Cigna Healthcare Standard 4-Tier Prescription Drug List Coverage as of January 1, 2024
Offered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, or their affiliates. 595201 t Standard 4-Tier 08/23 © 2023 Cigna Healthcare.
Cigna Healthcare Standard 4-Tier Prescription Drug List Injectable specialty medications are covered on Tier 4 (listed on pages 20-23).
What’s inside?
About this drug list
3
How to read this drug list
3
How to find your medication
5
Injectable specialty medications
20
Frequently Asked Questions (FAQs)
24
Exclusions and limitations for coverage
28
View the drug list online This document was last updated on 08/01/2023.* You can go online to see the most up-to-date list of medications your plan covers. myCigna ® App 1 or myCigna.com ® . Click on the Find Care & Costs tab. Then select Price a Medication, and type in your medication name.
Cigna.com/PDL. Scroll down until you see a pdf of the Cigna Standard 4-Tier Prescription Drug List (injectable 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 Healthcare SM ID card. We’re here 24/7/365.
* Drug list created: originally created 01/01/2004
Last updated: 08/01/2023, for changes starting 01/01/2024
Next planned update: 03/01/2024, for changes starting 07/01/2024
2
About this drug list This is a list of the most commonly prescribed medications covered on the Cigna Healthcare Standard 4-Tier Prescription Drug List as of January 1, 2024. 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 full 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 Healthcare Standard 4-Tier Prescription Drug List.
Medications are grouped by the condition they treat; Specialty medications are listed on Tier 4 (pages 19–27) 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) ARMOUR THYROID CYTOMEL 50mcg
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
DIVIGEL DUAVEE ESTRING (QL) PREMARIN PREMPHASE PREMPRO
Medications are listed in alphabetical order within each column
EVAMIST FEMRING INTRAROSA LEVO-T
Medications that have extra coverage requirements have an abbreviation listed next to them
MENOSTAR (QL) MINIVELLE (QL) OSPHENA TIROSINT UNITHROID VAGIFEM (QL) VIVELLE-DOT (QL)
Brand-name medications are in all capital letters
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 Healthcare 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 • Tier 3 – Typically Non-Preferred Brands • Tier 4 – Injectable Specialty Medications*
(Lowest-cost medication) (Medium-cost medication) (Higher-cost medication) (Highest-cost medication)
$
$$
$$$
$$$$
* Oral specialty medications are covered on a lower tier (tiers 1-3).
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)
P rior Authorization – Certain medications need approval from Cigna Healthcare 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 Healthcare. 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 Healthcare. 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 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 Healthcare .
(QL)
(ST)
(AGE)
* 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 Healthcare 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. Oral specialty medications have an asterisk next to them Specialty medications are used to treat complex medical conditions. They’re typically injected or infused and may need special handling (like refrigeration). Some plans may limit coverage to a 30-day supply and/or require you to use a preferred specialty pharmacy to receive coverage. In this drug list, injectable specialty medications are covered on Tier 4 (see pages 19-27). Oral specialty medications are covered on a lower tier (tiers 1-3). They're listed alphabetically by the condition they treat, and have an asterisk (*) next to them.
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. Some plans may cover certain non-covered medications Plans can choose to offer coverage of certain medications, products and/or drug classes that aren’t typically covered. In this drug list, these medications/products have a caret (^) next to them. Log in to the myCigna App or myCigna.com to see if your plan covers them. 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
GASTROINTESTINAL/HEARTBURN
13
AIDS/HIV
6
HORMONAL AGENTS
13, 14
ALLERGY/NASAL SPRAYS
6
INFECTIONS
14, 15
ALZHEIMER’S DISEASE
6
INFERTILITY
15
ANXIETY/DEPRESSION/ BIPOLAR DISORDER
6
MISCELLANEOUS
15
ASTHMA/COPD/RESPIRATORY
6, 7
MULTIPLE SCLEROSIS
15
ATTENTION DEFICIT HYPERACTIVITY DISORDER
7
NUTRITIONAL/DIETARY
15, 16
OSTEOPOROSIS PRODUCTS
16
BLOOD MODIFIERS/BLEEDING DISORDERS
7
PAIN RELIEF AND INFLAMMATORY DISEASE
16, 17
BLOOD PRESSURE/HEART MEDICATIONS
7, 8
PARKINSON’S DISEASE
17
BLOOD THINNERS/ANTI-CLOTTING
8
SCHIZOPHRENIA/ANTI-PSYCHOTICS
17
CANCER
8
SEIZURE DISORDERS
17
CHOLESTEROL MEDICATIONS
8
SKIN CONDITIONS
17, 18
CONTRACEPTION PRODUCTS
9, 10
SLEEP DISORDERS/SEDATIVES
18
COUGH/COLD MEDICATIONS
10
SMOKING CESSATION
18
DENTAL PRODUCTS
10, 11
SUBSTANCE ABUSE
18
DIABETES
11, 12
TRANSPLANT MEDICATIONS
18
URINARY TRACT CONDITIONS
18, 19
DIURETICS
12
VACCINES
19
EAR MEDICATIONS
12
VITAMINS
19
ERECTILE DYSFUNCTION
12
WEIGHT MANAGEMENT
19
EYE CONDITIONS
12 , 13
FEMININE PRODUCTS
13
5
Cigna Healthcare Standard 4-Tier Prescription Drug List Injectable specialty medications are covered on Tier 4 (listed on pages 20-23).
TIER 1 $
TIER 2 $$
TIER 3 $$$
TIER 1 $
TIER 2 $$ TIER 3 $$$ ANXIETY/DEPRESSION/BIPOLAR DISORDER 2
AIDS/HIV
efavirenz- emtricitabine- tenofovir* (QL) emtricitabine- tenofovir 200-300 mg*+ etravirine* ritonavir* tenofovir* (PA)
BIKTARVY* (QL) DESCOVY 200-25 MG TABLET*+ (PA) DOVATO* (QL) GENVOYA* (QL) ISENTRESS HD* (PA) ISENTRESS* JULUCA* (QL) PREZISTA* SYMTUZA* (QL) TIVICAY PD* TIVICAY* TRIUMEQ* (QL) TRIUMEQ PD* (QL)
CIMDUO* (PA) COMPLERA* (PA, QL) DELSTRIGO* (PA,QL) ODEFSEY* (PA, QL) PIFELTRO* (PA) PREZCOBIX* (PA) RUKOBIA* (PA,QL) STRIBILD* (PA, QL)
alprazolam alprazolam er alprazolam intensol alprazolam odt alprazolam xr amitriptyline bupropion (QL) bupropion sr (QL) bupropion xl 150 mg tablet (QL) bupropion xl 300 mg tablet (QL) buspirone citalopram (QL) citalopram solution, tablet (QL) clomipramine duloxetine (QL) escitalopram (QL) fluoxetine dr (QL) fluoxetine (QL) fluvoxamine (QL) fluvoxamine er (QL) lorazepam lorazepam intensol mirtazapine paroxetine cr (QL) paroxetine er (QL) paroxetine (QL) sertraline (QL) trazodone venlafaxine (QL) venlafaxine er (QL)
DESVENLAFAXINE ER (QL, ST) EMSAM (QL) FETZIMA (QL, ST) NUPLAZID* (PA) SPRAVATO* (PA) TRINTELLIX (QL, ST) XANAX XANAX XR
ALLERGY/NASAL SPRAYS
azelastine azelastine- fluticasone cromolyn
CLARINEX GASTROCROM
GRASTEK (PA, QL) ODACTRA (PA, QL) ORALAIR (PA, QL) PATANASE RAGWITEK (PA, QL) VISTARIL
desloratadine (QL) epinephrine (QL) fluticasone hydroxyzine hcl solution, syrup, tablet hydroxyzine pamoate ipratropium levocetirizine dihydrochloride mometasone (QL) olopatadine phenylephrine hcl promethazine solution, syrup, tablet
ASTHMA/COPD/RESPIRATORY
albuterol alyq* (PA)
ADEMPAS* (PA) ADVAIR HFA (QL) ALVESCO ANORO ELLIPTA (QL) ASMANEX (QL) ASMANEX HFA (QL) ATROVENT HFA (QL) BREO ELLIPTA (QL) BREZTRI AEROSPHERE (QL)
ADCIRCA* (PA) AIRDUO DIGIHALER (QL, ST) BRONCHITOL* (PA) BUDESONIDE- FORMOTEROL (QL) DALIRESP (QL) FLUTICASONE- SALMETEROL (QL) KALYDECO* (PA, QL) LETAIRIS* (PA)
ALZHEIMER’S DISEASE
ambrisentan* (PA) budesonide (QL) fluticasone- salmeterol (QL) ipratropium- albuterol montelukast tadalafil 20mg tablet* (PA) wixela inhub (QL)
donepezil donepezil odt memantine
ARICEPT EXELON
MESTINON NAMENDA NAMENDA XR (QL) NAMZARIC (QL)
memantine er (QL) pyridostigmine 60 mg/5 ml, 60 mg pyridostigmine er rivastigmine
6
Cigna Healthcare Standard 4-Tier Prescription Drug List Injectable specialty medications are covered on Tier 4 (listed on pages 20-23).
