cigna rx essential prescription drug list rx essential prescription drug list 4-tier insured by...

CignaRX ESSENTIALprescription drug list

“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 subsidiaries include Connecticut General Life Insurance Company (CGLIC), and Cigna HealthCare of Arizona, Inc. and its subsidiaries. In Arizona, HMO plans are offered by Cigna HealthCare of Arizona, Inc. All other Individual medical plans in Arizona are insured by CGLIC. In Texas, Open Access Plan plans are considered Preferred Provider plans with certain managed care features; Health Savings Plans are considered Preferred Provider plans with certain managed care features that are compatible with a Health Savings Account. ”Cigna Home Delivery Pharmacy’’ refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C.

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This cover page is for brokers only. Please discard if providing the list to customers.

The Cigna Rx Essential 4-Tier Prescription Drug List is applicable to plans in California, effective 1/1/2014.

Insured by Cigna Health and Life Insurance Company

CignaRX ESSENTIALprescription drug list

4-Tier

Insured by Cigna Health and Life Insurance Company

Offered by: Cigna Health and Life Insurance Company

Choosing the medication that is right for you is between you and your doctor. This prescription drug list offers you an extensive list of generic and brand name medications that are covered under your pharmacy plan.

Choosing where to fill your medication should be easy, too. With access to a broad network of national, regional and local retail pharmacies, as well as Cigna Home Delivery PharmacySM, you have convenient access to your medications – whether you pick them up or have them delivered to your home.

Within this document you will find a list of medications covered under your plan, in an easy-to-read format. You will see:

1. Medications split into four categories (generic, preferred brand, non-preferred brand and specialty medications)

2. Medications listed in alphabetical order

3. Symbols to let you know if there are any important details related to coverage

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Your four-tier prescription drug listA four-tier prescription drug list splits medications into four categories (or tiers):

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

2nd Tier – Preferred Brand Medications: Preferred brand medications will usually cost more than a generic, but may cost less than a non-preferred brand on a four-tier plan.

3rd Tier – Non-Preferred Brand Medications: Non-preferred brand medications generally have generic alternatives and/or one or more preferred brand options within the same drug class. You will usually pay more for non-preferred medications on a four-tier plan.

4th Tier – Specialty Medications: A mix of non-preferred brand name and generic medications at a higher cost to you than Tier 3 preferred brand medications.

Understanding Cigna’s prescription drug listEvery medication available on Cigna’s prescription drug list has been approved by the U.S. Food and Drug Administration (FDA). This list represents the medications covered under your plan. If you do not see a specific medication on this list, please check myCigna.com to see a current listing of all of the medications covered under your plan.

The symbols on the list mean

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

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 that a person 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 medication with the “ST” is covered.

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myCigna.comOur customer website that can help you manage your prescription coverage:

When you visit myCigna.com, you can:

• Look up the details of your specific pharmacy plan

• Research thousands of available medications

• Compare medication prices using the Prescription Drug Price Quote tool

• Ask a pharmacist questions

• And much, much more!

Medications delivered right to your homeCigna Home Delivery Pharmacy is designed for people who take prescription medications on a regular basis (including specialty medications). The benefits of Cigna Home Delivery Pharmacy include:

• QuickFill, our automatic refill reminder service, makes it simple for you to fill prescriptions through email or phone

• Up to a 90-day supply of non-specialty medications in one fill

• Specialty medications for more complex conditions, including those that require refrigeration and overnight delivery (limited to a 30-day supply in one fill, unless not allowed by state law)

• Delivery of medications to your door at no additional charge

• Licensed pharmacists available to help 24/7

• CoachRx: a free tool that can help with reminders, coaching and information. Visit Cigna.com/coachrx to learn more

• It’s easy to switch! Just call 1.800.285.4812

For more information, visit the Cigna Home Delivery Pharmacy page on myCigna.com.

Save time and money with the convenience of Cigna Home Delivery Pharmacy

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Health care reform and youThe Patient Protection and Affordable Care Act (PPACA), commonly referred to as “health care reform,” was signed into law on March 23, 2010. This important legislation will result in changes to every American’s health coverage. Some of the changes took effect in 2010, and most of the law’s effects will be felt by 2014. Cigna will comply with all provisions of the law including those that impact your pharmacy coverage plan. For example, depending upon the final government regulations, coverage of medications that have not traditionally been included in pharmacy plans, such as specific over-the-counter (OTC) medications, may be made available at no cost-share to you. As with all covered medications, we would require a prescription from your doctor to process the claim under your pharmacy plan (including OTC medications). To get the most current information, visit www.informedonreform.com or Cigna.com and look for the “Informed on Reform” link.

If you have questionsPlease call the toll-free number on the back of your Cigna ID card. We’re here to help.

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Cigna prescription drug list

DRUG NAME Tier NOTES (PA, ST, QL, AGE)

