CIGNA VALUE 4-TIER PRESCRIPTION DRUG LIST - Coverage as of January 1, 2022
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CIGNA VALUE 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. 916154 k Value 4-Tier O/I SRx 11/21
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) 43
Exclusions and limitations for coverage 47
View the drug list online
This document was last updated on 11/01/2021.* 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 Value 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: 11/01/2021, 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 Value 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.
Prescription medications used to treat allergies (ex. Allegra, Clarinex, Xyzal and generics) and
heartburn/stomach acid conditions (ex. Nexium, Prilosec and generics) aren’t covered on this
drug list. These medications are considered plan (or benefit) exclusions. You can get over-the-
counter (OTC) versions at the pharmacy without a prescription.
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 Value 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% (PA, ALORA (QL) listed on Tier 4 (pages 18–24)
cabergoline (QL) QL) ANDROGEL 1.0% (PA,
COVARYX ARMOUR THYROID QL)
COVARYX H.S. CYTOMEL 50MCG ANGELIQ
DECADRON DIVIGEL CLIMARA
desmopressin DUAVEE CLIMARA PRO
dexamethasone ESTRING (QL) COMBIPATCH Medications are listed in
estradiol-norethindrone PREMARIN CYTOMEL 5, 25mcg alphabetical order within
estrogen- PREMPHASE DEPO-TESTOSTERONE each column
methyltestosterone PREMPRO ELESTRIN
levothyroxine ENTOCORT EC
LEVOXYL ESTRACE
liothyronine ESTROGEL
medroxy-progesterone EVAMIST
methimazole FEMRING
methylprednisolone INTRAROSA
Medications that have extra
MIMVEY LEVO-T
coverage requirements will
MIMVEY LO MENOSTAR (QL)
have an abbreviation listed
NATURE-THROID MINIVELLE (QL)
next to them
NP THYROID OSPHENA
prednisolone TIROSINT Brand-name medications
prednisolone ODT UNITHROID are in all capital letters
prednisone VAGIFEM (QL)
prednisone intensol VIVELLE-DOT (QL)
progesterone Generic medications
are in all lowercase letters
This chart is just a sample. It may not show how these medications are actually covered on the Cigna Value 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 may not cover certain medications and products because they’re considered plan/benefit
exclusions. For example, your plan excludes prescription medications used to treat allergies (ex.
Allegra, Clarinex, Xyzal and generics) and heartburn/stomach acid conditions (ex. Nexium,
Prilosec and generics). 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
covers.
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 11
ALZHEIMER’S DISEASE 6 GASTROINTESTINAL/HEARTBURN 11, 12
ANXIETY/DEPRESSION/BIPOLAR 6 HORMONAL AGENTS 12, 13
DISORDER INFECTIONS 13
ASTHMA/COPD/RESPIRATORY 6 INFERTILITY 13
ATTENTION DEFICIT HYPERACTIVITY 6, 7 MISCELLANEOUS 13, 14
DISORDER NUTRITIONAL/DIETARY 14
BLOOD MODIFIERS/BLEEDING DISORDERS 7 OSTEOPOROSIS PRODUCTS 14
BLOOD PRESSURE/HEART MEDICATIONS 7 PAIN RELIEF AND INFLAMMATORY DISEASE 14
BLOOD THINNERS/ANTI-CLOTTING 8 PARKINSON’S DISEASE 14, 15
CANCER 7, 8 SCHIZOPHRENIA/ANTI-PSYCHOTICS 15
CHOLESTEROL MEDICATIONS 8 SEIZURE DISORDERS 16
CONTRACEPTION PRODUCTS 8–10 SKIN CONDITIONS 16
COUGH/COLD MEDICATIONS 10 SLEEP DISORDERS/SEDATIVES 16
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
5Cigna Value 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 (cont)
azelastine CLARINEX-D 12 fluvoxamine (QL)
azelastine- HOUR fluvoxamine er (QL)
fluticasone GASTROCROM lorazepam
cromolyn oral GRASTEK (PA, QL) lorazepam intensol
concentrate KARBINAL ER mirtazapine
desloratadine^ (QL) ODACTRA (PA, QL) paroxetine cr (QL)
fluticasone^ ORALAIR (PA, QL) paroxetine er (QL)
hydroxyzine hcl PATANASE paroxetine (QL)
solution, syrup, RAGWITEK (PA, QL) sertraline (QL)
tablet
VISTARIL trazodone
hydroxyzine
venlafaxine (QL)
pamoate
venlafaxine er (QL)
ipratropium
mometasone^ (QL) ASTHMA/COPD/RESPIRATORY
olopatadine albuterol ANORO ELLIPTA COMBIVENT
promethazine ALBUTEROL HFA ATROVENT HFA RESPIMAT
solution, syrup, (QL) BREZTRI DALIRESP (QL)
tablet budesonide AEROSPHERE LONHALA MAGNAIR
ALZHEIMER’S DISEASE fluticasone- DULERA REFILL (PA)
salmeterol FLOVENT DISKUS LONHALA MAGNAIR
donepezil ARICEPT
ipratropium- FLOVENT HFA STARTER (PA)
donepezil odt EXELON
albuterol INCRUSE ELLIPTA PULMICORT RESPULE
memantine MESTINON
montelukast QVAR REDIHALER SINGULAIR
memantine er (QL) NAMENDA
SEREVENT
pyridostigmine 60 NAMENDA XR (QL)
DISKUS
mg/5 ml, 60 mg NAMZARIC (QL)
SPIRIVA
pyridostigmine er
SPIRIVA RESPIMAT
rivastigmine
STIOLTO
ANXIETY/DEPRESSION/BIPOLAR DISORDER4 RESPIMAT
alprazolam CELEXA (QL, ST) SYMBICORT
