PRESCRIPTION DRUG LIST CHANGES - cignaforhcp.cigna.com · Zofran ODT ondansetron ODT HORMONAL AGENTS DDAVP desmopressin ... BLOOD PRESSURE/HEART MEDICATIONS BiDil 20-37.5mg#, captopril

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

909016 UPDATED_6/27/2018

Start date of change*

Drug class Medication not covered^ Generic and/or preferred brand alternatives

September 1, 2018

SKIN CONDITIONS Doxepin 5% Cream generic topical steroid (e.g. betamethasone) or topical tacrolimus

July 1, 2018 DIABETES Segluromet Synjardy, Synjardy XR, Xigduo XRSteglatro Farxiga, JardianceSteglujan Glyxambi, QTERN

GASTROINTESTINAL/HEARTBURN OmePPI omeprazoleINFECTIONS Mycobutin rifabutinMULTIPLE SCLEROSIS Copaxone Aubagio, Avonex, Betaseron, Extavia,

Gilenya, glatiramer, Glatopa, Plegridy, Rebif, Tecfidera

SEIZURE DISORDERS Lyrica CR duloxetine, gabapentin, lidocaine 5% topical patch, Lyrica

SKIN CONDITIONS diclofenac 3% gel, Solaraze Fluoroplex, fluorouracil, imiquimod, PicatoMay 15, 2018 EYE CONDITIONS Vyzulta bimatoprost, latanoprost, Travatan ZApril 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE Duzallo allopurinol, probenecid, UloricMarch 1, 2018 DIABETES Fiasp Humalog

PARKINSON’S DISEASE Gocovri amantadineFebruary 1, 2018 ASTHMA/COPD/RESPIRATORY ArmonAir QVAR, Pulmicort FlexhalerJanuary 13, 2018 GASTROINTESTINAL/HEARTBURN Syndros dronabinolJanuary 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipramine

Pamelor nortriptylineParnate tranylcypromineTofranil imipramine

ASTHMA/COPD/RESPIRATORY Zyflo montelukast, zafirlukast, zileuton ERZyflo CR zileuton ER

ATTENTION DEFICIT HYPERACTIVITY DISORDER

Desoxyn methamphetamineDexedrine dextroamphetamine, dextroamphetamine ER

PRESCRIPTION DRUG LIST CHANGES

Cigna Pharmacy Management® 2018

The medications listed below are changing coverage (or cost levels) on Cigna’s Prescription Drug List. Changes are listed by drug list name and by the date they begin.

STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST

STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont)



January 1, 2018 BLOOD PRESSURE/HEART MEDICATIONS Betapace sotalol tabletsCANCER Nilandron nilutamideDIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR

Invokana Farxiga, JardianceLantus, 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 alosetronMarinol dronabinolomeprazole bicarbonate packets, 40-1100mg capsules

omeprazole

Rowasa mesalamine enemaUceris tablet budesonide EC capsuleZegerid omeprazoleZofran ondansetronZofran ODT ondansetron ODT

HORMONAL AGENTS DDAVP desmopressinHectorol doxercalciferol capsule

INFECTIONS Augmentin, Augmentin ES, Augmentin XR amoxicillin-clavulanate ER, amoxicillin-clavulanate

Diflucan fluconazoleE.E.S. 200, Eryped 400 erythromycin ethylsuccinateMepron atovaquoneSporanox itraconazole

Targadox Avidoxy tablet, doxycycline hyclate, Morgidox capsule

Valcyte valganciclovir

Vancocin vancomycin capsule

Zovirax 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 sumatriptan

Lorzone chlorzoxazone

OxyContin Embeda, Hysingla ER, Xtampza ER





January 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE (cont)

Roxicodone oxycodone

Tivorbex indomethacin

Vanatol LQ butalbital/acetaminophen/caffeine tabs or caps

Vivlodex meloxicam

Zomig sumatriptan, zolmitriptan

Zorvolex diclofenac, diclofenac ER

PARKINSON'S DISEASE Lodosyn carbidopa

Requip XL ropinirole ER

SCHIZOPHRENIA/ANTI-PSYCHOTICS Geodon ziprasidoneZyprexa olanzapineZyprexa Zydis olanzapine ODT

SKIN CONDITIONS Cutivate fluticasone creamKenalog triamcinolone sprayLocoid lotion hydrocortisone butyrateLuzu ketoconazole creamSoriatane acitretinZiana clindamycin-tretinoin

SLEEP DISORDERS/SEDATIVES Nuvigil armodafinilProvigil modafinilRestoril temazepam

URINARY TRACT CONDITIONS Detrol tolterodineDetrol LA tolterodine ERDitropan XL oxybutynin EREnablex darifenacin ERGelnique darifenacin ER, oxybutynin ER, tolterodine

ER, trospium ER


Drug classNon-preferred brand medication

Generic and/or preferred brand alternatives

August 15, 2018 ASTHMA/COPD/RESPIRATORY Symdeko+ Please work with your patient to prescribe a lower-cost option, if appropriate.

July 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Arixtra+ fondaparinux

Lovenox+ enoxaparin

Reopro+ Please work with your patient to prescribe a lower-cost option, if appropriate.



Drug class Preferred brand medication

October 1, 2018 GASTROINTESTINAL/HEARTBURN Entyvio+

Nexium Powder PackJune 1, 2018 DIABETES Ozempic

VictozaApril 1, 2018 DIABETES QTERNJanuary 1, 2018 MISCELLANEOUS Nityr+





July 1, 2018 CANCER dexrazoxane+, Evomela+, Hycamtin capsule+, Nilandron+, nilutamide+, Zinecard

Please work with your patient to prescribe a lower-cost option, if appropriate.

CONTRACEPTION PRODUCTS Depo-Provera 150mg/ml medroxyprogesterone

LoSeasonique Amethia Lo, Camrese Lo, levonorg-eth estradiol 0.1/0.02/0.01mg

Nexplanon+, Paragard T 380-a+ Please work with your patient to prescribe a lower-cost option, if appropriate.

Seasonique Amethia, Ashlyna, Camrese, Daysee, levonorg-eth estradiol 0.15/0.03/0.01mg

DENTAL PRODUCTS Arestin+ Please work with your patient to prescribe a lower-cost option, if appropriate.

DIABETES Korlym+ Please work with your patient to prescribe a lower-cost option, if appropriate.

EYE CONDITIONS Cystaran+, Ozurdex+, Retisert+ Please work with your patient to prescribe a lower-cost option, if appropriate.

GASTROINTESTINAL/HEARTBURN alosetron+, Buphenyl+, Chenodal+, Ravicti+, sodium phenylbutyrate


HORMONAL AGENTS Aveed+, hydroxyprogesterone caproate+ Please work with your patient to prescribe a lower-cost option, if appropriate.

Depo-Provera 400mg/ml medroxyprogesterone

INFECTIONS Daraprim+, Sirturo+ Please work with your patient to prescribe a lower-cost option, if appropriate.

