Exhibit 60 - Cal Yrs 2024 _ 2025 City of Miami CIGNA Medicare Rx - Formulary Addendum Snapshot Rx Medicare PDP.pdf
PDF 767 KB Posted
- Attached to
- RFP No. 2130386 - Employee Health Benefits Plan
- Solicitation number
- RFP No. 2130386
- Issued by
- Florida
About this file
This document is a 2025 Cigna Rx Medicare (PDP) Formulary Addendum for the City of Miami, detailing a Medicare Prescription Drug Plan with a Medicare Broad Network. The plan covers prescription drugs across multiple tiers, with specific cost-sharing structures for one-month and long-term supplies at network pharmacies and mail-order services. The service area includes all 50 states, the District of Columbia, Puerto Rico, and the U.S. Virgin Islands, with coverage running from January 1 to December 31, 2025.
The plan offers additional benefits beyond standard Medicare coverage, including an Adherence Package and coverage for cough and cold drugs, erectile dysfunction drugs, and prescription vitamins. There is no deductible, and the maximum out-of-pocket limit for 2025 is $1,000. Notably, the plan caps insulin costs at $35 for a one-month supply regardless of the cost-sharing tier and provides most Part D vaccines at no cost. The plan includes various clinical management edits such as prior authorization requirements, quantity limits, and step therapy requirements, with specific provisions for opioid medications and high-risk medications.
View the file
Other files
Show 40 more
Latest 50 of 114 listed here. See the rest on GovTribe.
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
25_GFA_COM INT_25_1356911_C
City of Miami
2025 Cigna Rx Medicare (PDP) Formulary Addendum 2025 Enhanced Drug List Addendum
S5617_801_RXPDP A3
Medicare Broad Network
Please read: This document contains information about the policies and criteria and any additional coverage offered with your plan.
Please CignaMedicare.com/group/PDPresources to view the comprehensive 2025 Enhanced Drug List.
The drug list found on our website will be updated each month.
EXHIBIT 60
Are there any restrictions on my 2025 Cigna Rx Medicare (PDP) coverage?
Some covered drugs may have additional requirements or limits on coverage. You can identify these by looking to the right of the name of the drug on the drug list located on our website.
The requirements and limits for your plan are the following:
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 one-month supply.
This prescription drug has an administrative prior authorization requirement that is not waived. This drug may be covered under different benefits depending on circumstances.
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 apply to 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.
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.
HRM This high-risk medication requires prior authorization.
LA
Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Customer Service.
V
This vaccine is provided to adults at no cost when used based on recommendations by the Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP).
PA This drug requires prior authorization.
QL This drug has quantity limits.
ST This drug has step therapy requirements.
Where can I find drug list for my plan?
You can visit CignaMedicare.com/group/PDPresources to view the current list of covered drugs for the 2025 Enhanced Drug List. While there, you can also view documents that explain our prior authorization and step therapy restrictions as well as other useful plan information. To locate the drug list you need, simply visit the location above and search for the 2025 Enhanced Drug List.
What additional coverage is available with my plan?
The following preventive benefits are covered at a $0 copay (deductible does not apply):
Adherence Package
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 2025 Formulary document for details. If a plan deductible applies, any non-Part D coverage added to the plan will not be subject to the plan deductible. The cost-share for these drugs is the same as the cost-shares in the initial coverage phase based on the drug classification. The cost-share you pay on these drugs do not count toward your annual True Out-of-Pocket (TrOOP).
Covered Non-Part D Drugs:
Prescription Vitamins - Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations
Cough and Cold Drugs - Drugs used for the relief of cough or cold symptoms Erectile Dysfunction Drugs^ - Drugs used for the treatment of sexual or erectile dysfunction Courtesy Drugs/DESI Buy Up Courtesy Drugs: Drugs normally covered under commercial pharmacy plans but are excluded by CMS. DESI (Drug Efficacy Study Implementation) Drugs: Drugs that were introduced between 1938-1962 and approved for safety but not effectiveness. DESI drugs are not “grandfathered” or generally recognized as safe and effective (GRAS/E).
