CIGNA STANDARD 3-TIER PRESCRIPTION DRUG LIST - As of January 1, 2019 - Frederick County
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CIGNA STANDARD 3-TIER PRESCRIPTION DRUG LIST As of January 1, 2019 Offered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, or their affiliates. 595200 c Standard 3-Tier 08/18
Table of Contents
Getting started
Your prescription drug list 3
How to read your drug list 3
How to find your medication 5
Medications that are not covered 17
Prescription drug list FAQs 25
Exclusions and limitations 27
View your drug list online
This document was last updated 03/01/2018.* To see a current list of the medications covered
on your plan’s drug list, visit:
The myCigna® website – Once you’re registered, log in and select
Estimate Health Care Costs, then select Get drug costs.
Cigna.com/druglist – Select your drug list name – Standard 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 01/01/2004 Last updated: 03/01/2018, for changes Next planned update: 03/01/2019, for
that were effective 07/01/2018 changes that will be effective 07/01/2019
2Your prescription drug list
This document shows the most commonly prescribed medications covered on the Standard
Prescription Drug List as of January 1, 2019.1 All of these medications are approved by the U.S.
Food and Drug Administration (FDA). Medications are listed by the condition they treat, then
listed alphabetically within tiers or (cost-share levels).
It’s important to know that this is not a complete list of covered medications, and not all of the
medications listed here may be covered by your specific plan. You should log in to the myCigna
website or app, or check your plan materials, to learn more about the medications your plan covers.
How to read your drug list
Use the sample chart below to help you understand this drug list. This chart is just an example.
It may not show how these medications are actually covered on the Standard Prescription Drug List.
Tier (cost-share level) gives you
an idea of how much you may pay
TIER 1 TIER 2 for a medication
$ $$
BLOOD PRESSURE/HEART MEDICATIONS Medications are grouped by
afeditab CR Berinert* (PA) the condition they treat
amlodipine besylate Bidil
amlodipine besylate-benazepril Bystolic
amlodipine-valsartan Cinryze* (PA)
amlodipine-valsartan-HCTZ Coreg CR
atenolol Cozaar (ST)
Diovan (ST)
atenolol-chlorthalidone
Diovan HCT (ST) Medications are listed in
benazepril
Edarbi (ST) alphabetical order within
benazepril-HCTZ each column
Edarbyclor (ST)
candesartan cilexetil Exforge
cartia XT Exforge HCT
carvedilol Firazyr* (PA) Specialty medications have an
clonidine Hemangeol asterisk (*) listed next to them
digitek Inderal LA
digox Inderal XL
digoxin Innopran XL
diltiazem ER Lotrel Brand name medications
diltiazem CD Micardis (ST) are capitalized
diltiazem Multaq
dilt-XR Nitro-dur
enalapril Nitrolingual
Nitromist
flecainide acetate Generic medications
Nitronal are lowercase
hydralazine
Nitrostat
irbesartan
Northera* (PA) Medications that have extra
isosorbide mononitrat Norvasc coverage requirements will
Ranexa (ST) have an abbreviation listed
Tekturna next to them
Tekturna HCT
This chart is just a sample. It may not show how these medications are actually covered on the Standard Prescription Drug List.
3Tiers
Covered medications are divided into tiers or cost-share levels. Typically, the higher the tier, the
higher the price you’ll pay to fill the prescription.
› Tier 1 – Typically Generics (Lower-cost medication) $
› Tier 2 – Typically Preferred Brands (Medium-cost medication) $$
› 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 your doctor provides to make
sure you meet coverage guidelines for the medication. If approved, your plan will
cover the medication.
(ST) tep Therapy – Certain high-cost medications are part of the Step Therapy program.
S
Step Therapy encourages the use of lower-cost medications (typically generics and
preferred brands) that can be used to treat the same condition as the higher-cost
medication. These conditions include, but are not limited to, depression, high blood
pressure, high cholesterol, skin conditions and sleep disorders. Your plan doesn’t
cover the higher-cost Step Therapy medication until you try one or more alternatives
first (unless you receive approval from Cigna).
(QL) uantity Limits – For some medications, your plan will only cover up to a certain
Q
amount over a certain length of time. For example, 30mg per day for 30 days. Your
plan will only cover a larger amount if your doctor requests and receives approval
from Cigna.
(AGE) ge Requirements – You must be within a specific age range for your plan to cover
A
the medication. Some medications aren’t considered clinically appropriate for
individuals who aren’t within that age range.
* This may not apply to your plan because not all plans have extra coverage requirements like prior authorization, quantity limits, Step Therapy and/or age. Please log in to the myCigna website or
app, or check your plan materials, to find out if your plan includes these specific coverage requirements.
Brand name medications are capitalized
In this drug list, brand name medications are capitalized and generic medications are lowercase.
Specialty medications are marked with an asterisk
Specialty medications are used to treat complex conditions like multiple sclerosis, hepatitis C and
rheumatoid arthritis. In this drug list, specialty medications are marked with an asterisk (*). Some
plans may cover these medications on a specialty tier, may limit coverage to a 30-day supply and/or
require you to use a preferred specialty pharmacy to receive coverage. Please log in to the
myCigna website or app, or check your plan materials, to learn more about how your plan covers
specialty medications.
4No cost-share preventive medications are marked with a plus sign
Health care reform under the Patient Protection and Affordable Care Act (PPACA) requires that
most plans cover certain categories of medications and other products as preventive care services.
In this drug list, medications with a plus sign (+) next to them may be available to you at no cost-
share (copay, coinsurance and/or deductible). Please log in to the myCigna website or app, or check
your plan materials, to learn more about how your plan covers preventive medications.
Plan exclusions
Your plan excludes certain types of medications or products from coverage. This is known as a “plan
(or benefit) exclusion.” This means that your plan doesn’t cover any prescription medications in the
drug class or to treat the specific condition. There’s also no option to receive coverage through a
medication review process. In this drug list, these medications have a carat (^) next to them. Please
log in to the myCigna website or app, or check your plan materials, to find out if your plan excludes
your medication from coverage.
How to find your medication
Find your condition in the alphabetical list below. Then go to that page to see the covered
medications available to treat the condition.
