CIGNA VALUE 3-TIER PRESCRIPTION DRUG LIST - Starting January 1, 2021
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CIGNA VALUE 3-TIER PRESCRIPTION DRUG LIST Starting January 1, 2021 Offered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, or their affiliates. 876397 w Value 3-Tier 09/20
What’s inside?
About your prescription drug list 3
How to read your drug list 3
How to find your medication 5
Medications that are not covered 18
Prescription drug list FAQs 30
Exclusions and limitations 33
View your plan’s drug list online
This document was last updated on 09/01/2020.* You can go online to see a more current list
of medications your plan covers.
The myCigna® App or website – Log in and click on the “Find Care & Costs” tab.
Select “Price a Medication,” then type in your medication name.
Cigna.com/druglist – Select your drug list name – Value 3 Tier – from the
drop down menu. Then type in your medication name or view the full list.
Questions?
Call the toll-free number on your Cigna ID card. We’re here to help. You can also chat with us
online on the myCigna website, Monday–Friday, 9:00 am–8:00 pm EST.
* Drug list created: originally created 10/01/2011 Last updated: 09/01/2020, for changes Next planned update: 03/01/2021, for
starting 01/01/2021 changes starting 07/01/2021
2About your prescription drug list
This document shows the most commonly prescribed medications covered on the Value 3-Tier
Prescription Drug List as of January 1, 2021.1,2 All of these medications are approved by the U.S. Food and
Drug Administration (FDA). Medications are listed by the condition they treat, then listed alphabetically
within tiers (or cost-share levels). The Value 3-Tier Prescription Drug List is updated often so it’s
important to know that this is not a complete list of the medications your plan covers. Also, your
specific plan may not cover all of the medications in this document. Log in to the myCigna App or
website, or check your plan materials, to see which medications your plan covers.
The Value 3-Tier Prescription Drug List also excludes from coverage prescription medications that
are used to treat allergies (ex. Allegra, Clarinex, Xyzal and generics) and heartburn/stomach acid
conditions (ex. Nexium, Prilosec and generics). These medications have over-the-counter (OTC)
alternatives, which are available without a prescription.
How to read your drug list
Use the sample chart below to help you understand this drug list. This chart is just an example. It
may not show how these medications are actually covered on the Value 3-Tier Prescription Drug List.
Tier (cost-share level) gives you
an idea of the how much you may
TIER 1 TIER 2 pay for a medication
$ $$
BLOOD PRESSURE/HEART MEDICATIONS Medications are grouped by
afeditab CR Berinert* (PA) the condition they treat
amlodipine besylate Bidil
amlodipine besylate-benazepril Bystolic
amlodipine-valsartan Cinryze* (PA)
amlodipine-valsartan-HCTZ Coreg CR
atenolol Cozaar (ST)
atenolol-chlorthalidone Diovan (ST) Medications are listed in
benazepril Diovan HCT (ST) alphabetical order within
benazepril-HCTZ Edarbi (ST) each column
candesartan cilexetil Edarbyclor (ST)
cartia XT Exforge
carvedilol Exforge HCT
clonidine Firazyr* (PA) Specialty medications have an
digitek Hemangeol asterisk (*) listed next to them
digox Inderal LA
digoxin Inderal XL
diltiazem ER Innopran XL
diltiazem CD Lotrel Brand name medications
diltiazem Micardis (ST) are capitalized
dilt-XR Multaq
enalapril Nitro-dur
flecainide acetate Nitrolingual Generic medications
hydralazine Nitromist are lowercase
irbesartan Nitronal
isosorbide mononitrat Nitrostat
Northera* (PA) Medications that have extra
Norvasc coverage requirements will
Ranexa (ST) have an abbreviation listed
Tekturna next to them
Tekturna HCT
This chart is just a sample. It may not show how these medications are actually covered on the Value 3-Tier Prescription Drug List.
3Tiers
Covered medications are divided into tiers, or cost-share levels. Typically, the higher the tier, the
higher the price you’ll pay to fill the prescription.
› Tier 1 – Typically Generics (Lowest-cost medication) $
› Tier 2 – Typically Preferred Brands (Medium-cost medication) $$
› Tier 3 – Typically Non-Preferred Brands (Highest-cost medication) $$$
Abbreviations next to medications
Some medications on your drug list have extra requirements before your plan will cover them.* This
helps to make sure you’re receiving coverage for the right medication, at the right cost, in the right
amount and for the right situation. These medications will have an abbreviation next to them in the
drug list. Here’s what each of the abbreviations mean.
(PA) Prior Authorization – Cigna will review information your doctor provides to make
sure you meet coverage guidelines for the medication. If approved, your plan will
cover the medication.
(ST) tep Therapy – Certain high-cost medications are part of the Step Therapy program.
S
Step Therapy encourages the use of lower-cost medications (typically generics and
preferred brands) that can be used to treat the same condition as the higher-cost
medication. These conditions include, but are not limited to, depression, high blood
pressure, high cholesterol, skin conditions and sleep disorders. Your plan doesn’t
cover the higher-cost Step Therapy medication until you try one or more alternatives
first (unless you receive approval from Cigna).
(QL) uantity Limits – For some medications, your plan will only cover up to a certain
Q
amount over a certain length of time. For example, 30mg per day for 30 days. Your
plan will only cover a larger amount if your doctor requests and receives approval
from Cigna.
(AGE) ge Requirements – For certain medications, you must be within a specific
A
age range for your plan to cover them. This is because some medications aren’t
considered clinically appropriate for individuals who aren’t within that age range.
* These coverage requirements may not apply to your specific plan. That’s because some plans don’t have prior authorization, quantity limits, Step Therapy and/or age requirements. Log in to the
myCigna App or website, or check your plan materials, to find out if your plan includes these specific coverage requirements.
Brand name medications are capitalized
In this drug list, brand name medications are capitalized and generic medications are lowercase.
Specialty medications are marked with an asterisk
Specialty medications are used to treat complex medical conditions like multiple sclerosis, hepatitis
C and rheumatoid arthritis. In this drug list, specialty medications are marked with an asterisk (*).
Some plans may cover these medications on a specialty tier, 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 website, or check your plan materials, to learn more about how your plan covers
specialty medications.
4No cost-share preventive medications are marked with a plus sign
Health care reform under the Patient Protection and Affordable Care Act (PPACA) requires that
most plans cover certain categories of medications and other products as preventive care services.
In this drug list, medications with a plus sign (+) next to them may be available to you at no cost-
share (copay, coinsurance and/or deductible). Log in to the myCigna App or website, or check your
plan materials, to learn more about how your plan covers preventive medications.
Plan exclusions
Your plan excludes certain types of medications or products from coverage. This is known as a “plan
(or benefit) exclusion.” This means that your plan doesn’t cover any prescription medications in the
drug class or to treat the specific condition. There’s also no option to receive coverage through a
medication review process. In this drug list, these medications have a caret (^) next to them. Log in
to the myCigna App or website, or check your plan materials, to find out if your plan excludes your
medication from coverage.
