28 28 Frequently Asked Questions (FAQs) Here are answers to questions you may have about your drug list and prescription medication coverage. Q. Why do you make changes to the drug list? A. We review and update the drug list on a regular basis to make sure you have coverage for low-cost, safe and effective medications. We make changes for many reasons; for example, when a new medication comes out or is no longer available, or when a medication’s price changes. These changes may include: • Moving a medication to a lower cost tier. This can happen at any time during the year. • Moving a brand medication to a higher cost tier when a generic comes out. This can happen at any time during the year. • Moving a medication to a higher cost tier and/or no longer covering a medication. This typically happens twice a year on January 1 and July 1. • Adding extra coverage rules (requirements) to a medication. This typically happens twice a year on January 1 and July 1. When we make a change that affects your medication (for example, it’ll cost more, won’t be covered, and/or has an extra coverage requirement), we let you know before it happens. This way, you have time to talk with your doctor about your options. Only you and your doctor can decide what’s best for your treatment. Q. Why doesn’t my plan cover certain medications? A. To help lower your overall health care costs, your plan doesn’t cover certain high-cost brand-name medications that have lower-cost alternatives that can treat the same condition. If your medication isn’t covered and your doctor feels a different medication isn’t right for you, your doctor’s office can ask us to cover it through our review process. There are also some medications and products that your plan won't cover for any reason because they’re a “plan (or benefit) exclusion.” This means the medication or product isn’t on your drug list, and there’s no option to ask us to cover it through our review process. For example, your plan doesn’t cover (or “excludes”) medications that the U.S. Food and Drug Administration (FDA) hasn’t approved. Q. How do you decide which medications to cover? A. The Cigna Healthcare Prescription Drug List is developed with the help of the Cigna Healthcare Pharmacy and Therapeutics (P&T) Committee, which is a group of practicing doctors and pharmacists, most of whom work outside of Cigna Healthcare. The group meets regularly to review medical evidence and information provided by federal agencies, drug manufacturers, medical professional associations, national organizations and peer-reviewed journals about the safety and effectiveness of medications that are newly approved by the FDA and medications already on the market. The Cigna Healthcare Health Plan Commercial Value Assessment Committee (HVAC) then looks at the results of the P&T Committee’s clinical review, as well as the medication’s overall value and other factors before adding it to, or removing it from, the drug list. Q. Why do certain medications need approval before my plan will cover them? A. The review process helps make sure you’re getting coverage for the right medication, at the right cost, in the right amount and for the right situation. Q. How do I know if a medication needs approval? A. Check your drug list or log in to the myCigna App or myCigna.com and use the Price a Medication tool. If the medication has: • PA (Prior Authorization) or ST (Step Therapy) next to it, it needs approval before your plan will cover it. • QL (Quantity Limit) next to it, you may need approval depending on how much you’re filling at one time. • AGE (Age Requirement) next to it, you may need approval depending on your age. Q. What types of medications typically need approval? A. Medications that: • May not be safe when you take them with other medications. • Have lower-cost alternatives that work just as well at treating the same condition.