View
1
Download
0
Category
Preview:
Citation preview
The Performance Prescription Drug List lets you and your doctor choose medications that work best for you. The following is a list of the most commonly used medications covered under your plan.
This list is designed to cover your prescription medications at three levels. The amount you pay depends on the tier from which you and your doctor select your medication. If there is more than one medication appropriate for your condition, we suggest that you talk to your doctor about lower-cost choices like generic medications and preferred brand medications to see if they could be right for you.
874988 a 05/14
Offered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company or their affiliates.
PERFORMANCE prescription drug list
Prescription Drug List July 2014
2
1st Tier – Generic Medications: Generic medications have the same ingredients, safety, dosage, quality and strength as their brand name counterparts. You will usually pay less for generic medications under your plan.
2nd Tier – Preferred Brand Medications: Preferred brand medications will usually cost more than a generic, but less than a non-preferred brand medication under your plan.
3rd Tier – Non-Preferred Brand Medications: Non-preferred brand medications are those that generally have generic alternatives and/or a preferred brand medication within the same drug class. You will usually pay more for a non-preferred brand under your plan.
3 2
The symbols on the list mean
If a medication on the list has one of the following symbols, your doctor may need to get an authorization for coverage of that medication.
If you have any questions
Remember, this list is just a sample of the most commonly used medications. You can use the Prescription Drug Price Quote tool available on myCigna.com to see and compare the prices of all medications covered under your plan. Or, you can call the number on the back of your ID card to speak with a customer service representative at any time.
PA: Prior Authorization may be required for different reasons. To learn the requirements needed for coverage of a specific medication, feel free to give us a call.
QL: Quantity Limit means you may have coverage for a limited amount of a specific medication.
AGE: Age Requirement means an individual must be within a specific age group for a specific medication to be covered.
ST: Step Therapy is a prior authorization program that requires you to try other medications available to treat the same condition before the “ST” medication is covered.
* Medications marked with an asterisk are considered to be specialty medications. Some plans may cover specialty medications at different benefit levels or may require the use of a preferred specialty pharmacy. Refer to the your plan documents for more information.
4
NoN-Preferred GeNerics Preferred BraNds BraNds
Perfo
rman
ce P
resc
riptio
n Dr
ug L
ist ADD/ADHD AND STIMULANTS
amphetamineclonidine HCldexmethylphenidate HCldexmethylphenidate HCl ERdextroamphetaminedextroamphetamine/
amphetamine ERMetadate ER-
methylphenidate HClmethamphetaminemethylphenidate/
ER/ER 24 HRmodafanilprocentra
Adderall XRFocalin XRIntunivRitalin LAStratteraVyvanse
Adderall (PA, ST)Concerta (PA, ST)Daytrana (PA, ST)Desoxyn (PA, ST)Dexadrine (PA, ST)Focalin (PA, ST)KapvayMetadate CD (PA, ST)Methylin (PA, ST)NuvigilProvigilQuillivant XR (PA, ST)Ritalin (PA, ST)Ritalin SR (PA, ST)Zenzedi (PA, ST)
