PRESCRIPTION DRUG LIST CHANGES For Providers 2018 Changes are being made to Cigna s Prescription Drug List that may affect some of your patients. These changes are listed by drug list name and by effective date. Below is the list of medications that are changing coverage levels. If you have patients who continue to fill prescriptions for these medications on or after the date listed, they will be responsible for the full cost and will not receive coverage for these medications. We encourage you to speak with your affected patients to see if there are covered alternative medications that may work for them. Please note that the coverage status of medications under our Prescription Drug Lists are always subject to the cost-share requirements, exclusions and coverage limitations of particular benefit plans. STANDARD PRESCRIPTION DRUG LIST Drug(s) not covered in drug class^ January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipramine Pamelor Parnate Tofranil Drug(s) covered in drug class nortriptyline tranylcypromine imipramine ASTHMA/COPD/RESPIRATORY Zyflo montelukast, zafirlukast, zileuton ER ATTENTION DEFICIT HYPERACTIVITY DISORDER Zyflo CR Desoxyn Dexedrine zileuton ER methamphetamine dextroamphetamine, dextroamphetamine ER BLOOD PRESSURE/HEART MEDICATIONS Betapace sotalol tablets CANCER Nilandron nilutamide DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR Invokana Farxiga, Jardiance Lantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba Novolin, Novolog Humalog, Humulin GASTROINTESTINAL/HEARTBURN Cortifoam, Uceris rectal foam Anucort-HC, Colocort, Hemmorex-HC, hydrocortisone, Procto-Med HC, Procto- Pak, Proctosol-HC, Proctozone-HC Lotronex alosetron Marinol dronabinol omeprazole bicarbonate packets, omeprazole 40-1100mg capsules Rowasa mesalamine enema Uceris tablet budesonide EC capsule 909016 UPDATED_10/27/2017
STANDARD PRESCRIPTION DRUG LIST (cont.) Drug(s) not covered in drug class^ Drug(s) covered in drug class January 1, 2018 GASTROINTESTINAL/HEARTBURN (cont) Zegerid omeprazole Zofran ondansetron Zofran ODT ondansetron ODT HORMONAL AGENTS DDAVP desmopressin Hectorol doxercalciferol capsule INFECTIONS Augmentin, Augmentin ES, Augmentin XR amoxicillin-clavulanate ER, amoxicillinclavulanate Diflucan fluconazole E.E.S. 200, Eryped 400 erythromycin ethylsuccinate Mepron atovaquone Sporanox itraconazole Targadox Valcyte Vancocin Zovirax Avidoxy tablet, doxycycline hyclate, Morgidox capsule valganciclovir vancomycin capsule acyclovir MISCELLANEOUS Gralise, Horizant gabapentin PAIN RELIEF AND INFLAMMATORY DISEASE Cambia diclofenac, diclofenac ER, etodolac, etodolac ER, fenoprofen, Fenortho, flurbiprofen, ibuprofen, indomethacin, indomethacin ER, ketoprofen, Ketorolac, meclofenamate, mefenamic acid, meloxicam, nabumetone D.H.E. 45, Migranal dihydroergotamine Imitrex, Sumavel DosePro Lorzone OxyContin Roxicodone Tivorbex Vanatol LQ Vivlodex Zomig Zorvolex sumatriptan chlorzoxazone Embeda, Hysingla ER, Xtampza ER oxycodone indomethacin PARKINSON'S DISEASE Lodosyn carbidopa Requip XL butalbital/acetaminophen/caffeine tabs or caps meloxicam sumatriptan, zolmitriptan diclofenac, diclofenac ER ropinirole ER SCHIZOPHRENIA/ANTI-PSYCHOTICS Geodon ziprasidone Zyprexa Zyprexa Zydis olanzapine olanzapine ODT
STANDARD PRESCRIPTION DRUG LIST (cont.) Drug(s) not covered in drug class^ Drug(s) covered in drug class January 1, 2018 SKIN CONDITIONS Cutivate fluticasone cream Kenalog triamcinolone spray Locoid lotion hydrocortisone butyrate Luzu ketoconazole cream Soriatane acitretin Ziana clindamycin-tretinoin SLEEP DISORDERS/SEDATIVES Nuvigil armodafinil Provigil modafinil Restoril temazepam URINARY TRACT CONDITIONS Detrol tolterodine Detrol LA tolterodine ER Ditropan XL oxybutynin ER Enablex darifenacin ER Gelnique darifenacin ER, oxybutynin ER, tolterodine ER, trospium ER Non-preferred brand drug(s) Generic and/or preferred brand alternatives January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal spray ATTENTION DEFICIT HYPERACTIVITY Adderall XR dextroamphetamine-amphetamine ER DISORDER Focalin XR dexmethylphenidate ER SKIN CONDITIONS Ala-Scalp hydrocortisone Analpram HC lotion hydrocortisone-pramoxine Capex shampoo fluocinolone Cordran flurandrenolide Differin adapalene Metrogel metronidazole gel Naftin naftifine Nucort, Texacort hydrocortisone Drug(s) requiring prior authorization January 1, 2018 GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi HORMONAL AGENTS Androderm, Androgel, Striant, testosterone Additional information This medication will only be covered by your patient s plan if you request and Drug(s) with quantity limits Additional information January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone Your patient s plan only covers this ALZHEIMER'S DISEASE Namenda XR, Namzaric medication up to a certain amount over a ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine 25mg, 100mg, Marplan, certain number of days. Larger amounts Pristiq will only be covered if you request and ASTHMA/COPD/RESPIRATORY Perforomist BLOOD PRESSURE/HEART MEDICATIONS Ranexa CANCER Fareston, nilutamide EYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan
STANDARD PRESCRIPTION DRUG LIST (cont.) Drug(s) with quantity limits Additional information January 1, 2018 HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem MISCELLANEOUS Nuedexta OSTEOPOROSIS PRODUCTS alendronate PAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, Mitigare SCHIZOPHRENIA/ Fanapt ANTI-PSYCHOTICS SEIZURE DISORDERS Gabitril, Potiga SKIN CONDITIONS Denavir, Regranex, Santyl, Vectical SLEEP DISORDERS/SEDATIVES Hetlioz January 1, 2018 Step Therapy medications^^ Your patient s plan only covers this medication up to a certain amount over a certain number of days. Larger amounts will only be covered if you request and Generic and/or preferred brand alternatives ATTENTION DEFICIT HYPERACTIVITY Focalin XR dexmethylphenidate ER DISORDER SCHIZOPHRENIA/ANTI-PSYCHOTICS Orap pimozide SKIN CONDITIONS Ala-Scalp hydrocortisone Capex shampoo fluocinolone Cordran flurandrenolide Nucort, Texacort hydrocortisone Drug strength with limitations ++ (Your plan doesn t cover 2 capsules/tablets per day of this strength) Covered drug strength (Prescription must be for 1 capsule/tablet per day of this strength) January 1, 2018 ALLERGY/NASAL SPRAYS desloratadine ODT 2.5mg desloratadine ODT 5mg ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg Fetzima ER 40mg Fetzima ER 80mg Trintellix 5mg Trintellix 20mg BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg Benicar 20mg Benicar 40mg Benicar HCT 20-12.5mg Bystolic 10mg Tekturna 150mg Tekturna HCT 150-12.5mg Benicar HCT 40-25mg Bystolic 20mg Tekturna 300mg CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg Livalo 2mg Tekturna HCT 300-25mg Livalo 4mg DIABETES Farxiga 5mg Farxiga 10mg PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg
STANDARD PRESCRIPTION DRUG LIST (cont.) PERFORMANCE PRESCRIPTION DRUG LIST Drug strength with limitations ++ (Your plan doesn t cover 2 capsules/tablets per day of this strength) Covered drug strength (Prescription must be for 1 capsule/tablet per day of this strength) January 1, 2018 SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg Aptiom 400mg Aptiom 800mg Fycompa 4mg Fycompa 8mg Fycompa 6mg Fycompa 12mg Trokendi XR 25mg Trokendi XR 50mg Trokendi XR 100mg Trokendi XR 200mg SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg Non-preferred brand drug(s) Generic and/or preferred brand alternatives January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal spray ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER DIABETES Lantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Tresiba, Levemir GASTROINTESTINAL/HEARTBURN omeprazole bicarbonate packet, omeprazole 40mg-1100mg capsule, 20mg-1100mg INFECTIONS Eryped 400 erythromycin PAIN RELIEF AND INFLAMMATORY DISEASE OxyContin Embeda, Hysingla ER, Xtampza ER Vanatol LQ butalbital/acetaminophen/caffeine tabs or caps SKIN CONDITIONS Ala-Scalp hydrocortisone topical Capex shampoo fluocinolone scalp Cordran flurandrenolide topical Differin adapalene Kenalog spray triamcinolone spray Locoid lotion hydrocortisone butyrate Metrogel metronidazole gel Naftin naftifine Nucort, Texacort hydrocortisone Drug(s) requiring prior authorization Additional information January 1, 2018 DIABETES Lantus, Lantus SoloStar, Toujeo SoloStar This medication will only be covered by GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi your patient s plan if you request and HORMONAL AGENTS Androderm, Androgel, Axiron, Fortesta, Natesto, Striant, Testim, Testopel, testosterone, Vogelxo PAIN RELIEF AND INFLAMMATORY DISEASE Roxicodone Drug(s) with quantity limits Additional information January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone, Nasonex Your patient s plan only covers this ALZHEIMER'S DISEASE Namenda XR, Namzaric medication up to a certain amount over a ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine 25mg, 100mg, Marplan, certain number of days. Larger amounts will only be covered if you request and Pristiq
PERFORMANCE PRESCRIPTION DRUG LIST (cont.) Drug(s) with quantity limits Additional information January 1, 2018 ASTHMA/COPD/RESPIRATORY Perforomist Your patient s plan only covers this BLOOD PRESSURE/HEART MEDICATIONS Ranexa medication up to a certain amount over a CANCER Fareston, Nilandron, nilutamide certain number of days. Larger amounts will only be covered if you request and DIABETES Jentadueto, Tradjenta EYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle Dot, yuvafem INFECTIONS Zovirax MISCELLANEOUS Nuedexta OSTEOPOROSIS PRODUCTS alendronate PAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, Mitigare SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify Maintena, Aristada, Fanapt, Invega Trinza, Risperdal Consta, Zyprexa Relprevv SEIZURE DISORDERS Gabitril, Potiga SKIN CONDITIONS Denavir, Regranex, Santyl, Vectical, Zyclara SLEEP DISORDERS/SEDATIVES Hetlioz Step Therapy medications^^ Generic and/or Preferred Brand Alternatives January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER Focalin XR dexmethylphenidate ER SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify aripiprazole Orap pimozide SKIN CONDITIONS Locoid lotion hydrocortisone butyrate SLEEP DISORDERS/SEDATIVES Silenor eszopiclone, zolpidem Drug strength with limitations ++ (Your plan doesn t cover 2 capsules/tablets per day of this strength) Covered drug strength (Prescription must be for 1 capsule/tablet per day of this strength) January 1, 2018 ALLERGY/NASAL SPRAYS desloratadine ODT 2.5mg desloratadine ODT 5mg ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg Fetzima ER 40mg Fetzima ER 80mg Trintellix 5mg Trintellix 20mg BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg Benicar 20mg Benicar 40mg Benicar HCT 20-12.5mg Benicar HCT 40-25mg Bystolic 10mg Bystolic 20mg Tekturna 150mg Tekturna 300mg Tekturna HCT 150-12.5mg Tekturna HCT 300-25mg CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg Livalo 2mg Livalo 4mg DIABETES Farxiga 5mg Farxiga 10mg
PERFORMANCE PRESCRIPTION DRUG LIST (cont.) VALUE PRESCRIPTION DRUG LIST Drug strength with limitations ++ (Your plan doesn t cover 2 capsules/tablets per day of this strength) Covered drug strength (Prescription must be for 1 capsule/tablet per day of this strength) January 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg Aptiom 400mg Aptiom 800mg Fycompa 4mg Fycompa 8mg Fycompa 6mg Fycompa 12mg Trokendi XR 25mg Trokendi XR 50mg Trokendi XR 100mg Trokendi XR 200mg SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg Non-preferred brand drug(s) Generic and/or preferred brand alternatives January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal spray ASTHMA/COPD/RESPIRATORY Spiriva, Spiriva Respimat Incruse Ellipta Stiolto Respimat Anoro Ellipta ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER Focalin XR dexmethylphenidate ER DIABETES Apidra Humalog Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR Invokana Farxiga, Jardiance Kombiglyze XR, Onglyza alogliptin, alogliptin-metformin, Janumet, Janumet XR, Januvia Toujeo Basaglar, Tresiba, Levemir PAIN RELIEF AND INFLAMMATORY DISEASE D.H.E. 45 dihydroergotamine Imitrex sumatriptan OxyContin Embeda, Hysingla ER, Xtampza ER Vanatol LQ butalbital/acetaminophen/caffeine tabs or caps Zomig nasal spray sumatriptan, zolmitriptan SKIN CONDITIONS Differin adapalene Metrogel metronidazole gel Naftin naftifine Drug(s) requiring prior authorization Additional information January 1, 2018 DIABETES Lantus, Lantus SoloStar, Toujeo SoloStar This medication will only be covered by GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend capsule, powder your patient s plan if you request and packet, tripack, Sancuso, Varubi HORMONAL AGENTS Androderm, Androgel, Axiron, Fortesta, Natesto, Striant, Testim, Testopel, testosterone, Vogelxo PAIN RELIEF AND INFLAMMATORY DISEASE Roxicodone
