CIGNA PERFORMANCE 3-TIER PRESCRIPTION DRUG LIST - As of July 1, 2019
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
CIGNA PERFORMANCE 3-TIER PRESCRIPTION DRUG LIST As of July 1, 2019 Offered by Cigna Health and Life Insurance Company or Connecticut General Life Insurance Company 827293 x Performance 3-Tier 03/19
Table of Contents
Getting started
Your prescription drug list 3
How to read your drug list 3
How to find your medication 5
Medications that are not covered 17
Prescription drug list FAQs 25
Exclusions and limitations 27
View your drug list online
This document was last updated 03/01/2019.* 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
“Coverage.” Then select “Pharmacy” from the drop down menu.
Cigna.com/druglist – Select your drug list name – Performance 3 Tier – from the
drop down menu.
Questions?
Call the toll-free number on the back of your Cigna ID card. We’re here to help. If it’s easier, you
can also chat with us online on the myCigna website, Monday–Friday, 9:00 am–8:00 pm EST.
* Drug list created: originally created 01/01/2008 Last updated: 03/01/2019, for changes Next planned update: 09/01/2019, for
starting 07/01/2019 changes starting 01/01/2020
2Your prescription drug list
This document shows the most commonly prescribed medications covered on the Performance
3-Tier Prescription Drug List as of July 1, 2019.1 All of these medications are approved by the U.S.
Food and Drug Administration (FDA). Medications are listed by the condition they treat, then
listed alphabetically within tiers (or cost-share levels).
The Performance 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 on this list. You should log in to the myCigna app or website, or check your plan
materials, to learn more about the medications your plan covers.
How to read your drug list
Use the sample chart below to help you understand this drug list. This chart is just an example.
It may not show how these medications are actually covered on the Performance 3-Tier Prescription
Drug List.
Tier (cost-share level) gives you
an idea of how much you may
TIER 1 TIER 2 pay for a medication
$ $$
BLOOD PRESSURE/HEART MEDICATIONS Medications are grouped by
afeditab CR Berinert* (PA) the condition they treat
amlodipine besylate Bidil
amlodipine besylate-benazepril Bystolic
amlodipine-valsartan Cinryze* (PA)
amlodipine-valsartan-HCTZ Coreg CR
atenolol Cozaar (ST)
Diovan (ST)
atenolol-chlorthalidone
Diovan HCT (ST) Medications are listed in
benazepril
Edarbi (ST) alphabetical order within
benazepril-HCTZ each column
Edarbyclor (ST)
candesartan cilexetil Exforge
cartia XT Exforge HCT
carvedilol Firazyr* (PA) Specialty medications have an
clonidine Hemangeol asterisk (*) listed next to them
digitek Inderal LA
digox Inderal XL
digoxin Innopran XL
diltiazem ER Lotrel Brand name medications
diltiazem CD Micardis (ST) are capitalized
diltiazem Multaq
dilt-XR Nitro-dur
Nitrolingual
enalapril
NitroMist
flecainide acetate Generic medications
Nitronal
hydralazine are lowercase
Nitrostat
irbesartan Northera* (PA) Medications that have extra
isosorbide mononitrat Norvasc coverage requirements will
Ranexa (ST) have an abbreviation listed
Tekturna next to them
Tekturna HCT
This chart is just a sample. It may not show how these medications are actually covered
on the Performance 3-Tier Prescription Drug List. 3Tiers
Covered medications are divided into tiers, or cost-share levels. Typically, the higher the tier, the
higher the price you’ll pay to fill the prescription.
› Tier 1 – Typically Generics (Lower-cost medication) $
› Tier 2 – Typically Preferred Brands (Medium-cost medication) $$
› 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
A
age range for your plan to cover them. This is because some medications aren’t
considered clinically appropriate for individuals who aren’t within that age range.
* This may not apply to your plan because not all plans have extra coverage requirements like prior authorization, quantity limits, Step Therapy and/or age. Please log in to the myCigna 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. Please 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). Please 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. Please
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
AIDS/HIV 6 EYE CONDITIONS 11
ALLERGY/NASAL SPRAYS 6 FEMININE PRODUCTS 11
ALZHEIMER’S DISEASE 6 GASTROINTESTINAL/HEARTBURN 11, 12
ANXIETY/DEPRESSION/BIPOLAR 6 HORMONAL AGENTS 12
DISORDER INFECTIONS 12, 13
ASTHMA/COPD/RESPIRATORY 6, 7 INFERTILITY 13
ATTENTION DEFICIT HYPERACTIVITY 7 MISCELLANEOUS 13
DISORDER
MULTIPLE SCLEROSIS 13
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 15
CHOLESTEROL MEDICATIONS 8 SCHIZOPHRENIA/ANTI-PSYCHOTICS 15
CONTRACEPTIVE PRODUCTS 8–10 SEIZURE DISORDERS 15
COUGH/COLD MEDICATIONS 10 SKIN CONDITIONS 15, 16
DENTAL PRODUCTS 10 SLEEP DISORDERS/SEDATIVES 16
DIABETES 10, 11 SMOKING CESSATION 16
DIURETICS 11 SUBSTANCE ABUSE 16
EAR MEDICATIONS 11 TRANSPLANT MEDICATIONS 16
ERECTILE DYSFUNCTION 11 URINARY TRACT CONDITIONS 16
5Cigna Performance 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
AIDS/HIV ANXIETY/DEPRESSION/
abacavir-lamivudine* Atripla* Complera* BIPOLAR DISORDER (cont)
atazanavir* Biktarvy* Evotaz* alprazolam intensol Fetzima (ST, QL)
ritonavir* Descovy* Juluca* alprazolam ODT Forfivo XL (ST, QL)
tenofovir* Genvoya* Odefsey* alprazolam XR Pristiq (ST, QL)
Intelence* Prezcobix* amitriptyline Prozac (ST, QL)
Isentress HD* Stribild* bupropion (QL) Sarafem (ST)
Isentress* Viread* 300mg tablet bupropion SR (QL) Trintellix (ST)
Norvir* packet, bupropion XL (QL) Viibryd (ST)
solution buspirone Wellbutrin SR (ST, QL)
Prezista* citalopram (QL) Xanax
Reyataz* clomipramine Xanax XR