INFERTILITY Makena+ Please work with your patient to prescribe a lower-cost option, if appropriate.

MISCELLANEOUS Asclera+, Carbaglu+, Ferriprox+, Flebogamma DIF+, Keveyis+, Varithena+


Orfadin+ Nityr

PAIN RELIEF AND INFLAMMATORY DISEASE (NON-NARCOTIC)

Colcrys colchicine

PARKINSON’S DISEASE Azilect rasagiline

SEIZURE DISORDERS Lamictal ODT lamotrigine ODT

SKIN CONDITIONS Ameluz+, Levulan+ Please work with your patient to prescribe a lower-cost option, if appropriate.

Tazorac 0.1% cream tazarotene

SLEEP DISORDERS/SEDATIVES Hetlioz+ Please work with your patient to prescribe a lower-cost option, if appropriate.

TRANSPLANT MEDICATIONS Cellcept+ mycophenolate

Neoral 25mg capsule, solution+ cyclosporine modified, Gengraf

Sandimmune 100mg capsule+ cyclosporine

URINARY TRACT CONDITIONS Thiola+ Please work with your patient to prescribe a lower-cost option, if appropriate.

March 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic Please work with your patient to prescribe a lower-cost option, if appropriate.

HORMONAL AGENTS Depo-Testosterone testosterone cypionate






February 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Bevyxxa enoxaparin, Fragmin

January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal spray


Adderall XR dextroamphetamine-amphetamine ER

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 class Medication requiring prior authorization^^

July 1, 2018 CANCER Hycamtin++, Targretin++, tretinoin capsule++, Xeloda++

MISCELLANEOUS Nityr, Orfadin++

PAIN RELIEF AND INFLAMMATORY DISEASE (NARCOTIC)

Diskets, Dolophine, methadone++, Methadose

March 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic

January 1, 2018 GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi

HORMONAL AGENTS Androderm, Androgel, Striant, testosterone

MISCELLANEOUS NityrStart date of change*

Drug class Medication with quantity limits^^

September 1, 2018

SKIN CONDITIONS Prudoxin, Zonalon

August 15, 2018 ASTHMA/COPD/RESPIRATORY Symdeko

July 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER bupropion ER#, Celexa#, citalopram#, desvenlafaxiner ER#, duloxetine#, Effexor XR#, Effexor#, Emsam#, escitalopram#, Fetzima#, fluoxetine#, fluvoxamine ER#, fluvoxamine#, Forfivo XL#, Khedezla, paroxetine CR#, paroxetine#, Paxil CR#, Pexeva#, Prozac, sertraline#, venlafaxine ER#, Wellbutrin SR, Wellbutrin XL, Zoloft

BLOOD PRESSURE/HEART MEDICATIONS BiDil 20-37.5mg#, captopril-HCTZ, dofetilide#, Tikosyn

CHOLESTEROL MEDICATIONS simvastatin, Zocor

GASTROINTESTINAL/HEARTBURN Aciphex, Dexilant, esomeprazole, lansoprazole DR, Nexium DR, Nexium, omeprazole DR, omeprazole, omeprazole bicarbonate, pantoprazole, Prevacid SoluTab, Prilosec, prilosec 2.5mg, Protonix, rabeprazole

NUTRITIONAL/DIETARY Auryxia


Cafergot, ergotamine-caffeine, diclofenac 1%, Voltaren





July 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE (NARCOTIC)

acetaminophen-caffeine-dihyrocodeine, acetaminophen-codeine, Arymo, asa-butalb-caff-codeine, aspirin-caff-dihydrocodeine, belladonna-opium, buprenorphine, butalb-acetaminoph-caff-codeine, butorphanol, carisoprodol-asa-codeine, codeine sulfate, Embeda, Exalgo, Fentanyl (all dosage forms), Flowtuss, Hycofenix, hydrocodone-acetaminophen, hydrocodone-ibuprofen, Hydromet, hydromorphone, Hysingla ER, Kadian, Lorcet, Lortab, meperidine, Morphabond ER, morphine, morphine ER, nalbuphine, Nucynta, Nucynta ER, Obredon, Opana ER, opium tincture, Oxecta, oxycodone, oxycodone ER, oxycodone-acetaminophen, oxycodone-aspirin, oxycodone-ibuprofen, OxyContin, oxymorphone, oxymorphone ER, pentazocine-acetaminophen, pentazocine-naloxone, Primlev, promethazine-codeine, Talwin, tramadol ER, tramadol-acetaminophen, Trezix, Tussigon, Tussionex, Xtampza ER, Zohydro ER, Zutripro

SEIZURE DISORDERS Banzel#

SKIN CONDITIONS calcitriol, Vectical

SLEEP DISORDERS/SEDATIVES RozeremFebruary 1, 2018 BLOOD THINNERS/ANTI-CLOTTING BevyxxaJanuary 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone

ALZHEIMER'S DISEASE Namenda XR, NamzaricANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine 25mg, 100mg, Marplan, PristiqASTHMA/COPD/RESPIRATORY PerforomistBLOOD PRESSURE/HEART MEDICATIONS RanexaCANCER Fareston, nilutamideEYE CONDITIONS bimatoprost eye drops, Cystaran, ZioptanHORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafemMISCELLANEOUS NuedextaOSTEOPOROSIS PRODUCTS alendronatePAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, MitigareSCHIZOPHRENIA/ANTI-PSYCHOTICS FanaptSEIZURE DISORDERS Gabitril, PotigaSKIN CONDITIONS Denavir, Regranex, Santyl, VecticalSLEEP DISORDERS/SEDATIVES Hetlioz



Drug class Step Therapy medication^^Generic and/or preferred brand alternatives

April 1, 2018 ASTHMA/COPD/RESPIRATORY Trelegy Ellipta## Advair, Anoro Ellipta, Breo Ellipta, Stiolto Respimat, Symbicort

January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER

Focalin XR## dexmethylphenidate ER

SCHIZOPHRENIA/ANTI-PSYCHOTICS Orap## pimozide

SKIN CONDITIONS Ala-Scalp## hydrocortisoneCapex shampoo## fluocinoloneCordran## flurandrenolideNucort, Texacort## hydrocortisone



Drug class

Medication strength with limitations** (Your plan doesn’t cover 2 capsules/tablets per day of this strength)

Covered medication 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 10mg


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


Trokendi XR 25mg Trokendi XR 50mg

Trokendi XR 100mg Trokendi XR 200mg SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg


LEGACY (PERFORMANCE) PRESCRIPTION DRUG LIST




June 1, 2018 DIABETES Ozempic

Victoza

April 1, 2018 DIABETES QTERN

March 1, 2018 DIABETES Fiasp

January 1, 2018 MISCELLANEOUS Nityr+





July 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Reopro+ Please work with your patient to prescribe a lower-cost option, if appropriate.