ACARBOSE 1

ACCU-CHEK 2

ACCU-CHEK AVIVA PLUS 2

ACCU-CHEK FASTCLIX 2

ACCU-CHEK NANO SMARTVIEW 2

ACCU-CHEK SMARTVIEW 2

ACCU-CHEK SOFTCLIX 2

ACEBUTOLOL HCL 1

ACETAMINOPH-CAFF-DIHYDROCODEIN 1

ACETAMINOPHEN W/CODEINE 1

ACETAMINOPHEN-BUTALBITAL 1

ACETAMINOPHEN-CODEINE 1

ACETASOL HC 1

ACETAZOLAMIDE 1

ACETIC ACID 1

ACETIC ACID-ALUMINUM 1

ACETYLCYSTEINE 1

ACYCLOVIR 200 MG CAPSULE 1

ACYCLOVIR 200 MG/5 ML SUSP 1

ACYCLOVIR 400 MG TABLET 1

ACYCLOVIR 5% OINTMENT 1

ACYCLOVIR 800 MG TABLET 1

ADAPALENE 1 AGE

ADDERALL XR 1

AERO OTIC HC 1

AFEDITAB CR 1

AK-PENTOLATE 1

AK-POLY-BAC 1

ALAGESIC LQ 1

ALBUTEROL 0.083% INHAL SOLN 1

ALBUTEROL 2.5 MG/0.5 ML SOL 1

ALBUTEROL 5 MG/ML SOLUTION 1

ALBUTEROL SUL 0.63 MG/3 ML SOL 1

ALBUTEROL SUL 1.25 MG/3 ML SOL 1

ALBUTEROL SULF 2 MG/5 ML SYRUP 1

ALBUTEROL SULFATE 2 MG TAB 1

ALBUTEROL SULFATE 4 MG TAB 1

ALBUTEROL SULFATE ER 4 MG TAB 1

ALBUTEROL SULFATE ER 8 MG TAB 1

ALCAINE 1

ALCLOMETASONE DIPROPIONATE 1

ALENDRONATE SOD 70 MG/75 ML 1

ALENDRONATE SODIUM 10 MG TAB 1




ALENDRONATE SODIUM 5 MG TABLET 1


ALFUZOSIN HCL 1

ALINIA 3

ALLOPURINOL 1

ALPRAZOLAM 1

ALPRAZOLAM ER 1

ALPRAZOLAM INTENSOL 1

ALPRAZOLAM ODT 1

ALPRAZOLAM XR 1

ALTAFRIN 1

ALTAVERA 1

ALUMINUM CHLORIDE 1

ALYACEN 1

AMANTADINE 1

AMCINONIDE 1

AMETHIA 1

AMETHIA LO 1

AMETHYST 1

AMILORIDE HCL 1

AMILORIDE-HYDROCHLOROTHIAZIDE 1

AMINO ACID CERVICAL 1

AMIODARONE HCL 1

AMITIZA 3

AMITRIPTYLINE HCL 1

AMLODIPINE BESYLATE 1

AMLODIPINE BESYLATE-BENAZEPRIL 1

AMLODIPINE-ATORVASTATIN 1

AMMONIUM LACTATE 1

AMOX TR-POTASSIUM CLAVULANATE 1

AMOXAPINE 1

AMOXICILLIN 1

AMOXICILLIN-CLAVULANATE ER 1

AMPHETAMINE SALT COMBO 1

AMPICILLIN TRIHYDRATE 1

ANABAR 1

ANASTROZOLE 1

ANDROXY 1

ANTIPYRINE-BENZOCAINE 1

ANUCORT-HC 1

ANUDIL HC 1

6


BETAXOLOL HCL 1

BETHANECHOL CHLORIDE 1

BEYAZ 3

BICALUTAMIDE 50 MG TABLET 1

BILTRICIDE 3

BISOPROLOL FUMARATE 1

BISOPROLOL-HYDROCHLOROTHIAZIDE 1

BP 10-1 1

BRIELLYN 1

BRIMONIDINE TARTRATE 1

BROMFED DM 1

BROMFENAC SODIUM 1

BROMOCRIPTINE MESYLATE 1

BUDEPRION SR 1

BUDESONIDE 1

BUDESONIDE EC 3

BUMETANIDE 1

BUPAP 1

BUPRENORPHINE HCL 1

BUPRENORPHINE-NALOXONE 1

BUPROBAN 1

BUPROPION HCL 1

BUPROPION HCL SR 1

BUPROPION XL 1

BUSPIRONE HCL 1

BUTALB-CAFF-ACETAMINOPH-CODEIN 1

BUTALBITAL COMPOUND 1

BUTALBITAL COMPOUND-CODEINE 1

BUTALBITAL-ACETAMINOPHEN-CAFFE 1

BUTALBITAL-ASPIRIN-CAFFEINE 1

BUTORPHANOL TARTRATE 1 QL

BYDUREON 2 QL

BYETTA 2

CABERGOLINE 1 QL

CAFFEINE CITRATE 1

CALCIPOTRIENE 1

CALCITONIN-SALMON 1

CALCITRENE 1

CALCITRIOL 1

CALCIUM ACETATE 1

CAMILA 1

CAMPRAL 3

CAMRESE 1

CAMRESE LO 3

CANDESARTAN CILEXETIL 1


APEXICON E 1

APRACLONIDINE HCL 1

APRI 1

APRISO 2

ARANELLE 1

ARBINOXA 1

ARIMIDEX 3

ARMOUR THYROID 1

ASCOMP WITH CODEINE 1

ASPIRIN-CAFFEINE-DIHYDROCODEIN 1

ATENOLOL 1

ATENOLOL-CHLORTHALIDONE 1

ATORVASTATIN CALCIUM 1

ATOVAQUONE-PROGUANIL HCL 1 PA

ATROPINE CARE 1

ATROPINE SULFATE 1

AURAX 1

AURODEX 1

AUROGUARD 1

AVAR 1

AVAR-E 1

AVAR-E GREEN 1

AVIANE 1

AZELASTINE HCL 1

AZILECT 3

AZITHROMYCIN 1

AZOPT 2

AZURETTE 1

BACITRACIN 1

BACITRACIN/POLYMYXIN 1

BACITRACIN-POLYMYXIN 1

BACLOFEN 1

BAL-CARE DHA 1

BALSALAZIDE DISODIUM 1

BALZIVA 1

BAYCADRON 1

BELLADONNA-OPIUM 1

BELLADONNA-PHENOBARB ELIXIR 1

BELLADONNA-PHENOBARBITAL TAB 1

BENAZEPRIL HCL 1

BENAZEPRIL-HYDROCHLOROTHIAZIDE 1

BENZONATATE 1

BENZTROPINE MESYLATE 1

BETAMETHASONE DIPROPIONATE 1

BETAMETHASONE VALERATE 1

7


CANDESARTAN-HYDROCHLOROTHIAZID 1

CANTIL 3

CAPTOPRIL 1

CAPTOPRIL-HYDROCHLOROTHIAZIDE 1

CARBAMAZEPINE 100 MG TAB CHEW 1

CARBAMAZEPINE 100 MG/5 ML SUSP 1

CARBAMAZEPINE 200 MG TABLET 1

CARBAMAZEPINE 200 MG/10 ML LIQ 1

CARBAMAZEPINE ER 1

CARBAMAZEPINE ER 100 MG CAP 1



CARBAMAZEPINE XR 1

CARBIDOPA-LEVODOPA 1

CARBIDOPA-LEVODOPA-ENTACAPONE 1

CARBINOXAMINE MALEATE 1

CARISOPRODOL 1

CARISOPRODOL COMPOUND 1

CARISOPRODOL COMPOUND-CODEINE 1

CARISOPRODOL-ASPIRIN 1

CARISOPRODOL-ASPIRIN-CODEINE 1

CARTEOLOL HCL 1

CARTIA XT 1

CARVEDILOL 1

CAVAN-ALPHA KIT 1

CAVAN-EC SOD DHA 1

CAZIANT 1

CEENU 3

CEFACLOR 1

CEFACLOR ER 1

CEFADROXIL 1

CEFDINIR 1

CEFDITOREN PIVOXIL 1

CEFPODOXIME PROXETIL 1

CEFPROZIL 1

CEFUROXIME 1

CENTERGY 1

CENTERGY DM 1

CEPHALEXIN 125 MG/5 ML SUSP 1

CEPHALEXIN 250 MG CAPSULE 1

CEPHALEXIN 250 MG TABLET 1

CEPHALEXIN 250 MG/5 ML SUSP 1


CEPHALEXIN 500 MG TABLET 1



CERISA 1

CETIRIZINE HCL 1

CEVIMELINE HCL 1

CHATEAL 1

CHERATUSSIN AC 1

CHERATUSSIN DAC 1

CHLORDIAZEPOXIDE HCL 1

CHLORDIAZEPOXIDE-AMITRIPTYLINE 1

CHLORDIAZEPOXIDE-CLIDINIUM 1

CHLORHEXIDINE GLUCONATE 1

CHLOROQUINE PHOSPHATE 1

CHLOROTHIAZIDE 1

CHLORPROMAZINE 10 MG TABLET 1





CHLORPROPAMIDE 1

CHLORTHALIDONE 1

CHLORZOXAZONE 1

CHOICE-OB + DHA 1

CHOLESTYRAMINE 1

CHOLESTYRAMINE LIGHT 1

CHOLINE MAG TRISALICYLATE 1

CICLODAN 1

CICLOPIROX 1

CILOSTAZOL 1

CIMETIDINE 200 MG TABLET 1


CIMETIDINE 300 MG/5 ML LIQUID 1

CIMETIDINE 300 MG/5 ML SOLN 1



CIMETIDINE HCL 1

CIPROFLOXACIN 0.2% OTIC SOLN 1

CIPROFLOXACIN 0.3% EYE DROP 1

CIPROFLOXACIN ER 1

CIPROFLOXACIN HCL 100 MG TAB 1




CITALOPRAM HBR 10 MG TABLET 1

CITALOPRAM HBR 10 MG/5 ML SOLN 1



8


CLARIS 1

CLARITHROMYCIN 1

CLARITHROMYCIN ER 1

CLEANSING WASH 1

CLEMASTINE FUMARATE 1

CLINDACIN ETZ 1

CLINDACIN P 1

CLINDA-DERM 1

CLINDAMYCIN HCL 1

CLINDAMYCIN PALMITATE HCL 1

CLINDAMYCIN PEDIATRIC 1

CLINDAMYCIN PHOS-BENZOYL PEROX 1

CLINDAMYCIN PHOSPHATE 1

CLINDAMYCIN-BENZOYL PEROXIDE 1

CLOBETASOL EMOLLIENT 1

CLOBETASOL EMULSION 1

CLOBETASOL PROPIONATE 1

CLOMIPHENE CITRATE 1

CLOMIPRAMINE HCL 1

CLONAZEPAM 1

CLONIDINE PATCH 1

CLONIDINE TABLET 1

CLOPIDOGREL 1

CLORAZEPATE DIPOTASSIUM 1

CLORPRES 1

CLOTRIMAZOLE 1

CLOTRIMAZOLE-BETAMETHASONE 1

CLOZAPINE 1

CLOZAPINE ODT 1

C-NATE DHA 1

COARTEM 3 QL

CODEINE SULFATE 1

CO-GESIC 1

COLCRYS 3

COLESTIPOL HCL 1

COLOCORT 1

COMPLETE ALLERGY MEDICINE 1

COMPLETE NATAL DHA 1

COMPLETENATE 1

COMPLETE-RF PRENATAL 1

COMPRO 1

CO-NATAL FA 1

CONSTULOSE 1

CORMAX 1

CORTANE-B 1


CORTIC 1

CORTISONE ACETATE 1

CORTISPORIN-TC 3

COVARYX 1

COVARYX H.S. 1

C-PHED TANNATE 1

CROMOLYN SODIUM 1

CRYSELLE 1

CUPRIMINE 3

CYANOCOBALAMIN 1

CYANOCOBALAMIN INJECTION 1

CYCLAFEM 1

CYCLESSA 1

CYCLOBENZAPRINE 10 MG TABLET 1

CYCLOBENZAPRINE 5 MG TABLET 1

CYCLOBENZAPRINE 7.5 MG TABLET 1

CYCLOPENTOLATE HCL 1

CYPROHEPTADINE HCL 1

CYTRA-2 1

CYTRA-3 1

CYTRA-K 1

DANAZOL 1

DANTROLENE SODIUM 1

DAPSONE 3

DASETTA 1

DAYSEE 1

DEMECLOCYCLINE HCL 1

DENTA 5000 PLUS 1

DENTAGEL 1

DEPADE 1

DEPEN 3

DEPO-TESTOSTERONE 1

DERMAZENE 1

DESIPRAMINE HCL 1

DESMOPRESSIN ACETATE 1

DESOGEN 3

DESONIDE 1

DESOXIMETASONE 1

DEXAMETHASONE 1

DEXAMETHASONE INTENSOL 1

DEXAMETHASONE SODIUM PHOSPHATE 1

DEXILANT 2 ST

DEXMETHYLPHENIDATE HCL 1

DEXTROAMPHETAMINE SULFATE 1

DIAZEPAM 1

9


DIBENZYLINE 3

DICLOFENAC POTASSIUM 1

DICLOFENAC SODIUM 1

DICLOFENAC SODIUM-MISOPROSTOL 1

DICLOXACILLIN SODIUM 1

DICYCLOMINE 10 MG CAPSULE 1

DICYCLOMINE 10 MG/5 ML SYRUP 1

DICYCLOMINE 20 MG TABLET 1

DIFLORASONE DIACETATE 1

DIFLUNISAL 1

DIGOXIN 125 MCG TABLET 1

DIGOXIN 250 MCG TABLET 1

DIGOXIN 50 MCG/ML SOLUTION 1

DIHYDROERGOTAMINE 1 MG/ML AM 1

DIHYDROERGOTAMINE 1 MG/ML VL 1

DIHYDROERGOTAMINE 4 MG/ML SPRY 1 QL

DILT-CD 1

DILTIAZEM 24HR CD 1

DILTIAZEM 24HR ER 1

DILTIAZEM ER 1

DILTIAZEM HCL 1

DILT-XR 1

DILTZAC ER 1

DIPHENHYDRAMINE HCL 1

DIPHENOXYLATE-ATROPINE 1

DIPYRIDAMOLE 1

DISKETS 1

DISOPYRAMIDE PHOSPHATE 1

DISULFIRAM 1

DIVALPROEX SODIUM 1

DIVALPROEX SODIUM ER 1

DOLOREX 1

DONEPEZIL HCL 1

DORZOLAMIDE HCL 1

DORZOLAMIDE-TIMOLOL 1

DOXAZOSIN MESYLATE 1

DOXEPIN HCL 1

DOXYCYCLINE HYCLATE 1

DOXYCYCLINE MONOHYDRATE 1

DOXY-LEMMON 1

DRITHOCREME HP 1

DRONABINOL 1

DROSPIRENONE-ETHINYL ESTRADIOL 1

DUET DHA BALANCED 1

DULERA 2


DURAXIN 1

ECONAZOLE NITRATE 1

ED DOXY-CAPS 1

ED-SPAZ 1

EEMT 1

EEMT H.S. 1

EFFER-K 25 MEQ TABLET EFF 1

ELIMITE 1

ELINEST 1

ELIPHOS 1

ELITE OB DHA 1

ELITE-OB 1

ELITE-OB 400 1

ELLA 3

ELMIRON 3

EMOQUETTE 1

ENALAPRIL MALEATE 1

ENALAPRIL-HYDROCHLOROTHIAZIDE 1

ENDACOF-C 1

ENDOCET 1

ENDODAN 1

ENPRESSE 1

ENSKYCE 1

ENTACAPONE 1

ENULOSE 1

EPIDRIN 1

EPINASTINE HCL 1

EPINEPHRINE 1

EPIPEN 2

EPIPEN 2-PAK 2

EPIPEN JR 2

EPIPEN JR 2-PAK 2

EPITOL 1

EPLERENONE 1

EPROSARTAN MESYLATE 1

ERGOCALCIFEROL (VITAMIN D2) 1

ERGOLOID MESYLATES 1

ERRIN 1

ERY 1

ERYTHROCIN STEARATE 1

ERYTHROMYCIN 1

ERYTHROMYCIN ETHYLSUCCINATE 1

ERYTHROMYCIN-BENZOYL PEROXIDE 1

ERYTHROMYCIN-SULFISOXAZOLE 1

ESCITALOPRAM OXALATE 1

1 0


ESTARYLLA 1

ESTAZOLAM 1

ESTRADIOL PATCH 1

ESTRADIOL TABLET 1

ESTRADIOL-NORETHINDRONE ACETAT 1

ESTROGEN & METHYLTESTOSTERONE 1

ESTROGEN-METHYLTESTOSTERONE 1

ESTROPIPATE 1

ESTROSTEP FE 3

ETHAMBUTOL HCL 1

ETHOSUXIMIDE 1

ETHYL CHLORIDE 1

ETIDRONATE DISODIUM 1

ETODOLAC 1

EVISTA 3

EXEMESTANE 3

EXOTIC-HC 1

EXTRA-VIRT PLUS DHA 1

FALMINA 1

FAMCICLOVIR 1

FAMOTIDINE 20 MG TABLET 1

FAMOTIDINE 40 MG TABLET 1

FAMOTIDINE 40 MG/5 ML SUSP 1

FARESTON 3

FELBAMATE 3

FELODIPINE ER 1

FEM PH 1

FEMCON FE 3

FENOFIBRATE 1

FENOFIBRIC ACID 1

FENOPROFEN CALCIUM 1

FENTANYL PATCH 1 QL

FEXOFENADINE HCL 1

FINASTERIDE 1

FLAVOXATE HCL 1

FLECAINIDE ACETATE 1

FLUCONAZOLE 10 MG/ML SUSP 1

FLUCONAZOLE 100 MG TABLET 1



FLUCONAZOLE 40 MG/ML SUSP 1


FLUCYTOSINE 1

FLUDROCORTISONE ACETATE 1

FLUNISOLIDE 1


FLUOCINOLONE ACETONIDE 1

FLUOCINOLONE ACETONIDE OIL 1

FLUOCINONIDE 1

FLUOCINONIDE EMOLLIENT 1

FLUOCINONIDE-E 1

FLUORABON 1

FLUORIDE 1

FLUORITAB 1

FLUOROMETHOLONE 1

FLUOROURACIL 1

FLUOXETINE 20 MG/5 ML SOLUTION 1

FLUOXETINE DR 1

FLUOXETINE HCL 10 MG CAPSULE 1

FLUOXETINE HCL 10 MG TABLET 1





FLUPHENAZINE HCL 1

FLURA-TAB 1

FLURAZEPAM HCL 1

FLURBIPROFEN 1

FLURBIPROFEN SODIUM 1

FLUTICASONE PROPIONATE 1

FLUVASTATIN SODIUM 1

FLUVOXAMINE MALEATE 1

FOLBECAL 1

FOLCAL DHA 1

FOLCAPS OMEGA-3 1

FOLIC ACID 1

FOLINATAL PLUS B 1

FOLIVANE-OB 1

FOLIVANE-PRX DHA NF 1

FORADIL 2

FORMADON 1

FORTICAL 1

FOSINOPRIL SODIUM 1

FOSINOPRIL-HYDROCHLOROTHIAZIDE 1

FUROSEMIDE 1

GABAPENTIN 1

GALANTAMINE HBR 1

GALANTAMINE HYDROBROMIDE 1

GARAMYCIN 1

GAVILYTE-C 1

GAVILYTE-G 1

1 1


GAVILYTE-N 1

GEMFIBROZIL 1

GENERESS FE 3

GENERLAC 1

GENTAK 1

GENTAMICIN SULFATE 1

GIANVI 1

GILDAGIA 1

GILDESS 1

GILDESS FE 1

GLIMEPIRIDE 1

GLIPIZIDE 1

GLIPIZIDE ER 1

GLIPIZIDE XL 1

GLIPIZIDE-METFORMIN 1

GLYBURIDE 1

GLYBURIDE MICRONIZED 1

GLYBURIDE-METFORMIN HCL 1

GLYCOPYRROLATE 1

GRANISETRON HCL 1

GRANISOL 1

GRISEOFULVIN 1

GRISEOFULVIN ULTRAMICROSIZE 1

GUAIATUSSIN AC 1

GUAIFENESIN AC 1

GUAIFENESIN DAC 1

GUAIFENESIN-CODEINE 1

GUANFACINE HCL 1

GUANIDINE HCL 1

HALAC 1

HALOBETASOL PROPIONATE 1

HALONATE PAC 1

HALOPERIDOL 1

HALOPERIDOL LACTATE 1

HEATHER 1

HEMENATAL OB 1

HEMENATAL OB + DHA 1

HEMRIL 1

HEPARIN SODIUM 1

HOMATROPAIRE 1

HOMATROPINE 1

HUMALOG 2

HUMALOG MIX 50-50 2

HUMALOG MIX 75-25 2

HUMULIN 70-30 2


HUMULIN N 2

HUMULIN R 2

HYDRALAZINE HCL 1

HYDROCHLOROTHIAZIDE 12.5 MG CP 1

HYDROCHLOROTHIAZIDE 12.5 MG TB 1

HYDROCHLOROTHIAZIDE 25 MG TAB 1

HYDROCHLOROTHIAZIDE 50 MG TAB 1

HYDROCODONE BIT-IBUPROFEN 1

HYDROCODONE BT-HOMATROPINE MBR 1

HYDROCODONE-ACETAMINOPHEN 1

HYDROCODONE-CHLORPHENIRAMINE 1

HYDROCODONE-HOMATROPINE MBR 1

HYDROCODONE-IBUPROFEN 1

HYDROCORTISONE 1% ABSORBASE 1

HYDROCORTISONE 1% CREAM 1

HYDROCORTISONE 1% LOTION 1

HYDROCORTISONE 1% OINTMENT 1

HYDROCORTISONE 10 MG TABLET 1

HYDROCORTISONE 100 MG/60 ML 1

HYDROCORTISONE 2.5% CREAM 1

HYDROCORTISONE 2.5% LOTION 1

HYDROCORTISONE 2.5% OINTMENT 1



HYDROCORTISONE ACETATE 1

HYDROCORTISONE BUTYRATE 1

HYDROCORTISONE VALERATE 1

HYDROCORTISONE-ACETIC ACID 1

HYDROCORTISONE-IODOQUINOL 1

HYDROCORTISONE-PRAMOXINE 1

HYDROCORTISONE-PRAMOXINE HCL 1

HYDROMET 1

HYDROMORPHONE HCL 1

HYDROXYCHLOROQUINE SULFATE 1

HYDROXYUREA 1

HYDROXYZINE HCL 1

HYDROXYZINE PAMOATE 1

HYOMAX-SL 1

HYOPHEN 1

HYOSCYAMINE 1

HYOSCYAMINE 0.125 MG ODT 1

HYOSCYAMINE 0.125 MG TAB SL 1

HYOSCYAMINE 0.125 MG/5 ML ELIX 1

HYOSCYAMINE 0.125 MG/ML DROP 1

HYOSCYAMINE 125 MCG/5 ML ELIX 1

1 2


HYOSCYAMINE ER 0.375 MG TAB 1

HYOSCYAMINE SULF 0.125 MG TAB 1

HYOSYNE 1

HYPERCARE 1

IBANDRONATE SODIUM 1

IBUPROFEN 1

IBUPROHM 1

IMIPRAMINE HCL 1

IMIPRAMINE PAMOATE 1

IMIQUIMOD 1

INATAL ADVANCE 1

INATAL ULTRA 1

INDAPAMIDE 1

INDOMETHACIN 1

INTROVALE 1

IODOFLEX 1

IODOSORB 1

IOPHEN-C NR 1

IPRATROPIUM 0.03% SPRAY 1

IPRATROPIUM 0.06% SPRAY 1

IPRATROPIUM BR 0.02% SOLN 1

IPRATROPIUM-ALBUTEROL 1

IRBESARTAN 1

IRBESARTAN-HYDROCHLOROTHIAZIDE 1

ISOCHRON 1

ISODITRATE 1

ISOMETHEPT-DICHLORALP-ACETAMIN 1

ISOMETHEPTENE-CAFF-ACETAMINOPH 1

ISONIAZID 100 MG TABLET 1

ISONIAZID 300 MG TABLET 1

ISONIAZID 50 MG/5 ML SOLUTION 1

ISOSORBIDE DINITRATE 1

ISOSORBIDE MONONITRATE 1

ISOSORBIDE MONONITRATE ER 1

ISOXSUPRINE HCL 1

ISRADIPINE 1

ITRACONAZOLE 1 QL

JANTOVEN 1

JENCYCLA 1

JENTADUETO 2

JINTELI 1

JOLESSA 1

JOLIVETTE 1

JUNEL 1

JUNEL FE 1


K EFFERVESCENT 1

KALEXATE 1

KARIVA 1

KELNOR 1-35 1

KETOCONAZOLE 1

KETODAN 1

KETOPROFEN 1

KETOROLAC 0.4% OPHTH SOLUTION 1

KETOROLAC 0.5% OPHTH SOLUTION 1

KETOROLAC 10 MG TABLET 1 QL

KG-FED PEDIATRIC 1

KIONEX 1

KLOR-CON 10 1

KLOR-CON 8 1

KLOR-CON M10 1

KLOR-CON M20 1

KLOR-CON-EF 1

KURVELO 1

LABETALOL HCL 1

LACTATED RINGERS 1

LACTULOSE 1

LAMOTRIGINE 1

LANSOPRAZOLE 1

LATANOPROST 1

LAVOCLEN-4 1

LEENA 1

LEFLUNOMIDE 1

LESSINA 1

LETROZOLE 1

LEUKERAN 3

LEVALBUTEROL CONCENTRATE 1

LEVALBUTEROL HCL 1

LEVEMIR 2

LEVEMIR FLEXPEN 2

LEVETIRACETAM 1

LEVLEN 28 1

LEVOBUNOLOL HCL 1

LEVOCARNITINE 1

LEVOCETIRIZINE DIHYDROCHLORIDE 1

LEVOFLOXACIN 1

LEVOMEFOLATE DHA 1

LEVOMEFOLATEPNV 1

LEVONEST 1

LEVONORGESTREL 1

LEVONORGESTREL-ETH ESTRADIOL 1

1 3


LEVONORG-ETH ESTRAD ETH ESTRAD 1

LEVORA-28 1

LEVORPHANOL TARTRATE 1

LEVOTHROID 1

LEVOTHYROXINE SODIUM 1

LEVOXYL 1

LEXUSS 210 1

LIDOCAINE 1

