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2022 CIGNACOMPREHENSIVE DRUG LIST(Formulary)PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUTALL OF THE DRUGS WE COVER IN THIS PLAN.Plan coveredCigna Essential Rx (PDP)HPMS Approved Formulary File Submission ID 22232, Version Number 9This formulary was updated on 05/01/2022. For more recent information or other questions, please contact Cigna Customer Service,at 1-800-222-6700 (TTY users should call 711), 8 a.m. – 8 p.m. local time, 7 days a week. Our automated phone system may answeryour call during weekends from April 1 – September 30, or visit CignaMedicare.com. The Formulary, pharmacy network, and/orprovider network may change at any time. 22 F S5617 ESS V05May 2022 INT 22 98644 C Final 10e
Note to existing customers: This formulary has changed since last year. Please review this document to make surethat it still contains the drugs you take.When this drug list (formulary) refers to “we,” “us,” or “our,” it means Cigna. When it refers to “plan” or “our plan,”it means Cigna Essential Rx (PDP).This document includes a list of the drugs (formulary) for our plans, which is current as of May 2022. For an updatedformulary, please contact us. Our contact information, along with the date we last updated the formulary, appears onthe front and back cover pages.You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacynetwork, and/or copayments/coinsurance may change on January 1, 2023, and from time to time during the year.What is the Cigna Comprehensive Drug List?A drug list is a list of covered drugs selected by Cigna inconsultation with a team of health care providers, whichrepresents the prescription therapies believed to be a necessarypart of a quality treatment program. Cigna will generallycover the drugs listed in our drug list as long as the drugis medically necessary, the prescription is filled at a Cignanetwork pharmacy, and other plan rules are followed. For moreinformation on how to fill your prescriptions, please review yourEvidence of Coverage.include information on how to request an exception, andyou can also find information in the section entitled “How doI request an exception to the Cigna Drug List?” Drugs removed from the market. If the Food and DrugAdministration (FDA) deems a drug on our drug list to beunsafe or the drug’s manufacturer removes the drug from themarket, we will immediately remove the drug from our druglist and provide notice to customers who take the drug. Other changes. We may make other changes that affectcustomers currently taking a drug. For instance, we mayadd a generic drug that is not new to the market to replacea brand name drug currently on the drug list; or add newrestrictions to the brand name drug or move it to a differentcost-sharing tier or both. Or we may make changes basedon new clinical guidelines and/or studies. If we remove drugsfrom our drug list, add prior authorization, quantity limits, and/or step therapy restrictions on a drug or move a drug to ahigher cost-sharing tier, we must notify affected customersof the change at least 30 days before the change becomeseffective, or at the time the customer requests a refill of thedrug, at which time the customer will receive a 30-day supplyof the drug.Can the Drug List (formulary) change?Most changes in drug coverage happen on January 1, but wemay add or remove drugs on the drug list during the year, movethem to different cost-sharing tiers, or add new restrictions. Wemust follow Medicare rules in making these changes.Changes that can affect you this year. In the below cases,you will be affected by coverage changes during the year: New generic drugs. We may immediately remove a brandname drug on our drug list if we are replacing it with a newgeneric drug that will appear on the same or lower costsharing tier and with the same or fewer restrictions. Also,when adding the new generic drug, we may decide to keepthe brand name drug on our drug list, but immediately moveit to a different cost-sharing tier or add new restrictions. If youare currently taking that brand name drug, we may not tellyou in advance before we make that change, but we will laterprovide you with information about the specific change(s) wehave made.