^Some drugs are subject to prior authorization and quantity limitations even though these limitations may be waived in other treatment categories. Please review your 2025 formulary for more information.
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.
CAPITALIZED = BRAND NAME DRUG Lowercase italic = Generic drug
2025 Adherence Package
Preventive drugs are used to improve outcomes for asthma, blood pressure with selected heart drugs, blood thinners, high cholesterol, diabetes, Part D covered diabetic supplies, osteoporosis, and prenatal vitamins. If you have questions about which drugs are right for you, talk to your doctor. You do not have to pay a copay or coinsurance for the preventive drugs on this list if filled at a pharmacy in the Cigna Healthcare Medicare network. All quantity limits, prior authorization and step therapy in the full drug list apply.
Asthma Inhalation Solns (PART D Only)
Inhalers and Inhalation Devices albuterol solution ^ budesonide susp ^ cromolyn sod soln ^ formoterol soln ^ ipratropium-albut ^ levalbuterol soln ^ albuterol HFA COMBIVENT RESPMT SEREVENT DISKUS ADVAIR HFA fluticasone HFA, DISKUS PERFOROMIST ANORO ELLIPTA fluticasone-salmeterol inh TRELEGY ELLIPTA
ARNUITY ELLIPTA INCRUSE ELLIPTA VENTOLIN HFA
ATROVENT HFA INH ipratropium bromide inh WIXELA INHUB BREO ELLIPTA levalbuterol HFA
Oral Products albuterol tab, syrp montelukast tabs theophylline ER, CR theophylline elixir, soln zafirlukast tab
Blood Pressure/Selected Heart Drugs acebutolol cap captopril tab, -hctz guanfacine nebivolol tabs telmisartan-amlodipine acetazolamide ir, er CARTIA XT hydralazine tab nicardipine cap telmisartan-hctz aliskiren tab carvedilol tab hydrochlorothiazide nifedipine er tab terazosin cap amiloride tab carvedilol er cap indapamide tab nimodipine cap TIADYLT ER CAP amiloride-hctz chlorthalidone tab irbesartan tab nisoldipine er tab timolol maleate tab amlodipine tab clonidine tab, patch irbesartan-hctz olmesartan torsemide tab amlodipine-atorv DILT-XR isradipine cap olm-aml-hctz trandolapril tab Amlodipine-benz diltiazem tab KERENDIA TABS olmesartan-hctz trandolapril-verap er amlodipine-olmes diltiazem cd labetalol tab perindopril tab triamterene caps amlodipine-valsart. diltiazem er lisinopril tab pindolol tab triamterene-hctz amlodipine-val-hctz doxazosin tab lisinopril-hctz prazosin cap valsartan tab atenolol tab EDARBI losartan tab propranolol,er valsartan-hctz atenolol-chlorthalid EDARBYCLOR losartan-hctz quinapril tab verapamil cap pellet benazepril tab enalapril tab MATZIM LA quinapril-hctz verapamil tab, er benazepril-hctz enalapril-hctz methazolamide tab ramipril cap verapamil sr cap betaxolol tab ENTRESTO metolazone tab sotalol tab verapamil tab bisoprolol tab eplerenone tab metoprolol succ er sotalol af tab bisoprolol-hctz ethacrynic acid tab metoprolol tart tab spironolactone tab bumetanide tab felodipine er metoprolol-hctz spironolactone-hctz BYSTOLIC fosinopril tab minoxidil tab TAZTIA XT candesartan tab fosinopril-hctz moexipril tab telmisartan tab candesartan-hctz furosemide oral nadolol tab
^This prescription drug has a Part B versus D administrative prior authorization requirement.
