CIGNA STANDARD 3-TIER PRESCRIPTION DRUG LIST - Starting July 1, 2020
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CIGNA STANDARD 3-TIER PRESCRIPTION DRUG LIST Starting July 1, 2020 Offered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, or their affiliates. 595200 k Standard 3-Tier 04/20
What’s inside?
About your prescription drug list 3
How to read your drug list 3
How to find your medication 5
Medications that are not covered 19
Prescription drug list FAQs 30
Exclusions and limitations 33
Go online to find out which medications your plan covers.
This document was last updated 03/01/2020.* You can go online to see your plan’s current
coverage information.
The myCigna® app or website – Once you log in, click on “Coverage,” then
select “Pharmacy” from the down menu. Under “Prescriptions,” type in the
medication name.
Cigna.com/druglist – Select your drug list name – Standard 3 Tier – from the
drop down menu.
Questions?
Call the toll-free number on your Cigna ID card. We’re here to help. You can also chat with us
online on the myCigna website, Monday–Friday, 9:00 am–8:00 pm EST.
* Drug list created: originally created 01/01/2004 Last updated: 03/01/2020, for changes Next planned update: 09/01/2020, for
starting 07/01/2020 changes starting 01/01/2021
2About your prescription drug list
This document shows the most commonly prescribed medications covered on the Standard
3-Tier Prescription Drug List as of July 1, 2020.1,2 All of these medications are approved by the U.S.
Food and Drug Administration (FDA). Medications are listed by the condition they treat, then
listed alphabetically within tiers (or cost-share levels).
The Standard 3-Tier Prescription Drug List is updated often so it’s important to know that this is
not a complete list of the medications your plan covers. Also, your specific plan may not cover all
of the medications in this document. Log in to the myCigna app or website, or check your plan
materials, to learn more about the medications your plan covers.
How to read your drug list
Use the sample chart below to help you understand this drug list. This chart is just an example.
It may not show how these medications are actually covered on the Standard 3-Tier Prescription
Drug List.
Tier (cost-share level) gives you
an idea of how much you may pay
TIER 1 TIER 2 for a medication
$ $$
BLOOD PRESSURE/HEART MEDICATIONS Medications are grouped by
afeditab CR Berinert* (PA) the condition they treat
amlodipine besylate Bidil
amlodipine besylate-benazepril Bystolic
amlodipine-valsartan Cinryze* (PA)
amlodipine-valsartan-HCTZ Coreg CR
atenolol Cozaar (ST)
Diovan (ST)
atenolol-chlorthalidone Medications are listed in
Diovan HCT (ST)
benazepril alphabetical order within
Edarbi (ST)
benazepril-HCTZ each column
Edarbyclor (ST)
candesartan cilexetil Exforge
cartia XT Exforge HCT
carvedilol Firazyr* (PA) Specialty medications have an
clonidine Hemangeol asterisk (*) listed next to them
digitek Inderal LA
digox Inderal XL
digoxin Innopran XL
diltiazem ER Lotrel Brand name medications
diltiazem CD Micardis (ST) are capitalized
diltiazem Multaq
dilt-XR Nitro-dur
enalapril Nitrolingual
NitroMist
flecainide acetate Generic medications
Nitronal
hydralazine are lowercase
Nitrostat
irbesartan Northera* (PA) Medications that have extra
isosorbide mononitrat Norvasc coverage requirements will
Ranexa (ST) have an abbreviation listed
Tekturna next to them
Tekturna HCT
This chart is just a sample. It may not show how these medications are actually covered on the Standard 3-Tier Prescription Drug List.
3Tiers
Covered medications are divided into tiers or cost-share levels. Typically, the higher the tier, the
higher the price you’ll pay to fill the prescription.
› Tier 1 – Typically Generics (Lowest-cost medication) $
› Tier 2 – Typically Preferred Brands (Medium-cost medication) $$
› Tier 3 – Typically Non-Preferred Brands (Highest-cost medication) $$$
Abbreviations next to medications
Some medications on your drug list have extra requirements before your plan will cover them.* This
helps to make sure you’re receiving coverage for the right medication, at the right cost, in the right
amount and for the right situation. These medications will have an abbreviation next to them in the
drug list. Here’s what each of the abbreviations mean.
(PA)
Prior Authorization – Cigna will review information your doctor provides to make
sure you meet coverage guidelines for the medication. If approved, your plan will
cover the medication.
(ST) tep Therapy – Certain high-cost medications are part of the Step Therapy program.
S
Step Therapy encourages the use of lower-cost medications (typically generics and
preferred brands) that can be used to treat the same condition as the higher-cost
medication. These conditions include, but are not limited to, depression, high blood
pressure, high cholesterol, skin conditions and sleep disorders. Your plan doesn’t
cover the higher-cost Step Therapy medication until you try one or more alternatives
first (unless you receive approval from Cigna).
(QL) uantity Limits – For some medications, your plan will only cover up to a certain
Q
amount over a certain length of time. For example, 30mg per day for 30 days. Your
plan will only cover a larger amount if your doctor requests and receives approval
from Cigna.
(AGE) ge Requirements – For certain medications, you must be within a specific
A
age range for your plan to cover them. This is because some medications aren’t
considered clinically appropriate for individuals who aren’t within that age range.
* These coverage requirements may not apply to your specific plan. That’s because some plans don’t have prior authorization, quantity limits, Step Therapy and/or age requirements. Log in to the
myCigna app or website, or check your plan materials, to find out if your plan includes these specific coverage requirements.
Brand name medications are capitalized
In this drug list, brand name medications are capitalized and generic medications are lowercase.
Specialty medications are marked with an asterisk
Specialty medications are used to treat complex medical conditions like multiple sclerosis,
hepatitis C and rheumatoid arthritis. In this drug list, specialty medications are marked with an
asterisk (*). Some plans may cover these medications on a specialty tier, limit coverage to a 30-day
supply and/or require you to use a preferred specialty pharmacy to receive coverage. Log in to the
myCigna app or website, or check your plan materials, to learn more about how your plan covers
specialty medications.
4No cost-share preventive medications are marked with a plus sign
Health care reform under the Patient Protection and Affordable Care Act (PPACA) requires that
most plans cover certain categories of medications and other products as preventive care services.
In this drug list, medications with a plus sign (+) next to them may be available to you at no cost-
share (copay, coinsurance and/or deductible). Log in to the myCigna app or website, or check your
plan materials, to learn more about how your plan covers preventive medications.
Plan exclusions
Your plan excludes certain types of medications or products from coverage. This is known as a “plan
(or benefit) exclusion.” This means that your plan doesn’t cover any prescription medications in the
drug class or to treat the specific condition. There’s also no option to receive coverage through a
medication review process. In this drug list, these medications have a caret (^) next to them. Log in
to the myCigna app or website, or check your plan materials, to find out if your plan excludes your
medication from coverage.
How to find your medication
Find your condition in the alphabetical list below. Then go to that page to see the covered
medications available to treat the condition.