packet desvenlafaxine ER Zoloft (ST, QL)
Selzentry* desvenlafaxine ER (QL)
Tivicay* duloxetine (QL)
Triumeq* escitalopram (QL)
Truvada* fluoxetine (QL)
Viread* 150mg, fluoxetine DR (QL)
200mg, 250 fluvoxamine (QL)
mg tablet, fluvoxamine ER (QL)
powder lorazepam
ALLERGY/NASAL SPRAYS lorazepam intensol
mirtazapine
Adyphren Astepro
paroxetine (QL)
Adyphren Amp Clarinex-D 12 Hour
paroxetine CR (QL)
azelastine EpinephrineSnap-V
paroxetine ER (QL)
cromolyn EPIsnap
sertraline (QL)
cyproheptadine Karbinal ER
trazodone
desloratadine Semprex-D
venlafaxine (QL)
epinephrine (QL) Sinuva* (PA)
venlafaxine ER (QL)
flunisolide
fluticasone ASTHMA/COPD/RESPIRATORY
hydroxyzine albuterol Advair Diskus Adcirca* (PA)
ipratropium budesonide Advair HFA Adempas* (PA)
mometasone (QL) ipratropium-albuterol Anoro Ellipta Aralast NP* (PA)
olopatadine montelukast Atrovent HFA Arcapta Neohaler
Phenergan Breo Ellipta Daliresp (QL)
promethazine Combivent Fasenra* (PA)
ALZHEIMER’S DISEASE Respimat Glassia* (PA)
Incruse Ellipta Kalydeco* (PA, QL)
donepezil Mestinon Mestinon tablet
ProAir HFA Letairis* (PA)
donepezil ODT syrup Namenda
ProAir Nucala* (PA)
memantine Namenda Namenda XR (QL)
RespiClick OFEV* (PA)
memantine ER titration pak Namzaric (QL)
Pulmicort Opsumit* (PA)
pyridostigmine Regonol
Flexhaler Orenitram ER* (PA)
pyridostigmine ER
Pulmozyme* Orkambi* (PA, QL)
rivastigmine
(PA) Pulmicort
ANXIETY/DEPRESSION/BIPOLAR DISORDER QVAR Repatha* (PA)
alprazolam Celexa (ST, QL) Redihaler Revatio* (PA)
alprazolam ER Effexor XR (ST, QL) Serevent Symdeko* (PA, QL)
Diskus Tracleer* (PA)
6Cigna Performance 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
ASTHMA/COPD/RESPIRATORY (cont) BLOOD PRESSURE/HEART MEDICATIONS (cont)
Spiriva Tyvaso* (PA) Aspir 81+ Tekturna Cardizem LA
Spiriva Uptravi* (PA) aspirin EC+ Tekturna HCT Cinryze* (PA)
Respimat aspirin+ Coreg CR
Stiolto Aspir-Low+ Cozaar (ST)
Respimat atenolol Diovan (ST)
Striverdi atenolol- Diovan HCT (ST)
Respimat chlorthalidone Edarbi (ST)
Symbicort benazepril Edarbyclor (ST)
Trelegy Ellipta benazepril-HCTZ Epaned (ST)
(ST) Bufferin+ Exforge
Ventolin HFA candesartan Firazyr* (PA)
Xolair* (PA) Cartia XT Haegarda* (PA)
ATTENTION DEFICIT HYPERACTIVITY DISORDER carvedilol Hemangeol
carvedilol ER Inderal LA
atomoxetine Vyvanse (PA) Adderall (ST)
clonidine Inderal XL
dexmethylphenidate Adzenys ER (PA)
digitek Innopran XL
dexmethylphenidate Adzenys XR-ODT (PA)
ER Digox Kapspargo Sprinkle
Daytrana (PA)
dextroamphetamine- digoxin Nitro-Dur
Dyanavel XR (PA)
amphetamine diltiazem Nitrolingual
Evekeo (ST)
dextroamphetamine- diltiazem CD Nitromist
Focalin (ST)
amphetamine ER diltiazem ER Nitrostat
Methylin (ST)
guanfacine ER Dilt-XR Northera* (PA)
QuilliChew ER (PA)
Metadate ER dofetilide (QL) Norvasc
Quillivant XR (PA)
methylphenidate doxazosin Ranexa (ST, QL)
Ritalin (ST)
methylphenidate CD Ecotrin+ Tiazac
methylphenidate ER EcPirin+ Tikosyn (QL)
methylphenidate LA enalapril Toprol XL
Relexxii flecainide Tribenzor
BLOOD MODIFIERS/BLEEDING DISORDERS hydralazine Vasotec (ST)
irbesartan
tranexamic acid* Amicar* Amicar* 500mg,
irbesartan-HCTZ
1,000mg 0.25gram/ml
isosorbide
tablet Ceprotin* (PA)
isosorbide ER
Aranesp* (PA) Hemlibra* (PA)
labetalol
Droxia Promacta* (PA)
lisinopril
Epogen* (PA) Siklos (PA)
lisinopril-HCTZ
Granix*
losartan
Neulasta* (PA)
losartan-HCTZ
Procrit* (PA)
Matzim LA
Soliris* (PA)
metoprolol
Zarxio*
nadolol
BLOOD PRESSURE/HEART MEDICATIONS nifedipine
amlodipine Bystolic Azor nifedipine ER
amlodipine-benazepril Byvalson Bayer Chewable olmesartan
amlodipine- Corlanor (PA) Aspirin+ olmesartan-
olmesartan Entresto Benicar (ST) amlodipine-HCTZ
amlodipine-valsartan Multaq Benicar HCT (ST) olmesartan-HCTZ
amlodipine-valsartan- Nitro-Dur Berinert* (PA) propafenone
HCTZ 0.3mg, 0.8mg BiDil (QL) propafenone ER
7Cigna Performance 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
BLOOD PRESSURE/HEART MEDICATIONS (cont) CANCER (cont)
propranolol Pomalyst* (PA)
propranolol ER Stivarga* (PA)
quinapril Sylatron* (PA)
ramipril Tafinlar* (PA)
Taztia XT Tagrisso* (PA)
telmisartan Targretin* capsule
telmisartan-HCTZ (PA)
tri-buffered aspirin+ Tecentriq* (PA)
valsartan Verzenio* (PA)
valsartan-HCTZ Votrient* (PA)
verapamil Xalkori* (PA)
verapamil ER Xtandi* (PA)
verapamil SR
Zelboraf* (PA)
BLOOD THINNERS/ANTI-CLOTTING Zytiga* (PA)
aspirin-dipyridamole Brilinta Bevyxxa (QL) CHOLESTEROL MEDICATIONS
ER Eliquis Coumadin
atorvastatin 10mg, Repatha* (PA) Crestor (ST)
clopidogrel Fragmin* (QL) Pradaxa
20mg + Korlym* (PA)
enoxaparin* (QL) Xarelto Savaysa
atorvastatin 40mg, Vascepa
fondaparinux* (QL) Zontivity
80mg Vytorin (ST)
Jantoven
colesevelam Welchol
prasugrel
ezetimibe Zetia
warfarin
CANCER fenofibrate
fenofibric acid
anastrozole Actimmune* Afinitor Disperz* (PA)
bexarotene* (PA) (PA) Afinitor* (PA) fluvastatin+
capecitabine* (PA) Avastin* (PA) Alecensa* (PA) fluvastatin ER+
exemestane Gleostine Bosulif* (PA) lovastatin 20mg,
imatinib* (PA) Herceptin* (PA) Cabometyx* (PA) 40mg+
letrozole Intron A* (PA) Cometriq* (PA) niacin ER
mercaptopurine Lupron Depot* Cotellic* (PA) Niacor
methotrexate* (PA) Erivedge* (PA) omega-3 acid ethyl
tamoxifen+ Nexavar* (PA) Erleada* (PA) esters
temozolomide* (PA) Revlimid* (PA) Fareston (QL) pravastatin+
Rituxan* (PA) Gazyva* (PA) rosuvastatin 5mg,
Sprycel* (PA) Gleevec* (PA) 10mg (QL)+
Sutent* (PA) Ibrance* (PA)
rosuvastatin 20mg,
Tarceva* (PA) Iclusig* (PA)
40mg (QL)
Tasigna* (PA) Imbruvica* (PA)
Trexall* Inlyta* (PA) simvastatin 10mg,
Valstar* Jakafi* (PA) 20mg, 40mg+
Kadcyla* (PA) simvastatin 80mg (QL)
Lenvima* (PA) CONTRACEPTIVE PRODUCTS
Lonsurf* (PA) All contraceptive products may be covered if you meet specific
Lynparza* (PA) gender requirements.