2025 Adherence Package Continued Blood Thinners aspirin-dipyridam er clopidogrel tab ELIQUIS prasugrel tab XARELTO susp BRILINTA dabigatran caps ELIQUIS START PK warfarin tab XARELTO SRT PK cilostazol tab dipyridamole tab JANTOVEN tab XARELTO tabs
Cholesterol atorvastatin tab ezetimibe-simvast fluvastatin cap,er tb NEXLETOL pitavastatin tab pravastatin tab cholestyramine, light fenofibrate cap gemfibrozil tab NEXLIZET prevalite pwd pkt colesevelam pck,tab (not 30 mg, 90mg) icosapent ethyl NIACOR rosuvastatin tab colestipol granule, tab fenofibrate tab LIVALO niacin, er RX simvastatin tab ezetimibe fenofibric acid, dr lovastatin tabs omega-3 ethyl estRX VASCEPA
Diabetes
Oral Products acarbose tabs glyburide-metformin JENTADUETO pioglitazone tab saxagliptin-metfm er FARXIGA GLYXAMBI metformin er osm pioglitazone-glimpir SYNJARDY tab glimepiride tab JANUMET tab metformin tab pioglitazone-metfm SYNJARDY XR tab glipizide ER, XL, tab JANUMET XR metformin er tab repaglinide tab TRADJENTA glipizide-metformin JANUVIA miglitol tab RYBELSUS tab TRIJARDY XR glyburide tb,micro tb JARDIANCE nateglinide tab saxagliptin XIGDUO XR Insulins HUMALOG JR KWK insulin lispro JR HUMULIN 70/30 vial LYUMJEV TRESIBA HUMALOG KWKPN insulin lispro KWKPN HUMULIN N SOLIQUA PEN XULTOPHY PEN HUMALOG vial insulin lispro vial HUMULIN R TOUJEO MAX
HUMALOG MIX
KWKPN
insulin lispro mix
75/25 KWKPN LANTUS VIALS TOUJEO SOLOSTR
HUMALOG MIX vial
HUMULIN 70/30
KWKPN LANTUS SOLOSTR TRESIBA FLXTCH
Injectable Non-Insulin
BYDUREON BCISE MOUNJARO PEN OZEMPIC TRULICITY VICTOZA PEN
Diabetic Supplies
ALCOHOL SWABS INSULIN PEN NDLE OMNIPOD pks OMNIPOD STR KIT VGO 20, 30, 40
GAUZE PADS 2 X 2 INSULIN SYRGES OMNIPOD DASH
Osteoporosis alendronate ibandronate tab raloxifene tab risedronate dr tab calcitonin-salmon pamidronate inj risedronate tab zoledronic acid inj
Prenatal Vitamins
Formulary Prescription Prenatal Vitamins
You can find information on what the symbols and abbreviations on this table mean by going to page 1.
2025 Cough and Cold Buy Up (Prescription Only)
Drug Name Drug Tier Requirements / Limits
Cough and Cold Supplemental Benefits benzonatate capsules 100mg, 150 mg, 200mg 1 + benzonatate pearle 100 mg cap 1 +
BROMFED DM 2‐30‐10 MG/5 ML SYR 2 +
bromphen‐pse‐dm 2‐30‐10 mg/5ml syr 1 +
CAPCOF LIQUID 2 +
codeine‐guaifen 10‐100 mg/5 ml 1 +
CODITUSSIN AC LIQUID 2 +
CODITUSSIN DAC LIQUID 2 +
g tussin ac liquid 1 + guaiatussin ac liquid 1 + guaifen‐codeine 100‐10mg/5ml 1 +
GUAIFEN‐COD 100‐10MG/ML, 200‐20MG/10ML 2 +
guaifenesin ac cough syrup 1 + guaifenesin dac oral solution 1 + guaifenesin‐codeine syrup (generics) 1 +
HISTEX‐AC SYRUP 2 +
HYCODAN 5 MG‐1.5 MG TABLET 2 +
HYCODAN 5 MG‐1.5 MG/5 ML CUP 2 +
HYCODAN 5 MG‐1.5 MG/5 ML SOLN 2 +
hydrocodone‐chlorphen er susp 1 +
HYDROCODONE‐HOMATROP 5 ML CUP 2 +
hydrocodone‐homatropine 5‐1.5 1 + hydrocodone‐homatropine soln 1 + hydromet 5mg‐1.5mg/5ml soln 1 +
MAR‐COF BP LIQUID 2 +
You can find information on what the symbols and abbreviations on this table mean by going to page 1.