alprazolam er EFFEXOR XR (QL, ST) TRELEGY ELLIPTA
alprazolam intensol FETZIMA (QL, ST) ATTENTION DEFICIT HYPERACTIVITY DISORDER4
alprazolam odt PAXIL (QL, ST)
amphetamine (PA) ADDERALL (PA,ST)
alprazolam xr PAXIL CR (QL, ST)
atomoxetine (QL) DAYTRANA (PA, QL)
amitriptyline PROZAC (QL, ST)
dexmethylp- EVEKEO 5 MG, 10
bupropion (QL) REMERON
henidate (PA) MG (PA,ST)
bupropion sr (QL) TRINTELLIX (QL, ST)
dexmethylp- FOCALIN (PA,ST)
bupropion xl 150 mg VIIBRYD (QL, ST)
henidate er (PA, QL) INTUNIV
tablet (QL) WELLBUTRIN SR (QL, dextroamphetamin METHYLIN (PA)
bupropion xl 300 mg ST) -amphetamine (PA) QUILLIVANT XR (PA,
tablet (QL) XANAX dextroamp- QL)
buspirone XANAX XR hetamine- RITALIN (PA, ST)
citalopram (QL) ZOLOFT (QL, ST) amphetamine (PA) STRATTERA (QL)
clomipramine guanfacine er
desvenlafaxine er 6
methylphenidate er
(QL) (la) (PA, QL)
duloxetine (QL)
escitalopram (QL)
fluoxetine dr (QL)
fluoxetine (QL)
6Cigna Value 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 DISORDER4 BLOOD PRESSURE/HEART MEDICATIONS (cont)
(cont) losartan-hctz
methylphenidate er matzim la
(PA, QL) metoprolol succinate
methylphenidate metoprolol tablet
(PA) nadolol
methylphenidate cd nifedipine
(PA, QL) nifedipine er
methylphenidate er olmesartan (QL)
(cd) (PA, QL) olmesartan-
methylphenidate la amlodipine-hctz
(PA, QL) olmesartan-hctz (QL)
BLOOD MODIFIERS/BLEEDING DISORDERS prazosin
propranolol tablet
DROXIA SIKLOS (PA)
propranolol er
ZIEXTENZO (PA)
ramipril
BLOOD PRESSURE/HEART MEDICATIONS ranolazine er (QL)
amlodipine CORLANOR (PA) BIDIL (QL) taztia xt
amlodipine- ENTRESTO CALAN SR telmisartan (QL)
benazepril CARDIZEM LA telmisartan-hctz (QL)
AMLODIPINE- 120MG (QL) tiadylt er
OLMESARTAN (QL) CARDURA valsartan
amlodipine-valsartan CATAPRES-TTS 1 valsartan-hctz
atenolol CATAPRES-TTS 2 verapamil er
benazepril CATAPRES-TTS 3 verapamil er pm
bisoprolol COREG (ST) verapamil tablet
bisoprolol-hctz CORGARD (ST) verapamil sr
candesartan EPANED BLOOD THINNERS/ANTI-CLOTTING
cartia xt HEMANGEOL
adult aspirin BRILINTA BAYER CHEWABLE
carvedilol INDERAL LA (ST)
regimen+ ELIQUIS (PA) ASPIRIN+
CARVEDILOL ER (QL) INDERAL XL (ST)
aspirin ec+ XARELTO (PA) COUMADIN (PA)
clonidine INNOPRAN XL (ST)
aspirin+ EFFIENT
diltiazem 12hr er KAPSPARGO
aspirin-dipyridamole PLAVIX
diltiazem 24hr er SPRINKLE (ST)
er PRADAXA (PA)
diltiazem 24hr er (cd) KATERZIA (QL)
children's aspirin+ SAVAYSA (PA, QL)
diltiazem 24hr er (la) LOPRESSOR (ST)
clopidogrel ZONTIVITY
diltiazem 24hr er (xr) MINIPRESS
jantoven
diltiazem NITROSTAT
low dose aspirin ec+
DILT-XR NORVASC
prasugrel
DOFETILIDE (QL) PROCARDIA XL
st. joseph aspirin ec+
doxazosin RANEXA (QL)
st. joseph aspirin+
enalapril TENORETIC 100 (ST)
warfarin
flecainide TENORETIC 50 (ST)
hydralazine tablet TENORMIN (ST) CANCER
irbesartan TIAZAC anastrozole+ GLEOSTINE
labetalol tablet TIKOSYN (PA, QL) exemestane+ TREXALL
lisinopril TOPROL XL (ST) hydroxyurea
lisinopril-hctz VERELAN letrozole
losartan VERELAN PM methotrexate
ZIAC (ST) tamoxifen+
7Cigna Value 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
$ $$ $$$ $ $$ $$$
CANCER (cont) CONTRACEPTION PRODUCTS (cont)
temozolomide* (PA) CRYSELLE+
CHOLESTEROL MEDICATIONS CYCLAFEM+
CYRED+
atorvastatin+ VASCEPA (PA) CADUET (QL)
CYRED EQ+
colesevelam LIPOFEN (ST)
DASETTA+
ezetimibe NIASPAN
DAYSEE+
ezetimibe- TRICOR (ST)
DEBLITANE+
simvastatin TRILIPIX (ST)
desogestrel-ethinyl
fenofibrate WELCHOL
estradiol+
fenofibric acid ZETIA
desogestrel-ethinyl
fluvastatin er+
estradiol - ethinyl
fluvastatin+
estradiol+
icosapent ethyl
DOLISHALE+
lovastatin+
drospirenone-
omega-3 acid ethyl
ethinyl estradiol-
esters
levomefolate+
pravastatin+
drospirenone-ethinyl
rosuvastatin+ (QL)
estradiol+
simvastatin tablet+
ECONTRA EZ+
(QL)
ECONTRA ONE-
CONTRACEPTION PRODUCTS STEP+
AFIRMELLE+ LO LOESTRIN FE ANNOVERA ELINEST+
AFTERA+ BEYAZ ELURYNG+
ALTAVERA+ ELLA+ EMOQUETTE+
ALYACEN+ ESTROSTEP FE ENPRESSE+
AMETHIA+ LAYOLIS FE+ ENSKYCE+
AMETHYST+ LOESTRIN FE ERRIN+
APRI+ MICROGESTIN 24 FE ESTARYLLA+
ARANELLE+ MINASTRIN 24 FE ethynodiol-ethinyl
ASHLYNA+ NUVARING estradiol+
AUBRA+ SAFYRAL etonogestrel-ethinyl
AUBRA EQ+ TODAY estradiol+
AUROVELA+ CONTRACEPTIVE FALMINA+
AUROVELA FE+ SPONGE+ FAYOSIM+
AUROVELA 24 FE+ TWIRLA+ FEMCAP+
AVIANE+ VCF FEMYNOR+
AYUNA+ CONTRACEPTIVE GEMMILY+
AZURETTE+ FILM+ GYNOL II+
BALZIVA+ YASMIN 28 HAILEY+
BLISOVI FE+ YAZ HAILEY FE+
BLISOVI 24 FE+ HAILEY 24 FE+
BRIELLYN+ HEATHER+
CAMILA+ ICLEVIA+
CAMRESE+ INCASSIA+
CAMRESE LO+ ISIBLOOM+
CAYA CONTOURED+ JAIMIESS+
CAZIANT+ JASMIEL+
CHARLOTTE 24 FE+ JENCYCLA+
CHATEAL+ JOLESSA+
CHATEAL EQ+
8Cigna Value 4-Tier Prescription Drug List
Specialty medications are covered on Tier 4 (listed on pages 18-24).
