CIGNA PERFORMANCE 3-TIER PRESCRIPTION DRUG LIST - Coverage as of July 1, 2022
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CIGNA PERFORMANCE 3-TIER PRESCRIPTION DRUG LIST Coverage as of July 1, 2022 Offered by Cigna Health and Life Insurance Company or Connecticut General Life Insurance Company 932539 e Performance 3-Tier 05/22
What’s inside?
About this drug list 3
How to read this drug list 3
How to find your medication 5
Medications that aren’t covered - and their covered alternatives 19
Frequently Asked Questions (FAQs) 35
Exclusions and limitations for coverage 39
View the drug list online
This document was last updated on 05/01/2022.* You can go online to see the current list of
medications your plan covers.
myCigna® App or myCigna.com. Click on the Find Care & Costs tab. Then
select Price a Medication, and type in your medication name.
Cigna.com/druglist. Select Performance 3 Tier from the dropdown menu. Then type
in your medication name or view the full list.
Questions?
› myCigna.com: Click to Chat - Monday-Friday, 9:00 am-8:00 pm EST.
› By phone: Call the toll-free number on your Cigna ID card. We’re here 24/7/365.
* Drug list created: originally created 01/01/2004 Last updated: 05/01/2022, for changes Next planned update: 08/01/2022, for
starting 07/01/2022 changes starting 01/01/2023
2About this drug list
This is a list of the most commonly prescribed medications covered on the Cigna Performance
3-Tier Prescription Drug List as of July 1, 2022.1,2 Medications are listed by the condition they treat,
then listed alphabetically within tiers (or cost-share levels).
The drug list is updated often so it isn’t a complete list of the medications your plan covers.
Also, your specific plan may not cover all of these medications. Log in to the myCigna App or
myCigna.com, or check your plan materials, to see all of the medications your plan covers.
How to read this drug list
Use the chart below to help you read this drug list. This chart is just an example. It may not show
how these medications are actually covered on the Cigna Performance 3-Tier Prescription Drug
List.
Tier (cost-share level) gives you
an idea of how much you may
TIER 1 TIER 2 pay for a medication
$ $$
BLOOD PRESSURE/HEART MEDICATIONS Medications are grouped by
afeditab CR BERINERT* (PA) the condition they treat
amlodipine BIDIL
amlodipine-benazepril BYSTOLIC
amlodipine-valsartan CINRYZE* (PA)
amlodipine-valsartan-HCTZ COREG CR
atenolol COZAAR (ST)
DIOVAN (ST)
atenolol-chlorthalidone
DIOVAN HCT (ST) Medications are listed in
benazepril
EDARBI (ST) alphabetical order within
benazepril-HCTZ each column
EDARBYCLOR (ST)
candesartan cilexetil EXFORGE
cartia XT EXFORGE HCT
carvedilol FIRAZYR* (PA) Specialty medications have an
clonidine HEMANGEOL asterisk (*) listed next to them
digitek INDERAL LA
digox INDERAL XL
digoxin INNOPRAN XL
diltiazem ER LOTREL Brand-name medications
diltiazem CD MICARDIS (ST) are in all capital letters
diltiazem MULTAQ
dilt-XR NITRO-DUR
NITROLINGUAL
enalapril
NITROMIST
flecainide Generic medications
NITRONAL
hydralazine are in all lowercase letters
NITROSTAT
irbesartan NORTHERA* (PA) Medications that have extra
isosorbide mononitrat NORVASC coverage requirements have an
RANEXA (ST) abbreviation listed next to
TEKTURNA them
TEKTURNA HCT
This chart is just a sample. It may not show how these medications are actually covered on the Cigna Performance 3-Tier Prescription Drug List.
3Tiers
Covered medications are divided into tiers or cost-share levels. Typically, the higher the tier, the
higher the price you’ll pay to fill the prescription.
› Tier 1 – Typically Generics (Lowest-cost medication) $
› Tier 2 – Typically Preferred Brands (Medium-cost medication) $$
› Tier 3 – Typically Non-Preferred Brands (Highest-cost medication) $$$
Abbreviations next to medications
In this drug list, medications that have limits and/or extra coverage requirements have an
abbreviation listed next to them.* Here’s what they mean.
(PA)
Prior Authorization – Certain medications need approval from Cigna before your
plan will cover them. These medications have a (PA) next to them. Your plan won’t
cover these medications unless your doctor requests, and receives, approval from
Cigna.
(QL) uantity Limits – Some medications have a quantity limit - meaning, your plan will
Q
only cover up to a certain amount over a certain length of time. These medications
have a (QL) next to them. Your plan will only cover a larger amount if your doctor
requests, and receives, approval from Cigna.
(ST) tep Therapy – Certain high-cost medications aren’t covered until you try one or
S
more lower-cost alternatives first.** These medications have a (ST) next to them.
You have many covered options to choose from, and they’re used to treat the same
condition.
(AGE) ge Requirements – Certain medications will only be covered if you’re within
A
a specific age range. These medications have (AGE) next to them. If you’re not
within the allowed age range, your plan will only cover the medication if your
doctor requests, and receives, approval from Cigna.
* These coverage requirements may not apply to your specific plan. Log in to the myCigna App or myCigna.com, or check your plan materials, to find out if your plan includes prior authorization,
quantity limits, Step Therapy, and/or age requirements.
** If your doctor feels an alternative isn’t right for you, he or she can ask Cigna to consider approving coverage of your medication.
Brand-name medications are in all capital letters
In this drug list, generic medications are listed in all lowercase letters and brand-name medications
are listed in all capital letters.
Specialty medications have an asterisk next to them
Specialty medications are used to treat complex medical conditions. In this drug list, specialty
medications have an asterisk (*) next to them. Some plans cover specialty medications on a
specialty tier, limit coverage to a 30-day supply, and/or require you to use a preferred specialty
pharmacy to get coverage. Log in to the myCigna App or myCigna.com, or check your plan
materials, to see how your plan covers these medications.
4No cost-share preventive medications have a plus sign next to them
Health care reform under the Patient Protection and Affordable Care Act (PPACA) requires plans
to cover certain preventive medications and products at 100%, or no cost-share ($0), to you. In
this drug list, these medications have a plus sign (+) next to them. Log in to the myCigna App or
myCigna.com, or check your plan materials, to see how your plan covers these medications.
Plan/benefit exclusions
Your plan doesn’t cover certain medications and products because they’re considered plan/benefit