MAR‐COF CG LIQUID 2 +
MAXI‐TUSS AC LIQUID 2 +
MAXI‐TUSS CD LIQUID 2 +
m‐clear wc liquid 1 +
M‐END PE LIQUID 2 +
NINJACOF‐XG LIQUID 2 +
OBREDON 2.5‐200 MG/5 ML SOLN 2 +
pcm la tablet 1 + pe‐guai drops 1 +
POLY‐TUSSIN AC LIQUID 2 +
promethazine‐codeine syrup, solution 1 + promethazine‐dm solution 1 + promethazine‐dm syrup 6.25‐15mg/5ml 1 + promethazine‐pe‐codeine syrup 1 + promethazine‐vc codeine solution 1 +
RESPA A.R. TABLET SA 2 +
TUXARIN ER 8‐54.3 MG TABLET 2 +
TUZISTRA XR 14.7‐2.8 MG/5 ML 2 +
virtussin ac 10‐100 MG/5 ml liquid 1 + virtussin ac w‐alc 10‐100 MG/5 1 + virtussin dac liquid 1 +
You can find information on what the symbols and abbreviations on this table mean by going to page 1.
2025 Erectile Dysfunction and Lifestyle Supplemental Benefits
Sexual Dysfunction Supplemental Benefits
ADDYI 2 QL 30/30,+
CAVERJECT VIALS 2 QL 6/30,+
CAVERJECT IMPULSE 2 QL 6/30,+
CIALIS 2.5 MG, 5 MG 2 PA, ^, QL 8/30,+
CIALIS 10 MG, 20 MG 2 PA, ^, QL 8/30,+
EDEX 10 MCG, 20 MCG, 40 MCG CARTRIDGES 2 QL 6/30,+
IFE‐BIMIX 30/1 150‐5 MG/5 ML 2 +
MUSE 250 MCG, 500 MCG, 1000 MCG URETHRAL
SUPPOSITORY
2 QL 6/30,+
sildenafil 25 mg, 50 mg, 100 mg tablets (generic Viagra) 1 QL 8/30,+
STENDRA 50 MG, 100 MG, 200 MG TABLETS 2 QL 8/30,+
tadalafil 2.5 mg, 5 mg (generic Cialis) 1 PA, ^, QL 8/30,+ tadalafil 10 mg, 20 mg (generic Cialis) 1 PA, ^, QL 8/30,+
TRI‐MIX 150 MG‐5 MG‐50 MCG VL 2 +
vardenafil tab 2.5 mg, 5 mg, 10 mg, 20 mg tablets 1 QL 8/30,+ vardenafil odt tab 1 QL 8/30,+
VIAGRA 25 MG, 50 MG, 100 MG 2 QL 8/30,+
VYLEESI 2 QL 30/30,+
You can find information on what the symbols and abbreviations on this table mean by going to page 1.
2025 Prescription Vitamins Supplemental Benefits
Prescription Vitamins Supplemental Benefits
ACCRUFER 30 MG CAPSULE 2 +
AQUASOL A 100,000 UNITS/2ML VIAL 2 +
ascorbic acid 500 mg/ml vial 1 +
AZESCHEW CHEW 2 +
BACMIN CAPLET 2 +
B‐12 COMPLIANCE INJ KIT 2 +
b‐complex 100 injection 1 + cyanocobalamin 1,000 mcg/ml 1 + cyanocobalamin 500 mcg spray 1 +
DERMACINRX PUREFOLIX TABLET 2 +
dodex 1,000 mcg/ml, 10,000 mcg/10 ml, 30,000 mcg/30ml 1 +
DRISDOL 1.25 MG (50,000 UNIT) 2 +
DUET DHA 400 COMBO PACK, BALANCED 2 +
FERAHEME 510 MG/17 ML VIAL 2 +
FERRLECIT 62.5 MG/5 ML VIAL 2 +
FERUMOXYTOL 510 MG/17 ML VIAL 2 +
folic acid 1 mg tablet 1 + folic acid 5 mg/ml vial 1 + hydroxocobalamin 1,000 mcg/ml 1 +
INFED 100 MG/2ML VIAL 2 +
INFUVITE ADULT, PEDIATRIC 2 +
INJECTAFER 100 MG/2 ML VIAL 2 +
INJECTAFER 750 MG/15 ML VIAL 2 +
KOSHER PRENATAL PLUS IRON TAB 2 +
MEPHYTON 5 MG TABLET 2 +
METHYLCOBALAMIN 10,000 MCG VIAL 2 +
MONOFERRIC 1,000 MG/10 ML VIAL 2 +
You can find information on what the symbols and abbreviations on this table mean by going to page 1.
