TABLET [SINEMET]   2 Generic $2.00$6.00None
CARBIDOPA-LEVODOPA 25-100 TABLET   2 Generic $2.00$6.00None
CARBIDOPA-LEVODOPA 25-250 TABLET   2 Generic $2.00$6.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CARTEOLOL HCL 1% EYE DROPS   2 Generic $2.00$6.00None
CARTIA XT 120MG CAPSULE SA   3 Preferred Brand $30.00$90.00None
CARTIA XT 180MG CAPSULE SA   3 Preferred Brand $30.00$90.00None
CARTIA XT 240MG CAPSULE SA   3 Preferred Brand $30.00$90.00None
CARTIA XT 300 MG CAPSULE   3 Preferred Brand $30.00$90.00None
CARVEDILOL 12.5 MG TABLET   6 Select Care Drugs $0.00$0.00None
CARVEDILOL 25 MG TABLET [Coreg]   6 Select Care Drugs $0.00$0.00None
CARVEDILOL 3.125 MG TABLET [Coreg]   6 Select Care Drugs $0.00$0.00None
CARVEDILOL 6.25 MG TABLET [Coreg]   6 Select Care Drugs $0.00$0.00None
CASPOFUNGIN ACETATE 50 MG VIAL   5 Specialty Tier 25%N/AP
CASPOFUNGIN ACETATE 70 MG VIAL   5 Specialty Tier 25%N/AP
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CAYSTON KIT 75 MG/VIAL   5 Specialty Tier 25%N/AP Q:84
/56Days
CAZIANT 28 DAY TABLET   4 Non-Preferred Drug 37%37%None
CEFACLOR 125 MG/5 ML ORAL SUSPENSION [Ceclor]   4 Non-Preferred Drug 37%37%None
CEFACLOR 250 MG CAPSULES   4 Non-Preferred Drug 37%37%None
CEFACLOR 250 MG/5 ML ORAL SUSPENSION [Ceclor]   4 Non-Preferred Drug 37%37%None
CEFACLOR 375 MG/5 ML ORAL SUSPENSION [Ceclor]   4 Non-Preferred Drug 37%37%None
CEFACLOR 500 MG CAPSULES   4 Non-Preferred Drug 37%37%None
CEFACLOR ER 500MG TABLET SR 12HR   4 Non-Preferred Drug 37%37%None
CEFADROXIL 1 GM TABLET   3 Preferred Brand $30.00$90.00None
CEFADROXIL 250 MG/5 ML ORAL SUSPENSION [Duricef]   3 Preferred Brand $30.00$90.00None
CEFADROXIL 500 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
CEFADROXIL 500 MG/5 ML SUSPENSION   3 Preferred Brand $30.00$90.00None
CEFAZOLIN 1 GM VIAL 25/Box   4 Non-Preferred Drug 37%37%None
Cefazolin 10g/1 10 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 PACKAGE   4 Non-Preferred Drug 37%37%None
CEFAZOLIN 500 MG VIAL   4 Non-Preferred Drug 37%37%None
CEFDINIR 125 MG/5 ML SUSPENSION   4 Non-Preferred Drug 37%37%None
CEFDINIR 250 MG/5 ML ORAL SUSPENSION [Omnicef]   4 Non-Preferred Drug 37%37%None
CEFDINIR 300 MG CAPSULE   4 Non-Preferred Drug 37%37%None
CEFEPIME HCL 1 GM VIAL [Maxipime]   4 Non-Preferred Drug 37%37%None
CEFEPIME HCL 2 GRAM VIAL [Maxipime]   4 Non-Preferred Drug 37%37%None
CEFIXIME 100 MG/5 ML SUSPENSION [Suprax]   4 Non-Preferred Drug 37%37%None
CEFIXIME 200 MG/5 ML SUSPENSION [Suprax]   4 Non-Preferred Drug 37%37%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CEFIXIME 400 MG CAPSULE [Suprax]   4 Non-Preferred Drug 37%37%Q:30
/30Days
CEFOTETAN 1GM VIAL 1EA x 10   4 Non-Preferred Drug 37%37%None
CEFOTETAN 2GM VIAL 1EA x 10   4 Non-Preferred Drug 37%37%None
CEFOXITIN 1 GM VIAL [Mefoxin]   4 Non-Preferred Drug 37%37%None
CEFOXITIN 10 GM VIAL   4 Non-Preferred Drug 37%37%None
CEFOXITIN 2 GM VIAL [Mefoxin]   4 Non-Preferred Drug 37%37%None
CEFPODOXIME 100 MG TABLET [Vantin]   4 Non-Preferred Drug 37%37%None
CEFPODOXIME 100 MG/5 ML ORAL SUSPENSION [Vantin]   4 Non-Preferred Drug 37%37%None
CEFPODOXIME 200 MG TABLET   4 Non-Preferred Drug 37%37%None
CEFPODOXIME 50 MG/5 ML SUSPENSION   4 Non-Preferred Drug 37%37%None
CEFPROZIL 125 MG/5 ML SUSPENSION   3 Preferred Brand $30.00$90.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CEFPROZIL 250 MG TABLET   3 Preferred Brand $30.00$90.00None
CEFPROZIL 250 MG/5 ML SUSPENSION   3 Preferred Brand $30.00$90.00None
CEFPROZIL 500 MG TABLET   3 Preferred Brand $30.00$90.00None
CEFTAZIDIME 1 GM VIAL [Tazidime]   4 Non-Preferred Drug 37%37%None
CEFTAZIDIME FOR INJECTION 2GM/VIAL 10 X 2 CRTN   4 Non-Preferred Drug 37%37%None
CEFTAZIDIME FOR INJECTION 6GM/VIAL 6 X 6 CRTN   4 Non-Preferred Drug 37%37%None
CEFTRIAXONE 1 GM VIAL   4 Non-Preferred Drug 37%37%None
CEFTRIAXONE 10 GM VIAL [Rocephin]   4 Non-Preferred Drug 37%37%None
CEFTRIAXONE 2 GM VIAL [Rocephin]   4 Non-Preferred Drug 37%37%None
CEFTRIAXONE 250 MG VIAL   4 Non-Preferred Drug 37%37%None
CEFTRIAXONE 500 MG VIAL   4 Non-Preferred Drug 37%37%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CEFUROXIME 1.5 GM/VIAL FOR INJECTION   4 Non-Preferred Drug 37%37%None
CEFUROXIME 750 MG FOR INJECTION   4 Non-Preferred Drug 37%37%None
CEFUROXIME AXETIL 250 MG TABLET   3 Preferred Brand $30.00$90.00None
CEFUROXIME AXETIL 500 MG TABLET [Ceftin]   3 Preferred Brand $30.00$90.00None
CEFUROXIME SOD 7.5 GM VIAL [Zinacef]   4 Non-Preferred Drug 37%37%None
CELECOXIB 100 MG CAPSULE [Celebrex]   4 Non-Preferred Drug 37%37%Q:60
/30Days
CELECOXIB 200 MG CAPSULE [Celebrex]   4 Non-Preferred Drug 37%37%Q:60
/30Days
CELECOXIB 400 MG CAPSULE [Celebrex]   4 Non-Preferred Drug 37%37%Q:60
/30Days
CELECOXIB 50 MG CAPSULE [Celebrex]   4 Non-Preferred Drug 37%37%Q:60
/30Days
CELONTIN 300 MG KAPSEAL   3 Preferred Brand $30.00$90.00None
CEPHALEXIN 125 MG/5 ML SUSPENSION   2 Generic $2.00$6.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CEPHALEXIN 250 MG CAPSULE   2 Generic $2.00$6.00None
CEPHALEXIN 250 MG/5 ML SUSPENSION   2 Generic $2.00$6.00None
CEPHALEXIN 500 MG CAPSULE   2 Generic $2.00$6.00None
CHANTIX 0.5 MG TABLET   3 Preferred Brand $30.00$90.00None
