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
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