TIER 1 $
TIER 2 $$ TIER 3 $$$ ASTHMA/COPD/RESPIRATORY (cont.) COMBIVENT RESPIMAT (QL) DULERA (QL) INCRUSE ELLIPTA OFEV* (PA) OPSUMIT* (PA)
TIER 1 $ TIER 3 $$$ BLOOD PRESSURE/HEART MEDICATIONS (cont.) amlodipine- olmesartan (QL) amlodipine- valsartan atenolol TIER 2 $$ TEKTURNA HCT (QL) VERQUVO (PA,QL)
LONHALA MAGNAIR (PA, QL) ORENITRAM ER* (PA) ORKAMBI* (PA, QL) PULMICORT RESPULES (QL) SINGULAIR TRIKAFTA* (PA, QL) TYVASO REFILL KIT* (PA)
CALAN SR CARDIZEM LA (QL) CARDURA CATAPRES-TTS 1 CATAPRES-TTS 2 CATAPRES-TTS 3 COZAAR (ST) DIOVAN (ST) DIOVAN HCT (ST) EPANED MICARDIS (QL, ST) MICARDIS HCT (QL, ST) MINIPRESS NITROSTAT NORTHERA* (PA) NORVASC ORLADEYO* (PA, QL) PACERONE 100 MG, 400 MG TABLET (PA) PROCARDIA XL SOTYLIZE TEKTURNA (QL) TEKTURNA HCT (QL) TIAZAC TIKOSYN (PA, QL) TRIBENZOR VALSARTAN (ST) VALSARTAN 4MG/ ML SOLUTION (ST) VERELAN VERELAN PM ZESTORETIC (ST) ZESTRIL (ST) EXFORGE HCT HYZAAR (ST) LOTENSIN (ST)
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) doxazosin droxidopa* enalapril flecainide guanfacine hydralazine tablet irbesartan irbesartan- hctz labetalol tablet lisinopril lisinopril-hctz losartan metoprolol metyrosine (PA) nadolol nebivolol (QL) nifedipine nifedipine er olmesartan (QL) olmesartan- amlodipine-hctz olmesartan-hctz (QL) pacerone pacerone 200 mg tablet
PULMOZYME* (PA) QVAR REDIHALER SPIRIVA HANDIHALER (QL) STIOLTO RESPIMAT (QL) STRIVERDI RESPIMAT (QL) TRACLEER* (PA) TRELEGY ELLIPTA (QL)
ATTENTION DEFICIT HYPERACTIVITY DISORDER 2 amphetamine (PA) atomoxetine (QL) dexmethylph- enidate (PA, QL) dexmethylph- enidate er (PA, QL) guanfacine er methylphenidate (PA) methylphenidate capsule (PA,QL) methylphenidate cd (PA, QL) methylphenidate er (PA, QL) methylphenidate er (cd) (PA, QL) methylphenidate er (la) (PA, QL) methylphenidate la (PA, QL) MYDAYIS (PA, QL) VYVANSE (PA, QL) ADDERALL (PA, ST) ADZENYS XR-ODT (PA, QL) AZSTARYS (PA, ST, QL) DAYTRANA (PA, QL) DYANAVEL XR (PA, QL) EVEKEO ODT (PA) FOCALIN (PA, ST) METHYLIN (PA) METHYL- PHENIDATE ER 72 MG TAB (QL) QUILLICHEW ER (PA, QL) QUILLIVANT XR (PA, QL) RITALIN (PA, ST)
BLOOD MODIFIERS/BLEEDING DISORDERS DOPTELET* (PA) SIKLOS (PA) TAVALISSE* (PA) BLOOD PRESSURE/HEART MEDICATIONS DROXIA
tranexamic acid 650 mg*
amiodarone tablet amlodipine amlodipine- benazepril
CORLANOR (PA) ENTRESTO (QL) NORLIQVA (PA,QL)
ALTACE (ST) AVALIDE (ST) AVAPRO (ST) BIDIL (QL)
7
Cigna Healthcare Standard 4-Tier Prescription Drug List Injectable specialty medications are covered on Tier 4 (listed on pages 20-23).
TIER 1 $ TIER 3 $$$ BLOOD PRESSURE/HEART MEDICATIONS (cont.) prazosin propranolol tablet propranolol er ramipril ranolazine er (QL) sajazir* (PA) taztia xt TIER 2 $$
TIER 1 $
TIER 2 $$
TIER 3 $$$
CANCER (cont.)
NERLYNX* (PA) NINLARO* (PA, QL) ODOMZO* (PA) ORGOVYX* (PA) PIQRAY* (PA) POMALYST* (PA, QL) PURIXAN* RETEVMO* (PA,QL) ROZLYTREK* (PA) SCEMBLIX* (PA,QL) STIVARGA* (PA, QL) TAFINLAR* (PA, QL) TAGRISSO* (PA) TALZENNA* (PA,QL) TASIGNA* (PA, QL) TIBSOVO* (PA) TUKYSA* (PA) VITRAKVI* (PA) WELIREG* (PA, QL) XELODA* (PA) XOSPATA* (PA) ZELBORAF* (PA)
telmisartan (QL) telmisartan-hctz (QL) tiadylt er valsartan-hctz verapamil er verapamil er pm verapamil tablet verapamil sr
BLOOD THINNERS/ANTI-CLOTTING
clopidogrel jantoven prasugrel warfarin
BRILINTA ELIQUIS (PA) XARELTO (PA)
ARIXTRA (QL) PLAVIX PRADAXA (PA) SAVAYSA (PA,QL) ZONTIVITY ALUNBRIG* (PA, QL) ARIMIDEX AROMASIN AYVAKIT* (PA,QL) BOSULIF* (PA, QL) BRAFTOVI* (PA) COMETRIQ* (PA, QL) COTELLIC* (PA) EXKIVITY* (PA) GAVRETO* (PA,QL) IBRANCE* (PA, QL) ICLUSIG* (PA, QL) INLYTA* (PA) JAKAFI* (PA, QL) KISQALI* (PA,QL) KISQALI FEMARA CO-PACK* (PA,QL) LENVIMA* (PA) LONSURF* (PA) LUMAKRAS* (PA,QL) MEKINIST* (PA,QL) MEKTOVI* (PA)
CANCER
CHOLESTEROL MEDICATIONS
abiraterone* (PA) anastrozole+ capecitabine* (PA) everolimus* (PA, QL) sodium (QL) hydroxyurea imatinib* (QL) lenalidomide* (PA,QL) letrozole mercaptopurine methotrexate tamoxifen+ temozolomide* (PA) exemestane+ fondaparinux
ALECENSA* (PA, QL)
atorvastatin 10 mg, 20 mg+ colesevelam
NEXLETOL (PA, QL) NEXLIZET (PA, QL)
CADUET (QL) LIPOFEN (ST) ROSZET (PA) TRICOR (ST) TRILIPIX (ST) VYTORIN (ST) WELCHOL ZETIA
BRUKINSA* (PA, QL) CABOMETYX* (PA) ERIVEDGE* (PA) ERLEADA* (PA) GLEOSTINE IMBRUVICA* (PA, QL) LYNPARZA* (PA, QL) REVLIMID* (PA, QL) RUBRACA* (PA, QL) SPRYCEL* (PA, QL) TREXALL VENCLEXTA* (PA) VENCLEXTA STARTING PACK* (PA) VERZENIO* (PA) XTANDI* (PA) ZEJULA* (PA, QL)
REPATHA (PA) VASCEPA (PA)
ezetimibe ezetimibe- simvastatin fenofibrate fenofibric acid fluvastatin+
fluvastatin er+ icosapent ethyl lovastatin 10 mg lovastatin 20mg, 40mg tablet+ omega-3 acid ethyl esters pravastatin+ rosuvastatin 5mg, 10 mg+ (QL) simvastatin 80mg (QL) simvastatin 10 mg, 20 mg, 40 mg+ (QL)
8
Cigna Healthcare Standard 4-Tier Prescription Drug List Injectable specialty medications are covered on Tier 4 (listed on pages 20-23).
