prescription drug list changes - cigna drug list changes ... omeprazole bicarbonate packets, ......
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909015 UPDATED_10/17/2017
The medications listed below are changing coverage (or cost levels) on Cigna’s Prescription Drug List. Changes are listed by drug list name and by the date they begin.
If you’re enrolled with Cigna, you can log into myCigna.com to find out how these changes may affect your specific plan.
STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST
PRESCRIPTION DRUG LIST CHANGESCigna Pharmacy Management® 2018
Start date of change*
Drug class Medication not covered^ Generic and/or preferred brand alternatives
January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipramine
Pamelor nortriptyline
Parnate tranylcypromine
Tofranil imipramine
ASTHMA/COPD/RESPIRATORY Zyflo montelukast, zafirlukast, zileuton ER
Zyflo CR zileuton ER
ATTENTION DEFICIT HYPERACTIVITY DISORDER
Desoxyn methamphetamineDexedrine dextroamphetamine,
dextroamphetamine ERBLOOD PRESSURE/HEART MEDICATIONS Betapace sotalol tabletsCANCER Nilandron nilutamideDIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR
Invokana Farxiga, JardianceLantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba Novolin, Novolog Humalog, Humulin
GASTROINTESTINAL/HEARTBURN Cortifoam, Uceris rectal foam Anucort-HC, Colocort, Hemmorex-HC, hydrocortisone, Procto-Med HC, Procto-Pak, Proctosol-HC, Proctozone-HC
Lotronex alosetronMarinol dronabinolomeprazole bicarbonate packets, 40-1100mg capsules
omeprazole
Rowasa mesalamine enemaUceris tablet budesonide EC capsule
STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont)
Start date of change*
Drug class Medication not covered^ Generic and/or preferred brand alternatives
January 1, 2018 GASTROINTESTINAL/HEARTBURN (cont) Zegerid omeprazoleZofran ondansetronZofran ODT ondansetron ODT
HORMONAL AGENTS DDAVP desmopressinHectorol doxercalciferol capsule
INFECTIONS Augmentin, Augmentin ES, Augmentin XR amoxicillin-clavulanate ER, amoxicillin-clavulanate
Diflucan fluconazoleE.E.S. 200, Eryped 400 erythromycin ethylsuccinateMepron atovaquoneSporanox itraconazole
Targadox Avidoxy tablet, doxycycline hyclate, Morgidox capsule
Valcyte valganciclovir
Vancocin vancomycin capsule
Zovirax acyclovir
MISCELLANEOUS Gralise, Horizant gabapentin
PAIN RELIEF AND INFLAMMATORY DISEASE Cambia diclofenac, diclofenac ER, etodolac, etodolac ER, fenoprofen, Fenortho, flurbiprofen, ibuprofen, indomethacin, indomethacin ER, ketoprofen, Ketorolac, meclofenamate, mefenamic acid, meloxicam, nabumetone
D.H.E. 45, Migranal dihydroergotamine
Imitrex, Sumavel DosePro sumatriptan
Lorzone chlorzoxazone
OxyContin Embeda, Hysingla ER, Xtampza ER
Roxicodone oxycodone
Tivorbex indomethacin
Vanatol LQ butalbital/acetaminophen/caffeine tabs or caps
Vivlodex meloxicam
Zomig sumatriptan, zolmitriptan
Zorvolex diclofenac, diclofenac ER
PARKINSON'S DISEASE Lodosyn carbidopa
Requip XL ropinirole ER
SCHIZOPHRENIA/ANTI-PSYCHOTICS Geodon ziprasidone
Zyprexa olanzapine
Zyprexa Zydis olanzapine ODT
STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont)
Start date of change*
Drug class Medication not covered^ Generic and/or preferred brand alternatives
January 1, 2018 SKIN CONDITIONS Cutivate fluticasone creamKenalog triamcinolone sprayLocoid lotion hydrocortisone butyrateLuzu ketoconazole creamSoriatane acitretinZiana clindamycin-tretinoin
SLEEP DISORDERS/SEDATIVES Nuvigil armodafinilProvigil modafinilRestoril temazepam
URINARY TRACT CONDITIONS Detrol tolterodineDetrol LA tolterodine ERDitropan XL oxybutynin EREnablex darifenacin ERGelnique darifenacin ER, oxybutynin ER, tolterodine
ER, trospium ERStart date of change*
Drug classNon-preferred brand medication
Generic and/or preferred brand alternatives
January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal sprayATTENTION DEFICIT HYPERACTIVITY DISORDER
Adderall XR dextroamphetamine-amphetamine ER
Focalin XR dexmethylphenidate ERSKIN CONDITIONS Ala-Scalp hydrocortisone
Analpram HC lotion hydrocortisone-pramoxineCapex shampoo fluocinoloneCordran flurandrenolideDifferin adapaleneMetrogel metronidazole gelNaftin naftifineNucort, Texacort hydrocortisone
Start date of change*
Drug classMedication requiring prior authorization
Additional information
January 1, 2018 GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi
Your plan will only cover this medication if your doctor requests and receives approval from Cigna.HORMONAL AGENTS Androderm, Androgel, Striant, testosterone
Start date of change*
Drug class Medication with quantity limits Additional information
January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone Your plan only covers a certain amount of this medication over a certain number of days. Your plan will only cover a larger amount if your doctor requests and receives approval from Cigna.
ALZHEIMER'S DISEASE Namenda XR, NamzaricANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine 25mg, 100mg, Marplan,
PristiqASTHMA/COPD/RESPIRATORY PerforomistBLOOD PRESSURE/HEART MEDICATIONS RanexaCANCER Fareston, nilutamideEYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan
STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont)
Start date of change*
Drug class Medication with quantity limits Additional information
January 1, 2018 HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem
Your plan only covers a certain amount of this medication over a certain number of days. Your plan will only cover a larger amount if your doctor requests and receives approval from Cigna.
