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2022 Medicare Part D Plan’s Negotiated Retail Drug Price

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2022 Medicare Prescription Drug Price Information
Cigna Extra Rx (PDP) (S5617-256-0)
Benefit Details         

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Cigna Extra Rx (PDP) Formulary
A  B  C  D  E  F  G  H  I  J  K  L  M  N  O  P  Q  R  S  T  U  V  W  X  Y  Z  0-9 
This Plan Uses Lower Cost-Sharing for Preferred Pharmacies
LEVOXYL 25 MCG TABLET  
Plan’s average negotiated retail drug price in
CMS PDP Region 11, includes: FL
$24.60* 30-Day Supply
$73.80* 90-Day Supply
Formulary (Drug List) drug tier:Tier #3: Preferred Brand
This Tier has No Deductible.
Does this plan offer any Gap coverage?Yes
Does this drug have Gap coverage?No, this drug IS NOT covered in the gap, but all drugs receive the donut hole discount.
Drug Usage Management Restrictions:None
Formulary (Drug List) Tier Cost-Sharing Details
  30-Day Supply
Cost-Sharing
90-Day Supply
Cost-Sharing
Preferred Pharmacy Standard Pharmacy Mail- Order** Preferred Pharmacy Standard Pharmacy Mail- Order**
Initial $100 Deductible Cost Sharing:
 $42.00 $47.00 $42.00 $126.00 $141.00 $126.00
Initial Coverage Phase Cost-Sharing:
 $42.00 $47.00 $42.00 $126.00 $141.00 $126.00
Coverage Gap Phase Cost-Sharing Incl. Donut Hole Discount (Generics 75%):
 25% 25% 25% 25% 25% 25%
Coverage Gap Phase Cost-Sharing Incl. Donut Hole Discount (Brand 75%):
 25% 25% 25% 25% 25% 25%
Catastrophic Coverage Phase Cost-Sharing for Generic & Preferred Multi-Source Drugs:
 The greater of 5% or $3.95 The greater of 5% or $3.95
Catastrophic Coverage Phase Cost-Sharing for Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs):
 The greater of 5% or $9.85 The greater of 5% or $9.85
Your Estimated Cost for Purchases During Each Coverage Phase
  30-Day Supply
Cost-Sharing
90-Day Supply
Cost-Sharing
Preferred Pharmacy Standard Pharmacy Mail- Order** Preferred Pharmacy Standard Pharmacy Mail- Order**
Your Estimated Cost in Deductible Phase:
 $24.60 $24.60 $24.60 $73.80 $73.80 $73.80
Your Estimated Cost Initial Coverage Phase:
 $24.60 $24.60 $24.60 $73.80 $73.80 $73.80
Your Estimated Cost in Gap if Drug is Generic (75% discount):
 $6.15$6.15$6.15 $18.45$18.45$18.45
Your Estimated Cost in Gap if Drug is Brand-Name (75% discount):
 $6.15$6.15$6.15 $18.45$18.45$18.45
Your Estimated Cost in Catastrophic Coverage Phase (Generic):
 $3.95 $3.95 $3.95 $3.95 $3.95 $3.95
Your Estimated Cost in Catastrophic Coverage (Brand-Name or Non-Preferred Multi-Source Drugs):
 $9.85 $9.85 $9.85 $9.85 $9.85 $9.85
Tier Cost-Sharing Details and Your Costs with Explanations
  30-Day Supply
Cost-Sharing
90-Day Supply
Cost-Sharing
Preferred Pharmacy Standard Pharmacy Mail- Order** Preferred Pharmacy Standard Pharmacy Mail- Order**
--- If you purchase during the Initial Deductible Phase ---
Initial $100 Deductible Cost Sharing:
 $42.00 $47.00 $42.00 $126.00 $141.00 $126.00
Your Estimated Cost in Deductible Phase:
 $24.60 $24.60 $24.60 $73.80 $73.80 $73.80
Explanation for 30-Day Preferred Pharmacy purchase:
 This plan has coverage for all Tier 3 drugs during the initial deductible phase. Since the negotiated retail price of this drug ($24.60) is less than your cost-sharing amount ($42.00), you pay the negotiated retail price ($24.60) during the deductible phase. Read more about the "Lesser Of" Logic.
--- If you purchase during the Initial Coverage Phase ---
Initial Coverage Phase Cost-Sharing:
 $42.00 $47.00 $42.00 $126.00 $141.00 $126.00
Your Estimated Cost Initial Coverage Phase:
 $24.60 $24.60 $24.60 $73.80 $73.80 $73.80
Explanation for 30-Day Preferred Pharmacy purchase:
 Since the negotiated retail price of this drug ($24.60) is less than your cost-sharing cost ($42.00), you pay the negotiated retail price ($24.60) during the initial coverage phase. Read more about the "Lesser Of" Logic.
--- If you purchase during the Coverage Gap Phase (Donut Hole) ---
Your Estimated Cost in Gap if Drug is Generic (75% discount):
 $6.15$6.15$6.15 $18.45$18.45$18.45
Explanation for 30-Day Preferred Pharmacy purchase:
 Your cost is the negotiated retail price of $24.60 x 25%.
Your Estimated Cost in Gap if Drug is Brand-Name (75% discount):
 $6.15$6.15$6.15 $18.45$18.45$18.45
Explanation for 30-Day Preferred Pharmacy purchase:
 Your costs is the negotiated retail price of $24.60 x 25%.
--- If you purchase during the Catastrophic Coverage Phase ---
Catastrophic Coverage Phase Cost-Sharing for Generic & Preferred Multi-Source Drugs:
 The greater of 5% or $3.95 The greater of 5% or $3.95
Your Estimated Cost in Catastrophic Coverage Phase (Generic):
 $3.95 $3.95 $3.95 $3.95 $3.95 $3.95
Explanation for 30-Day Preferred Pharmacy purchase:
 In the catastrophic coverage phase, you will pay the greater of 5% of the retail drug price or the minimum cost-share of $3.95. Calculating 5% of $24.60 = $1.23. Since $1.23 is less than $3.95, you would pay $3.95 for this drug at a preferred pharmacy, if it is a generic or preferred multi-source drug.
Catastrophic Coverage Phase Cost-Sharing for Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs):
 The greater of 5% or $9.85 The greater of 5% or $9.85
Your Estimated Cost in Catastrophic Coverage (Brand-Name or Non-Preferred Multi-Source Drugs):
 $9.85 $9.85 $9.85 $9.85 $9.85 $9.85
Explanation for 30-Day Preferred Pharmacy purchase:
 In the catastrophic coverage phase, you will pay the greater of 5% of the retail drug price or the minimum cost-share of $9.85. Calculating 5% of $24.60 = $1.23. Since $1.23 is less than $9.85, you would pay $9.85 for this drug at any pharmacy, if it is not a generic or preferred multi-source drug.
Cigna Extra Rx (PDP)
Average Negotiated Retail Drug Price History
 30-Day Supply90 Day Supply
September, 2022: $24.60$73.80
June, 2022: $24.60$73.80
March, 2022: $24.30$72.90
January, 2022: $23.40$70.20
September, 2021: $15.90$47.70
June, 2021: $20.10$59.40
March, 2021: $20.10$59.40
January, 2021: $19.80$58.50
September, 2020: $18.60$53.10
June, 2020: $19.50$57.60
March, 2020: $19.50$57.60
January, 2020: $18.90$55.80
September, 2019: $6.82$26.05
June, 2019: $7.06$20.64
March, 2019: $6.52$18.67
January, 2019: $6.42$18.32
September, 2018: $7.71$20.88
June, 2018: $8.73$23.77
March, 2018: $8.88$24.53
January, 2018: $8.88$24.53
September, 2017: $13.96$36.41
June, 2017: n/an/a
March, 2017: n/an/a
January, 2017: n/an/a
September, 2016: $7.45$21.94
June, 2016: $7.98$22.12
April, 2016: $5.95$15.04
January, 2016: $6.04$15.18
September, 2015: $8.14$21.53
June, 2015: $8.21$21.39
April, 2015: $8.00$20.77
January, 2015: $8.54$22.39
September, 2014: n/an/a
June, 2014: n/an/a
March, 2014: n/an/a
January, 2014: n/an/a
October, 2013: n/an/a
January, 2013: n/a--
April, 2012: n/a--
September, 2010: n/a--
Notes:
*The Medicare drug plan’s average negotiated retail drug price is based on several variables: the medication, the quantity of your prescription, the specific Medicare Part D plan, and the pharmacies in the plan’s service area. In this case, the average of the LEVOXYL 25 MCG TABLET prices that the Cigna Extra Rx (PDP) has negotiated with each of the retail pharmacies in the plan’s service area (CMS PDP Region 11, includes: FL). In other words, when you use the Cigna Extra Rx (PDP) to purchase LEVOXYL 25 MCG TABLET, you may pay slightly more or slightly less than the figures shown in the table above depending on the pharmacy where you fill your prescription and the quantity of your prescription. The example average retail prices used above are based on a quantity of 30 for the 30-day supply and a quantity of 90 for the 90-day supply.

