CIGNA ADVANTAGE 3-TIER PRESCRIPTION DRUG LIST - As of January 1, 2019 - Cigna Client ...
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CIGNA ADVANTAGE 3-TIER PRESCRIPTION DRUG LIST As of January 1, 2019 Offered by Cigna Health and Life Insurance Company or Connecticut General Life Insurance Company 887152 m Advantage 3-Tier 08/18
Table of Contents
Getting started
Your prescription drug list 3
How to read your drug list 3
How to find your medication 5
Medications that are not covered 16
Prescription drug list FAQs 26
Exclusions and limitations 29
View your drug list online
This document was last updated 03/01/2018.* To see a current list of the medications covered
on your plan’s drug list, visit:
The myCigna® website – Once you’re registered, log in and select
Estimate Health Care Costs, then select Get drug costs.
Cigna.com/druglist – Select your drug list name – Advantage 3 Tier – from the
drop down menu.
Questions? – Call the toll-free number on the back of your Cigna ID card.
We’re here to help. If it’s easier, 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 03/01/2011 Last updated: 03/01/2018, for changes Next planned update: 03/01/2019, for
that were effective 07/01/2018 changes that will be effective 07/01/2019
2Your prescription drug list
This document shows the most commonly prescribed medications covered on the Advantage
Prescription Drug List as of January 1, 2019.1 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). It’s important to know that this is not a complete list
of covered medications, and not all of the medications listed here may be covered by your specific
plan. You should log in to the myCigna website or app, or check your plan materials, to learn more
about the medications your plan covers.
The Advantage Prescription Drug List excludes from coverage prescription medications used to treat
heartburn/stomach acid conditions (e.g., Nexium, Prilosec and any generics) and allergies (e.g., Allegra,
Clarinex, Xyzal and any generics). These medications are available over-the-counter at the pharmacy
without a prescription.
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 Advantage Prescription
Drug List.
Tier (cost-share level) gives you
an idea of how much you may pay
TIER 1 TIER 2 for a medication
$ $$
BLOOD PRESSURE/HEART MEDICATIONS Medications are grouped by
afeditab CR Berinert* (PA) the condition they treat
amlodipine besylate Bidil
amlodipine besylate-benazepril Bystolic
amlodipine-valsartan Cinryze* (PA)
amlodipine-valsartan-HCTZ Coreg CR
atenolol Cozaar (ST)
atenolol-chlorthalidone Diovan (ST)
benazepril Diovan HCT (ST) Medications are listed in
benazepril-HCTZ Edarbi (ST) alphabetical order within
each column
candesartan cilexetil Edarbyclor (ST)
cartia XT Exforge
carvedilol Exforge HCT
clonidine Firazyr* (PA) Specialty medications have an
digitek Hemangeol asterisk (*) listed next to them
digox Inderal LA
digoxin Inderal XL
diltiazem ER Innopran XL
diltiazem CD Lotrel Brand name medications
diltiazem Micardis (ST) are capitalized
dilt-XR Multaq
enalapril Nitro-dur
flecainide acetate Nitrolingual Generic medications
hydralazine Nitromist are lowercase
irbesartan Nitronal
isosorbide mononitrat Nitrostat
Northera* (PA) Medications that have extra
coverage requirements will
Norvasc have an abbreviation listed
Ranexa (ST) next to them
Tekturna
Tekturna HCT
This chart is just a sample. It may not show how these medications are actually covered on the Advantage Prescription Drug List.
3Tiers
Covered medications are divided into tiers, or cost-share levels. Typically, the higher the tier, the
higher the price you’ll pay to fill the prescription.
› Tier 1 – Typically Generics (Lower-cost medication) $
› Tier 2 – Typically Preferred Brands (Medium-cost medication) $$
› Tier 3 – Typically Non-Preferred Brands (Higher-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 provided by your doctor 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 – You must be within a specific age range for your plan to cover
A
the medication. Some medications aren’t considered clinically appropriate for
individuals who aren’t within that age range.
* This may not apply to your plan because not all plans have extra coverage requirements like prior authorization, quantity limits, Step Therapy and/or age. Please log in to the myCigna website
or app, 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 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, may limit coverage to a 30-day supply
and/or require you to use a preferred specialty pharmacy to receive coverage. Please log in to the
myCigna website or app, 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). Please log in to the myCigna website or app, 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 carat (^) next to them. Please
log in to the myCigna website or app, or check your plan materials, to find out if your plan excludes
your medication from coverage.
How to find your medication on the drug list
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 FEMININE PRODUCTS 11
ALLERGY/NASAL SPRAYS 6 GASTROINTESTINAL/HEARTBURN 11
ALZHEIMER’S DISEASE 6 HORMONAL AGENTS 11, 12
ANXIETY/DEPRESSION/BIPOLAR 6 INFECTIONS 12
DISORDER
INFERTILITY 12
ASTHMA/COPD/RESPIRATORY 6
MISCELLANEOUS 12
ATTENTION DEFICIT HYPERACTIVITY 6, 7
MULTIPLE SCLEROSIS 13
DISORDER
NUTRITIONAL/DIETARY 13
BLOOD MODIFIERS/BLEEDING DISORDERS 7
OSTEOPOROSIS PRODUCTS 13
BLOOD PRESSURE/HEART MEDICATIONS 7
BLOOD THINNERS/ANTI-CLOTTING 7 PAIN RELIEF AND INFLAMMATORY DISEASE 13, 14