Condition Page Condition Page
AIDS/HIV 6 GASTROINTESTINAL/HEARTBURN 12
ALLERGY/NASAL SPRAYS 6 HORMONAL AGENTS 13
ALZHEIMER’S DISEASE 6 INFECTIONS 13, 14
ANXIETY/DEPRESSION/BIPOLAR 6
INFERTILITY 14
DISORDER
MISCELLANEOUS 14
ASTHMA/COPD/RESPIRATORY 6, 7
ATTENTION DEFICIT HYPERACTIVITY 7 MULTIPLE SCLEROSIS 14
DISORDER NUTRITIONAL/DIETARY 14
BLOOD MODIFIERS/BLEEDING DISORDERS 7 OSTEOPOROSIS PRODUCTS 14
BLOOD PRESSURE/HEART MEDICATIONS 7, 8
PAIN RELIEF AND INFLAMMATORY DISEASE 14, 15
BLOOD THINNERS/ANTI-CLOTTING 8
PARKINSON’S DISEASE 15
CANCER 8
SCHIZOPHRENIA/ANTI-PSYCHOTICS 16
CHOLESTEROL MEDICATIONS 8, 9
SEIZURE DISORDERS 16
CONTRACEPTION PRODUCTS 9, 10
SKIN CONDITIONS 16, 17
COUGH/COLD MEDICATIONS 11
SLEEP DISORDERS/SEDATIVES 17
DENTAL PRODUCTS 11
DIABETES 11 SMOKING CESSATION 17
DIURETICS 11 SUBSTANCE ABUSE 17
EAR MEDICATIONS 11 TRANSPLANT MEDICATIONS 17
ERECTILE DYSFUNCTION 11 URINARY TRACT CONDITIONS 17
EYE CONDITIONS 11, 12 VACCINES 17, 18
FEMININE PRODUCTS 12 WEIGHT MANAGEMENT 18
5Cigna Standard 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
AIDS/HIV ANXIETY/DEPRESSION/BIPOLAR
abacavir- Atripla* (PA) Cimduo* (PA) DISORDER (cont)
lamivudine* (PA) Biktarvy* Complera* (PA) bupropion (QL) Pristiq (ST, QL)
atazanavir* (PA) Descovy* Evotaz* (PA) bupropion SR (QL) Prozac (ST, QL)
ritonavir* Genvoya* Juluca* (PA) bupropion XL (QL) Remeron
tenofovir* (PA) Intelence* (PA) Odefsey* (PA) buspirone Sarafem (ST)
Isentress* Prezcobix* (PA) citalopram (QL) Trintellix (ST, QL)
Isentress HD* (PA) Stribild* (PA) clomipramine Viibryd (ST, QL)
Prezista* desvenlafaxine ER Wellbutrin SR (ST,
Selzentry* (PA) (QL) QL)
Symfi* duloxetine (QL) Xanax
Symfi Lo* escitalopram (QL) Xanax XR
Symtuza* fluoxetine (QL) Zoloft (ST, QL)
Tivicay* fluoxetine DR (QL)
Triumeq* fluvoxamine (QL)
Truvada*
fluvoxamine ER
Viread 150mg,
(QL)
200mg, 250mg
lorazepam
tablet, powder*
lorazepam intensol
(PA)
mirtazapine
ALLERGY/NASAL SPRAYS paroxetine (QL)
azelastine Clarinex paroxetine CR (QL)
cromolyn Clarinex-D 12 Hour paroxetine ER (QL)
cyproheptadine Gastrocrom sertraline (QL)
desloratadine (QL) Grastek (PA, QL) trazodone
epinephrine (QL) Karbinal ER venlafaxine (QL)
fluticasone Odactra (PA, QL) venlafaxine ER (QL)
hydroxyzine Patanase
ASTHMA/COPD/RESPIRATORY
ipratropium Ragwitek (PA, QL)
mometasone (QL) Vistaril albuterol Advair HFA Adcirca* (PA)
olopatadine albuterol HFA Anoro Ellipta Adempas* (PA)
promethazine Alyq* (PA) Atrovent HFA Arcapta Neohaler
solution, syrup, budesonide Breo Ellipta Brovana
tablet fluticasone- Combivent Daliresp (QL)
salmeterol Respimat Kalydeco* (PA, QL)
ALZHEIMER’S DISEASE
montelukast Dulera Letairis* (PA)
donepezil Namenda Titration Aricept Flovent
tadalafil 20mg* Lonhala Magnair
donepezil ODT Pack Exelon Flovent HFA
(PA) (PA)
memantine Mestinon Incruse Ellipta
Wixela Inhub Nucala auto-
memantine ER (QL) Namenda tablet Ofev* (PA)
pyridostigmine Namenda XR (QL) injector, syringe*
Opsumit* (PA)
pyridostigmine ER Namzaric (QL) (PA)
ProAir HFA
rivastigmine Orenitram ER* (PA)
ProAir RespiClick
Orkambi* (PA, QL)
ANXIETY/DEPRESSION/BIPOLAR DISORDER Pulmicort Flexhaler
Perforomist (QL)
alprazolam Celexa (ST, QL) Pulmozyme* (PA)
QVAR RediHaler Pulmicort Respule
alprazolam ER Effexor XR (ST, QL) Revatio oral
alprazolam intensol Fetzima (ST, QL) Serevent
Symbicort suspension,
alprazolam ODT Forfivo XL (ST, QL) tablet* (PA)
alprazolam XR Paxil (ST, QL) Trelegy Ellipta
Ventolin HFA Singulair
amitriptyline Paxil CR (ST, QL) Symdeko* (PA, QL)
Xolair* (PA)
6Cigna Standard 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
ASTHMA/COPD/RESPIRATORY (cont) BLOOD PRESSURE/HEART MEDICATIONS
Tracleer tablet* (PA) Adult Aspirin Bystolic (ST, QL) Adalat CC
Tyvaso* (PA) Regimen+ Corlanor (PA) Altace (ST)
Uptravi* (PA) amiodarone Entresto Atacand (ST)
ATTENTION DEFICIT HYPERACTIVITY amlodipine Multaq Atacand HCT (ST)
DISORDER amlodipine- Tekturna HCT (QL) Avalide (ST)
benazepril Avapro (ST)
atomoxetine (QL) Vyvanse (PA age, Adderall (PA age, amlodipine- Azor (QL)
clonidine ER QL) ST) olmesartan (QL) Benicar (ST, QL)
dexmethylphenidate Adzenys ER (PA amlodipine- Benicar HCT (ST,
(PA age) age, QL) valsartan QL)
dexmethylphenidate Adzenys XR-ODT amlodipine- BiDil (QL)
ER (PA age, QL) (PA age, QL)
dextroamphetamine- valsartan-hctz Calan SR
Daytrana (PA age, Aspir EC+ Cardizem LA (QL)
amphetamine
(PA age) QL) Aspir-Low+ Cardura
dextroamphetamine- Dyanavel XR aspirin EC+ Catapres-TTS 1
amphetamine ER (PA age, QL) aspirin 325mg Catapres-TTS 2
(PA age, QL) Evekeo ODT tablet+ Catapres-TTS 3
guanfacine ER (PA age) atenolol Coreg (ST)
metadate ER Focalin (PA age, ST) Bayer Aspirin Coreg CR (ST, QL)
(PA age, QL) Intuniv ER 325mg tablet+ Corgard (ST)
methylphenidate Kapvay benazepril Cozaar (ST)
(PA age) Methylin (PA age) benazepril-HCTZ Diovan (ST)
methylphenidate QuilliChew ER (PA candesartan Diovan HCT (ST)
CD (PA age, QL) age, QL) candesartan-HCTZ Edarbi (ST, QL)
methylphenidate cartia XT Edarbyclor (ST)
Quillivant XR (PA
ER (PA age, QL) carvedilol Epaned
methylphenidate age, QL)
Ritalin (PA age, ST) carvedilol ER (QL) Exforge
ER (CD) (PA age, Children’s Aspirin+ Exforge HCT
QL) Strattera (QL)
clonidine Firazyr* (PA)
methylphenidate
diltiazem Haegarda* (PA)
ER (LA) (PA age,
diltiazem 12hr ER Hemangeol
QL)
methylphenidate diltiazem 24hr ER Hyzaar (ST)
LA (PA age, QL) diltiazem 24hr ER Inderal LA (ST)
Relexxii (PA age, (CD) Inderal XL (ST)
QL) diltiazem 24hr ER InnoPran XL (ST)
(LA) Kapspargo Sprinkle
BLOOD MODIFIERS/BLEEDING DISORDERS
diltiazem 24hr ER (ST)
aminocaproic acid* Amicar oral Amicar tablet* (XR) Lopressor (ST)
tranexamic acid* solution* Hemlibra* (PA) Dilt-XR Lotensin (ST)
Aranesp*^ (PA) Lysteda* dofetilide (QL) Lotensin HCT (ST)
Droxia Neupogen*^ (PA) doxazosin Lotrel
Epogen*^ (PA) Nivestym*^ (PA) Ecotrin+ Micardis (ST, QL)
Fulphila*^ (PA) Promacta* (PA) Ecpirin+ Micardis HCT (ST,
Granix*^ Siklos (PA) enalapril QL)
Neulasta*^ (PA) Tavalisse* (PA) flecainide Minipress