How to find your medication
Find 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 GASTROINTESTINAL/HEARTBURN 12
ALLERGY/NASAL SPRAYS 6 HORMONAL AGENTS 12, 13
ALZHEIMER’S DISEASE 6 INFECTIONS 13
ANXIETY/DEPRESSION/BIPOLAR 6 INFERTILITY 14
DISORDER
MISCELLANEOUS 14
ASTHMA/COPD/RESPIRATORY 6
MULTIPLE SCLEROSIS 14
ATTENTION DEFICIT HYPERACTIVITY 7
NUTRITIONAL/DIETARY 14
DISORDER
BLOOD MODIFIERS/BLEEDING DISORDERS 7 OSTEOPOROSIS PRODUCTS 14
BLOOD PRESSURE/HEART MEDICATIONS 7, 8 PAIN RELIEF AND INFLAMMATORY 14, 15
DISEASE
BLOOD THINNERS/ANTI-CLOTTING 8
PARKINSON’S DISEASE 15
CANCER 8
SCHIZOPHRENIA/ANTI-PSYCHOTICS 15
CHOLESTEROL MEDICATIONS 8, 9
SEIZURE DISORDERS 15, 16
CONTRACEPTION PRODUCTS 9, 10
COUGH/COLD MEDICATIONS 11 SKIN CONDITIONS 16
DENTAL PRODUCTS 11 SLEEP DISORDERS/SEDATIVES 16
DIABETES 11 SMOKING CESSATION 16, 17
DIURETICS 11 SUBSTANCE ABUSE 17
EAR MEDICATIONS 11 TRANSPLANT MEDICATIONS 17
ERECTILE DYSFUNCTION 11 URINARY TRACT CONDITIONS 17
EYE CONDITIONS 11, 12 VACCINES 17
FEMININE PRODUCTS 12 WEIGHT MANAGEMENT 17
5Cigna Value 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
AIDS/HIV ANXIETY/DEPRESSION/BIPOLAR DISORDER (cont)
abacavir- Atripla* (PA) CIMDUO* (PA) bupropion SR (QL) Remeron
lamivudine* (PA) Biktarvy* Complera* (PA) bupropion XL (QL) Sarafem (ST)
atazanavir* (PA) Descovy* (PA) Evotaz* (PA) buspirone Trintellix (ST, QL)
ritonavir* Genvoya* Intelence* (PA) citalopram (QL) Viibryd (ST, QL)
tenofovir* (PA) Isentress* Juluca* (PA) clomipramine Wellbutrin SR (ST, QL)
Isentress HD* Odefsey* (PA) desvenlafaxine ER Xanax
(PA) Prezcobix* (PA) (QL) Xanax XR
Prezista* Stribild* (PA) duloxetine (QL) Zoloft (ST, QL)
Selzentry* (PA) escitalopram (QL)
Symfi* fluoxetine (QL)
Symfi Lo* fluoxetine DR (QL)
Symtuza* fluvoxamine (QL)
Tivicay* fluvoxamine ER (QL)
Triumeq* lorazepam
Truvada* lorazepam intensol
Viread 150mg, mirtazapine
200mg, 250mg paroxetine (QL)
tablet, powder* paroxetine CR (QL)
(PA) paroxetine ER (QL)
ALLERGY/NASAL SPRAYS sertraline (QL)
azelastine^ Clarinex-D 12 Hour trazodone
cromolyn Gastrocrom venlafaxine (QL)
cyproheptadine Grastek (PA, QL) venlafaxine ER (QL)
epinephrine (QL) Karbinal ER ASTHMA/COPD/RESPIRATORY
flunisolide^ Odactra (PA, QL) albuterol Anoro Ellipta Adcirca* (PA)
fluticasone^ Patanase albuterol HFA Atrovent HFA Adempas* (PA)
hydroxyzine capsule, Ragwitek (PA, QL) alyq* (PA) Dulera Brovana
solution, tablet Vistaril budesonide Flovent Combivent Respimat
ipratropium fluticasone- Flovent HFA Daliresp (QL)
mometasone^ (QL) salmeterol Incruse Ellipta Kalydeco* (PA, QL)
olopatadine montelukast Ofev* (PA) Letairis* (PA)
promethazine tadalafil 20mg* (PA) Opsumit* (PA) Lonhala Magnair (PA)
ALZHEIMER’S DISEASE Wixela Inhub QVAR RediHaler Nucala auto-injector,
donepezil Aricept Serevent syringe* (PA)
donepezil ODT Exelon Symbicort Orenitram ER* (PA)
memantine Mestinon Tracleer 32mg Orkambi* (PA, QL)
memantine ER (QL) Namenda tablet tablet for Perforomist (QL)
pyridostigmine Namenda XR (QL) suspension* Pulmicort Respule
pyridostigmine ER Namzaric (QL) (PA) Pulmozyme* (PA)
rivastigmine Trelegy Ellipta Revatio oral
Xolair* (PA) suspension, tablet*
ANXIETY/DEPRESSION/BIPOLAR DISORDER
(PA)
alprazolam Celexa (ST, QL) Singulair
alprazolam ER Effexor XR (ST, QL) Symdeko* (PA, QL)
alprazolam intensol Fetzima (ST, QL) Tracleer tablet* (PA)
alprazolam ODT Forfivo XL (ST, QL) Tyvaso* (PA)
alprazolam XR Paxil (ST, QL) Uptravi* (PA)
amitriptyline Paxil CR (ST, QL)
bupropion (QL) Prozac (ST, QL)
6Cigna Value 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
ATTENTION DEFICIT HYPERACTIVITY DISORDER BLOOD PRESSURE/HEART MEDICATIONS (cont)
atomoxetine (QL) Adderall (PA age, ST Adult Aspirin Coreg (ST)
clonidine ER Daytrana (PA age, QL) Regimen+ Coreg CR (ST, QL)
dexmethylphenidate Evekeo (PA age, ST) Aspir EC+ Corgard (ST)
(PA age) Focalin (PA age, ST) aspirin EC+ Epaned
dexmethylphenidate Intuniv ER aspirin 325 mg Haegarda* (PA)
ER (PA age, QL) Kapvay tablet+ Hemangeol
dextroamphetamine- Methylin (PA age) Aspir-Low+ Inderal LA (ST)
amphetamine Quillivant XR (PA age, atenolol Inderal XL (ST)
(PA age) QL) Bayer Aspirin 325mg InnoPran XL (ST)
dextroamphetamine- Ritalin tablet tablet+ Kapspargo Sprinkle
amphetamine ER Strattera (QL) benazepril (ST)
(PA age, QL) benazepril-HCTZ Lopressor (ST)
guanfacine ER candesartan Minipress
metadate ER candesartan-HCTZ Multaq
(PA age, QL) cartia XT Nitrostat
methylphenidate carvedilol Northera* (PA)
(PA age) carvedilol ER (QL) Norvasc
methylphenidate CD Children’s Aspirin+ Pacerone 100mg,
(PA age, QL) clonidine 400mg (PA)
methylphenidate ER diltiazem Procardia
(CD) (PA age, QL) diltiazem 12hr ER Procardia XL
methylphenidate ER diltiazem 24hr ER Ranexa (QL)
(LA) (PA age, QL) diltiazem 24hr ER Rythmol SR (PA)
methylphenidate ER (CD) Takhzyro* (PA)
(PA age, QL) diltiazem 24hr ER Tenormin (ST)
methylphenidate LA (LA) Tiazac
(PA age, QL) diltiazem 24hr ER Tikosyn (PA, QL)
Relexxii (PA age, QL) (XR) Toprol XL (ST)
BLOOD MODIFIERS/BLEEDING DISORDERS Dilt-XR Verelan
aminocaproic acid* Aranesp*^ (PA) Amicar* dofetilide (QL) Verelan PM
tranexamic acid* Droxia Hemlibra* (PA) doxazosin
Epogen*^ (PA) Lysteda* Ecotrin+
Fulphila* (PA) Neupogen*^ (PA) Ecpirin+
Granix*^ Nivestym*^ (PA) enalapril
Neulasta*^ (PA) Promacta* (PA) flecainide
Procrit*^ (PA) Siklos (PA) hydralazine
irbesartan
Retacrit*^ (PA) Tavalisse* (PA)
irbesartan-HCTZ
Udenyca*^ (PA)
isosorbide
Zarxio*^
mononitrate
BLOOD PRESSURE/HEART MEDICATIONS isosorbide
amiodarone Corlanor (PA) Adalat CC mononitrate ER
amlodipine Entresto BiDil (QL) labetalol
amlodipine- Calan lisinopril
benazepril Calan SR lisinopril-HCTZ
amlodipine- Cardizem LA (QL) losartan
olmesartan (QL) Cardura losartan-HCTZ
amlodipine-valsartan Catapres-TTS 1 Low Dose Aspirin EC+
amlodipine- Catapres-TTS 2 Matzim LA
valsartan-HCTZ Catapres-TTS 3
7Cigna Value 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
BLOOD PRESSURE/HEART MEDICATIONS (cont) CANCER (cont)
metoprolol exemestane Erivedge* (PA) Alecensa* (PA)
nadolol imatinib* (PA) Gleostine Bosulif* (PA)
nifedipine letrozole Ibrance* (PA) Cabometyx* (PA)
nifedipine ER mercaptopurine Lupron Depot*^ Cometriq* (PA)
olmesartan (QL) methotrexate (PA) Erleada* (PA)
