CIGNA ADVANTAGE 3-TIER PRESCRIPTION DRUG LIST - As of January 1, 2020 - Cigna Client ...
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CIGNA ADVANTAGE 3-TIER PRESCRIPTION DRUG LIST As of January 1, 2020 Offered by Cigna Health and Life Insurance Company or Connecticut General Life Insurance Company 887152 t Advantage 3-Tier 10/19
Table of Contents
Getting started
About your prescription drug list 3
How to read your drug list 3
How to find your medication 5
Medications that are not covered 18
Prescription drug list FAQs 30
Exclusions and limitations 33
View your drug list online
This document was last updated 09/01/2019.* Here’s where you can find a current list of the
medications your plan covers:
The myCigna® app or website – Once you’re registered, log in and click on
Prescriptions. Then, click on Price a Medication.
Cigna.com/druglist – Select your drug list name – Advantage 3 Tier – from the
drop down menu.
Questions?
Call the toll-free number on 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: 09/01/2019, for changes Next planned update: 03/01/2020, for
starting 01/01/2020 changes starting 07/01/2020
2About your prescription drug list
This document shows the most commonly prescribed medications covered on the Advantage 3-Tier
Prescription Drug List as of January 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 Advantage 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. You
should log in to the myCigna app or website, or check your plan materials, to learn more about the
medications your plan covers.
The Advantage 3-Tier Prescription Drug List also excludes from coverage prescription medications
that are used to treat allergies (ex. Allegra, Clarinex, Xyzal and generics) and heartburn/stomach acid
conditions (ex. Nexium, Prilosec and generics). These medications have over-the-counter (OTC)
alternatives, which are available 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 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
$ $$
BLOOD PRESSURE/HEART MEDICATIONS Medications are grouped by
afeditab CR Berinert* (PA) the condition they treat
amlodipine besylate Bidil
amlodipine besylate-benazepril Bystolic
amlodipine-valsartan Cinryze* (PA)
amlodipine-valsartan-HCTZ Coreg CR
atenolol Cozaar (ST)
atenolol-chlorthalidone Diovan (ST)
benazepril Diovan HCT (ST) Medications are listed in
benazepril-HCTZ Edarbi (ST) alphabetical order within
each column
candesartan cilexetil Edarbyclor (ST)
cartia XT Exforge
carvedilol Exforge HCT
clonidine Firazyr* (PA) Specialty medications have an
digitek Hemangeol asterisk (*) listed next to them
digox Inderal LA
digoxin Inderal XL
diltiazem ER Innopran XL
diltiazem CD Lotrel Brand name medications
diltiazem Micardis (ST) are capitalized
dilt-XR Multaq
enalapril Nitro-dur
flecainide acetate Nitrolingual Generic medications
hydralazine Nitromist are lowercase
irbesartan Nitronal
isosorbide mononitrat Nitrostat
Northera* (PA) Medications that have extra
coverage requirements will
Norvasc have an abbreviation listed
Ranexa (ST) next to them
Tekturna
Tekturna HCT
This chart is just a sample. It may not show how these medications are actually covered on the Advantage 3-Tier Prescription Drug List.
3Tiers
Covered medications are divided into tiers, or cost-share levels. Typically, the higher the tier, the
higher the price you’ll pay to fill the prescription.
› Tier 1 – Typically Generics (Lower-cost medication) $
› Tier 2 – Typically Preferred Brands (Medium-cost medication) $$
› 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 – For certain medications, you must be within a specific age range
A
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 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. Log in to the myCigna
app or website, or check your plan materials, to learn more about how your plan covers specialty
medications.
4No cost-share preventive medications are marked with a plus sign
Health care reform under the Patient Protection and Affordable Care Act (PPACA) requires that
most plans cover certain categories of medications and other products as preventive care services.
In this drug list, medications with a plus sign (+) next to them may be available to you at no cost-
share (copay, coinsurance and/or deductible). Log in to the myCigna app or website, or check your
plan materials, to learn more about how your plan covers preventive medications.
Plan exclusions
Your plan excludes certain types of medications or products from coverage. This is known as a “plan
(or benefit) exclusion.” This means that your plan doesn’t cover any prescription medications in the
drug class or to treat the specific condition. There’s also no option to receive coverage through a
medication review process. In this drug list, these medications have a caret (^) next to them. Log in
to the myCigna app or website, or check your plan materials, to find out if your plan excludes your
medication from coverage.
How to find your medication 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
BLOOD PRESSURE/HEART MEDICATIONS 3 FEMININE PRODUCTS 11