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
CONTRACEPTION PRODUCTS (cont) CONTRACEPTION PRODUCTS (cont)
JULEBER+ norethindrone-
JUNEL+ ethinyl estradiol+
JUNEL FE+ norethindrone-
JUNEL FE 24+ ethinyl estradiol-
KAITLIB FE+ ferrous fumarate
KALLIGA+ norgestimate-ethinyl
KARIVA+ estradiol+
KELNOR 1-35+ NORLYDA+
KELNOR 1-50+ NORTREL+
KURVELO+ NYLIA+
LARIN+ NYMYO+
LARIN FE+ OCELLA+
LARIN 24 FE+ OPCICON ONE-
LARISSIA+ STEP+
LEENA+ OPTION 2+
LESSINA+ ORSYTHIA+
LEVONEST+ PHILITH+
levonorgestrel+ PIMTREA+
levonorgestrel- PIRMELLA+
ethinyl estradiol+ PORTIA+
levonorgestrel- PREVIFEM+
ethinyl estradiol RECLIPSEN+
ethinyl estradiol+ RIVELSA+
LEVORA+ SETLAKIN+
LILLOW+ SHAROBEL+
LOJAIMIESS+ SIMLIYA+
LORYNA+ SIMPESSE+
LOW-OGESTREL+ SPRINTEC+
LO-ZUMANDIMINE+ SRONYX+
LUTERA+ SYEDA+
LYLEQ+ TAKE ACTION+
LYZA+ TARINA FE+
MARLISSA+ TARINA FE 1-20 EQ+
MERZEE+ TARINA 24 FE+
MICROGESTIN+ TILIA FE+
MICROGESTIN FE+ TRI FEMYNOR+
MILI+ TRI-ESTARYLLA+
MONO-LINYAH+ TRI-LEGEST FE+
MY CHOICE+ TRI-LINYAH+
MY WAY+ TRI-LO-ESTARYLLA+
NECON+ TRI-LO-MARZIA+
NEW DAY+ TRI-LO-MILI+
NIKKI+ TRI-LO-SPRINTEC+
NORA-BE+ TRI-MILI+
norethindrone+ TRI-NYMYO+
norethindrone- TRI-PREVIFEM+
ethinyl estradiol- TRI-SPRINTEC+
iron+ TRIVORA+
TRI-VYLIBRA LO+
9Cigna Value 4-Tier Prescription Drug List
Specialty medications are covered on Tier 4 (listed on pages 18-24).
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
CONTRACEPTION PRODUCTS (cont) DENTAL PRODUCTS (cont)
TRI-VYLIBRA+ sodium fluoride 5000
TULANA+ plus
TYDEMY+ triamcinolone
VCF CONTRACEPTIVE acetonide
FOAM+ DIABETES
VCF CONTRACEPTIVE
ACCU-CHEK BAQSIMI (QL) AMARYL
GEL+
SMARTVIEW BASAGLAR CEQUR
VELIVET+
CONTRL SOLUTION DEXCOM G6 (PA, CONTOUR NEXT
VESTURA+
ACCUTREND QL) TEST STRIP
VIENVA+
GLUCOSE CONTROL FARXIGA (QL, ST) CONTOUR TEST
VIORELE+
BD LANCETS FREESTYLE LIBRE STRIP
VOLNEA+
BD PEN NEEDLE 14 DAY SENSOR CYCLOSET
VYFEMLA+
CONTOUR SOLUTION (PA, QL) PRECISION XTRA
VYLIBRA+
DROPLET FREESTYLE LIBRE KETONE-GLUC KIT
WERA+
DROPSAFE 2 SENSOR (PA, RIOMET
wide seal
glimepiride QL)
diaphragm+
glipizide GLYXAMBI (QL,
WYMZYA FE+
glipizide er ST)
XULANE+
glipizide xl HUMULIN
ZAFEMY+
metformin JANUMET (QL,
ZARAH+
metformin er ST)
ZOVIA 1-35+
NOVOFINE JANUMET XR (QL,
ZOVIA 1-35E+
NOVOTWIST ST)
ZUMANDIMINE+
TECHLITE JANUVIA (QL, ST)
COUGH/COLD MEDICATIONS TRUE METRIX JARDIANCE (QL,
bromphen-iramine- HYCODAN (PA, QL) CONTROL ST)
pseudoephed TESSALON PERLE SOULTION LYUMJEV
-dm TUZISTRA XR (PA, TRUEPLUS SYRINGE OMNIPOD DASH
hydrocodone- QL) ONETOUCH
homatropine ULTRA TEST
(PA,QL) STRIP
promethazine-dm ONETOUCH
DENTAL PRODUCTS VERIO TEST
chlorhexidine CLINPRO 5000 STRIP
DENTA 5000 PLUS FLORIVA+^ RYBELSUS (PA,
DENTAGEL FLUORIDEX QL)
doxycycline hyclate SENSITIVITY RELIEF SOLIQUA 100-33
FLUORIDEX DAILY PREVIDENT SYMLINPEN
DEFENSE 1.1% SYNJARDY/XR
ORALONE (QL, ST)
PERIDEX XIGDUO XR (QL,
PERIOGARD ST)
SF 1.1% GEL TRIJARDY XR (ST,
SF 5000 PLUS QL)
sodium fluoride V-GO 20
V-GO 30
sodium fluoride 5000
V-GO 40
dry mouth
VICTOZA (PA, QL)
10Cigna Value 4-Tier Prescription Drug List
Specialty medications are covered on Tier 4 (listed on pages 18-24).
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
DIABETES (cont) EYE CONDITIONS (cont)
XULTOPHY prednisolone FML S.O.P. 0.1%
ZEGALOGUE timolol OINTMENT
(QL) tobramycin- ILEVRO
DIURETICS dexamethasone INVELTYS
travoprost ISTALOL
acetazolamide tablet TRIAMTERENE-HCTZ
LOTEMAX
acetazolamide er CAROSPIR
LOTEMAX SM
capsule DIURIL
MAXITROL
bumetanide tablet INSPRA
MOXEZA
chlorthalidone KERENDIA
NEVANAC
eplerenone LASIX
OCUFLOX
furosemide solution, MAXZIDE
PRED FORTE
tablet
PROLENSA
hydrochloro-
RHOPRESSA
thiazide
ROCKLATAN
spironolactone
TIMOPTIC
triamterene-hctz
TIMOPTIC-XE
EAR MEDICATIONS TOBRADEX
ciprofloxacin- CIPRODEX TOBRADEX ST
dexamethasone CIPRO HC TRUSOPT
neomycin-polymyxin CORTISPORIN-TC VIGAMOX
b-hydrocortisone DERMOTIC ZIRGAN
ofloxacin OTOVEL ZYLET
ERECTILE DYSFUNCTION FEMININE PRODUCTS
SILDENAFIL^ (QL) CIALIS^ (QL, ST) FEM PH
TADALAFIL^ (QL) MUSE^ (PA, QL) GYNAZOLE 1
VARDENAFIL^ (QL) STENDRA^ (QL, ST) miconazole 3 200
VIAGRA^ (QL, ST) mg