olmesartan- tamoxifen+ Nexavar* (PA) Gleevec* (PA)
amlodipine-HCTZ temozolomide* (PA) Revlimid* (PA) Imbruvica* (PA)
olmesartan-HCTZ Sprycel* (PA) Inlyta* (PA)
(QL) Sutent* (PA) Jakafi* (PA)
Pacerone 200mg Tasigna* (PA) Kisqali* (PA)
tablet Trexall Lenvima* (PA)
Tykerb* (PA) Lonsurf* (PA)
prazosin
Verzenio* (PA) Lynparza* (PA)
propafenone
Mekinist* (PA)
propafenone ER
Nerlynx* (PA)
propranolol solution,
Ninlaro* (PA)
tablet Odomzo* (PA)
propranolol ER Pomalyst* (PA)
ramipril Purixan*
St. Joseph Aspirin+ Rubraca* (PA)
ranolazine ER (QL) Stivarga* (PA)
Taztia XT Tafinlar* (PA)
telmisartan (QL) Tagrisso* (PA)
telmisartan-HCTZ Targretin capsule*
(QL) (PA)
valsartan Temodar capsule*
valsartan-HCTZ (PA)
verapamil capsule, Venclexta* (PA)
tablet Votrient* (PA)
verapamil ER Xalkori* (PA)
verapamil ER PM Xeloda* (PA)
verapamil SR Xtandi* (PA)
BLOOD THINNERS/ANTI-CLOTTING
Zejula* (PA)
CHOLESTEROL MEDICATIONS
aspirin-dipyridamole Brilinta Aggrenox
ER Eliquis (PA) Arixtra* (QL) amlodipine- Repatha (PA) Caduet (QL)
clopidogrel Fragmin* (QL) Bevyxxa (QL) atorvastatin (QL) Vascepa (PA) Lipofen (ST)
enoxaparin* (QL) Xarelto (PA) Coumadin (PA) atorvastatin+ Lovaza
fondaparinux* (QL) Effient colesevelam Niaspan
Jantoven Lovenox* (QL) ezetimibe TriCor (ST)
prasugrel Plavix ezetimibe- Triglide (ST)
warfarin simvastatin Trilipix (ST)
Pradaxa (PA)
fenofibrate Welchol
Savaysa (PA, QL)
fenofibric acid Zetia
Zontivity
fluvastatin ER+
CANCER fluvastatin+
lovastatin 10mg
abiraterone* (PA) Actimmune* (PA) Afinitor 2.5mg, 5mg,
lovastatin 20mg,
anastrozole Afinitor 10mg* 7.5mg* (PA)
40mg+
capecitabine* (PA) (PA) Afinitor Disperz* (PA)
niacin
8Cigna Value 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
CHOLESTEROL MEDICATIONS (cont) CONTRACEPTION PRODUCTS (cont)
niacin ER Dasetta+
niacor Daysee+
omega-3 acid ethyl Deblitane+
esters Delyla+
desogestrel-ethinyl
pravastatin+
estradiol+
rosuvastatin (QL) desogestrel-ethinyl
rosuvastatin 5mg, estradiol ethinyl
10mg+ (QL) estradiol
simvastatin 80mg dospirenone-
(QL) ethinyl estradiol-
simvastatin 10mg, levomefolate+
20mg, 40mg+ drospirenone-ethinyl
estradiol+
CONTRACEPTION PRODUCTS
Econtra EZ+
Afirmelle
+
Lo Loestrin FE Annovera+ Econtra One-Step+
Aftera+ Ella+ Elinest+
Altavera+ Estrostep FE eluryng vaginal ring
Alyacen+ Layolis FE Emoquette+
Amethia+ Loestrin FE Enpresse+
Amethia Lo+ Minastrin 24 FE Enskyce+
Amethyst+ NuvaRing Errin+
Safyral Estarylla+
Apri+
Skyla* ethynodiol-ethinyl
Aranelle+
Today Contraceptive estradiol+
Ashlyna+ etonogestrel-EE
Aubra+ Sponge+
Yasmin 28 vaginal ring
Aubra EQ+ Falmina+
Yaz
Aurovela+ Fayosim+
Aurovela FE+ FemCap+
Aurovela 24 FE+ Femynor+
Aviane+ Gianvi+
Ayuna+ Gynol II+
Azurette+ Hailey 24 FE+
Balziva+ Heather+
Bekyree+ Incassia+
Introvale+
Blisovi FE+
Isibloom+
Blisovi 24 FE+ Jasmiel+
Briellyn+ Jencycla+
Camila+ Jolessa+
Camrese+ Juleber+
Camrese LO+ Junel+
Caya Contoured+ Junel FE+
Caziant+ Junel FE 24+
Chateal+ Kaitlib FE+
Chateal EQ+ Kalliga+
Cryselle+ Kariva+
Cyclafem+ Kelnor 1-35+
Cyred+ Kelnor 1-50+
Cyred EQ+ Kurvelo+
9Cigna Value 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
CONTRACEPTION PRODUCTS (cont) CONTRACEPTION PRODUCTS (cont)
Larin+
Philith
+
Larin FE+ Pimtrea+
Larin 24 FE+ Pirmella+
Larissia+ Portia+
Leena 28 tablet+ Previfem+
Lessina+ Reclipsen+
Levonest+ Rivelsa tablet+
levonorgestrel+ Setlakin+
levonorgestrel- Sharobel+
ethinyl estradiol+ Simliya+
levonorgestrel-ethinyl Simpesse+
estradiol ethinyl Sprintec+
estradiol+ Sronyx+
Levora-28+ Syeda+
Lillow+ Tarina 24 FE+
Loryna+ Tarina FE 1-20 EQ+
Low-Ogestrel+ Tilia FE 28+
Lo-Zumandimine+ Tri Femynor+
Lutera+ Tri-Estarylla+
Lyza+ Tri-Legest FE+
Marlissa+ Tri-Linyah+
medroxyprogesterone Tri-Lo-Estarylla+
150mg/ml+ Tri-Lo-Marzia+
Melodetta 24 FE+ Tri-Lo-Mili+
Mibelas 24 FE+ Tri-Lo-Sprintec+
Microgestin+ Tri-Mili+
Microgestin FE+ Tri-Previfem+
Mili+ Tri-Sprintec+
Mono-Linyah+ Trivora-28+
My Choice+ Tri-Vylibra+
My Way+ Tri-Vylibra Lo+
Necon+ Tulana+
Nikki+ Tydemy+
Nora-BE+ VCF foam, gel+
norethindrone+ Velivet+
norethindrone- Vienva+
ethinyl estradiol+ Viorele+
norethindrone- Vyfemla+
ethinyl estradiol- Vylibra+
iron+ Wera+
norgestimate-ethinyl Wide Seal
estradiol+ Diaphragm+
Norlyda+ Wymzya FE+
Norlyroc+ Xulane+
Nortrel+ Zarah+
Ocella+ Zovia+
Option 2+ Zumandimine+
Orsythia+
10Cigna Value 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
COUGH/COLD MEDICATIONS DIABETES (cont)
Bromfed DM Tessalon Perle Soliqua
brompheniramine- Tuzistra XR (PA, QL) Steglatro (ST, QL)
pseudoephedrine- SymlinPen
DM Synjardy (ST, QL)
hydrocodone- Synjardy XR (ST,
chlorpheniramine QL)
ER (PA) Tresiba (QL)
Trulicity (ST, QL)
DENTAL PRODUCTS
V-Go
chlorhexidine Floriva+^ Victoza (ST, QL)
doxycycline Fluorabon+^ Xigduo XR (ST,
fluoride+^ QL)
Fluoritab+^ Xultophy
Flura-Drops+^ DIURETICS
Ludent Fluoride+^
acetazolamide Aldactone
Oralone acetazolamide ER Diuril
Paroex bumetanide tablet Dyazide
Peridex chlorthalidone Dyrenium
Periogard eplerenone Inspra
sodium fluoride furosemide tablet, Jynarque* (PA)
0.25mg, 0.5mg, solution Lasix
1mg+^ hydrochlorothiazide Maxzide
triamcinolone spironolactone Maxzide-25 mg
DIABETES triamterene-HCTZ Samsca*
glimepiride Baqsimi (QL) Amaryl EAR MEDICATIONS
glipizide Basaglar (QL) Cycloset neomycin- Cipro HC
glipizide ER Bydureon (ST, Glucophage polymyxin-HC Ciprodex
glipizide XL QL) Glucophage XR ofloxacin drops Coly-Mycin S
metformin Byetta (ST, QL) Korlym* (PA) Cortisporin-TC
metformin ER Farxiga (ST, QL) Riomet Dermotic
NovoTwist Freestyle Libre Otovel
pioglitazone Sensor (PA, QL) ERECTILE DYSFUNCTION
Glucagon
Emergency Kit sildenafil oral Caverject^ (PA, QL)
(QL) suspension, tablet^ Cialis^ (PA age, ST,
Glyxambi (ST, QL) (PA age, QL) QL)
Humalog (QL) tadalafil 5mg^ (PA Muse^ (PA, QL)
Humulin (QL) age, QL) Stendra^ (PA age,
Insulin Lispro vardenafil^ (PA age, ST, QL)
(QL) QL) Viagra^ (PA age, ST,
Janumet (ST, QL) QL)
Janumet XR (ST, EYE CONDITIONS
QL) azelastine^ Combigan Acuvail
Januvia (ST, QL) brimonidine Restasis Alphagan P
Jardiance (ST, QL) ciprofloxacin Simbrinza Alrex
Levemir (QL) dorzolamide Azasite
OneTouch test dorzolamide-timolol Azopt
strips epinastine^ Besivance
Ozempic (ST, QL) erythromycin Betimol
Segluromet (ST, fluorometholone Betoptic S
QL) gatifloxacin Bromsite