AIDS/HIV 6 GASTROINTESTINAL/HEARTBURN 12
ALLERGY/NASAL SPRAYS 6 HORMONAL AGENTS 12
ALZHEIMER’S DISEASE 6 INFECTIONS 13
ANXIETY/DEPRESSION/BIPOLAR 6 INFERTILITY 13
DISORDER
MISCELLANEOUS 13
ASTHMA/COPD/RESPIRATORY 6
MULTIPLE SCLEROSIS 13
ATTENTION DEFICIT HYPERACTIVITY 7
NUTRITIONAL/DIETARY 14
DISORDER
OSTEOPOROSIS PRODUCTS 14
BLOOD MODIFIERS/BLEEDING DISORDERS 7
PAIN RELIEF AND INFLAMMATORY DISEASE 14, 15
BLOOD PRESSURE/HEART MEDICATIONS 7, 8
BLOOD THINNERS/ANTI-CLOTTING 8 PARKINSON’S DISEASE 15
CANCER 8 SCHIZOPHRENIA/ANTI-PSYCHOTICS 15
CHOLESTEROL MEDICATIONS 8 SEIZURE DISORDERS 15
CONTRACEPTION PRODUCTS 9, 10 SKIN CONDITIONS 15, 16
COUGH/COLD MEDICATIONS 10 SLEEP DISORDERS/SEDATIVES 16
DENTAL PRODUCTS 10 SMOKING CESSATION 16
DIABETES 11 SUBSTANCE ABUSE 16
DIURETICS 11 TRANSPLANT MEDICATIONS 16
EAR MEDICATIONS 11 URINARY TRACT CONDITIONS 16
EYE CONDITIONS 11 VACCINES 17
5Cigna Advantage 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
AIDS/HIV ANXIETY/DEPRESSION/
abacavir- Atripla* (PA) Cimduo* (PA) BIPOLAR DISORDER (cont)
lamivudine* (PA) Biktarvy* Complera* (PA) buspirone Trintellix (ST, QL)
atazanavir* (PA) Descovy* (PA) Evotaz* (PA) citalopram (QL) Viibryd (ST, QL)
ritonavir* Genvoya* Juluca* (PA) clomipramine Wellbutrin SR (ST,
tenofovir* (PA) Intelence* (PA) Odefsey* (PA) desvenlafaxine ER QL)
Isentress* Prezcobix* (PA) (QL) Xanax
Isentress HD* (PA) Stribild* (PA) duloxetine (QL) Xanax XR
Prezista* Symtuza* (PA) escitalopram (QL) Zoloft (ST, QL)
Selzentry* (PA) fluoxetine (QL)
Symfi* fluoxetine DR (QL)
Symfi Lo* fluvoxamine (QL)
Tivicay* fluvoxamine ER
Triumeq* (QL)
Truvada* lorazepam
Viread 150 mg, lorazepam intensol
200mg, 250mg mirtazapine
tablet, powder* paroxetine (QL)
(PA) paroxetine CR (QL)
ALLERGY/NASAL SPRAYS paroxetine ER (QL)
sertraline (QL)
Adyphren Astepro trazodone
Adyphren Amp Clarinex-D 12 Hour venlafaxine (QL)
azelastine EpinephrineSnap-V venlafaxine ER (QL)
cromolyn EPIsnap
cyproheptadine Gastrocrom ASTHMA/COPD/RESPIRATORY
epinephrine (QL) Grastek (PA, QL) albuterol Advair HFA Adcirca* (PA)
fluticasone Karbinal ER albuterol HFA Anoro Ellipta Adempas* (PA)
hydroxyzine Odactra (PA, QL) Alyq* (PA) Atrovent HFA Brovana
ipratropium Patanase budesonide Breo Ellipta Combivent
mometasone (QL) Ragwitek (PA, QL) fluticasone- Dulera Respimat
olopatadine Vistaril salmeterol Flovent Daliresp (QL)
Phenergan montelukast Flovent HFA Kalydeco* (PA, QL)
promethazine tadalafil 20mg* (PA) Incruse Ellipta Lonhala Magnair
ALZHEIMER’S DISEASE Wixela Inhub Letairis* (PA) (PA)
OFEV* (PA) Nucala* (PA)
donepezil Aricept Opsumit* (PA) Orenitram ER* (PA)
donepezil ODT Exelon ProAir HFA Orkambi* (PA, QL)
memantine Mestinon ProAir RespiClick Perforomist (QL)
memantine ER (QL) Namenda tablet QVAR RediHaler Pulmicort respule
pyridostigmine Namenda XR (QL) Serevent Pulmozyme* (PA)
pyridostigmine ER Namzaric (QL) Symbicort Revatio oral
rivastigmine Regonol Tracleer 32 suspension,
ANXIETY/DEPRESSION/BIPOLAR DISORDER mg tablet for tablet* (PA)
alprazolam Celexa (ST, QL) suspension* (PA) Singulair
alprazolam ER Effexor XR (ST, QL) Trelegy Ellipta Symdeko* (PA, QL)
alprazolam intensol Fetzima (ST, QL) Xolair* (PA) Tracleer tablet* (PA)
alprazolam ODT Forfivo XL (ST, QL) Tyvaso* (PA)
alprazolam XR Paxil (ST, QL) UPTRAVI* (PA)
amitriptyline Paxil CR (ST, QL)
bupropion (QL) Prozac (ST, QL)
bupropion SR (QL) Remeron
bupropion XL (QL) Sarafem (ST)
6Cigna Advantage 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
ATTENTION DEFICIT HYPERACTIVITY DISORDER BLOOD PRESSURE/HEART MEDICATIONS (cont)
atomoxetine (QL) Adderall Aspir EC+ Epaned
clonidine ER Adhansia XR aspirin EC+ Firazyr* (PA)
dexmethylphenidate Daytrana (PA age, aspirin 325 mg Haegarda* (PA)
(PA age) QL) tablet+ Hemangeol
dexmethylphenidate Evekeo ODT Aspir-Low+ Inderal LA (ST)
ER (PA age, QL) Focalin (PA age, ST) atenolol Inderal XL (ST)
dextroamphetamine- Intuniv Bayer Aspirin InnoPran XL (ST)
amphetamine ER Kapvay 325mg tablet+ Kapspargo Sprinkle
(PA age, QL) Methylin (PA age, benazepril (ST)
dextroamphetamine- ST) benazepril-HCTZ Lopressor (ST)
amphetamine Quillivant XR (PA candesartan Minipress
(PA age) age, QL) candesartan-HCTZ Multaq
guanfacine ER Ritalin tablet cartia XT Nitrostat
metadate ER Strattera (QL) carvedilol Northera* (PA)
(PA age, QL) carvedilol ER (QL) Norvasc
methylphenidate Children’s Aspirin+ Pacerone 100mg,
(PA age) clonidine 400mg (PA)
methylphenidate diltiazem Procardia
CD (PA age, QL) diltiazem 12hr ER Procardia XL
methylphenidate diltiazem 24hr ER Ranexa (QL)
ER (CD) diltiazem 24hr ER Rythmol SR (PA)
(PA age, QL) (CD) Takhzyro* (PA)
methylphenidate diltiazem 24hr ER Tenormin (ST)
ER (LA) (LA) Tiazac
(PA age, QL) diltiazem 24hr ER Tikosyn (PA, QL)
methylphenidate (XR) Toprol XL (ST)
ER (PA age, QL) Dilt-XR Verelan
methylphenidate dofetilide (QL) Verelan PM
LA (PA age, QL) doxazosin
Relexxii (PA age, QL) Ecotrin+
BLOOD MODIFIERS/BLEEDING DISORDERS ecpirin+
aminocaproic acid* Aranesp* (PA) Amicar tablet, oral enalapril
tranexamic acid* Droxia solution* flecainide
Epogen* (PA) Cyklokapron* hydralazine
Fulphila* (PA) Hemlibra* (PA) irbesartan