Procrit*^ (PA) hydralazine Nitrostat
Retacrit*^ (PA) irbesartan Northera* (PA)
Udenyca*^ (PA) irbesartan-HCTZ Norvasc
Zarxio*^ isosorbide Pacerone 100mg,
isosorbide ER 400mg (PA)
7Cigna Standard 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
BLOOD PRESSURE/HEART MEDICATIONS (cont) BLOOD THINNERS/ANTI-CLOTTING (cont)
labetalol Prinivil (ST) Savaysa (QL)
lisinopril Procardia Zontivity
lisinopril-HCTZ Procardia XL CANCER
losartan Ranexa (QL) abiraterone* (PA) Actimmune* (PA)
Afinitor* (PA)
losartan-HCTZ Rythmol SR (PA) anastrozole Erivedge* (PA)
Afinitor Disperz* (PA)
Low Dose Aspirin Takhzyro* (PA) capecitabine* (PA) Gleostine Alecensa* (PA)
EC+ Tekturna (QL) exemestane Ibrance* (PA)
Bosulif* (PA)
Matzim LA Tenormin (ST) imatinib* (PA) Lupron Depot*^
Cabometyx* (PA)
metoprolol Tiazac ER letrozole (PA) Cometriq* (PA)
nadolol Tikosyn (PA, QL) mercaptopurine Nexavar* (PA)
Erleada* (PA)
nifedipine Toprol XL (ST) methotrexate Revlimid* (PA)
Gleevec* (PA)
nifedipine ER Tribenzor tamoxifen+ Sprycel* (PA)
Imbruvica* (PA)
olmesartan (QL) Vasotec (ST) temozolomide* Sutent* (PA)
Inlyta* (PA)
olmesartan- Verelan (PA) Tasigna* (PA)
Jakafi* (PA)
amlodipine-HCTZ Verelan PM Trexall Kisqali* (PA)
olmesartan-HCTZ Zestoretic (ST) Verzenio* (PA)
Lenvima* (PA)
(QL) Zestril (ST) Lonsurf* (PA)
Pacerone 200mg Lynparza* (PA)
prazosin Mekinist* (PA)
propafenone Nerlynx* (PA)
propafenone ER Ninlaro* (PA)
propranolol Odomzo* (PA)
solution, tablet Pomalyst* (PA)
propranolol ER Purixan*
ramipril Rubraca* (PA)
ranolazine ER (QL) Stivarga* (PA)
St. Joseph Aspirin+ Tafinlar* (PA)
Taztia XT Tagrisso* (PA)
telmisartan (QL) Targretin capsule*
telmisartan-HCTZ (PA)
(QL) Temodar capsule*
valsartan (PA)
valsartan-HCTZ Tykerb* (PA)
verapamil capsule, Venclexta* (PA)
tablet Votrient* (PA)
verapamil ER Xalkori* (PA)
verapamil ER PM Xeloda* (PA)
verapamil SR Xtandi* (PA)
Zejula* (PA)
BLOOD THINNERS/ANTI-CLOTTING CHOLESTEROL MEDICATIONS
aspirin- Brilinta Aggrenox amlodipine- Repatha (PA) Caduet (QL)
dipyridamole ER Eliquis Arixtra* (QL) atorvastatin (QL) Vascepa (PA) Crestor (ST, QL)
clopidogrel Fragmin* (QL) Bevyxxa (QL) atorvastatin 10mg, Lipofen (ST)
enoxaparin* (QL) Xarelto Coumadin (PA) 20mg+ Lovaza
fondaparinux* (QL) Effient atorvastatin 40mg, Niaspan ER
Jantoven Lovenox* (QL) 80mg Pravachol (ST)
prasugrel Plavix colesevelam TriCor (ST)
warfarin Pradaxa ezetimibe Triglide (ST)
8Cigna Standard 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
CHOLESTEROL MEDICATIONS (cont) CONTRACEPTION PRODUCTS (cont)
ezetimibe- Trilipix (ST) Camrese+
simvastatin Vytorin (ST) Camrese Lo+
fenofibrate Welchol Caya Contoured+
fenofibric acid Zetia Caziant+
fluvastatin+ Zocor (ST, QL) Chateal+
fluvastatin ER+ Chateal EQ+
lovastatin 10mg Cryselle+
lovastatin 20mg, Cyclafem+
40mg+ Cyred+
niacin Cyred EQ+
Dasetta+
niacin ER
Daysee+
Niacor
Deblitane+
omega-3 acid ethyl
Delyla+
esters desogestrel-ethinyl
pravastatin+ estradiol+
rosuvastatin 5mg, desogestrel-ethinyl
10mg+ (QL) estradiol ethinyl
rosuvastatin 20mg, estradiol
40mg (QL) dospirenone-
simvastatin 10mg, ethinyl estradiol-
20mg, 40mg+ levomefolate+
simvastatin 80mg drospirenone-
(QL) ethinyl estradiol+
CONTRACEPTION PRODUCTS Econtra EZ+
Econtra One-Step+
Afirmelle +
Lo Loestrin FE Annovera+
Elinest+
Aftera+ Taytulla Balcoltra eluryng vaginal
Altavera+ Ella+ ring+
Alyacen +
Estrostep FE Emoquette+
Amethia+ Layolis FE Enpresse+
Amethia Lo +
Loestrin FE Enskyce+
Amethyst+ Minastrin 24 FE Errin+
Apri+ Natazia Estarylla+
Aranelle+ NuvaRing ethynodiol-ethinyl
Ashlyna +
Safyral estradiol+
Aubra+ Skyla* etonogestrel-EE
Aubra EQ+ Today vaginal ring+
Aurovela 24 FE+ Contraceptive Falmina+
Aurovela FE +
Sponge+ Fayosim+
Aurovela +
Yasmin 28 FemCap+
Aviane+ Yaz Femynor+
Ayuna+ Gianvi+
Azurette+ Gynol II+
Balziva+ Hailey 24 FE+
Bekyree+ Heather+
Blisovi 24 FE+ Incassia+
Introvale+
Blisovi FE+
Isibloom+
Briellyn+
Jasmiel+
Camila+
Jencycla+
9Cigna Standard 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
CONTRACEPTION PRODUCTS (cont) CONTRACEPTION PRODUCTS (cont)
Jolessa
+
Norlyda +
Juleber+ Norlyroc+
Junel+ Nortrel+
Junel FE+ Ocella+
Junel FE 24+ Option 2+
Kaitlib FE+ Orsythia+
Kalliga+ Philith+
Kariva+ Pimtrea+
Kelnor 1-35+ Pirmella+
Kelnor 1-50+ Portia+
Kurvelo+ Previfem+
Larin+ Reclipsen+
Larin FE+ Rivelsa tablet+
Larin FE 24+ Setlakin+
Larissia+ Sharobel+
Leena 28 tablet+ Simliya+
Lessina+ Simpesse+
Levonest+ Sprintec+
levonorgestrel+ Sronyx+
levonorgestrel- Syeda+
ethinyl estradiol+ Tarina FE+
levonorgestrel- Tarina FE 1-20 EQ+
ethinyl estradiol- Tilia FE 28+
ethinyl estradiol+ Tri Femynor+
Levora-28+ Tri-Estarylla+
Lillow+ Tri-Legest FE+
Loryna+ Tri-Linyah+
Low-Ogestrel+ Tri-Lo-Estarylla+
Lo-Zumandimine+ Tri-Lo-Marzia+
Lutera+ Tri-Lo-Mili+
Lyza+ Tri-Lo-Sprintec+
Marlissa+ Tri-Mili+
medroxyprogesterone Tri-Previfem+
150mg/ml+ Tri-Sprintec+
Melodetta 24 FE+ Trivora-28+
Mibelas 24 FE+ Tri Vylibra+
Microgestin+ Tri Vylibra Lo+
Microgestin FE+ Tulana+
Mili+ Tydemy+
Mono-Linyah+ VCF foam, gel+
My Choice+ Velivet+
My Way+ Vienva+
Necon+ Viorele+
Nikki+ Vyfemla+
Nora-BE+ Vylibra+
norethindrone+ Wera+
norethindrone- Wide Seal
ethinyl estradiol+ Diaphragm+
norethindrone- Wymzya FE+
ethinyl estradiol- Xulane+
iron+ Zarah+
norgestimate- Zovia+
ethinyl estradiol+ Zumandimine+
10Cigna Standard 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
COUGH/COLD MEDICATIONS DIABETES (cont)
Bromfed DM Tessalon Perle QTERN (ST, QL)
brompheniramine- Tuzistra XR (PA, QL) Segluromet (ST, QL)
pseudoephedrine- Soliqua
DM Steglatro (ST, QL)
hydrocodone- SymlinPen
chlorpheniramine Synjardy (ST, QL)
ER (PA) Synjardy XR (ST, QL)
DENTAL PRODUCTS
Tresiba (QL)
Trulicity (ST, QL)
chlorhexidine Floriva+^ V-Go
doxycycline 20mg Fluorabon+^ Victoza (ST, QL)
fluoride ^
+
Xigduo XR (ST, QL)
Fluoritab+^ Xultophy
Flura-Drops+^ DIURETICS
Ludent+^
Oralone acetazolamide Diuril Aldactone
acetazolamide ER Dyrenium Dyazide
Paroex
