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Cigna Standard 4-Tier Prescription Drug List
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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 starting 01/01/2022
Next planned update: 03/01/2022, for changes starting 07/01/2022
2
About 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.
Medications are grouped by the condition they treat; Speciality medications are listed on Tier 4 (pages 19–25) Tier (cost-share level) gives you an idea of how much you may pay for a medication
TIER 1 $
TIER 2 $$
TIER 3 $$$
HORMONAL AGENTS ANDRODERM (PA, QL) ANDROGEL 1.62% (PA, QL)
AMABELZ budesonide EC cabergoline (QL) COVARYX COVARYX H.S. DECADRON desmopressin dexamethasone estradiol- norethindrone estrogen- methyltestosterone levothyroxine LEVOXYL liothyronine medroxy-progesterone methimazole methylprednisolone MIMVEY MIMVEY LO NATURE-THROID NP THYROID prednisolone prednisolone ODT prednisone prednisone intensol progesterone
ACTIVELLA ALORA (QL) ANDROGEL 1.0% (PA, QL) ANGELIQ CLIMARA CLIMARA PRO Combipatch CYTOMEL 5, 25mcg DEPO-TESTOSTERONE ELESTRIN ENTOCORT EC ESTRACE ESTROGEL
ARMOUR THYROID CYTOMEL 50mcg
DIVIGEL DUAVEE ESTRING (QL) PREMARIN PREMPHASE PREMPRO SYNTHROID
Medications are listed in alphabetical order within each column
EVAMIST FEMRING INTRAROSA LEVO-T
Medications that have extra coverage requirements will have an abbreviation listed next to them Brand-name medications are in all capital letters
MENOSTAR (QL) MINIVELLE (QL) OSPHENA TIROSINT UNITHROID VAGIFEM (QL) VIVELLE-DOT (QL)
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 Standard 4-Tier Prescription Drug List.
3
Tiers 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 › Tier 2 – Typically Preferred Brands
$
(Lowest-cost medication) (Medium-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. $$ › Tier 3 – Typically Non-Preferred Brands (Higher-cost medication) $$$ › Tier 4 – Specialty Medications (Highest-cost medication) $$$$
(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. Quantity Limits – Some medications have a quantity limit. This means your plan will 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.
(QL)
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. (ST) Step Therapy – Certain high-cost medications aren’t covered until you try one or 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) Age Requirements – Certain medications will only be covered if you’re within 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.
4
No 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
FEMININE PRODUCTS
12
ALLERGY/NASAL SPRAYS
6
GASTROINTESTINAL/HEARTBURN
12
ALZHEIMER’S DISEASE
6
HORMONAL AGENTS
12, 13
ANXIETY/DEPRESSION/BIPOLAR DISORDER
6
INFECTIONS
13, 14
ASTHMA/COPD/RESPIRATORY
6
INFERTILITY
14
ATTENTION DEFICIT HYPERACTIVITY DISORDER
6, 7
MISCELLANEOUS
14
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
VACCINES
17
EAR MEDICATIONS
11
WEIGHT MANAGEMENT
17
ERECTILE DYSFUNCTION
11
EYE CONDITIONS
11, 12
5
Cigna Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 18-24).
TIER 1 $
TIER 2 $$ TIER 3 $$$ ALLERGY/NASAL SPRAYS
TIER 1 $ TIER 3 $$$ ANXIETY/DEPRESSION/BIPOLAR DISORDER 4 (cont) fluoxetine (QL) fluvoxamine (QL) fluvoxamine er (QL) lorazepam lorazepam intensol mirtazapine TIER 2 $$
azelastine azelastine- fluticasone cromolyn desloratadine (QL) fluticasone hydroxyzine hcl solution, syrup, tablet hydroxyzine pamoate ipratropium mometasone (QL) olopatadine promethazine solution, syrup, tablet
CLARINEX CLARINEX-D 12 HOUR GASTROCROM GRASTEK (PA, QL) KARBINAL ER ODACTRA (PA, QL) PATANASE RAGWITEK (PA, QL) VISTARIL
paroxetine cr (QL) paroxetine er (QL) paroxetine (QL) sertraline (QL) trazodone venlafaxine (QL) venlafaxine er (QL)
ASTHMA/COPD/RESPIRATORY
albuterol albuterol hfa (QL) ambrisentan* (PA)
ADVAIR HFA ANORO ELLIPTA ATROVENT HFA BREO ELLIPTA BREZTRI AEROSPHERE COMBIVENT RESPIMAT DULERA FLOVENT DISKUS FLOVENT HFA INCRUSE ELLIPTA
DALIRESP (QL) LETAIRIS* (PA) LONHALA MAGNAIR REFILL (PA) LONHALA MAGNAIR STARTER (PA) PULMICORT
ALZHEIMER’S DISEASE
donepezil donepezil odt memantine ARICEPT EXELON MESTINON NAMENDA 10 MG TABLET NAMENDA 5 MG TABLET NAMENDA XR (QL) NAMZARIC (QL) ANXIETY/DEPRESSION/BIPOLAR DISORDER 4 alprazolam alprazolam er alprazolam intensol alprazolam odt memantine er (QL) pyridostigmine 60 mg/5 ml, 60 mg pyridostigmine er rivastigmine NAMENDA 5-10 MG TITRATION PK
budesonide fluticasone- salmeterol ipratropium- albuterol montelukast
RESPULES SINGULAIR
PULMICORT FLEXHALER
CELEXA (QL, ST) EFFEXOR XR (QL, ST) FETZIMA (QL, ST) PAXIL (QL, ST) PAXIL CR (QL, ST) PRISTIQ (QL, ST) PROZAC (QL, ST) REMERON SPRAVATO* (PA) TRINTELLIX (QL, ST) VIIBRYD (QL, ST) WELLBUTRIN SR (QL, ST) XANAX XANAX XR ZOLOFT (QL, ST)
QVAR REDIHALER SEREVENT DISKUS SPIRIVA SPIRIVA RESPIMAT STIOLTO RESPIMAT SYMBICORT TRELEGY ELLIPTA
alprazolam xr amitriptyline bupropion (QL) bupropion sr (QL) bupropion xl 150 mg tablet (QL) bupropion xl 300 mg tablet (QL) buspirone citalopram (QL) clomipramine desvenlafaxine er (QL) duloxetine (QL) escitalopram (QL) fluoxetine dr (QL)
ATTENTION DEFICIT HYPERACTIVITY DISORDER 4
amphetamine (PA) atomoxetine (QL) dexmethyl- phenidate (PA) dexmethyl- phenidate er (PA, QL) dextroamphet- amine-amphet er (PA, QL)
MYDAYIS (PA, QL) VYVANSE (PA, QL)
ADDERALL (PA,ST) ADZENYS ER (PA, QL) ADZENYS XR-ODT (PA, QL) AMPHETAMINE ER (PA,QL) DAYTRANA (PA, QL) DYANAVEL XR (PA, QL)
6
Cigna Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 18-24).