Mekinist* (PA)
Altavera+ Lo Loestrin FE Beyaz
Nerlynx* (PA)
Alyacen+ NuvaRing+ Ella+
Ninlaro* (PA)
Amethia Lo +
Taytulla Estrostep FE
Perjeta* (PA)
8Cigna Performance 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
CONTRACEPTIVE PRODUCTS (cont) CONTRACEPTIVE PRODUCTS (cont)
All contraceptive products may be covered if you meet specific All contraceptive products may be covered if you meet specific
gender requirements. gender requirements.
Amethyst+ FC2 Female Condom+ Heather+
Apri +
Kyleena* Introvale+
Aranelle+ Loestrin FE Isibloom+
Ashlyna+ LoSeasonique Jencycla+
Aubra EQ+ Microgestin+ Jolessa+
Aviane +
Minastrin 24 FE Jolivette+
Azurette+ Mirena* Juleber+
Balziva+ Nexplanon* Junel FE 24+
Bekyree+ Skyla* Junel FE+
Blisovi 24 FE+
Today Contraceptive Junel+
Blisovi FE+ Sponge+ Kaitlib FE+
Briellyn +
Wide Seal Kariva+
Camila+ Diaphragm+ Kelnor 1-35+
Camrese Lo +
Kelnor 1-50+
Camrese+ Kurvelo+
Caziant+ Larin FE 24+
Chateal EQ+ Larin FE+
Chateal+ Larin+
Cryselle+ Larissia+
Cyclafem+ Leena+
Cyred+ Lessina+
Dasetta+ Levonest+
Daysee+ levonorgestrel-ethinyl
Deblitane+ estradiol+
Delyla+ Levora-28+
desogestrel-ethinyl Lillow+
estradiol+ Loryna+
drospirenone-ethinyl Low-Ogestrel+
estradiol+ Lutera+
drospirenone- Lyza+
ethinyl estradiol- Marlissa+
levomefolate+ medroxyprogesterone
Econtra EZ+ 150mg/ml+
Econtra One-Step+ Melodetta 24 FE+
Elinest+ Mibelas 24 FE+
Emoquette+ Microgestin FE+
Enpresse+ Mili+
Enskyce+ Mono-Linyah+
Errin+ Mononessa+
Estarylla+ My Choice+
ethynodiol-ethinyl My Way+
estradiol+ Myzilra+
Falmina+ Necon 0.5/35+
Fayosim+ Nikki+
Femynor Nora-BE+
Gianvi+ norethindrone+
Hailey 24 FE
9Cigna Performance 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
CONTRACEPTIVE PRODUCTS (cont) CONTRACEPTIVE PRODUCTS (cont)
All contraceptive products may be covered if you meet specific All contraceptive products may be covered if you meet specific
gender requirements. gender requirements.
norethindrone-ethinyl Wymzya FE+
estradiol+ Xulane+
norethindrone-ethinyl Zarah+
estradiol-iron+ Zovia 1-35E+
norgestimate-ethinyl COUGH/COLD MEDICATIONS
estradiol+
benzonatate Tessalon Perle
Norlyda+
Bromfed DM Tussionex
Norlyroc+
brompheniramine- Tuzistra XR (QL)
Nortrel+
pseudoephedrine-
Ocella+
DM
Opcicon One-Step+
hydrocodone-
Option 2+
chlorpheniramine ER
Orsythia+
hydrocodone-
Philith+
homatropine (QL)
Pimtrea+
Hydromet (QL)
Pirmella+
Portia+ DENTAL PRODUCTS
Previfem+ chlorhexidine Fluorabon+ Clinpro 5000
Reclipsen+ Denta 5000 plus PreviDent 5000 Escavite+
Rivelsa+ Dentagel Escavite D+
Setlakin+ doxycycline Floriva+
Sprintec+ fluoride+ MVC-Fluoride+
Sronyx+ Fluoridex Poly-Vi-Flor with Iron+
Syeda+ Fluoritab+ PreviDent
Tarina FE 1-20 EQ+ Flura-Drops+ PreviDent 5000 Plus
Tarina FE+ Ludent Fluoride+ Quflora+
Tilia FE+ multivitamin-iron-
Tri Femynor+ fluoride+
Tri-Estarylla+ Oralone
Tri-Legest FE+ Paroex
Tri-Linyah+ Peridex
Tri-Lo-Estarylla+ SF
Tri-Lo-Marzia+ SF 5000 Plus
Tri-Lo-Sprintec+ sodium fluoride+
Tri-Mili+ triamcinolone
Tri-Previfem Tri-Vitamin with
Tri-Sprintec+ Fluoride+
Trivora-28+ DIABETES
Tri-Vylibra+
Tulana+ glimepiride Accu-Chek Cycloset
Tydemy+ glipizide test strips and NovoTwist
VCF+ glipizide ER meters
Vienva+ glipizide XL Basaglar
Viorele+ metformin Bydureon (QL)
Vyfemla+ metformin ER Byetta (QL)
Vylibra+ Dexcom G6
Wera+ sensors
10Cigna Performance 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
DIABETES (cont) EYE CONDITIONS
Farxiga azelastine Alphagan P Acuvail
FreeStyle Libre bacitracin 0.1% Alphagan P 0.15%
sensors bimatoprost (QL) Azasite Alrex
GlucaGen brimonidine Azopt Bepreve
HypoKit (QL) ciprofloxacin Betimol Besivance
Glucagon dorzolamide-timolol Betoptic S Bromsite
Emergency erythromycin Lotemax drops, Cequa
Kit (QL) fluorometholone gel Combigan
Glyxambi gatifloxacin Moxeza Cosopt PF
Humalog ketorolac Pazeo Cystaran* (QL)
Humulin latanoprost Pred Mild Durezol
Janumet moxifloxacin Restasis Eylea* (PA)
Janumet XR
neomycin-polymyxin- Simbrinza Ilevro
Januvia
dexamethasone Tobradex Iluvien*
Jardiance
ofloxacin ointment Inveltys
Kombiglyze XR
Levemir olopatadine Travatan Z Lotemax ointment
OneTouch test polymyxin B-TMP Xiidra Lucentis* (PA)
strips and prednisolone Lumigan
meters timolol Nevanac
Onglyza tobramycin Omnipred
Ozempic (QL) tobramycin- Ozurdex*
Qtern dexamethasone Pataday
Soliqua Patanol
SymlinPen Pred Forte
Synjardy Prolensa
Synjardy XR Tobradex drops
Tresiba Tobradex ST
Trulicity (QL) Vigamox
Victoza (QL) Zioptan (ST, QL)
Xigduo XR Zirgan
Xultophy Zylet
DIURETICS FEMININE PRODUCTS
acetazolamide Diuril Aldactone Fem pH AVC
bumetanide Dyrenium Carospir Gynazole 1 Relagard
chlorthalidone Jynarque* (PA) Miconazole 3
eplerenone Lasix terconazole
furosemide Samsca*
GASTROINTESTINAL/HEARTBURN
hydrochlorothiazide
spironolactone Alophen +
Amitiza Aciphex (ST, QL)
triamterene-HCTZ alosetron* Apriso Aciphex Sprinkle (QL)
Anucort-HC Canasa Akynzeo* (PA, QL)
EAR MEDICATIONS
balsalazide Carafate Bonjesta
neomycin-polymyxin- Cipro HC Coly-Mycin S bisacodyl+ suspension Carafate tablet
HC Ciprodex Dermotic chlordiazepoxide- Creon Cholbam* (PA)
ofloxacin drops Otovel clidinium Dexilant (QL) Clenpiq
ERECTILE DYSFUNCTION Clearlax+ Entyvio* (PA) CoLyte with Flavor
sildenafil (PA age, QL) Muse (QL) Cialis (ST, QL) dicyclomine GoLYTELY Packets+
tadalafil (PA, QL) Viagra (ST, QL) diphenoxylate- packet Correctol+
vardenafil (QL) atropine Linzess Diclegis
11Cigna Performance 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
GASTROINTESTINAL/HEARTBURN (cont) HORMONAL AGENTS (cont)
dronabinol Pentasa Donnatal desmopressin tablet, Cytomel Aveed* (PA)
Ducodyl+ Zenpep Dulcolax tablet+ spray, solution 50mcg Climara
esomeprazole (QL) Gattex* (PA) desmopressin* vial, Divigel Climara Pro
famotidine Gialax+ ampule, powder Duavee CombiPatch
GaviLax+ GoLYTELY+ solution dexamethasone Estring (QL) Cytomel 5mcg,
GaviLyte-C+ Lialda (ST) dexamethasone Forteo* 25mcg
GaviLyte-G+ MiraLAX+ intensol Ganirelix*^ Deltasone
GaviLyte-N+ Movantik (PA) EEMT Humatrope* Depo-Testosterone
GentleLax+ MoviPrep+ (PA) Egrifta* (PA)
EEMT H.S.
