2014 FORMULARY CHANGE NOTICE PLEASE NOTE THESE IMPORTANT CHANGES TO YOUR 2014 FORMULARY (LIST OF COVERED DRUGS)
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1 Cigna Medicare Rx Secure-Xtra (PDP) 2014 FORMULARY CHANGE NOTICE PLEASE NOTE THESE IMPORTANT CHANGES TO YOUR 2014 FORMULARY (LIST OF COVERED DRUGS) Effective date of : 03/01/2014 ASACOL 400MG TABLET deletion strength removed cimetidine hcl 150mg/ml injection deletion dosage form removed ELSPAR UNIT INJECTION deletion drug removed from endocet 7.5mg/500mg & 10mg/650mg deletion strengths with greater than 325mg of acetaminophen per tablet removed from FREAMINE III 8.5% IV SOLUTION deletion strength removed hydrocodone/acetaminophen deletion 2.5mg/500mg tablet a 03/2014 strength with greater than 325mg of acetaminophen per tablet removed from Apriso, Lialda or Pentasa famotidine injection, ranitidine injection endocet 7.5mg/325mg & 10mg/325mg hydrocodone/ acetaminophen 2.5mg/325mg T3 T1 T2 T2 Last updated 03/2014 S5617_14_15733 Approved HPMS approved formulary file submission ID version number v08
2 Effective date of : 03/01/2014 (continued) LEUKINE 500MCG/ML INJECTION deletion strength removed LEVOTHROID deletion brand drug removed MAXAIR AUTOHALER deletion drug removed from ONSOLIS FILM deletion drug removed from orphenadrine/aspirin/caffeine deletion drug removed from PREZISTA 400MG TABLET deletion strength removed tobramycin sulfate/sodium chloride deletion strength removed 60mg/50ml piggyback TYZINE 0.1% NASAL DROPS deletion strength removed LEUKINE 250MCG/ML INJECTION levothyroxine sodium PROAIR fentanyl citrate oral transmucosal lozenge (requires PA) PREZISTA 600MG, 800MG TABLET TYZINE 0.05% NASAL DROPS T5 T1 T3 T5 T5 T4 Effective date of : 02/01/2014 ALORA enhancement removed PA ANGELIQ enhancement removed PA ascomp/codeine enhancement removed PA benztropine mesylate tablet enhancement removed PA butalbital/acetaminophen T2 2
3 Effective date of : 02/01/2014 (continued) butalbital/acetaminophen/caffeine T2 butalbital/acetaminophen/caffeine/ enhancement removed PA codeine butalbital/aspirin/caffeine T2 carbinoxamine maleate solution & tablet enhancement removed PA chlorpropamide enhancement removed PA chlorzoxazone enhancement removed PA clemastine fumarate 2.68mg tablet enhancement removed PA cyproheptadine hcl syrup & tablet enhancement removed PA DEMEROL INJECTION enhancement removed PA digoxin enhancement removed PA diphenydramine hcl 50mg capsule enhancement removed PA diphenydramine hcl 50mg/ml injection enhancement removed PA dipyridamole enhancement removed PA disopyramide phosphate 100mg & 150mg enhancement removed PA capsules DIVIGEL enhancement removed PA ENJUVIA enhancement removed PA ergoloid mesylates enhancement removed PA esomeprazole sodium 20mg, 40mg T2 injection estradiol tablets enhancement removed PA estradiol/norethindrone tablets enhancement removed PA ESTRASORB enhancement removed PA estropipate enhancement removed PA glyburide & glyburide micronized enhancement removed PA 3
4 Effective date of : 02/01/2014 (continued) glyburide/metformin hcl enhancement removed PA guanfacine hcl enhancement removed PA hydroxyzine hcl enhancement removed PA hydroxyzine pamoate enhancement removed PA indomethacin & indomethacin er enhancement removed PA INTUNIV enhancement removed PA jinteli enhancement removed PA ketorolace tromethamine injection & enhancement removed PA tablet LANOXIN enhancement removed PA lomedia 24 fe T2 MACRODANTIN 25MG CAPSULE enhancement removed PA MEGACE SUSPENSION enhancement removed PA MEGACE ES SUSPENSION enhancement removed PA megestrol acetate suspension enhancement removed PA MENEST enhancement removed PA meperidine hcl injection & tablet enhancement removed PA meperitab enhancement removed PA meprobamate enhancement removed PA methyldopa enhancement removed PA methyldopa/hctz enhancement removed PA methyldopate hcl injection enhancement removed PA metronidazole 375mg capsule T2 moderiba 200mg tablet T2 moderiba 200mg-400mg, 400mg-400mg, 600mg-400mg & 600mg-600mg dosepack T5 4