TIER 1 $
TIER 2 $$ TIER 3 $$$ ATTENTION DEFICIT HYPERACTIVITY DISORDER 4 (cont)
TIER 1 $ TIER 3 $$$ BLOOD PRESSURE/HEART MEDICATIONS (cont) doxazosin droxidopa* enalapril flecainide hydralazine tablet irbesartan labetalol tablet lisinopril lisinopril-hctz losartan losartan-hctz matzim la metoprolol succinate metoprolol nadolol nifedipine nifedipine er olmesartan (QL) olmesartan- TIER 2 $$ KAPSPARGO SPRINKLE (ST) KATERZIA (QL) LOPRESSOR (ST) LOTENSIN (ST) LOTREL MICARDIS (QL, ST) MICARDIS HCT (QL, ST)
dextroamphet- amine- amphetamine (PA) guanfacine er methylphenidate er (la) (PA, QL) methylphenidate er (PA, QL) methylphenidate (PA) methylphenidate cd (PA, QL) methylphenidate er (cd) (PA, QL) methylphenidate la (PA, QL)
EVEKEO (PA,ST) FOCALIN (PA,ST) INTUNIV METHYLIN (PA) QUILLICHEW ER (PA, QL) QUILLIVANT XR (PA, QL)
RITALIN (PA,ST) STRATTERA (QL)
MINIPRESS NITROSTAT NORTHERA* (PA) NORVASC ORLADEYO* (PA, QL) PRINIVIL (ST) PROCARDIA XL RANEXA (QL) TEKTURNA (QL) TENORMIN (ST) TENORETIC 50 (ST) TENORETIC 100 (ST) TIAZAC TIKOSYN (PA, QL) TOPROL XL (ST) TRIBENZOR VASOTEC (ST) VERELAN VERELAN PM ZESTORETIC (ST) ZESTRIL (ST) ZIAC (ST)
BLOOD MODIFIERS/BLEEDING DISORDERS DROXIA SIKLOS (PA) BLOOD PRESSURE/HEART MEDICATIONS
amlodipine-hctz olmesartan-hctz (QL) prazosin propranolol tablet propranolol er ramipril ranolazine er (QL) taztia xt telmisartan (QL) telmisartan-hctz (QL) tiadylt er valsartan valsartan-hctz verapamil er verapamil er pm verapamil tablet verapamil sr
amlodipine amlodipine- benazepril amlodipine- olmesartan (QL) amlodipine- valsartan atenolol benazepril bisoprolol bisoprolol-hctz candesartan cartia xt carvedilol carvedilol er (QL) clonidine diltiazem 12hr er diltiazem 24hr er diltiazem 24hr er (cd) diltiazem 24hr er (la) diltiazem 24hr er (xr) diltiazem DILT-XR dofetilide (QL)
BYSTOLIC (QL, ST) CORLANOR (PA) ENTRESTO TEKTURNA HCT (QL)
ADALAT CC ALTACE (ST) ATACAND (ST) AVAPRO (ST) AZOR (QL)
BENICAR (QL, ST) BENICAR HCT (ST) BIDIL (QL) CALAN SR CARDIZEM LA 120mg (QL) CARDURA CATAPRES-TTS 1 CATAPRES-TTS 2 CATAPRES-TTS 3 COREG (ST) CORGARD (ST) COZAAR (ST) DIOVAN (ST) DIOVAN HCT (ST) EPANED EXFORGE
BLOOD THINNERS/ANTI-CLOTTING
adult aspirin regimen+ aspirin ec+ aspirin+ aspirin- dipyridamole er children's aspirin+ clopidogrel
BRILINTA ELIQUIS (PA) XARELTO (PA)
BAYER CHEWABLE ASPIRIN+ EFFIENT PLAVIX PRADAXA (PA) SAVAYSA (PA, QL) ZONTIVITY
HEMANGEOL HYZAAR (ST)
INDERAL LA (ST) INDERAL XL (ST) INNOPRAN XL (ST)
7
Cigna Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 18-24).
TIER 1 $ TIER 3 $$$ BLOOD THINNERS/ANTI-CLOTTING (cont) jantoven low dose aspirin ec+ prasugrel st. joseph aspirin ec+ st. joseph aspirin+ warfarin CANCER TIER 2 $$
TIER 1 $
TIER 2 $$ TIER 3 $$$ CONTRACEPTION PRODUCTS (cont)
AUROVELA 24 FE+ AUROVELA FE+ AUROVELA+ AVIANE+ AYUNA+ AZURETTE+ BALZIVA+ BLISOVI 24 FE+ BLISOVI FE+ BRIELLYN+ CAMILA+ CAMRESE LO+ CAMRESE+ CAYA CONTOURED+ CAZIANT+ CHARLOTTE 24 FE+ CHATEAL EQ+
NUVARING SAFYRAL SLYND TAYTULLA TODAY CONTRACEPTIVE SPONGE+ TWIRLA+ VCF CONTRACEPTIVE FILM+ YASMIN 28 YAZ
anastrozole+ exemestane+ hydroxyurea letrozole methotrexate tamoxifen+ temozolomide* (PA)
GLEOSTINE TREXALL
CHOLESTEROL MEDICATIONS
CHATEAL+ CRYSELLE+
atorvastatin+ colesevelam ezetimibe ezetimibe- simvastatin fenofibrate
NEXLETOL (PA, QL) NEXLIZET (PA, QL) REPATHA (PA) ROSZET VASCEPA (PA)
CADUET (QL) LIPOFEN (ST) NIASPAN TRICOR (ST) TRILIPIX (ST) VYTORIN (ST) WELCHOL ZETIA ZOCOR (QL, ST)
CYCLAFEM+ CYRED EQ+ CYRED+ DASETTA+ DAYSEE+ DEBLITANE+ desogestrel-ethinyl estradiol+ desogestrel-ethinyl estradiol - ethinyl estradiol+ DOLISHALE+ drospirenone- ethinyl estradiol- levomefolate+ drospirenone- ethinyl estradiol+
fenofibric acid fluvastatin er+ fluvastatin+ icosapent ethyl lovastatin+ omega-3 acid ethyl esters pravastatin+ rosuvastatin+ (QL) simvastatin tablet+ (QL)
CONTRACEPTION PRODUCTS
AFIRMELLE+ AFTERA+ ALTAVERA+ ALYACEN+ AMETHIA+ AMETHYST+ APRI+ ARANELLE+ ASHLYNA+ AUBRA EQ+ AUBRA+
LO LOESTRIN FE
BALCOLTRA BEYAZ ELLA+ ESTROSTEP FE
ECONTRA EZ+ ECONTRA ONE- STEP+ ELINEST+ ELURYNG+ EMOQUETTE+
LAYOLIS FE+ LOESTRIN FE MICROGESTIN 24 FE MINASTRIN 24 FE NATAZIA NEXTSTELLIS
ENPRESSE+ ENSKYCE+ ERRIN+ ESTARYLLA+
8
Cigna Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 18-24).
TIER 1 $
TIER 2 $$ TIER 3 $$$ CONTRACEPTION PRODUCTS (cont)
TIER 1 $
TIER 2 $$ TIER 3 $$$ CONTRACEPTION PRODUCTS (cont)
ethynodiol-ethinyl estradiol+ etonogestrel- ethinyl estradiol+
LO- ZUMANDIMINE+ LUTERA+ LYLEQ+ LYZA+ MARLISSA+ MERZEE+ MICROGESTIN FE+ MICROGESTIN+ MILI+ MONO-LINYAH+ MY CHOICE+
FALMINA+ FAYOSIM+ FEMCAP+
FEMYNOR+ GEMMILY+ GYNOL II+ HAILEY 24 FE+ HAILEY FE+ HAILEY+ HEATHER+ ICLEVIA+ INCASSIA+ ISIBLOOM+ JAIMIESS+ JASMIEL+ JENCYCLA+ JOLESSA+ JULEBER+ JUNEL FE 24+ JUNEL FE+ JUNEL+ KAITLIB FE+ KALLIGA+ KARIVA+ KELNOR 1-35+ KELNOR 1-50+ KURVELO+ LARIN 24 FE+ LARIN FE+ LARIN+ LARISSIA+ LEENA+ LESSINA+ LEVONEST+
MY WAY+ NECON+ NEW DAY+ NIKKI+ NORA-BE+
norethindrone+ norethindrone- ethinyl estradiol- iron+ norethindrone- ethinyl estradiol+ norethindrone- ethinyl estradiol- ferrous fumarate norgestimate- ethinyl estradiol+
NORLYDA+ NORTREL+ NYLIA+
NYMYO+ OCELLA+ OPCICON ONE- STEP+
OPTION 2+ ORSYTHIA+ PHILITH+ PIMTREA+ PIRMELLA+ PORTIA+ PREVIFEM+ RECLIPSEN+ RIVELSA+ SETLAKIN+ SHAROBEL+ SIMLIYA+ SIMPESSE+ SPRINTEC+
levonorgestrel+ levonorgestrel- ethinyl estradiol+ levonorgestrel- ethinyl estradiol ethinyl estradiol+ LEVORA-28+ LILLOW+ LOJAIMIESS+ LORYNA+ LOW-OGESTREL+
9
Cigna Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 18-24).
