Exhibit 07 - Cal Yr 2024 City of Miami CIGNA EGWP Medicare - Evidence of Coverage Snapshot.pdf

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January 1 – December 31, 2024

Evidence of Coverage Snapshot

City of Miami

S5617 – 801_Enhanced Drug List_B2

Although Medicare is a federal program, Cigna Rx Medicare (PDP) is available only to individuals who live in our plan service area. To remain a member of our plan, you must keep living in this service area. The service area for this plan includes all 50 States, the District of Columbia, Puerto Rico, and the U.S. Virgin Islands.

Please Note: This document provides additional details for the Medicare prescription drug coverage outlined in your Evidence of Coverage booklet.

Both this Snapshot document and your Evidence of Coverage booklet are important legal documents and should be kept together in a safe place.

Please visit CignaMedicare.com/Group/PDPresources to view the Evidence of Coverage and Drug List.

Your Medicare Prescription Drug Coverage as a Customer of Cigna Rx Medicare (PDP) Medicare Prescription Drug Plan

Please see Chapter 4, Section 2.1 in your Evidence of Coverage booklet for a detailed description of the table shown below. You can find the Evidence of Coverage booklet online at CignaMedicare.com/Group/PDPresources.

What you pay for a drug depends on which “drug payment stage” you are in when you get the drug.

As shown in the table on the next page, there are “drug payment stages” for your prescription drug coverage under Cigna Rx Medicare (PDP). How much you pay for a drug depends on which of these stages you are in at the time you get a prescription filled or refilled. Keep in mind, you are always responsible for the plan’s monthly premium regardless of the drug payment stage.

Questions? We’re here to help. Please call Customer Service at 1-800-558-9562 (TTY 711). We are available for phone calls 8 a.m. – 8 p.m. local time, 7 days a week. From April 1- September 30, Monday – Friday, 8 a.m. – 8 p.m. local time. Messaging service used weekends, after hours, and on federal holidays.

EXHIBIT 07

Stage 1

Yearly Deductible Stage

Stage 2

Initial Coverage

Stage 3

Coverage Gap Stage

Stage 4

Catastrophic Coverage Stage

Because there is no deductible for the plan, this payment stage does not apply to you.

You begin in this stage when you fill your first covered Part D prescription of the year.

During this stage, the plan pays its share of the cost of your drugs and you pay your share of the cost.

You pay the same copays/coinsurance as the Initial Coverage Stage.

During this stage, the plan will pay the cost of your drugs for the rest of the calendar year (through

December 31, 2024).

For a 30-day supply, you pay $0.

Stage 1

Yearly Deductible

(Details are in

Section 4 of Chapter 4 in your Evidence of Coverage Booklet.)

Stage 2

Initial Coverage

You stay in this stage until your year-to-date “total drug costs” (your payments plus any Part D plan’s payments, plus any payments made on your behalf) total $5,030.

Section 5 of Chapter 4 in your Evidence of Coverage Booklet.)

Stage 3

Coverage Gap Stage

You stay in this stage until your year-to-date “out-of-pocket costs” (your payments or TrOOP) reach a total of $8,000. This amount and rules for counting costs toward this amount have been set by Medicare.

Section 6 of Chapter 4 in your Evidence of Coverage Booklet.)

Stage 4

Catastrophic Coverage Stage

Section 7 of Chapter 4 in your Evidence of Coverage Booklet.)

Deductible Stage Information

There is no Deductible for Cigna Rx Medicare (PDP)

You do not pay a deductible for your covered Part D prescription drugs. You begin in the

Initial Coverage Stage when you fill your first prescription of the year. See Section 5 for information about your coverage in the Initial Coverage Stage.

Your plan includes a member maximum out-of-pocket limit. The maximum you will pay in 2024 for your covered prescriptions is $1,000.

Your Medicare Prescription Drug Coverage as a Member of Cigna Rx Medicare (PDP) Medicare Prescription Drug Plan

Please see Chapter 4, Section 5.2 in your Evidence of Coverage booklet for a detailed description of the table shown below.

Your share of the cost when you get a one-month supply of a covered Part D prescription drug:

Cost-Sharing Tiers Network

Pharmacy

The Plan’s Mail-Order

Service

Network Long-Term

Care Pharmacy

Out-of- Network

Pharmacy

Tier 1 $15 $15 $15 $15

Tier 2 $40 $40 $40 $40

Tier 3 $60 $60 $60 $60

Tier 4 $60 $60 $60 $60

Please see Chapter 4, Section 5.3 in your Evidence of Coverage booklet for a detailed description of the table shown below.

Your share of the cost when you get a long-term supply (60-day and 90-day supply) of a covered Part D prescription drug:

Cost-Sharing Tiers Network Pharmacy

60 / 90

The Plan’s

Mail-Order Service 60 / 90

Tier 1 $30 / $0 $30 / $0

Tier 2 $80 / $80 $80 / $80

Tier 3 $120 / $120 $120 / $120

Tier 4* N/A / N/A N/A / N/A

*Specialty drugs are limited to a 30-day supply

Additional Benefits Offered

Your plan covers additional drugs not normally covered in a Medicare Prescription Drug Plan as indicated in the Formulary Drug List by the + symbol. Please see your 2024 Formulary document for details. The cost-share you pay on these drugs do not count toward your annual TrOOP.

Cough and Cold Drugs Erectile Dysfunction Drugs^ Prescription Vitamins

^Sexual dysfunction medications are subject to prior authorization and quantity limitations even though these limitations may be waived in other treatment categories.

Please review your 2024 formulary for more information.

The following preventive benefits are covered at a $0 copay (deductible does not apply):

• Adherence Package

Important Message About What You Pay for Insulin You won’t pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it’s on. If your plan has a Part D deductible, this will apply even if you haven’t paid your deductible. If your insulin is on a tier where cost-sharing is lower than $35, you will pay the lower cost for your insulin.

Important Message About What You Pay for Vaccines

Our plan covers most Part D vaccines at no cost to you. If your plan has a Part D deductible, this will apply even if you haven’t paid your deductible. Call Customer

Service for more information.

Clinical Management Edits Your plan includes the following clinical management edits (see definitions, Chapter 3, Section 4.2 of your Evidence of Coverage).

PA This drug requires prior authorization.

QL This drug has quantity limits.

ST This drug has step therapy requirements.

Opioid medication available as a 7-day supply or less for first time opioid user. For continued use this drug may only be available as a month supply.

+ This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug.

^ This prescription drug has an administrative prior authorization requirement that is not waived. This drug may be covered under different benefits depending on circumstances.

HRM PA This high-risk medication requires prior authorization.

B/D PA

This prescription drug has a Part B versus D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending on circumstances.

LA Limited Availability drug. This drug may be available only at certain pharmacies.

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Subsidiaries of The Cigna Group contract with Medicare to offer Part D Prescription Drug Plans (PDP) in select states. Enrollment in a Cigna Healthcare product depends on contract renewal. © 2023 Cigna Healthcare