LIDOCAINE HCL 1

LIDOCAINE HCL VISCOUS 1

LIDOCAINE-HYDROCORTISONE 1

LIDOCAINE-PRILOCAINE 1

LIDOCORT 1

LIOTHYRONINE SODIUM 1

LISINOPRIL 1

LISINOPRIL-HYDROCHLOROTHIAZIDE 1

LITHIUM 1

LITHIUM CARBONATE 150 MG CAP 1


LITHIUM CARBONATE 300 MG TAB 1


LITHIUM CARBONATE ER 300 MG TB 1

LITHIUM ER 450 MG TABLET 1

L-METHYLFOLATE CALCIUM 1

L-METHYLFOLATE FORMULA 1

L-METHYLFOLATE FORTE 1

L-METHYLFOLATE PNV DHA 1

LO LOESTRIN FE 2

LODOSYN 3

LOESTRIN 3

LOESTRIN 24 FE 2

LOESTRIN FE 3

LOHIST-DM 1

LOPERAMIDE 1

LORAZEPAM 1

LORAZEPAM INTENSOL 1

LORYNA 1

LOSARTAN POTASSIUM 1

LOSARTAN-HYDROCHLOROTHIAZIDE 1

LOSEASONIQUE 3

LOVASTATIN 1

LOW-OGESTREL 1

LOXAPINE 1

LUDENT FLUORIDE 1

LUGOL'S 1


LUSAIR 1

LUTERA 1

LYRICA 3

LYSODREN 3

MACNATAL CN DHA 1

MALATHION 1

MAPROTILINE HCL 1

MARLEXATE 1

MARLISSA 1

MATERNITY 1

MATZIM LA 1

MAXAIR AUTOHALER 3 ST

MAXIDONE 1

MAXITROL 1

M-CLEAR WC 1

MECLIZINE HCL 1

MECLOFENAMATE SODIUM 1

MEDROXYPROGESTERONE ACETATE 1

MEFENAMIC ACID 1

MEFLOQUINE HCL 1 PA

MEGESTROL ACETATE 1

MELOXICAM 15 MG TABLET 1

MELOXICAM 7.5 MG TABLET 1

MELOXICAM 7.5 MG/5 ML SUSP 1

M-END WC 1

MENEST 3

MEPERIDINE HCL 1

MEPERITAB 1

MEPHYTON 3

MEPROBAMATE 1

MEPRON 3

MERCAPTOPURINE 3

MESALAMINE 1

MESEHIST WC 1

METAPROTERENOL SULFATE 1

METAXALONE 1

METFORMIN HCL 1

METFORMIN HCL ER 1

METHADONE 1

METHADONE HCL 1

METHAMPHETAMINE HCL 1

METHAZOLAMIDE 1

METHENAMINE HIPPURATE 1

METHENAMINE MANDELATE 1

METHIMAZOLE 1

1 4


METHITEST 1

METHOCARBAMOL 1

METHSCOPOLAMINE BROMIDE 1

METHYCLOTHIAZIDE 1

METHYLDOPA 1

METHYLDOPA-HYDROCHLOROTHIAZIDE 1

METHYLERGONOVINE MALEATE 1

METHYLPHENIDATE ER 1

METHYLPHENIDATE ER-LA 1

METHYLPHENIDATE HCL 1

METHYLPHENIDATE HCL CD 1

METHYLPHENIDATE SR 1

METHYLPREDNISOLONE 1

METIPRANOLOL 1

METOCLOPRAMIDE HCL 1

METOLAZONE 1

METOPROLOL SUCCINATE 1

METOPROLOL TARTRATE 1

METOPROLOL-HYDROCHLOROTHIAZIDE 1

METRONIDAZOLE 1

MEXILETINE HCL 1

MICONAZOLE 3 1

MICROGESTIN 1

MICROGESTIN FE 1

MICRONOR 3

MIDAZOLAM HCL 1

MIDODRINE HCL 1

MIGERGOT 1

MILLIPRED 1

MIMVEY 1

MINASTRIN 24 FE 3

MINITRAN 1

MINOCYCLINE HCL 1

MINOXIDIL 1

MIRCETTE 3

MIRTAZAPINE 1

MISOPROSTOL 1

MOBAN 3

MODAFINIL 1

MOEXIPRIL HCL 1

MOEXIPRIL-HYDROCHLOROTHIAZIDE 1

MOMETASONE FUROATE 1

MONO-LINYAH 1

MONONESSA 1

MONTELUKAST SODIUM 1


MORGIDOX 1

MORPHINE SULFATE 1

MORPHINE SULFATE CR 1

MORPHINE SULFATE ER 1

MOXEZA 2

MULTAQ 3

MULTIVITAMIN AND FLUORIDE 1

MULTI-VITAMIN W-FLUORIDE-IRON 1

MULTIVITAMIN WITH FLUORIDE 1

MULTI-VITAMIN WITH FLUORIDE 1

MULTIVITAMINS W-FLUORIDE-IRON 1

MULTIVITAMINS WITH FLUORIDE 1

MUPIROCIN 1

MY WAY 1

MYCOBUTIN 3

MYNATAL 1

MYNATAL ADVANCE 1

MYNATAL PLUS 1

MYNATAL-Z 1

MYNATE 90 PLUS 1

MYOXIN 1

MYTUSSIN DAC 1

MYZILRA 1

NABUMETONE 1

NADOLOL 1

NADOLOL-BENDROFLUMETHIAZIDE 1

NALTREXONE HCL 1

NAMENDA 3

NAPHAZOLINE HCL 1

NAPROXEN 125 MG/5 ML SUSPEN 1

NAPROXEN 250 MG TABLET 1



NAPROXEN DR 375 MG TABLET 1

NAPROXEN DR 500 MG TABLET 1

NAPROXEN EC 375 MG TABLET 1

NAPROXEN EC 500 MG TABLET 1

NAPROXEN SODIUM 1

NARATRIPTAN 1 QL

NARATRIPTAN HCL 1 QL

NATAL-V RX 1

NATALVIRT 90 DHA 1

NATALVIRT CA 1

NATAZIA 3

NATEGLINIDE 1

1 5


NATURE-THROID 1

NEBUPENT 3

NECON 1

NEFAZODONE HCL 1

NEOCIN-PG 1

NEOFRIN 1

NEOMYCIN SULFATE 1

NEOMYCIN/POLYMYXIN/GRAMICIDIN 1

NEOMYCIN-BACITRACIN-POLY-HC 1

NEOMYCIN-BACITRACIN-POLYMYXIN 1

NEOMYCIN-POLYMYXIN B 1

NEOMYCIN-POLYMYXIN-DEXAMETH 1

NEOMYCIN-POLYMYXIN-GRAMICIDIN 1

NEOMYCIN-POLYMYXIN-HC 1

NEOMYCIN-POLYMYXIN-HYDROCORT 1

NEO-POLYCIN 1

NEO-POLYCIN HC 1

NEURIN-12 1

NEXT CHOICE 1

NEXT CHOICE ONE DOSE 1

NIASPAN 3

NICARDIPINE HCL 1

NIFEDIAC CC 1

NIFEDICAL XL 1

NIFEDIPINE 1

NIFEDIPINE ER 1

NIMODIPINE 1

NISOLDIPINE 1

NITRO-BID 1

NITROFURANTOIN 1

NITROFURANTOIN MONO-MACRO 1

NITROGLYCERIN 1

NITROGLYCERIN PATCH 1

NITRO-TIME 1

NIZATIDINE 15 MG/ML SOLUTION 1

NIZATIDINE 150 MG CAPSULE 1

NIZATIDINE 300 MG CAPSULE 1

NORA-BE 1

NORDETTE-28 3

NORETHINDRONE 1

NORETHINDRONE ACETATE 1

NORGESTIMATE-ETHINYL ESTRADIOL 1

NORINYL 1+35 3

NORINYL 1+50 3

NOROXIN 3


NOR-Q-D 3

NORTREL 1

NORTRIPTYLINE 10 MG/5 ML SOL 1

NORTRIPTYLINE HCL 10 MG CAP 1




NP THYROID 1

NULEV 1

NUTRI-TAB OB 1

NUTRI-TAB OB + DHA 1

NUVARING 2

NYAMYC 1

NYDAMAX 1

NYSTATIN 100,000 UNIT/GM CREAM 1

NYSTATIN 100,000 UNIT/GM POWD 1

NYSTATIN 100,000 UNITS/GM OINT 1

NYSTATIN 100,000 UNITS/ML SUSP 1

NYSTATIN 150,000,000 UNITS PWD 1


NYSTATIN 500,000 UNIT ORAL TAB 1

NYSTATIN 500,000 UNITS/5 ML 1


NYSTATIN VAGINAL TABLET 1

NYSTATIN-TRIAMCINOLONE 1

NYSTOP 1

OBSTETRIX DHA 1

OCELLA 1

OFLOXACIN 1

OGESTREL 1