TIER 1 $
TIER 2 $$ TIER 3 $$$ CONTRACEPTION PRODUCTS (cont)
TIER 1 $
TIER 2 $$ TIER 3 $$$ COUGH/COLD MEDICATIONS
SRONYX+ SYEDA+
bromphenir- amine- pseudoephedrine -dm hydrocodone- homatropine (PA, QL) promethazine-dm
HYCODAN (PA, QL) TESSALON PERLE TUZISTRA XR (PA, QL)
TAKE ACTION+ TARINA 24 FE+ TARINA FE 1-20 EQ+ TARINA FE+ TILIA FE+
TRI FEMYNOR+ TRI-ESTARYLLA+ TRI-LEGEST FE+ TRI-LINYAH+ TRI-LO- ESTARYLLA+ TRI-LO-MARZIA+ TRI-LO-MILI+ TRI-LO-SPRINTEC+ TRI-MILI+ TRI-NYMYO+ TRI-PREVIFEM+ TRI-SPRINTEC+ TRIVORA-28+ TRI-VYLIBRA LO+ TRI-VYLIBRA+ TULANA+ TYDEMY+ VCF CONTRACEPTIVE FOAM+ VCF CONTRACEPTIVE GEL+ VELIVET+ VESTURA+ VIENVA+
DENTAL PRODUCTS
chlorhexidine DENTA 5000 PLUS DENTAGEL doxycycline hyclate FLUORIDEX DAILY DEFENSE 1.1% ORALONE PERIDEX
PREVIDENT 0.2% RINSE
CLINPRO 5000 FLORIVA+^ FLUORIDEX SENSITIVITY RELIEF PREVIDENT 1.1% GEL PREVIDENT 5000 PREVIDENT 5000 BOOSTER PLUS PREVIDENT 5000 ENAMEL PROTECT PREVIDENT 5000 ORTHO DEFENSE PREVIDENT 5000 PLUS PREVIDENT 5000 SENSITIVE AMARYL CEQUR CYCLOSET GLUCAGON EMERGENCY KIT (QL) GVOKE (QL) PRECISION XTRA KETONE-GLUC KIT RIOMET
PERIOGARD SF 1.1% GEL SF 5000 PLUS
sodium fluoride sodium fluoride 5000 dry mouth sodium fluoride 5000 plus triamcinolone ACCU-CHEK COMPACT PLUS CONTROL ACCU-CHEK GUIDE L1-L2 CONTROL SOLUTION ACCU-CHEK AVIVA SOLUTION ACCU-CHEK SOFTCLIX LANCET KIT ACCU-CHEK FASTCLIX LANCING DEVICE ACCU-CHEK
DIABETES
BASAGLAR (QL) BAQSIMI (QL) DEXCOM G6 (PA, QL) DROPLET DROPSAFE FARXIGA (QL, ST) FREESTYLE LIBRE 14 DAY SENSOR (PA, QL) FREESTYLE LIBRE 2 SENSOR (PA, QL) GLUCAGEN HYPO KIT GLYXAMBI (QL, ST) HUMULIN (QL) JANUMET (QL, ST) JANUMET XR (QL, ST) JANUVIA (QL, ST) JARDIANCE (QL, ST)
VIORELE+ VOLNEA+ VYFEMLA+ VYLIBRA+ WERA+ wide seal diaphragm+ WYMZYA FE+
XULANE+ ZAFEMY+ ZARAH+
MULTICLIX LANCET KIT ACCU-CHEK SMARTVIEW
ZOVIA 1-35+ ZOVIA 1-35E+ ZUMANDIMINE+
CONTROL SOLUTION
10
Cigna Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 18-24).
TIER 1 $
TIER 2 $$
TIER 3 $$$
TIER 1 $
TIER 2 $$
TIER 3 $$$
DIABETES (cont) LYUMJEV (QL) OMNIPOD DASH (PA, QL) ONETOUCH ULTRA TEST STRIP ONETOUCH VERIO TEST STRIP QTERN (QL, ST) RYBELSUS (PA, QL) SOLIQUA 100-33 SYMLINPEN SYNJARDY (QL, ST) SYNJARDY XR (QL, ST) TRIJARDY XR (ST, QL) V-GO 20 V-GO 30 V-GO 40 VICTOZA (PA, QL) XIGDUO XR (QL, ST) Xultophy
DIURETICS (cont)
ACCUTREND GLUCOSE CONTROL BD LANCETS BD PEN NEEDLE CONTOUR SOLUTION CONTOUR NEXT LEV 1 CONTROL SOLUTION CONTOUR SOLUTION CONTOUR SOLUTION CONTOUR NEXT LEV 2 CONTROL SOLUTION glimepiride glipizide glipizide er glipizide xl INPEN metformin metformin er NOVOTWIST TECHLITE TRUE METRIX LEVEL 1 CONTROL SOULTION TRUE METRIX LEVEL 2 CONTROL SOLUTION TRUE METRIX LEVEL 3 CONTROL SOLUTION TRUEPLUS SYRINGE ACETAZOLAMIDE TABLET ACETAZOLAMIDE ER CAPSULE BUMETANIDE TABLET chlorthalidone eplerenone furosemide solution, tablet hydrochloro- thiazide
spironolactone triamterene-hctz
EAR MEDICATIONS
ciprofloxacin- dexamethasone neomycin- polymyxin b-hydrocortisone ofloxacin
CIPRO HC
CIPRODEX CORTISPORIN-TC DERMOTIC OTOVEL
ERECTILE DYSFUNCTION
sildenafil^ (QL) tadalafil^ (QL) vardenafil^ (QL)
MUSE^ (PA, QL)
CIALIS^ (QL, ST) STENDRA^ (QL, ST) VIAGRA^ (QL, ST)
EYE CONDITIONS
bimatoprost (QL) brimonidine brinzolamide ciprofloxacin dorzolamide dorzolamide- timolol erythromycin fluorometholone ketorolac latanoprost loteprednol moxifloxacin eye drops neomycin- polymyxin b-dexamethasone ofloxacin olopatadine polymyxin b sulfate- trimethoprim prednisolone timolol tobramycin- dexamethasone travoprost
ALPHAGAN P 0.1% DROPS
ACULAR ACULAR LS ACUVAIL ALPHAGAN P 0.15% EYE DROPS
AZASITE BETIMOL
BETOPTIC S COMBIGAN EYSUVIS (QL) FML FORTE 0.25% EYE DROPS FML S.O.P. 0.1% OINTMENT FLAREX LOTEMAX SM
ALREX AZOPT BEPREVE
BESIVANCE BROMSITE CEQUA COSOPT COSOPT PF DUREZOL
RESTASIS RESTASIS MULTIDOSE SIMBRINZA XIIDRA ZERVIATE
FML LIQUIFILM 0.1% EYE DROP ILEVRO INVELTYS ISTALOL LASTACAFT
LOTEMAX MAXITROL MOXEZA NEVANAC OCUFLOX PRED FORTE PROLENSA
DIURETICS
DIURIL
ALDACTONE CAROSPIR INSPRA KERENDIA LASIX MAXZIDE
RHOPRESSA ROCKLATAN TIMOPTIC TIMOPTIC-XE TOBRADEX EYE DROPS
11
Cigna Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 18-24).