Granix* Lysteda* irbesartan-HCTZ
Neulasta* (PA) Neupogen* (PA) isosorbide
Procrit* (PA) Nivestym* (PA) mononitrate
Retacrit* (PA) Promacta* (PA) isosorbide
Udenyca* (PA) Siklos (PA) mononitrate ER
Zarxio* Tavalisse* (PA) labetalol
lisinopril
BLOOD PRESSURE/HEART MEDICATIONS lisinopril-HCTZ
amiodarone Corlanor (PA) Adalat CC losartan
amlodipine Entresto BiDil (QL) losartan-HCTZ
amlodipine- Calan Low Dose Aspirin
benazepril Calan SR EC+
amlodipine- Cardizem LA (QL) Matzim LA
olmesartan (QL) Cardura metoprolol
amlodipine- Catapres-TTS 1 nadolol
valsartan Catapres-TTS 2 nifedipine
amlodipine- Catapres-TTS 3 nifedipine ER
valsartan-HCTZ Coreg (ST) olmesartan (QL)
Adult Aspirin Coreg CR (ST, QL) olmesartan-
Regimen+ Corgard (ST) amlodipine-HCTZ
7Cigna Advantage 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
BLOOD PRESSURE/HEART MEDICATIONS (cont) CANCER (cont)
olmesartan-HCTZ Lynparza* (PA)
(QL) Mekinist* (PA)
Pacerone 200 mg Nerlynx* (PA)
tablet Ninlaro* (PA)
prazosin Odomzo* (PA)
propafenone Pomalyst* (PA)
propafenone ER Purixan*
propranolol Rubraca* (PA)
propranolol ER
Stivarga* (PA)
ramipril
St. Joseph Aspirin+ Tafinlar* (PA)
ranolazine ER (QL) Tagrisso* (PA)
Taztia XT Targretin capsule*
telmisartan (QL) (PA)
telmisartan-HCTZ Temodar* (PA)
(QL) Trelstar*
valsartan Venclexta* (PA)
valsartan-HCTZ Votrient* (PA)
verapamil Xalkori* (PA)
verapamil ER Xeloda* (PA)
verapamil ER PM Xtandi* (PA)
verapamil SR 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) Lipofen (ST)
clopidogrel Lovenox* (QL) Bevyxxa (QL) atorvastatin+ Lovaza
enoxaparin* (QL) Xarelto Coumadin (PA) colesevelam Niaspan
fondaparinux* (QL) ezetimibe TriCor (ST)
Jantoven Effient
Fragmin* (QL) ezetimibe- Triglide (ST)
prasugrel simvastatin Trilipix (ST)
warfarin Plavix
fenofibrate Welchol
Pradaxa fenofibric acid Zetia
Savaysa (QL) fluvastatin ER+
Zontivity fluvastatin+
CANCER lovastatin 10mg
abiraterone* (PA) Actimmune* (PA) Afinitor Disperz* lovastatin+ 20mg,
anastrozole Erivedge* (PA) 40mg
(PA)
capecitabine* (PA) Gleostine niacin
Afinitor* (PA) niacin ER
exemestane Ibrance* (PA) Alecensa* (PA)
imatinib* (PA) Nexavar* (PA) niacor
Bosulif* (PA) omega-3 acid ethyl
letrozole Revlimid* (PA) Cabometyx* (PA)
mercaptopurine Sprycel* (PA) esters
Cometriq* (PA) pravastatin+
methotrexate Sutent* (PA)
tamoxifen+ Tasigna* (PA) Erleada* (PA) rosuvastatin
temozolomide* Trexall Gleevec* (PA) calcium (QL)
(PA) Tykerb* (PA) Imbruvica* (PA) rosuvastatin
Verzenio* (PA) Inlyta* (PA) calcium+ 5mg,
Jakafi* (PA) 10mg (QL)
Kisqali* (PA) simvastatin 80mg
(QL)
Lenvima* (PA)
simvastatin 10mg,
Lonsurf* (PA) 20mg, 40mg+
Lupron Depot* (PA)
8Cigna Advantage 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
CONTRACEPTION PRODUCTS CONTRACEPTION PRODUCTS (cont)
Afirmelle
+
Lo Loestrin FE Annovera+
Emoquette+
Aftera+ NuvaRing+ Balcoltra Enpresse+
Altavera + Taytulla Caya contoured+ Enskyce+
Alyacen+ Ella+ Errin+
Amethia+ Estrostep FE Estarylla+
Amethia Lo+ Femcap+ ethynodiol-ethinyl
Amethyst+ Kyleena* estradiol+
Apri+ Layolis FE
Falmina+
Loestrin FE
Aranelle+ Fayosim+
Minastrin 24 FE
Ashlyna+ Femynor+
Mirena*
Aubra+ Natazia Gianvi+
Aubra EQ+ Safyral Gynol II+
Aurovela+ Skyla* Hailey 24 FE+
Aurovela FE+ Today Heather+
Aurovela 24 FE+ Contraceptive Incassia+
Aviane+ Sponge+ Introvale+
Ayuna+ Wide seal Isibloom+
Azurette+ diaphragm+ Jasmiel+
Balziva+ Yasmin 28 Jencycla+
Bekyree+ Yaz Jolessa+
Blisovi FE+ Juleber+
Blisovi 24 FE+ Junel+
Briellyn+ Junel FE+
Camila+ Junel FE 24+
Camrese+ Kaitlib FE+
Camrese LO+ Kalliga+
Caziant+ Kariva+
Chateal+ Kelnor 1-35+
Chateal EQ+ Kelnor 1-50+
Cryselle+ Kurvelo+
Cyclafem+ Larin+
Cyred+ Larin FE+
Cyred EQ+ Larin 24 FE+
Dasetta+ Larissia+
Daysee+ Leena 28 tablet+
Deblitane+ Lessina+
Delyla+ Levonest+
desogestrel-ethinyl levonorgestrel+
estradiol+ levonorgestrel-
desogestrel-ethinyl ethinyl estradiol+
estradiol ethinyl levonorgestrel-
estradiol ethinyl estradiol
dospirenone- ethinyl estradiol+
ethinyl estradiol- Levora-28+
levomefolate+ Lillow+
drospirenone- Loryna+
ethinyl estradiol+ Low-Ogestrel+
Econtra EZ+ Lo-Zumandimine+
Econtra One-Step+ Lutera+
Elinest+ Lyza+
9Cigna Advantage 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
CONTRACEPTION PRODUCTS (cont) CONTRACEPTION PRODUCTS (cont)
Marlissa
+
Tri-Lo-Marzia+
medroxyprogesterone Tri-Lo-Mili+
150mg/ml+ Tri-Lo-Sprintec+
Melodetta 24 FE+ Tri-Mili+
Mibelas 24 FE+ Tri-Previfem+
Microgestin+ Tri-Sprintec+
Microgestin FE+ Trivora-28+
Mili+ Tri-Vylibra+
Mono-Linyah+ Tri-Vylibra Lo+
My Choice+ Tulana+
My Way+ Tydemy+
Necon+ VCF+ foam, gel
Nikki+ Velivet+
Nora-BE+ Vienva+
norethindrone+ Viorele+
norethindrone- Vyfemla+
ethinyl estradiol+ Vylibra+
norethindrone- Wera+
ethinyl estradiol- Wymzya FE+
iron+ Xulane+
norgestimate- Zarah+
ethinyl estradiol+ Zovia+
Norlyda+ Zumandimine+
Norlyroc+
COUGH/COLD MEDICATIONS
Nortrel+
Ocella+ Bromfed DM Tessalon Perle
Option 2+ brompheniramine- Tuzistra XR (PA, QL)
Orsythia+ pseudoephedrine-
Philith+ DM
Pimtrea+ hydrocodone-
chlorpheniramine
Pirmella+
ER (PA)
Portia+
Previfem+ DENTAL PRODUCTS
Reclipsen+ chlorhexidine Clinpro 5000