MISCELLANEOUS NuedextaOSTEOPOROSIS PRODUCTS alendronatePAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, MitigareSCHIZOPHRENIA/ ANTI-PSYCHOTICS
Fanapt
SEIZURE DISORDERS Gabitril, PotigaSKIN CONDITIONS Denavir, Regranex, Santyl, VecticalSLEEP DISORDERS/SEDATIVES Hetlioz
Start date of change*
Drug class Step Therapy medication^^Generic and/or preferred brand alternatives
January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER
Focalin XR dexmethylphenidate ER
SCHIZOPHRENIA/ANTI-PSYCHOTICS Orap pimozide
SKIN CONDITIONS Ala-Scalp hydrocortisoneCapex shampoo fluocinoloneCordran flurandrenolideNucort, Texacort hydrocortisone
Start date of change*
Drug class
Medication strength with limitations++ (Your plan doesn’t cover 2 capsules/tablets per day of this strength)
Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)
January 1, 2018 ALLERGY/NASAL SPRAYS desloratadine ODT 2.5mg desloratadine ODT 5mg
ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg
Fetzima ER 40mg Fetzima ER 80mg
Trintellix 5mg Trintellix 10mg
Trintellix 10mg Trintellix 20mg
BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg
Benicar 20mg Benicar 40mg
Benicar HCT 20-12.5mg Benicar HCT 40-25mg
Bystolic 10mg Bystolic 20mg
Tekturna 150mg Tekturna 300mg
Tekturna HCT 150-12.5mg Tekturna HCT 300-25mg
CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg
Livalo 2mg Livalo 4mg
DIABETES Farxiga 5mg Farxiga 10mg
PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg
SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg
PERFORMANCE PRESCRIPTION DRUG LIST
Start date of change*
Drug class
Medication strength with limitations++ (Your plan doesn’t cover 2 capsules/tablets per day of this strength)
Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)
January 1, 2018 SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg Aptiom 400mg Aptiom 800mg Fycompa 4mg Fycompa 8mg Fycompa 6mg Fycompa 12mg Trokendi XR 25mg Trokendi XR 50mg Trokendi XR 100mg Trokendi XR 200mg
SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg
STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont)
Start date of change*
Drug classNon-preferred brand medication
Generic and/or preferred brand alternatives
January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal spray
ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ERDIABETES Lantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Tresiba, Levemir GASTROINTESTINAL/HEARTBURN omeprazole bicarbonate packet,
40mg-1100mg capsule, 20mg-1100mgomeprazole
INFECTIONS Eryped 400 erythromycinPAIN RELIEF AND INFLAMMATORY DISEASE OxyContin Embeda, Hysingla ER, Xtampza ER
Vanatol LQ butalbital/acetaminophen/caffeine tabs or caps
SKIN CONDITIONS Ala-Scalp hydrocortisone topicalCapex shampoo fluocinolone scalpCordran flurandrenolide topicalDifferin adapaleneKenalog spray triamcinolone sprayLocoid lotion hydrocortisone butyrateMetrogel metronidazole gelNaftin naftifineNucort, Texacort hydrocortisone
Start date of change*
Drug classMedication requiring prior authorization
Additional information
January 1, 2018 DIABETES Lantus, Lantus SoloStar, Toujeo SoloStar Your plan will only cover this medication if your doctor requests and receives approval from Cigna.
GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, VarubiHORMONAL AGENTS Androderm, Androgel, Axiron, Fortesta,
Natesto, Striant, Testim, Testopel, testosterone, Vogelxo
PAIN RELIEF AND INFLAMMATORY DISEASE RoxicodoneStart date of change*
Drug class Medication with quantity limits Additional information
January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone, Nasonex Your plan only covers a certain amount of this medication over a certain number of days. Your plan will only cover a larger amount if your doctor requests and receives approval from Cigna.
ALZHEIMER'S DISEASE Namenda XR, NamzaricANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine 25mg, 100mg, Marplan,
PristiqASTHMA/COPD/RESPIRATORY Perforomist
Start date of change*
Drug class Medication with quantity limits Additional information
January 1, 2018 BLOOD PRESSURE/HEART MEDICATIONS Ranexa Your plan only covers a certain amount of this medication over a certain number of days. Your plan will only cover a larger amount if your doctor requests and receives approval from Cigna.
CANCER Fareston, Nilandron, nilutamideDIABETES Jentadueto, TradjentaEYE CONDITIONS bimatoprost eye drops, Cystaran, ZioptanHORMONAL AGENTS Alora, estradiol patch, Estring, Menostar,
Minivelle, Vagifem, Vivelle Dot, yuvafemINFECTIONS Zovirax MISCELLANEOUS NuedextaOSTEOPOROSIS PRODUCTS alendronatePAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, MitigareSCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify Maintena, Aristada, Fanapt, Invega
Trinza, Risperdal Consta, Zyprexa RelprevvSEIZURE DISORDERS Gabitril, PotigaSKIN CONDITIONS Denavir, Regranex, Santyl, Vectical, ZyclaraSLEEP DISORDERS/SEDATIVES Hetlioz
PERFORMANCE PRESCRIPTION DRUG LIST (cont)
Start date of change*
Drug class Step Therapy medication^^Generic and/or Preferred Brand Alternatives
January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER
Focalin XR dexmethylphenidate ER
SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify aripiprazole
Orap pimozide
SKIN CONDITIONS Locoid lotion hydrocortisone butyrate
SLEEP DISORDERS/SEDATIVES Silenor eszopiclone, zolpidem
Start date of change*
Drug class
Medication strength with limitations++ (Your plan doesn’t cover 2 capsules/tablets per day of this strength)
Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)
January 1, 2018 ALLERGY/NASAL SPRAYS desloratadine ODT 2.5mg desloratadine ODT 5mg
ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg
Fetzima ER 40mg Fetzima ER 80mg
Trintellix 5mg Trintellix 10mg
Trintellix 10mg Trintellix 20mg
BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg
Benicar 20mg Benicar 40mg
Benicar HCT 20-12.5mg Benicar HCT 40-25mg
Bystolic 10mg Bystolic 20mg
Tekturna 150mg Tekturna 300mg
Tekturna HCT 150-12.5mg Tekturna HCT 300-25mg
CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg
Livalo 2mg Livalo 4mg
DIABETES Farxiga 5mg Farxiga 10mg
VALUE PRESCRIPTION DRUG LIST
PERFORMANCE PRESCRIPTION DRUG LIST (cont)
Start date of change*
Drug class
Medication strength with limitations++ (Your plan doesn’t cover 2 capsules/tablets per day of this strength)
Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)
January 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg
Aptiom 400mg Aptiom 800mg Fycompa 4mg Fycompa 8mg Fycompa 6mg Fycompa 12mg Trokendi XR 25mg Trokendi XR 50mg Trokendi XR 100mg Trokendi XR 200mg
SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg
Start date of change*
Drug classNon-preferred brand medication
Generic and/or preferred brand alternatives
January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal sprayASTHMA/COPD/RESPIRATORY Spiriva, Spiriva Respimat Incruse Ellipta
Stiolto Respimat Anoro ElliptaATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER
Focalin XR dexmethylphenidate ERDIABETES Apidra Humalog
Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR Invokana Farxiga, Jardiance Kombiglyze XR, Onglyza alogliptin, alogliptin-metformin, Janumet,
Janumet XR, JanuviaToujeo Basaglar, Tresiba, Levemir
PAIN RELIEF AND INFLAMMATORY DISEASE D.H.E. 45 dihydroergotamineImitrex sumatriptanOxyContin Embeda, Hysingla ER, Xtampza ERVanatol LQ butalbital/acetaminophen/caffeine tabs
or capsZomig nasal spray sumatriptan, zolmitriptan
SKIN CONDITIONS Differin adapaleneMetrogel metronidazole gelNaftin naftifine
Start date of change*
Drug classMedication requiring prior authorization
Additional information
January 1, 2018 DIABETES Lantus, Lantus SoloStar, Toujeo SoloStar Your plan will only cover this medication if your doctor requests and receives approval from Cigna.
GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend capsule, powder packet, tripack, Sancuso, Varubi
HORMONAL AGENTS Androderm, Androgel, Axiron, Fortesta, Natesto, Striant, Testim, Testopel, testosterone, Vogelxo
PAIN RELIEF AND INFLAMMATORY DISEASE Roxicodone
VALUE PRESCRIPTION DRUG LIST (cont)
Start date of change*
Drug class Medication with quantity limits Additional information
January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, Nasonex, mometasone Your plan only covers a certain amount of this medication over a certain number of days. Your plan will only cover a larger amount if your doctor requests and receives approval from Cigna.
ALZHEIMER'S DISEASE Namenda XR, Namzaric
ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine ER, Marplan, Pristiq
ASTHMA/COPD/RESPIRATORY Perforomist
BLOOD PRESSURE/HEART MEDICATIONS Ranexa
CANCER Fareston, Nilandron, nilutamide
DIABETES Jentadueto, Tradjenta
EYE CONDITIONS bimatoprost, Cystaran, Zioptan
HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem
INFECTIONS Zovirax
MISCELLANEOUS Nuedexta
OSTEOPOROSIS PRODUCTS alendronate
PAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, Mitigare
SCHIZOPHRENIA/ANTI-PSYCHOTICS Fanapt
SEIZURE DISORDERS Gabitril, Potiga
SKIN CONDITIONS Denavir, Regranex, Santyl, Vectical, Zyclara
SLEEP DISORDERS/SEDATIVES Hetlioz
Start date of change*
Drug class Step Therapy medication^^Generic and/or preferred brand alternatives
January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ERFocalin XR dexmethylphenidate ER
DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XRInvokana Farxiga, Jardiance
SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify aripiprazoleOrap pimozide
SKIN CONDITIONS Locoid lotion hydrocortisone butyrate SLEEP DISORDERS/SEDATIVES Silenor zolpidem, eszopiclone
Start date of change*
Drug class
Medication strength with limitations++ (Your plan doesn’t cover 2 capsules/tablets per day of this strength)
Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)
January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg Fetzima ER 40mg Fetzima ER 80mg Trintellix 5mg Trintellix 10mg Trintellix 10mg Trintellix 20mg
BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg Benicar 20mg Benicar 40mg Benicar HCT 20-12.5mg Benicar HCT 40-25mg
VALUE PRESCRIPTION DRUG LIST (cont)
Start date of change*
Drug class
Medication strength with limitations++ (Your plan doesn’t cover 2 capsules/tablets per day of this strength)
Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)
January 1, 2018 BLOOD PRESSURE/HEART MEDICATIONS (cont)
Bystolic 10mg Bystolic 20mg Tekturna 150mg Tekturna 300mg Tekturna HCT 150-12.5mg Tekturna HCT 300-25mg
CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg Livalo 2mg Livalo 4mg
DIABETES Farxiga 5mg Farxiga 10mg PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg
Aptiom 400mg Aptiom 800mg Fycompa 4mg Fycompa 8mg Fycompa 6mg Fycompa 12mg Trokendi XR 25mg Trokendi XR 50mg Trokendi XR 100mg Trokendi XR 200mg
SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg
ADVANTAGE PRESCRIPTION DRUG LIST
Start date of change*
Drug classNon-preferred brand medication
Generic and/or preferred brand alternatives
January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal sprayASTHMA/COPD/RESPIRATORY Spiriva, Spiriva Respimat Incruse Ellipta
Stiolto Respimat Anoro ElliptaATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ERDIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR
Invokana Farxiga, Jardiance Kombiglyze XR, Onglyza alogliptin, alogliptin-metformin, Janumet,
Janumet XR, JanuviaToujeo Basaglar, Tresiba, Levemir
PAIN RELIEF AND INFLAMMATORY DISEASE OxyContin Embeda, Hysingla ER, Xtampza ERVanatol LQ butalbital/acetaminophen/caffeine tabs
or capsSKIN CONDITIONS Differin adapalene
Metrogel metronidazole gelNaftin naftifine
Start date of change*
Drug classMedication requiring prior authorization
Additional information
January 1, 2018 DIABETES Lantus, Lantus SoloStar, Toujeo SoloStar Your plan will only cover this medication if your doctor requests and receives approval from Cigna.
GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi
HORMONAL AGENTS Androderm, Androgel, Axiron, Fortesta, Natesto, Striant, Testim, Testopel, Vogelxo, testosterone gel, Vogelxo
PAIN RELIEF AND INFLAMMATORY DISEASE Roxicodone
Start date of change*
Drug class Step Therapy medication^^Generic and/or preferred brand alternatives
January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER
Adderall XR dextroamphetamine-amphetamine ER
Focalin XR dexmethylphenidate ER
DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR
Invokana Farxiga, Jardiance
SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify aripiprazole
Orap pimozide
SKIN CONDITIONS Locoid lotion hydrocortisone butyrate
SLEEP DISORDERS/SEDATIVES Silenor eszopiclone, zaleplon, zolpidem, zolpidem ER
Start date of change*
Drug class
Medication strength with limitations++ (Your plan doesn’t cover 2 capsules/tablets per day of this strength)
Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)
January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg
Fetzima ER 40mg Fetzima ER 80mg
Trintellix 5mg Trintellix 10mg
Trintellix 10mg Trintellix 20mg
BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg
Benicar 20mg Benicar 40mg
Benicar HCT 20-12.5mg Benicar HCT 40-25mg
Start date of change*
Drug class Medication with quantity limits Additional information
January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, Nasonex, mometasone Your plan only covers a certain amount of this medication over a certain number of days. Your plan will only cover a larger amount if your doctor requests and receives approval from Cigna.
ALZHEIMER'S DISEASE Namenda XR, NamzaricANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine ER, Marplan, PristiqASTHMA/COPD/RESPIRATORY PerforomistBLOOD PRESSURE/HEART MEDICATIONS RanexaCANCER Fareston, Nilandron, nilutamideDIABETES Jentadueto, TradjentaEYE CONDITIONS bimatoprost eye drops, Cystaran, ZioptanHORMONAL AGENTS Alora, estradiol patch, Estring, Menostar,
Minivelle, Vagifem, Vivelle-Dot, yuvafem
INFECTIONS Zovirax MISCELLANEOUS NuedextaOSTEOPOROSIS PRODUCTS alendronatePAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, MitigareSCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify Maintena, Aristada, Fanapt, Invega
Trinza, Risperdal Consta, Zyprexa RelprevvSEIZURE DISORDERS Gabitril, PotigaSKIN CONDITIONS Denavir, Regranex, Santyl, Vectical, ZyclaraSLEEP DISORDERS/SEDATIVES Hetlioz
ADVANTAGE PRESCRIPTION DRUG LIST (cont)
Start date of change*
Drug classNon-preferred brand medication
Generic and/or preferred brand alternatives
January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal sprayATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER
Focalin XR dexmethylphenidate ER CANCER Nilandron nilutamide
DIABETES Apidra Humalog, NovologLantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba
GASTROINTESTINAL/HEARTBURN omeprazole bicarbonate packet, 40mg-1100mg capsule, 20mg-1100 mg capsule
omeprazole
INFECTIONS Eryped 400 erythromycinPAIN RELIEF AND INFLAMMATORY DISEASE D.H.E. 45 dihydroergotamine
Imitrex sumatriptanOxyContin Embeda, Hysingla ER, Xtampza ERVanatol LQ butalbital/acetaminophen/caffeine tabs
or capsSKIN CONDITIONS Ala-Scalp hydrocortisone
Analpram HC hydrocortisone-pramoxineCapex shampoo fluocinoloneCordran flurandrenolideDifferin adapaleneKenalog triamcinolone sprayLocoid lotion hydrocortisone butyrateMetrogel metronidazole gelNaftin naftifineNucort, Texacort hydrocortisone
Start date of change*
Drug class
Medication strength with limitations++ (Your plan doesn’t cover 2 capsules/tablets per day of this strength)
Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)
January 1, 2018 BLOOD PRESSURE/HEART MEDICATIONS (cont)
Bystolic 10mg Bystolic 20mg Tekturna 150mg Tekturna 300mg Tekturna HCT 150-12.5mg Tekturna HCT 300-25mg
CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg Livalo 2mg Livalo 4mg
DIABETES Farxiga 5mg Farxiga 10mg PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg
Aptiom 400mg Aptiom 800mg Fycompa 4mg Fycompa 8mg Fycompa 6mg Fycompa 12mg Trokendi XR 25mg Trokendi XR 50mg Trokendi XR 100mg Trokendi XR 200mg
SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg
ADVANTAGE PRESCRIPTION DRUG LIST (cont)
LEGACY PRESCRIPTION DRUG LIST
Start date of change*
Drug classMedication requiring prior authorization
Additional information
January 1, 2018 DIABETES Lantus, Lantus SoloStar, Toujeo SoloStar Your plan will only cover this medication if your doctor requests and receives approval from Cigna.
GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend capsule, powder packet, tripack, Sancuso, Varubi
HORMONAL AGENTS Androderm, Androgel, Axiron, Fortesta, Natesto, Striant, Testim, testosterone, Vogelxo
PAIN RELIEF AND INFLAMMATORY DISEASE RoxicodoneStart date of change*
Drug class Medication with quantity limits Additional information
January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, Nasonex, mometasone Your plan only covers a certain amount of this medication over a certain number of days. Your plan will only cover a larger amount if your doctor requests and receives approval from Cigna.
