CIGNA STANDARD 4-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 4-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. 916152 j Standard 4-Tier O/I SRx 08/21
What’s inside?
About this drug list 3
How to read this drug list 3
How to find your medication 5
Specialty medications 18
Medications that aren’t covered 25
Frequently Asked Questions (FAQs) 41
Exclusions and limitations for coverage 45
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/PDL. Scroll down until you see a pdf of the Cigna Standard 4-Tier
Prescription Drug List (all specialty medications covered on Tier 4).
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 4-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 4-Tier Prescription Drug List.
Tier (cost-share level) gives you
an idea of how much you may
pay for a medication
TIER 1 TIER 2 TIER 3
$ $$ $$$
Medications are grouped by
HORMONAL AGENTS the condition they treat;
AMABELZ ANDRODERM (PA, QL) ACTIVELLA Speciality medications are
budesonide EC ANDROGEL 1.62% ALORA (QL) listed on Tier 4 (pages 19–25)
cabergoline (QL) (PA, QL) ANDROGEL 1.0% (PA,
COVARYX ARMOUR THYROID QL)
COVARYX H.S. CYTOMEL 50mcg ANGELIQ
DECADRON DIVIGEL CLIMARA
desmopressin DUAVEE CLIMARA PRO
Medications are listed in
dexamethasone ESTRING (QL) Combipatch
PREMARIN CYTOMEL 5, 25mcg alphabetical order within
estradiol-
norethindrone PREMPHASE DEPO-TESTOSTERONE each column
estrogen- PREMPRO ELESTRIN
methyltestosterone SYNTHROID ENTOCORT EC
levothyroxine ESTRACE
LEVOXYL ESTROGEL
liothyronine EVAMIST
medroxy-progesterone FEMRING
methimazole INTRAROSA Medications that have extra
methylprednisolone LEVO-T coverage requirements will
MIMVEY MENOSTAR (QL) have an abbreviation listed
MIMVEY LO MINIVELLE (QL) next to them
NATURE-THROID OSPHENA
NP THYROID TIROSINT Brand-name medications
prednisolone UNITHROID are in all capital letters
prednisolone ODT VAGIFEM (QL)
prednisone VIVELLE-DOT (QL) Generic medications
prednisone intensol are in all lowercase letters
progesterone
This chart is just a sample. It may not show how these medications are actually covered on the Cigna Standard 4-Tier Prescription Drug List.
3Tiers
Covered medications are divided into tiers or cost-share levels. Typically, the higher the tier, the
higher the price you’ll pay to fill the prescription.
› Tier 1 – Typically Generics (Lowest-cost medication) $
› Tier 2 – Typically Preferred Brands (Medium-cost medication) $$
› Tier 3 – Typically Non-Preferred Brands (Higher-cost medication) $$$
› Tier 4 – Specialty Medications (Highest-cost medication) $$$$
Abbreviations next to medications
In this drug list, medications that have limits and/or extra coverage requirements have an
abbreviation listed next to them.* Here’s what they mean.
(PA) Prior Authorization – Certain medications need approval from Cigna before your
plan will cover them. These medications have a (PA) next to them. Your plan won’t
cover these medications unless your doctor requests, and receives, approval from
Cigna.
(QL) uantity Limits – Some medications have a quantity limit. This means your plan will
Q
only cover up to a certain amount over a certain length of time. These medications
have a (QL) next to them. Your plan will only cover a larger amount if your doctor
requests, and receives, approval from Cigna.
(ST) tep Therapy – Certain high-cost medications aren’t covered until you try one or
S
more lower-cost alternatives first.** These medications have a (ST) next to them.
You have many covered options to choose from, and they’re used to treat the same
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, oral and
injectable specialty medications are covered on Tier 4 (see pages 18-24). Injectable specialty
medications are marked with an asterisk (*) and oral specialty medications are marked with a double
asterisk (**).
Your plan may also limit coverage to a 30-day supply and/or require you to use a preferred specialty
pharmacy to receive coverage. Log in to the myCigna App or myCigna.com, or check your plan
materials, to learn more about how your plan covers specialty 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
ALLERGY/NASAL SPRAYS 6 FEMININE PRODUCTS 12
ALZHEIMER’S DISEASE 6 GASTROINTESTINAL/HEARTBURN 12
ANXIETY/DEPRESSION/BIPOLAR 6 HORMONAL AGENTS 12, 13
DISORDER INFECTIONS 13, 14
ASTHMA/COPD/RESPIRATORY 6 INFERTILITY 14
ATTENTION DEFICIT HYPERACTIVITY 6, 7 MISCELLANEOUS 14
DISORDER
NUTRITIONAL/DIETARY 14, 15
BLOOD MODIFIERS/BLEEDING DISORDERS 7 OSTEOPOROSIS PRODUCTS 15
BLOOD PRESSURE/HEART MEDICATIONS 7 PAIN RELIEF AND INFLAMMATORY DISEASE 15, 16
BLOOD THINNERS/ANTI-CLOTTING 7, 8 PARKINSON’S DISEASE 16
CANCER 8 SCHIZOPHRENIA/ANTI-PSYCHOTICS 16
CHOLESTEROL MEDICATIONS 8 SEIZURE DISORDERS 16
CONTRACEPTION PRODUCTS 8–10 SKIN CONDITIONS 16, 17
COUGH/COLD MEDICATIONS 10 SLEEP DISORDERS/SEDATIVES 17
DENTAL PRODUCTS 10 SMOKING CESSATION 17
DIABETES 10, 11 SUBSTANCE ABUSE 17
DIURETICS 11 URINARY TRACT CONDITIONS 17
EAR MEDICATIONS 11 VACCINES 17
ERECTILE DYSFUNCTION 11 WEIGHT MANAGEMENT 17
EYE CONDITIONS 11, 12
5Cigna Standard 4-Tier Prescription Drug List
Specialty medications are covered on Tier 4 (listed on pages 18-24).
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
ALLERGY/NASAL SPRAYS ANXIETY/DEPRESSION/BIPOLAR DISORDER4
azelastine CLARINEX (cont)
azelastine- CLARINEX-D 12 fluoxetine (QL)
fluticasone HOUR fluvoxamine (QL)
cromolyn GASTROCROM fluvoxamine er
desloratadine (QL) GRASTEK (PA, QL) (QL)
fluticasone KARBINAL ER lorazepam
hydroxyzine hcl ODACTRA (PA, QL) lorazepam intensol
solution, syrup, PATANASE mirtazapine
tablet RAGWITEK (PA, QL) paroxetine cr (QL)
hydroxyzine VISTARIL paroxetine er (QL)
pamoate paroxetine (QL)
ipratropium sertraline (QL)
mometasone (QL) trazodone
olopatadine venlafaxine (QL)
promethazine venlafaxine er (QL)
solution, syrup, ASTHMA/COPD/RESPIRATORY
tablet
albuterol ADVAIR HFA DALIRESP (QL)
ALZHEIMER’S DISEASE albuterol hfa (QL) ANORO ELLIPTA LETAIRIS* (PA)
donepezil NAMENDA 5-10 ARICEPT ambrisentan* (PA) ATROVENT HFA LONHALA
donepezil odt MG TITRATION PK EXELON budesonide BREO ELLIPTA MAGNAIR REFILL
memantine MESTINON fluticasone- BREZTRI (PA)
memantine er (QL) NAMENDA 10 MG salmeterol AEROSPHERE LONHALA
pyridostigmine 60 TABLET ipratropium- COMBIVENT MAGNAIR
mg/5 ml, 60 mg NAMENDA 5 MG albuterol RESPIMAT STARTER (PA)
pyridostigmine er TABLET montelukast DULERA PULMICORT
rivastigmine NAMENDA XR (QL) FLOVENT DISKUS RESPULES
NAMZARIC (QL) FLOVENT HFA SINGULAIR
ANXIETY/DEPRESSION/BIPOLAR DISORDER4 INCRUSE ELLIPTA
PULMICORT
alprazolam CELEXA (QL, ST) FLEXHALER
alprazolam er EFFEXOR XR (QL, QVAR REDIHALER
alprazolam intensol ST) SEREVENT DISKUS
alprazolam odt FETZIMA (QL, ST) SPIRIVA
alprazolam xr PAXIL (QL, ST) SPIRIVA RESPIMAT
amitriptyline PAXIL CR (QL, ST) STIOLTO RESPIMAT
bupropion (QL) PRISTIQ (QL, ST) SYMBICORT
bupropion sr (QL) PROZAC (QL, ST) TRELEGY ELLIPTA
bupropion xl 150 REMERON ATTENTION DEFICIT HYPERACTIVITY
mg tablet (QL) SPRAVATO* (PA)
bupropion xl 300 DISORDER4
TRINTELLIX (QL, ST)
mg tablet (QL) amphetamine (PA) MYDAYIS (PA, QL) ADDERALL (PA,ST)
VIIBRYD (QL, ST)
buspirone atomoxetine (QL) VYVANSE (PA, QL) ADZENYS ER (PA,
WELLBUTRIN SR
citalopram (QL) dexmethyl- QL)
(QL, ST)
clomipramine phenidate (PA) ADZENYS XR-ODT
XANAX
desvenlafaxine er dexmethyl- (PA, QL)
XANAX XR
(QL) phenidate er (PA, AMPHETAMINE ER
ZOLOFT (QL, ST)
duloxetine (QL) QL) (PA,QL)
escitalopram (QL) dextroamphet- DAYTRANA (PA, QL)
fluoxetine dr (QL) amine-amphet er DYANAVEL XR (PA,
(PA, QL) QL)
6Cigna Standard 4-Tier Prescription Drug List
Specialty medications are covered on Tier 4 (listed on pages 18-24).
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
ATTENTION DEFICIT HYPERACTIVITY BLOOD PRESSURE/HEART MEDICATIONS (cont)
DISORDER4 (cont) doxazosin KAPSPARGO
dextroamphet- EVEKEO (PA,ST) droxidopa* SPRINKLE (ST)
amine- FOCALIN (PA,ST) enalapril KATERZIA (QL)
amphetamine (PA) INTUNIV flecainide LOPRESSOR (ST)
guanfacine er METHYLIN (PA) hydralazine tablet LOTENSIN (ST)
methylphenidate QUILLICHEW ER irbesartan LOTREL
er (la) (PA, QL) (PA, QL) labetalol tablet MICARDIS (QL, ST)
methylphenidate QUILLIVANT XR (PA, lisinopril MICARDIS HCT (QL,
er (PA, QL) QL) lisinopril-hctz ST)
methylphenidate RITALIN (PA,ST) losartan MINIPRESS
(PA) STRATTERA (QL) losartan-hctz NITROSTAT
methylphenidate matzim la NORTHERA* (PA)
cd (PA, QL) metoprolol NORVASC
methylphenidate succinate ORLADEYO* (PA,
er (cd) (PA, QL) metoprolol QL)
methylphenidate la nadolol PRINIVIL (ST)
(PA, QL) nifedipine PROCARDIA XL
BLOOD MODIFIERS/BLEEDING DISORDERS nifedipine er RANEXA (QL)
olmesartan (QL) TEKTURNA (QL)
DROXIA SIKLOS (PA)
olmesartan- TENORMIN (ST)
BLOOD PRESSURE/HEART MEDICATIONS amlodipine-hctz TENORETIC 50 (ST)
amlodipine BYSTOLIC (QL, ST) ADALAT CC olmesartan-hctz TENORETIC 100
amlodipine- CORLANOR (PA) ALTACE (ST) (QL) (ST)
benazepril ENTRESTO ATACAND (ST) prazosin TIAZAC
amlodipine- TEKTURNA HCT AVAPRO (ST) propranolol tablet TIKOSYN (PA, QL)
olmesartan (QL) (QL) AZOR (QL) propranolol er TOPROL XL (ST)
amlodipine- BENICAR (QL, ST) ramipril TRIBENZOR
valsartan BENICAR HCT (ST) ranolazine er (QL) VASOTEC (ST)
atenolol BIDIL (QL) taztia xt VERELAN
benazepril CALAN SR telmisartan (QL) VERELAN PM
bisoprolol CARDIZEM LA telmisartan-hctz ZESTORETIC (ST)
bisoprolol-hctz 120mg (QL) (QL) ZESTRIL (ST)
candesartan CARDURA tiadylt er ZIAC (ST)
cartia xt CATAPRES-TTS 1 valsartan
carvedilol CATAPRES-TTS 2 valsartan-hctz
carvedilol er (QL) CATAPRES-TTS 3 verapamil er
clonidine COREG (ST) verapamil er pm
diltiazem 12hr er CORGARD (ST) verapamil tablet
diltiazem 24hr er COZAAR (ST) verapamil sr
diltiazem 24hr er DIOVAN (ST) BLOOD THINNERS/ANTI-CLOTTING
(cd) DIOVAN HCT (ST) adult aspirin BRILINTA BAYER CHEWABLE
diltiazem 24hr er EPANED regimen+ ELIQUIS (PA) ASPIRIN+
(la) EXFORGE aspirin ec+ XARELTO (PA) EFFIENT
diltiazem 24hr er HEMANGEOL aspirin+ PLAVIX
(xr) HYZAAR (ST) aspirin- PRADAXA (PA)
diltiazem INDERAL LA (ST) dipyridamole er SAVAYSA (PA, QL)
DILT-XR INDERAL XL (ST) children's aspirin+ ZONTIVITY
dofetilide (QL) INNOPRAN XL (ST) clopidogrel
7Cigna Standard 4-Tier Prescription Drug List
Specialty medications are covered on Tier 4 (listed on pages 18-24).
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
BLOOD THINNERS/ANTI-CLOTTING (cont) CONTRACEPTION PRODUCTS (cont)
jantoven AUROVELA 24 FE+ NUVARING
low dose aspirin AUROVELA FE+ SAFYRAL
ec+ AUROVELA+ SLYND
prasugrel AVIANE+ TAYTULLA
st. joseph aspirin AYUNA+ TODAY
ec+ AZURETTE+ CONTRACEPTIVE
st. joseph aspirin+ BALZIVA+ SPONGE+
warfarin BLISOVI 24 FE+ TWIRLA+
CANCER BLISOVI FE+ VCF
BRIELLYN+ CONTRACEPTIVE
anastrozole+ GLEOSTINE
CAMILA+ FILM+
exemestane+ TREXALL
CAMRESE LO+ YASMIN 28
hydroxyurea
CAMRESE+ YAZ
letrozole
CAYA
methotrexate
CONTOURED+
tamoxifen+
CAZIANT+
temozolomide*
CHARLOTTE 24
(PA)
FE+
CHOLESTEROL MEDICATIONS CHATEAL EQ+
atorvastatin+ NEXLETOL (PA, QL) CADUET (QL) CHATEAL+
colesevelam NEXLIZET (PA, QL) LIPOFEN (ST) CRYSELLE+
ezetimibe REPATHA (PA) NIASPAN CYCLAFEM+
ezetimibe- ROSZET TRICOR (ST) CYRED EQ+
simvastatin VASCEPA (PA) TRILIPIX (ST) CYRED+
fenofibrate VYTORIN (ST) DASETTA+
fenofibric acid WELCHOL DAYSEE+
fluvastatin er+ ZETIA DEBLITANE+
fluvastatin+ ZOCOR (QL, ST) desogestrel-ethinyl
icosapent ethyl estradiol+
lovastatin+ desogestrel-ethinyl
omega-3 acid ethyl estradiol - ethinyl
estradiol+
esters
DOLISHALE+
pravastatin+
drospirenone-
rosuvastatin+ (QL)
ethinyl estradiol-
simvastatin tablet+
levomefolate+
(QL)
drospirenone-
CONTRACEPTION PRODUCTS ethinyl estradiol+
AFIRMELLE+ LO LOESTRIN FE BALCOLTRA ECONTRA EZ+
AFTERA+ BEYAZ ECONTRA ONE-
ALTAVERA+ ELLA+ STEP+
ALYACEN+ ESTROSTEP FE ELINEST+
AMETHIA+ LAYOLIS FE+ ELURYNG+
AMETHYST+ LOESTRIN FE EMOQUETTE+
APRI+ MICROGESTIN 24 ENPRESSE+
ARANELLE+ FE ENSKYCE+
ASHLYNA+ MINASTRIN 24 FE ERRIN+
AUBRA EQ+ NATAZIA ESTARYLLA+
AUBRA+ NEXTSTELLIS
8Cigna Standard 4-Tier Prescription Drug List
Specialty medications are covered on Tier 4 (listed on pages 18-24).
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
CONTRACEPTION PRODUCTS (cont) CONTRACEPTION PRODUCTS (cont)
ethynodiol-ethinyl LO-
estradiol+ ZUMANDIMINE+
etonogestrel- LUTERA+
ethinyl estradiol+ LYLEQ+
FALMINA+ LYZA+
FAYOSIM+ MARLISSA+
FEMCAP+ MERZEE+
FEMYNOR+ MICROGESTIN FE+
GEMMILY+ MICROGESTIN+
GYNOL II+ MILI+
HAILEY 24 FE+ MONO-LINYAH+
HAILEY FE+ MY CHOICE+
HAILEY+ MY WAY+
HEATHER+ NECON+
ICLEVIA+ NEW DAY+
INCASSIA+ NIKKI+
ISIBLOOM+ NORA-BE+
JAIMIESS+ norethindrone+
JASMIEL+ norethindrone-
JENCYCLA+ ethinyl estradiol-
JOLESSA+ iron+
JULEBER+ norethindrone-
JUNEL FE 24+ ethinyl estradiol+
JUNEL FE+ norethindrone-
JUNEL+ ethinyl estradiol-
KAITLIB FE+ ferrous fumarate
KALLIGA+ norgestimate-
KARIVA+ ethinyl estradiol+
KELNOR 1-35+ NORLYDA+
KELNOR 1-50+ NORTREL+
KURVELO+ NYLIA+
LARIN 24 FE+ NYMYO+
LARIN FE+ OCELLA+
LARIN+ OPCICON ONE-
LARISSIA+ STEP+
LEENA+ OPTION 2+
LESSINA+ ORSYTHIA+
LEVONEST+ PHILITH+
levonorgestrel+ PIMTREA+
levonorgestrel- PIRMELLA+
ethinyl estradiol+ PORTIA+
levonorgestrel- PREVIFEM+
ethinyl estradiol RECLIPSEN+
ethinyl estradiol+ RIVELSA+
LEVORA-28+ SETLAKIN+
LILLOW+ SHAROBEL+
LOJAIMIESS+ SIMLIYA+
LORYNA+ SIMPESSE+
LOW-OGESTREL+ SPRINTEC+
9Cigna Standard 4-Tier Prescription Drug List
Specialty medications are covered on Tier 4 (listed on pages 18-24).
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
CONTRACEPTION PRODUCTS (cont) COUGH/COLD MEDICATIONS
SRONYX+ bromphenir- HYCODAN (PA, QL)
SYEDA+ amine- TESSALON PERLE
TAKE ACTION+ pseudoephedrine TUZISTRA XR (PA,
TARINA 24 FE+ -dm QL)
TARINA FE 1-20 hydrocodone-
EQ+ homatropine (PA,
TARINA FE+ QL)
TILIA FE+ promethazine-dm
TRI FEMYNOR+ DENTAL PRODUCTS
TRI-ESTARYLLA+
chlorhexidine PREVIDENT 0.2% CLINPRO 5000
TRI-LEGEST FE+
DENTA 5000 PLUS RINSE FLORIVA+^
TRI-LINYAH+
DENTAGEL FLUORIDEX
TRI-LO-
doxycycline hyclate SENSITIVITY RELIEF
ESTARYLLA+ FLUORIDEX DAILY PREVIDENT 1.1%
TRI-LO-MARZIA+ DEFENSE 1.1% GEL
TRI-LO-MILI+ ORALONE
PREVIDENT 5000
TRI-LO-SPRINTEC+ PERIDEX
PREVIDENT 5000
TRI-MILI+ PERIOGARD
BOOSTER PLUS
TRI-NYMYO+ SF 1.1% GEL
PREVIDENT 5000
TRI-PREVIFEM+ SF 5000 PLUS
ENAMEL PROTECT
TRI-SPRINTEC+ sodium fluoride
PREVIDENT 5000
TRIVORA-28+ sodium fluoride
ORTHO DEFENSE
TRI-VYLIBRA LO+ 5000 dry mouth
PREVIDENT 5000
TRI-VYLIBRA+ sodium fluoride
PLUS
TULANA+ 5000 plus
triamcinolone PREVIDENT 5000
TYDEMY+
SENSITIVE
VCF
CONTRACEPTIVE DIABETES
FOAM+ ACCU-CHEK BASAGLAR (QL) AMARYL
VCF COMPACT PLUS BAQSIMI (QL) CEQUR
CONTRACEPTIVE CONTROL DEXCOM G6 (PA, CYCLOSET
GEL+ ACCU-CHEK GUIDE QL) GLUCAGON
VELIVET+ L1-L2 CONTROL DROPLET EMERGENCY KIT
VESTURA+ SOLUTION DROPSAFE (QL)
VIENVA+ ACCU-CHEK AVIVA FARXIGA (QL, ST) GVOKE (QL)
VIORELE+ SOLUTION FREESTYLE LIBRE PRECISION XTRA
VOLNEA+ ACCU-CHEK 14 DAY SENSOR KETONE-GLUC KIT
VYFEMLA+ SOFTCLIX LANCET (PA, QL) RIOMET
VYLIBRA+ KIT FREESTYLE LIBRE 2
WERA+ ACCU-CHEK SENSOR (PA, QL)
wide seal FASTCLIX GLUCAGEN HYPO
diaphragm+ LANCING DEVICE KIT
WYMZYA FE+ ACCU-CHEK GLYXAMBI (QL, ST)
XULANE+ MULTICLIX HUMULIN (QL)
ZAFEMY+ LANCET KIT JANUMET (QL, ST)
ZARAH+ ACCU-CHEK JANUMET XR (QL,
ZOVIA 1-35+ SMARTVIEW ST)
ZOVIA 1-35E+ CONTROL JANUVIA (QL, ST)
ZUMANDIMINE+ SOLUTION JARDIANCE (QL, ST)
10Cigna Standard 4-Tier Prescription Drug List
Specialty medications are covered on Tier 4 (listed on pages 18-24).
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
DIABETES (cont) DIURETICS (cont)
ACCUTREND LYUMJEV (QL) spironolactone
GLUCOSE OMNIPOD DASH triamterene-hctz
CONTROL (PA, QL) EAR MEDICATIONS
BD PEN NEEDLE ONETOUCH ULTRA
ciprofloxacin- CIPRO HC CIPRODEX
CONTOUR TEST STRIP
dexamethasone CORTISPORIN-TC
SOLUTION ONETOUCH VERIO
neomycin- DERMOTIC
CONTOUR NEXT TEST STRIP
polymyxin OTOVEL
LEV 1 CONTROL QTERN (QL, ST)
b-hydrocortisone
SOLUTION RYBELSUS (PA, QL)
ofloxacin
CONTOUR SOLIQUA 100-33
SOLUTION SYMLINPEN ERECTILE DYSFUNCTION
CONTOUR SYNJARDY (QL, ST) sildenafil^ (QL) MUSE^ (PA, QL) CIALIS^ (QL, ST)
SOLUTION SYNJARDY XR (QL, tadalafil^ (QL) STENDRA^ (QL, ST)
CONTOUR NEXT ST) vardenafil^ (QL) VIAGRA^ (QL, ST)
LEV 2 CONTROL TRIJARDY XR (ST, EYE CONDITIONS
SOLUTION QL)
bimatoprost (QL) ALPHAGAN P 0.1% ACULAR
glimepiride V-GO 20
brimonidine DROPS ACULAR LS
glipizide V-GO 30
brinzolamide AZASITE ACUVAIL
glipizide er V-GO 40
ciprofloxacin BETIMOL ALPHAGAN P
glipizide xl VICTOZA (PA, QL)
dorzolamide BETOPTIC S 0.15% EYE DROPS
INPEN XIGDUO XR (QL, ST)
dorzolamide- COMBIGAN ALREX
metformin Xultophy
timolol EYSUVIS (QL) AZOPT
metformin er
erythromycin FML FORTE 0.25% BEPREVE
NOVOFINE
fluorometholone EYE DROPS BESIVANCE
NOVOTWIST
ketorolac FML S.O.P. 0.1% BROMSITE
TECHLITE
latanoprost OINTMENT CEQUA
TRUE METRIX
loteprednol FLAREX COSOPT
LEVEL 1 CONTROL
moxifloxacin eye LOTEMAX SM COSOPT PF
SOULTION
drops RESTASIS DUREZOL
TRUE METRIX
neomycin- RESTASIS FML LIQUIFILM
LEVEL 2 CONTROL
polymyxin MULTIDOSE 0.1% EYE DROP
SOLUTION
b-dexamethasone SIMBRINZA ILEVRO
TRUE METRIX
ofloxacin XIIDRA INVELTYS
LEVEL 3 CONTROL
olopatadine ZERVIATE ISTALOL
SOLUTION
polymyxin LASTACAFT
TRUEPLUS SYRINGE
b sulfate- LOTEMAX
DIURETICS trimethoprim MAXITROL
ACETAZOLAMIDE DIURIL ALDACTONE prednisolone MOXEZA
TABLET CAROSPIR timolol NEVANAC
ACETAZOLAMIDE INSPRA tobramycin- OCUFLOX
ER CAPSULE
BUMETANIDE KERENDIA dexamethasone PRED FORTE
TABLET LASIX travoprost PROLENSA
chlorthalidone MAXZIDE RHOPRESSA
eplerenone ROCKLATAN
furosemide TIMOPTIC
solution, tablet TIMOPTIC-XE
hydrochloro- TOBRADEX EYE
thiazide DROPS
11Cigna Standard 4-Tier Prescription Drug List
Specialty medications are covered on Tier 4 (listed on pages 18-24).
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
EYE CONDITIONS (cont) GASTROINTESTINAL/HEARTBURN (cont)
TOBRADEX ST LAXATIVE EC 5 MG
TRUSOPT TABLET+
VIGAMOX mesalamine
ZIRGAN mesalamine dr
ZYLET mesalamine er
FEMININE PRODUCTS metoclopramide
solution, tablet
FEM PH
metoclopramide
GYNAZOLE 1
odt
miconazole 3 200
misoprostol
mg
NATURA-LAX+
terconazole
omeprazole (QL)
GASTROINTESTINAL/HEARTBURN ondansetron
ALOPHEN PILLS+ AMITIZA ACIPHEX (QL, ST) ondansetron odt
ANUCORT-HC CLENPIQ+ AKYNZEO 300-0.5 pantoprazole
balsalazide DEXILANT (QL) MG CAPSULE suspension, tablet
bisacodyl tablet+ LINZESS APRISO (QL)
cinacalcet* LITHOSTAT BONJESTA peg
CLEARLAX+ NEXIUM DR 2.5 MG CANASA 3350-electrolyte+
CONSTULOSE PACKET (QL) CARAFATE PEG3350-SODIUM
dicyclomine NEXIUM DR 5 MG CORRECTOL+ SULFATE-SODIUM
capsule, solution, CHLORIDE-
PACKET (QL) CUVPOSA POTASSIUM
tablet
esomeprazole PANCREAZE DICLEGIS CHLORIDE-
20 mg capsule, PENTASA DONNATAL SODIUM
40 mg capsule, SUPREP+ DULCOLAX EC 5 ASCORBATE-
packets (QL) SUTAB+ MG TABLET+ ASCORBIC ACID+
famotidine VIBERZI MIRALAX+ PEG-PREP+
40 mg/5 ml MOVANTIK (PA) polyethylene glycol
suspension, 20 PREVACID DR 30 3350+
mg tablet, 40 mg MG CAPSULE (QL, prochlorperazine
tablet ST) tablet
GAVILAX+ PROTONIX (QL, ST) promethazine
GAVILYTE-C+ RECTIV suppository
GAVILYTE-G+ RELISTOR (PA) promethegan
GAVILYTE-N+ SANCUSO (PA, QL) PURELAX+
GENTLE SFROWASA rabeprazole tablet
LAXATIVE+ SUCRAID* (PA) (QL)
GENTLELAX+ SYMPROIC (PA) scopolamine
GLYCOLAX+ TRANSDERM-SCOP SMOOTHLAX+
glycopyrrolate URSO sucralfate
tablet URSO FORTE ursodiol
HEMMOREX-HC VARUBI (PA, QL) WOMEN'S GENTLE
hydrocortisone VIOKACE LAXATIVE+
lansoprazole (QL) WOMEN'S
LAXACLEAR+ LAXATIVE+
LAXATIVE PEG HORMONAL AGENTS
3350+ AMABELZ ANDRODERM (PA, ACTIVELLA
LAXATIVE 5 MG budesonide ec QL) ALORA (QL)
TABLET+ DIVIGEL
12Cigna Standard 4-Tier Prescription Drug List
Specialty medications are covered on Tier 4 (listed on pages 18-24).
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
HORMONAL AGENTS (cont) INFECTIONS (cont)
budesonide er (PA, DUAVEE ANDROGEL (PA, QL) albendazole CLEOCIN 75 MG ALBENZA
QL) ESTRING (QL) ANGELIQ amoxicillin CAPSULE ALINIA
cabergoline (QL) MEDROL 2 MG ARMOUR THYROID amoxicillin- ERY-TAB DR 333 MG BACTRIM
COVARYX TABLET AYGESTIN clavulanate er TABLET BACTRIM DS
COVARYX H.S. ORIAHNN (PA, QL) BIJUVA amoxicillin- EURAX 10% CREAM BAXDELA (PA)
DECADRON ORILISSA (PA, QL) CLIMARA clavulanate FIRVANQ CIPRO TABLET
desmopressin PREMARIN TABLET, CLIMARA PRO atovaquone SOLOSEC CLEOCIN 150 MG
dexamethasone VAGINAL CREAM COMBIPATCH atovaquone- VIBRAMYCIN 50 CAPSULE
APPLICATOR
intensol CRINONE 4% GEL proguanil MG/5 ML SYRUP CLEOCIN 300 MG
PREMPHASE
DOTTI (QL) CYTOMEL AVIDOXY XIFAXAN (QL) CAPSULE
PREMPRO
EEMT ELESTRIN azithromycin CLEOCIN 100 MG
EEMT H.S. ENTOCORT EC packet, VAGINAL OVULE
estradiol (once ESTRACE suspension, tablet CLEOCIN 2%
weekly) ESTROGEL cefdinir VAGINAL CREAM
estradiol 10mcg EVAMIST cefuroxime tablet CLINDESSE
vaginal insert (QL) IMVEXXY (QL) cephalexin CRESEMBA
estradiol (twice INTRAROSA ciprofloxacin CAPSULE (PA)
weekly) (QL) LEVOTHYROXINE clarithromycin DIFICID (QL)
estradiol- CAPSULE clarithromycin er ELIMITE
MEDROL 8MG,
norethindrone 16MG, 32MG clindamycin ERYPED 200
estrogen- TABLET COREMINO ER QL) ERY-TAB DR 250 MG
methyltestos- MEDROL 4 MG dapsone tablets TABLET
terone DOSEPAK doxycycline hyclate ERY-TAB DR 500 MG
EUTHYROX MENOSTAR (QL) capsule, tablet TABLET
LEVO-T MINIVELLE (QL) doxycycline EURAX 10%
levothyroxine MYFEMBREE (QL)
tablet monohydrate LOTION
LEVOXYL OSPHENA EMVERM FLAGYL
liothyronine PROMETRIUM erythromycin HIPREX
LYLLANA (QL) RAYALDEE erythromycin KEFLEX
medroxyprog- TIROSINT-SOL ethylsuccinate MACROBID
esterone UNITHROID famciclovir MACRODANTIN
methimazole VAGIFEM (QL) fluconazole MALARONE (PA)
methylpred- VIVELLE-DOT (QL) hydroxychlo- NATROBA
nisolone roquine NUVESSA
MIMVEY ivermectin ORAVIG
norethindrone levofloxacin PLAQUENIL
NP THYROID solution, tablet posaconazole
methenamine suspension
prednisone
metronidazole gel, PRIFTIN
prednisone
capsule, tablet SIVEXTRO TABLET
intensol
minocycline (PA)
progesterone tablet
minocycline er SKLICE
testosterone (PA,
tablet (QL) STROMECTOL
QL)
mondoxyne nl sulfatrim
WESTHROID
MORGIDOX URIBEL
YUVAFEM (QL)
nitazoxanide VALTREX
INFECTIONS VIBRAMYCIN 25
nitrofurantoin
acyclovir capsule, CIPRO SUSPENSION AEMCOLO (QL) MG/5 ML SUSP
suspension, tablet
13Cigna Standard 4-Tier Prescription Drug List
Specialty medications are covered on Tier 4 (listed on pages 18-24).
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
INFECTIONS (cont) MISCELLANEOUS (cont)
nitrofurantoin XENLETA 600mg TECHLITE LANCETS COMPACT SPACE
monohydrate- tablet (PA, QL) TRUEPLUS KETONE CHAMBER (QL)
macrocrystal XOFLUZA (QL) TEST STRIP EASIVENT (QL)
nystatin ZITHROMAX FLEXICHAMBER
suspension, tablet ZITHROMAX TRI- (QL)
penicillin v PAK INSPIRACHAMBER
potassium ZYVOX (QL)
permethrin SUSPENSION, MICROCHAMBER
posaconazole TABLET (PA) (QL)
tablet NITYR* (PA)
sulfamethoxazole- OPTICHAMBER
trimethoprim DIAMOND (QL)
suspension, tablet POCKET CHAMBER
terbinafine (QL)
tetracycline PRO COMFORT
valacyclovir SPACER WITH
valganciclovir MASK (QL)
vancomycin PROCARE SPACER
capsule, solution WITH CHILD MASK
vandazole (QL)
INFERTILITY RITEFLO (QL)
SPACE CHAMBER
clomiphene ^ CRINONE 8% GEL^
(QL)
ENDOMETRIN^
SPACE CHAMBER-
MISCELLANEOUS MEDIUM MASK
ACCU-CHEK ACE AEROSOL ADDYI^ (PA, QL) (QL)
SAFE-T-PRO 23G CLOUD BRISDELLE (QL) SPACE CHAMBER-
LANCETS ENHANCER (QL) NUEDEXTA (QL) SMALL MASK (QL)
ACCU-CHEK AEROCHAMBER VORTEX (QL)
SOFTCLIX MINI (QL) VORTEX VHC FROG
LANCETS AEROCHAMBER MV MASK (QL)
ACCU-CHEK (QL) VORTEX VHC
MULTICLIX AEROCHAMBER LADYBUG MASK
LANCETS PLUS FLOW-VU (QL)
ACCU-CHEK (QL) NUTRITIONAL/DIETARY
FASTCLIX LANCET AEROCHAMBER
calcitriol capsule, CITRANATAL 90 ALIVE PRENATAL+
DRUM WITH
solution^ DHA AURYXIA (QL)
FC2 FEMALE FLOWSIGNAL (QL)
FA-8+ CITRANATAL BRAINSTRONG
CONDOM+ AEROCHAMBER
folic acid^+ ASSURE PRENATAL+
KETONE CARE TEST Z-STAT PLUS (QL)
klor-con CITRANATAL CLASSIC
STRIP AEROTRACH PLUS
KLOR-CON 10 MEQ B-CALM PRENATAL+
KETONE TEST STRIP (QL)
TABLET CITRANATAL DHA EXPECTA
KETOSTIX REAGENT AEROVENT PLUS
KLOR-CON 8 MEQ CITRANATAL PRENATAL+
MICROLET (QL) FOSRENOL 1,000
TABLET HARMONY
PRECISION XTRA BREATHRITE (QL) MG CHEWABLE
KLOR-CON M10 CITRANATAL RX
sodium chloride CLEVER CHOICE TABLET
TABLET DRISDOL^ FOSRENOL 500
inhalation vial. HOLDING
KLOR-CON M10 MG CHEWABLE
Irrigation solution CHAMBER (QL)
TABLET TABLET
vial
14Cigna Standard 4-Tier Prescription Drug List
Specialty medications are covered on Tier 4 (listed on pages 18-24).
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
NUTRITIONAL/DIETARY (cont) PAIN RELIEF AND INFLAMMATORY DISEASE
MULTI-VITAMIN FLORIVA FOSRENOL 750 acetaminophen- AIMOVIG (PA) ANALPRAM HC 1%
W-FLUORIDE- CHEWABLE MG CHEWABLE codeine (PA) AJOVY (PA) CREAM
IRON+ TABLET+ TABLET allopurinol tablet BELBUCA (QL) ANALPRAM HC
K-TAB ER ASPIRIN EC+ 2.5%-1% CREAM
MULTIVITAMIN FOSRENOL 1,000 EMGALITY (PA) ANALPRAM HC
LOKELMA aspirin tablet+
WITH FLUORIDE+ MG POWDER baclofen tablet HYSINGLA ER (PA) 2.5%-1% CREAM
MULTIVITAMIN- PACK MINI PRENATAL+ NUCYNTA (PA) SINGLE
buprenorphine
IRON-FLUORIDE FOSRENOL 750 MG OB COMPLETE^ patch (QL) NURTEC ODT (PA, ARAVA
ONE DAILY POWDER PACKET ONE A DAY butalbital- QL) BUTRANS (QL)
PRENATAL+ MEPHYTON^ WOMEN'S acetaminophen- PROCTOFOAM-HC CELEBREX (QL, ST)
potassium chloride NEEVO DHA^ PRENATAL DHA+ caffeine (QL) RASUVO (PA) COLCRYS
10%, capsule, OB COMPLETE ONE-A-DAY carisoprodol REDITREX (PA) EC-NAPROSYN (ST)
packet, tablet PETITE PRENATAL-1+ celecoxib (QL) SAVELLA ECOTRIN EC 325
prenatal OB COMPLETE PHOSLYRA colchicine UBRELVY (PA, QL) MG TABLET+
complete+ PREMIER PRENATAL cyclobenzaprine ULORIC (QL) ESGIC (QL)
PRENATAL PERRY PRENATAL+ FORMULA-DHA+ diclofenac 1% gel XTAMPZA ER (PA) FEXMID
GUMMIES+ POLY-VI-FLOR WITH RENVELA (QL) ZTLIDO FLECTOR (PA, QL)
PRENATAL MULTI+ IRON+ SIMILAC diclofenac dr
LAZANDA (PA)
prenatal multi- POLY-VI-FLOR+ PRENATAL+ diclofenac ec
LICART (PA, QL)
dha+ PRENATE^ STUART ONE+ EC-NAPROXEN
LIDODERM
PRENATAL PRIMACARE ULTRA PRENATAL ECOTRIN EC 81 MG
MITIGARE
MULTIVITAMIN+ QUFLORA PLUS DHA+ TABLET+
MOBIC (ST)
PRENATAL PEDIATRIC 1 VELTASSA eletriptan (QL)
NAPROSYN (ST)
MULTIVITAMIN- MG CHEWABLE ENDOCET (PA)
NUCYNTA ER (PA)
DHA+ TABLET+ febuxostat (QL)
OTREXUP (PA)
PRENATAL ONE QUFLORA fentanyl (PA)
OXAYDO (PA)
DAILY+ PEDIATRIC 0.25 FIORICET (QL)
PERCOCET (PA)
PRENATAL VITAMIN MG/ML DROP+ frovatriptan (QL)
PROCORT
+ DHA+ QUFLORA GLYDO
SKELAXIN
PRENATAL VIT+ PEDIATRIC 0.5 MG/ hydrocodone- ULTRAM 50 MG
PRENATAL ML DROP+ acetaminophen TABLET (QL)
VITAMINS+ ROCALTROL^ (PA) VTOL LQ
hydromorphone ZANAFLEX
PRENATAL+ TRI-VI-FLOR+ ZEBUTAL (QL)
sevelamer VELPHORO er (PA)
hydromorphone ZOHYDRO ER (PA)
carbonate ZYLOPRIM
TRI-VITE WITH (PA)
FLUORIDE+ IBU
vitamin d2 1.25 mg ibuprofen
(50,000 unit)^ indomethacin
VITAMINS A,C,D indomethacin er
AND FLUORIDE+ ketorolac
tromethamine
OSTEOPOROSIS PRODUCTS (QL)
alendronate ACTONEL (ST) leflunomide
ibandronate 150 ATELVIA (ST) lidocaine 5%
mg tablet BINOSTO (ST) ointment (QL)
raloxifene+ BONIVA 150 MG lidocaine 5% patch
risedronate TABLET (ST) lidocaine viscous
risedronate dr EVISTA meloxicam tablet
FOSAMAX (ST) metaxalone
15Cigna Standard 4-Tier Prescription Drug List
Specialty medications are covered on Tier 4 (listed on pages 18-24).
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
PAIN RELIEF AND INFLAMMATORY DISEASE SEIZURE DISORDERS
(cont) carbamazepine DILANTIN 30 MG APTIOM 600, 800
methocarbamol carbamazepine er CAPSULE (PA) MG TABLETS (PA)
MORPHINE (PA) clonazepam FYCOMPA (PA, QL) APTIOM 200, 400
MORPHINE ER (PA) MG TABLETS(PA,
divalproex NAYZILAM (PA, QL) QL)
NALFON 600 MG
TABLET (ST) divalproex er VIMPAT SOLTUION, BRIVIACT ORAL
NALOCET (PA) EPITOL TABLET (PA) SOLUTION, TABLET
oxycodone (PA) gabapentin (PA)
oxycodone er (PA) lamotrigine CARBATROL (PA)
oxycodone- lamotrigine (blue) DEPAKOTE (PA)
acetaminophen lamotrigine (green) DEPAKOTE ER (PA)
(PA) lamotrigine DEPAKOTE
PROLATE TABLET (orange) SPRINKLE (PA)
(PA) lamotrigine er DILANTIN 100 MG
rizatriptan (QL) lamotrigine odt CAPSULE (PA)
sumatriptan (QL) lamotrigine odt DILANTIN 50 MG
tizanidine (blue) INFATAB (PA)
tramadol 50 mg lamotrigine odt KLONOPIN (PA)
tablet (QL) (green) LYRICA ORAL
tramadol er (QL) lamotrigine odt SOLUTION (PA)
VANADOM (orange) NEURONTIN (PA)
levetiracetam OXTELLAR XR (PA)
PARKINSON’S DISEASE solution, tablet PHENYTEK (PA)
benztropine tablet KYNMOBI (PA) AZILECT (QL) levetiracetam er SPRITAM (PA)
carbidopa- MIRAPEX ER (QL) oxcarbazepine TEGRETOL (PA)
levodopa NEUPRO pregabalin capsule, TEGRETOL XR (PA)
carbidopa- OSMOLEX ER (QL) solution VALTOCO (PA, QL)
levodopa er RYTARY ROWEEPRA XCOPRI (PA, QL)
pramipexole SINEMET 10-100 SUBVENITE
pramipexole er (QL) SINEMET 25-100 SUBVENITE (BLUE)
rasagiline (QL) TASMAR SUBVENITE (GREEN)
ropinirole er XADAGO (ST) SUBVENITE
ropinirole (ORANGE)
SCHIZOPHRENIA/ANTI-PSYCHOTICS4 topiramate
aripiprazole (QL) LATUDA (QL) FANAPT (QL, ST) topiramate er
aripiprazole odt INVEGA (QL, ST) vigabatrin*
asenapine REXULTI (QL, ST) vigadrone*
chlorpromazine RISPERDAL (ST) SKIN CONDITIONS
tablet SAPHRIS (ST) ACCUTANE DRYSOL ANALPRAM HC
haloperidol SECUADO (ST) adapalene (PA) EUCRISA 2.5%-1% LOTION
olanzapine tablet SEROQUEL (ST) adapalene-benzoyl NAFTIN AVAR 9.5-5%
olanzapine odt SEROQUEL XR (ST) peroxide PICATO CLEANSING PADS
paliperidone er VRAYLAR (QL, ST) AMNESTEEM PRAMOSONE 1% BRYHALI (ST)
(QL) AVAR CLEANSER LOTION CALCIPOTRIENE
quetiapine azelaic acid PRAMOSONE 1%- FOAM
quetiapine er betamethasone 1% CREAM CAPEX SHAMPOO
risperidone augmented PRAMOSONE 1%- (ST)
risperidone odt betamethasone 1% OINTMENT CLEOCIN T
ziprasidone tablet dipropionate CLINDACIN ETZ KIT
16Cigna Standard 4-Tier Prescription Drug List
Specialty medications are covered on Tier 4 (listed on pages 18-24).
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
SKIN CONDITIONS (cont) SLEEP DISORDERS/SEDATIVES
BP 10-1 PRAMOSONE 2.5%- CLINDACIN PAC KIT armodafinil (PA) DAYVIGO (QL, ST) LUNESTA (ST)
calcipotriene 1% OINTMENT CLODERM (ST) eszopiclone SUNOSI (PA, QL) SILENOR (QL, ST)
cream, ointment, SANTYL (QL) DESOWEN (ST) modafinil (PA)
solution DOVONEX temazepam
calcipotriene- EFUDEX zolpidem
betamethasone ELIDEL zolpidem er (QL)
CLARAVIS EVOCLIN SMOKING CESSATION4
CLINDACIN ETZ PRAMOSONE 2.5%-
1% PLEDGET bupropion sr+^ CHANTIX^ NICODERM CQ 14
CLINDACIN P 1% 1% CREAM
NICODERM CQ 21 NICOTROL NS+^ MG/24HR PATCH+
PLEDGETS PRAMOSONE 2.5%-
MG/24HR PATCH+ NICOTROL+^ NICODERM CQ 7
CLINDAMYCIN 1% LOTION
1% FOAM, GEL, nicotine gum+ MG/24HR PATCH+
PROTOPIC
LOTION, PLEDGET, nicotine lozenge+ NICORETTE+
REGRANEX (PA, QL)
SOLUTION nicotine patch+
TEMOVATE (ST)
clindamycin- QUIT 2+
VECTICAL (QL)
benzoyl QUIT 4+
XEPI
peroxoxide STOP SMOKING
clindamycin- AID+
tretinoin
SUBSTANCE ABUSE
clobetasol
clocortolone buprenorphine- LUCEMYRA (QL) BUNAVAIL
CLODAN naloxone NARCAN (QL) KLOXXADO (QL)
clotrimazole- ZUBSOLV SUBOXONE
betamethasone URINARY TRACT CONDITIONS
dapsone 5% gel, alfuzosin er ELMIRON AVODART
7.5% gel pump cevimeline K-PHOS ORIGINAL EVOXAC
fluocinonide darifenacin er (QL) FLOMAX
fluorouracil cream, finasteride PROSCAR
topical solution oxybutynin PYRIDIUM
isotretinoin oxybutynin er RAPAFLO (QL)
ketoconazole phenazopyridine UROCIT-K
KETODAN potassium er UROXATRAL
metronidazole silodosin (QL)
mupirocin solifenacin (QL)
MYORISAN tamsulosin
NEUAC GEL tolterodine
pimecrolimus tolterodine er (QL)
ROSADAN
VACCINES
sodium
sulfacetamide- Vaccines are now covered under the Cigna pharmacy benefit.
Not all plans cover vaccines in the same way. Log in to the myCigna
sulfur
App or myCigna.com, or check your plan materials, to find out how
SSS 10-5
your specific plan covers them.
SULFACLEANSE 8-4
tacrolimus ROTARIX+
ointment ROTATEQ+
tazarotene 0.1% WEIGHT MANAGEMENT
cream megestrol WEGOVY^ (PA, QL) CONTRAVE^ (PA)
tretinoin (PA) suspension QSYMIA^ (PA)
TRIDERM phentermine ^ SAXENDA^ (PA)
ZENATANE
17Specialty medications
The oral and injectable specialty medications listed below are covered on Tier 4 and need approval
from Cigna before your plan will cover them.