Rivelsa tablet+ Denta 5000 Plus Floriva+
Setlakin+ dentagel Fluorabon+
Sharobel+ doxycycline Fluoridex Sensitivity
Simliya+ fluoride+ Relief
Simpesse+ Fluoridex Daily PreviDent
Sprintec+ Defense PreviDent 5000,
Sronyx+ Fluoritab+ PreviDent 5000
Syeda+ Flura-Drops+ Plus
Tarina 24 FE+ Ludent Fluoride+
Tarina FE 1-20 EQ+ Oralone
Tilia FE 28+ Paroex
Peridex
Tri Femynor+
Periogard
Tri-Estarylla+
SF 5000 Plus
Tri-Legest FE+ sodium fluoride+^
Tri-Linyah+ 0.25mg, 0.5mg, 1mg
Tri-Lo-Estarylla+ triamcinolone
10Cigna Advantage 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
DIABETES EYE CONDITIONS
glimepiride Basaglar (QL) Amaryl azelastine Combigan Acuvail
glipizide Bydureon (ST, QL) Cycloset brimonidine Restasis Alphagan P 0.15%
glipizide ER Byetta (ST, QL) Glucophage ciprofloxacin Simbrinza Alrex
glipizide XL Farxiga (ST, QL) Glucophage XR dorzolamide Travatan Z Azasite
metformin Freestyle Libre Korlym* (PA) dorzolamide- Xiidra Azopt
metformin ER Sensor (PA, QL) NovoTwist timolol Besivance
pioglitazone GlucaGen HypoKit Riomet erythromycin Betimol
(QL) fluorometholone Betoptic S
Glucagon gatifloxacin Bromsite
Emergency Kit (QL) latanoprost Cequa
Glyxambi (ST, QL) moxifloxacin Cosopt
Humalog (QL) neomycin- Cosopt PF
Humulin (QL) polymyxin- Cystaran* (QL)
Insulin Lispro (QL) dexamethasone Durezol
Janumet (QL) ofloxacin Ilevro
Janumet XR (QL) olopatadine Inveltys
Januvia (ST, QL) polymyxin B-TMP Istalol
Jardiance (ST, QL) prednisolone Lotemax
Levemir (QL) solution Lotemax ointment
OneTouch test strips timolol solution Lotemax SM
Ozempic (ST, QL) tobramycin Maxitrol
Segluromet (QL) tobramycin- Moxeza
Soliqua dexamethasone Nevanac
Steglatro (ST, QL) Ocuflox
SymlinPen Oxervate* (PA)
Synjardy (QL) Polytrim
Synjardy XR (QL) Pred Forte
Tresiba (QL) Prolensa
Trulicity (ST, QL) Rhopressa
V-Go Timoptic
Victoza (ST, QL) Timoptic-XE
Xigduo XR (QL) Tobradex drops,
Xultophy ointment
DIURETICS Tobradex ST
Trusopt
acetazolamide Aldactone Vigamox
acetazolamide ER Diuril Xalatan
bumetanide Dyazide Zioptan (ST, QL)
chlorthalidone Dyrenium Zirgan
eplerenone Inspra Zylet
furosemide Jynarque* (PA) Zymaxid
hydrochlorothiazide Lasix
spironolactone Maxzide FEMININE PRODUCTS
triamterene-HCTZ Maxzide-25 mg Fem pH AVC
Samsca* Gynazole 4
EAR MEDICATIONS Miconazole
3 vaginal
neomycin- Cipro HC suppository
polymyxin-HC Ciprodex terconazole
ofloxacin drops Coly-Mycin S
Cortisporin-TC
Dermotic
Otovel
11Cigna Advantage 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
GASTROINTESTINAL/HEARTBURN HORMONAL AGENTS
Alophen +
Amitiza Akynzeo capsule Amabelz Armour Thyroid Activella
Anucort-HC Apriso (PA, QL) budesonide EC 30mg, 60mg, Alora (QL)
balsalazide Carafate suspension Bonjesta budesonide ER (PA, 90mg, 120mg, Androderm (PA, QL)
bisacodyl+ CLENPIQ+ Canasa QL) 180mg, 240mg, AndroGel (PA, QL)
Bisa-Lax+ Creon Carafate tablet cabergoline (QL) 300mg, tablet Angeliq
chlordiazepoxide- Entyvio*^ (PA) Cholbam* (PA) CovARYX Duavee Armour Thyroid
clidinium Linzess Correctol+ CovARYX H.S. Forteo* (PA, QL) Cetrotide*^ (PA)
cinacalcet* Pentasa Diclegis Decadron Humatrope* (PA) Climara
ClearLax+ Prepopik+ Donnatal desmopressin Norditropin Climara Pro
dicyclomine SUPREP+ Dulcolax+ solution, spray, FlexPro* (PA) CombiPatch
capsule, solution, Trulance Gattex* (PA) tablet Orilissa (PA, QL) Cytomel
tablet Zenpep Gialax+ desmopressin* Premarin Deltasone
diphenoxylate- Kristalose ampule, vial Premphase Depo-Testosterone
atropine Lithostat dexamethasone Prempro Divigel
dronabinol Lomotil dexamethasone Sandostatin LAR Elestrin
Ducodyl+ MiraLax+ intensol Depot* (PA) Emflaza* (PA)
famotidine Motegrity EEMT Serostim* (PA) Entocort EC
suspension Movantik (PA) EEMT H.S. Zorbtive* (PA) Estrace
GaviLyte-C+ Ocaliva* (PA) estradiol patch, Estring (QL)
GaviLyte-G+ Pancreaze vaginal insert (QL) EstroGel
GaviLyte-N+ Pertzye estradiol- Euthyrox
GentleLax+ Ravicti* (PA) norethindrone Evamist
GlycoLax+ Rectiv acetate Ganirelix*^ (PA)
HealthyLax+ Relistor (PA) estrogen- Imvexxy (QL)
Hemmorex-HC Sancuso (PA, QL) methyltestosterone Intrarosa
hydrocortisone Sensipar* levothyroxine Levo-T
LaxaClear+ sfRowasa Levoxyl Lupron Depot* (PA)
mesalamine Sucraid* (PA) liothyronine Lupron Depot-PED*
mesalamine DR Symproic (PA) Lopreeza (PA)
metoclopramide Transderm-Scop medroxyprogesterone Medrol
metoclopramide Urso methimazole Menostar (QL)
ODT Urso Forte methylprednisolone Minivelle (QL)
QC Natura-Lax+ Varubi (PA, QL) dosepak, tablet Natpara* (PA)
ondansetron Viberzi Mimvey Noctiva (PA)
ondansetron ODT Viokace Mimvey LO Osphena
PEG 3350 and Xermelo* (PA) Nature-Throid Prometrium
Electrolytes+ NP Thyroid Rayaldee
PEG-Prep+ prednisolone Somatuline Depot*
Phenadoz prednisolone ODT (PA)
polyethylene glycol prednisone Somavert* (PA)
3350+ prednisone intensol Striant (PA, QL)
PowderLax+ progesterone Synthroid
prochlorperazine capsule, vial Thyrogen*
suppository, TaperDex Tirosint
tablet, vial testosterone (PA, QL) Triostat
promethazine testosterone Unithroid
Promethegan cypionate Vagifem (QL)
ranitidine syrup thyroid Vivelle-Dot (QL)
sucralfate Westhroid
TriLyte With Flavor WP Thyroid
Packets+ Yuvafem (QL)