CANCER dexrazoxane+, Evomela+, Hycamtin capsule+, Nilandron+, nilutamide+, Zinecard


Fusilev+ leucovorin

CONTRACEPTION PRODUCTS LoSeasonique Amethia Lo, Camrese Lo, levonorg-eth estradiol 0.1/0.02/0.01mg





Segluromet Invokamet, Synjardy, Synjardy XR, Xigduo XR

Steglatro Farxiga, Invokana, JardianceSteglujan Glyxambi, QTERN





Saizen+ Humatrope



MISCELLANEOUS Asclera+, Carbaglu+, Ferriprox+,

Flebogamma DIF+, Keveyis+, Varithena+


Orfadin+ Nityr

MULTIPLE SCLEROSIS Copaxone+ Aubagio, Avonex, Betaseron, Extavia, Gilenya, glatiramer, Glatopa, Plegridy, Rebif, Tecfidera


Colcrys colchicine



LEGACY (PERFORMANCE) PRESCRIPTION DRUG LIST (cont)






July 1, 2018 SEIZURE DISORDERS Lamictal ODT lamotrigine ODT

Lyrica CR duloxetine, gabapentin, lidocaine 5% topical patch, Lyrica


Tazorac 0.1% cream tazarotene


TRANSPLANT MEDICATIONS Cellcept tablet, capsule, suspension+ mycophenolate tablet, capsule, suspension

Neoral 25mg capsule, solution+ cyclosporine modified, Gengraf

Sandimmune 100mg capsule+ cyclosporine


May 15, 2018 EYE CONDITIONS Vyzulta bimatoprost, latanoprost, Travatan Z

April 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE Duzallo allopurinol, probenecid, Uloric


PARKINSON’S DISEASE Gocovri amantadine

February 1, 2018 ASTHMA/COPD/RESPIRATORY ArmonAir QVAR, Pulmicort Flexhaler

BLOOD THINNERS/ANTI-CLOTTING Bevyxxa enoxaparin, Fragmin

January 13, 2018 GASTROINTESTINAL/HEARTBURN Syndros dronabinol

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, 40mg-1100mg capsule, 20mg-1100mg

omeprazole

INFECTIONS Eryped 400 erythromycin

PAIN RELIEF AND INFLAMMATORY DISEASE OxyContin Embeda, Hysingla ER, Xtampza ER


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







MULTIPLE SCLEROSIS Copaxone


Diskets, Dolophine, methadone tablet, solution++, methadone intensol++, Methadose

April 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE Duzallo


January 13, 2018 GASTROINTESTINAL/HEARTBURN Syndros

January 1, 2018 DIABETES Lantus, Lantus SoloStar, Toujeo SoloStar

GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi

HORMONAL AGENTS Androderm, Androgel, Axiron, Fortesta, Natesto, Striant, Testim, Testopel, testosterone, Vogelxo

MISCELLANEOUS Nityr

PAIN RELIEF AND INFLAMMATORY DISEASE RoxicodoneStart date of change*


September 1, 2018

SKIN CONDITIONS Doxepin 5% Cream, Prudoxin, Zonalon

August 15, 2018 ASTHMA/COPD/RESPIRATORY SymdekoJuly 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Aplenzin#, bupropion ER#, Celexa#, citalopram#, Cymbalta#, desvenlafaxiner ER#, duloxetine#,

Effexor XR#, Effexor#, Emsam#, escitalopram#, Fetzima#, fluoxetine#, fluvoxamine ER#,

fluvoxamine#, Forfivo XL#, Khedezla, Lexapro, paroxetine CR#, paroxetine#, Paxil CR#, Pexeva#,

Prozac, sertraline#, venlafaxine ER#, Wellbutrin SR, Wellbutrin XL, Zoloft



DIABETES Jentadueto XR

GASTROINTESTINAL/HEARTBURN Aciphex, Dexilant, esomeprazole, lansoprazole DR, lansoprazole, Nexium DR, Nexium, OmePPI, omeprazole DR, omeprazole, omeprazole bicarbonate, pantoprazole, Prevacid Solutab, Prilosec, prilosec 2.5mg, Protonix, rabeprazole, Zegerid









July 1, 2018 SCHIZOPHRENIA/ANTI-PSYCHOTICS Invega Sustenna#


SKIN CONDITIONS calcitriol, Vectical

SLEEP DISORDERS/SEDATIVES Rozerem

February 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Bevyxxa

January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone, Nasonex

ALZHEIMER'S DISEASE Namenda XR, Namzaric

ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine 25mg, 100mg, Marplan, Pristiq

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 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



Drug class Step Therapy medication^^Generic and/or Preferred Brand Alternatives

July 1, 2018 ERECTILE DYSFUNCTION Cialis## Please work with your patient to prescribe a lower-cost option, if appropriate.

Viagra## sildenafil, Cialis


February 1, 2018 ASTHMA/COPD/RESPIRATORY ArmonAir## QVAR, Pulmicort Flexhaler

January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR## dextroamphetamine-amphetamine ER


SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify## aripiprazole

Orap## pimozide

SKIN CONDITIONS Locoid lotion## hydrocortisone butyrate

SLEEP DISORDERS/SEDATIVES Silenor## eszopiclone, zolpidem



Drug class








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






SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg


LEGACY (STANDARD) PRESCRIPTION DRUG LIST





VictozaApril 1, 2018 DIABETES QTERN

March 1, 2018 DIABETES FiaspJanuary 1, 2018 MISCELLANEOUS Nityr+






July 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Arixtra+ fondaparinuxLovenox+ enoxaparinReopro+ Please work with your patient to prescribe

a lower-cost option, if appropriate.CANCER dexrazoxane+, Evomela+, Hycamtin

capsule+, Nilandron+, nilutamide+, ZinecardPlease work with your patient to prescribe a lower-cost option, if appropriate.

CONTRACEPTION PRODUCTS Depo-Provera 150mg/ml medroxyprogesteroneLoSeasonique Amethia Lo, Camrese Lo, levonorg-eth

estradiol 0.1/0.02/0.01mgNexplanon+, Paragard T 380-a+ Please work with your patient to prescribe

a lower-cost option, if appropriate.Seasonique Amethia, Ashlyna, Camrese, Daysee,

levonorg-eth estradiol 0.15/0.03/0.01mgDENTAL PRODUCTS Arestin+ Please work with your patient to prescribe

a lower-cost option, if appropriate.DIABETES Korlym+ Please work with your patient to prescribe

a lower-cost option, if appropriate.Segluromet Invokamet, Synjardy, Synjardy XR,

Xigduo XRSteglatro Farxiga, Invokana, JardianceSteglujan Glyxambi, QTERN


GASTROINTESTINAL/HEARTBURN alosetron+, Buphenyl+, Chenodal+, Lotronex+, Ravicti+, sodium phenylbutyrate



Depo-Provera 400mg/ml medroxyprogesteroneSaizen Humatrope





Orfadin+ NityrMULTIPLE SCLEROSIS Copaxone+ Aubagio, Avonex, Betaseron, Extavia,



Colcrys colchicine


SEIZURE DISORDERS Lamictal ODT lamotrigine ODTLyrica CR duloxetine, gabapentin, lidocaine 5%

topical patch, Lyrica

LEGACY (STANDARD) PRESCRIPTION DRUG LIST (cont)




July 1, 2018 SKIN CONDITIONS Ameluz+, Levulan+ Please work with your patient to prescribe a lower-cost option, if appropriate.