GlycoLax+ NuLYTELY with Flavor Lupron Depot* Elestrin
estradiol patch (QL)
HealthyLax+ Packets+ (PA) Entocort EC
estradiol-
Hemmorex-HC Premarin
Ocaliva* (PA) norethindrone Estrace
hydrocortisone Premphase
OsmoPrep+ acetate EstroGel
lansoprazole (QL) Prempro
Pancreaze estrogen- Euthyrox
lansoprazole-
Pertzye methyltestosterone Sandostatin Evamist
amoxicillin-
Prepopik+ levothyroxine LAR Femring
clarithromycin
Prevacid (ST, QL) Levoxyl Depot* (PA) H.P. Acthar* (PA)
(combo pak)
Ravicti* (PA) liothyronine Serostim* (PA) Intrarosa
LaxaClear+
mesalamine Rectiv medroxyprogesterone Somavert* (PA) Levo-T
metoclopramide Relistor (PA) Synthroid Lupron Depot-Ped*
Methergine
metoclopramide ODT Sancuso (PA, QL) Zorbtive* (PA) (PA) 30mg
methimazole
Natura-Lax+ Sensipar* methylergonovine Menostar (QL)
omeprazole (QL) sfRowasa methylprednisolone Minivelle (QL)
ondansetron Sucraid* (PA) Mimvey Natpara* (PA)
ondansetron ODT Suprep+ Mimvey LO Osphena
pantoprazole (QL) Sustol (PA) Nature-Throid Prometrium
PEG-3350 and Symproic (PA) Rayaldee
NP Thyroid
electrolytes Transderm-Scop Somatuline Depot*
prednisolone
PEG-Prep+ Varubi* (PA, QL) (PA)
Phenadoz prednisolone ODT
Viberzi Striant (PA, QL)
Powderlax+ prednisone
Viokace Supprelin LA* (PA)
promethazine prednisone intensol
Xermelo* (PA) Testopel (PA)
promethegan progesterone
Thyrogen*
Purelax+ testosterone (PA, QL)
Tirosint
rabeprazole (QL) testosterone
Triostat
ranitidine cypionate
Unithroid
Smooth LAX+ thyroid
Vagifem (QL)
sucralfate Westhroid
Vivelle-Dot (QL)
TriLyte with Flavor WP Thyroid
Packets+ Yuvafem (QL)
ursodiol
HORMONAL AGENTS
Amabelz Androderm Activella INFECTIONS
budesonide ER (PA, QL) (PA, QL) Alora (QL) acyclovir Baraclude* Albenza
cabergoline (QL) AndroGel 1% AndroGel 1.62%, 1% amoxicillin solution Alinia
Covaryx (PA, QL) (2.5g) (PA, QL) amoxicillin- Cipro Bactrim
Covaryx H.S. Armour Angeliq clavulanate ER Daraprim* (PA) Bactrim DS
Decadron Thyroid Armour Thyroid 15mg amoxicillin- Kitabis Pak* Baraclude* tablet
Crinone tablet clavulanate
12Cigna Performance 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
INFECTIONS (cont) INFECTIONS (cont)
atovaquone ledipasvir- Cayston* vancomycin
atovaquone-proguanil sofosbuvir* Cleocin Vandazole
Avidoxy (PA) Clindesse voriconazole (PA)
azithromycin Mavyret* (PA) Cresemba (PA) INFERTILITY
cefdinir Pegasys Dificid (QL)
chorionic Crinone^ Makena* (PA)
cefixime ProClick* (PA) E.E.S. 400
gonadotropin*^ (PA) Endometrin^ Menopur*^
cefpodoxime Pegasys* (PA) EryPed 200
clomiphene^ Follistim AQ*^
cefuroxime sofosbuvir- Ery-Tab
hydroxyprogesterone
cephalexin velpatasvir* Firvanq
caproate* (PA)
ciprofloxacin (PA) Harvoni* (PA)
clarithromycin Sovaldi* (PA) MetroGel-Vaginal MISCELLANEOUS
clarithromycin ER Thalomid* (PA) Minocin disulfiram Cerdelga* (PA) Austedo* (PA)
clindamycin Vosevi* (PA) Monurol Nebusal 3% Elaprase* (PA) Botox* (PA)
Coremino Natroba Pulmosal Nityr* (PA) Brisdelle (QL)
dapsone Noxafil sodium chloride TechLITE Cerezyme* (PA)
Doxy 100 Nuvessa tetrabenazine* (PA) Lancets Dysport* (PA)
doxycycline PegIntron* (PA) trientine* (PA) Vivitrol* Esbriet* (PA)
doxycycline IR-DR Plaquenil Exjade*
Emverm Prevymis* Ferriprox*
entecavir* Sivextro (PA) Ingrezza* (PA)
erythromycin Sklice Jadenu*
erythromycin ES Solosec Kuvan* (PA)
famciclovir Sulfatrim Lumizyme* (PA)
fluconazole Suprax Myalept* (PA)
hydroxychloroquine Synagis* (PA) Naglazyme* (PA)
itraconazole Tamiflu (QL) Nuedexta (QL)
levofloxacin Tobi Podhaler* Strensiq* (PA)
metronidazole Uretron D-S Syprine* (PA)
minocycline Uribel Vimizim* (PA)
minocycline ER Urogesic-Blue VPRIV* (PA)
Mondoxyne NL UTA Xenazine* (PA)
Morgidox Valtrex Xeomin* (PA)
nitrofurantoin Vemlidy* MULTIPLE SCLEROSIS
nitrofurantoin mono- Vibramycin
macro Xifaxan glatiramer* (PA) Ampyra* (PA) Gilenya 0.25mg
nystatin Zepatier* (PA) Glatopa* (PA) Aubagio* (PA) Lemtrada* (PA)
Okebo Avonex Pen* Ocrevus* (PA)
oseltamivir (QL) (PA) Tysabri* (PA)
penicillin Avonex* (PA)
permethrin Betaseron*
Soloxide (PA)
sulfamethoxazole- Extavia* (PA)
TMP Gilenya* (PA)
terbinafine 0.5mg
tetracycline Plegridy* (PA)
tinidazole Rebif* (PA)
tobramycin* ampule Tecfidera* (PA)
valacyclovir
valganciclovir
13Cigna Performance 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 CitraNatal Auryxia (QL) DISEASE (cont)
calcitriol Klor-Con M15 Klor-Con 10 diclofenac Uloric Hyalgan* (PA)
calcium OB Complete Klor-Con 8 diclofenac (QL) Xtampza ER Ilaris* (PA)
cyanocobalamin Petite KPN+ diclofenac ER (PA) Kadian (PA)
injection Prenate Mini K-Tab ER dihydroergotamine Kevzara* (PA)
FA-8+ Vitafol Mephyton (QL) Kineret* (PA)
folic acid 1mg vitaMedMD Nascobal eletriptan (QL) Lazanda (PA)
folic acid 0.4mg, One RX OB Complete Endocet (PA) Mitigare
0.8mg+ VitaPearl Perry Prenatal+ etodolac Monovisc* (PA)
Klor-Con Phoslyra etodolac ER Morphabond ER (PA)
Klor-Con M10 Physicians EZ Use fenoprofen MS Contin (PA)
Klor-Con M20 B-12 fentanyl (PA) Nucynta ER (PA)
Klor-Con Sprinkle Renagel Fioricet (QL) Orencia* (PA)
lanthanum Renvela frovatriptan (QL) Orthovisc* (PA)
potassium chloride Urosex+ Glydo Otrexup* (PA)
Prena1 Pearl Velphoro hydrocodone- Oxaydo (PA)
prenatal vitamin+ Veltassa acetaminophen (PA) Pennsaid (ST)
Prenatal+ hydromorphone (PA) Percocet (PA)
sevelamer hydromorphone ER Procort
Vitamin D2 (PA) Relpax (QL)
OSTEOPOROSIS PRODUCTS IBU Roxybond (PA)
ibuprofen Simponi* (PA)
alendronate (QL) Tymlos* Evista
indomethacin Syprine* (PA)
calcitonin-salmon Fosamax Plus D (ST)
indomethacin ER Synvisc-One* (PA)
ibandronate tablet Prolia* (PA)
ketorolac carpuject Taltz* (PA)
