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 2
About 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 $ $$ BLOOD PRESSURE/HEART MEDICATIONS Medications are grouped by afeditab CR Berinert* (PA) the condition they treat amlodipine besylate Bidil amlodipine besylate-benazepril Bystolic amlodipine-valsartan Cinryze* (PA) amlodipine-valsartan-HCTZ Coreg CR atenolol Cozaar (ST) Diovan (ST) atenolol-chlorthalidone Medications are listed in Diovan HCT (ST) benazepril alphabetical order within Edarbi (ST) benazepril-HCTZ each column Edarbyclor (ST) candesartan cilexetil Exforge cartia XT Exforge HCT carvedilol Firazyr* (PA) Specialty medications have an clonidine Hemangeol asterisk (*) listed next to them digitek Inderal LA digox Inderal XL digoxin Innopran XL diltiazem ER Lotrel Brand name medications diltiazem CD Micardis (ST) are capitalized diltiazem Multaq dilt-XR Nitro-dur enalapril Nitrolingual NitroMist flecainide acetate Generic medications Nitronal hydralazine are lowercase Nitrostat irbesartan Northera* (PA) Medications that have extra isosorbide mononitrat Norvasc coverage requirements will Ranexa (ST) have an abbreviation listed Tekturna next to them Tekturna HCT This chart is just a sample. It may not show how these medications are actually covered on the Standard 3-Tier Prescription Drug List. 3
Tiers Covered medications are divided into tiers or cost-share levels. Typically, the higher the tier, the higher the price you’ll pay to fill the prescription. › Tier 1 – Typically Generics (Lowest-cost medication) $ › Tier 2 – Typically Preferred Brands (Medium-cost medication) $$ › 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. 4
No 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 5
Cigna 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) 6
Cigna 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) 7
Cigna 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) 8
Cigna Standard 3-Tier Prescription Drug List TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3 $ $$ $$$ $ $$ $$$ CHOLESTEROL MEDICATIONS (cont) CONTRACEPTION PRODUCTS (cont) ezetimibe- Trilipix (ST) Camrese+ simvastatin Vytorin (ST) Camrese Lo+ fenofibrate Welchol Caya Contoured+ fenofibric acid Zetia Caziant+ fluvastatin+ Zocor (ST, QL) Chateal+ fluvastatin ER+ Chateal EQ+ lovastatin 10mg Cryselle+ lovastatin 20mg, Cyclafem+ 40mg+ Cyred+ niacin Cyred EQ+ Dasetta+ niacin ER Daysee+ Niacor Deblitane+ omega-3 acid ethyl Delyla+ esters desogestrel-ethinyl pravastatin+ estradiol+ rosuvastatin 5mg, desogestrel-ethinyl 10mg+ (QL) estradiol ethinyl rosuvastatin 20mg, estradiol 40mg (QL) dospirenone- simvastatin 10mg, ethinyl estradiol- 20mg, 40mg+ levomefolate+ simvastatin 80mg drospirenone- (QL) ethinyl estradiol+ CONTRACEPTION PRODUCTS Econtra EZ+ Econtra One-Step+ Afirmelle + Lo Loestrin FE Annovera+ Elinest+ Aftera+ Taytulla Balcoltra eluryng vaginal Altavera+ Ella+ ring+ Alyacen + Estrostep FE Emoquette+ Amethia+ Layolis FE Enpresse+ Amethia Lo + Loestrin FE Enskyce+ Amethyst+ Minastrin 24 FE Errin+ Apri+ Natazia Estarylla+ Aranelle+ NuvaRing ethynodiol-ethinyl Ashlyna + Safyral estradiol+ Aubra+ Skyla* etonogestrel-EE Aubra EQ+ Today vaginal ring+ Aurovela 24 FE+ Contraceptive Falmina+ Aurovela FE + Sponge+ Fayosim+ Aurovela + Yasmin 28 FemCap+ Aviane+ Yaz Femynor+ Ayuna+ Gianvi+ Azurette+ Gynol II+ Balziva+ Hailey 24 FE+ Bekyree+ Heather+ Blisovi 24 FE+ Incassia+ Introvale+ Blisovi FE+ Isibloom+ Briellyn+ Jasmiel+ Camila+ Jencycla+ 9
Cigna Standard 3-Tier Prescription Drug List TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3 $ $$ $$$ $ $$ $$$ CONTRACEPTION PRODUCTS (cont) CONTRACEPTION PRODUCTS (cont) Jolessa + Norlyda + Juleber+ Norlyroc+ Junel+ Nortrel+ Junel FE+ Ocella+ Junel FE 24+ Option 2+ Kaitlib FE+ Orsythia+ Kalliga+ Philith+ Kariva+ Pimtrea+ Kelnor 1-35+ Pirmella+ Kelnor 1-50+ Portia+ Kurvelo+ Previfem+ Larin+ Reclipsen+ Larin FE+ Rivelsa tablet+ Larin FE 24+ Setlakin+ Larissia+ Sharobel+ Leena 28 tablet+ Simliya+ Lessina+ Simpesse+ Levonest+ Sprintec+ levonorgestrel+ Sronyx+ levonorgestrel- Syeda+ ethinyl estradiol+ Tarina FE+ levonorgestrel- Tarina FE 1-20 EQ+ ethinyl estradiol- Tilia FE 28+ ethinyl estradiol+ Tri Femynor+ Levora-28+ Tri-Estarylla+ Lillow+ Tri-Legest FE+ Loryna+ Tri-Linyah+ Low-Ogestrel+ Tri-Lo-Estarylla+ Lo-Zumandimine+ Tri-Lo-Marzia+ Lutera+ Tri-Lo-Mili+ Lyza+ Tri-Lo-Sprintec+ Marlissa+ Tri-Mili+ medroxyprogesterone Tri-Previfem+ 150mg/ml+ Tri-Sprintec+ Melodetta 24 FE+ Trivora-28+ Mibelas 24 FE+ Tri Vylibra+ Microgestin+ Tri Vylibra Lo+ Microgestin FE+ Tulana+ Mili+ Tydemy+ Mono-Linyah+ VCF foam, gel+ My Choice+ Velivet+ My Way+ Vienva+ Necon+ Viorele+ Nikki+ Vyfemla+ Nora-BE+ Vylibra+ norethindrone+ Wera+ norethindrone- Wide Seal ethinyl estradiol+ Diaphragm+ norethindrone- Wymzya FE+ ethinyl estradiol- Xulane+ iron+ Zarah+ norgestimate- Zovia+ ethinyl estradiol+ Zumandimine+ 10
Cigna Standard 3-Tier Prescription Drug List TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3 $ $$ $$$ $ $$ $$$ 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 11
Cigna 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+ 12
Cigna 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) 13
Cigna 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) 14
Cigna 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) 15
Cigna 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 16
Cigna 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+ 17
Cigna 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) 18
Medications 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. 19
MEDICATIONS 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. 20
MEDICATIONS 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. 21
MEDICATIONS 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. 22
MEDICATIONS 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. 23
MEDICATIONS 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. 24
MEDICATIONS 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. 25
MEDICATIONS 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. 26
MEDICATIONS 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. 27
MEDICATIONS 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. 28
MEDICATIONS 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. 29
Prescription 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. 30
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