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2024 Medicare Prescription Drug Plan Cost-Sharing Details
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2024 Medicare Advantage Prescription Drug
Formulary (Drug List) Cost-Sharing Details
Cigna Alliance Medicare (HMO) (H4513-064-0)
Benefits & Contact Info        
all covered insulin pay $35 or less
This plan is available in Brazoria County, TX

Click on a letter below to view the
Cigna Alliance Medicare (HMO) 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
  30-Day Supply
Cost-Sharing		 90-Day Supply
Cost-Sharing
Preferred Pharmacy Standard Pharmacy Mail- Order* Preferred Pharmacy Standard Pharmacy Mail- Order*
This plan does not have an Initial Deductible:n/an/an/an/an/an/a
Initial Coverage Phase Cost-Sharing
Tier 1: Preferred Generic: $0.00 $9.00 $0.00 $0.00 $27.00 $0.00
Tier 2: Generic: $4.00 $15.00 $4.00 $12.00 $45.00 $0.00
Tier 3: Preferred Brand: $45.00 $47.00 $45.00 $135.00 $141.00 $135.00
Tier 4: Non-Preferred Drug: $95.00 $100.00 $95.00 $285.00 $300.00 $285.00
Tier 5: : 33% 33% 33% n/a n/a n/a
Coverage Gap (Donut Hole) Phase Cost Sharing
75% Generic and 75% Brand Donut Hole Discount applies to all drugs even those with coverage in the gap
Tier 1: Preferred Generic: $0.00(A) $9.00(A) $0.00(A) $0.00(A) $27.00(A) $0.00(A)
All Formulary Generic Drugs: 25% 25% 25% 25% 25% 25%
All Formulary Brand-Name Drugs: 25% 25% 25% 25% 25% 25%
Catastrophic Coverage Phase Cost Sharing
All Formulary Drugs:


 $0 cost-sharing.
The Inflation Reduction Act (IRA) of 2022 eliminates beneficiary cost-sharing once your TrOOP reaches the established maximum cap on out-of-pocket spending for Part D formulary drugs (RxMOOP).
Notes:
*The mail-order cost-sharing is the plan’s "preferred" mail-order cost-sharing.
(A) Coverage Gap cost-sharing applies to all drugs on the designated tier. Drugs that are covered in the coverage gap also receive the donut hole discount.
(P) Coverage Gap cost-sharing applies to only some of drugs on the designated drug tier. Drugs that are covered in the coverage gap also receive the donut hole discount.
Go to the Cigna Alliance Medicare (HMO) 2024 Formulary Browser by choosing a letter below:
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 
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