ibandronate* syringe, Xgeva* (PA)
ketorolac (QL) Tremfya* (PA)
vial
leflunomide Voltaren (ST, QL)
raloxifene+
lidocaine Xeljanz XR* (PA)
risedronate
lidocaine (QL) Xeljanz* (PA)
risedronate DR
lidocaine viscos Zohydro ER (PA)
PAIN RELIEF AND INFLAMMATORY DISEASE lidocaine-prilocaine
acetaminophen- Actemra* (PA) Abstral (PA) Lidopril
codeine (PA) Belbuca (QL) Actiq (PA) Lidopril XR
allopurinol Cuprimine* Analpram HC Lido-Prilo Caine Pack
baclofen (PA) Arymo ER (PA) Livixil Pak
buprenorphine (QL) Depen* (PA) Benlysta* (PA) Lorcet (PA)
butalbital- Embeda (PA) Buprenex Lorcet HD (PA)
acetaminophen- Enbrel* (PA) Butrans (QL) Lorcet Plus (PA)
caffeine-codeine (PA) Humira* (PA) Celebrex (ST, QL) Lortab (PA)
butalbital- Hysingla ER Cimzia* (PA) meloxicam
acetaminophen- (PA) Colcrys Metaxall
caffeine (QL) Nucynta (PA) Cosentyx* (PA) metaxalone
carisoprodol Otezla* (PA) Dupixent* (PA) methocarbamol
celecoxib (QL) Rasuvo* (PA) Duragesic (PA) morphine (PA)
chlorzoxazone Remicade* Durolane* (PA) morphine ER (PA)
colchicine (PA) Euflexxa* (PA) nabumetone
cyclobenzaprine R Savella Fentora (PA) Nalfon (ST)
Dermacinx Empricaine Stelara* (PA) Flector (ST, QL) Nalocet (PA)
DermacinRx Prizopak Subsys (PA) Gelsyn-3* (PA) naproxen
14Cigna Performance 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
PAIN RELIEF AND INFLAMMATORY SCHIZOPHRENIA/ANTI-PSYCHOTICS (cont)
DISEASE (cont) paliperidone ER Saphris (ST)
naproxen DS quetiapine Seroquel (ST)
oxycodone (PA) quetiapine ER Seroquel XR (ST)
oxycodone ER (PA) risperidone Vraylar (ST)
oxycodone- risperidone ODT
acetaminophen (PA) ziprasidone
oxymorphone (PA) SEIZURE DISORDERS
oxymorphone ER (PA)
carbamazepine Keppra vial Aptiom (PA)
Phrenilin Forte (QL)
carbamazepine ER Lyrica Banzel (PA, QL)
Prikaan
clonazepam Vimpat tablet, Briviact
Prikaan Lite
divalproex solution (PA) Briviact (PA)
Prilolid
divalproex ER Carbatrol
Prilovix
Epitol Depakote
Primlev (PA)
gabapentin Depakote ER
Profeno
lamotrigine Dilantin
Relador Pak
lamotrigine (blue, Fycompa (PA)
Relador Pak Plus
green, orange) Klonopin
rizatriptan (QL)
lamotrigine ER Onfi
sumatriptan (QL)
lamotrigine ODT Oxtellar XR (PA)
sumatriptan-naproxen
levetiracetam Phenytek
(QL)
levetiracetam ER Spritam (PA)
tizanidine
oxcarbazepine Tegretol
tramadol (QL)
Roweepra Tegretol XR
tramadol ER (QL)
Roweepra XR Vimpat vial
Verdrocet (PA)
Subvenite
Vicodin (PA)
Subvenite (blue,
Vicodin ES (PA)
green, orange)
Vicodin HP (PA)
topiramate
PARKINSON’S DISEASE topiramate ER
amantadine Apokyn* (PA) Azilect SKIN CONDITIONS
benztropine Neupro
adapalene (PA age) Eucrisa Benzamycin
bromocriptine Rytary
adapalene-benzoyl Finacea Celacyn
carbidopa-levodopa Sinemet
peroxide Naftin gel Desonate (ST)
carbidopa-levodopa Sinemet CR
Ala-Cort Santyl (QL) Desowen (ST)
ER Tasmar
Amnesteem (QL) Dovonex
pramipexole Xadago
Avar Drysol
pramipexole ER
Avar-E Ecoza
rasagiline
Avar-E Green Elidel
ropinirole
betamethasone Enstilar
ropinirole ER
dipropionate Impoyz (ST)
SCHIZOPHRENIA/ANTI-PSYCHOTICS augmented Naftin cream
aripiprazole Abilify Maintena (QL) betamethasone Nizoral
aripiprazole ODT Aristada (QL) dipropionate Olux (ST)
chlorpromazine Fanapt (ST, QL) BP 10-1 Picato
haloperidol Invega Sustenna (QL) calcipotriene Soolantra
olanzapine Invega Trinza (QL) calcipotriene- Sorilux
olanzapine ODT Latuda (ST) betamethasone DP Taclonex
olanzapine-fluoxetine Rexulti (ST) Calcitrene Targretin* gel
15Cigna Performance 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
SKIN CONDITIONS (cont) SLEEP DISORDERS/SEDATIVES
Claravis (QL) Temovate (ST) armodafinil (PA) Belsomra (ST) Hetlioz* (PA)
Clindacin ETZ Topicort (ST) eszopiclone Silenor (ST) Lunesta (ST)
Clindacin P Tridesilon (ST) modafinil (PA) Rozerem (ST, QL)
clindamycin Xolegel temazepam Xyrem* (PA)
clindamycin-benzoyl zolpidem
peroxide zolpidem ER
clindamycin-tretinoin SMOKING CESSATION
clobetasol
bupropion SR+ 150mg Chantix Nicorette+
Clodan shampoo
NicoDerm CQ+ Nicotrol Zyban
clotrimazole-
Nicorelief+ Nicotrol NS
betamethasone
nicotine gum+
dapsone
nicotine lozenge+
desonide
nicotine patch+
diflorasone diacetate
Quit 2+
fluocinonide
Quit 4+
fluorouracil
flurandrenolide SUBSTANCE ABUSE
hydrocortisone buprenorphine Bunavail
imiquimod 5% cream buprenorphine- Narcan
isotretinoin (QL) naloxone Probuphine
ketoconazole Suboxone
metronidazole Zubsolv
mupirocin TRANSPLANT MEDICATIONS
Myorisan (QL)
Neuac gel azathioprine* Prograf* Astagraf XL*
Nolix mycophenolate* CellCept*
nystatin-triamcinolone mycophenolic acid* Envarsus XR*
oxiconazole sirolimus* Myfortic*
Plixda (PA age) tacrolimus* Neoral*
Procto-Med HC Prograf* 1mg capsule
Procto-Pak Zortress*
Proctosol-HC URINARY TRACT CONDITIONS
Proctozone-HC darifenacin ER Cystagon* Avodart
Psorcon dutasteride Elmiron Procysbi* (PA)
Rosadan finasteride Thiola* Pyridium
rosanil oxybutynin Rapaflo
sodium oxybutynin ER
sulfacetamide-sulfur phenazopyridine
SSS 10-5 potassium ER
Sulfacleanse 8-4 tamsulosin
tacrolimus tolterodine
tazarotene tolterodine ER
tretinoin
tretinoin (PA age)
tretinoin microsphere
(PA age)
triamcinolone
Triderm
Zenatane (QL)
16Medications that are not covered
The medications listed below aren’t covered on your plan’s drug list.^^ This means that if you fill a
prescription for any of these medications, you’ll pay its full cost out-of-pocket. We want you to know your
plan covers other medications that are used to treat the same condition.^^ We’ve listed some below
for you and your doctor to consider. You should call your doctor’s office to talk about your options.