– If we make these other changes, you or your prescribercan ask us to make an exception and continue to cover thebrand name drug for you. The notice we provide you willalso include information on how to request an exception,and you can find information in the section below titled“How do I request an exception to the Cigna Drug List?”Changes that will not affect you if you are currently takingthe drug. Generally, if you are taking a drug on our 2022 druglist that was covered at the beginning of the year, we will notdiscontinue or reduce coverage of the drug during the 2022– If we make such a change, you or your prescriber can askus to make an exception and continue to cover the brandname drug for you. The notice we provide you will alsoMay 20221
Prior Authorization: Cigna requires you or your doctor toget prior authorization for certain drugs. This means that youwill need to get approval from Cigna before you fill theseprescriptions. If you don’t get approval, Cigna may not coverthe drug.coverage year except as described above. This means thesedrugs will remain available at the same cost-sharing and withno new restrictions for those customers taking them for theremainder of the coverage year. You will not get direct noticethis year about changes that do not affect you. However, onJanuary 1 of the next year, such changes would affect you, andit is important to check the drug list for the new benefit year forany changes to drugs. Quantity Limits: For certain drugs, Cigna limits the amountof the drug that Cigna will cover. For example, Cigna allowsfor 1 tablet per day for atorvastatin 40mg. This applies toa standard one-month supply (for total quantity of 30 per30 days) or three-month supply (for total quantity of 90 per90 days).The enclosed drug list is current as of May 2022. To get updatedinformation about the drugs covered by Cigna, please contactus. Our contact information appears on the front and back coverpages. If there are significant changes made to the printeddrug list within the covered year, you may be notified by mailidentifying the changes. Drug lists located on our website arereviewed and updated on a monthly basis. Step Therapy: In some cases, Cigna requires you to first trycertain drugs to treat your medical condition before we willcover another drug for that condition. For example, if Drug Aand Drug B both treat your medical condition, Cigna may notcover Drug B unless you try Drug A first. If Drug A does notwork for you, Cigna will then cover Drug B.How do I use the Drug List?There are two ways to find your drug within the drug list: Non-Extended Days Supply: For certain drugs, Cigna limitsthe amount of the drug that Cigna will cover to only a 30-daysupply or less, at one time. For example, customers whohave not had any recent fill of opioid pain medications withinthe past 108 days (referred to as “opioid naïve”) are limitedto a maximum of 7 days’ supply of opioid pain medication.Customers who have received a recent fill of an opioid painmedication (not opioid naïve) are limited to up to a month’ssupply of that medication at one time. Other high cost drugsmay be subject to a non-extended day supply restriction,as well.Medical ConditionThe drug list begins on page 18. The drugs in this drug listare grouped into categories depending on the type of medicalconditions that they are used to treat. For example, drugsused to treat a heart condition are listed under the category,“CARDIOVASCULAR, HYPERTENSION / LIPIDS.” If you knowwhat your drug is used for, look for the category name in the listthat begins on page 18. Then look under the category name foryour drug.Covered Drug IndexIf you are not sure what category to look under, you shouldlook for your drug in the Covered Drugs Index that begins onpage 63. The Covered Drugs Index provides an alphabeticallist of all of the drugs included in this document. Both brandname drugs and generic drugs are listed in the Index. Look inthe Index and find your drug. Next to your drug, you will see thepage number where you can find coverage information. Turn tothe page listed in the Covered Drug Index and find the name ofyour drug