CANCER 8 PARKINSON’S DISEASE 14
CHOLESTEROL MEDICATIONS 8 SCHIZOPHRENIA/ANTI-PSYCHOTICS 14
CONTRACEPTIVE PRODUCTS 8–10 SEIZURE DISORDERS 14
COUGH/COLD MEDICATIONS 10 SKIN CONDITIONS 15
DENTAL PRODUCTS 10 SLEEP DISORDERS/SEDATIVES 15
DIABETES 10 SMOKING CESSATION 15
DIURETICS 10 SUBSTANCE ABUSE 15
EAR MEDICATIONS 10 TRANSPLANT MEDICATIONS 15
EYE CONDITIONS 10, 11 URINARY TRACT CONDITIONS 15
5Cigna Advantage 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
AIDS/HIV ANXIETY/DEPRESSION/BIPOLAR
DISORDER (cont)
abacavir- Atripla* Complera*
lamivudine* Biktarvy* Evotaz* citalopram (QL) Trintellix (ST)
atazanavir* Descovy* Odefsey* clomipramine Viibryd (ST)
ritonavir* Genvoya* Prezcobix* desvenlafaxine ER Wellbutrin SR (ST,
tenofovir * Intelence* Stribild* (QL) QL)
Isentress HD* duloxetine (QL) Zoloft (ST, QL)
Viread 300mg*
Isentress* escitalopram (QL)
Norvir packet, fluoxetine (QL)
capsule, fluoxetine DR (QL)
solution* paroxetine (QL)
Prezista* paroxetine CR (QL)
Reyataz packet* paroxetine ER (QL)
Selzentry* sertraline (QL)
Tivicay* trazodone
Triumeq* venlafaxine (QL)
Truvada* venlafaxine ER (QL)
Viread powder, 150, ASTHMA/COPD/RESPIRATORY
200, 250mg*
albuterol Advair Diskus Adcirca* (PA)
ALLERGY/NASAL SPRAYS budesonide Advair HFA Adempas* (PA)
Adyphren Clarinex-D 12 Hour inhalation Anoro Ellipta Aralast NP* (PA)
Adyphren Amp EpinephrineSnap-V ipratropium- Atrovent HFA Combivent
azelastine EPIsnap albuterol Breo Ellipta Respimat
cromolyn Karbinal ER montelukast Incruse Ellipta Daliresp (QL)
cyproheptadine Ryvent Fasenra* (PA)
ProAir HFA
epinephrine auto- Glassia* (PA)
Semprex-D ProAir RespiClick
injector (QL) Kalydeco* (PA, QL)
Sinuva* (PA) QVAR RediHaler Letairis* (PA)
flunisolide
fluticasone Striverdi Respimat Nucala* (PA)
hydroxyzine Symbicort Ofev* (PA)
ipratropium Trelegy Ellipta (ST) Opsumit* (PA)
mometasone spray Orenitram ER* (PA)
(QL) Orkambi* (PA, QL)
olopatadine Pulmicort
Phenergan Pulmozyme* (PA)
promethazine Remodulin* (PA)
ALZHEIMER’S DISEASE
Symdeko* (PA, QL)
Tracleer* (PA)
donepezil Mestinon Tyvaso* (PA)
donepezil ODT Namenda Uptravi* (PA)
memantine Namenda XR (QL) Xolair* (PA)
memantine ER Namzaric (QL) ATTENTION DEFICIT HYPERACTIVITY
pyridostigmine Regonol DISORDER
pyridostigmine ER atomoxetine Adderall (ST)
rivastigmine dexmethylphenidate Daytrana (PA)
ANXIETY/DEPRESSION/BIPOLAR DISORDER dexmethylphenidate Evekeo (ST)
amitriptyline Effexor XR (ST, QL) ER Focalin (ST)
bupropion (QL) Fetzima (ST, QL) dextroamphetamine- Methylin (ST)
bupropion SR (QL) Forfivo XL (ST, QL) amphetamine ER Quillivant XR (PA)
bupropion XL (QL) Prozac (ST, QL) dextroamphetamine- Ritalin (ST)
buspirone Sarafem (ST) amphetamine
guanfacine ER
6Cigna Advantage 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
ATTENTION DEFICIT HYPERACTIVITY BLOOD PRESSURE/HEART MEDICATIONS (cont)
DISORDER (cont) Ecotrin+
Metadate ER EcPirin+
methylphenidate enalapril
methylphenidate flecainide
CD hydralazine
methylphenidate ER irbesartan
methylphenidate LA isosorbide
BLOOD MODIFIERS/BLEEDING DISORDERS isosorbide ER
tranexamic acid* Aranesp* (PA) Bebulin* (PA) labetalol
Granix* Ceprotin* (PA) lisinopril
Neulasta* (PA) Epogen* (PA) lisinopril-HCTZ
Soliris* (PA) Procrit* (PA) losartan
Zarxio* Promacta* (PA) losartan-HCTZ
Matzim LA
BLOOD PRESSURE/HEART MEDICATIONS metoprolol
Aspir 81+ Corlanor (PA) Bayer Chewable nadolol
Afeditab CR Entresto (PA) Aspirin+ nifedipine
amlodipine Berinert* (PA) nifedipine ER
amlodipine- BiDil (QL) olmesartan
benazepril Cardizem LA olmesartan-
amlodipine- Cinryze* (PA) amlodipine-HCTZ
olmesartan Coreg CR olmesartan-HCTZ
amlodipine- Epaned (ST) propafenone
valsartan Firazyr* (PA) propafenone ER
amlodipine- Haegarda* (PA) propranolol
valsartan-HCTZ Hemangeol propranolol ER
Aspir-Low+ Inderal LA quinapril
aspirin+
Inderal XL ramipril
aspirin EC+
Innopran XL Taztia XT
atenolol
Multaq telmisartan
atenolol-
chlorthalidone Nitro-Dur telmisartan-HCTZ
benazepril Nitrolingual tri-buffered aspirin+
benazepril-HCTZ Nitromist valsartan
bisoprolol Nitrostat valsartan-HCTZ
Bufferin + Northera* (PA) verapamil
candesartan Norvasc verapamil ER
Cartia XT Ranexa (ST, QL) verapamil SR
carvedilol Tiazac BLOOD THINNERS/ANTI-CLOTTING
carvedilol ER Tikosyn (QL)
clonidine Toprol XL aspirin- Brilinta Bevyxxa (QL)
Digitek dipyridamole ER Eliquis Coumadin
Digox clopidogrel Xarelto Effient
digoxin enoxaparin* (QL) Fragmin* (QL)
Dilt-XR fondaparinux* (QL) Pradaxa
diltiazem Jantoven Savaysa
diltiazem CD prasugrel Zontivity
diltiazem ER warfarin
dofetilide (QL)
doxazosin
7Cigna Advantage 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
CANCER CHOLESTEROL MEDICATIONS (cont)
anastrozole Actimmune* (PA)
Afinitor Disperz* fluvastatin ER 80mg+
bexarotene* (PA) Avastin* (PA)(PA) lovastatin 20mg,
capecitabine* (PA) Fareston (QL)
Afinitor* (PA) 40mg+
imatinib* (PA) Herceptin* (PA)
Alecensa* (PA) niacin ER
letrozole Intron A* (PA)
Arimidex Niacor
mercaptopurine Nexavar* (PA)
Bosulif* (PA) omega-3 acid ethyl
Revlimid* (PA)
Cabometyx* (PA) esters
methotrexate*
Rituxan* (PA)
Cometriq* (PA) pravastatin 10mg,
tamoxifen+ Sprycel* (PA)
temozolomide* Cotellic* (PA) 20mg, 40mg, 80mg +
Sutent* (PA)Erivedge* (PA) rosuvastatin 5mg,
(PA) Tarceva* (PA)
Erleada* (PA) 10mg+
Tasigna* (PA)
Gazyva* (PA) simvastatin 10mg,
Trexall*
Gilotrif* (PA) 20mg, 40 mg+ (QL)
Valstar*
Gleevec* (PA) Triklo
Ibrance* (PA) CONTRACEPTIVE PRODUCTS
Iclusig* (PA)
Imbruvica* (PA) Aftera +
Lo Loestrin FE Beyaz
Inlyta* (PA) Altavera+ Taytulla Caya Contoured+
Jakafi* (PA) Alyacen +
Ella+