11Cigna Value 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
EYE CONDITIONS (cont) GASTROINTESTINAL/HEARTBURN (cont)
latanoprost Cosopt dronabinol Lomotil
moxifloxacin Cosopt PF Ducodyl+ MiraLax+
neomycin- Cystaran* (QL) famotidine Movantik (PA)
polymyxin- Durezol suspension MuGard
dexamethasone Ilevro GaviLyte-C+ Ocaliva* (PA)
ofloxacin Inveltys GaviLyte-G+ Ravicti* (PA)
polymyxin B-TMP Istalol GaviLyte-N+ Rectiv
prednisolone Lotemax GentleLax+ Relistor (PA)
solution Lotemax ointment GlycoLax+ Sancuso (PA, QL)
timolol solution Lotemax SM HealthyLax+ sfRowasa
tobramycin Maxitrol Hemmorex-HC Sucraid* (PA)
tobramycin- Moxeza hydrocortisone Symproic (PA)
dexamethasone Nevanac LaxaClear+ Transderm-Scop
Ocuflox mesalamine Urso
Oxervate* (PA) mesalamine DR Urso Forte
Polytrim metoclopramide Varubi (PA, QL)
Pred Forte metoclopramide Viberzi
Prolensa ODT Viokace
Rhopressa ondansetron Xermelo* (PA)
Timoptic ondansetron ODT
Timoptic-XE PEG 3350 and
Tobradex drops, Electrolytes+
ointment PEG-Prep+
Tobradex ST Phenadoz
Trusopt polyethylene glycol
Vigamox 3350+
Zirgan PowderLax+
Zylet prochlorperazine
Zymaxid suppository, tablet
promethazine
FEMININE PRODUCTS
Promethegan
Fem pH AVC ranitidine syrup
gynazole 1 sucralfate
miconazole 3 vaginal TriLyte With Flavor
suppository Packets+
terconazole ursodiol
GASTROINTESTINAL/HEARTBURN HORMONAL AGENTS
Alophen +
Amitiza Akynzeo capsule (PA, Amabelz Cetrotide*^ (PA) Activella
Anucort-HC Apriso QL) budesonide EC Duavee Alora (QL)
balsalazide Carafate Bonjesta budesonide ER Forteo* (PA, QL) Androderm (PA, QL)
bisacodyl+ suspension Canasa (PA, QL) Ganirelix*^ (PA) AndroGel (PA, QL)
Bisa-Lax+ CLENPIQ+ Carafate tablet cabergoline (QL) Humatrope* (PA) Angeliq
chlordiazepoxide- Entyvio*^ (PA) Cholbam* (PA) CovARYX Increlex* (PA) Armour Thyroid
clidinium Pancreaze DR Correctol+ CovARYX HS
Lupron Depot*^ Climara
cinacalcet* Pentasa Diclegis Decadron
desmopressin (PA) Climara Pro
ClearLax+ Prepopik+ Donnatal Lupron Depot- CombiPatch
solution, spray,
dicyclomine capsule, SUPREP+ Dulcolax+ tablet PED*^ (PA) Crinone 4%
solution, tablet Gattex* (PA) dexamethasone Norditropin Cytomel
diphenoxylate- Kristalose dexamethasone FlexPro* (PA) Depo-Testosterone
atropine Lithostat intensol Orilissa (PA, QL) Divigel
12Cigna Value 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
HORMONAL AGENTS (cont) INFECTIONS (cont)
EEMT Premarin tablet Egrifta* (PA) ciprofloxacin Xifaxan 550mg Flagyl
EEMT H.S. Premphase Elestrin clarithromycin (QL) Keflex
estradiol patch, Prempro Emflaza* (PA) clarithromycin ER Kitabis Pak* (PA, QL)
vaginal insert (QL) Sandostatin LAR Entocort EC clindamycin Levaquin
estradiol- Depot*^ (PA) Estrace
norethindrone clindamycin Macrobid
Serostim* (PA) Estring (QL) phosphate Macrodantin
estrogen- Somavert* (PA) EstroGel
methyltestosterone Coremino (QL) Malarone (PA)
Zorbtive* (PA) Euthyrox
levothyroxine dapsone MetroGel-Vaginal
Evamist
Levoxyl doxycycline Monurol
liothyronine Imvexxy (QL)
Intrarosa Emverm Natroba
Lopreeza
Levo-T entecavir* (QL) Noxafil suspension
medroxyprogesterone
methimazole Medrol erythromycin Nuvessa
methylprednisolone Menostar (QL) erythromycin ES Nuzyra* (PA)
dosepak, tablet Minivelle (QL) famciclovir Oravig
Mimvey Natpara* (PA) fluconazole Plaquenil (PA)
Mimvey LO Noctiva (PA) hydroxychloroquine Prevymis tablet*
Nature-Throid Osphena itraconazole Priftin
NP Thyroid Prometrium levofloxacin eye Sivextro tablet (PA)
prednisolone Rayaldee
prednisolone ODT drops, solution, Sklice
Somatuline Depot*^
prednisone tablet Solosec
(PA)
prednisone intensol metronidazole Sulfatrim
Striant (PA, QL)
progesterone minocycline Suprax
Synthroid
capsule minocycline ER (QL) Tamiflu (QL)
testosterone (PA, QL) TIROSINT (PA)
TIROSINT-SOL (PA) Mondoxyne NL Urogesic-Blue
testosterone
Unithroid nitrofurantoin Valtrex
cypionate
thyroid Vagifem (QL) Nitrofurantoin Vemlidy*
Westhroid Vivelle-Dot (QL) Mono-Macro Vibramycin syrup,
WP Thyroid nystatin suspension
Yuvafem (QL) Okebo Xofluza (QL)
oseltamivir (QL) Zepatier* (PA)
INFECTIONS penicillin V Zithromax packet,
acyclovir capsule, Baraclude Albenza permethrin suspension, tablet
suspension, tablet solution* Alinia sulfamethoxazole- Zyvox (PA)
albendazole Epclusa* (PA) Arikayce* (PA) TMP
amoxicillin Firvanq Bactrim terbinafine tablet
amoxicillin- Harvoni* (PA, QL) Bactrim DS
clavulanate ER tetracycline capsule
Ledipasvir- Baxdela (PA)
amoxicillin- tobramycin ampule*
Sofosbuvir* (PA) Cayston* (PA, QL)
clavulanate Mavyret* (PA) Cipro (PA, QL)
atovaquone Pegasys* (PA) Cleocin valacyclovir
atovaquone- Sofosbuvir- Clindesse valganciclovir
proguanil Velpatasvir* (PA) Cresemba capsule vancomycin capsule
Avidoxy Vandazole
Sovaldi* (PA, QL) (PA)
azithromycin
Thalomid* (PA) Daraprim* (PA) voriconazole tablet
cefdinir
TOBI Podhaler* Dificid (QL) (PA)
cefpodoxime
(PA, QL) Elimite
cefuroxime
cephalexin Vosevi* (PA) EryPed 200
13Cigna Value 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
INFERTILITY NUTRITIONAL/DIETARY (cont)
chorionic Gonal-F*^ (PA) Crinone 8%^ Klor-Con Sprinkle Vitafol+
gonadotropin Menopur*^ (PA) Endometrin^ lanthanum vitaPearl
10,000 unit vial*^ Novarel*^ (PA) Follistim AQ*^ (PA) phytonadione tablet
(PA) Ovidrel*^ (PA) potassium chloride
clomiphene tablet^ capsule, packet,
solution, tablet
MISCELLANEOUS
Prena1 Pearl
disulfiram Cerdelga* (PA) Addyi^ (PA, QL) Prenatal+
Nebusal 3% Esbriet* (PA) Austedo* (PA) Prenatal Vitamin+
PulmoSal Nityr* (PA) Brisdelle (QL) sevelamer
sodium chloride Strensiq* (PA) Exjade* (PA) vitamin D2
inhalation vial Ferriprox* (PA) vitamin D3 5,000
TechLITE Lancets Galafold* (PA) unit+
tetrabenazine* (PA) Ingrezza* (PA)
OSTEOPOROSIS PRODUCTS
trientine* (PA) Jadenu* (PA)
Kuvan* (PA) alendronate (QL) Fosamax Plus D Actonel (ST)
Myalept* (PA) calcitonin-salmon (ST) Atelvia (ST)
Nuedexta (QL) ibandronate tablet Tymlos* (PA, QL) Binosto (ST)
Orfadin* (PA) raloxifene+ Boniva tablet (ST)
Palynziq* (PA) risedronate Evista
Tiglutik* (PA) risedronate DR Fosamax (ST)
MULTIPLE SCLEROSIS PAIN RELIEF AND INFLAMMATORY DISEASE
glatiramer* (PA) Avonex* (PA) Gilenya 0.25mg acetaminophen- Actemra* (PA, Abstral (PA)
Glatopa* (PA) Betaseron* (PA) codeine (PA) QL) Analpram HC
Extavia* (PA) allopurinol Ajovy (PA) Arava
Gilenya 0.5mg* aprizio pak Aimovig (PA) Arymo ER (PA)
(PA) baclofen tablet Belbuca (QL) Benlysta* (PA)
Plegridy* (PA) buprenorphine (QL) Embeda (PA) Butrans (QL)
Rebif* (PA) butalbital- Emgality (PA) Celebrex (ST, QL)
Rebif Rebidose* acetaminophen- Enbrel* (PA, QL) Cimzia* (PA, QL)
(PA) caffeine (QL) Humira* (PA, QL) Colcrys
Tecfidera* (PA) carisoprodol Hysingla ER (PA) Depen* (PA)
celecoxib (QL) Morphabond ER D-Penamine* (PA)
NUTRITIONAL/DIETARY colchicine (PA) Dupixent* (PA)
calcitriol capsule, Drisdol Auryxia (QL) cyclobenzaprine Otezla* (PA, QL) Duragesic (PA)
solution Floriva+ CitraNatal DermacinRx Rasuvo (PA) EC-naprosyn (ST)
calcium 667mg Mephyton Klor-Con M15 Empricaine Remicade*^ (PA) Esgic (QL)
cyanocobalamin OB Complete KPN+ DermacinRx Prizopak Simponi Aria* Fexmid
injection Petite K-Tab ER diclofenac (QL) (PA) Ilaris*^ (PA)
daily prenatal+ Quflora+ Lokelma diclofenac ER Stelara Ilumya* (PA, QL)
FA-8+ Rocaltrol EC-naproxen 45mg/0.5ml, Kadian (PA)
OB Complete
folic acid 1mg eletriptan (QL) 90mg/ml* (PA, Kevzara* (PA, QL)
Perry Prenatal+
endocet (PA) QL) Lidoderm
folic acid 0.4mg, Phoslyra
etodolac Taltz* (PA, QL) Mitigare
0.8mg+ Prenate Mini
etodolac ER Tremfya* (PA, QL) Mobic (ST)
Klor-Con Prenate Pixie fentanyl (PA) Xeljanz XR* (PA, MS Contin (PA)
Klor-Con 10 PrimaCare Fioricet (QL) QL) Nalfon 400 mg (ST)
Klor-Con 8 Renvela frovatriptan (QL) Xeljanz* (PA, QL)
Klor-Con M10 Naprosyn (ST)
Velphoro Glydo Xtampza ER (PA)
Klor-Con M20 Norco (PA)
Veltassa Ztlido Nucynta (PA)
14Cigna Value 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
PAIN RELIEF AND INFLAMMATORY DISEASE (cont) PAIN RELIEF AND INFLAMMATORY DISEASE (cont)
hydrocodone- Nucynta ER (PA) Relador Pak
acetaminophen Olumiant* (PA, QL) Relador Pak Plus
(PA) Orencia syringe* (PA, rizatriptan (QL)
hydromorphone QL) sumatriptan (QL)
solution, Otrexup (PA) sumatriptan-
suppository, tablet Oxaydo (PA) naproxen (QL)
(PA) Percocet (PA) tizanidine
hydromorphone ER Procort tramadol (QL)
(PA) Proctofoam-HC tramadol ER (QL)
IBU Qmiiz ODT (ST, QL) Vicodin HP (PA)
ibuprofen tablet Roxybond (PA) PARKINSON’S DISEASE
indomethacin Savella
Simponi 100mg/ml* benztropine Apokyn* (PA) Azilect (QL)
capsule bromocriptine Duopa*
indomethacin ER (PA, QL)
Skelaxin carbidopa-levodopa Mirapex
ketorolac (QL) carbidopa-levodopa Mirapex ER (QL)
leflunomide Tylenol-Codeine No.3
(PA) ER Neupro
lidocaine (QL) pramipexole Osmolex ER (QL)
lidocaine viscous Tylenol-Codeine No.4
(PA) pramipexole ER (QL) Parlodel
lidocaine-prilocaine rasagiline (QL) Rytary
Uloric (QL)
Lidopril ropinirole Sinemet
Ultram (QL)
Lidopril XR ropinirole ER Sinemet CR
Zanaflex
Lido-Prilo Caine Pack Tasmar
Zebutal (QL)
Livixil Pak Xadago (ST)
Zohydro ER (PA)
Lorcet (PA)
Zyloprim SCHIZOPHRENIA/ANTI-PSYCHOTICS
Lorcet HD (PA)
Lorcet Plus (PA) aripiprazole (QL) Latuda (QL) Fanapt (ST, QL)
Lortab (PA) aripiprazole ODT Invega (ST, QL)
meloxicam chlorpromazine Rexulti (ST, QL)
Metaxall tablet Risperdal (ST)
metaxalone olanzapine tablet Saphris (ST)
methocarbamol olanzapine ODT Seroquel (ST)
tablet Seroquel XR (ST)
paliperidone ER (QL)
morphine solution, Vraylar (ST, QL)
quetiapine
suppository, tablet quetiapine ER
(PA) risperidone
morphine ER (PA)
risperidone ODT
nabumetone
ziprasidone
Nalfon 600mg (ST)
Nalocet (PA) SEIZURE DISORDERS
naproxen carbamazepine Dilantin 30 mg Aptiom (PA, QL)
oxycodone (PA) carbamazepine ER capsule (PA) Banzel (PA, QL)
oxycodone ER (PA) clonazepam Fycompa (PA, QL) Briviact solution,
oxycodone- divalproex VIMPAT (PA) tablet (PA)
acetaminophen divalproex ER Carbatrol (PA)
(PA) epitol Depakote (PA)
Phrenilin Forte (QL) gabapentin Depakote ER (PA)
Prilolid lamotrigine Depakote Sprinkle (PA)
Prilovix lamotrigine (blue, Dilantin 50mg and
Primlev (PA) green, orange) 100mg (PA)
15Cigna Value 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
SEIZURE DISORDERS (cont) SKIN CONDITIONS (cont)
lamotrigine ER Epidiolex* (PA) fluorouracil cream,
lamotrigine ODT Klonopin (PA) topical solution
levetiracetam Lyrica oral solution hydrocortisone
solution, tablet (PA) isotretinoin (QL)
levetiracetam ER Neurontin (PA) ketoconazole
oxcarbazepine Onfi (PA) metronidazole
Roweepra Oxtellar XR (PA) Micort HC 2.5%
Roweepra XR Phenytek (PA) cream
Subvenite Tegretol (PA) mupirocin
Subvenite (Blue, Tegretol XR (PA) Myorisan (QL)
Green, Orange) Neuac gel
topiramate Nolix
topiramate ER
oxiconazole nitrate
vigabatrin*
pimecrolimus
Vigadrone*
Procto-Med HC
SKIN CONDITIONS Procto-Pak
adapalene (PA age) Eucrisa Bryhali (ST) Proctosol-HC
adapalene-benzoyl Fluoroplex Celacyn Proctozone-HC
peroxide Targretin gel* Centany Rosadan cream, gel
Amnesteem (QL) Cleocin T sodium
Avar Cleanser Cloderm (ST) sulfacetamide-
Avar-E Dermasorb TA (ST) sulfur
Avar-E Green Drysol SSS 10-5
azelaic acid Ecoza Sulfacleanse 8-4
betamethasone Efudex tacrolimus ointment
dipropionate Elidel tazarotene
augmented Evoclin
tretinoin (PA age)
betamethasone Lotrisone
tretinoin
BP 10-1 MiCort-HC 2.5%
microsphere (PA
calcipotriene cream (ST)
Mimyx age)
calcipotriene- triamcinolone
betamethasone DP Naftin
Nizoral triderm
Calcitrene Zenatane (QL)
Claravis (QL) Picato
Clindacin ETZ Pramosone SLEEP DISORDERS/SEDATIVES
Protopic armodafinil (PA) Silenor (ST, QL) Hetlioz* (PA)
pledget
Regranex (PA, QL) eszopiclone Lunesta (ST)
Clindacin P pledget
Santyl (QL) Rozerem (ST, QL)
clindamycin-benzoyl modafinil (PA)
Temovate (ST) Xyrem* (PA)
peroxide temazepam
Tolak
clindamycin zolpidem
Topicort (ST)
phosphate Ultravate cream, zolpidem ER (QL)
clindamycin- ointment (ST) SMOKING CESSATION
tretinoin Valchlor*
clobetasol bupropion SR +
Chantix^
Xepi
Clodan shampoo NicoDerm CQ NicoDerm CQ
clotrimazole- 21mg/24hr+ 7mg/24hr,
betamethasone Nicorelief+ 14mg/24hr+
dapsone nicotine gum+ Nicorette+
desoximetasone nicotine lozenge+ Nicotrol^
fluocinonide nicotine patch+
16Cigna Value 3-Tier Prescription Drug List
TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3
$ $$ $$$ $ $$ $$$
SMOKING CESSATION (cont) VACCINES (cont)
Quit 2+
Nicotrol NS^ For plans renewing on 2/1/20 and later: Starting on the date
Quit 4+ Zyban^ your new plan year begins, vaccines will be covered under your
pharmacy benefit. Not all plans will cover vaccines in the same way.
