CIGNA LEGACY (PERFORMANCE) 4-TIER PRESCRIPTION DRUG LIST - Coverage as of July 1, 2021
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CIGNA LEGACY (PERFORMANCE) 4-TIER PRESCRIPTION DRUG LIST Coverage as of July 1, 2021 Offered by Cigna Health and Life Insurance Company or Connecticut General Life Insurance Company 891395 t Legacy (Performance) 4-Tier 04/21
What’s inside?
About this drug list 3
How to read this drug list 3
How to find your medication 5
Specialty medications 20
Frequently Asked Questions (FAQs) 29
Exclusions and limitations for coverage 33
View the drug list online
This document was last updated on 04/01/2021.* You can go online to see the current list of
medications your plan covers.
myCigna® App and/or myCigna.com – Click on the “Find Care & Costs” tab and select
“Price a Medication.” Then type in your medication name to see how it’s covered.
Cigna.com/PDL – Scroll down until you see a pdf of the Cigna Legacy (Performance)
4-Tier Prescription Drug List (all specialty medications covered on Tier 4).
Questions?
› Click to chat: myCigna.com, Monday-Friday, 9:00 am-8:00 pm EST.
› By phone: Call the toll-free number on your Cigna ID card. We’re here 24/7/365.
* Drug list created: originally created 01/01/2004 Last updated: 04/01/2021, for changes Next planned update: 06/01/2021, for
starting 07/01/2021 changes starting 07/01/2021
2About this drug list
This is a list of the most commonly prescribed medications covered on the Cigna Legacy
(Performance) 4-Tier Prescription Drug List as of July 1, 2021.1,2 Medications are listed by the
condition they treat, then listed alphabetically within tiers (or cost-share levels).
The drug list is updated often so it isn’t a complete list of the medications your plan covers. Also,
your specific plan may not cover all of these medications. Log in to the myCigna App and
myCigna.com, or check your plan materials, to see all of the medications your plan covers.
How to read this drug list
Use the chart below to help you read this drug list. This chart is just an example. It may not show
how these medications are actually covered on the Cigna Legacy Performance 4-Tier Prescription
Drug List.
Tier (cost-share level) gives you
an idea of how much you may
pay for a medication
TIER 1 TIER 2 TIER 3
$ $$ $$$
Medications are grouped by
HORMONAL AGENTS the condition they treat;
Amabelz Androderm (PA, QL) Activella Speciality medications are
budesonide EC AndroGel 1.62% Alora (QL) listed on Tier 4 (pages 20–28)
cabergoline (QL) (PA, QL) AndroGel 1.0% (PA, QL)
Covaryx Armour Thyroid Angeliq
Covaryx H.S. Cytomel 50mcg Climara
Decadron Divigel Climara Pro
desmopressin Duavee Combipatch
Medications are listed in
dexamethasone Estring (QL) Cytomel 5, 25mcg
Premarin alphabetical order within
estradiol- Depo-Testosterone
norethindrone Premphase Elestrin each column
estrogen- Prempro Entocort EC
methyltestosterone Synthroid Estrace
levothyroxine Estrogel
Levoxyl Evamist
liothyronine Femring
medroxy-progesterone Intrarosa Medications that have extra
methimazole Levo-T coverage requirements will
methylprednisolone Menostar (QL) have an abbreviation listed
Mimvey Minivelle (QL) next to them
Mimvey Lo Osphena
Nature-Throid Tirosint
NP Thyroid Brand name medications
Unithroid
prednisolone Vagifem (QL) are capitalized
prednisolone ODT Vivelle-Dot (QL)
prednisone Generic medications
prednisone intensol are lowercase
progesterone
This chart is just a sample. It may not show how these medications are actually covered on the Cigna Legacy (Performance) 4-Tier Prescription Drug List.
3Tiers
Covered medications are divided into tiers, or cost-share levels. Typically, the higher the tier, the
higher the price you’ll pay to fill the prescription.
› Tier 1 – Typically Generics (Lowest-cost medication) $
› Tier 2 – Typically Preferred Brands (Medium-cost medication) $$
› Tier 3 – Typically Non-Preferred Brands (Higher-cost medication) $$$
› Tier 4 – Specialty Medications (Highest-cost medication) $$$$
Abbreviations next to medications
In this drug list, medications that have limits and/or extra coverage requirements have an
abbreviation listed next to them.* Here’s what they mean.
(PA)
Prior Authorization – Certain medications need approval from Cigna before your
plan will cover them. These medications have a (PA) next to them. Your plan won’t
cover these medications unless your doctor requests, and receives, approval from
Cigna.
(QL) uantity Limits – Some medications have a quantity limit. This means your plan will
Q
only cover up to a certain amount over a certain length of time. These medications
have a (QL) next to them. Your plan will only cover a larger amount if your doctor
requests, and receives, approval from Cigna.
(ST) tep Therapy – Certain high-cost medications aren’t covered until you try one or
S
more lower-cost alternatives first.** These medications have a (ST) next to them. You
have many covered options to choose from, and they’re used to treat the same con-
dition.
(AGE) ge Requirements – Certain medications will only be covered if you’re within a
A
specific age range. These medications have (AGE) next to them. If you’re not within
the allowed age range, your plan will only cover the medication if your doctor
requests, and receives, approval from Cigna.
* These coverage requirements may not apply to your specific plan. Log in to the myCigna App or myCigna.com, or check your plan materials, to find out if your plan includes prior authorization,
quantity limits, Step Therapy and/or age requirements.
** If your doctor feels an alternative isn’t right for you, he or she can ask Cigna to consider approving coverage of your medication.
Brand-name medications are capitalized
In this drug list, brand-name medications are capitalized. Generic medications are lowercase.
Specialty medications have an asterisk next to them
Specialty medications are used to treat complex medical conditions. In this drug list, oral and
injectable specialty medications are covered on Tier 4 (see page 20). Injectable specialty
medications have an asterisk (*) after them and oral specialty medications have a double asterisk
(**) after them.
Your plan may also 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 and myCigna.com, or check
your plan materials, to see about how your plan covers these medications.
4No cost-share preventive medications have a plus sign next to them
Health care reform under the Patient Protection and Affordable Care Act (PPACA) requires plans to
cover certain preventive medications and products at 100%, or no cost-share ($0), to you. In this
drug list, these medications have a plus sign (+) next to them. Log in to the myCigna App and/or
myCigna.com, or check your plan materials, to see how your plan covers these medications.
Plan/benefit exclusions
Your plan doesn’t cover certain medications and products because they’re considered plan/benefit
exclusions. This means there’s no option to receive coverage through Cigna’s review process by
showing that you need the medication for your treatment. In this drug list, these medications have a
caret (^) next to them. Log in to the myCigna App and myCigna.com, or check your plan materials,
to see which medications your plan excludes.
How to find your medication
First, look for 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
ALLERGY/NASAL SPRAYS 6 FEMININE PRODUCTS 12
ALZHEIMER’S DISEASE 6 GASTROINTESTINAL/HEARTBURN 12, 13
ANXIETY/DEPRESSION/BIPOLAR 6 HORMONAL AGENTS 13
DISORDER INFECTIONS 13, 14
ASTHMA/COPD/RESPIRATORY 6,7 INFERTILITY 14
ATTENTION DEFICIT HYPERACTIVITY 7 MISCELLANEOUS 14
DISORDER
MULTIPLE SCLEROSIS 14
BLOOD MODIFIERS/BLEEDING DISORDERS 7
NUTRITIONAL/DIETARY 14
BLOOD PRESSURE/HEART MEDICATIONS 7, 8
OSTEOPOROSIS PRODUCTS 14
BLOOD THINNERS/ANTI-CLOTTING 8
PAIN RELIEF AND INFLAMMATORY DISEASE 14, 15
CANCER 8 PARKINSON’S DISEASE 16
CHOLESTEROL MEDICATIONS 8 SCHIZOPHRENIA/ANTI-PSYCHOTICS 16
CONTRACEPTION PRODUCTS 8–10 SEIZURE DISORDERS 16
COUGH/COLD MEDICATIONS 10 SKIN CONDITIONS 16, 17
DENTAL PRODUCTS 10 SLEEP DISORDERS/SEDATIVES 18
DIABETES 11 SMOKING CESSATION 18
DIURETICS 11 SUBSTANCE ABUSE 18
EAR MEDICATIONS 11 URINARY TRACT CONDITIONS 18
ERECTILE DYSFUNCTION 11 VACCINES 18, 19
EYE CONDITIONS 11, 12
5Cigna Legacy (Performance) 4-Tier Prescription Drug List
Specialty medications are covered on Tier 4 (listed on page 20).