TIER 1 $
TIER 2 $$
TIER 3 $$$
TIER 1 $ TIER 3 $$$ GASTROINTESTINAL/HEARTBURN (cont) LAXATIVE EC 5 MG TABLET+ mesalamine TIER 2 $$
EYE CONDITIONS (cont)
TOBRADEX ST TRUSOPT VIGAMOX ZIRGAN ZYLET
mesalamine dr mesalamine er metoclopramide solution, tablet metoclopramide odt misoprostol NATURA-LAX+ omeprazole (QL) ondansetron ondansetron odt pantoprazole suspension, tablet (QL) peg 3350-electrolyte+ PEG3350-SODIUM SULFATE-SODIUM CHLORIDE- POTASSIUM CHLORIDE- SODIUM ASCORBATE- ASCORBIC ACID+ PEG-PREP+ polyethylene glycol 3350+ prochlorperazine tablet promethazine suppository promethegan PURELAX+ rabeprazole tablet (QL) scopolamine SMOOTHLAX+ sucralfate ursodiol WOMEN'S GENTLE LAXATIVE+ WOMEN'S LAXATIVE+
FEMININE PRODUCTS
FEM PH GYNAZOLE 1 miconazole 3 200 mg terconazole
GASTROINTESTINAL/HEARTBURN
ALOPHEN PILLS+ ANUCORT-HC balsalazide bisacodyl tablet+ cinacalcet* CLEARLAX+ CONSTULOSE dicyclomine capsule, solution, tablet esomeprazole 20 mg capsule, 40 mg capsule, packets (QL) famotidine 40 mg/5 ml suspension, 20 mg tablet, 40 mg tablet GAVILAX+
AMITIZA CLENPIQ+ DEXILANT (QL) LINZESS LITHOSTAT NEXIUM DR 2.5 MG PACKET (QL) NEXIUM DR 5 MG PACKET (QL) PANCREAZE
ACIPHEX (QL, ST) AKYNZEO 300-0.5 MG CAPSULE BONJESTA CANASA CARAFATE CORRECTOL+ CUVPOSA DICLEGIS DONNATAL DULCOLAX EC 5 MG TABLET+ MIRALAX+ MOVANTIK (PA) PREVACID DR 30 MG CAPSULE (QL, ST) PROTONIX (QL, ST) RECTIV RELISTOR (PA) SANCUSO (PA, QL) SFROWASA SUCRAID* (PA) SYMPROIC (PA) TRANSDERM-SCOP URSO URSO FORTE VARUBI (PA, QL) VIOKACE
PENTASA SUPREP+ SUTAB+ VIBERZI
GAVILYTE-C+ GAVILYTE-G+ GAVILYTE-N+ GENTLE LAXATIVE+ GENTLELAX+ GLYCOLAX+ glycopyrrolate tablet
HEMMOREX-HC hydrocortisone lansoprazole (QL) LAXACLEAR+ LAXATIVE PEG 3350+ LAXATIVE 5 MG TABLET+
HORMONAL AGENTS
AMABELZ budesonide ec
ANDRODERM (PA, QL) DIVIGEL
ACTIVELLA ALORA (QL)
12
Cigna Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 18-24).
TIER 1 $
TIER 2 $$ TIER 3 $$$ HORMONAL AGENTS (cont)
TIER 1 $
TIER 2 $$
TIER 3 $$$
INFECTIONS (cont)
budesonide er (PA, QL) cabergoline (QL) COVARYX COVARYX H.S. DECADRON desmopressin dexamethasone intensol DOTTI (QL) EEMT EEMT H.S. estradiol (once weekly) estradiol 10mcg vaginal insert (QL) estradiol (twice weekly) (QL) estradiol- norethindrone estrogen- methyltestos- terone EUTHYROX LEVO-T levothyroxine tablet LEVOXYL liothyronine
DUAVEE ESTRING (QL) MEDROL 2 MG TABLET
ANDROGEL (PA, QL) ANGELIQ ARMOUR THYROID AYGESTIN BIJUVA CLIMARA CLIMARA PRO COMBIPATCH CRINONE 4% GEL CYTOMEL ELESTRIN ENTOCORT EC ESTRACE ESTROGEL EVAMIST IMVEXXY (QL) INTRAROSA LEVOTHYROXINE CAPSULE MEDROL 8MG, 16MG, 32MG TABLET MEDROL 4 MG DOSEPAK MENOSTAR (QL) MINIVELLE (QL) MYFEMBREE (QL) OSPHENA PROMETRIUM RAYALDEE TIROSINT-SOL UNITHROID VAGIFEM (QL) VIVELLE-DOT (QL)
albendazole amoxicillin amoxicillin- clavulanate er
CLEOCIN 75 MG CAPSULE ERY-TAB DR 333 MG TABLET FIRVANQ SOLOSEC VIBRAMYCIN 50 MG/5 ML SYRUP XIFAXAN (QL)
ALBENZA ALINIA BACTRIM BACTRIM DS
ORIAHNN (PA, QL) ORILISSA (PA, QL) PREMARIN TABLET, VAGINAL CREAM APPLICATOR PREMPHASE PREMPRO
amoxicillin- clavulanate atovaquone atovaquone- proguanil AVIDOXY azithromycin packet, suspension, tablet cefdinir cefuroxime tablet cephalexin ciprofloxacin clarithromycin clarithromycin er clindamycin COREMINO ER QL) dapsone tablets doxycycline hyclate capsule, tablet doxycycline monohydrate EMVERM
BAXDELA (PA) CIPRO TABLET CLEOCIN 150 MG CAPSULE CLEOCIN 300 MG CAPSULE CLEOCIN 100 MG VAGINAL OVULE CLEOCIN 2% VAGINAL CREAM CLINDESSE CRESEMBA CAPSULE (PA) DIFICID (QL) ELIMITE ERYPED 200 ERY-TAB DR 250 MG TABLET ERY-TAB DR 500 MG TABLET
FLAGYL HIPREX KEFLEX MACROBID
erythromycin erythromycin ethylsuccinate
MACRODANTIN MALARONE (PA) NATROBA NUVESSA ORAVIG PLAQUENIL posaconazole suspension PRIFTIN SIVEXTRO TABLET (PA) STROMECTOL sulfatrim URIBEL VALTREX VIBRAMYCIN 25 MG/5 ML SUSP XENLETA 600mg tablet (PA, QL)
LYLLANA (QL) medroxyprog- esterone methimazole methylpred- nisolone MIMVEY norethindrone NP THYROID
famciclovir fluconazole hydroxychlo- roquine ivermectin levofloxacin solution, tablet methenamine metronidazole gel, capsule, tablet minocycline minocycline er tablet (QL) mondoxyne nl MORGIDOX
prednisone prednisone intensol progesterone tablet testosterone (PA, QL) WESTHROID YUVAFEM (QL)
nitazoxanide nitrofurantoin
INFECTIONS
acyclovir capsule, suspension, tablet
CIPRO SUSPENSION AEMCOLO (QL)
13
Cigna 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 monohydrate- macrocrystal nystatin suspension, tablet penicillin v potassium permethrin posaconazole tablet sulfamethoxazole- trimethoprim suspension, tablet terbinafine tetracycline valacyclovir valganciclovir vancomycin capsule, solution vandazole
XOFLUZA (QL) ZITHROMAX ZITHROMAX TRI- PAK ZYVOX SUSPENSION, TABLET (PA)
TECHLITE LANCETS TRUEPLUS KETONE TEST STRIP
COMPACT SPACE CHAMBER (QL) EASIVENT (QL) FLEXICHAMBER (QL) INSPIRACHAMBER (QL) MICROCHAMBER (QL) NITYR* (PA) OPTICHAMBER DIAMOND (QL) POCKET CHAMBER (QL) PRO COMFORT SPACER WITH MASK (QL) PROCARE SPACER WITH CHILD MASK (QL) RITEFLO (QL) SPACE CHAMBER (QL) SPACE CHAMBER- MEDIUM MASK (QL)
INFERTILITY
clomiphene ^
CRINONE 8% GEL^ ENDOMETRIN^
MISCELLANEOUS
ACCU-CHEK SAFE-T-PRO 23G LANCETS ACCU-CHEK SOFTCLIX LANCETS ACCU-CHEK MULTICLIX LANCETS ACCU-CHEK FASTCLIX LANCET DRUM FC2 FEMALE CONDOM+ KETONE CARE TEST STRIP KETONE TEST STRIP KETOSTIX REAGENT MICROLET PRECISION XTRA sodium chloride inhalation vial. Irrigation solution vial
ACE AEROSOL CLOUD
ADDYI^ (PA, QL) BRISDELLE (QL) NUEDEXTA (QL)
SPACE CHAMBER- SMALL MASK (QL) VORTEX (QL) VORTEX VHC FROG MASK (QL) VORTEX VHC LADYBUG MASK (QL) NUTRITIONAL/DIETARY
ENHANCER (QL) AEROCHAMBER MINI (QL) AEROCHAMBER MV (QL) AEROCHAMBER PLUS FLOW-VU (QL) AEROCHAMBER WITH FLOWSIGNAL (QL) AEROCHAMBER Z-STAT PLUS (QL) AEROTRACH PLUS (QL) AEROVENT PLUS (QL) BREATHRITE (QL) CLEVER CHOICE HOLDING CHAMBER (QL)
calcitriol capsule, solution^ FA-8+ folic acid^+ klor-con KLOR-CON 10 MEQ TABLET KLOR-CON 8 MEQ TABLET KLOR-CON M10 TABLET KLOR-CON M10 TABLET
CITRANATAL 90 DHA CITRANATAL ASSURE CITRANATAL B-CALM CITRANATAL DHA CITRANATAL HARMONY CITRANATAL RX DRISDOL^
ALIVE PRENATAL+ AURYXIA (QL) BRAINSTRONG PRENATAL+ CLASSIC PRENATAL+ EXPECTA PRENATAL+ FOSRENOL 1,000 MG CHEWABLE TABLET FOSRENOL 500 MG CHEWABLE TABLET
14
Cigna Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 18-24).