in the drug name column of the list.You can find out if your drug has any additional requirementsor limits by looking in the drug list that begins on page 18. Youcan also get more information about the restrictions applied tospecific covered drugs by visiting our website. We have postedonline documents that explain our prior authorization and steptherapy restrictions. You may also ask us to send you a copy.Our contact information, along with the date we last updated thedrug list, appears on the front and back cover pages.You can ask Cigna to make an exception to these restrictionsor limits or for a list of other, similar drugs that may treatyour health condition. See the section, “How do I request anexception to the Cigna drug list?” on page 3 for informationabout how to request an exception.What are generic drugs?Cigna covers both brand name drugs and generic drugs. Ageneric drug is approved by the FDA as having the same activeingredient as the brand name drug. Generally, generic drugscost less than brand name drugs.Options for Maintenance MedicationsTaking the medications prescribed by your doctor (or otherprescriber) is important to your health.Are there any restrictions on my coverage?Some covered drugs may have additional requirements or limitson coverage. These requirements and limits may include:May 20222
We are committed to helping you control your chronic conditionsby making it easy for you to receive your maintenancemedications. There are several ways we can work togetherto accomplish this goal:How do I request an exception to the Cigna Drug List?You can ask Cigna to make an exception to our coverage rules.There are several types of exceptions that you can ask usto make. Talk with your doctor about whether a 90-day supply of yourongoing, stable medications may be appropriate. Takingthese medications every day as prescribed is important foryour overall health, and getting 90-day prescriptions of thesemedications can help ensure that you do not miss a dose. You can ask us to cover a drug even if it is not on our druglist. If approved, this drug will be covered at a pre-determinedcost-sharing level, and you would not be able to ask us toprovide the drug at a lower cost-sharing level. You can ask us to waive coverage restrictions or limits onyour drug. For example, for certain drugs, Cigna limits theamount of the drug that we will cover. If your drug has aquantity limit, you can ask us to waive the limit and covera greater amount. You can receive a 90-day supply at most retail pharmacies orthrough one of our mail-order pharmacies. Talk to your pharmacist if you are experiencing any newchallenges with your maintenance medications. You can ask us to cover a formulary drug at a lower costsharing level, unless the drug is on the specialty tier. Ifapproved, this would lower the amount you must pay foryour drug. This applies to the following circumstances:How can I use my prescription drug coverage to savemoney on my medications?There may be opportunities for you to save money on yourmedications using your Cigna coverage.– If the drug you’re taking is a brand name drug, you canask us to cover your drug at the cost-sharing amountthat applies to the lowest tier that contains brand namealternatives for treating your condition. Ask your doctor (or other prescriber) if there are anylower-cost generic alternatives available for any of yourcurrent medications. Some plans may offer a 0 copay for Tier 1 and 2 genericdrugs filled at a preferred retail and/or mail-order pharmacies.Check the Drug Tier and Cost-share Tables on page 5 to seeif your plan offers these savings.– If the drug you’re taking is a generic drug, you can ask usto cover your drug at the cost-sharing amount that appliesto the lowest tier that contains either brand or genericalternatives for treating your condition. Explore whether the ‘CMS Extra Help’ program may offeradditional financial support for your medications.