VALUE PRESCRIPTION DRUG LIST (cont.) Drug(s) with quantity limits Additional information January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, Nasonex, mometasone Your patient s plan only covers this ALZHEIMER'S DISEASE Namenda XR, Namzaric medication up to a certain amount over a ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine ER, Marplan, Pristiq certain number of days. Larger amounts will only be covered if you request and ASTHMA/COPD/RESPIRATORY Perforomist BLOOD PRESSURE/HEART MEDICATIONS Ranexa CANCER Fareston, Nilandron, nilutamide DIABETES Jentadueto, Tradjenta EYE CONDITIONS bimatoprost, Cystaran, Zioptan HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem INFECTIONS Zovirax MISCELLANEOUS Nuedexta OSTEOPOROSIS PRODUCTS alendronate PAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, Mitigare SCHIZOPHRENIA/ANTI-PSYCHOTICS Fanapt SEIZURE DISORDERS Gabitril, Potiga SKIN CONDITIONS Denavir, Regranex, Santyl, Vectical, Zyclara SLEEP DISORDERS/SEDATIVES Hetlioz Step Therapy medications^^ Generic and/or preferred brand alternatives January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER Focalin XR dexmethylphenidate ER DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR Invokana Farxiga, Jardiance SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify aripiprazole Orap pimozide SKIN CONDITIONS Locoid lotion hydrocortisone butyrate SLEEP DISORDERS/SEDATIVES Silenor zolpidem, eszopiclone Drug strength with limitations ++ (Your plan doesn t cover 2 capsules/tablets per day of this strength) Covered drug strength (Prescription must be for 1 capsule/tablet per day of this strength) January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg Fetzima ER 40mg Fetzima ER 80mg Trintellix 5mg Trintellix 20mg BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg Benicar 20mg Benicar 40mg Benicar HCT 20-12.5mg Benicar HCT 40-25mg Bystolic 10mg Bystolic 20mg Tekturna 150mg Tekturna 300mg Tekturna HCT 150-12.5mg Tekturna HCT 300-25mg
VALUE PRESCRIPTION DRUG LIST (cont.) Drug strength with limitations ++ (Your plan doesn t cover 2 capsules/tablets per day of this strength) Covered drug strength (Prescription must be for 1 capsule/tablet per day of this strength) January 1, 2018 CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg Livalo 2mg Livalo 4mg DIABETES Farxiga 5mg Farxiga 10mg PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg Aptiom 400mg Aptiom 800mg Fycompa 4mg Fycompa 8mg Fycompa 6mg Fycompa 12mg Trokendi XR 25mg Trokendi XR 50mg Trokendi XR 100mg Trokendi XR 200mg SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg ADVANTAGE PRESCRIPTION DRUG LIST Non-preferred brand drug(s) Generic and/or preferred brand alternatives January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal spray ASTHMA/COPD/RESPIRATORY Spiriva, Spiriva Respimat Incruse Ellipta Stiolto Respimat Anoro Ellipta ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR Invokana Farxiga, Jardiance Kombiglyze XR, Onglyza alogliptin, alogliptin-metformin, Janumet, Janumet XR, Januvia Toujeo Basaglar, Tresiba, Levemir PAIN RELIEF AND INFLAMMATORY DISEASE OxyContin Embeda, Hysingla ER, Xtampza ER Vanatol LQ butalbital/acetaminophen/caffeine tabs or caps SKIN CONDITIONS Differin adapalene Metrogel metronidazole gel Naftin naftifine Drug(s) requiring prior authorization Additional information January 1, 2018 DIABETES Lantus, Lantus SoloStar, Toujeo SoloStar This medication will only be covered by GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi your patient s plan if you request and HORMONAL AGENTS Androderm, Androgel, Axiron, Fortesta, Natesto, Striant, Testim, Testopel, Vogelxo, testosterone gel, Vogelxo PAIN RELIEF AND INFLAMMATORY DISEASE Roxicodone Drug(s) with quantity limits Additional information January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, Nasonex, mometasone Your patient s plan only covers this ALZHEIMER'S DISEASE Namenda XR, Namzaric medication up to a certain amount over a certain number of days. Larger amounts ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine ER, Marplan, Pristiq will only be covered if you request and
ADVANTAGE PRESCRIPTION DRUG LIST(cont.) January 1, 2018 Drug(s) with quantity limits Additional information January 1, 2018 ASTHMA/COPD/RESPIRATORY Perforomist Your patient s plan only covers this BLOOD PRESSURE/HEART MEDICATIONS Ranexa medication up to a certain amount over a certain number of days. Larger amounts CANCER Fareston, Nilandron, nilutamide will only be covered if you request and DIABETES Jentadueto, Tradjenta EYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan HORMONAL AGENTS INFECTIONS MISCELLANEOUS OSTEOPOROSIS PRODUCTS PAIN RELIEF AND INFLAMMATORY DISEASE SCHIZOPHRENIA/ANTI-PSYCHOTICS SEIZURE DISORDERS SKIN CONDITIONS SLEEP DISORDERS/SEDATIVES ATTENTION DEFICIT HYPERACTIVITY DISORDER Step Therapy medications^^ Adderall XR Focalin XR Generic and/or preferred brand alternatives dextroamphetamine-amphetamine ER dexmethylphenidate ER DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR Invokana Farxiga, Jardiance SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify aripiprazole Orap pimozide SKIN CONDITIONS Locoid lotion hydrocortisone butyrate SLEEP DISORDERS/SEDATIVES Silenor eszopiclone, zaleplon, zolpidem, zolpidem ER Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem Zovirax Nuedexta alendronate Daliresp, Mitigare Abilify Maintena, Aristada, Fanapt, Invega Trinza, Risperdal Consta, Zyprexa Relprevv Gabitril, Potiga Denavir, Regranex, Santyl, Vectical, Zyclara Hetlioz Drug strength with limitations ++ (Your plan doesn t cover 2 capsules/tablets per day of this strength) Covered drug strength (Prescription must be for 1 capsule/tablet per day of this strength) January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg Fetzima ER 40mg Fetzima ER 80mg Trintellix 5mg Trintellix 20mg BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg Benicar 20mg Benicar 40mg Benicar HCT 20-12.5mg Benicar HCT 40-25mg Bystolic 10mg Bystolic 20mg Tekturna 150mg Tekturna 300mg Tekturna HCT 150-12.5mg Tekturna HCT 300-25mg