CHANTIX 1 MG CONT MONTH BOX   3 Preferred Brand $30.00$90.00None
CHANTIX 1 MG TABLET   3 Preferred Brand $30.00$90.00None
CHANTIX STARTING MONTH BOX   3 Preferred Brand $30.00$90.00None
CHEMET 100 MG CAPSULE   4 Non-Preferred Drug 37%37%None
CHLORHEXIDINE GLUCONATE 0.12% RINSE   2 Generic $2.00$6.00None
CHLOROQUINE PH 250 MG TABLET   2 Generic $2.00$6.00None
CHLOROQUINE PH 500 MG TABLET   2 Generic $2.00$6.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CHLORPROMAZINE 10 MG TABLET   4 Non-Preferred Drug 37%37%None
CHLORPROMAZINE 100 MG TABLET   4 Non-Preferred Drug 37%37%None
CHLORPROMAZINE 200 MG TABLET   4 Non-Preferred Drug 37%37%None
CHLORPROMAZINE 25 MG TABLET   4 Non-Preferred Drug 37%37%None
CHLORPROMAZINE 50 MG TABLET   4 Non-Preferred Drug 37%37%None
CHLORTHALIDONE 25 MG TABLET   2 Generic $2.00$6.00None
CHLORTHALIDONE 50 MG TABLET   2 Generic $2.00$6.00None
CHOLESTYRAMINE LIGHT POWDER   4 Non-Preferred Drug 37%37%None
CHOLESTYRAMINE PACKET   4 Non-Preferred Drug 37%37%None
CICLOPIROX 0.77% CREAM (g) [Loprox]   4 Non-Preferred Drug 37%37%Q:90
/28Days
CICLOPIROX 0.77% TOPICAL SUSPENSION   4 Non-Preferred Drug 37%37%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CICLOPIROX 1% SHAMPOO   4 Non-Preferred Drug 37%37%Q:120
/28Days
CICLOPIROX 8% SOLUTION [Penlac]   4 Non-Preferred Drug 37%37%None
Cilastatin 250 MG / Imipenem 250 MG Injection   4 Non-Preferred Drug 37%37%None
Cilastatin 500 MG / Imipenem 500 MG Injection   4 Non-Preferred Drug 37%37%None
CILOSTAZOL 100 MG TABLET   2 Generic $2.00$6.00None
CILOSTAZOL 50 MG TABLET   2 Generic $2.00$6.00None
CILOXAN 0.3% OINTMENT   3 Preferred Brand $30.00$90.00None
CIMDUO 300-300 MG TABLET   5 Specialty Tier 25%N/AQ:30
/30Days
Cimetidine 200mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC   3 Preferred Brand $30.00$90.00None
Cimetidine 300 MG Oral Tablet   3 Preferred Brand $30.00$90.00None
CIMETIDINE 400 MG TABLET [Tagamet]   3 Preferred Brand $30.00$90.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
Cimetidine 800mg/1 100 FILM COATED TABLETS in BOTTLE, PLASTIC   3 Preferred Brand $30.00$90.00None
CINACALCET HCL 30 MG TABLET [Sensipar]   4 Non-Preferred Drug 37%37%Q:60
/30Days
CINACALCET HCL 60 MG TABLET [Sensipar]   4 Non-Preferred Drug 37%37%Q:60
/30Days
CINACALCET HCL 90 MG TABLET [Sensipar]   4 Non-Preferred Drug 37%37%Q:120
/30Days
Cinryze 500[iU]/5mL 1 VIAL per CARTON / 5 mL in 1 VIAL   5 Specialty Tier 25%N/AP Q:20
/30Days
CIPRODEX OTIC SUSPENSION   3 Preferred Brand $30.00$90.00None
CIPROFLOXACIN 0.3% EYE DROPS [Ciloxan]   2 Generic $2.00$6.00None
CIPROFLOXACIN HCL 100 MG TABLET [Cipro]   4 Non-Preferred Drug 37%37%None