TIER 1 $
TIER 2 $$ TIER 3 $$$ NUTRITIONAL/DIETARY (cont)
TIER 1 $ TIER 3 $$$ PAIN RELIEF AND INFLAMMATORY DISEASE acetaminophen- codeine (PA) allopurinol tablet ASPIRIN EC+ TIER 2 $$ AIMOVIG (PA) AJOVY (PA)
MULTI-VITAMIN W-FLUORIDE- IRON+ MULTIVITAMIN WITH FLUORIDE+ MULTIVITAMIN- IRON-FLUORIDE ONE DAILY PRENATAL+ potassium chloride 10%, capsule, packet, tablet prenatal complete+ PRENATAL GUMMIES+ PRENATAL MULTI+ prenatal multi- dha+ PRENATAL MULTIVITAMIN+ PRENATAL MULTIVITAMIN- DHA+ PRENATAL ONE DAILY+ PRENATAL VITAMIN + DHA+ PRENATAL VIT+ PRENATAL
FLORIVA CHEWABLE TABLET+ FOSRENOL 1,000 MG POWDER PACK FOSRENOL 750 MG POWDER PACKET
FOSRENOL 750 MG CHEWABLE TABLET K-TAB ER LOKELMA MINI PRENATAL+ OB COMPLETE^ ONE A DAY WOMEN'S PRENATAL DHA+ ONE-A-DAY PRENATAL-1+ PHOSLYRA PRENATAL FORMULA-DHA+ RENVELA SIMILAC PRENATAL+ STUART ONE+ ULTRA PRENATAL PLUS DHA+ VELTASSA
ANALPRAM HC 1% CREAM ANALPRAM HC 2.5%-1% CREAM ANALPRAM HC 2.5%-1% CREAM SINGLE ARAVA BUTRANS (QL) CELEBREX (QL, ST) COLCRYS EC-NAPROSYN (ST) ECOTRIN EC 325 MG TABLET+ ESGIC (QL) FEXMID FLECTOR (PA, QL) LAZANDA (PA) LICART (PA, QL) LIDODERM MITIGARE MOBIC (ST) NAPROSYN (ST) NUCYNTA ER (PA) OXAYDO (PA) PERCOCET (PA) PROCORT SKELAXIN ULTRAM 50 MG TABLET (QL) VTOL LQ ZANAFLEX ZEBUTAL (QL) ZOHYDRO ER (PA) ZYLOPRIM
BELBUCA (QL) EMGALITY (PA) HYSINGLA ER (PA) NUCYNTA (PA) NURTEC ODT (PA, QL) PROCTOFOAM-HC REDITREX (PA) SAVELLA UBRELVY (PA, QL) ULORIC (QL) XTAMPZA ER (PA) ZTLIDO
aspirin tablet+ baclofen tablet buprenorphine patch (QL) butalbital- acetaminophen-
MEPHYTON^ NEEVO DHA^ OB COMPLETE PETITE OB COMPLETE PREMIER
caffeine (QL) carisoprodol celecoxib (QL) colchicine
cyclobenzaprine diclofenac 1% gel (QL) diclofenac dr diclofenac ec EC-NAPROXEN ECOTRIN EC 81 MG TABLET+ eletriptan (QL) ENDOCET (PA) febuxostat (QL) fentanyl (PA) FIORICET (QL) frovatriptan (QL) GLYDO hydrocodone- acetaminophen (PA) hydromorphone er (PA) hydromorphone (PA) IBU ibuprofen indomethacin indomethacin er ketorolac tromethamine (QL)
PERRY PRENATAL+ POLY-VI-FLOR WITH IRON+ POLY-VI-FLOR+ PRENATE ^ PRIMACARE QUFLORA PEDIATRIC 1 MG CHEWABLE TABLET+ QUFLORA PEDIATRIC 0.25 MG/ML DROP+ QUFLORA PEDIATRIC 0.5 MG/ ML DROP+
VITAMINS+ PRENATAL+
ROCALTROL^ TRI-VI-FLOR+ VELPHORO
sevelamer carbonate TRI-VITE WITH FLUORIDE+ vitamin d2 1.25 mg (50,000 unit)^ VITAMINS A,C,D AND FLUORIDE+
OSTEOPOROSIS PRODUCTS
alendronate ibandronate 150 mg tablet raloxifene+ risedronate risedronate dr
ACTONEL (ST) ATELVIA (ST) BINOSTO (ST) BONIVA 150 MG TABLET (ST) EVISTA FOSAMAX (ST)
leflunomide lidocaine 5% ointment (QL)
lidocaine 5% patch lidocaine viscous meloxicam tablet metaxalone
15
Cigna Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 18-24).