Condition Page Condition Page
AIDS/HIV 6 GASTROINTESTINAL/HEARTBURN 11, 12
ALLERGY/NASAL SPRAYS 6 HORMONAL AGENTS 12
ALZHEIMER’S DISEASE 6 INFECTIONS 12, 13
ANXIETY/DEPRESSION/BIPOLAR 6
INFERTILITY 13
DISORDER
MISCELLANEOUS 13
ASTHMA/COPD/RESPIRATORY 6
ATTENTION DEFICIT HYPERACTIVITY 7 MULTIPLE SCLEROSIS 13
DISORDER NUTRITIONAL/DIETARY 13
BLOOD MODIFIERS/BLEEDING DISORDERS 7 OSTEOPOROSIS PRODUCTS 13
BLOOD PRESSURE/HEART MEDICATIONS 7
PAIN RELIEF AND INFLAMMATORY DISEASE 13, 14
BLOOD THINNERS/ANTI-CLOTTING 8
PARKINSON’S DISEASE 15
CANCER 8
SCHIZOPHRENIA/ANTI-PSYCHOTICS 15
CHOLESTEROL MEDICATIONS 8
SEIZURE DISORDERS 15
CONTRACEPTIVE PRODUCTS 8–10
SKIN CONDITIONS 15, 16
COUGH/COLD MEDICATIONS 10
SLEEP DISORDERS/SEDATIVES 16
DENTAL PRODUCTS 10
DIABETES 10 SMOKING CESSATION 16
DIURETICS 11 SUBSTANCE ABUSE 16
EAR MEDICATIONS 11 TRANSPLANT MEDICATIONS 16
ERECTILE DYSFUNCTION 11 URINARY TRACT CONDITIONS 16
EYE CONDITIONS 11 WEIGHT MANAGEMENT 16
FEMININE PRODUCTS 11
5Cigna Standard 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
AIDS/HIV ANXIETY/DEPRESSION/BIPOLAR DISORDER
abacavir- Atripla* Complera* amitriptyline Effexor XR (ST, QL)
lamivudine* Biktarvy* Evotaz* bupropion (QL) Fetzima (ST, QL)
atazanavir* Descovy* Odefsey* bupropion SR (QL) Forfivo XL (ST, QL)
ritonavir* Genvoya* Prezcobix* bupropion XL (QL) Pristiq (ST, QL)
tenofovir* Intelence* Stribild* buspirone Prozac (ST, QL)
Isentress HD* Viread 300mg* citalopram (QL) Sarafem (ST)
Isentress* clomipramine Trintellix (ST, QL)
Norvir packet, desvenlafaxine Viibryd (ST, QL)
capsule, ER (QL) Wellbutrin SR (ST, QL)
solution* duloxetine (QL) Zoloft (ST, QL)
Prezista* escitalopram (QL)
Reyataz packet* fluoxetine (QL)
Selzentry* fluoxetine DR (QL)
Tivicay* paroxetine (QL)
Triumeq* paroxetine CR (QL)
Truvada* paroxetine ER (QL)
Viread powder, sertraline (QL)
150, 200, trazodone
250mg* venlafaxine (QL)
venlafaxine ER (QL)
ALLERGY/NASAL SPRAYS
ASTHMA/COPD/RESPIRATORY
azelastine Clarinex-D 12 Hour
albuterol Advair Diskus Adcirca* (PA)
cromolyn solution Karbinal ER
budesonide Advair HFA Adempas* (PA)
cyproheptadine Ryvent
inhalation Anoro Ellipta Arcapta Neohaler
desloratadine (QL) Semprex-D
ipratropium- Atrovent HFA Daliresp (QL)
epinephrine auto-
albuterol Breo Ellipta Kalydeco* (PA, QL)
injector (PA, QL)
montelukast Combivent Letairis* (PA)
flunisolide
Respimat Ofev* (PA)
fluticasone
Incruse Ellipta Opsumit* (PA)
hydroxyzine
ProAir HFA Orenitram ER* (PA)
capsule, solution,
ProAir RespiClick Orkambi* (PA, QL)
syrup, tablet
Pulmicort Pulmicort
ipratropium
Flexhaler Symdeko* (PA, QL)
mometasone spray
Pulmozyme* Tracleer* (PA)
(QL)
(PA) Tyvaso* (PA)
olopatadine spray
QVAR RediHaler Uptravi* (PA)
promethazine syrup,
Serevent Diskus
tablet
Spiriva
Stiolto Respimat
ALZHEIMER’S DISEASE Striverdi
donepezil Mestinon syrup Mestinon tablet Respimat
donepezil ODT Namenda Namenda tablet Symbicort
memantine Titration Pak Namenda XR (QL) Trelegy Ellipta
memantine ER (QL) Namzaric (QL) (ST)
pyridostigmine Ventolin HFA
pyridostigmine ER Xolair* (PA)
rivastigmine
6Cigna Standard 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
ATTENTION DEFICIT BLOOD PRESSURE/HEART MEDICATIONS (cont)
HYPERACTIVITY DISORDER clonidine patch, Nitromist
atomoxetine (QL) Vyvanse (PA age) Adderall (ST) tablet Nitrostat
dexmethylphenidate Adzenys ER (PA age) Digitek Northera* (PA)
dextroamphetamine- Adzenys XR-ODT (PA Digox Norvasc
amphetamine age) digoxin solution, Ranexa (ST, QL)
ER (QL) Daytrana (PA age) tablet Tiazac
Dilt-XR
dextroamphetamine- Dyanavel XR (PA age) Tikosyn (QL)
diltiazem CD
amphetamine Evekeo (ST) diltiazem ER Toprol XL
guanfacine ER Focalin (ST) diltiazem tablet Tribenzor
Metadate ER Methylin (ST) dofetilide (QL) Vasotec (ST)
methylphenidate Quillichew ER (PA doxazosin
methylphenidate age) Ecotrin+
CD (QL) Quillivant XR (PA age) EcPirin+
methylphenidate Ritalin (ST) enalapril
ER (QL) flecainide
methylphenidate hydralazine tablet
LA (QL) irbesartan
isosorbide
BLOOD MODIFIERS/BLEEDING DISORDERS isosorbide ER
tranexamic acid Aranesp*^ (PA) Promacta* (PA) labetalol
tablet* Epogen*^ (PA) lisinopril
Granix*^ lisinopril-HCTZ
Neulasta*^ (PA) losartan
Procrit*^ (PA) losartan-HCTZ
Matzim LA
Zarxio*^
metoprolol
BLOOD PRESSURE/HEART MEDICATIONS nadolol
Afeditab CR Bystolic (QL) Azor (QL) nifedipine
amlodipine Byvalson Bayer Chewable nifedipine ER
amlodipine- Corlanor (PA) Aspirin+ olmesartan (QL)
benazepril Entresto (PA) Benicar (ST, QL) olmesartan-
amlodipine- amlodipine-HCTZ
Multaq Benicar HCT (ST, QL)
olmesartan (QL) olmesartan-HCTZ
Nitro-Dur 0.3, BiDil (QL) (QL)
amlodipine-
0.8mg Cardizem LA (QL) propafenone
valsartan
amlodipine- Tekturna (QL) Coreg CR (QL) propafenone ER
valsartan-HCTZ Tekturna HCT Cozaar (ST) propranolol ER
Aspir 81 + (QL) Diovan (ST) propranolol tablet,
Aspir-Low + Diovan HCT (ST) solution
aspirin EC + Edarbi (ST, QL) quinapril
aspirin +
Edarbyclor (ST) ramipril
atenolol Epaned (ST) Taztia XT
atenolol- Firazyr* (PA) telmisartan (QL)
chlorthalidone Haegarda* (PA) telmisartan-HCTZ
benazepril (QL)
Hemangeol
benazepril-HCTZ tri-buffered aspirin+
Inderal LA valsartan
bisoprolol
Inderal XL valsartan-HCTZ
Bufferin+
candesartan Innopran XL verapamil ER
Cartia XT Nitro-Dur 0.1, 0.2, 0.4, verapamil SR
carvedilol 0.6mg verapamil tablet,
carvedilol ER (QL) Nitrolingual capsule
7Cigna Standard 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
BLOOD THINNERS/ANTI-CLOTTING CHOLESTEROL MEDICATIONS
aspirin- Brilinta Bevyxxa (QL) atorvastatin 10mg, Repatha* (PA) Crestor (ST, QL)
dipyridamole ER Eliquis Coumadin 20mg+ Korlym* (PA)
clopidogrel Fragmin* (QL) Effient ezetimibe Kynamro* (PA)
enoxaparin* (QL) Xarelto Pradaxa ezetimibe- Vascepa
fondaparinux* (QL) Savaysa (QL) simvastatin Vytorin (ST)
Jantoven Zontivity fenofibrate Zetia
prasugrel fenofibric acid
warfarin fluvastatin 20mg,
40mg+
fluvastatin ER 80mg+
CANCER
lovastatin 20mg,
anastrozole Actimmune* Afinitor Disperz* (PA) 40mg+
bexarotene* (PA) (PA) Afinitor* (PA) niacin ER
capecitabine* (PA) Intron A*^ (PA) Alecensa* (PA) Niacor
imatinib* (PA) Nexavar* (PA) Arimidex omega-3 acid ethyl
letrozole Revlimid* (PA) Bosulif* (PA) esters
mercaptopurine Sprycel* (PA) Cabometyx* (PA) pravastatin 10mg,
methotrexate* Sutent* (PA) Cometriq* (PA) 20mg, 40mg,
tamoxifen+ Tarceva* (PA) Cotellic* (PA) 80mg+
temozolomide* (PA) Tasigna* (PA) Erivedge* (PA) rosuvastatin 5mg,
Trexall* Erleada* (PA) 10mg (QL)+
Fareston (QL) simvastatin 10mg,
Gilotrif* (PA) 20mg, 40 mg (QL)+
Gleevec* (PA) Triklo
Ibrance* (PA)
CONTRACEPTIVE PRODUCTS
Iclusig* (PA)
Imbruvica* (PA) Aftera +
Lo Loestrin FE Beyaz
Inlyta* (PA) Altavera+ NuvaRing Ella+
Alyacen +
Taytulla Estrostep FE
Jakafi* (PA)
Amethia Lo+ Loestrin FE
Lenvima* (PA) Amethia+
Lonsurf* (PA) LoSeasonique
Amethyst+ Microgestin+
Lynparza* (PA) Apri+
Mekinist* (PA) Minastrin 24 FE
Aranelle+
Nerlynx* (PA) Ashlyna + Seasonique
Ninlaro* (PA) Aubra + Skyla*
Pomalyst* (PA) Aviane + Today Contraceptive
Stivarga* (PA) Azurette + Sponge+
Sylatron* (PA) Balziva +
Tafinlar* (PA) Bekyree+
Tagrisso* (PA) Blisovi 24 FE+
Blisovi FE+
Targretin* (PA)
Briellyn+
Verzenio* (PA) Camila+
Votrient* (PA) Camrese Lo+
Xalkori* (PA) Camrese+
Xtandi* (PA) Caya Contoured+
Zelboraf* (PA) Caziant+
Zytiga* (PA) Chateal+
Cryselle+
Cyclafem+
8Cigna Standard 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
CONTRACEPTIVE PRODUCTS (cont) CONTRACEPTIVE PRODUCTS (cont)
Cyred+
Levonest+
Dasetta+ levonorgestrel-
Daysee+ ethinyl estradiol+
Deblitane+ Levora-28+
Delyla+ Lillow+
desogestrel-ethinyl Loryna+
estradiol+ Low-Ogestrel+
drospirenone- Lutera+
ethinyl estradiol- Lyza+
levomefibrate+ Marlissa+
drospirenone- medroxyprogesterone
ethinyl estradiol+ 150mg/ml+
Econtra EZ+ Melodetta 24 FE
Econtra One-Step+ Mibelas 24 FE+
Elinest+ Microgestin FE+
Emoquette+ Mili+
Enpresse+ Mono-Linyah+
Enskyce+ Mononessa+
Errin+ My Choice+
Estarylla+ My Way+
ethynodiol-ethinyl Myzilra+
estradiol+ Necon 0.5/35+
Falmina+ Necon 7/7/7+
Fayosim+ Nikki+
FC2 Female Nora-BE+
Condom+ norethindrone-
Femcap+ ethinyl estradiol-
Femynor+ norethindrone-
Gianvi+ ethinyl estradiol+
Heather+ norethindrone+
Introvale+ norgestimate-
iron+ ethinyl estradiol+
Isibloom+ Norlyda+
jencycla+ Norlyroc+
Jolessa+ Nortrel+
Jolivette+ Ocella+
Juleber+ Opcicon One-Step+
Junel FE 24+ Option 2+
Junel FE+ Orsythia+
Junel+ Philith+
Kaitlib FE+ Pimtrea+
Kariva+ Pirmella+
Kelnor 1-35+ Portia+
Kelnor 1-50+ Previfem+
Kimidess+ Quasense+
Kurvelo+ Rajani+
Larin 24 FE+ Reclipsen+
Larin FE+ Rivelsa+
Larin+ Setlakin+
Larissia+ Sharobel+
Leena+ Sprintec+
Lessina+ Sronyx+
9Cigna Standard 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
CONTRACEPTIVE PRODUCTS (cont) DENTAL PRODUCTS
Syeda+ chlorhexidine rinse Fluorabon^
Tarina FE+ doxycycline
Tilia FE+ fluoride^
Tri Femynor+ Fluoritab^
Tri-Estarylla+ Flura-Drops^
Tri-Legest FE+ Ludent Fluoride^
Tri-Linyah+ Oralone
Tri-Lo-Estarylla+ Paroex
Tri-Lo-Marzia+
Peridex
Tri-Lo-Sprintec+
Tri-Mili+ Periogard
Tri-Previfem+ sodium fluoride^
Tri-Sprintec+ triamcinolone paste
Tri-Vylibra+
Trinessa Lo+
DIABETES
Trinessa+
Trivora-28+ glimepiride Basaglar Cycloset
Tulana+ glipizide Bydureon (QL) Glucophage
Tydemy+ glipizide ER Byetta (QL) Glucophage XR
VCF+ glipizide XL Farxiga (QL) Riomet
Velivet+ metformin GlucaGen VGo
Vienva+ metformin ER HypoKit (QL)
Viorele+ NovoTwist Glucagon
Vyfemia+ Emergency
Vylibra+
Kit (QL)
Wera+
Wide Seal Glyxambi
Diaphragm+ Humalog
Wymzya FE+ Humulin
Xulane+ Janumet
Zarah Janumet XR
Zenchent+ Januvia (QL)
Zovia 1-35e+ Jardiance
Zovia 1-50e+ Kombiglyze XR
Levemir
COUGH/COLD MEDICATIONS OneTouch test
strips and
benzonatate Tessalon Perle meters
Bromfed DM Tussionex (QL) Onglyza (QL)
brompheniramine- Tuzistra XR (QL) QTERN
pseudoephedrine- Soliqua
DM SymlinPen
hydrocodone- Synjardy
chlorpheniramine Synjardy XR
ER (QL) Tresiba
hydrocodone- Trulicity (QL)
homatropine (QL) Victoza (QL)
Hydromet (QL) Xigduo XR (QL)
Tussigon (QL) Xultophy
10Cigna Standard 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
DIURETICS GASTROINTESTINAL/HEARTBURN
acetazolamide Diuril Aldactone Alophen +
Amitiza Aciphex (ST, QL)
capsule, tablet Dyrenium Carospir alosetron* Apriso Aciphex Sprinkle (QL)
chlorthalidone Jynarque* (PA) Anucort-HC Canasa Akynzeo* (PA, QL)
eplerenone Lasix balsalazide Carafate Bonjesta
furosemide solution, Samsca* Bisa-Lax+ suspension Carafate tablet
tablet bisacodyl+ Creon Cholbam* (PA)
hydrochlorothiazide chlordiazepoxide- Dexilant (QL) Clenpiq
spironolactone clidinium Entyvio*^ (PA) CoLyte With Flavor
triamterene-HCTZ clarithromycin GoLytely powder Packets+
EAR MEDICATIONS Clearlax+ Linzess Correctol+
dicyclomine Pentasa Diclegis
neomycin- Cipro HC Coly-Mycin S
capsule, solution, Zenpep Donnatal
polymyxin-HC Ciprodex Dermotic
tablet Dulcolax+
ofloxacin drops Otovel
diphenoxylate- Gattex* (PA)
ERECTILE DYSFUNCTION atropine Gialax+
sildenafil^ (QL) Cialis^ (QL) Viagra^ (ST, QL) dronabinol GoLytely solution+
Muse^ (QL) Ducodyl+ Lialda (ST)
esomeprazole (QL) Miralax+
famotidine Movantik (PA)
EYE CONDITIONS
suspension, tablet MoviPrep+
azelastine Alphagan P 0.1% Acuvail Gavilax+ Nulytely with flavor
brimonidine Azasite Alphagan P 0.15% Gavilyte-C+ packets+
ciprofloxacin drops Azopt Alrex Gavilyte-G+ Ocaliva* (PA)
dorzolamide-timolol Betimol Bepreve Gavilyte-n+ OsmoPrep+
erythromycin Betoptic S Besivance GentleLax+ Pancreaze
ointment Lotemax drops, Bromsite Glycolax+ Pertzye
fluorometholone gel Combigan HealthyLax+ Prepopik+
gatifloxacin Moxeza Cosopt PF Hemmorex-HC Prevacid capsule
ketorolac solution Pazeo Cystaran* (QL) hydrocortisone (ST, QL)
latanoprost Restasis Durezol suppository Ravicti*
moxifloxacin drops Simbrinza Ilevro lansoprazole (QL) Rectiv
neomycin- Tobradex Lotemax ointment lansoprazole- Relistor (PA)
polymyxin- ointment Lumigan amoxicillin- Sancuso (PA, QL)
dexamethasone Travatan Z Nevanac LaxaClear+ Sensipar*
ofloxacin drops Xiidra Pataday mesalamine sfRowasa
olopatadine drops Patanol metoclopramide Sucraid*
polymyxin B-TMP Prolensa ODT Suprep+
prednisolone drops Tobradex drops metoclopramide Symproic (PA)
timolol Tobradex ST solution, tablet Transderm Scop
tobramycin drops Vigamox Natura-Lax+ Varubi* (PA, QL)
tobramycin- Zioptan (ST, QL) omeprazole (QL) Viberzi
dexamethasone Zirgan ondansetron Viokace
Zylet ondansetron ODT
FEMININE PRODUCTS pantoprazole (QL)
PEG 3350-electrolyte
Fem pH AVC
PEG 3350-
Gynazole 1 Relagard
electrolytes+
miconazole 3
PEG-Prep+
terconazole
Phenadoz
11Cigna Standard 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
GASTROINTESTINAL/HEARTBURN (cont) HORMONAL AGENTS (cont)
Powderlax+
prednisone
promethazine prednisone intensol
suppository progesterone
Promethegan capsule
Purelax+ testosterone
rabeprazole (QL) (PA, QL)
ranitidine capsule, testosterone
syrup, tablet cypionate
scopolamine thyroid
Smooth LAX+ Unithroid 75mcg
sucralfate Westhroid
TriLyte with flavor WP Thyroid
packets+ Yuvafem (QL)
ursodiol INFECTIONS
HORMONAL AGENTS acyclovir capsule, Albenza Alinia
Amabelz Androderm Activella suspension, Baraclude Bactrim
budesonide EC (PA, QL) Alora (QL) tablet solution* Bactrim DS
cabergoline (QL) AndroGel 1.62% AndroGel 1.0% amoxicillin Cipro Baraclude tablet*
Covaryx (PA, QL) (PA, QL) amoxicillin- Daraprim* (PA) (QL)
Covaryx H.S. Armour Thyroid Angeliq clavulanate ER E.E.S. 400 Cayston*
amoxicillin- Epclusa* (PA) Cleocin
Decadron Cytomel 50mcg Armour Thyroid
clavulanate Ery-Tab 333, Clindesse
desmopressin Divigel 15mg atovaquone 500mg Cresemba (PA)
solution, spray, Duavee Climara Avidoxy tablet Harvoni* (PA) Dificid (QL)
tablet Estring (QL) Climara Pro azithromycin Kitabis Pak* EryPed 200
dexamethasone Forteo* Combipatch packet, suspension, Mavyret* (PA) Ery-Tab 250mg
elixir, liquid, tablet Ganirelix*^ Cytomel 5, 25mcg tablet PegIntron* (PA) Monurol
dexamethasone Humatrope* (PA) Depo-Testosterone cefdinir Sovaldi* (PA) Noxafil suspension,
intensol Levo-T Egrifta* (PA) cefixime Thalomid* (PA) tablet
EEMT Lupron Depot*^ Elestrin cefuroxime tablet Uretron D-S Plaquenil
EEMT H.S. (PA) Emflaza* (PA) cephalexin Vibramycin syrup Sulfatrim
estradiol (QL) Premarin cream, Entocort EC ciprofloxacin Vosevi* (PA) Suprax