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
ALLERGY/NASAL SPRAYS ANXIETY/DEPRESSION/BIPOLAR DISORDER (cont)
azelastine Clarinex fluvoxamine ER (QL) Remeron
carbinoxamine Clarinex-D 12 Hour lorazepam oral Sarafem (ST)
4mg/5ml liquid, DYMISTA (ST) concentrate, tablet Tofranil (PA)
4mg tablet EpiPen (PA, QL) lorazepam intensol Trintellix (ST, QL)
carbinoxamine 6mg EpiPen Jr (PA, QL) mirtazapine Viibryd (ST, QL)
tablet (PA) Gastrocrom paroxetine (QL) Wellbutrin SR (ST,
cromolyn oral GRASTEK (PA, QL) paroxetine CR (QL) QL)
concentrate Karbinal ER paroxetine ER (QL) Wellbutrin XL (PA,
cyproheptadine ODACTRA (PA, QL) sertraline (QL) QL)
desloratadine (QL) Oralair (PA, QL) trazodone Xanax
epinephrine (QL) Patanase
venlafaxine (QL) Xanax XR
fluticasone QNASL (ST)
hydroxyzine QNASL Children venlafaxine ER (QL) Zoloft (ST, QL)
capsule, solution, RAGWITEK (PA, QL) ASTHMA/COPD/RESPIRATORY
syrup tablet RyVent(PA) albuterol ADVAIR HFA ADVAIR DISKUS
ipratropium SYMJEPI (PA, QL) albuterol HFA ANORO ELLIPTA (ST)
mometasone (QL) Vistaril budesonide Asmanex HFA AirDuo Digihaler
olopatadine XHANCE (ST) fluticasone- Asmanex Twisthaler (ST)
promethazine
salmeterol Atrovent HFA Alvesco (ST)
solution, syrup,
tablet montelukast BEVESPI AirDuo RespiClick
Wixela Inhub BREO ELLIPTA (ST)
ALZHEIMER’S DISEASE BREZTRI Alvesco (ST)
donepezil Mestinon syrup Aricept Combivent Arcapta Neohaler
donepezil ODT Namenda Titration Exelon Respimat ArmonAir Digihaler
memantine Pack Mestinon tablet Dulera (ST)
memantine ER (QL) Namenda tablet Flovent Diskus ArmonAir
pyridostigmine Namenda XR (QL) Flovent HFA RespiClick (ST)
pyridostigmine ER Namzaric (QL) INCRUSE ELLIPTA Arnuity Ellipta (ST)
rivastigmine Pulmicort Flexhaler Brovana
QVAR RediHaler Daliresp (QL)
Serevent Diskus Lonhala Magnair
Symbicort (PA)
ANXIETY/DEPRESSION/BIPOLAR DISORDER Perforomist (QL)
TRELEGY ELLIPTA
alprazolam Anafranil (PA) ProAir Digihaler
alprazolam ER Aplenzin (PA, QL) (PA, QL)
alprazolam intensol Ativan tablet (PA) ProAir HFA (PA, QL(
alprazolam ODT Celexa (ST, QL) ProAir RespiClick
alprazolam XR Cymbalta (PA, QL) (PA, QL)
amitriptyline Drizalma Sprinkle Proventil HFA (PA,
bupropion (QL) DR (ST, QL) QL)
bupropion SR (QL) Effexor XR (ST, QL) Pulmicort Respule
bupropion XL (QL) EMSAM (QL) Seebri Neohaler
buspirone Fetzima (ST, QL) (ST)
citalopram (QL) Forfivo XL (ST, QL) Spiriva HandiHaler
clomipramine Lexapro (PA, QL) (ST)
desvenlafaxine ER Pamelor (PA) Spiriva Respimat
(QL) Parnate (PA) (ST)
duloxetine (QL) Paxil (ST, QL) Stiolto Respimat
escitalopram (QL) Paxil CR (ST, QL) (ST)
fluoxetine (QL) Pexeva (PA, QL) Striverdi Respimat
fluoxetine DR (QL) Pristiq ER (ST, QL) (ST)
fluvoxamine (QL) Prozac (ST, QL)
6Cigna Legacy (Performance) 4-Tier Prescription Drug List
Specialty medications are covered on Tier 4 (listed on page 20).
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
ASTHMA/COPD/RESPIRATORY (cont) BLOOD PRESSURE/HEART MEDICATIONS
Tudorza Pressair Adult Aspirin Bystolic (ST, QL) Adalat CC
(ST) Regimen+ Corlanor (PA) Altace (ST)
Utibron Neohaler amiodarone tablet Entresto Atacand (ST)
(ST) amlodipine NEXLIZET (PA, QL) Atacand HCT (ST)
Ventolin HFA (PA, amlodipine- Tekturna HCT (QL) Avalide (ST)
QL) benazepril Avapro (ST)
Xopenex HFA (QL) amlodipine- Azor (QL)
YUPELRI (PA) olmesartan (QL) Benicar (ST, QL)
Zyflo (PA) amlodipine- Benicar HCT (ST,
ATTENTION DEFICIT HYPERACTIVITY DISORDER valsartan QL)
amlodipine- Betapace (PA)
atomoxetine (QL) Vyvanse (PA age, Adderall XR (PA
valsartan-HCTZ BiDil (QL)
clonidine ER QL) age, QL, ST)
Aspir EC+ Calan SR
dexmethylphenidate ADHANSIA XR (PA
Aspir-Low+ Cardizem (PA)
(PA age) age, ST, QL)
aspirin 325mg Cardizem CD (PA)
dexmethylphenidate Adzenys ER (PA
tablet+ Cardizem LA (QL)
ER (PA age, QL) age, QL)
aspirin EC+ Cardura
dextroamphetamine- Adzenys XR-ODT
atenolol Catapres-TTS 1
amphetamine (PA (PA age, QL)
benazepril Catapres-TTS 2
age) Aptensio XR (PA,
benazepril-HCTZ Catapres-TTS 3
dextroamphetamine- QL, ST)
candesartan Conjupri (PA)
amphetamine ER Cotempla XR-ODT
candesartan-HCTZ Consensi (PA, QL)
(PA age, QL) (PA, QL)
Cartia XT Coreg (ST)
guanfacine ER Daytrana (PA age,
carvedilol Coreg CR (ST, QL)
metadate ER (PA QL)
carvedilol ER (QL) Corgard (ST)
age, QL) Desoxyn (PA)
Children’s Aspirin+ Cozaar (ST)
methylphenidate Dexedrine (PA, QL)
clonidine Diovan (ST)
(PA age) Dyanavel XR (PA
diltiazem tablet Diovan HCT (ST)
methylphenidate age, QL)
diltiazem 12hr ER Ecotrin EC 325mg+
CD (PA age, QL) Evekeo (PA age, ST)
diltiazem 24hr ER Edarbi (ST, QL)
methylphenidate ER Evekeo ODT (PA
diltiazem 24hr ER Edarbyclor (ST)
(PA age, QL) age)
(CD) Epaned
methylphenidate ER Focalin (PA age, ST)
diltiazem 24hr ER Exforge
(CD) (PA age, QL) Intuniv ER
(LA) Exforge HCT
methylphenidate ER Jornay PM (PA, QL,
diltiazem 24hr ER GoNitro
(LA) (PA age, QL) ST)
(XR) Hemangeol
methylphenidate LA Methylin (PA)
Dilt-XR Hyzaar (ST)
(PA age, QL) Mydayis ER (PA, QL,
dofetilide (QL) Inderal LA (ST)
Relexxii ER (PA age, ST) doxazosin Inderal XL (ST)
QL) QuilliChew ER (PA Ecotrin EC 81mg+ InnoPran XL (ST)
age, QL) ecpirin+ Isordil (PA)
Quillivant XR (PA enalapril Isordil Titradose
age, QL) flecainide (PA)
Ritalin tablet (PA hydralazine tablet
Kapspargo Sprinkle
age, ST) irbesartan
irbesartan-HCTZ (ST)
Strattera (QL)
isosorbide Lanoxin tablet (PA)
BLOOD MODIFIERS/BLEEDING DISORDERS Lopressor (ST)
mononitrate
Droxia Siklos (PA) isosorbide Lotensin (ST)
mononitrate ER Lotensin HCT (ST)
7Cigna Legacy (Performance) 4-Tier Prescription Drug List
Specialty medications are covered on Tier 4 (listed on page 20).
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
BLOOD PRESSURE/HEART MEDICATIONS (cont) CANCER
labetalol tablet Micardis (ST, QL) anastrozole Gleostine Nilandron (PA)
lisinopril Micardis HCT (ST, exemestane Trexall Tabloid
lisinopril-HCTZ QL) letrozole
losartan Minipress mercaptopurine
losartan-HCTZ MULTAQ methotrexate
Low Dose Aspirin Nitrostat tamoxifen+
EC+
Norpace (PA)
Matzim LA
metoprolol tablet Norpace CR CHOLESTEROL MEDICATIONS
nadolol Norvasc
amlodipine- NEXLETOL (PA, QL) Antara (PA)
nifedipine Pacerone 100mg,
atorvastatin (QL) Repatha (PA) Caduet (QL)
nifedipine ER 400mg (PA)
atorvastatin 10mg, Vascepa (PA) CRESTOR (ST, QL)
olmesartan (QL) Prinivil (ST) 20mg+ Fenoglide (PA)
olmesartan- Procardia atorvastatin 40mg, FloLipid (ST)
amlodipine-HCTZ Procardia XL 80mg Ezallor Sprinkle (ST,
olmesartan-HCTZ Ranexa (QL) colesevelam QL)
(QL) Rythmol SR (PA) ezetimibe Lipitor (PA)
prazosin Tekturna (QL) ezetimibe- Lipofen (ST)
propafenone Tenoretic 50 (ST)
propafenone ER simvastatin Livalo (ST, QL)
Tenoretic 100 (ST) fenofibrate Lovaza
propranolol
solution, tablet Tenormin (ST) fenofibric acid Niaspan ER
propranolol ER Tiazac ER fluvastatin+ Pravachol (ST)
ramipril Tikosyn (PA, QL) fluvastatin ER+ TriCor (ST)
ranolazine ER (QL) Toprol XL (ST) lovastatin 10mg Triglide (ST)
St. Joseph Aspirin+ Tribenzor lovastatin 20mg, Trilipix DR (ST)
telmisartan (QL) Vasotec (ST) 40mg+ Vytorin (ST)
telmisartan-HCTZ Verelan niacin Welchol
(QL) Verelan PM niacin ER Zetia
valsartan Zestoretic (ST) Niacor Zocor (ST, QL)
valsartan-HCTZ Zestril (ST) omega-3 acid Zypitamag (ST)
verapamil capsule, ethyl esters
tablet pravastatin+
verapamil ER rosuvastatin 5mg,
verapamil ER PM 10mg+ (QL)
verapamil SR rosuvastatin 20mg,
BLOOD THINNERS/ANTI-CLOTTING
40mg (QL)
simvastatin 10mg,
aspirin- BRILINTA Aggrenox 20mg, 40mg+
dipyridamole ER Eliquis (PA) Bayer Aspirin simvastatin 80mg
clopidogrel Xarelto (PA) chewable tablet+ (QL)
enoxaparin* (QL) Bevyxxa (QL) CONTRACEPTION PRODUCTS
fondaparinux* (QL) Coumadin (PA)
Afirmelle+
Lo Loestrin FE Annovera+
Jantoven Effient
Aftera+ Balcoltra
prasugrel Lovenox* (QL)
Altavera+ Beyaz
warfarin Pradaxa (PA)
Alyacen+ Ella+
Savaysa 15mg, Amethia+ Estrostep FE
30mg (PA, QL) Amethia Lo+ Layolis FE
Savaysa 60mg (PA) Amethyst+ Loestrin FE
Yosprala (PA) Apri+ Minastrin 24 FE
Zontivity Aranelle+ Natazia
8Cigna Legacy (Performance) 4-Tier Prescription Drug List
Specialty medications are covered on Tier 4 (listed on page 20).