Kadcyla* (PA) Amethia+ Estrostep FE
Lenvima* (PA) Amethia Lo+ FC2 Female
Lonsurf* (PA) Amethyst+ Condom+
Lynparza* (PA) Apri +
Femcap+
Mekinist* (PA) Aranelle +
Kyleena*
Nerlynx* (PA) Ashlyna+ Loestrin FE
Ninlaro* (PA) Aubra+ LoSeasonique
Perjeta* (PA) Aviane+ Microgestin+
Pomalyst* (PA) Azurette +
Minastrin 24 FE
Stivarga* (PA) Balziva+ Mirena*
Sylatron* (PA) Bekyree+ NuvaRing
Tafinlar* (PA) Blisovi 24 FE+ Seasonique
Tagrisso* (PA) Blisovi FE+ Skyla*
Targretin* (PA) Briellyn+ Today
Tecentriq* (PA) Camila+ Contraceptive
Verzenio* (PA) Camrese+ Sponge+
Votrient* (PA) Camrese Lo +
Wide Seal
Xalkori* (PA) Caziant+ Diaphragm+
Xtandi* (PA) Chateal+
Zelboraf* (PA) Cryselle+
Zytiga* (PA) Cyclafem+
CHOLESTEROL MEDICATIONS Cyred+
atorvastatin 10mg, Repatha* (PA) Korlym* (PA) Dasetta+
20mg+ Kynamro* (PA) Daysee+
ezetimibe Vascepa Deblitane+
ezetimibe- Delyla+
Welchol
simvastatin desogestrel-ethinyl
Zetia
fenofibrate estradiol+
fenofibric acid drospirenone-
fluvastatin 20mg, ethinyl estradiol-
40mg+ levomefibrate+
8Cigna Advantage 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
CONTRACEPTIVE PRODUCTS (cont) CONTRACEPTIVE PRODUCTS (cont)
drospirenone- medroxy-
ethinyl estradiol+ progesterone
Econtra EZ+ 150mg/ml+
Econtra One-Step+ Melodetta 24 FE+
Elinest+ Mibelas 24 FE+
Emoquette+ Microgestin FE+
Enpresse+ Mili+
Enskyce+ Mono-Linyah+
Errin+ Mononessa+
Estarylla+ My Choice+
ethynodiol-ethinyl My Way+
estradiol+ Myzilra+
Falmina+ Necon 0.5/35+
Fayosim+ Necon 7/7/7+
Nikki+
Femynor+
Nora-BE+
Gianvi+
norethindrone+
Heather+
norethindrone-
Introvale+
ethinyl estradiol+
Isibloom+ norethindrone-
jencycla+ ethinyl estradiol-
Jolessa+ iron+
Jolivette+ norgestimate-
Juleber+ ethinyl estradiol+
Junel+ Norlyda+
Junel FE+ Norlyroc+
Junel FE 24+ Nortrel+
Kaitlib FE+ Ocella+
Kariva+ Opcicon One-Step+
Kelnor 1-35+ Option 2+
Kelnor 1-50+ Orsythia+
Kimidess+ Philith+
Kurvelo+ Pimtrea+
Larin+ Pirmella+
Larin 24 FE+ Portia+
Larin FE+ Previfem+
Larissia+ Quasense+
Leena+ Rajani+
Lessina+ Reclipsen+
Levonest+ Rivelsa+
levonorgestrel- Setlakin+
ethinyl estradiol+ Sharobel+
Levora-28+ Sprintec+
Lillow+ Sronyx+
Loryna+ Syeda+
Low-Ogestrel+ Tarina FE+
Lutera+ Tilia FE+
Tri Femynor+
Lyza+
Tri-Estarylla+
Marlissa+
Tri-Legest FE+
9Cigna Advantage 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
CONTRACEPTIVE PRODUCTS (cont) DIABETES
Tri-Linyah
+
glimepiride Basaglar Cycloset
Tri-Lo-Estarylla+ glipizide Bydureon (QL) Glucagon
Tri-Lo-Marzia+ glipizide ER Byetta (QL) Emergency Kit
Tri-Lo-Sprintec+ glipizide XL Farxiga (QL)
Tri-Mili+ metformin GlucaGen HypoKit Glucophage
Tri-Previfem+ metformin ER (QL) Glucophage XR
Tri-Sprintec+ Glyxambi
Riomet
Tri-Vylibra+ Humalog
Trinessa Lo+ Humulin VGo
Trinessa+ Janumet
Trivora-28+ Janumet XR
Tulana+ Januvia
Tydemy+ Jardiance
VCF+ Levemir
Velivet+ OneTouch test
Vienva+ strips and meters
Viorele+ Soliqua
Vyfemia+ SymlinPen
Vylibra+ Synjardy
Wera+ Synjardy XR
Wymzya FE+ Tresiba
Xulane+ Trulicity (QL)
Zarah+ Victoza (QL)
Zenchent+ Xigduo XR
Zovia 1-35e+ Xultophy
Zovia 1-50e+ DIURETICS
COUGH/COLD MEDICATIONS acetazolamide Aldactone
benzonatate Tessalon Perle chlorthalidone Carospir
Bromfed DM Tussionex (QL) eplerenone Diuril
brompheniramine- Tuzistra XR (QL) furosemide Dyrenium
pseudoephedrine- hydrochlorothiazide Jynarque* (PA)
DM spironolactone Lasix
hydrocodone-
triamterene-HCTZ Samsca*
chlorpheniramine
ER (QL) EAR MEDICATIONS
hydrocodone- neomycin- Cipro HC
homatropine (QL) polymyxin-HC Ciprodex
Hydromet (QL) ofloxacin drops Coly-Mycin S
Tussigon (QL)
Dermotic
DENTAL PRODUCTS Otovel
chlorhexidine rinse Clinpro 5000 EYE CONDITIONS
Denta 5000 plus Prevident
Dentagel azelastine Restasis Acuvail
Prevident 5000 Alphagan P
doxycycline brimonidine Simbrinza
Fluoridex ciprofloxacin drops Travatan Z Alrex
Oralone dorzolamide- Xiidra Azasite
Paroex timolol Azopt
Peridex erythromycin Besivance
Periogard Betimol
ointment
sodium fluoride Betoptic S
SF 5000 plus fluorometholone Bromsite
triamcinolone paste gatifloxacin Combigan
10Cigna Advantage 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
EYE CONDITIONS (cont) GASTROINTESTINAL/HEARTBURN (cont)
ketorolac solution Cosopt PF lansoprazole- Prepopik+
latanoprost Cystaran* (QL) amoxicillin- Ravicti* (PA)
moxifloxacin drops Durezol clarithromycin Rectiv
neomycin- Eylea* (PA) LaxaClear+ Relistor (PA)
polymyxin- Ilevro mesalamine Sancuso (PA, QL)
dexamethasone Iluvien* metoclopramide Sensipar*
metoclopramide
ofloxacin drops Lotemax sfRowasa
ODT
olopatadine drops Lucentis* (PA) Sucraid*
Natura-Lax+
polymyxin B-TMP Moxeza ondansetron Suprep+
prednisolone drops Nevanac ondansetron ODT Sustol (PA)
timolol Ozurdex* PEG 3350- Symproic (PA)
tobramycin drops Prolensa electrolyte+ Transderm Scop
tobramycin- Tobradex PEG-Prep+ Varubi* (PA, QL)
dexamethasone Tobradex ST Phenadoz Viberzi
Vigamox Powderlax+ Viokace
Zioptan (ST, QL) promethazine
Zirgan suppository
Zylet Promethegan
Purelax+
FEMININE PRODUCTS
scopolamine
Fem pH AVC Smooth LAX+
Gynazole 1 Relagard sucralfate
miconazole 3 TriLyte with flavor
terconazole packets+
GASTROINTESTINAL/HEARTBURN ursodiol
Alophen+ Amitiza Akynzeo* (PA, QL) HORMONAL AGENTS
alosetron* Apriso Bonjesta Amabelz AndroGel 1.62% Activella
Anucort-HC Creon Canasa budesonide EC (PA, QL) Alora (QL)
balsalazide Entyvio* (PA) Carafate cabergoline (QL) Duavee Androderm (PA, QL)
Bisa-Lax+ Linzess Cholbam* (PA) Covaryx Forteo* AndroGel 1.0% (PA,
bisacodyl+ Pentasa Clenpiq Covaryx H.S. Humatrope* (PA) QL)
chlordiazepoxide- Zenpep CoLyte With Flavor Decadron Premarin Angeliq