SUBSTANCE ABUSE
Log in to the myCigna App or website, or check your plan materials,
buprenorphine- Lucemyra (QL) Bunavail to find out how your specific plan covers them.
naloxone NARCAN (QL) Suboxone FLUBLOK
Zubsolv QUADRIVALENT+
TRANSPLANT MEDICATIONS FLUCELVAX
azathioprine tablet* Astagraf XL* QUADRIVALENT+
FLUALVAL
mycophenolate Cellcept capsule,
QUADRIVALENT+
capsule, suspension, tablet* Fluzone High-
suspension, tablet* Envarsus XR* dose+
mycophenolic acid* Myfortic* Fluzone
sirolimus* Prograf capsule, Quadrivalent
tacrolimus capsule* granule packet* Pedi+
Rapamune* Fluzone
Zortress* Quadrivalent+
GARDASIL 9+
URINARY TRACT CONDITIONS
HAVRIX+
cevimeline Cystagon* Avodart HEPLISAV-B+
darifenacin ER (QL) Cystagon* Hiberix+
finasteride 5mg Elmiron Infanrix DTaP+
oxybutynin Evoxac IPOL+
oxybutynin ER Flomax KINRIX+
phenazopyridine Proscar Menactra+
Menveo A-C-Y-W-
potassium ER Pyridium
135-DIP+
silodosin (QL) Rapaflo (QL) M-M-R II+
solifenacin (QL) Thiola* PEDIARIX+
tamsulosin Thiola EC* PedvaxHIB+
tolterodine Urocit-K Pentacel+
tolterodine ER (QL) PNEUMOVAX 23+
trospium Prevnar 13+
trospium ER ProQuad+
Quadracel DTaP-
VACCINES
IPV+
For plans renewing on 2/1/20 and later: Starting on the date Recombivax HB+
your new plan year begins, vaccines will be covered under your SHINGRIX+
pharmacy benefit. Not all plans will cover vaccines in the same way. Tenivac+
Log in to the myCigna App or website, or check your plan materials, Trumenba+
to find out how your specific plan covers them. Twinrix+
Diphtheria and ActHIB+ FluMist Quad Nasal+ VAQTA+
Tetanus Toxoids- Rotarix+ VARIVAX+
Adacel Tdap +
ZOSTAVAX+
ped+ Afluria Quad+ RotaTeq+
TdVax+ WEIGHT MANAGEMENT
BEXSERO+
Boostrix Tdap+ Lomaira^ Belviq^ (PA)
DAPTACEL DTaP+ phentermine^ Belviq XR^ (PA)
Engerix-B+ Contrave^ (PA)
Qsymia^ (PA)
FLUAD+ Saxenda^ (PA)
FLUARIX
QUADRIVALENT+
17Medications that are not covered
The medications listed below aren’t covered on your plan’s drug list.^^ This means that if you fill a
prescription for any of these medications, you’ll pay its full cost out-of-pocket and the cost can’t be applied
to your annual deductible or out-of-pocket maximum. Your plan covers other medications that are used
to treat the same condition.^^ They’re listed below.
MEDICATIONS THAT ARE GENERIC AND/OR PREFERRED
DRUG CLASS
NOT COVERED^^ BRAND ALTERNATIVE(S)
AIDS/HIV Combivir* lamivudine-zidovudine*
Epivir* lamivudine*
Epzicom* abacavir-lamivudine*
Kaletra solution* lopinavir-ritonavir solution*
Lexiva tablet* fosamprenavir*
Norvir tablet* ritonavir*
Retrovir capsule, syrup* zidovudine capsule, syrup*
Reyataz capsule* atazanavir*
Sustiva* efavirenz*
Trizivir* abacavir-lamivudine-zidovudine*
Viramune* nevirapine*
Viramune XR* nevirapine ER*
Ziagen* abacavir*
ALLERGY/NASAL SPRAYS Auvi-Q epinephrine auto-injectors
EpiPen, EpiPen Jr
Dymista Generic nasal steroids (e.g. fluticasone^)
RyVent carbinoxamine 4mg tablet
carbinoxamine 6mg tablet
ANXIETY/DEPRESSION/BIPOLAR Anafranil clomipramine
Aplenzin bupropion XL
Wellbutrin XL
Ativan tablet lorazepam
Cymbalta duloxetine
Lexapro escitalopram
Pamelor nortriptyline capsules
Parnate tranylcypromine
Pexeva paroxetine/CR/ER
Pristiq bupropion XL
duloxetine
Tofranil imipramine tablet
ASTHMA/COPD/RESPIRATORY Advair Diskus Dulera
Advair HFA fluticasone-salmeterol
AirDuo RespiClick Symbicort
Breo Ellipta Wixela Inhub
Alvesco Flovent
Arnuity Ellipta QVAR RediHaler
Asmanex
Asmanex HFA
^^
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 and the cost can’t
be applied to your annual deductible or out-of-pocket maximum.
18MEDICATIONS THAT ARE GENERIC AND/OR PREFERRED
DRUG CLASS
NOT COVERED^^ BRAND ALTERNATIVE(S)
ASTHMA/COPD/RESPIRATORY (cont) Arcapta neohaler Striverdi Respimat
Bevespi Aerosphere Anoro Ellipta
Stiolto Respimat
Utibron Neohaler
Elixophyllin theophylline oral solution
ProAir HFA albuterol HFA
ProAir RespiClick
Proventil HFA
Ventolin HFA
Xopenex HFA
Pulmicort Flexhaler QVAR
Seebri Neohaler Incruse Ellipta
Spiriva
Spiriva Respimat
Tudorza Pressair
Striverdi Respimat Serevent Diskus
Yupelri Anoro Ellipta
Incruse Ellipta
Trelegy Ellipta
Zyflo montelukast
zafirlukast
zileuton ER
ATTENTION DEFICIT HYPERACTIVITY Adderall XR dexmethylphenidate ER
Adhansia XR dextroamphetamine-amphetamine ER
Aptensio XR methylphenidate ER/CD/LA
Concerta
Cotempla XR-ODT
Focalin XR
Mydayis
QuilliChew ER
Ritalin LA
Adzenys ER dexmethylphenidate ER
Adzenys XR-ODT methylphenidate ER/CD/LA
Desoxyn methamphetamine
Dexedrine dextroamphetamine
Dyanavel XR methylphenidate ER/CD/LA
Evekeo ODT amphetamine
dexmethylphenidate
dextroamphetamine
methamphetamine
methylphenidate
Vyvanse dexmethylphenidate ER
BLOOD PRESSURE/HEART MEDICATIONS Accupril quinapril
Accuretic quinapril HCTZ
Altace ramipril
Atacand candesartan
Atacand HCT candesartan HCTZ
Avalide irbesartan HCTZ
Avapro
^^
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 and the cost can’t
be applied to your annual deductible or out-of-pocket maximum.