ursodiol
12Cigna Advantage 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
INFECTIONS INFECTIONS (cont)
acyclovir capsule, Baraclude* 0.05 Albenza Soloxide
suspension, tablet, mg/ml Alinia sulfamethoxazole-
vial Firvanq Arikayce* (PA) TMP
albendazole Kitabis Pak* (PA, QL) Bactrim terbinafine tablet
amoxicillin Ledipasvir- Bactrim DS tetracycline capsule
amoxicillin- Sofosbuvir* (PA) Baraclude* 0.5 mg tobramycin
clavulanate ER Mavyret* (PA) (QL) ampule* (PA, QL)
amoxicillin- Pegasys* (PA) Baxdela (PA) valacyclovir
clavulanate Sofosbuvir- Cayston* (PA, QL) valganciclovir
atovaquone Velpatasvir* (PA) Cipro vancomycin bag,
atovaquone- Sovaldi* (PA) Cleocin capsule, vial
proguanil Thalomid* (PA) Clindesse Vandazole
Avidoxy TOBI Podhaler* (PA, Cresemba capsule voriconazole tablet
QL) (PA) (PA)
azithromycin
Vosevi* (PA) Daraprim* (PA) INFERTILITY
cefdinir
Xifaxan 550mg (QL) Dificid (QL)
cefpodoxime Elimite chorionic Gonal-F*^ (PA) Crinone 8%^
cefuroxime EryPed 200 gonadotropin Endometrin^
cephalexin Eurax 10,000 unit vial*^ Follistim AQ*^ (PA)
ciprofloxacin Flagyl (PA) Menopur*^ (PA)
clarithromycin Keflex clomiphene Novarel*^ (PA)
clarithromycin ER Levaquin tablet^ Ovidrel*^ (PA)
clindamycin Macrobid
clindamycin Macrodantin
phosphate Malarone (PA) MISCELLANEOUS
Coremino (QL) MetroGel-Vaginal
dapsone Monurol disulfiram Cerdelga* (PA) Austedo* (PA)
Doxy 100 Natroba Nebusal 3% Esbriet* (PA) Brisdelle (QL)
doxycycline Noxafil suspension, PulmoSal Nityr* (PA) Exjade* (PA)
Emverm tablet, vial sodium chloride Strensiq* (PA) Ferriprox* (PA)
Nuvessa irrigation solution, TechLITE Lancets Galafold* (PA)
entecavir* (QL)
Nuzyra* (PA) inhalation vial Ingrezza* (PA)
erythromycin
Oravig tetrabenazine* (PA) Jadenu* (PA)
erythromycin ES
Plaquenil (PA) trientine* (PA) Kuvan* (PA)
famciclovir Myalept* (PA)
fluconazole Prevymis tablet*
Priftin Nuedexta (QL)
hydroxychloroquine Orfadin* (PA)
itraconazole Sivextro tablet (PA)
Sklice Palynziq* (PA)
levofloxacin eye Tiglutik* (PA)
drops, solution, Solosec
Sulfatrim Vivitrol*
tablet, vial Xenazine* (PA)
Suprax
metronidazole
Tamiflu (QL) MULTIPLE SCLEROSIS
minocycline
Urogesic-Blue glatiramer* (PA) Ampyra* (PA) Gilenya 0.25mg
minocycline ER (QL) Valtrex
Mondoxyne NL Glatopa* (PA) Avonex* (PA)
Vemlidy* Betaseron* (PA)
nitrofurantoin Vibramycin syrup,
Nitrofurantoin Extavia* (PA)
suspension Gilenya 0.5mg* (PA)
Mono-Macro Xofluza (QL)
nystatin Plegridy* (PA)
Zepatier* (PA) Rebif Rebidose*
Okebo Zithromax packet,
oseltamivir (QL) (PA)
suspension, tablet, Rebif* (PA)
penicillin V vial
permethrin Tecfidera* (PA)
Zyvox (PA)
13Cigna Advantage 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
NUTRITIONAL/DIETARY PAIN RELIEF AND INFLAMMATORY
B-12 Compliance OB Complete Petite Auryxia (QL) DISEASE (cont)
calcitriol CitraNatal DermacinRx Xeljanz XR* (PA, QL) Dupixent* (PA)
calcium 667mg Drisdol Empricaine Xeljanz* (PA, QL) Duragesic (PA)
cyanocobalamin Escavite+ DermacinRx Xtampza ER (PA) EC-naprosyn (ST)
injection Escavite D+ Prizopak Ztlido Esgic (QL)
daily prenatal+ Floriva+ diclofenac (QL) Fexmid
FA-8+ Klor-Con M15 diclofenac ER Flector (ST, QL)
folic acid 1mg KPN+ EC-naproxen Frova (QL)
tablet, vial K-Tab ER eletriptan (QL) Gablofen
folic acid 0.4mg, Lokelma endocet (PA) Ilaris* (PA)
0.8mg+ Mephyton etodolac Ilumya* (PA, QL)
Klor-Con MVC-fluoride+ etodolac ER Kadian (PA)
Klor-Con 10 OB Complete fentanyl (PA) Kevzara* (PA, QL)
Klor-Con 8 Perry Prenatal+ Fioricet (QL) Lidoderm
Klor-Con M10 Phoslyra frovatriptan (QL) Mitigare
Klor-Con M20 Prenate Mini Glydo Mobic (ST)
Klor-Con Sprinkle Prenate Pixie hydrocodone- Morphabond ER
lanthanum PrimaCare acetaminophen (PA)
phytonadione Quflora+ (PA) MS Contin (PA)
potassium chloride Renvela hydromorphone Nalfon 400 mg (ST)
Prena1 Pearl Rocaltrol (PA) Naprosyn (ST)
Prenatal+ Urosex+ hydromorphone ER Norco (PA)
Prenatal Vitamin+ Velphoro (PA) Nucynta (PA)
sevelamer Veltassa IBU Nucynta ER (PA)
vitamin D2 Vitafol+ ibuprofen tablet Olumiant* (PA, QL)
vitamin D3 5,000 vitaPearl indomethacin Orencia* (PA, QL)
unit+ indomethacin ER Otrexup (PA)
OSTEOPOROSIS PRODUCTS ketorolac (QL) Oxaydo (PA)
leflunomide Percocet (PA)
alendronate Tymlos* (PA, QL) Actonel (ST) lidocaine (QL) Procort
sodium (QL) Atelvia (ST) lidocaine viscous Proctofoam-HC
calcitonin-salmon Binosto (ST) lidocaine-prilocaine Qmiiz ODT (ST, QL)
ibandronate Boniva tablet (ST) Lidopril Relpax (QL)
raloxifene+ Boniva syringe* Lidopril XR Roxybond (PA)
risedronate Evista Lido-Prilo Caine Savella
risedronate DR Fosamax (ST) Pack Simponi 100mg/
Fosamax Plus D (ST) Livixil Pak ml* (PA, QL)
PAIN RELIEF AND INFLAMMATORY DISEASE Lorcet (PA) Skelaxin
acetaminophen- Actemra* (PA, QL) Abstral (PA) Lorcet HD (PA) Subsys (PA)
codeine (PA) Aimovig (PA) Analpram HC Lorcet Plus (PA) Taltz* (PA, QL)
Belbuca (QL) Arava Lortab (PA) Tylenol-Codeine
allopurinol
Cosentyx* (PA, QL) Arymo ER (PA) meloxicam No.3 (PA)
aprizio pak
Embeda (PA) Benlysta* (PA) Metaxall Tylenol-Codeine
baclofen metaxalone No.4 (PA)
buprenorphine (QL) Enbrel* (PA, QL) Buprenex
Humira* (PA, QL) Butrans (QL) methocarbamol Uloric (QL)