Tazorac 0.1% cream tazaroteneSLEEP DISORDERS/SEDATIVES Hetlioz+ Please work with your patient to prescribe

a lower-cost option, if appropriate.TRANSPLANT MEDICATIONS Cellcept capsule, tablet, suspension+ mycophenolate

Neoral 25mg capsule, solution+ cyclosporine modified, GengrafSandimmune 100mg capsule+ cyclosporine


May 15, 2018 EYE CONDITIONS Vyzulta bimatoprost, latanoprost, Travatan ZApril 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE Duzallo allopurinol, probenecid, UloricMarch 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic Please work with your patient to prescribe

a lower-cost option, if appropriate.HORMONAL AGENTS Depo-Testosterone testosterone cypionatePARKINSON’S DISEASE Gocovri amantadine


BLOOD THINNERS/ANTI-CLOTTING Bevyxxa enoxaparin, FragminJanuary 13, 2018 GASTROINTESTINAL/HEARTBURN Syndros dronabinolJanuary 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal spray

ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ERFocalin XR dexmethylphenidate ER

CANCER Nilandron nilutamide

DIABETES Apidra Humalog, NovologLantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba

GASTROINTESTINAL/HEARTBURN omeprazole bicarbonate packet, 40mg-1100mg capsule, 20mg-1100 mg capsule

omeprazole

INFECTIONS Eryped 400 erythromycinPAIN RELIEF AND INFLAMMATORY DISEASE D.H.E. 45 dihydroergotamine

Imitrex sumatriptanOxyContin Embeda, Hysingla ER, Xtampza ERVanatol LQ butalbital/acetaminophen/caffeine tabs

or capsSKIN CONDITIONS Ala-Scalp hydrocortisone

Analpram HC hydrocortisone-pramoxineCapex shampoo fluocinoloneCordran flurandrenolideDifferin adapaleneKenalog triamcinolone sprayLocoid lotion hydrocortisone butyrateMetrogel metronidazole gelNaftin naftifineNucort, Texacort hydrocortisone







MULTIPLE SCLEROSIS CopaxonePAIN RELIEF AND INFLAMMATORY DISEASE (NARCOTIC)


April 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE Duzallo


January 13, 2018 GASTROINTESTINAL/HEARTBURN Syndros

January 1, 2018 DIABETES Lantus, Lantus SoloStar, Toujeo SoloStarGASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend capsule, powder packet, tripack, Sancuso, Varubi

HORMONAL AGENTS Androderm, Androgel, Axiron, Fortesta, Natesto, Striant, Testim, testosterone, Vogelxo

MISCELLANEOUS Nityr

PAIN RELIEF AND INFLAMMATORY DISEASE Roxicodone




September 1, 2018

SKIN CONDITIONS Doxepin 5% Cream, Prudoxin, Zonalon


July 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Aplenzin#, bupropion ER#, Celexa#, citalopram#, Cymbalta#, desvenlafaxiner ER#, duloxetine#, Effexor XR#, Effexor#, Emsam#, escitalopram#, Fetzima#, fluoxetine#, fluvoxamine ER#, fluvoxamine#, Forfivo XL#, Khedezla, Lexapro, paroxetine CR#, paroxetine#, Paxil CR#, Pexeva#, Prozac, sertraline#, venlafaxine ER#, Wellbutrin SR, Wellbutrin XL, Zoloft



DIABETES Jentadueto XR

GASTROINTESTINAL/HEARTBURN Aciphex, Dexilant, esomeprazole, lansoprazole DR, lansoprazole, Nexium DR, Nexium, OmePPI, omeprazole DR, omeprazole, omeprazole bicarbonate, pantoprazole, Prevacid SoluTab, Prilosec, prilosec 2.5mg, Protonix, rabeprazole, Zegerid







SKIN CONDITIONS calcitriol, VecticalSLEEP DISORDERS/SEDATIVES Rozerem





February 1, 2018 BLOOD THINNERS/ANTI-CLOTTING BevyxxaJanuary 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, Nasonex, mometasone

ALZHEIMER'S DISEASE Namenda XR, NamzaricANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine 25mg, 100mg, Marplan, PristiqASTHMA/COPD/RESPIRATORY PerforomistBLOOD PRESSURE/HEART MEDICATIONS RanexaCANCER Fareston, Nilandron, nilutamideDIABETES Jentadueto, TradjentaEYE CONDITIONS bimatoprost eye drops, Cystaran, ZioptanHORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafemINFECTIONS ZoviraxMISCELLANEOUS NuedextaOSTEOPOROSIS PRODUCTS alendronatePAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, MitigareSCHIZOPHRENIA/ANTI-PSYCHOTICS FanaptSEIZURE DISORDERS Gabitril, PotigaSKIN CONDITIONS Denavir, Regranex, Santyl, Vectical, ZyclaraSLEEP DISORDERS/SEDATIVES Hetlioz





February 1, 2018 ASTHMA/COPD/RESPIRATORY ArmonAir## QVAR, Pulmicort Flexhaler



SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify## aripiprazole

Orap## pimozide

SKIN CONDITIONS Locoid lotion## hydrocortisone butyrate

SLEEP DISORDERS/SEDATIVES Silenor## eszopiclone, zolpidem


Drug class



January 1, 2018 ALLERGY/NASAL SPRAYS desloratadine ODT 2.5mg desloratadine ODT 5mgANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg

Fetzima ER 40mg Fetzima ER 80mg Trintellix 5mg Trintellix 10mg Trintellix 10mg 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




Drug class



January 1, 2018 BLOOD PRESSURE/HEART MEDICATIONS (cont)

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


PERFORMANCE PRESCRIPTION DRUG LIST



September 1, 2018


July 1, 2018 DIABETES Segluromet Synjardy, Synjardy XR, Xigduo XR

Steglatro Farxiga, Invokana, Jardiance

Steglujan Glyxambi, QTERN

GASTROINTESTINAL/HEARTBURN OmePPI omeprazole

INFECTIONS Mycobutin rifabutin

MULTIPLE SCLEROSIS Copaxone Aubagio, Avonex, Betaseron, Extavia, Gilenya, glatiramer, Glatopa, Plegridy, Rebif, Tecfidera


SKIN CONDITIONS diclofenac 3% gel, Solaraze Fluoroplex, fluorouracil topical, imiquimod cream, Picato


April 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE Duzallo allopurinol, probenecid, Uloric

March 1, 2018 DIABETES Fiasp Humalog



PERFORMANCE PRESCRIPTION DRUG LIST (cont)



January 13, 2018 GASTROINTESTINAL/HEARTBURN Syndros dronabinolJanuary 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipramine

Pamelor nortriptylineParnate tranylcypromineTofranil imipramine

ASTHMA/COPD/RESPIRATORY Zyflo montelukast, zafirlukast, zileuton ERZyflo CR zileuton ER


Desoxyn methamphetamineDexedrine dextroamphetamine,

dextroamphetamine ERBLOOD PRESSURE/HEART MEDICATIONS Betapace sotalolCANCER Nilandron nilutamideDIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR

Invokana Farxiga, JardianceLantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba Novolin, Novolog Humalog, Humulin

GASTROINTESTINAL/HEARTBURN Cortifoam, Uceris rectal foam Colocort, Hemmorex-HC, hydrocortisone, Procto-Med HC, Procto-Pak, Proctosol-HC, Proctozone-HC

Marinol dronabinolomeprazole bicarbonate packet, 40mg-1100mg capsule, 20mg-1100mg

omeprazole

OmePPI omeprazole Rowasa mesalamine enemaUceris tablet budesonide EC capsuleZegerid omeprazoleZofran ondansetronZofran ODT ondansetron ODT

HORMONAL AGENTS Cortrosyn cosyntropinDDAVP desmopressinHectorol doxercalciferol


Diflucan fluconazoleE.E.S. 200, Eryped 400 erythromycinMepron atovaquoneSporanox itraconazoleTargadox Avidoxy, demeclocycline, doxycycline,

doxycycline IR-DR, minocycline, minocycline ER, mondoxyne NL, Morgidox capsule, tetracycline





January 1, 2018 INFECTIONS (cont) Vancocin vancomycin capsule

Zovirax 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 gabapentin

Imitrex, Sumavel DosePro sumatriptan

Lorzone chlorzoxazone



Tivorbex indomethacin


Vivlodex meloxicam


Zorvolex diclofenac, diclofenac 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








June 1, 2018 DIABETES OzempicVictoza

April 1, 2018 DIABETES QTERNJanuary 1, 2018 MISCELLANEOUS Nityr+








Fusilev+ leucovorin







GASTROINTESTINAL/HEARTBURN alosetron+, Buphenyl, Chenodal+, Ravicti+, sodium phenylbutyrate







Orfadin+ NityrPAIN RELIEF AND INFLAMMATORY DISEASE (NON-NARCOTIC)

Colcrys colchicine




Tazorac 0.1% cream tazaroteneSLEEP DISORDERS/SEDATIVES Hetlioz+ Please work with your patient to prescribe a

lower-cost option, if appropriate.






July 1, 2018 TRANSPLANT MEDICATIONS Cellcept+ mycophenolateNeoral 25mg capsule, solution+ cyclosporine modified, GengrafSandimmune 100mg capsule+ cyclosporine



February 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Bevyxxa enoxaparin, FragminJanuary 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal spray

ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ERSKIN CONDITIONS Ala-Scalp hydrocortisone

Analpram HC lotion hydrocortisone-pramoxineCapex shampoo fluocinoloneCordran flurandrenolideDifferin adapaleneMetrogel metronidazole gelNaftin naftifineNucort, Texacort hydrocortisone







March 1, 2018 GASTROINTESTINAL/HEARTBURN SymproicJanuary 1, 2018 GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi

HORMONAL AGENTS Androderm, Androgel, Striant, Testopel, testosteroneMISCELLANEOUS Nityr



September 1, 2018


August 15, 2018 ASTHMA/COPD/RESPIRATORY SymdekoJuly 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER bupropion ER#, Celexa#, citalopram#, desvenlafaxine ER#, duloxetine#, Effexor XR#,

Effexor#, Emsam#, escitalopram#, Fetzima#, fluoxetine#, fluvoxamine ER#, fluvoxamine#, Forfivo XL#, Khedezla, paroxetine CR#, paroxetine#, Paxil CR#, Pexeva#, Prozac, sertraline#, venlafaxine ER#, Wellbutrin SR, Wellbutrin XL, Zoloft



GASTROINTESTINAL/HEARTBURN Aciphex, Dexilant, esomeprazole, lansoprazole DR, lansoprazole, Nexium DR, Nexium, omeprazole DR, omeprazole, omeprazole bicarbonate, pantoprazole, Prevacid SoluTab, Prilosec, prilosec 2.5mg, Protonix, rabeprazole






July 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE (NON-NARCOTIC)




SCHIZOPHRENIA/ANTI-PSYCHOTICS Invega Sustenna#


SKIN CONDITIONS calcitriol, VecticalSLEEP DISORDERS/SEDATIVES Rozerem

February 1, 2018 BLOOD THINNERS/ANTI-CLOTTING BevyxxaJanuary 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone

ALZHEIMER'S DISEASE Namenda XR, NamzaricANXIETY/DEPRESSION/BIPOLAR DISORDER desvanlafaxine 25mg, 100mg, Marplan, PristiqASTHMA/COPD/RESPIRATORY PerforomistBLOOD PRESSURE/HEART MEDICATIONS RanexaCANCER Fareston, nilutamideEYE CONDITIONS bimatoprost eye drops, Cystaran, ZioptanHORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafemMISCELLANEOUS NuedextaOSTEOPOROSIS PRODUCTS alendronatePAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, MitigareSCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify Maintena, Aristada, Fanapt, Invega Trinza, Risperdal Consta, Zyprexa RelprevvSEIZURE DISORDERS Gabitril, PotigaSKIN CONDITIONS Denavir, Regranex, Santyl, VecticalSLEEP DISORDERS/SEDATIVES Hetlioz



July 1, 2018 ERECTILE DYSFUNCTION Cialis## Please work with your patient to prescribe a lower-cost option, if appropriate.

Viagra## sildenafil, CialisApril 1, 2018 ASTHMA/COPD/RESPIRATORY Trelegy Ellipta## Advair, Anoro Ellipta, Breo Ellipta, Stiolto

Respimat, SymbicortJanuary 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR## dextroamphetamine-amphetamine ER

Focalin XR## dexmethylphenidate ERSCHIZOPHRENIA/ANTI-PSYCHOTICS Orap## pimozideSLEEP DISORDERS/SEDATIVES Silenor## eszopiclone, zolpidem




Drug class








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




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


VALUE PRESCRIPTION DRUG LIST



September 1, 2018


July 1, 2018 DIABETES Segluromet Synjardy, Synjardy XR, Xigduo XRSteglatro Farxiga, JardianceSteglujan Glyxambi

INFECTIONS Mycobutin rifabutinMULTIPLE SCLEROSIS Copaxone Aubagio, Avonex, Betaseron, Extavia,



SKIN CONDITIONS diclofenac 3% gel, Solaraze Fluoroplex, fluorouracil topical, imiquimod cream, Picato


VALUE PRESCRIPTION DRUG LIST (cont)




April 1, 2018 DIABETES QTERN GlyxambiPAIN RELIEF AND INFLAMMATORY DISEASE Duzallo allopurinol, probenecid

March 1, 2018 DIABETES Fiasp HumalogPARKINSON’S DISEASE Gocovri amantadine

February 1, 2018 ASTHMA/COPD/RESPIRATORY ArmonAir QVAR


January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipraminePamelor nortriptyline