Drug Name Drug Tier Requirements / Limits mynatal capsule 1 + mynatal plus capsule 1 + mynatal‐z captab 1 +
NASCOBAL 500 MCG NASAL SPRAY 2 +
NEEVODHA CAPSULE 2 +
NEONATAL FE TABLET 2 +
NEONATAL PLUS VITAMIN TABLET 2 +
NESTABS ABC PRENATAL COMBO PK 2 +
newgen tablet 1 +
OBSTETRIX EC CAPLET 2 +
OBTREX DHA PRENATAL VITAMIN 2 +
PHYSICIANS EZ USE B‐12 KIT 2 +
PHYTONADIONE 1 MG/0.5 ML SYRINGE 2 +
PHYTONADIONE 10 MG/ML AMPUL 2 +
phytonadione 5mg tablet 1 +
POTABA 500 MG CAPSULE 2 +
prena1 chew tablet 1 + prena1 pearl softgel 1 + prena1 true combo pack 1 + prenatabs fa, rx tablet 1 + prenatal‐u capsule 1 +
PRENATE ELITE TABLET 2 +
PRENATE STAR TABLET 2 +
pyridoxine 100 mg/ml vial 1 +
R‐NATAL OB SOFTGEL 2 +
ROCALTROL 1 MCG/ML ORAL SOLN 2 +
sod fer gluc cplx 62.5 mg/5 ml 1 + thiamine 200 mg/2 ml vial 1 +
You can find information on what the symbols and abbreviations on this table mean by going to page 1.
Drug Name Drug Tier Requirements / Limits
TRIFERIC 27.2 MG/5 ML AMPULE 2 +
TRIFERIC 272 MG POWDER PACKET 2 +
trinatal rx 1 tablet 1 + trinate tablet 1 +
TRINAZ TABLET 2 +
TRISTART DHA SOFTGEL 2 +
VENOFER 100 MG/5 ML VIAL 2 +
VENOFER 200 MG/10 ML VIAL 2 +
VENOFER 50 MG/2.5 ML VIAL 2 +
VITAFOL NANO TABLET 2 +
VITALIPID N INFANT AMPULE 2 +
VITLIPID N ADULT AMPULE 2 +
VITATRUE COMBO PACK 2 +
vitamin D2 1.25mg (50,000 unit) RX 1 + vitamin K1 10 mg/ml, 1mg/0.5ml ampule 1 +
VITAPEARL SOFTGEL 2 +
VITATRUE COMBO PACK 2 +
zatean pn dha capsule 1 + zatean pn plus softgel 1 + zingiber tablet 1 +
ZIPHEX TABLET 2 +
1-800-558-9562 (TTY 711)
October 1 – March 31, 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. Customer service also has free language interpreter services available for non-English speakers.
CignaMedicare.com/group/PDPresources
Cigna Healthcare products and services are provided exclusively by or through operating subsidiaries of The Cigna Group. The Cigna names, logos, and marks, including THE CIGNA GROUP and CIGNA HEALTHCARE are owned by Cigna Intellectual Property, Inc. Subsidiaries of The Cigna Group contract with Medicare to offer Medicare Advantage HMO and PPO plans and Part D Prescription Drug Plans (PDP) in select states, and with select State Medicaid programs. Enrollment in a Cigna Healthcare product depends on contract renewal. © 2024 Cigna Healthcare
25_GSN_COM INT_25_1357004_C
January 1 – December 31, 2025
Evidence of Coverage Snapshot
City of Miami S5617 – 801_Enhanced Drug List_A3 Your Medicare pharmacy network is: Medicare Broad Network
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.