ALZHEIMER'S DISEASE Namenda XR, NamzaricANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine 25mg, 100mg, Marplan,
PristiqASTHMA/COPD/RESPIRATORY PerforomistBLOOD PRESSURE/HEART MEDICATIONS RanexaCANCER Fareston, Nilandron, nilutamideDIABETES Jentadueto, TradjentaEYE CONDITIONS bimatoprost eye drops, Cystaran, ZioptanHORMONAL AGENTS Alora, estradiol patch, Estring, Menostar,
Minivelle, Vagifem, Vivelle-Dot, yuvafemINFECTIONS ZoviraxMISCELLANEOUS NuedextaOSTEOPOROSIS PRODUCTS alendronatePAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, MitigareSCHIZOPHRENIA/ANTI-PSYCHOTICS FanaptSEIZURE DISORDERS Gabitril, PotigaSKIN CONDITIONS Denavir, Regranex, Santyl, Vectical, ZyclaraSLEEP DISORDERS/SEDATIVES Hetlioz
Start date of change*
Drug class Step Therapy medication^^Generic and/or preferred brand alternatives
January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER
Focalin XR dexmethylphenidate ER
SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify aripiprazole
Orap pimozide
SKIN CONDITIONS Locoid lotion hydrocortisone butyrate
SLEEP DISORDERS/SEDATIVES Silenor eszopiclone, zolpidem
Start date of change*
Drug class
Medication strength with limitations++ (Your plan doesn’t cover 2 capsules/tablets per day of this strength)
Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)
January 1, 2018 ALLERGY/NASAL SPRAYS desloratadine ODT 2.5mg desloratadine ODT 5mg
ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg
Fetzima ER 40mg Fetzima ER 80mg
LEGACY PRESCRIPTION DRUG LIST (cont)
Start date of change*
Drug class
Medication strength with limitations++ (Your plan doesn’t cover 2 capsules/tablets per day of this strength)
Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)
January 1, 2018 ANXIETY/DEPRESSION/ BIPOLAR DISORDER (cont)
Trintellix 5mg Trintellix 10mg
Trintellix 10mg Trintellix 20mg
BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg
Benicar 20mg Benicar 40mg
Benicar HCT 20-12.5mg Benicar HCT 40-25mg
Bystolic 10mg Bystolic 20mg
Tekturna 150mg Tekturna 300mg
Tekturna HCT 150-12.5mg Tekturna HCT 300-25mg
CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg
Livalo 2mg Livalo 4mg
DIABETES Farxiga 5mg Farxiga 10mg
PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg
SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg
SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg
Aptiom 400mg Aptiom 800mg
Fycompa 4mg Fycompa 8mg
Fycompa 6mg Fycompa 12mg
Trokendi XR 25mg Trokendi XR 50mg
Trokendi XR 100mg Trokendi XR 200mg
SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg
LEGACY PRESCRIPTION DRUG LIST (cont)
PERFORMANCE PRESCRIPTION DRUG LIST (with additional medications not covered)
Start date of change*
Drug class Medication not covered^ Generic and/or preferred brand alternatives
January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipramine
Pamelor nortriptyline
Parnate tranylcypromine
Tofranil imipramine
ASTHMA/COPD/RESPIRATORY Zyflo montelukast, zafirlukast, zileuton ER
Zyflo CR zileuton ER
ATTENTION DEFICIT HYPERACTIVITY DISORDER
Desoxyn methamphetamine
Dexedrine dextroamphetamine, dextroamphetamine ER
BLOOD PRESSURE/HEART MEDICATIONS Betapace sotalol
CANCER Nilandron nilutamide
DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR
Invokana Farxiga, Jardiance
Lantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba
Novolin, Novolog Humalog, Humulin
Start date of change*
Drug class Medication not covered^ Generic and/or preferred brand alternatives
January 1, 2018 GASTROINTESTINAL/HEARTBURN Cortifoam, Uceris rectal foam Colocort, Hemmorex-HC, hydrocortisone, Procto-Med HC, Procto-Pak, Proctosol-HC, Proctozone-HC
Marinol dronabinolomeprazole bicarbonate packet, 40mg-1100mg capsule, 20mg-1100mg
omeprazole
Rowasa mesalamine enemaUceris tablet budesonide EC capsuleZegerid omeprazoleZofran ondansetronZofran ODT ondansetron ODT
HORMONAL AGENTS Cortrosyn cosyntropinDDAVP desmopressinHectorol doxercalciferol
INFECTIONS Augmentin, Augmentin ES, Augmentin XR amoxicillin-clavulanate ER, amoxicillin-clavulanate
Diflucan fluconazoleE.E.S. 200, Eryped 400 erythromycinMepron atovaquoneSporanox itraconazoleTargadox Avidoxy, demeclocycline, doxycycline,
doxycycline IR-DR, minocycline, minocycline ER, mondoxyne NL, Morgidox capsule, tetracycline
Valcyte valganciclovirVancocin vancomycin capsuleZovirax acyclovir
PAIN RELIEF AND INFLAMMATORY DISEASE Cambia diclofenac, diclofenac ER, etodolac, etodolac ER, fenoprofen, Fenortho, flurbiprofen, ibuprofen, indomethacin, indomethacin ER, ketoprofen, Ketorolac, meclofenamate, mefenamic acid, meloxicam, nabumetone
D.H.E. 45, Migranal dihydroergotamineGralise, Horizant gabapentinImitrex, Sumavel DosePro sumatriptanLorzone chlorzoxazoneOxyContin Embeda, Hysingla ER, Xtampza ERRoxicodone oxycodoneTivorbex indomethacinVanatol LQ butalbital/acetaminophen/caffeine tabs
or capsVivlodex meloxicamZomig sumatriptan, zolmitriptanZorvolex diclofenac, diclofenac ER
PERFORMANCE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont)
Start date of change*
Drug classNon-preferred brand medication
Generic and/or preferred brand alternatives
January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal sprayATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER
SKIN CONDITIONS Ala-Scalp hydrocortisoneAnalpram HC lotion hydrocortisone-pramoxineCapex shampoo fluocinoloneCordran flurandrenolideDifferin adapaleneMetrogel metronidazole gelNaftin naftifineNucort, Texacort hydrocortisone
Start date of change*
Drug classMedication requiring prior authorization
Additional information
January 1, 2018 GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi Your plan will only cover this medication if your doctor requests and receives approval from Cigna.
HORMONAL AGENTS Androderm, Androgel, Striant, Testopel, testosterone
Start date of change*
Drug class Medication with quantity limits Additional information
January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone Your plan only covers a certain amount of this medication over a certain number of days. Your plan will only cover a larger amount if your doctor requests and receives approval from Cigna.
ALZHEIMER'S DISEASE Namenda XR, Namzaric
PERFORMANCE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont)
Start date of change*
Drug class Medication not covered^ Generic and/or preferred brand alternatives
January 1, 2018 PARKINSON'S DISEASE Lodosyn carbidopaRequip XL ropinirole ER
SCHIZOPHRENIA/ANTI-PSYCHOTICS Geodon capsule ziprasidoneZyprexa tablet olanzapineZyprexa Zydis olanzapine ODT
SKIN CONDITIONS Cutivate fluticasoneKenalog topical spray triamcinoloneLocoid hydrocortisone Luzu ketoconazoleSoriatane acitretinZiana clindamycin-tretinoin
SLEEP DISORDERS/SEDATIVES Nuvigil armodafinilProvigil modafinilRestoril temazepam
URINARY TRACT CONDITIONS Detrol tolterodineDetrol LA tolterodine ERDitropan XL oxybutynin EREnablex darifenacin ERGelnique darifenacin ER, oxybutynin ER, tolterodine
ER, trospium ER
PERFORMANCE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont)
Start date of change*
Drug class Medication with quantity limits Additional information
January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER desvanlafaxine 25mg, 100mg, Marplan, Pristiq
Your plan only covers a certain amount of this medication over a certain number of days. Your plan will only cover a larger amount if your doctor requests and receives approval from Cigna.