exclusions. This means there’s no option to receive coverage through Cigna’s review process
by showing that you need the medication or product for your treatment. In this drug list, these
medications have a caret (^) next to them. Log in to the myCigna App or myCigna.com, or check
your plan materials, to see which medications your plan excludes.
How to find your medication
First, look for your condition in the alphabetical list below. Then, go to that page to see the covered
medications available to treat the condition.
Condition Page Condition Page
AIDS/HIV 6 FEMININE PRODUCTS 12
ALLERGY/NASAL SPRAYS 6 GASTROINTESTINAL/HEARTBURN 12-13
ALZHEIMER’S DISEASE 6 HORMONAL AGENTS 13
ANXIETY/DEPRESSION/BIPOLAR 6 INFECTIONS 13-14
DISORDER INFERTILITY 14
ASTHMA/COPD/RESPIRATORY 6-7 MISCELLANEOUS 14
ATTENTION DEFICIT HYPERACTIVITY 7 MULTIPLE SCLEROSIS 14
DISORDER
NUTRITIONAL/DIETARY 14-15
BLOOD MODIFIERS/BLEEDING DISORDERS 7
OSTEOPOROSIS PRODUCTS 15
BLOOD PRESSURE/HEART MEDICATIONS 7-8 PAIN RELIEF AND INFLAMMATORY DISEASE 15-16
BLOOD THINNERS/ANTI-CLOTTING 8 PARKINSON’S DISEASE 16
CANCER 8 SCHIZOPHRENIA/ANTI-PSYCHOTICS 16
CHOLESTEROL MEDICATIONS 8 SEIZURE DISORDERS 16
CONTRACEPTION PRODUCTS 8-9 SKIN CONDITIONS 16-17
COUGH/COLD MEDICATIONS 9 SLEEP DISORDERS/SEDATIVES 17
DENTAL PRODUCTS 9-10 SMOKING CESSATION 17
DIABETES 10 SUBSTANCE ABUSE 17
DIURETICS 10 TRANSPLANT MEDICATIONS 17
EAR MEDICATIONS 11 URINARY TRACT CONDITIONS 17
ERECTILE DYSFUNCTION 12 VACCINES 17,
EYE CONDITIONS 12 WEIGHT MANAGEMENT 18
5Cigna Performance 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
AIDS/HIV ANXIETY/DEPRESSION/BIPOLAR
abacavir- BIKTARVY* CABENUVA* (PA) DISORDER3 (cont)
lamivudine* (PA) DESCOVY*+ (PA) CIMDUO* (PA) alprazolam xr EFFEXOR XR (QL,
efavirenz- DOVATO* COMPLERA* (PA) amitriptyline ST)
emtricitabine- GENVOYA* ODEFSEY* (PA) bupropion (QL) FETZIMA (QL, ST)
tenofovir* ISENTRESS HD* PIFELTRO* (PA)
(PA) PREZCOBIX* (PA) bupropion sr (QL) NUPLAZID* (PA)
emtricitabine- ISENTRESS* STRIBILD* (PA) bupropion xl 150 PAXIL (QL, ST)
tenofovir 200-300 JULUCA* TEMIXYS* (PA) mg tablet (QL) PAXIL CR (QL, ST)
mg*+ PREZISTA* bupropion xl 300 PRISTIQ (QL, ST)
etravirine* SYMTUZA* mg tablet (QL) PROZAC (QL, ST)
ritonavir* TIVICAY PD* buspirone REMERON
tenofovir* (PA) TIVICAY* citalopram (QL) SPRAVATO* (PA)
tenofovir disoproxilTRIUMEQ* clomipramine TRINTELLIX (QL, ST)
fumarate* (PA) TRIUMEQ PD* desvenlafaxine er VIIBRYD (QL, ST)
(QL) (QL) WELLBUTRIN SR
ALLERGY/NASAL SPRAYS duloxetine (QL) (QL, ST)
escitalopram (QL) XANAX
azelastine CLARINEX fluoxetine dr (QL) XANAX XR
azelastine- EPINEPHRINE fluoxetine (QL) ZOLOFT (QL, ST)
fluticasone PROFESSIONAL fluvoxamine (QL)
cromolyn EMS fluvoxamine er
desloratadine (QL) GASTROCROM (QL)
epinephrine (QL) GRASTEK (PA, QL) lorazepam
fluticasone KARBINAL ER lorazepam intensol
hydroxyzine hcl ODACTRA (PA, QL) mirtazapine
solution, syrup, ORALAIR (PA, QL) paroxetine cr (QL)
tablet PATANASE paroxetine er (QL)
hydroxyzine RAGWITEK (PA, QL) paroxetine (QL)
pamoate VISTARIL sertraline (QL)
ipratropium trazodone
levocetirizine venlafaxine (QL)
mometasone (QL) venlafaxine er (QL)
olopatadine ASTHMA/COPD/RESPIRATORY
promethazine
solution, syrup, albuterol ADEMPAS* (PA) ADCIRCA* (PA)
tablet albuterol hfa (QL) ADVAIR HFA AIRDUO DIGIHALER
alyq* (PA) ANORO ELLIPTA (ST)
ALZHEIMER’S DISEASE ambrisentan* (PA) ATROVENT HFA ARALAST NP* (PA)
donepezil MESTINON ARICEPT budesonide ATROVENT HFA BRONCHITOL* (PA)
donepezil odt 60 MG/5 ML EXELON fluticasone- BEVESPI DALIRESP (QL)
memantine SOLUTION MESTINON 180 MG salmeterol AEROSPHERE GLASSI
memantine er (QL) NAMENDA 5-10 TIMESPAN ipratropium- BREO ELLIPTA KALYDECO* (PA,
pyridostigmine 60 MG TITRATION MESTINON 60 MG BREZTRI QL)
albuterol
mg/5 ml, 60 mg PK TABLET AEROSPHERE LETAIRIS* (PA)
montelukast
pyridostigmine er NAMENDA 10 MG COMBIVENT LONHALA
rivastigmine TABLET tadalafil* (PA)
RESPIMAT MAGNAIR (PA)
NAMENDA 5 MG treprostinil* (PA)
DULERA ORENITRAM ER*
TABLET wixela inhub
FASENRA PEN* (PA)
NAMENDA XR (QL) (PA) ORKAMBI* (PA, QL)
NAMZARIC (QL)
regonol FLOVENT DISKUS PROLASTIN C* (PA)
FLOVENT HFA PULMICORT
ANXIETY/DEPRESSION/BIPOLAR DISORDER3
INCRUSE ELLIPTA RESPULES
alprazolam CELEXA (QL, ST) NUCALA* (PA)
alprazolam er DESVENLAFAXINE OFEV* (PA)
alprazolam intensol ER (QL,ST)
alprazolam odt
6Cigna Performance 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
ASTHMA/COPD/RESPIRATORY (cont) BLOOD MODIFIERS/BLEEDING DISORDERS
OPSUMIT* (PA) REVATIO 10 MG/ML, (cont)
PULMICORT 20 MG* (PA) NIVESTYM HEMLIBRA* (PA)
FLEXHALER SINGULAIR NYVEPRIA* (PA) LYSTEDA*
QVAR TRIKAFTA* (PA, QL) PROCRIT* (PA) NEUPOGEN* (PA)
REDIHALER RETACRIT* (PA) PROMACTA* (PA)
SEREVENT ZARXIO* SIKLOS (PA)
DISKUS ZIEXTENZO* (PA) TAVALISSE* (PA)
SPIRIVA UDENYCA* (PA)
SPIRIVA BLOOD PRESSURE/HEART MEDICATIONS
RESPIMAT amlodipine CORLANOR (PA) ADALAT CC
STIOLTO amlodipine- ENTRESTO ALTACE (ST)
RESPIMAT benazepril TEKTURNA HCT ATACAND (ST)
SYMBICORT amlodipine- (QL) AVAPRO (ST)
TRACLEER 32 olmesartan (QL) AZOR (QL)
MG TABLET FOR amlodipine- BENICAR (QL, ST)
valsartan BENICAR HCT (QL,
SUSP* (PA) ST)
TRELEGY ELLIPTA atenolol
benazepril BERINERT* (PA)
UPTRAVI* (PA) bisoprolol BIDIL (QL)
XOLAIR* (PA) bisoprolol-hctz CALAN SR
candesartan CARDIZEM LA
ATTENTION DEFICIT HYPERACTIVITY 120mg (QL)
DISORDER3 cartia xt
carvedilol CATAPRES-TTS 1
amphetamine (PA) MYDAYIS (PA, ADDERALL (PA,ST) carvedilol er (QL) CATAPRES-TTS 2
atomoxetine (QL) QL) ADZENYS ER (PA, clonidine CATAPRES-TTS 3
dexmethylphe- diltiazem 12hr er CINRYZE* (PA)
VYVANSE (PA, QL) COREG (ST)
nidate (PA) QL) ADZENYS XR-ODT diltiazem 24hr er
dexmethylphe- diltiazem 24hr er CORGARD (ST)
nidate er (PA, QL) (PA, QL) (cd) COZAAR (ST)
dextroamphe- amphetamine er diltiazem 24hr er DIOVAN (ST)
tamine- (PA,QL) (la) DIOVAN HCT (ST)
amphetamine (PA) AZSTARYS (PA, ST, diltiazem 24hr er EPANED
dextroamphe- (xr) EXFORGE
QL) EXFORGE HCT
tamine-amphet er DAYTRANA (PA, QL) diltiazem
(PA, QL) DILT-XR HAEGARDA* (PA)
DYANAVEL XR (PA, dofetilide (QL) HEMANGEOL
guanfacine er HYZAAR (ST)
QL) droxidopa*
methylphenidate er INDERAL LA (ST)
EVEKEO ODT (PA) enalapril
(PA, QL) flecainide INDERAL XL (ST)
FOCALIN (PA,ST) INNOPRAN XL (ST)
methylphenidate hydralazine tablet
INTUNIV ISOSORBIDE DINIT-
cd (PA, QL) icatibant* (PA)
METHYLIN (PA) irbesartan HYDRALAZINE
methylphenidate
QUILLICHEW ER labetalol tablet (QL)
er (cd) (PA, QL) KALBITOR* (PA)
(PA, QL) lisinopril
methylphenidate la KAPSPARGO
QUILLIVANT XR (PA, lisinopril-hctz
(PA, QL) losartan SPRINKLE (ST)
QL) KATERZIA (QL)
procentra (PA) losartan-hctz
RITALIN (PA,ST) LOPRESSOR (ST)
matzim la
STRATTERA (QL) metoprolol LOTENSIN (ST)