Stage 1
Yearly Deductible Stage
Stage 2
Initial Coverage Stage
Stage 3
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.
During this stage, the plan will pay the cost of your covered Part D drugs for the rest of the calendar year (through December 31, 2025).
For a 30-day supply, you pay $0.
Yearly Deductible Stage
(Details are in Section 4 of Chapter 4 in your Evidence of Coverage Booklet.)
Initial Coverage Stage
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 $2,000.
(Details are in Section 5 of Chapter 4 in your Evidence of Coverage Booklet.)
Stage 3 Catastrophic Coverage Stage
(Details are in 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 Chapter 4, 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 2025 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 and 5.4 in your Evidence of Coverage booklet for a detailed description of the table shown below.
Your share of the cost when you get up to a three-month supply of a covered Part D prescription drug:
Pharmacy Network: Medicare Medicare Broad Network Network
Tier Supply Retail Cost-Share Mail-Order Cost-Share
Tier 1
30-day $15 $15 60-day $30 $30 90-day $0 $0
Tier 2
30-day $40 $40 60-day $80 $80 90-day $80 $80
Tier 3
30-day $60 $60 60-day $120 $120 90-day $120 $120
Tier 4*
30-day $60 $60 60-day N/A N/A 90-day N/A N/A
*Specialty drugs are limited to a 30-day supply
Out-of-Network Coverage
If you get your drug at an out-of-network pharmacy, you will pay the same cost-share you would pay for a 30-day supply at an in-network retail pharmacy. If you reside in a long-term care facility, you will pay the standard retail cost-share at an in-network pharmacy.
Your Medicare Pharmacy Network is: Medicare Broad Network.
We may not pay you back the difference between what you paid for the drug at the out-of-network pharmacy and the amount that we would pay at an in-network pharmacy.
Coverage is limited to certain situations; see Chapter 5 of the Evidence of Coverage booklet for details.
Long Term Care Your share of the cost when you get a one-month (up to a 30-day or 31-day supply) in a network long-term care facility is the same as what you pay for a 30-day supply at a network pharmacy.
Additional Benefits Offered
• Adherence Package
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 2025 Formulary document for details. The following drug categories are excluded from CMS coverage. If a plan deductible applies, any non-Part D coverage added to the plan will not be subject to the plan deductible. The cost-share for these drugs is the same as the cost-shares in the initial coverage phase based on the drug classification. The cost-share you pay on these drugs do not count toward your annual True Out-of-Pocket (TrOOP).
Covered Non-Part D Drugs:
• Prescription Vitamins - Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations
• Cough and Cold Drugs - Drugs used for the relief of cough or cold symptoms
• Erectile Dysfunction Drugs^ - Drugs used for the treatment of sexual or erectile dysfunction
• Courtesy Drugs/DESI Buy Up - Courtesy Drugs: Drugs normally covered under commercial pharmacy plans but are excluded by CMS. DESI (Drug Efficacy Study Implementation) Drugs: Drugs that were introduced between 1938-1962 and approved for safety but not effectiveness. DESI drugs are not “grandfathered” or generally recognized as safe and effective (GRAS/E).
^Some drugs are subject to prior authorization and quantity limitations even though these limitations may be waived in other treatment categories. Please review your 2025 formulary for more information.
Not Covered Non-Part D Drugs:
The following drug categories are excluded from CMS coverage.
• Drugs used to promote fertility
• Drugs used for treatment of anorexia, weight loss, or weight gain
• Drugs used for cosmetic purposes or to promote hair growth
• Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale.
Important Message About What You Pay for Insulin You won’t pay more than $35 for a one-month supply of each covered insulin product regardless of the cost-sharing tier. If your insulin is on a tier where cost-sharing is lower than $35 you will pay the lower cost for your insulin.
You won’t pay more than 2 times the amount above for up to a two-month supply or 3 times the amount above for up to a three-month supply of each covered insulin product regardless of the cost-sharing tier. If your insulin is on a tier where cost-sharing is lower, you will pay the lower cost for your insulin.