clidinium Packets+ desmopressin* Premphase Armour Thyroid
Clearlax+ Correctol+ dexamethasone Prempro Aveed* (PA)
dicyclomine Diclegis dexamethasone Sandostatin LAR Climara
Donnatal
diphenoxylate- intensol Depot* (PA) Climara Pro
Dulcolax+
atropine EEMT Serostim* (PA) Combipatch
Gattex* (PA)
dronabinol EEMT H.S. Zorbtive* (PA) Cytomel
Gialax+
Ducodyl+ GoLytely+ estradiol (QL) Depo-Testosterone
Gavilax+ Lialda (ST) estradiol- Divigel
Gavilyte-C+ Miralax+ norethindrone Elestrin
Gavilyte-G+ Movantik (PA) levothyroxine Emflaza* (PA)
Gavilyte-n+ MoviPrep+ Levoxyl Entocort EC
GentleLax+ Nulytely with flavor liothyronine Estring (QL)
Glycolax+ packets+ medroxyprogesterone Estrogel
HealthyLax+ Ocaliva* (PA) methimazole Evamist
Hemmorex-HC OsmoPrep+ methylprednisolone Femring
hydrocortisone Pancreaze Mimvey Ganirelix*^
suppository Pertzye Mimvey Lo H.P. Acthar* (PA)
11Cigna Advantage 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
HORMONAL AGENTS (cont) INFECTIONS (cont)
Nature-Throid Intrarosa fluconazole Uribel
NP Thyroid Levo-T hydroxychloroquine Urogesic Blue
prednisolone Lupron Depot* (PA) itraconazole Uta
prednisolone ODT Menostar (QL) levofloxacin Valtrex
prednisone Minivelle (QL) metronidazole Vemlidy*
prednisone intensol Natpara* (PA) minocycline Vibramycin
minocycline ER suspension, syrup
progesterone Osphena
minocycline ER Xifaxan
testosterone (PA, Rayaldee Mondoxyne NL
QL) Somatuline Depot* Zepatier* (PA)
Morgidox
testosterone (PA) nitrofurantoin
cypionate Somavert* (PA) Okebo
thyroid Striant (PA, QL) oseltamivir (QL)
Unithroid 75mcg Supprelin LA* (PA) penicillin
Westhroid Synthroid Soloxide
WP Thyroid Testopel (PA) sulfamethoxazole-
Yuvafem (QL) Thyrogen* trimethoprim
Tirosint terbinafine
Triostat tinidazole
tobramycin*
Unithroid
valacyclovir
Vagifem (QL) valganciclovir
Vivelle-Dot (QL) vancomycin
INFECTIONS Vandazole
acyclovir Baraclude solution* Albenza voriconazole (PA)
amoxicillin Epclusa* (PA) Alinia INFERTILITY
amoxicillin- Harvoni* (PA) Bactrim clomiphene ^ Follistim AQ*^ Crinone^
clavulanate ER Kitabis Pak* Bactrim DS Endometrin^
amoxicillin- Mavyret* (PA) Baraclude tablet* Makena* (PA)
clavulanate Sovaldi* (PA) Cayston* Menopur*^
atovaquone Thalomid* (PA) Cipro
atovaquone- Vosevi* (PA) Cleocin MISCELLANEOUS
proguanil Clindesse NebuSal 3% Cerdelga* (PA) Addyi (QL)
Avidoxy Cresemba vial PulmoSal Elaprase* (PA) Austedo* (PA)
azithromycin Cresemba capsule sodium chloride Nityr* (PA) Botox* (PA)
cefdinir (PA) tetrabenazine* (PA) TechLITE lancets Cerezyme* (PA)
cefixime Daraprim* (PA) Dysport* (PA)
cefuroxime Dificid (QL) Esbriet* (PA)
cephalexin E.E.S. 400 Exjade*
ciprofloxacin EryPed 200 Ingrezza* (PA)
clarithromycin Ery-Tab Jadenu*
clarithromycin ER Minocin Kuvan* (PA)
clindamycin Monurol Lumizyme* (PA)
Coremino Noxafil Naglazyme* (PA)
dapsone PegIntron* (PA) NebuSal 6%
Doxy 100 Plaquenil Nuedexta (QL)
doxycycline Sulfatrim Strensiq* (PA)
doxycycline IR-DR Suprax Syprine* (PA)
Emverm Synagis* (PA) Vimizim* (PA)
entecavir* Tamiflu (QL) Vivitrol*
erythromycin Tobi Podhaler* VPRIV* (PA)
famciclovir Uretron D-S Xenazine* (PA)
Xeomin* (PA)
12Cigna Advantage 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
MULTIPLE SCLEROSIS PAIN RELIEF AND INFLAMMATORY DISEASE
glatiramer* (PA) Ampyra* (PA) Lemtrada* (PA) acetaminophen- Actemra* (PA) Abstral (PA, QL)
Glatopa* (PA) Avonex* (PA) Ocrevus* (PA) codeine (PA, QL) Embeda (PA, QL) Actiq (PA, QL)
Betaseron* (PA) Tysabri* (PA) allopurinol Enbrel* (PA) Analpram HC
Extavia* (PA) baclofen Humira* (PA) Arymo ER (PA, QL)
Gilenya* (PA) buprenorphine (QL) Hysingla ER (PA, QL) Benlysta* (PA)
Plegridy* (PA) butalb ital- Otezla* (PA) Buprenex
Rebif* (PA) acetaminophen- Rasuvo* (PA) Butrans (QL)
Tecfidera* (PA) caffeine-codeine Remicade* (PA) Celebrex (ST, QL)
NUTRITIONAL/DIETARY (PA, QL) Stelara* (PA) Cimzia* (PA)
butalbital- Xtampza ER (PA, Colcrys
B-12 Compliance OB Complete Auryxia (QL) acetaminophen- QL) Cosentyx* (PA)
calcitriol Poly-Vi-Flor+ CitraNatal caffeine (QL) Cuprimine* (PA)
calcium Prefera OB Concept DHA
carisoprodol Depen* (PA)
cyanocobalamin Prenate Escavite+
injection celecoxib (QL) Duragesic (PA, QL)
Tri-Vi-Flor+
Escavite D+
FA-8 +
Floriva+ colchicine Durolane* (PA)
fluoride +
Fluorabon+ cyclobenzaprine Euflexxa* (PA)
Fluoritab +
K-Tab ER DermacinRx Fentora (PA, QL)
Flura-Drops + Klor-Con 10 Empricaine Flector (ST, QL)
folic acid + Klor-Con 8 DermacinRx Gelsyn-3* (PA)
Klor-Con Klor-Con M15 Prizopak Hyalgan* (PA)
Klor-Con M10, M20 KPN+ diclofenac (QL) Ilaris* (PA)
lanthanum Mephyton diclofenac ER Kadian (PA, QL)
levocarnitine MVC-fluoride+ dihydroergotamine Kevzara* (PA)
Ludent Fluoride +
Nascobal (QL) Lazanda (PA, QL)
multivitamin-iron- Perry Prenatal+ eletriptan (QL) Mitigare
fluoride +
Phoslyra Endocet (PA, QL) Monovisc* (PA)
PNV-DHA Physicians EZ Use etodolac Morphabond ER
polyvitamins- B-12 etodolac ER
Poly-Vi-Flor With (PA, QL)
fluoride+ fenoprofen
potassium chloride Iron+ MS Contin (PA, QL)
Fenortho Nucynta (PA, QL)
Prena1 Pearl Prenate
Prenatal+ Quflora+ fentanyl (PA, QL) Nucynta ER (PA, QL)
prenatal vitamin + Renagel Fioricet (QL) Onzetra Xsail (QL)
Right Step+ Renvela frovatriptan (QL) Orencia* (PA)
sevelamer Tristart DHA Glydo Orthovisc* (PA)
sodium fluoride+ Urosex+ hydrocodone- Otrexup* (PA)
tri-vitamin with Velphoro acetaminophen Oxaydo (PA, QL)
fluoride + Veltassa (PA, QL) Pennsaid (ST)
tri-vitamin with Vitafol hydromorphone Percocet (PA, QL)
fluoride-iron + vitaMedMD One Rx (PA, QL) Procort
Virt-PN DHA vitaPearl hydromorphone ER Proctofoam-HC