GENERIC AND/OR PREFERRED
DRUG CLASS MEDICATIONS NOT COVERED^^
BRAND ALTERNATIVE(S)
AIDS/HIV Kaletra solution* lopinavir-ritonavir*
Norvir tablet* ritonavir*
Reyataz capsule* atazanavir*
Sustiva* efavirenz*
Videx EC* didanosine*
Viramune tablet* nevirapine*
Viramune XR* nevirapine ER*
Zerit* stavudine*
ALLERGY/NASAL SPRAYS Auvi-Q epinephrine auto injector
EpiPen, EpiPen Jr
Beconase AQ Generic nasal steroids (e.g., fluticasone)
Dymista
Nasonex
Omnaris
QNASL
Zetonna
QNASL Children’s budesonide
fluticasone
triamcinolone
ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipramine
Aplenzin bupropion XL
Wellbutrin XL
Ativan lorazepam
Cymbalta duloxetine
Lexapro escitalopram
Pamelor nortriptyline
Parnate tranylcypromine
Pexeva paroxetine/CR/ER
Tofranil imipramine
ASTHMA/COPD/RESPIRATORY Alvesco QVAR RediHaler
Arnuity Ellipta Pulmicort Flexhaler
Asmanex
Asmanex HFA
Flovent Diskus
Flovent HFA
Bevespi Anoro Ellipta
Utibron Neohaler Stiolto Respimat
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.
17GENERIC AND/OR PREFERRED
DRUG CLASS MEDICATIONS NOT COVERED^^
BRAND ALTERNATIVE(S)
ASTHMA/COPD/RESPIRATORY (cont) Dulera Advair Diskus
Advair HFA
Breo Ellipta
Symbicort
Elixophyllin theophylline oral solution
Proventil HFA ProAir HFA
Xopenex HFA ProAir RespiClick
Ventolin
Seebri Neohaler Incruse Ellipta
Tudorza Pressair Spiriva
Zyflo montelukast
zafirlukast
Zyflo CR zileuton ER
ATTENTION DEFICIT Cotempla XR-ODT dexmethylphenidate ER
HYPERACTIVITY DISORDER methylphenidate ER/CD/LA
dextroamphetamine-amphetamine ER
Vyvanse
Desoxyn methamphetamine
Dexedrine dextroamphetamine
Mydayis dextroamphetamine-amphetamine ER
Vyvanse
BLOOD PRESSURE/HEART MEDICATIONS Betapace sotalol
Cardizem diltiazem
Cardizem CD Cartia XT
diltiazem CD/ER
Isordil isosorbide dinitrate
Isordil Titradose
Lanoxin tablet Digitek
digoxin
CANCER Nilandron* nilutamide*
CHOLESTEROL MEDICATIONS Antara fenofibrate
Fenoglide
Lipitor atorvastatin
Zypitamag atorvastatin
fluvastatin
lovastatin
pravastatin
rosuvastatin
simvastatin
COUGH/COLD MEDICATIONS TussiCaps hydrocodone-chlorpheniramine ER
DIABETES Accu-Chek, Contour, FreeStyle all other test OneTouch test strips and meters
strips and meters
Adlyxin Byetta
Bydureon
Ozempic
Trulicity
Victoza
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.
18GENERIC AND/OR PREFERRED
DRUG CLASS MEDICATIONS NOT COVERED^^
BRAND ALTERNATIVE(S)
DIABETES (cont) Admelog Humalog
Afrezza Humulin
Apidra
Apidra SoloStar
Fiasp
Novolin, Novolog
Fortamet metformin ER (generic Glucophage XR)
Glumetza
metformin ER (generic Fortamet
and Glumetza)
Invokamet Synjardy, Synjardy XR, Xigduo XR
Invokamet XR
Segluromet
Invokana Farxiga
Jardiance
Jentadueto alogliptin-metformin
Jentadueto XR Janumet, Janumet XR
Kazano Kombiglyze XR
Nesina alogliptin
Tradjenta Januvia
Onglyza
Oseni alogliptin-pioglitazone
Januvia + pioglitazone
Lantus Basaglar, Levemir, Tresiba
Toujeo SoloStar
Steglatro Farxiga
Jardiance
DIURETICS Edecrin bumetanide
ethacrynic acid furosemide
torsemide
EYE CONDITIONS Vyzulta bimatoprost
latanoprost
Travatan Z
GASTROINTESTINAL/HEARTBURN Anusol-HC suppository Anucort-HC
Cortifoam Hemmorex-HC
Uceris foam hydrocortisone suppository
Asacol-HD Apriso
Colazal balsalazide
Delzicol Lialda
Dipentum Pentasa
mesalamine 800mg sulfasalazine
Librax chlordiazepoxide-clidinium
Lotronex alosetron
Marinol dronabinol
Nexium esomeprazole
Omeclamox-Pak lansoprazole-amoxicillin-clarithromycin
Pylera (combo pak)
OmePPI omeprazole
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.