ZENZEDI (PA,ST) succinate LOTREL
metoprolol MICARDIS (QL, ST)
BLOOD MODIFIERS/BLEEDING DISORDERS MICARDIS HCT (QL,
nadolol
aminocaproic acid ARANESP* (PA) CABLIVI* (PA) nebivolol (QL) ST)
0.25 gram/ml, 500 EMPAVELI* (PA) CYKLOKAPRON* nifedipine MINIPRESS
nifedipine er NITROSTAT
mg, 1,000 mg* EPOGEN* (PA) DOPTELET* (PA) NORTHERA* (PA)
tranexamic acid DROXIA FULPHILA* (PA) olmesartan (QL)
NORVASC
650 mg* NEULASTA* (PA) GRANIX* (PA) 7Cigna Performance 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
BLOOD PRESSURE/HEART MEDICATIONS CANCER (cont)
(cont) ONTRUZANT* (PA)
olmesartan- ORLADEYO* (PA, ORGOVYX* (PA)
amlodipine-hctz QL) POMALYST* (PA)
olmesartan-hctz PROCARDIA XL ROZLYTREK* (PA)
(QL) RANEXA (QL) STIVARGA* (PA)
prazosin RUCONEST* (PA) TAFINLAR* (PA)
propranolol tablet TAKHZYRO* PA TAGRISSO* (PA)
propranolol er TEKTURNA (QL) TARGRETIN* (PA)
ramipril TENORETIC 50 (ST) TASIGNA* (PA)
ranolazine er (QL) TENORETIC 100 (ST) TEMODAR
sajazir* (PA) TENORMIN (ST) CAPSULE* (PA)
taztia xt TIAZAC TUKYSA* (PA)
telmisartan (QL) TIKOSYN (PA, QL) UKONIQ* (PA, QL)
telmisartan-hctz TOPROL XL (ST) VENCLEXTA
(QL) TRIBENZOR STARTING PACK*
tiadylt er VASOTEC (ST) (PA)
valsartan VERELAN VENCLEXTA* (PA)
valsartan-hctz VERELAN PM VITRAKVI* (PA)
verapamil er ZESTORETIC (ST) XELODA* (PA)
verapamil er pm ZESTRIL (ST) XOSPATA* (PA)
verapamil tablet ZIAC (ST) XTANDI* (PA)
verapamil sr ZEJULA* (PA)
BLOOD THINNERS/ANTI-CLOTTING CHOLESTEROL MEDICATIONS
clopidogrel BRILINTA EFFIENT atorvastatin+ LIVALO (QL,ST) CADUET (QL)
enoxaparin* (QL) ELIQUIS (PA) LOVENOX* (QL) colesevelam NEXLETOL (PA, LIPOFEN (ST)
jantoven FRAGMIN* (QL) PLAVIX ezetimibe QL) ROSZET (PA)
prasugrel XARELTO (PA) PRADAXA (PA) fenofibrate NEXLIZET (PA, TRICOR (ST)
warfarin SAVAYSA (PA, QL) fenofibric acid QL) TRILIPIX (ST)
CANCER fluvastatin+ REPATHA (PA) WELCHOL
fluvastatin er+ VASCEPA (PA) ZETIA
abiraterone* (PA) ALECENSA* (PA) AFINITOR DISPERZ* icosapent ethyl ZOCOR (QL, ST)
anastrozole+ ERIVEDGE* (PA) (PA) lovastatin+
bexarotene* (PA) ERLEADA* (PA) AFINITOR* (PA) omega-3 acid ethyl
capecitabine* (PA) GLEOSTINE ALUNBRIG* (PA) esters
everolimus* (PA) IBRANCE* (PA) AYVAKIT* (PA,QL) pravastatin+
exemestane+ KANJINTI* (PA) BOSULIF* (PA) simvastatin tablet+
imatinib* (PA) LYNPARZA* (PA) BRAFTOVI* (PA)
letrozole MVASI* (PA) CABOMETYX* (PA) (QL)
methotrexate REVLIMID* (PA) CALQUENCE* (PA) CONTRACEPTION PRODUCTS
tamoxifen+ RUBRACA* (PA) COMETRIQ* (PA)
temozolomide* RUXIENCE* (PA) GLEEVEC* (PA) AFIRMELLE+ LO LOESTRIN FE ANNOVERA
(PA) SPRYCEL* (PA) ICLUSIG* (PA) ALTAVERA+ BALCOLTRA
TRAZIMERA* IMBRUVICA* (PA) ALYACEN+ BEYAZ
(PA) INLYTA* (PA) AMETHIA+ CAYA
TREXALL JAKAFI* (PA) AMETHYST+ CONTOURED+
VERZENIO* (PA) KISQALI* (PA) APRI+ ELLA+
ZIRABEV* (PA) LENVIMA* (PA) ARANELLE+ FEMCAP+
LONSURF* (PA) ASHLYNA+ KYLEENA*+
LUMAKRAS* (PA,QL) AUBRA EQ+ LAYOLIS FE+
MEKINIST* (PA) AUBRA+ LILETTA*+
MEKTOVI* (PA) AUROVELA 24 FE+ LOESTRIN FE
NERLYNX* (PA) AUROVELA FE+ MICROGESTIN 24 FE
NINLARO* (PA) AUROVELA+ MINASTRIN 24 FE
NUBEQA* (PA) AVIANE+ MIRENA*+
ODOMZO* (PA) AYUNA+ NATAZIA
OGIVRI* (PA) AZURETTE+ NEXPLANON*+
BALZIVA+ NEXTSTELLIS
8Cigna Performance 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
CONTRACEPTION PRODUCTS (cont) CONTRACEPTION PRODUCTS (cont)
BLISOVI 24 FE+ NUVARING JUNEL+
BLISOVI FE+ PARAGARD T 380- KAITLIB FE+
BRIELLYN+ A*+ KALLIGA+
CAMILA+ SAFYRAL KARIVA+
CAMRESE LO+ SKYLA*+ KELNOR 1-35+
CAMRESE+ SLYND KELNOR 1-50+
CAZIANT+ TAYTULLA KURVELO+
CHARLOTTE 24 TWIRLA+ LARIN 24 FE+
FE+ wide seal LARIN FE+
CHATEAL EQ+ diaphragm+ LARIN+
CHATEAL+ YASMIN 28 LARISSIA+
CRYSELLE+ YAZ LEENA+
CYCLAFEM+ LESSINA+
CYRED EQ+ LEVONEST+
CYRED+ levonorgestrel-
DASETTA+ ethinyl estradiol+
DAYSEE+
DEBLITANE+ levonorgestrel-
desogestrel-ethinyl ethinyl estradiol
estradiol+ ethinyl estradiol+
desogestrel-ethinyl LEVORA-28+
estradiol - ethinyl LILLOW+
estradiol+ LOJAIMIESS+
DOLISHALE+ LORYNA+
drospirenone- LOW-OGESTREL+
ethinyl estradiol- LO-
ZUMANDIMINE+
levomefolate+ LUTERA+
drospirenone- LYLEQ+
ethinyl estradiol+ LYZA+
ELINEST+ MARLISSA+
ELURYNG+ medroxyprogester-
ENPRESSE+ one+ 150mg/ml
ENSKYCE+ MERZEE+
ERRIN+ MICROGESTIN FE+
ESTARYLLA+ MICROGESTIN+
ethynodiol-ethinyl MILI+
estradiol+ MONO-LINYAH+
etonogestrel- NECON+
ethinyl estradiol+ NIKKI+
FALMINA+ NORA-BE+
FEMYNOR+ norethindrone+
GEMMILY+ norethindrone-
HAILEY 24 FE+ ethinyl estradiol-
HAILEY FE+ iron+
HAILEY+ norethindrone-
HEATHER+ ethinyl estradiol+
ICLEVIA+ norethindrone-
INCASSIA+ ethinyl estradiol-
ISIBLOOM+ ferrous fumarate
JAIMIESS+ norgestimate-
JASMIEL+ ethinyl estradiol+
JENCYCLA+ NORLYDA+
JOLESSA+ NORTREL+
JULEBER+ NYLIA+
JUNEL FE 24+ NYMYO+
JUNEL FE+ OCELLA+
9Cigna Performance 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
CONTRACEPTION PRODUCTS (cont) DENTAL PRODUCTS
ORSYTHIA+ chlorhexidine PREVIDENT CLINPRO 5000
PHILITH+ DENTA 5000 PLUS 5000 1.1% DRY FLORIVA+
PIMTREA+ DENTAGEL MOUTH FLUORIDEX
PIRMELLA+ doxycycline hyclate PREVIDENT 5000 SENSITIVITY RELIEF
PORTIA+ FLUORIDEX DAILY BOOSTER PLUS PREVIDENT 0.2%
PREVIFEM+ DEFENSE 1.1% PREVIDENT RINSE
RECLIPSEN+ ORALONE 5000 ENAMEL PREVIDENT 1.1%
RIVELSA+ PERIDEX PROTECT GEL
SETLAKIN+ PERIOGARD PREVIDENT PREVIDENT 5000
SHAROBEL+ SF 1.1% GEL 5000 ORTHO PLUS
SIMLIYA+ SF 5000 PLUS DEFENSE
SIMPESSE+ sodium fluoride+ PREVIDENT 5000
SPRINTEC+ drops SENSITIVE
SRONYX+ sodium fluoride
SYEDA+ 5000 dry mouth
TARINA 24 FE+ sodium fluoride
TARINA FE 1-20 5000 plus
EQ+ triamcinolone
TARINA FE+ DIABETES
taysofy+
TILIA FE+ glimepiride ACCU-CHEK ACCU-CHEK
TRI FEMYNOR+ glipizide GUIDE ME COMPACT PLUS
TRI-ESTARYLLA+ glipizide er GLUCOSE MTR CONTROL
TRI-LEGEST FE+ glipizide xl ACCU-CHEK ACCU-CHEK GUIDE
TRI-LINYAH+ metformin GUIDE L1-L2 CONTROL
TRI-LO- metformin er MONITOR SOLUTION
ESTARYLLA+ TECHLITE INSULIN SYSTEM ACCU-CHEK AVIVA
TRI-LO-MARZIA+ SYRINGE BAQSIMI (QL) SOLUTION
TRI-LO-MILI+ BD INSULIN ACCU-CHEK
TRI-LO-SPRINTEC+ SYRINGE SMARTVIEW
TRI-MILI+ BD LANCETS CONTROL
TRI-NYMYO+ BD PEN NEEDLE SOLUTION
TRI-SPRINTEC+ BYDUREON AUTOSHIELD DUO
TRIVORA-28+ BCISE (PA,QL) PEN NEEDLE
TRI-VYLIBRA LO+ BYETTA (PA,QL) CEQUR
TRI-VYLIBRA+ DEXCOM G6 (PA, CONTOUR
TULANA+ QL)
TYDEMY+ DROPLET
VELIVET+ DROPSAFE
VESTURA+ FARXIGA (QL, ST)
VIENVA+ FREESTYLE LIBRE
VIORELE+ 14 DAY SENSOR
VOLNEA+ (PA, QL)
VYFEMLA+ FREESTYLE LIBRE
VYLIBRA+ 2 SENSOR (PA,
WERA+ QL)
WYMZYA FE+ FREESTYLE LIBRE
XULANE+ READER (PA,
ZAFEMY+ QL)
ZOVIA 1-35+ GLUCAGEN
ZUMANDIMINE+ HYPO KIT (QL)
GLYXAMBI (QL,
COUGH/COLD MEDICATIONS ST)
brompheniramine- HYCODAN (PA, QL) HUMALOG (QL)
pseudoephedrine- TUXARIN ER (PA,QL) HUMULIN (QL)
dm TUZISTRA XR (PA, HUMULIN R (QL)
hydrocodone- QL)
homatropine
(PA,QL)
promethazine-dm 10Cigna Performance 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