TIER 1 $
TIER 2 $$ TIER 3 $$$ CONTRACEPTION PRODUCTS
TIER 1 $
TIER 2 $$ TIER 3 $$$ CONTRACEPTION PRODUCTS (cont.)
AFIRMELLE+ ALTAVERA+ ALYACEN+ AMETHIA+ AMETHYST+ APRI+
LO LOESTRIN FE NEXPLANON*+
ANNOVERA BALCOLTRA
ENSKYCE+ ERRIN+ ESTARYLLA+ ethynodiol-ethinyl estradiol+ etonogestrel- ethinyl estradiol+
BEYAZ ELLA+
KYLEENA*+ LAYOLIS FE+ LILETTA*+ LOESTRIN FE MICROGESTIN 24 FE MINASTRIN 24 FE MIRENA*+ NATAZIA NEXTSTELLIS NUVARING PARAGARD T 380- A*+
ARANELLE+ ASHLYNA+ AUBRA EQ+ AUBRA+ AUROVELA 24 FE+ AUROVELA FE+ AUROVELA+ AVIANE+ AYUNA+ AZURETTE+ BALZIVA+ BLISOVI 24 FE+ BLISOVI FE+ BRIELLYN+ CAMILA+ CAMRESE LO+ CAMRESE+ CAYA CONTOURED+ CAZIANT+ CHARLOTTE 24 FE+ CHATEAL EQ+ CHATEAL+ CRYSELLE+ CYRED EQ+ CYRED+ DASETTA+ DAYSEE+ DEBLITANE+ desogestrel-ethinyl estradiol+ desogestrel-ethinyl estradiol-ethinyl estradiol+ DOLISHALE+ drospirenone- ethinyl estradiol- levomefolate+ drospirenone- ethinyl estradiol+ ELINEST+
FALMINA+ FEMCAP+ FEMYNOR+ GEMMILY+ HAILEY 24 FE+ HAILEY FE+ HAILEY+ HEATHER+ ICLEVIA+ INCASSIA+ ISIBLOOM+ JAIMIESS+ JASMIEL+ JENCYCLA+ JOLESSA+ JULEBER+ JUNEL FE 24+ JUNEL FE+ JUNEL+ KAITLIB FE+ KALLIGA+ KARIVA+ KELNOR 1-35+ KELNOR 1-50+ KURVELO+ LARIN 24 FE+ LARIN FE+
SAFYRAL SKYLA*+ SLYND TAYTULLA TWIRLA+ TYBLUME VCF+ YASMIN 28 YAZ
LARIN+ LEENA+ LESSINA+ LEVONEST+ levonorgestrel- ethinyl estradiol+ LEVORA-28+ LOJAIMIESS+ LORYNA+ LOW-OGESTREL+ LO- ZUMANDIMINE+ LUTERA+ LYLEQ+ LYZA+
ELURYNG+ ENPRESSE+
9
Cigna Healthcare Standard 4-Tier Prescription Drug List Injectable specialty medications are covered on Tier 4 (listed on pages 20-23).
TIER 1 $
TIER 2 $$ TIER 3 $$$ CONTRACEPTION PRODUCTS (cont.)
TIER 1 $
TIER 2 $$ TIER 3 $$$ CONTRACEPTION PRODUCTS (cont.)
MARLISSA+ MEDROXY- PROGESTERONE+ MERZEE+ MICROGESTIN FE+ MICROGESTIN+ microgestin 24 fe+ MILI+ MONO-LINYAH+ NECON+ NIKKI+ NORA-BE+ norethindrone+ norethindrone- ethinyl estradiol- iron+ norethindrone- ethinyl estradiol+ norethindrone- ethinyl estradiol- ferrous fumarate norgestimate- ethinyl estradiol+ NORTREL+ NYLIA+
TRI-LINYAH+ TRI-LO- ESTARYLLA+ TRI-LO-MARZIA+ TRI-LO-MILI+ TRI-LO-SPRINTEC+ TRI-MILI+ TRI-NYMYO+ TRI-SPRINTEC+ TRIVORA-28+ TRI-VYLIBRA LO+ TRI-VYLIBRA+
TULANA+ TYDEMY+ VELIVET+ VESTURA+ VIENVA+ VIORELE+ VOLNEA+ VYFEMLA+ VYLIBRA+ WERA+ wide seal
diaphragm+ WYMZYA FE+
NYMYO+ OCELLA+ PHILITH+ PIMTREA+ PIRMELLA+ PORTIA+ RECLIPSEN+ RIVELSA+ SETLAKIN+ SHAROBEL+ SIMLIYA+ SIMPESSE+ SPRINTEC+ SRONYX+ SYEDA+
XULANE+ ZAFEMY+ ZOVIA 1-35+ ZUMANDIMINE+
COUGH/COLD MEDICATIONS
brompheniramine- pseudoephedrine -dm hydrocodone- chlorpheniramne er (PA) promethazine-dm chlorhexidine DENTA 5000 PLUS DENTAGEL doxycycline hyclate FLUORIDEX DAILY DEFENSE 1.1% ORALONE
HYCODAN (PA, QL) TUXARIN ER (PA,QL) TUZISTRA XR (PA, QL)
DENTAL PRODUCTS
CLINPRO 5000 FLORIVA+^ FLUORIDEX SENSITIVITY RELIEF JUST RIGHT 5000 PERIDEX PREVIDENT 1.1% GEL PREVIDENT 0.2% PREVIDENT 5000
TARINA 24 FE+ TARINA FE 1-20 EQ+ TARINA FE+
taysofy+ TILIA FE+
TRI FEMYNOR+ TRI-ESTARYLLA+ TRI-LEGEST FE+
PERIOGARD SF 1.1% GEL SF 5000 PLUS
10
Cigna Healthcare Standard 4-Tier Prescription Drug List Injectable specialty medications are covered on Tier 4 (listed on pages 20-23).
TIER 1 $
TIER 2 $$ TIER 3 $$$ DENTAL PRODUCTS (cont.)
TIER 1 $
TIER 2 $$
TIER 3 $$$
DIABETES (cont.) LYUMJEV (QL) MOUNJARO (PA, QL) OMNIPOD 5 G6 (GEN 5) (QL) OMNIPOD CLASSIC (GEN 3) (QL) OMNIPOD DASH (GEN 4) (QL) ONETOUCH ULTRA TEST STRIP ONETOUCH VERIO TEST STRIP OZEMPIC (PA, QL) QTERN (QL, ST) RYBELSUS (PA, QL) SOLIQUA 100-33 SYMLINPEN SYNJARDY (QL, ST) SYNJARDY XR (QL, ST) TRESIBA (QL) TRIJARDY XR (ST, QL) TRULICITY (PA,QL) V-GO 20 V-GO 30 V-GO 40 XIGDUO XR (QL, ST) XULTOPHY ZEGALOGUE (QL)
sodium fluoride sodium fluoride 5000 dry mouth sodium fluoride 5000 plus triamcinolone acetonide
PREVIDENT 5000 BOOSTER PLUS PREVIDENT 5000 DRY MOUTH PREVIDENT 5000 ENAMEL PROTECT PREVIDENT 5000 ORTHO DEFENSE PREVIDENT 5000 PLUS PREVIDENT 5000 SENSITIVE CEQUR CYCLOSET GLUCAGON EMERGENCY KIT (QL) GVOKE (QL) HUMALOG 100 UNIT/ML VIAL (QL) KORLYM* (PA) KETONE-GLUC KIT METFORMIN HCL 625 MG TABLET RIOMET RIOMET ER ULTIGUARD SAFE 1ML 30G 12.7MM ULTIGUARD SAFE 0.3ML 30G 12.7MM ULTIGUARD SAFEPACK 1ML 31G 8MM ULTIGUARD SAFEPACK- INSULIN SYRINGE ULTIGUARD SAFEPK 0.3ML 31G 8MM
EASY TOUCH EASY TOUCH FLIPLOCK
INSULIN, INSULIN SAFETY, INSULIN SYRINGE, LUER LOCK INSULIN, SHEATHLOCK INSULIN, UNI-SLIP, INSULIN SYRINGE glimepiride glipizide glipizide er glipizide xl GUARDIAN RT CHARGER GUARDIAN TEST PLUG HEALTHWISE INSULIN SYRINGE INPEN INSULIN SYRINGE U-500 LITE TOUCH LITETOUCH INSULIN SYRINGE MAGELLAN INSULIN SYRINGE MAGELLAN INSULIN SAFETY SYRINGE MAXI-COMFORT MAXICOMFORT II INSULIN SYRINGE metformin metformin er metformin 1,000 mg tablet metformin 500 mg tablet metformin 500 mg/5 ml solution metformin 850 mg tablet
DIABETES
ACCU-CHEK ADVOCATE SYRINGES ASSURE ID PEN NEEDLE BD INSULIN SYRINGE BD LANCETS BD PEN NEEDLE CARETOUCH INSULIN SYRINGE CEQUR SIMPLICITY INSERTER COMFORT EZ INSULIN SYRINGE CONTOUR SOLUTION CONTOUR NEXT LEV 1 CONTROL SOLUTION CONTOUR NEXT LEV 2 CONTROL SOLUTION DROPLET GENTEEL LANCING DEVICE DROPLET INSULIN SYRINGE DROPLET GENTEEL LANCING DEVICE DROPLET INSULIN SYRINGE EASY COMFORT INSULIN SYRINGE EASY GLIDE INSULIN SYRINGE
BAQSIMI (QL) BYDUREON (PA, QL) BYETTA (PA, QL) DEXCOM G6 RECEIVER (PA, QL) DEXCOM G6 SENSOR (PA, QL) DEXCOM G6 TRANSMITTER (PA, QL) DROPLET DROPSAFE FARXIGA (QL, ST) FREESTYLE LIBRE 14 DAY SENSOR (PA, QL) FREESTYLE LIBRE 2 SENSOR (PA, QL) GLUCAGEN (QL) GLYXAMBI (QL, ST) HUMALOG (QL) HUMALOG 100 UNIT/ML CARTRIDGE (QL) HUMULIN (QL) HUMULIN R (QL) INSULIN GLARGINE- YFGN (QL) INSULIN LISPRO (QL) JANUMET (QL, ST) JANUMET XR (QL, ST) JANUVIA (QL, ST) JARDIANCE (QL, ST)
metformin 850 mg/8.5ml cup microlet MINIMED RESERVOIR
11
Cigna Healthcare Standard 4-Tier Prescription Drug List Injectable specialty medications are covered on Tier 4 (listed on pages 20-23).