5 Effective date of : 02/01/2014 (continued) mycophenolic acid dr 180mg, 360mg T2 BvsD tablet niacin er 500mg tablet T2 QL 30 per 30 days niacin er 750mg, 1000mg tablet T2 QL 60 per 30 days nifedipine 10mg & 20mg capsule enhancement removed PA orphenadrine citrate 30mg/ml injection enhancement removed PA orphenadrine citrate er 100mg tablet enhancement removed PA palgic enhancement removed PA pentazocine/acetaminophen tablet enhancement removed PA pentazocine/naloxone tablet enhancement removed PA phenadoz suppository enhancement removed PA PREFEST enhancement removed PA PREMARIN TABLET enhancement removed PA PREMPHASE enhancement removed PA PREMPRO enhancement removed PA promethazine hcl enhancement removed PA promethazine vc enhancement removed PA promethagan suppository enhancement removed PA reserpine tablet enhancement removed PA sirolimus 0.5mg tablet T2 BvsD TALWIN INJECTION enhancement removed PA telmisartan 20mg, 40mg, 80mg tablet T2 QL 30 per 30 days telmisartan/amlodipine 40mg-5mg, 40mg-10mg, 80mg-5mg, 80mg-10mg tablet T2 QL 30 per 30 days 5
6 Effective date of : 02/01/2014 (continued) ticlopidine hcl enhancement removed PA tolterodine tartrate er 2mg, 4mg capsule T2 QL 30 per 30 days trihexyphenidyl hcl enhancement removed PA trimethobenzamide hcl 300mg capsule enhancement removed PA VIVELLE-DOT enhancement removed PA Effective date of : 01/01/2014 abacavir sulfate/lamivudine/zidovudine T5 acamprosate calcium T2 QL 180 per 30 days acitretin 10mg, 17.5mg & 25mg capsule T5 adefovir dipivoxil T5 ADEMPAS T5 QL 90 per 30 days ADRENALIN 1MG/ML INJECTION T3 AFINITOR DISPERZ 2MG & 3MG T5 QL 60 per 30 days AFINITOR DISPERZ 5MG T5 QL 120 per 30 days ASTAGRAF XL T4 BvsD azacitidine 100mg injection T2 BCG VACCINE T3 BETHKIS T5 BvsD BRINTELLIX T4 QL 30 per 30 days BUTRANS PATCH T3 QL 4 per 28 days 6
7 Effective date of : 01/01/2014 (continued) candesartan cilexetil T1 QL 30 per 30 days clemastine fumarate 0.67mg/5ml syrup T2 decitabine 50mg injection T5 BvsD diclofenac sodium 3% gel T2 donepezil hcl 23mg tablet T2 QL 30 per 30 days duloxetine hcl T2 QL 60 per 30 days ERWINAZE 10,000 UNITS VIAL T5 BvsD estradiol patch T2 fenofibrate 43mg & 130mg capsule T2 QL 30 per 30 days fenofibric acid 45mg capsule T2 QL 60 per 30 days fenofibric acid 135mg capsule T2 QL 30 per 30 days FETZIMA 20MG, 40MG, 80MG & 120MG T4 QL 30 per 30 days CAPSULE FETZIMA TITRATION PACK T4 QL 28 per 28 days FYCOMPA T4 gatifloxacin 0.5% solution T2 GILOTRIF T5 GRANIX T5 IMBRUVICA 140MG CAPSULE T5 INTELENCE 25MG TABLET T4 LATUDA 60MG TABLET T3 QL 30 per 30 days LIDODERM PATCH enhancement moved from tier 4 to tier 2 LOMUSTINE CAPSULE T3 lyza T2 metronidazole 1% gel T2 7
8 Effective date of : 01/01/2014 (continued) morphine sulfate er 10mg capsule T2 QL 60 per 30 days norethindrone 0.35mg tablet T2 nortriptyline hcl 10mg/5ml solution T2 NOXAFIL 100MG TABLET T5 ONCASPAR 750 UNIT/ML VIAL T5 BvsD ONFI 2.5MG/ML SUSPENSION T4 QL 480 per 30 days OXTELLAR XR T4 oxycodone hcl 5mg/5ml solution T2 paricalcitol capsule T2 BvsD pimtrea T2 pirmella T2 PRADAXA enhancement moved from tier 4 to tier 3 rabeprazole sodium T2 QL 60 per 30 days repaglinide T2 ROXICODONE 15MG TABLET T4 QL 300 per 30 days ROXICODONE 30MG TABLET enhancement QL increased to 300 per 30 days SUPREP BOWEL PREP T4 TIVICAY T5 tobramycin 300mg/5ml inhalation T5 BvsD solution VERSACLOZ T4 vestura T2 voriconazole 40mg/ml suspension T5 zenchent T2 ZOMIG 2.5MG NASAL SPRAY T4 QL 12 per 30 days 8
