CIGNA PERFORMANCE 4-TIER PRESCRIPTION DRUG LIST - Coverage as of January 1, 2022
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CIGNA PERFORMANCE 4-TIER PRESCRIPTION DRUG LIST Coverage as of January 1, 2022 Offered by Cigna Health and Life Insurance Company or Connecticut General Life Insurance Company 891394 v Performance 4-Tier 11/21
What’s inside?
About this drug list 3
How to read this drug list 3
How to find your medication 5
Specialty medications 17
Medications that aren’t covered 26
Frequently Asked Questions (FAQs) 42
Exclusions and limitations for coverage 46
View the drug list online
This document was last updated on 11/01/2021.* You can go online to see the current list of
medications your plan covers.
myCigna® App and myCigna.com. Click on the “Find Care & Costs” tab and select
“Price a Medication.” Then type in your medication name to see how it’s covered.
Cigna.com/PDL. Scroll down until you see a pdf of the Cigna Performance 4-Tier
Prescription Drug List (all specialty medications covered on Tier 4).
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: 11/01/2021, for changes Next planned update: 03/01/2022, for
starting 01/01/2022 changes starting 07/01/2022
2About this drug list
This is a list of the most commonly prescribed medications covered on the Cigna Performance
4-Tier Prescription Drug List as of January 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 4-Tier Prescription Drug List.
Tier (cost-share level) gives you
an idea of how much you may
pay for a medication
TIER 1 TIER 2 TIER 3
$ $$ $$$
Medications are grouped by
HORMONAL AGENTS the condition they treat;
AMABELZ ANDRODERM (PA, QL) ACTIVELLA Speciality medications are
budesonide EC ANDROGEL 1.62% ALORA (QL) listed on Tier 4 (pages 20–
cabergoline (QL) (PA, QL) ANDROGEL 1.0% (PA, 28)
COVARYX ARMOUR THYROID QL)
COVARYX H.S. CYTOMEL 50mcg ANGELIQ
DECADRON DIVIGEL CLIMARA
desmopressin DUAVEE CLIMARA PRO
Medications are listed in
dexamethasone ESTRING (QL) COMBIPATCH
PREMARIN CYTOMEL 5, 25mcg alphabetical order within
estradiol-
norethindrone PREMPHASE DEPO-TESTOSTERONE each column
estrogen- PREMPRO ELESTRIN
methyltestosterone ENTOCORT EC
levothyroxine ESTRACE
LEVOXYL ESTROGEL
liothyronine EVAMIST
medroxy-progesterone FEMRING
methimazole INTRAROSA Medications that have extra
methylprednisolone LEVO-T coverage requirements will
MIMVEY MENOSTAR (QL) have an abbreviation listed
MIMVEY LO MINIVELLE (QL) next to them
NATURE-THROID OSPHENA
NP THYROID Brand-name medications
TIROSINT
prednisolone UNITHROID are in all capital letters
prednisolone ODT VAGIFEM (QL)
prednisone VIVELLE-DOT (QL) Generic medications
prednisone intensol are in all lowercase letters
progesterone
This chart is just a sample. It may not show how these medications are actually covered on the Cigna Performance 4-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) $$
› Tier 3 – Typically Non-Preferred Brands (Higher-cost medication) $$$
› Tier 4 – Specialty Medications (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. This means 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, oral and
injectable specialty medications are covered on Tier 4 (see pages 17-25). Injectable specialty
medications are marked with an asterisk (*) and oral specialty medications are marked with a double
asterisk (**).
Your plan may also limit coverage to a 30-day supply and/or require you to use a preferred specialty
pharmacy to receive coverage. Log in to the myCigna App or myCigna.com, or check your plan
materials, to learn more about how your plan covers specialty 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 may not cover certain medications and products because they’re considered plan/benefit
exclusions. 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 covers.
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
ALLERGY/NASAL SPRAYS 6 EYE CONDITIONS 11
ALZHEIMER’S DISEASE 6 FEMININE PRODUCTS 11
ANXIETY/DEPRESSION/BIPOLAR 6 GASTROINTESTINAL/HEARTBURN 11-12
DISORDER HORMONAL AGENTS 12
ASTHMA/COPD/RESPIRATORY 6-7 INFECTIONS 12-13
ATTENTION DEFICIT HYPERACTIVITY 7 INFERTILITY 13
DISORDER
MISCELLANEOUS 13
BLOOD MODIFIERS/BLEEDING DISORDERS 7
NUTRITIONAL/DIETARY 13-14
BLOOD PRESSURE/HEART MEDICATIONS 7,
OSTEOPOROSIS PRODUCTS 14
BLOOD THINNERS/ANTI-CLOTTING 7
PAIN RELIEF AND INFLAMMATORY DISEASE 14
CANCER 7-8
PARKINSON’S DISEASE 14-15
CHOLESTEROL MEDICATIONS 8
SCHIZOPHRENIA/ANTI-PSYCHOTICS 15
CONTRACEPTION PRODUCTS 8-10
SEIZURE DISORDERS 15
COUGH/COLD MEDICATIONS 10
SKIN CONDITIONS 15-16
DENTAL PRODUCTS 10
SLEEP DISORDERS/SEDATIVES 16
DIABETES 10
SMOKING CESSATION 16
DIURETICS 10-11
SUBSTANCE ABUSE 16
EAR MEDICATIONS 11 URINARY TRACT CONDITIONS 16
ERECTILE DYSFUNCTION 11 VACCINES 16
5Cigna Performance 4-Tier Prescription Drug List
Specialty medications are covered on Tier 4 (listed on pages 17-25).
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
ALLERGY/NASAL SPRAYS ANXIETY/DEPRESSION/BIPOLAR DISORDER4
azelastine CLARINEX (cont)
azelastine- CLARINEX-D 12 fluoxetine dr (QL) XANAX XR
fluticasone HOUR fluoxetine (QL) ZOLOFT (QL, ST)
cromolyn GASTROCROM fluvoxamine (QL)
desloratadine (QL) GRASTEK (PA, QL) fluvoxamine er
fluticasone KARBINAL ER (QL)
hydroxyzine hcl ODACTRA (PA, QL) lorazepam
solution, syrup, ORALAIR (PA, QL) lorazepam intensol
tablet PATANASE mirtazapine
hydroxyzine RAGWITEK (PA, QL) paroxetine cr (QL)
pamoate VISTARIL paroxetine er (QL)
ipratropium paroxetine (QL)
mometasone (QL) sertraline (QL)
olopatadine trazodone
promethazine venlafaxine (QL)
solution, syrup, venlafaxine er (QL)
tablet ASTHMA/COPD/RESPIRATORY
ALZHEIMER’S DISEASE albuterol ADVAIR HFA DALIRESP (QL)
donepezil MESTINON ARICEPT albuterol hfa (QL) ANORO ELLIPTA LONHALA
donepezil odt 60 MG/5 ML EXELON ambrisentan* (PA) ATROVENT HFA MAGNAIR REFILL
memantine SOLUTION MESTINON 180 MG budesonide BEVESPI (PA)
memantine er (QL) NAMENDA 5-10 MG TIMESPAN fluticasone- AEROSPHERE
LONHALA
pyridostigmine 60 TITRATION PK MESTINON 60 MG salmeterol BREO ELLIPTA
mg/5 ml, 60 mg TABLET BREZTRI MAGNAIR STARTER
ipratropium- (PA)
pyridostigmine er NAMENDA 10 MG AEROSPHERE
albuterol PULMICORT
rivastigmine TABLET COMBIVENT
NAMENDA 5 MG montelukast RESPULES
RESPIMAT
TABLET DULERA SINGULAIR
NAMENDA XR (QL) FLOVENT DISKUS
NAMZARIC (QL)
FLOVENT HFA
ANXIETY/DEPRESSION/BIPOLAR DISORDER4 INCRUSE ELLIPTA
alprazolam CELEXA (QL, ST) OPSUMIT* (PA)
alprazolam er EFFEXOR XR (QL, PULMICORT
alprazolam intensol ST) FLEXHALER
alprazolam odt FETZIMA (QL, ST) QVAR REDIHALER
alprazolam xr PAXIL (QL, ST)
SEREVENT DISKUS
amitriptyline PAXIL CR (QL, ST)
bupropion (QL) PRISTIQ (QL, ST) SPIRIVA
bupropion sr (QL) PROZAC (QL, ST) SPIRIVA RESPIMAT
bupropion xl 150 REMERON STIOLTO RESPIMAT
mg tablet (QL) SPRAVATO* (PA) SYMBICORT
bupropion xl 300 TRINTELLIX (QL, ST) TRELEGY ELLIPTA
mg tablet (QL) VIIBRYD (QL, ST) ATTENTION DEFICIT HYPERACTIVITY DISORDER4
buspirone WELLBUTRIN SR
citalopram (QL) (QL, ST) amphetamine (PA) MYDAYIS (PA, QL) ADDERALL (PA,ST)
clomipramine XANAX atomoxetine (QL) VYVANSE (PA, QL) ADZENYS ER (PA,
desvenlafaxine er dexmethylphe- QL)
(QL) nidate (PA) ADZENYS XR-ODT
duloxetine (QL) dexmethylphe-
nidate er (PA, QL) (PA, QL)
escitalopram (QL)
dextroamphe- amphetamine er
tamine-amphet er (PA,QL)
(PA, QL)
6Cigna Performance 4-Tier Prescription Drug List
Specialty medications are covered on Tier 4 (listed on pages 17-25).