TIER 1 $
TIER 2 $$
TIER 3 $$$
TIER 1 $
TIER 2 $$
TIER 3 $$$
DIABETES (cont.)
DIURETICS
ACETAZOLAMIDE TABLET ACETAZOLAMIDE ER CAPSULE BUMETANIDE TABLET chlorthalidone eplerenone furosemide solution, tablet hydrochloro- thiazide spironolactone triamterene-hctz ciprofloxacin- dexamethasone neomycin- polymyxin b-hydrocortisone ofloxacin
CAROSPIR (PA) DIURIL KERENDIA (PA, QL)
JYNARQUE* (PA) MAXZIDE
MONOJECT MONOJECT
INSULIN SAFETY SYRINGE, INSULIN SYRINGE PARADIGM PRODIGY INSULIN SYRINGE PRO COMFORT INSULIN SYRINGE PURE COMFORT PEN NEEDLE SAFETYGLIDE INSULIN SYRINGE, SYRINGE SURE COMFORT SURE COMFORT INSULIN SYRINGE TOPCARE ULTRA COMFORT TRUE COMFORT INSULIN SYRINGE TRUE COMFORT PRO INS SYRINGE TRUE METRIX LEVEL 1, 2, 3 CONTROL SOULTION TRUEPLUS SYRINGE TRUETRACK BLOOD GLUCOSE SYSTEM ULTICARE ULTIGUARD SAFE0.5ML 30G 12.7MM ULTIGUARD SAFEPK 0.5ML 31G 8MM ULTRACARE INSULIN SYRINGE ULTRA COMFORT ULTRA FLO INSULIN SYRINGE ULTRA-THIN II VANISHPOINT VANISHPOINT INSULIN SYRINGE VEO INSULIN SYRINGE
EAR MEDICATIONS
CIPRO HC
CIPRODEX CIPROFLOXACIN HCL- FLUOCINOLONE CORTISPORIN-TC DERMOTIC OTOVEL
ERECTILE DYSFUNCTION
sildenafil^ (QL) tadalafil^ (QL) vardenafil^ (QL)
MUSE^ (PA, QL)
CIALIS^ (QL, ST) STENDRA^ (QL, ST) VIAGRA^ (QL, ST)
EYE CONDITIONS AZASITE BESIVANCE BETOPTIC S BROMSITE COMBIGAN EYSUVIS (QL) INVELTYS FLAREX FML FORTE 0.25% EYE DROPS FML S.O.P. 0.1% OINTMENT LOTEMAX 0.5% EYE OINTMENT LOTEMAX SM 0.38% OPHTHALMIC GEL LOTEMAX SM SIMBRINZA
bepotastine bimatoprost (QL) brimonidine brimonidine tartrate- timolol brinzolamide ciprofloxacin cyclosporine difluprednate dorzolamide- timolol erythromycin fluorometholone ketorolac ketorolac solution latanoprost loteprednol moxifloxacin eye drops
ACUVAIL ALREX CEQUA CYSTADROPS* (PA, QL) CYSTARAN* (PA, QL) ILEVRO LOTEMAX NEVANAC OXERVATE* (PA) PROLENSA
RHOPRESSA ROCKLATAN TRUSOPT ZIRGAN ZYLET
12
Cigna Healthcare Standard 4-Tier Prescription Drug List Injectable specialty medications are covered on Tier 4 (listed on pages 20-23).
TIER 1 $
TIER 2 $$ TIER 3 $$$ GASTROINTESTINAL/HEARTBURN (cont.)
TIER 1 $
TIER 2 $$
TIER 3 $$$
EYE CONDITIONS (cont.)
mesalaminex mesalamine dr mesalamine er metoclopramide solution, tablet misoprostol 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+ prochlorperazine tablet promethazine promethegan rabeprazole tablet (QL) scopolamine sucralfate AMABELZ budesonide dr budesonide ec budesonide er (PA, QL) cabergoline (QL) desmopressin dexamethasone intensol DOTTI (QL) estradiol 10mcg vaginal insert (QL) estradiol (twice weekly) (QL) estradiol- norethindrone EUTHYROX
SYMPROIC (PA) TRANSDERM-SCOP URSO URSO FORTE VARUBI (PA, QL) VIOKACE XERMELO* (PA)
neomycin- polymyxin b-dexamethasone ofloxacin polymyxin b sulfate-
TOBRADEX ST XIIDRA ZERVIATE
trimethoprim prednisolone timolol tobramycin tobramycin- dexamethasone travoprost GYNAZOLE 1 miconazole 3 200 mg terconazole
FEMININE PRODUCTS
GASTROINTESTINAL/HEARTBURN
ANUCORT-HC balsalazide constulose cinacalcet* DEXLANS- OPRAZOLE DR (QL) dicyclomine capsule, solution, tablet dronabinol esomeprazole 20 mg capsule, 40 mg capsule, packets (QL) famotidine 40 mg/5 ml suspension, 20 mg tablet, 40 mg tablet GAVILYTE-C+ GAVILYTE-G+ glycopyrrolate HEMMOREX-HC hydrocortisone lactulose lansoprazole (QL) lubiprostone
CLENPIQ+ DEXILANT (QL) DEXILANT DR 30 MG CAPSULE (QL) ENTYVIO *^ (PA) LINZESS LITHOSTAT NEXIUM DR 2.5 MG PACKET (QL) NEXIUM DR 5 MG PACKET (QL) PANCREAZE SUTAB+ TRULANCE VIBERZI
APRISO BONJESTA CANASA CARAFATE CHOLBAM* (PA) CUVPOSA CYTOTEC DEXILANT DR 60 MG CAPSULE (QL) DICLEGIS LEVBID ER LEVSIN 0.125 MG TABLET LEVSIN-SL MOTOFEN MOVANTIK (PA) NULEV OCALIVA* (PA) PREVACID DR 30 MG CAPSULE (QL, ST) PROTONIX (QL, ST) RAVICTI* (PA) RECTIV RELISTOR (PA) SANCUSO (PA, QL) SFROWASA SUCRAID* (PA)
HORMONAL AGENTS
ANDRODERM (PA, QL) COMBIPATCH DUAVEE ESTROGEL ESTRING (QL) INTRAROSA MEDROL 2 MG TABLET MYFEMBREE (QL) ORIAHNN (PA, QL) ORILISSA (PA, QL) OSPHENA (QL) PREMARIN TABLET, VAGINAL CREAM
ACTIVELLA ANDROGEL (PA, QL) ANGELIQ AYGESTIN BIJUVA CRINONE 4% (PA) CYTOMEL DEPO- TESTOSTERONE EVAMIST INTRAROSA (QL) ISTURISA* (PA, QL) MEDROL 8MG, 16MG, 32MG TABLET MEDROL 4 MG DOSEPAK
APPLICATOR PREMPHASE
13
Cigna Healthcare Standard 4-Tier Prescription Drug List Injectable specialty medications are covered on Tier 4 (listed on pages 20-23).