CIPROFLOXACIN HCL 250 MG TABLET [Cipro]   2 Generic $2.00$6.00None
CIPROFLOXACIN HCL 500 MG TABLET [Cipro]   2 Generic $2.00$6.00None
CIPROFLOXACIN HCL 750 MG TABLET [Cipro]   2 Generic $2.00$6.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CIPROFLOXACIN-D5W 200 MG/100 ML PIGGYBACK [Cipro]   4 Non-Preferred Drug 37%37%None
CITALOPRAM HBR 10 MG TABLET [Celexa]   6 Select Care Drugs $0.00$0.00Q:120
/30Days
CITALOPRAM HBR 10 MG/5 ML SOLUTION [Celexa]   4 Non-Preferred Drug 37%37%Q:600
/30Days
CITALOPRAM HBR 20 MG TABLET [Celexa]   6 Select Care Drugs $0.00$0.00Q:60
/30Days
CITALOPRAM HBR 40 MG TABLET   6 Select Care Drugs $0.00$0.00Q:90
/30Days
CLARAVIS 10 MG CAPSULE   4 Non-Preferred Drug 37%37%None
CLARAVIS 20 MG CAPSULE   4 Non-Preferred Drug 37%37%None
Claravis 30mg 3 BLISTER PACK per CARTON / 10 CAPSULE per BLISTER PACK   4 Non-Preferred Drug 37%37%None
CLARAVIS 40 MG CAPSULE   4 Non-Preferred Drug 37%37%None
CLARITHROMYCIN 125 MG/5ML FOR ORAL SUSPENSION   4 Non-Preferred Drug 37%37%None
CLARITHROMYCIN 250 MG TABLET   4 Non-Preferred Drug 37%37%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CLARITHROMYCIN 250 MG/5MLFOR ORAL SUSPENSION   4 Non-Preferred Drug 37%37%None
CLARITHROMYCIN 500 MG TABLET [Biaxin]   4 Non-Preferred Drug 37%37%None
CLARITHROMYCIN ER 500 MG TABLET 24H [Biaxin XL]   4 Non-Preferred Drug 37%37%None
CLINDAMYCIN 150mg/ml vl 25x6ml   4 Non-Preferred Drug 37%37%None
CLINDAMYCIN 2% VAGINAL CREAM w/APPL [Clindesse]   4 Non-Preferred Drug 37%37%None
CLINDAMYCIN HCL 150 MG CAPSULE [Cleocin]   2 Generic $2.00$6.00None
CLINDAMYCIN HCL 300 MG CAPSULE   2 Generic $2.00$6.00None
CLINDAMYCIN HCL 75 MG 200 CAPSULE BOTTLE   2 Generic $2.00$6.00None
CLINDAMYCIN PEDIATR 75 MG/5 ML SOLN RECON [Cleocin Pediatric]   4 Non-Preferred Drug 37%37%None
CLINDAMYCIN PH 1% SOLUTION   4 Non-Preferred Drug 37%37%None
CLINDAMYCIN PH 300 MG/2 ML VIAL [Cleocin]   4 Non-Preferred Drug 37%37%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CLINDAMYCIN PH 600 MG/4 ML VIAL [Cleocin]   4 Non-Preferred Drug 37%37%None
CLINDAMYCIN PHOSP 1% LOTION [ClindaMax]   4 Non-Preferred Drug 37%37%None
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE   4 Non-Preferred Drug 37%37%None
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX   4 Non-Preferred Drug 37%37%None
Clindamycin-d5w 300 mg/50 ml   4 Non-Preferred Drug 37%37%None
Clindamycin-d5w 600 mg/50 ml   4 Non-Preferred Drug 37%37%None
Clindamycin-d5w 900 mg/50 ml   4 Non-Preferred Drug 37%37%None
CLINIMIX 5/20 SOLUTION   4 Non-Preferred Drug 37%37%P
