cigna performance 3-tier prescription drug list · 2020-07-22 · 3-tier prescription drug list as...

The Performance Prescription Drug List lets you and your doctor choose medications that work best for you. The following is a list of the most commonly used medications covered under your plan.

This list is designed to cover your prescription medications at three levels. The amount you pay depends on the tier from which you and your doctor select your medication. If there is more than one medication appropriate for your condition, we suggest that you talk to your doctor about lower-cost choices like generic medications and preferred brand medications to see if they could be right for you.

874988 a 05/14

Offered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company or their affiliates.

PERFORMANCE prescription drug list

Prescription Drug List July 2014

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1st Tier – Generic Medications: Generic medications have the same ingredients, safety, dosage, quality and strength as their brand name counterparts. You will usually pay less for generic medications under your plan.

2nd Tier – Preferred Brand Medications: Preferred brand medications will usually cost more than a generic, but less than a non-preferred brand medication under your plan.

3rd Tier – Non-Preferred Brand Medications: Non-preferred brand medications are those that generally have generic alternatives and/or a preferred brand medication within the same drug class. You will usually pay more for a non-preferred brand under your plan.

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The symbols on the list mean

If a medication on the list has one of the following symbols, your doctor may need to get an authorization for coverage of that medication.

If you have any questions

Remember, this list is just a sample of the most commonly used medications. You can use the Prescription Drug Price Quote tool available on myCigna.com to see and compare the prices of all medications covered under your plan. Or, you can call the number on the back of your ID card to speak with a customer service representative at any time.

PA: Prior Authorization may be required for different reasons. To learn the requirements needed for coverage of a specific medication, feel free to give us a call.

QL: Quantity Limit means you may have coverage for a limited amount of a specific medication.

AGE: Age Requirement means an individual must be within a specific age group for a specific medication to be covered.

ST: Step Therapy is a prior authorization program that requires you to try other medications available to treat the same condition before the “ST” medication is covered.

* Medications marked with an asterisk are considered to be specialty medications. Some plans may cover specialty medications at different benefit levels or may require the use of a preferred specialty pharmacy. Refer to the your plan documents for more information.

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NoN-Preferred GeNerics Preferred BraNds BraNds

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amphetamineclonidine HCldexmethylphenidate HCldexmethylphenidate HCl ERdextroamphetaminedextroamphetamine/

amphetamine ERMetadate ER-

methylphenidate HClmethamphetaminemethylphenidate/

ER/ER 24 HRmodafanilprocentra

Adderall XRFocalin XRIntunivRitalin LAStratteraVyvanse

Adderall (PA, ST)Concerta (PA, ST)Daytrana (PA, ST)Desoxyn (PA, ST)Dexadrine (PA, ST)Focalin (PA, ST)KapvayMetadate CD (PA, ST)Methylin (PA, ST)NuvigilProvigilQuillivant XR (PA, ST)Ritalin (PA, ST)Ritalin SR (PA, ST)Zenzedi (PA, ST)

AIDS/HIV

abacavir*abacavir/lamivudine/

zidovudine*didanosine*lamivudine*lamivudine/zidovudine*nevirapine*stavudine*zidovudine*

Aptivus*Crixivan*Emtriva*Epzicom*Fuzeon* (PA)Invirase*Isentress*Kaletra*Lexiva*Norvir*Prezista*Rescriptor*Reyataz*Selzentry*Sustiva*Trizivir*Truvada*Viracept*Viramune XR*Viread*

Atripla*Combivir*Complera*Edurant*Epivir*Fulyzaq (PA)Intelence*Retrovir*Stribild*Videx*Viramune*Zerit*Ziagen*

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ALzHEIMER’S DISEASE

donepezil HClgalantamine hydrobromiderivastigmine tartrate capsules

Aricept (23 mg) Aricept (5 and 10 mg)Aricept ODTCognexExelonNamenda XRRazadyneRazadyne ER

ANXIETY

alprazolambuspironediazepamlorazepamoxazepam

Lorazepam IntensolNiravam

ASTHMA AND RESPIRATORY

albuterol sulfate (nebulizer solution)budesonide (nebulizer solution)caffeine citratecromolyn sodium (nebulizer solution)dyphyllineguaifenesin/dyphyllineguaifenesin/theophyllineipratropium bromide (nebulizer solution)

Advair, Advair HFAAsmanexAtrovent HFACombivent RespimatFlovent Diskus/HFAMaxairProAir HFAPulmicortPulmozyme* (PA)QvarSereventSpirivaSymbicort

AccolateAccuneb nebulizer (PA, ST)Adcirca* (PA)Adempas* (PA)AerospanAlvescoAnoro ElliptaArcaptaBreo Ellipta (ST)Brovana nebulizer (PA, ST)DalirespDuleraLetairis*

ALLERGY

azelastine nasalclemastine fumaratecyproheptadinecyproheptadine HCldesloratadineepinastineepinephrine (QL)flunisolide nasalfluticasone nasalhydroxyzineipratropium nasallevocetirizinemontelukasttriamcinolone nasal