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
ATTENTION DEFICIT HYPERACTIVITY BLOOD PRESSURE/HEART MEDICATIONS
DISORDER4 (cont) (cont)
dextroamphe- AZSTARYS (PA, QL, irbesartan KAPSPARGO
tamine- ST) labetalol tablet SPRINKLE (ST)
amphetamine (PA) lisinopril KATERZIA (QL)
DAYTRANA (PA, QL) lisinopril-hctz LOPRESSOR (ST)
guanfacine er DYANAVEL XR (PA, losartan LOTENSIN (ST)
methylphenidate er QL) losartan-hctz LOTREL
(la) (PA, QL) EVEKEO (PA,ST) MICARDIS (QL, ST)
methylphenidate er matzim la MICARDIS HCT (QL,
FOCALIN (PA,ST) metoprolol
(PA, QL) ST)
INTUNIV succinate MINIPRESS
methylphenidate METHYLIN (PA) metoprolol NITROSTAT
(PA) QUILLICHEW ER nadolol NORVASC
methylphenidate (PA, QL) nifedipine PRINIVIL (ST)
cd (PA, QL) QUILLIVANT XR (PA, nifedipine er PROCARDIA XL
methylphenidate olmesartan (QL) RANEXA (QL)
QL) olmesartan-
er (cd) (PA, QL) TEKTURNA (QL)
RITALIN (PA,ST) amlodipine-hctz TENORETIC 100 (ST)
methylphenidate la STRATTERA (QL) olmesartan-hctz TENORETIC 50 (ST)
(PA, QL) (QL) TENORMIN (ST)
BLOOD MODIFIERS/BLEEDING DISORDERS prazosin TIAZAC
propranolol tablet TIKOSYN (PA, QL)
DROXIA SIKLOS (PA) propranolol er TOPROL XL (ST)
BLOOD PRESSURE/HEART MEDICATIONS ramipril TRIBENZOR
ranolazine er (QL) VASOTEC (ST)
amlodipine BYSTOLIC (QL, ST) ADALAT CC taztia xt VERELAN
amlodipine- CORLANOR (PA) ALTACE (ST) telmisartan (QL) VERELAN PM
benazepril ENTRESTO ATACAND (ST) telmisartan-hctz ZESTORETIC (ST)
amlodipine- TEKTURNA HCT AVAPRO (ST) (QL) ZESTRIL (ST)
olmesartan (QL) (QL) AZOR (QL) tiadylt er ZIAC (ST)
amlodipine- BENICAR (QL, ST) valsartan
valsartan BENICAR HCT (QL, valsartan-hctz
atenolol ST) verapamil er
benazepril BIDIL (QL) verapamil er pm
bisoprolol CALAN SR verapamil tablet
bisoprolol-hctz CARDIZEM LA verapamil sr
candesartan 120mg (QL)
CARDURA BLOOD THINNERS/ANTI-CLOTTING
cartia xt
carvedilol CATAPRES-TTS 1 adult aspirin BRILINTA BAYER CHEWABLE
carvedilol er (QL) CATAPRES-TTS 2 regimen+ ELIQUIS (PA) ASPIRIN+
clonidine CATAPRES-TTS 3 aspirin ec+ XARELTO (PA) COUMADIN (PA)
diltiazem 12hr er COREG (ST) aspirin+ EFFIENT
diltiazem 24hr er CORGARD (ST) aspirin- PLAVIX
diltiazem 24hr er COZAAR (ST) dipyridamole er PRADAXA (PA)
(cd) DIOVAN (ST) children's aspirin+ SAVAYSA (PA, QL)
diltiazem 24hr er DIOVAN HCT (ST) clopidogrel ZONTIVITY
(la) EPANED jantoven
diltiazem 24hr er EXFORGE low dose aspirin
(xr) HEMANGEOL ec+
diltiazem HYZAAR (ST) prasugrel
DILT-XR INDERAL LA (ST) st. joseph aspirin
dofetilide (QL) INDERAL XL (ST) ec+
doxazosin INNOPRAN XL (ST) st. joseph aspirin+
droxidopa* warfarin
enalapril CANCER
flecainide
hydralazine tablet anastrozole+
7Cigna Performance 4-Tier Prescription Drug List
Specialty medications are covered on Tier 4 (listed on pages 17-25).
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
CANCER (cont) CONTRACEPTION PRODUCTS (cont)
exemestane+ GLEOSTINE CHARLOTTE 24
hydroxyurea TREXALL FE+
letrozole CHATEAL EQ+
methotrexate CHATEAL+
tamoxifen+ CRYSELLE+
CHOLESTEROL MEDICATIONS
CYCLAFEM+
CYRED EQ+
atorvastatin+ NEXLETOL (PA, QL) CADUET (QL) CYRED+
colesevelam NEXLIZET (PA, QL) LIPOFEN (ST) DASETTA+
ezetimibe REPATHA (PA) NIASPAN DAYSEE+
ezetimibe- VASCEPA (PA) PRAVACHOL (ST) DEBLITANE+
simvastatin ROSZET (PA) desogestrel-ethinyl
fenofibrate TRICOR (ST) estradiol+
fenofibric acid TRILIPIX (ST) desogestrel-ethinyl
fluvastatin er+ VYTORIN (ST) estradiol - ethinyl
fluvastatin+ WELCHOL estradiol+
icosapent ethyl ZETIA DOLISHALE+
lovastatin+ ZOCOR (QL, ST) drospirenone-
omega-3 acid ethyl ethinyl estradiol-
esters
pravastatin+ levomefolate+
rosuvastatin+ (QL) drospirenone-
ethinyl estradiol+
simvastatin tablet+ ECONTRA EZ+
(QL) ECONTRA ONE-
CONTRACEPTION PRODUCTS STEP+
ELINEST+
AFIRMELLE+ LO LOESTRIN FE ANNOVERA ELURYNG+
AFTERA+ BALCOLTRA EMOQUETTE+
ALTAVERA+ BEYAZ ENPRESSE+
ALYACEN+ CAYA ENSKYCE+
AMETHIA+ CONTOURED+ ERRIN+
AMETHYST+ ELLA+ ESTARYLLA+
APRI+ ESTROSTEP FE ethynodiol-ethinyl
ARANELLE+ FEMCAP+ estradiol+
ASHLYNA+ KYLEENA*+ etonogestrel-
AUBRA EQ+ LAYOLIS FE+ ethinyl estradiol+
AUBRA+ FALMINA+
AUROVELA 24 FE+ LOESTRIN FE FAYOSIM+
AUROVELA FE+ MICROGESTIN 24 FE FEMYNOR+
AUROVELA+ MINASTRIN 24 FE GEMMILY+
AVIANE+ NATAZIA GYNOL II+
AYUNA+ NEXTSTELLIS HAILEY 24 FE+
AZURETTE+ NUVARING HAILEY FE+
BALZIVA+ SAFYRAL HAILEY+
BLISOVI 24 FE+ SLYND HEATHER+
BLISOVI FE+ TAYTULLA ICLEVIA+
BRIELLYN+ TODAY INCASSIA+
CAMILA+ CONTRACEPTIVE ISIBLOOM+
CAMRESE LO+ SPONGE+ JAIMIESS+
CAMRESE+ TWIRLA+ JASMIEL+
CAZIANT+ VCF JENCYCLA+
CONTRACEPTIVE JOLESSA+
FILM+ JULEBER+
wide seal JUNEL FE 24+
diaphragm+ JUNEL FE+
YASMIN 28 JUNEL+
YAZ
8Cigna Performance 4-Tier Prescription Drug List
Specialty medications are covered on Tier 4 (listed on pages 17-25).