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
CONTRACEPTION PRODUCTS (cont) CONTRACEPTION PRODUCTS (cont)
Ashlyna+
NuvaRing etonogestrel-ethinyl
Aubra+ Safyral estradiol vaginal
Aubra EQ+ Slynd ring+
Aurovela+ Taytulla Falmina+
Aurovela FE+ Today Fayosim+
Aurovela 24 FE+ Contraceptive FemCap+
Aviane+ Sponge+ Femynor+
Ayuna+ Yasmin 28 Gianvi+
Azurette+ YAZ Gynol II+
Balziva+ Hailey 24 FE+
Bekyree+ Heather+
Blisovi FE+ Incassia+
Blisovi 24 FE+ Introvale+
Briellyn+ Isibloom+
Camila+ Jasmiel+
Camrese+ Jencycla+
Camrese Lo+ Jolessa+
Caya Contoured+ Juleber+
Caziant+ Junel+
Chateal+ Junel FE+
Chateal EQ+ Junel FE 24+
Cryselle+ Kaitlib FE+
Cyclafem+ Kalliga+
Cyred+ Kariva+
Cyred EQ+ Kelnor 1-35+
Dasetta+ Kelnor 1-50+
Daysee+ Kurvelo+
Deblitane+ Larin+
Delyla+ Larin FE+
desogestrel-ethinyl Larin 24 FE+
estradiol+ Larissia+
desogestrel-ethinyl Leena 28 tablet+
estradiol-ethinyl Lessina+
estradiol Levonest+
dospirenone- levonorgestrel+
ethinyl estradiol- levonorgestrel-
levomefolate+
ethinyl estradiol+
drospirenone-
levonorgestrel-
ethinyl estradiol+
Econtra EZ+ ethinyl estradiol-
Econtra One-Step+ ethinyl estradiol+
Elinest+ Levora-28+
EluRyng vaginal Lillow+
ring+ Loryna+
Emoquette+ Low-Ogestrel+
Enpresse+ Lo-Zumandimine+
Enskyce+ Lutera+
Errin+ Lyza+
Estarylla+ Marlissa+
ethynodiol-ethinyl medroxy-
estradiol+ progesterone
150mg/ml+
9Cigna Legacy (Performance) 4-Tier Prescription Drug List
Specialty medications are covered on Tier 4 (listed on page 20).
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
CONTRACEPTION PRODUCTS (cont) CONTRACEPTION PRODUCTS (cont)
Melodetta 24 FE +
Tri-Previfem+
Mibelas 24 FE+ Tri-Sprintec+
Microgestin+ Trivora-28+
Microgestin FE+ Tri-Vylibra+
Mili+ Tri-Vylibra Lo+
Mono-Linyah+ Tulana+
My Choice+ Tydemy+
My Way+ VCF+ foam, gel
Necon+ Velivet+
Nikki+ Vienva+
Nora-BE+ Viorele+
norethindrone+ Vyfemla+
norethindrone- Vylibra+
ethinyl estradiol+ Wera+
norethindrone- Wide Seal
ethinyl estradiol- Diaphragm+
iron+ Wymzya FE+
norgestimate- Xulane+
ethinyl estradiol+ Zarah+
Norlyda+
Zovia+
Norlyroc+
Zumandimine+
Nortrel+
Ocella+ COUGH/COLD MEDICATIONS
Option 2+ benzonatate 150mg TussiCaps (PA) Tessalon Perle
Orsythia+ (PA) Tuzistra XR (PA, QL)
Philith+ Bromfed DM
Pimtrea+ brompheniramine-
Pirmella+ pseudoephedrine-
Portia+ DM
Previfem+
hydrocodone-
Reclipsen+
chlorpheniramine
Rivelsa tablet+
ER (PA)
Setlakin+
Sharobel+ DENTAL PRODUCTS
Simliya+ chlorhexidine Floriva+
Simpesse+ doxycycline 20mg Fluorabon+
Sprintec+ tablet
Sronyx+ fluoride+
Syeda+ Fluoritab+
Tarina 24 FE+ Flura-Drops+
Tarina FE 1-20 EQ+
Ludent+
Tilia FE 28+
Oralone
Tri Femynor+
Paroex
Tri-Estarylla+
Tri-Legest FE+ Peridex
Tri-Linyah+ Periogard
Tri-Lo-Estarylla+ sodium fluoride+
Tri-Lo-Marzia+ 0.25mg, 0.5mg,
Tri-Lo-Mili+ 1mg
Tri-Lo-Sprintec+ triamcinolone 0.1%
Tri-Mili+ paste
10Cigna Legacy (Performance) 4-Tier Prescription Drug List
Specialty medications are covered on Tier 4 (listed on page 20).
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
DIABETES DIABETES (cont)
Accu-Chek Baqsimi (QL) Admelog (QL) Ultra-Fine Nano pen V-Go
AutoShield Duo pen BASAGLAR (QL) Admelog SoloStar needle Victoza (ST, QL)
needle Bydureon (ST, QL) (QL) Veo insulin syringe Xigduo XR (ST, QL)
Contour Next Byetta (ST, QL) Afrezza (PA, QL) Xultophy
solution Dexcom G6 sensor Agamatrix AMP
glimepiride (PA, QL) test strips
glipizide Farxiga (ST, QL) Amaryl DIURETICS
glipizide ER Fiasp (QL) Apidra (QL)
acetazolamide Diuril Aldactone
Droplet insulin Freestyle Libre Apidra SoloStar tablet Dyrenium CaroSpir
syringe, pen Sensor (PA, QL) (QL) acetazolamide ER Dyazide
needle GlucaGen HypoKit CeQur Simplicity bumetanide tablet Edecrin (PA)
DropSafe pen (QL) Contour test strips chlorthalidone Inspra
needle Glucagon Contour Next test eplerenone Lasix
glipizide XL Emergency Kit (QL) strips furosemide solution, Maxzide
GLUCOCARD 01 Glyxambi (ST, QL) Cycloset tablet
Control solution Humalog (QL) Fortamet ER (PA) hydrochlorothiazide
GLUCOCARD Humulin (QL) Freestyle test strips spironolactone
Expression solution Insulin Aspart (QL) GLUCOCARD test triamterene-HCTZ
GLUCOCARD Shine Insulin Lispro (QL) strips EAR MEDICATIONS
Guardian RT, test Invokamet (ST, QL) Glucophage neomycin- Cipro HC Coly-Mycin S
plug Invokamet XR (ST, QL) Glucophage XR polymyxin-HC Ciprodex Cortisporin-TC
InPen (for Humalog) Invokana (ST, QL) Glumetza ER (PA) ofloxacin drops Dermotic
Insulin Syringe Janumet (ST, QL) Gvoke (QL) OTOVEL
metformin Janumet XR (ST, QL) Jentadueto (PA, ERECTILE DYSFUNCTION
metformin ER (PA) Januvia (ST, QL) QL)
sildenafil (PA age, MUSE (PA, QL) Caverject Impulse
Microlet 2 lancing Jardiance (ST, QL) Jentadueto XR (PA,
QL) (PA, QL)
device Kombiglyze XR (ST, QL)
tadalafil 2.5mg, Cialis (PA age, QL)
Microlet Next QL) Kazano (PA, QL) 10mg, 20mg (PA STENDRA (PA age,
lancing device Levemir (QL) Kombiglyze XR (PA, age, QL) QL)
MiniMed reservoir LYUMJEV (QL) QL) tadalafil 5mg (PA, VIAGRA (PA age,
Multi-Lancet Novolin (QL) Korlym* (PA) QL) QL)
NovoFine Novolog (QL) Lantus (PA, QL) vardenafil
NovoTwist OmniPod DASH (PA, Nesina (PA, QL) (PA age, QL)
OnteTouch Delica QL) Onglyza (PA, QL) EYE CONDITIONS
lancing device OneTouch test strips Oseni (PA, QL)
OneTouch Verio Onglyza (ST, QL) Ozempic (ST, QL) azelastine Alphagan P 0.1% ACUVAIL
control solution Ozempic (ST, QL) Prescision Xtra test brimonidine drops Alphagan P 0.15%
Paradigm reservoir QTERN (ST, QL) strips ciprofloxacin AzaSite Alrex
pioglitazone Relion Novolin (QL) Riomet dorzolamide Azopt BEPREVE
dorzolamide- BETIMOL Besivance
TechLite syringes, Segluromet (ST, QL) Riomet ER
timolol Betoptic S BromSite
pen needles SOLIQUA 100-33 Rybelsus (ST, QL)
erythromycin Ciloxan ointment Cequa
TRUEplus syringes, Steglatro (ST, QL) Semglee (PA, QL)
fluorometholone Combigan Ciloxan drops
needles SymlinPen Steglujan (ST, QL) gatifloxacin EYsuVIS (QL) Cosopt
Ultra-Fine Micro pen Synjardy (ST, QL) Tradjenta (PA, QL) latanoprost Flarex Cosopt PF
needle Synjardy XR (ST, QL) TRUEtrack strips moxifloxacin LOTEMAX gel Cystaran* (PA, QL)
Ultra-Fine Mini pen TRESIBA (QL) neomycin- LOTEMAX SM DUREZOL
needle Trijardy XR (ST, QL) polymyxin- Moxeza ILEVRO
Trulicity (ST, QL) dexamethasone Pazeo Inveltys
11Cigna Legacy (Performance) 4-Tier Prescription Drug List
Specialty medications are covered on Tier 4 (listed on page 20).