– If the drug you’re taking is a biological product, you canask us to cover your drug at the cost-sharing amount thatapplies to the lowest tier that contains biological productalternatives for treating your condition. If your medication is not covered in the Cigna drug list, talkwith your doctor about alternative medications which arecovered on the drug list.Please note, if we grant your request to cover a drug that isnot on our drug list, you may not ask us to provide this drugat a lower cost-sharing level.What if my drug is not on the Drug List?If your drug is not included in this drug list, you should firstcontact Customer Service and ask if your drug is covered. Ifyou learn that Cigna does not cover your drug, you havetwo options:Generally, Cigna will only approve your request for an exceptionif the alternative drug is included in our drug list, the lower costsharing drug or additional utilization restrictions would not beas effective in treating your condition and/or would cause youto have adverse medical effects. You can ask Customer Service for a list of similar drugs thatare covered by Cigna. When you receive the list, show it toyour doctor and ask him or her to prescribe a similar drug thatis covered by Cigna.You should contact us to ask us for an initial coverage decisionfor a drug list, tiering or utilization restriction exception. Whenyou request a drug list, tiering or utilization restrictionexception you should submit a statement from yourprescriber or doctor supporting your request. Generally,we must make our decision within 72 hours of getting yourprescriber’s supporting statement. You can request an You can ask Cigna to make an exception and cover yourdrug. See the next section for information about how torequest an exception.May 20223
expedited (fast) exception if you or your doctor believe that yourhealth could be seriously harmed by waiting up to 72 hours fora decision. If your request to expedite is granted, we must giveyou a decision no later than 24 hours after we get a supportingstatement from your doctor or other prescriber.In order to accommodate unexpected transitions of ourcustomers that do not leave time for advanced planning, suchas level-of-care changes due to discharge from a hospital to anursing facility or to a home, Cigna will allow a one-time 31-daysupply (unless the prescription is written for fewer days).What do I do before I can talk to my doctor about changingmy drugs or requesting an exception?As a new or existing customer in our plan you may be takingdrugs that are not on our drug list. Or, you may be taking a drugthat is on our drug list but your ability to get it is limited. Forexample, you may need a prior authorization from us beforeyou can fill your prescription. You should talk to your doctorto decide if you should switch to an appropriate drug that wecover or request a drug list exception so that we will cover thedrug you take. While you talk to your doctor to determine theright course of action for you, we may cover your drug up to a30-day supply, in certain cases during the first 90 days you area customer of our plan.Cigna’s Drug ListThe comprehensive drug list that begins on page 18 providescoverage information about all of the drugs covered by Cigna. Ifyou have trouble finding your drug in the list, turn to the CoveredDrug Index that begins on page 63.The first column of the chart lists the drug name. Brand namedrugs are capitalized (e.g., TRELEGY ELLIPTA) and genericdrugs are listed in lower-case italics (e.g., atorvastatin).The information in the Requirements/Limits column tells you ifCigna has any special requirements for coverage of your drug.We provide quantity limits on certain drugs which are indicatedwith a QL in the Covered Drugs by Category list on page 18along with the amount dispensed per the days supplied. (Forexample: atorvastatin 40mg QL 30/30; this means the drugatorvastatin 40mg is limited to 30 tablets per 30 days. For90-day supplies, this quantity limit would be expanded to90 tablets per 90 days).For each of your drugs that is not on our drug list or if yourability to get your drugs is limited, we will cover a temporary30-day supply. If your prescription is written for fewer days,we’ll allow refills to provide up to a maximum 30-day supply ofmedication. After your first 30-day supply, we will not pay forthese drugs without a drug list exception, even if you have beena customer of the plan less