A formulary is a list of drugs that are covered by a Cigna-HealthSpring plan. We will generally cover the drugs on our drug list as long as the drug is filled at a network pharmacy and other coverage rules are followed.
Each Medicare Part D Prescription Drug Plan must follow the rules set forth by Medicare in covering Part D drugs. In addition, Medicare must approve our drug list each year.
Not all prescription drugs are included on the drug list. In some cases, the law prohibits Medicare coverage of certain types of drugs. In other cases, we have decided not to include a particular drug on our drug list because we may have an alternative drug that can be taken.
Whether your prescription drug is covered will depend on whether it is on the plan's list of covered drugs. Medicare prescription drug plans must include at least two drugs in every drug category. In addition, each Medicare Part D Prescription Drug Plan must:
- Make sure you have convenient access to retail pharmacies.
- Have a process to request exceptions to the drug list.
- Provide useful information to you, such as how drug lists and medication management programs work, information on saving money with generic drugs, and grievance and appeal processes.
For information about alternative drugs that are covered, or how to request an exception to a Cigna-HealthSpring list of covered drugs, please contact us.
During a plan year, we may make certain changes to our list of covered drugs. Most changes throughout the year will have a positive impact on customers such as adding new drugs to our drug list, removing restrictions, or moving a drug to a lower cost-sharing tier. Plans are limited in their ability to make changes during the year that will have a negative impact on customers. A negative change would be removing a drug, or moving it to a higher cost-sharing tier, or adding a new requirement. If there are negative changes in most cases we will post a notice on this site before the change becomes effective. If you are taking the drug with the change you will generally be notified on your Explanation of Benefits (EOB) statement. We also may make a change when a new generic becomes available.
From year to year our drug list may change. It is important that you check the drug list included in your annual notice of change (ANOC) or our website, to confirm the coverage of your drugs for the next year.
All Cigna-HealthSpring Prescription Drug Plans cover both brand-name drugs and generic drugs. Generic drugs have the same active-ingredients as brand name drugs. Generic drugs usually cost less than brand-name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand-name drugs.
There are some covered drugs on the drug list that have additional requirements or limits on coverage. These include:
Prior Authorization - This means that you or your doctor will need to get approval from our plan before you begin taking this medication. If you don’t get the needed approval, we may not cover the drug.
Quantity Limits - This means that we limit the amount of the drug that we will cover. For example, if we allow 1 tablet per day for Drug ABC, for a one-month supply this would be a quantity of 30 per 30 days (abbreviated as 30/30).
Step Therapy - This means that you must first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.
Medicare requires that certain medications and durable medical equipment (such as diabetic test strips, nebulizers and wheelchairs) be covered under Part B. Medicare Part D plans usually do not cover drugs that are covered under Medicare Part B. Medicare Part B will typically cover drugs that are administered at a hospital or doctor's office.
You will need to go to one of the pharmacies within the network, except in unusual circumstances or emergencies. All you need to do is present your Cigna-HealthSpring prescription drug card at the retail pharmacy. You can also get your routine maintenance prescription medications through a mail-order pharmacy.
Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. Here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:
- You travel outside the health plan’s service area and run out of, or lose, covered Part D drugs, or become ill and need a covered Part D drug and cannot access a network pharmacy.
- You are unable to obtain a covered Part D drug in a timely manner within the service area because, for example, there is no network pharmacy within a reasonable driving distance that provides 24-hour service.
- You are filling a prescription for a covered Part D drug and that particular drug is not regularly stocked at an accessible network retail or mail order pharmacy.
- The Part D drugs are dispensed by an out-of-network institution-based pharmacy while in an emergency facility, provider-based clinic, outpatient surgery, or other outpatient setting.
In these situations, please check first with Customer Service to see if there is a network pharmacy nearby.
You will present your plan's prescription drug card at the pharmacy or send the prescription drug card number if you're using a mail-order pharmacy. The pharmacy will electronically access your information - whether or not you still have part of your deductible to pay, what copay or coinsurance will apply.
This is a program that may assist qualified Cigna-HealthSpring Rx customers who:
- Take multiple prescription drugs
- Have a chronic illness
- Expect to spend a significant amount of money on prescription drugs each year
MTMP can help identify potential errors and gaps in your care by:
- Helping reduce the risk of medication errors - especially if you have chronic conditions, take several medications or see multiple doctors
- Providing current information on proven medical practices to help you and your doctor determine the most effective treatment
- Helping you understand your condition and medications, so you can take an active role in managing your health.