AsteproEpipen (QL)Epipen Jr. (QL)NasonexVeramyst

Adrenaclick (QL)AstelinAtrovent (nasal)AUVI-Q (QL)Beconase AQ (PA, ST)Dymista (PA, ST)Flonase (PA, ST)Nasacort AQ (PA, ST)Omnaris (PA, ST)PatanaseQNASL (PA, ST)Rhinocort AQ (PA, ST)Semprex-DSingulairTavist SyrupXyzalZetonna (PA, ST)

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levalbuterol HCl (nebulizer solution)metaproterenol sulfate (syrup, tabs)montelukast sodiumracepinephine HClsildenafil* (PA)terbutaline sulfatetheophylline anhydrouszafirlukast

Ventolin HFAXolair* (PA)

LufyllinOpsumit* (PA)Orenitram ER* (PA)Perforomist (PA, ST)Proventil HFARevatio* (PA)S-2 RacepinephineSingulairTracleer*Tudorza Pressair (ST)Ventavis*Xopenex HFAXopenex nebulizer (PA, ST)

BIRTH CONTROL

AltaveraAlyacenAmethiaAmethia LoAmethystApriAranelleAubraAvianeAzuretteBalzivaBriellynCamilaCamreseCamrese LoCaziantChatealCryselleCyclafemDasettaDayseedesogestrel-ethinyl estradiolElinestEmoquetteEnpressEnskyceErrinEstaryllaethinyl estradiol/drospirenoneFalminaGianvi

BeYazLomedia 24 FELoSeasoniqueMinastrin 24 FENuvaRingOrtho EvraOrtho TriCyclen Lo

AngeliqBreviconCyclessaDepo-Provera SubqDesogenEllaEstrostep FEFem FEGeneress FELoestrinLoestrin FEMircetteModiconNataziaNordetteNorinyl 1+35Norinyl 1+50Nor-QDOrtho MicronorOrtho-CeptOrtho-CyclenOrtho-Novum 7-7-7Ortho-Tri-CyclenOvcon-35QuartetteSafyralSeasonaleSeasoniqueTri-NorinylYasmin 28Yaz

Please check your Summary Plan Description to determine whether these medications are covered under your specific plan.

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BIRTH CONTROL (CONTINUED)

GildagiaGildessHeatherIntrovaleJencyclaJolessaJunelJunel FEKarivaKelnorKurveloLarinLarin FELeenaLessinaLevonestlevonorgestrellevonorgestrel-ethestralevonorgestrel-ethin estradiolLevoral-norgest-eth estr/ethin estraLorynaLow-OgestrelLuteraLyzaMarlissaMicrogestinMicrogestin FEMono-LinyahMononessaMyzilraNeconNext ChoiceNora-Benoreth a-et estra/fe fumaratenorethindronenorgestimate-ethinyl estradiolnorgestrel-ethinyl estradiolNortrelOcellaOgestrelOrsythiaPhilithPimtreaPirmellaPortia


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PrevifemQuasenseReclipsenSprintecSronyxSyedaTilia FETri-EstaryllaTri-Legest FETri-LinyahTrinessaTri-PrevifemTri-SprintecTrivoraVelivetVesturaVioreleVyfemlaWeraWymzya FEZarahZenchentZeosaZovia

BLADDER PROBLEMS

flavoxateoxybutynin/XLpotassium citrate ERtolterodine tartratetrospium chloride

Detrol LAElmironToviazVESIcare

Detrol (PA,ST)Ditropan, Ditropan XL (PA,ST)Enablex (PA,ST)Gelnique (PA,ST)Myrbetriq (PA,ST)Oxytrol (PA,ST) (men only)Sanctura, Sanctura XR (PA,ST)

CANCER

anastrozoleazacitidine*bicalutamide*capecitabineexemestaneflutamide*letrozolelomustinetamoxifen citratetemozolomide* (PA)

Gleevec* (PA)Granix*Hexalen*LeukeranLupron Depot* (PA)LysodrenMatulane*MyleranNeulasta* (PA)Neupogen* (PA)

Afinitor* (PA)Afinitor Disperz* (PA)ArimidexAromasinBosulif* (PA)Caprelsa* (PA)Casodex*Cometriq* (PA)DroxiaErivedge* (PA)


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HIGH BLOOD PRESSURE/HEART MEDICATIONS

acebutolol HClacetazolamideamiloride HClamlodipine/atorvastatin

calciumamlodipine besylateamlodipine besylate/

benazeprilapresolineatenolol

BenicarBenicar HCTBystolicCoreg CRDiovanExforgeExforge HCTTarkaTekturnaTekturna HCT

Accupril (PA,ST)Accuretic (PA,ST)Aceon (PA,ST)Altace (PA,ST)AmturnideAtacand (PA, ST)Avalide (PA, ST)Avapro (PA, ST)AzorBetapace AF

CANCER (CONTINUED)

Nexavar* (PA)Revlimid* (PA)Sprycel* (PA)Sutent* (PA)Tarceva* (PA)Thalomid* (PA)Xeloda*Zolinza* (PA)