Parnate tranylcypromine

Tofranil imipramineASTHMA/COPD/RESPIRATORY Spiriva, Spiriva Respimat Incruse Ellipta

Stiolto Respimat Anoro Ellipta

Zyflo montelukast, zafirlukast, zileuton ER

Zyflo CR zileuton ER


Desoxyn methamphetamine

Dexedrine dextroamphetamine, dextroamphetamine ER

BLOOD PRESSURE/HEART MEDICATIONS Betapace sotalol tablet


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, Patanol, Pazeo

azelastine, epinastine, olopatadine

Elestat epinastine

GASTROINTESTINAL/HEARTBURN Marinol dronabinol

Rowasa mesalamine enema

Zofran ondansetron

Zofran ODT ondansetron ODT

HORMONAL AGENTS DDAVP nasal spray, tablet desmopressin nasal spray, tablets

Hectorol doxercalciferol


Diflucan fluconazole

E.E.S. 200, Eryped 400 erythromycinMepron atovaquone





January 1, 2018 INFECTIONS (cont) Sporanox itraconazoleTargadox doxycycline


Vancocin vancomycin capsule

Zovirax acyclovirPAIN RELIEF AND INFLAMMATORY DISEASE D.H.E. 45, Migranal dihydroergotamine

Imitrex sumatriptanOxyContin Embeda, Hysingla ER, Xtampza ERRoxicodone oxycodoneVanatol LQ butalbital/acetaminophen/caffeine tabs

or capsZomig sumatriptan, zolmitriptan



SCHIZOPHRENIA/ANTI-PSYCHOTICS Geodon ziprasidone

Zyprexa tablet olanzapine tablet


SKIN CONDITIONS Acanya, Atralin, Avita, Azelex, Differin, Epiduo, Epiduo Forte, Fabior, Onexton, Retin-A, Retin-A Micro, Tretin-X, Veltin

Aczone, adapalene, Ala-Cort, alclometasone, amcinonide, Apexicon E, Avar, Avar-E, BenzePRO, benzoyl peroxide, betamethasone, BP 10-1, BPO, Clindacin ETZ, Clindacin P, clindamycin, clindamycin-benzoyl peroxide, clindamycin-tretinoin, clobetasol, clocortolone, Clodan, Cormax, desonide, desoximetasone, fluocinolone, halobetasol, hydrocortisone, Micort-HC, mometasone, prednicarbate, Psorcon, Scalacort, tretinoin, triamcinolone, Trianex, Triderm

Cutivate fluticasone

Dovonex, Sorilux calcipotriene

Enstilar, Taclonex calcipotriene-betamethasone DP

Soriatane acitretin

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





January 1, 2018 SLEEP DISORDERS/SEDATIVES Nuvigil armodafinilProvigil modafinilRestoril temazepam

URINARY TRACT CONDITIONS Detrol, Detrol LA, Ditropan XL, Enablex, Gelnique

darifenacin ER, oxybutynin ER, tolterodine, tolterodine ER, trospium ER





VictozaJanuary 1, 2018 MISCELLANEOUS Nityr+





July 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Arixtra+ fondaparinux

Lovenox+ enoxaparin

Reopro+ Please work with your patient to prescribe a lower-cost option, if appropriate.

CANCER dexrazoxane+, Evomela+, Nilandron+, nilutamide+, Zinecard


Targretin capsule+ bexarotene

CONTRACEPTION PRODUCTS Depo-Provera 150mg/ml medroxyprogesterone

LoSeasonique Amethia Lo, Camrese Lo, levonorg-eth estradiol 0.1/0.02/0.01mg









Depo-Provera 400mg/ml medroxyprogesterone








July 1, 2018 MISCELLANEOUS Asclera+, Carbaglu+, Ferriprox+, Flebogamma DIF+, Keveyis+, Varithena+


PARKINSON'S DISEASE Azilect rasagiline




TRANSPLANT MEDICATIONS Cellcept+ mycophenolateNeoral 25mg capsule, solution+ cyclosporine modified, Gengraf



HORMONAL AGENTS Depo-Testosterone testosterone cypionateFebruary 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Bevyxxa enoxaparin, FragminJanuary 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER








January 1, 2018 GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend capsule, powder packet, tripack, Sancuso, Varubi

HORMONAL AGENTS Androderm, Androgel, Striant testosterone

MISCELLANEOUS Nityr



September 1, 2018



July 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER bupropion ER#, Celexa#, citalopram#, desvenlafaxine ER#, duloxetine#, Effexor XR#, Effexor#, Emsam#, escitalopram#, Fetzima#, fluoxetine#, fluvoxamine ER#, fluvoxamine#, Forfivo XL#, Khedezla, paroxetine CR#, paroxetine#, Paxil CR#, Pexeva#, Prozac, sertraline#, venlafaxine ER#, Wellbutrin SR, Wellbutrin XL, Zoloft


CHOLESTEROL MEDICATIONS simvastatin



Cafergot, ergotamine-caffeine

diclofenac 1% gel, Voltaren








SKIN CONDITIONS calcitriol



January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone


ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine ER, Marplan



CANCER Fareston, nilutamide


HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem




SCHIZOPHRENIA/ANTI-PSYCHOTICS Fanapt


SKIN CONDITIONS Denavir, Regranex, Santyl

SLEEP DISORDERS/SEDATIVES Hetlioz






SCHIZOPHRENIA/ANTI-PSYCHOTICS Orap## pimozide

SLEEP DISORDERS/SEDATIVES Silenor## zolpidem, eszopiclone




Drug class



January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg



Trintellix 10mg 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





Trokendi XR 100mg Trokendi XR 200mg SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg

ADVANTAGE PRESCRIPTION DRUG LIST



September 1, 2018


July 1, 2018 DIABETES Segluromet Synjardy, Synjardy XR, Xigduo XR

Steglatro Farxiga, Jardiance

Steglujan Glyxambi

INFECTIONS Mycobutin rifabutin

MULTIPLE SCLEROSIS Copaxone Aubagio, Avonex, Betaseron, Extavia, Gilenya, glatiramer, Glatopa, Plegridy, Rebif, Tecfidera


SKIN CONDITIONS diclofenac 3% gel, Solaraze Fluoroplex, fluorouracil, imiquimod, Picato


April 1, 2018 DIABETES QTERN Glyxambi

PAIN RELIEF AND INFLAMMATORY DISEASE Duzallo allopurinol, probenecid

March 1, 2018 DIABETES Fiasp Humalog


February 1, 2018 ASTHMA/COPD/RESPIRATORY ArmonAir QVAR



ADVANTAGE PRESCRIPTION DRUG LIST (cont)