EYE CONDITIONS terconazole
BIMATOPROST (QL) COMBIGAN ACULAR GASTROINTESTINAL/HEARTBURN
brimonidine EYSUVIS (QL) ACULAR LS ALOPHEN PILLS+ AMITIZA AKYNZEO 300-0.5
brinzolamide RESTASIS ACUVAIL ANUCORT-HC CLENPIQ+ MG CAPSULE
ciprofloxacin SIMBRINZA ALPHAGAN P balsalazide LINZESS APRISO
dorzolamide ALREX bisacodyl tablet+ NEXIUM DR 2.5 BONJESTA
dorzolamide-timolol AZASITE CLEARLAX+ MG PACKET (QL) CANASA
erythromycin AZOPT CONSTULOSE NEXIUM DR 5 MG CARAFATE
fluorome-tholone BESIVANCE PACKET (QL)
dicyclomine capsule, CORRECTOL+
ketorolac BETIMOL PANCREAZE
solution, tablet CUVPOSA
latanoprost BETOPTIC S esomeprazole 20 PENTASA
DICLEGIS
loteprednol BROMSITE mg capsule, 40 mg SUPREP+
DONNATAL
moxifloxacin eye CILOXAN 0.3% capsule, packets^ SUTAB+
DULCOLAX EC 5 MG
drops OINTMENT (QL) VIBERZI
TABLET+
famotidine 40 mg/5
neomycin-polymyxin COSOPT/PF LIALDA
ml suspension
b-dexamethasone DUREZOL GAVILAX+ LITHOSTAT
ofloxacin FLAREX GAVILYTE-C+ MIRALAX+
olopatadine^ FML FORTE 0.25% GAVILYTE-G+ MOVANTIK (PA)
polymyxin b sulfate- EYE DROPS GAVILYTE-N+ RECTIV*
trimethoprim FML LIQUIFILM 0.1% RELISTOR (PA)
EYE DROP SANCUSO (PA, QL)
11Cigna Value 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
$ $$ $$$ $ $$ $$$
GASTROINTESTINAL/HEARTBURN (cont) GASTROINTESTINAL/HEARTBURN (cont)
GENTLE LAXATIVE SFROWASA ursodiol
TABLET+ SYMPROIC (PA) WOMEN'S GENTLE
GENTLELAX+ TRANSDERM-SCOP LAXATIVE+
GLYCOLAX+ URSO WOMEN'S
glycopyrrolate tablet
URSO FORTE LAXATIVE+
HEMMOREX-HC
VARUBI (PA, QL) HORMONAL AGENTS
hydrocortisone
VIOKACE
lansoprazole^ (QL) AMABELZ DUAVEE ACTIVELLA
LAXACLEAR+ budesonide ec MYFEMBREE ALORA (QL)
LAXATIVE PEG 3350+ BUDESONIDE ER (PA, QL) ANDRODERM (PA,
LAXATIVE 5 MG (PA, QL) ORIAHNN (PA, QL)
TABLET+ CABERGOLINE (QL) QL) ANDROGEL (PA, QL)
LAXATIVE EC 5 MG COVARYX ORILISSA (PA, QL) ANGELIQ
TABLET+ COVARYX H.S. PREMARIN ARMOUR THYROID
mesalamine DECADRON TABLET, AYGESTIN
mesalamine dr desmopressin VAGINAL CREAM BIJUVA
mesalamine er dexamethasone APPLICATOR CLIMARA
metoclopramide intensol PREMPHASE CLIMARA PRO
solution, tablet DOTTI (QL) PREMPRO COMBIPATCH
metoclopramide odt EEMT CRINONE 4% GEL
misoprostol EEMT H.S. CYTOMEL
NATURA-LAX+ estradiol (once DIVIGEL
OMEPRAZOLE^ (QL) weekly) ELESTRIN
ondansetron estradiol 10mcg ENTOCORT EC
ondansetron odt vaginal insert (QL) ESTRACE
PANTOPRAZOLE ^ estradiol (twice ESTRING (QL)
(QL) weekly) (QL) ESTROGEL
peg 3350- estradiol- EVAMIST
electrolyte+ norethindrone IMVEXXY (QL)
peg3350-sodium acetat INTRAROSA
sulfate-sodium estrogen- levothyroxine
chloride-potassium methyltest- capsule (PA)
chloride-sodium osterone MEDROL
ascorbate-ascorbic EUTHYROX MENOSTAR (QL)
acid+ LEVO-T MINIVELLE (QL)
PEG-PREP+ levothyroxine tablet OSPHENA
LEVOXYL PROMETRIUM
polyethylene glycol
liothyronine RAYALDEE
3350+
LYLLANA (QL) UNITHROID
prochlorperazine
medroxypro- TIROSINT-SOL (PA)
tablet
gesterone VAGIFEM (QL)
promethazine
methimazole
suppository
methylpred-nisolone
promethegan
MIMVEY
PURELAX+
norethindrone
rabeprazole tablet^
NP THYROID
(QL)
prednisone
scopolamine
prednisone intensol
SMOOTHLAX+
progesterone tablet
sucralfate
12Cigna Value 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)
TESTOSTERONE (PA, VIVELLE-DOT (QL) mondoxyne nl XENLETA 600MG
QL) MORGIDOX TABLET (PA, QL)
WESTHROID nitazoxanide XOFLUZA (QL)
YUVAFEM nitrofurantoin ZITHROMAX
INFECTIONS nitrofurantoin ZITHROMAX TRI-PAK
monohydrate- ZYVOX
acyclovir capsule, EURAX 10% AEMCOLO (QL)
macrocrystal SUSPENSION,
suspension, tablet CREAM ALBENZA
nystatin suspension, TABLET (PA)
albendazole FIRVANQ ALINIA
tablet
amoxicillin XIFAXAN (QL) BACTRIM
penicillin v
amoxicillin- BACTRIM DS
potassium
clavulanate er BAXDELA TABLET
permethrin
amoxicillin- (PA)
posaconazole tablet
clavulanate CIPRO
sulfamethoxazole-
atovaquone CLEOCIN
trimethoprim
atovaquone- CLINDESSE
suspension, tablet
proguanil CRESEMBA CAPSULE
terbinafine
AVIDOXY (PA)
tetracycline
azithromycin packet, DIFICID (QL)
valacyclovir
suspension, tablet ELIMITE
valganciclovir
cefdinir ERYPED 200
vancomycin capsule,
cefuroxime tablet ERY-TAB DR
solution