bumetanide tablet Inspra
Peridex
chlorthalidone Jynarque* (PA)
Periogard
eplerenone Lasix
sodium fluoride+^ furosemide Maxzide
triamcinolone hydrochlorothiazide Samsca*
0.1% paste spironolactone
DIABETES triamterene-HCTZ
glimepiride Basaglar (QL) Amaryl EAR MEDICATIONS
glipizide Bydureon (ST, QL) Cycloset neomycin- Cipro HC Coly-Mycin S
glipizide ER Byetta (ST, QL) Glucophage polymyxin-HC Ciprodex Cortisporin-TC
glipizide XL Farxiga (ST, QL) Glucophage XR ofloxacin drops Dermotic
metformin Freestyle Libre Korlym* (PA) Otovel
metformin ER Sensor (PA, QL) Riomet ERECTILE DYSFUNCTION
NovoTwist GlucaGen HypoKit
pioglitazone (QL) sildenafil^ (PA age, Muse^ (PA, QL) Cialis^ (PA age, ST,
Glucagon QL) QL)
Emergency Kit tadalafil^ 2.5mg, Stendra^ (PA age,
(QL) 10mg, 20mg (PA ST, QL)
age, QL) Viagra^ (PA age,
Glyxambi (ST, QL)
tadalafil^ 5mg (PA, ST, QL)
Humalog (QL)
QL)
Humulin (QL)
vardenafil^ (PA age,
Janumet (ST, QL)
QL)
Janumet XR
(ST, QL) EYE CONDITIONS
Januvia (ST, QL) azelastine Alphagan P 0.1% Acuvail
Jardiance (ST, QL) brimonidine drops Alphagan P 0.15%
Kombiglyze XR (ST, ciprofloxacin Azasite Alrex
QL) dorzolamide Azopt Bepreve
Levemir (QL) dorzolamide- Betimol Besivance
OneTouch test timolol Betoptic S Bromsite
strips erythromycin Combigan Cequa
Onglyza (ST, QL) fluorometholone Cosopt
Lotemax drops, gel
Ozempic (ST, QL) gatifloxacin Cosopt PF
11Cigna Standard 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
EYE CONDITIONS (cont) GASTROINTESTINAL/HEARTBURN (cont)
latanoprost Lumigan Cystaran* (QL) Ducodyl+ Kristalose
moxifloxacin Moxeza Durezol esomeprazole Lomotil
neomycin- Pazeo Ilevro capsule (QL) MiraLax+
polymyxin- Restasis Inveltys famotidine Motegrity
dexamethasone Simbrinza Istalol suspension, Movantik (PA)
ofloxacin Tobradex eyeLastacaft tablets Ocaliva* (PA)
polymyxin B-TMP ointment Lotemax ointment GaviLax+
Pancreaze
prednisolone Xiidra Maxitrol GaviLyte-C+
GaviLyte-G+ Pertzye
solution Nevanac
GaviLyte-N+ Prevacid DR (ST,
timolol solution Ocuflox
GentleLax+ QL)
tobramycin Oxervate* (PA)
tobramycin- Patanol GlycoLax+ Protonix
dexamethasone Polytrim HealthyLax+ suspension, tablet
Pred Forte Hemmorex-HC (ST, QL)
Prolensa hydrocortisone Ravicti* (PA)
Rhopressa suppository Rectiv
Timoptic lansoprazole (QL) Relistor (PA)
Timoptic-XE LaxaClear+ Sancuso (PA, QL)
Tobradex drops mesalamine Sensipar*
mesalamine DR
Tobradex ST sfRowasa
metoclopramide
Travatan Z Sucraid* (PA)
solution, tablet
Trusopt Symproic (PA)
metoclopramide
Vigamox ODT Transderm-Scop
Xalatan omeprazole (QL) Urso
Zioptan (ST, QL) ondansetron Urso Forte
Zirgan ondansetron ODT Varubi (PA, QL)
Zylet pantoprazole tablet Viberzi
Zymaxid (QL) Viokace
FEMININE PRODUCTS PEG Xermelo* (PA)
Fem pH AVC 3350-Electrolyte+
gynazole 1 PEG-Prep+
miconazole 3 Phenadoz
suppository polyethylene glycol
terconazole 3350+
prochlorperazine
GASTROINTESTINAL/HEARTBURN suppository, tablet
Alophen +
Amitiza Aciphex (ST, QL) promethazine
alosetron* Apriso ER Aciphex Sprinkle solution, syrup,
Anucort-HC Carafate (QL) tablet
balsalazide suspension Akynzeo capsule Promethegan
bisacodyl+ CLENPIQ+ (PA, QL) QC Natura-Lax+
Bisa-Lax+ Creon Bonjesta rabeprazole (QL)
chlordiazepoxide- Dexilant (QL) Canasa ranitidine capsules,
clidinium Entyvio*^ Carafate tablet tablets, syrup
cinacalcet* Linzess Cholbam* (PA) SmoothLAX+
Lithostat sucralfate
ClearLax+ Correctol+
Pentasa TriLyte With Flavor
dicyclomine Diclegis
Prepopik + Packets+
diphenoxylate- Donnatal ursodiol
SUPREP+
atropine Dulcolax+ Women’s Gentle
Trulance
dronabinol Gattex* (PA) Laxative+
Zenpep
Women’s Laxative+
12Cigna Standard 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
HORMONAL AGENTS INFECTIONS
Amabelz Androderm (PA, Activella acyclovir capsule, Baraclude solution* Albenza
budesonide EC QL) Alora (QL) suspension, tablet Cipro suspension Alinia
budesonide ER (PA, Armour Thyroid AndroGel (PA, QL) albendazole Cleocin 75mg Arikayce* (PA)
QL) Cetrotide*^ (PA) Angeliq amoxicillin capsule Bactrim
cabergoline (QL) Divigel Climara amoxicillin- Daraprim* (PA) Bactrim DS
CovARYX Duavee Climara Pro Firvanq Baraclude tablet*
clavulanate
CovARYX HS Estring (QL) CombiPatch Kitabis Pak* (PA, (QL)
amoxicillin- QL) Baxdela (PA)
Decadron Euthyrox Crinone^
desmopressin Forteo* (PA, QL) Cytomel clavulanate ER Ledipasvir- Cayston* (PA, QL)
solution, spray, Ganirelix*^ (PA) Depo-Testosterone atovaquone Sofosbuvir* (PA) Cipro tablet
tablet Humatrope* (PA) Egrifta* (PA) atovaquone- Mavyret* (PA) Cleocin
dexamethasone Increlex* (PA) Elestrin proguanil Pegasys* (PA) Clindesse
dexamethasone Levo-T Emflaza* (PA) Avidoxy Sofosbuvir- Cresemba capsule
intensol Lupron Depot*^ Entocort EC azithromycin Velpatasvir* (PA) (PA)
Dotti (QL) (PA) Estrace cefdinir Sovaldi* (PA, QL) Dificid (QL)
EEMT Lupron Depot- EstroGel Thalomid* (PA) Elimite
cefpodoxime
EEMT H.S. PED*^ (PA) Evamist TOBI Podhaler* (PA, EryPed 200
cefuroxime QL) Flagyl
estradiol (QL) Medrol 2mg Imvexxy (QL) cephalexin
estradiol- Norditropin Intrarosa Vibramycin syrup Keflex
ciprofloxacin Vosevi* (PA) Levaquin
norethindrone FlexPro* (PA) Medrol 4mg, 8mg,
clarithromycin Xifaxan (QL) Macrobid
estrogen- Orilissa (PA, QL) 16mg, 32mg
methyltestosterone Premarin cream, Menostar (QL) clarithromycin ER Macrodantin
clindamycin Malarone (PA)
levothyroxine tablet Minivelle (QL)
Coremino (QL) Monurol
Levoxyl Premphase Natpara* (PA)
dapsone Natroba
liothyronine Prempro Noctiva (PA)
Noxafil suspension,
Lopreeza Sandostatin LAR Osphena doxycycline
tablet
medroxy- Depot*^ (PA) Prometrium Emverm Nuvessa
progesterone Serostim* (PA) Rayaldee entecavir* (QL) Nuzyra* (PA)
methimazole Somavert* (PA) Somatuline erythromycin Oravig
methylprednisolone Synthroid Depot*^ (PA) famciclovir Plaquenil (PA)
dosepak, tablet Unithroid Striant (PA, QL) fluconazole Prevymis tablet*
Mimvey Zorbtive* (PA) Tirosint Priftin
hydroxychloroquine
Nature-Throid Vagifem (QL) Sivextro tablet (PA)
NP Thyroid Vivelle-Dot (QL) itraconazole