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
EYE CONDITIONS (cont) GASTROINTESTINAL/HEARTBURN (cont)
ofloxacin Restasis Istalol esomeprazole Cortifoam (PA)
polymyxin B-TMP Restasis Multidose LASTACAFT capsule (QL) Creon (PA)
prednisolone Simbrinza Lotemax 0.5% famotidine Diclegis
solution Tobradex eye drops, ointment suspension, 20mg Donnatal
timolol solution ointment LUMIGAN (PA) and 40mg tablet Dulcolax tablet+
tobramycin Xiidra Maxitrol GaviLyte-C+ Kristalose
tobramycin- Zerviate Nevanac GaviLyte-G+ Lialda (ST)
dexamethasone Ocuflox GaviLyte-N+ Librax (PA)
Patanol GentleLax+ Lomotil
Polytrim GlycoLax+ Lotronex* (PA)
Pred Forte HealthyLax+ Lubiprostone (PA)
PROLENSA Hemmorex-HC Marinol (PA)
Rhopressa hydrocortisone MiraLax+
Rocklatan suppository Motegrity (PA)
TIMOPTIC lansoprazole (QL) Motofen
TIMOPTIC-XE LaxaClear+ Movantik (PA)
TobraDex drops mesalamine Nexium DR
TobraDex ST mesalamine DR capsule, 10mg,
TRAVATAN Z (PA) metoclopramide 20mg, 40mg
Trusopt solution, tablet packet (PA, QL)
Vigamox metoclopramide Omeclamox-Pak
VYZULTA (PA) ODT (PA)
Xalatan (PA) omeprazole- Pertzye (PA)
Xelpros (PA) bicarbonate (PA, PLENVU (PA)
Zioptan (PA, QL) QL) Prevacid DR (ST,
Zirgan omeprazole DR QL)
Zylet capsule (QL) Prevacid SoluTab
Zymaxid ondansetron (PA, QL)
ondansetron ODT Protonix
FEMININE PRODUCTS pantoprazole tablet suspension, tablet
Fem pH AVC (QL) (ST, QL)
GYNAZOLE 1 PEG PYLERA (PA)
miconazole 3 3350-Electrolytes+ RECTIV
suppository PEG-Prep+ RELISTOR (PA)
terconazole Pepcid (PA) Reltone (PA)
GASTROINTESTINAL/HEARTBURN Phenadoz Rowasa (PA)
polyethylene glycol SANCUSO (PA, QL)
Alophen +
Amitiza Aciphex Sprinkle
3350+ sfRowasa
Anucort-HC CLENPIQ+ (QL)
balsalazide CREON PowderLax+ Symproic (PA)
Aciphex tablet (ST,
bisacodyl EC tablet+ DEXILANT (QL) prochlorperazine SYNDROS (PA)
QL)
Bisa-Lax+ Linzess Actigall suppository, tablet Talicia DR (PA)
chlordiazepoxide- LITHOSTAT Akynzeo capsule promethazine Transderm-Scop
clidinium Nexium DR 2.5mg, (PA, QL) suppository Trulance (PA)
ClearLax+ 5mg packet (QL) Anusol-HC Promethegan UCERIS foam (PA,
dicyclomine Pancreaze DR suppository (PA) PureLax+ QL)
capsule, solution, Pentasa Apriso ER (ST) QC Natura-Lax+ Urso
tablet Prepopik+ Bonjesta rabeprazole (QL) Urso Forte
diphenoxylate- SUPREP+ Canasa ranitidine capsule, VARUBI (PA, QL)
atropine Sutab Carafate syrup, 150mg and Zenpep (PA)
dronabinol Viberzi CLENPIQ 300mg tablet Zofran (PA)
Ducodyl+ Correctol+ Smooth Lax+
12Cigna Legacy (Performance) 4-Tier Prescription Drug List
Specialty medications are covered on Tier 4 (listed on page 20).
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
GASTROINTESTINAL/HEARTBURN (cont) HORMONAL AGENTS (cont)
Women’s Gentle Zuplenz (PA, QL) WP Thyroid Vogelxo (PA, QL)
Laxative+ Yuvafem (QL) XYOSTED (PA, QL)
Women’s Laxative+ INFECTIONS
HORMONAL AGENTS acyclovir capsule, Augmentin Acticlate (ST)
Amabelz ANDRODERM (PA, Activella suspension, tablet 125-31.25 mg/ml Aemcolo DR (QL)
budesonide EC QL) Alkindi Sprinkle albendazole suspension (PA) Albenza
budesonide ER (PA, Divigel (PA) amoxicillin Cipro suspension Alinia
QL) Duavee Alora (QL) amoxicillin- Cleocin 75 mg Arakoda (PA)
cabergoline (QL) Estring (QL) AndroGel (PA, QL) clavulanate capsule Augmentin
CovARYX Euthyrox Angeliq amoxicillin- E.E.S. 400 250-62.5mg/ml
CovARYX HS Levo-T Armour Thyroid clavulanate ER Eurax cream suspension, 500-
Decadron Medrol 2mg Bijuva atovaquone Firvanq 125 tablet (PA)
desmopressin Oriahnn (PA, QL) Climara atovaquone- Solosec Augmention ES-
solution, spray, Orilissa (PA, QL) Climara Pro proguanil Vibramycin syrup 600 (PA)
Avidoxy Xifaxan (QL) Bactrim
tablet Premarin cream, CombiPatch
azithromycin Bactrim DS
dexamethasone tablet Crinone 4%
packet, suspension, Baraclude 1mg
dexamethasone PREMPHASE DDAVP nasal spray, tablet tablet (PA)
intensol PREMPRO solution, tablet cefdinir Baxdela tablets
Dotti (QL) (PA) cefpodoxime (PA)
EEMT Depo-Testosterone cefuroxime tablet Cipro tablet
EEMT H.S. EstroGel cephalexin Cleocin
estradiol (QL) Evamist ciprofloxacin Clindesse
estradiol- Fortesta (PA, QL) clarithromycin Cresemba capsule
norethindrone Imvexxy (QL) clarithromycin ER (PA)
estrogen- JATENZO (PA, QL) clindamycin DIFICID (QL)
methyltestosterone Intrarosa capsule, cream, Diflucan (PA)
HiDex Medrol 4mg, 8mg, solution Doryx MPC (PA)
levothyroxine tablet 16mg, 32mg Coremino ER (QL) E.E.S. 200 (PA)
Levoxyl Menostar (QL) dapsone Elimite
Lopreeza Minivelle (QL) doxycycline EryPed 200
medroxyprogesterone Natesto (PA, QL) Emverm EryPed 400 (PA)
methimazole Nocdurna (PA) erythromycin Eurax lotion
methylprednisolone Noctiva (PA) erythromycin ES Flagyl
dosepak, tablet ORTIKOS ER (PA, famciclovir Keflex
Mimvey QL) fluconazole Levaquin
Nature-Throid Osphena hydroxychloroquine Macrobid
NP Thyroid Prometrium itraconazole Macrodantin
prednisolone Rayaldee ER levofloxacin Malarone (PA)
solution, tablet Mepron (PA)
prednisolone ODT Rayos DR
metronidazole Minocin (PA)
prednisone Striant (PA, QL)
capsule, tablet, Minolera ER (ST)
prednisone intensol Synthroid vaginal gel Monurol
progesterone Testim (PA, QL) minocycline Mycobutin (PA)
capsule THYQUIDITY (PA) minocycline ER (QL) Natroba
TaperDex (PA) Tirosint Mondoxyne NL Noxafil suspension
testosterone (PA, Tirosint-SOL nitrofurantoin Noxafil tablet (PA)
QL) UCERIS tablet (PA, nitrofurantoin Nuvessa
testosterone QL) mono-macro ORACEA (PA)
cypionate Unithroid nystatin Oravig
thyroid Vagifem (QL) Okebo
Westhroid Vivelle-Dot (QL) oseltamivir (QL)
13Cigna Legacy (Performance) 4-Tier Prescription Drug List
Specialty medications are covered on Tier 4 (listed on page 20).