TIER 1 $
TIER 2 $$ TIER 3 $$$ HORMONAL AGENTS (cont.)
TIER 1 $
TIER 2 $$
TIER 3 $$$
INFECTIONS (cont.)
fyremadel^ (PA) LEVO-T levothyroxine tablet LEVOXYL liothyronine LYLLANA (QL) medroxy- progesterone methyl- prednisolone millipred MIMVEY norethindrone NP THYROID prednisone prednisone intensol prednisolone solution prednisolone odt prednisolone sodium phosphate progesterone tablet testosterone cypionate YUVAFEM (QL)
PREMPRO
MENOSTAR (QL) PROMETRIUM RAYALDEE
cephalexin ciprofloxacin clarithromycin clarithromycin er clindamycin clindamycin (pediatric) coremino (QL) dapsone tablets doxycycline monohydrate EMVERM entecavir* (QL) erythromycin erythromycin ethylsuccinate chloroquine itraconazole levofloxacin solution, tablet methenamine metronidazole gel, capsule, tablet minocycline minocycline er tablet (QL) mondoxyne nl nitazoxanide nitrofurantoin nitrofurantoin monohydrate- macrocrystal nystatin suspension, tablet oseltamivir (QL) penicillin v potassium permethrin 5% cream posaconazole tablet sulfamethoxazole- trimethoprim suspension, tablet famciclovir fluconazole flucytosine fosfomycin hydroxy-
XIFAXAN (QL)
CLINDESSE DARAPRIM* (PA) DIFICID (QL) ELIMITE ERYPED 200 ERY-TAB DR 250 MG, 500 MG TABLET EURAX 10* LOTION FLAGYL HIPREX KITABIS PAK* (PA, QL) LIVTENCITY* (PA, QL) MACROBID MACRODANTIN MALARONE (PA) MONUROL NATROBA NUZYRA 150 MG TABLET* (PA,QL) PLAQUENIL (PA) posaconazole suspension PREVYMIS TABLET* PRIFTIN SIVEXTRO 200 MG TABLET (PA) SKLICE sulfatrim TAMIFLU (QL) URIBEL VALTREX VFEND (PA) VIEKIRA PAK* (PA,QL) XENLETA (PA, QL) XOFLUZA (QL) ZEPATIER* (PA, QL) ZITHROMAX ZITHROMAX TRI- PAK ZYVOX SUSPENSION, TABLET (PA)
teriparatide* UNITHROID
INFECTIONS
acyclovir capsule, suspension, tablet albendazole
BARACLUDE SOLUTION* e.e.s. 400
AEMCOLO (QL) ALINIA ANCOBON ARIKAYCE* (PA) BACTRIM BACTRIM DS BAXDELA 450 MG TABLET (PA) CAYSTON* (PA, QL) CIPRO 250MG, 500MG TABLET CIPRO TABLET CLEOCIN PEDIATRIC CLEOCIN 150, 300 MG CAPSULE CLEOCIN 100 MG VAGINAL OVULE CLEOCIN 2% VAGINAL CREAM
amoxicillin amoxicillin- clavulanate er
EPCLUSA* (PA, QL) EURAX 10% CREAM FIRVANQ HARVONI* (PA, QL) LAGEVRIO (EUA) (QL) SOVALDI* (PA, QL) THALOMID* (PA) TOBI PODHALER* (PA, QL) VEMLIDY* VIBRAMYCIN 50 MG/5 ML SYRUP VOSEVI* (PA, QL) PAXLOVID (QL) PEGASYS* (PA)
amoxicillin- clavulanate atovaquone atovaquone- proguanil AVIDOXY azithromycin packet, suspension, tablet cefadroxil cefdinir cefpodoxime cefuroxime tablet
terbinafine tetracycline
14
Cigna Healthcare Standard 4-Tier Prescription Drug List Injectable specialty medications are covered on Tier 4 (listed on pages 20-23).
TIER 1 $
TIER 2 $$
TIER 3 $$$
TIER 1 $
TIER 2 $$
TIER 3 $$$
INFECTIONS (cont.)
MISCELLANEOUS (cont.)
tobramycin ampule* (PA,QL) valacyclovir valganciclovir vancomycin capsule, solution vandazole voriconazole (PA)
KIMONO MAXX+ (QL) KIMONO MICROTHIN AQUA LUBE+ (QL) KIMONO MICROTHIN+ (QL) KIMONO TEXTURED+ (QL) MICROLET NOVAMAX PLUS ONETOUCH LANCETS POGO AUTOMATIC TEST CARTRIDGE PRECISION XTRA sapropterin* (PA) sodium chloride inhalation vial, irrigation solution vial TECHLITE LANCETS TRUEPLUS KETONE TEST STRIP TRUSTEX+ (QL) TRUSTEX CONDOM+ (QL) TRUSTEX LATEX CONDOM+ (QL) TRUSTEX-RIA+ (QL)
POCKET CHAMBER (QL) PROCARE SPACER WITH CHILD MASK (QL) RITEFLO (QL) SPACE CHAMBER (QL) SPACE CHAMBER- MEDIUM MASK (QL) SPACE CHAMBER- SMALL MASK (QL) VORTEX (QL) VORTEX VHC FROG MASK (QL) VORTEX VHC LADYBUG MASK (QL)
INFERTILITY clomiphene ^ ENDOMETRIN^ PREGNYL*^ (PA)
CHORIONIC GONADOTROPIN 10,000 UNIT VIAL*^ (PA) CRINONE 8%^ (PA)
MISCELLANEOUS
ACCU-CHEK FASTCLIX LANCET DRUM ACCU-CHEK MULTICLIX LANCETS ACCU-CHEK SAFE- T-PRO 23G LANCETS ACCU-CHEK CONDOMS+ (QL) deferiprone* (PA) disulfiram DROPLET LANCETS DUREX AVANTI BARE REAL FEEL+ (QL) FANTASY+ (QL) FORA GTEL KETONE TEST STRIP GOJJI BLOOD KETONE TEST STRIP KETONE CARE TEST STRIP SOFTCLIX LANCETS AIMSCO+ (QL) cinacalcet* KETONE TEST STRIP KETOSTIX REAGENT KIMONO+ (QL)
ACE AEROSOL CLOUD
ADDYI^ (PA, QL) AUSTEDO* (PA) BRISDELLE (QL) EVRYSDI* (PA) GALAFOLD* HYPER-SAL INGREZZA INITIATION PACK* (PA, QL) INGREZZA* (PA) NUEDEXTA (QL) ORFADIN* (PA) PALYNZIQ* (PA) PRO COMFORT SPACER WITH MASK (QL) RADICAVA ORS* (PA,QL) TIGLUTIK* (PA) VYNDAMAX* (PA, QL)
ENHANCER (QL) AEROCHAMBER MINI (QL) AEROCHAMBER MV (QL) AEROCHAMBER PLUS FLOW-VU (QL) AEROCHAMBER Z-STAT PLUS (QL) AEROTRACH PLUS (QL) AEROVENT PLUS (QL) BREATHRITE (QL) CERDELGA* (PA) CLEVER CHOICE HOLDING CHAMBER (QL) COMPACT SPACE CHAMBER (QL) EASIVENT (QL) ESBRIET* (PA) FLEXICHAMBER (QL) MICROCHAMBER (QL) NITYR* (PA) OPTICHAMBER DIAMOND (QL)
MULTIPLE SCLEROSIS
dalfampridine er* (PA) dimethyl fumarate*
BAFIERTAM* (PA) GILENYA* (PA) MAYZENT* (PA) VUMERITY* (PA) ZEPOSIA* (PA)
FIRDAPSE* (PA,QL) MAVENCLAD* (PA) PONVORY* (PA)
NUTRITIONAL/DIETARY
betaine anhydrous* cyanocobalamin injection dodex fluoride+^ folic acid+^ folic acid capsule, tablet+ folitab 500+ klor-con KLOR-CON 8 MEQ
CITRANATAL ASSURE CITRANATAL B-CALM CITRANATAL DHA CITRANATAL HARMONY CITRANATAL RX FLORIVA CHEWABLE TABLET+
ACCRUFER^ AURYXIA (QL) CITRANATAL BLOOM^ DRISDOL^ K-TAB ER OB COMPLETE^ PHOSLYRA PRENATAL FORMULA-DHA+ ROCALTROL^
15
Cigna Healthcare Standard 4-Tier Prescription Drug List Injectable specialty medications are covered on Tier 4 (listed on pages 20-23).