TIER 1 $ TIER 3 $$$ PAIN RELIEF AND INFLAMMATORY DISEASE (cont) TIER 2 $$
TIER 1 $
TIER 2 $$
TIER 3 $$$
SEIZURE DISORDERS
carbamazepine carbamazepine er clonazepam divalproex divalproex er EPITOL
DILANTIN 30 MG CAPSULE (PA) FYCOMPA (PA, QL) NAYZILAM (PA, QL) VIMPAT SOLTUION, TABLET (PA)
APTIOM 600, 800 MG TABLETS (PA) APTIOM 200, 400 MG TABLETS(PA, QL) BRIVIACT ORAL SOLUTION, TABLET (PA) CARBATROL (PA) DEPAKOTE (PA) DEPAKOTE ER (PA) DEPAKOTE SPRINKLE (PA) DILANTIN 100 MG CAPSULE (PA) DILANTIN 50 MG INFATAB (PA) KLONOPIN (PA) LYRICA ORAL SOLUTION (PA) NEURONTIN (PA) OXTELLAR XR (PA) PHENYTEK (PA) SPRITAM (PA) TEGRETOL (PA) TEGRETOL XR (PA) VALTOCO (PA, QL) XCOPRI (PA, QL)
methocarbamol MORPHINE (PA) MORPHINE ER (PA) NALFON 600 MG TABLET (ST) NALOCET (PA) oxycodone (PA) oxycodone er (PA) oxycodone- acetaminophen (PA) PROLATE TABLET (PA) rizatriptan (QL) sumatriptan (QL) tizanidine tramadol 50 mg tablet (QL) tramadol er (QL) VANADOM
gabapentin lamotrigine
lamotrigine (blue) lamotrigine (green) lamotrigine (orange) lamotrigine er
lamotrigine odt lamotrigine odt (blue) lamotrigine odt (green) lamotrigine odt (orange) levetiracetam
PARKINSON’S DISEASE
solution, tablet levetiracetam er oxcarbazepine pregabalin capsule, solution
benztropine tablet carbidopa- levodopa carbidopa- levodopa er pramipexole pramipexole er (QL) rasagiline (QL) ropinirole er ropinirole
KYNMOBI (PA)
AZILECT (QL) MIRAPEX ER (QL) NEUPRO OSMOLEX ER (QL) RYTARY SINEMET 10-100 SINEMET 25-100 TASMAR XADAGO (ST)
ROWEEPRA SUBVENITE
SUBVENITE (BLUE) SUBVENITE (GREEN)
SUBVENITE (ORANGE) topiramate topiramate er
SCHIZOPHRENIA/ANTI-PSYCHOTICS 4
aripiprazole (QL) aripiprazole odt asenapine chlorpromazine tablet haloperidol olanzapine tablet olanzapine odt paliperidone er (QL) quetiapine quetiapine er risperidone risperidone odt ziprasidone tablet
LATUDA (QL)
FANAPT (QL, ST) INVEGA (QL, ST) REXULTI (QL, ST) RISPERDAL (ST) SAPHRIS (ST) SECUADO (ST) SEROQUEL (ST) SEROQUEL XR (ST) VRAYLAR (QL, ST)
vigabatrin* vigadrone*
SKIN CONDITIONS
ACCUTANE adapalene (PA) adapalene-benzoyl peroxide AMNESTEEM AVAR CLEANSER azelaic acid betamethasone augmented betamethasone dipropionate
DRYSOL EUCRISA NAFTIN PRAMOSONE 1% LOTION PRAMOSONE 1%- 1% CREAM PRAMOSONE 1%- 1% OINTMENT PRAMOSONE 2.5%- 1% OINTMENT
ANALPRAM HC 2.5%-1% LOTION AVAR 9.5-5% CLEANSING PADS BRYHALI (ST) CALCIPOTRIENE FOAM CAPEX SHAMPOO (ST) CLEOCIN T CLINDACIN ETZ KIT
16
Cigna 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 $$$ SLEEP DISORDERS/SEDATIVES
SKIN CONDITIONS (cont)
BP 10-1 calcipotriene cream, ointment, solution calcipotriene- betamethasone CLARAVIS CLINDACIN ETZ 1% PLEDGET CLINDACIN P 1% PLEDGETS CLINDAMYCIN 1% FOAM, GEL, LOTION, PLEDGET, SOLUTION clindamycin- benzoyl peroxoxide clindamycin- tretinoin clobetasol clocortolone CLODAN clotrimazole- betamethasone dapsone 5% gel, 7.5% gel pump fluocinonide fluorouracil cream, topical solution isotretinoin ketoconazole KETODAN metronidazole mupirocin MYORISAN NEUAC GEL pimecrolimus ROSADAN sodium sulfacetamide- sulfur SSS 10-5 SULFACLEANSE 8-4 tacrolimus ointment tazarotene 0.1% cream tretinoin (PA) TRIDERM ZENATANE
SANTYL (QL)
CLINDACIN PAC KIT CLODERM (ST) DESOWEN (ST) DOVONEX EFUDEX ELIDEL EVOCLIN PRAMOSONE 2.5%- 1% CREAM PRAMOSONE 2.5%- 1% LOTION PROTOPIC REGRANEX (PA, QL)
armodafinil (PA) eszopiclone modafinil (PA) temazepam zolpidem zolpidem er (QL)
DAYVIGO (QL, ST) SUNOSI (PA, QL)
LUNESTA (ST) SILENOR (QL, ST)
SMOKING CESSATION 4
bupropion sr+^ NICODERM CQ 21 MG/24HR PATCH+ nicotine gum+ nicotine lozenge+ nicotine patch+
CHANTIX^ NICOTROL NS+^ NICOTROL+^
NICODERM CQ 14 MG/24HR PATCH+ NICODERM CQ 7 MG/24HR PATCH+ NICORETTE+
TEMOVATE (ST) VECTICAL (QL) XEPI
QUIT 2+ QUIT 4+ STOP SMOKING AID+
SUBSTANCE ABUSE
buprenorphine- naloxone
LUCEMYRA (QL) NARCAN (QL) ZUBSOLV
BUNAVAIL KLOXXADO (QL) SUBOXONE
URINARY TRACT CONDITIONS
alfuzosin er cevimeline darifenacin er (QL) finasteride oxybutynin oxybutynin er phenazopyridine potassium er silodosin (QL) solifenacin (QL) tamsulosin tolterodine tolterodine er (QL)
ELMIRON K-PHOS ORIGINAL
AVODART EVOXAC FLOMAX
PROSCAR PYRIDIUM RAPAFLO (QL) UROCIT-K UROXATRAL
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 suspension phentermine ^
WEGOVY^ (PA, QL) CONTRAVE^ (PA) QSYMIA^ (PA)
17
Specialty 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 CANCER
abiraterone** (PA)
ACTEMRA SYRINGE* (PA, QL) ACTEMRA ACTPEN* (PA, QL)
PAIN RELIEF AND INFLAMMATORY DISEASE PAIN RELIEF AND INFLAMMATORY DISEASE
ACTIMMUNE* (PA) ADCIRCA** (PA) ADEMPAS** (PA) AFINITOR** (PA)
CANCER
ASTHMA/COPD/RESPIRATORY ASTHMA/COPD/RESPIRATORY
CANCER CANCER CANCER
AFINITOR DISPERZ** (PA)