19MEDICATIONS THAT ARE GENERIC AND/OR PREFERRED
DRUG CLASS
NOT COVERED^^ BRAND ALTERNATIVE(S)
BLOOD PRESSURE/HEART MEDICATIONS Azor amlodipine-olmesartan
(cont) Benicar olmesartan
Benicar HCT olmesartan HCTZ
Betapace sotalol oral
Bystolic Generic beta blockers (e.g. metoprolol, atenolol)
Cardizem diltiazem
Cardizem CD diltiazem CD
Cozaar losartan
Diovan valsartan
Diovan HCT valsartan HCTZ
Edarbi Generic ARBs (e.g. losartan, calsartan)
Edarbyclor Generic ARBs + HCTZ (e.g. losartan-HCTZ)
Exforge amlodipine-valsartan
Exforge HCT amlodipine-valsartan HCTZ
Firazyr* icatibant
Hyzaar losartan HCTZ
Isordil isosorbide dinitrate
Isordil Titradose isosorbide dinitrate
digoxin
Lanoxin Digitex
digoxin
Lotensin benazepril
Lotensin HCT benazepril HCTZ
Lotrel amlodipine-benazepril
Micardis telmisartan
Micardis HCT telmisartan HCTZ
Prinvil lisinopril
Zestril
Tarka trandolapril-verapamil
Tekturna Generica ACE/ARBs
Tekturna HCT Generica ACE/ARBs + HCTZ
Tribenzor olmesartan-amlodipine-HCTZ
Twynsta telmisartan-amlodipine
Vaseretic enalapril-HCTZ
Vasotec enalapril
Zestoretic lisinopril HCTZ
BLOOD THINNERS/ANTI-CLOTTING Yosprala aspirin or enteric aspirin
CANCER Nilandron nilutamide
Tarceva* erlotinib*
Yonsa* abiraterone*
Zytiga*
^^
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 and the cost can’t
be applied to your annual deductible or out-of-pocket maximum.
20MEDICATIONS THAT ARE GENERIC AND/OR PREFERRED
DRUG CLASS
NOT COVERED^^ BRAND ALTERNATIVE(S)
CHOLESTEROL MEDICATIONS Antara fenofibrate
Fenoglide
Altoprev atorvastatin
Ezallor Sprinkle lovastatin
Livalo pravastatin
Zypitamag rosuvastatin
simvastatin
Crestor rosuvastatin
Lescol XL fluvastatin
Lipitor atorvastatin
Pravachol pravastatin
Vytorin ezetimibe-simvastatin
CONTRACEPTION PRODUCTS Balcoltra Generic oral contraceptives
Natazia (e.g. levonorgestrel-ethinyl estradiol)
Slynd
Taytulla
COUGH/COLD MEDICATIONS benzonatate 150mg benzonatate 100mg, 200mg
TussiCaps hydrocodone-chlorpheniramine ER
promethazine with codeine syrup
DIABETES Accu-Chek Aviva Plus test strips One Touch test strips (e.g. Ultra; Verio)
Accu-Chek Guide test strips
Accu-Chek Smartview
Accutrend glucose
Adlyxin Byetta
Bydureon
Ozempic
Trulicity
Victoza
Ademelog Humalog
Afrezza Humulin
Apidra
Apidra SoloStar
Fiasp
Novolin, Novolog
alogliptin Janumet
alogliptin-metformin Janumet XR
Januvia
metformin
alogliptin-pioglitazone Janumet
Janumet XR
Januvia
pioglitazone
Fortamet metformin ER (generic to Glucophage XR)
Glumetza
metformin ER (generic to Fortamet and
Glumetza)
^^
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 and the cost can’t
be applied to your annual deductible or out-of-pocket maximum.
21MEDICATIONS THAT ARE GENERIC AND/OR PREFERRED
DRUG CLASS
NOT COVERED^^ BRAND ALTERNATIVE(S)
DIABETES (cont) GlucaGen HypoKit Baqsimi
Gvoke Glucagon Emergency Kit
Invokamet Segluromet
Invokamet XR Synjardy
Synjardy XR
Xigduo XR
Invokana Farxiga
Jardiance
metformin
Steglatro
Jentadueto Janumet
Jentadueto XR Janumet XR
Kazano
Lantus Basaglar
Toujeo SoloStar Levemir vial or Levemir Flextouch
Tresiba FlexTouch
Nesina Januvia
Tradjenta Janumet
Janumet XR
metformin
Oseni Generic TZDs (e.g. pioglitazone)
Janumet
Janumet XR
Januvia
QTERN Glyxambi
Steglujan metformin
DIURETICS Edecrin bumetanide
ethacrynic acid furosemide
torsemide
EYE CONDITIONS Alocril cromolyn
Alomide
Pataday azelastine^
Patanol epinastine^
olopatadine
Cequa Restasis
Restasis MultiDose
Xiidra
Lumigan bimatoprost
Travatan Z latanoprost
Xalatan travoprost
Xelpros
Zioptan
Vyzulta bimatoprost
latanoprost
Lumigan
^^
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 and the cost can’t
be applied to your annual deductible or out-of-pocket maximum.
22MEDICATIONS THAT ARE GENERIC AND/OR PREFERRED
DRUG CLASS
NOT COVERED^^ BRAND ALTERNATIVE(S)
GASTROINTESTINAL/HEARTBURN Anusol HC suppository hydrocortisone suppository
Asacol HD Apriso
Colazal balsalazide
Delzicol mesalamine tablets or capsules
Dipentum Pentasa
sulfasalazine
CoLyte with Flavor Packets+ Clenpiq+
GoLytely+ GaviLyte-C+
MoviPrep+ GaviLyte-G+
NuLYTELY with flavor packs+ GaviLyte-N+
OsmoPrep+ 3550 Electrolyte+
Plenvu+ Prepopik+
SuPrep+
Cortifoam Prescription hydrocortisone enema, rectal
Uceris foam cream, suppository
Creon Pancreaze
Pertzye
Zenpep
Librax chlordiazepoxide-clidinium
Linzess Amitiza
Motegrity
Trulance
Zelnorm
Marinol dronabinol
Syndros
Omeclamox-Pak lansoprazole-amoxicillin-clarithromycin (combo
Pylera pack)
Rowasa mesalamine rectal enema suspension
Sensipar* cinacalcet
Zofran ondansetron
Zuplenz ondansetron
ondansetron ODT
HORMONAL AGENTS Cortrosyn cosyntropin
DDAVP desmopressin
Dxevo dexamethasone 1.5mg tablet
TaperDex 7-Day
Fortesta AndgroGel
Natesto testosterone
Testim
Vogelxo
Xyosted
Genotropin* Humatrope* (PA)
Nutropin AQ nuspin*
Omnitrope*
Saizen*
Saizen-Saizenprep*
Zomacton*
^^
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 and the cost can’t
be applied to your annual deductible or out-of-pocket maximum.
23MEDICATIONS THAT ARE GENERIC AND/OR PREFERRED
DRUG CLASS
NOT COVERED^^ BRAND ALTERNATIVE(S)
HORMONAL AGENTS (cont) Nocdurna desompression acetate nasal spray or tablets
Rayos prednisone
Uceris tablets budesonide tablet
dexamethasone
hydrocortisone
methylprednisolone
prednisolone
prednisone
INFECTIONS Acticlate Generic products (e.g. doxycycline; minocycline)
Doryx
Doryx MPC
Minocin capsule
Minolira ER
Oracea
Seysara
Solodyn
Targadox
Vibramycin
Ximino
Arakoda atovaquone-proguanil
doxycycline
hydroxychloroquine
quinine
Augmentin/ES amoxicillin-clavulanate
Baraclude tablet* entecavir tablet
Bethkis* tobramycin inhalation solution*
Tobi
Diflucan fluconazole
E.E.S. 200 erythromycin granules
Eryped 400 erythromycin ethylsuccinate
Mepron atovaquone
Mycobutin rifabutin
Noxafil tablet posaconazole DR 100mg tablet
Sitavig acyclovir tablet
famciclovir tablet
valacyclovir tablet
Sporanox itraconazole oral
Tolsura
Valcycte valganciclovir
Vancocin vancomycin oral capsule
Zovirax acyclovir
MISCELLANEOUS Horizant gabapentin
Syprine* Depen*
penicillamine*
trientine*
Xenazine* tetrabenazine*
^^
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 and the cost can’t
be applied to your annual deductible or out-of-pocket maximum.
