ADDITIONAL 2017 FORMULARY CHANGES CIGNA COMMERCIAL CUSTOMERS Cigna will be making additional formulary changes that may impact customers at your pharmacy. We have included a list of drugs by drug class that will be considered non-covered, non-preferred brand or require approval from Cigna for coverage, as well as the covered alternatives. We sent letters to the customers explaining the changes to their current medications. However, if a customer with Cigna pharmacy benefits does come in and attempts to refill a medication that is not covered, when appropriate, we ask that you assist him or her in the following ways: Mention the alternative covered drugs available in the chart below Urge the customer to meet with the prescriber to discuss these alternatives or please call the prescriber to facilitate the new prescription Help the customer fill out the simple form below to bring to his or her prescriber If you have questions, please see below: Question: Point of Service and Processing Phone Number: 800.244.6224 Issue Type: Refill too Soon Drug Coverage Issues Copay Issues You will need the following information for the phone prompts: Customer ID Customer DOB Prescription Information Pharmacy Contract Provider.Relations@optum.com Contract inquiries Reimbursement Optum.com/pharmacycareservices Select Pharmacists Reimbursement All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Tel-Drug, Inc., Tel- Drug of Pennsylvania, L.L.C., and HMO or service company subsidiaries of Cigna Health Corporation. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. 2017 Cigna. 01/17
Drug Coverage Changes by Class Please note that this list only applies to our non-medicare Standard Prescription Drug List and does not reflect the entire list of covered and not-covered drugs for this or any other Cigna drug list. Drug class Non-preferred Generic and/or preferred brand** medication** brand alternatives Infections Daklinza + Epclusa +, Harvoni +, Sovaldi + Generic and/or preferred Drug class Medication not covered^ brand alternatives Cardizem diltiazem Blood Pressure/ Heart Isordil Titradose isosorbide dinitrate Medications Lanoxin digitek, digox, digoxin Cholesterol Medications Antara, Fenoglide fenofibrate Cough/Cold Medications Tussicaps hydrocodone-chlorpheniramne ER, promethazine-codeine Diuretics Edecrin, ethacrynic acid bumetanide,furosemide, torsemide anucort-hc, Grx Hicort 25, hemmorex- Anusol-HC suppository Gastrointestinal/ HC, hydrocortisone, rectacort HC Heartburn lansoprazole-amoxicilin-clarithromycin Omeclamox- pak, Prevpac, Pylera (combo pak) Hormonal Agents Dexpak dexamethasone Infections Onmel itraconazole, terbinafine Conzip tramadol, tramadol ER acetaminophen-codeine, hydrocodone acetaminophen, hydromorphone ER, Levorphanol tartate hydromorphone, lorcet, lorcet HD, lorcet plus, oxycodone, oxycodone ER, tramadol, verdrocet, vicodin, vicodin Skin Conditions Naprelan, naproxen CR, naproxen ER, Zipsor Zomig ZMT Aldara Anusol-HC cream Clobex Ertaczo Extina Halog Locoid lipocream Loprox Oxistat ES, vicodin HP diclofenac, diclofenac ER, etodolac, etodolac ER, fenoprofen, flurbiprofen, ibuprofen, indomethacin, ketoprofen, ketorolac, meclofenamate, mefenamic acid, meloxicam, nabumetone, naproxen, naproxen DS, oxaprozin, piroxicam, sulindac, tolmentin zolmitriptan ODT imiquimod hydrocortisone, protco-med HC proctosol-hc, proctozone-hc clobetasol, clodan shampoo ketoconazole ketoconazole, ketodan clobetasol propionate, halobetasol propionate hydrocortisone butyrate ciclodan, ciclopriox clotrimazole econazole nitrate, ketoconazole, oxiconazole nitrate