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
INFECTIONS (cont) NUTRITIONAL/DIETARY
penicillin V Plaquenil (PA) calcitriol capsule, CitraNatal Auryxia (QL)
permethrin Priftin solution Floriva+ Fosrenol chew
sulfamethoxazole- Seysara (PA) cyanocobalamin Fosrenol packet K-Tab ER
TMP suspension, Sitavig (PA, QL) injection Klor-Con M15 NASCOBAL (PA)
tablet Sivextro tablet (PA) daily prenatal+ Mephyton Phoslyra
terbinafine tablet Sklice FA-8+ NeevoDHA PreGenna (PA)
tetracycline Solodyn (PA)
folic acid 0.4mg, OB Complete Renvela
valacyclovir Solosec
valganciclovir Sporanox (PA) 0.8mg+ Perry Prenatal+ Trinaz (PA)
vancomycin capsule Sulfatrim folic acid 1mg Prenate Velphoro
Vandazole Suprax Klor-Con 8, 10 PrimaCare Veltassa
voriconazole TargaDOX (PA) Klor-Con M10, M20 Quflora drop, 1mg vitaPearl
suspension, tablet Tamiflu (QL) Klor-Con Sprinkle tablet+
(PA) TOLSURA lanthanum Rocaltrol
Urogesic-Blue phytonadione tablet Tri-vi-flor+
Valcyte (PA) potassium chloride VELPHORO
Valtrex capsule, packet, Vitafol
Vancocin (PA) solution, tablet
Vibramycin capsule Prenatal+
(PA)
Prenatal Vitamin+
Vibramycin
suspension sevelamer
Xenleta (PA, QL) vitamin D2 1.25mg
Xofluza (QL) vitamin D3 5,000
Zithromax packet, unit+
suspension, tablet OSTEOPOROSIS PRODUCTS
Zithromax Tri-Pak
alendronate (QL) Actonel (ST)
Zovirax suspension
(PA) calcitonin-salmon Atelvia (ST)
Zyvox (PA) ibandronate tablet Binosto (ST)
raloxifene+ Boniva tablet (ST)
risedronate Evista
risedronate DR Fosamax (ST)
Fosamax Plus D
INFERTILITY (ST)
chorionic Crinone 8%^
gonadotropin Endometrin^ PAIN RELIEF AND INFLAMMATORY DISEASE
clomiphene acetaminophen- Aimovig (PA) Allzital (PA)
tablet^
codeine (PA) AJOVY (PA) Amrix ER 15mg
MISCELLANEOUS allopurinol BELBUCA (QL) (PA, QL)
Accu-Chek lancets Addyi (PA, QL) Aprizio Pak Emgality(PA) Amrix ER 30mg
disulfiram Brisdelle (QL) baclofen tablet Hysingla ER (PA) (PA)
Droplet lancets Horizant (PA) BUPAP (PA) MorphaBond ER Amrix ER (QL)
Fingerstix NUEDEXTA (QL) buprenorphine (PA) Analpram HC
Microlet langets patch, tablet (QL) NUCYNTA (PA) Arava
Nebusal 3% butalbital- Nurtec ODT (PA, QL) Arymo ER (PA)
OneTouch lancets
acetaminophen- proctofoam-HC Butrans (QL)
PULMOSAL
Single-Let caffeine (PA) Rasuvo (PA) Cambia (PA)
TechLITE lancets carisoprodol RediTrex (PA) Celebrex (ST, QL)
celecoxib (QL) Savella Colcrys
14Cigna Legacy (Performance) 4-Tier Prescription Drug List
Specialty medications are covered on Tier 4 (listed on page 20).
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
PAIN RELIEF AND INFLAMMATORY DISEASE (cont) PAIN RELIEF AND INFLAMMATORY DISEASE (cont)
colchicine UBRELVY (PA, QL) diclofenac patch Lidopril Tosymra (PA, QL)
cyclobenzaprine Uloric (QL) (PA, QL) Lidopril XR Treximet (PA, QL)
cyclobenzaprine ER Xtampza ER (PA) DUEXIS (PA) Lido-Prilo Caine Tylenol-Codeine
(QL) ZTlido Duragesic (PA) Pack No.3 (PA)
DermacinRx EC-Naprosyn (ST) Livixil Pak Tylenol-Codeine
Empricaine Ergomar (PA) Lorcet (PA) No.4 (PA)
DermacinRx Esgic (QL) Lorcet HD (PA) Ultram (QL)
Prizopak Fexmid Lorcet Plus (PA) Vanatol LQ (PA)
diclofenac DR Flector (PA, QL) Lortab (PA) Vanatol S (PA)
diclofenac EC Frova (PA, QL) meloxicam Vimovo (PA, QL)
diclofenac ER GLOPERBA (PA, QL) metaxalone Voltaren 1% gel
diclofenac 1% gel GRALISE (PA) methocarbamol (PA, QL)
(QL) Imitrex (PA, QL) tablet Zanaflex
diclofenac 1.5% Indocin (PA) morphine solution, Zebutal (QL)
topical solution Kadian ER (PA) suppository, tablet Zembrace
(PA) Licart (PA, QL) (PA) SYMTOUCH (PA,
EC-Naproxen Lidoderm morphine ER (PA) QL)
eletriptan (QL) Lorzone (PA) nabumetone Zipsor (PA)
Endocet (PA) Maxalt (PA) Nalfon 600mg (ST) Zohydro ER (PA)
etodolac Maxalt-MLT (PA) Nalocet (PA) Zomig (PA, QL)
etodolac ER MIGRANAL (PA, QL) naproxen Zomig ZMT (PA,
Fenortho (PA) Mitigare naproxen CR (PA) QL)
fentanyl (PA) Mobic (ST) naproxen DR Zorvolex (PA)
Fioricet (QL) MS Contin (PA) naproxen ER (PA) Zyloprim
frovatriptan (QL) Nalfon 400 mg (ST) oxycodone (PA)
Glydo NAPRELAN (PA) oxycodone ER (PA)
hydrocodone- Naprosyn (ST) oxycodone-
acetaminophen Norco (PA) acetaminophen
(PA) Nucynta ER (PA) (PA)
hydromorphone ONZETRA Xsail (PA, Prilolid
solution, QL) Prilovix
suppository, tablet Otrexup (PA) Primlev (PA)
(PA) Oxaydo (PA) Relador Pak
hydromorphone ER OxyContin (PA) Relador Pak Plus
(PA) PENNSAID pump rizatriptan (QL)
IBU (PA) sumatriptan (QL)
ibuprofen 400mg, PENNSAID solution sumatriptan-
600mg, 800mg packet (PA, ST) naproxen (QL)
tablet Percocet (PA) tizanidine
indomethacin Procort tramadol (QL)
capsule QDOLO (PA, QL) tramadol ER (QL)
indomethacin ER Qmiiz ODT (ST, QL) Vicodin HP (PA)
ketorolac (QL) RELPAX (PA, QL)
leflunomide REYVOW (PA, QL)
levorphanol (PA) Roxicodone (PA)
lidocaine (QL) Skelaxin
lidocaine viscous SPRIX (PA, QL)
lidocaine-prilocaine SUBSYS (PA)
15Cigna Legacy (Performance) 4-Tier Prescription Drug List
Specialty medications are covered on Tier 4 (listed on page 20).
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
PARKINSON’S DISEASE SEIZURE DISORDERS (cont)
benztropine tablet KYNMOBI (PA) Azilect (QL) divalproex ER VIMPAT solution, BRIVIACT solution,
bromocriptine Gocovri ER Epitol tablet (PA) tablet (PA)
carbidopa-levodopa Lodosyn (PA) gabapentin Carbatrol ER (PA)
carbidopa-levodopa Mirapex lamotrigine Depakote (PA)
ER Mirapex ER (QL) lamotrigine (blue, Depakote ER (PA)
pramipexole Neupro green, orange) Depakote Sprinkle
pramipexole ER (QL) Ongentys (PA, QL) lamotrigine ER (PA)
rasagiline (QL) Osmolex ER (QL) lamotrigine ODT Dilantin 50mg,
ropinirole Parlodel levetiracetam 100mg (PA)
ropinirole ER REQUIP XL (PA) solution, tablet Keppra solution,
RYTARY levetiracetam ER tablet (PA)
Sinemet oxcarbazepine Klonopin (PA)
Sinemet CR Roweepra Lamictal (PA)
Tasmar Roweepra XR Lamictal XR (PA)
XADAGO (ST) Subvenite Lyrica (PA)
Zelapar (PA) Subvenite (Blue, Lyrica CR
Green, Orange) Mysoline (PA)
topiramate Neurontin (PA)
topiramate ER Onfi (PA)
SCHIZOPHRENIA/ANTI-PSYCHOTICS Oxtellar XR (PA)
Phenytek (PA)
aripiprazole (QL) Latuda (QL) Abilify MyCite (PA)
Qudexy XR (PA)
aripiprazole ODT Fanapt (ST, QL)
chlorpromazine Geodon capsule Spritam (PA)
tablet (PA) Sympazan (PA)
olanzapine tablet Invega ER (ST, QL) Tegretol (PA)
olanzapine ODT Invega Sustenna Tegretol XR (PA)
paliperidone ER (QL) (QL) Trokendi XR 50mg,
quetiapine Invega Trinza (QL) 200mg (PA)
quetiapine ER Perseris ER Syringe Trokendi XR 25mg,
risperidone Kit (QL) 100mg (PA, QL)
risperidone ODT REXULTI (ST, QL) VALTOCO (PA, QL)
ziprasidone Risperdal (ST) XCOPRI
Saphris (ST) SKIN CONDITIONS
Secuado (ST) adapalene (PA age) Aczone 7.5% gel ABSORICA (ST, QL)
Seroquel (ST) adapalene-benzoyl ARAZLO ABSORICA LD (ST,
Seroquel XR (ST) peroxide Drysol QL)
Versacloz (PA) Amnesteem (QL) EPIDUO FORTE Acanya
Vraylar (ST, QL) Anusol-HC cream Eucrisa Aczone 5% gel
ZYPREXA tablet (PA) Fluoroplex AKLIEF
(PA) Apexicon E (PA) HALOG (PA, QL) Aldara (PA)
ZYPREXA ZYDIS Avar NAFTIN gel Amzeeq (PA)
(PA) Avar-E Oxistat 1% lotion Atralin (PA age)
SEIZURE DISORDERS Avar-E Green (PA) Avita (PA age)
azelaic acid Pramosone BenzaClin (PA)
carbamazepine Dilantin 30 mg (PA) Aptiom (PA, QL)
Bensal HP (PA) 1%-1% cream, BRYHALI (ST)
carbamazepine ER Fycompa (PA, QL) Banzel (PA, QL)
betamethasone 1% lotion, Capex (ST)
clonazepam Nayzilam (PA, QL)
dipropionate
divalproex ointment Carac (PA)
augmented
16Cigna Legacy (Performance) 4-Tier Prescription Drug List
Specialty medications are covered on Tier 4 (listed on page 20).