ADVANTAGE PRESCRIPTION DRUG LIST (cont.) Drug strength with limitations ++ (Your plan doesn t cover 2 capsules/tablets per day of this strength) Non-preferred brand drug(s) Covered drug strength (Prescription must be for 1 capsule/tablet per day of this strength) January 1, 2018 CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg Livalo 2mg Livalo 4mg DIABETES Farxiga 5mg Farxiga 10mg PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg Aptiom 400mg Aptiom 800mg Fycompa 4mg Fycompa 8mg Fycompa 6mg Fycompa 12mg Trokendi XR 25mg Trokendi XR 50mg Trokendi XR 100mg Trokendi XR 200mg SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg LEGACY PRESCRIPTION DRUG LIST Generic and/or preferred brand alternatives January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal spray ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER Focalin XR dexmethylphenidate ER CANCER Nilandron nilutamide DIABETES Apidra Humalog, Novolog Lantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba GASTROINTESTINAL/HEARTBURN omeprazole bicarbonate packet, omeprazole 40mg-1100mg capsule, 20mg-1100 mg capsule INFECTIONS Eryped 400 erythromycin PAIN RELIEF AND INFLAMMATORY DISEASE D.H.E. 45 dihydroergotamine Imitrex sumatriptan OxyContin Embeda, Hysingla ER, Xtampza ER Vanatol LQ butalbital/acetaminophen/caffeine tabs or caps SKIN CONDITIONS Ala-Scalp hydrocortisone Analpram HC hydrocortisone-pramoxine Capex shampoo fluocinolone Cordran flurandrenolide Differin adapalene Kenalog triamcinolone spray Locoid lotion hydrocortisone butyrate Metrogel metronidazole gel Naftin naftifine Nucort, Texacort hydrocortisone
LEGACY PRESCRIPTION DRUG LIST (cont.) Drug(s) requiring prior authorization Additional information January 1, 2018 DIABETES Lantus, Lantus SoloStar, Toujeo SoloStar This medication will only be covered by GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend capsule, powder packet, tripack, Sancuso, Varubi your patient s plan if you request and HORMONAL AGENTS Androderm, Androgel, Axiron, Fortesta, Natesto, Striant, Testim, testosterone, Vogelxo PAIN RELIEF AND INFLAMMATORY DISEASE Roxicodone Drug(s) with quantity limits Additional information January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, Nasonex, mometasone Your patient s plan only covers this ALZHEIMER'S DISEASE Namenda XR, Namzaric medication up to a certain amount over a ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine 25mg, 100mg, Marplan, certain number of days. Larger amounts Pristiq will only be covered if you request and ASTHMA/COPD/RESPIRATORY Perforomist BLOOD PRESSURE/HEART MEDICATIONS Ranexa CANCER Fareston, Nilandron, nilutamide DIABETES Jentadueto, Tradjenta EYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem INFECTIONS Zovirax MISCELLANEOUS Nuedexta OSTEOPOROSIS PRODUCTS alendronate PAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, Mitigare SCHIZOPHRENIA/ANTI-PSYCHOTICS Fanapt SEIZURE DISORDERS Gabitril, Potiga SKIN CONDITIONS Denavir, Regranex, Santyl, Vectical, Zyclara SLEEP DISORDERS/SEDATIVES Hetlioz Step Therapy medications^^ Generic and/or preferred brand alternatives January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER Focalin XR SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify aripiprazole Orap dexmethylphenidate ER pimozide SKIN CONDITIONS Locoid lotion hydrocortisone butyrate SLEEP DISORDERS/SEDATIVES Silenor eszopiclone, zolpidem Drug strength with limitations ++ (Your plan doesn t cover 2 capsules/tablets per day of this strength) Covered drug strength (Prescription must be for 1 capsule/tablet per day of this strength) January 1, 2018 ALLERGY/NASAL SPRAYS desloratadine ODT 2.5mg desloratadine ODT 5mg ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg Fetzima ER 40mg Fetzima ER 80mg
LEGACY PRESCRIPTION DRUG LIST (cont.) January 1, 2018 Drug strength with limitations ++ (Your plan doesn t cover 2 capsules/tablets per day of this strength) Covered drug strength (Prescription must be for 1 capsule/tablet per day of this strength) ANXIETY/DEPRESSION/ Trintellix 5mg BIPOLAR DISORDER (cont) Trintellix 20mg BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg Benicar 20mg Benicar 40mg Benicar HCT 20-12.5mg Benicar HCT 40-25mg Bystolic 10mg Bystolic 20mg Tekturna 150mg Tekturna 300mg Tekturna HCT 150-12.5mg Tekturna HCT 300-25mg CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg Livalo 2mg Livalo 4mg DIABETES Farxiga 5mg Farxiga 10mg PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg Aptiom 400mg Aptiom 800mg Fycompa 4mg Fycompa 8mg Fycompa 6mg Fycompa 12mg Trokendi XR 25mg Trokendi XR 50mg Trokendi XR 100mg Trokendi XR 200mg SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg PERFORMANCE PRESCRIPTION DRUG LIST (with additional medications not covered) Drug(s) not covered in drug class^ Drug(s) covered in drug class January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipramine Pamelor nortriptyline Parnate tranylcypromine Tofranil imipramine ASTHMA/COPD/RESPIRATORY Zyflo montelukast, zafirlukast, zileuton ER Zyflo CR zileuton ER ATTENTION DEFICIT HYPERACTIVITY Desoxyn methamphetamine DISORDER Dexedrine dextroamphetamine, dextroamphetamine ER BLOOD PRESSURE/HEART MEDICATIONS Betapace sotalol CANCER Nilandron nilutamide DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR Invokana Farxiga, Jardiance Lantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba Novolin, Novolog Humalog, Humulin