than 90 days.What is a preferred network pharmacy?If your plan has preferred network pharmacies, you willtypically save money by using these pharmacies. Yourprescription drug costs (like a copay or coinsurance) willtypically be less at a preferred network pharmacy because ithas a preferred agreement with your plan. or you can visitCigna.com/member-resources for the most currentPharmacy Directory.If you are a resident of a long-term care facility and you need adrug that is not on our drug list or if your ability to get your drugsis limited, but you are past the first 90 days of membership inour plan, we will cover a 31-day emergency supply of that drugwhile you pursue a drug list exception.For more informationFor more detailed information about your Cigna prescription drug coverage, please review your Evidence of Coverage andother plan materials.If you have questions about Cigna, please contact us. Our contact information, along with the date we last updated the druglist, appears on the front and back cover pages.If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE(1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.May 20224
Drug Tier and Cost-Share TableThe following table represents the plan name, plan service area,the drug tier number as it appears on the drug list, and the costshare amount for that tier number. Tier 1 is for Preferred Genericdrugs. Tier 2 is for Generic drugs. Tier 3 is for Preferred Branddrugs. Tier 4 is for Non-Preferred drugs. Tier 5 is for Specialtytier drugs. Please refer to the following chart. You may also referto your Evidence of Coverage document for additional details.the name “Tier 3: Preferred Brand Drugs” is just a description ofthe majority of the drugs in the tier. It does not mean that thereare only brand drugs in that tier.For customers receiving Extra Help: Your Low IncomeSubsidy (LIS) copay level will be based on how the Food andDrug Administration (FDA) classifies certain drugs. Due tothis, a generic drug may receive a preferred brand copay, or apreferred brand drug may receive a generic drug copay. Pleasesee your LIS Rider for additional information on these copaylevels. Or call Customer Service for further clarification regardinga specific drug.Cigna is not always able to keep all generic medications in thePreferred Generic and Generic drug tiers, and some genericmedications may be in Tier 3, Tier 4 or Tier 5. Keep in mind thatTo locate your drug cost, please refer to the table(s) below to find your service area and the Prescription Drug plan inwhich you are currently enrolled or would like to enroll.If you qualified for Extra Help with your drug costs, your costs may be different from those described below. Pleaserefer to your Evidence of Coverage (EOC) or call Customer Service to find out what your costs are.Cigna uses preferred network pharmacies. See your Pharmacy Directory or visit Cigna.com/member-resources tosearch for a preferred retail or mail-order pharmacy near you.Cigna Essential Rx (PDP)ALABAMATier 1: Preferred Generic DrugsLong-term CareStandardPreferredStandardPreferred31 st-SharingCost-SharingCost-SharingOut-of-network30 days*30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days 0 / 0 / 0 19 / 38 / 57 0 / 0 / 0 19 / 38 / 57 19 6 / 12 / 18 20 / 40 / 60 6 / 12 / 0 20 / 40 / 60 20Tier 3: Preferred Brand Drugs18%20%18%20%20%Tier 4: Non-Preferred Drugs49%50%49%50%50%25% (30 days)25% (30 days)25% (30 days)25% (30 days)25% 0 / 0 / 0 19 / 38 / 57 0 / 0 / 0 19 / 38 / 57 19 6 / 12 / 18 20 / 40 / 60 6 / 12 / 0 20 / 40 / 60 20Tier 3: Preferred Brand Drugs18%20%18%20%20%Tier 4: Non-Preferred Drugs47%49%47%49%49%25% (30 days)25% (30 days)25% (30 days)25% (30 days)25%Tier 2: Generic DrugsTier 5: Specialty TierALASKATier 1: Preferred Generic DrugsTier 2: Generic DrugsTier 5: Specialty Tier* You will pay the copay or percentage of the drug cost shown above plus the difference between the Out-of-Network pharmacy billedcharge and our typical Standard Retail pharmacy billed costs.May 20225