vitamin D2 1.25mg VP-PNV-DHA (PA, QL) Relpax (QL)
Zatean-PN DHA IBU Savella
OSTEOPOROSIS PRODUCTS ibuprofen Subsys (PA, QL)
alendronate (QL) Tymlos* Evista indomethacin Synera
calcitonin-salmon Fosamax Plus D indomethacin ER Synvisc* (PA)
ibandronate* (ST) ketorolac (QL) Synvisc-One* (PA)
raloxifene +
Prolia* (PA) leflunomide Taltz* (PA)
risedronate Xgeva* (PA) lidocaine (QL) Tremfya* (PA)
risedronate DR lidocaine viscous Uloric
13Cigna Advantage 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
PAIN RELIEF AND INFLAMMATORY PARKINSON’S DISEASE
DISEASE (cont) amantadine Apokyn* (PA)
lidocaine-prilocaine Voltaren (ST, QL) benztropine Azilect
Lidopril Xeljanz XR* (PA) bromocriptine Neupro
Lidopril XR Xeljanz* (PA) carbidopa- Rytary
Lido-Prilo Caine Pack Zohydro ER (PA, QL) levodopa Sinemet
LiproZonePak carbidopa- Sinemet CR
Livixil Pak levodopa ER Tasmar
Lorcet (PA, QL) pramipexole Xadago
Lorcet HD (PA, QL) pramipexole ER
Lorcet Plus (PA, QL)
rasagiline
Lortab (PA, QL)
ropinirole
Medolor Pak
ropinirole ER
meloxicam
Metaxall SCHIZOPHRENIA/ANTI-PSYCHOTICS
metaxalone aripiprazole Abilify Maintena
methocarbamol aripiprazole ODT (QL)
morphine (PA, QL) chlorpromazine Aristada (QL)
morphine syringe, haloperidol Fanapt (ST, QL)
vial (QL) olanzapine Invega Sustenna
morphine ER (PA, olanzapine ODT (QL)
QL) paliperidone ER Invega Trinza (QL)
naproxen
quetiapine Latuda (ST)
naproxen DS
quetiapine ER Rexulti (ST)
oxycodone (PA, QL)
risperidone Saphris (ST)
oxycodone ER (PA,
QL) risperidone ODT Seroquel (ST)
oxycodone- ziprasidone Seroquel XR (ST)
acetaminophen Vraylar (ST)
(PA, QL) SEIZURE DISORDERS
oxymorphone (PA, carbamazepine Dilantin 30mg Aptiom (PA)
QL) carbamazepine ER Lyrica Banzel (PA, QL)
oxymorphone ER divalproex Briviact (PA)
(PA, QL) divalproex ER Carbatrol
Phrenilin Forte (QL) Epitol Depakote
Prilolid gabapentin Depakote ER
Primlev (PA, QL) lamotrigine Dilantin 50mg,
Profeno lamotrigine (blue, 100mg, susp.
Relador Pak
green, orange) Fycompa (PA)
Relador Pak Plus
lamotrigine ER Keppra vial
rizatriptan (QL)
lamotrigine ODT Oxtellar XR (PA)
sumatriptan (QL)
lamotrigine ODT Phenytek
sumatriptan-
(blue, green, Spritam (PA)
naproxen (QL)
tizanidine orange) Tegretol
tramadol (QL) levetiracetam Tegretol XR
tramadol ER (QL) levetiracetam ER Vimpat (PA)
Verdrocet (PA, QL) oxcarbazepine
Vicodin (PA, QL) Roweepra
Vicodin ES (PA, QL) Roweepra XR
Vicodin HP (PA, QL) topiramate
topiramate ER
14Cigna Advantage 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
SKIN CONDITIONS SKIN CONDITIONS (cont)
adapalene (PA age) Eucrisa Benzamycin SSS 10-5
adapalene-benzoyl Targretin* Celacyn gel SulfaCleanse 8-4
peroxide Desowen (ST) tacrolimus
Ala-Cort 2.5% Drysol tazarotene
Amnesteem (QL) Ecoza tretinoin (PA age)
Avar triamcinolone
Avar-E Elidel
Triderm
BenzePrO Finacea
Zenatane (QL)
BP 10-1 Naftin
calcipotriene Picato SLEEP DISORDERS/SEDATIVES
calcipotriene- Santyl (QL) armodafinil (PA) Belsomra (ST) Rozerem (ST, QL)
betamethasone Sklice eszopiclone Silenor (ST) Xyrem* (PA)
DP Soolantra modafinil (PA)
Calcitrene Topicort (ST) zolpidem
Claravis (QL) Tridesilon (ST) zolpidem ER
Clindacin ETZ
SMOKING CESSATION
Clindacin P
clindamycin bupropion SR+ Nicorette+
clindamycin- NicoDerm CQ+
benzoyl peroxide Nicorelief+
clindamycin- nicotine gum+
tretinoin nicotine lozenge+
clobetasol nicotine patch+
Clodan shampoo Quit 2+
clotrimazole- Quit 4+
betamethasone SUBSTANCE ABUSE
dapsone
desonide buprenorphine Bunavail Sublocade*
fluocinonide buprenorphine- Narcan
fluorouracil naloxone Probuphine
flurandrenolide naloxone Suboxone
hydrocortisone naltrexone (QL) Zubsolv
imiquimod TRANSPLANT MEDICATIONS
isotretinoin (QL)
ketoconazole azathioprine* Prograf* Astagraf XL*
metronidazole mycophenolate* Cellcept*
mupirocin mycophenolic Envarsus XR*
Myorisan (QL) acid* Myfortic*
Neuac gel sirolimus* Neoral*
Nolix tacrolimus* Zortress*
nystatin- URINARY TRACT CONDITIONS
triamcinolone
oxiconazole darifenacin ER Avodart
permethrin dutasteride Cystagon*
Procto-Med HC finasteride 5mg Elmiron
Procto-Pak oxybutynin K-Phos Original
Proctosol-HC oxybutynin ER Procysbi* (PA)
Proctozone-HC phenazopyridine Pyridium
Rosadan potassium ER Rapaflo
Rosanil tamsulosin Thiola*
Scalacort tolterodine
sodium tolterodine ER
sulfacetamide- trospium
sulfur trospium ER
15Medications 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. We want you to know your
plan covers other medications that are used to treat the same condition.^^ We’ve listed some below for
you and your doctor to consider. You should call your doctor’s office to talk about your options.
GENERIC AND/OR PREFERRED
DRUG CLASS MEDICATION(S) NOT COVERED^^
BRAND ALTERNATIVE(S)
ALLERGY/NASAL SPRAYS Auvi-Q epinephrine auto-injector
EpiPen, EpiPen Jr
Beconase AQ Generic nasal steroids (e.g., fluticasone)
Dymista
Nasonex
Omnaris
QNASL
Zetonna
QNASL Children budesonide
fluticasone
triamcinolone
ANXIETY/DEPRESSION/ Anafranil clomipramine
BIPOLAR DISORDER Aplenzin bupropion XL
Wellbutrin XL
Ativan lorazepam
Cymbalta duloxetine
Lexapro escitalopram
Pamelor nortriptyline
Parnate tranylcypromine
Pexeva paroxetine/CR/ER
Pristiq bupropion SR/XL
duloxetine
venlafaxine ER
All generic SSRIs
Tofranil imipramine
ASTHMA/COPD/RESPIRATORY Alvesco QVAR RediHaler
ArmonAir RespiClick
Arnuity Ellipta
Asmanex
Asmanex HFA
Flovent Diskus
Flovent HFA
Pulmicort Flexhaler
Arcapta Neohaler Striverdi Respimat
Serevent Diskus
Bevespi Anoro Ellipta
Stiolto Respimat
Utibron Neohaler
^^
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.