FarestonFemaraGilotrif (PA)Imbruvica* (PA)Inlyta* (PA)Jakafi* (PA)Mekinist* (PA)PanretinPomalyst (PA)Stivarga* (PA)Sylatron* (PA)Tafinlar* (PA)Targretin* (PA)Tasigna* (PA)Tykerb* (PA) ValchlorVotrient* (PA)Xalkori* (PA)Xtandi* (PA)Zelboraf* (PA)Zytiga* (PA)

CARDIOVASCULARBLOOD THINNER/ANTI-CLOTTING

anagrelide*cilostazolclopidogreldipyridamoleenoxaparin*fondaparinux*heparinJantoventiclopidinewarfarin

AggrenoxArixtraEffientFragminXarelto

Agrylin*BrillintaCoumadinEliquis (ST)LovenoxPlavixPletalPradaxa (ST)

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benazepril HClbenazepril HCl/amlodipinebenazepril HCl/HCTZbendroflumethiazide/nadololbetaxolol HClbisoprolol fumaratebisoprolol/HCTZbumetanidecandesartancandesartan cilexetilcandesartan HCTZcaptoprilcaptopril/HCTZcarvedilolchlorothiazidechlorthalidonechlorthalidone/atenololclonidineclonidine HClClorpresdiltiazemdiltiazem 24HR ERdoxazosin mesylateenalapril maleateenalapril maleate/HCTZeplerenoneeprosartan mesylatefelodipinefosinopril sodiumfosinopril sodium/HCTZfurosemideguanfacinehydralazine HClhydrochlorothiazidehydrochlorothiazide/

amilor HClhydroflumethiazideindapamideirbesartanirbesartan/HCTZisradipinelabetalol HCllisinoprillisinopril/HCTZlosartan potassiumlosartan potassium/HCTZ

CarduraCardura XLCatapres, Catapres TTSCoregCorgardCovera-HSCozaar (PA, ST)Diovan HCT (PA, ST)DutoprolDynacirc CREdarbi (PA,ST)Edarbychlor (PA, ST)Hyzaar (PA, ST)Inderal LAInnopran XLLevatolLotensin (PA,ST)Lotensin HCT (PA,ST)LotrelMavik (PA,ST)Micardis (PA, ST)Micardis HCT (PA, ST)MonoprilMonopril HCTNexiclon XRNorpaceNorpace CRNorvascPrinivil (PA,ST)Prinzide (PA,ST)SularTekamloTeveten (PA, ST)Teveten HCT (PA, ST)Toprol XLTribenzor (ST)TwynstaUniretic (PA,ST)Univasc (PA,ST)Vaseretic (PA,ST)Vasotec (PA,ST)VerelanZestoretic (PA,ST)Zestril (PA,ST)

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CARDIOVASCULAR (CONTINUED)


methazolamidemethyldopamethyldopa/HCTZmetolazonemetoprolol/HCTZmetoprolol succinatemetoprolol tartrateminoxidilmoexipril HClmoexipril HCl/HCTZnadololnicardipine HClnifedipinenimodipineperindopril erbuminepindololprazosin HClpropranolol HClpropranolol/HCTZquinaprilquinapril HCl/HCTZramiprilreserpinereserpine/HCTZsotalol HClspironolactonespironolactone/HCTZtelmisartantelmisartan/amlodipinetelmisartan/HCTZterazosin HCltimolol maleatetorsemidetrandolapriltriamterene/HCTZvalsartanvalsartan/HCTZVecamyl-mecamylamine HClverapamilverapamil SR

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CHOLESTEROL LOWERING

atorvastatincholestyraminecholestyramine/aspartamecholestyramine powdercholestyramine/sucrosecolestipolfenofibratefenofibric acidfluvastatin/XLgemfibrozillovastatinniacinomega-3-acid ethyl esterspravastatin sodiumsimvastatin

Crestor (5 & 10 MG) (PA,ST)Crestor (20 & 40 MG)LovazaNiaspanSimcorWelcholZetia

AdvicorAltoprev (PA,ST)AntaraCaduetColestidFenoglideJuxtapid* (PA)Kynamro* (PA)LescolLescol XRLipitor (PA,ST)LiptruzetLivalo (PA, ST)LofibraMevacor (PA,ST)Pravachol (PA,ST)TriCorTrilipixVascepa (ST)Vytorin (PA,ST)Zocor (PA,ST)

CARDIOVASCULAR (CONTINUED)

OTHER

amiodaronedigoxindisopyramideflecainideisosorbide dinitrateisosorbide mononitratenitroglycerinprocainamidepropafenone SR

MultaqNitrolingual sprayTikosyn

LanoxinNitromistRanexa (ST)Rythmol SRSamsca (PA)

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DIABETES

acarbosechlorpropamideglimepirideglipizideglipizide/metforminglucagonglyburideglyburide micronizedglyburide/metforminmetformin/ERnateglinidepioglitazonepioglitazone/glimepiridepioglitazone/metforminrepaglinidetolazamidetolbutamide