Cigna Essential Rx (PDP)ARIZONATier 1: Preferred Generic DrugsLong-term CareStandardPreferredStandardPreferred31 st-SharingCost-SharingCost-SharingOut-of-network30 days*30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days 0 / 0 / 0 19 / 38 / 57 0 / 0 / 0 19 / 38 / 57 19 6 / 12 / 18 20 / 40 / 60 6 / 12 / 0 20 / 40 / 60 20Tier 3: Preferred Brand Drugs18%20%18%20%20%Tier 4: Non-Preferred Drugs50%50%50%50%50%25% (30 days)25% (30 days)25% (30 days)25% (30 days)25% 0 / 0 / 0 19 / 38 / 57 0 / 0 / 0 19 / 38 / 57 19 6 / 12 / 18 20 / 40 / 60 6 / 12 / 0 20 / 40 / 60 20Tier 3: Preferred Brand Drugs18%20%18%20%20%Tier 4: Non-Preferred Drugs41%42%41%42%42%25% (30 days)25% (30 days)25% (30 days)25% (30 days)25% 0 / 0 / 0 19 / 38 / 57 0 / 0 / 0 19 / 38 / 57 19 6 / 12 / 18 20 / 40 / 60 6 / 12 / 0 20 / 40 / 60 20Tier 3: Preferred Brand Drugs18%20%18%20%20%Tier 4: Non-Preferred Drugs42%44%42%44%44%25% (30 days)25% (30 days)25% (30 days)25% (30 days)25% 0 / 0 / 0 19 / 38 / 57 0 / 0 / 0 19 / 38 / 57 19 6 / 12 / 18 20 / 40 / 60 6 / 12 / 0 20 / 40 / 60 20Tier 3: Preferred Brand Drugs18%20%18%20%20%Tier 4: Non-Preferred Drugs47%48%47%48%48%25% (30 days)25% (30 days)25% (30 days)25% (30 days)25% 0 / 0 / 0 19 / 38 / 57 0 / 0 / 0 19 / 38 / 57 19 6 / 12 / 18 20 / 40 / 60 6 / 12 / 0 20 / 40 / 60 20Tier 3: Preferred Brand Drugs18%20%18%20%20%Tier 4: Non-Preferred Drugs46%48%46%48%48%25% (30 days)25% (30 days)25% (30 days)25% (30 days)25%Tier 2: Generic DrugsTier 5: Specialty TierARKANSASTier 1: Preferred Generic DrugsTier 2: Generic DrugsTier 5: Specialty TierCALIFORNIATier 1: Preferred Generic DrugsTier 2: Generic DrugsTier 5: Specialty TierCOLORADOTier 1: Preferred Generic DrugsTier 2: Generic DrugsTier 5: Specialty TierCONNECTICUTTier 1: Preferred Generic DrugsTier 2: Generic DrugsTier 5: Specialty Tier* You will pay the copay or percentage of the drug cost shown above plus the difference between the Out-of-Network pharmacy billedcharge and our typical Standard Retail pharmacy billed costs.May 20226
Cigna Essential Rx (PDP)DELAWARETier 1: Preferred Generic DrugsLong-term CareStandardPreferredStandardPreferred31 st-SharingCost-SharingCost-SharingOut-of-network30 days*30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days 0 / 0 / 0 19 / 38 / 57 0 / 0 / 0 19 / 38 / 57 19 6 / 12 / 18 20 / 40 / 60 6 / 12 / 0 20 / 40 / 60 20Tier 3: Preferred Brand Drugs18%20%18%20%20%Tier 4: Non-Preferred Drugs43%43%43%43%43%25% (30 days)25% (30 days)25% (30 days)25% (30 days)25% 0 / 0 / 0 19 / 38 / 57 0 / 0 / 0 19 / 38 / 57 19 6 / 12 / 18 20 / 40 / 60 6 / 12 / 0 20 / 40 / 60 20Tier 3: Preferred Brand Drugs18%20%18%20%20%Tier 4: Non-Preferred Drugs43%43%43%43%43%25% (30 days)25% (30 days)25% (30 days)25% (30 days)25% 0 / 0 / 0 19 / 38 / 57 0 / 0 / 0 19 / 38 / 57 19 6 / 12 / 18 20 / 40 / 60 6 / 12 / 0 20 / 40 / 60 20Tier 3: Preferred Brand Drugs18%20%18%20%20%Tier 4: Non-Preferred Drugs50%50%50%50%50%25% (30 days)25% (30 days)25% (30 days)25% (30 days)25% 0 / 0 / 0 19 / 38 / 57 0 / 0 / 0 19 / 38 / 57 19 6 / 12 / 18 20 / 40 / 60 6 / 12 / 0 20 / 40 / 60 20Tier 3: Preferred Brand Drugs18%20%18%20%20%Tier 4: Non-Preferred Drugs50%50%50%50%50%25% (30 days)25% (30 days)25% (30 days)25% (30 days)25% 0 / 0 / 0 19 / 38 / 57 0 / 0 / 0 19 / 38 / 57 19 6 / 12 / 18 20 / 40 / 60 6 / 12 / 0 20 / 40 / 60 20Tier 3: Preferred Brand Drugs18%20%18%20%20%Tier 4: Non-Preferred Drugs43%43%43%43%43%25% (30 days)25% (30 days)25% (30 days)25% (30 days)25%Tier 2: Generic DrugsTier 5: Specialty TierDISTRICT OF COLUMBIATier 1: Preferred Generic DrugsTier 2: Generic DrugsTier 5: Specialty TierFLORIDATier 1: Preferred Generic DrugsTier 2: Generic DrugsTier 5: Specialty TierGEORGIATier 1: Preferred Generic DrugsTier 2: Generic DrugsTier 5: Specialty TierHAWAIITier 1: Preferred Generic DrugsTier 2: Generic DrugsTier 5: Specialty Tier* You will pay the copay or percentage of the drug cost shown above plus the difference between the Out-of-Network pharmacy billedcharge and our typical Standard Retail pharmacy billed costs.May 20227