DIABETES (cont) DIABETES (cont)
INSULIN CYCLOSET TRULICITY
SYRINGE DEXCOM G4 (PA,QL)
JANUMET (QL, DEXCOM G5 V-GO 20
ST) DEXCOM G5-G4 V-GO 30
JANUMET XR SENSOR V-GO 40
(QL, ST) FREESTYLE VEO INSULIN
JANUVIA (QL, FREEDOM LITE SYRINGE
ST) GLUCAGON VICTOZA (PA,
JARDIANCE (QL, EMERGENCY KIT QL)
ST) (QL) XIGDUO XR (QL,
LEVEMIR (QL) GLUCOCARD ST)
LYUMJEV (QL) EXPRESSION XULTOPHY
MICROLET GLUCOCARD SHINE ZEGALOGUE
NEXT LANCING GVOKE (QL) (QL)
DEVICE INPEN
MULTI-LANCET KORLYM* (PA) DIURETICS
NOVOFINE PARADIGM
NOVOTWIST RESERVOIR, acetazolamide DIURIL ALDACTONE
OMNIPOD DASH REMOTE CONTROL tablet KERENDIA (PA, CAROSPIR
PODS (GEN 4) POGO AUTOMATIC acetazolamide er QL) INSPRA
(PA,QL) BLOOD GLUC SYS capsule JYNARQUE* (PA)
ONETOUCH PRECISION XTRA bumetanide tablet LASIX
ULTRA TEST MONITOR NFRS chlorthalidone MAXZIDE
STRIP PRECISION XTRA eplerenone
ONETOUCH MONITOR furosemide
ULTRAMINI PRECISION XTRA solution, tablet
ONETOUCH KETONE-GLUC KIT hydrochloro-
VERIO FLEX RIOMET thiazide
METER TRUE METRIX spironolactone
ONETOUCH torsemide
VERIO IQ METER triamterene-hctz
ONETOUCH EAR MEDICATIONS
VERIO METER
ONETOUCH ciprofloxacin- CIPRO HC CIPROFLOXACIN-
VERIO REFLECT dexamethasone FLUOCINOLONE
METER neomycin- CIPRODEX
ONETOUCH polymyxin CORTISPORIN-TC
VERIO TEST b-hydrocortisone DERMOTIC
STRIP ofloxacin OTOVEL
OZEMPIC (PA,QL) ERECTILE DYSFUNCTION
QTERN (QL, ST)
RYBELSUS (PA, sildenafil (QL) MUSE (QL) CIALIS (QL, ST)
QL) tadalafil (QL) STENDRA (QL, ST)
SEMGLEE (QL) vardenafil (QL) VIAGRA (QL, ST)
SOLIQUA 100-33 EYE CONDITIONS
SYMLINPEN
SYNJARDY (QL, bimatoprost (QL) ALPHAGAN P ACUVAIL
ST) brimonidine 0.1% DROPS ALPHAGAN P 0.15%
SYNJARDY XR brinzolamide AZASITE EYE DROPS
(QL, ST) ciprofloxacin BETIMOL ALREX
TECHLITE difluprednate BETOPTIC S AZOPT
NEEDLE dorzolamide- COMBIGAN BEPREVE
TRESIBA (QL) timolol EYSUVIS (QL) BESIVANCE
TRIJARDY XR (ST, erythromycin FLAREX BROMSITE
QL) fluorometholone FML FORTE CEQUA
TRUEPLUS latanoprost 0.25% EYE COSOPT
SYRINGE loteprednol COSOPT PF
DROPS
11Cigna Performance 3-Tier Prescription Drug List
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EYE CONDITIONS (cont) GASTROINTESTINAL/HEARTBURN
moxifloxacin eye FML S.O.P. 0.1%
CYSTADROPS* (PA, famotidine 40 mg/5 VARUBI (PA, QL)
drops OINTMENT QL) ml suspension, 20 VIOKACE
neomycin- FLAREX CYSTARAN* (PA, QL) mg tablet, 40 mg
LOTEMAX SM DUREZOL tablet
polymyxin GAVILYTE-C+
RESTASIS FML LIQUIFILM
b-dexamethasone MULTIDOSE GAVILYTE-G+
ofloxacin 0.1% EYE DROP
SIMBRINZA ILEVRO GAVILYTE-N+
polymyxin XIIDRA GAVILYTE-N+
b sulfate- INVELTYS
ZERVIATE ISTALOL HEMMOREX-HC
trimethoprim hydrocortisone
prednisolone LOTEMAX
MAXITROL lansoprazole (QL)
timolol mesalamine
tobramycin- OCUFLOX
OXERVATE* (PA) mesalamine dr
dexamethasone mesalamine er
travoprost PRED FORTE
PROLENSA metoclopramide
RHOPRESSA solution, tablet
ROCKLATAN metoclopramide
TIMOPTIC odt
TIMOPTIC-XE omeprazole (QL)
TOBRADEX EYE ondansetron
ondansetron odt
DROPS
TOBRADEX ST pantoprazole
VIGAMOX suspension, tablet
ZIRGAN (QL)
ZYLET peg
3350-electrolyte+
FEMININE PRODUCTS
peg3350-sodium
GYNAZOLE 1 sulfate-sodium
miconazole 3 200 chloride-
mg potassium
terconazole chloride-sodium
ascorbate-ascorbic
GASTROINTESTINAL/HEARTBURN acid+
alosetron* AMITIZA ACIPHEX (QL, ST) PEG-PREP+
ANUCORT-HC CLENPIQ+ APRISO prochlorperazine
balsalazide DEXILANT (QL) BONJESTA tablet
cinacalcet* ENTYVIO* (PA) CANASA rabeprazole tablet
dicyclomine LINZESS CARAFATE (QL)
capsule, solution, NEXIUM DR 2.5 CHOLBAM* (PA) scopolamine
tablet MG PACKET DICLEGIS sucralfate
esomeprazole GATTEX* (PA)
(QL) HORMONAL AGENTS
20 mg capsule, MOVANTIK (PA)
40 mg capsule, NEXIUM DR 5 OCALIVA* (PA) AMABELZ ANDRODERM ACTHAR GEL* (PA)
packets (QL) MG PACKET PREVACID DR 30 budesonide dr (PA, QL) ACTIVELLA
(QL) MG CAPSULE (QL, budesonide ec CETROTIDE*^ ALORA (QL)
PANCREAZE ST) budesonide er (PA, (PA) ANDROGEL (PA, QL)
PENTASA PROTONIX (ST, QL) QL) CRINONE ANGELIQ
SUPREP+ RAVICTI* (PA) cabergoline (QL) DIVIGEL AYGESTIN
SUTAB+ RECTIV desmopressin* DUAVEE BIJUVA
VIBERZI RELISTOR (PA) ampule, vial ESTRING (QL) BYNFEZIA* (PA)
SANCUSO (PA, QL) dexamethasone FORTEO* (PA, CLIMARA
SFROWASA intensol QL) CLIMARA PRO
SUCRAID* (PA) DOTTI (QL) HUMATROPE* COMBIPATCH
SYMPROIC (PA) estradiol (once (PA) CYTOMEL
TRANSDERM-SCOP weekly) LUPRON DEPOT* DEPO-
URSO (PA) TESTOSTERONE
URSO FORTE
12Cigna Performance 3-Tier Prescription Drug List
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HORMONAL AGENTS (cont) INFECTIONS (cont)
estradiol 10mcg LUPRON DEPOT- ELESTRIN COREMINO ER QL) SOFOSBUVIR- CRESEMBA
vaginal insert (QL) PED* (PA) EMFLAZA* (PA) dapsone tablets VELPATASVIR* CAPSULE (PA)
estradiol (twice MEDROL 2 MG ESTRACE doxycycline (PA) DARAPRIM* (PA)
weekly) (QL) TABLET ESTROGEL capsule, tablet SOLOSEC DIFICID (QL)
estradiol- EVAMIST doxycycline SOVALDI* (PA, e.e.s. 400
MYFEMBREE FENSOLVI* (PA) monohydrate QL) ELIMITE
norethindrone
EUTHYROX (PA,QL) IMVEXXY (QL) EMVERM VEMLIDY* ERYPED 200
LEVO-T NORDITROPIN INTRAROSA entecavir* (QL) VOSEVI* (PA) ERY-TAB DR
levothyroxine tablet FLEXPRO* (PA) ISTURISA* (PA, QL) erythromycin XIFAXAN (QL) EURAX 10% LOTION
LEVOXYL ORIAHNN (PA, LANREOTIDE* (PA) erythromycin FLAGYL
liothyronine QL) LUPANETA PACK* ethylsuccinate KITABIS PAK* (PA,
LYLLANA (QL) ORILISSA (PA, (PA) famciclovir QL)
medroxyprog- QL) MEDROL 8MG, fluconazole MACROBID
esterone PREMARIN 16MG, 32MG hydroxychlor- MACRODANTIN
methylpred- TABLET, TABLET oquine MALARONE (PA)
nisolone VAGINAL MEDROL 4 MG ivermectin 3 mg NUVESSA
MIMVEY CREAM DOSEPAK tablet (PA) NUZYRA TABLET*
norethindrone APPLICATOR MENOSTAR (QL) levofloxacin (PA, QL)
NP THYROID PREMPHASE MINIVELLE (QL) solution, tablet PLAQUENIL (PA)
prednisone PREMPRO MYFEMBREE (QL) metronidazole gel, posaconazole
prednisone intensol SEROSTIM* (PA) OSPHENA capsule, tablet suspension
progesterone vial* SOMATULINE PROMETRIUM minocycline PREVYMIS TABLET*
testosterone (PA, DEPOT* (PA) RAYALDEE minocycline er PRIFTIN
QL) SOMAVERT* (PA) SANDOSTATIN LAR tablet (QL) posaconazole
testosterone DEPOT* (PA) mondoxyne nl suspension
cypionate SKYTROFA* (PA) nitazoxanide SIVEXTRO TABLET
YUVAFEM (QL) SUPPRELIN LA* (PA) nitrofurantoin (PA)
TRIOSTAT nitrofurantoin SKLICE
TRIPTODUR* (PA) monohydrate- STROMECTOL (PA)
UNITHROID macrocrystal sulfatrim
VAGIFEM (QL) nystatin TAMIFLU (QL)
VIVELLE-DOT (QL) suspension, tablet URIBEL
oseltamivir (QL) VALTREX
INFECTIONS penicillin v XENLETA 600mg
acyclovir capsule, BARACLUDE AEMCOLO (QL) potassium tablet (PA, QL)
suspension, tablet SOLUTION* ALBENZA posconazole tablet XOFLUZA (QL)
albendazole CLEOCIN 75 MG ALINIA sulfamethoxazole- ZEPATIER* (PA)
amoxicillin CAPSULE ARIKAYCE* (PA) trimethoprim ZITHROMAX