ACCU-CHEK test stripsApidraApidra SoloStarBD Insulin Syringes/

Pen NeedlesBydureon (QL)ByettaFortametGlucaGen HypoKitGlucagon Emergency Kit (QL)HumalogHumulinJanumetJanumet XRJanuviaKombiglyze XRLantusLantus SoloStar

Actoplus MetActoplus Met XRActosAmarylAvandametAvandarylAvandiaCyclosetDuetactFarxiga (PA,ST)Glucophage XRGlysetInvokana (ST)Jentadueto (ST)Kazano (ST)Nesina (ST)Oseni (ST)Prandin

DEPRESSION

amitriptylinebupropionbupropion SRcitalopramdesipraminedesvenlafaxineduloxetine HClescitalopramfluoxetinefluvoxamineimipraminemirtazapinenortriptylineparoxetineparoxetine CRprotriptylinesertralinetrazodonetrimipraminetrimipramine maleatevenlafaxinevenlafaxine XR

CymbaltaPristiqWellbutrin XL

Aplenzin (PA,ST)Brintellix (PA,ST)Celexa (PA,ST)Desvenlafaxine ER (PA,ST)Desvenlafaxine Fumarate

(PA,ST)Effexor XR (PA,ST)EmsamFetzima (PA,ST)Forfivo XL (PA,ST)Khedezla (PA,ST)Lexapro (PA,ST)Luvox CRMarplanPaxil (PA,ST)Paxil CR (PA,ST)Pexeva (PA,ST)Prozac (PA,ST)RemeronSarafem (PA,ST)TofranilVenlafaxine HCl ER (PA,ST)Viibryd (PA,ST)VivactilWellbutrin (PA,ST)Wellbutrin SR (PA,ST)Zoloft (PA,ST)

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ENDOCRINE AND METABOLIC – OTHER

allopurinolcabergoline (QL)desmopressin*fluoxymesteroneoctreotide* (PA)

ColcrysIncrelex* (PA)LupronDepot-PED* (PA)Megace ESNilandronSandostatin* (PA)Sandostatin LAR* (PA)Somavert* (PA)Uloric

Egrifta* (PA)Signifor* (PA)Somatuline Depot* (PA)

EYE CONDITIONS

apraclonidine HClatropineazelastinebrimonidinebromfenacbromfenac sodiumciprofloxacindiclofenacdorzolamidedorzolamide/timololepinastineflurbiprofengatifloxacinketorolaclatanoprostlevobunolollevofloxacinpilocarpinetimololtobramycin/dexamethasonetravoprosttrifluridine

AlomideAlphagan P (0.10%)AzaSiteAzoptBetoptic SCiloxan (ointment)IopidineLotemax (drops & gel)MaxidexMoxezaPatadayPatanolRestasisTobradex ointmentTravatan ZVexolVigamox

Acular LSAlocrilAlrexBepreveBesivanceCiloxan (drops)CosoptCystaranDurezolElestatEmadineIlevroIquixLastacaftLotemax (ointment)OptivarProlensaResculaSimbrinza (ST)TimopticTobradex (drops)Tobradex STTrusoptVoltarenZioptan (ST)Zymaxid

DIABETES (CONTINUED)

LevemirNovoFine/NovoTwist needlesNovolinNovologOne Touch test stripsOnglyzaPrandimetSymlinPenVictoza

PrecoseStarlixTradjenta (ST)

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GASTROINTESTINAL (NOT HEARTBURN/ULCER)

balsalazidebudesonidecromolyn sodium (solution)PEG 3350/potassium/ sodium bicarb/saltPEG 3350/potassium/ sodium bicarb/salt/ sodium sulf

AprisoAsacol HDCanasaCreonDelzicolGoLytelyHumira* (PA)LialdaPentasaUrso/Urso ForteZenpep

AmitizaCimzia* (PA)ColazalColyteEntocort ECGiazoLinzessNuLytelyPancreazePertzyePrepopikRelistor (PA)Remicade* (PA)Simponi* (PA)SuclearSucraid*UcerisUltresaViokace

GROWTH HORMONES

Humatrope* (PA)Saizen* (PA))

Genotropin* (PA)Nordiflex* (PA)Norditropin* (PA)Nutropin* (PA)Nutropin AQ* (PA)Omnitrope* (PA)Serostim* (PA)Tev-Tropin* (PA)

HEARTBURN/ULCER

cimetidinefamotidinelansoprazolelansoprazole/amoxicillin/

clarithromycinmetoclopramidemetoclopramide HClmisoprostolnizatidineomeprazoleomeprazole/sodium bicarbonatepantoprazolerabeprazole HClranitidinesucralfate

Nexium Aciphex (PA, ST)Aciphex Sprinkle (PA,ST)Dexilant (PA, ST)Esomeprazole Strontium

(PA,ST)Prevacid (PA, ST)PrevpacPrilosec (PA, ST)Protonix (PA, ST)Zantac EffertabZantac SyrupZegerid (PA, ST)

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estradiolestradiol/norethindrone acetateestropipateethinyl estradiollevothroidlevothyroxineLevoxylliothyroninemedroxyprogesteroneprogesterone, micronizedtestosterone cypionatetestosterone enanthatethyroidUnithroid