9 Cost-sharing tier description key Utilization management requirements/limits key 1: Preferred generic drugs. 2: Non-preferred generic drugs. 3: Preferred brand drugs. 4: Non-preferred brand drugs. 5: Specialty tier. B vs D: Coverage determination for Part B or Part D required. Note: Inhalant solutions used in a nebulizer are only covered under Part D when the member is located in a long term care (LTC) setting. PA: Prior authorization is required. QL: Quantity limits apply. RA: Restricted access. This prescription may be available only at certain pharmacies. ST: Step therapy is required. You have a right to ask us to make a coverage determination, including an exception to this. You can ask us to make a coverage determination about the drug(s) or payment you need, including an exception. Look in your Evidence of Coverage for information about how to ask for a coverage decision, including an exception. If you have any questions, please contact Customer Service at from 8 am 8 pm, local time, 7 days a week. (TTY users call 711). This information is available for free in other languages. Please call our customer service number at , from 8 am 8 pm, local time, 7 days a week. (TTY users should call 711). Esta información está disponible de forma gratuita en otros idiomas. Por favor, llame a nuestro servicio al cliente al de 8 am 8 pm hora local, los 7 días de la semana. (Los usuarios de TTY deben llamar al 711). This amendment forms a part of the issued to you by Cigna Health and Life Insurance Company describing the benefits provided under the policy(ies) specified above. Cigna, Cigna Medicare Services, Cigna Medicare Rx (PDP) and the Tree of Life logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries, including Cigna Health and Life Insurance Company (CHLIC), and not by Cigna Corporation. Cigna Medicare Rx is a PDP plan with a Medicare contract. Enrollment in Cigna Medicare Rx depends on contract renewal a 03/ Cigna Corporation. Some content provided under license.
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FREE PICK-UP & DELIVERY Flu-Shots Specialty prescription Compounding Wellness center providing health screenings for hypertension and diabetes $3 Special Generic Prescription Drug Program only offered
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Medicationstoavoidintheelderly Description Medicationstoavoid 1 (nonformularyin2016) Adversesideeffects/concerns Formularyalternatives 2,3 Alphaagonists, central Analgesics Androgen Anti anxiety guanabenz
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2014 Quantity Limits (QL) Criteria
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2016 List of Covered Drugs (Formulary)
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ulary ulary Effective ADDS 00472088282 ACETASOL HC 2%; 1% SOLN Pref(1) no 1/29/2009 3/1/2009 68382026101 ACETAZOLAMIDE 500MG CP12 Pref(1) yes 3/24/2009 5/1/2009 00078056651 AFINITOR 5MG TABS Pref (4);
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Drug Name (specify drug) Quantity Frequency Strength
Prior Authorization Form GEHA FEDERAL - STANDARD OPTION 1363-M Opioids IR MME Limit and Post Limit This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,
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Allergy, Cough and Cold. Analgesic. Anti-Anxiety. Antibiotic
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PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES Select Formulary October 1, 2018 Updates. Formulary. Alternatives
PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES Select October 1, 2018 Updates Drug Name efavirenz 600mg (Brand = Sustiva ) trientine (Brand = Syprine ) hydrocortisone lot 0.1% (Brand = Locoid ) sumatriptan-naproxen
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Prior Authorization Form MEDICA HEALTH PLAN IA EXCHANGE 1362-M Opioids IR Labeling Post Limit (HMF) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,
Acyclovir Ointment. Aetna Better Health Pennsylvania. Products Affected. acyclovir ointment 5 % external Details. Criteria
Medications that require Step Therapy (ST) require trial and failure of preferred formulary agents prior to their authorization. If the prerequisite medications have been filled within the specified time