OLANZAPINE 1

OLANZAPINE ODT 1

OLANZAPINE-FLUOXETINE HCL 1

OMEPRAZOLE 1

ONDANSETRON HCL 1

ONDANSETRON ODT 1

OPIUM 1

ORPHENADRINE CITRATE 1

ORPHENADRINE COMPOUND 1

ORPHENADRINE COMPOUND FORTE 1

ORSYTHIA 1

ORTHO EVRA 3

ORTHO TRI-CYCLEN 3

ORTHO TRI-CYCLEN LO 3

ORTHO-CEPT 3

1 6


ORTHO-CYCLEN 3

ORTHO-NOVUM 3

OSCIMIN 1

OSCIMIN SL 1

OSCIMIN SR 1

OTICIN 1

OTICIN HC 1

OTO-END 10 1

OTOMAX-HC 1

OTOZIN 1

OVCON-35 1

OXANDROLONE 1

OXAPROZIN 1

OXAZEPAM 1

OXCARBAZEPINE 1

OXYBUTYNIN 5 MG TABLET 1

OXYBUTYNIN 5 MG/5 ML SYRUP 1

OXYBUTYNIN CHLORIDE ER 1

OXYCODONE CONCENTRATE 1

OXYCODONE HCL 1

OXYCODONE HCL-ACETAMINOPHEN 1

OXYCODONE HCL-ASPIRIN 1

OXYCODONE HCL-IBUPROFEN 1

OXYCODONE-ACETAMINOPHEN 1

OXYMORPHONE HCL 10 MG TABLET 1

OXYMORPHONE HCL 5 MG TABLET 1

OXYMORPHONE HCL ER 10 MG TAB 1 QL





OXYMORPHONE HCL ER 5 MG TABLET 1 QL

OXYMORPHONE HCL ER 7.5 MG TAB 1 QL

PAIRE OB PLUS DHA 1

PALGIC 1

PANCRELIPASE 5,000 3

PANTOPRAZOLE SODIUM 1

PAPAVERINE HCL 1

PARCAINE 1

PAREGORIC 1

PAROMOMYCIN SULFATE 1

PAROXETINE HCL 1

PASER 3

PATADAY 2

PEDI-DRI 1


PEG 3350-ELECTROLYTE 1

PEG-3350 AND ELECTROLYTES 1

PEG-3350 WITH FLAVOR PACKS 1

PEGANONE 3

PENICILLIN V POTASSIUM 1

PENTAZOCINE-ACETAMINOPHEN 1

PENTAZOCINE-NALOXONE HCL 1

PENTOXIFYLLINE 1

PERINDOPRIL ERBUMINE 1

PERMETHRIN 1

PERPHENAZINE 1

PERPHENAZINE-AMITRIPTYLINE 1

PHENADOZ 1

PHENAZOPYRIDINE HCL 1

PHENELZINE SULFATE 1

PHENERGAN 1

PHENOBARBITAL 1

PHENYLEPHRINE HCL 1

PHENYTOIN 1

PHENYTOIN SODIUM EXTENDED 1

PHILITH 1

PHOSPHA 250 NEUTRAL 1

PHOSPHASAL 1

PILOCARPINE HCL 1

PINDOLOL 1

PINNACAINE 1

PIOGLITAZONE HCL 1

PIOGLITAZONE-GLIMEPIRIDE 1

PIOGLITAZONE-METFORMIN 1

PIRMELLA 1

PIROXICAM 1

PLAN B ONE-STEP 3

PNV FOLIC ACID + IRON 1

PNV OB+DHA 1

PNV-DHA 1

PNV-DHA + DOCUSATE 1

PNV-FIRST 1

PNV-OB WITH DHA 1

PNV-OMEGA 1

PNV-SELECT 1

PNV-TOTAL 1

PODOFILOX 1

POLYCIN 1

POLYETHYLENE GLYCOL 3350 1

POLYMYXIN B SUL-TRIMETHOPRIM 1

1 7


POLYVITAMINS-FLUORIDE 1

PORTIA 1

POTASSIUM BICARBONATE 1

POTASSIUM CHLORIDE 1

POTASSIUM CITRATE 1

PR NATAL 400 1

PR NATAL 400 EC 1

PR NATAL 430 1

PR NATAL 430 EC 1

PR OTIC SOLUTION 1

PRAMCORT 1

PRAMIPEXOLE DIHYDROCHLORIDE 1

PRAMOXINE-HC 1

PRASCION 1

PRASCION FC 1

PRASCION RA 1

PRAVASTATIN SODIUM 1

PRAZOSIN HCL 1

PREDNICARBATE 1

PREDNISOLONE 1

PREDNISOLONE ACETATE 1

PREDNISOLONE SOD PHOSPHATE 1

PREDNISOLONE SODIUM PHOSPHATE 1

PREDNISONE 1

PREDNISONE INTENSOL 1

PREFEST 1

PREHIST 1

PRENA1 1

PRENA1 CHEW 1

PRENA1 PLUS 1

PRENAISSANCE 1

PRENAISSANCE 90 DHA 1

PRENAISSANCE BALANCE 1

PRENAISSANCE DHA 1

PRENAISSANCE DHA HARMONY 1

PRENAISSANCE HARMONY DHA 1

PRENAISSANCE NEXT 1

PRENAISSANCE PLUS 1

PRENAISSANCE PROMISE 1

PRENAPLUS 1

PRENATAL 19 1

PRENATAL AD 1

PRENATAL LOW IRON 1

PRENATAL MV & MIN 1

PRENATAL PLUS 1


PRENATAL VITAMINS 1

PRENATAL-U 1

PREVALITE 1

PREVIFEM 1

PRIFTIN 3

PRIMAQUINE 1

PRIMIDONE 1

PROAIR HFA 2

PROBENECID 1

PROBENECID-COLCHICINE 1

PROCENTRA 1

PROCHLORPERAZINE 1

PROCHLORPERAZINE MALEATE 1

PROCTOCREAM-HC 1

PROCTO-PAK 1

PROCTOSOL-HC 1

PROCTOZONE-HC 1

PROGESTERONE 1

PROGESTERONE IN OIL 1

PROMACET 1

PROMACTA 12.5 MG TABLET 3 PA

PROMETHAZINE HCL 1

PROMETHAZINE VC 1

PROMETHAZINE VC-CODEINE 1

PROMETHAZINE-CODEINE 1

PROMETHAZINE-DM 1

PROMETHAZINE-PHENYLEPHRINE 1

PROMETHEGAN 1

PROPAFENONE HCL 1

PROPANTHELINE BROMIDE 1

PROPARACAINE HCL 1

PROPRANOLOL HCL 1

PROPRANOLOL-HYDROCHLOROTHIAZID 1

PROPYLTHIOURACIL 1

PROTRIPTYLINE HCL 1

PRUDOXIN 1

PYRAZINAMIDE 1

PYRIDOSTIGMINE BROMIDE 1

PYRIL D 1

QUADRAPAX 1

QUALAQUIN 3

QUARTETTE 3

QUASENSE 1

QUETIAPINE FUMARATE 1

QUINAPRIL HCL 1

1 8


QUINAPRIL-HYDROCHLOROTHIAZIDE 1

QUINIDINE GLUCONATE 1

QUINIDINE SULFATE 1

QUININE SULFATE 1

QVAR 2

RAMIPRIL 1

RANITIDINE 15 MG/ML SYRUP 1

RANITIDINE 150 MG CAPSULE 1

RANITIDINE 150 MG TABLET 1

RANITIDINE 150 MG/10 ML SYRUP 1

RANITIDINE 300 MG CAPSULE 1

RANITIDINE 300 MG TABLET 1

RECLIPSEN 1

RECTACORT-HC 1

REGENECARE 1

RELCOF C 1

RELENZA 3 QL

RELNATE DHA 1

RENAGEL 3

REPAN-CF 1

RESERPINE 1

RHINOFLEX 1

RIFAMPIN 1

RIMANTADINE HCL 1

RISPERIDONE 1

RISPERIDONE M-TAB 1

RISPERIDONE ODT 1

RIVASTIGMINE 1

RIZATRIPTAN 1 QL

ROPINIROLE HCL 1

ROSADAN 1

ROSANIL 1

ROXICET 1

RU-HIST FORTE 1

SAFYRAL 3

SALSALATE 1

SAMSCA 3 PA

SAPHRIS 3 ST

SEASONIQUE 3

SEB-PREV 1

SECONAL SODIUM 1

SELEGILINE HCL 1

SELENIUM SULFIDE 1

SE-NATAL 19 1

SERTRALINE 20 MG/ML ORAL CONC 1


SERTRALINE HCL 100 MG TABLET 1



SE-TAN DHA 1

SETONET 1

SF 1

SF 5000 PLUS 1

SILVER NITRATE 1

SILVER SULFADIAZINE 1

SIMVASTATIN 1

SODIUM CHLORIDE 1