24MEDICATIONS THAT ARE GENERIC AND/OR PREFERRED
DRUG CLASS
NOT COVERED^^ BRAND ALTERNATIVE(S)
MULTIPLE SCLEROSIS Ampyra ER* dalfampridine ER
Aubagio* Gilenya*
Mayzent*
Tecfidera*
Copaxone* Avonex*
Betaseron*
Extavia*
Gilenya*
glatiramer*
Glatopa*
Plegridy*
Rebif*
Tecfidera*
NUTRITIONAL/DIETARY Azesco Any generic prenatal vitamin
PreGenna
Trinaz
Nascobal cyanocobalamin injection
PAIN RELIEF AND INFLAMMATORY Allzital butalbital-acetaminophen tablets
butalbital-acetaminophen-caffeine capsules
and tablets
Amerge generic triptans (e.g. naratriptan; sumatriptan)
Frova
Maxalt
Maxalt MLT
Relpax
Amrix cyclobenzaprine
Other generic muscle relaxants
BUPAP butalbital-acetaminophen tablets
Cambia Generic prescription NSAID (e.g.celecoxib,
Duexis meloxicam)
Ergomar
Fenortho
Indocin
Naprelan
Treximet
Vimovo
Zipsor
ConZip Tramadol
Tramadol ER
Cosentyx* Enbrel*
Humira*
Otezla*
Stelara*
Taltz*
Cuprimine* Depen*
penicillamine*
trientine*
D.H.E. 45 dihydroergotamine injection
^^
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 and the cost can’t
be applied to your annual deductible or out-of-pocket maximum.
25MEDICATIONS THAT ARE GENERIC AND/OR PREFERRED
DRUG CLASS
NOT COVERED^^ BRAND ALTERNATIVE(S)
PAIN RELIEF AND INFLAMMATORY (cont) diclofenac 1.3% patch diclofenac 1% gel, generic oral NSAIDs
Flector 1.3% patch (e.g. celecoxib; meloxicam)
Voltaren 1% gel
Gralise gabapentin
Imitrex sumatriptan
Zembrace Symtouch
Kineret* Enbrel* (PA)
Simponi* Humira* (PA)
levorphanol codeine with acetaminophen
Embeda
hydrocodone with acetaminophen
Hysingla
oxycodone with acetaminophen
Tramadol
Xtampza ER
Lorzone chlorzoxazone 500mg
Migranal dihydroergotamine nasal spray
ONZETRA Xsail Generic triptans (e.g. nasal sumatriptan; narat-
riptan tablet)
Oxycontin Embeda ER (PA)
Hysingla ER (PA)
Xtampza ER
Pennsaid diclofenac 1% gel
Roxicodone oxycodone
Siliq* Enbrel* (PA)
Humira* (PA)
Stelara*
Soriatane acitretin
Sprix ketorolac tablet
SUBSYS fentanyl lozenge or buccal tablet
Tivorbex indomethacin
Vanatol LQ butalbital-acetaminophen-caffeine
Vanatol S
Vivlodex meloxicam
Zomig sumatriptan
zolmitriptan
Zomig ZMT zolmitriptan ODT
Zorvolex diclofenac
PARKINSON’S DISEASE Gocovri amantadine
Lodosyn carbidopa
Requip XL ropinirole extended release
Zelapar selegiline tablets or capsules
SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify aripiprazole
Abilify MyCite
FazaClo clozapine
Versacloz clozapine ODT
Geodon capsule ziprasidone
Zyprexa olanzapine
Zyprexa Zydis olanzapine ODT
^^
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 and the cost can’t
be applied to your annual deductible or out-of-pocket maximum.
26MEDICATIONS THAT ARE GENERIC AND/OR PREFERRED
DRUG CLASS
NOT COVERED^^ BRAND ALTERNATIVE(S)
SEIZURE DISORDERS Felbatol felbamate
Keppra oral solution, tablet levetiracetam
Keppra XR levetiracetam ER
Lamictal lamotrigine
Lamictal (blue, green, orange) lamotrigine (blue, green, orange)
Lamictal ODT lamotrigine ODT
Lamictal ODT (blue, green, orange) lamotrigine ODT (blue, green, orange)
Lamictal XR lamotrigine ER
Lamictal XR (blue, green, orange) lamotrigine ER (blue, green, orange)
Lyrica CR duloxetine
gabapentin
lidocaine 5% patch
Mysoline primidone
Qudexy XR topiramate ER
Trokendi XR
Sabril* vigabatrin*
Sympazan clobazam
Topamax topiramate
Trileptal oxcarbazepine
Zonegran zonisamide
SKIN CONDITIONS Absorica Myorisan or Zenatane
Acanya Use generic products (e.g. adapalene; tretinoin;
Aczone clindamycin-benzoyl peroxide)
Aktipak
Altreno
Atralin
Avita
Azelex
Differin
Duac
Epiduo
Epiduo Forte
Fabior
Onexton
Retin-A
Retin-A Micro
Tazorac
Veltin
Ziana
Aldara imiquimod 5% cream
Zyclara
Anusol-HC cream hydrocortisone cream
Apexicon E betamethasone, clobetasol, halobetasol
diflorasone
Impoyz
Olux
Olux-E
Psorcon
Bensal HP salicylic acid 6% cream, cream kit, gel, lotion
Benzaclin clindamycin-benzoyl peroxide
Neuac Kit
^^
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 and the cost can’t
be applied to your annual deductible or out-of-pocket maximum.
27MEDICATIONS THAT ARE GENERIC AND/OR PREFERRED
DRUG CLASS
NOT COVERED^^ BRAND ALTERNATIVE(S)
SKIN CONDITIONS (cont) Carac fluorouracil 0.5% cream
Clindagel clindamycin gel, topical solution
Condylox imiquimod 5% cream packet
podofilox 0.5% topical solution
Cutivate lotion fluticasone topical lotion
Denavir acyclovir tablet
Zovirax cream, ointment famciclovir tablet
valacyclovir tablet
diclofenac 3% gel Fluoroplex
imiquimod 5% cream
Picato
topical fluorouracil
Dovonex calcipotriene
Duobrii halobetasol plus
tazarotene cream
Enstilar calcipotriene
Taclonex calcipotriene-betamethasone DP
tazarotene cream
topical betamethasone
Ertaczo ketoconazole cream
Exelderm topical econazole
topical ketoconazole
topical oxiconazole
Extina ketoconazole cream, foam
Finacea foam azelaic acid, topical metronidazole
Finacea gel
MetroCream
MetroGel
MetroLotion
Soolantra
flurandrenolide betamethasone
hydrocortisone butyrate lipid cream, fluocinolone
lotion fluticasone
Pandel
HALOG clobetasol cream, ointment
halobetasol cream, ointment
Jublia ciclopirox topical solution
Kerydin itraconazole capsules
terbinafine tablets
Kenalog spray triamcinolone acetonide aerosol spray
Lexette clobetasol cream, ointment
halobetasol cream, foam, ointment
Locoid hydrocortisone cream, lipid cream, ointment,
solution
Locoid Lipocream hydrocortisone lipid cream
Loprox ciclopirox cream, shampoo
Luzu econazole
ketoconazole cream
luliconazole
oxiconazole
^^
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 and the cost can’t
be applied to your annual deductible or out-of-pocket maximum.
28MEDICATIONS THAT ARE GENERIC AND/OR PREFERRED
DRUG CLASS
NOT COVERED^^ BRAND ALTERNATIVE(S)
SKIN CONDITIONS (cont) Noritate metronidazole cream
Oxistat etoconazole cream
Penlac ciclopirox solution
Prudoxin Generic topical steroid (e.g. topical tacrolimus)
Zonalon
Sernivo clobetasol spray
triamcinolone acetonide aerosol spray
Sorilux calcipotriene
Trianex triamcinolone cream, ointment
Tridesilon alclometasone
desonide
triamcinolone
Ultravate clobetasol lotion
Vanos fluocinonide 0.1% cream
Vectical calcitriol ointment
Verdeso desonide cream, ointment
Xerese acyclovir tablet
famciclovir tablet
hydrocortisone prescription cream
valacyclovir tablet
Xolegel ciclopirox 0.77% gel
ciclopirox 1% shampoo
ketoconazole 2% cream
ketoconazole 2% foam
selenium 2.5% lotion
sodium sulfacetamide 10% shampoo
SLEEP DISORDERS/SEDATIVES Ambien zolpidem
Ambien CR zolpidem ER
Ativan lorazepam
Belsomra Dayvigo
Edluar zolpidem/ER
Intermezzo
Nuvigil armodafinil
Provigil modafinil
Restoril temazepam
Zolpimist Belsomra
eszopiclone
Silenor
zaleplon
zolpidem/ER
SUBSTANCE ABUSE Evzio narcan nasal spray
URINARY TRACT CONDITIONS Detrol tolterodine
Detrol LA tolterodine ER
Ditropan XL oxybutynin ER
Enablex darifenacin ER
Gelnique darifenacin ER
Myrbetriq oxybutynin ER
Toviaz tolterodine ER
VESIcare trospium ER
Procysbi* Cystagon*
^^
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 and the cost can’t
be applied to your annual deductible or out-of-pocket maximum.
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