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
CONTRACEPTION PRODUCTS (cont) CONTRACEPTION PRODUCTS (cont)
KAITLIB FE+ OCELLA+
KALLIGA+ OPCICON ONE-
KARIVA+ STEP+
KELNOR 1-35+ OPTION 2+
KELNOR 1-50+ ORSYTHIA+
KURVELO+ PHILITH+
LARIN 24 FE+ PIMTREA+
LARIN FE+ PIRMELLA+
LARIN+ PORTIA+
LARISSIA+ PREVIFEM+
LEENA+ RECLIPSEN+
LESSINA+ RIVELSA+
LEVONEST+ SETLAKIN+
levonorgestrel+ SHAROBEL+
levonorgestrel- SIMLIYA+
ethinyl estradiol+ SIMPESSE+
SPRINTEC+
levonorgestrel- SRONYX+
ethinyl estradiol SYEDA+
ethinyl estradiol+ TAKE ACTION+
LEVORA-28+ TARINA 24 FE+
LILLOW+ TARINA FE 1-20
LOJAIMIESS+ EQ+
LORYNA+ TARINA FE+
LOW-OGESTREL+ TILIA FE+
LO- TRI FEMYNOR+
ZUMANDIMINE+ TRI-ESTARYLLA+
LUTERA+ TRI-LEGEST FE+
LYLEQ+ TRI-LINYAH+
LYZA+ TRI-LO-
MARLISSA+ ESTARYLLA+
MERZEE+ TRI-LO-MARZIA+
MICROGESTIN FE+ TRI-LO-MILI+
MICROGESTIN+ TRI-LO-SPRINTEC+
MILI+ TRI-MILI+
MONO-LINYAH+ TRI-NYMYO+
MY CHOICE+ TRI-PREVIFEM+
MY WAY+ TRI-SPRINTEC+
NECON+ TRIVORA-28+
NEW DAY+ TRI-VYLIBRA LO+
NIKKI+ TRI-VYLIBRA+
NORA-BE+ TULANA+
norethindrone+ TYDEMY+
norethindrone- VCF
ethinyl estradiol- CONTRACEPTIVE
iron+ FOAM+
norethindrone- VCF
ethinyl estradiol+ CONTRACEPTIVE
norethindrone- GEL+
ethinyl estradiol- VELIVET+
ferrous fumarate VESTURA+
norgestimate- VIENVA+
ethinyl estradiol+ VIORELE+
NORLYDA+ VOLNEA+
NORTREL+ VYFEMLA+
NYLIA+ VYLIBRA+
NYMYO+ WERA+
9Cigna Performance 4-Tier Prescription Drug List
Specialty medications are covered on Tier 4 (listed on pages 17-25).
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
CONTRACEPTION PRODUCTS (cont) DIABETES (cont)
WYMZYA FE+ metformin er GLUCAGEN HYPO ENLITE GLUCOSE
XULANE+ KIT (QL) SENSOR
ZAFEMY+ GLYXAMBI (QL, ST) EVERSENSE SMART
ZARAH+ HUMULIN (QL) TRANSMITTER
ZOVIA 1-35+ JANUMET (QL, ST) GLUCAGON
ZOVIA 1-35E+ JANUMET XR (QL, EMERGENCY KIT
ZUMANDIMINE+ ST) (QL)
COUGH/COLD MEDICATIONS
JANUVIA (QL, ST) GUARDIAN
JARDIANCE (QL, ST) CONNECT
brompheniramine- HYCODAN (PA, QL) LYUMJEV (QL) TRANSMITTER
pseudoephedrine- TESSALON PERLE NOVOFINE GUARDIAN LINK 3
dm TUZISTRA XR (PA, NOVOTWIST GUARDIAN SENSOR
hydrocodone- QL) OMNIPOD DASH 3
homatropine (PA, QL) GVOKE (QL)
(PA,QL) ONETOUCH ULTRA INPEN
promethazine-dm TEST STRIP PRECISION XTRA
DENTAL PRODUCTS ONETOUCH MONITOR NFRS
ULTRAMINI PRECISION XTRA
chlorhexidine PREVIDENT 5000 CLINPRO 5000 ONETOUCH VERIO MONITOR
DENTA 5000 PLUS PREVIDENT 5000 FLORIVA+ FLEX METER PRECISION XTRA
DENTAGEL 1.1% DRY MOUTH FLUORIDEX ONETOUCH VERIO KETONE-GLUC KIT
doxycycline hyclate PREVIDENT 5000 SENSITIVITY RELIEF IQ METER RIOMET
FLUORIDEX DAILY BOOSTER PLUS PREVIDENT 0.2% ONETOUCH VERIO TRUE METRIX
DEFENSE 1.1% PREVIDENT 5000 RINSE METER
ORALONE ENAMEL PROTECT PREVIDENT 1.1% ONETOUCH VERIO
PERIDEX PREVIDENT 5000 GEL REFLECT METER
PERIOGARD ORTHO DEFENSE PREVIDENT 5000 ONETOUCH VERIO
SF 1.1% GEL PREVIDENT 5000 PLUS TEST STRIP
SF 5000 PLUS SENSITIVE QTERN (QL, ST)
sodium fluoride RYBELSUS (PA, QL)
sodium fluoride SOLIQUA 100-33
5000 dry mouth SYMLINPEN
sodium fluoride SYNJARDY/XR (QL,
5000 plus ST)
triamcinolone TECHLITE
DIABETES TRIJARDY XR (ST,
QL)
glimepiride ACCU-CHEK AVIVA ACCU-CHEK TRUEPLUS SYRINGE
glipizide PLUS METER COMPACT PLUS V-GO 20
glipizide er BAQSIMI (QL) CONTROL V-GO 30
glipizide xl BASAGLAR (QL) ACCU-CHEK GUIDE V-GO 40
metformin BD LANCETS L1-L2 CONTROL VICTOZA (PA, QL)
BD PEN NEEDLE SOLUTION XIGDUO XR (QL, ST)
DEXCOM G6 (PA, ACCU-CHEK AVIVA XULTOPHY
QL) SOLUTION ZEGALOGUE (QL)
DROPLET ACCU-CHEK
DROPSAFE SMARTVIEW DIURETICS
FARXIGA (QL, ST) CONTROL acetazolamide DIURIL ALDACTONE
FREESTYLE LIBRE 14 SOLUTION tablet CAROSPIR
DAY SENSOR (PA, AMARYL acetazolamide er INSPRA
QL) CEQUR capsule KERENDIA
FREESTYLE LIBRE 2 CONTOUR bumetanide tablet LASIX
SENSOR (PA, QL) CYCLOSET chlorthalidone MAXZIDE
DEXCOM G4 eplerenone
DEXCOM G5 furosemide
DEXCOM G5-G4 solution, tablet
SENSOR hydrochloro-
thiazide
10Cigna Performance 4-Tier Prescription Drug List
Specialty medications are covered on Tier 4 (listed on pages 17-25).
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
DIURETICS (cont) FEMININE PRODUCTS
spironolactone FEM PH
triamterene-hctz GYNAZOLE 1
EAR MEDICATIONS miconazole 3 200
mg
ciprofloxacin- CIPRO HC CIPRODEX terconazole
dexamethasone CORTISPORIN-TC
neomycin- DERMOTIC GASTROINTESTINAL/HEARTBURN
polymyxin OTOVEL ALOPHEN PILLS+ AMITIZA ACIPHEX (QL, ST)
b-hydrocortisone ANUCORT-HC CLENPIQ+ AKYNZEO 300-0.5
ofloxacin balsalazide DEXILANT (QL) MG CAPSULE
ERECTILE DYSFUNCTION bisacodyl tablet+ LINZESS APRISO
cinacalcet* LITHOSTAT BONJESTA
sildenafil (QL) MUSE (QL) CIALIS (QL, ST)
tadalafil (QL) STENDRA (QL, ST) CLEARLAX+ NEXIUM DR 2.5 MG CANASA
CONSTULOSE PACKET (QL) CARAFATE
vardenafil (QL) VIAGRA (QL, ST) CORRECTOL+
dicyclomine NEXIUM DR 5 MG
EYE CONDITIONS capsule, solution, CUVPOSA
tablet PACKET (QL) DICLEGIS
bimatoprost (QL) ALPHAGAN P 0.1% ACULAR PANCREAZE DONNATAL
brimonidine DROPS ACULAR LS esomeprazole
20 mg capsule, PENTASA DULCOLAX EC 5
brinzolamide AZASITE ACUVAIL SUPREP+
ciprofloxacin BETIMOL ALPHAGAN P 0.15% 40 mg capsule, MG TABLET+
packets (QL) SUTAB+
dorzolamide BETOPTIC S EYE DROPS LIALDA
dorzolamide- CILOXAN 0.3% ALREX famotidine 40 mg/5 VIBERZI MIRALAX+
timolol OINTMENT AZOPT ml suspension, 20 MOVANTIK (PA)
erythromycin COMBIGAN BEPREVE mg tablet, 40 mg PREVACID DR 30
fluorometholone EYSUVIS (QL) BESIVANCE tablet MG CAPSULE (QL,
ketorolac GAVILAX+ ST)
FML FORTE 0.25% BROMSITE GAVILYTE-C+
latanoprost EYE DROPS CEQUA PROTONIX (QL, ST)
loteprednol COSOPT GAVILYTE-G+ RECTIV
FML S.O.P. 0.1% COSOPT PF GAVILYTE-N+ RELISTOR (PA)
moxifloxacin eye GAVILYTE-N+
OINTMENT DUREZOL SANCUSO (PA, QL)
drops FLAREX GENTLELAX+
FML LIQUIFILM SFROWASA
neomycin- LOTEMAX SM GLYCOLAX+ SYMPROIC (PA)
polymyxin RESTASIS 0.1% EYE DROP glycopyrrolate
ILEVRO TRANSDERM-SCOP
b-dexamethasone RESTASIS tablet URSO
MULTIDOSE INVELTYS HEMMOREX-HC
ofloxacin ISTALOL URSO FORTE
olopatadine SIMBRINZA hydrocortisone VARUBI (PA, QL)
XIIDRA LASTACAFT lansoprazole (QL)
polymyxin LOTEMAX VIOKACE
b sulfate- ZERVIATE LAXACLEAR+
MAXITROL
trimethoprim MOXEZA LAXATIVE PEG
prednisolone NEVANAC 3350+
timolol OCUFLOX LAXATIVE 5 MG
tobramycin- PRED FORTE
dexamethasone TABLET+
PROLENSA LAXATIVE EC 5 MG
travoprost RHOPRESSA TABLET+
ROCKLATAN mesalamine
TIMOPTIC mesalamine dr
TIMOPTIC-XE mesalamine er
TOBRADEX EYE metoclopramide
DROPS solution, tablet
TOBRADEX ST metoclopramide
TRUSOPT odt
VIGAMOX misoprostol
ZIRGAN NATURA-LAX+
ZYLET omeprazole (QL)
ondansetron
11Cigna Performance 4-Tier Prescription Drug List
Specialty medications are covered on Tier 4 (listed on pages 17-25).