amoxicillin- EPCLUSA* (PA, BACTRIM suspension, tablet ZITHROMAX TRI-
QL) BACTRIM DS terbinafine PAK
clavulanate er tetracycline
EURAX 10% BAXDELA (PA) ZYVOX
amoxicillin- CREAM CAYSTON* (PA, QL) tobramycin SUSPENSION,
clavulanate HARVONI* (PA, CIPRO TABLET ampule* (PA, QL) TABLET (PA)
atovaquone QL) valacyclovir
atovaquone- CLEOCIN 150 MG valganciclovir
LEDIPASVIR-
proguanil SOFOSBUVIR* CAPSULE vancomycin
AVIDOXY (PA) CLEOCIN 300 MG capsule, solution
azithromycin MAVYRET* (PA, CAPSULE vandazole
packet, QL) CLEOCIN 100 MG
suspension, tablet INFERTILITY
MOLNUPIRAVIR VAGINAL OVULE
cefdinir (QL) CRINONE 8% FOLLISTIM* (PA)
cefuroxime tablet CLEOCIN 2% GEL^ MAKENA* (PA)
PAXLOVID (QL)
cephalexin PEGASYS* (PA) VAGINAL CREAM ENDOMETRIN^ MENOPUR*^ (PA)
ciprofloxacin CLINDESSE GONAL-F*^ (PA) NOVAREL 10,000
clindamycin NOVAREL 5,000 UNITS VIAL*^ (PA)
UNIT VIAL*^
(PA)
OVIDREL*^ (PA)
13Cigna Performance 3-Tier Prescription Drug List
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MISCELLANEOUS NUTRITIONAL/DIETARY (cont)
deferiprone ACCU-CHEK ADDYI (QL) MULTI-VITAMIN OB COMPLETE K-TAB ER
500mg* (PA) SAFE-T-PRO CEREZYME* (PA) W-FLUORIDE- DHA MEPHYTON
disulfiram 23G LANCETSDYSPORT* (PA) IRON+ OB COMPLETE PERRY PRENATAL+
sapropterin* (PA) ACCU-CHEK AUSTEDO* (PA) ONE PHOSLYRA
sodium chloride SOFTCLIX EVRYSDI* (PA) MULTIVITAMIN OB COMPLETE POLY-VI-FLOR WITH
inhalation vial. LANCETS INGREZZA* (PA) WITH FLUORIDE+ PETITE IRON+
Irrigation solution ACCU-CHEK INGREZZA MULTIVITAMIN- OB COMPLETE POLY-VI-FLOR+
vial MULTICLIX INITIATION PACK* IRON-FLUORIDE PREMIER PRENATAL
LANCETS (PA, QL) potassium chloride PRENATE FORMULA-DHA+
ACCU-CHEK KETONE CARE TEST 10%, capsule, CHEWABLE PRENATE
FASTCLIX STRIP packet, tablet PRENATE DHA QUFLORA
LANCET DRUMKETONE TEST STRIP sevelamer PRENATE ELITE PEDIATRIC 1
CERDELGA* (PA)
KETOSTIX REAGENT carbonate PRENATE MG CHEWABLE
DROPLET NUEDEXTA (QL) TRI-VITE WITH ENHANCE TABLET+
LANCETS ORFADIN* (PA) FLUORIDE+ PRENATE QUFLORA
ESBRIET* (PA)
PALYNZIQ* (PA) vitamin d2 1.25 mg ESSENTIAL PEDIATRIC 0.25
MICROLET POGO AUTOMATIC (50,000 unit)^ PRENATE MINI MG/ML DROP+
NITYR* (PA) TEST CARTRIDGE VITAMINS A,C,D PRENATE PIXIE QUFLORA
ONETOUCH PRECISION XTRA AND FLUORIDE+ PRENATE PEDIATRIC 0.5 MG/
DELICA TEGSEDI* (PA) RESTORE ML DROP+
ONETOUCH TIGLUTIK* (PA) PRIMACARE RENVELA
LANCETS TRUEPLUS KETONE TRI-VI-FLOR+ ROCALTROL
STRENSIQ* (PA)
TEST STRIP VELPHORO
TECHLITE VYLEESI* (PA, QL) VELTASSA
LANCETS VYNDAMAX* (PA,
OSTEOPOROSIS PRODUCTS
QL)
MULTIPLE SCLEROSIS
alendronate FORTEO* (PA,QL) ACTONEL (ST)
ibandronate* 150 TYMLOS* (PA, ATELVIA (ST)
dalfampridine er* AVONEX* (PA) MAVENCLAD* (PA) mg tablet QL) BINOSTO (ST)
(PA) AUBAGIO* (PA) OCREVUS* (PA) raloxifene+ EVISTA
dimethyl fumarate* BAFIERTAM* (PA) PONVORY* (PA) risedronate FOSAMAX (ST)
(PA) BETASERON* risedronate dr
glatiramer* (PA) (PA) teriparatide* (PA,
glatopa* (PA) EXTAVIA* (PA) QL)
GILENYA* (PA)
PAIN RELIEF AND INFLAMMATORY DISEASE
KESIMPTA PEN*
(PA) acetaminophen- ACTEMRA* ARCALYST* (PA)
MAYZENT* (PA) codeine (PA) (PA,QL) ARAVA
PLEGRIDY* (PA) allopurinol tablet AIMOVIG (PA) BENLYSTA* (PA)
PONVORY* (PA) baclofen tablet AJOVY (PA) BUPRENEX9PA0
REBIF* (PA) buprenorphine AVSOLA* (PA) BUTRANS (QL)
VUMERITY* (PA) patch (QL) BELBUCA (QL) CELEBREX (QL, ST)
ZEPOSIA* (PA) butalbital- CIMZIA* (PA, QL) COLCRYS
NUTRITIONAL/DIETARY
acetaminophen- DUPIXENT* (PA) DEPEN* (PA)
caffeine (QL) EMGALITY (PA) DUROLANE* (PA)
calcitriol CITRANATAL 90 ACCRUFER carisoprodol ENBREL* (PA,QL) EC-NAPROSYN (ST)
cyanocobalamin DHA AURYXIA (QL) celecoxib (QL) HUMIRA* ESGIC (QL)
injection CITRANATAL CITRANATAL colchicine (PA,QL) EUFLEXXA* (PA)
dodex ASSURE BLOOM cyclobenzaprine HYSINGLA ER FEXMID
fluoride+ CITRANATAL DRISDOL diclofenac 1% gel (PA) FLECTOR (PA, QL)
folic acid^+ B-CALM FLORIVA+ (QL) INFLECTRA* (PA) GABLOFEN
klor-con CITRANATAL diclofenac dr NUCYNTA (PA) GELSYN-3* (PA)
KLOR-CON 8 MEQ DHA diclofenac ec NURTEC ODT GLASSIA*
TABLET CITRANATAL (PA, QL) HYALGAN* (PA)
HARMONY EC-NAPROXEN OTEZLA* (PA, HYMOVIS* (PA)
KLOR-CON 10 MEQ CITRANATAL RX ECOTRIN EC 81 MG QL) ILARIS* (PA)
TABLET LOKELMA TABLET+ PROCTOFOAM- ILUMYA* (PA, QL)
NEEVO DHA eletriptan (QL) HC KEVZARA* (PA, QL)
KINERET* (PA,QL)
14Cigna Performance 3-Tier Prescription Drug List
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PAIN RELIEF AND INFLAMMATORY DISEASE SCHIZOPHRENIA/ANTI-PSYCHOTICS3
(cont) aripiprazole (QL) LATUDA (QL) ABILIFY MAINTENA
ENDOCET (PA) RASUVO (PA) LAZANDA (PA) aripiprazole odt (QL)
febuxostat (QL) REDITREX (PA) LICART (PA, QL) asenapine ARISTADA (QL)
FIORICET (QL) RINVOQ* (PA, MITIGARE chlorpromazine ARISTADA INITIO
GEL-ONE* (PA) QL) MONOVISC* (PA) tablet FANAPT (QL, ST)
GLYDO SAVELLA NAPROSYN (ST) olanzapine tablet INVEGA (QL, ST)
hydrocodone- SIMPONI 100 NUCYNTA ER (PA) olanzapine odt PERSERIS (QL)
acetaminophen MG/ML* (PA, OLUMIANT* (PA, paliperidone er (QL) REXULTI (QL, ST)
(PA) QL) QL) quetiapine RISPERDAL (ST)
IBU SIMPONI ARIA* ORENCIA* (PA, QL) quetiapine er SAPHRIS (ST)
ibuprofen (PA) ORTHOVISC* (PA) risperidone SECUADO (ST)
indomethacin SKYRIZI* (PA, QL) OTREXUP (PA) risperidone odt SEROQUEL (ST)
indomethacin er STELARA* OXAYDO (PA) ziprasidone tablet SEROQUEL XR (ST)
ketorolac (PA,QL) PERCOCET (PA) VRAYLAR (QL, ST)
tromethamine TALTZ* (PA, QL) RENFLEXIS* (PA) SEIZURE DISORDERS
(QL) TREMFYA* (PA, SILIQ* (PA, QL)
leflunomide QL) SIMPONI 50 MG/0.5 carbamazepine FYCOMPA (PA, APTIOM 600, 800
lidocaine 5% TRUDHESA (PA, ML* (PA, QL) carbamazepine er QL) mg tablets (PA)
ointment (QL) QL) SKELAXIN clonazepam NAYZILAM (PA, APTIOM 200, 400
lidocaine 5% patch UBRELVY (PA, SYNVISC* (PA) divalproex QL) mg tablets(PA, QL)
lidocaine viscous QL) TRILURON* (PA) divalproex er BANZEL (PA, QL)
meloxicam tablet XELJANZ XR* ULORIC (QL) EPITOL BRIVIACT ORAL
metaxalone (PA, QL) ULTRAM 50 MG gabapentin SOLUTION, TABLET
methocarbamol XELJANZ* (PA, TABLET (QL) lamotrigine (PA)
morphine (PA) QL) ZANAFLEX lamotrigine (blue) CARBATROL (PA)
morphine er (PA) XTAMPZA ER ZEBUTAL (QL) lamotrigine (green) DEPAKOTE (PA)
oxycodone (PA) (PA) ZOHYDRO ER (PA) lamotrigine DEPAKOTE ER (PA)
oxycodone er (PA) ZTLIDO ZYLOPRIM (orange) DEPAKOTE
oxycodone- lamotrigine er SPRINKLE (PA)
acetaminophen lamotrigine odt DIASTAT (PA)
(PA) lamotrigine odt DILANTIN (PA)
penicillamine* (PA) (blue) EPIDIOLEX* (PA)
PROLATE TABLET FINTEPLA* (PA)
lamotrigine odt FYCOMPA (PA, QL)
(PA) (green)
rizatriptan (QL) KLONOPIN (PA)
lamotrigine odt LYRICA ORAL
sumatriptan (QL) (orange)
SUPARTZ FX* (PA) SOLUTION (PA)
levetiracetam NEURONTIN (PA)
tramadol 50 mg solution, tablet OXTELLAR XR (PA)
tablet (QL) levetiracetam er PHENYTEK (PA)
tramadol er (QL) oxcarbazepine SPRITAM (PA)
VANADOM pregabalin capsule, TEGRETOL (PA)
VISCO-3* (PA) solution TEGRETOL XR (PA)
ROWEEPRA VALTOCO (PA, QL)
PARKINSON’S DISEASE XCOPRI (PA, QL)
rufinamide (PA, QL)
benztropine tablet KYNMOBI (PA) AZILECT (QL) SUBVENITE
carbidopa- DUOPA*
levodopa INBRIJA* (PA) SUBVENITE (BLUE)
carbidopa- MIRAPEX ER (QL) SUBVENITE (GREEN)
levodopa er NEUPRO SUBVENITE
pramipexole NOURIANZ* (PA, (ORANGE)
pramipexole er (QL) QL) topiramate
rasagiline (QL) OSMOLEX ER (QL) topiramate er
ropinirole er RYTARY vigabatrin*
ropinirole SINEMET 10-100 vigadrone*
SINEMET 25-100
TASMAR
XADAGO (ST)
15Cigna Performance 3-Tier Prescription Drug List
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SKIN CONDITIONS SLEEP DISORDERS/SEDATIVES (cont)
ACCUTANE EUCRISA ANALPRAM HC modafinil (PA) SUNOSI (PA, QL)
LUNESTA (ST)
adapalene (PA) NAFTIN 2.5%-1% LOTION zolpidem SILENOR (QL, ST)
adapalene-benzoyl PICATO AVAR 9.5-5% zolpidem er (QL) WAKIX* (PA, QL)
peroxide PRAMOSONE XYREM* (PA)
LOTION CLEANSING PADS XYWAV* (PA)
AMNESTEEM BRYHALI (ST)
AVAR CLEANSER SANTYL (QL)
calcipotriene foam SMOKING CESSATION3
azelaic acid CAPEX SHAMPOO
BP 10-1 bupropion sr+ 150 NICOTROL NS+ APO-VARENICLINE
(ST) mg tablet NICOTROL+
calcipotriene- CLEOCIN T
betamethasone varenicline+
CLINDACIN ETZ KIT
CLARAVIS SUBSTANCE ABUSE
CLINDACIN ETZ 1% CLINDACIN PAC KIT
PLEDGET CLODERM (ST) buprenorphine- LUCEMYRA (QL) KLOXXADO (QL)
CLINDACIN P 1% DESOWEN naloxone NARCAN (QL) SUBLOCADE*
PLEDGETS DRYSOL ZUBSOLV SUBOXONE
clindamycin 1% EFUDEX ZIMHI (QL)
foam, gel, lotion, ELIDEL
EVOCLIN TRANSPLANT MEDICATIONS
pledget, solution
clindamycin- PROTOPIC everolimus 0.25 mg CELLCEPT VIAL* ASTAGRAF XL*
benzoyl TARGRETIN* tablet* PROGRAF* CELLCEPT ORAL
peroxoxide TEMOVATE (ST) everolimus 0.5 mg SUSPENSION,
clindamycin- VALCHLOR* tablet* TABLET*
tretinoin VECTICAL (QL) mycophenolate ENVARSUS XR*
XEPI mofetil* MYFORTIC*
clobetasol mycophenolic NEORAL*
CLODAN acid* RAPAMUNE*
clotrimazole- sirolimus* REZUROCK* (PA)
betamethasone tacrolimus capsule* ZORTRESS*
dapsone 5% gel,
URINARY TRACT CONDITIONS
7.5% gel pump
fluocinonide alfuzosin er CYSTAGON* AVODART
fluorouracil cream, cevimeline ELMIRON EVOXAC
topical solution dutasteride K-PHOS FLOMAX
isotretinoin finasteride ORIGINAL PROSCAR
ketoconazole oxybutynin PYRIDIUM
KETODAN oxybutynin er RAPAFLO (QL)
metronidazole phenazopyridine UROCIT-K
MYORISAN potassium er UROXATRAL
NEUAC GEL silodosin (QL)
pimecrolimus solifenacin (QL)
ROSADAN tamsulosin
sodium tolterodine
sulfacetamide- tolterodine er (QL)
sulfur VACCINES
SSS 10-5 Vaccines are now covered under the Cigna pharmacy benefit.
SULFACLEANSE 8-4
Not all plans cover vaccines in the same way. Log in to the
tacrolimus
ointment myCigna App or myCigna.com, or check your plan materials, to
tazarotene 0.1% find out how your specific plan covers them.
cream ACTHIB+
tretinoin (PA) ADACEL TDAP+
TRIDERM
ZENATANE AFLURIA QUAD
2021-2022+
SLEEP DISORDERS/SEDATIVES AFLURIA QUAD
doxepin (QL) DAYVIGO (QL, HETLIOZ LQ* (PA) 2021-22 (3YR
eszopiclone ST) HETLIOZ* (PA) UP)+
16Cigna Performance 3-Tier Prescription Drug List
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$ $$ $$$ $ $$ $$$
VACCINES (cont) VACCINES (cont)
Vaccines are now covered under the Cigna pharmacy benefit. Vaccines are now covered under the Cigna pharmacy benefit.
Not all plans cover vaccines in the same way. Log in to the Not all plans cover vaccines in the same way. Log in to the
myCigna App or myCigna.com, or check your plan materials, to myCigna App or myCigna.com, or check your plan materials, to
find out how your specific plan covers them. find out how your specific plan covers them.
AFLURIA QUAD MODERNA
2021-22 (6- COVID-19
35MO)+ BOOSTER (EUA)+
BEXSERO+ MODERNA
BOOSTRIX TDAP+ COVID-19 VACCINE
COMIRNATY+ (EUA)+
DAPTACEL DTAP+ PEDIARIX+
DENGVAXIA+ PEDVAXHIB+
DIPHTHERIA- PENTACEL+
TETANUS PFIZER COVID (12Y
TOXOIDS-PED+ UP) VAC(EUA)+
ENGERIX-B ADULT+ PFIZER COVID (5-
ENGERIX-B 11Y) VAC (EUA)+
PEDIATRIC- PFIZER COVID-19
ADOLESCENT+ VACCINE (EUA)+
FLUAD QUAD 2021- PNEUMOVAX 23+
2022+ PREHEVBRIO+
FLUARIX QUAD PREVNAR 13+
2021-2022+ PREVNAR 20+
FLUBLOK QUAD PROQUAD+
2021-2022+ QUADRACEL DTAP-
FLUCELVAX QUAD IPV VIAL+
2021-2022+ RECOMBIVAX HB+
FLULAVAL QUAD SHINGRIX+ (QL)
2021-2022+ TDVAX+
FLULAVAL QUAD TENIVAC+
2021-2022+ TRUMENBA+
FLUZONE HIGH- TWINRIX+
DOSE QUAD VARIVAX VACCINE+
2021-22+ VAXELIS+
FLUZONE QUAD VAXNEUVANCE+
2021-2022+
GARDASIL 9+ WEIGHT MANAGEMENT
HEPLISAV-B+ megestrol
HIBERIX+ suspension
INFANRIX DTAP+
IPOL+
JANSSEN COVID-19
VACCINE (EUA)+
KINRIX+
MENACTRA+
MENQUADFI+
MENVEO A-C-Y-W-
135-DIP+
M-M-R II VACCINE+
17Medications that aren’t covered - and their covered alternative(s)
These medications aren’t covered on the Cigna Performance 3-Tier Prescription Drug List.^^ However,
there are other medications available that are used to treat the same condition. They’re listed below.
MEDICATION NAME^^ GENERIC AND/OR PREFERRED BRAND
DRUG CLASS
(Not covered) ALTERNATIVE(S)
AIDS/HIV ATRIPLA* efavirenz-emtricitabine-tenofovir*
COMBIVIR* lamivudine-zidovudine*
EMTRIVA* emtricitabine*
EPIVIR* lamivudine*
EPZICOM* abacavir-lamivudine*
INTELENCE 100MG, 200MG TABLET* etravirine*
KALETRA* lopinavir-ritonavir*
LEXIVA 700MG TABLET* fosamprenavir 700mg tablet*
NORVIR 100MG TABLET* ritonavir 100mg tablet*
RETROVIR CAPSULE, SYRUP* zidovudine capsule, syrup*
REYATAZ CAPSULE* atazanavir capsules*
SUSTIVA* efavirenz*
SYMFI* efavirenz-lamivudine-tenofovir*
SYMFI LO*
TRIZIVIR* abacavir-lamivudine-zidovudine tablet*
TRUVADA* emtricitabine-tenofovir*
VIRAMUNE* nevirapine*
VIRAMUNE XR* nevirapine ER*
VIREAD 300MG TABLET* tenofovir 300mg tablet*
ZIAGEN* abacavir*
ALLERGY/NASAL SPRAYS AUVI-Q epinephrine auto-injectors
EPIPEN
EPIPEN JR
SYMJEPI
BECONASE AQ generic nasal steroids (e.g. fluticasone)
NASONEX
OMNARIS
QNASL
ZETONNA
carbinoxamine 6mg tablet carbinoxamine 4mg tablet
RYVENT
dexchlorpheniramine carbinoxamine oral solution
RYCLORA cyproheptadine syrup
hydroxyzine syrup
DYMISTA azelastine-fluticasone
Generic nasal steroids (e.g. fluticasone)
QNASL CHILDREN'S flunisolide
XHANCE fluticasone
mometasone
ALZHEIMER'S DISEASE pyridostigmine 30mg tablet (QL) pyridostigmine 60mg tablet
ANXIETY/DEPRESSION/BIPOLAR DISORDER ANAFRANIL clomipramine
APLENZIN bupropion XL 150, 300 mg tablets
ATIVAN TABLET lorazepam
LOREEV XR
^^
T his medication isn’t covered on this drug list. If your doctor feels a different medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the non-covered medication. If you
don’t get approval and you continue to fill a prescription for a medication that isn’t covered, you’ll pay its full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t
be applied to your annual deductible or out-of-pocket maximum.