cephalexin EURAX 10% LOTION
vandazole
ciprofloxacin FLAGYL
clarithromycin HIPREX INFERTILITY
clarithromycin er KEFLEX clomiphene ^ CRINONE 8% GEL^
clindamycin MACROBID ENDOMETRIN^
COREMINO ER QL) MACRODANTIN MISCELLANEOUS
dapsone MALARONE (PA)
ACCU-CHEK ACE AEROSOL ADDYI^ (PA, QL)
doxycycline hyclate NATROBA
FC2 FEMALE CLOUD BRISDELLE (QL)
capsule, tablet NUVESSA
CONDOM+ ENHANCER (QL) NUEDEXTA (QL)
doxycycline ORAVIG
KETONE CARE TEST AEROCHAMBER
monohydrate PLAQUENIL
STRIP MINI (QL)
EMVERM POSACONAZOLE
KETONE TEST STRIP AEROCHAMBER
erythromycin SUSPENSION
KETOSTIX REAGENT MV (QL)
erythromycin PRIFTIN
MICROLET AEROCHAMBER
ethylsuccinate SIVEXTRO TABLET
PRECISION XTRA PLUS FLOW-VU
famciclovir (PA)
sodium chloride (QL)
fluconazole SKLICE
inhalation vial, AEROCHAMBER
hydroxychlor- SOLOSEC
irrigation solution, WITH
oquine STROMECTOL
vial FLOWSIGNAL
ivermectin SULFATRIM
TECHLITE LANCETS (QL)
levofloxacin solution, URIBEL
TRUEPLUS KETONE AEROCHAMBER
tablet VALTREX
TEST STRIP Z-STAT PLUS
methenamine VIBRAMYCIN
(QL)
metronidazole gel, 25 MG/5 ML
AEROTRACH
capsule, tablet SUSPENSION
PLUS (QL)
minocycline VIBRAMYCIN 50
AEROVENT PLUS
minocycline er (QL) MG/5 ML SYRUP
(QL)
13Cigna Value 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
$ $$ $$$ $ $$ $$$
MISCELLANEOUS (cont) NUTRITIONAL/DIETARY (cont)
BREATHRITE (QL) KLOR-CON M10 FOSRENOL 750 CITRANATAL DHA
CLEVER CHOICE TABLET MG POWDER CITRANATAL
HOLDING MULTI-VITAMIN PACKET HARMONY
CHAMBER (QL) W-FLUORIDE- MEPHYTON^ CITRANATAL RX
IRON+
COMPACT SPACE NEEVO DHA^ CLASSIC PRENATAL+
MULTIVITAMIN WITH
CHAMBER (QL) FLUORIDE+ OB COMPLETE EXPECTA
EASIVENT (QL) MULTIVITAMIN-IRON- PREMIER PRENATAL+
ESBRIET* (PA) FLUORIDE OB COMPLETE FOSRENOL 1,000 MG
FLEXICHAMBER ONE DAILY PREMIER TABLET CHEW
(QL) PRENATAL+ POLY-VI-FLOR FOSRENOL 500 MG
INSPIRACHA- potassium chloride WITH IRON+ TABLET CHEW
MBER (QL) 10%, capsule, POLY-VI-FLOR+ FOSRENOL 750 MG
MICROCHAMBER packet, tablet PRENATE^ TABLET CHEW
(QL) prenatal complete+ QUFLORA K-TAB ER
OPTICHAMBER PRENATAL PEDIATRIC 1 LOKELMA
DIAMOND (QL) GUMMIES+ MG CHEWABLE MINI PRENATAL+
POCKET PRENATAL MULTI+ TABLET+ OB COMPLETE^
CHAMBER (QL) prenatal multi-dha+ QUFLORA ONE A DAY
PRO COMFORT PRENATAL PEDIATRIC 0.25 WOMEN'S
SPACER WITH MULTIVITAMIN+ MG/ML DROP+ PRENATAL DHA+
MASK (QL) PRENATAL QUFLORA ONE-A-DAY
PROCARE SPACER MULTIVITAMIN- PEDIATRIC 0.5 PRENATAL-1+
WITH CHILD DHA+ MG/ML DROP+ PERRY PRENATAL+
MASK (QL) PRENATAL ONE ROCALTROL^ PHOSLYRA
RITEFLO (QL) DAILY+ TRI-VI-FLOR+ PRENATAL
SPACE CHAMBER PRENATAL VITAMIN + FORMULA-DHA+
(QL) DHA+ PRIMACARE
SPACE CHAMBER- PRENATAL VITAMIN+ RENVELA
MEDIUM MASK PRENATAL SIMILAC PRENATAL+
(QL) VITAMINS+ STUART ONE+
SPACE CHAMBER- PRENATAL+ ULTRA PRENATAL
SMALL MASK sevelamer carbonate PLUS DHA+
(QL) TRI-VITE WITH VELPHORO
VORTEX (QL) FLUORIDE+ VELTASSA
VORTEX VHC vitamin d2 1.25 mg
FROG MASK (QL) (50,000 unit)^
VORTEX VHC VITAMINS A,C,D AND
LADYBUG MASK FLUORIDE+
(QL) OSTEOPOROSIS PRODUCTS
NUTRITIONAL/DIETARY
alendronate FOSAMAX PLUS ACTONEL (ST)
calcitriol capsule, DRISDOL^ ACCRUFER^ ibandronate 150 mg D (ST) ATELVIA (ST)
solution^ FLORIVA ALIVE PRENATAL+ tablet BINOSTO (ST)
FA-8+ CHEWABLE AURYXIA (QL) raloxifene + BONIVA 150 MG
folic acid^+ TABLET+ BRAINSTRONG risedronate TABLET (ST)
klor-con FOSRENOL 1,000 PRENATAL+ risedronate dr EVISTA
KLOR-CON 8 MEQ MG POWDER CITRANATAL 90 DHA FOSAMAX (ST)
TABLET PACK CITRANATAL ASSURE
KLOR-CON 10 MEQ PAIN RELIEF AND INFLAMMATORY DISEASE
CITRANATAL
TABLET AIMOVIG (PA)
B-CALM
14Cigna Value 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 (cont) PAIN RELIEF AND INFLAMMATORY DISEASE (cont)
ACETAMINOPHEN- AJOVY (PA) ANALPRAM HC 1% morphine (PA)
CODEINE (PA) BELBUCA (QL) CREAM morphine er (PA)
allopurinol tablet EMGALITY (PA) ANALPRAM HC 2.5%- NALFON 600 MG
ASPIRIN EC+ HYSINGLA ER (PA) 1% CREAM TABLET (ST)
aspirin tablet+ ANALPRAM HC 2.5%-
NURTEC ODT (PA, NALOCET (PA)
baclofen tablet 1% CREAM SINGLE
QL) oxycodone (PA)
buprenorphine ARAVA
patch (QL) RASUVO (PA) oxycodone er (PA)
BUTRANS (QL)
butalbital- REDITREX (PA) oxycodone-
CELEBREX (QL, ST)