TIER 1 $
TIER 2 $$ TIER 3 $$$ NUTRITIONAL/DIETARY (cont.)
TIER 1 $ TIER 3 $$$ PAIN RELIEF AND INFLAMMATORY DISEASE (cont.) celecoxib (QL) colchicine 0.6 mg tablet TIER 2 $$
KLOR-CON 10 MEQ KLOR-CON M10 TABLET lanthanum MULTI-VITAMIN W-FLUORIDE- IRON+ potassium chloride 10%, capsule, packet, tablet sevelamer sodium fluoride+^ taron-prex prenatal^ vitamin d2 1.25 mg (50,000 unit)^ VITAMINS A,C,D AND FLUORIDE+
FOSRENOL 1,000 MG POWDER PACK FOSRENOL 750 MG POWDER PACKET LOKELMA NEEVO DHA^ OB COMPLETE ONE OB COMPLETE PETITE OB COMPLETE PREMIER OB COMPLETE WITH DHA 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+
TRI-VI-FLOR+ VELPHORO VELTASSA
HYSINGLA ER (PA) LICART (PA, QL) MITIGARE NUCYNTA (PA) NURTEC ODT (PA, QL) OTEZLA* (PA, QL) OTREXUP (PA) PROCTOFOAM-HC QULIPTA (PA, QL) REDITREX (PA) RINVOQ* (PA, QL) SAVELLA TRUDHESA (PA,QL) UBRELVY (PA, QL) XELJANZ* (PA, QL) XELJANZ XR* (PA, QL) XTAMPZA ER (PA) ZTLIDO
BUTRANS (QL) CELEBREX (QL, ST) DEPEN* (PA, QL) EC-NAPROSYN (ST) FEXMID KEVZARA* (PA, QL) KINERET* (PA,QL) NAPROSYN (ST) NUCYNTA ER (PA) OLUMIANT* (PA, QL) OTREXUP (PA) PERCOCET (PA) PROCORT REMICADE*^ (PA) ROXYBOND (PA) ZANAFLEX ZEBUTAL (QL) ZOHYDRO ER (PA)
cyclobenzaprine diclofenac 1% gel, tablet (QL) diclofenac dr diclofenac ec EC-NAPROXEN ECOTRIN EC 81 MG TABLET+ eletriptan (QL) ENDOCET (PA) febuxostat (QL) fentanyl patch (PA) frovatriptan (QL) FIORICET (QL) GLYDO hydrocodone- acetaminophen (PA) hydromorphone (PA) hydromorphone er (PA) IBU ibuprofen indomethacin indomethacin er ketorolac tromethamine (QL) leflunomide lidocaine patch, ointment, solution (QL) meloxicam tablet metaxalone methocarbamol MORPHINE (PA) MORPHINE ER (PA) nabumetone NALOCET (PA) oxycodone (PA) oxycodone er (PA) oxycodone- acetaminophen (PA)
OSTEOPOROSIS PRODUCTS
alendronate ibandronate 150 mg tablet raloxifene+ risedronate risedronate dr
ACTONEL (ST) ATELVIA (ST) BINOSTO (ST) BONIVA (ST) EVISTA
PAIN RELIEF AND INFLAMMATORY DISEASE
acetaminophen- codeine (PA) allopurinol tablet baclofen tablet buprenorphine patch (QL) butalbital- acetaminophen-
AIMOVIG (PA) AJOVY (PA)
ANALPRAM HC ARAVA BUTRANS (QL) CELEBREX (QL, ST) DEPEN* (PA, QL) EC-NAPROSYN (ST) FEXMID KEVZARA* (PA, QL) ANALPRAM HC ARAVA
BELBUCA (QL) EMGALITY (PA) FLECTOR (PA, QL) AIMOVIG (PA) AJOVY (PA) BELBUCA (QL) EMGALITY (PA) FLECTOR (PA, QL)
caffeine (QL) carisoprodol
16
Cigna Healthcare Standard 4-Tier Prescription Drug List Injectable specialty medications are covered on Tier 4 (listed on pages 20-23).
TIER 1 $ TIER 3 $$$ PAIN RELIEF AND INFLAMMATORY DISEASE (cont.) penicillamine* (PA, QL) PROLATE TABLET (PA) rizatriptan (QL) TIER 2 $$
TIER 1 $
TIER 2 $$ TIER 3 $$$ SEIZURE DISORDERS (cont.)
EPITOL gabapentin lacosamide lamotrigine
BRIVIACT TABLET (PA) CARBATROL (PA) DEPAKOTE (PA) DEPAKOTE ER (PA) DEPAKOTE SPRINKLE (PA) DIASTAT (PA) EPIDIOLEX* (PA) FINTEPLA* (PA) KLONOPIN (PA) LYRICA ORAL SOLUTION (PA) NEURONTIN (PA) OXTELLAR XR (PA) PHENYTEK (PA) SPRITAM (PA) TEGRETOL XR (PA) VALTOCO (PA, QL) XCOPRI (PA, QL)
lamotrigine (blue) lamotrigine (green) lamotrigine (orange) lamotrigine er
sumatriptan (QL) sumatriptan succ- naproxen sod (QL) tramadol 50 mg tablet (QL) tramadol er (QL) VANADOM
lamotrigine odt lamotrigine odt (blue) lamotrigine odt (green) lamotrigine odt (orange) levetiracetam
PARKINSON’S DISEASE
benztropine tablet carbidopa- levodopa carbidopa- levodopa er pramipexole (QL) pramipexole er (QL) rasagiline (QL) ropinirole er ropinirole
KYNMOBI (PA)
AZILECT (QL) INBRIJA* (PA) MIRAPEX ER (QL) NEUPRO NOURIANZ* (PA, QL) OSMOLEX ER (QL) RYTARY SINEMET 10-100 SINEMET 25-100 XADAGO (ST)
solution, tablet levetiracetam er pregabalin capsule, solution ROWEEPRA rufinamide (PA,QL) SUBVENITE SUBVENITE (BLUE) SUBVENITE (GREEN)
SCHIZOPHRENIA/ANTI-PSYCHOTICS 2
SUBVENITE (ORANGE) topiramate topiramate er vigabatrin* vigadrone*
aripiprazole (QL) aripiprazole odt asenapine chlorpromazine tablet clozapine clozapine odt olanzapine tablet olanzapine odt paliperidone er (QL) quetiapine quetiapine er risperidone risperidone odt ziprasidone tablet carbamazepine carbamazepine er clonazepam divalproex divalproex er
LATUDA (QL) REXULTI (QL, ST)
CAPLYTA (QL, ST) CLOZARIL (ST) FANAPT (QL, ST) INVEGA (QL, ST) RISPERDAL (ST) SAPHRIS (ST) SECUADO (ST) SEROQUEL (ST) SEROQUEL XR (ST) VRAYLAR (QL, ST)
SKIN CONDITIONS
ACCUTANE adapalene-benzoyl peroxide AMNESTEEM AVAR CLEANSER azelaic acid betamethasone diprop augmented betamethasone dipropionate BP 10-1 calcipotriene cream, ointment, solution
CIBINQO* (PA,QL) DRYSOL EUCRISA (ST)
ANALPRAM HC 2.5%-1% LOTION AVAR 9.5-5% CLEANSING PADS BRYHALI (ST) CALCIPOTRIENE FOAM CAPEX SHAMPOO (ST) CLEOCIN T CLINDACIN ETZ KIT CLINDACIN PAC KIT CLODERM (ST) DOVONEX EFUDEX
NAFTIN PICATO SANTYL (QL)
SEIZURE DISORDERS
FYCOMPA (PA,QL) NAYZILAM (PA, QL)
APTIOM (PA,QL) BANZEL (PA, QL) BRIVIACT 10 MG/ML ORAL SOLUTION (PA)
17
Cigna Healthcare Standard 4-Tier Prescription Drug List Injectable specialty medications are covered on Tier 4 (listed on pages 20-23).