MEDICATION NAME DRUG CLASS
abacavir-lamivudine** (PA) AIDS/HIV
abiraterone** (PA) CANCER
ACTEMRA SYRINGE* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
ACTEMRA ACTPEN* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
ACTIMMUNE* (PA) CANCER
ADCIRCA** (PA) ASTHMA/COPD/RESPIRATORY
ADEMPAS** (PA) ASTHMA/COPD/RESPIRATORY
AFINITOR** (PA) CANCER
AFINITOR DISPERZ** (PA) CANCER
ALECENSA** (PA) CANCER
alosetron** GASTROINTESTINAL/HEARTBURN
ALUNBRIG** (PA) CANCER
ALYQ** (PA) ASTHMA/COPD/RESPIRATORY
AMICAR** BLOOD MODIFIERS/BLEEDING DISORDERS
aminocaproic acid** BLOOD MODIFIERS/BLEEDING DISORDERS
APOKYN* (PA) PARKINSON'S DISEASE
ARANESP*^ (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
ARIKAYCE** (PA) INFECTIONS
ARIXTRA* (QL) BLOOD THINNERS/ANTI-CLOTTING
atazanavir** (PA) AIDS/HIV
ATRIPLA** (PA) AIDS/HIV
ASTAGRAF XL** TRANSPLANT MEDICATIONS
AUSTEDO** (PA) MISCELLANEOUS
AVONEX* (PA) MULTIPLE SCLEROSIS
AVSOLA*^ (PA) PAIN RELIEF AND INFLAMMATORY DISEASE
azathioprine** TRANSPLANT MEDICATIONS
BAFIERTAM** (PA) MULTIPLE SCLEROSIS
BARACLUDE SOLUTION** INFECTIONS
BENLYSTA* (PA) PAIN RELIEF AND INFLAMMATORY DISEASE
BETASERON* (PA) MULTIPLE SCLEROSIS
BIKTARVY** AIDS/HIV
BOSULIF** (PA) CANCER
BYNFEZIA* (PA) HORMONAL AGENTS
CABOMETYX** (PA) CANCER
capecitabine** (PA) CANCER
CAYSTON** (PA, QL) INFECTIONS
CELLCEPT** TRANSPLANT MEDICATIONS
CERDELGA** (PA) MISCELLANEOUS
18MEDICATION NAME DRUG CLASS
CETROTIDE*^ (PA) HORMONAL AGENTS
CHOLBAM** (PA) GASTROINTESTINAL/HEARTBURN
chorionic gonadotropin*^ (PA) INFERTILITY
CIMDUO** (PA) AIDS/HIV
CIMZIA* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
cinacalcet** GASTROINTESTINAL/HEARTBURN
COMETRIQ** (PA) CANCER
COMPLERA** (PA) AIDS/HIV
CYSTARAN** (QL) EYE CONDITIONS
CYSTAGON** URINARY TRACT CONDITIONS
DARAPRIM**+ (PA) INFECTIONS
DEPEN** (PA) PAIN RELIEF AND INFLAMMATORY DISEASE
DESCOVY** AIDS/HIV
DOVATO** AIDS/HIV
DUOPA** PARKINSON'S DISEASE
DUPIXENT* (PA) PAIN RELIEF AND INFLAMMATORY DISEASE
EGRIFTA* (PA) HORMONAL AGENTS
EMFLAZA** (PA) HORMONAL AGENTS
ENBREL* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
entecavir** (QL) INFECTIONS
enoxaparin* (QL) BLOOD THINNERS/ANTI-CLOTTING
ENTYVIO*^ (PA) GASTROINTESTINAL/HEARTBURN
ENVARSUS XR** TRANSPLANT MEDICATIONS
EPCLUSA** (PA, QL) INFECTIONS
EPIDIOLEX** (PA) SEIZURE DISORDERS
EPOGEN*^ (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
ERIVEDGE** (PA) CANCER
ERLEADA** (PA) CANCER
ESBRIET** (PA) MISCELLANEOUS
EVOTAZ** (PA) AIDS/HIV
EXJADE** (PA) MISCELLANEOUS
EXTAVIA* (PA) MULTIPLE SCLEROSIS
FASENRA PEN* (PA) ASTHMA/COPD/RESPIRATORY
FENSOLVI**^ (PA) HORMONAL AGENTS
FERRIPROX** (PA) MISCELLANEOUS
FIRDAPSE** (PA, QL) MULTIPLE SCLEROSIS
FOLLISTIM AQ*^ (PA) INFERTILITY
fondaparinux* (QL) BLOOD THINNERS/ANTI-CLOTTING
FORTEO* (PA, QL) HORMONAL AGENTS
FRAGMIN* (QL) BLOOD THINNERS/ANTI-CLOTTING
FULPHILA* (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
GALAFOLD** (PA) MISCELLANEOUS
19MEDICATION NAME DRUG CLASS
GANIRELIX*^ (PA) HORMONAL AGENTS
GATTEX* (PA) GASTROINTESTINAL/HEARTBURN
GENVOYA** AIDS/HIV
GILENYA 0.5MG** (PA) MULTIPLE SCLEROSIS
glatiramer* (PA) MULTIPLE SCLEROSIS
GLATOPA* (PA) MULTIPLE SCLEROSIS
GLEEVEC** (PA) CANCER
GONAL-F*^ (PA) INFERTILITY
GONAL-F RFF*^ (PA) INFERTILITY
GRANIX*^ BLOOD MODIFIERS/BLEEDING DISORDERS
HAEGARDA* (PA) BLOOD PRESSURE/HEART MEDICATIONS
HARVONI** (PA, QL) INFECTIONS
HEMLIBRA* (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
HETLIOZ** (PA) SLEEP DISORDERS/SEDATIVES
HUMATROPE* (PA) HORMONAL AGENTS
HUMIRA* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
IBRANCE** (PA) CANCER
ILARIS*^ (PA) PAIN RELIEF AND INFLAMMATORY DISEASE
ILUMYA* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
imatinib** (PA) CANCER
IMBRUVICA** (PA) CANCER
INBRIJA** (PA) PARKINSON’S DISEASE
INCRELEX* (PA) HORMONAL AGENTS
INFLECTRA*^ (PA) PAIN RELIEF AND INFLAMMATORY DISEASE
INLYTA** (PA) CANCER
INTELENCE** (PA) AIDS/HIV
ISENTRESS** AIDS/HIV
ISENTRESS HD** (PA) AIDS/HIV
JADENU** (PA) MISCELLANEOUS
JADENU SPRINKLE** (PA) MISCELLANEOUS
JAKAFI** (PA) CANCER
JULUCA** AIDS/HIV
JYNARQUE** (PA) DIURETICS
KALBITOR*^ (PA) BLOOD PRESSURE/HEART MEDICATIONS
KALYDECO** (PA, QL) ASTHMA/COPD/RESPIRATORY
KESIMPTA PEN* (PA) MULTIPLE SCLEROSIS
KEVZARA* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
KINERET* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
KISQALI** (PA) CANCER
KISQALI FEMARA** (PA) CANCER
KITABIS PAK** (PA, QL) INFECTIONS
KORLYM** (PA) DIABETES
20MEDICATION NAME DRUG CLASS
KUVAN** (PA) MISCELLANEOUS
KYLEENA** +
CONTRACEPTIVE PRODUCTS
LEDIPASVIR-SOFOSBUVIR** (PA) INFECTIONS
LENVIMA** (PA) CANCER
LETAIRIS** (PA) ASTHMA/COPD/RESPIRATORY
LONSURF** (PA) CANCER
LORBRENA** (PA) CANCER
LOVENOX* (QL) BLOOD THINNERS/ANTI-CLOTTING
LUPANETA**^ (PA) CANCER
LUPRON DEPOT*^ (PA) CANCER
LUPRON DEPOT-PED*^ (PA) HORMONAL AGENTS
LYNPARZA** (PA) CANCER
LYSTEDA** BLOOD MODIFIERS/BLEEDING DISORDERS
MAVENCLAD** (PA) MULTIPLE SCLEROSIS
MAVYRET** (PA) INFECTIONS
MAYZENT** (PA) MULTIPLE SCLEROSIS
MEKINIST** (PA) CANCER
MENOPUR*^ (PA) INFERTILITY
MIRENA**+ CONTRACEPTION PRODUCTS
MYALEPT* (PA) MISCELLANEOUS
mycophenolate** TRANSPLANT MEDICATIONS
mycophenolic acid** TRANSPLANT MEDICATIONS
MYFORTIC** TRANSPLANT MEDICATIONS
NATPARA* (PA) HORMONAL AGENTS
NERLYNX** (PA) CANCER
NEULASTA*^ (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
NEUPOGEN*^ (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