acetaminophen- UBRELVY (PA, QL) acetaminophen
COLCRYS
caffeine (QL) XTAMPZA ER (PA) (PA)
EC-NAPROSYN (ST)
carisoprodol ZTLIDO penicillamine* (PA)
ECOTRIN EC 325 MG
CELECOXIB (QL) PROLATE TABLET (PA)
TABLET+
colchicine rizatriptan (QL)
ESGIC (QL)
cyclobenzaprine sumatriptan (QL)
FEXMID
DICLOFENAC 1% tizanidine
LAZANDA (PA)
GEL (QL) tramadol 50 mg
LIDODERM
diclofenac dr tablet (QL)
MITIGARE
diclofenac ec tramadol er (QL)
MOBIC (ST)
EC-NAPROXEN VANADOM
NAPROSYN (ST)
ECOTRIN EC 81 MG PARKINSON’S DISEASE
NUCYNTA (PA)
TABLET+ benztropine tablet KYNMOBI (PA) AZILECT (QL)
NUCYNTA ER (PA)
eletriptan (QL) carbidopa-levodopa MIRAPEX ER (QL)
OTREXUP(PA)
ENDOCET (PA) carbidopa-levodopa NEUPRO
OXAYDO (PA)
FEBUXOSTAT (QL) er OSMOLEX ER (QL)
PERCOCET (PA)
FENTANYL (PA) pramipexole RYTARY
PROCORT
FIORICET (QL) PRAMIPEXOLE ER SINEMET 10-100
PROCTOFOAM-HC
FROVATRIPTAN (QL) (QL) SINEMET 25-100
QMIIZ ODT (ST)
GLYDO RASAGILINE (QL) TASMAR
SAVELLA
hydrocodone- ROPINIROLE ER XADAGO (ST)
SKELAXIN
acetaminophen ROPINIROLE
ULORIC (QL)
(PA)
ULTRAM 50 MG SCHIZOPHRENIA/ANTI-PSYCHOTICS4
hydromorphone er
TABLET (QL)
(PA) ARIPIPRAZOLE (QL) LATUDA (QL) FANAPT (QL, ST)
VTOL LQ
hydromorphone aripiprazole odt INVEGA (QL, ST)
ZANAFLEX
(PA) asenapine REXULTI (QL, ST)
ZEBUTAL (QL)
IBU chlorpromazine RISPERDAL (ST)
ZOHYDRO ER (PA)
ibuprofen tablet SAPHRIS (ST)
ZYLOPRIM
indomethacin haloperidol SECUADO (ST)
indomethacin er olanzapine tablet SEROQUEL (ST)
ketorolac olanzapine odt SEROQUEL XR (ST)
tromethamine (QL) PALIPERIDONE ER VRAYLAR (QL, ST)
leflunomide (QL)
lidocaine 5% quetiapine
ointment (QL) quetiapine er
lidocaine 5% patch risperidone
lidocaine viscous risperidone odt
meloxicam tablet ziprasidone tablet
metaxalone
methocarbamol
15Cigna Value 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
$ $$ $$$ $ $$ $$$
SEIZURE DISORDERS SKIN CONDITIONS (cont)
carbamazepine DILANTIN 30 MG APTIOM (PA, QL) CLARAVIS EVOCLIN
carbamazepine er CAPSULE (PA) BRIVIACT ORAL CLINDACIN ETZ 1% NAFTIN
clonazepam FYCOMPA (PA, SOLUTION, TABLET PLEDGET PICATO
divalproex QL) (PA) CLINDACIN P 1% PRAMOSONE
divalproex er NAYZILAM (PA, CARBATROL (PA) PLEDGETS
PROTOPIC
clindamycin 1%
EPITOL QL) DEPAKOTE (PA) REGRANEX (PA, QL)
foam, gel, lotion,
gabapentin VIMPAT DEPAKOTE ER (PA) pledget, solution SANTYL (QL)
lamotrigine SOLTUION, DEPAKOTE SPRINKLE clindamycin-benzoyl TEMOVATE (ST)
lamotrigine (blue) TABLET (PA) (PA) peroxoxide XEPI
lamotrigine (green) DILANTIN 100 MG clindamycin-
lamotrigine (orange) CAPSULE (PA) tretinoin
lamotrigine er DILANTIN 50 MG clobetasol
lamotrigine odt INFATAB (PA) clocortolone
lamotrigine odt KLONOPIN (PA) CLODAN
(blue) LYRICA ORAL clotrimazole-
lamotrigine odt SOLUTION (PA) betamethasone
(green)
NEURONTIN (PA) dapsone gel
lamotrigine odt
OXTELLAR XR (PA) fluocinonide
(orange)
PHENYTEK (PA) fluorouracil cream,
levetiracetam
SPRITAM (PA) topical solution
solution, tablet
TEGRETOL (PA) isotretinoin
levetiracetam er
TEGRETOL XR (PA) ketoconazole
oxcarbazepine
VALTOCO (PA, QL) KETODAN
pregabalin capsule,
solution XCOPRI (PA, QL) metronidazole
ROWEEPRA mupirocin
SUBVENITE MYORISAN
SUBVENITE (BLUE) NEUAC GEL
SUBVENITE (GREEN) pimecrolimus
SUBVENITE ROSADAN
(ORANGE) sodium
topiramate sulfacetamide-
topiramate er sulfur
SKIN CONDITIONS SSS 10-5
ACCUTANE EUCRISA ANALPRAM HC SULFACLEANSE 8-4
ADAPALENE (PA) 2.5%-1% LOTION tacrolimus ointment
adapalene-benzoyl AVAR 9.5-5% tazarotene 0.1%
peroxide CLEANSING PADS cream
AMNESTEEM BRYHALI (ST) TRETINOIN (PA)
AVAR CLEANSER calcipotriene foam TRIDERM
azelaic acid CAPEX SHAMPOO ZENATANE
betamethasone (ST) SLEEP DISORDERS/SEDATIVES
augmented CLEOCIN T ARMODAFINIL (PA) DAYVIGO (QL, ST) LUNESTA (ST)
betamethasone CLINDACIN ETZ KIT eszopiclone SUNOSI (PA, QL) SILENOR (QL, ST)
dipropionate CLINDACIN PAC KIT MODAFINIL (PA)
BP 10-1 CLODERM (ST) temazepam
calcipotriene cream, DESOWEN (ST) zolpidem
ointment, solution DRYSOL ZOLPIDEM ER (QL)
calcipotriene- EFUDEX
betamethasone ELIDEL
16Cigna Value 4-Tier Prescription Drug List
Specialty medications are covered on Tier 4 (listed on pages 18-24).