PERFORMANCE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont.) Drug(s) not covered in drug class^ Drug(s) covered in drug class January 1, 2018 GASTROINTESTINAL/HEARTBURN Cortifoam, Uceris rectal foam Colocort, Hemmorex-HC, hydrocortisone, Procto-Med HC, Procto-Pak, Proctosol-HC, Proctozone-HC Marinol dronabinol omeprazole bicarbonate packet, 40mg- omeprazole 1100mg capsule, 20mg-1100mg Rowasa mesalamine enema Uceris tablet budesonide EC capsule Zegerid omeprazole Zofran ondansetron Zofran ODT ondansetron ODT HORMONAL AGENTS Cortrosyn cosyntropin DDAVP Hectorol desmopressin doxercalciferol INFECTIONS Augmentin, Augmentin ES, Augmentin XR amoxicillin-clavulanate ER, amoxicillinclavulanate Diflucan fluconazole E.E.S. 200, Eryped 400 Mepron Sporanox Targadox Valcyte Vancocin Zovirax erythromycin atovaquone itraconazole Avidoxy, demeclocycline, doxycycline, doxycycline IR-DR, minocycline, minocycline ER, mondoxyne NL, Morgidox capsule, tetracycline valganciclovir vancomycin capsule acyclovir PAIN RELIEF AND INFLAMMATORY DISEASE Cambia diclofenac, diclofenac ER, etodolac, etodolac ER, fenoprofen, Fenortho, flurbiprofen, ibuprofen, indomethacin, indomethacin ER, ketoprofen, Ketorolac, meclofenamate, mefenamic acid, meloxicam, nabumetone D.H.E. 45, Migranal dihydroergotamine Gralise, Horizant Imitrex, Sumavel DosePro Lorzone OxyContin Roxicodone Tivorbex Vanatol LQ gabapentin sumatriptan chlorzoxazone Embeda, Hysingla ER, Xtampza ER oxycodone indomethacin butalbital/acetaminophen/caffeine tabs or caps
PERFORMANCE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont.) January 1, 2018 Non-preferred brand drug(s) Generic and/or preferred brand alternatives January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal spray ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER SKIN CONDITIONS Ala-Scalp hydrocortisone Analpram HC lotion hydrocortisone-pramoxine Capex shampoo fluocinolone Cordran flurandrenolide Differin adapalene Metrogel metronidazole gel Naftin naftifine Nucort, Texacort hydrocortisone Drug(s) not covered in drug class^ Drug(s) requiring prior authorization January 1, 2018 GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi HORMONAL AGENTS Androderm, Androgel, Striant, Testopel, testosterone Drug(s) covered in drug class PAIN RELIEF AND INFLAMMATORY Vivlodex meloxicam DISEASE (cont) Zomig sumatriptan, zolmitriptan Zorvolex diclofenac, diclofenac ER PARKINSON'S DISEASE Lodosyn carbidopa Requip XL ropinirole ER SCHIZOPHRENIA/ANTI-PSYCHOTICS Geodon capsule ziprasidone Zyprexa tablet olanzapine Zyprexa Zydis olanzapine ODT SKIN CONDITIONS Cutivate fluticasone Kenalog topical spray triamcinolone Locoid hydrocortisone Luzu ketoconazole Soriatane acitretin Ziana clindamycin-tretinoin SLEEP DISORDERS/SEDATIVES Nuvigil armodafinil Provigil modafinil Restoril temazepam URINARY TRACT CONDITIONS Detrol tolterodine Detrol LA tolterodine ER Ditropan XL oxybutynin ER Enablex darifenacin ER Gelnique darifenacin ER, oxybutynin ER, tolterodine ER, trospium ER Additional information This medication will only be covered by your patient s plan if you request and receive approval from Cigna.
PERFORMANCE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont.) Drug(s) with quantity limits Additional information January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone Your patient s plan only covers this ALZHEIMER'S DISEASE Namenda XR, Namzaric medication up to a certain amount over a certain number of days. Larger amounts ANXIETY/DEPRESSION/BIPOLAR DISORDER desvanlafaxine 25mg, 100mg, Marplan, will only be covered if you request and Pristiq ASTHMA/COPD/RESPIRATORY Perforomist BLOOD PRESSURE/HEART MEDICATIONS Ranexa CANCER Fareston, nilutamide EYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem MISCELLANEOUS Nuedexta OSTEOPOROSIS PRODUCTS alendronate PAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, Mitigare SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify Maintena, Aristada, Fanapt, Invega Trinza, Risperdal Consta, Zyprexa Relprevv SEIZURE DISORDERS Gabitril, Potiga SKIN CONDITIONS Denavir, Regranex, Santyl, Vectical SLEEP DISORDERS/SEDATIVES Hetlioz Step Therapy medications^^ Generic and/or preferred brand alternatives January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER Focalin XR SCHIZOPHRENIA/ANTI-PSYCHOTICS Orap pimozide dexmethylphenidate ER SLEEP DISORDERS/SEDATIVES Silenor eszopiclone, zolpidem Drug strength with limitations ++ (Your plan doesn t cover 2 capsules/tablets per day of this strength) Covered drug strength (Prescription must be for 1 capsule/tablet per day of this strength) January 1, 2018 ALLERGY/NASAL SPRAYS desloratadine ODT 2.5mg desloratadine ODT 5mg ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg Fetzima ER 40mg Fetzima ER 80mg Trintellix 5mg Trintellix 20mg BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg Benicar 20mg Benicar 40mg Benicar HCT 20-12.5mg Benicar HCT 40-25mg Bystolic 10mg Bystolic 20mg Tekturna 150mg Tekturna 300mg Tekturna HCT 150-12.5mg Tekturna HCT 300-25mg CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg Livalo 2mg Livalo 4mg DIABETES Farxiga 5mg Farxiga 10mg
PERFORMANCE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont.) Drug strength with limitations ++ (Your plan doesn t cover 2 capsules/tablets per day of this strength) VALUE PRESCRIPTION DRUG LIST (with additional medications not covered) Covered drug strength (Prescription must be for 1 capsule/tablet per day of this strength) January 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg Aptiom 400mg Aptiom 800mg Fycompa 4mg Fycompa 8mg Fycompa 6mg Fycompa 12mg Trokendi XR 25mg Trokendi XR 50mg Trokendi XR 100mg Trokendi XR 200mg SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg Drug(s) not covered in drug class^ Drug(s) covered in drug class January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipramine Pamelor nortriptyline Parnate tranylcypromine Tofranil imipramine ASTHMA/COPD/RESPIRATORY Spiriva, Spiriva Respimat Incruse Ellipta Stiolto Respimat Anoro Ellipta Zyflo montelukast, zafirlukast, zileuton ER Zyflo CR zileuton ER ATTENTION DEFICIT HYPERACTIVITY Desoxyn methamphetamine DISORDER Dexedrine dextroamphetamine, dextroamphetamine ER BLOOD PRESSURE/HEART MEDICATIONS Betapace sotalol tablet CANCER Nilandron nilutamide DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR Invokana Farxiga, Jardiance Kombiglyze XR, Onglyza alogliptin, alogliptin-metformin, Janumet, Janumet XR, Januvia Lantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba EYE CONDITIONS Alocril, Alomide cromolyn eye drops Bepreve, Emadine, Lastacaft, Pataday, azelastine, epinastine, olopatadine Patanol, Pazeo Elestat epinastine GASTROINTESTINAL/HEARTBURN Marinol dronabinol Rowasa mesalamine enema Zofran ondansetron Zofran ODT ondansetron ODT