NEXAVAR** (PA) CANCER
NINLARO** (PA) CANCER
NITYR** (PA) MISCELLANEOUS
NIVESTYM*^ BLOOD MODIFIERS/BLEEDING DISORDERS
NORDITROPIN FLEXPRO* (PA) HORMONAL AGENTS
NORTHERA** (PA) BLOOD PRESSURE/HEART MEDICATIONS
NOURIANZ** (PA, QL) PARKINSON’S DISEASE
NOVAREL*^ (PA) INFERTILITY
NUBEQA** (PA) CANCER
NUCALA* (PA) ASTHMA/COPD/RESPIRATORY
NUZYRA** (PA) INFECTIONS
NYVEPRIA* (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
OCALIVA** (PA) GASTROINTESTINAL/HEARTBURN
ODEFSEY** (PA) AIDS/HIV
ODOMZO** (PA) CANCER
21MEDICATION NAME DRUG CLASS
OFEV** (PA) ASTHMA/COPD/RESPIRATORY
OLUMIANT** (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
OPSUMIT** (PA) ASTHMA/COPD/RESPIRATORY
ORENCIA* CLICKJET, SYRINGE (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
ORENITRAM ER** (PA) ASTHMA/COPD/RESPIRATORY
ORFADIN** (PA) MISCELLANEOUS
ORKAMBI** (PA, QL) ASTHMA/COPD/RESPIRATORY
OTEZLA** (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
OVIDREL*^ (PA) INFERTILITY
OXERVATE** (PA) EYE CONDITIONS
PALYNZIQ* (PA) MISCELLANEOUS
PEGASYS* (PA) INFECTIONS
PLEGRIDY* (PA) MULTIPLE SCLEROSIS
POMALYST** (PA) CANCER
PREVYMIS** INFECTIONS
PREZCOBIX** (PA) AIDS/HIV
PREZISTA** AIDS/HIV
PROCRIT*^ (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
PROGRAF** TRANSPLANT MEDICATIONS
PROMACTA** (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
PULMOZYME** (PA) ASTHMA/COPD/RESPIRATORY
PURIXAN** CANCER
RAPAMUNE** TRANSPLANT MEDICATIONS
RAVICTI** (PA) GASTROINTESTINAL/HEARTBURN
REBIF* (PA) MULTIPLE SCLEROSIS
REBIF REBIDOSE* (PA) MULTIPLE SCLEROSIS
REMICADE*^ (PA) PAIN RELIEF AND INFLAMMATORY DISEASE
RETACRIT*^ (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
REVATIO** SUSPENSION, TABLET (PA) ASTHMA/COPD/RESPIRATORY
REVLIMID** (PA) CANCER
RINVOQ ER** (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
ritonavir** AIDS/HIV
RUBRACA** (PA) CANCER
RUCONEST*^ (PA) BLOOD PRESSURE/HEART MEDICATIONS
SAMSCA** DIURETICS
SANDOSTATIN*^ (PA) HORMONAL AGENTS
SANDOSTATIN LAR DEPOT*^ (PA) HORMONAL AGENTS
SELZENTRY** (PA) AIDS/HIV
SEROSTIM* (PA) HORMONAL AGENTS
SIMPONI* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
SIMPONI ARIA* (PA) PAIN RELIEF AND INFLAMMATORY DISEASE
sirolimus** TRANSPLANT MEDICATIONS
22MEDICATION NAME DRUG CLASS
SKYLA**+ CONTRACEPTION PRODUCTS
SKYRIZI* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
sofosbuvir-velpatasvir** (PA) INFECTIONS
SOMATULINE DEPOT*^ (PA) HORMONAL AGENTS
SOMAVERT* (PA) HORMONAL AGENTS
SOVALDI** (PA, QL) INFECTIONS
SPRYCEL** (PA) CANCER
STELARA* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
STRENSIQ* (PA) MISCELLANEOUS
STRIBILD** (PA) AIDS/HIV
STIVARGA** (PA) CANCER
SUCRAID** (PA) GASTROINTESTINAL/HEARTBURN
SUTENT** (PA) CANCER
SYMDEKO** (PA, QL) ASTHMA/COPD/RESPIRATORY
SYMFI** AIDS/HIV
SYMFI LO** AIDS/HIV
SYMTUZA** AIDS/HIV
tacrolimus capsule** TRANSPLANT MEDICATIONS
tadalafil 20mg** (PA) ASTHMA/COPD/RESPIRATORY
TAFINLAR** (PA) CANCER
TAGRISSO** (PA) CANCER
TAKHZYRO* (PA) BLOOD PRESSURE/HEART MEDICATIONS
TALTZ* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
TALZENNA** (PA) CANCER
TARGRETIN** (PA) CANCER
TARGRETIN GEL** SKIN CONDITIONS
TASIGNA** (PA) CANCER
TAVALISSE** (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
TEGSEDI* (PA) MISCELLANEOUS
TEMIXYS** (PA) AIDS/HIV
TEMODAR** (PA) CANCER
temozolomide** (PA) CANCER
tenofovir** (PA) AIDS/HIV
teriparatide* (PA, QL) HORMONAL AGENTS
tetrabenazine** (PA) MISCELLANEOUS
THALOMID** (PA) INFECTIONS
THIOLA** URINARY TRACT CONDITIONS
TIGLUTIK** (PA) MISCELLANEOUS
TIVICAY** AIDS/HIV
TOBI PODHALER** (PA, QL) INFECTIONS
tobramycin 300 mg/5ml** (PA, QL) INFECTIONS
TRACLEER** (PA) ASTHMA/COPD/RESPIRATORY
23MEDICATION NAME DRUG CLASS
tranexamic acid** BLOOD MODIFIERS/BLEEDING DISORDERS
TREMFYA* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
trientine** (PA) MISCELLANEOUS
TRIUMEQ** AIDS/HIV
TYKERB** (PA) CANCER
TYMLOS* (PA, QL) OSTEOPOROSIS PRODUCTS
TYVASO** (PA) ASTHMA/COPD/RESPIRATORY
UDENYCA*^ (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
UPTRAVI** (PA) ASTHMA/COPD/RESPIRATORY
VALCHLOR** SKIN CONDITIONS
VEMLIDY** INFECTIONS
VENCLEXTA** (PA) CANCER
VERZENIO** (PA) CANCER
VIREAD** (PA) AIDS/HIV
vigabatrin** SEIZURE DISORDERS
VIGADRONE** SEIZURE DISORDERS
VIZIMPRO** (PA) CANCER
VOSEVI** (PA) INFECTIONS
VOTRIENT** (PA) CANCER
VUMERITY** (PA) MULTIPLE SCLEROSIS
VYLEESI*^ (PA, QL) MISCELLANEOUS
WAKIX** (PA, QL) SLEEP DISORDERS/SEDATIVES
XALKORI** (PA) CANCER
XELJANZ** (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
XELJANZ XR** (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
XELODA** (PA) CANCER
XERMELO** (PA) GASTROINTESTINAL/HEARTBURN
XOLAIR* (PA) ASTHMA/COPD/RESPIRATORY
XTANDI** (PA) CANCER
XYREM** (PA) SLEEP DISORDERS/SEDATIVES
ZARXIO*^ BLOOD MODIFIERS/BLEEDING DISORDERS
ZEJULA** (PA) CANCER
ZEPATIER** (PA) INFECTIONS
ZEPOSIA** (PA) MULTIPLE SCLEROSIS
ZIEXTENZO* (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
ZORBTIVE* (PA) HORMONAL AGENTS
ZORTRESS** TRANSPLANT MEDICATIONS
24Medications 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.
25GENERIC 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.
26GENERIC 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.
27GENERIC 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.
28GENERIC 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.
29GENERIC 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.
30You can also read