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.
Cigna Healthcare products and services are provided exclusively by or through operating subsidiaries of The Cigna Group. The Cigna names, logos, and marks, including THE CIGNA GROUP and CIGNA HEALTHCARE are owned by Cigna Intellectual Property, Inc.
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. © 2024 Cigna Healthcare
24_GFA_COM INT_24_1088532_C
2024 Cigna Rx Medicare (PDP) Formulary Addendum 2024 Enhanced Drug List Addendum
S5617_801_RXPDP B2
Please read: This document contains information about the policies and criteria and any additional coverage offered with your plan.
Please visit or CignaMedicare.com/group/PDPresources to view the comprehensive 2024 Enhanced Drug List.
The drug list found on our website will be updated each month.
Are there any restrictions on my 2024 Cigna Rx Medicare (PDP) coverage?
Some covered drugs may have additional requirements or limits on coverage. You can identify these by looking to the right of the name of the drug on the drug list located on our website. The requirements and limits for your plan are the following:
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 one-month supply.
This prescription drug has an administrative prior authorization requirement that is not waived. This drug may be covered under different benefits depending on circumstances.
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 apply to 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.
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.
HRM This high-risk medication requires prior authorization.
LA
Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Customer Service.
V
This vaccine is provided to adults at no cost when used based on recommendations by the Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP).
PA This drug requires prior authorization.
QL This drug has quantity limits.
ST This drug has step therapy requirements.
Where can I find the list of covered drugs for my plan?
You can visit CignaMedicare.com/group/PDPresources to view the current list of covered drugs for the 2024 Enhanced Drug List. While there, you can also view documents that explain our prior authorization and step therapy restrictions as well as other useful plan information. To locate the drug list you need, simply visit the location above and search for the 2024 Enhanced Drug List.
24_GFA_S5617_COM INT_24_1088532_C
What additional coverage is available with my plan?
The following pages include additional coverage offered by City of Miami. This coverage includes drugs that are normally excluded from CMS coverage that City of Miami has added to your plan. The cost share you pay for these drugs does not count towards your annual TrOOP.
Erectile Dysfunction Drugs^ Cough and Cold Drugs Prescription Vitamins ^Some drugs are subject to prior authorization and quantity limitations even though these limitations may be waived in other treatment categories. Please review your 2024 Enhanced drug list for more information.
Preventive Benefits 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.
1-800-558-9562 (TTY 711)
October 1 – March 31, 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. Customer service also has free language interpreter services available for non-English speakers.
CignaMedicare.com/group/PDPresources
Cigna Healthcare products and services are provided exclusively by or through operating subsidiaries of The Cigna Group. The Cigna names, logos, and marks, including THE CIGNA GROUP and CIGNA HEALTHCARE are owned by Cigna Intellectual Property, Inc. Subsidiaries of The Cigna Group contract with Medicare to offer Medicare Advantage HMO and PPO plans and Part D Prescription Drug Plans (PDP) in select states, and with select State Medicaid programs. Enrollment in a Cigna Healthcare product depends on contract renewal. © 2023 Cigna Healthcare
24_GSN_COM INT_24_1088433_C
January 1 – December 31, 2024
Evidence of Coverage Snapshot
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.
Yearly Deductible Stage
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.
Yearly Deductible
(Details are in
Section 4 of Chapter 4 in your Evidence of Coverage Booklet.)
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.
• 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.
Cigna Healthcare products and services are provided exclusively by or through operating subsidiaries of The Cigna Group. The Cigna names, logos, and marks, including THE CIGNA GROUP and CIGNA HEALTHCARE are owned by Cigna Intellectual Property, Inc.
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
| 0013208_3202272_RET_RXPDP_FORMULARY |
| 0013208_3202272_RET_RXPDP_Snapshot |
| 0013208_3202272_RMEPDP_RXPDP_FORMULARY |
| 0013208_3202272_RMEPDP_RXPDP_Snapshot |
File details come from the government source that posted it. Updated .