Cigna Essential Rx (PDP)IDAHOTier 1: Preferred Generic DrugsLong-term CareStandardPreferredStandardPreferred31 st-SharingCost-SharingCost-SharingOut-of-network30 days*30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days 0 / 0 / 0 19 / 38 / 57 0 / 0 / 0 19 / 38 / 57 19 6 / 12 / 18 20 / 40 / 60 6 / 12 / 0 20 / 40 / 60 20Tier 3: Preferred Brand Drugs18%20%18%20%20%Tier 4: Non-Preferred Drugs50%50%50%50%50%25% (30 days)25% (30 days)25% (30 days)25% (30 days)25% 0 / 0 / 0 19 / 38 / 57 0 / 0 / 0 19 / 38 / 57 19 6 / 12 / 18 20 / 40 / 60 6 / 12 / 0 20 / 40 / 60 20Tier 3: Preferred Brand Drugs18%20%18%20%20%Tier 4: Non-Preferred Drugs50%50%50%50%50%25% (30 days)25% (30 days)25% (30 days)25% (30 days)25% 0 / 0 / 0 19 / 38 / 57 0 / 0 / 0 19 / 38 / 57 19 6 / 12 / 18 20 / 40 / 60 6 / 12 / 0 20 / 40 / 60 20Tier 3: Preferred Brand Drugs18%20%18%20%20%Tier 4: Non-Preferred Drugs50%50%50%50%50%25% (30 days)25% (30 days)25% (30 days)25% (30 days)25% 0 / 0 / 0 19 / 38 / 57 0 / 0 / 0 19 / 38 / 57 19 6 / 12 / 18 20 / 40 / 60 6 / 12 / 0 20 / 40 / 60 20Tier 3: Preferred Brand Drugs18%20%18%20%20%Tier 4: Non-Preferred Drugs50%50%50%50%50%25% (30 days)25% (30 days)25% (30 days)25% (30 days)25% 0 / 0 / 0 19 / 38 / 57 0 / 0 / 0 19 / 38 / 57 19 6 / 12 / 18 20 / 40 / 60 6 / 12 / 0 20 / 40 / 60 20Tier 3: Preferred Brand Drugs18%20%18%20%20%Tier 4: Non-Preferred Drugs50%50%50%50%50%25% (30 days)25% (30 days)25% (30 days)25% (30 days)25%Tier 2: Generic DrugsTier 5: Specialty TierILLINOISTier 1: Preferred Generic DrugsTier 2: Generic DrugsTier 5: Specialty TierINDIANATier 1: Preferred Generic DrugsTier 2: Generic DrugsTier 5: Specialty TierIOWATier 1: Preferred Generic DrugsTier 2: Generic DrugsTier 5: Specialty TierKANSASTier 1: Preferred Generic DrugsTier 2: Generic DrugsTier 5: Specialty Tier* You will pay the copay or percentage of the drug cost shown above plus the difference between the Out-of-Network pharmacy billedcharge and our typical Standard Retail pharmacy billed costs.May 20228
Cigna Essential Rx (PDP)KENTUCKYTier 1: Preferred Generic DrugsLong-term CareStandardPreferredStandardPreferred31 st-SharingCost-SharingCost-SharingOut-of-network30 days*30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days 0 / 0 / 0 19 / 38 / 57 0 / 0 / 0 19 / 38 / 57 19 6 / 12 / 18 20 / 40 / 60 6 / 12 / 0 20 / 40 / 60 20Tier 3: Preferred Brand Drugs18%20%18%20%20%Tier 4: Non-Preferred Drugs50%50%50%50%50%25% (30 days)25% (30 days)25% (30 days)25% (30 days)25% 0 / 0 / 0 19 / 38 / 57 0 / 0 / 0 19 / 38 / 57 19 5 / 10 / 15 20 / 40 / 60 5 / 10 / 0 20 / 40 / 60 20Tier 3: Preferred Brand Drugs18%19%18%19%19%Tier 4: Non-Preferred Drugs40%41%40%41%41%25% (30 days)25% (30 days)25% (30 days)25% (30 days)25% 0 / 0 / 0 19 / 38 / 57 0 / 0 / 0 19 / 38 / 57 19 6 / 12 / 18 20 / 40 / 60 6 / 12 / 0 20 / 40 / 60 20Tier 3: Preferred Brand Drugs18%20%18%20%20%Tier 4: Non-Preferred Drugs50%50%50%50%50%25% (30 days)25% (30 days)25% (30 days)25% (30 days)25% 0 / 0 / 0 19 / 38 / 57 0 / 0 / 0 19 / 38 / 57 19 6 / 12 / 18 20 / 40 / 60 6 / 12 / 0 20 / 40 / 60 20Tier 3: Preferred Brand Drugs18%20%18%20%20%Tier 4: Non-Preferred Drugs43%43%43%43%43%25% (30 days)25% (30 days)25% (30 days)25% (30 days)25% 0 / 0 / 0 19 / 38 / 57 0 / 0 / 0 19 / 38 / 57 19 6 / 12 / 18 20 / 40 / 60 6 / 12 / 0 20 / 40 / 60 20Tier 3: Preferred Brand Drugs18%20%18%20%20%Tier 4: Non-Preferred Drugs46%48%46%48%48%25% (30 days)25% (30 days)25% (30 days)25% (30 days)25%Tier 2: Generic DrugsTier 5: Specialty TierLOUISIANATier 1: Preferred Generic DrugsTier 2: Generic DrugsTier 5: Specialty TierMAINETier 1: Preferred Generic DrugsTier 2: Generic DrugsTier 5: Specialty TierMARYLANDTier 1: Preferred Generic DrugsTier 2: Generic DrugsTier 5: Specialty TierMASSACHUSETTSTier 1: Preferred Generic DrugsTier 2: Generic DrugsTier 5: Specialty Tier* You will pay the copay or percentage of the drug cost shown above plus the difference between the Out-of-Network pharmacy billedcharge and our typical Standard Retail pharmacy billed costs.May 20229
Cigna Essential Rx (PDP)MICHIGANTier 1: Preferred Generic DrugsLong-term CareStandardPreferredStandardPreferred31 st-SharingCost-SharingCost-SharingOut-of-network30 days*30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days 0 /
Feb 01, 2022 · (Formulary) HPMS Approved Formulary File Submission ID 22232, Version Number 6 This formulary was updated on 02/01/2022. For more recent information or other questions, please contact Cigna Customer Service, at 1-800-222-6700 (TTY users should call 711), 8 a.m. – 8 p.m. local t
