Cigna Extra Rx (PDP) Formulary



Below is the 2023 Formulary, or prescription drug list, from Cigna Extra Rx (PDP) by Cigna Health And Life Insurance Company. A formulary is a continually updated list of available medications and prescription drug cost information. Examining a plans formulary can help you find a 2023 Medicare Part-D in Virginia 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 Extra Rx (PDP)(S5617-252) plan has a $100 drug deductible. A deductible is the amount of expenses that must be paid out of pocket before the Initial Coverage period begins. However, some drugs do not require that the deductible is met before you receive coverage. You can see if the deductible is required below in the "Does the Deductible Apply" column. 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 Health And Life Insurance Company 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 Extra Rx (PDP)
Plan ID: S5617-252
Formulary
Provider: Cigna Health And Life Insurance Company
Plan Year:2023
Premium:$60.30
Deductible:$100
Initial Coverage Limit:$4660
Coverage Area:Virginia
Similar Plan:S5617-253


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
⇅ Click the Header to Sort
Drug
Name⇅
Tier
Level
Deductible
Apply
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Cabergoline
3N$45$47$45NN
Cabometyx
531%31%31%30/30YN
Calcipotriene
4Y50%50%50%120/30NN
Calcitriol
3N$45$47$45NN
Calcium Acetate
3N$45$47$45360/30NN
Calquence
531%31%31%60/30YN
Camila
3N$45$47$45NN
Camrese Lo
3N$45$47$45NN
Candesartan
3N$45$47$4530/30NN
Candesartan Cilexetil And Hydrochlorothiazide
3N$45$47$45NN
Caplyta
4Y50%50%50%30/30NN
Caprelsa
531%31%31%30/30YN
Captopril
4Y50%50%50%NN
Carbamazepine
4Y50%50%50%NN
Carbidopa
4Y50%50%50%NN
Carbidopa And Levodopa
2N$10$20$10NN
Carbidopa, Levodopa, And Entacapone
4Y50%50%50%NN
Carglumic Acid
531%31%31%YN
Carteolol Hydrochloride
2N$10$20$10NN
Cartia
2N$10$20$10NN
Carvedilol Phosphate
4Y50%50%50%NN
Caspofungin Acetate
4Y50%50%50%YN
Cayston
531%31%31%84/28YN
Caziant
3N$45$47$45NN
Cefaclor
4Y50%50%50%NN
Cefadroxil
3N$45$47$45NN
Cefazolin
4Y50%50%50%NN
Cefdinir
4Y50%50%50%NN
Cefixime
4Y50%50%50%NN
Cefotetan
4Y50%50%50%YN
Cefoxitin
4Y50%50%50%YN
Cefpodoxime Proxetil
4Y50%50%50%NN
Cefprozil
3N$45$47$45NN
Ceftazidime
4Y50%50%50%YN
Ceftriaxone Sodium
4Y50%50%50%NN
Cefuroxime
4Y50%50%50%YN
Celecoxib
3N$45$47$4560/30NN
Celontin
3N$45$47$45NN
Cephalexin
2N$10$20$10NN
Chemet
4Y50%50%50%YN
Chlorpromazine Hydrochloride
4Y50%50%50%NN
Chlorthalidone
2N$10$20$10NN
Cholestyramine
3N$45$47$45NN
Ciclopirox
4Y50%50%50%120/28NN
Ciclopirox Olamine
4Y50%50%50%60/28NN
Cilostazol
2N$10$20$10NN
Ciloxan
3N$45$47$45NN
Cimduo
4Y50%50%50%NN
Cinacalcet Hydrochloride
4Y50%50%50%120/30NN
Cipro
4Y50%50%50%NN
Ciprofloxacin
4Y50%50%50%NN
Ciprofloxacin And Dexamethasone
3N$45$47$45NN
Citalopram Hydrobromide
4Y50%50%50%NN
Claravis
4Y50%50%50%NN
Clarithromycin
4Y50%50%50%NN
Clenpiq
3N$45$47$45NN
Clindamycin
4Y50%50%50%YN
Clindamycin Hydrochloride
2N$10$20$10NN
Clindamycin In 5 Percent Dextrose
4Y50%50%50%YN
Clindamycin Palmitate Hydrochloride (pediatric)
4Y50%50%50%NN
Clindamycin Phosphate
3N$45$47$45NN
Clinimix
4Y50%50%50%YN
Clinimix E
4Y50%50%50%YN
Clobazam
4Y50%50%50%480/30YN
Clobetasol Propionate
4Y50%50%50%125/28NN
Clodan
4Y50%50%50%236/28NN
Clomipramine Hydrochloride
4Y50%50%50%NN
Clonazepam
4Y50%50%50%300/30NN
Clonidine Hydrochloride
1N$4$15$4NN
Clonidine Transdermal System
3N$45$47$454/28NN
Clorazepate Dipotassium
4Y50%50%50%180/30NN
Clotrimazole
3N$45$47$45NN
Clotrimazole And Betamethasone Dipropionate
4Y50%50%50%60/28NN
Clotrimazole Topical Solution Usp, 1%
3N$45$47$4530/28NN
Clozapine
4Y50%50%50%NN
Coartem
4Y50%50%50%24/30NN
Colchicine
3N$45$47$45120/30NN
Colesevelam Hydrochloride
3N$45$47$45NN
Colestipol Hydrochloride
3N$45$47$45NN
Collagenase Santyl
4Y50%50%50%300/30NN
Combivent Respimat
4Y50%50%50%8/30NN
Complera
4Y50%50%50%30/30NN
Compro
4Y50%50%50%NN
Copaxone
531%31%31%30/30YN
Corlanor
4Y50%50%50%60/30YN
Cotellic
531%31%31%63/28YN
Creon
3N$45$47$45NN
Cresemba
4Y50%50%50%NN
Cromolyn Sodium
2N$10$20$10NN
Cryselle
3N$45$47$45NN
Cyclobenzaprine Hydrochloride
3N$45$47$45YN
Cyclophosphamide
3N$45$47$45YN
Cycloset
4Y50%50%50%180/30NN
Cyclosporine
4Y50%50%50%YN
Cyred Eq
3N$45$47$45NN
Cystagon
4Y50%50%50%NN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for S5617-252

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $100. 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 2022 is $320. 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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