Cigna Extra Rx (PDP)
S5617 - 260
Plan Not Rated
Cigna Extra Rx (PDP) is a Medicare Prescription Drug Plan by Cigna.
This page features plan details for 2022 Cigna Extra Rx (PDP) S5617 – 260.
Locations
Cigna Extra Rx (PDP) is offered in the following locations.
Plan Overview
Cigna Extra Rx (PDP) offers the following coverage and cost-sharing.
| Insurer: | Cigna |
| Drugs Covered: | Yes |
Please Note:
- This plan does not charge an annual deductible for all drugs. The $100.00 annual deductible only applies to drugs on certain tiers.
Ready to sign up for Cigna Extra Rx (PDP) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST
Premium Breakdown
Cigna Extra Rx (PDP) has a monthly premium of $58.10. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $0.00 | $ | $58.10 | $0.00 | $ |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
- You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.
Drug Info
Cigna Extra Rx (PDP) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $100.00 |
| Initial Coverage Limit: | $4,430.00 |
| Catastrophic Coverage Limit: | $7,050.00 |
| Drug Benefit Type: | Enhanced |
| Gap Coverage: | Yes |
| Formulary Link: | Formulary Link |
Part D Premium Reduction
The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs. The table below shows how the LIS impacts the Part D premium of this plan.| Part D | LIS 25% | LIS 50% | LIS 75% | LIS Full |
|---|---|---|---|---|
| $58.10 | $54.7 | $51.3 | $48.0 | $44.60 |
Initial Coverage Phase
After you pay your $100.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $4,430.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $4.00 copay | $15.00 copay | $4.00 copay | $15.00 copay |
| 2 (Generic) | $10.00 copay | $20.00 copay | $10.00 copay | $20.00 copay |
| 3 (Preferred Brand) | $42.00 copay | $47.00 copay | $42.00 copay | $47.00 copay |
| 4 (Non-Preferred Drug) | 50% | 50% | 50% | 50% |
| 5 (Specialty Tier) | 31% | 31% | 31% | 31% |
| 6 (Select Care Drugs) | $0.00 copay | $11.00 copay | $0.00 copay | $11.00 copay |
60 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | ||||
| 2 (Generic) | ||||
| 3 (Preferred Brand) | ||||
| 4 (Non-Preferred Drug) | ||||
| 5 (Specialty Tier) | ||||
| 6 (Select Care Drugs) |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $12.00 copay | $45.00 copay | $0.00 copay | $45.00 copay |
| 2 (Generic) | $30.00 copay | $60.00 copay | $4.00 copay | $60.00 copay |
| 3 (Preferred Brand) | $126.00 copay | $141.00 copay | $126.00 copay | $141.00 copay |
| 4 (Non-Preferred Drug) | 50% | 50% | 50% | 50% |
| 5 (Specialty Tier) | ||||
| 6 (Select Care Drugs) | $0.00 copay | $33.00 copay | $0.00 copay | $33.00 copay |
Gap Coverage Phase
30 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $4.00 copay | $15.00 copay | $4.00 copay | $15.00 copay |
| 2 (Generic) | $10.00 copay | $20.00 copay | $10.00 copay | $20.00 copay |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $12.00 copay | $45.00 copay | $0.00 copay | $45.00 copay |
| 2 (Generic) | $30.00 copay | $60.00 copay | $4.00 copay | $60.00 copay |
| Tier | Cost |
|---|---|
| All other tiers (Generic) | 25% |
| All other tiers (Brand-name) | 25% |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,050.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.
| Drug Type | Cost Share |
|---|---|
| Generic drugs | $3.95 copay or 5% (whichever costs more) |
| Brand-name drugs | $9.85 copay or 5% (whichever costs more) |
Ready to sign up for Cigna Extra Rx (PDP) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST