CIGNA STANDARD 3-TIER PRESCRIPTION DRUG LIST - Coverage as of January 1, 2022
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
CIGNA STANDARD 3-TIER PRESCRIPTION DRUG LIST Coverage as of January 1, 2022 Offered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, or their affiliates. 595200 o Standard 3-Tier 08/21
What’s inside?
About this drug list 3
How to read this drug list 3
How to find your medication 5
Medications that aren’t covered 20
Frequently Asked Questions (FAQs) 36
Exclusions and limitations for coverage 40
View the drug list online
This document was last updated on 08/01/2021.* You can go online to see the current list of
medications your plan covers.
myCigna® App and myCigna.com. Click on the “Find Care & Costs” tab and select
“Price a Medication.” Then type in your medication name to see how it’s covered.
Cigna.com/druglist. Select Standard 3 Tier from the drop down menu. Then type
in your medication name or view the full list.
Questions?
› myCigna.com: Click to chat Monday-Friday, 9:00 am-8:00 pm EST.
› By phone: Call the toll-free number on your Cigna ID card. We’re here 24/7/365.
Drug list created: originally created 01/01/2004 Last updated: 08/01/2021, for changes Next planned update: 03/01/2022, for
starting 01/01/2022 changes starting 07/01/2022
2About this drug list
This is a list of the most commonly prescribed medications covered on the Cigna Standard 3-Tier
Prescription Drug List as of January 1, 2022.1,2 Medications are listed by the condition they treat, then
listed alphabetically within tiers (or cost-share levels).
The drug list is updated often so it isn’t a complete list of the medications your plan covers. Also,
your specific plan may not cover all of these medications. Log in to the myCigna App or myCigna.
com, or check your plan materials, to see all of the medications your plan covers.
How to read this drug list
Use the chart below to help you read this drug list. This chart is just an example. It may not show
how these medications are actually covered on the Cigna Standard 3-Tier Prescription Drug List.
Tier (cost-share level) gives you
an idea of how much you may pay
TIER 1 TIER 2 for a medication
$ $$
BLOOD PRESSURE/HEART MEDICATIONS Medications are grouped by
afeditab CR BERINERT* (PA) the condition they treat
amlodipine besylate BIDIL
amlodipine besylate-benazepril BYSTOLIC
amlodipine-valsartan CINRYZE* (PA)
amlodipine-valsartan-HCTZ COREG CR
atenolol COZAAR (ST)
DIOVAN (ST)
atenolol-chlorthalidone Medications are listed in
DIOVAN HCT (ST)
benazepril alphabetical order within
EDARBI (ST)
benazepril-HCTZ each column
EDARBYCLOR (ST)
candesartan cilexetil EXFORGE
cartia XT EXFORGE HCT
carvedilol FIRAZYR* (PA) Specialty medications have an
clonidine HEMANGEOL asterisk (*) listed next to them
digitek INDERAL LA
digox INDERAL XL
digoxin INNOPRAN XL
diltiazem ER LOTREL Brand-name medications
diltiazem CD MICARDIS (ST) are in all capital letters
diltiazem MULTAQ
dilt-XR NITRO-DUR
enalapril NITROLINGUAL
NITROMIST
flecainide acetate Generic medications
NITRONAL
hydralazine are in all lowercase letters
NITROSTAT
irbesartan NORTHERA* (PA) Medications that have extra
isosorbide mononitrat NORVASC coverage requirements will
RANEXA (ST) have an abbreviation listed
TEKTURNA next to them
TEKTURNA HCT
This chart is just a sample. It may not show how these medications are actually covered on the Cigna Standard 3-Tier Prescription Drug List.
3Tiers
Covered medications are divided into tiers or cost-share levels. Typically, the higher the tier, the
higher the price you’ll pay to fill the prescription.
› Tier 1 – Typically Generics (Lowest-cost medication) $
› Tier 2 – Typically Preferred Brands (Medium-cost medication) $$
› Tier 3 – Typically Non-Preferred Brands (Highest-cost medication) $$$
Abbreviations next to medications
In this drug list, medications that have limits and/or extra coverage requirements have an
abbreviation listed next to them.* Here’s what they mean.
(PA)
Prior Authorization – Certain medications need approval from Cigna before your
plan will cover them. These medications have a (PA) next to them. Your plan won’t
cover these medications unless your doctor requests, and receives, approval from
Cigna.
(QL) uantity Limits – Some medications have a quantity limit. This means your plan will
Q
only cover up to a certain amount over a certain length of time. These medications
have a (QL) next to them. Your plan will only cover a larger amount if your doctor
requests, and receives, approval from Cigna.
(ST) tep Therapy – Certain high-cost medications aren’t covered until you try one or
S
more lower-cost alternatives first.** These medications have a (ST) next to them.
You have many covered options to choose from, and they’re used to treat the same
condition.
(AGE) ge Requirements – Certain medications will only be covered if you’re within a
A
specific age range. These medications have (AGE) next to them. If you’re not within
the allowed age range, your plan will only cover the medication if your doctor
requests, and receives, approval from Cigna.
* These coverage requirements may not apply to your specific plan. Log in to the myCigna App or myCigna.com, or check your plan materials, to find out if your plan includes prior authorization,
quantity limits, Step Therapy, and/or age requirements.
** If your doctor feels an alternative isn’t right for you, he or she can ask Cigna to consider approving coverage of your medication.
Brand-name medications are in all capital letters
In this drug list, generic medications are listed in all lowercase letters and brand-name medications
are listed in all capital letters.
Specialty medications have an asterisk next to them
Specialty medications are used to treat complex medical conditions. In this drug list, specialty
medications have an asterisk (*) next to them. Some plans cover specialty medications on a
specialty tier, limit coverage to a 30-day supply, and/or require you to use a preferred specialty
pharmacy to get coverage. Log in to the myCigna App or myCigna.com, or check your plan
materials, to see how your plan covers these medications.
4No cost-share preventive medications have a plus sign next to them
Health care reform under the Patient Protection and Affordable Care Act (PPACA) requires plans to
cover certain preventive medications and products at 100%, or no cost-share ($0), to you. In this
drug list, these medications have a plus sign (+) next to them. Log in to the myCigna App or
myCigna.com, or check your plan materials, to see how your plan covers these medications.
Plan/benefit exclusions
Your plan doesn’t cover certain medications and products because they’re considered plan/benefit
exclusions. This means there’s no option to receive coverage through Cigna’s review process by
showing that you need the medication or product for your treatment. In this drug list, these
medications have a caret (^) next to them. Log in to the myCigna App or myCigna.com, or check
your plan materials, to see which medications your plan excludes.
How to find your medication
First, look for your condition in the alphabetical list below. Then, go to that page to see the covered
medications available to treat the condition.
Condition Page Condition Page
AIDS/HIV 6 GASTROINTESTINAL/HEARTBURN 13
ALLERGY/NASAL SPRAYS 6 HORMONAL AGENTS 13, 14
ALZHEIMER’S DISEASE 6 INFECTIONS 14, 15
ANXIETY/DEPRESSION/BIPOLAR 6
INFERTILITY 15
DISORDER
MISCELLANEOUS 15
ASTHMA/COPD/RESPIRATORY 6, 7
ATTENTION DEFICIT HYPERACTIVITY 7 MULTIPLE SCLEROSIS 15
DISORDER NUTRITIONAL/DIETARY 15, 16
BLOOD MODIFIERS/BLEEDING DISORDERS 7 OSTEOPOROSIS PRODUCTS 16
BLOOD PRESSURE/HEART MEDICATIONS 7, 8
PAIN RELIEF AND INFLAMMATORY DISEASE 16, 17
BLOOD THINNERS/ANTI-CLOTTING 8
PARKINSON’S DISEASE 17
CANCER 8
SCHIZOPHRENIA/ANTI-PSYCHOTICS 17
CHOLESTEROL MEDICATIONS 9
SEIZURE DISORDERS 17, 18
CONTRACEPTION PRODUCTS 9-11
SKIN CONDITIONS 18
COUGH/COLD MEDICATIONS 11
SLEEP DISORDERS/SEDATIVES 18
DENTAL PRODUCTS 11
DIABETES 11, 12 SMOKING CESSATION 18
DIURETICS 12 SUBSTANCE ABUSE 19
EAR MEDICATIONS 12 TRANSPLANT MEDICATIONS 19
ERECTILE DYSFUNCTION 12 URINARY TRACT CONDITIONS 19
EYE CONDITIONS 12 VACCINES 19
FEMININE PRODUCTS 13 WEIGHT MANAGEMENT 19
5Cigna Standard 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
AIDS/HIV ANXIETY/DEPRESSION/BIPOLAR DISORDER4
abacavir- BIKTARVY* CIMDUO* (PA) (cont)
lamivudine* (PA) DESCOVY*+ (PA) COMPLERA* (PA) alprazolam xr PAXIL CR (QL, ST)
efavirenz- DOVATO* EVOTAZ* (PA) amitriptyline PRISTIQ (QL, ST)
emtricitabine- GENVOYA* ODEFSEY* (PA) bupropion (QL) PROZAC (QL, ST)
tenofovir* ISENTRESS HD* (PA) PIFELTRO* (PA) bupropion sr (QL) REMERON
emtricitabine- ISENTRESS* PREZCOBIX* (PA) bupropion xl 150 SPRAVATO* (PA)
tenofovir*+ JULUCA* STRIBILD* (PA) mg tablet (QL) TRINTELLIX (QL, ST)
ritonavir* PREZISTA* bupropion xl 300 VIIBRYD (QL, ST)
tenofovir* (PA) mg tablet (QL)
SELZENTRY* (PA) WELLBUTRIN SR
buspirone
SYMTUZA* (QL, ST)
citalopram (QL)
TIVICAY PD* XANAX
clomipramine
TIVICAY* XANAX XR
desvenlafaxine er
TRIUMEQ* ZOLOFT (QL, ST)
(QL)
ALLERGY/NASAL SPRAYS duloxetine (QL)
azelastine CLARINEX escitalopram (QL)
azelastine- CLARINEX-D 12 fluoxetine dr (QL)
fluticasone HOUR fluoxetine (QL)
cromolyn GASTROCROM fluvoxamine (QL)
desloratadine (QL) GRASTEK (PA, QL) fluvoxamine er
fluticasone KARBINAL ER (QL)
hydroxyzine hcl ODACTRA (PA, QL) lorazepam
solution, syrup, PATANASE lorazepam intensol
tablet RAGWITEK (PA, QL) mirtazapine
hydroxyzine VISTARIL paroxetine cr (QL)
pamoate paroxetine er (QL)
ipratropium paroxetine (QL)
mometasone (QL) sertraline (QL)
olopatadine trazodone
promethazine venlafaxine (QL)
solution, syrup, venlafaxine er (QL)
tablet ASTHMA/COPD/RESPIRATORY
ALZHEIMER’S DISEASE albuterol ADVAIR HFA ADCIRCA* (PA)
donepezil NAMENDA 5-10 ARICEPT albuterol hfa (QL) ANORO ELLIPTA ADEMPAS* (PA)
donepezil odt MG TITRATION PK EXELON alyq* (PA) ATROVENT HFA BRONCHITOL* (PA)
memantine MESTINON ambrisentan* (PA) BREO ELLIPTA DALIRESP (QL)
memantine er (QL) NAMENDA 10 MG budesonide BREZTRI KALYDECO* (PA,
pyridostigmine 60 TABLET fluticasone- AEROSPHERE QL)
mg/5 ml, 60 mg NAMENDA 5 MG salmeterol COMBIVENT LETAIRIS* (PA)
pyridostigmine er TABLET RESPIMAT LONHALA
rivastigmine NAMENDA XR (QL) ipratropium- DULERA MAGNAIR REFILL
NAMZARIC (QL) albuterol FASENRA PEN* (PA) (PA)
ANXIETY/DEPRESSION/BIPOLAR DISORDER4 montelukast FLOVENT DISKUS LONHALA
tadalafil* (PA) FLOVENT HFA MAGNAIR
alprazolam CELEXA (QL, ST)
INCRUSE ELLIPTA STARTER (PA)
alprazolam er EFFEXOR XR (QL, NUCALA * (PA(
alprazolam intensol ST) ORENITRAM ER*
OFEV* (PA)
alprazolam odt FETZIMA (QL, ST) (PA)
OPSUMIT* (PA)
PAXIL (QL, ST) ORKAMBI* (PA, QL)
6Cigna Standard 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
ASTHMA/COPD/RESPIRATORY (cont) BLOOD MODIFIERS/BLEEDING DISORDERS
PULMICORT PULMICORT (cont)
FLEXHALER RESPULES tranexamic acid NYVEPRIA* (PA) LYSTEDA*
PULMOZYME* (PA) REVATIO 10 MG/ 650 mg* PROCRIT*^ (PA) PROMACTA* (PA)
QVAR REDIHALER ML, 20 MG* (PA) RETACRIT*^ (PA) SIKLOS (PA)
SEREVENT DISKUS SINGULAIR ZARXIO*^ TAVALISSE* (PA)
SPIRIVA SYMDEKO* (PA, QL) ZIEXTENZO (PA) UDENCAYA* (PA)
SPIRIVA RESPIMAT TRACLEER 125 MG
BLOOD PRESSURE/HEART MEDICATIONS
STIOLTO RESPIMAT TABLET* (PA)
SYMBICORT amlodipine BYSTOLIC (QL, ST) ADALAT CC
TRACLEER 62.5 MG
TRACLEER 32 MG amlodipine- CORLANOR (PA) ALTACE (ST)
TABLET* (PA)
TABLET FOR SUSP* TRIKAFTA* (PA, QL) benazepril ENTRESTO ATACAND (ST)
(PA) amlodipine- TEKTURNA HCT AVAPRO (ST)
TYVASO* (PA) (QL)
TRELEGY ELLIPTA olmesartan (QL) AZOR (QL)
UPTRAVI* (PA) amlodipine- BENICAR (QL, ST)
XOLAIR* (PA) valsartan BENICAR HCT (ST)
ATTENTION DEFICIT HYPERACTIVITY atenolol BIDIL (QL)
DISORDER4 benazepril CALAN SR
bisoprolol CARDIZEM LA
amphetamine (PA) MYDAYIS (PA, QL) ADDERALL (PA,ST)
bisoprolol-hctz 120mg (QL)
atomoxetine (QL) VYVANSE (PA, QL) ADZENYS ER (PA,
candesartan CARDURA
dexmethylph- QL)
cartia xt CATAPRES-TTS 1
enidate (PA) ADZENYS XR-ODT
carvedilol CATAPRES-TTS 2
dexmethylph- (PA, QL)
carvedilol er (QL) CATAPRES-TTS 3
enidate er (PA, amphetamine er
clonidine COREG (ST)
QL) (PA,QL)
diltiazem 12hr er CORGARD (ST)
dextroamph- DAYTRANA (PA, QL)
diltiazem 24hr er COZAAR (ST)
etamine-amphet DYANAVEL XR (PA,
diltiazem 24hr er DIOVAN (ST)
er (PA, QL) QL)
(cd) DIOVAN HCT (ST)
dextroamph- EVEKEO (PA,ST)
diltiazem 24hr er EPANED
etamine- FOCALIN (PA,ST)
(la) EXFORGE
amphetamine (PA) INTUNIV
diltiazem 24hr er HAEGARDA* (PA)
guanfacine er METHYLIN (PA)
(xr) HEMANGEOL
methylphenidate QUILLICHEW ER
diltiazem HYZAAR (ST)
er (la) (PA, QL) (PA, QL)
DILT-XR INDERAL LA (ST)
methylphenidate QUILLIVANT XR (PA,
dofetilide (QL) INDERAL XL (ST)
er (PA, QL) QL)
doxazosin INNOPRAN XL (ST)
methylphenidate RITALIN (PA,ST)
droxidopa* KALBITOR*^ (PA)
(PA) STRATTERA (QL)
enalapril KAPSPARGO
methylphenidate
flecainide SPRINKLE (ST)
cd (PA, QL)
hydralazine tablet KATERZIA (QL)
methylphenidate
irbesartan LOPRESSOR (ST)
er (cd) (PA, QL)
labetalol tablet LOTENSIN (ST)
methylphenidate la
lisinopril LOTREL
(PA, QL)
lisinopril-hctz MICARDIS (QL, ST)
BLOOD MODIFIERS/BLEEDING DISORDERS losartan MICARDIS HCT (QL,
aminocaproic acid ARENSEP*^ (PA) DOPTELET* (PA) metoprolol ST)
0.25 gram/ml, 500 DROXIA FULPHILA* (PA) succinate MINIPRESS
mg, 1,000 mg* NEULASTA* (PA) GRANIX*^ (PA)
NIVESTYM*^ (PA)
7Cigna Standard 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
BLOOD PRESSURE/HEART MEDICATIONS (cont) CANCER (cont)
metoprolol NITROSTAT capecitabine* (PA) IBRANCE* (PA) ALECENSA* (PA)
nadolol NORTHERA* (PA) everolimus* (PA) NEXAVAR* (PA) ALUNBRIG* (PA)
nifedipine NORVASC exemestane+ REVLIMID* (PA) BOSULIF* (PA)
nifedipine er ORLADEYO* (PA, hydroxyurea SPRYCEL* (PA) BRAFTOVI* (PA)
olmesartan (QL) QL) imatinib* (PA) SUTENT* (PA) CABOMETYX* (PA)
olmesartan- PRINIVIL (ST) letrozole TREXALL CALQUENCE* (PA)
amlodipine-hctz PROCARDIA XL methotrexate VERZENIO* (PA) COMETRIQ* (PA)
olmesartan-hctz RANEXA (QL) tamoxifen+ GLEEVEC* (PA)
(QL) RUCONEST*^ (PA) temozolomide* ICLUSIG* (PA)
prazosin TAKHZYRO* (PA) (PA) IMBRUVICA* (PA)
propranolol tablet TEKTURNA (QL) INLYTA* (PA)
propranolol er TENORMIN (ST) JAKAFI* (PA)
ramipril TENORETIC 50 (ST) KISQALI* (PA)
ranolazine er (QL) TENORETIC 100 LENVIMA* (PA)
taztia xt (ST) LONSURF* (PA)
telmisartan (QL) TIAZAC LYNPARZA* (PA)
telmisartan-hctz TIKOSYN (PA, QL) MEKINIST* (PA)
(QL) TOPROL XL (ST) MEKTOVI* (PA)
tiadylt er TRIBENZOR NERLYNX* (PA)
valsartan VASOTEC (ST) NINLARO* (PA)
valsartan-hctz VERELAN NUBEQA* (PA)
verapamil er VERELAN PM ODOMZO* (PA)
verapamil er pm ZESTORETIC (ST) ORGOVYX* (PA)
verapamil tablet ZESTRIL (ST) PIQRAY* (PA)
verapamil sr ZIAC (ST) POMALYST* (PA)
BLOOD THINNERS/ANTI-CLOTTING ROZLYTREK* (PA)
RUBRACA* (PA)
adult aspirin BRILINTA BAYER CHEWABLE
RYDAPT* (PA)
regimen+ ELIQUIS (PA) ASPIRIN+
STIVARGA* (PA)
aspirin ec+ FRAGMIN* (QL) EFFIENT
XARELTO (PA) TAFINLAR* (PA)
aspirin+ PLAVIX
TAGRISSO* (PA)
aspirin- PRADAXA (PA)
TARGRETIN* (PA)
dipyridamole er SAVAYSA (PA, QL)
TASIGNA* (PA)
children's aspirin+ ZONTIVITY
TEMODAR
clopidogrel
CAPSULE* (PA)
jantoven
TUKYSA* (PA)
low dose aspirin
UKONIQ* (PA, QL)
ec+
VENCLEXTA
prasugrel
STARTING PACK*
st. joseph aspirin
(PA)
ec+
VENCLEXTA* (PA)
st. joseph aspirin+
VITRAKVI* (PA)
warfarin
VOTRIENT* (PA)
CANCER XALKORI* (PA)
abiraterone* (PA) ERIVEDGE* (PA) AFINITOR* (PA) XELODA* (PA)
anastrozole+ ERLEADA* (PA) AFINITOR DISPERZ* XOSPATA* (PA)
bexarotene* (PA) GLEOSTINE (PA) XTANDI* (PA)
ZEJULA* (PA)
8Cigna Standard 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
CHOLESTEROL MEDICATIONS CONTRACEPTION PRODUCTS (cont)
atorvastatin+ NEXLETOL (PA, QL) CADUET (QL) CAZIANT+
colesevelam NEXLIZET (PA, QL) LIPOFEN (ST) CHARLOTTE 24
ezetimibe REPATHA (PA) NIASPAN FE+
ezetimibe- ROSZET TRICOR (ST) CHATEAL EQ+
simvastatin VASCEPA (PA) TRILIPIX (ST) CHATEAL+
fenofibrate VYTORIN (ST) CRYSELLE+
fenofibric acid WELCHOL CYCLAFEM+
fluvastatin er+ ZETIA CYRED EQ+
fluvastatin+ ZOCOR (QL, ST) CYRED+
icosapent ethyl DASETTA+
lovastatin+ DAYSEE+
omega-3 acid ethyl DEBLITANE+
esters desogestrel-ethinyl
pravastatin+ estradiol+
rosuvastatin+ (QL) desogestrel-ethinyl
simvastatin tablet+ estradiol - ethinyl
estradiol+
(QL)
DOLISHALE+
CONTRACEPTION PRODUCTS drospirenone-
AFIRMELLE+ LO LOESTRIN FE BALCOLTRA ethinyl estradiol-
AFTERA+ BEYAZ levomefolate+
ALTAVERA+ ELLA+ drospirenone-
ALYACEN+ ESTROSTEP FE ethinyl estradiol+
AMETHIA+ KYLEENA*+ ECONTRA EZ+
AMETHYST+ LAYOLIS FE+ ECONTRA ONE-
APRI+ LILETTA*+ STEP+
ARANELLE+ LOESTRIN FE ELINEST+
ASHLYNA+ MICROGESTIN 24 ELURYNG+
AUBRA EQ+ FE EMOQUETTE+
AUBRA+ MINASTRIN 24 FE ENPRESSE+
AUROVELA 24 FE+ MIRENA*+ ENSKYCE+
AUROVELA FE+ NATAZIA ERRIN+
AUROVELA+ NEXTSTELLIS ESTARYLLA+
AVIANE+ NUVARING ethynodiol-ethinyl
AYUNA+ PARAGARD T 380- estradiol+
AZURETTE+ A*+ etonogestrel-
BALZIVA+ SAFYRAL ethinyl estradiol+
BLISOVI 24 FE+ SKYLA*+ FALMINA+
BLISOVI FE+ SLYND FAYOSIM+
BRIELLYN+ TAYTULLA FEMCAP+
CAMILA+ TODAY FEMYNOR+
CAMRESE LO+ CONTRACEPTIVE GEMMILY+
CAMRESE+ SPONGE+ GYNOL II+
CAYA TWIRLA+ HAILEY 24 FE+
CONTOURED+ VCF HAILEY FE+
CONTRACEPTIVE HAILEY+
FILM+ HEATHER+
YASMIN 28 ICLEVIA+
YAZ INCASSIA+
9Cigna Standard 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
CONTRACEPTION PRODUCTS (cont) CONTRACEPTION PRODUCTS (cont)
ISIBLOOM+ NIKKI+
JAIMIESS+ NORA-BE+
JASMIEL+ norethindrone+
JENCYCLA+ norethindrone-
JOLESSA+ ethinyl estradiol-
JULEBER+ iron+
JUNEL FE 24+ norethindrone-
JUNEL FE+ ethinyl estradiol+
JUNEL+ norethindrone-
KAITLIB FE+ ethinyl estradiol-
KALLIGA+ ferrous fumarate
KARIVA+ norgestimate-
KELNOR 1-35+ ethinyl estradiol+
KELNOR 1-50+ NORLYDA+
KURVELO+ NORTREL+
LARIN 24 FE+ NYLIA+
LARIN FE+ NYMYO+
LARIN+ OCELLA+
LARISSIA+ OPCICON ONE-
LEENA+ STEP+
LESSINA+ OPTION 2+
LEVONEST+ ORSYTHIA+
levonorgestrel+ PHILITH+
levonorgestrel- PIMTREA+
ethinyl estradiol+ PIRMELLA+
levonorgestrel- PORTIA+
ethinyl estradiol PREVIFEM+
ethinyl estradiol+ RECLIPSEN+
LEVORA-28+ RIVELSA+
LILLOW+ SETLAKIN+
LOJAIMIESS+ SHAROBEL+
LORYNA+ SIMLIYA+
LOW-OGESTREL+ SIMPESSE+
LO- SPRINTEC+
ZUMANDIMINE+ SRONYX+
LUTERA+ SYEDA+
LYLEQ+ TAKE ACTION+
LYZA+ TARINA 24 FE+
MARLISSA+ TARINA FE 1-20
MERZEE+ EQ+
MICROGESTIN FE+ TARINA FE+
MICROGESTIN+ TILIA FE+
MILI+ TRI FEMYNOR+
MONO-LINYAH+ TRI-ESTARYLLA+
MY CHOICE+ TRI-LEGEST FE+
MY WAY+ TRI-LINYAH+
NECON+ TRI-LO-
NEW DAY+ ESTARYLLA+
10Cigna Standard 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
CONTRACEPTION PRODUCTS (cont) DENTAL PRODUCTS (cont)
TRI-LO-MARZIA+ DENTA 5000 PLUS FLORIVA+^
TRI-LO-MILI+ DENTAGEL FLUORIDEX
TRI-LO-SPRINTEC+ doxycycline hyclate SENSITIVITY RELIEF
TRI-MILI+ FLUORIDEX DAILY PREVIDENT 1.1%
TRI-NYMYO+ DEFENSE 1.1% GEL
ORALONE
TRI-PREVIFEM+ PREVIDENT 5000
PERIDEX
TRI-SPRINTEC+ PREVIDENT 5000
PERIOGARD
TRIVORA-28+ BOOSTER PLUS
SF 1.1% GEL
TRI-VYLIBRA LO+ PREVIDENT 5000
SF 5000 PLUS
TRI-VYLIBRA+ ENAMEL PROTECT
sodium fluoride
TULANA+ PREVIDENT 5000
sodium fluoride
TYDEMY+ ORTHO DEFENSE
5000 dry mouth
VCF PREVIDENT 5000
sodium fluoride
CONTRACEPTIVE PLUS
5000 plus
FOAM+ PREVIDENT 5000
triamcinolone
VCF SENSITIVE
acetonide
CONTRACEPTIVE
GEL+ DIABETES
VELIVET+ ACCU-CHEK BASAGLAR (QL) AMARYL
VESTURA+ COMPACT PLUS BAQSIMI (QL) CEQUR
VIENVA+ CONTROL DEXCOM G6 (PA, CYCLOSET
VIORELE+ ACCU-CHEK GUIDE QL) GLUCAGON
VOLNEA+ L1-L2 CONTROL DROPLET EMERGENCY KIT
VYFEMLA+ SOLUTION DROPSAFE (QL)
VYLIBRA+ ACCU-CHEK AVIVA FARXIGA (QL, ST) GVOKE (QL)
WERA+ SOLUTION FREESTYLE LIBRE KORLYM* (PA)
wide seal ACCU-CHEK 14 DAY SENSOR PRECISION XTRA
diaphragm+ SOFTCLIX LANCET (PA, QL) KETONE-GLUC KIT
WYMZYA FE+ KIT FREESTYLE LIBRE 2 RIOMET
XULANE+ ACCU-CHEK SENSOR (PA, QL)
ZAFEMY+ FASTCLIX GLUCAGEN HYPO
ZARAH+ LANCING DEVICE KIT
ZOVIA 1-35+ ACCU-CHEK GLYXAMBI (QL, ST)
ZOVIA 1-35E+ MULTICLIX HUMULIN (QL)
ZUMANDIMINE+ LANCET KIT JANUMET (QL, ST)
ACCU-CHEK JANUMET XR (QL,
SMARTVIEW ST)
CONTROL JANUVIA (QL, ST)
COUGH/COLD MEDICATIONS
SOLUTION JARDIANCE (QL, ST)
brompheniramine- HYCODAN (PA, QL) ACCUTREND LYUMJEV (QL)
pseudoephedrine TESSALON PERLE GLUCOSE OMNIPOD DASH
-dm TUZISTRA XR (PA, CONTROL (PA, QL)
hydrocodone- QL) BD LANCETS ONETOUCH ULTRA
homatropine (PA, BD PEN NEEDLE TEST STRIP
QL) CONTOUR ONETOUCH VERIO
promethazine-dm SOLUTION TEST STRIP
DENTAL PRODUCTS CONTOUR NEXT QTERN (QL, ST)
chlorhexidine PREVIDENT 0.2% CLINPRO 5000 LEV 1 CONTROL RYBELSUS (PA, QL)
RINSE SOLUTION SOLIQUA 100-33
11Cigna Standard 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
DIABETES (cont) ERECTILE DYSFUNCTION
CONTOUR SYMLINPEN sildenafil^ (QL) MUSE^ (PA, QL) CIALIS^ (QL, ST)
SOLUTION SYNJARDY (QL, ST) tadalafil^ (QL) STENDRA^ (QL, ST)
CONTOUR SYNJARDY XR (QL, vardenafil^ (QL) VIAGRA^ (QL, ST)
SOLUTION ST) EYE CONDITIONS
CONTOUR NEXT TRIJARDY XR (ST,
bimatoprost (QL) ALPHAGAN P 0.1% ACULAR
LEV 2 CONTROL QL)
brimonidine DROPS ACULAR LS
SOLUTION V-GO 20
brinzolamide AZASITE ACUVAIL
glimepiride V-GO 30
ciprofloxacin BETIMOL ALPHAGAN P
glipizide V-GO 40
dorzolamide BETOPTIC S 0.15% EYE DROPS
glipizide er VICTOZA (PA, QL)
dorzolamide- COMBIGAN ALREX
glipizide xl XIGDUO XR (QL, ST)
timolol EYSUVIS (QL) AZOPT
INPEN Xultophy
erythromycin FML FORTE 0.25% BEPREVE
metformin
fluorometholone EYE DROPS BESIVANCE
metformin er
ketorolac FML S.O.P. 0.1% BROMSITE
NOVOTWIST
latanoprost OINTMENT CEQUA
NOVOFINE
loteprednol FLAREX COSOPT
TECHLITE
moxifloxacin eye LOTEMAX SM COSOPT PF
TRUE METRIX
drops RESTASIS CYSTADROPS* (PA,
LEVEL 1 CONTROL
neomycin- RESTASIS QL)
SOULTION
polymyxin MULTIDOSE CYSTARAN* (PA,
TRUE METRIX
b-dexamethasone SIMBRINZA QL)
LEVEL 2 CONTROL
ofloxacin XIIDRA DUREZOL
SOLUTION
olopatadine ZERVIATE FML LIQUIFILM
TRUE METRIX
polymyxin 0.1% EYE DROP
LEVEL 3 CONTROL
b sulfate- ILEVRO
SOLUTION
trimethoprim INVELTYS
TRUEPLUS SYRINGE
prednisolone ISTALOL
DIURETICS timolol LASTACAFT
ACETAZOLAMIDE DIURIL ALDACTONE tobramycin- LOTEMAX
TABLET CAROSPIR dexamethasone MAXITROL
ACETAZOLAMIDE INSPRA travoprost MOXEZA
ER CAPSULE
BUMETANIDE JYNARQUE* (PA) NEVANAC
TABLET KERENDIA OCUFLOX
chlorthalidone LASIX OXERVATE* (PA)
eplerenone MAXZIDE PRED FORTE
furosemide PROLENSA
solution, tablet RHOPRESSA
hydrochlorot- ROCKLATAN
hiazide TIMOPTIC
spironolactone TIMOPTIC-XE
triamterene-hctz TOBRADEX EYE
DROPS
EAR MEDICATIONS
TOBRADEX ST
ciprofloxacin- CIPRO HC CIPRODEX TRUSOPT
dexamethasone CORTISPORIN-TC VIGAMOX
neomycin- DERMOTIC ZIRGAN
polymyxin OTOVEL ZYLET
b-hydrocortisone
ofloxacin
12Cigna Standard 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
FEMININE PRODUCTS GASTROINTESTINAL/HEARTBURN (cont)
FEM PH metoclopramide
GYNAZOLE 1 solution, tablet
miconazole 3 200 metoclopramide
mg odt
terconazole misoprostol
GASTROINTESTINAL/HEARTBURN NATURA-LAX+
omeprazole (QL)
ALOPHEN PILLS+ AMITIZA ACIPHEX (QL, ST)
ondansetron
alosetron* CLENPIQ+ AKYNZEO 300-0.5
ondansetron odt
ANUCORT-HC DEXILANT (QL) MG CAPSULE
pantoprazole
balsalazide ENTYVIO *^ (PA) APRISO
suspension, tablet
bisacodyl tablet+ LINZESS BONJESTA
(QL)
cinacalcet* LITHOSTAT CANASA
peg
CLEARLAX+ NEXIUM DR 2.5 MG CARAFATE
3350-electrolyte+
CONSTULOSE PACKET (QL) CHENODAL* (PA) PEG3350-SODIUM
dicyclomine NEXIUM DR 5 MG CHOLBAM* (PA) SULFATE-SODIUM
capsule, solution, PACKET (QL) CORRECTOL+ CHLORIDE-
tablet POTASSIUM
esomeprazole PANCREAZE CUVPOSA
PENTASA DICLEGIS CHLORIDE-
20 mg capsule, SODIUM
40 mg capsule, SUPREP+ DONNATAL ASCORBATE-
packets (QL) SUTAB+ DULCOLAX EC 5 ASCORBIC ACID+
famotidine VIBERZI MG TABLET+ PEG-PREP+
40 mg/5 ml MIRALAX+ polyethylene glycol
suspension, 20 MOVANTIK (PA) 3350+
mg tablet, 40 mg OCALIVA* (PA) prochlorperazine
tablet PREVACID DR 30 tablet
GAVILAX+ MG CAPSULE (QL, promethazine
GAVILYTE-C+ ST)
suppository
GAVILYTE-G+ PROTONIX (QL, ST)
promethegan
GAVILYTE-N+ RAVICTI* (PA)
PURELAX+
GENTLE RECTIV
rabeprazole tablet
LAXATIVE+ RELISTOR (PA)
(QL)
GENTLELAX+ SANCUSO (PA, QL)
scopolamine
GLYCOLAX+ SFROWASA
SMOOTHLAX+
glycopyrrolate SUCRAID* (PA)
sucralfate
tablet SYMPROIC (PA)
ursodiol
HEMMOREX-HC TRANSDERM-SCOP
WOMEN'S GENTLE
hydrocortisone URSO
LAXATIVE+
lansoprazole (QL) URSO FORTE
WOMEN'S
LAXACLEAR+ VARUBI (PA, QL)
LAXATIVE+
LAXATIVE PEG VIOKACE
HORMONAL AGENTS
3350+
LAXATIVE 5 MG AMABELZ ANDRODERM (PA, ACTIVELLA
TABLET+ budesonide ec QL) ALORA (QL)
LAXATIVE EC 5 MG budesonide er (PA, CETROTIDE*^ (PA) ANDROGEL (PA, QL)
TABLET+ QL) DIVIGEL ANGELIQ
mesalaminex` cabergoline (QL) DUAVEE ARMOUR THYROID
mesalamine dr COVARYX ESTRING (QL)
mesalamine er FORTEO* (PA, QL)
13Cigna Standard 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
HORMONAL AGENTS (cont) INFECTIONS (cont)
COVARYX H.S. LUPRON DEPOT- AYGESTIN amoxicillin- EPCLUSA* (PA, QL) BAXDELA (PA)
DECADRON PED*^ (PA) BIJUVA clavulanate ERY-TAB DR 333 MG CAYSTON* (PA, QL)
desmopressin MEDROL 2 MG BYNFEZIA* atovaquone TABLET CIPRO TABLET
dexamethasone TABLET CLIMARA atovaquone- EURAX 10% CREAM CLEOCIN 150 MG
intensol ORIAHNN (PA, QL) CLIMARA PRO proguanil FIRVANQ CAPSULE
DOTTI (QL) ORILISSA (PA, QL) COMBIPATCH AVIDOXY HARVONI* (PA, QL) CLEOCIN 300 MG
EEMT PREMARIN TABLET, CRINONE 4% GEL azithromycin LEDIPASVIR- CAPSULE
EEMT H.S. VAGINAL CREAM CYTOMEL packet, SOFOSBUVIR* (PA) CLEOCIN 100 MG
APPLICATOR
estradiol (once ELESTRIN suspension, tablet MAVYRET* (PA) VAGINAL OVULE
PREMPHASE
weekly) EMFLAZA* (PA) cefdinir SOFOSBUVIR- CLEOCIN 2%
PREMPRO
estradiol 10mcg ENTOCORT EC cefuroxime tablet VELPATASVIR* (PA) VAGINAL CREAM
SOMAVERT* (PA)
vaginal insert (QL) ESTRACE cephalexin SOLOSEC CLINDESSE
SOMATULINE
estradiol (twice ESTROGEL ciprofloxacin SOVALDI* (PA, QL) CRESEMBA
DEPOT*^ (PA)
weekly) (QL) EVAMIST clarithromycin THALOMID* (PA) CAPSULE (PA)
estradiol- FENSOLVI* clarithromycin er VIBRAMYCIN 50 DIFICID (QL)
norethindrone IMVEXXY (QL) clindamycin MG/5 ML SYRUP ELIMITE
estrogen- INTRAROSA COREMINO ER QL) VOSEVI* (PA) ERYPED 200
methyltestos- ISTURISA* (PA, QL) dapsone tablets XIFAXAN (QL) ERY-TAB DR 250 MG
terone LUPANETA PACK*^ doxycycline hyclate TABLET
EUTHYROX (PA) capsule, tablet ERY-TAB DR 500 MG
LEVO-T LEVOTHYROXINE doxycycline TABLET
levothyroxine CAPSULE
tablet monohydrate EURAX 10* LOTION
MEDROL 8MG,
LEVOXYL 16MG, 32MG EMVERM FLAGYL
liothyronine TABLET entecavir* (QL) FOLLISTIM*^ (PA)
LYLLANA (QL) MEDROL 4 MG erythromycin HIPREX
medroxyprog- DOSEPAK erythromycin KEFLEX
esterone MENOSTAR (QL) ethylsuccinate KITABIS PAK* (PA,
methimazole MINIVELLE (QL) famciclovir QL)
methylpred- MYFEMBREE (QL) fluconazole MACROBID
nisolone OSPHENA hydroxychlo- MACRODANTIN
MIMVEY PROMETRIUM roquine MALARONE (PA)
norethindrone RAYALDEE ivermectin NATROBA
NP THYROID teriparatide* levofloxacin NUVESSA
prednisone TIROSINT-SOL solution, tablet NUZYRA TABLET*
prednisone UNITHROID methenamine (QL)
intensol VAGIFEM (QL) metronidazole gel, ORAVIG
progesterone tablet VIVELLE-DOT (QL) capsule, tablet PLAQUENIL
testosterone (PA, minocycline posaconazole
minocycline er suspension
QL)
tablet (QL) PREVYMIS TABLET*
WESTHROID
mondoxyne nl PRIFTIN
YUVAFEM (QL)
MORGIDOX SIVEXTRO TABLET
INFECTIONS (PA)
nitazoxanide
acyclovir capsule, BARACLUDE AEMCOLO (QL) nitrofurantoin SKLICE
suspension, tablet SOLUTION* ALBENZA nitrofurantoin STROMECTOL
albendazole CIPRO SUSPENSION ALINIA monohydrate- sulfatrim
amoxicillin CLEOCIN 75 MG ARIKAYCE* (PA) macrocrystal URIBEL
amoxicillin- CAPSULE BACTRIM nystatin VALTREX
clavulanate er DARAPRIM* (PA) BACTRIM DS suspension, tablet VEMLIDY*
14Cigna Standard 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
INFECTIONS (cont) MISCELLANEOUS (cont)
penicillin v VIBRAMYCIN 25 sodium chloride COMPACT SPACE VYNDAQEL* (PA,
potassium MG/5 ML SUSP inhalation vial. CHAMBER (QL) QL)
permethrin XENLETA 600mg Irrigation solution
EASIVENT (QL)
posaconazole tablet (PA, QL) vial ESBRIET* (PA)
tablet XOFLUZA (QL) TECHLITE LANCETS FLEXICHAMBER
pyrimethamine* ZEPATIER* (PA) trientine * (PA) (QL)
(PA) ZITHROMAX TRUEPLUS KETONE INSPIRACHAMBER
sulfamethoxazole- ZITHROMAX TRI- TEST STRIP (QL)
trimethoprim PAK MICROCHAMBER
suspension, tablet ZYVOX (QL)
terbinafine SUSPENSION, NITYR* (PA)
tetracycline TABLET (PA) OPTICHAMBER
tobramycin DIAMOND (QL)
ampule* (PA,QL) POCKET CHAMBER
valacyclovir (QL)
valganciclovir PRO COMFORT
vancomycin SPACER WITH
capsule, solution MASK (QL)
vandazole PROCARE SPACER
INFERTILITY WITH CHILD MASK
(QL)
clomiphene ^ GONAL F*^ (PA) CRINONE 8% GEL^
RITEFLO (QL)
NOVAREL* ENDOMETRIN^
SPACE CHAMBER
OVIDREL*^ (PA)
(QL)
MISCELLANEOUS SPACE CHAMBER-
ACCU-CHEK ACE AEROSOL ADDYI^ (PA, QL) MEDIUM MASK
SAFE-T-PRO 23G CLOUD AUSTEDO* (PA) (QL)
LANCETS ENHANCER (QL) BRISDELLE (QL) SPACE CHAMBER-
ACCU-CHEK AEROCHAMBER EVRYSDI* (PA) SMALL MASK (QL)
SOFTCLIX MINI (QL) GALAFOLD* (PA) STRENSIQ (PA)
LANCETS AEROCHAMBER MV INGREZZA VORTEX (QL)
ACCU-CHEK (QL) INITIATION PACK* VORTEX VHC FROG
MULTICLIX AEROCHAMBER (PA, QL) MASK (QL)
LANCETS PLUS FLOW-VU INGREZZA* (PA) VORTEX VHC
ACCU-CHEK (QL) NUEDEXTA (QL) LADYBUG MASK
FASTCLIX LANCET AEROCHAMBER ORFADIN* (PA) (QL)
DRUM WITH TEGSEDI* (PA) MULTIPLE SCLEROSIS
deferiprone FLOWSIGNAL (QL) TIGLUTIK* (PA)
dalfampridine er* AUBAGIO* (PA) MAVENCLAD* (PA)
500mg* (PA) AEROCHAMBER VYLEESI*^ (PA, QL)
(PA) AVONEX* (PA) PONVORY* (PA)
FC2 FEMALE Z-STAT PLUS (QL) VYNDAMAX* (PA,
dimethyl fumarate* BAFIERTAM* (PA)
CONDOM+ AEROTRACH PLUS QL)
(PA) GILENYA* (PA)
KETONE CARE TEST (QL) VYNDAQEL* (PA,
KESIMPTA PEN*
STRIP AEROVENT PLUS QL)
(PA)
KETONE TEST STRIP (QL) TEGSEDI* (PA)
MAYZENT* (PA)
KETOSTIX REAGENT BREATHRITE (QL) TIGLUTIK* (PA)
VUMERITY* (PA)
MICROLET CERDELGA* (PA) VYLEESI*^ (PA, QL)
ZEPOSIA* (PA)
PRECISION XTRA CLEVER CHOICE VYNDAMAX* (PA,
HOLDING QL) NUTRITIONAL/DIETARY
CHAMBER (QL) ALIVE PRENATAL+
15Cigna Standard 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
NUTRITIONAL/DIETARY (cont) NUTRITIONAL/DIETARY (cont)
FA-8+ CITRANATAL AURYXIA (QL) PRENATAL
folic acid^+ ASSURE BRAINSTRONG VITAMIN+
klor-con CITRANATAL PRENATAL+ PRENATAL
KLOR-CON 10 MEQ B-CALM CLASSIC VITAMINS+
TABLET CITRANATAL DHA PRENATAL+ PRENATAL+
KLOR-CON 8 MEQ CITRANATAL EXPECTA sevelamer
TABLET HARMONY PRENATAL+ carbonate
KLOR-CON M10 CITRANATAL RX FOSRENOL 1,000 TRI-VITE WITH
TABLET DRISDOL^ MG CHEWABLE FLUORIDE+
TABLET
KLOR-CON M10 FLORIVA FOSRENOL 500 vitamin d2 1.25 mg
TABLET CHEWABLE MG CHEWABLE (50,000 unit)^
MULTI-VITAMIN TABLET+ TABLET VITAMINS A,C,D
W-FLUORIDE- FOSRENOL 1,000 FOSRENOL 750 AND FLUORIDE+
IRON+ MG POWDER MG CHEWABLE
TABLET OSTEOPOROSIS PRODUCTS
MULTIVITAMIN PACK
K-TAB ER alendronate TYMLOS* (PA, QL) ACTONEL (ST)
WITH FLUORIDE+ FOSRENOL 750 MG
LOKELMA ibandronate 150 ATELVIA (ST)
MULTIVITAMIN- POWDER PACKET
MINI PRENATAL+ mg tablet BINOSTO (ST)
IRON-FLUORIDE MEPHYTON^
OB COMPLETE^ raloxifene+ BONIVA 150 MG
ONE DAILY NEEVO DHA^
ONE A DAY risedronate TABLET (ST)
PRENATAL+ OB COMPLETE
WOMEN'S risedronate dr EVISTA
potassium chloride PETITE
PRENATAL DHA+ FOSAMAX (ST)
10%, capsule, OB COMPLETE
packet, tablet PREMIER ONE-A-DAY PAIN RELIEF AND INFLAMMATORY DISEASE
prenatal PERRY PRENATAL+ PRENATAL-1+ acetaminophen- AIMOVIG (PA) ANALPRAM HC 1%
complete+ POLY-VI-FLOR WITH PHOSLYRA codeine (PA) AJOVY (PA) CREAM
PRENATAL IRON+ PRENATAL allopurinol tablet AVSOLA*^ (PA) ANALPRAM HC
FORMULA-DHA+ ASPIRIN EC+ 2.5%-1% CREAM
GUMMIES+ POLY-VI-FLOR+ BELBUCA (QL) ANALPRAM HC
RENVELA aspirin tablet+
PRENATAL MULTI+ PRENATE^ baclofen tablet DUPIXENT* (PA) 2.5%-1% CREAM
prenatal multi- PRIMACARE SIMILAC EMGALITY (PA)
buprenorphine SINGLE
dha+ QUFLORA PRENATAL+ HYSINGLA ER (PA)
patch (QL) ARAVA
PRENATAL PEDIATRIC 1 STUART ONE+ butalbital- INFLECTRA*^ (PA, BUTRANS (QL)
MULTIVITAMIN+ MG CHEWABLE ULTRA PRENATAL acetaminophen- QL) CELEBREX (QL, ST)
PRENATAL TABLET+ PLUS DHA+ caffeine (QL) NUCYNTA (PA) COLCRYS
MULTIVITAMIN- QUFLORA VELTASSA carisoprodol NURTEC ODT (PA, DEPEN* (PA)
DHA+ PEDIATRIC 0.25 celecoxib (QL) QL) EC-NAPROSYN (ST)
PRENATAL ONE MG/ML DROP+ colchicine OTEZLA* (PA, QL) ECOTRIN EC 325
DAILY+ QUFLORA cyclobenzaprine PROCTOFOAM-HC MG TABLET+
prenatal multi- PEDIATRIC 0.5 MG/ diclofenac 1% gel RASUVO (PA)
ESGIC (QL)
dha+ ML DROP+ (QL) REDITREX (PA) FEXMID
PRENATAL ROCALTROL^ diclofenac dr RINVOQ* (PA, QL) FLECTOR (PA, QL)
MULTIVITAMIN+ TRI-VI-FLOR+ diclofenac ec SAVELLA ILUMYA* (PA, QL)
PRENATAL VELPHORO EC-NAPROXEN SIMPONI ARIA* (PA) KEVZARA* (PA, QL)
MULTIVITAMIN- ECOTRIN EC 81 MG SKYRIZI* (PA, QL)
LAZANDA (PA)
DHA+ TABLET+ TALTZ* (PA, QL) LICART (PA, QL)
PRENATAL ONE eletriptan (QL) UBRELVY (PA, QL) LIDODERM
DAILY+ ENDOCET (PA) ULORIC (QL) MITIGARE
PRENATAL VITAMIN febuxostat (QL) XELJANZ* (PA, QL) MOBIC (ST)
+ DHA+ fentanyl (PA) XELJANZ XR* (PA, NAPROSYN (ST)
FIORICET (QL) QL) NUCYNTA ER (PA)
16Cigna Standard 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
PAIN RELIEF AND INFLAMMATORY DISEASE PARKINSON’S DISEASE (cont)
(cont) carbidopa- NEUPRO
frovatriptan (QL) XTAMPZA ER (PA) OLUMIANT* (PA, levodopa er NOURIANZ* (PA,
GLYDO ZTLIDO QL) pramipexole QL)
hydrocodone- ORENCIA* (PA, QL) pramipexole er (QL) OSMOLEX ER (QL)
acetaminophen OTREXUP (PA) rasagiline (QL) RYTARY
(PA) OXAYDO (PA) ropinirole er SINEMET 10-100
hydromorphone PERCOCET (PA) ropinirole SINEMET 25-100
er (PA) PROCORT TASMAR
hydromorphone REMICADE*^ (PA) XADAGO (ST)
(PA) SKELAXIN SCHIZOPHRENIA/ANTI-PSYCHOTICS4
IBU ULTRAM 50 MG
TABLET (QL) aripiprazole (QL) LATUDA (QL) FANAPT (QL, ST)
ibuprofen
VTOL LQ aripiprazole odt INVEGA (QL, ST)
indomethacin ZANAFLEX asenapine REXULTI (QL, ST)
indomethacin er ZEBUTAL (QL) chlorpromazine RISPERDAL (ST)
ketorolac ZOHYDRO ER (PA) tablet SAPHRIS (ST)
tromethamine ZYLOPRIM haloperidol SECUADO (ST)
(QL)
olanzapine tablet SEROQUEL (ST)
leflunomide
olanzapine odt SEROQUEL XR (ST)
lidocaine 5%
paliperidone er VRAYLAR (QL, ST)
ointment (QL)
(QL)
lidocaine 5% patch
quetiapine
meloxicam tablet
quetiapine er
metaxalone
risperidone
methocarbamol
MORPHINE (PA) risperidone odt
MORPHINE ER (PA) ziprasidone tablet
NALFON 600 MG SEIZURE DISORDERS
TABLET (ST)
NALOCET (PA) carbamazepine DILANTIN 30 MG APTIOM 600, 800
carbamazepine er CAPSULE (PA) MG TABLETS (PA)
oxycodone (PA)
oxycodone er (PA) FYCOMPA (PA, QL) APTIOM 200, 400
clonazepam MG TABLETS(PA,
oxycodone- NAYZILAM (PA, QL) QL)
divalproex VIMPAT SOLTUION, BRIVIACT ORAL
acetaminophen
(PA) divalproex er TABLET (PA) SOLUTION, TABLET
penicillamine* (PA) EPITOL (PA)
PROLATE TABLET gabapentin CARBATROL (PA)
(PA) lamotrigine DEPAKOTE (PA)
rizatriptan (QL) DEPAKOTE ER (PA)
sumatriptan (QL) lamotrigine (blue) DEPAKOTE
tizanidine lamotrigine (green) SPRINKLE (PA)
tramadol 50 mg lamotrigine DILANTIN 100 MG
tablet (QL) (orange) CAPSULE (PA)
tramadol er (QL) lamotrigine er DILANTIN 50 MG
VANADOM INFATAB (PA)
lamotrigine odt EPIDIOLEX* (PA)
PARKINSON’S DISEASE lamotrigine odt FINTEPLA* (PA)
benztropine tablet KYNMOBI (PA) AZILECT (QL) (blue) KLONOPIN (PA)
carbidopa- DUOPA* lamotrigine odt LYRICA ORAL
levodopa INBRIJA* (PA) (green) SOLUTION (PA)
MIRAPEX ER (QL)
17Cigna Standard 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
SEIZURE DISORDERS (cont) SKIN CONDITIONS (cont)
lamotrigine odt NEURONTIN (PA) clocortolone
(orange) OXTELLAR XR (PA) CLODAN
levetiracetam PHENYTEK (PA) clotrimazole-
solution, tablet SPRITAM (PA) betamethasone
levetiracetam er TEGRETOL XR (PA) dapsone 5% gel,
pregabalin capsule, VALTOCO (PA, QL) 7.5% gel pump
solution XCOPRI (PA, QL) fluocinonide
ROWEEPRA fluorouracil cream,
SUBVENITE topical solution
SUBVENITE (BLUE) isotretinoin
SUBVENITE (GREEN) ketoconazole
SUBVENITE KETODAN
(ORANGE) metronidazole
topiramate mupirocin
topiramate er MYORISAN
vigabatrin* NEUAC GEL
vigadrone* pimecrolimus
SKIN CONDITIONS ROSADAN
sodium
ACCUTANE DRYSOL ANALPRAM HC
sulfacetamide-
adapalene (PA) EUCRISA 2.5%-1% LOTION
sulfur
adapalene-benzoyl NAFTIN AVAR 9.5-5%
SSS 10-5
peroxide PICATO CLEANSING PADS
SULFACLEANSE 8-4
AMNESTEEM PRAMOSONE 1% BRYHALI (ST)
CALCIPOTRIENE tacrolimus
AVAR CLEANSER LOTION
FOAM ointment
azelaic acid PRAMOSONE 1%-
CAPEX SHAMPOO tazarotene 0.1%
betamethasone 1% CREAM
(ST) cream
augmented PRAMOSONE 1%-
CLEOCIN T tretinoin (PA)
betamethasone 1% OINTMENT
TRIDERM
dipropionate PRAMOSONE 2.5%- CLINDACIN ETZ KIT
CLINDACIN PAC KIT ZENATANE
BP 10-1 1% OINTMENT
calcipotriene SANTYL (QL) CLODERM (ST) SLEEP DISORDERS/SEDATIVES
cream, ointment, DESOWEN (ST) armodafinil (PA) DAYVIGO (QL, ST) HETLIOZ LQ* (PA)
solution DOVONEX eszopiclone SUNOSI (PA, QL) HETLIOZ* (PA)
calcipotriene- EFUDEX modafinil (PA) LUNESTA (ST)
betamethasone ELIDEL temazepam SILENOR (QL, ST)
CLARAVIS EVOCLIN zolpidem WAKIX* (PA, QL)
CLINDACIN ETZ PRAMOSONE 2.5%- zolpidem er (QL) XYREM* (PA)
1% PLEDGET 1% CREAM
CLINDACIN P 1% XYWAV* (PA)
PRAMOSONE 2.5%-
PLEDGETS SMOKING CESSATION4
CLINDAMYCIN 1% LOTION
1% FOAM, GEL, PROTOPIC bupropion sr+^ CHANTIX^ NICODERM CQ 14
LOTION, PLEDGET, REGRANEX (PA, QL) NICODERM CQ 21 NICOTROL NS+^ MG/24HR PATCH+
SOLUTION TARGRETIN* MG/24HR PATCH+ NICOTROL+^ NICODERM CQ 7
clindamycin- TEMOVATE (ST) nicotine gum+ MG/24HR PATCH+
benzoyl VECTICAL (QL) nicotine lozenge+ NICORETTE+
peroxoxide XEPI nicotine patch+
clindamycin QUIT 2+/QUIT 4+
tretinoin STOP SMOKING
clobetasol AID+
18Cigna Standard 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
SUBSTANCE ABUSE WEIGHT MANAGEMENT
buprenorphine- LUCEMYRA (QL) BUNAVAIL megestrol WEGOVY^ (PA, QL) CONTRAVE^ (PA)
naloxone NARCAN (QL) KLOXXADO (QL) suspension QSYMIA^ (PA)
ZUBSOLV SUBOXONE phentermine ^ SAXENDA^ (PA)
TRANSPLANT MEDICATIONS
azathioprine* ASTAGRAF XL*
everolimus 0.25 mg CELLCEPT ORAL
tablet* SUSPENSION,
everolimus 0.5 mg
tablet* TABLET*
mycophenolate ENVARSUS XR*
mofetil* MYFORTIC*
mycophenolic NEORAL*
PROGRAF 0.2
acid* MG GRANULE
sirolimus* PACKET*
tacrolimus* PROGRAF 0.5 MG
CAPSULE*
PROGRAF 1 MG
CAPSULE*
PROGRAF 1
MG GRANULE
PACKET*
PROGRAF 5 MG
CAPSULE*
RAPAMUNE*
ZORTRESS*
URINARY TRACT CONDITIONS
alfuzosin er CYSTAGON* AVODART
cevimeline ELMIRON EVOXAC
darifenacin er (QL) K-PHOS ORIGINAL FLOMAX
finasteride PROSCAR
oxybutynin PYRIDIUM
oxybutynin er RAPAFLO (QL)
phenazopyridine UROCIT-K
potassium er UROXATRAL
silodosin (QL)
solifenacin (QL)
tamsulosin
tolterodine
tolterodine er (QL)
VACCINES
Vaccines are now covered under the Cigna pharmacy benefit.
Not all plans cover vaccines in the same way. Log in to the myCigna
App or myCigna.com, or check your plan materials, to find out how
your specific plan covers them.
ROTARIX+
ROTATEQ+
19Medications that aren’t covered
Your plan covers other medications that are used to treat the same condition.^^ They’re listed below.
GENERIC AND/OR PREFERRED BRAND
DRUG CLASS MEDICATION NAME^^
ALTERNATIVE(S)
AIDS/HIV ATRIPLA* efavirenz-emtricitabine-tenofovir*
COMBIVIR* lamivudine-zidovudine*
EMTRIVA* emtricitabine*
EPIVIR* lamivudine*
EPZICOM* abacavir-lamivudine*
INTELENCE 100MG, 200MG TABLET* etravirine*
KALETRA* lopinavir-ritonavir*
LEXIVA 700MG TABLET* fosamprenavir 700mg tablet*
NORVIR 100MG TABLET* ritonavir 100mg tablet*
RETROVIR CAPSULE, SYRUP* zidovudine capsule, syrup*
REYATAZ CAPSULE* atazanavir capsules*
SUSTIVA* efavirenz*
SYMFI* efavirenz-lamivudine-tenofovir*
SYMFI LO*
TRIZIVIR* abacavir-lamivudine-zidovudine tablet*
TRUVADA* emtricitabine-tenofovir*
VIRAMUNE* nevirapine*
VIRAMUNE XR* nevirapine ER*
VIREAD 300MG TABLET* tenofovir 300mg tablet*
ZIAGEN* abacavir*
ALLERGY/NASAL SPRAYS AUVI-Q epinephrine auto-injectors
EPIPEN
EPIPEN JR
SYMJEPI
BECONASE AQ generic nasal steroids (e.g. fluticasone)
NASONEX
OMNARIS
QNASL
ZETONNA
carbinoxamine 6mg tablet carbinoxamine 4mg tablet
RYVENT
dexchlorpheniramine carbinoxamine oral solution
RYCLORA cyproheptadine syrup
hydroxyzine syrup
DYMISTA azelastine-fluticasone
Generic nasal steroids (e.g. fluticasone)
QNASL CHILDREN'S flunisolide
XHANCE fluticasone
mometasone
ALZHEIMER'S DISEASE pyridostigmine 30mg tablet (QL) pyridostigmine 60mg tablet
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t
be applied to your annual deductible or out-of-pocket maximum.
20GENERIC AND/OR PREFERRED BRAND
DRUG CLASS MEDICATION NAME^^
ALTERNATIVE(S)
ANXIETY/DEPRESSION/BIPOLAR DISORDER ANAFRANIL clomipramine
APLENZIN bupropion XL 150, 300 mg tablets
ATIVAN TABLET lorazepam
bupropion xl 450mg tablet bupropion xl 150mg tablets
FORFIVO XL
CYMBALTA desvenlafaxine ER
duloxetine
escitalopram
DRIZALMA SPRINKLE duloxetine dr capsules
LEXAPRO escitalopram
PAMELOR nortriptyline capsules
PARNATE tranylcypromine
PEXEVA paroxetine
paroxetine cr
TOFRANIL imipramine
WELLBUTRIN XL bupropion xl
escitalopram
fluoxetine
ASTHMA/COPD/RESPIRATORY ADVAIR DISKUS ADVAIR HFA
AIRDUO DIGIHALER BREO ELLIPTA
AIRDUO RESPICLICK DULERA
fluticasone-salmeterol
SYMBICORT
WIXELA INHUB
ALVESCO FLOVENT DISKUS
ARMONAIR DIGIHALER FLOVENT HFA
ARNUITY ELLIPTA PULMICORT FLEXHALER
ASMANEX, ASMANEX HFA QVAR
BROVANA arformoterol
budesonide-formoterol SYMBICORT
DUAKLIR PRESSAIR ANORO ELLIPTA
UTIBRON NEOHALER BEVESPI AEROSPHERE
STIOLTO RESPIMAT
ELIXOPHYLLIN theophylline er
theophylline oral solution
levalbuterol hfa albuterol hfa
PROAIR DIGIHALER
PROAIR HFA
PROAIR RESPICLICK
PROVENTIL HFA
VENTOLIN HFA
XOPENEX HFA
PERFOROMIST formoterol
SEEBRI NEOHALER INCRUSE ELLIPTA
TUDORZA PRESSAIR SPIRIVA RESPIMAT
STRIVERDI RESPIMAT SEREVENT DISKUS
^^
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. Also, the cost can’t
be applied to your annual deductible or out-of-pocket maximum.
21GENERIC AND/OR PREFERRED BRAND
DRUG CLASS MEDICATION NAME^^
ALTERNATIVE(S)
ASTHMA/COPD/RESPIRATORY (cont) YUPELRI ANORO ELLIPTA
BEVESPI AEROSPHERE
BREZTIRI AEROSPHERE
INCRUSE ELLIPTA
SPIRIVA
STIOLTO RESPIMAT
TRELEGY ELLIPTA
ZYFLO montelukast
zafirlukast
zileuton er
ATTENTION DEFICIT HYPERACTIVITY ADDERALL XR dexmethylphenidate er
ADHANSIA XR dextroamphetamine-amphetamine er
APTENSIO XR methylphenidate er
CONCERTA MYDAYIS
COTEMPLA XR-ODT VYVANSE
FOCALIN XR
JORNAY PM
RITALIN LA
DESOXYN methamphetamine
DEXEDRINE dexmethylphenidate er
dextroamphetamine er
dextroamphetamine-amphetamine er
QELBREE atomoxetine
RELEXXII methylphenidate er 36mg tablet
BLOOD PRESSURE/HEART MEDICATIONS BETAPACE sotalol
CARDIZEM diltiazem
CARDIZEM CD diltiazem CD
CONJUPRI amlodipine
felodipine er
nicardipine
nifedipine
CONSENSI amlodipine
celecoxib
EDARBI generic ARBs (e.g. losartan; valsartan)
EDARBYCLOR generic ARBs + HCTZ (e.g. losartan-HCTZ)
FIRAZYR* icatibant
GONITRO nitroglycerin sublingual tablet or spray
ISORDIL isosorbide dinitrate
ISORDIL TITRADOSE
LANOXIN digoxin
MULTAQ amiodarone
disopyramide
dofetilide
flecainide
propafenone
quinidine
sotalol af
BLOOD THINNERS/ANTI-CLOTTING aspirin-omeprazole aspirin or enteric aspirin
YOSPRALA
^^
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. Also, the cost can’t
be applied to your annual deductible or out-of-pocket maximum.
22GENERIC AND/OR PREFERRED BRAND
DRUG CLASS MEDICATION NAME^^
ALTERNATIVE(S)
CANCER CYCLOPHOSPHAMIDE TABLET* cyclophosphamide capsule*
NILANDRON nilutamide
TARCEVA* erlotinib
YONSA* abiraterone
ZYTIGA*
CHOLESTEROL MEDICATIONS ANTARA fenofibrate
FENOGLIDE
CRESTOR rosuvastatin+
EZALLOR SPRINKLE generic statins (e.g. atorvastatin; simvastatin)
FLOLIPID
LIVALO
SIMVASTATIN 20mg/5ml SUSPENSION
JUXTAPID* REPATHA
PRALUENT
LIPITOR atorvastatin+
ezetimibe-simvastatin
rosuvastatin+
niacin 500mg tablet niacin er
NIACOR
ZYPITAMAG atorvastatin+
lovastatin+
pravastatin+
rosuvastatin+
simvastatin+
COUGH/COLD MEDICATIONS benzonatate 150mg benzonatate 100mg, 200mg
TUSSICAPS hydrocodone-chlorpheniramine er suspension
promethazine with codeine syrup
DIABETES ACCU-CHEK AVIVA PLUS TEST STRIPS ONE TOUCH TEST STRIPS (e.g. Ultra; Verio)
ACCU-CHEK COMPACT PLUS STRIPS
ACCU-CHEK GUIDE TEST STRIPS
ACCU-CHEK SMARTVIEW TEST STRIPS
CVS ADVANCED GLUCOSE TEST STRIPS
ADVOCATE TEST STRIPS
ASSURE 4 TEST STRIPS
ASSURE PLATINUM TEST STRIPS
ASSURE PRISM MULTI TEST STRIPS
CONTOUR TEST STRIPS
FREESTYLE TEST STRIPS
FREESTYLE TEST STRIPS NFRS
RELION TEST STRIPS
ADLYXIN BYDUREON
BYETTA
metformin
OZEMPIC
TRULICITY
VICTOZA
ADMELOG HUMALOG
ADMELOG SOLOSTAR LYUMJEV
APIDRA, APIDRA SOLOSTAR
FIASP
^^
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. Also, the cost can’t
be applied to your annual deductible or out-of-pocket maximum.GENERIC AND/OR PREFERRED BRAND
DRUG CLASS MEDICATION NAME^^
ALTERNATIVE(S)
DIABETES (cont) FIASP FLEXTOUCH HUMALOG
FIASP PENFILL LYUMJEV
INSULIN ASPART
NOVOLOG
AFREZZA HUMALOG
HUMULIN R
LYUMJEV
alogliptin JANUMET
alogliptin-metformin JANUMET XR
JENTADUETO JANUVIA
JENTADUETO XR metformin
KAZANO
KOMBIGLYZE XR
NESINA
ONGLYZA
TRADJENTA
alogliptin-pioglitazone JANUMET
OSENI JANUMET XR
JANUVIA
pioglitazone
FORTAMET metformin er (generic to GLUCOPHAGE XR)
GLUMETZA
metformin er gastric
metformin er osmotic
INSULIN ASPART PRO HUMALOG MIX
NOVOLOG MIX
INVOKAMET SYNJARDY
INVOKAMET XR SYNJARDY XR
SEGLUROMET XIGDUO XR
INVOKANA FARXIGA
STEGLATRO JARDIANCE
metformin
LANTUS BASAGLAR
LANTUS SOLOSTAR LEVEMIR
SEMGLEE TRESIBA FLEXTOUCH
TOUJEO MAX SOLOSTAR
TOUJEO SOLOSTAR
NOVOLIN HUMULIN
STEGLUJAN GLYXAMBI
metformin
QTERN
TRIJARDY XR
DIURETICS EDECRIN bumetanide
ethacrynic acid furosemide
torsemide
EYE CONDITIONS LUMIGAN bimatoprost
TRAVATAN Z latanoprost
VYZULTA travoprost
XALATAN
XELPROS
ZIOPTAN
^^
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. Also, the cost can’t
be applied to your annual deductible or out-of-pocket maximum.