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
GASTROINTESTINAL/HEARTBURN (cont) HORMONAL AGENTS (cont)
ondansetron odt estrogen- IMVEXXY (QL)
pantoprazole methyltesto- INTRAROSA
suspension, tablet sterone levothyroxine
EUTHYROX capsule
(QL) LEVO-T MEDROL 8MG,
peg levothyroxine tablet 16MG, 32MG
3350-electrolyte+ LEVOXYL TABLET
peg3350-sodium liothyronine MEDROL 4 MG
sulfate-sodium LYLLANA (QL) DOSEPAK
chloride- medroxyprog- MENOSTAR (QL)
potassium esterone MINIVELLE (QL)
chloride-sodium methimazole OSPHENA
ascorbate-ascorbic methylpred- PROMETRIUM
acid+ nisolone RAYALDEE
PEG-PREP+ MIMVEY TIROSINT-SOL
polyethylene glycol norethindrone
3350+ UNITHROID
NP THYROID VAGIFEM (QL)
prochlorperazine prednisone VIVELLE-DOT (QL)
tablet prednisone intensol
promethazine testosterone (PA,
suppository QL)
promethegan WESTHROID
PURELAX+ YUVAFEM (QL)
rabeprazole tablet INFECTIONS
(QL)
scopolamine acyclovir capsule, CIPRO SUSPENSION AEMCOLO (QL)
SMOOTHLAX+ suspension, tablet CLEOCIN 75 MG ALBENZA
sucralfate albendazole CAPSULE ALINIA
ursodiol amoxicillin EURAX 10% CREAM BACTRIM
WOMEN'S GENTLE amoxicillin- FIRVANQ BACTRIM DS
LAXATIVE+ clavulanate er SOLOSEC BAXDELA (PA)
WOMEN'S XIFAXAN (QL) CIPRO TABLET
amoxicillin-
LAXATIVE+ clavulanate CLEOCIN 150 MG
HORMONAL AGENTS atovaquone CAPSULE
atovaquone- CLEOCIN 300 MG
AMABELZ ANDRODERM (PA, ACTIVELLA proguanil
budesonide ec QL) ALORA (QL) CAPSULE
AVIDOXY CLEOCIN 100 MG
budesonide er (PA, CRINONE ANDROGEL (PA, QL) azithromycin
QL) DIVIGEL ANGELIQ packet, VAGINAL OVULE
cabergoline (QL) DUAVEE ARMOUR THYROID suspension, tablet CLEOCIN 2%
COVARYX ESTRING (QL) AYGESTIN cefdinir VAGINAL CREAM
COVARYX H.S. MEDROL 2 MG BIJUVA cefuroxime tablet CLINDESSE
DECADRON TABLET CLIMARA cephalexin CRESEMBA
desmopressin MYFEMBREE (PA, CLIMARA PRO ciprofloxacin CAPSULE (PA)
dexamethasone COMBIPATCH clarithromycin DIFICID (QL)
intensol QL) CYTOMEL
ORIAHNN (PA, QL) ELESTRIN clarithromycin er ELIMITE
DOTTI (QL) clindamycin ERYPED 200
EEMT ORILISSA (PA, QL) ENTOCORT EC
PREMARIN TABLET, ESTRACE COREMINO ER QL) ERY-TAB DR
EEMT H.S. EURAX 10% LOTION
estradiol (once VAGINAL CREAM ESTROGEL dapsone tablets
APPLICATOR doxycycline hyclate FLAGYL
weekly) EVAMIST HIPREX
PREMPHASE capsule, tablet
estradiol 10mcg PREMPRO doxycycline KEFLEX
vaginal insert (QL) monohydrate MACROBID
estradiol (twice EMVERM MACRODANTIN
weekly) (QL) entecavir* (QL) MALARONE (PA)
estradiol- erythromycin NATROBA
norethindrone
12Cigna Performance 4-Tier Prescription Drug List
Specialty medications are covered on Tier 4 (listed on pages 17-25).
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
INFECTIONS (cont) MISCELLANEOUS (cont)
erythromycin NUVESSA ACCU-CHEK FC2 FEMALE
ethylsuccinate ORAVIG FASTCLIX LANCET CONDOM+
famciclovir PLAQUENIL DRUM KETONE CARE TEST
fluconazole posaconazole MICROLET STRIP
hydroxychlor- suspension TECHLITE LANCETS KETONE TEST STRIP
oquine PRIFTIN KETOSTIX REAGENT
ivermectin SIVEXTRO TABLET NUEDEXTA (QL)
levofloxacin (PA) PRECISION XTRA
solution, tablet SKLICE TRUEPLUS KETONE
methenamine STROMECTOL TEST STRIP
metronidazole gel, sulfatrim
capsule, tablet URIBEL NUTRITIONAL/DIETARY
minocycline VALTREX calcitriol CITRANATAL 90 ACCRUFER
minocycline er VIBRAMYCIN FA-8+ DHA ALIVE PRENATAL+
tablet (QL) 25 MG/5 ML folic acid^+ CITRANATAL AURYXIA (QL)
mondoxyne nl SUSPENSION klor-con ASSURE BRAINSTRONG
MORGIDOX VIBRAMYCIN 50 KLOR-CON 10 MEQ CITRANATAL PRENATAL+
nitazoxanide MG/5 ML SYRUP B-CALM CLASSIC
nitrofurantoin XENLETA 600mg TABLET
CITRANATAL DHA PRENATAL+
nitrofurantoin tablet (PA, QL) KLOR-CON 8 MEQ CITRANATAL DRISDOL
monohydrate- XOFLUZA (QL) TABLET HARMONY EXPECTA
macrocrystal ZITHROMAX KLOR-CON M10 CITRANATAL RX PRENATAL+
nystatin ZITHROMAX TRI- TABLET FOSRENOL 1,000 FLORIVA+
suspension, tablet PAK MG POWDER PACK FOSRENOL 1,000
penicillin v ZYVOX KLOR-CON M10
TABLET FOSRENOL 750 MG MG CHEWABLE
potassium SUSPENSION, POWDER PACKET TABLET
permethrin TABLET (PA) MULTI-VITAMIN OB COMPLETE FOSRENOL 500 MG
posaconazole W-FLUORIDE- PETITE CHEWABLE TABLET
tablet IRON+ OB COMPLETE FOSRENOL 750 MG
pyrimethamine* MULTIVITAMIN PREMIER CHEWABLE TABLET
(PA) PRIMACARE K-TAB ER
sulfamethoxazole- WITH FLUORIDE+
TRI-VI-FLOR+ LOKELMA
trimethoprim MULTIVITAMIN- VELPHORO MEPHYTON
suspension, tablet IRON-FLUORIDE MINI PRENATAL+
terbinafine ONE DAILY NEEVO DHA
tetracycline PRENATAL+ ONE A DAY
valacyclovir potassium chloride WOMEN'S
valganciclovir 10%, capsule, PRENATAL DHA+
vancomycin packet, tablet ONE-A-DAY
capsule, solution prenatal complete+ PRENATAL-1+
vandazole PRENATAL PERRY PRENATAL+
GUMMIES+ PHOSLYRA
INFERTILITY
PRENATAL MULTI+ POLY-VI-FLOR WITH
clomiphene ^ CRINONE 8% GEL^ prenatal multi- IRON+
ENDOMETRIN^ dha+ POLY-VI-FLOR+
PRENATAL PRENATAL
MISCELLANEOUS
MULTIVITAMIN+ FORMULA-DHA+
PRENATAL PRENATE
sodium chloride ACCU-CHEK ADDYI (QL) MULTIVITAMIN- QUFLORA
inhalation vial. SAFE-T-PRO 23G BRISDELLE (QL) DHA+ PEDIATRIC 1
Irrigation solution LANCETS PRENATAL ONE MG CHEWABLE
vial ACCU-CHEK DAILY+ TABLET+
SOFTCLIX QUFLORA
LANCETS PRENATAL VITAMIN PEDIATRIC 0.25
ACCU-CHEK + DHA+ MG/ML DROP+
MULTICLIX PRENATAL QUFLORA
LANCETS VITAMIN+ PEDIATRIC 0.5 MG/
ML DROP+
13Cigna Performance 4-Tier Prescription Drug List
Specialty medications are covered on Tier 4 (listed on pages 17-25).