AloraAnadrol-50AndrodermAndroGelArmour ThyroidDivigelEnjuviaEstradermPremarinPremphasePremproSynthroidTestimVivelle-Dot

ActivellaAxiron (ST)CenestinCombipatchCytomelDepot TestosteroneEstraceFemhrtFemringFortesta (ST)MenestMinivellePrefestPrometriumVagifem

INFECTIONS

acycloviradefovir dipivoxil*amantadineamoxicillinamoxicillin/clavulanateatovaquoneazithromycincefaclor ERcefadroxilcefdinircefprozilceftibuten dihydrateceftriaxonecefuroxime axetilcephalexinciclopiroxciprofloxacinclarithromycinclindamycinclindamycin phosphatecycloserinedoxycyclineerythromycinfamciclovirfluconazoleflucytosineganciclovir*gentamicin sulfategriseofulvin microsizegriseofulvin ultramicrosize

Baraclude*Cipro HC OticCiprodexEpivir HBV*Gris-PegIncivek* (PA)Intron-A* (PA)Mycostatin (tabs)Pegasys* (PA)Peg Intron* (PA)PrimsolTamiflu (QL)Tobi*Valcyte

AncobonAugmentinAugmentin ES 600Augmentin XRAveloxBactrobanBethkis*BiaxinBiaxin XLCayston* (ST)CedaxCefzilCetraxalCiclodanCipro XRCoartem (QL)Copegus*Dificid (PA)Ery-TabFamvirFlagyl 375Flagyl ERFloxin OticGaramycin*Grifulvin VHepsera*Infergen* (PA)KeflexKeftabLamisil (QL)

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INFECTIONS (CONTINUED)

itraconazole (QL) ketoconazolelamivudine*metronidazoleminocyclineminocycline SRModeriba*moxifloxacin HClmupirocinnitrofurantoinnystatinofloxacinpenicillin v potassiumribavirin*rifabutinrifampinrimantadinesulfamethoxazole/trimethoprimterbinafine (QL)terconazoletetracyclinetobramycinvalacyclovirvancomycinvoriconazole (PA)

Levaquin MalaroneMonurolMoxatagNoxafilOlysio* (PA)OmnicefOnmel (QL,ST)PenlacPriftinRebetol*Relenza (QL)RocephinSirturoSolodyn (ST)Sovaldi* (PA)Sporanox (QL)SupraxTobi Podhaler*Tyzeka*ValtrexVfend (PA)Victrelis* (PA)ZithromaxZyvox (PA)

MIGRAINE

acetaminophen/caffeine butalbitaldihydroergotamine (QL)mesylate (QL)naratriptan (QL)rizatriptan (QL)sumatriptan (QL)sumatriptan succinate (QL)zolmitriptan (QL)

Treximet (QL) Alsuma (QL)Amerge (QL)Axert (QL)DHE 45 (QL)Frova (QL)Imitrex (QL)Maxalt (QL)Maxalt MLT (QL)Migranal (QL)Relpax (QL)Sumavel DosePro (QL)Zomig/Zomig ZMT (QL)

MULTIPLE SCLEROSIS

Ampyra* (PA)Avonex/Avonex Pen* (PA)Copaxone* (PA)Rebif* (PA)Rebif Rebidose* (PA)Tecfidera* (PA)

Aubagio* (PA)Betaseron* (PA)Extavia* (PA)Gilenya* (PA)

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PAIN RELIEF AND INFLAMMATORY DISEASE

buprenorphinebutalbit/acetamin/caff/ codeinebutorphanol nasal (QL)codeine phos/carisoprodol/ asacodeine phosphatecodeine phosphate/aspirincodeine sulfatecyclophosphamide*dexamethasonediclofenacdiclofenac-misoprostoldihy-cod tt/apap/caffeinedihydrocodeine/aspirinetodolacfenoprofenfentanyl citrate (lozenge on stick) (PA)fentanyl transdermal (QL)flurbiprofenhydrocodone bitartrate/apaphydrocodone bitartrate/ aspirinhydromorphone HCl

Actimmune* (PA)AvinzaCelebrexDilaudid-5DipentumEnbrel* (PA)Fentora (PA)Humira* (PA)Indocin (suppository)KadianLidodermLyricaNucynta (ST)Nucynta ER (QL)OxyContin (QL)PonstelRoxicetSavellaTrexall*Vimovo

Abstral (PA)Actemra* (PA)Actiq (PA)Ansaid (PA,ST)Arthrotec (PA, ST)Butrans (QL)Cambia (PA, ST)Cimzia* (PA)Conzip (PA,ST)Demerol (PA,ST)Dilaudid (PA,ST)Duexis (PA, ST)Duragesic (QL)Exalgo (QL)Fioricet w/codeineFlector (PA, ST)Horizant (ST)Hycet (PA,ST)Kineret* (PA)Lazanda (PA)Lortab (PA,ST)Mobic (PA, ST)Nalfon (PA,ST)Naprelan (PA, ST)Norco (PA,ST)