ALECENSA** (PA)
alosetron**
GASTROINTESTINAL/HEARTBURN
ALUNBRIG** (PA)
CANCER
ALYQ** (PA) AMICAR**
ASTHMA/COPD/RESPIRATORY
BLOOD MODIFIERS/BLEEDING DISORDERS BLOOD MODIFIERS/BLEEDING DISORDERS
aminocaproic acid** APOKYN* (PA) ARANESP*^ (PA) ARIKAYCE** (PA) ARIXTRA* (QL) atazanavir** (PA) ATRIPLA** (PA) ASTAGRAF XL** AUSTEDO** (PA) AVONEX* (PA) AVSOLA*^ (PA) azathioprine** BAFIERTAM** (PA)
PARKINSON'S DISEASE
BLOOD MODIFIERS/BLEEDING DISORDERS
INFECTIONS
BLOOD THINNERS/ANTI-CLOTTING
AIDS/HIV AIDS/HIV
TRANSPLANT MEDICATIONS
MISCELLANEOUS
MULTIPLE SCLEROSIS
PAIN RELIEF AND INFLAMMATORY DISEASE
TRANSPLANT MEDICATIONS
MULTIPLE SCLEROSIS
BARACLUDE SOLUTION**
INFECTIONS
BENLYSTA* (PA) BETASERON* (PA)
PAIN RELIEF AND INFLAMMATORY DISEASE
MULTIPLE SCLEROSIS
BIKTARVY**
AIDS/HIV CANCER
BOSULIF** (PA) BYNFEZIA* (PA)
HORMONAL AGENTS
CABOMETYX** (PA) capecitabine** (PA) CAYSTON** (PA, QL)
CANCER CANCER
INFECTIONS
CELLCEPT**
TRANSPLANT MEDICATIONS
CERDELGA** (PA)
MISCELLANEOUS
18
MEDICATION NAME
DRUG CLASS
CETROTIDE*^ (PA) CHOLBAM** (PA)
HORMONAL AGENTS
GASTROINTESTINAL/HEARTBURN
chorionic gonadotropin*^ (PA)
INFERTILITY
CIMDUO** (PA) CIMZIA* (PA, QL)
AIDS/HIV
PAIN RELIEF AND INFLAMMATORY DISEASE
cinacalcet**
GASTROINTESTINAL/HEARTBURN
COMETRIQ** (PA) COMPLERA** (PA) CYSTARAN** (QL)
CANCER AIDS/HIV
EYE CONDITIONS
CYSTAGON**
URINARY TRACT CONDITIONS
DARAPRIM** + (PA)
INFECTIONS
DEPEN** (PA) DESCOVY**
PAIN RELIEF AND INFLAMMATORY DISEASE
AIDS/HIV AIDS/HIV
DOVATO** DUOPA**
PARKINSON'S DISEASE
DUPIXENT* (PA) EGRIFTA* (PA) EMFLAZA** (PA) ENBREL* (PA, QL) entecavir** (QL) enoxaparin* (QL) ENTYVIO*^ (PA) ENVARSUS XR** EPCLUSA** (PA, QL) EPIDIOLEX** (PA) EPOGEN*^ (PA) ERIVEDGE** (PA)
PAIN RELIEF AND INFLAMMATORY DISEASE
HORMONAL AGENTS HORMONAL AGENTS
PAIN RELIEF AND INFLAMMATORY DISEASE
INFECTIONS
BLOOD THINNERS/ANTI-CLOTTING GASTROINTESTINAL/HEARTBURN
TRANSPLANT MEDICATIONS
INFECTIONS
SEIZURE DISORDERS
BLOOD MODIFIERS/BLEEDING DISORDERS
CANCER CANCER
ERLEADA** (PA) ESBRIET** (PA) EVOTAZ** (PA) EXJADE** (PA) EXTAVIA* (PA)
MISCELLANEOUS
AIDS/HIV
MISCELLANEOUS
MULTIPLE SCLEROSIS
FASENRA PEN* (PA) FENSOLVI**^ (PA) FERRIPROX** (PA) FIRDAPSE** (PA, QL) FOLLISTIM AQ*^ (PA) fondaparinux* (QL)
ASTHMA/COPD/RESPIRATORY
HORMONAL AGENTS
MISCELLANEOUS
MULTIPLE SCLEROSIS
INFERTILITY
BLOOD THINNERS/ANTI-CLOTTING
FORTEO* (PA, QL) FRAGMIN* (QL) FULPHILA* (PA) GALAFOLD** (PA)
HORMONAL AGENTS
BLOOD THINNERS/ANTI-CLOTTING
BLOOD MODIFIERS/BLEEDING DISORDERS
MISCELLANEOUS
19
MEDICATION NAME
DRUG CLASS
GANIRELIX*^ (PA)
HORMONAL AGENTS
GATTEX* (PA) GENVOYA**
GASTROINTESTINAL/HEARTBURN
AIDS/HIV
GILENYA 0.5MG** (PA)
MULTIPLE SCLEROSIS MULTIPLE SCLEROSIS MULTIPLE SCLEROSIS
glatiramer* (PA) GLATOPA* (PA) GLEEVEC** (PA) GONAL-F*^ (PA)
CANCER
INFERTILITY INFERTILITY
GONAL-F RFF*^ (PA)
GRANIX*^
BLOOD MODIFIERS/BLEEDING DISORDERS BLOOD PRESSURE/HEART MEDICATIONS
HAEGARDA* (PA) HARVONI** (PA, QL) HEMLIBRA* (PA) HETLIOZ** (PA) HUMATROPE* (PA) HUMIRA* (PA, QL) IBRANCE** (PA) ILARIS*^ (PA) ILUMYA* (PA, QL) imatinib** (PA) IMBRUVICA** (PA) INBRIJA** (PA) INCRELEX* (PA) INFLECTRA*^ (PA)
INFECTIONS
BLOOD MODIFIERS/BLEEDING DISORDERS
SLEEP DISORDERS/SEDATIVES
HORMONAL AGENTS
PAIN RELIEF AND INFLAMMATORY DISEASE
CANCER
PAIN RELIEF AND INFLAMMATORY DISEASE PAIN RELIEF AND INFLAMMATORY DISEASE
CANCER CANCER
PARKINSON’S DISEASE HORMONAL AGENTS
PAIN RELIEF AND INFLAMMATORY DISEASE
INLYTA** (PA)
CANCER AIDS/HIV AIDS/HIV AIDS/HIV
INTELENCE** (PA)
ISENTRESS**
ISENTRESS HD** (PA)
JADENU** (PA)
MISCELLANEOUS MISCELLANEOUS
JADENU SPRINKLE** (PA)
JAKAFI** (PA)
CANCER AIDS/HIV DIURETICS
JULUCA**
JYNARQUE** (PA) KALBITOR*^ (PA)
BLOOD PRESSURE/HEART MEDICATIONS
KALYDECO** (PA, QL) KESIMPTA PEN* (PA) KEVZARA* (PA, QL) KINERET* (PA, QL)
ASTHMA/COPD/RESPIRATORY
MULTIPLE SCLEROSIS
PAIN RELIEF AND INFLAMMATORY DISEASE PAIN RELIEF AND INFLAMMATORY DISEASE
KISQALI** (PA)
CANCER CANCER
KISQALI FEMARA** (PA) KITABIS PAK** (PA, QL)
INFECTIONS
KORLYM** (PA)
DIABETES
20
MEDICATION NAME
DRUG CLASS
KUVAN** (PA) KYLEENA** +
MISCELLANEOUS
CONTRACEPTIVE PRODUCTS
LEDIPASVIR-SOFOSBUVIR** (PA)
INFECTIONS
LENVIMA** (PA) LETAIRIS** (PA) LONSURF** (PA) LORBRENA** (PA) LOVENOX* (QL) LUPANETA**^ (PA)
CANCER
ASTHMA/COPD/RESPIRATORY
CANCER CANCER
BLOOD THINNERS/ANTI-CLOTTING
CANCER CANCER
LUPRON DEPOT*^ (PA)
LUPRON DEPOT-PED*^ (PA)
HORMONAL AGENTS
LYNPARZA** (PA)
CANCER
LYSTEDA**
BLOOD MODIFIERS/BLEEDING DISORDERS
MAVENCLAD** (PA) MAVYRET** (PA) MAYZENT** (PA) MEKINIST** (PA) MENOPUR*^ (PA)
MULTIPLE SCLEROSIS
INFECTIONS
MULTIPLE SCLEROSIS
CANCER
INFERTILITY
MIRENA** +
CONTRACEPTION PRODUCTS