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
NUTRITIONAL/DIETARY (cont) PAIN RELIEF AND INFLAMMATORY DISEASE
PRENATAL RENVELA (cont)
VITAMINS+ ROCALTROL hydromorphone er ZYLOPRIM
PRENATAL+ SIMILAC (PA)
sevelamer PRENATAL+ IBU
carbonate STUART ONE+ ibuprofen
TRI-VITE WITH ULTRA PRENATAL indomethacin
FLUORIDE+ PLUS DHA+ indomethacin er
vitamin d2 1.25 mg VELTASSA ketorolac
(50,000 unit)^ tromethamine
VITAMINS A,C,D (QL)
AND FLUORIDE+ leflunomide
OSTEOPOROSIS PRODUCTS lidocaine 5%
ointment (QL)
alendronate ACTONEL (ST) lidocaine 5% patch
ibandronate 150 ATELVIA (ST) lidocaine viscous
mg tablet BINOSTO (ST) meloxicam tablet
raloxifene+ BONIVA 150 MG metaxalone
risedronate TABLET (ST) methocarbamol
risedronate dr EVISTA morphine (PA)
FOSAMAX (ST) morphine er (PA)
PAIN RELIEF AND INFLAMMATORY DISEASE NALFON 600 MG
TABLET (ST)
acetaminophen- AIMOVIG (PA) ANALPRAM HC 1% NALOCET (PA)
codeine (PA) AJOVY (PA) CREAM oxycodone (PA)
allopurinol tablet BELBUCA (QL) ANALPRAM HC oxycodone er (PA)
ASPIRIN EC+ EMGALITY (PA) 2.5%-1% CREAM oxycodone-
aspirin tablet+ HYSINGLA ER (PA) ANALPRAM HC acetaminophen
baclofen tablet NUCYNTA (PA) 2.5%-1% CREAM (PA)
buprenorphine NURTEC ODT (PA, SINGLE PROLATE TABLET
patch (QL) QL) ARAVA (PA)
butalbital- PROCTOFOAM-HC BUTRANS (QL) rizatriptan (QL)
acetaminophen- RASUVO (PA) CELEBREX (QL, ST) sumatriptan (QL)
caffeine (QL) REDITREX (PA) COLCRYS tizanidine
carisoprodol RINVOQ* (PA, QL) EC-NAPROSYN (ST)
celecoxib (QL) SAVELLA ECOTRIN EC 325 tramadol 50 mg
colchicine UBRELVY (PA, QL) MG TABLET+ tablet (QL)
cyclobenzaprine ULORIC (QL) ESGIC (QL) tramadol er (QL)
diclofenac 1% gel XELJANZ XR* (PA, FEXMID VANADOM
(QL) QL) FLECTOR (PA, QL)
XTAMPZA ER (PA) LAZANDA (PA) PARKINSON’S DISEASE
diclofenac dr
diclofenac ec ZTLIDO LICART (PA, QL) benztropine tablet KYNMOBI (PA) AZILECT (QL)
LIDODERM carbidopa- MIRAPEX ER (QL)
EC-NAPROXEN MITIGARE levodopa NEUPRO
ECOTRIN EC 81 MG MOBIC (ST) carbidopa- OSMOLEX ER (QL)
TABLET+ NAPROSYN (ST) levodopa er RYTARY
eletriptan (QL) NUCYNTA ER (PA) pramipexole SINEMET 10-100
ENDOCET (PA) OTREXUP (PA) pramipexole er (QL) SINEMET 25-100
febuxostat (QL) OXAYDO (PA) rasagiline (QL) TASMAR
fentanyl (PA) PERCOCET (PA) ropinirole er XADAGO (ST)
FIORICET (QL) PROCORT ropinirole
frovatriptan (QL) QMIIZ ODT (ST)
SKELAXIN SCHIZOPHRENIA/ANTI-PSYCHOTICS4
GLYDO
hydrocodone- ULTRAM 50 MG aripiprazole (QL) LATUDA (QL) ARISTADA (QL)
acetaminophen TABLET (QL) aripiprazole odt FANAPT (QL, ST)
(PA) VTOL LQ asenapine INVEGA (QL, ST)
hydromorphone ZANAFLEX chlorpromazine PERSERIS
(PA) ZEBUTAL (QL) tablet REXULTI (QL, ST)
ZOHYDRO ER (PA) RISPERDAL (ST)
14Cigna Performance 4-Tier Prescription Drug List
Specialty medications are covered on Tier 4 (listed on pages 17-25).
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
SCHIZOPHRENIA/ANTI-PSYCHOTICS4 (cont) azelaic acid PRAMOSONE 1%- CAPEX SHAMPOO
betamethasone 1% OINTMENT CLEOCIN T
haloperidol SAPHRIS (ST) augmented PRAMOSONE 2.5%- CLINDACIN ETZ KIT
olanzapine tablet SECUADO (ST) betamethasone 1% OINTMENT
olanzapine odt SEROQUEL (ST) CLINDACIN PAC KIT
dipropionate SANTYL (QL) CLODERM (ST)
paliperidone er (QL) SEROQUEL XR (ST) BP 10-1
quetiapine VRAYLAR (QL, ST) DESOWEN
calcipotriene DOVONEX
quetiapine er cream, ointment,
risperidone DRYSOL
solution EFUDEX
risperidone odt calcipotriene-
ziprasidone tablet ELIDEL
betamethasone EVOCLIN
SEIZURE DISORDERS CLARAVIS PRAMOSONE 2.5%-
CLINDACIN ETZ 1% 1% CREAM
carbamazepine FYCOMPA (PA, QL) APTIOM 600, 800 PLEDGET
carbamazepine er NAYZILAM (PA, QL) mg tablets (PA) PRAMOSONE 2.5%-
CLINDACIN P 1% 1% LOTION
clonazepam VIMPAT SOLTUION, APTIOM 200, 400 PLEDGETS
divalproex TABLET (PA) mg tablets(PA, QL) PROTOPIC
clindamycin 1% REGRANEX (PA, QL)
divalproex er BRIVIACT ORAL foam, gel, lotion,
EPITOL SOLUTION, TABLET TEMOVATE (ST)
pledget, solution VECTICAL (QL)
gabapentin (PA) clindamycin-
lamotrigine CARBATROL (PA) XEPI
benzoyl
lamotrigine (blue) DEPAKOTE (PA) peroxoxide
lamotrigine (green) DEPAKOTE ER (PA) clindamycin-
lamotrigine DEPAKOTE tretinoin
(orange) SPRINKLE (PA)
lamotrigine er DILANTIN (PA) clobetasol
lamotrigine odt KLONOPIN (PA) clocortolone
lamotrigine odt LYRICA ORAL CLODAN
(blue) SOLUTION (PA) clotrimazole-
NEURONTIN (PA) betamethasone
lamotrigine odt OXTELLAR XR (PA) dapsone 5% gel,
(green) PHENYTEK (PA)
lamotrigine odt 7.5% gel pump
SPRITAM (PA) fluocinonide
(orange) TEGRETOL (PA)
levetiracetam fluorouracil cream,
TEGRETOL XR (PA) topical solution
solution, tablet VALTOCO (PA, QL)
levetiracetam er isotretinoin
XCOPRI (PA, QL) ketoconazole
oxcarbazepine
KETODAN
pregabalin capsule, metronidazole
solution mupirocin
ROWEEPRA MYORISAN
SUBVENITE NEUAC GEL
SUBVENITE (BLUE) pimecrolimus
SUBVENITE (GREEN) ROSADAN
SUBVENITE sodium
(ORANGE) sulfacetamide-
topiramate sulfur
topiramate er SSS 10-5
vigabatrin* SULFACLEANSE 8-4
vigadrone* tacrolimus
ointment
SKIN CONDITIONS tazarotene 0.1%
ACCUTANE EUCRISA ANALPRAM HC cream
adapalene (PA) NAFTIN tretinoin (PA)
2.5%-1% LOTION TRIDERM
adapalene-benzoyl PICATO AVAR 9.5-5%
peroxide PRAMOSONE 1% ZENATANE
LOTION CLEANSING PADS
AMNESTEEM BRYHALI (ST)
AVAR CLEANSER PRAMOSONE 1%-
1% CREAM calcipotriene foam
15Cigna Performance 4-Tier Prescription Drug List
Specialty medications are covered on Tier 4 (listed on pages 17-25).
TIER 1 TIER 2 TIER 3
$ $$ $$$
SLEEP DISORDERS/SEDATIVES
armodafinil (PA) DAYVIGO (QL, ST)
HETLIOZ LQ* (PA)
eszopiclone SUNOSI (PA, QL)HETLIOZ* (PA)
modafinil (PA) LUNESTA (ST)
temazepam SILENOR (QL, ST)
zolpidem WAKIX* (PA, QL)
zolpidem er (QL) XYREM* (PA)
XYWAV* (PA)
SMOKING CESSATION4
bupropion sr+ NICOTROL NS+ CHANTIX^ (PA)
NICODERM CQ 21 NICOTROL+ NICODERM CQ 14
MG/24HR PATCH+ MG/24HR PATCH+
nicotine gum+ NICODERM CQ 7
nicotine lozenge+ MG/24HR PATCH+
nicotine patch+ NICORETTE+
QUIT 2+
QUIT 4+
STOP SMOKING
AID+
SUBSTANCE ABUSE
buprenorphine- KLOXXADO (QL) BUNAVAIL
naloxone LUCEMYRA (QL) SUBOXONE
NARCAN (QL)
ZUBSOLV
URINARY TRACT CONDITIONS
alfuzosin er ELMIRON AVODART
cevimeline K-PHOS ORIGINAL EVOXAC
darifenacin er (QL) FLOMAX
finasteride PROSCAR
oxybutynin PYRIDIUM
oxybutynin er RAPAFLO (QL)
phenazopyridine UROCIT-K
potassium er UROXATRAL
silodosin (QL)
solifenacin (QL)
tamsulosin
tolterodine
tolterodine er (QL)
VACCINES
Vaccines are now covered under the Cigna pharmacy benefit. Not
all plans cover vaccines in the same way. Log in to the myCigna App
or myCigna.com, or check your plan materials, to find out how your
specific plan covers them.
ROTARIX+
ROTATEQ+
WEIGHT MANAGEMENT
megestrol WEGOVY (QL)
suspension
16Specialty medications
The oral and injectable specialty medications listed below are covered on Tier 4 and may need
approval from Cigna before your plan will cover them.
MEDICATION NAME DRUG CLASS
abacavir-lamivudine** (PA) AIDS/HIV
abiraterone** (PA) CANCER
ACTEMRA* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
ACTEMRA ACTPEN* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
ACTIMMUNE* (PA) CANCER
ADCIRCA** (PA) ASTHMA/COPD/RESPIRATORY
ADEMPAS** (PA) ASTHMA/COPD/RESPIRATORY
AFINITOR** (PA) CANCER
AFINITOR DISPERZ** (PA) CANCER
ALECENSA** (PA) CANCER
alosetron** GASTROINTESTINAL/HEARTBURN
ALUNBRIG** (PA) CANCER
ALYQ** (PA) ASTHMA/COPD/RESPIRATORY
AMICAR** BLOOD MODIFIERS/BLEEDING DISORDERS
aminocaproic acid** BLOOD MODIFIERS/BLEEDING DISORDERS
APOKYN* (PA) PARKINSON'S DISEASE
ARALAST NP* (PA) ASTHMA/COPD/RESPIRATORY
ARANESP* (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
ARIKAYCE** (PA) INFECTIONS
ARIXTRA* (QL) BLOOD THINNERS/ANTI-CLOTTING
ASTAGRAF XL** TRANSPLANT MEDICATIONS
atazanavir** (PA) AIDS/HIV
ATRIPLA** (PA) AIDS/HIV
AUSTEDO** (PA) MISCELLANEOUS
AVEED* HORMONAL AGENTS
AVONEX* (PA) MULTIPLE SCLEROSIS
AVSOLA* (PA) PAIN RELIEF AND INFLAMMATORY DISEASE
azathioprine** TRANSPLANT MEDICATIONS
BAFIERTAM** (PA) MULTIPLE SCLEROSIS
BARACLUDE** (PA, QL) INFECTIONS
BENLYSTA* (PA) PAIN RELIEF AND INFLAMMATORY DISEASE
BERINERT* BLOOD PRESSURE/HEART MEDICATIONS
BETASERON* (PA) MULTIPLE SCLEROSIS
BIKTARVY** AIDS/HIV
BONIVA* OSTEOPOROSIS PRODUCTS
BOSULIF** (PA) CANCER
BOTOX* MISCELLANEOUS
BRONCHITOL** (PA) ASTHAM/COPD/RESPIRATORY
17MEDICATION NAME DRUG CLASS
BYNFEZIA* (PA) HORMONAL AGENTS
CABOMETYX** (PA) CANCER
capecitabine** (PA) CANCER
CAYSTON** (PA, QL) INFECTIONS
CELLCEPT** TRANSPLANT MEDICATIONS
CERDELGA** (PA) MISCELLANEOUS
CEREZYME* (PA) MISCELLANEOUS
CETROTIDE*^ (PA) HORMONAL AGENTS
CHOLBAM** (PA) GASTROINTESTINAL/HEARTBURN
chorionic gonadotropin*^ (PA) INFERTILITY
CIMDUO** (PA) AIDS/HIV
CIMZIA* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
CINACALCET** GASTROINTESTINAL/HEARTBURN
CINRYZE* (PA) BLOOD PRESSURE/HEART MEDICATIONS
COMETRIQ** (PA) CANCER
COMPLERA** (PA) AIDS/HIV
CYSTARAN** (PA, QL) EYE CONDITIONS
CYKLOKAPRON* BLOOD MODIFIERS/BLEEDING DISORDERS
CYSTAGON** URINARY TRACT CONDITIONS
DARAPRIM** (PA) INFECTIONS
DEPEN** (PA) PAIN RELIEF AND INFLAMMATORY DISEASE
DESCOVY**+ AIDS/HIV
desmopressin ampule, vial* HORMONAL AGENTS
DOVATO** AIDS/HIV
DUPIXENT* (PA) PAIN RELIEF AND INFLAMMATORY DISEASE
DUROLANE* (PA) PAIN RELIEF AND INFLAMMATORY DISEASE
DYSPORT* (PA) MISCELLANEOUS
EGRIFTA* (PA) HORMONAL AGENTS
ELAPRASE* MISCELLANEOUS
ELIGARD* CANCER
EMFLAZA** (PA) HORMONAL AGENTS
EMPAVELI* (PA) MISCELLANEOUS
ENBREL* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
enoxaparin* (QL) BLOOD THINNERS/ANTI-CLOTTING
entecavir** (QL) INFECTIONS
ENTYVIO* (PA) EYE CONDITIONS
ENVARSUS XR** TRANSPLANT MEDICATIONS
EPCLUSA** (PA, QL) INFECTIONS
EPIDIOLEX** (PA) SEIZURE DISORDERS
EPOGEN* (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
ERIVEDGE** (PA) CANCER
ERLEADA** (PA) CANCER
18MEDICATION NAME DRUG CLASS
ESBRIET** (PA) MISCELLANEOUS
EUFLEXXA* PAIN RELIEF AND INFLAMMATORY DISEASE
EVOTAZ** (PA) AIDS/HIV
EXJADE** (PA) MISCELLANEOUS
EXTAVIA* (PA) MULTIPLE SCLEROSIS
FASENRA* (PA) ASTHMA/COPD/RESPIRATORY
FENSOLVI* (PA) HORMONAL AGENTS
FERRIPROX** (PA) MISCELLANEOUS
FIRDAPSE** (PA, QL) MULTIPLE SCLEROSIS
FOLLISTIM AQ*^ (PA) INFERTILITY
fondaparinux* (QL) BLOOD THINNERS/ANTI-CLOTTING
FORTEO* (PA, QL) HORMONAL AGENTS
FRAGMIN* (QL) BLOOD THINNERS/ANTI-CLOTTING
FULPHILA* (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
GALAFOLD** (PA) MISCELLANEOUS
GANIRELIX*^ (PA) HORMONAL AGENTS
GATTEX* (PA) GASTROINTESTINAL/HEARTBURN
GAVRETO** (PA, QL) CANCER
GEL-ONE* (PA) PAIN RELIEF AND INFLAMMATORY DISEASE
GELSYN-3* (PA) PAIN RELIEF AND INFLAMMATORY DISEASE
GENVOYA** AIDS/HIV
GILENYA** (PA) MULTIPLE SCLEROSIS
GLASSIA* (PA) ASTHMA/COPD/RESPIRATORY
glatiramer* (PA) MULTIPLE SCLEROSIS
GLATOPA* (PA) MULTIPLE SCLEROSIS
GLEEVEC** (PA) CANCER
GONAL-F*^ (PA) INFERTILITY
GONAL-F RFF*^ (PA) INFERTILITY
GONAL-F RFF REDI-JECT*^ (PA) INFERTILITY
GRANIX* (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
HAEGARDA* (PA) BLOOD PRESSURE/HEART MEDICATIONS
HARVONI** (PA, QL) INFECTIONS
HEMLIBRA* (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
HERCEPTIN* (PA) CANCER
HETLIOZ** (PA) SLEEP DISORDERS/SEDATIVES
HUMATROPE* (PA) HORMONAL AGENTS
HUMIRA* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
HYALGAN* (PA) PAIN RELIEF AND INFLAMMATORY DISEASE
HYMOVIS* (PA) PAIN RELIEF AND INFLAMMATORY DISEASE
ibandronate syringe, vial * OSTEOPOROSIS PRODUCTS
IBRANCE** (PA) CANCER