ASTHMA/COPD/RESPIRATORY Perforomist
BLOOD PRESSURE/HEART MEDICATIONS Ranexa
CANCER Fareston, nilutamide
EYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan
HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem
MISCELLANEOUS Nuedexta
OSTEOPOROSIS PRODUCTS alendronate
PAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, Mitigare
SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify Maintena, Aristada, Fanapt, Invega Trinza, Risperdal Consta, Zyprexa Relprevv
SEIZURE DISORDERS Gabitril, Potiga
SKIN CONDITIONS Denavir, Regranex, Santyl, Vectical
SLEEP DISORDERS/SEDATIVES Hetlioz
Start date of change*
Drug class Step Therapy medication^^Generic and/or preferred brand alternatives
January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER
Focalin XR dexmethylphenidate ER
SCHIZOPHRENIA/ANTI-PSYCHOTICS Orap pimozide
SLEEP DISORDERS/SEDATIVES Silenor eszopiclone, zolpidem
Start date of change*
Drug class
Medication strength with limitations++ (Your plan doesn’t cover 2 capsules/tablets per day of this strength)
Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)
January 1, 2018 ALLERGY/NASAL SPRAYS desloratadine ODT 2.5mg desloratadine ODT 5mg
ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg
Fetzima ER 40mg Fetzima ER 80mg
Trintellix 5mg Trintellix 10mg
Trintellix 10mg Trintellix 20mg
BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg
Benicar 20mg Benicar 40mg
Benicar HCT 20-12.5mg Benicar HCT 40-25mg
Bystolic 10mg Bystolic 20mg
Tekturna 150mg Tekturna 300mg
Tekturna HCT 150-12.5mg Tekturna HCT 300-25mg
CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg
Livalo 2mg Livalo 4mg
DIABETES Farxiga 5mg Farxiga 10mg
VALUE PRESCRIPTION DRUG LIST (with additional medications not covered)
Start date of change*
Drug class
Medication strength with limitations++ (Your plan doesn’t cover 2 capsules/tablets per day of this strength)
Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)
January 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg
SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg
SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg
Aptiom 400mg Aptiom 800mg
Fycompa 4mg Fycompa 8mg
Fycompa 6mg Fycompa 12mg
Trokendi XR 25mg Trokendi XR 50mg
Trokendi XR 100mg Trokendi XR 200mg
SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg
PERFORMANCE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont)
Start date of change*
Drug class Medication not covered^ Generic and/or preferred brand alternatives
January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipraminePamelor nortriptylineParnate tranylcypromineTofranil imipramine
ASTHMA/COPD/RESPIRATORY Spiriva, Spiriva Respimat Incruse ElliptaStiolto Respimat Anoro ElliptaZyflo montelukast, zafirlukast, zileuton ERZyflo CR zileuton ER
ATTENTION DEFICIT HYPERACTIVITY DISORDER
Desoxyn methamphetamineDexedrine dextroamphetamine,
dextroamphetamine ERBLOOD PRESSURE/HEART MEDICATIONS Betapace sotalol tabletCANCER Nilandron nilutamideDIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR
Invokana Farxiga, JardianceKombiglyze XR, Onglyza alogliptin, alogliptin-metformin, Janumet,
Janumet XR, JanuviaLantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba
EYE CONDITIONS Alocril, Alomide cromolyn eye dropsBepreve, Emadine, Lastacaft, Pataday, Patanol, Pazeo
azelastine, epinastine, olopatadine
Elestat epinastineGASTROINTESTINAL/HEARTBURN Marinol dronabinol
Rowasa mesalamine enemaZofran ondansetronZofran ODT ondansetron ODT
VALUE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont)
Start date of change*
Drug class Medication not covered^ Generic and/or preferred brand alternatives
January 1, 2018 HORMONAL AGENTS DDAVP nasal spray, tablet desmopressin nasal spray, tablets
Hectorol doxercalciferol
INFECTIONS Augmentin, Augmentin ES, Augmentin XR amoxicillin-clavulanate ER, amoxicillin-clavulanate
Diflucan fluconazole
E.E.S. 200, Eryped 400 erythromycin
Mepron atovaquone
Sporanox itraconazole
Targadox doxycycline
Valcyte valganciclovir
Vancocin vancomycin capsule
Zovirax acyclovir
PAIN RELIEF AND INFLAMMATORY DISEASE D.H.E. 45, Migranal dihydroergotamine
Imitrex sumatriptan
OxyContin Embeda, Hysingla ER, Xtampza ER
Roxicodone oxycodone
Vanatol LQ butalbital/acetaminophen/caffeine tabs or caps
Zomig sumatriptan, zolmitriptan
PARKINSON'S DISEASE Lodosyn carbidopa
Requip XL ropinirole ER
SCHIZOPHRENIA/ANTI-PSYCHOTICS Geodon ziprasidone
Zyprexa tablet olanzapine tablet
Zyprexa Zydis olanzapine ODT
SKIN CONDITIONS Acanya, Atralin, Avita, Azelex, Differin, Epiduo, Epiduo Forte, Fabior, Onexton, Retin-A, Retin-A Micro, Tretin-X, Veltin
Aczone, adapalene, Ala-Cort, alclometasone, amcinonide, Apexicon E, Avar, Avar-E, BenzePRO, benzoyl peroxide, betamethasone, BP 10-1, BPO, Clindacin ETZ, Clindacin P, clindamycin, clindamycin-benzoyl peroxide, clindamycin-tretinoin, clobetasol, clocortolone, Clodan, Cormax, desonide, desoximetasone, fluocinolone, halobetasol, hydrocortisone, Micort-HC, mometasone, prednicarbate, Psorcon, Scalacort, tretinoin, triamcinolone, Trianex, Triderm
Cutivate fluticasone
Dovonex, Sorilux calcipotriene
Enstilar, Taclonex calcipotriene-betamethasone DP
Soriatane acitretin
VALUE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont)
Start date of change*
Drug class Medication not covered^ Generic and/or preferred brand alternatives
January 1, 2018 SKIN CONDITIONS (cont) Tazorac adapalene, Ala-Cort, alclometasone, amcinonide, Apexicon E, Avar, Benzepro, benzoyl peroxide, betamethasone, BP 10-1, BPO, Clindacin ETZ, Clindacin P, clindamycin, clobetasol, clocortolone, Clodan, Cormax, desonide, desoximetasone, fluocinolone, halobetasol, hydrocortisone, Micort-HC, mometasone, prednicarbate, Psorcon, Scalacort, triamcinolone, Trianex, Triderm
Vectical calcitriol ointment
SLEEP DISORDERS/SEDATIVES Nuvigil armodafinil
Provigil modafinil
Restoril temazepam
URINARY TRACT CONDITIONS Detrol, Detrol LA, Ditropan XL, Enablex, Gelnique
darifenacin ER, oxybutynin ER, tolterodine, tolterodine ER, trospium ER
Start date of change*
Drug classNon-preferred brand medication
Generic and/or preferred brand alternatives
January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER
Start date of change*
Drug classMedication requiring prior authorization
Additional information
January 1, 2018 GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend capsule, powder packet, tripack, Sancuso, Varubi
Your plan will only cover this medication if your doctor requests and receives approval from Cigna. HORMONAL AGENTS Androderm, Androgel, Striant testosterone
Start date of change*
Drug class Medication with quantity limits Additional information
January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone Your plan only covers a certain amount of this medication over a certain number of days. Your plan will only cover a larger amount if your doctor requests and receives approval from Cigna.