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
SKIN CONDITIONS (cont) SKIN CONDITIONS (cont)
betamethasone Picato Celacyn Rosadan 0.75% Oxistat 1% cream
BP 10-1 Promiseb cream Centany cream (PA) (PA)
calcipotriene Santyl (QL) Cleocin T Rosadan 0.75% gel Pandel (PA)
calcipotriene- Tazorac gel, 0.05% Clindagel (PA) sodium Picato
betamethasone DP cream Clobex (PA) sulfacetamide- Pramosone 2.5%-
Clindacin ETZ Cloderm (ST) sulfur 1% cream, lotion
pledget Condylox (PA) SSS 10-5 Psorcon (QL)
Clindacin P pledget Sulfacleanse 8-4 Qbrexza
Cordran (PA)
clindamycin- tacrolimus ointment REGRANEX (PA, QL)
Cutivate (PA)
benzoyl peroxide tazarotene Retin-A (PA age)
Denavir (QL) tretinoin (PA age)
clindamycin DesOwen (ST) RETIN-A MICRO (PA
phosphate tretinoin age)
Diferin 0.1% cream microsphere (PA
clindamycin- and lotion, 0.3% Sernivo (PA)
tretinoin age) Soolantra (PA)
gel pump (PA triamcinolone
clobetasol Sorilux (PA)
age) Trianex (PA)
Clodan shampoo Taclonex (PA)
Dovonex Triderm
clotrimazole- Tazorac 0.1%
Duobrii Zenatane (QL)
betamethasone cream
dapsone gel Ecoza
Efudex Tolak
desoximetasone Topicort (ST))
diclofenac 3% gel Elidel
Enstilar (PA) Ultravate (PA)
(PA) Ultravate X (ST)
diflorasone (PA) Epiduo
ERTACZO (PA) Vanos (PA)
fluocinonide Vectical (QL)
fluorouracil cream, Evoclin
Exelderm (PA) Verdeso (PA)
solution
Extina (PA) VELTIN
flurandrenolide (PA)
Fabior Vusion (PA)
halobetasol
Finacea (PA) Winlevi (PA)
hydrocortisone
2.5% HALOG cream, Wynzora (PA)
hydrocortisone ointment (PA) Xepi
butyrate 0.1% Impeklo (PA) XERESE (PA, QL)
lotion. 0.1% lipid Impoyz (PA) Xolegel (PA)
cream, lipo cream Jublia (PA) ZIANA (PA)
(PA) Kenalog 0.147 mg/ Zilxi (PA)
isotretinoin (QL) gm spray (PA) Zonalon (PA, QL)
ketoconazole Kerydin (PA) ZOVIRAX cream,
metronidazole LEXETTE (ST) ointment (PA, QL)
MiCort HC 2.5% Locoid (PA) Zyclara 2.5% cream
cream Loprox suspension pump, 3.75%
mupirocin Lotrisone cream (PA, QL)
Myorisan (QL) LUZU (PA) Zyclara 3.75%
Neuac gel MetroCream (PA) cream pump (PA)
Nolix MetroGel (PA)
oxiconazole MetroLotion (PA)
pimecrolimus Noritate (PA)
Procto-Med HC
Olux (PA)
Procto-Pak
Olux-E (PA)
Proctosol-HC
ONEXTON
Proctozone-HC
17Cigna Legacy (Performance) 4-Tier Prescription Drug List
Specialty medications are covered on Tier 4 (listed on page 20).
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
SLEEP DISORDERS/SEDATIVES VACCINES
armodafinil (PA) DAYVIGO (ST, QL) Ambien (PA) Vaccines are now covered under your pharmacy benefit. Not all
eszopiclone Silenor (ST, QL) Ambien CR (PA, plans cover vaccines in the same way. Log in to the myCigna App
or myCigna.com, or check your plan materials, to find out how your
modafinil (PA) SUNOSI (PA, QL) QL) specific plan covers them.
temazepam Ativan (PA)
Diphtheria and ActHIB+
zolpidem Belsomra (PA) Tetanus Toxoids- Adacel Tdap+
zolpidem ER (QL) Edluar 5mg (PA, QL) ped+ Afluria Quad+
Edluar 10mg (PA) TdVax+ BEXSERO+
Intermezzo (PA) Boostrix Tdap+
Lunesta (ST) DAPTACEL DTaP+
Nuvigil (PA) Engerix-B+
Provigil (PA) FLUAD+
Restoril (PA) FLUARIX
Rozerem (ST, QL) QUADRIVALENT+
ZolpiMiST (PA)
FLUBLOK
SMOKING CESSATION QUADRIVALENT+
bupropion SR +
CHANTIX NicoDerm CQ FLUCELVAX
NicoDerm CQ Nicotrol 7mg/24hr, QUADRIVALENT+
21mg/24hr+ Nicotrol NS 14mg/24hr+ FLUALVAL
Nicorelief+ Nicorette+ QUADRIVALENT+
nicotine gum+ Fluzone High-dose+
nicotine lozenge+ Fluzone
nicotine patch+ Quadrivalent Pedi+
Quit 2+ Fluzone
Quit 4+ Quadrivalent+
SUBSTANCE ABUSE GARDASIL 9+
buprenorphine- Lucemyra (QL) Bunavail HAVRIX+
naloxone NARCAN (QL) Evzio (PA, QL) HEPLISAV-B+
Zubsolv Suboxone Hiberix+
URINARY TRACT CONDITIONS Infanrix DTaP+
IPOL+
cevimeline Elmiron Avodart
KINRIX+
darifenacin ER (QL) Toviaz (QL) Evoxac
finasteride 5mg Flomax Menactra+
oxybutynin Gelnique (ST) Menveo A-C-Y-W-
oxybutynin ER Myrbetriq ER (ST, 135-DIP+
phenazopyridine QL) M-M-R II+
potassium citrate ER Proscar PEDIARIX+
silodosin (QL) Pyridium PedvaxHIB+
solifenacin (QL) RAPAFLO (QL) Pentacel+
tamsulosin Urocit-K PNEUMOVAX 23+
tolterodine VESIcare (ST) Prevnar 13+
tolterodine ER (QL) ProQuad+
trospium Quadracel DTaP-
trospium ER IPV+
Recombivax HB+
SHINGRIX+
Tenivac+
Trumenba+
Twinrix+
18Cigna Legacy (Performance) 4-Tier Prescription Drug List
Specialty medications are covered on Tier 4 (listed on page 20).
TIER 1 TIER 2 TIER 3
$ $$ $$$
VACCINES (cont)
Vaccines are now covered under your pharmacy benefit. Not all
plans cover vaccines in the same way. Log in to the myCigna App
or myCigna.com, or check your plan materials, to find out how your
specific plan covers them.
VAQTA+
VARIVAX+
ZOSTAVAX+
19Specialty medications
The oral and injectable specialty medications listed below are covered on Tier 4 and need approval
from Cigna before your plan will cover them.