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


Desoxyn methamphetamine

Dexedrine dextroamphetamine, dextroamphetamine ER

BLOOD PRESSURE/HEART MEDICATIONS Betapace sotalol tablet


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, Patanol, Pazeo

azelastine, epinastine, olopatadine

Elestat epinastine

GASTROINTESTINAL/HEARTBURN Marinol dronabinol

Rowasa mesalamine enema

Zofran ondansetron

Zofran ODT ondansetron ODT

HORMONAL AGENTS Cortrosyn cosyntropin

DDAVP desmopressin

Hectorol doxercalciferol


Diflucan fluconazoleE.E.S. 200, Eryped 400 erythromycinMepron atovaquoneSporanox itraconazoleTargadox doxycyclineValcyte valganciclovirVancocin vancomycin capsuleZovirax acyclovir





January 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE D.H.E. 45, Migranal dihydroergotamine

Imitrex sumatriptan







SCHIZOPHRENIA/ANTI-PSYCHOTICS Geodon ziprasidone

Zyprexa tablet olanzapine


SKIN CONDITIONS Acanya, Atralin, Avita, Azelex, Differin, Epiduo, Epiduo Forte, Fabior, Onexton, Retin-A, Retin-A Micro, Tretin-X, Veltin

Aczone, adapalene, Ala-Cort, alclometasone, amcinonide, Apexicon E, Avar, Avar-E, BenzePRO, benzoyl peroxide, betamethasone, BP 10-1, BPO, Clindacin ETZ, Clindacin P, clindamycin, clindamycin-benzoyl peroxide, clindamycin-tretinoin, clobetasol, clocortolone, Clodan, Cormax, desonide, desoximetasone, fluocinolone, halobetasol, hydrocortisone, Micort-HC, mometasone, prednicarbate, Psorcon, Scalacort, tretinoin, triamcinolone, Trianex, Triderm

Cutivate fluticasone

Dovonex, Sorilux calcipotriene

Enstilar, Taclonex calcipotriene-betamethasone DP

Soriatane acitretin

Tazorac 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

Vectical calcitriol

SLEEP DISORDERS/SEDATIVES Nuvigil armodafinil

Provigil modafinil

Restoril temazepam






Nexium Powder Pack June 1, 2018 DIABETES Ozempic

VictozaJanuary 1, 2018 MISCELLANEOUS Nityr+



January 1, 2018 URINARY TRACT CONDITIONS Detrol tolterodineDetrol LA tolterodine ERDitropan XL oxybutynin EREnablex darifenacin ERGelnique darifenacin ER, oxybutynin ER, tolterodine

ER, trospium ER








Fusilev+ leucovorin

Targretin capsule+ bexarotene

















July 1, 2018 MISCELLANEOUS Asclera+, Carbaglu+, Ferriprox+, Flebogamma DIF+, Keveyis+, Varithena+


PARKINSON'S DISEASE Azilect rasagiline




TRANSPLANT MEDICATIONS Cellcept+ mycophenolate



February 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Bevyxxa enoxaparin

January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER








January 1, 2018 GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi

HORMONAL AGENTS Androderm, Androgel, Striant, Testopel, testosterone

MISCELLANEOUS Nityr



September 1, 2018



July 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER bupropion ER#, Celexa#, citalopram#, desvenlafaxine ER#, duloxetine#, Effexor XR#, Effexor#, Emsam#, escitalopram#, Fetzima#, fluoxetine#, fluvoxamine ER#, fluvoxamine#, Forfivo XL#, Khedezla, paroxetine CR#, paroxetine#, Paxil CR#, Pexeva#, Prozac#, sertraline#, venlafaxine ER#, Wellbutrin SR, Wellbutrin XL, Zoloft


CHOLESTEROL MEDICATIONS simvastatin










SCHIZOPHRENIA/ANTI-PSYCHOTICS Invega Sustenna#


SKIN CONDITIONS calcitriol



January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone


ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine ER, Marplan



CANCER Fareston, nilutamide


HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem




SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify Maintena, Aristada, Fanapt, Invega Trinza, Risperdal Consta, Zyprexa Relprevv


SKIN CONDITIONS Denavir, Regranex, Santyl

SLEEP DISORDERS/SEDATIVES HetliozStart date of change*



January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR## dextroamphetamine-amphetamine ERFocalin XR## dexmethylphenidate ER

SCHIZOPHRENIA/ANTI-PSYCHOTICS Orap## pimozideSLEEP DISORDERS/SEDATIVES Silenor## eszopiclone, zaleplon, zolpidem,

zolpidem ER



Drug class



January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg







SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg







CIGNA RX ESSENTIAL 5-TIER PRESCRIPTION DRUG LIST


MEDICATION NOT COVERED^GENERIC AND/OR PREFERRED BRAND ALTERNATIVES

January 1, 2018 Adderall XR dextroamphetamine-amphetamine ERAzilect rasagiline mesylateCimzia Humira (requires prior authorization), Enbrel (requires prior authorization),

Remicade (requires prior authorization)Combivir lamivudine/zidovudinediclofenac sodium 1.5% topical solution diclofenac sodium 1% gelEmend capsules aprepitant capsulesEpiPen and EpiPen Jr epinephrine auto-injectors Epivir lamivudineFuzeon 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 dropsmetformin hcl ER (generic Fortamet) metformin hcl ER (generic Glucophage XR)Natroba spinosadNilandron nilutamideNitrostat nitroglycerin sublingual tabletsOrencia Actemra (requires prior authorization)Pennsaid 2% Pump diclofenac sodium 1% gel




January 1, 2018 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

Valcyte 50mg/ml solution valganciclovir hcl 50mg/ml solution

Videx EC didanosine DR

Viracept Talk with your doctor about switching to a covered alternative.

Viramune nevirapine

Viramune XR nevirapine ER

Zebutal 50-325-40mg capsule butalbital/acetaminophen/caffeine 50-325-40mg capsule

Zerit stavudine

Zetia ezetimibe

Ziagen 20mg/ml oral solution abacavir 20mg/ml oral solution

Ziagen 300mg tablet abacavir 300mg tablet


EXCLUDED MEDICATION 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 number of days. Your plan will only cover larger amounts if your doctor requests and receives approval from Cigna.

lidocaine 5% ointment


STEP THERAPY MEDICATION^^GENERIC AND/OR PREFERRED BRAND ALTERNATIVES

January 1, 2018 Saizen Humatrope (requires prior authorization)


CIGNA RX ESSENTIAL 5-TIER PRESCRIPTION DRUG LIST (cont.)

CIGNA RX PLUS PRESCRIPTION DRUG LISTStart date of change*


January 1, 2018 Adderall XR dextroamphetamine-amphetamine ERAzilect rasagiline mesylateBenicar olmesartan medoxomilBenicar HCT olmesartan medoxomil/hydrochlorothiazideCombivir lamivudine/zidovudineCordran 0.05% lotion flurandrenolide 0.05% lotiondiclofenac sodium 1.5% topical solution diclofenac sodium 1% gelDoral quazepamEdecrin ethacrynic acidEmend capsules aprepitant capsulesEpiPen and EpiPen Jr epinephrine auto-injectors Epivir lamivudineGlatopa 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)

Naftin 2% cream naftifine hcl 2% cream

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.