Penlac Ciclodan, ciclopirox Plexion sulfacetamide-sulfur, SS 10-2, Zencia Prudoxin doxepin Salex salicylic acid Trianex Triamcinolone acetonide, triderm Ala-cort, alclometasone dipropionate, aminonide, apexicon, betamethasone dipropinate, betamethasone valerate, clobetasol emollient, clobetaslon emulsion, clobetasol propionate, clocortonlone pivalate, clodan, cormax, desonide, desoximetasone, diflorasone Ultravate diacetate, fluocinolene acetonide, fluocinonide, fluocinonide-e, flurandrenolide, fluticasone propionate, halobetasol propionate, hydrocortisone, hydrocortisone butyrate, hydrocortisone valerate, micort-hc, mometasone furoate, prednicarbate, psorcon, scalacort, tacrolimus, triamcinolone acetonide, trianex, triderm Ultravate X clobetasol propionate, halobetasol propionate Verdeso desonide Vusion ketoconazole Zonalon doxepin, prudoxin Sleep Disorders/ Ambien zolpidem Sedatives Ambien CR zolpidem ER Drug class Medication requiring prior authorization Additional information Miscellaneous Syprine acetaminophen-codeine, butalbitalacetaminophencaffeinecodeine, butalbital-caffeineacetaminophencodeine, Dilaudid, Duragesic, Embeda, Endocet, fentanyl patch, hydrocodone-acetaminophen, hydrocodoneibuprofen, hydromorphone, hydromorphone ER, Hysingla ER, Ibudone, Kadian ER, levorphanol tartrate, Lorcet, Lorcet HD, Ask your doctor to call us. Your plan will Lorcet Plus, Lortab, morphine sulfate, morphine only cover your medication if your sulfate ER, doctor requests and receives approval Nucynta, Nucynta ER, Opana, Opana ER, from Cigna. Oxaydo, oxycodoneacetaminophen, oxycodone, oxycodone ER, oxymorphone ER, oxymorphone, Oxycontin, Percocet, Primlev, Reprexain, Roxicodone, Verdrocet, Vicodin, Vicodin ES, Vicodin HP, Xartemis XR, Xtampza ER, Xylon 10, Zohydro ER Cuprimine, Depen Titratab
Drug class Cough/ Cold Medications Gastrointestinal/ Heartburn Miscellaneous Medication with quantity limits Flowtuss, hycofenix, Hydrocod-cpmpseudoephedrine, Hydrocodone BT-homatropine, Hydrocodone-chlorpheniramne ER, Hydrocodonehomatropine, hydromet, obredon, Promethazine VC-codeine, Promethazine-codeine, Promethazine-phenyleph-codeine, Rezira, Tussicaps, Tussigon, Tussionex, Tuzistra XR, Vituz, Zutripro Opium Tincture Evzio, Naltrexone Abstral, acetaminophen-codeine, actiq, alfentanil, asa-butalb-caffeine-codeine, ascomp with codeine, aspirin- caffeine- dihydocodein, astramorph-pf belladonna- opium, butalbitalacetaminophen-caffeine- codeine, butalbitalcaffeine-acetaminophen-codeine, butalbital compound-codeine, butalbital-acetaminophencaffeine, butalbital-aspirin-caffeine, butorphanol, capacet, carisoprodol compound-codeine, carisoprodol-aspirin-codeine, codeine, Demerol, dihydrocodein-acetaminoph-caffeine, Dilaudid, diskets, Duragesic, dolophine, duramorph, Endocet, esgic, fentanyl patch, fentanylbupivacacaine, fentora, fioricet, fioricet with codeine, fiorinal, finorinal with codeine, hycet, hydrocodone-acetaminophen, hydrocodoneibuprofen, hydromorphone, Ibudone, infumorph, ionsys, lazanda, levorphanol, Lorcet, Lorcet HD, Lorcet Plus, Lortab, meperidine, methadone intensol, methadose, morphine,, nalbuphine, norco, Opana, Oxaydo, oxycodone- aspirin, oxycodone- ibuprofen, oxycodoneacetaminophen, oxymorphone, Oxycontin, pentazocine- naloxone, Percocet, Primlev, Reprexain, Roxicodone, subsys, sufentanil,synalgos- dc, talwin, trezix, Tylenol-codeine, ultiva, Verdrocet, Vicodin, Vicodin ES, Vicodin HP, Xodol,10-300, xodol 5-300, xodol 7.5-300, zamicet, zebutal Additional information Your plan only covers a certain amount of this medication. If your doctor writes a prescription for an amount more than what s allowed, it will only be covered in that amount if your doctor requests and receives approval from Cigna. * Drug is not covered unless approved through a medical necessity review. Customers should speak with their provider about switching to a covered alternative drugs. ^ In Step Therapy, customers must try the most cost-effective, appropriate drugs available before their plan approves more expensive brand name drugs.
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