levofloxacin Sklice
prednisolone Solosec
prednisolone ODT solution, tablet
Sulfatrim
prednisone metronidazole Suprax
prednisone minocycline Tamiflu (QL)
intensol minocycline ER Urogesic-Blue
progesterone (QL) Valtrex
capsule Mondoxyne NL Vemlidy*
TaperDex Morgidox capsule Vfend suspension,
testosterone nitrofurantoin tablet (PA)
(PA, QL) Vibramycin
nitrofurantoin
testosterone - suspension
mono-macro
cypionate Xofluza (QL)
thyroid nystatin
Zepatier* (PA)
Westhroid Okebo Zithromax packet,
WP Thyroid oseltamivir (QL) suspension, tablet
Yuvafem (QL) penicillin V Zyvox (PA)
13Cigna Standard 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
INFECTIONS (cont) NUTRITIONAL/DIETARY
permethrin calcitriol capsule, CitraNatal Auryxia (QL)
sulfamethoxazole- solution Drisdol Fosrenol chew
TMP suspension, calcium 667mg Floriva+ K-Tab ER
tablet cyanocobalamin Fosrenol packet Lokelma
terbinafine tablet injection Klor-Con M15 Phoslyra
tetracycline Daily Prenatal+ Mephyton Renvela
tobramycin FA-8+ MVC-Fluoride+ Velphoro
ampule* (PA, QL) folic acid 1mg OB Complete Veltassa
valacyclovir
folic acid 0.4mg, Perry Prenatal+
VitaPearl
valganciclovir
0.8mg+ Prenate Mini
vancomycin
capsule Klor-Con 8 Prenate Pixie
Vandazole Klor-Con 10 PrimaCare
voriconazole Klor-Con M10 Quflora Ped 1mg
suspension, tablet Klor-Con M20 chew, drops+
(PA) lanthanum Rocaltrol
INFERTILITY phytonadione Tri-Vi-Flor+
tablet
chorionic Gonal-F*^ (PA) Crinone 8%^ potassium chloride
gonadotropin Menopur*^ (PA) Endometrin^
capsule, packet,
10,000 unit vial*^ Novarel*^ (PA) Follistim AQ*^ (PA)
(PA) Ovidrel*^ (PA) solution, tablet
clomiphene tablet^ Prena1 Pearl
Prenatal+
MISCELLANEOUS
prenatal vitamin+
disulfiram Cerdelga* (PA)
Addyi^ (PA, QL) sevelamer
Nebusal 3% Esbriet* (PA)
Austedo* (PA) vitamin D2
PULMOSAL Nityr* (PA) Brisdelle (QL) vitamin D3
sodium chloride Strensiq* (PA)
Exjade* (PA)
inhalation vial Ferriprox* (PA) OSTEOPOROSIS PRODUCTS
TechLITE Lancets Galafold* (PA) alendronate (QL) Tymlos* (PA, QL) Actonel (ST)
tetrabenazine* (PA) Ingrezza* (PA) calcitonin-salmon Atelvia (ST)
trientine* (PA) Jadenu* (PA) ibandronate tablet Binosto (ST)
Jadenu Sprinkle* raloxifene +
Boniva tablet (ST)
(PA) risedronate Evista
Kuvan* (PA) risedronate DR Fosamax (ST)
Myalept* (PA) Fosamax Plus D (ST)
Nuedexta (QL)
Orfadin* (PA) PAIN RELIEF AND INFLAMMATORY DISEASE
Palynziq* (PA) acetaminophen- Actemra* (PA, QL) Analpram HC
Tiglutik* (PA) codeine (PA) Aimovig (PA) Arava
MULTIPLE SCLEROSIS allopurinol Ajovy (PA) Arymo ER (PA)
glatiramer* (PA) Ampyra* (PA) aprizio pak Belbuca (QL) Benlysta* (PA)
Glatopa* (PA) Avonex* (PA) baclofen tablet Cosentyx* (PA, QL) Butrans (QL)
Betaseron* (PA) buprenorphine Depen* (PA) Celebrex (ST, QL)
Extavia* (PA) Cimzia* (PA, QL)
patch, tablet (QL) Emgality(PA)
Gilenya* (PA) Colcrys
butalbital- Enbrel* (PA, QL)
Plegridy* (PA) Diclofenac patch
acetaminophen- Humira* (PA, QL) (ST, QL)
Rebif* (PA)
Rebif Rebidose* caffeine (QL) Hysingla ER (PA) Dupixent* (PA)
(PA) carisoprodol Morphabond ER Duragesic (PA)
Tecfidera* (PA) celecoxib (QL) (PA) EC-Naprosyn (ST)
14Cigna Standard 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
PAIN RELIEF AND INFLAMMATORY PAIN RELIEF AND INFLAMMATORY
DISEASE (cont) DISEASE (cont)
colchicine Nucynta (PA) Esgic (QL) meloxicam
cyclobenzaprine Otezla* (PA, QL) Fexmid metaxalone
DermacinRx Proctofoam-HC Flector (ST, QL) methocarbamol
Empricaine Rasuvo (PA) Frova (QL) tablet
DermacinRx Remicade*^ (PA) Ilaris*^ (PA) morphine solution,
Prizopak Savella Ilumya* (PA, QL) suppository, tablet
diclofenac (QL) Simponi Aria* (PA) Kadian (PA)
(PA)
diclofenac ER Stelara Kevzara* (PA, QL)
morphine ER (PA)
EC-naproxen 45mg/0.5ml, Kineret* (PA, QL)
90mg/ml* (PA, QL) Lidoderm nabumetone
eletriptan (QL) Nalfon 600mg (ST)
Endocet (PA) Tremfya* (PA, QL) Mitigare
Uloric (QL) Mobic (ST) Nalocet (PA)
etodolac
Xeljanz* (PA, QL) MS Contin (PA) naproxen
etodolac ER
Xeljanz XR* (PA,QL) Nalfon 400 mg (ST) oxycodone (PA)
fentanyl (PA)
Xtampza ER (PA) Naprosyn (ST) oxycodone ER (PA)
Fioricet (QL)
Ztlido Norco (PA) oxycodone-
frovatriptan (QL) Nucynta ER (PA) acetaminophen
Glydo Olumiant* (PA, QL) (PA)
hydrocodone- Orencia syringe*
acetaminophen Prilolid
(PA, QL) Prilovix
(PA) Otrexup (PA)
hydromorphone Primlev (PA)
Oxaydo (PA)
solution, Relador Pak
Percocet (PA)
suppository, tablet Procort Relador Pak Plus
(PA) Qmiiz ODT (ST, QL) rizatriptan (QL)
hydromorphone Relpax (QL) sumatriptan (QL)
ER (PA) Simponi* (PA, QL) sumatriptan-
IBU Skelaxin naproxen (QL)
ibuprofen 400mg, Taltz* (PA, QL) tizanidine
600mg, 800mg Tylenol-Codeine tramadol (QL)
indomethacin No.3 (PA) tramadol ER (QL)
capsule Tylenol-Codeine Vicodin HP (PA)
indomethacin ER No.4 (PA)
PARKINSON’S DISEASE
ketorolac (QL) Ultram (QL)
Voltaren (ST, QL) benztropine Apokyn* (PA) Azilect (QL)
leflunomide bromocriptine Duopa*
lidocaine (QL) Zanaflex
Zebutal (QL) carbidopa- Mirapex
lidocaine viscous levodopa Mirapex ER (QL)
lidocaine-prilocaine Zohydro ER (PA)
Zyloprim carbidopa- Neupro
Lidopril levodopa ER Osmolex ER (QL)
Lidopril XR pramipexole Parlodel
Lido-Prilo Caine pramipexole ER Rytary
Pack (QL) Sinemet
Livixil Pak rasagiline (QL) Sinemet CR
Lorcet (PA) ropinirole Tasmar
Lorcet HD (PA) ropinirole ER Xadago (ST)
Lorcet Plus (PA)
Lortab (PA)
15Cigna Standard 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
SCHIZOPHRENIA/ANTI-PSYCHOTICS SKIN CONDITIONS (cont)
aripiprazole (QL) Latuda (QL) Fanapt (ST, QL) betamethasone Pramosone 1%-1% Cordran 0.05%
aripiprazole ODT Invega (ST, QL) BP 10-1 cream and 1% cream, lotion,
chlorpromazine Rexulti (ST, QL) calcipotriene lotion, 1%-1% ointment, tape
tablet Risperdal (ST) calcipotriene- ointment, 2.5%- (ST)
olanzapine tablet Saphris (ST) betamethasone 1% ointment Dovonex
olanzapine ODT Seroquel (ST) DP Santyl (QL) Ecoza
paliperidone ER Seroquel XR (ST) Claravis (QL) Soolantra Efudex
(QL) Vraylar (ST, QL) Clindacin ETZ Elidel
quetiapine pledget Evoclin