CLINIMIX 5%-15% IV SOLUTION   4 Non-Preferred Drug 37%37%P
CLINIMIX E 4.25%-10% IV SOLUTION   4 Non-Preferred Drug 37%37%P
CLINISOL 15% SOLUTION   4 Non-Preferred Drug 37%37%P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CLOBAZAM 10 MG TABLET [ONFI]   4 Non-Preferred Drug 37%37%Q:60
/30Days
CLOBAZAM 2.5 MG/ML ORAL SUSPENSION [ONFI]   4 Non-Preferred Drug 37%37%Q:480
/30Days
CLOBAZAM 20 MG TABLET [ONFI]   4 Non-Preferred Drug 37%37%Q:60
/30Days
CLOCORTOLONE PIVALATE 0.1% CREAM (g) [Cloderm]   4 Non-Preferred Drug 37%37%None
CLOMIPRAMINE 25 MG CAPSULE   4 Non-Preferred Drug 37%37%P
CLOMIPRAMINE 50 MG CAPSULE   4 Non-Preferred Drug 37%37%P
CLOMIPRAMINE 75 MG CAPSULE   4 Non-Preferred Drug 37%37%P
CLONAZEPAM 0.125 MG DIS TABLET RAPDIS [Klonopin]   4 Non-Preferred Drug 37%37%Q:90
/30Days
CLONAZEPAM 0.25 MG ODT TABLET RAPDIS [Klonopin]   4 Non-Preferred Drug 37%37%Q:90
/30Days
CLONAZEPAM 0.5 MG DIS TABLET RAPDIS [Klonopin]   4 Non-Preferred Drug 37%37%Q:90
/30Days
CLONAZEPAM 0.5 MG TABLET [Klonopin]   2 Generic $2.00$6.00Q:120
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CLONAZEPAM 1 MG DIS TABLET RAPDIS [Klonopin]   4 Non-Preferred Drug 37%37%Q:120
/30Days
CLONAZEPAM 1 MG TABLET [Klonopin]   2 Generic $2.00$6.00Q:120
/30Days
CLONAZEPAM 2 MG ODT TABLET RAPDIS [Klonopin]   4 Non-Preferred Drug 37%37%Q:300
/30Days
CLONAZEPAM 2 MG TABLET [Klonopin]   2 Generic $2.00$6.00Q:300
/30Days
Clonidine 0.1mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   4 Non-Preferred Drug 37%37%Q:4
/28Days
Clonidine 0.2mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   4 Non-Preferred Drug 37%37%Q:4
/28Days
Clonidine 0.3mg/d 4 POUCH per CARTON / 1 PATCH in 1 POUCH / 7 d in 1 PATCH   4 Non-Preferred Drug 37%37%Q:8
/28Days
CLONIDINE HCL 0.1 MG TABLET   2 Generic $2.00$6.00None
CLONIDINE HCL 0.2 MG TABLET   2 Generic $2.00$6.00None
CLONIDINE HCL 0.3 MG TABLET   2 Generic $2.00$6.00None
CLOPIDOGREL 75 MG TABLET [Plavix]   6 Select Care Drugs $0.00$0.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CLORAZEPATE 15 MG TABLET   4 Non-Preferred Drug 37%37%Q:180
/30Days
CLORAZEPATE 3.75 MG TABLET   4 Non-Preferred Drug 37%37%Q:180
/30Days
CLORAZEPATE 7.5 MG TABLET   4 Non-Preferred Drug 37%37%Q:360
/30Days
CLOTRIMAZOLE 1% CREAM (g) [Mycelex]   2 Generic $2.00$6.00None
CLOTRIMAZOLE 1% SOLUTION   3 Preferred Brand $30.00$90.00Q:30
/28Days
CLOTRIMAZOLE 10 MG TROCHE   2 Generic $2.00$6.00None
CLOTRIMAZOLE-BETAMETHASONE LOT   4 Non-Preferred Drug 37%37%Q:60
/28Days
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE 0.64; 10mg/g; mg/g 45 g in 1 TUBE   4 Non-Preferred Drug 37%37%Q:45
/28Days