MYALEPT* (PA) mycophenolate** mycophenolic acid** MYFORTIC** NATPARA* (PA) NERLYNX** (PA) NEULASTA*^ (PA) NEUPOGEN*^ (PA) NEXAVAR** (PA) NINLARO** (PA)
MISCELLANEOUS
TRANSPLANT MEDICATIONS TRANSPLANT MEDICATIONS TRANSPLANT MEDICATIONS
HORMONAL AGENTS
CANCER
BLOOD MODIFIERS/BLEEDING DISORDERS BLOOD MODIFIERS/BLEEDING DISORDERS
CANCER CANCER
NITYR** (PA) NIVESTYM*^
MISCELLANEOUS
BLOOD MODIFIERS/BLEEDING DISORDERS
NORDITROPIN FLEXPRO* (PA)
HORMONAL AGENTS
NORTHERA** (PA)
BLOOD PRESSURE/HEART MEDICATIONS
NOURIANZ** (PA, QL)
PARKINSON’S DISEASE
NOVAREL*^ (PA) NUBEQA** (PA) NUCALA* (PA) NUZYRA** (PA) NYVEPRIA* (PA) OCALIVA** (PA) ODEFSEY** (PA) ODOMZO** (PA)
INFERTILITY
CANCER
ASTHMA/COPD/RESPIRATORY
INFECTIONS
BLOOD MODIFIERS/BLEEDING DISORDERS
GASTROINTESTINAL/HEARTBURN
AIDS/HIV CANCER
21
MEDICATION 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) OTEZLA** (PA, QL) OVIDREL*^ (PA) OXERVATE** (PA) PALYNZIQ* (PA) PEGASYS* (PA) PLEGRIDY* (PA) POMALYST** (PA)
ASTHMA/COPD/RESPIRATORY
PAIN RELIEF AND INFLAMMATORY DISEASE
INFERTILITY
EYE CONDITIONS MISCELLANEOUS
INFECTIONS
MULTIPLE SCLEROSIS
CANCER
PREVYMIS**
INFECTIONS
PREZCOBIX** (PA)
AIDS/HIV AIDS/HIV
PREZISTA**
PROCRIT*^ (PA)
BLOOD MODIFIERS/BLEEDING DISORDERS
PROGRAF**
TRANSPLANT MEDICATIONS
PROMACTA** (PA) PULMOZYME** (PA)
BLOOD MODIFIERS/BLEEDING DISORDERS
ASTHMA/COPD/RESPIRATORY
PURIXAN**
CANCER
RAPAMUNE** RAVICTI** (PA)
TRANSPLANT MEDICATIONS GASTROINTESTINAL/HEARTBURN
REBIF* (PA)
MULTIPLE SCLEROSIS MULTIPLE SCLEROSIS
REBIF REBIDOSE* (PA)
REMICADE*^ (PA) RETACRIT*^ (PA)
PAIN RELIEF AND INFLAMMATORY DISEASE 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 CANCER
RUBRACA** (PA) RUCONEST*^ (PA)
BLOOD PRESSURE/HEART MEDICATIONS
SAMSCA**
DIURETICS
SANDOSTATIN*^ (PA)
HORMONAL AGENTS HORMONAL AGENTS
SANDOSTATIN LAR DEPOT*^ (PA)
SELZENTRY** (PA) SEROSTIM* (PA) SIMPONI* (PA, QL) SIMPONI ARIA* (PA)
AIDS/HIV
HORMONAL AGENTS
PAIN RELIEF AND INFLAMMATORY DISEASE PAIN RELIEF AND INFLAMMATORY DISEASE
sirolimus**
TRANSPLANT MEDICATIONS
22
MEDICATION NAME
DRUG CLASS
SKYLA** +
CONTRACEPTION PRODUCTS
SKYRIZI* (PA, QL)
PAIN RELIEF AND INFLAMMATORY DISEASE
sofosbuvir-velpatasvir** (PA) SOMATULINE DEPOT*^ (PA)
INFECTIONS
HORMONAL AGENTS HORMONAL AGENTS
SOMAVERT* (PA) SOVALDI** (PA, QL)
INFECTIONS
SPRYCEL** (PA)
CANCER
STELARA* (PA, QL) STRENSIQ* (PA) STRIBILD** (PA) STIVARGA** (PA) SUCRAID** (PA) SUTENT** (PA) SYMDEKO** (PA, QL)
PAIN RELIEF AND INFLAMMATORY DISEASE
MISCELLANEOUS
AIDS/HIV CANCER
GASTROINTESTINAL/HEARTBURN
CANCER
ASTHMA/COPD/RESPIRATORY
SYMFI**
AIDS/HIV AIDS/HIV AIDS/HIV
SYMFI LO** SYMTUZA**
tacrolimus capsule** tadalafil 20mg** (PA) TAFINLAR** (PA) TAGRISSO** (PA) TAKHZYRO* (PA) TALTZ* (PA, QL) TALZENNA** (PA) TARGRETIN** (PA) TARGRETIN GEL** TASIGNA** (PA)
TRANSPLANT MEDICATIONS ASTHMA/COPD/RESPIRATORY
CANCER CANCER
BLOOD PRESSURE/HEART MEDICATIONS PAIN RELIEF AND INFLAMMATORY DISEASE
CANCER CANCER
SKIN CONDITIONS
CANCER
TAVALISSE** (PA) TEGSEDI* (PA) TEMIXYS** (PA) TEMODAR** (PA)
BLOOD MODIFIERS/BLEEDING DISORDERS
MISCELLANEOUS
AIDS/HIV CANCER CANCER AIDS/HIV
temozolomide** (PA)
tenofovir** (PA)
teriparatide* (PA, QL) tetrabenazine** (PA) THALOMID** (PA)
HORMONAL AGENTS
MISCELLANEOUS
INFECTIONS
THIOLA**
URINARY TRACT CONDITIONS
TIGLUTIK** (PA)
MISCELLANEOUS
TIVICAY**
AIDS/HIV
TOBI PODHALER** (PA, QL)
INFECTIONS INFECTIONS
tobramycin 300 mg/5ml** (PA, QL)
TRACLEER** (PA)
ASTHMA/COPD/RESPIRATORY
23
MEDICATION NAME
DRUG CLASS
tranexamic acid** TREMFYA* (PA, QL)
BLOOD MODIFIERS/BLEEDING DISORDERS PAIN RELIEF AND INFLAMMATORY DISEASE
trientine** (PA)
MISCELLANEOUS
TRIUMEQ**
AIDS/HIV CANCER
TYKERB** (PA)
TYMLOS* (PA, QL) TYVASO** (PA) UDENYCA*^ (PA) UPTRAVI** (PA) VALCHLOR**
OSTEOPOROSIS PRODUCTS ASTHMA/COPD/RESPIRATORY
BLOOD MODIFIERS/BLEEDING DISORDERS
ASTHMA/COPD/RESPIRATORY
SKIN CONDITIONS
VEMLIDY**
INFECTIONS
VENCLEXTA** (PA) VERZENIO** (PA) VIREAD** (PA) vigabatrin** VIGADRONE** VIZIMPRO** (PA) VOSEVI** (PA) VOTRIENT** (PA) VUMERITY** (PA) VYLEESI*^ (PA, QL) WAKIX** (PA, QL) XALKORI** (PA) XELJANZ** (PA, QL) XELJANZ XR** (PA, QL)
CANCER CANCER AIDS/HIV
SEIZURE DISORDERS SEIZURE DISORDERS
CANCER
INFECTIONS
CANCER
MULTIPLE SCLEROSIS
MISCELLANEOUS
SLEEP DISORDERS/SEDATIVES
CANCER
PAIN RELIEF AND INFLAMMATORY DISEASE PAIN RELIEF AND INFLAMMATORY DISEASE
XELODA** (PA) XERMELO** (PA) XOLAIR* (PA) XTANDI** (PA) XYREM** (PA)
CANCER
GASTROINTESTINAL/HEARTBURN ASTHMA/COPD/RESPIRATORY
CANCER
SLEEP DISORDERS/SEDATIVES
ZARXIO*^
BLOOD MODIFIERS/BLEEDING DISORDERS
ZEJULA** (PA) ZEPATIER** (PA) ZEPOSIA** (PA) ZIEXTENZO* (PA) ZORBTIVE* (PA)
CANCER
INFECTIONS
MULTIPLE SCLEROSIS
BLOOD MODIFIERS/BLEEDING DISORDERS
HORMONAL AGENTS
ZORTRESS**
TRANSPLANT MEDICATIONS
24