TIER 1 TIER 2 TIER 3
$ $$ $$$
SMOKING CESSATION4
bupropion sr+^ CHANTIX^ (PA)
NICODERM CQ 21 NICODERM CQ 14
MG/24HR PATCH+ MG/24HR PATCH+
nicotine gum+ NICODERM CQ 7
nicotine lozenge+ MG/24HR PATCH+
nicotine patch+ NICORETTE+
QUIT 2+ NICOTROL NS+^
QUIT 4+ NICOTROL+^
STOP SMOKING AID+
SUBSTANCE ABUSE
buprenorphine- KLOXXADO (QL) BUNAVAIL
naloxone LUCEMYRA (QL) SUBOXONE
NARCAN (QL)
ZUBSOLV
URINARY TRACT CONDITIONS
alfuzosin er AVODART
cevimeline ELMIRON
DARIFENACIN ER EVOXAC
(QL) FLOMAX
finasteride K-PHOS ORIGINAL
oxybutynin PROSCAR
oxybutynin er PYRIDIUM
phenazopyridine RAPAFLO (QL)
potassium er UROCIT-K
SILODOSIN (QL) UROXATRAL
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+
WEIGHT MANAGEMENT
megestrol WEGOVY^ (PA, CONTRAVE^ (PA)
suspension QL) QSYMIA^ (PA)
phentermine ^ SAXENDA^ (PA)
17Specialty medications
The oral and injectable specialty medications listed below are covered on Tier 4 and may 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
ALUNBRIG** (PA) CANCER
ALYQ** (PA) ASTHMA/COPD/RESPIRATORY
AMICAR** BLOOD MODIFIERS/BLEEDING DISORDERS
aminocaproic acid 0.25 gram/ml, tablets ** 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 tablet** 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
BRONCHITOL (PA) ASTMA/COPD/RESPIRATORY
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
COMETRIQ** (PA) CANCER
COMPLERA** (PA) AIDS/HIV
CYSTAGON** URINARY TRACT CONDITIONS
CYSTARAN** (PA, QL) EYE CONDITIONS
DARAPRIM** (PA) INFECTIONS
DEPEN** (PA) PAIN RELIEF AND INFLAMMATORY DISEASE
DESCOVY**+(PA) AIDS/HIV
DOVATO** AIDS/HIV
DUOPA** PARKINSON'S DISEASE
DUPIXENT* (PA) PAIN RELIEF AND INFLAMMATORY DISEASE
EGRIFTA* (PA) HORMONAL AGENTS
EMFLAZA** (PA) HORMONAL AGENTS
EMPAVELI* (PA) MISCELLANEOUS
ENBREL* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
enoxaparin* (QL) BLOOD THINNERS/ANTI-CLOTTING
entecavir** (QL) INFECTIONS
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** (PA) MULTIPLE SCLEROSIS
glatiramer* (PA) MULTIPLE SCLEROSIS
GLATOPA* (PA) MULTIPLE SCLEROSIS
GLEEVEC** (PA) CANCER
GONAL-F*^ (PA) INFERTILITY
GONAL-F RFF*^ (PA) INFERTILITY
GONAL F RFF REDI-JECT*^ (PA) INFERTILITY
GRANIX*^ (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
HAEGARDA* (PA) BLOOD PRESSURE/HEART MEDICATIONS
HARVONI** (PA, QL) INFECTIONS
HEMLIBRA* (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
HETLIOZ** (PA) SLEEP DISORDERS/SEDATIVES
HUMATROPE* (PA) HORMONAL AGENTS
HUMIRA* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
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
INGREZZA** (PA) MISCELLANEOUS
INLYTA** (PA) CANCER
INTELENCE** (PA) AIDS/HIV
ISENTRESS** AIDS/HIV
ISENTRESS HD** (PA) AIDS/HIV
JADENU** (PA) MISCELLANEOUS
JADENU SPRINKLE** (PA) MISCELLANEOUS
JAKAFI** (PA) CANCER
JULUCA** AIDS/HIV
JYNARQUE** (PA) DIURETICS
KALBITOR*^ (PA) BLOOD PRESSURE/HEART MEDICATIONS
KALYDECO** (PA, QL) ASTHMA/COPD/RESPIRATORY
KESIMPTA* (PA) MULTIPLE SCLEROSIS
KEVZARA* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
KISQALI** (PA) CANCER
KITABIS PAK** (PA, QL) INFECTIONS
KORLYM** (PA) DIABETES
20MEDICATION NAME DRUG CLASS KUVAN** (PA) MISCELLANEOUS KYLEENA**+ CONTRACEPTION 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 LUMAKRAS* (PA, QL) CANCER LUPANETA PACK**^ (PA) HORMONAL AGENTS LUPRON DEPOT*^ (PA) CANCER LUPRON DEPOT-PED*^ (PA) CANCER 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 NEULASTA ONPRO*^ (PA) BLOOD MODIFIERS/BLEEDING DISORDERS NEUPOGEN*^ (PA) BLOOD MODIFIERS/BLEEDING DISORDERS NEXAVAR** (PA) CANCER NINLARO** (PA) CANCER NITYR** (PA) MISCELLANEOUS NIVESTYM*^ (PA) 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
MEDICATION NAME DRUG CLASS
ODEFSEY** (PA) AIDS/HIV
ODOMZO** (PA) CANCER
OFEV** (PA) ASTHMA/COPD/RESPIRATORY
OLUMIANT** (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
OPSUMIT** (PA) ASTHMA/COPD/RESPIRATORY
ORENCIA* (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
PONVORY** (PA) MULTIPLE SCLEROSIS
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** (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
22MEDICATION NAME DRUG CLASS SIMPONI* 100MG/ML (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE SIMPONI ARIA* (PA) PAIN RELIEF AND INFLAMMATORY DISEASE sirolimus** TRANSPLANT MEDICATIONS SKYLA**+ CONTRACEPTION PRODUCTS SKYRIZI* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE sofosbuvir-velpatasvir** (PA) INFECTIONS 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 GEL** (PA) SKIN CONDITIONS TASIGNA** (PA) CANCER TAVALISSE** (PA) BLOOD MODIFIERS/BLEEDING DISORDERS TECFIDERA** (PA) MULTIPLE SCLEROSIS TEGSEDI* (PA) MISCELLANEOUS TEMODAR** (PA) CANCER TEMIXYS** (PA) AIDS/HIV temozolomide** (PA) CANCER tenofovir** (PA) AIDS/HIV teriparatide* (PA, QL) HORMONAL AGENTS tetrabenazine** (PA) MISCELLANEOUS THALOMID** (PA) INFECTIONS THIOLA** URINARY TRACT CONDITIONS THIOLA EC** URINARY TRACT CONDITIONS TIGLUTIK** (PA) MISCELLANEOUS
MEDICATION NAME DRUG CLASS
TIVICAY** AIDS/HIV
TOBI PODHALER** (PA, QL) INFECTIONS
tobramycin 300 mg/5ml ampule** (PA, QL) INFECTIONS
TRACLEER** (PA) ASTHMA/COPD/RESPIRATORY
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
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)
ALZHEIMER'S DISEASE pyridostigmine 30mg tablet (QL) pyridostigmine 60mg tablet
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
25
DRIZALMA SPRINKLE duloxetine dr capsules
LEXAPRO escitalopram
^^
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 PAMELOR nortriptyline capsules
(cont) PARNATE tranylcypromine
PEXEVA paroxetine
paroxetine cr
