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
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