16GENERIC AND/OR PREFERRED
DRUG CLASS MEDICATION(S) NOT COVERED^^
BRAND ALTERNATIVE(S)
ASTHMA/COPD/RESPIRATORY (cont) Dulera Advair Diskus
Advair HFA
Breo Ellipta
Symbicort
Elixophyllin theophylline oral solution
Proventil HFA ProAir HFA
Ventolin HFA ProAir RespiClick
Xopenex HFA
Seebri Neohaler Incruse Ellipta
Spiriva
Spiriva Respimat
Tudorza Pressair
Zyflo montelukast
zafirlukast
Zyflo CR zileuton ER
ATTENTION DEFICIT HYPERACTIVITY Cotempla XR-ODT dexmethylphenidate ER
DISORDER methylphenidate ER/CD/LA
dextroamphetamine-amphetamine ER
Desoxyn methamphetamine
Dexedrine dextroamphetamine
Mydayis dextroamphetamine-amphetamine ER
dexmethylphenidate ER
methylphenidate ER/CD/LA
Vyvanse dexmethylphenidate ER
dextroamphetamine-amphetamine ER
methylphenidate ER/LA/CD
BLOOD PRESSURE/HEART MEDICATIONS Accupril quinapril
Accuretic quinapril-HCTZ
Altace ramipril
Atacand candesartan
Atacand-HCT candesartan-HCTZ
Avalide irbesartan-HCTZ
Avapro irbesartan
Azor amlodipine-olmesartan
Benicar olmesartan
Benicar HCT olmesartan-HCTZ
Betapace sotalol
Bystolic Generic beta blockers (e.g., metoprolol,
atenolol)
Byvalson Generic ARBs + generic beta blockers
Cardizem diltiazem
Cardizem CD Cartia XT
diltiazem CD/ER
Cozaar losartan
Diovan valsartan
^^
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.
17GENERIC AND/OR PREFERRED
DRUG CLASS MEDICATION(S) NOT COVERED^^
BRAND ALTERNATIVE(S)
BLOOD PRESSURE/HEART MEDICATIONS Diovan HCT valsartan-HCTZ
(cont) Edarbi Generic ARBs (e.g., losartan, valsartan)
Edarbyclor Generic ARBs + HCTZ (e.g., losartan-HCTZ)
Exforge amlodipine-valsartan
Exforge HCT amlodipine-valsartan-HCTZ
Hyzaar losartan-HCTZ
Isordil isosorbide dinitrate
Isordil Titradose
Lanoxin Digitek
digoxin
Lotensin benazepril
Lotensin HCT benazepril-HCTZ
Lotrel amlodipine-benazepril
Micardis telmisartan
Micardis HCT telmisartan-HCTZ
Prinivil lisinopril
Zestril
Tarka trandolapril-verapamil ER
Tekturna Generic ACE/ARBs
Tekturna HCT Generic ACE/ARBs + HCTZ
Tribenzor olmesartan-amlodipine-HCTZ
Twynsta telmisartan-amlodipine
Vaseretic enalapril-HCTZ
Vasotec enalapril
Zestoretic lisinopril-HCTZ
BLOOD THINNERS/ANTI-CLOTTING Yosprala IR or EC aspirin
CANCER Nilandron nilutamide
CHOLESTEROL MEDICATIONS Altoprev atorvastatin
fluvastatin
lovastatin
pravastatin
rosuvastatin
simvastatin
Antara fenofibrate
Fenoglide
Crestor rosuvastatin
FloLipid simvastatin
Zocor
Lescol XL 80mg fluvastatin
Lipitor atorvastatin
^^
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.
18GENERIC AND/OR PREFERRED
DRUG CLASS MEDICATION(S) NOT COVERED^^
BRAND ALTERNATIVE(S)
CHOLESTEROL MEDICATIONS (cont) Livalo atorvastatin
fluvastatin
lovastatin
pravastatin
rosuvastatin
simvastatin
Vytorin ezetimibe-simvastatin
Pravachol pravastatin
Zypitamag atorvastatin
fluvastatin
lovastatin
pravastatin
rosuvastatin
simvastatin
COUGH/COLD MEDICATIONS Tussicaps hydrocodone-chlorpheniramine ER
DIABETES Accu-Chek, Contour, Freestyle, all other OneTouch test strips and meters
test strips and meters
Adlyxin Byetta
Tanzeum Bydureon
Ozempic
Trulicity
Victoza
Admelog Humalog
Afrezza Humulin
Apridra
Apridra SoloStar
Fiasp
Novolin, Novolog
Fortamet metformin ER (generic Glucophage XR)
Glumetza
metformin ER (generic Fortamet and
Glumetza)
Invokamet Synjardy, Synjardy XR, Xigduo XR
Invokamet XR
Segluromet
Invokana Farxiga
Jardiance
Jentadueto alogliptin-metformin
Jentadueto XR Janumet, Janumet XR
Kazano
Kombiglyze XR
Nesina alogliptin
Onglyza Januvia
Tradjenta
Oseni alogliptin-pioglitazone
Januvia + pioglitazone
Lantus Basaglar, Levemir, Tresiba
Toujeo SoloStar
^^
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.
19GENERIC AND/OR PREFERRED
DRUG CLASS MEDICATION(S) NOT COVERED^^
BRAND ALTERNATIVE(S)
DIABETES (cont) QTERN Glyxambi
Steglatro Farxiga
Jardiance
DIURETICS Edecrin bumetanide
ethacrynic acid furosemide
torsemide
EYE CONDITIONS Alocril cromolyn
Alomide
Bepreve azelastine
Elestat epinastine
Emadine olopatadine
Lastacaft
Pataday
Patanol
Pazeo
Lumigan bimatoprost
Vyzulta latanoprost
Travatan Z
GASTROINTESTINAL/HEARTBURN Anusol-HC suppository Anucort-HC
Cortifoam Hemmorex-HC
Uceris foam hydrocortisone suppository
Asacol-HD Apriso
Colazal balsalazide
Delzicol Lialda
Dipentum Pentasa
Giazo sulfasalazine
mesalamine 800mg tablet sulfasalazine DR
Librax chlordiazepoxide-clidinium
Lotronex alosetron
Marinol dronabinol
Omeclamox-Pak lansoprazole-amoxicillin-clarithromycin
Prevpac (combo pak)
Pylera
Pepcid famotidine
Rowasa mesalamine enema
Syndros dronabinol
Trulance Amitiza, Linzess
Zofran ondansetron
Zofran ODT ondansetron ODT
Zuplenz ondansetron
ondansetron ODT
HORMONAL AGENTS Cortrosyn cosyntropin
DDAVP desmopressin
Dexpak dexamethasone
TaperDex
^^
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.
20GENERIC AND/OR PREFERRED
DRUG CLASS MEDICATION(S) NOT COVERED^^
BRAND ALTERNATIVE(S)
HORMONAL AGENTS (cont) Fortesta AndroGel 1.62%
Natesto testosterone
Testim
Vogelxo
Genotropin Humatrope (PA)
Norditropin
Nutropin AQ
Omnitrope
Saizen
Zomacton
Hectorol doxercalciferol
Rayos prednisone
prednisone intensol
Uceris tablet dexamethasone
hydrocortisone
methylprednisolone
prednisone
prednisolone
INFECTIONS Acticlate Generic products (e.g., doxycycline;
Doryx minocycline)
Minocin capsule
Monodox
Oracea
Solodyn
Vibramycin capsule
Ximino
Augmentin/ES/XR amoxicillin-clavulanate ER
Bethkis Kitabis Pak
Tobi tobramycin
Diflucan fluconazole
E.E.S. 200 erythromycin ethylsuccinate
Eryped 400
Mepron atovaquone
Mycobutin rifabutin
Onmel itraconazole
terbinafine
Sitavig acyclovir (oral)
famciclovir
valacyclovir
Sporanox itraconazole
Targadox doxycycline
Valcyte valganciclovir
Vancocin vancomycin
Zovirax acyclovir (oral)
INFERTILITY Gonal-F Follistim AQ (PA)
^^
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.