quetiapine ER Clindacin P pledget Finacea gel
risperidone clindamycin- Impoyz (ST)
risperidone ODT benzoyl peroxide Lotrisone
ziprasidone clindamycin MetroCream
SEIZURE DISORDERS phosphate MetroGel
carbamazepine Dilantin 30 mg Aptiom (PA, QL) clindamycin- MetroLotion
carbamazepine ER capsule (PA) Banzel (PA, QL) tretinoin MiCort-HC 2.5%
clonazepam Fycompa (PA, QL) Briviact solution, clobetasol cream (ST)
divalproex Lyrica oral solution tablet (PA) Clodan shampoo Mimyx
divalproex ER Vimpat solution, Carbatrol (PA) clotrimazole- Naftin cream
Epitol tablet (PA) Depakote (PA) betamethasone Nizoral
gabapentin Depakote ER (PA) dapsone Olux (ST)
lamotrigine Depakote Sprinkle desoximetasone Picato
lamotrigine (blue, (PA) diflorasone Pramosone 2.5%-
green, orange) Dilantin 50mg, fluocinonide 1% cream, lotion
lamotrigine ER 100mg (PA) fluorouracil cream, Protopic
lamotrigine ODT Epidiolex* (PA) topical solution Regranex (PA, QL)
levetiracetam Klonopin (PA) flurandrenolide Sorilux
solution, tablet Neurontin (PA) hydrocortisone Targretin gel*
levetiracetam ER Onfi (PA) isotretinoin (QL) Temovate (ST)
oxcarbazepine Oxtellar XR (PA) ketoconazole Tolak
Roweepra Phenytek (PA) metronidazole Topicort (ST)
Roweepra XR Tegretol (PA) Micort HC 2.5% Valchlor*
subvenite Tegretol XR (PA) cream Xepi
subvenite (Blue, mupirocin Xolegel
Green, Orange) Myorisan (QL)
topiramate Neuac gel
topiramate ER Nolix
vigabatrin* oxiconazole
Vigadrone* pimecrolimus
Procto-Med HC
SKIN CONDITIONS Procto-Pak
adapalene (PA age) Cordran 0.025% Bryhali (ST) Proctosol-HC
adapalene-benzoyl cream Celacyn Proctozone-HC
peroxide Drysol Centany Psorcon
Amnesteem (QL) Eucrisa Cleocin T Rosadan
Avar Finacea foam Cloderm (ST) sodium
Avar-E Fluoroplex Condylox
Avar-E Green sulfacetamide-
Naftin gel sulfur
azelaic acid
16Cigna Standard 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
SKIN CONDITIONS (cont) URINARY TRACT CONDITIONS
SSS 10-5 cevimeline Cystagon* Avodart
Sulfacleanse 8-4 darifenacin ER (QL) Elmiron Evoxac
tacrolimus finasteride 5mg Thiola* Flomax
ointment oxybutynin Procysbi* (PA)
tazarotene oxybutynin ER Proscar
tretinoin (PA age) phenazopyridine Pyridium
tretinoin potassium ER Rapaflo (QL)
microsphere (PA
silodosin (QL) Urocit-K
age)
triamcinolone solifenacin (QL)
triderm tamsulosin
Zenatane (QL) tolterodine
SLEEP DISORDERS/SEDATIVES
tolterodine ER (QL)
trospium
armodafinil (PA) Belsomra (ST) Hetlioz* (PA) trospium ER
eszopiclone Silenor (ST, QL) Lunesta (ST)
VACCINES
modafinil (PA) Rozerem (ST, QL)
temazepam Xyrem* (PA) For plans renewing on 2/1/20 and later: On your plan's renewal
zolpidem date, vaccines will be covered under the pharmacy benefit.
Not all plans will cover vaccines in the same way. Log in to the
zolpidem ER (QL)
myCigna app or website, or check your plan materials, to find out
SMOKING CESSATION how your specific plan covers them.
bupropion SR +
Chantix^ NicoDerm CQ Diphtheria and ActHIB+ FluMist Quad
NicoDerm CQ Nicotrol^ 7mg/24hr, Tetanus Toxoids- Adacel Tdap+ Nasal+
21mg/24hr +
Nicotrol NS^ 14mg/24hr+ ped+ Afluria Quad +
Rotarix+
Nicorelief+
Nicorette+ TdVax+ BEXSERO +
RotaTeq+
nicotine gum +
Boostrix Tdap+
nicotine lozenge+ DAPTACEL DTaP+
nicotine patch+ Engerix-B+
Quit 2+ FLUAD+
Quit 4+ FLUARIX
SUBSTANCE ABUSE QUADRIVALENT+
FLUBLOK
buprenorphine- Bunavail Suboxone QUADRIVALENT+
naloxone Lucemyra (QL) FLUCELVAX
NARCAN (QL) QUADRIVALENT+
Zubsolv FLUALVAL
TRANSPLANT MEDICATIONS QUADRIVALENT+
azathioprine tablet* Astagraf XL* Fluzone High-
mycophenolate Cellcept capsule, dose+
capsule, suspension, Fluzone
suspension, tablet* tablet* Quadrivalent Pedi+
Envarsus XR* Fluzone
mycophenolic acid*
Myfortic* Quadrivalent+
sirolimus*
Prograf capsule, GARDASIL 9+
tacrolimus capsule*
packet* HAVRIX+
Rapamune* HEPLISAV-B+
Zortress* Hiberix+
Infanrix DTaP+
IPOL+
KINRIX+
17Cigna Standard 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3
$ $$ $$$
VACCINES (cont)
For plans renewing on 2/1/20 and later: On your plan's renewal
date, vaccines will be covered under the pharmacy benefit.
Not all plans will cover vaccines in the same way. Log in to the
myCigna app or website, or check your plan materials, to find out
how your specific plan covers them.
Menactra+
Menveo A-C-Y-W-
135-DIP+
M-M-R II+
PEDIARIX+
PedvaxHIB+
Pentacel+
PNEUMOVAX 23+
Prevnar 13+
ProQuad+
Quadracel DTaP-
IPV+
Recombivax HB+
SHINGRIX+
Tenivac+
Trumenba+
Twinrix+
VAQTA+
VARIVAX+
ZOSTAVAX+
WEIGHT MANAGEMENT
Lomaira^ Belviq^ (PA)
phentermine^ Belviq XR^ (PA)
Contrave^ (PA)
Qsymia^ (PA)
Saxenda^ (PA)
18Medications that are not covered
The medications listed below aren’t covered on your plan’s drug list.^^ This means that if you fill a
prescription for any of these medications, you’ll pay its full cost out-of-pocket. Your plan covers other
medications that are used to treat the same condition.^^ They’re listed below.
MEDICATIONS THAT ARE GENERIC AND/OR PREFERRED
DRUG CLASS
NOT COVERED^^ BRAND ALTERNATIVE(S)
AIDS/HIV Combivir* lamivudine-zidovudine*
Epivir* lamivudine*
Epzicom* abacavir-lamivudine*
Kaletra solution* lopinavir-ritonavir solution*
Lexiva tablet* fosamprenavir*
Norvir tablet* ritonavir*
Retrovir capsule, syrup* zidovudine capsule, syrup*
Reyataz capsule* atazanavir*
Sustiva* efavirenz*
Trizivir* abacavir-lamivudine-zidovudine*
Viramune* nevirapine*
Viramune XR* nevirapine ER*
Ziagen* abacavir*
ALLERGY/NASAL SPRAYS Auvi-Q epinephrine auto-injectors
EpiPen, EpiPen Jr
Beconase AQ Generic nasal steroids (e.g. fluticasone)
Dymista
Nasonex
Omnaris
QNASL
Zetonna
QNASL Children’s budesonide
fluticasone
triamcinolone
RyVent carbinoxamine 4mg tablet
carbinoxamine 6mg tablet
ANXIETY/DEPRESSION/BIPOLAR Anafranil clomipramine
Aplenzin bupropion XL
Wellbutrin XL
Ativan tablet lorazepam
Cymbalta duloxetine
Lexapro escitalopram
Pamelor nortriptyline capsules
Parnate tranylcypromine
Pexeva paroxetine/CR/ER
Tofranil imipramine tablet
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.