VALUE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont.) Drug(s) not covered in drug class^ Drug(s) covered in drug class January 1, 2018 HORMONAL AGENTS DDAVP nasal spray, tablet desmopressin nasal spray, tablets Hectorol doxercalciferol INFECTIONS Augmentin, Augmentin ES, Augmentin XR amoxicillin-clavulanate ER, amoxicillin-clavulanate Diflucan fluconazole E.E.S. 200, Eryped 400 Mepron Sporanox Targadox Valcyte Vancocin Zovirax erythromycin atovaquone itraconazole doxycycline valganciclovir vancomycin capsule acyclovir PAIN RELIEF AND INFLAMMATORY DISEASE D.H.E. 45, Migranal dihydroergotamine Imitrex OxyContin Roxicodone Vanatol LQ Zomig sumatriptan Embeda, Hysingla ER, Xtampza ER oxycodone PARKINSON'S DISEASE Lodosyn carbidopa Requip XL butalbital/acetaminophen/caffeine tabs or caps sumatriptan, zolmitriptan ropinirole ER SCHIZOPHRENIA/ANTI-PSYCHOTICS Geodon ziprasidone SKIN CONDITIONS Zyprexa tablet Zyprexa Zydis Acanya, Atralin, Avita, Azelex, Differin, Epiduo, Epiduo Forte, Fabior, Onexton, Retin-A, Retin-A Micro, Tretin-X, Veltin Cutivate Dovonex, Sorilux Enstilar, Taclonex Soriatane olanzapine tablet olanzapine ODT Aczone, adapalene, Ala-Cort, alclometasone, amcinonide, Apexicon E, Avar, Avar-E, BenzePRO, benzoyl peroxide, betamethasone, BP 10-1, BPO, Clindacin ETZ, Clindacin P, clindamycin, clindamycinbenzoyl peroxide, clindamycin-tretinoin, clobetasol, clocortolone, Clodan, Cormax, desonide, desoximetasone, fluocinolone, halobetasol, hydrocortisone, Micort-HC, mometasone, prednicarbate, Psorcon, Scalacort, tretinoin, triamcinolone, Trianex, Triderm fluticasone calcipotriene calcipotriene-betamethasone DP acitretin
VALUE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont.) Drug(s) not covered in drug class^ Drug(s) covered in drug class January 1, 2018 SKIN CONDITIONS (cont) Tazorac adapalene, Ala-Cort, alclometasone, amcinonide, Apexicon E, Avar, Benzepro, benzoyl peroxide, betamethasone, BP 10-1, BPO, Clindacin ETZ, Clindacin P, clindamycin, clobetasol, clocortolone, Clodan, Cormax, desonide, desoximetasone, fluocinolone, halobetasol, hydrocortisone, Micort-HC, mometasone, prednicarbate, Psorcon, Scalacort, triamcinolone, Trianex, Triderm Vectical calcitriol ointment SLEEP DISORDERS/SEDATIVES Nuvigil armodafinil URINARY TRACT CONDITIONS Provigil Restoril Detrol, Detrol LA, Ditropan XL, Enablex, Gelnique Non-preferred brand drug(s) modafinil temazepam darifenacin ER, oxybutynin ER, tolterodine, tolterodine ER, trospium ER Generic and/or preferred brand alternatives January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER Drug(s) requiring prior authorization January 1, 2018 GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend capsule, powder packet, tripack, Sancuso, Varubi HORMONAL AGENTS Androderm, Androgel, Striant testosterone Additional information This medication will only be covered by your patient s plan if you request and Drug(s) with quantity limits Additional information January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone Your patient s plan only covers this ALZHEIMER'S DISEASE Namenda XR, Namzaric medication up to a certain amount over a certain number of days. Larger amounts ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine ER, Marplan will only be covered if you request and ASTHMA/COPD/RESPIRATORY Perforomist BLOOD PRESSURE/HEART MEDICATIONS Ranexa CANCER EYE CONDITIONS HORMONAL AGENTS MISCELLANEOUS OSTEOPOROSIS PRODUCTS PAIN RELIEF AND INFLAMMATORY DISEASE SCHIZOPHRENIA/ANTI-PSYCHOTICS SEIZURE DISORDERS SKIN CONDITIONS SLEEP DISORDERS/SEDATIVES Fareston, nilutamide bimatoprost eye drops, Cystaran, Zioptan Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem Nuedexta alendronate Daliresp, Mitigare Fanapt Gabitril, Potiga Denavir, Regranex, Santyl Hetlioz
VALUE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont.) Step Therapy medications^^ Generic and/or preferred brand alternatives January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER Focalin XR SCHIZOPHRENIA/ANTI-PSYCHOTICS Orap pimozide dexmethylphenidate ER SLEEP DISORDERS/SEDATIVES Silenor zolpidem, eszopiclone Drug strength with limitations ++ (Your plan doesn t cover 2 capsules/tablets per day of this strength) Covered drug strength (Prescription must be for 1 capsule/tablet per day of this strength) January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg Fetzima ER 40mg Trintellix 5mg Fetzima ER 80mg Trintellix 20mg DIABETES Farxiga 5mg Farxiga 10mg PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg Aptiom 400mg Fycompa 4mg Fycompa 6mg Trokendi XR 25mg Trokendi XR 100mg Aptiom 800mg Fycompa 8mg Fycompa 12mg Trokendi XR 50mg Trokendi XR 200mg SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg ADVANTAGE PRESCRIPTION DRUG LIST (with additional medications not covered) Drug(s) not covered in drug class^ January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipramine Pamelor Parnate Tofranil Drug(s) covered in drug class nortriptyline tranylcypromine imipramine ASTHMA/COPD/RESPIRATORY Spiriva, Spiriva Respimat Incruse Ellipta ATTENTION DEFICIT HYPERACTIVITY DISORDER Stiolto Respimat Zyflo Zyflo CR Desoxyn Dexedrine Anoro Ellipta BLOOD PRESSURE/HEART MEDICATIONS Betapace sotalol tablet CANCER Nilandron nilutamide montelukast, zafirlukast, zileuton ER zileuton ER methamphetamine dextroamphetamine, dextroamphetamine ER