butalbital- morphine (PA) Ultram (QL)
acetaminophen- Hysingla ER (PA) Celebrex (ST, QL)
Otezla* (PA, QL) Cimzia* (PA, QL) morphine ER (PA) Voltaren (ST, QL)
caffeine (QL) nabumetone Zanaflex
carisoprodol Rasuvo (PA) Colcrys
Remicade* (PA) Depen* (PA) Nalfon 600mg (ST) Zebutal (QL)
celecoxib (QL) Nalocet (PA) Zohydro ER (PA)
Simponi Aria* (PA) Diclofenac patch
colchicine naproxen Zyloprim
Stelara* (PA, QL) (ST, QL)
cyclobenzaprine oxycodone (PA)
Tremfya* (PA, QL) D-Penamine* (PA)
14Cigna Advantage 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
PAIN RELIEF AND INFLAMMATORY SEIZURE DISORDERS
DISEASE (cont) carbamazepine Dilantin 30 mg Aptiom (PA, QL)
oxycodone ER (PA) carbamazepine ER capsule (PA) Banzel (PA, QL)
oxycodone- clonazepam Fycompa (PA, QL) Briviact solution,
acetaminophen divalproex tablet (PA)
(PA) divalproex ER Carbatrol (PA)
Phrenilin Forte (QL) epitol Depakote (PA)
Prilolid gabapentin Depakote ER (PA)
Prilovix lamotrigine Depakote Sprinkle
Primlev (PA) lamotrigine (blue, (PA)
Relador Pak green, orange) Dilantin 50mg and
Relador Pak Plus lamotrigine ER 100mg (PA)
rizatriptan (QL) lamotrigine ODT Epidiolex* (PA)
sumatriptan (QL) levetiracetam Keppra 500 mg/5
sumatriptan- levetiracetam ER ml vial
naproxen (QL) oxcarbazepine Klonopin (PA)
tizanidine Roweepra Neurontin (PA)
tramadol (QL) Roweepra XR Onfi (PA)
tramadol ER (QL) Subvenite Oxtellar XR (PA)
Vicodin (PA) Subvenite (Blue, Phenytek (PA)
Vicodin ES (PA) Green, Orange) Tegretol (PA)
Vicodin HP (PA) topiramate Tegretol XR (PA)
topiramate ER Vimpat (PA)
PARKINSON’S DISEASE
vigabatrin*
benztropine Apokyn* (PA) Vigadrone*
bromocriptine Azilect (QL)
carbidopa- Mirapex SKIN CONDITIONS
levodopa Mirapex ER (QL) adapalene (PA age) Eucrisa Bryhali (ST)
carbidopa- Neupro adapalene-benzoyl Fluoroplex Celacyn
levodopa ER Osmolex ER (QL) peroxide Promiseb Centany
pramipexole Parlodel Amnesteem (QL) Soolantra Cleocin T
pramipexole ER Rytary Avar Cleanser Targretin* gel Cloderm (ST)
(QL) Sinemet Avar-E Condylox
rasagiline (QL) Sinemet CR Avar-E Green Cordran (ST)
ropinirole Tasmar azelaic acid Dermasorb TA (ST)
ropinirole ER Xadago (ST) betamethasone Drysol
dipropionate Ecoza
SCHIZOPHRENIA/ANTI-PSYCHOTICS
augmented Efudex
aripiprazole (QL) Latuda (QL) Aristada initio betamethasone Elidel
aripiprazole ODT Zyprexa 10mg vial Fanapt (ST, QL) BP 10-1 Evoclin
chlorpromazine Invega (ST, QL) calcipotriene Finacea
olanzapine Perseris (QL) calcipotriene- Impoyz (ST)
olanzapine ODT Rexulti (ST, QL) betamethasone Lotrisone
paliperidone ER Risperdal (ST) DP MetroCream
(QL) Saphris (ST) Calcitrene MetroGel
quetiapine Seroquel (ST) Claravis (QL) MetroLotion
quetiapine ER Seroquel XR (ST) Clindacin ETZ MiCort-HC 2.5%
risperidone Vraylar (ST, QL) pledget cream (ST)
risperidone ODT Clindacin P pledget Mimyx
ziprasidone clindamycin- Naftin
benzoyl peroxide Nizoral
clindamycin Olux (ST)
phosphate Picato
Pramosone
15Cigna Advantage 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
SKIN CONDITIONS (cont) SMOKING CESSATION
clindamycin- Protopic bupropion SR +
NicoDerm CQ
tretinoin Regranex (PA, QL) NicoDerm CQ 7mg/24hr,
clobetasol Santyl (QL) 21mg/24hr+ 14mg/24hr+
Clodan shampoo Temovate (ST) Nicorelief+ Nicorette+
clotrimazole- Tolak nicotine gum+
betamethasone Topicort (ST) nicotine lozenge+
dapsone Tri-Luma nicotine patch+
desoximetasone Ultravate cream, Quit 2+
diflorasone ointment (ST) Quit 4+
fluocinonide Valchlor*
fluorouracil (PA) Xepi
flurandrenolide Xolegel
hydrocortisone
isotretinoin (QL)
ketoconazole
metronidazole SUBSTANCE ABUSE
Micort HC 2.5% buprenorphine- Bunavail Suboxone
cream naloxone Lucemyra (QL)
mupirocin NARCAN (QL)
Myorisan (QL) Probuphine
Neuac gel Zubsolv
Nolix TRANSPLANT MEDICATIONS
oxiconazole nitrate
pimecrolimus azathioprine* CellCept vial* Astagraf XL*
Procto-Med HC mycophenolate* Prograf 5 mg/ml CellCept capsule,
Procto-Pak mycophenolic ampule* suspension,
Proctosol-HC acid* tablet*
Proctozone-HC sirolimus* Envarsus XR*
Psorcon tacrolimus* capsule Myfortic*
Rosadan Prograf capsule,
sodium granule packet*
sulfacetamide- Rapamune*
sulfur Zortress*
SSS 10-5 URINARY TRACT CONDITIONS
Sulfacleanse 8-4
cevimeline Avodart
tacrolimus
darifenacin ER (QL) Cystagon*
ointment
finasteride 5mg Elmiron
tazarotene
oxybutynin Evoxac
tretinoin (PA age)
oxybutynin ER Flomax
tretinoin
phenazopyridine Procysbi* (PA)
microsphere (PA
potassium ER Proscar
age)
silodosin (QL) Pyridium
triamcinolone
solifenacin (QL) Rapaflo (QL)
triderm
tamsulosin Thiola*
Zenatane (QL)
tolterodine Urocit-K
SLEEP DISORDERS/SEDATIVES tolterodine ER (QL)
armodafinil (PA) Belsomra (ST) Hetlioz* (PA) trospium
eszopiclone Silenor (ST, QL) Lunesta (ST) trospium ER
modafinil (PA) Rozerem (ST, QL)
temazepam Xyrem* (PA)
zolpidem
zolpidem ER (QL)
16Cigna Advantage 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
VACCINES VACCINES (cont)
For plans renewing on 2/1/20 and later, on your plan's renewal For plans renewing on 2/1/20 and later, on your plan's renewal
date vaccines will be covered under the pharmacy benefit. date vaccines will be covered under the pharmacy benefit.