CLOZAPINE 100 MG TABLET [Clozaril]   4 Non-Preferred Drug 37%37%None
CLOZAPINE 200 MG TABLET   4 Non-Preferred Drug 37%37%None
CLOZAPINE 25 MG TABLET [Clozaril]   3 Preferred Brand $30.00$90.00None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CLOZAPINE 50 MG TABLET   3 Preferred Brand $30.00$90.00None
CLOZAPINE ODT 100 MG TABLET RAPDIS [Fazaclo]   4 Non-Preferred Drug 37%37%Q:270
/30Days
CLOZAPINE ODT 12.5 MG TABLET RAPDIS [Fazaclo]   4 Non-Preferred Drug 37%37%None
CLOZAPINE ODT 150 MG TABLET RAPDIS [Fazaclo]   4 Non-Preferred Drug 37%37%Q:180
/30Days
CLOZAPINE ODT 200 MG TABLET RAPDIS [Fazaclo]   4 Non-Preferred Drug 37%37%Q:120
/30Days
CLOZAPINE ODT 25 MG TABLET RAPDIS [Fazaclo]   4 Non-Preferred Drug 37%37%None
COARTEM 20MG-120MG   4 Non-Preferred Drug 37%37%Q:24
/30Days
COLCHICINE 0.6 MG CAPSULE [Mitigare]   3 Preferred Brand $30.00$90.00Q:60
/30Days
COLCHICINE 0.6 MG TABLET [Colcrys]   4 Non-Preferred Drug 37%37%Q:120
/30Days
COLESTIPOL HCL GRANULES PACKET [Colestid]   4 Non-Preferred Drug 37%37%None
COLESTIPOL MICRONIZED 1 GM TABLET [Colestid]   4 Non-Preferred Drug 37%37%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
COLISTIMETHATE 150 MG VIAL [Coly-Mycin M]   4 Non-Preferred Drug 37%37%None
COMBIGAN 0.2%-0.5% DROPS   3 Preferred Brand $30.00$90.00None
COMBIVENT RESPIMAT INHAL SPRAY   4 Non-Preferred Drug 37%37%Q:8
/30Days
COMETRIQ 100 MG DAILY-DOSE PACK   5 Specialty Tier 25%N/AP Q:56
/28Days
COMETRIQ 140 MG DAILY-DOSE PACK   5 Specialty Tier 25%N/AP Q:112
/28Days
COMETRIQ 60 MG DAILY-DOSE PACK   5 Specialty Tier 25%N/AP Q:84
/28Days
COMPLERA 200; 27.5; 300mg/1; mg/1; mg/1   4 Non-Preferred Drug 37%37%Q:30
/30Days
COMPRO 25MG SUPPOSITORY   4 Non-Preferred Drug 37%37%None
CONSTULOSE 10 GM/15 ML SOLN   2 Generic $2.00$6.00None
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN   5 Specialty Tier 25%N/AP Q:30
/30Days
COPAXONE 40 MG/ML SYRINGE   5 Specialty Tier 25%N/AP Q:12
/28Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
COPIKTRA 15 MG CAPSULE   5 Specialty Tier 25%N/AP Q:60
/30Days
COPIKTRA 25 MG CAPSULE   5 Specialty Tier 25%N/AP Q:60
/30Days
CORLANOR 5 MG TABLET   4 Non-Preferred Drug 37%37%P Q:60
/30Days
CORLANOR 7.5 MG TABLET   4 Non-Preferred Drug 37%37%P Q:60
/30Days
Cortisone 25 MG TABLET   4 Non-Preferred Drug 37%37%None
COTELLIC 20 MG TABLET   5 Specialty Tier 25%N/AP Q:63
/28Days
Creon 256.11mg/1 1 BOTTLE per CARTON / 70 CAPSULE, DELAYED RELEASE in 1 BOTTLE   3 Preferred Brand $30.00$90.00None
CREON DELAYED RELEASE CAPSULES 12000MG 100 BOTTLE   3 Preferred Brand $30.00$90.00None