21GENERIC AND/OR PREFERRED
DRUG CLASS MEDICATION(S) NOT COVERED^^
BRAND ALTERNATIVE(S)
MULTIPLE SCLEROSIS Copaxone Aubagio, Avonex, Betaseron, Extavia,
Gilenya, glatiramer, Glatopa, Plegridy, Rebif,
Tecfidera
PAIN RELIEF AND INFLAMMATORY DISEASE Amrix cyclobenzaprine
Other generic muscle relaxants
Belbuca buprenorphine
Bupap butalbital-acetaminophen tablet
Tencon
Cambia Generic prescription NSAIDs (e.g.,
diclofenac 1.5% solution celecoxib,
Duexis meloxicam)
Naprelan
naproxen CR
naproxen ER
Pennsaid
Tivorbex
Vimovo
Vivlodex
Zipsor
Zorvolex
Conzip tramadol
tramadol ER
D.H.E. 45 dihydroergotamine
Duzallo allopurinol, probenecid
Gralise gabapentin
Imitrex sumatriptan
Zembrace SymTouch
Kineret Actemra (PA)
Enbrel (PA)
Humira (PA)
Remicade (PA)
Simponi Actemra (PA)
Simponi Aria Enbrel (PA)
Entyvio (PA)
Humira (PA)
Remicade (PA)
Stelara (PA)
Siliq Enbrel (PA)
Humira (PA)
Remicade (PA)
Stelara (PA)
levorphanol Generic products (e.g., acetaminophen-
codeine, hydromorphone, oxycodone)
Lorzone chlorzoxazone
Migranal dihydroergotamine
^^
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.
22GENERIC AND/OR PREFERRED
DRUG CLASS MEDICATION(S) NOT COVERED^^
BRAND ALTERNATIVE(S)
PAIN RELIEF AND INFLAMMATORY DISEASE OxyContin Xtampza ER (PA)
(cont) Embeda ER (PA)
Hysingla ER (PA)
Roxicodone oxycodone
Soriatane acitretin
Sprix ketorolac
Treximet Generic NSAIDs
Generic triptans (e.g., sumatriptan,
naratriptan)
Vanatol LQ butalbital-acetaminophen-caffeine
Zomig zolmitriptan
sumatriptan
Zomig ZMT zolmitriptan ODT
PARKINSON’S DISEASE Gocovri amantadine
Lodosyn carbidopa
Requip XL ropinirole ER
SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify aripiprazole
Fazaclo clozapine
Versacloz clozapine ODT
Geodon ziprasidone
Zyprexa olanzapine
Zyprexa Zydis olanzapine ODT
SEIZURE DISORDERS Lyrica CR duloxetine
gabapentin
lidocaine 5% patch
Lyrica
Mysoline primidone
SKIN CONDITIONS Absorica Claravis
Myorisan
Zenatane
Acanya Generic products (e.g. adapalene, tretinoin,
Atralin clindamycin-benzoyl peroxide)
Avita
Azelex
Differin
Epiduo
Epiduo Forte
Fabior
Onexton
Retin-A
Tazorac
Tretin-X
Veltin
Ziana
Aldara imiquimod cream
^^
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.
23GENERIC AND/OR PREFERRED
DRUG CLASS MEDICATION(S) NOT COVERED^^
BRAND ALTERNATIVE(S)
SKIN CONDITIONS (cont) Anusol-HC cream hydrocortisone
Procto-Med HC
Proctosol-HC
Proctozone-HC
Bensal HP salicylic acid
Benzaclin clindamycin-benzoyl peroxide
Duac Neuac gel
Neuac Kit
Carac fluorouracil
Clindagel clindamycin
Clobex clobetasol
Cutivate Generic topical steroid (e.g.
betamethasone)
diclofenac 3% gel Fluoroplex
fluorouracil
imiquimod
Picato (NPB)
Dovonex calcipotriene
Sorilux
Enstilar calcipotriene-betamethasone DP
Taclonex
Ertaczo ketoconazole
Extina
Vusion
Luzu luliconazole
econazole
ketoconazole cream
oxiconazole
Halog clobetasol
Ultravate X halobetasol
Jublia Ciclodan
Kerydin ciclopirox
itraconazole
terbinafine
Kenalog triamcinolone
Locoid hydrocortisone
Locoid Lipocream
Loprox cream, kit ciclopirox
Noritate metronidazole
Rosadan
Oxistat clotrimazole
econazole
ketoconazole
Penlac Ciclodan
ciclopirox
Prudoxin Generic topical steroid (e.g.,
Zonalon betamethasone)
tacrolimus (topical)
^^
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.
24GENERIC AND/OR PREFERRED
DRUG CLASS MEDICATION(S) NOT COVERED^^
BRAND ALTERNATIVE(S)
SKIN CONDITIONS (cont) Sernivo betamethasone
fluocinonide
hydrocortisone
Siliq Enbrel (PA)
Humira (PA)
Soriatane acitretin
Trianex triamcinolone
Triderm
Ultravate lotion clobetasol
Vanos fluocinonide
Vectical calcitriol ointment
Verdeso desonide
Xerese acyclovir (oral) + hydrocortisone
famciclovir + hydrocortisone
valacyclovir + hydrocortisone
Zyclara imiquimod
SLEEP DISORDERS/SEDATIVES Ambien zolpidem
Ambien CR zolpidem ER
Edluar
Intermezzo
Nuvigil armodafinil
Provigil modafinil
Restoril temazepam
SUBSTANCE ABUSE Evzio Narcan
URINARY TRACT CONDITIONS Detrol darifenacin ER
Detrol LA oxybutynin ER
Ditropan XL tolterodine ER
Enablex trospium ER
Gelnique
Myrbetriq
Oxytrol
Toviaz
VESIcare
^^
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.
25Prescription drug list FAQs
Understanding your prescription medication Your plan may also exclude certain medications
coverage can be confusing. Below are answers to or products from coverage. This is known as a
some commonly asked questions. “plan (or benefit) exclusion.” For example, your
plan excludes:
Why do you make changes to the drug list?
› Medications that are available over-the-
Cigna regularly reviews and updates the counter, without a prescription. These
prescription drug list. We make changes for include medications commonly used to treat
many reasons – like when new medications heartburn and stomach acid conditions
become available or are no longer available, or (ex. Nexium, Prilosec and any generics) and
when medication prices change. We try to give allergies (ex. Allegra, Clarinex, Xyzal and
you many options to choose from to treat your any generics).
health condition. These changes may include:1
› Medications used to treat lifestyle conditions
› Moving a medication to a lower cost tier. (like infertility, weight loss, erectile
This can happen at any time during the year. dysfunction, smoking cessation2).
› Moving a brand medication to a higher cost › Medications that aren’t approved by the U.S.
tier when a generic becomes available. This Food and Drug Administration (FDA).
can happen at any time during the year.