Not all plans will cover vaccines in the same way. Log in to the 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 myCigna app or website, or check your plan materials, to find out
how your specific plan covers them. how your specific plan covers them.
Diphtheria and Act-HIB+ Rotarix+
Tetanus Toxoids- Adacel Tdap+ RotaTeq+
ped+ Afluria Quad+ TENIVAC+
TdVax+ BEXSERO+ Trumenba+
Boostrix Tdap+ Twinrix+
DAPTACEL DTaP+ VAQTA+
Engerix-B+ VARIVAX+
FLUAD+ ZOSTAVAX+
FLUARIX
QUADRIVALENT+
FLUBLOK
QUADRIVALENT+
FLUCELVAX
QUADRIVALENT+
FLUALVAL
QUADRIVALENT+
FluMist Quad
Nasal+
Fluzone High-
Dose+
Fluzone
Quadrivalent Pedi+
Fluzone
Quadrivalent+
GARDASIL 9+
HAVRIX+
HEPLISAV-B+
Hiberix+
Infanrix DTaP+
IPOL+
KINRIX+
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+
17Medications 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
Pristiq bupropion XL
duloxetine
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.
18MEDICATIONS 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
Asmanex HFA
Arcapta neohaler Striverdi Respimat
Bevespi Aerosphere Anoro Ellipta
Stiolto Respimat
Utibron Neohaler
Elixophyllin theophylline oral solution
Proventil HFA ProAir
Ventolin HFA
Xopenex HFA
Pulmicort Flexhaler QVAR
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
Aptensio XR dextroamphetamine-amphetamine ER
Concerta methylphenidate ER/CD/LA
Cotempla XR-ODT
Focalin XR
Mydayis
QuilliChew ER
Ritalin LA
Adzenys ER dexmethylphenidate ER
Adzenys XR-ODT methylphenidate ER/CD/LA
Desoxyn methamphetamine
Dexedrine dextroamphetamine
Dyanavel XR methylphenidate ER/CD/LA
Vyvanse dexmethylphenidate 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.
19MEDICATIONS THAT ARE GENERIC AND/OR PREFERRED
DRUG CLASS
NOT COVERED^^ BRAND ALTERNATIVE(S)
BLOOD PRESSURE/HEART MEDICATIONS Accupril quinapril
Accuretic quinapril HCTZ
Altace ramipril
Atacand candesartan
Atacand HCT candesartan HCTZ
Avalide irbesartan HCTZ
Avapro
Azor amlodipine-olmesartan
Benicar olmesartan
Benicar HCT olmesartan HCTZ
Betapace sotalol oral
Bystolic Generic beta blockers (e.g. metoprolol,
atenolol)
Cardizem diltiazem
Cardizem CD diltiazem CD
Cozaar losartan
Diovan valsartan
Diovan HCT valsartan HCTZ
Edarbi Generic ARBs (e.g. losartan, calsartan)
Edarbyclor Generic ARBs + HCTZ (e.g. losartan-HCTZ)
Exforge amlodipine-valsartan
Exforge HCT amlodipine-valsartan HCTZ
Hyzaar losartan HCTZ
Isordil isosorbide dinitrate
Isordil Titradose isosorbide dinitrate
digoxin
Lanoxin Digitex
digoxin
Lotensin benazepril
Lotensin HCT benazepril HCTZ
Lotrel amlodipine-benazepril
Micardis telmisartan
Micardis HCT telmisartan HCTZ
Prinvil lisinopril
Zestril
Tarka trandolapril-verapamil
Tekturna Generica ACE/ARBs
Tekturna HCT Generica ACE/ARBs + HCTZ
Tribenzor olmesartan-amlodipine-HCTZ
Twynsta telmisartan-amlodipine
Vaseretic enalapril-HCTZ
Vasotec enalapril
Zestoretic lisinopril HCTZ
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.
20MEDICATIONS THAT ARE GENERIC AND/OR PREFERRED
DRUG CLASS
NOT COVERED^^ BRAND ALTERNATIVE(S)
BLOOD THINNERS/ANTI-CLOTTING Yosprala aspirin or enteric aspirin
CANCER Nilandron nilutamide
Tarceva* erlotinib*
Yonsa* abiraterone*
Zytiga*
CHOLESTEROL MEDICATIONS Antara fenofibrate
Fenoglide
Altoprev atorvastatin
Ezallor Sprinkle lovastatin
Livalo pravastatin
Zypitamag rosuvastatin
simvastatin
Crestor rosuvastatin
Lescol XL fluvastatin
Lipitor atorvastatin
Pravachol pravastatin
Vytorin ezetimibe-simvastatin
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
alogliptin-metformin Janumet XR
Januvia
metformin
alogliptin-pioglitazone Janumet
Janumet XR
Januvia
pioglitazone
Fortamet metformin ER (generic to Glucophage XR)
Glumetza
metformin ER (generic to Fortamet and
Glumetza)
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.
21MEDICATIONS THAT ARE GENERIC AND/OR PREFERRED
DRUG CLASS
NOT COVERED^^ BRAND ALTERNATIVE(S)
DIABETES (cont) Invokamet Segluromet
Invokamet XR Synjardy
Synjardy XR
Xigduo XR
Invokana Farxiga
Jardiance
metformin
Steglatro
Jentadueto Janumet
Jentadueto XR Janumet XR
Kazano
Lantus Basaglar
Toujeo SoloStar Levemir vial or Levemir Flextouch
Tresiba FlexTouch
Nesina Januvia
Tradjenta Janumet
Janumet XR
metformin
Oseni Generic TZDs (e.g. pioglitazone)
Janumet
Janumet XR
Januvia
QTERN Glyxambi
Steglujan metformin
DIURETICS Edecrin bumetanide
ethacrynic acid furosemide
torsemide
EYE CONDITIONS Alocril cromolyn
Alomide
Bepreve azelastine
Lastacaft epinastine
Pataday olopatadine
Patanol
Pazeo
Lumigan bimatoprost
latanoprost
Travatan Z
Vyzulta bimatoprost
latanoprost
Lumigan
Travatan Z
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.