NAUSEA AND VOMITING

dronabinolgranisetronondansetronprochlorperazinepromethazinetrimethobenzamide

Emend (QL) Anzemet* (QL)DiclegisKytrilMarinolSancuso (QL)ScopaceZofranZuplenz (QL, ST)

OSTEOPOROSIS

alendronate sodiumcalcitonin-salmonetidronate disodiumForticalibandronate sodium*raloxifene HCl

EvistaForteo*Miacalcin

Actonel (PA,ST)Atelvia (PA,ST)Binosto (PA,ST)Boniva* (inj)Boniva (tab) (PA,ST)Fosamax (PA,ST)Fosamax Plus D (PA,ST)Skelid (PA,ST)

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PAIN RELIEF AND INFLAMMATORY DISEASE (CONTINUED)

ibuprofenibuprofen/hydrocod bitindomethacinketoprofenketorolac (QL)leflunamidelevorphanol tartratelidocainelidocaine-prilocainemeclofenamatemefenamic acidmeloxicammeperidine HClmetaxalonemethotrexate*methylprednisolonemorphine SRmorphine sulfatenabumetonenaproxenopiumopium/belladonna alkaloidsorphenadrine/aspirin/caffeineoxaprozinoxycodone HCloxycodone HCl/

acetaminophenoxycodone/aspirinoxymorphoneOxymorphone HClpentazocine HCl/

acetaminophenpentazocine HCl/naloxone HClpiroxicamprednisonesulindactolmetintramadol HCl/acetaminophentramadol HCl/ER

Onsolis (PA)Opana (QL)Opana ER (QL)Otrexup* (PA)Oxecta (PA,ST)Pennsaid (PA, ST)Percocet (PA,ST)Percodan (PA,ST)Primalev (PA,ST)ProdrinQufloraRayos (ST)Remicade* (PA)Rheumatrex*Roxicodone (PA,ST)RyzoltSimponi* (PA)Simponi Aria* (PA)SkelaxinSprix (QL)SuboxoneSubsys (PA)Synalgos (PA,ST)Ultracet (PA,ST)Ultram (PA,ST)Ultram ER (PA,ST)Vicodin (PA,ST)Vicoprofen (PA,ST)Voltaren Gel (PA, ST)Voltaren XR (PA,ST)Xartemis XR (QL)Xeljanz* (PA)Xodol (PA,ST)Zamicet (PA,ST)Zohydro (QL)Zolvit (PA,ST)Zorvolex (PA,ST)

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SCHIzOPHRENIA

clozapinehaloperidolloxapineolanzapineolanzapine/fluoxetine HClquetiapinerisperidonethiothixeneziprasidone

Seroquel XR AbilifyAbilify DiscmeltClozaril (PA, ST)Fanapt (PA, ST)Fazaclo (PA, ST)Geodon (PA, ST)Invega (PA, ST)Latuda (PA, ST)MobanOrapRisperdal/ Risperdal M (PA, ST)Saphris (PA, ST)Seroquel (PA,ST)Versacloz (PA,ST)Zyprexa/Zyprexa Zydis (PA, ST)

PROSTATE

alfuzosindoxazosinfinasterideleuprolide acetate* (PA)prazosintamsulosinterazosin

AvodartCialis (PA,QL)JalynUroxatral

Firmagon* (PA)FlomaxProscarRapafloZoladex* (PA)

PARkINSON’S DISEASE

amantadinebenztropinebromocriptinecarbidopacarbidopa/levodopacarbidopa/levodopa CRcarbidopa/levodopa/

entacaponeentacaponepramipexoleropiniroleropinirole XLselegiline

Apokyn* (PA)AzilectRequip XL

ComtanEldeprylLodosynMirapexMirapex ERNeuproParcopaRequipSinemet CRStalevoTasmarZelapar

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SEIzURE

carbamazepineclonazepamdiazepamdivalproexfelbamategabapentinlamotriginelevetiracetamoxcarbazepinephenytointiagabine HCltopiramatevalproatevalproate sodiumzonisamide

CelontinDiastatDiastat AcudialFelbatolGabitrilKeppraLamictal ODTLyricaPeganoneVimpat

AptiomBanzelCarbatrolDepakote (all forms)FycompaKeppra XRLamictalLamictal/ XRNeurontinOxtellar XRPotigaSaphrisStavzorTegretol XRTopamaxTrileptalZonegran

SEXUAL DYSFUNCTION

* Please check yourSummary Plan Description to determine whether thismedication is coveredunder your plan.