ALZHEIMER'S DISEASE Namenda XR, Namzaric
ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine ER, Marplan
ASTHMA/COPD/RESPIRATORY Perforomist
BLOOD PRESSURE/HEART MEDICATIONS Ranexa
CANCER Fareston, nilutamide
EYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan
HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem
MISCELLANEOUS Nuedexta
OSTEOPOROSIS PRODUCTS alendronate
PAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, Mitigare
SCHIZOPHRENIA/ANTI-PSYCHOTICS Fanapt
SEIZURE DISORDERS Gabitril, Potiga
SKIN CONDITIONS Denavir, Regranex, Santyl
SLEEP DISORDERS/SEDATIVES Hetlioz
ADVANTAGE PRESCRIPTION DRUG LIST (with additional medications not covered)
Start date of change*
Drug class Step Therapy medication^^Generic and/or preferred brand alternatives
January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER
Focalin XR dexmethylphenidate ER
SCHIZOPHRENIA/ANTI-PSYCHOTICS Orap pimozide
SLEEP DISORDERS/SEDATIVES Silenor zolpidem, eszopiclone
VALUE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont)
Start date of change*
Drug class
Medication strength with limitations++ (Your plan doesn’t cover 2 capsules/tablets per day of this strength)
Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)
January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg
Fetzima ER 40mg Fetzima ER 80mg
Trintellix 5mg Trintellix 10mg
Trintellix 10mg Trintellix 20mg
DIABETES Farxiga 5mg Farxiga 10mg
PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg
SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg
SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg
Aptiom 400mg Aptiom 800mg
Fycompa 4mg Fycompa 8mg
Fycompa 6mg Fycompa 12mg
Trokendi XR 25mg Trokendi XR 50mg
Trokendi XR 100mg Trokendi XR 200mg
SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg
Start date of change*
Drug class Medication not covered^ Generic and/or preferred brand alternatives
January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipramine
Pamelor nortriptyline
Parnate tranylcypromine
Tofranil imipramine
ASTHMA/COPD/RESPIRATORY Spiriva, Spiriva Respimat Incruse Ellipta
Stiolto Respimat Anoro Ellipta
Zyflo montelukast, zafirlukast, zileuton ERZyflo CR zileuton ER
ATTENTION DEFICIT HYPERACTIVITY DISORDER
Desoxyn methamphetamineDexedrine dextroamphetamine, dextroamphetamine
ERBLOOD PRESSURE/HEART MEDICATIONS Betapace sotalol tabletCANCER Nilandron nilutamide
Start date of change*
Drug class Medication not covered^ Generic and/or preferred brand alternatives
January 1, 2018 DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XRInvokana Farxiga, JardianceKombiglyze XR, Onglyza alogliptin, alogliptin-metformin, Janumet,
Janumet XR, JanuviaLantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba
EYE CONDITIONS Alocril, Alomide cromolyn eye dropsBepreve, Emadine, Lastacaft, Pataday, Patanol, Pazeo
azelastine, epinastine, olopatadine
Elestat epinastineGASTROINTESTINAL/HEARTBURN Marinol dronabinol
Rowasa mesalamine enemaZofran ondansetronZofran ODT ondansetron ODT
HORMONAL AGENTS Cortrosyn cosyntropinDDAVP desmopressinHectorol doxercalciferol
INFECTIONS Augmentin, Augmentin ES, Augmentin XR amoxicillin-clavulanate ER, amoxicillin-clavulanate
Diflucan fluconazoleE.E.S. 200, Eryped 400 erythromycin
Mepron atovaquone
Sporanox itraconazole
Targadox doxycycline
Valcyte valganciclovir
Vancocin vancomycin capsule
Zovirax acyclovir
PAIN RELIEF AND INFLAMMATORY DISEASE D.H.E. 45, Migranal dihydroergotamine
Imitrex sumatriptan
OxyContin Embeda, Hysingla ER, Xtampza ER
Roxicodone oxycodone
Vanatol LQ butalbital/acetaminophen/caffeine tabs or caps
Zomig sumatriptan, zolmitriptan
PARKINSON'S DISEASE Lodosyn carbidopa
Requip XL ropinirole ER
SCHIZOPHRENIA/ANTI-PSYCHOTICS Geodon ziprasidone
Zyprexa tablet olanzapine
Zyprexa Zydis olanzapine ODT
ADVANTAGE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont)
ADVANTAGE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont)
Start date of change*
Drug class Medication not covered^ Generic and/or preferred brand alternatives
January 1, 2018 SKIN CONDITIONS Acanya, Atralin, Avita, Azelex, Differin, Epiduo, Epiduo Forte, Fabior, Onexton, Retin-A, Retin-A Micro, Tretin-X, Veltin
Aczone, adapalene, Ala-Cort, alclometasone, amcinonide, Apexicon E, Avar, Avar-E, BenzePRO, benzoyl peroxide, betamethasone, BP 10-1, BPO, Clindacin ETZ, Clindacin P, clindamycin, clindamycin-benzoyl peroxide, clindamycin-tretinoin, clobetasol, clocortolone, Clodan, Cormax, desonide, desoximetasone, fluocinolone, halobetasol, hydrocortisone, Micort-HC, mometasone, prednicarbate, Psorcon, Scalacort, tretinoin, triamcinolone, Trianex, Triderm
Cutivate fluticasone
Dovonex, Sorilux calcipotriene
Enstilar, Taclonex calcipotriene-betamethasone DP
Soriatane acitretin
Tazorac adapalene, Ala-Cort, alclometasone, amcinonide, Apexicon E, Avar, Avar-E, Benzepro, benzoyl peroxide, betamethasone, BP 10-1, BPO, Clindacin ETZ, Clindacin P, clindamycin, clobetasol, clocortolone, Clodan, Cormax, desonide, desoximetasone, fluocinolone, halobetasol, hydrocortisone, Micort-HC, mometasone, prednicarbate, Psorcon, Scalacort, triamcinolone, Trianex, Triderm
Vectical calcitriol
SLEEP DISORDERS/SEDATIVES Nuvigil armodafinil
Provigil modafinil
Restoril temazepam
URINARY TRACT CONDITIONS Detrol tolterodine
Detrol LA tolterodine ER
Ditropan XL oxybutynin ER
Enablex darifenacin ER
Gelnique darifenacin ER, oxybutynin ER, tolterodine ER, trospium ER
Start date of change*
Drug classNon-preferred brand medication
Generic and/or preferred brand alternatives
January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER
ADVANTAGE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont)
Start date of change*