19MEDICATIONS THAT ARE GENERIC AND/OR PREFERRED
DRUG CLASS
NOT COVERED^^ BRAND ALTERNATIVE(S)
ASTHMA/COPD/RESPIRATORY Advair Diskus Advair HFA
AirDuo RespiClick Breo Ellipta
Dulera
fluticasone-salmeterol
Symbicort
Wixela Inhub
Alvesco Flovent
Arnuity Ellipta QVAR RediHaler
Asmanex Pulmicort Flexhaler
Asmanex HFA
Bevespi Aerosphere Anoro Ellipta
Stiolto Respimat
Utibron Neohaler
Elixophyllin theophylline oral solution
Proventil HFA ProAir
Xopenex HFA Ventolin HFA
Seebri Neohaler Incruse Ellipta
Spiriva
Spiriva Respimat
Tudorza Pressair
Striverdi Respimat Serevent Diskus
Yupelri Anoro Ellipta
Incruse Ellipta
Trelegy Ellipta
Zyflo montelukast
zafirlukast
zileuton ER
ATTENTION DEFICIT HYPERACTIVITY Adderall XR dexmethylphenidate ER
Adhansia XR dextroamphetamine-amphetamine ER
Aptensio XR methylphenidate ER/CD/LA
Concerta Vyvanse
Cotempla XR-ODT
Mydayis
Focalin XR
Ritalin LA
Desoxyn methamphetamine
Dexedrine dextroamphetamine
BLOOD PRESSURE/HEART MEDICATIONS Betapace sotalol oral
Cardizem diltiazem
Cardizem CD diltiazem CD
Firazyr* icatibant
Isordil isosorbide dinitrate
Isordil Titradose isosorbide dinitrate
digoxin
BLOOD THINNERS/ANTI-CLOTTING Yosprala aspirin or enteric aspirin
CANCER Nilandron nilutamide
Tarceva* erlotinib*
Yonsa* abiraterone*
Zytiga*
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.
20MEDICATIONS THAT ARE GENERIC AND/OR PREFERRED
DRUG CLASS
NOT COVERED^^ BRAND ALTERNATIVE(S)
CHOLESTEROL MEDICATIONS Antara fenofibrate
Fenoglide
Ezallor Sprinkle atorvastatin
Livalo lovastatin
Zypitamag pravastatin
rosuvastatin
simvastatin
Lipitor atorvastatin
Praluent Pen Repatha
COUGH/COLD MEDICATIONS benzonatate 150mg benzonatate 100mg, 200mg
TussiCaps hydrocodone-chlorpheniramine ER
promethazine with codeine syrup
DIABETES Accu-Chek Aviva Plus test strips One Touch test strips (e.g. Ultra; Verio)
Accu-Chek Guide test strips
Accu-Chek Smartview
Accutrend glucose
Adlyxin Byetta
Bydureon
Ozempic
Trulicity
Victoza
Ademelog Humalog
Afrezza Humulin
Apidra
Apidra SoloStar
Fiasp
Novolin, Novolog
alogliptin Janumet
Janumet XR
Januvia
Kombiglyze XR
metformin
Onglyza
alogliptin-metformin Janumet
Janumet XR
Januvia
Kombiglyze XR
metformin
Onglyza
alogliptin-pioglitazone Janumet
Janumet XR
Januvia
Kombiglyze XR
Onglyza
pioglitazone
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.
21MEDICATIONS THAT ARE GENERIC AND/OR PREFERRED
DRUG CLASS
NOT COVERED^^ BRAND ALTERNATIVE(S)
DIABETES (cont) Fortamet metformin ER (generic to Glucophage XR)
Glumetza
metformin ER (generic to Fortamet and
Glumetza)
Invokamet Segluromet
Invokamet XR Synjardy
Synjardy XR
Xigduo XR
Invokana Farxiga
Jardiance
metformin
Steglatro
Jentadueto Janumet
Jentadueto XR Janumet XR
Kazano Kombiglyze XR
Lantus Basaglar
Toujeo SoloStar Levemir vial or Levemir Flextouch
Tresiba FlexTouch
Nesina Januvia
Tradjenta Janumet
Janumet XR
Kombiglyze XR
metformin
Onglyza
Oseni Generic TZDs (e.g. pioglitazone)
Janumet
Janumet XR
Januvia
Kombiglyze XR
Onglyza
Steglujan Glyxambi
metformin
QTERN
DIURETICS Edecrin bumetanide
ethacrynic acid furosemide
torsemide
EYE CONDITIONS Vyzulta bimatoprost
latanoprost
Lumigan
Travatan Z
GASTROINTESTINAL/HEARTBURN Anusol HC suppository hydrocortisone suppository
Asacol HD Apriso
Colazal balsalazide
Delzicol mesalamine tablets or capsules
Dipentum Pentasa
sulfasalazine
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.
22MEDICATIONS THAT ARE GENERIC AND/OR PREFERRED
DRUG CLASS
NOT COVERED^^ BRAND ALTERNATIVE(S)
GASTROINTESTINAL/HEARTBURN (cont) CoLyte with Flavor Packets+ Clenpiq+
GoLytely+ GaviLyte-C+
MoviPrep+ GaviLyte-G+
NuLYTELY with flavor packs+ GaviLyte-N+
OsmoPrep+ 3550 Electrolyte+
Plenvu+ Prepopik+
SuPrep+
Cortifoam Prescription hydrocortisone enema, rectal
Uceris foam cream, suppository
Librax chlordiazepoxide-clidinium
Marinol dronabinol
Syndros
Nexium capsule esomeprazole
Omeclamox-Pak lansoprazole-amoxicillin-clarithromycin
Pylera (combo pack)
OmePPI omeprazole
Zegerid packet, 40mg capsule
Pepcid famotodine
Prevacid SoluTab Generic prescription PPIs (e.g. lansopra-
zole)
Rowasa mesalamine rectal enema suspension
Zofran ondansetron
Zuplenz ondansetron
ondansetron ODT
HORMONAL AGENTS Cortrosyn cosyntropin
DDAVP desmopressin
Dxevo dexamethasone
Fortesta AndgroGel
Natesto testosterone
Testim
Vogelxo
Xyosted
Genotropin* Humatrope* (PA)
Nutropin AQ nuspin*
Omnitrope*
Saizen*
Saizen-Saizenprep*
Zomacton*
Nocdurna desompression acetate nasal spray or
tablets
Rayos prednisone
Uceris tablets budesonide tablet
dexamethasone
hydrocortisone
methylprednisolone
prednisolone
prednisone
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.
23MEDICATIONS THAT ARE GENERIC AND/OR PREFERRED
DRUG CLASS
NOT COVERED^^ BRAND ALTERNATIVE(S)
INFECTIONS Acticlate Generic products (e.g. doxycycline; mino-
Doryx cycline)
Doryx MPC
Minocin capsule
Minolira ER
Oracea
Seysara
Solodyn
Targadox
Vibramycin
Ximino
Arakoda atovaquone-proguanil
doxycycline
hydroxychloroquine
quinine
Augmentin/ES amoxicillin-clavulanate
Bethkis* tobramycin inhalation solution*
Tobi
Diflucan fluconazole
E.E.S. 200 erythromycin granules
Epclusa* sofosbuvir-velpatasvir*
Eryped 400 erythromycin ethylsuccinate
Harvoni* ledipasvir-sofosbuvir*
Mepron atovaquone
Mycobutin rifabutin
Sitavig acyclovir tablet
famciclovir tablet
valacyclovir tablet
Sporanox itraconazole oral
Tolsura
Valcycte valganciclovir
Vancocin vancomycin oral capsule
Zovirax acyclovir
MISCELLANEOUS Horizant gabapentin
Syprine* Depen*
penicillamine*
trientine*
Xenazine* tetrabenazine*
MULTIPLE SCLEROSIS Aubagio* Gilenya*
Mayzent*
Tecfidera*
Copaxone* Avonex*
Betaseron*
Extavia*
Gilenya*
glatiramer*
Glatopa*
Plegridy*
Rebif*
Tecfidera*
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.
24MEDICATIONS THAT ARE GENERIC AND/OR PREFERRED
DRUG CLASS
NOT COVERED^^ BRAND ALTERNATIVE(S)
NUTRITIONAL/DIETARY Azesco Any generic prenatal vitamin
Nascobal cyanocobalamin injection
PAIN RELIEF AND INFLAMMATORY Allzital butalbital-acetaminophen tablets
butalbital-acetaminophen-caffeine cap-
sules and tablets
Amrix cyclobenzaprine
Other generic muscle relaxants
Bupap butalbital-acetaminophen tablets
Cambia Generic prescription NSAID (e.g.celecoxib,
Duexis meloxicam)
Ergomar
Fenortho
Indocin
Naprelan
Treximet
Vimovo
Zipsor
ConZip Tramadol
Tramadol ER
Cuprimine* Depen*
penicillamine*
trientine*
D.H.E. 45 dihydroergotamine injection
Gloperba colchicine, probenecid-colchicine
Gralise gabapentin
Imitrex sumatriptan
Zembrace Symtouch
levorphanol codeine with acetaminophen
Embeda
hydrocodone with acetaminophen
Hysingla
oxycodone with acetaminophen
Tramadol
Xtampza ER
Lido-Sorb lidocaine cream, ointment
Lidozion
Lorzone chlorzoxazone 500mg
Migranal dihydroergotamine nasal spray
ONZETRA Xsail Generic triptans (e.g. nasal sumatriptan;
naratriptan tablet)
Oxycontin Embeda ER (PA)
Hysingla ER (PA)
Xtampza ER
Pennsaid diclofenac 1% gel
Roxicodone oxycodone
Siliq* Cosentyx*
Enbrel*
Humira*
Stelara*
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.
