Cigna TotalCare (HMO D-SNP) Formulary



Below is the 2023 Formulary, or prescription drug list, from Cigna TotalCare (HMO D-SNP) by Cigna Healthcare Of Georgia, 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 Georgia 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 TotalCare (HMO D-SNP)(H0439-002) plan has a $505 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 Healthcare Of Georgia, 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 TotalCare (HMO D-SNP)
Plan ID: H0439-002
Provider: Cigna Healthcare Of Georgia, Inc
Plan Year:2023
Premium:$26.30
Deductible:$505
Initial Coverage Limit:$4660
Coverage Area:Georgia
Similar Plan:H0439-003


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
Deductible
Apply
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Cabergoline
3YNA15%NANN
Cabometyx
5NA15%NA30/30YN
Calcipotriene
4YNA15%NA120/30NN
Calcitriol
4YNA15%NANN
Calcium Acetate
3YNA15%NA360/30NN
Calquence
5NA15%NA60/30YN
Camila
3YNA15%NANN
Camrese Lo
3YNA15%NANN
Candesartan
1YNA15%NA30/30NN
Candesartan Cilexetil And Hydrochlorothiazide
1YNA15%NANN
Caplyta
5NA15%NA30/30NN
Caprelsa
5NA15%NA30/30YN
Captopril
1YNA15%NANN
Carbamazepine
2YNA15%NANN
Carbidopa
4YNA15%NANN
Carbidopa And Levodopa
2YNA15%NANN
Carbidopa, Levodopa, And Entacapone
3YNA15%NANN
Carglumic Acid
5NA15%NAYN
Carteolol Hydrochloride
2YNA15%NANN
Cartia
2YNA15%NANN
Carvedilol Phosphate
3YNA15%NANN
Caspofungin Acetate
4YNA15%NAYN
Cayston
5NA15%NA84/28YN
Caziant
3YNA15%NANN
Cefaclor
3YNA15%NANN
Cefadroxil
3YNA15%NANN
Cefazolin
4YNA15%NANN
Cefdinir
2YNA15%NANN
Cefixime
4YNA15%NANN
Cefotetan
4YNA15%NAYN
Cefoxitin
4YNA15%NAYN
Cefpodoxime Proxetil
2YNA15%NANN
Cefprozil
2YNA15%NANN
Ceftazidime
4YNA15%NAYN
Ceftriaxone Sodium
4YNA15%NANN
Cefuroxime
4YNA15%NAYN
Celecoxib
3YNA15%NA60/30NN
Celontin
3YNA15%NANN
Cephalexin
2YNA15%NANN
Cevimeline
4YNA15%NANN
Chemet
4YNA15%NAYN
Chlorpromazine Hydrochloride
2YNA15%NANN
Chlorthalidone
2YNA15%NANN
Cholestyramine
3YNA15%NANN
Ciclopirox
3YNA15%NA120/28NN
Ciclopirox Olamine
3YNA15%NA60/28NN
Cilostazol
2YNA15%NANN
Ciloxan
3YNA15%NANN
Cimduo
5NA15%NANN
Cinacalcet Hydrochloride
4YNA15%NA120/30NN
Cipro
4YNA15%NANN
Ciprofloxacin
3YNA15%NANN
Ciprofloxacin And Dexamethasone
3YNA15%NANN
Citalopram Hydrobromide
3YNA15%NANN
Claravis
4YNA15%NANN
Clarithromycin
3YNA15%NANN
Clenpiq
3YNA15%NANN
Clindacin Etz
2YNA15%NA69/30NN
Clindamycin
4YNA15%NAYN
Clindamycin Hydrochloride
2YNA15%NANN
Clindamycin In 5 Percent Dextrose
4YNA15%NAYN
Clindamycin Palmitate Hydrochloride (pediatric)
4YNA15%NANN
Clindamycin Phosphate
3YNA15%NANN
Clinimix
4YNA15%NAYN
Clinimix E
4YNA15%NAYN
Clobazam
4YNA15%NA480/30YN
Clobetasol Propionate
4YNA15%NA236/28NN
Clocortolone Pivalate Cream
4YNA15%NANN
Clodan
4YNA15%NA236/28NN
Clomipramine Hydrochloride
4YNA15%NANN
Clonazepam
2YNA15%NA300/30NN
Clonidine Hydrochloride
1YNA15%NANN
Clonidine Transdermal System
4YNA15%NA4/28NN
Clorazepate Dipotassium
3YNA15%NA180/30NN
Clotrimazole
2YNA15%NANN
Clotrimazole And Betamethasone Dipropionate
2YNA15%NA60/28NN
Clotrimazole Topical Solution Usp, 1%
3YNA15%NA30/28NN
Clozapine
3YNA15%NANN
Coartem
4YNA15%NA24/30NN
Colchicine
3YNA15%NA120/30NN
Colesevelam Hydrochloride
3YNA15%NANN
Colestipol Hydrochloride
3YNA15%NANN
Collagenase Santyl
4YNA15%NA300/30NN
Combivent Respimat
3YNA15%NA8/30NN
Complera
5NA15%NA30/30NN
Compro
2YNA15%NANN
Copaxone
5NA15%NA30/30YN
Corlanor
4YNA15%NA60/30YN
Cotellic
5NA15%NA63/28YN
Creon
3YNA15%NANN
Cresemba
5NA15%NANN
Cromolyn Sodium
2YNA15%NANN
Cryselle
3YNA15%NANN
Cyclobenzaprine Hydrochloride
3YNA15%NAYN
Cyclophosphamide
3YNA15%NAYN
Cycloset
4YNA15%NA180/30NN
Cyclosporine
4YNA15%NAYN
Cyred Eq
3YNA15%NANN
Cystagon
4YNA15%NANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H0439-002

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $505. 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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