Tikosyn dofetilide


Trizivir abacavir/lamivudine/zidovudine

Vagifem yuvafem


Videx EC didanosine DR


Viramune nevirapine





January 1, 2018 Zebutal 50-325-40mg capsule butalbital/acetaminophen/caffeine 50-325-40mg capsule

Zerit stavudine

Zetia ezetimibe




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.

Novacort



January 1, 2018 Epinephrine auto-injectors Your plan only covers this medication up to a certain amount over a certain number of days. Your plan will only cover larger amounts if your doctor requests and receives approval from Cigna.

Lidocaine 5% ointment




CIGNA RX PLUS PRESCRIPTION DRUG LIST (FLORIDA ONLY)



January 1, 2018 Adderall XR dextroamphetamine-amphetamine ER

Azilect rasagiline mesylate

Benicar olmesartan medoxomil

Benicar HCT olmesartan medoxomil/hydrochlorothiazide

Cimzia Humira (requires prior authorization), Enbrel (requires prior authorization), Remicade (requires prior authorization)

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

Glatopa Copaxone (requires prior authorization)

Gleevec imatinib mesylate (requires prior authorization)

Maxitrol eye drops neomycin/polymyxin/dexamethasone eye drops

metformin hcl ER (generic Fortamet) metformin hcl ER (generic Glucophage XR)

Naftin 2% cream naftifine hcl 2% cream


CIGNA RX PLUS PRESCRIPTION DRUG LIST (cont.)



January 1, 2018 Natroba spinosad

Nilandron nilutamide

Nitrostat nitroglycerin sublingual tablets

Orencia Actemra (requires prior authorization)

Pennsaid 2% Pump diclofenac sodium 1% gel

Rayos prednisone

Simponi Humira (requires prior authorization), Enbrel (requires prior authorization), Remicade (requires prior authorization)



Tikosyn dofetilide


Vagifem yuvafem



Zetia ezetimibe




Novacort








CIGNA RX PREMIERE PRESCRIPTION DRUG LIST



January 1, 2018 Adderall XR dextroamphetamine-amphetamine ER

Azilect rasagiline mesylate

Benicar olmesartan medoxomil

Benicar HCT olmesartan medoxomil/hydrochlorothiazide

Combivir lamivudine/zidovudine

CIGNA RX PLUS PRESCRIPTION DRUG LIST (FLORIDA ONLY) (cont.)




January 1, 2018 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 capsulesEpiPen and EpiPen Jr epinephrine auto-injectors Epivir lamivudineGlatopa 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 dropsmetformin hcl ER (generic Fortamet) metformin hcl ER (generic Glucophage XR)Naftin 2% cream naftifine hcl 2% creamNatroba spinosadNilandron nilutamideNitrostat nitroglycerin sublingual tabletsPennsaid 2% Pump diclofenac sodium 1% gelRayos prednisoneRescriptor Talk with your doctor about switching to a covered alternative.Retrovir zidovudineSelzentry Talk with your doctor about switching to a covered alternative.Stelara Cosentyx (requires prior authorization)Tamiflu capsules oseltamivir phosphate capsulesTikosyn dofetilideTrianex triamcinolone ointmentTrizivir abacavir/lamivudine/zidovudineVagifem yuvafemValcyte 50mg/ml solution valganciclovir hcl 50mg/ml solutionVidex EC didanosine DR


Viramune nevirapine



Zerit stavudine

Zetia ezetimibe


Ziana clindamycin/tretinoin

CIGNA RX PREMIERE PRESCRIPTION DRUG LIST (cont.)





Novacort








Health benefit plans vary, but in general to be eligible for coverage a drug must be approved by the Food and Drug Administration (FDA), prescribed by a health care professional, purchased from a licensed pharmacy and medically necessary. If your plan provides coverage for certain prescription drugs with no cost-share, you may be required to use an in-network pharmacy to fill the prescription. If you use a pharmacy that does not participate in your plan’s network, your prescription may not be covered, or reimbursement may be limited by your plan’s copayment, coinsurance or deductible requirements. Certain features described in this document may not be applicable to your specific health plan, and plan features may vary by location and plan type. Refer to your plan documents for costs and complete details of your plan’s prescription drug coverage.

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, Cigna Health Management, Inc., Tel-Drug, Inc., Tel-Drug of Pennsylvania, L.L.C., and HMO or service company subsidiaries of Cigna Health Corporation, including Cigna HealthCare of Arizona, Inc., Cigna HealthCare of California, Inc., Cigna HealthCare of Colorado, Inc., Cigna HealthCare of Connecticut, Inc., Cigna HealthCare of Florida, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Illinois, Inc., Cigna HealthCare of Indiana, Inc., Cigna HealthCare of St. Louis, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of New Jersey, Inc., Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of Tennessee, Inc., and Cigna HealthCare of Texas, Inc. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.

909016 © 2018 Cigna. Some content provided under license. UPDATED_6/27/2018


* State laws in Texas and Louisiana require health insurance plans to cover your medications at your current benefit level until your plan renews. This means that if your medication is taken off the drug list, is moved to a higher cost-share tier or needs approval, your plan can’t make these changes until your renewal date. To find out if these state laws apply to your plan, please call Customer Service using the number on the back of your ID card.

+ This is a specialty medication. Some plans cover these medications on a specialty tier, may limit you to a 30-day supply and/or require you to use Cigna Specialty Pharmacy (our home delivery pharmacy) to fill your prescription. For plans that cover specialty medications on a specialty tier, this change will not affect the cost of the medication. If you’re enrolled with Cigna, log in to the myCigna website or app or check your plan materials to learn more about your plan’s coverage requirements for specialty medications.

++ Approval may be required for new prescriptions filled on or after July 1st.^ These medications require approval from Cigna before they may be covered by your plan. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider

approving coverage of your medication.^^ These changes may not apply to your plan. Not all plans include requirements for prior authorization, quantity limits and/or Step Therapy. If you’re enrolled with Cigna, please check your plan

materials or log in to the myCigna website or app starting July 1st to learn more about how your plan covers these medications.# Quantity limits may apply to new prescriptions filled on or after July 1st.

## This is a Step Therapy medication. Step Therapy medications aren’t covered by your plan without approval from Cigna. Your plan requires you to try a lower-cost alternative first. Typically, these are generics or lower-cost preferred brands.

** Your plan doesn’t cover more than one tablet/capsule in this strength a day. If your doctor feels a higher strength of this medication once each day isn’t right for you, he or she can ask Cigna to consider approving coverage of your current medication strength.

Cigna reserves the right to make changes to the Drug List without notice.

CIGNA RX PREMIERE PRESCRIPTION DRUG LIST (cont.)

Documents

PRESCRIPTION DRUG LIST CHANGES - cignaforhcp.cigna.com · Zofran ODT ondansetron ODT HORMONAL AGENTS DDAVP desmopressin ... BLOOD PRESSURE/HEART MEDICATIONS BiDil 20-37.5mg#, captopril