PRISTIQ desvenlafaxine succinate er
bupropion sr
duloxetine
escitalopram
sertraline
venlafaxine er
TOFRANIL imipramine
WELLBUTRIN XL bupropion xl
escitalopram
fluoxetine
ASTHMA/COPD/RESPIRATORY ADVAIR HFA DULERA
ADVAIR DISKUS fluticasone-salmeterol
AIRDUO DIGIHALER SYMBICORT
AIRDUO RESPICLICK WIXELA INHUB
BREO ELLIPTA
ALVESCO FLOVENT DISKUS
ARMONAIR DIGIHALER FLOVENT HFA
ARNUITY ELLIPTA QVAR
ASMANEX, ASMANEX HFA
PULMICORT FLEXHALER
ARCAPTA NEOHALER SEREVENT DISKUS
STRIVERDI RESPIMAT
BEVESPI AEROSPHERE ANORO ELLIPTA
DUAKLIR PRESSAIR STIOLTO RESPIMAT
UTIBRON NEOHALER
BROVANA arformoterol
budesonide-formoterol SYMBICORT
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
YUPELRI ANORO ELLIPTA
BREZTRI AEROSPHERE
INCRUSE ELLIPTA
26 SPIRIVA
STIOLTO RESPIMAT
TRELEGY ELLIPTA
^^
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)
ASTHMA/COPD/RESPIRATORY (cont) ZYFLO montelukast
zafirlukast
zileuton er
ATTENTION DEFICIT HYPERACTIVITY ADDERALL XR dexmethylphenidate er
ADHANSIA XR dextroamphetamine-amphetamine er
ADZENYS ER methylphenidate er
ADZENYS XR-ODT
APTENSIO XR
AZSTARYS
CONCERTA
COTEMPLA XR-ODT
DYANAVEL XR
FOCALIN XR
JORNAY PM
MYDAYIS
QUILLICHEW ER
RITALIN LA
VYVANSE
DESOXYN methamphetamine
DEXEDRINE dexmethylphenidate er
dextroamphetamine er
dextroamphetamine-amphetamine er
EVEKEO ODT amphetamine
dexmethylphenidate
dextroamphetamine
methamphetamine
methylphenidate
methylphenidate er 72mg tablet methylphenidate er 36mg tablet
RELEXXII
QELBREE atomoxetine
BLOOD PRESSURE/HEART MEDICATIONS ACCUPRIL quinapril
ACCURETIC quinapril-hctz
ALTACE ramipril
ATACAND candesartan
ATACAND HCT candesartan-hctz
AVALIDE irbesartan-hctz
AVAPRO irbesartan-hctz
AZOR amlodipine-olmesartan
BENICAR olmesartan
BENICAR HCT olmesartan-hctz
BETAPACE sotalol
BYSTOLIC generic beta blockers (e.g. metoprolol;
atenolol)
CARDIZEM diltiazem
CARDIZEM CD diltiazem CD
27
CONJUPRI amlodipine
felodipine er
nicardipine
nifedipine
^^
These 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)
BLOOD PRESSURE/HEART MEDICATIONS (cont) CONSENSI amlodipine
celecoxib
COZAAR losartan
DIOVAN valsartan
DIOVAN HCT valsartan-hctz
EDARBI generic ARBs (e.g. losartan; valsartan)
EDARBYCLOR generic ARBs + HCTZ (e.g. losartan-HCTZ)
EXFORGE amlopidine-valsartan
EXFORGE HCT amlopidine-valsartan hctz
FIRAZYR* icatibant
GONITRO nitroglycerin sublingual tablet or spray
HYZAAR losartan-hctz
ISORDIL isosorbide dinitrate
ISORDIL TITRADOSE
LANOXIN digoxin
LOTENSIN benazepril
LOTENSIN HCT benazepril-hctz
LOTREL amlodipine-benazepril
MICARDIS telmisartan
MICARDIS HCT telmisartan-hctz
MULTAQ amiodarone
disopyramide
dofetilide
flecainide
propafenone
quinidine
sotalol af
PRINIVIL lisinopril
ZESTRIL
TARKA trandolapril-verapamil
TEKTURNA aliskiren
TEKTURNA HCT generic ACE inhibitor + HCT (e.g. benazepril-
HCT)
generic ARB + HCT (e.g. losartan-HCT)
TRIBENZOR olmesartan-amlodipine-hctz
VASERETIC enalapril-hctz
VASOTEC enalapril
ZESTORETIC lisinopril-hctz
BLOOD THINNERS/ANTI-CLOTTING aspirin-omeprazole aspirin or enteric aspirin
YOSPRALA
CANCER CYCLOPHOSPHAMIDE TABLET* cyclophosphamide capsule*
NILANDRON nilutamide
28
TARCEVA* erlotinib
YONSA* abiraterone
ZYTIGA*
^^
These 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)
CHOLESTEROL MEDICATIONS ANTARA fenofibrate
FENOGLIDE
ALTOPREV lovastatin+
atorvastatin+
simvastatin+
rosuvastatin+
CRESTOR rosuvastatin+
EZALLOR SPRINKLE generic statins (e.g. atorvastatin; simvastatin)
FLOLIPID
LIVALO
SIMVASTATIN 20mg/5ml SUSPENSION
NEXLIZET
JUXTAPID* REPATHA
PRALUENT
LESCOL XL fluvastatin er+
LIPITOR atorvastatin+
ezetimibe-simvastatin
rosuvastatin+
NEXLETOL generic statins (e.g. atorvastatin; simvastatin)
ROSZET ezetimibe-simvastatin
niacin 500mg tablet niacin er
NIACOR
PRAVACHOL pravastatin+
VYTORIN ezetimibe-simvastatin
ZYPITAMAG atorvastatin+
lovastatin+
pravastatin+
rosuvastatin+
simvastatin+
CONTRACEPTION PRODUCTS BALCOLTRA generic oral contraceptives
NATAZIA
NEXSTELLIS
SLYND
TAYTULLA
TWIRLA
COUGH/COLD MEDICATIONS benzonatate 150mg benzonatate 100mg, 200mg
TUSSICAPS hydrocodone-chlorpheniramine er suspension
promethazine with codeine syrup
DIABETES ACCU-CHEK TEST STRIPS ONE TOUCH TEST STRIPS (e.g. Ultra; Verio)
CVS TEST STRIPS
ADVOCATE TEST STRIPS
ASSURE TEST STRIPS
CONTOUR TEST STRIPS
FREESTYLE TEST STRIPS
RELION TEST STRIPS
ADLYXIN BYDUREON
29 BYETTA
metformin
OZEMPIC
TRULICITY
VICTOZA
^^
These 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)
DIABETES (cont) ADMELOG HUMALOG
ADMELOG SOLOSTAR LYUMJEV
APIDRA, APIDRA SOLOSTAR
FIASP
FIASP FLEXTOUCH
FIASP PENFILL
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
GLUCAGEN HYPOKIT glucagon emergency kit (generic)
GVOKE BAQSIMI
ZEGALOGUE
INSULIN ASPART PRO HUMALOG MIX
NOVOLOG MIX
INVOKAMET SYNJARDY
INVOKAMET XR SYNJARDY XR
SEGLUROMET XIGDUO XR
INVOKANA FARXIGA
STEGLATRO JARDIANCE
metformin
INSULIN GLARGINE BASAGLAR
LANTUS/LANTUS SOLOSTAR LEVEMIR
SEMGLEE TRESIBA FLEXTOUCH
TOUJEO MAX SOLOSTAR
TOUJEO SOLOSTAR
NOVOLIN HUMULIN
QTERN GLYXAMBI
STEGLUJAN metformin
TRIJARDY XR
30
DIURETICS EDECRIN bumetanide
ethacrynic acid furosemide
torsemide
^^
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.
30GENERIC AND/OR PREFERRED BRAND
DRUG CLASS MEDICATION NAME^^
ALTERNATIVE(S)
EYE CONDITIONS ALOCRIL cromolyn
ALOMIDE
CEQUA RESTASIS
RESTASIS MULTIDOSE
XIIDRA
LUMIGAN bimatoprost
TRAVATAN Z latanoprost
VYZULTA travoprost
XALATAN
XELPROS
ZIOPTAN
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
^^
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.
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