How do you decide which medications
› Moving a medication to a higher cost tier are covered?
and/or no longer covering a medication. This
typically happens twice a year on January 1st The Cigna Prescription Drug List is developed
and July 1st. with the help of Cigna’s Pharmacy and
Therapeutics (P&T) Committee, which is a group
› Adding requirements to a medication. For of practicing doctors and pharmacists, most of
example, requiring approval from Cigna whom work outside of Cigna. The group meets
before a medication may be covered or regularly to review medical evidence and
adding a quantity limit to a medication. information provided by federal agencies,
When a medication changes tiers or is no longer drug manufacturers, medical professional
covered, you may pay a different amount to fill associations, national organizations and peer-
that medication. It’s important to know that when reviewed journals medications about the safety
we make a change that affects the coverage of and effectiveness of medications that are newly
a medication you’re taking, we let you know approved by the FDA and medications already
before it begins so you have time to talk with on the market. The Cigna Pharmacy
your doctor. Management® Business Decision Team then
looks at the results of the P&T Committee’s
Why doesn’t my plan cover certain clinical review, as well as the medication’s overall
medications? value and other factors before adding it to, or
To help lower your overall health care costs, your removing it from, the drug list.
plan doesn’t cover certain high-cost brand Which medications are covered under the
medications because they have lower-cost, health care reform law?
covered alternatives which are used to treat the
The Patient Protection and Affordable Care Act
same condition. Meaning, the alternative works
(PPACA), commonly referred to as “health care
the same or similar to the non-covered
reform,” was signed into law on March 23, 2010.
medication. If you’re taking a medication that
Under this law, certain preventive medications
your plan doesn’t cover and your doctor feels an
(including some over-the-counter medicines)
alternative isn’t right for you, he or she can ask
may be available to you at no cost-share ($0),
Cigna to consider approving coverage of your
depending on your plan. Please log in to the
medication.
myCigna website or app, or check your plan
26Prescription drug list FAQs (cont)
materials, to learn more about how your plan › Have the same active ingredient, strength and
covers preventive medications. You can also dosage form as the brand name medication
view the PPACA No Cost-Share Preventive
Medications drug list on Cigna.com/druglist. › Deliver the same amount of active ingredients
into the bloodstream in the same amount of
For more information about health care reform, time as the brand name medication
visit www.informedonreform.com or Cigna.com.
› Be used in the same way as the brand
Are medications newly approved by the name medication
FDA covered on my drug list? Generics typically cost much less than brand
name medications – in some cases, up to 85%
Newly approved medications may not be
less.4 Just because generics cost less than brands,
covered on your drug list for the first six
it doesn’t mean they’re lower-quality medications.
months after they receive FDA approval. These
include, but are not limited to, medications, How can I get help with my specialty
medical supplies or devices covered under medication?
standard pharmacy benefit plans. We review
Cigna Specialty Pharmacy can help you manage
all newly approved medications to determine
your health and prescription needs.5 Their
if they should be covered – and if so, at what
team of medical condition experts provide
tier level. If your doctor feels a currently
personalized, 24/7 support. They’ll help you
covered medication isn’t right for you, he or she
get approval for coverage of your medication,
can ask Cigna to consider approving coverage
answer any questions you have about your
of the newly approved medication.
medication and its cost, help you work through
How can I find out how much I’ll pay for a any side effects and make sure you have any
specific medication? supplies you need (at no extra cost). They’ll
also help you set up home delivery of your
You can use the Drug Cost tool on the myCigna
medication and give you information about
website or app to estimate how much your
financial assistance programs (if you need help
medication may cost3 and view lower cost
paying for your medication). To learn more
alternatives, if available.
about the services they provide, please call
How can I save money on my prescription 800.351.3606 or go to Cigna.com/specialty-
medications? pharmacyservices.
You may be able to save money by switching to Can I fill my prescriptions by mail?
a medication that’s on a lower tier (ex. generic Yes, as long as your plan offers home delivery.5
or preferred brand) or by filling a 90-day supply,
if your plan allows. You should talk with your
› If you’re taking a medication every day to
treat an ongoing health condition like
doctor to find out if one of these options, may
diabetes, high blood pressure, high
work for you.
cholesterol or asthma, you can order up to a
What’s the difference between brand name and 90-day supply through Cigna Home Delivery
generic medications? Pharmacy.SM To learn more, call 800.835.3784
or go to Cigna.com/home-delivery-pharmacy.
The FDA requires generic medications to provide
the same clinical benefit as its brand name › If you’re taking a specialty medication to treat
versions.4 The FDA also requires generic makers a complex condition like multiple sclerosis,
to prove that the generic works in the same way hepatitis C and rheumatoid arthritis, you can
as the brand name medication. This means that fill your prescription through Cigna Specialty
generic equivalent medications must:4 Pharmacy (our home delivery pharmacy).
To learn more, call 800.351.3606 or go to
Cigna.com/specialty-pharmacy-services.
27Prescription drug list FAQs (cont)
Where can I find more information about my
prescription medication plan?
You can use the online tools and resources on
the myCigna website or app to help you better
understand and manage your pharmacy
benefits. You can view your drug list or search
for a specific medication, use the Drug Cost
tool to estimate how much your medications
may cost, find an in-network pharmacy near
you, review your pharmacy claims and payment
history, and track Cigna Home Delivery
Pharmacy5 orders and request refills.
28Exclusions and limitations
Health benefit plans vary, but in general to be eligible for coverage a drug must be approved by
the Food and Drug Administration (FDA), prescribed by a health care professional, purchased
from a licensed pharmacy and be medically necessary. If your plan provides coverage for certain
preventive prescription drugs with no cost-share, you may be required to use an in-network
pharmacy to fill the prescription. If you use a pharmacy that does not participate in your plan’s
network, the prescription may not be covered. Certain drugs may require prior authorization, or be
subject to step therapy, quantity limits or other utilization management requirements.
Plans generally do not provide coverage for the following under the pharmacy benefit, except as
required by state or federal law, or by the terms of your specific plan:6
› over-the-counter (OTC) medicines (those that › replacement of prescription medications and
do not require a prescription) except insulin related supplies due to loss or theft;
unless state or federal law requires coverage › medications which are to be taken by or
of such medicines; administered to a covered person while they
› prescription medications or supplies for which are a patient in a licensed hospital, skilled
there is a prescription or OTC therapeutic nursing facility, rest home or similar institution
equivalent or therapeutic alternative; which operates on its premises or allows to
› doctor-administered injectable medications be operated on its premises a facility for
covered under the Plan’s medical benefit, dispensing pharmaceuticals;
unless otherwise covered under the Plan’s › prescriptions more than one year from the
prescription drug list or approved by Cigna; date of issue; or
› implantable contraceptive devices covered › coverage for prescription medication
under the Plan’s medical benefit; products for the amount dispensed (days’
› medications that are not medically necessary; supply) which is more than the applicable
supply limit, or is less than any applicable
› experimental or investigational medications,
supply minimum set forth in The Schedule, or
including FDA-approved medications used for
which is more than the quantity limit(s) or
purposes other than those approved by the
dosage limit(s) set by the P&T Committee.
FDA unless the medication is recognized for
the treatment of the particular indication; › more than one prescription order or refill for a
given prescription supply period for the same
› medications that are not approved by the
prescription medication product prescribed
Food & Drug Administration (FDA);
by one or more doctors and dispensed by
› prescription and non-prescription devices,
one or more pharmacies.
supplies, and appliances other than those
supplies specifically listed as covered; › prescription medication products dispensed
outside the jurisdiction of the United States,
› medications used for fertility, sexual
except as required for emergency or urgent
dysfunction, cosmetic purposes, weight loss,
care treatment.
smoking cessation, or athletic enhancement;
In addition to the plan’s standard pharmacy
› prescription vitamins (other than prenatal
exclusions, certain new FDA-approved
vitamins) or dietary supplements unless state or
medication products (including, but not limited
federal law requires coverage of such products;
to, medications, medical supplies or devices that
› immunization agents, biological products are covered under standard pharmacy benefit
for allergy immunization, biological sera, plans) may not be covered for the first six
blood, blood plasma and other blood months of market availability unless approved
products or fractions and medications by Cigna as medically necessary.
used for travel prophylaxis;
29You can also read