TIER 1 $
TIER 2 $$
TIER 3 $$$
TIER 1 $
TIER 2 $$ TIER 3 $$$ SLEEP DISORDERS/SEDATIVES
SKIN CONDITIONS (cont.)
armodafinil (PA) doxepin (QL) eszopiclone modafinil (PA) temazepam zolpidem zolpidem tartrate er (QL)
DAYVIGO (QL, ST) SUNOSI (PA, QL)
HETLIOZ LQ* (PA) HETLIOZ* (PA) WAKIX* (PA, QL) XYREM* (PA, QL) XYWAV* (PA, QL)
CLARAVIS CLINDACIN ETZ 1% PLEDGET CLINDACIN P 1% PLEDGETS CLINDAMYCIN 1% FOAM, GEL, LOTION, PLEDGET, SOLUTION clindamycin- benzoyl peroxoxide clindamycin tretinoin clobetaso CLOCORTOLONE PIVALATE CLODAN clotrimazole- betamethasone dapsone 5% gel, 7.5% gel pump DROPSAFE PREP PADS fluorouracil cream, topical solution isotretinoin ketoconazole KETODAN metronidazole MYORISAN NEUAC GEL pimecrolimus ROSADAN sodium sulfacetamide- sulfur tacrolimus ointment tazarotene 0.1% cream tretinoin (PA) SSS 10-5 SULFACLEANSE 8-4 TRIDERM
EVOCLIN OPZELURA (PA) PLEXION PRAMOSONE 2.5%-1% CREAM, LOTION REGRANEX (PA, QL) TEMOVATE (ST) TWYNEO VECTICAL (QL) XEPI
SMOKING CESSATION 2
bupropion sr+^ NICOTROL NS+^ NICOTROL+^
APO-VARENICLINE NICODERM CQ+ VARENICLINE+^
SUBSTANCE ABUSE
buprenorphine- naloxone naltrexone hcl (QL)
KLOXXADO (QL) LUCEMYRA (QL) NARCAN (QL) ZUBSOLV
SUBOXONE ZIMHI (QL)
TRANSPLANT MEDICATIONS
everolimus 0.25 mg tablet* everolimus 0.5 mg tablet* mycophenolate mofetil* mycophenolic acid* sirolimus* tacrolimus*
ASTAGRAF XL* CELLCEPT ORAL SUSPENSION, TABLET* ENVARSUS XR* IMURAN* MYFORTIC* NEORAL* PROGRAF 0.2 MG GRANULE PACKET* PROGRAF 0.5 MG CAPSULE* PROGRAF 1 MG CAPSULE* PROGRAF 1 MG GRANULE PACKET* PROGRAF 5 MG CAPSULE* RAPAMUNE* REZUROCK* (PA) ZORTRESS*
URINARY TRACT CONDITIONS
alfuzosin er cevimeline finasteride oxybutynin
CYSTAGON* ELMIRON K-PHOS ORIGINAL
FLOMAX PROSCAR PYRIDIUM RAPAFLO (QL)
VALCHLOR* ZENATANE
18
Cigna Healthcare Standard 4-Tier Prescription Drug List Injectable specialty medications are covered on Tier 4 (listed on pages 20-23).
TIER 1 $
TIER 2 $$ TIER 3 $$$ URINARY TRACT CONDITIONS (cont.)
TIER 1 $
TIER 2 $$
TIER 3 $$$
VACCINES (cont.) 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. PEDVAXHIB+ PEDIARIX+ PEDVAXHIB+ PENTACEL+ PFIZER COVID (6M-4Y) VACCINE (EUA)+ PFIZER COVID (12Y UP) VAC(EUA)+
oxybutynin er phenazopyridine potassium er silodosin (QL) solifenacin (QL) tamsulosin tolterodine tolterodine er (QL) trospium trospium er
UROCIT-K UROXATRAL
VACCINES 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. ACTHIB+ ADACEL TDAP+ BEXSERO+ BOOSTRIX TDAP+ COMIRNATY+ DAPTACEL DTAP+
PFIZER COVID-19 VACCINE (EUA)+ PNEUMOVAX 23+ PREHEVBRIO+ PREVNAR 13+ PREVNAR 20+ PROQUAD+ QUADRACEL DTAP- IPV+ RECOMBIVAX HB+
DENGVAXIA+ DIPHTHERIA- TETANUS TOXOIDS-PED+ ENGERIX-B ADULT+ ENGERIX-B PEDIATRIC- ADOLESCENT+ GARDASIL 9+ HEPLISAV-B+ HIBERIX+ INFANRIX DTAP+ IPOL+ JANSSEN COVID-19 VACCINE (EUA)+ KINRIX+ MENACTRA+ MENQUADFI+ MENVEO A-C-Y-W- 135-DIP+ NOVAVAX COVID-19 VACCINE, ADJ (EUA)+ PEDIARIX+
SHINGRIX+ (QL) SPIKEVAX COVID (18Y UP) VACCINE+ TDVAX+ TENIVAC+ TRUMENBA+ TWINRIX+ VARIVAX VACCINE+ VAXELIS+ VAXNEUVANCE+ VITAMINS POLY-VI-FLOR+ POLY-VI-FLOR WITH IRON+ WEIGHT MANAGEMENT
megestrol suspension phentermine^
WEGOVY^ (PA, QL) CONTRAVE^ (PA) IMCIVREE*^ (PA,QL) QSYMIA^ (PA) SAXENDA^ (PA)
19
Injectable specialty medications The medications listed below are covered on Tier 4.
MEDICATION NAME
DRUG CLASS
ACTEMRA SYRINGE (PA, QL) ACTEMRA ACTPEN (PA, QL)
Pain Relief and Inflammatory Disease Pain Relief and Inflammatory Disease
ACTIMMUNE (PA)
Cancer
ADALIMUMAB-ADAZ (CF) (PA, QL)
Pain Relief and Inflammatory Disease
ADBRY (PA)
Skin Conditions
ADVATE^ (PA)
Blood Modifiers/Bleeding Disorders Blood Modifiers/Bleeding Disorders Blood Modifiers/Bleeding Disorders Pain Relief and Inflammatory Disease Blood Modifiers/Bleeding Disorders
ADYNOVATE^ (PA) AFSTYLA^ (PA) ARACALYST (PA) ARANESP^ (PA)
AVONEX (PA)
Multiple Sclerosis Multiple Sclerosis
AVONEX PEN (PA) AVSOLA^ (PA) BENLYSTA* (PA) BETASERON (PA) BYNFEZIA (PA) CABENUVA^ (PA)
Pain Relief and Inflammatory Disease Pain Relief and Inflammatory Disease
Multiple Sclerosis Multiple Sclerosis
AIDS/HIV
CABLIVI^ (PA)
Blood Modifiers/Bleeding Disorders
CETROTIDE^ (PA)
Hormonal Agents
chorionic gonadotropin^ (PA)
Infertility
CIMZIA (PA, QL)
Pain Relief and Inflammatory Disease Pain Relief and Inflammatory Disease Pain Relief and Inflammatory Disease Pain Relief and Inflammatory Disease Pain Relief and Inflammatory Disease Pain Relief and Inflammatory Disease Pain Relief and Inflammatory Disease
COSENTYX (2 SYRINGES) (PA, QL)
COSENTYX SENSOREADY (2 PENS) (PA, QL) COSENTYX SENSOREADY PEN (PA, QL)
COSENTYX SYRINGE (PA, QL)
CYLTEZO (PA, QL) DUPIXENT (PA)
EGRIFTA (PA)
Hormonal Agents
ELOCTATE^ (PA) EMPAVELI (PA) ENBREL (PA, QL) ENTYVIO^ (PA) EPOGEN^ (PA) ESPEROCT^ (PA)
Blood Modifiers/Bleeding Disorders Blood Modifiers/Bleeding Disorders Pain Relief and Inflammatory Disease
Gastrointestinal/Heartburn
Blood Modifiers/Bleeding Disorders Blood Modifiers/Bleeding Disorders
EXTAVIA (PA)
Multiple Sclerosis
FASENRA PEN (PA)
Asthma/COPD/Respiratory
20
Injectable specialty medications (Cont.) The medications listed below are covered on Tier 4.