22MEDICATIONS THAT ARE GENERIC AND/OR PREFERRED
DRUG CLASS
NOT COVERED^^ BRAND ALTERNATIVE(S)
GASTROINTESTINAL/HEARTBURN Anusol HC suppository hydrocortisone suppository
Asacol HD Apriso
Colazal balsalazide
Delzicol mesalamine tablets or capsules
Dipentum Pentasa
sulfasalazine
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
Omeclamox-Pak lansoprazole-amoxicillin-clarithromycin
Pylera (combo pack)
Rowasa mesalamine rectal enema suspension
Zofran ondansetron
Zuplenz ondansetron
ondansetron ODT
HORMONAL AGENTS Cortrosyn cosyntropin
DDAVP desmopressin
Dxevo dexamethasone
Fortesta AndgroGel
Natesto testosterone
Testim
Vogelxo
Xyosted
Genotropin* Humatrope* (PA)
Nutropin AQ nuspin*
Omnitrope*
Saizen*
Saizen-Saizenprep*
Zomacton*
Nocdurna desompression acetate nasal spray or
tablets
Rayos prednisone
Uceris tablets budesonide tablet
dexamethasone
hydrocortisone
methylprednisolone
prednisolone
prednisone
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.
23MEDICATIONS THAT ARE GENERIC AND/OR PREFERRED
DRUG CLASS
NOT COVERED^^ BRAND ALTERNATIVE(S)
INFECTIONS Acticlate Generic products (e.g. doxycycline;
Doryx minocycline)
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*
MULTIPLE SCLEROSIS Aubagio* Gilenya*
Mayzent*
Tecfidera*
Copaxone* Aubagio*
Avonex*
Betaseron*
Extavia*
Gilenya*
glatiramer*
Glatopa*
Plegridy*
Rebif*
Tecfidera*
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.
24MEDICATIONS THAT ARE GENERIC AND/OR PREFERRED
DRUG CLASS
NOT COVERED^^ BRAND ALTERNATIVE(S)
NUTRITIONAL/DIETARY Azesco Any generic prenatal vitamin
Nascobal cyanocobalamin injection
PAIN RELIEF AND INFLAMMATORY Ajovy butalbital-acetaminophen tablets
Allzital butalbital-acetaminophen tablets
butalbital-acetaminophen-caffeine
capsules 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
Gralise gabapentin
Imitrex sumatriptan
Zembrace Symtouch
Kineret* Enbrel* (PA)
Simponi* Humira* (PA)
levorphanol codeine with acetaminophen
Embeda
hydrocodone with acetaminophen
Hysingla
oxycodone with acetaminophen
Tramadol
Xtampza ER
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
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.
25MEDICATIONS THAT ARE GENERIC AND/OR PREFERRED
DRUG CLASS
NOT COVERED^^ BRAND ALTERNATIVE(S)
PAIN RELIEF AND INFLAMMATORY (cont) Siliq* Cosentyx*
Enbrel* (PA)
Humira* (PA)
Stelara*
Soriatane acitretin
Sprix ketorolac 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 (bluee, green, orange) lamotrigine ER (blue, green, orange)
Lyrica CR duloxetine
gabapentin
lidocaine 5% patch
Lyrica
Mysoline primidone
Qudexy XR topiramate ER
Sabril* vigabatrin*
Sympazan clobazam
Topamax topiramate
Zonegran zonisamide
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.
26MEDICATIONS THAT ARE GENERIC AND/OR PREFERRED
DRUG CLASS
NOT COVERED^^ BRAND ALTERNATIVE(S)
SKIN CONDITIONS Absorica Myorisan or Zenatane
Acanya Use generic products (e.g. adapalene;
Aczone tretinoin; clindamycin-benzoyl peroxide)
Aktipak
Altreno
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
Dovonex calcipotriene
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
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.
27MEDICATIONS THAT ARE GENERIC AND/OR PREFERRED
DRUG CLASS
NOT COVERED^^ BRAND ALTERNATIVE(S)
SKIN CONDITIONS (cont) Extina ketoconazole cream, foam
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,
ointment, 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
Zonalon tacrolimus)
Sernivo clobetasol spray
triamcinolone acetonide aerosol spray
Sorilux calcipotriene
Trianex triamcinolone cream, ointment
Ultravate clobetasol lotion
Vanos fluocinonide 0.1% cream
Vectical calcitriol ointment
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
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.
28MEDICATIONS THAT ARE GENERIC AND/OR PREFERRED
DRUG CLASS
NOT COVERED^^ BRAND ALTERNATIVE(S)
SUBSTANCE ABUSE Evzio narcan nasal spray
URINARY TRACT CONDITIONS Detrol tolterodine
Detrol LA tolterodine ER
Ditropan XL oxybutynin ER
Enablex darifenacin ER
Gelnique darifenacin ER
Myrbetriq oxybutynin ER
Toviaz tolterodine ER
VESIcare trospium ER
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.
29Prescription drug list FAQs
Understanding your prescription medication Your plan may also exclude certain medications
coverage can be confusing. Below are answers 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:1,2
› 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 cessation3).
› 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 coverage requirements to a of practicing doctors and pharmacists, most of
medication. For example, requiring whom work outside of Cigna. The group meets
approval from Cigna before a medication regularly to review medical evidence and
may be covered or adding a quantity limit information provided by federal agencies,
to a medication. drug manufacturers, medical professional
When a medication changes tiers or is no longer associations, national organizations and peer-
covered, you may pay a different amount to fill reviewed journals medications about the safety
that medication. It’s important to know that when and effectiveness of medications that are newly
we make a change that affects the coverage of approved by the FDA and medications already
a medication you’re taking, we let you know on the market. The Cigna Pharmacy
before it begins so you have time to talk with Management® Business Decision Team then
your doctor. looks at the results of the P&T Committee’s
clinical review, as well as the medication’s overall
Why doesn’t my plan cover certain value and other factors before adding it to, or
medications? removing it from, the drug list.
To help lower your overall health care costs, your Which medications are covered under the
plan doesn’t cover certain high-cost brand health care reform law?
medications because they have lower-cost,
The Patient Protection and Affordable Care Act
covered alternatives which are used to treat the
(PPACA), commonly referred to as “health care
same condition. Meaning, the alternative works
reform,” was signed into law on March 23, 2010.
the same or similar to the non-covered
Under this law, certain preventive medications
medication. If you’re taking a medication that
(including some over-the-counter medicines)
your plan doesn’t cover and your doctor feels an
may be available to you at no cost-share ($0),
alternative isn’t right for you, he or she can ask
Cigna to consider approving coverage of your
medication.
30You can also read