estradiol- tablet Estrace clarithromycin Tamiflu (QL)
clarithromycin ER Tobi Podhaler*
norethindrone Premphase Estrogel
clindamycin Uribel
estrogen- Prempro Evamist Coremino (QL) Urogesic-Blue
methyltestosterone Sandostatin LAR Femring dapsone UTA
levothyroxine tablet Depot*^ (PA) Intrarosa doxycycline capsule, Valtrex
Levoxyl Serostim* (PA) Menostar (QL) suspension, tablet Vemlidy*
liothyronine Somavert* (PA) Minivelle (QL) doxycycline IR-DR Vibramycin
medroxyprogesterone Synthroid Natpara* (PA) Emverm suspension
dose pack, tablet Unithroid Osphena entecavir* (QL) Xifaxan
methimazole Zorbtive* (PA) Rayaldee erythromycin Zepatier* (PA)
methylprednisolone Somatuline Depot*^ famciclovir
Mimvey (PA) fluconazole
Mimvey Lo Striant (PA, QL) hydroxychloroquine
itraconazole
Nature-Throid Tirosint
levofloxacin
NP Thyroid Vagifem (QL) solution, tablet
prednisolone Vivelle-Dot (QL) metronidazole
prednisolone ODT capsule, tablet
12Cigna Standard 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
INFECTIONS (cont) NUTRITIONAL/DIETARY
minocycline calcitriol capsule, CitraNatal 90 Auryxia (QL)
minocycline ER (QL) solution DHA Concept DHA
Mondoxyne NL calcium capsule Escavite D+ Fluorabon+
Morgidox cyanocobalamin Escavite+ K-Tab ER
nitrofurantoin FA-8+ Floriva+ Klor-Con 10
Okebo fluoride+ Klor-Con M15 Klor-Con 8
oseltamivir (QL) Fluoritab+ Mephyton KPN+
penicillin VK tablet Flura-Drops+ MVC-fluoride+ Phoslyra
folic acid 1mg+ Nascobal Renagel
Soloxide
Klor-Con OB Complete Renvela
sulfamethoxazole- Klor-Con M10 Perry Prenatal+ Velphoro
trimethoprim Klor-Con M20 Poly-Vi-Flor With Veltassa
suspension, tablet lanthanum Iron+
terbinafine levocarnitine Poly-Vi-Flor+
tinidazole Ludent Fluoride+ Prefera OB
tobramycin* multivitamin-iron- Prenate
valacyclovir fluoride+ Quflora+
valganciclovir PNV-DHA Tri-Vi-Flor+
vancomycin capsule polyvitamins- Tristart DHA
Vandazole fluoride+ Urosex+
voriconazole (PA) potassium chloride Vitafol
Prena1 Pearl vitaMedMD
INFERTILITY prenatal vitamin+ One Rx
clomiphene^ Follistim AQ*^ Crinone^ Prenatal+ vitaPearl
Endometrin^ Right Step+ VP-PNV-DHA
sevelamer
MISCELLANEOUS sodium fluoride+
tri-vitamin with
NebuSal 3% Cerdelga* (PA) Addyi^ (QL) fluoride-iron+
PulmoSal Nityr* (PA) Austedo* (PA) tri-vitamin with
sodium chloride Esbriet* (PA) fluoride+
inhalation Exjade* Virt-PN DHA
TechLITE lancets Ingrezza* (PA) vitamin D2 1.25mg
tetrabenazine* (PA) Jadenu* Zatean-PN DHA
Kuvan* (PA) OSTEOPOROSIS PRODUCTS
NebuSal 6% alendronate (QL) Tymlos* Evista
Nuedexta (QL) calcitonin-salmon Fosamax Plus D (ST)
Strensiq* (PA) ibandronate tablet
Syprine* (PA) raloxifene+
Xenazine* (PA) risedronate
risedronate DR
MULTIPLE SCLEROSIS
PAIN RELIEF AND INFLAMMATORY DISEASE
glatiramer* (PA) Ampyra* (PA) acetaminophen- Actemra* (PA) Abstral (PA, QL)
Glatopa* (PA) Aubagio* (PA) codeine (PA, QL) Cuprimine* (PA) Actiq (PA, QL)
Avonex* (PA) allopurinol Depen* (PA) Analpram HC
Betaseron* (PA) baclofen Embeda (PA, QL) Arymo ER (PA, QL)
Extavia* (PA) buprenorphine (QL) Enbrel* (PA) Benlysta* (PA)
Gilenya* (PA) butalbital- Humira* (PA) Butrans (QL)
Plegridy* (PA) acetaminophen- Hysingla ER Celebrex (ST, QL)
Rebif* (PA) caffeine-codeine (PA, QL) Cimzia* (PA)
Tecfidera* (PA) (PA, QL) Nucynta (PA, QL) Colcrys
13Cigna Standard 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
PAIN RELIEF AND INFLAMMATORY PAIN RELIEF AND INFLAMMATORY
DISEASE (cont) DISEASE (cont)
butalbital- Otezla* (PA) Cosentyx* (PA) Lorcet HD (PA, QL)
acetaminophen- Proctofoam-HC Duragesic (PA, QL) Lorcet Plus (PA, QL)
caffeine (QL) Rasuvo* (PA) Fentora (PA, QL) Lortab (PA, QL)
carisoprodol Remicade*^ (PA) Flector (ST, QL) Medolor pak
celecoxib (QL) Savella Ilaris*^ (PA) meloxicam
colchicine Stelara* (PA) Kadian (PA, QL) Metaxall
cyclobenzaprine Subsys (PA, QL) Kevzara* (PA) metaxalone
DermacinRx Uloric (QL) Kineret* (PA) methocarbamol
Empricaine Xtampza ER Lazanda (PA, QL) tablet
DermacinRx (PA, QL) Mitigare morphine (PA, QL)
Prizopak Morphabond ER (PA, morphine ER
diclofenac (QL) QL) (PA, QL)
diclofenac ER MS Contin (PA, QL) naproxen
dihydroergotamine Nucynta ER (PA, QL) naproxen DS
(QL) Onzetra Xsail (QL) oxycodone (PA, QL)
eletriptan (QL) Orencia* (PA) oxycodone ER
Endocet (PA, QL) Otrexup* (PA) (PA, QL)
etodolac Oxaydo (PA, QL) oxycodone-
etodolac ER Pennsaid (ST) acetaminophen
fenoprofen Percocet (PA, QL) (PA, QL)
Fenortho Procort oxymorphone
fentanyl (PA, QL) Relpax (QL) (PA, QL)
Fioricet (QL) Simponi* (PA) oxymorphone ER
frovatriptan (QL) Synera (PA, QL)
Glydo Taltz* (PA) Phrenilin Forte (QL)
hydrocodone- Tremfya* (PA) Prilolid
acetaminophen Voltaren (ST, QL) Primlev (PA, QL)
(PA, QL) Xeljanz XR* (PA) Profeno