MEDICATION NAME
DRUG CLASS
FENSOLVI^ (PA)
Hormonal Agents
FOLLISTIM AQ^ (PA)
Infertility
FRAGMIN* (QL) FULPHILA (PA)
Blood Thinners/Anti-Clotting
Blood Modifiers/Bleeding Disorders
GANIRELIX^ GATTEX (PA)
Hormonal Agents
Gastrointestinal/Heartburn
GENOTROPIN (PA)
Hormonal Agents Multiple Sclerosis Multiple Sclerosis
glatiramer (PA)
glatopa (PA)
GRANIX^
Blood Modifiers/Bleeding Disorders Blood Presssure/Heart Medications Blood Modifiers/Bleeding Disorders Pain Relief and Inflammatory Disease Pain Relief and Inflammatory Disease Pain Relief and Inflammatory Disease Pain Relief and Inflammatory Disease
HAEGARDA (PA) HEMLIBRA (PA) HUMIRA (PA, QL) HYRIMOZ (PA, QL)
ILARIS^ (PA)
ILUMYA (PA, QL) INCRELEX (PA) INFLECTRA (PA) INFLIXIMAB^ (PA)
Hormonal Agents
Pain Relief and Inflammatory Disease Pain Relief and Inflammatory Disease Blood Modifiers/Bleeding Disorders Blood Modifiers/Bleeding Disorders
JIVI^ (PA)
KALBITOR^ (PA) KESIMPTA PEN (PA) KEVZARA (PA, QL) KINERET (PA, QL) KOGENATE FS^ (PA)
Multiple Sclerosis
Pain Relief and Inflammatory Disease Pain Relief and Inflammatory Disease Blood Modifiers/Bleeding Disorders Blood Modifiers/Bleeding Disorders
KOVALTRY^ (PA)
LANREOTIDE ACETATE^ (PA) LUPRON DEPOT-PED^ (PA)
Hormonal Agents Hormonal Agents
MIRCERA^ (PA) MYALEPT (PA) NATPARA (PA) NEULASTA (PA)
Blood Modifiers/Bleeding Disorders
Miscellaneous
Hormonal Agents
Blood Modifiers/Bleeding Disorders Blood Modifiers/Bleeding Disorders Blood Modifiers/Bleeding Disorders Blood Modifiers/Bleeding Disorders Blood Modifiers/Bleeding Disorders
NEULASTA ONPRO^ (PA)
NEUPOGEN^ (PA) NIVESTYM^ (PA) NOVOEIGHT^ (PA)
21
Injectable specialty medications (Cont.) The medications listed below are covered on Tier 4.
MEDICATION NAME
DRUG CLASS
NUCALA (PA) NUWIQ^ (PA)
Asthma/COPD/Respiratory
Blood Modifiers/Bleeding Disorders Blood Modifiers/Bleeding Disorders
NYVEPRIA (PA) OMNITROPE (PA)
Hormonal Agents
ORENCIA SYRINGE (PA, QL)
Pain Relief and Inflammatory Disease
PALYNZIQ (PA) PEGASYS (PA) PHESGO^ (PA) PLEGRIDY (PA) PROCRIT^ (PA)
Miscellaneous
Infections
Cancer
Multiple Sclerosis
Blood Modifiers/Bleeding Disorders
REBIF (PA)
Multiple Sclerosis Multiple Sclerosis
REBIF REBIDOSE (PA) RECOMBINATE^ (PA)
Blood Modifiers/Bleeding Disorders Blood Modifiers/Bleeding Disorders Pain Relief and Inflammatory Disease Blood Modifiers/Bleeding Disorders Blood Presssure/Heart Medications Blood Presssure/Heart Medications
RELEUKO^ (PA) REMICADE^ (PA) RETACRIT^ (PA) RUCONEST^ (PA)
SAJAZIR (PA)
SANDOSTATIN^ (PA)
Hormonal Agents Hormonal Agents Hormonal Agents Hormonal Agents
SANDOSTATIN LAR^ (PA)
SEROSTIM (PA)
SIGNIFOR LAR^ (PA)
SILIQ (PA, QL)
Pain Relief and Inflammatory Disease Pain Relief and Inflammatory Disease Pain Relief and Inflammatory Disease Pain Relief and Inflammatory Disease
SIMPONI (PA, QL) SIMPONI ARIA (PA) SKYRIZI (PA, QL) SKYTROFA (PA, QL)
Hormonal Agents Hormonal Agents Hormonal Agents
SOMATULINE DEPOT^ (PA)
SOMAVERT (PA)
STELARA SYRINGE, 45MG/0.5ML VIAL (PA, QL)
Pain Relief and Inflammatory Disease
STRENSIQ (PA) TAKHZYRO (PA) TALTZ (PA, QL) TEGSEDI (PA) TEZSPIRE* (PA)
Miscellaneous
Blood Presssure/Heart Medications Pain Relief and Inflammatory Disease
Miscellaneous
Asthma/COPD/Respiratory
22
Injectable specialty medications (Cont.) The medications listed below are covered on Tier 4.
MEDICATION NAME
DRUG CLASS
TREMFYA (PA, QL) UDENYCA^ (PA) VOXZOGO^ (PA) VYLEESI^ (PA, QL)
Pain Relief and Inflammatory Disease Blood Modifiers/Bleeding Disorders
Miscellaneous Miscellaneous
XOLAIR (PA)
Asthma/COPD/Respiratory
XYNTHA^ (PA)
Blood Modifiers/Bleeding Disorders Blood Modifiers/Bleeding Disorders Blood Modifiers/Bleeding Disorders Blood Modifiers/Bleeding Disorders
XYNTHA SOLOFUSE^ (PA)
ZARXIO^
ZIEXTENZO (PA) ZORBTIVE (PA)
Hormonal Agents
23
Frequently Asked Questions (FAQs) Understanding your prescription medication coverage can be confusing. Here are answers to some commonly asked questions.
Q. Why do you make changes to the drug list? A. To help make sure you have access to coverage for safe, clinically effective and low-cost medications, Cigna Healthcare regularly reviews and updates the prescription drug list. We make changes for many reasons – like when new medications become available or are no longer available, or when medication prices change. These changes may include : • Moving a medication to a lower cost tier. This can happen at any time during the year. • Moving a brand medication to a higher cost tier when a generic becomes available. This can happen at any time during the year. • Moving a medication to a higher cost tier and/or no longer covering a medication. This typically happens twice a year on January 1 st and July 1 st . • Adding extra coverage requirements to a medication. When we make a change that affects the coverage of a medication you’re taking, we let you know before it happens. This way, you have time to talk with your doctor about your options. Only you and your doctor can decide what’s best for your treatment . Q. Why doesn’t my plan cover certain medications? A. To help lower your overall health care costs, your plan doesn’t cover certain high-cost brand-name medications that have lower-cost alternatives. That’s because these lower-cost options work the same as, or similar to, the non-covered medication. If you’re taking a medication that isn’t covered and your doctor feels a different medication isn’t right for you, he or she can ask Cigna Healthcare to consider approving your medication through their coverage review process. There are also certain medications and products that cannot covered by your plan for any reason because they're considered to be a “plan or benefit exclusion.” This means the medication or product isn't on your plan's drug list, and there's no option to ask
Cigna Healthcare to consider approving it through their coverage review process. For example, your plan doesn’t cover, or "excludes," medications that aren’t approved by the U.S. Food and Drug Administration (FDA) . Q. How do you decide which medications to cover? A. The Cigna Healthcare Prescription Drug List is developed with the help of the Cigna Healthcare Pharmacy and Therapeutics (P&T) Committee, which is a group of practicing doctors and pharmacists, most of whom work outside of Cigna Healthcare. The group meets regularly to review medical evidence and information provided by federal agencies, drug manufacturers, medical professional associations, national organizations and peer-reviewed journals about the safety and effectiveness of medications that are newly approved by the FDA and medications already on the market. The Cigna Healthcare Health Plan Commercial Value Assessment Committee (HVAC) then looks at the results of the P&T Committee’s clinical review, as well as the medication’s overall value and other factors before adding it to, or removing it from, the drug list. Q. Why do certain medications need approval before my plan will cover them? A. The review process helps to make sure you’re receiving coverage for the right medication, at the right cost, in the right amount and for the right situation. Q. How do I know if I’m taking a medication that needs approval? A. Log in to the myCigna App or myCigna.com , or check your plan materials, to learn more about how your plan covers your medications. If your medication has a (PA) or (ST) next to it, your medication needs approval before your plan will cover it. If it has a (QL) next to it, you may need approval depending on the amount you’re filling. If it has (AGE) next to it, you may need approval depending on the covered age range for the medication.
24
Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Page 11 Page 12 Page 13 Page 14 Page 15 Page 16 Page 17 Page 18 Page 19 Page 20 Page 21 Page 22 Page 23 Page 24 Page 25 Page 26 Page 27 Page 28 Page 29 Page 30 Page 31Made with FlippingBook - professional solution for displaying marketing and sales documents online