CREON DELAYED RELEASE CAPSULES 24000MG 100 BOTTLE   3 Preferred Brand $30.00$90.00None
CREON DELAYED RELEASE CAPSULES 6000MG 100 BOTTLE   3 Preferred Brand $30.00$90.00None
CREON DR 36,000 UNITS 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
CRESEMBA 186 MG CAPSULE   4 Non-Preferred Drug 37%37%None
CRIXIVAN 200MG CAPSULE   4 Non-Preferred Drug 37%37%Q:270
/30Days
CRIXIVAN 400mg, 180 CAPSULE BOTTLE   4 Non-Preferred Drug 37%37%Q:180
/30Days
CROMOLYN 100 MG/5 ML ORAL CONC [Gastrocrom]   3 Preferred Brand $30.00$90.00None
CROMOLYN 20 MG/2 ML NEB SOLN AMPUL-NEB [Intal]   2 Generic $2.00$6.00P Q:240
/30Days
CROMOLYN SODIUM 4% 40MG 10ML BOTTLE   2 Generic $2.00$6.00None
CYCLAFEM 1-35-28 TABLET [Pirmella]   2 Generic $2.00$6.00None
CYCLAFEM 7-7-7-28 TABLET   3 Preferred Brand $30.00$90.00None
CYCLOBENZAPRINE 10 MG TABLET [Flexeril]   3 Preferred Brand $30.00$90.00P
CYCLOBENZAPRINE 5 MG TABLET   3 Preferred Brand $30.00$90.00P
CYCLOPHOSPHAMIDE 25 MG CAPSULE   3 Preferred Brand $30.00$90.00P
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CYCLOPHOSPHAMIDE 50 MG CAPSULE   3 Preferred Brand $30.00$90.00P
CYCLOSPORINE 100MG CAPSULE   4 Non-Preferred Drug 37%37%P
CYCLOSPORINE 25MG CAPSULE   4 Non-Preferred Drug 37%37%P
CYCLOSPORINE MODIFIED 100 MG   4 Non-Preferred Drug 37%37%P
CYCLOSPORINE MODIFIED 25 MG   4 Non-Preferred Drug 37%37%P
CYCLOSPORINE MODIFIED 50 MG   4 Non-Preferred Drug 37%37%P
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOTTLE   4 Non-Preferred Drug 37%37%P
CYRED 28 DAY TABLET [Solia]   3 Preferred Brand $30.00$90.00None
CYSTADANE 1 GRAM/1.7 ML POWDER   5 Specialty Tier 25%N/ANone
CYSTAGON 150MG CAPSULE   4 Non-Preferred Drug 37%37%None
CYSTAGON 50MG CAPSULE   4 Non-Preferred Drug 37%37%None
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CYSTARAN 0.44% EYE DROPS   5 Specialty Tier 25%N/AP Q:60
/28Days

Chart Legend:

Below are a few notes to help you understand the above 2020 Medicare Part D Cigna-HealthSpring Rx Secure (PDP) Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug or Medicare Advantage 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 $435 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.
    • Tier Number* - Some Part D drug plans exclude one or more drug tiers from the plan’s 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 - This is what you will pay for formulary drugs in 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 initial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $4020) 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 2020 )

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 Medicare plan provider.