Cigna Alliance Medicare (HMO) Formulary



Below is the 2023 Formulary, or prescription drug list, from Cigna Alliance Medicare (HMO) by Cigna Healthcare Of Arizona, Inc. A formulary is a continually updated list of available medications and prescription drug cost information. Examining a plans formulary can help you find a Arizona Medicare Part-C plan that covers your prescriptions. It also helps you compare costs among Medicare Part D and Medicare Advantage plans available to you. You’ll want to make sure the medicines you are currently taking are covered under any plans you are considering enrolling in.

This Cigna Alliance Medicare (HMO)(H0354-028) plan has a $0 drug deductible. The Initial Coverage Limit (ICL) for this plan is $4660. The Initial Coverage Period is the period after the Deductible has been met but before the Coverage Gap phase. Once you and your plan provider have spent $4660 on covered drugs. (Combined amount plus your deductible) You will enter the coverage gap. (AKA "donut hole") Once you reach the coverage gap you will be required to pay 25% of the plan's cost for covered brand-name prescription drugs unless your plan offers additional coverage. You can see if this plan offers coverage in the "donut hole" by clicking the "Coverage Gap" link above the chart.

In 2023 if you have spent $7400 in expenditures you enter the Catastrophic Phase. During the Catastrophic Period you will begin to receive significant coverage. Cigna Healthcare Of Arizona, Inc will begin paying approximately 95% of your covered medication expenses. You can see if this plan covers your drugs in the Catastrophic Phase by clicking the "Catastrophic" link above the chart.



Plan Overview

Plan Name:Cigna Alliance Medicare
Plan ID: H0354-028
Provider: Cigna Healthcare Of Arizona, Inc
Plan Year:2023
Premium:$0.00
Deductible:$0
Initial Coverage Limit:$4660
Coverage Area:Arizona
Similar Plan:H0354-029


Change Table Options:

Drugs Starting Letter:
Coverage Phase:

*Tip Click the Drug name to Compare Coverage and Retail Cost for Every Plan In Your Area
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Drug
Name⇅
Tier
Level
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Cabergoline
3$47$47$47NN
Cabometyx
533%33%33%30/30YN
Calcipotriene
4$100$100$100120/30NN
Calcitriol
4$100$100$100NN
Calcium Acetate
3$47$47$47360/30NN
Calquence
533%33%33%60/30YN
Camila
3$47$47$47NN
Camrese Lo
3$47$47$47NN
Candesartan
1$0$10$030/30NN
Candesartan Cilexetil And Hydrochlorothiazide
1$0$10$0NN
Caplyta
533%33%33%30/30NN
Caprelsa
533%33%33%30/30YN
Captopril
1$0$10$0NN
Carbamazepine
2$5$20$5NN
Carbidopa
4$100$100$100NN
Carbidopa And Levodopa
2$5$20$5NN
Carbidopa, Levodopa, And Entacapone
3$47$47$47NN
Carglumic Acid
533%33%33%YN
Carteolol Hydrochloride
2$5$20$5NN
Cartia
2$5$20$5NN
Carvedilol Phosphate
3$47$47$47NN
Caspofungin Acetate
4$100$100$100YN
Cayston
533%33%33%84/28YN
Caziant
3$47$47$47NN
Cefaclor
3$47$47$47NN
Cefadroxil
3$47$47$47NN
Cefazolin
4$100$100$100NN
Cefdinir
2$5$20$5NN
Cefixime
4$100$100$100NN
Cefotetan
4$100$100$100YN
Cefoxitin
4$100$100$100YN
Cefpodoxime Proxetil
2$5$20$5NN
Cefprozil
2$5$20$5NN
Ceftazidime
4$100$100$100YN
Ceftriaxone Sodium
4$100$100$100NN
Cefuroxime
4$100$100$100YN
Celecoxib
3$47$47$4760/30NN
Celontin
3$47$47$47NN
Cephalexin
2$5$20$5NN
Cevimeline
4$100$100$100NN
Chemet
4$100$100$100YN
Chlorpromazine Hydrochloride
2$5$20$5NN
Chlorthalidone
2$5$20$5NN
Cholestyramine
3$47$47$47NN
Ciclopirox
3$47$47$47120/28NN
Ciclopirox Olamine
3$47$47$4760/28NN
Cilostazol
2$5$20$5NN
Ciloxan
3$47$47$47NN
Cimduo
533%33%33%NN
Cinacalcet Hydrochloride
4$100$100$100120/30NN
Cipro
4$100$100$100NN
Ciprofloxacin
3$47$47$47NN
Ciprofloxacin And Dexamethasone
3$47$47$47NN
Citalopram Hydrobromide
3$47$47$47NN
Claravis
4$100$100$100NN
Clarithromycin
3$47$47$47NN
Clenpiq
3$47$47$47NN
Clindacin Etz
2$5$20$569/30NN
Clindamycin
4$100$100$100YN
Clindamycin Hydrochloride
2$5$20$5NN
Clindamycin In 5 Percent Dextrose
4$100$100$100YN
Clindamycin Palmitate Hydrochloride (pediatric)
4$100$100$100NN
Clindamycin Phosphate
3$47$47$47NN
Clinimix
4$100$100$100YN
Clinimix E
4$100$100$100YN
Clobazam
4$100$100$100480/30YN
Clobetasol Propionate
4$100$100$100236/28NN
Clocortolone Pivalate Cream
4$100$100$100NN
Clodan
4$100$100$100236/28NN
Clomipramine Hydrochloride
4$100$100$100NN
Clonazepam
2$5$20$5300/30NN
Clonidine Hydrochloride
1$0$10$0NN
Clonidine Transdermal System
4$100$100$1004/28NN
Clorazepate Dipotassium
3$47$47$47180/30NN
Clotrimazole
2$5$20$5NN
Clotrimazole And Betamethasone Dipropionate
2$5$20$560/28NN
Clotrimazole Topical Solution Usp, 1%
3$47$47$4730/28NN
Clozapine
3$47$47$47NN
Coartem
4$100$100$10024/30NN
Colchicine
3$47$47$47120/30NN
Colesevelam Hydrochloride
3$47$47$47NN
Colestipol Hydrochloride
3$47$47$47NN
Collagenase Santyl
4$100$100$100300/30NN
Combivent Respimat
3$47$47$478/30NN
Complera
533%33%33%30/30NN
Compro
2$5$20$5NN
Copaxone
533%33%33%30/30YN
Corlanor
4$100$100$10060/30YN
Cotellic
533%33%33%63/28YN
Creon
3$47$47$47NN
Cresemba
533%33%33%NN
Cromolyn Sodium
2$5$20$5NN
Cryselle
3$47$47$47NN
Cyclobenzaprine Hydrochloride
3$47$47$47YN
Cyclophosphamide
3$47$47$47YN
Cycloset
4$100$100$100180/30NN
Cyclosporine
4$100$100$100YN
Cyred Eq
3$47$47$47NN
Cystagon
4$100$100$100NN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H0354-028