Drug classMedication requiring prior authorization
Additional information
January 1, 2018 GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi
Your plan will only cover this medication if your doctor requests and receives approval from Cigna. HORMONAL AGENTS Androderm, Androgel, Striant,
Testopel, testosteroneStart date of change*
Drug class Medication with quantity limits Additional information
January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone Your plan only covers a certain amount of this medication over a certain number of days. Your plan will only cover a larger amount if your doctor requests and receives approval from Cigna.
ALZHEIMER'S DISEASE Namenda XR, Namzaric
ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine ER, Marplan
ASTHMA/COPD/RESPIRATORY Perforomist
BLOOD PRESSURE/HEART MEDICATIONS Ranexa
CANCER Fareston, nilutamide
EYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan
HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem
MISCELLANEOUS Nuedexta
OSTEOPOROSIS PRODUCTS alendronate
PAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, Mitigare
SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify Maintena, Aristada, Fanapt, Invega Trinza, Risperdal Consta, Zyprexa Relprevv
SEIZURE DISORDERS Gabitril, Potiga
SKIN CONDITIONS Denavir, Regranex, Santyl
SLEEP DISORDERS/SEDATIVES Hetlioz
Start date of change*
Drug class Step Therapy medication^^Generic and/or preferred brand alternatives
January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER
Focalin XR dexmethylphenidate ER
SCHIZOPHRENIA/ANTI-PSYCHOTICS Orap pimozide
SLEEP DISORDERS/SEDATIVES Silenor eszopiclone, zaleplon, zolpidem, zolpidem ER
Start date of change*
Drug class
Medication strength with limitations++ (Your plan doesn’t cover 2 capsules/tablets per day of this strength)
Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)
January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg
Fetzima ER 40mg Fetzima ER 80mg
Trintellix 5mg Trintellix 10mg
Trintellix 10mg Trintellix 20mg
DIABETES Farxiga 5mg Farxiga 10mg
PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg
SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg
Start date of change*
Drug class
Medication strength with limitations++ (Your plan doesn’t cover 2 capsules/tablets per day of this strength)
Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)
January 1, 2018 SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg
Aptiom 400mg Aptiom 800mg
Fycompa 4mg Fycompa 8mg
Fycompa 6mg Fycompa 12mg
Trokendi XR 25mg Trokendi XR 50mg
Trokendi XR 100mg Trokendi XR 200mg
SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg
ADVANTAGE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont)
* State laws in Texas and Louisiana require your plan to cover your medications at your current benefit level until your plan renews. This means that if your medication is taken off the drug list, is moved to a higher cost-share tier or needs approval, your plan can’t make these changes until your renewal date. To find out if these state laws apply to your plan, please call Customer Service using the number on the back of your ID card.
++ Your plan doesn’t cover more than one tablet/capsule in this strength a day. If your doctor feels a higher strength of this medication once each day isn’t right for you, he or she can ask Cigna to consider approving coverage of your current medication strength.
^ These medications require approval from Cigna before they’re covered by your plan. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving coverage of your medication.
^^ This is a Step Therapy medication. Step Therapy medications aren’t covered by your plan without approval from Cigna. In Step Therapy, you have to try lower-cost alternatives first before the higher-cost brand medication may be covered. Typically, you start by taking generics or lower-cost preferred brands.
Health benefit plans vary, but in general to be eligible for coverage a drug must be approved by the Food and Drug Administration (FDA), prescribed by a health care professional, purchased from a licensed pharmacy and medically necessary. If your plan provides coverage for certain prescription drugs with no cost-share, you may be required to use an in-network pharmacy to fill the prescription. If you use a pharmacy that does not participate in your plan’s network, your prescription may not be covered, or reimbursement may be limited by your plan’s copayment, coinsurance or deductible requirements. Certain features described in this document may not be applicable to your specific health plan, and plan features may vary by location and plan type. Refer to your plan documents for costs and complete details of your plan’s prescription drug coverage.
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Health Management, Inc., Tel-Drug, Inc., Tel-Drug of Pennsylvania, L.L.C., and HMO or service company subsidiaries of Cigna Health Corporation, including Cigna HealthCare of Arizona, Inc., Cigna HealthCare of California, Inc., Cigna HealthCare of Colorado, Inc., Cigna HealthCare of Connecticut, Inc., Cigna HealthCare of Florida, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Illinois, Inc., Cigna HealthCare of Indiana, Inc., Cigna HealthCare of St. Louis, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of New Jersey, Inc., Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of Tennessee, Inc., and Cigna HealthCare of Texas, Inc. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.
909015 © 2017 Cigna. Some content provided under license. UPDATED_10/17/2017
Cigna reserves the right to make changes to the Drug List without notice.