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
Made with FlippingBook - professional solution for displaying marketing and sales documents online