A formulary is a list of all drugs that are covered under our Cigna-HealthSpring plans. We will generally cover the drugs on our drug list as long as the drug is medically necessary, the prescription is filled at a network pharmacy and other coverage rules are followed.
Each health insurance plan must follow the rules set forth by Medicare in covering Part D drugs. In addition, Medicare must approve our drug list each year and as changes are made.
The drugs on the drug list are selected by our health insurance plan with the help of a team of health care professionals. We select the prescription therapies believed to be a necessary part of a quality treatment program. Both brand-name drugs and generic drugs are included on the list of covered drugs.
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. This is one example.
Whether your prescription drug is covered will depend on whether it is on the health insurance plan's list of covered drugs. Medicare prescription drug plans must include at least two drugs in every drug category. In addition, each Part D plan must:
- Make sure you have convenient access to retail pharmacies.
- Have a process to request exceptions to the drug list about our coverage rules.
- 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 on how to obtain an exception to a Cigna-HealthSpring Rx Prescription drug plan list of covered drugs, please contact us.
We may make certain changes to our list of covered drugs throughout the year. Changes in the drug list may affect which drugs are covered and how much you will pay when filling your prescription. If we remove drugs from our drug list, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost cost-sharing tier, we will post a notice on this site at least 60 days before the change becomes effective. In addition, you will be notified on your Explanation of Benefits (EOB) mailing, if you are taking the affected drug.
If the FDA deems a drug on our list of covered drugs unsafe, or if a drug is removed from the market by the manufacturer, we will take appropriate actions to help ensure the safety of our customers. These actions may include removing the drug from the drug list. If we do remove the drug, we will provide notification to customers who are taking the drug.
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 - you or your doctor may be required to get a prior authorization for some drugs. This means that you will need to get approval from your health plan prior to filling your prescription. If you do not obtain approval, the drug may not be covered.
Quantity Limits - For some drugs, the quantity that is covered may be limited by the health insurance plan.
Step Therapy - you may be required to first try certain drugs first to treat your medical condition before we will cover another prescription drug for that condition.
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.
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. Going out-of-network will cost more.
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.
Your prescription may be covered in certain situations.
Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy.
What are the circumstances when Cigna-HealthSpring would cover prescriptions filled at an out-of-network 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 health plan's prescription drug card at the pharmacy or send the prescription drug card number if you're using a mail-order pharmacy. The card will electronically access your information - whether or not you still have part of your deductible to pay, what health coverage you're entitled to, whether you have extra coverage that reduces your cost and what your copay or coinsurance should be.
For customers who take multiple medications, the Medication Therapy Management (MTM) program may be able to help.
MTMP 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.