ILARIS* (PA) PAIN RELIEF AND INFLAMMATORY DISEASE
19MEDICATION NAME DRUG CLASS
ILUMYA* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
imatinib** (PA) CANCER
IMBRUVICA** (PA) CANCER
INBRIJA** (PA) PARKINSON’S DISEASE
INCRELEX* (PA) HORMONAL AGENTS
INFLECTRA* (PA) PAIN RELIEF AND INFLAMMATORY DISEASE
INGREZZA** (PA, QL) MISCELLANEOUS
INLYTA** (PA) CANCER
ISENTRESS** AIDS/HIV
ISENTRESS HD** (PA) AIDS/HIV
JADENU** (PA) MISCELLANEOUS
JADENU SPRINKLE** (PA) MISCELLANEOUS
JAKAFI** (PA) CANCER
JULUCA** AIDS/HIV
JYNARQUE** (PA) DIURETICS
KALBITOR* (PA) BLOOD PRESSURE/HEART MEDICATIONS
KALYDECO** (PA, QL) ASTHMA/COPD/RESPIRATORY
KAJNITI* (PA) CANCER
KEVZARA* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
KINERET* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
KISQALI** (PA) CANCER
KITABIS PAK** (PA, QL) INFECTIONS
KORLYM** (PA) DIABETES
KUVAN** (PA) MISCELLANEOUS
KYLEENA**+ CONTRACEPTION PRODUCTS
ledipasvir-sofosbuvir** (PA) INFECTIONS
LENVIMA** (PA) CANCER
LETAIRIS** (PA) ASTHMA/COPD/RESPIRATORY
LONSURF** (PA) CANCER
LORBRENA** (PA) CANCER
LOVENOX* (QL) BLOOD THINNERS/ANTI-CLOTTING
LUMAKRAS* (PA, QL) CANCER
LUMIZYME* (PA) MISCELLANEOUS
LUPANETA PACK** (PA) HORMONAL AGENTS
LUPRON DEPOT* (PA) CANCER
LUPRON DEPOT-PED* (PA) HORMONAL AGENTS
LYNPARZA** (PA) CANCER
LYSTEDA** BLOOD MODIFIERS/BLEEDING DISORDERS
MAKENA* (PA) INFERTILITY
MAVENCLAD** (PA) MULTIPLE SCLEROSIS
MAVYRET** (PA) INFECTIONS
MAYZENT** (PA) MULTIPLE SCLEROSIS
20MEDICATION NAME DRUG CLASS
MEKINIST** (PA) CANCER
MENOPUR*^ (PA) INFERTILITY
MIRENA*+ CONTRACEPTION PRODUCTS
MONOVISC* (PA) PAIN RELIEF AND INFLAMMATORY DISEASE
MVASI* (PA) CANCER
MYALEPT* (PA) MISCELLANEOUS
mycophenolate** TRANSPLANT MEDICATIONS
mycophenolic acid** TRANSPLANT MEDICATIONS
MYFORTIC** TRANSPLANT MEDICATIONS
NATPARA* (PA) HORMONAL AGENTS
NERLYNX** (PA) CANCER
NEULASTA* (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
NEULASTA ONPRO* (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
NEUPOGEN* (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
NEXAVAR** (PA) CANCER
NEXPLANON*+ CONTRACEPTION PRODUCTS
NINLARO** (PA) CANCER
NITYR** (PA) MISCELLANEOUS
NIVESTYM* BLOOD MODIFIERS/BLEEDING DISORDERS
NORDITROPIN FLEXPRO* (PA) HORMONAL AGENTS
NORTHERA** (PA) BLOOD PRESSURE/HEART MEDICATIONS
NOURIANZ** (PA, QL) PARKINSON’S DISEASE
NOVAREL*^ (PA) INFERTILITY
NUBEQA** (PA) CANCER
NUCALA* (PA) ASTHMA/COPD/RESPIRATORY
NUTROPIN AQ NUSPIN* HORMONAL AGENTS
NUZYRA** (QL) INFECTIONS
NYVEPRIA* (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
OCALIVA** (PA) GASTROINTESTINAL/HEARTBURN
OCREVUS* (PA) MULTIPLE SCLEROSIS
ODEFSEY** (PA) AIDS/HIV
ODOMZO** (PA) CANCER
OFEV** (PA) ASTHMA/COPD/RESPIRATORY
OGIVRI* (PA) CANCER
OLUMIANT** (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
OPSUMIT** (PA) ASTHMA/COPD/RESPIRATORY
ORENCIA* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
ORENITRAM ER** (PA) ASTHMA/COPD/RESPIRATORY
ORFADIN** (PA) MISCELLANEOUS
ORKAMBI** (PA, QL) ASTHMA/COPD/RESPIRATORY
ORTHOVISC* (PA) PAIN RELIEF AND INFLAMMATORY DISEASE
OTEZLA** (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
21MEDICATION NAME DRUG CLASS
OVIDREL*^ (PA) INFERTILITY
OXERVATE** (PA) EYE CONDITIONS
PALYNZIQ* (PA) MISCELLANEOUS
PEGASYS* (PA) INFECTIONS
PLEGRIDY* (PA) MULTIPLE SCLEROSIS
POMALYST** (PA) CANCER
PONVORY** (PA) MULTIPLE SCLEROSIS
PREVYMIS** INFECTIONS
PREZCOBIX** (PA) AIDS/HIV
PREZISTA** AIDS/HIV
PROCRIT* (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
PROLASTIN C* (PA) ASTHMA/COPD/RESPIRATORY
PROLIA* (PA) OSTEOPOROSIS PRODUCTS
PROMACTA** (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
PULMOZYME** (PA) ASTHMA/COPD/RESPIRATORY
PURIXAN** CANCER
RAPAMUNE** TRANSPLANT MEDICATIONS
RAVICTI** (PA) GASTROINTESTINAL/HEARTBURN
REBIF* (PA) MULTIPLE SCLEROSIS
REBIF REBIDOSE* (PA) MULTIPLE SCLEROSIS
REMODULIN* (PA) ASTHMA/COPD/RESPIRATORY
RENFLEXIS* (PA) PAIN RELIEF AND INFLAMMATORY DISEASE
RETACRIT* (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
REVATIO** (PA) ASTHMA/COPD/RESPIRATORY
REVLIMID** (PA) CANCER
RIABNI* (PA) CANCER
RINVOQ ER** (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
ritonavir** AIDS/HIV
RUBRACA** (PA) CANCER
RUCONEST* (PA) BLOOD PRESSURE/HEART MEDICATIONS
RUXIENCE* (PA) CANCER
SAMSCA** DIURETICS
SANDOSTATIN* (PA) HORMONAL AGENTS
SANDOSTATIN LAR DEPOT* (PA) HORMONAL AGENTS
SELZENTRY** (PA) AIDS/HIV
SEROSTIM* (PA) HORMONAL AGENTS
SILIQ* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
SIMPONI* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
SIMPONI ARIA* (PA) PAIN RELIEF AND INFLAMMATORY DISEASE
sirolimus** TRANSPLANT MEDICATIONS
SKYLA**+ CONTRACEPTION PRODUCTS
SKYRIZI* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
22MEDICATION NAME DRUG CLASS
sofosbuvir-velpatasvir** (PA) INFECTIONS
SOLIRIS* (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
SOMATULINE DEPOT* (PA) HORMONAL AGENTS
SOMAVERT* (PA) HORMONAL AGENTS
SOVALDI** (PA, QL) INFECTIONS
SPRYCEL** (PA) CANCER
STELARA* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
STRENSIQ* (PA) MISCELLANEOUS
STIVARGA** (PA) CANCER
STRIBILD** (PA) AIDS/HIV
SUBLOCADE* substance abuse
SUCRAID** (PA) GASTROINTESTINAL/HEARTBURN
SUPARTZ FX* (PA) PAIN RELIEF AND INFLAMMATORY DISEASE
SUPPRELIN LA** (PA) HORMONAL AGENTS
SUTENT** (PA) CANCER
SYMDEKO** (PA, QL) ASTHMA/COPD/RESPIRATORY
SYMFI** AIDS/HIV
SYMFI LO** AIDS/HIV
SYMTUZA** AIDS/HIV
SYNAGIS* (PA) INFECTIONS
SYNVISC* (PA) PAIN RELIEF AND INFLAMMATORY DISEASE
SYPRINE** (PA) MISCELLANEOUS
tacrolimus capsule** TRANSPLANT MEDICATIONS
tadalafil 20mg** (PA) ASTHMA/COPD/RESPIRATORY
TAFINLAR** (PA) CANCER
TAGRISSO** (PA) CANCER
TAKHZYRO* (PA) BLOOD PRESSURE/HEART MEDICATIONS
TALTZ* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
TALZENNA** (PA) CANCER
TARGRETIN** (PA) CANCER
TASIGNA** (PA) CANCER
TAVALISSE** (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
TEGSEDI* (PA) MISCELLANEOUS