19GENERIC AND/OR PREFERRED
DRUG CLASS MEDICATIONS NOT COVERED^^
BRAND ALTERNATIVE(S)
GASTROINTESTINAL/HEARTBURN (cont) Pepcid famotidine
Prevacid SoluTab lansoprazole
Rowasa mesalamine enema
Syndros dronabinol
Trulance Amitiza, Linzess
Zegerid omeprazole
Zofran ondansetron
Zuplenz ondansetron
ondansetron ODT
HORMONAL AGENTS Cortrosyn cosyntropin
DDAVP desmopressin
DexPak dexamethasone
TaperDex
Fortesta AndroGel 1.62%
Natesto testosterone
Testim
Vogelxo
Genotropin* Humatrope* (PA)
Norditropin*
Nutropin AQ*
Omnitrope*
Saizen*
Zomacton*
Hectorol doxercalciferol
Rayos prednisone
prednisone intensol
Uceris tablet budesonide 9mg tablet
dexamethasone
hydrocortisone
methylprednisolone
prednisone
prednisolone
INFECTIONS Acticlate Generic products (e.g., doxycycline;
Doryx minocycline)
Minocin capsule
Oracea
Solodyn
Vibramycin capsule
Ximino
Augmentin/ES amoxicillin-clavulanate ER
Bethkis* Kitabis Pak*
TOBI* tobramycin*
Diflucan fluconazole
E.E.S. 200 erythromycin ES
Eryped 400
Mepron atovaquone
Mycobutin rifabutin
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.
20GENERIC AND/OR PREFERRED
DRUG CLASS MEDICATIONS NOT COVERED^^
BRAND ALTERNATIVE(S)
INFECTIONS (cont) Sitavig acyclovir (oral)
famciclovir
valacyclovir
Sporanox itraconazole
Targadox doxycycline
Valcyte valganciclovir
Vancocin vancomycin
Zovirax acyclovir (oral)
famciclovir
valacyclovir
INFERTILITY Bravelle*^ Follistim AQ*^ (PA)
Gonal-F*^
MISCELLANEOUS Horizant gabapentin
MULTIPLE SCLEROSIS Copaxone* Aubagio*, Avonex*, Betaseron*, Extavia*,
Gilenya*, glatiramer*, Glatopa*, Plegridy*,
Rebif*, Tecfidera*
PAIN RELIEF AND INFLAMMATORY DISEASE Amrix cyclobenzaprine
Other generic muscle relaxants
Bupap butalbital-acetaminophen tablet
Tencon
Cambia Generic prescription NSAIDs (e.g.,
diclofenac 1.5% solution celecoxib, meloxicam)
Duexis
Naprelan
naproxen CR
naproxen ER
Pennsaid 2% pump
Tivorbex
Vimovo
Vivlodex
Zipsor
Zorvolex
ConZip tramadol
tramadol ER
D.H.E. 45 dihydroergotamine
Gralise gabapentin
Imitrex sumatriptan
Zembrace SymTouch
levorphanol Generic products (e.g., acetaminophen-
codeine, hydromorphone, oxycodone)
Lidozion lidocaine cream
Lorzone chlorzoxazone
Migranal dihydroergotamine
OxyContin Xtampza ER (PA)
Embeda ER (PA)
Hysingla ER (PA)
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.
21GENERIC AND/OR PREFERRED
DRUG CLASS MEDICATIONS NOT COVERED^^
BRAND ALTERNATIVE(S)
PAIN RELIEF AND INFLAMMATORY Roxicodone oxycodone
DISEASE (cont) Siliq Enbrel (PA)
Humira (PA)
Remicade (PA)
Stelara (PA)
Soriatane acitretin
SPRIX ketorolac
Treximet Generic NSAIDs
Generic triptans (e.g., sumatriptan,
naratriptan)
Vanatol LQ butalbital-acetaminophen-caffeine
Zomig zolmitriptan
sumatriptan
Zomig ZMT zolmitriptan ODT
PARKINSON’S DISEASE Gocovri amantadine
Lodosyn carbidopa
Requip XL ropinirole ER
SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify aripiprazole
FazaClo clozapine
Versacloz clozapine ODT
Geodon ziprasidone
Zyprexa olanzapine
Zyprexa Zydis olanzapine ODT
SEIZURE DISORDERS Lyrica CR duloxetine
gabapentin
lidocaine 5% patch
Lyrica
Mysoline primidone
SKIN CONDITIONS Absorica Myorisan
Zenatane
Aldara imiquimod 5% cream
Anusol-HC cream hydrocortisone
Procto-Med HC
Proctosol-HC
Proctozone-HC
Bensal HP salicylic acid
BenzaClin clindamycin-benzoyl peroxide
Duac Neuac gel
Neuac Kit
Carac fluorouracil
Clindagel clindamycin
Clobex clobetasol
Cutivate fluticasone
diclofenac 3% gel Fluoroplex
fluorouracil
imiquimod 5% cream
Picato
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.
22GENERIC AND/OR PREFERRED
DRUG CLASS MEDICATIONS NOT COVERED^^
BRAND ALTERNATIVE(S)
SKIN CONDITIONS (cont) Ertaczo ketoconazole
Extina
Luzu
Vusion
Halog clobetasol
Ultravate X halobetasol
Jublia Ciclodan solution
Kerydin ciclopirox
itraconazole
terbinafine
Kenalog triamcinolone
Locoid hydrocortisone
Locoid Lipocream
Loprox cream, shampoo ciclopirox
Noritate metronidazole
Rosadan
Oxistat ketoconazole
Penlac Ciclodan solution
ciclopirox
Prudoxin Generic topical steroid (e.g.,
Zonalon betamethasone
tacrolimus (topical)
Sernivo clobetasol spray
triamcinolone spray
Soriatane acitretin
Trianex triamcinolone
Triderm
Ultravate lotion clobetasol
Vanos fluocinonide
Verdeso desonide
Xerese acyclovir (oral) + hydrocortisone
famciclovir + hydrocortisone
valacyclovir + hydrocortisone
Ziana clindamycin-tretinoin gel
Zyclara imiquimod 5% cream
SLEEP DISORDERS/SEDATIVES Ambien zolpidem
Ambien CR zolpidem ER
Edluar
Intermezzo
Nuvigil armodafinil
Provigil modafinil
Restoril temazepam
SUBSTANCE ABUSE Evzio Narcan
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.
23GENERIC AND/OR PREFERRED
DRUG CLASS MEDICATIONS NOT COVERED^^
BRAND ALTERNATIVE(S)
URINARY TRACT CONDITIONS Detrol darifenacin ER
Detrol LA oxybutynin ER
Ditropan XL tolterodine ER
Enablex trospium ER
Gelnique
Myrbetriq
Oxytrol
Toviaz
VESIcare
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.
24Prescription drug list FAQs
Understanding your prescription medication “plan (or benefit) exclusion.” For example, your
coverage can be confusing. Below are answers plan excludes medications that aren’t approved
to some commonly asked questions. by the U.S. Food and Drug Administration (FDA).
Why do you make changes to the drug list? How do you decide which medications
are covered?
Cigna regularly reviews and updates the
prescription drug list. We make changes for The Cigna Prescription Drug List is developed
many reasons – like when new medications with the help of Cigna’s Pharmacy and
become available or are no longer available, or Therapeutics (P&T) Committee, which is a group
when medication prices change. We try to give of practicing doctors and pharmacists, most of
you many options to choose from to treat your whom work outside of Cigna. The group meets
health condition. These changes may include:1 regularly to review medical evidence and
› Moving a medication to a lower cost tier. This information provided by federal agencies, drug
can happen at any time during the year. manufacturers, medical professional associations,
national organizations and peer-reviewed
› Moving a brand medication to a higher cost
journals medications about the safety and
tier when a generic becomes available. This
effectiveness of medications that are newly
can happen at any time during the year.
approved by the FDA and medications
› Moving a medication to a higher cost tier and/ already on the market. The Cigna Pharmacy
or no longer covering a medication. This Management® Business Decision Team then looks
typically happens twice a year on January 1st at the results of the P&T Committee’s clinical
and July 1st. review, as well as the medication’s overall value
› Adding requirements to a medication. For and other factors before adding it to, or
example, requiring approval from Cigna before removing it from, the drug list.
a medication may be covered or adding a
quantity limit to a medication. Which medications are covered under the
health care reform law?