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $0. Some plans offer select Pre-deductible drug Coverage
2. Initial Coverage: (ICL) After you reach the plans deductible but before the Initial Coverage limit of $4660
3. Coverage Gap: (AKA Donut Hole) After you reach the plans ICL but before the Catastrophic of $7400 in 2023.
4. Catastrophic: Anything over $7400 you will receive a significant increase in coverage.

Definitions:

Premium: A monthly flat fee that varies by plan.
Deductible: The amount you must pay each year for your prescriptions before your plan begins to pay its share of your covered drugs. The max in 2023 is $505. Some plans have a $0 Deductible.
Tier Level: Medicare drug plans place drugs into different "tiers" on their formularies. Drugs in each tier have a different cost. A drug in a lower tier will generally cost you less.
Quantity Limit Amount/Days: Certain drugs have a Quantity Limit. That means the plan will only cover the drug up to a designated quantity or amount. If your prescribing doctor feels it is necessary to exceed the set limit, he or she must get prior approval before the higher quantity will be covered.
Prior Authorization: Certain Drugs require you or your doctor to get prior authorization to be covered. Usually just an additional form. If you dont get approval, the plan may not cover the drug.
Does the Deduct Apply: Some drugs do not require that the deductible is met before you receive coverage.
Step Therapy: Means you must first try one drug to treat your medical condition before the plan will cover another drug for the same condition. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.
Cost Preferred: Your Cost for the Drug at the Providers In-Network Preferred Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Non-Preferred: Your Cost for the Prescription Drug at a Non-Preferred Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Mail: Your Cost for Prescription Drugs through a Mail Order Pharmacy. As a Percent of the total drug cost or a flat rate.


What if a drug I need is not listed?

Please check the formulary for different brand and generic names. If you still cannot locate your drugs, your plan may not offer coverage. Talk to your doctor first about changing your prescription to a drug on your plan's formulary. If this is not an option, you can request an exception to have the plan review its coverage decision based on your individual circumstances.

Last updated on

Source:CMS Formulary Data Q4 2022
Source:NDC Directory by FDA.gov

**We make every attempt to keep our information accurate. But please check with the plan providers to verify all information.

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