25MEDICATIONS THAT ARE GENERIC AND/OR PREFERRED
DRUG CLASS
NOT COVERED^^ BRAND ALTERNATIVE(S)
PAIN RELIEF AND INFLAMMATORY (cont) Soriatane acitretin
Sprix ketorolac tablet
SUBSYS fentanyl lozenge or buccal tablet
Tivorbex indomethacin
Vanatol LQ butalbital-acetaminophen-caffeine
Vanatol S
Vivlodex meloxicam
Zomig sumatriptan
zolmitriptan
Zomig ZMT zolmitriptan ODT
Zorvolex diclofenac
PARKINSON’S DISEASE Gocovri amantadine
Lodosyn carbidopa
Requip XL ropinirole extended release
Zelapar selegiline tablets or capsules
SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify aripiprazole
Abilify MyCite
FazaClo clozapine
Versacloz clozapine ODT
Geodon capsule ziprasidone
Zyprexa olanzapine
Zyprexa Zydis olanzapine ODT
SEIZURE DISORDERS Felbatol felbamate
Keppra oral solution, tablet levetiracetam
Keppra XR levetiracetam ER
Lamictal lamotrigine
Lamictal (blue, green, orange) lamotrigine (blue, green, orange)
Lamictal ODT lamotrigine ODT
Lamictal ODT (blue, green, orange) lamotrigine ODT (blue, green, orange)
Lamictal XR lamotrigine ER
Lamictal XR (blue, green, orange) lamotrigine ER (blue, green, orange)
Lyrica CR duloxetine
gabapentin
lidocaine 5% patch
Lyrica
Mysoline primidone
Qudexy XR topiramate ER
Sabril* vigabatrin*
Sympazan clobazam
Topamax topiramate
Zonegran zonisamide
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.
26MEDICATIONS THAT ARE GENERIC AND/OR PREFERRED
DRUG CLASS
NOT COVERED^^ BRAND ALTERNATIVE(S)
SKIN CONDITIONS Absorica Myorisan or Zenatane
Acanya Use generic products (e.g. adapalene;
Aczone tretinoin; clindamycin-benzoyl peroxide)
Aktipak
Altreno
Amzeeq
Atralin
Avita
Azelex
Differin
Duac
Epiduo
Epiduo Forte
Fabior
Onexton
Retin-A
Retin-A Micro
Tazorac
Veltin
Ziana
Aldara imiquimod 5% cream
Zyclara
Anusol-HC cream hydrocortisone cream
Bensal HP salicylic acid 6% cream, cream kit, gel, lotion
Benzaclin clindamycin-benzoyl peroxide
Neuac Kit
Carac fluorouracil 0.5% cream
Clindagel clindamycin gel, topical solution
Cutivate lotion fluticasone topical lotion
Denavir acyclovir tablet
Zovirax cream, ointment famciclovir tablet
valacyclovir tablet
diclofenac 3% gel Fluoroplex
imiquimod 5% cream
Picato
topical fluorouracil
Duobrii halobetasol plus
tazarotene cream
Enstilar calcipotriene
Taclonex calcipotriene-betamethasone DP
tazarotene cream
topical betamethasone
Ertaczo ketoconazole cream
Exelderm topical econazole
topical ketoconazole
topical oxiconazole
Extina ketoconazole cream, foam
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.
27MEDICATIONS THAT ARE GENERIC AND/OR PREFERRED
DRUG CLASS
NOT COVERED^^ BRAND ALTERNATIVE(S)
SKIN CONDITIONS (cont) HALOG clobetasol cream, ointment
halobetasol cream, ointment
Jublia ciclopirox topical solution
Kerydin itraconazole capsules
terbinafine tablets
Kenalog spray triamcinolone acetonide aerosol spray
Lexette clobetasol cream, ointment
halobetasol cream, foam, ointment
Locoid hydrocortisone cream, lipid cream, oint-
ment, solution
Locoid Lipocream hydrocortisone lipid cream
Loprox ciclopirox cream, shampoo
Luzu econazole
ketoconazole cream
luliconazole
oxiconazole
Noritate metronidazole cream
Oxistat etoconazole cream
Penlac ciclopirox solution
Prudoxin Generic topical steroid (e.g. topical tacro-
Zonalon limus)
Sernivo clobetasol spray
triamcinolone acetonide aerosol spray
Trianex triamcinolone cream, ointment
Ultravate clobetasol lotion
Vanos fluocinonide 0.1% cream
Verdeso desonide cream, ointment
Xerese acyclovir tablet
famciclovir tablet
hydrocortisone prescription cream
valacyclovir tablet
SLEEP DISORDERS/SEDATIVES Ambien zolpidem
Ambien CR zolpidem ER
Ativan lorazepam
Edluar zolpidem/ER
Intermezzo
Nuvigil armodafinil
Provigil modafinil
Restoril temazepam
Zolpimist Belsomra
eszopiclone
Silenor
zaleplon
zolpidem/ER
SUBSTANCE ABUSE Evzio narcan nasal spray
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.
28MEDICATIONS THAT ARE GENERIC AND/OR PREFERRED
DRUG CLASS
NOT COVERED^^ BRAND ALTERNATIVE(S)
URINARY TRACT CONDITIONS Detrol tolterodine
Detrol LA tolterodine ER
Ditropan XL oxybutynin ER
Enablex darifenacin ER
Gelnique darifenacin ER
Myrbetriq oxybutynin ER
Toviaz tolterodine ER
VESIcare trospium ER
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.
29Prescription drug list FAQs
Understanding your prescription medication Your plan may also exclude certain medications
coverage can be confusing. Below are answers or products from coverage. This is known as a
to some commonly asked questions. “plan (or benefit) exclusion.” For example, your
plan excludes medications that aren’t approved
Why do you make changes to the drug list?
by the U.S. Food and Drug Administration (FDA).
Cigna regularly reviews and updates the
How do you decide which medications
prescription drug list. We make changes for
are covered?
many reasons – like when new medications
become available or are no longer available, or The Cigna Prescription Drug List is developed
when medication prices change. We try to give with the help of Cigna’s Pharmacy and
you many options to choose from to treat your Therapeutics (P&T) Committee, which is a group
health condition. These changes may include:1,2 of practicing doctors and pharmacists, most of
› Moving a medication to a lower cost tier. This whom work outside of Cigna. The group meets
can happen at any time during the year. regularly to review medical evidence and
information provided by federal agencies, drug
› Moving a brand medication to a higher cost
manufacturers, medical professional associations,
tier when a generic becomes available. This
national organizations and peer-reviewed
can happen at any time during the year.
journals medications about the safety and
› Moving a medication to a higher cost tier and/ effectiveness of medications that are newly
or no longer covering a medication. This approved by the FDA and medications
typically happens twice a year on January 1st already on the market. The Cigna Pharmacy
and July 1st. Management® Business Decision Team then looks
› Adding coverage requirements to a medication. at the results of the P&T Committee’s clinical
For example, requiring approval from Cigna review, as well as the medication’s overall value
before a medication may be covered or adding and other factors before adding it to, or
a quantity limit to a medication. removing it from, the drug list.
When a medication changes tiers or is no longer
Which medications are covered under the
covered, you may pay a different amount to fill
health care reform law?
that medication. It’s important to know that
when we make a change that affects the The Patient Protection and Affordable Care Act
coverage of a medication you’re taking, we let (PPACA), commonly referred to as “health care
you know before it begins so you have time to reform,” was signed into law on March 23, 2010.
talk with your doctor. Under this law, certain preventive medications
(including some over-the-counter medicines)
Why doesn’t my plan cover certain may be available to you at no cost-share ($0),
medications? depending on your plan. Log in to the myCigna
To help lower your overall health care costs, app or website, or check your plan materials, to
your plan doesn’t cover certain high-cost brand learn more about how your plan covers
medications because they have lower-cost, preventive medications. You can also view the
covered alternatives which are used to treat the PPACA No Cost-Share Preventive Medications
same condition. Meaning, the alternative works drug list on Cigna.com/druglist.
the same or similar to the non-covered
For more information about health care reform,
medication. If you’re taking a medication that
visit www.informedonreform.com or Cigna.com.
your plan doesn’t cover and your doctor feels
an alternative isn’t right for you, he or she can
ask Cigna to consider approving coverage of
your medication.
30You can also read