24GENERIC AND/OR PREFERRED BRAND
DRUG CLASS MEDICATION NAME^^
ALTERNATIVE(S)
GASTROINTESTINAL/HEARTBURN ANUSOL-HC 25MG SUPPOSITORY hydrocortisone 25mg suppository
ASACOL HD balsalazide
COLAZAL mesalamine tablets or capsules
DELZICOL PENTASA
DIPENTUM sulfasalazine
COLYTE WITH FLAVOR PACKETS+ CLENPIQ+
GOLYTELY+ GAVILYTE-C+
MOVIPREP+ GAVILYTE-G+
NULYTELY WITH FLAVOR PACKS+ GAVILYTE-N+
OSMOPREP+ PEG 3350 ELECTROLYTE+
PLENVU+ SUPREP+
SUTAB+
CORTIFOAM COLOCORT
UCERIS 2MG RECTAL FOAM hydrocortisone
CREON PANCREAZE
PERTZYE
ZENPEP
GIMOTI* metoclopramide oral solution or tablet
HELIDAC bismuth subsalicylate
lansoprazole-amoxicillin-clarithromycin pak
metronidazole
tetracycline
KRISTALOSE CONSTULOSE
lactulose 10gm packet ENULOSE
lactulose oral solution
LIBRAX chlordiazepoxide
LOTRONEX* alosetron*
lubiprostone AMITIZA
MARINOL dronabinol
SYNDROS
MOTEGRITY AMITIZA
TRULANCE LINZESS
ZELNORM
NEXIUM 10MG, 20MG, 40MG PACKET, esomeprazole packets, esomeprazole
20MG, 40MG CAPSULE magnesium
OMECLAMOX-PAK lansoprazole-amoxicillin-clarithromycin pak
PYLERA
TALICIA
OMEPPI omeprazole
omeprazole-bicarbonate
ZEGERID PACKET
PEPCID famotodine suspension
PREVACID SOLUTAB esomeprazole, lansoprazole, pantoprazole
RELTONE ursodiol
ROWASA mesalamine rectal enema suspension
SENSIPAR* cinacalcet
^^
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. Also the cost can’t
be applied to your annual deductible or out-of-pocket maximum.GENERIC AND/OR PREFERRED BRAND
DRUG CLASS MEDICATION NAME^^
ALTERNATIVE(S)
GASTROINTESTINAL/HEARTBURN (cont) ZEGERID CAPSULE DEXILANT
lansoprazole
omeprazole
ZOFRAN ondansetron
ZUPLENZ ondansetron
ondansetron odt
HORMONAL AGENTS ALKINDI SPRINKLE hydrocortisone 5mg tablet
DDAVP desmopressin nasal spray or tablets
NOCDURNA
DEXABLISS dexamethasone 1.5mg tablet
dexamethasone 6, 10, 13 Day 1.5MG tablets
DEXPAK
DXEVO
HIDEX
TAPERDEX
ZCORT
FORTESTA ANDRODERM
JATENZO generic topical testosterone
NATESTO
TESTIM
VOGELXO
XYOSTED
GENOTROPIN* HUMATROPE*
NUTROPIN AQ NUSPIN* NORDITROPIN*
OMNITROPE*
SAIZEN*
SAIZEN-SAIZENPREP*
ZOMACTON*
HEMADY dexamethasone 5mg tablet
MYCAPSSA* BYNFEZIA*
ORTIKOS budesonide capsule
RAYOS methylprednisolone
prednisone
SYNTHROID levothyroxine
THYQUIDITY EUTHYROX
LEVO-T
levothyroxine
LEVOXYL
UCERIS 9MG ER TABLET budesonide 9mg tablet
dexamethasone
hydrocortisone
methylprednisolone
prednisolone
prednisone
INFECTIONS ACTICLATE Generic products (e.g. doxycycline;
DORYX minocycline)
DORYX MPC
MINOCIN 50MG PEL CAPSULE
MINOCYCLINE ER 45, 90, 135MG CAPSULE
MINOLIRA ER
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy. Also the cost can’t
be applied to your annual deductible or out-of-pocket maximum.GENERIC AND/OR PREFERRED BRAND
DRUG CLASS MEDICATION NAME^^
ALTERNATIVE(S)
INFECTIONS (cont) MONODOX Generic products (e.g. doxycycline;
SEYSARA minocycline)
SOLODYN
TARGADOX
VIBRAMYCIN 100MG CAPSULE
XIMINO
ARAKODA atovaquone-proguanil
doxycycline
hydroxychloroquine
mefloquine
quinine
AUGMENTIN amoxicillin/clavulanate
AUGMENTIN XR
BARACLUDE TABLET* entecavir tablet*
BETHKIS* tobramycin inhalation solution*
TOBI*
DIFLUCAN fluconazole
doxycycline hyclate dr 80mg tablet generic products (e.g. minocycline)
DOXYCYCLINE IR-DR doxycycline hyclate dr 50mg tablet
ORACEA doxycycline monohydrate 50mg tablet
minocycline er 45mg
E.E.S. 200 erythromycin granules
ERYPED 400 erythromycin
HUMATIN paromomycin
MEPRON atovaquone
MYCOBUTIN rifabutin
nitrofurantoin 25mg/5ml suspension nitrofurantoin capsule
sulfamethoxazole-trimethoprim suspension
NOXAFIL DR 100MG TABLET posaconazole dr 100mg tablet
SITAVIG acyclovir tablet
famciclovir tablet
valacyclovir tablet
SPORANOX itraconazole
TOLSURA oral itraconazole
VALCYTE valganciclovir
VANCOCIN vancomycin oral solution or capsule
ZOVIRAX acyclovir
MISCELLANEOUS HORIZANT gabapentin
KUVAN* sapropterin tablet & powder packet*
SYPRINE* penicillamine*
trientine*
XENAZINE* tetrabenazine*
MULTIPLE SCLEROSIS AMPYRA* dalfampridine er*
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t
be applied to your annual deductible or out-of-pocket maximum.
27GENERIC AND/OR PREFERRED BRAND
DRUG CLASS MEDICATION NAME^^
ALTERNATIVE(S)
MULTIPLE SCLEROSIS (cont) COPAXONE* BETASERON*
EXTAVIA*
glatiramer*
GLATOPA*
KESIMPTA*
PLEGRIDY*
REBIF*
TECFIDERA* AUBAGIO*
BAFIERTAM*
dimethyl*
GILENYA*
MAYZENT*
PONVORY*
VUMERITY*
NUTRITIONAL/DIETARY AZESCHEW Any generic prenatal vitamin
AZESCO
DERMACINRX PRENATRIX
DERMACINRX PRENATRYL
PNV TABS 20-1
PREGEN DHA
PREGENNA
TRINAZ
ZALVIT
NASCOBAL cyanocobalamin injection
PAIN RELIEF AND INFLAMMATORY DISEASE ALLZITAL butalbutal-acetaminophen 50-325mg tablet
BUPAP
butalbital-acetaminophen 25-35mg, 50-300mg
tablets
AMERGE generic triptans (e.g. sumatriptan; naratriptan)
ERGOMAR
FROVA 2.5MG TABLET
MAXALT
MAXALT MLT
RELPAX
AMRIX carisoprodol
cyclobenzaprine er chlorzoxazone 500mg
cyclobenzaprine tablets
methocarbamol
orphenadrine er
metaxalone
CAMBIA Generic NSAID (e.g. celecoxib; meloxicam)
DUEXIS
fenoprofen 200mg capsule
fenoprofen 400mg capsule
FENORTHO
INDOCIN
indomethacin 20mg capsule
ketoprofen 25mg capsule
meloxicam 5mg, 10mg capsule
NALFON 400MG CAPSULE
NAPRELAN
NAPROSYN 125MG/5ML SUSPENSION
^^
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. Also, the cost can’t
be applied to your annual deductible or out-of-pocket maximum.
28GENERIC AND/OR PREFERRED BRAND
DRUG CLASS MEDICATION NAME^^
ALTERNATIVE(S)
PAIN RELIEF AND INFLAMMATORY DISEASE naproxen Generic NSAID (e.g. celecoxib; meloxicam)
(cont) naproxen sodium cr
naproxen sodium er
naproxen-esomeprazole mag
RELAFEN
RELAFEN DS
TIVORBEX
VIMOVO
VIVLODEX
ZIPSOR
ZORVOLEX
CAPITAL WITH CODEINE acetaminophen-codeine
chlorzoxazone 250mg chlorzoxazone 500mg
chlorzoxazone 375mg methocarbamol 500mg
chlorzoxazone 750mg
CONZIP tramadol
tramadol er
COSENTYX* ENBREL*
HUMIRA*
OTEZLA*
STELARA*
TALTZ*
CUPRIMINE* penicillamine*
trientine*
D.H.E.45 dihydroergotamine injection
diclofenac 1.5% solution generic nsaid (e.g. celecoxib; meloxicam)
diclofenac 35mg capsule diclofenac 1% gel
PENNSAID
dihydroergotamine 4mg/ml spray sumatriptan nasal spray
IMITREX NASAL SPRAY
MIGRANAL
ONZETRA XSAIL
ZOLMITRIPTAN NASAL SPRAY
ZOMIG
GLOPERBA colchicine
probenecid-colchicine
GRALISE gabapentin
IMITREX CARTRIDGE dihydroergotamine
IMITREX PEN INJECTOR sumatriptan
IMITREX TABLET dihydroergotamine
eletriptan
rizatriptan
sumatriptan tablets
KETOROLAC 15.75MG NASAL SPRAY ketorolac tablet
SPRIX
levorphanol codeine with acetaminophen
hydrocodone with acetaminophen
HYSINGLA ER
oxycodone with acetaminophen
tramadol
XTAMPZA ER
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t
be applied to your annual deductible or out-of-pocket maximum.
29You can also read