hydromorphone Xeljanz* (PA) Relador Pak
(PA, QL) Zohydro ER (PA, QL) Relador Pak Plus
hydromorphone ER rizatriptan (QL)
(PA, QL) sumatriptan (QL)
IBU sumatriptan-
ibuprofen naproxen (QL)
indomethacin tizanidine
indomethacin ER tramadol (QL)
ketorolac (QL) tramadol ER (QL)
leflunomide Verdrocet (PA, QL)
lidocaine (QL) Vicodin (PA, QL)
lidocaine viscous Vicodin ES (PA, QL)
lidocaine-prilocaine Vicodin HP (PA, QL)
Lidopril
Lidopril XR
Lido-Prilo Caine
Pack
LiproZonePak
Livixil Pak
Lorcet (PA, QL)
14Cigna Standard 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
PARKINSON’S DISEASE SKIN CONDITIONS
amantadine Apokyn* (PA) Azilect (QL) adapalene (PA age) Drysol Benzamycin
benztropine tablet Duopa* adapalene-benzoyl Eucrisa Celacyn gel
bromocriptine Neupro peroxide Finacea Desowen (ST)
carbidopa-levodopa Rytary Ala-Cort 2.5% Naftin gel Dovonex
carbidopa-levodopa Sinemet Amnesteem (QL) Santyl (QL) Ecoza
ER Sinemet CR Avar cleanser Elidel
pramipexole Tasmar Avar-E Enstilar
pramipexole ER (QL) Xadago BenzePrO Naftin cream
rasagiline (QL) BP 10-1 Picato
ropinirole BPO gel Sklice
ropinirole ER calcipotriene Soolantra
SCHIZOPHRENIA/ANTI-PSYCHOTICS calcipotriene- Sorilux
aripiprazole (QL) Fanapt (ST, QL) betamethasone DP Taclonex
aripiprazole ODT Latuda (ST, QL) Calcitrene Targretin*
chlorpromazine Rexulti (ST, QL) Claravis (QL) Topicort (ST)
tablet Saphris (ST) Clindacin ETZ Tridesilon (ST)
haloperidol Seroquel (ST) Clindacin P
concentrate, tablet Seroquel XR (ST) clindamycin
olanzapine Vraylar (ST, QL) clindamycin-
olanzapine ODT benzoyl peroxide
tablet clindamycin-
paliperidone ER (QL) tretinoin
quetiapine clobetasol
quetiapine ER Clodan solution,
risperidone cream, shampoo
risperidone ODT clotrimazole-
ziprasidone betamethasone
SEIZURE DISORDERS dapsone
desonide
carbamazepine Dilantin 30mg Aptiom (PA, QL)
carbamazepine ER Lyrica Banzel (PA, QL) fluocinonide
divalproex Vimpat (PA) Briviact (PA) fluorouracil cream,
divalproex ER Carbatrol solution
Epitol Depakote flurandrenolide
gabapentin Depakote ER hydrocortisone
lamotrigine Dilantin 50mg, imiquimod
lamotrigine (blue, 100mg, susp. isotretinoin (QL)
green, orange) Fycompa (PA, QL) ketoconazole
lamotrigine ER Oxtellar XR (PA) metronidazole
lamotrigine ODT Phenytek cream, gel
lamotrigine ODT Spritam (PA) mupirocin
(blue, green, Tegretol Myorisan (QL)
orange) Tegretol XR Neuac gel
levetiracetam Nolix
levetiracetam ER nystatin-
oxcarbazepine triamcinolone
Roweepra oxiconazole
Roweepra XR permethrin
topiramate Procto-Med HC
topiramate ER Procto-Pak
15Cigna Standard 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
SKIN CONDITIONS (cont) TRANSPLANT MEDICATIONS
Proctosol-HC azathioprine tablet* Prograf 0.5mg, Astagraf XL*
Proctozone-HC mycophenolate 5mg* Cellcept capsule,
Rosadan capsule, suspension, tablet*
Rosanil suspension, tablet* Envarsus XR*
Scalacort mycophenolic acid* Myfortic*
sodium sirolimus* Neoral*
sulfacetamide- tacrolimus* Prograf 1mg*
sulfur Zortress*
SSS 10-5 URINARY TRACT CONDITIONS
SulfaCleanse 8-4
darifenacin ER (QL) Cystagon* Avodart
tacrolimus
dutasteride Elmiron Procysbi* (PA)
tazarotene
finasteride K-Phos Original Pyridium
tretinoin (PA age)
oxybutynin Thiola* Rapaflo (QL)
triamcinolone
oxybutynin ER
Triderm
phenazopyridine
Zenatane (QL)
potassium ER
tamsulosin
SLEEP DISORDERS/SEDATIVES tolterodine
armodafinil (PA) Belsomra (ST) Rozerem (ST, QL) tolterodine ER (QL)
eszopiclone Silenor (ST, QL) Xyrem* (PA) trospium
modafinil (PA) trospium ER
zolpidem WEIGHT MANAGEMENT
zolpidem ER (QL) Lomaira^ Belviq XR^
phentermine^ Belviq^
Contrave^
Qsymia^
SMOKING CESSATION Saxenda^
bupropion SR +
Chantix^ Nicorette+
NicoDerm CQ+ Nicotrol^ Zyban^
Nicorelief+
nicotine gum+
nicotine lozenge+
nicotine patch+
Quit 2+
Quit 4+
SUBSTANCE ABUSE
buprenorphine Bunavail
tablet Narcan
buprenorphine- Suboxone
naloxone Zubsolv
naloxone
naltrexone (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 MEDICATION(S) NOT COVERED^^
BRAND ALTERNATIVE(S)
ALLERGY/NASAL SPRAYS Auvi-Q epinephrine auto-injector
EpiPen, EpiPen Jr
Beconase AQ Generic nasal steroids (e.g., fluticasone)
Dymista
Nasonex
Omnaris
QNASL
Zetonna
QNASL Children budesonide
fluticasone
triamcinolone
ANXIETY/DEPRESSION/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
ArmonAir RespiClick Pulmicort Flexhaler
Arnuity Ellipta
Asmanex
Asmanex HFA
Flovent Diskus
Flovent HFA
Bevespi Anoro Ellipta
Utibron Neohaler Stiolto Respimat
Dulera Advair Diskus
Advair HFA
Breo Ellipta
Symbicort
Elixophyllin theophylline oral solution
Proventil HFA ProAir HFA
Xopenex HFA ProAir RespiClick
Ventolin HFA
Seebri Neohaler Incruse Ellipta
Tudorza Pressair Spiriva
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.