SODIUM CITRATE & CITRIC ACID 1

SODIUM FLUORIDE 1

SODIUM PHENYLBUTYRATE 1

SODIUM POLYSTYRENE SULFONATE 1

SODIUM SULFACETAMIDE 1

SODIUM SULFACETAMIDE-SULFUR 1

SOFTCLIX 2

SOTALOL 1

SOTALOL AF 1

SPECTRACEF 1

SPINOSAD 1

SPIRONOLACTONE 1

SPIRONOLACTONE-HCTZ 1

SPRINTEC 1

SPS 1

SRONYX 1

SSS 10-5 1

STANNOUS FLUORIDE 1

STROMECTOL 3

STRONG IODINE 1

SUCRALFATE 1

SUDATUSS-2 1

SUDATUSS-SF 1

SULFACETAMIDE SODIUM 1

SULFACETAMIDE-PREDNISOLONE 1

SULFACLEANSE 8-4 1

SULFADIAZINE 1

SULFAMETHOXAZOLE-TRIMETHOPRIM 1

SULFAMIDE 1

SULFASALAZINE 1

SULFASALAZINE DR 1

SULFAZINE 1

SULFAZINE EC 1

SULINDAC 1

1 9


SUMATRIPTAN 1 QL

SUMATRIPTAN SUCCINATE 1 QL

SUMYCIN 1

SUTTAR-2 1

SUTTAR-SF 1

SYEDA 1

SYMAX 1

SYMAX-SL 1

SYMAX-SR 1

SYNTHROID 3

TABLOID 40 MG TABLET 3

TAMIFLU 2 QL

TAMOXIFEN CITRATE 1

TAMSULOSIN HCL 1

TARON-BC 1

TARON-C DHA 1

TARON-CRYSTALS 1

TARON-PREX PRENATAL 1

TAZTIA XT 1

TEMAZEPAM 1

TENCON 1

TERAZOSIN HCL 1

TERBINAFINE HCL 1 QL

TERBUTALINE SULFATE 1

TERCONAZOLE 1

TESTIM 2

TESTOSTERONE CYPIONATE 1

TESTOSTERONE ENANTHATE 1

TETCAINE 1

TETRACAINE HCL 1

TETRACYCLINE HCL 1

THEOPHYLLINE ANHYDROUS 1

THIORIDAZINE HCL 1

THIOTHIXENE 1

TIAGABINE HCL 1

TICLOPIDINE HCL 1

TIKOSYN 3

TILIA FE 1

TIMOLOL MALEATE 1

TINIDAZOLE 1

TIZANIDINE HCL 1

TL-CARE DHA 1

TL-HIST CM 1

TL-SELECT 1

TOBRAMYCIN 1


TOBRAMYCIN SULFATE 1

TOBRAMYCIN-DEXAMETHASONE 1

TOLAZAMIDE 1

TOLBUTAMIDE 1

TOLMETIN SODIUM 1

TOLTERODINE TARTRATE 1

TOPIRAGEN 1

TOPIRAMATE 1

TORSEMIDE 1

TRADJENTA 2

TRAMADOL HCL 1

TRAMADOL HCL ER 1

TRAMADOL HCL-ACETAMINOPHEN 1

TRANDOLAPRIL 1

TRANEXAMIC ACID 1

TRANYLCYPROMINE SULFATE 1

TRAVATAN Z 2

TRAZODONE HCL 1

TREAGAN OTIC 1

TRECATOR 3

TRETINOIN 0.01% GEL 1

TRETINOIN 0.025% CREAM 1 AGE

TRETINOIN 0.025% GEL 1



TRETINOIN 10 MG CAPSULE 3

TRETINOIN MICROSPHERE 1 AGE

TRI RX 1

TRIADVANCE 1

TRIAMCINOLONE ACETONIDE 1

TRIAMTERENE W/HCTZ 1

TRIAMTERENE-HCTZ 1

TRIAMTERENE-HYDROCHLOROTHIAZID 1

TRIANEX 1

TRIAZOLAM 1

TRICITRATES 1

TRI-ESTARYLLA 1

TRIFLUOPERAZINE HCL 1

TRIFLURIDINE 1

TRIHEXYPHENIDYL HCL 1

TRI-LEGEST FE 1

TRI-LINYAH 1

TRILYTE WITH FLAVOR PACKETS 1

TRIMESIS RX 1

TRIMETHOBENZAMIDE HCL 1

2 0


TRIMETHOPRIM 1

TRIMETHOPRIM-POLYMYXIN B SULF 1

TRIMIPRAMINE MALEATE 1

TRINATAL GT 1

TRINATAL RX 1 1

TRINATAL ULTRA 1

TRINESSA 1

TRIPLE-VITAMIN W-FLUORIDE 1

TRI-PREVIFEM 1

TRI-SPRINTEC 1

TRIVEEN-DUO DHA 1

TRIVEEN-ONE 1

TRIVEEN-PRX RNF 1

TRIVEEN-TEN 1

TRIVEEN-U 1

TRI-VI-FLOR 1

TRI-VI-FLORO 1

TRI-VIT WITH FLUORIDE-IRON 1

TRI-VITAMIN WITH FLUORIDE 1

TRIVORA-28 1

TROPICAMIDE 1

TROSPIUM CHLORIDE 1

TRUST NATAL DHA 1

TUDORZA PRESSAIR 2

TUSNEL C 1

TUSSIGON 1

U-CORT 1

ULTIMATE OB DHA 1

ULTIMATECARE ONE 1

ULTIMATECARE ONE NF 1

UNITHROID 1

UR N-C 1

URIN D.S. 1

URSODIOL 1

USTELL 1

VAGIFEM 3

VALACYCLOVIR 1

VALCYTE 3

VALPROIC ACID 1

VALSARTAN-HYDROCHLOROTHIAZIDE 1

VANCOMYCIN HCL 1

VANDAZOLE 1

VASOLEX 1

VELIVET 1

VEMAVITE-PRX 2 1


VENA-BAL DHA 1

VENATAL COMPLETE DHA 1

VENATAL-FA 1

VENLAFAXINE HCL 1

VENLAFAXINE HCL ER 1

VERAPAMIL ER 1

VERAPAMIL ER PM 1

VERAPAMIL HCL 1

VESICARE 2 ST

VESTURA 1

VIGAMOX 2

VINACAL 1

VINATE AZ 1

VINATE CALCIUM 1

VINATE GT 1

VINATE IC 1

VINATE II 1

VINATE ONE 1

VINATE PN CARE 1

VINATE ULTRA 1

VINATE-M 1

VIORELE 1

VIREAD POWDER 3

VIRTI-SULF 1

VIRT-PN 1

VIRT-PN DHA 1

VIRT-PN PLUS 1

VIRT-SELECT 1

VITAFOL-OB 1

VITAFOL-PN 1

VITAMIN D2 1

VITAMINS A,C,D & FLUORIDE 1

VITAMINS A,D,C & FLUORIDE 1

VITASPIRE 1

V-NATAL 1

V-NATAL DHA 1

VOL-NATE 1

VOL-PLUS 1

VOL-TAB RX 1

VORICONAZOLE 1 PA

VP-CH-PNV 1

VP-ERA OB PLUS 1

VP-GGR-B6 1

VP-HEME ONE 1

VYNATAL-FA 1

2 1


VYTORIN 2 ST

WARFARIN SODIUM 1

WERA 1

WESTHROID 1

WESTHROID-P 1

WYMZYA FE 1

XOLOX 1

YASMIN 28 3

YAZ 3

ZAFIRLUKAST 1

ZALEPLON 1

ZARAH 1

ZATEAN-CH 1

ZATEAN-PN 1

ZATEAN-PN DHA 1

ZATEAN-PN PLUS 1

ZAZOLE 1

ZENCHENT 1

ZENCHENT FE 1

ZENCIA 1

ZENPEP 2

ZEOSA 1

ZETONNA 3

ZGESIC 1

ZINC SULFATE 1

ZINGIBER 1

ZIPRASIDONE HCL 1

ZOLMITRIPTAN 1 QL

ZOLMITRIPTAN ODT 1 QL

ZOLPIDEM TARTRATE 1

ZOLPIDEM TARTRATE ER 1

ZONISAMIDE 1

ZOVIA 1-35E 1

ZOVIA 1-50E 1

Z-PRAM 1

2 2

Specialty medications

AABACAVIRÂCTIMMUNE^ (PA)ADCIRCA^ (PA)AFINITOR DISPERZ^ (PA)AFINITOR^ (PA)ALKERAN 2 MG TABLETAMINOCAPROIC ACID 1,000 MG TABÂMINOCAPROIC ACID 25% SOLUTIONÂMINOCAPROIC ACID 500 MG TABÂNAGRELIDE HCL^ (PA)ANZEMET 100 MG TABLET (PA, QL)ANZEMET 20 MG/ML VIAL (PA)ANZEMET 50 MG TABLET (PA, QL)APOKYN^ (PA)APTIVUSÂRANESP (PA)ARCALYST (PA)ATRIPLAÂVONEX ADMINISTRATION PACK^ (PA)AVONEX PEN^ (PA)AVONEX^ (PA)AZATHIOPRINE^