18MEDICATION NAME^^ GENERIC AND/OR PREFERRED BRAND
DRUG CLASS
(Not covered) ALTERNATIVE(S)
ANXIETY/DEPRESSION/BIPOLAR DISORDER bupropion xl 450mg tablet bupropion xl 150mg tablets
(cont) FORFIVO XL
CYMBALTA desvenlafaxine ER
duloxetine
escitalopram
CITALOPRAM HBR citalopram tablet
DRIZALMA SPRINKLE duloxetine dr capsules
LEXAPRO escitalopram
PAMELOR nortriptyline capsules
PARNATE tranylcypromine
PEXEVA paroxetine
paroxetine cr
TOFRANIL imipramine
WELLBUTRIN XL bupropion xl
escitalopram
fluoxetine
ASTHMA/COPD/RESPIRATORY ADVAIR DISKUS ADVAIR HFA
AIRDUO RESPICLICK BREO ELLIPTA
DULERA
fluticasone-salmeterol
SYMBICORT
WIXELA INHUB
ALVESCO FLOVENT DISKUS
ARMONAIR DIGIHALER FLOVENT HFA
ARNUITY ELLIPTA PULMICORT FLEXHALER
ASMANEX, ASMANEX HFA QVAR
BROVANA arformoterol
budesonide-formoterol SYMBICORT
DUAKLIR PRESSAIR ANORO ELLIPTA
BEVESPI AEROSPHERE
STIOLTO RESPIMAT
ELIXOPHYLLIN theophylline er
theophylline oral solution
ALBUTEROL HFA Generic PROAIR or PROVENTIL (albuterol hfa)
levalbuterol hfa
PROAIR DIGIHALER
PROAIR HFA
PROAIR RESPICLICK
PROVENTIL HFA
VENTOLIN HFA
XOPENEX HFA
PERFOROMIST formoterol
TUDORZA PRESSAIR INCRUSE ELLIPTA
SPIRIVA RESPIMAT
STRIVERDI RESPIMAT SEREVENT DISKUS
YUPELRI ANORO ELLIPTA
BEVESPI AEROSPHERE
BREZTIRI AEROSPHERE
INCRUSE ELLIPTA
SPIRIVA
STIOLTO RESPIMAT
TRELEGY ELLIPTA
^^
This medication isn’t covered on this drug list. If your doctor feels a different medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the non-covered medication. If you
don’t get approval and you continue to fill a prescription for a medication that isn’t covered, you’ll pay its full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t
be applied to your annual deductible or out-of-pocket maximum. 19MEDICATION NAME^^ GENERIC AND/OR PREFERRED BRAND
DRUG CLASS
(Not covered) ALTERNATIVE(S)
ASTHMA/COPD/RESPIRATORY (cont) ZYFLO montelukast
zafirlukast
zileuton er
ATTENTION DEFICIT HYPERACTIVITY ADDERALL XR dexmethylphenidate er
ADHANSIA XR dextroamphetamine-amphetamine er
APTENSIO XR methylphenidate er
CONCERTA MYDAYIS
COTEMPLA XR-ODT VYVANSE
FOCALIN XR
JORNAY PM
RITALIN LA
DESOXYN methamphetamine
DEXEDRINE dexmethylphenidate er
dextroamphetamine er
dextroamphetamine-amphetamine er
QELBREE atomoxetine
RELEXXII methylphenidate er 36mg tablet
BLOOD PRESSURE/HEART MEDICATIONS BETAPACE sotalol
BYSTOLIC nebivolol
CARDIZEM diltiazem
CARDIZEM CD diltiazem CD
CONJUPRI amlodipine
felodipine er
nicardipine
nifedipine
CONSENSI amlodipine
celecoxib
EDARBI generic ARBs (e.g. losartan; valsartan)
EDARBYCLOR generic ARBs + HCTZ (e.g. losartan-HCTZ)
FIRAZYR* icatibant
GONITRO nitroglycerin sublingual tablet or spray
ISORDIL isosorbide dinitrate
ISORDIL TITRADOSE
LANOXIN digoxin
MULTAQ amiodarone
disopyramide
dofetilide
flecainide
propafenone
quinidine
sotalol af
BLOOD THINNERS/ANTI-CLOTTING aspirin-omeprazole aspirin or enteric aspirin
YOSPRALA
CANCER BESREMI* hydroxyurea capsule
CYCLOPHOSPHAMIDE TABLET* cyclophosphamide capsule*
NILANDRON nilutamide
TARCEVA* erlotinib
YONSA* abiraterone
ZYTIGA*
^^
This medication isn’t covered on this drug list. If your doctor feels a different medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the non-covered medication. If you
don’t get approval and you continue to fill a prescription for a medication that isn’t covered, you’ll pay its full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t
be applied to your annual deductible or out-of-pocket maximum.
20MEDICATION NAME^^ GENERIC AND/OR PREFERRED BRAND
DRUG CLASS
(Not covered) ALTERNATIVE(S)
CHOLESTEROL MEDICATIONS ANTARA fenofibrate
FENOGLIDE
CRESTOR rosuvastatin+
EZALLOR SPRINKLE generic statins (e.g. atorvastatin; simvastatin)
FLOLIPID
SIMVASTATIN 20mg/5ml SUSPENSION
JUXTAPID* REPATHA
PRALUENT
LIPITOR atorvastatin+
ezetimibe-simvastatin
rosuvastatin+
niacin 500mg tablet niacin er
NIACOR
ROSUVASTATIN-EZETIMIBE atorvastatin+
ZYPITAMAG lovastatin+
pravastatin+
rosuvastatin+
simvastatin+
COUGH/COLD MEDICATIONS benzonatate 150mg benzonatate 100mg, 200mg
TUSSICAPS hydrocodone-chlorpheniramine er suspension
promethazine with codeine syrup
DIABETES ACCU-CHEK AVIVA PLUS TEST STRIPS ONE TOUCH TEST STRIPS (e.g. Ultra; Verio)
ACCU-CHEK COMPACT PLUS STRIPS
ACCU-CHEK GUIDE TEST STRIPS
ACCU-CHEK SMARTVIEW TEST STRIPS
CVS ADVANCED GLUCOSE TEST STRIPS
ADVOCATE TEST STRIPS
ASSURE 4 TEST STRIPS
ASSURE PLATINUM TEST STRIPS
ASSURE PRISM MULTI TEST STRIPS
CONTOUR TEST STRIPS
FREESTYLE TEST STRIPS
FREESTYLE TEST STRIPS NFRS
RELION TEST STRIPS
RIGHTEST GT333 TEST STRIPS
ADLYXIN BYDUREON
BYETTA
metformin
OZEMPIC
TRULICITY
VICTOZA
ADMELOG HUMALOG
ADMELOG SOLOSTAR LYUMJEV
APIDRA, APIDRA SOLOSTAR
FIASP
FIASP FLEXTOUCH
FIASP PENFILL
INSULIN ASPART
NOVOLOG
^^
T his medication isn’t covered on this drug list. If your doctor feels a different medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the non-covered medication. If you
don’t get approval and you continue to fill a prescription for a medication that isn’t covered, you’ll pay its full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t
be applied to your annual deductible or out-of-pocket maximum.
21MEDICATION NAME^^ GENERIC AND/OR PREFERRED BRAND
DRUG CLASS
(Not covered) ALTERNATIVE(S)
DIABETES (cont) AFREZZA HUMALOG
HUMULIN R
LYUMJEV
alogliptin JANUMET
alogliptin-metformin JANUMET XR
JENTADUETO JANUVIA
JENTADUETO XR metformin
KAZANO
KOMBIGLYZE XR
NESINA
ONGLYZA
TRADJENTA
alogliptin-pioglitazone JANUMET
OSENI JANUMET XR
JANUVIA
pioglitazone
BASAGLAR LEVEMIR
LANTUS TRESIBA FLEXTOUCH
LANTUS SOLOSTAR
TOUJEO MAX SOLOSTAR
TOUJEO SOLOSTAR
FORTAMET metformin er (generic to GLUCOPHAGE XR)
GLUMETZA
metformin er gastric
metformin er osmotic
INSULIN ASPART PRO HUMALOG MIX
NOVOLOG MIX
INVOKAMET SYNJARDY
INVOKAMET XR SYNJARDY XR
SEGLUROMET XIGDUO XR
INVOKANA FARXIGA
STEGLATRO JARDIANCE
metformin
NOVOLIN HUMULIN
STEGLUJAN GLYXAMBI
metformin
QTERN
TRIJARDY XR
DIURETICS EDECRIN bumetanide
ethacrynic acid furosemide
torsemide
THALITONE chlorthalidone
EYE CONDITIONS LUMIGAN bimatoprost
TRAVATAN Z latanoprost
VYZULTA travoprost
XALATAN
XELPROS
ZIOPTAN
RESTASIS cyclosporine 0.05% eye emulsion
TYRVAYA XIIDRA
RESTASIS MULTIDOSE
^^
T his medication isn’t covered on this drug list. If your doctor feels a different medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the non-covered medication. If you
don’t get approval and you continue to fill a prescription for a medication that isn’t covered, you’ll pay its full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t
be applied to your annual deductible or out-of-pocket maximum.