When a medication changes tiers or is no longer
covered, you may pay a different amount to fill The Patient Protection and Affordable Care Act
that medication. It’s important to know that (PPACA), commonly referred to as “health care
when we make a change that affects the reform,” was signed into law on March 23, 2010.
coverage of a medication you’re taking, we let Under this law, certain preventive medications
you know before it begins so you have time to (including some over-the-counter medicines)
talk with your doctor. may be available to you at no cost-share ($0),
depending on your plan. Please log in to the
Why doesn’t my plan cover certain myCigna app or website, or check your plan
medications? materials, to learn more about how your plan
To help lower your overall health care costs, covers preventive medications. You can also
your plan doesn’t cover certain high-cost brand view the PPACA No Cost-Share Preventive
medications because they have lower-cost, Medications drug list on Cigna.com/druglist.
covered alternatives which are used to treat the
For more information about health care reform,
same condition. Meaning, the alternative works
visit www.informedonreform.com or Cigna.com.
the same or similar to the non-covered
medication. If you’re taking a medication that Are medications newly approved by the
your plan doesn’t cover and your doctor feels FDA covered on my drug list?
an alternative isn’t right for you, he or she can
Newly approved medications may not be
ask Cigna to consider approving coverage of
covered on your drug list for the first six months
your medication.
after they receive FDA approval. These include,
Your plan may also exclude certain medications but are not limited to, medications, medical
or products from coverage. This is known as a supplies or devices covered under standard
25Prescription drug list FAQs (cont)
pharmacy benefit plans. We review all newly How can I get help with my specialty medication?
approved medications to determine if they
Cigna Specialty Pharmacy can help you manage
should be covered – and if so, at what tier level.
your health and prescription needs.4 Their
If your doctor feels a currently covered
team of medical condition experts provide
medication isn’t right for you, he or she can ask
personalized, 24/7 support. They’ll help you
Cigna to consider approving coverage of the
get approval for coverage of your medication,
newly approved medication.
answer any questions you have about your
How can I find out how much I’ll pay for a medication and its cost, help you work through
specific medication? any side effects and make sure you have any
supplies you need (at no extra cost). They’ll
Prescription prices can vary by pharmacy. Before also help you set up home delivery of your
you pick up your prescription, compare your medication and give you information about
costs online. You can log in to the myCigna app financial assistance programs (if you need help
or website and click on “Price A Medication” to paying for your medication). To learn more
see how much your medication will cost you about the services they provide, please call
at the different pharmacies in your network. 800.351.3606 or go to Cigna.com/specialty-
You can also see if there are lower-cost pharmacyservices.
alternatives available.2
Can I fill my prescriptions by mail?
How can I save money on my prescription
medications? Yes, as long as your plan offers home delivery.4
You may be able to save money by switching › If you’re taking a medication every day to
to a medication that’s on a lower tier (ex. generic treat an ongoing health condition like
or preferred brand) or by filling a 90-day supply, diabetes, high blood pressure, high cholesterol
if your plan allows. You should talk with your or asthma, you can order up to a 90-day
doctor to find out if one of these options may supply through Cigna Home Delivery
work for you. Pharmacy.SM To learn more, call 800.835.3784
or go to Cigna.com/home-delivery-pharmacy.
What’s the difference between brand name and
generic medications?
› If you’re taking a specialty medication to treat
a complex condition like multiple sclerosis,
The FDA requires generic medications to provide hepatitis C and rheumatoid arthritis, you can
the same clinical benefit as its brand name fill your prescription through Cigna Specialty
versions.3 The FDA also requires generic makers Pharmacy (our home delivery pharmacy).
to prove that the generic works in the same way To learn more, call 800.351.3606 or go to
as the brand name medication. This means that Cigna.com/specialty-pharmacy-services.
generic equivalent medications must:3
Where can I find more information about my
› Have the same active ingredient, strength and
prescription medication plan?
dosage form as the brand name medication
› Deliver the same amount of active ingredients You can use the online tools and resources on the
into the bloodstream in the same amount of myCigna app or website to help you better
time as the brand name medication understand your pharmacy benefits. You can
view your drug list or search for a specific
› Be used in the same way as the brand medication, price a medication, find an
name medication in-network pharmacy near you, review your
Generics typically cost much less than brand pharmacy claims and payment history, and
name medications – in some cases, up to 85% track Cigna Home Delivery Pharmacy4 orders
less.3 Just because generics cost less than brands, and request refills.
it doesn’t mean they’re lower-quality medications.
26Exclusions and limitations
Health benefit plans vary, but in general to be eligible for coverage a drug must be approved by
the Food and Drug Administration (FDA), prescribed by a health care professional, purchased
from a licensed pharmacy and be medically necessary. If your plan provides coverage for certain
preventive prescription drugs with no cost-share, you may be required to use an in-network
pharmacy to fill the prescription. If you use a pharmacy that does not participate in your plan’s
network, the prescription may not be covered. Certain drugs may require prior authorization, or be
subject to step therapy, quantity limits or other utilization management requirements.
Plans generally do not provide coverage for the following under the pharmacy benefit, except as
required by state or federal law, or by the terms of your specific plan:5
› over-the-counter (OTC) medicines (those that › replacement of prescription medications and
do not require a prescription) except insulin related supplies due to loss or theft;
unless state or federal law requires coverage › medications which are to be taken by or
of such medicines; administered to a covered person while they
› prescription medications or supplies for which are a patient in a licensed hospital, skilled
there is a prescription or OTC therapeutic nursing facility, rest home or similar institution
equivalent or therapeutic alternative; which operates on its premises or allows to
› doctor-administered injectable medications be operated on its premises a facility for
covered under the Plan’s medical benefit, dispensing pharmaceuticals;
unless otherwise covered under the Plan’s › prescriptions more than one year from the
prescription drug list or approved by Cigna; date of issue; or
› implantable contraceptive devices covered › coverage for prescription medication
under the Plan’s medical benefit; products for the amount dispensed (days’
› medications that are not medically necessary; supply) which is more than the applicable
supply limit, or is less than any applicable
› experimental or investigational medications,
supply minimum set forth in The Schedule, or
including FDA-approved medications used for
which is more than the quantity limit(s) or
purposes other than those approved by the
dosage limit(s) set by the P&T Committee.
FDA unless the medication is recognized for
the treatment of the particular indication; › more than one prescription order or refill for a
given prescription supply period for the same
› medications that are not approved by the
prescription medication product prescribed
Food & Drug Administration (FDA);
by one or more doctors and dispensed by
› prescription and non-prescription devices,
one or more pharmacies.
supplies, and appliances other than those
supplies specifically listed as covered; › prescription medication products dispensed
outside the jurisdiction of the United States,
› medications used for fertility, sexual
except as required for emergency or urgent
dysfunction, cosmetic purposes, weight loss,
care treatment.
smoking cessation, or athletic enhancement;
In addition to the plan’s standard pharmacy
› prescription vitamins (other than prenatal
exclusions, certain new FDA-approved
vitamins) or dietary supplements unless state or
medication products (including, but not limited
federal law requires coverage of such products;
to, medications, medical supplies or devices that
› immunization agents, biological products are covered under standard pharmacy benefit
for allergy immunization, biological sera, plans) may not be covered for the first six
blood, blood plasma and other blood months of market availability unless approved
products or fractions and medications by Cigna as medically necessary.
used for travel prophylaxis;
27You can also read