MEDICATION NAME DRUG CLASS
abacavir-lamivudine** (PA) AIDS/HIV
abiraterone** (PA) CANCER
ACTEMRA syringe* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
ACTEMRA ACTPen* PAIN RELIEF AND INFLAMMATORY DISEASE
Actimmune* (PA) CANCER
Adcirca** (PA) ASTHMA/COPD/RESPIRATORY
Adempas** (PA) ASTHMA/COPD/RESPIRATORY
Afinitor** (PA) CANCER
Afinitor Disperz** (PA) CANCER
Alecensa** (PA) CANCER
ALUNBRIG** (PA) CANCER
Alyq** (PA) ASTHMA/COPD/RESPIRATORY
aminocaproic acid** BLOOD MODIFIERS/BLEEDING DISORDERS
Ampyra** (PA) MULTIPLE SCLEROSIS
Apokyn* (PA) PARKINSON'S DISEASE
Aralast NP* (PA) ASTHMA/COPD/RESPIRATORY
Aranesp* (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
Arikayce** (PA) INFECTIONS
Arixtra* (QL) BLOOD THINNERS/ANTI-CLOTTING
atazanavir** (PA) AIDS/HIV
Atripla** (PA) AIDS/HIV
Astagraf XL** TRANSPLANT MEDICATIONS
Aubagio** (PA) MULTIPLE SCLEROSIS
Austedo** (PA) MISCELLANEOUS
Aveed* HORMONAL AGENTS
Avonex* (PA) MULTIPLE SCLEROSIS
Avsola* (PA) PAIN RELIEF AND INFLAMMATORY DISEASE
azathioprine** TRANSPLANT MEDICATIONS
Bafiertam** (PA) MULTIPLE SCLEROSIS
Baraclude** (PA) INFECTIONS
Benlysta* (PA) PAIN RELIEF AND INFLAMMATORY DISEASE
Berinert* BLOOD PRESSURE/HEART MEDICATIONS
Betaseron* (PA) MULTIPLE SCLEROSIS
Bethkis** (PA, QL) INFECTIONS
Biktarvy** AIDS/HIV
Boniva** OSTEOPOROSIS PRODUCTS
Bosulif** (PA) CANCER
Botox* MISCELLANEOUS
Bynfezia* (PA) HORMONAL AGENTS
20MEDICATION NAME DRUG CLASS
Cabometyx** (PA) CANCER
capecitabine** (PA) CANCER
Cayston** (PA, QL) INFECTIONS
Cellcept** TRANSPLANT MEDICATIONS
Cerdelga** (PA) MISCELLANEOUS
Cerezyme* MISCELLANEOUS
Cetrotide*^ (PA) HORMONAL AGENTS
Cholbam** (PA) GASTROINTESTINAL/HEARTBURN
chorionic gonadotropin*^ (PA) INFERTILITY
Cimduo** (PA) AIDS/HIV
Cimzia* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
Cinryze* BLOOD PRESSURE/HEART MEDICATIONS
Cometriq** (PA) CANCER
Complera** (PA) AIDS/HIV
Copaxone* (PA) MULTIPLE SCLEROSIS
Cosentyx* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
Cyklokapron* BLOOD MODIFIERS/BLEEDING DISORDERS
Cystagon** URINARY TRACT CONDITIONS
Cystaran** (PA, QL) EYE CONDITIONS
Daraprim** (PA) INFECTIONS
DDAVP ampule, vial* (PA) HORMONAL AGENTS
Depen** (PA) PAIN RELIEF AND INFLAMMATORY DISEASE
DESCOVY**+ AIDS/HIV
desmopressin ampule, vial* HORMONAL AGENTS
Dovato** AIDS/HIV
Duopa** PARKINSON'S DISEASE
Dupixent* (PA) PAIN RELIEF AND INFLAMMATORY DISEASE
Durolane* PAIN RELIEF AND INFLAMMATORY DISEASE
Dysport* MISCELLANEOUS
Egrifta* (PA) HORMONAL AGENTS
Elaprase* MISCELLANEOUS
Eligard* CANCER
Emflaza** (PA) HORMONAL AGENTS
Enbrel* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
entecavir** (QL) INFECTIONS
Entyvio* (PA) GASTROINTESTINAL/HEARTBURN
Envarsus XR** TRANSPLANT MEDICATIONS
Epclusa** (PA) INFECTIONS
Epidiolex** (PA) SEIZURE DISORDERS
Epogen*^ (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
Erivedge** (PA) CANCER
Erleada** (PA) CANCER
Esbriet** (PA) MISCELLANEOUS
21MEDICATION NAME DRUG CLASS
Euflexxa* PAIN RELIEF AND INFLAMMATORY DISEASE
Evotaz** (PA) AIDS/HIV
Exjade** (PA) MISCELLANEOUS
Extavia* (PA) MULTIPLE SCLEROSIS
Fasenra Pen* (PA) ASTHMA/COPD/RESPIRATORY
FENSOLVI*^ (PA) HORMONAL AGENTS
Ferriprox** (PA) MISCELLANEOUS
Firazyr* (PA) BLOOD PRESSURE/HEART MEDICATIONS
Follistim AQ*^ (PA) INFERTILITY
fondaparinux* (QL) BLOOD THINNERS/ANTI-CLOTTING
Forteo* (PA, QL) HORMONAL AGENTS
Fragmin* (QL) BLOOD THINNERS/ANTI-CLOTTING
Fulphila* (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
Galafold** (PA) MISCELLANEOUS
Ganirelix* (PA) HORMONAL AGENTS
Gattex* (PA) GASTROINTESTINAL/HEARTBURN
Gel-One* PAIN RELIEF AND INFLAMMATORY DISEASE
Gelsyn-3* PAIN RELIEF AND INFLAMMATORY DISEASE
GENOTROPIN* (PA) HORMONAL AGENTS
Genvoya** AIDS/HIV
Gilenya** (PA) MULTIPLE SCLEROSIS
Glassia* ASTHMA/COPD/RESPIRATORY
glatiramer* (PA) MULTIPLE SCLEROSIS
Glatopa* (PA) MULTIPLE SCLEROSIS
Gleevec** (PA) CANCER
Gonal-f*^ (PA) INFERTILITY
GONAL-f RFF*^ (PA) INFERTILITY
GRANIX* (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
Haegarda* (PA) BLOOD PRESSURE/HEART MEDICATIONS
Harvoni** (PA, QL) INFECTIONS
Hemlibra* (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
Hetlioz** (PA) SLEEP DISORDERS/SEDATIVES
Humatrope* (PA) HORMONAL AGENTS
Humira* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
Hyalgan* PAIN RELIEF AND INFLAMMATORY DISEASE
Hymovis* PAIN RELIEF AND INFLAMMATORY DISEASE
hydroxyprogesterone caproate* INFERTILITY
ibandronate syringe, vial * OSTEOPOROSIS PRODUCTS
Ibrance** (PA) CANCER
Ilaris* (PA) PAIN RELIEF AND INFLAMMATORY DISEASE
Ilumya* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
imatinib** (PA) CANCER
Imbruvica** (PA) CANCER
22MEDICATION NAME DRUG CLASS
Inbrija** (PA) PARKINSON’S DISEASE
Increlex* (PA) HORMONAL AGENTS
Inflectra* PAIN RELIEF AND INFLAMMATORY DISEASE
Ingrezza** (PA) MISCELLANEOUS
Inlyta** (PA) CANCER
Intelence** (PA) AIDS/HIV
Isentress** AIDS/HIV
Isentress HD** (PA) AIDS/HIV
Jadenu** (PA) MISCELLANEOUS
Jadenu Sprinkle** (PA) MISCELLANEOUS
Jakafi** (PA) CANCER
Juluca** (PA) AIDS/HIV
Jynarque** (PA) DIURETICS
Kalbitor* BLOOD PRESSURE/HEART MEDICATIONS
Kalydeco** (PA, QL) ASTHMA/COPD/RESPIRATORY
Kanjinti* (PA) CANCER
Kesimpta* (PA) MULTIPLE SCLEROSIS
Kevzara* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
Kineret* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
Kisqali** (PA) CANCER
Kitabis Pak** (PA, QL) INFECTIONS
Korlym** (PA) DIABETES
Kuvan** (PA) MISCELLANEOUS
Kyleena**+ CONTRACEPTION PRODUCTS
ledipasvir-sofosbuvir** (PA) INFECTIONS
Lenvima** (PA) CANCER
Letairis** (PA) ASTHMA/COPD/RESPIRATORY
Lonsurf** (PA) CANCER
Lotronex** (PA) GASTROINTESTINAL/HEARTBURN
Lorbrena** (PA) CANCER
Lovenox* (QL) BLOOD THINNERS/ANTI-CLOTTING
Lumizyme* MISCELLANEOUS
Lupaneta Pack* (PA) HORMONAL AGENTS
LUPRON DEPOT* (PA) CANCER
LUPRON DEPOT-PED* (PA) HORMONAL AGENTS
Lynparza** (PA) CANCER
Lysteda** BLOOD MODIFIERS/BLEEDING DISORDERS
Makena* INFERTILITY
Mavenclad** MULTIPLE SCLEROSIS
Mavyret** (PA) INFECTIONS
Mayzent* (PA) MULTIPLE SCLEROSIS
Mekinist** (PA) CANCER
Menopur*^ (PA) INFERTILITY
23MEDICATION NAME DRUG CLASS
Mirena**+ CONTRACEPTION PRODUCTS
Monovisc* PAIN RELIEF AND INFLAMMATORY DISEASE
MVASI* (PA) CANCER
Myalept* (PA) MISCELLANEOUS
mycophenolate** TRANSPLANT MEDICATIONS
mycophenolic acid** TRANSPLANT MEDICATIONS
Myfortic** TRANSPLANT MEDICATIONS
Natpara* (PA) HORMONAL AGENTS
Nerlynx** (PA) CANCER
Neulasta* (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
Neupogen* (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
Nexavar** (PA) CANCER
Nexplanon* CONTRACEPTION PRODUCTS
Ninlaro** (PA) CANCER
Nityr** (PA) MISCELLANEOUS
Nivestym*^ BLOOD MODIFIERS/BLEEDING DISORDERS
Norditropin FlexPro* (PA) HORMONAL AGENTS
Northera** (PA) BLOOD PRESSURE/HEART MEDICATIONS
Nourianz** (PA, QL) PARKINSON’S DISEASE
Novarel*^ (PA) INFERTILITY
Nubeqa** (PA) CANCER
Nucala* (PA) ASTHMA/COPD/RESPIRATORY
Nutropin AQ Nuspin* (PA) HORMONAL AGENTS
NUZYRA** tablet (PA) INFECTIONS
Nyvepria* (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
Ocaliva** (PA) GASTROINTESTINAL/HEARTBURN
Ocrevus* MULTIPLE SCLEROSIS
Odefsey** (PA) AIDS/HIV
Odomzo** (PA) CANCER
OFEV** (PA) ASTHMA/COPD/RESPIRATORY
Ogivri* (PA) CANCER
Olumiant** (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
Omnitrope* (PA) HORMONAL AGENTS
Opsumit** (PA) ASTHMA/COPD/RESPIRATORY
ORENCIA* syringe (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
Orenitram ER** (PA) ASTHMA/COPD/RESPIRATORY
Orfadin** (PA) MISCELLANEOUS
Orkambi** (PA, QL) ASTHMA/COPD/RESPIRATORY
Orthovisc* PAIN RELIEF AND INFLAMMATORY DISEASE
Otezla** (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
Ovidrel*^ (PA) INFERTILITY
Oxervate** (PA) EYE CONDITIONS
Palynziq* (PA) MISCELLANEOUS
24MEDICATION NAME DRUG CLASS
Pegasys* (PA) INFECTIONS
Plegridy* (PA) MULTIPLE SCLEROSIS
Pomalyst** (PA) CANCER
Prevymis** INFECTIONS
Prezcobix** (PA) AIDS/HIV
Prezista** AIDS/HIV
PROCRIT*^ (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
Procysbi** (PA) URINARY TRACT CONDITIONS
Prograf** TRANSPLANT MEDICATIONS
Prolastin C* (PA) ASTHMA/COPD/RESPIRATORY
Prolia* OSTEOPOROSIS PRODUCTS
Promacta** (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