22MEDICATION NAME^^ GENERIC AND/OR PREFERRED BRAND
DRUG CLASS
(Not covered) ALTERNATIVE(S)
GASTROINTESTINAL/HEARTBURN ANUSOL-HC 25MG SUPPOSITORY hydrocortisone 25mg suppository
ASACOL HD balsalazide
COLAZAL mesalamine tablets or capsules
DELZICOL PENTASA
DIPENTUM sulfasalazine
BYLVAY* cholestyramine powder/packet
LIVMARLI* rifampin
ursodiol tablet
CORTIFOAM COLOCORT
UCERIS 2MG RECTAL FOAM hydrocortisone
CREON PANCREAZE
PERTZYE
ZENPEP
DARTISLA glycopyrrolate 1mg tablet
glycopyrrolate 1.5mg tablet glycopyrrolate 2mg tablet
ROBINUL
ROBINUL FORTE
DEXLANSOPRAZOLE DR DEXILANT
GIMOTI* metoclopramide oral solution or tablet
GOLYTELY+ CLENPIQ+
MOVIPREP+ GAVILYTE-C+
NULYTELY WITH FLAVOR PACKS+ GAVILYTE-G+
OSMOPREP+ GAVILYTE-N+
PLENVU+ PEG 3350 ELECTROLYTE+
SUPREP+
SUTAB+
KRISTALOSE CONSTULOSE
lactulose 10gm packet ENULOSE
lactulose oral solution
LIBRAX chlordiazepoxide
LOTRONEX* alosetron*
lubiprostone AMITIZA
MARINOL dronabinol
SYNDROS
MOTEGRITY AMITIZA
TRULANCE LINZESS
ZELNORM
NEXIUM 10MG, 20MG, 40MG PACKET, esomeprazole packets, esomeprazole magnesium
20MG, 40MG CAPSULE
OMECLAMOX-PAK lansoprazole-amoxicillin-clarithromycin pak
PYLERA
TALICIA
OMEPPI omeprazole
omeprazole-bicarbonate
ZEGERID PACKET
PEPCID famotodine suspension
PREVACID SOLUTAB esomeprazole, lansoprazole, pantoprazole
RELTONE ursodiol
^^
T his medication isn’t covered on this drug list. If your doctor feels a different medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the non-covered medication. If you
don’t get approval and you continue to fill a prescription for a medication that isn’t covered, you’ll pay its full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t
be applied to your annual deductible or out-of-pocket maximum.
23MEDICATION NAME^^ GENERIC AND/OR PREFERRED BRAND
DRUG CLASS
(Not covered) ALTERNATIVE(S)
GASTROINTESTINAL/HEARTBURN (cont) ROWASA mesalamine rectal enema suspension
SENSIPAR* cinacalcet
ZEGERID CAPSULE DEXILANT
lansoprazole
omeprazole
ZOFRAN ondansetron
ZUPLENZ ondansetron
ondansetron odt
HORMONAL AGENTS ALKINDI SPRINKLE hydrocortisone 5mg tablet
ARMOUR THYROID np thyroid
WP THYROID
DDAVP desmopressin nasal spray or tablets
NOCDURNA
DEXABLISS dexamethasone 1.5mg tablet
dexamethasone 6, 10, 13 Day 1.5MG tablets
DXEVO
HIDEX
TAPERDEX
ZCORT
FORTESTA ANDRODERM
JATENZO generic topical testosterone
NATESTO
TESTIM
VOGELXO
XYOSTED
GENOTROPIN* HUMATROPE*
NUTROPIN AQ NUSPIN* NORDITROPIN*
OMNITROPE*
SAIZEN*
SAIZEN-SAIZENPREP*
ZOMACTON*
HEMADY dexamethasone 5mg tablet
LEVOTHYROXINE CAPSULE Generic SYNTHROID (also called levothyroxine tablet)
SYNTHROID
TIROSINT
TIROSINT-SOL
MYCAPSSA* BYNFEZIA*
ORTIKOS budesonide capsule
RAYOS methylprednisolone
prednisone
THYQUIDITY EUTHYROX
LEVO-T
levothyroxine tablet
LEVOXYL
UCERIS 9MG ER TABLET budesonide 9mg tablet
dexamethasone
hydrocortisone
methylprednisolone
prednisolone
prednisone
^^
T his medication isn’t covered on this drug list. If your doctor feels a different medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the non-covered medication. If you
don’t get approval and you continue to fill a prescription for a medication that isn’t covered, you’ll pay its full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t
be applied to your annual deductible or out-of-pocket maximum.
24MEDICATION NAME^^ GENERIC AND/OR PREFERRED BRAND
DRUG CLASS
(Not covered) ALTERNATIVE(S)
INFECTIONS ACTICLATE Generic products (e.g. doxycycline; minocycline)
DORYX
DORYX MPC
MINOCIN 50MG PEL CAPSULE
MINOCYCLINE ER 45, 90, 135MG CAPSULE
MINOLIRA ER
MONODOX
SEYSARA
SOLODYN
soloxide
TARGADOX
VIBRAMYCIN 100MG CAPSULE
XIMINO
ARAKODA atovaquone-proguanil
doxycycline
hydroxychloroquine
mefloquine
quinine
AUGMENTIN amoxicillin/clavulanate
AUGMENTIN XR
BARACLUDE TABLET* entecavir tablet*
BETHKIS* tobramycin inhalation solution*
TOBI*
BREXAFEMME fluconazole
DIFLUCAN
doxycycline hyclate dr 80mg tablet generic products (e.g. minocycline)
DOXYCYCLINE IR-DR doxycycline hyclate dr 50mg tablet
LYMEPAK doxycycline monohydrate 50mg tablet
ORACEA minocycline er 45mg
E.E.S. 200 erythromycin granules
ERYPED 400 erythromycin
HUMATIN paromomycin
MEPRON atovaquone
MYCOBUTIN rifabutin
nitrofurantoin 25mg/5ml suspension nitrofurantoin capsule
sulfamethoxazole-trimethoprim suspension
NOXAFIL DR 100MG TABLET posaconazole dr 100mg tablet
SITAVIG acyclovir tablet
famciclovir tablet
valacyclovir tablet
SPORANOX itraconazole
TOLSURA oral itraconazole
VALCYTE valganciclovir
VANCOCIN vancomycin oral solution or capsule
ZOVIRAX acyclovir
MISCELLANEOUS EXSERVAN* riluzole*
TIGLUTIK*
HORIZANT gabapentin
KUVAN* sapropterin tablet & powder packet*
SYPRINE* penicillamine*
trientine*
^^
This medication isn’t covered on this drug list. If your doctor feels a different medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the non-covered medication. If you
don’t get approval and you continue to fill a prescription for a medication that isn’t covered, you’ll pay its full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t
be applied to your annual deductible or out-of-pocket maximum.
25MEDICATION NAME^^ GENERIC AND/OR PREFERRED BRAND
DRUG CLASS
(Not covered) ALTERNATIVE(S)
MISCELLANEOUS (cont) XENAZINE* tetrabenazine*
MULTIPLE SCLEROSIS AMPYRA* dalfampridine er*
COPAXONE* BETASERON*
EXTAVIA*
glatiramer*
GLATOPA*
KESIMPTA*
PLEGRIDY*
REBIF*
TECFIDERA* AUBAGIO*
BAFIERTAM*
dimethyl*
GILENYA*
MAYZENT*
PONVORY*
VUMERITY*
NUTRITIONAL/DIETARY AZESCHEW Any generic prenatal vitamin
AZESCO
DERMACINRX PRENATRIX
DERMACINRX PRENATRYL
PNV TABS 20-1
PREGEN DHA
PREGENNA
TRINAZ
ZALVIT
NASCOBAL cyanocobalamin injection
PAIN RELIEF AND INFLAMMATORY DISEASE ALLZITAL butalbutal-acetaminophen 50-325mg tablet
BUPAP
butalbital-acetaminophen 25-35mg, 50-
300mg tablets
AMERGE generic triptans (e.g. sumatriptan; naratriptan)
ERGOMAR
FROVA 2.5MG TABLET
MAXALT
MAXALT MLT
RELPAX
AMRIX carisoprodol
cyclobenzaprine er chlorzoxazone 500mg
cyclobenzaprine tablets
methocarbamol
orphenadrine er
metaxalone
BACLOFEN baclofen tablet
^^
T his medication isn’t covered on this drug list. If your doctor feels a different medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the non-covered medication. If you
don’t get approval and you continue to fill a prescription for a medication that isn’t covered, you’ll pay its full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t
be applied to your annual deductible or out-of-pocket maximum.
26MEDICATION NAME^^ GENERIC AND/OR PREFERRED BRAND
DRUG CLASS
(Not covered) ALTERNATIVE(S)
PAIN RELIEF AND INFLAMMATORY DISEASE CAMBIA Generic NSAID (e.g. celecoxib; meloxicam)
(cont) DUEXIS
ELYXYB
fenoprofen 200mg capsule
fenoprofen 400mg capsule
FENORTHO
ibuprofen-famotidine
INDOCIN
indomethacin 20mg capsule
ketoprofen 25mg capsule
lofena
meloxicam 5mg, 10mg capsule
NALFON 400MG CAPSULE
NAPRELAN
NAPROSYN 125MG/5ML SUSPENSION
naproxen
naproxen sodium cr
naproxen sodium er
naproxen-esomeprazole mag
RELAFEN
RELAFEN DS
TIVORBEX
VIMOVO
VIVLODEX
ZIPSOR
ZORVOLEX
chlorzoxazone 250mg chlorzoxazone 500mg
chlorzoxazone 375mg methocarbamol 500mg
chlorzoxazone 750mg
CONZIP tramadol
tramadol er
COSENTYX* ENBREL*
HUMIRA*
OTEZLA*
STELARA*
TALTZ*
CUPRIMINE* penicillamine*
trientine*
D.H.E.45 dihydroergotamine injection
diclofenac 1.5% solution generic nsaid (e.g. celecoxib; meloxicam)
diclofenac 35mg capsule diclofenac 1% gel
PENNSAID
dihydroergotamine 4mg/ml spray sumatriptan nasal spray
IMITREX NASAL SPRAY
MIGRANAL
ONZETRA XSAIL
ZOLMITRIPTAN NASAL SPRAY
ZOMIG
GLOPERBA colchicine
probenecid-colchicine
GRALISE gabapentin
IMITREX CARTRIDGE dihydroergotamine
IMITREX PEN INJECTOR sumatriptan
^^
T his medication isn’t covered on this drug list. If your doctor feels a different medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the non-covered medication. If you
don’t get approval and you continue to fill a prescription for a medication that isn’t covered, you’ll pay its full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t
be applied to your annual deductible or out-of-pocket maximum. 27You can also read