ADVANTAGE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont.) Drug(s) not covered in drug class^ Drug(s) covered in drug class January 1, 2018 DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR Invokana Farxiga, Jardiance Kombiglyze XR, Onglyza alogliptin, alogliptin-metformin, Janumet, Janumet XR, Januvia Lantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba EYE CONDITIONS Alocril, Alomide cromolyn eye drops Bepreve, Emadine, Lastacaft, Pataday, azelastine, epinastine, olopatadine Patanol, Pazeo Elestat epinastine GASTROINTESTINAL/HEARTBURN Marinol dronabinol Rowasa mesalamine enema Zofran ondansetron Zofran ODT ondansetron ODT HORMONAL AGENTS Cortrosyn cosyntropin DDAVP desmopressin Hectorol doxercalciferol INFECTIONS Augmentin, Augmentin ES, Augmentin XR amoxicillin-clavulanate ER, amoxicillin-clavulanate Diflucan fluconazole E.E.S. 200, Eryped 400 erythromycin Mepron Sporanox Targadox Valcyte Vancocin Zovirax atovaquone itraconazole doxycycline valganciclovir vancomycin capsule acyclovir PAIN RELIEF AND INFLAMMATORY DISEASE D.H.E. 45, Migranal dihydroergotamine Imitrex OxyContin Roxicodone Vanatol LQ Zomig sumatriptan Embeda, Hysingla ER, Xtampza ER oxycodone PARKINSON'S DISEASE Lodosyn carbidopa Requip XL butalbital/acetaminophen/caffeine tabs or caps sumatriptan, zolmitriptan ropinirole ER SCHIZOPHRENIA/ANTI-PSYCHOTICS Geodon ziprasidone Zyprexa tablet Zyprexa Zydis olanzapine olanzapine ODT
ADVANTAGE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont.) Drug(s) not covered in drug class^ January 1, 2018 SKIN CONDITIONS Acanya, Atralin, Avita, Azelex, Differin, Epiduo, Epiduo Forte, Fabior, Onexton, Retin-A, Retin-A Micro, Tretin-X, Veltin Cutivate Dovonex, Sorilux Enstilar, Taclonex Soriatane Tazorac Vectical Drug(s) covered in drug class Aczone, adapalene, Ala-Cort, alclometasone, amcinonide, Apexicon E, Avar, Avar-E, BenzePRO, benzoyl peroxide, betamethasone, BP 10-1, BPO, Clindacin ETZ, Clindacin P, clindamycin, clindamycinbenzoyl peroxide, clindamycin-tretinoin, clobetasol, clocortolone, Clodan, Cormax, desonide, desoximetasone, fluocinolone, halobetasol, hydrocortisone, Micort-HC, mometasone, prednicarbate, Psorcon, Scalacort, tretinoin, triamcinolone, Trianex, Triderm fluticasone calcipotriene calcipotriene-betamethasone DP acitretin SLEEP DISORDERS/SEDATIVES Nuvigil armodafinil Provigil Restoril adapalene, Ala-Cort, alclometasone, amcinonide, Apexicon E, Avar, Avar-E, Benzepro, benzoyl peroxide, betamethasone, BP 10-1, BPO, Clindacin ETZ, Clindacin P, clindamycin, clobetasol, clocortolone, Clodan, Cormax, desonide, desoximetasone, fluocinolone, halobetasol, hydrocortisone, Micort-HC, mometasone, prednicarbate, Psorcon, Scalacort, triamcinolone, Trianex, Triderm calcitriol modafinil temazepam URINARY TRACT CONDITIONS Detrol tolterodine Detrol LA Ditropan XL Enablex Gelnique Non-preferred brand drug(s) tolterodine ER oxybutynin ER darifenacin ER darifenacin ER, oxybutynin ER, tolterodine ER, trospium ER Generic and/or preferred brand alternatives January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER
ADVANTAGE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont.) Drug(s) requiring prior authorization January 1, 2018 GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi HORMONAL AGENTS Androderm, Androgel, Striant, Testopel, testosterone Additional information This medication will only be covered by your patient s plan if you request and Drug(s) with quantity limits Additional information January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone Your patient s plan only covers this ALZHEIMER'S DISEASE Namenda XR, Namzaric medication up to a certain amount over a ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine ER, Marplan certain number of days. Larger amounts ASTHMA/COPD/RESPIRATORY Perforomist will only be covered if you request and BLOOD PRESSURE/HEART MEDICATIONS Ranexa CANCER Fareston, nilutamide EYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem MISCELLANEOUS Nuedexta OSTEOPOROSIS PRODUCTS alendronate PAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, Mitigare SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify Maintena, Aristada, Fanapt, Invega Trinza, Risperdal Consta, Zyprexa Relprevv SEIZURE DISORDERS Gabitril, Potiga SKIN CONDITIONS Denavir, Regranex, Santyl SLEEP DISORDERS/SEDATIVES Hetlioz Step Therapy medications^^ Generic and/or preferred brand alternatives January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER Focalin XR dexmethylphenidate ER SCHIZOPHRENIA/ANTI-PSYCHOTICS Orap pimozide SLEEP DISORDERS/SEDATIVES Silenor eszopiclone, zaleplon, zolpidem, zolpidem ER Drug strength with limitations ++ (Your plan doesn t cover 2 capsules/tablets per day of this strength) Covered drug strength (Prescription must be for 1 capsule/tablet per day of this strength) January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg Fetzima ER 40mg Fetzima ER 80mg Trintellix 5mg Trintellix 20mg DIABETES Farxiga 5mg Farxiga 10mg PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg Aptiom 400mg Aptiom 800mg
ADVANTAGE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont.) Drug strength with limitations ++ (Your plan doesn t cover 2 capsules/tablets per day of this strength) Covered drug strength (Prescription must be for 1 capsule/tablet per day of this strength) January 1, 2018 SEIZURE DISORDERS (cont) Fycompa 4mg Fycompa 8mg Fycompa 6mg Fycompa 12mg Trokendi XR 25mg Trokendi XR 50mg Trokendi XR 100mg Trokendi XR 200mg SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg CIGNA RX ESSENTIAL 5-TIER PRESCRIPTION DRUG LIST MEDICATION NOT COVERED^ GENERIC AND/OR PREFERRED BRAND ALTERNATIVES January 1, 2018 Adderall XR dextroamphetamine-amphetamine ER Azilect rasagiline mesylate Cimzia Humira (requires prior authorization), Enbrel (requires prior authorization), Remicade (requires prior authorization) Combivir lamivudine/zidovudine diclofenac sodium 1.5% topical solution diclofenac sodium 1% gel Emend capsules aprepitant capsules EpiPen and EpiPen Jr epinephrine auto-injectors Epivir lamivudine Fuzeon Talk with your doctor about switching to a covered alternative. Glatopa Copaxone (requires prior authorization) Gleevec imatinib mesylate (requires prior authorization) Invirase Talk with your doctor about switching to a covered alternative. Maxitrol eye drops neomycin/polymyxin/dexamethasone eye drops metformin hcl ER (generic Fortamet) metformin hcl ER (generic Glucophage XR) Natroba spinosad Nilandron nilutamide Nitrostat nitroglycerin sublingual tablets Orencia Actemra (requires prior authorization) Pennsaid 2% Pump diclofenac sodium 1% gel Rayos prednisone Rescriptor Talk with your doctor about switching to a covered alternative. Retrovir zidovudine Selzentry Talk with your doctor about switching to a covered alternative. Stelara Cosentyx (requires prior authorization) Tamiflu capsules oseltamivir phosphate capsules Tikosyn dofetilide Trianex triamcinolone ointment Trizivir abacavir/lamivudine/zidovudine Vagifem yuvafem