Pulmozyme** (PA) ASTHMA/COPD/RESPIRATORY
Purixan** CANCER
Rapamune** TRANSPLANT MEDICATIONS
Ravicti** (PA) GASTROINTESTINAL/HEARTBURN
Rebif* (PA) MULTIPLE SCLEROSIS
Rebif Rebidose* (PA) MULTIPLE SCLEROSIS
Rebif Rebidose* (PA) MULTIPLE SCLEROSIS
Remicade* (PA) PAIN RELIEF AND INFLAMMATORY DISEASE
Remodulin* ASTHMA/COPD/RESPIRATORY
Renflexis* PAIN RELIEF AND INFLAMMATORY DISEASE
Retacrit* (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
REVATIO** suspension, tablet (PA) ASTHMA/COPD/RESPIRATORY
Revlimid** (PA) CANCER
RINVOQ** (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
ritonavir** AIDS/HIV
Rubraca** (PA) CANCER
Ruconest* BLOOD PRESSURE/HEART MEDICATIONS
Ruxience* (PA) CANCER
Sabril** (PA) SEIZURE DISORDERS
Samsca** DIURETICS
Sandostatin LAR Depot* (PA) HORMONAL AGENTS
Selzentry** (PA) AIDS/HIV
Sensipar** (PA) GASTROINTESTINAL/HEARTBURN
Serostim* (PA) HORMONAL AGENTS
Siliq* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
Simponi* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
Simponi Aria* (PA) PAIN RELIEF AND INFLAMMATORY DISEASE
sirolimus** TRANSPLANT MEDICATIONS
Skyla**+ CONTRACEPTION PRODUCTS
Skyrizi* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
sofosbuvir-velpatasvir** (PA) INFECTIONS
25MEDICATION NAME DRUG CLASS
Soliris* BLOOD MODIFIERS/BLEEDING DISORDERS
Somatuline Depot* (PA) HORMONAL AGENTS
Somavert* (PA) HORMONAL AGENTS
Sovaldi** (PA, QL) INFECTIONS
Sprycel** (PA) CANCER
Stelara* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
Strensiq* (PA) MISCELLANEOUS
Stribild** (PA) AIDS/HIV
Stivarga** (PA) CANCER
Sublocade* SUBSTANCE ABUSE
Sucraid** (PA) GASTROINTESTINAL/HEARTBURN
Supartz FX* PAIN RELIEF AND INFLAMMATORY DISEASE
Supprelin LA** (PA) HORMONAL AGENTS
Sutent** (PA) CANCER
Symdeko** (PA, QL) ASTHMA/COPD/RESPIRATORY
Symfi** AIDS/HIV
Symfi LO** AIDS/HIV
Symtuza** (PA) AIDS/HIV
Synagis* INFECTIONS
Synvisc* PAIN RELIEF AND INFLAMMATORY DISEASE
SYPRINE** (PA, QL) MISCELLANEOUS
tacrolimus capsule** TRANSPLANT MEDICATIONS
tadalafil 20mg** (PA) ASTHMA/COPD/RESPIRATORY
Tafinlar** (PA) CANCER
Tagrisso** (PA) CANCER
Takhzyro* (PA) BLOOD PRESSURE/HEART MEDICATIONS
Taltz* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
Talzenna** (PA) CANCER
Targretin** (PA) CANCER
Tasigna** (PA) CANCER
Tavalisse** (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
Tecfidera** (PA) MULTIPLE SCLEROSIS
Tegsedi* (PA) MISCELLANEOUS
Temixys** (PA) AIDS/HIV
Temodar** (PA) CANCER
temozolomide** (PA) CANCER
tenofovir** (PA) AIDS/HIV
Teriparatide* (PA, QL) HORMONAL AGENTS
tetrabenazine** (PA) MISCELLANEOUS
Thalomid** (PA) INFECTIONS
Thiola** URINARY TRACT CONDITIONS
Thyrogen* HORMONAL AGENTS
Tiglutik** (PA) MISCELLANEOUS
26MEDICATION NAME DRUG CLASS
Tivicay** AIDS/HIV
TOBI podhaler** (PA, QL) INFECTIONS
tobramycin ampule** (PA, QL) INFECTIONS
Tracleer** (PA) ASTHMA/COPD/RESPIRATORY
tranexamic acid** BLOOD MODIFIERS/BLEEDING DISORDERS
Trazimera* (PA) CANCER
Trelstar* CANCER
Tremfya* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
treprostinil* (PA) ASTHMA/COPD/RESPIRATORY
trientine** (PA) MISCELLANEOUS
Triluron* (PA) PAIN RELIEF AND INFLAMMATORY DISEASE
Triptodur* HORMONAL AGENTS
Triumeq** AIDS/HIV
Trivisc* PAIN RELIEF AND INFLAMMATORY DISEASE
Truvada** (PA) AIDS/HIV
Tykerb** (PA) CANCER
Tymlos* (PA, QL) OSTEOPOROSIS PRODUCTS
Tysabri* (PA) MULTIPLE SCLEROSIS
Tyvaso** (PA) ASTHMA/COPD/RESPIRATORY
Udenyca*^ (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
Uptravi** (PA) ASTHMA/COPD/RESPIRATORY
Valchlor** SKIN CONDITIONS
Vemlidy** INFECTIONS
Venclexta** (PA) CANCER
Verzenio** (PA) CANCER
vigabatrin** SEIZURE DISORDERS
vigadrone** SEIZURE DISORDERS
Visco-3* PAIN RELIEF AND INFLAMMATORY DISEASE
Vivitrol* MISCELLANEOUS
Vizimpro** (PA) CANCER
Vosevi** (PA) INFECTIONS
Votrient** (PA) CANCER
Vumerity** (PA) MULTIPLE SCLEROSIS
VYLEESI* (PA, QL) MISCELLANEOUS
Wakix** (PA, QL) SLEEP DISORDERS/SEDATIVES
Xalkori** (PA) CANCER
Xeljanz** (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
Xeljanz XR** (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
Xeloda** (PA) CANCER
Xenazine** (PA) MISCELLANEOUS
Xermelo** (PA) GASTROINTESTINAL/HEARTBURN
XGEVA* OSTEOPOROSIS PRODUCTS
Xiaflex* PAIN RELIEF AND INFLAMMATORY DISEASE
27MEDICATION NAME DRUG CLASS
Xolair* (PA) ASTHMA/COPD/RESPIRATORY
Xtandi** (PA) CANCER
Xyrem** (PA) SLEEP DISORDERS/SEDATIVES
Yonsa** (PA, QL) SLEEP DISORDERS/SEDATIVES
Zarxio* BLOOD MODIFIERS/BLEEDING DISORDERS
Zejula** (PA) CANCER
Zepatier** (PA) INFECTIONS
Zeposia** (PA) MULTIPLE SCLEROSIS
Ziextenzo* (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
Zirabev* (PA) CANCER
Zomacton* (PA) HORMONAL AGENTS
Zorbtive* (PA) HORMONAL AGENTS
Zortress** TRANSPLANT MEDICATIONS
Zytiga** (PA) CANCER
28Frequently Asked Questions (FAQs)
Understanding your prescription medication coverage can be confusing. Here are answers
to some commonly asked questions.
Q. Why do you make changes to the drug list? manufacturers, medical professional associations,
national organizations and peer-reviewed
A. Cigna regularly reviews and updates the
journals about the safety and effectiveness of
prescription drug list. We make changes for
medications that are newly approved by the FDA
many reasons – like when new medications
and medications already on the market. The
become available or are no longer available, or
Cigna Pharmacy Management® Business
when medication prices change. We try to give
Decision Team then looks at the results of the
you many options to choose from to treat your
P&T Committee’s clinical review, as well as the
health condition. These changes may include:1,2
medication’s overall value and other factors
› Moving a medication to a lower cost tier. This before adding it to, or removing it from, the
can happen at any time during the year. drug list.
› Moving a brand medication to a higher cost
tier when a generic becomes available. This Q. Why do certain medications need approval
can happen at any time during the year. before my plan will cover them?
› Moving a medication to a higher cost tier and/ A. The review process helps to make sure you’re
or no longer covering a medication. This receiving coverage for the right medication, at
typically happens twice a year on January 1st the right cost, in the right amount and for the
and July 1st. right situation.
› Adding extra coverage requirements to a
medication. Q. How do I know if I’m taking a medication
When we make a change that affects the that needs approval?
coverage of a medication you’re taking, we let A. Log in to the myCigna App or myCigna.com,
you know before it happens. This way, you have or check your plan materials, to learn more about
time to talk with your doctor about your options. how your plan covers your medications. If your
medication has a (PA) or (ST) next to it, your
Q. Why doesn’t my plan cover certain medication needs approval before your plan will
medications? cover it. If it has a (QL) next to it, you may need
A. Your plan may exclude certain medications or approval depending on the amount you’re filling.
products from coverage. This is known as a “plan If is has (AGE) next to it, you may need approval
(or benefit) exclusion.” For example, your plan depending on the covered age range for the
excludes medications that aren’t approved by medication.
the U.S. Food and Drug Administration (FDA).
With excluded medications, there’s no option to Q. What types of medications typically need
receive coverage through Cigna’s coverage approval?
review process. A. Medications that:
Q. How do you decide which medications › May be unsafe when combined with other
to cover? medications
A. The Cigna Prescription Drug List is developed › Have lower-cost, equally effective alternatives
with the help of Cigna’s Pharmacy and available
Therapeutics (P&T) Committee, which is a group › Should only be used for certain health
of practicing doctors and pharmacists, most of conditions
whom work outside of Cigna. The group meets › Are often misused or abused
regularly to review medical evidence and
information provided by federal agencies, drug
29You can also read