Cialis (PA,QL)Muse (PA, QL)Viagra (PA, QL)

Caverject (PA, QL)Edex (PA, QL)Levitra (PA, QL)OsphenaStaxyn (PA, QL)Stendra (PA, QL)

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acitretinadapalene (AGE)alclometasone dipropionateamcinonideamnesteem (QL)Apexicon E (diflorasone

diacetate)betamethasonebetamethasone dipropionatebetamethasone dipropionate/

propylene glycolbetamethasone valeratecalcipotrienecalcitriol ointmentClaravis (QL)clinicamycinphosphate/

benzoyl peroxide gelclobetasol propionateclobetasol propionate/emollclocortolone pivalatedesonidedesoximetasonediclofenac sodiumdiflorasone diacetatefluocinolone acetonidefluocinonidefluocinonide/emollientfluorouracil topicalfluticasone propionatehalobetasol prop/ammonium

lachalobetasol propionatehydrocortisonehydrocortisone acetate/aloe

verahydrocortisone acetate/ureahydrocortisone butyratehydrocortisone valerateimiquimodIsotretinoin (QL)mafenide acetatemetronidazolemometasonepodofiloxprednicarbatesalicylic acidSotret (QL)

Benzaclin (Gel w/pump)Benzamycin PakCapex Shampoo (PA, ST)CaracCarmol HC (PA,ST)Cloderm (PA,ST)Cordran (PA, ST)Cordran SP (PA, ST)Derma-Smoothe/FS (PA, ST)Differin (AGE)Dovonex creamEnbrel* (PA)ExeldermFluoroplexFuracinHumira* (PA)Kenalog spray (PA, ST)KlaronLocoid (lotion)Locoid LipocreamLoprox shampooMetrogel 1%NaftinNoritateNucort (PA, ST)OraceaRetin-A Micro (AGE)SoriataneTazoracTexacort (PA, ST)

Absorica (QL)AcanyaAclovate (PA, ST)Ala-Scalp HP (PA, ST)AldaraAphthasolAqua Glycolic HC (PA, ST)Atralin (AGE)AvarAvar LSBenzaclinBenzefoamClindacin PacClobex (PA, ST) Cloderm (PA, ST)CondyloxCutivate (PA, ST)Delos AcneDermasorb AFDermasorb HC (PA,ST)Dermasorb TA (PA,ST)Dermasorb XMDermatop (PA, ST)Desonate (PA, ST)Desowen (PA, ST)Diprolene (PA, ST)Diprolene AF (PA, ST)DovonexDuac CSEcozaElidel (PA, ST)Elocon (PA, ST)Epiduo (AGE)First Hydrocortisone (PA, ST)Halog (PA, ST)Kenalog (PA, ST)Luxiq (PA, ST)LuzuMetrogelMetrolotionMomexin (PA, ST)NuzonOlux (PA, ST)Olux-e (PA, ST)Otezla* (PA)Pandel (PA, ST)Panretin* (PA)Pediaderm HC (PA, ST)

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SLEEP

eszopiclonezaleplonzolpidemzolpidem ER

Silenor Ambien (PA, ST)Ambien CR (PA, ST)Edluar (PA, ST)Intermezzo (PA, ST)Lunesta (PA, ST)Rozerem (PA, ST)Sonata (PA, ST)Zolpimist (PA, ST)

SkIN CONDITIONS (CONTINUED)

sulfacetamidesulfacetamide sodium/sulfursulfacetamidesulfursulfacetamide/sulfur/cleansertretinoin (AGE)triamcinolone acetonideurea

Plexion Protopic (PA, ST)Psorcon (PA, ST)Psorcon ERegranex (PA)Remicade* (PA)RiaxRosulaScalacort DK (PA, ST)Soriatane CKStelara* (PA)Sumadan XLTSynalar (PA, ST)TaclonexTemovate (PA, ST)Topicort (PA, ST)Topicort LP (PA, ST)Tretin-X (PA)Ultrasal-ERUltravate (PA, ST)Vanos (PA, ST)VecticalVerdeso (PA, ST)VytoneWestcort (PA, ST)XolegelXolegel CorepakZianaZyclara (PA, ST)

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VITAMINS

Available as generic where ^ is noted.

calcitriolcyanocobalaminfolic acid

Active OB^Bal-Care DHA EssentialCitranatalCitranatal Assure^Citranatal B-CalmCitranatal Harmony^Duet DHADuet DHA ECFocalgin-B^Gesticare DHAInfanate BalanceNatachewNatafortNeevoNeevo DHANestabsNestabs ABCNestabs DHA^Nexa PlusOB CompleteOB Complete DHAOB Complete OneOB Complete PetiteOB Complete PremierPNV Folic Acid-IronPNV-DHA PlusPrecare PremierPrefera-OB OnePreferaOB Prenatal VitaminPrenaissance Next-BPrenataPrenatal 19Prenate AMPrenate ChewablePrenate DHAPrenate ElitePrenate Enhance

TRANSPLANT

azathioprine*cyclosporine*mycophenolate moefetil*mycophenolate sodium*sirolimus*tacrolimus*

Azasan*Cellcept*Neoral*Prograf*Rapamune*Sandimmune*

Imuran*Myfortic*Zortress*

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VITAMINS (CONTINUED)

Available as generic where ^ is noted.