CIGNA RX ESSENTIAL 5-TIER PRESCRIPTION DRUG LIST (cont.) MEDICATION NOT COVERED^ GENERIC AND/OR PREFERRED BRAND ALTERNATIVES January 1, 2018 Valcyte 50mg/ml solution valganciclovir hcl 50mg/ml solution Videx EC Viracept Viramune Viramune XR Zebutal 50-325-40mg capsule Zerit Zetia Ziagen 20mg/ml oral solution Ziagen 300mg tablet EXCLUDED MEDICATION didanosine DR Talk with your doctor about switching to a covered alternative. nevirapine nevirapine ER butalbital/acetaminophen/caffeine 50-325-40mg capsule stavudine ezetimibe abacavir 20mg/ml oral solution abacavir 300mg tablet ADDITIONAL INFORMATION January 1, 2018 lidocaine hcl 3% lotion This medication is not approved by the U.S. Food and Drug Administration (FDA). Talk with your doctor. There may be alternative FDA-approved prescription medications or over-the-counter medicines (those that don t need a prescription) available to treat your condition. MEDICATION WITH QUANTITY LIMITS ADDITIONAL INFORMATION January 1, 2018 epinephrine auto-injectors Your plan only covers this medication up to a certain amount over a certain lidocaine 5% ointment number of days. Your plan will only cover larger amounts if your doctor requests and receives approval from Cigna. STEP THERAPY MEDICATION^^ GENERIC AND/OR PREFERRED BRAND ALTERNATIVES January 1, 2018 Saizen Humatrope (requires prior authorization) CIGNA RX PLUS PRESCRIPTION DRUG LIST MEDICATION NOT COVERED^ GENERIC AND/OR PREFERRED BRAND ALTERNATIVES January 1, 2018 Adderall XR dextroamphetamine-amphetamine ER Azilect rasagiline mesylate Benicar olmesartan medoxomil Benicar HCT olmesartan medoxomil/hydrochlorothiazide Combivir lamivudine/zidovudine Cordran 0.05% lotion flurandrenolide 0.05% lotion diclofenac sodium 1.5% topical solution diclofenac sodium 1% gel Doral quazepam Edecrin ethacrynic acid Emend capsules aprepitant capsules EpiPen and EpiPen Jr epinephrine auto-injectors Epivir lamivudine Glatopa Copaxone (requires prior authorization)
CIGNA RX PLUS PRESCRIPTION DRUG LIST (cont.) MEDICATION NOT COVERED^ GENERIC AND/OR PREFERRED BRAND ALTERNATIVES January 1, 2018 Gleevec imatinib mesylate (requires prior authorization) Invirase Maxitrol eye drops metformin hcl ER (generic Fortamet) Naftin 2% cream Natroba Nilandron Nitrostat Orencia Pennsaid 2% Pump Rayos Rescriptor Retrovir Selzentry Stelara Tamiflu capsules Tikosyn Trianex Trizivir Vagifem Valcyte 50mg/ml solution Videx EC Viracept Viramune Viramune XR Zebutal 50-325-40mg capsule Zerit Zetia Ziagen 300mg tablet EXCLUDED MEDICATION Talk with your doctor about switching to a covered alternative. neomycin/polymyxin/dexamethasone eye drops metformin hcl ER (generic Glucophage XR) naftifine hcl 2% cream spinosad nilutamide nitroglycerin sublingual tablets Actemra (requires prior authorization) diclofenac sodium 1% gel prednisone Talk with your doctor about switching to a covered alternative. zidovudine Talk with your doctor about switching to a covered alternative. Cosentyx (requires prior authorization) oseltamivir phosphate capsules dofetilide triamcinolone ointment abacavir/lamivudine/zidovudine yuvafem valganciclovir hcl 50mg/ml solution didanosine DR Talk with your doctor about switching to a covered alternative. nevirapine nevirapine ER butalbital/acetaminophen/caffeine 50-325-40mg capsule stavudine ezetimibe abacavir 300mg tablet ADDITIONAL INFORMATION January 1, 2018 Lidocaine hcl 3% lotion This medication is not approved by the U.S. Food and Drug Administration Novacort (FDA). Talk with your doctor. There may be alternative FDA-approved prescription medications or over-the-counter medicines (those that don t need a prescription) available to treat your condition.
CIGNA RX PLUS PRESCRIPTION DRUG LIST (cont.) MEDICATION WITH QUANTITY LIMITS ADDITIONAL INFORMATION January 1, 2018 Epinephrine auto-injectors Your plan only covers this medication up to a certain amount over a certain Lidocaine 5% ointment number of days. Your plan will only cover larger amounts if your doctor requests and receives approval from Cigna. STEP THERAPY MEDICATION^^ GENERIC AND/OR PREFERRED BRAND ALTERNATIVES January 1, 2018 Saizen Humatrope (requires prior authorization) CIGNA RX PLUS PRESCRIPTION DRUG LIST (FLORIDA ONLY) MEDICATION NOT COVERED^ GENERIC AND/OR PREFERRED BRAND ALTERNATIVES January 1, 2018 Adderall XR dextroamphetamine-amphetamine ER Azilect Benicar Benicar HCT Cimzia Cordran 0.05% lotion diclofenac sodium 1.5% topical solution Doral Edecrin Emend capsules EpiPen and EpiPen Jr Glatopa Gleevec Maxitrol eye drops metformin hcl ER (generic Fortamet) Naftin 2% cream Natroba Nilandron Nitrostat Orencia Pennsaid 2% Pump Rayos Simponi Stelara Tamiflu capsules Tikosyn Trianex rasagiline mesylate olmesartan medoxomil olmesartan medoxomil/hydrochlorothiazide Humira (requires prior authorization), Enbrel (requires prior authorization), Remicade (requires prior authorization) flurandrenolide 0.05% lotion diclofenac sodium 1% gel quazepam ethacrynic acid aprepitant capsules epinephrine auto-injectors Copaxone (requires prior authorization) imatinib mesylate (requires prior authorization) neomycin/polymyxin/dexamethasone eye drops metformin hcl ER (generic Glucophage XR) naftifine hcl 2% cream spinosad nilutamide nitroglycerin sublingual tablets Actemra (requires prior authorization) diclofenac sodium 1% gel prednisone Humira (requires prior authorization), Enbrel (requires prior authorization), Remicade (requires prior authorization) Cosentyx (requires prior authorization) oseltamivir phosphate capsules dofetilide triamcinolone ointment