BBARACLUDE^BICALUTAMIDE 50 MG TABLET^BOSULIF^ (PA)

CCAPRELSA (PA)CIMZIA^ (PA)COMETRIQ (PA)COMPLERA^COPAXONE^ (PA)CRIXIVAN^CYCLOPHOSPHAMIDE 25 MG TAB^CYCLOPHOSPHAMIDE 50 MG TABLET^CYCLOSPORINE 100 MG CAPSULE^CYCLOSPORINE 100 MG/ML SOLN^CYCLOSPORINE 25 MG CAPSULE^CYCLOSPORINE MODIFIED^CYSTADANECYSTAGON

DDIDANOSINE^

EEDURANTÊGRIFTA^ (PA)EMCYTÊMEND 125 MG CAPSULE (PA, QL)EMEND 150 MG VIAL (PA)EMEND 40 MG CAPSULE (PA, QL)EMEND 80 MG CAPSULE (PA, QL)EMEND TRIFOLD PACK (PA, QL)EMTRIVAÊNOXAPARIN SODIUMEPIVIR HBVÊPOGEN (PA)EPZICOMÊRIVEDGE^ (PA)ETOPOSIDE 50 MG CAPSULEÊXJADEEXTAVIA^ (PA, ST)

FFIRAZYR^ (PA)FIRMAGON (PA)FLUTAMIDE^FONDAPARINUX SODIUMFORTEO^FRAGMINFUZEON^ (PA)

GGATTEX (PA)GENGRAF^GENOTROPIN^ (PA, ST)GLEEVEC^ (PA)

HHECORIA^HEPSERA^HEXALEN^HUMATROPE^ (PA)HYCAMTIN 0.25 MG CAPSULE^HYCAMTIN 1 MG CAPSULE^

IICLUSIG (PA)ILARIS (PA)INCIVEK^ (PA)INCRELEX^ (PA)INFERGEN^ (PA)INLYTA^ (PA)INTELENCEÎNTRON A^ (PA)INVIRASEÎSENTRESS^

JJAKAFI (PA)JUXTAPID (PA)

KKALETRA^KUVAN^

LLAMIVUDINE^LAMIVUDINE-ZIDOVUDINE^LETAIRIS^LEUCOVORIN CALCIUM 10 MG TAB^LEUCOVORIN CALCIUM 15 MG TAB^LEUCOVORIN CALCIUM 25 MG TAB^LEUCOVORIN CALCIUM 5 MG TAB^LEUKINE (PA)LEUPROLIDE ACETATE^ (PA)LEXIVA^LUPRON DEPOT^ (PA)LUPRON DEPOT-PED^ (PA)

MMATULANEMESNEX 400 MG TABLETMETHOTREXATE 2.5 MG TABLET^MYCOPHENOLATE MOFETIL^

Îf you live in Colorado, Florida or South Carolina, these specialty medications must be obtained through Cigna Home Delivery Pharmacy. Only your first prescription can be obtained at a network retail pharmacy. All subsequent refills must be obtained through Cigna Home Delivery Pharmacy. To maximize your benefits, all other medications are available through one of our specialty pharmacies, at a network retail pharmacy or through your physician’s office, if necessary.

The following specialty medications are typically covered under the fourth tier.

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Specialty medications

^If you live in Colorado, Florida or South Carolina, these specialty medications must be obtained through Cigna Home Delivery Pharmacy. Only your first prescription can be obtained at a network retail pharmacy. All subsequent refills must be obtained through Cigna Home Delivery Pharmacy. To maximize your benefits, all other medications are available through one of our specialty pharmacies, at a network retail pharmacy or through your physician’s office, if necessary.

NNEULASTA (PA)NEUPOGEN (PA)NEVIRAPINE^NEXAVAR^ (PA)NORDITROPIN FLEXPRO^ (PA, ST)NORDITROPIN NORDIFLEX^ (PA, ST)NORDITROPIN^ (PA, ST)NORVIR^NUTROPIN AQ NUSPIN^ (PA, ST)NUTROPIN AQ^ (PA, ST)NUTROPIN^ (PA, ST)

OOCTREOTIDE ACETATE^ (PA)OMNITROPE^ (PA, ST)ORENCIA 125 MG/ML SYRINGE^ (PA)ORFADIN

PPANRETIN^ (PA)PEGINTRON REDIPEN^ (PA)PEGINTRON^ (PA)PREZISTA^PROMACTA 25 MG TABLET^ (PA)PROMACTA 50 MG TABLET^ (PA)PROMACTA 75 MG TABLET^ (PA)PULMOZYME^ (PA)

RRAPAMUNE^REBETOL^REBETRON 1000^ (PA)REBETRON 1200^ (PA)REBETRON 600^ (PA)REBIF^ (PA)RESCRIPTORREVLIMID^ (PA)REYATAZ^RHEUMATREX^RIBAVIRIN^RILUZOLE^

SSABRILSAIZEN^ (PA)SELZENTRY^SENSIPARSEROSTIM 4 MG VIAL^ (PA, ST)SEROSTIM 6 MG VIAL^ (PA)SILDENAFIL^ (PA)SOMATULINE DEPOT (PA)SOMAVERT (PA)SPRYCEL^ (PA)STAVUDINE^STELARA^ (PA, ST)STIVARGA^ (PA)SUCRAIDSUSTIVA^SUTENT^ (PA)SYLATRON 4-PACK^ (PA)SYNAREL^ (PA)

TTABLOID 40 MG TABLETTACROLIMUS^TARCEVA^ (PA)TARGRETIN^TASIGNA^ (PA)TEMODAR 100 MG CAPSULE^ (PA)TEMODAR 140 MG CAPSULE^ (PA)TEMODAR 180 MG CAPSULE^ (PA)TEMODAR 20 MG CAPSULE^ (PA)TEMODAR 250 MG CAPSULE^ (PA)TEMODAR 5 MG CAPSULE^ (PA)THALOMID^ (PA)TRACLEER^TRIZIVIR^TRUVADA^TYKERB^ (PA)TYVASOTYZEKA^

VVENTAVISVICTRELIS^ (PA, ST)VIDEX^VIRACEPT^VIRAZOLE^VIREAD 150 MG TABLET^VIREAD 200 MG TABLET^VIREAD 250 MG TABLET^VIREAD 300 MG TABLET^VOTRIENT^ (PA)

XXALKORI^ (PA)XELODA^XENAZINEXOLAIR^ (PA)XTANDI^ (PA)XYREM

ZZAVESCA (PA)ZELBORAF^ (PA)ZEMPLAR 1 MCG CAPSULE^ZEMPLAR 2 MCG CAPSULE^ZEMPLAR 4 MCG CAPSULE^ZIDOVUDINE^ZOLADEX^ (PA)ZOLINZA (PA)ZORTRESS^ZYTIGA^ (PA)

The following specialty medications are typically covered under the fourth tier.

2 4

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. 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.

3. Any medications that are experimental or investigational within the meaning set forth in the policy.

4. 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.

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

6. Implantable contraceptive products.

7. Any prescription vitamins (other than prenatal vitamins), dietary supplements and fluoride products.

8. 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.

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

10. 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).

11. Replacement of prescription medications and related supplies due to loss or theft, except in the case of a natural disaster.

12. Medications used to enhance athletic performance.

13. 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.

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

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

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“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 Cigna Health and Life Insurance Company, Cigna HealthCare of Arizona, Inc., Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C. ”Cigna Home Delivery Pharmacy’’ refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C.

863932 08/13 ©2013 Cigna

Cigna reserves the right to make changes to this drug list without notice. Your plan may cover additional medications; please refer to your policy 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.

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