**The mail-order cost-sharing is the plan’s "preferred" mail-order cost-sharing.

Return to the Cigna Extra Rx (PDP) 2022 Formulary Browser by choosing a letter below:
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Chart Legend:

What does all this mean? Below are a few notes to help you understand the above 2022 Medicare Part D Cigna Extra Rx (PDP) Plan Formulary.


  • Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region). The plan name is followed by the plan type (PDP, HMO, HMO-POS, PPO, PFFS, etc.)

  • Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.

  • Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $480 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.

  • Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
    • Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.
    • No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.

  • Plan ID: This is the Medicare Part D prescription drug plan's unique ID.

  • Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
    • Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have five (5) tiers 1=Preferred Generics, 2=Generics, 3=Preferred Brands, 4=Non-preferred Brands, 5=Specialty Drugs.
    • Tier Number* - Some Part D drug plans exclude one or more drug tiers from the plan’s deductible. If the drug tier field above is followed by * (example: 2*), then this drug tier is excluded from the plan’s deductible.
  • Cost Sharing - Copay / Coinsurance - This is what you will pay for formulary drugs in the Initial Coverage Phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
    • Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the initial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $4,430) at a "Preferred" network pharmacy. In most cases, the "Preferred" network pharmacy cost-sharing is lower than the standard (non-preferred) network pharmacy cost-sharing.

      * When the text "$35 or less" appears, this Part D plan may offer this particular insulin as part of the Senior Savings Model.  The Senior Savings Model stipulates that the insulin will cost no more than $35 in the deductible, initial coverage, and coverage gap phases of your Part D plan. Please contact the drug plan for more details.

    • Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
  • Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
    • None - This drug does not fall under any drug utilization management controls.
    • P - Prior Authorization -This drug is subject to prior authorization.
    • S - Step Therapy -This drug is subject to step therapy.
    • Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.






(Chart Source: Centers for Medicare and Medicaid files: CMS Data September 2022)

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Medicare plan provider.