Prenate MiniPrenate PlusPrenate RestoreProvida OBStuart PrenatalStuartnatal PlusStuartnatal Plus 3TL-Select DHATricareTricare Prenatal Compleat Tricare Prenatal DHA One^Vinate CareVinate DHAVita Fol-OB DHAVitafol-OneVitafol UltraVitapearlViva DHAVP-PNV-DHA

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aminocaproic acid*buprenorphinebuprenorphine HCl/

naloxone HCl Cyclobenzaprinedoxercalciferolhydrocodonehydrocodone/

chlorpheniramine suspension

hydrocortisoneleucovorin*levocarnitinelindanemegestrolmethocarbamolnaltrexoneparicalcitol*pentoxifyllinepramoxine/hydrocortisonepseudoephed/

hydrocodone/cpmriluzole*sodium phenylbutyratespinosadtizanidinetranexamic acid

Analpram AdvancedAnalpram-EAnalpram HCAnamantle HC ForteAranesp* (PA)BuphenylChantixEpogen* (PA)Follistim AQ* (PA)FosrenolPramosoneProcrit* (PA)Proctofoam-HCPulmuzyme* (PA)RenvelaRilutek*SuboxoneTussiCapsZavesca* (PA)

Arcalyst* (PA)Brisdelle (QL)CortifoamCuvposaEpifoamGattex* (PA)GlycateHectorolHetlioz (PA)Ilaris* (PA)Kuvan*Lupaneta Pack* (PA)LystedaNatrobaNimotopNuedextaPhosloPhoslyraProcysbi* (PA)Promacta* (PA)Ravicti* (PA)RectivRenagelReviaSkliceSubutexTussionexUlesfiaVituzZanaflexZemplar*Zubsolv (ST)Zutripro

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ExCLUSIONS & LIMITATIONS

Plans typically do not provide coverage for the following, except as required by law or by the terms of your specific plan:

1. Any medications available over-the-counter (OTC) that do not require a prescription by federal or state law, and any medication that is a pharmaceutical alternative to an OTC medication other than insulin. [examples include OTC Benadryl, Maalox, Sudafed PE, etc.].

2. Medications that are therapeutically equivalent as determined by the Cigna HealthCare Pharmacy and Therapeutics Committee in which at least one of the medications within the class is available over the counter [examples include Rx equivalents to OTC Allegra, Claritin and Zyrtec (Allegra D, Clarinex, Xyzal) and Rx equivalents to OTC Prevacid, Prilosec, Zantac (Aciphex, Kapidex, Nexium, Axid, Pepcid, Zantac)].

3. Any injectable infertility medications, and any injectable medications that require health care professional supervision and are not typically considered self-administered medications. The following are examples of health care professional-supervised medications: injectables used to treat hemophilia and RSV (respiratory syncytial virus), chemotherapy injectables and endocrine and metabolic agents.

4. Any medications that are experimental or investigational within the meaning set forth in the summary plan description.

5. Food and Drug Administration (FDA) approved medications used for purposes other than those approved by the FDA unless the medication is recognized for the treatment of the particular indication in one of the standard reference compendia (The United States Pharmacopoeia Drug Information or The American Hospital Formulary Service Drug Information) or in medical literature. Medical literature means scientific studies published in a peer-reviewed national professional medical journal.

6. Any prescription and non-prescription supplies (such as ostomy supplies), devices and appliances.

7. Any contraceptive medications and prescription appliances for contraception.

8. Implantable contraceptive products. 9. Any fertility medication. 10. Any prescription vitamins (other than

prenatal vitamins), dietary supplements and fluoride products.

11. Medications used for cosmetic purposes, such as medications used to reduce wrinkles, medications to promote hair growth, medications used to control perspiration and fade cream products.

12. Any diet pills or appetite suppressants (anorectics).

13. Immunization agents, biological products for allergy immunization, biological sera, blood, blood plasma and other blood products or fractions and medications used for travel prophylaxis (the prevention of travel-related diseases).

14. Replacement of prescription medications and related supplies due to loss or theft.

15. Medications used to enhance athletic performance.

16. Medications that are to be taken by, or administered to, a customer while the customer is a patient in a licensed hospital, skilled nursing facility, rest home or similar institution which operates on its premises, or allows to be operated on its premises, a facility for dispensing pharmaceuticals.

17. Prescriptions more than one year from the original date of issue.

Cigna reserves the right to make changes to this drug list without notice. Your plan may cover additional medications; please refer to your Summary Plan Description for details. Cigna does not take responsibility for any medication decisions made by the doctor or pharmacist. Cigna may receive payments from manufacturers of certain preferred brand medications, and in limited instances, certain non-preferred brand medications, that may or may not be shared with your plan depending on its arrangement with Cigna. Depending upon plan design, market conditions, the extent to which manufacturer payments are shared with your plan and other factors as of the date of service, the preferred brand medication may or may not represent the lowest-cost brand medication within its class for you and/or your plan.

874988 a 05/14 © 2014 Cigna. Some content provided under license.

“Cigna,” the “Tree of Life” logo and “GO YOU” are registered service marks, and “Cigna Home Delivery Pharmacy” is a service mark of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, Tel-Drug, Inc., Tel-Drug of Pennsylvania, L.L.C., and HMO subsidiaries of Cigna Health Corporation. “Cigna Specialty Pharmacy Services” refers to the specialty drug division of Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C., doing business as Cigna Home Delivery Pharmacy.

cigna performance 3-tier prescription drug list · 2020-07-22 · 3-tier prescription drug list as...

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