17GENERIC AND/OR PREFERRED
DRUG CLASS MEDICATION(S) NOT COVERED^^
BRAND ALTERNATIVE(S)
ASTHMA/COPD/RESPIRATORY (cont) Zyflo montelukast
zafirlukast
Zyflo CR zileuton ER
ATTENTION DEFICIT HYPERACTIVITY Cotempla XR-ODT dexmethylphenidate ER
DISORDER methylphenidate ER/CD/LA
dextroamphetamine-amphetamine ER
Vyvanse
Desoxyn methamphetamine
Dexedrine dextroamphetamine
Mydayis dextroamphetamine-amphetamine ER
dexmethylphenidate ER
methylphenidate ER/CD/LA
Vyvanse
BLOOD PRESSURE/HEART MEDICATIONS Betapace sotalol
Cardizem diltiazem
Cardizem CD Cartia XT
diltiazem CD/ER
Isordil isosorbide dinitrate
Isordil Titradose
Lanoxin Digitek
digoxin
BLOOD THINNERS/ANTI-CLOTTING Yosprala IR or EC aspirin
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 OneTouch test strips and meters
test strips and meters
Adlyxin Byetta
Tanzeum Bydureon
Ozempic
Trulicity
Victoza
Admelog Humalog
Afrezza Humulin
Apridra
Apridra SoloStar
Fiasp
Novolin, Novolog
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.
18GENERIC AND/OR PREFERRED
DRUG CLASS MEDICATION(S) NOT COVERED^^
BRAND ALTERNATIVE(S)
DIABETES (cont) 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
Giazo sulfasalazine
mesalamine 800mg tablet sulfasalazine DR
Librax chlordiazepoxide-clidinium
Lotronex alosetron
Marinol dronabinol
Nexium esomeprazole
Omeclamox-Pak lansoprazole-amoxicillin-clarithromycin
Prevpac (combo pak)
Pylera
OmePPI omeprazole
Pepcid famotidine
Prevacid SoluTab lansoprazole
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.
19GENERIC AND/OR PREFERRED
DRUG CLASS MEDICATION(S) NOT COVERED^^
BRAND ALTERNATIVE(S)
GASTROINTESTINAL/HEARTBURN (cont) Rowasa mesalamine enema
Syndros dronabinol
Trulance Amitiza, Linzess
Zegerid omeprazole
Zofran ondansetron
Zofran ODT ondansetron ODT
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 dexamethasone
hydrocortisone
methylprednisolone
prednisone
prednisolone
INFECTIONS Acticlate Generic products (e.g., doxycycline;
Doryx minocycline)
Minocin capsule
Monodox
Oracea
Solodyn
Vibramycin capsule
Ximino
Augmentin/ES/XR amoxicillin-clavulanate ER
Bethkis Kitabis Pak
Tobi tobramycin
Diflucan fluconazole
E.E.S. 200 erythromycin ethylsuccinate
Eryped 400
Mepron atovaquone
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.
20GENERIC AND/OR PREFERRED
DRUG CLASS MEDICATION(S) NOT COVERED^^
BRAND ALTERNATIVE(S)
INFECTIONS (cont) Mycobutin rifabutin
Onmel itraconazole
terbinafine
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
MULTIPLE SCLEROSIS Copaxone Aubagio, Avonex, Betaseron, Extavia,
Gilenya, glatiramer, Glatopa, Plegridy,
Rebif, Tecfidera
PAIN RELIEF AND INFLAMMATORY DISEASE Amrix cyclobenzaprine
Other generic muscle relaxants
Belbuca buprenorphine
Bupap butalbital-acetaminophen tablet
Tencon
Cambia Generic prescription NSAIDs (e.g.,
diclofenac 1.5% solution celecoxib, meloxicam)
Duexis
Naprelan
naproxen CR
naproxen ER
Pennsaid
Tivorbex
Vimovo
Vivlodex
Zipsor
Zorvolex
Conzip tramadol
tramadol ER
D.H.E. 45 dihydroergotamine
Duzallo allopurinol, probenecid
Gralise gabapentin
Imitrex sumatriptan
Zembrace SymTouch
Kineret Actemra (PA)
Enbrel (PA)
Humira (PA)
Remicade (PA)
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.
21GENERIC AND/OR PREFERRED
DRUG CLASS MEDICATION(S) NOT COVERED^^
BRAND ALTERNATIVE(S)
PAIN RELIEF AND INFLAMMATORY Simponi Actemra (PA)
DISEASE (cont) Simponi Aria Enbrel (PA)
Entyvio (PA)
Humira (PA)
Remicade (PA)
Stelara (PA)
Siliq Enbrel (PA)
Humira (PA)
Remicade (PA)
Stelara (PA)
levorphanol Generic products (e.g., acetaminophen-
codeine, hydromorphone, oxycodone)
Lido-K lidocaine cream
Lidozion
Lorzone chlorzoxazone
Migranal dihydroergotamine
OxyContin Xtampza ER (PA)
Embeda ER (PA)
Hysingla ER (PA)
Roxicodone oxycodone
Soriatane acitretin
Sprix ketorolac
Treximet Generic NSAIDs
Generic triptans (e.g., sumatriptan,
naratriptan)
Vanatol LQ butalbital-acetaminophen-caffeine
Zomig zolmitriptan
sumatriptan
Zomig ZMT zolmitriptan ODT
PARKINSON’S DISEASE Gocovri amantadine
Lodosyn carbidopa
Requip XL ropinirole ER
SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify aripiprazole
Fazaclo clozapine
Versacloz clozapine ODT
Geodon ziprasidone
Zyprexa olanzapine
Zyprexa Zydis olanzapine ODT
SEIZURE DISORDERS Lyrica CR duloxetine
gabapentin
lidocaine 5% patch
Lyrica
Mysoline primidone
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.
22GENERIC AND/OR PREFERRED
DRUG CLASS MEDICATION(S) NOT COVERED^^
BRAND ALTERNATIVE(S)
SKIN CONDITIONS Absorica Claravis
Myorisan
Zenatane
Aldara imiquimod cream
Anusol-HC cream hydrocortisone
Procto-Med HC
Proctosol-HC
Proctozone-HC
Bensal HP salicylic acid
Salex
Benzaclin clindamycin-benzoyl peroxide
Duac Neuac gel
Neuac Kit
Carac fluorouracil
Clindagel clindamycin
Clobex clobetasol
Cutivate Generic topical steroid (e.g.
betamethasone)
diclofenac 3% gel Fluoroplex
fluorouracil
imiquimod
Picato (NPB)
Ertaczo ketoconazole
Extina
Vusion
Luzu luliconazole
econazole
ketoconazole cream
oxiconazole
Halog clobetasol
Ultravate X halobetasol
Jublia Ciclodan
Kerydin ciclopirox
itraconazole
terbinafine
Kenalog triamcinolone
Locoid hydrocortisone
Locoid Lipocream
Loprox cream, kit ciclopirox
Noritate metronidazole
Rosadan
Oxistat clotrimazole
econazole
ketoconazole
Penlac Ciclodan
ciclopirox
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.