TEMIXYS** (PA) AIDS/HIV
TEMODAR** (PA) CANCER
temozolomide** (PA) CANCER
tenofovir** (PA) AIDS/HIV
teriparatide* (PA, QL) HORMONAL AGENTS
tetrabenazine** (PA) MISCELLANEOUS
THALOMID** (PA) INFECTIONS
THIOLA** URINARY TRACT CONDITIONS
THYROGEN* HORMONAL AGENTS
23MEDICATION NAME DRUG CLASS
TIGLUTIK** (PA) MISCELLANEOUS
TIVICAY** AIDS/HIV
TOBI PODHALER** (PA, QL) INFECTIONS
tobramycin 300 mg/5ml ampule** (PA, QL) INFECTIONS
TRACLEER** (PA) ASTHMA/COPD/RESPIRATORY
tranexamic acid** BLOOD MODIFIERS/BLEEDING DISORDERS
TRAZIMERA* (PA) CANCER
TRELSTAR* CANCER
TREMFYA* (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
treprostinil* (PA) ASTHMA/COPD/RESPIRATORY
trientine** (PA) MISCELLANEOUS
TRILURON* (PA) PAIN RELIEF AND INFLAMMATORY DISEASE
TRIPTODUR* (PA) HORMONAL AGENTS
TRIUMEQ** AIDS/HIV
TRIVISC* PAIN RELIEF AND INFLAMMATORY DISEASE
TRUVADA** (PA) AIDS/HIV
TYKERB** (PA) CANCER
TYMLOS* (PA, QL) OSTEOPOROSIS PRODUCTS
TYSARBI* (PA) MULTIPLE SCLEROSIS
TYVASO** (PA) ASTHMA/COPD/RESPIRATORY
UDENYCA* (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
UPTRAVI** (PA) ASTHMA/COPD/RESPIRATORY
VALCHLOR** SKIN CONDITIONS
VEMLIDY** INFECTIONS
VENCLEXTA** (PA) CANCER
VERZENIO** (PA) CANCER
VIREAD** (PA) AIDS/HIV
vigabatrin** SEIZURE DISORDERS
vigadrone** SEIZURE DISORDERS
VISCO-3* (PA) PAIN RELIEF AND INFLAMMATORY DISEASE
VIVITROL* MISCELLANEOUS
VIZIMPRO** (PA) CANCER
VOSEVI** (PA) INFECTIONS
VOTRIENT** (PA) CANCER
VUMERITY DR** (PA) MULTIPLE SCLEROSIS
VYLEESI* (PA, QL) MISCELLANEOUS
WAKIX** (PA, QL) SLEEP DISORDERS/SEDATIVES
XALKORI** (PA) CANCER
XELJANZ** (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
XELJANZ XR** (PA, QL) PAIN RELIEF AND INFLAMMATORY DISEASE
XELODA** (PA) CANCER
XERMELO** (PA) GASTROINTESTINAL/HEARTBURN
24MEDICATION NAME DRUG CLASS
XGEVA* OSTEOPOROSIS PRODUCTS
XIAFLEX* PAIN RELIEF AND INFLAMMATORY DISEASE
XOLAIR* (PA) ASTHMA/COPD/RESPIRATORY
XTANDI** (PA) CANCER
XYREM** (PA) SLEEP DISORDERS/SEDATIVES
YONSA** (PA) CANCER
ZARXIO* BLOOD MODIFIERS/BLEEDING DISORDERS
ZEJULA** (PA) CANCER
ZEPATIER** (PA) INFECTIONS
ZEPOSIA** (PA) MULTIPLE SCLEROSIS
ZIEXTENZO* (PA) BLOOD MODIFIERS/BLEEDING DISORDERS
ZIRABEV* (PA) CANCER
ZORBTIVE* (PA) HORMONAL AGENTS
ZORTRESS** TRANSPLANT MEDICATIONS
25Medications that aren’t covered
Your plan covers other medications that are used to treat the same condition.^^ They’re listed below.
GENERIC AND/OR PREFERRED BRAND
DRUG CLASS MEDICATION NAME^^
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
bupropion xl 450mg tablet bupropion xl 150mg tablets
FORFIVO XL
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the 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.
26GENERIC AND/OR PREFERRED BRAND
DRUG CLASS MEDICATION NAME^^
ALTERNATIVE(S)
ANXIETY/DEPRESSION/BIPOLAR DISORDER CYMBALTA desvenlafaxine ER
(cont) duloxetine
escitalopram
DRIZALMA SPRINKLE duloxetine dr capsules
LEXAPRO escitalopram
PAMELOR nortriptyline capsules
PARNATE tranylcypromine
PEXEVA paroxetine
paroxetine cr
TOFRANIL imipramine
WELLBUTRIN XL bupropion xl
escitalopram
fluoxetine
ADVAIR DISKUS ADVAIR HFA
AIRDUO DIGIHALER BREO ELLIPTA
AIRDUO RESPICLICK 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
UTIBRON NEOHALER BEVESPI AEROSPHERE
STIOLTO RESPIMAT
ELIXOPHYLLIN theophylline er
theophylline oral solution
levalbuterol hfa albuterol hfa
PROAIR DIGIHALER
PROAIR HFA
PROAIR RESPICLICK
PROVENTIL HFA
VENTOLIN HFA
XOPENEX HFA
PERFOROMIST formoterol
SEEBRI NEOHALER INCRUSE ELLIPTA
TUDORZA PRESSAIR SPIRIVA RESPIMAT
STRIVERDI RESPIMAT SEREVENT DISKUS
YUPELRI ANORO ELLIPTA
BEVESPI AEROSPHERE
BREZTIRI AEROSPHERE
INCRUSE ELLIPTA
SPIRIVA
STIOLTO RESPIMAT
TRELEGY ELLIPTA
ZYFLO montelukast
zafirlukast
zileuton er
^^
These medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the 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.
27GENERIC AND/OR PREFERRED BRAND
DRUG CLASS MEDICATION NAME^^
ALTERNATIVE(S)
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 CYCLOPHOSPHAMIDE TABLET* cyclophosphamide capsule*
NILANDRON nilutamide
TARCEVA* erlotinib
YONSA* abiraterone
ZYTIGA*
CHOLESTEROL MEDICATIONS ANTARA fenofibrate
FENOGLIDE
CRESTOR rosuvastatin+
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the 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.
28GENERIC AND/OR PREFERRED BRAND
DRUG CLASS MEDICATION NAME^^
ALTERNATIVE(S)
CHOLESTEROL MEDICATIONS EZALLOR SPRINKLE generic statins (e.g. atorvastatin; simvastatin)
FLOLIPID
LIVALO
SIMVASTATIN 20mg/5ml SUSPENSION
JUXTAPID* REPATHA
PRALUENT
LIPITOR atorvastatin+
ezetimibe-simvastatin
rosuvastatin+
niacin 500mg tablet niacin er
NIACOR
ZYPITAMAG atorvastatin+
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
ADLYXIN BYDUREON
BYETTA
metformin
OZEMPIC
TRULICITY
VICTOZA
ADMELOG HUMALOG
ADMELOG SOLOSTAR LYUMJEV
APIDRA, APIDRA SOLOSTAR
FIASP
FIASP FLEXTOUCH
FIASP PENFILL
INSULIN ASPART
NOVOLOG
AFREZZA HUMALOG
HUMULIN R
LYUMJEV
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the 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.
29GENERIC AND/OR PREFERRED BRAND
DRUG CLASS MEDICATION NAME^^
ALTERNATIVE(S)
DIABETES (cont) 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
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
INSULIN GLARGINE BASAGLAR
LANTUS/LANTUS SOLOSTAR LEVEMIR
SEMGLEE TRESIBA FLEXTOUCH
TOUJEO MAX SOLOSTAR
TOUJEO SOLOSTAR
NOVOLIN HUMULIN
STEGLUJAN GLYXAMBI
metformin
QTERN
TRIJARDY XR
DIURETICS EDECRIN bumetanide
ethacrynic acid furosemide
torsemide
EYE CONDITIONS LUMIGAN bimatoprost
TRAVATAN Z latanoprost
VYZULTA travoprost
XALATAN
XELPROS
ZIOPTAN
GASTROINTESTINAL/HEARTBURN ANUSOL-HC 25MG SUPPOSITORY hydrocortisone 25mg suppository
ASACOL HD balsalazide
COLAZAL mesalamine tablets or capsules
DELZICOL PENTASA
DIPENTUM sulfasalazine
^^
T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the 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.
30You can also read