23GENERIC AND/OR PREFERRED
DRUG CLASS MEDICATION(S) NOT COVERED^^
BRAND ALTERNATIVE(S)
SKIN CONDITIONS (cont) Plexion sodium sulfacetamide-sulfur
Prudoxin Generic topical steroid (e.g.,
Zonalon betamethasone)
tacrolimus (topical)
Sernivo betamethasone
fluocinonide
hydrocortisone
Soriatane acitretin
Trianex triamcinolone
Triderm
Ultravate lotion clobetasol
Vanos fluocinonide
Verdeso desonide
Xerese acyclovir (oral) + hydrocortisone
famciclovir + hydrocortisone
valcyclovir + hydrocortisone
Ziana tretinoin
clindamycin-benzoyl peroxide
Zyclara imiquimod
SLEEP DISORDERS/SEDATIVES Ambien zolpidem
Ambien CR zolpidem ER
Edluar
Intermezzo
Nuvigil armodafinil
Provigil modafinil
Restoril temazepam
SUBSTANCE ABUSE Evzio Narcan
URINARY TRACT CONDITIONS Detrol darifenacin ER
Detrol LA oxybutynin ER
Ditropan XL tolterodine ER
Enablex trospium ER
Gelnique
Myrbetriq
Oxytrol
Toviaz
VESIcare
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.
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 website or app, 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
You can use the Drug Cost tool on the myCigna also help you set up home delivery of your
website or app to estimate how much your medication and give you information about
medication may cost and view lower cost2 financial assistance programs (if you need help
alternatives, if available. paying for your medication). To learn more
How can I save money on my prescription about the services they provide, please call
medications? 800.351.3606 or go to Cigna.com/specialty-
pharmacyservices.
You may be able to save money by switching
to a medication that’s on a lower tier (ex. generic Can I fill my prescriptions by mail?
or preferred brand) or by filling a 90-day supply, Yes, as long as your plan offers home delivery.4
if your plan allows. You should talk with your
doctor to find out if one of these options may › If you’re taking a medication every day to
work for you. treat an ongoing health condition like
diabetes, high blood pressure, high cholesterol
What’s the difference between brand name and or asthma, you can order up to a 90-day
generic medications? supply through Cigna Home Delivery
The FDA requires generic medications to provide Pharmacy.SM To learn more, call 800.835.3784
the same clinical benefit as its brand name or go to Cigna.com/home-delivery-pharmacy.
versions.3 The FDA also requires generic makers › If you’re taking a specialty medication to treat
to prove that the generic works in the same way a complex condition like multiple sclerosis,
as the brand name medication. This means that hepatitis C and rheumatoid arthritis, you can
generic equivalent medications must:3 fill your prescription through Cigna Specialty
Pharmacy (our home delivery pharmacy).
› Have the same active ingredient, strength and
dosage form as the brand name medication To learn more, call 800.351.3606 or go to
Cigna.com/specialty-pharmacy-services.
› Deliver the same amount of active ingredients
into the bloodstream in the same amount of Where can I find more information about my
time as the brand name medication prescription medication plan?
› Be used in the same way as the brand You can use the online tools and resources on the
name medication myCigna website or app to help you better
Generics typically cost much less than brand understand your pharmacy benefits. You can
name medications – in some cases, up to view your drug list or search for a specific
85% less.3 Just because generics cost medication, use the Drug Cost tool to estimate
less than brands, it doesn’t mean they’re how much your medication may cost, find an
lower-quality medications. in-network pharmacy near you, review your
pharmacy claims and payment history, and track
Cigna Home Delivery Pharmacy4 orders and
request refills.
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;
27Cigna reserves the right to make changes to the Drug List without notice. Your plan may
cover additional medications; please refer to your enrollment materials for details. Cigna
does not take responsibility for any medication decisions made by the doctor or pharmacist.
Cigna may receive payments from manufacturers of certain preferred brand medications, and
in limited instances, certain non-preferred brand medications, that may or may not be shared
with your plan depending on its arrangement with Cigna. Depending upon plan design,
market conditions, the extent to which manufacturer payments are shared with your plan
and other factors as of the date of service, the preferred brand medication may or may not
represent the lowest-cost brand medication within its class for you and/or your plan.
1. State laws in Texas and Louisiana may require your plan to cover your medications at your current benefit level until your plan renews. This means that if your medication is taken off the drug
list, is moved to a higher cost-share tier or needs approval, these changes may not begin until your renewal date. To find out if these state laws apply to your plan, please call Customer Service
using the number on the back of your ID card.
2. Prices are not guaranteed, and even though a price is displayed in the Drug Cost tool, it’s not a guarantee of coverage. Your costs and coverage may change by the time you fill your prescription
at the pharmacy, and medication costs at individual pharmacies can vary. Coverage and pricing may change. For example, your pharmacy’s retail cash price for a specific medication may be less
than the price shown in the Drug Cost tool.
3. U.S. Food and Drug Administration (FDA) website, “Generic Drug Facts.” Last updated 06/04/18.
4. Not all plans are the same, so some plans may not include Cigna Home Delivery Pharmacy or Cigna Specialty Pharmacy. Please log in to the myCigna website or app, or check your plan materials,
to learn more about the pharmacies in your plan’s network.
5. Costs and complete details of the plan’s prescription drug coverage are set forth in the plan documents. If there are any differences between the information provided here and the plan
documents, the information in the plan documents takes complete precedence.
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company (CHLIC), Connecticut General
Life Insurance Company, Cigna Behavioral Health, Inc., Cigna Health Management, Inc., Tel-Drug, Inc., Tel-Drug of Pennsylvania, L.L.C., and HMO or service company subsidiaries of Cigna Health
Corporation, including Cigna HealthCare of Arizona, Inc., Cigna HealthCare of California, Inc., Cigna HealthCare of Colorado, Inc., Cigna HealthCare of Connecticut, Inc., Cigna HealthCare of Florida, Inc.,
Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Illinois, Inc., Cigna HealthCare of Indiana, Inc., Cigna HealthCare of St. Louis, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of New
Jersey, Inc., Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of Tennessee, Inc. (CHC-TN), and Cigna HealthCare of Texas, Inc. “Cigna Specialty Pharmacy” refers to the specialty drug division
of Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C., doing business as Cigna Home Delivery Pharmacy. Policy forms: OK - HP-APP-1 et al (CHLIC), OR - HP-POL38 02-13 (CHLIC), TN - HP-POL43/
HC-CER1V1 et al (CHLIC), GSA-COVER, et al (CHC-TN). The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.
595200 c Standard 3-Tier 08/18 © 2018 Cigna. Some content provided under license.You can also read