AIDS/HIV
abacavir*abacavir/lamivudine/
zidovudine*didanosine*lamivudine*lamivudine/zidovudine*nevirapine*stavudine*zidovudine*
Aptivus*Crixivan*Emtriva*Epzicom*Fuzeon* (PA)Invirase*Isentress*Kaletra*Lexiva*Norvir*Prezista*Rescriptor*Reyataz*Selzentry*Sustiva*Trizivir*Truvada*Viracept*Viramune XR*Viread*
Atripla*Combivir*Complera*Edurant*Epivir*Fulyzaq (PA)Intelence*Retrovir*Stribild*Videx*Viramune*Zerit*Ziagen*
5 4
NoN-Preferred GeNerics Preferred BraNds BraNds
ALzHEIMER’S DISEASE
donepezil HClgalantamine hydrobromiderivastigmine tartrate capsules
Aricept (23 mg) Aricept (5 and 10 mg)Aricept ODTCognexExelonNamenda XRRazadyneRazadyne ER
ANXIETY
alprazolambuspironediazepamlorazepamoxazepam
Lorazepam IntensolNiravam
ASTHMA AND RESPIRATORY
albuterol sulfate (nebulizer solution)budesonide (nebulizer solution)caffeine citratecromolyn sodium (nebulizer solution)dyphyllineguaifenesin/dyphyllineguaifenesin/theophyllineipratropium bromide (nebulizer solution)
Advair, Advair HFAAsmanexAtrovent HFACombivent RespimatFlovent Diskus/HFAMaxairProAir HFAPulmicortPulmozyme* (PA)QvarSereventSpirivaSymbicort
AccolateAccuneb nebulizer (PA, ST)Adcirca* (PA)Adempas* (PA)AerospanAlvescoAnoro ElliptaArcaptaBreo Ellipta (ST)Brovana nebulizer (PA, ST)DalirespDuleraLetairis*
ALLERGY
azelastine nasalclemastine fumaratecyproheptadinecyproheptadine HCldesloratadineepinastineepinephrine (QL)flunisolide nasalfluticasone nasalhydroxyzineipratropium nasallevocetirizinemontelukasttriamcinolone nasal
AsteproEpipen (QL)Epipen Jr. (QL)NasonexVeramyst
Adrenaclick (QL)AstelinAtrovent (nasal)AUVI-Q (QL)Beconase AQ (PA, ST)Dymista (PA, ST)Flonase (PA, ST)Nasacort AQ (PA, ST)Omnaris (PA, ST)PatanaseQNASL (PA, ST)Rhinocort AQ (PA, ST)Semprex-DSingulairTavist SyrupXyzalZetonna (PA, ST)
6
NoN-Preferred GeNerics Preferred BraNds BraNds
Perfo
rman
ce P
resc
riptio
n Dr
ug L
ist ASTHMA AND RESPIRATORY (CONTINUED)
levalbuterol HCl (nebulizer solution)metaproterenol sulfate (syrup, tabs)montelukast sodiumracepinephine HClsildenafil* (PA)terbutaline sulfatetheophylline anhydrouszafirlukast
Ventolin HFAXolair* (PA)
LufyllinOpsumit* (PA)Orenitram ER* (PA)Perforomist (PA, ST)Proventil HFARevatio* (PA)S-2 RacepinephineSingulairTracleer*Tudorza Pressair (ST)Ventavis*Xopenex HFAXopenex nebulizer (PA, ST)
BIRTH CONTROL
AltaveraAlyacenAmethiaAmethia LoAmethystApriAranelleAubraAvianeAzuretteBalzivaBriellynCamilaCamreseCamrese LoCaziantChatealCryselleCyclafemDasettaDayseedesogestrel-ethinyl estradiolElinestEmoquetteEnpressEnskyceErrinEstaryllaethinyl estradiol/drospirenoneFalminaGianvi
BeYazLomedia 24 FELoSeasoniqueMinastrin 24 FENuvaRingOrtho EvraOrtho TriCyclen Lo
AngeliqBreviconCyclessaDepo-Provera SubqDesogenEllaEstrostep FEFem FEGeneress FELoestrinLoestrin FEMircetteModiconNataziaNordetteNorinyl 1+35Norinyl 1+50Nor-QDOrtho MicronorOrtho-CeptOrtho-CyclenOrtho-Novum 7-7-7Ortho-Tri-CyclenOvcon-35QuartetteSafyralSeasonaleSeasoniqueTri-NorinylYasmin 28Yaz
Please check your Summary Plan Description to determine whether these medications are covered under your specific plan.
7 6
NoN-Preferred GeNerics Preferred BraNds BraNds
BIRTH CONTROL (CONTINUED)
GildagiaGildessHeatherIntrovaleJencyclaJolessaJunelJunel FEKarivaKelnorKurveloLarinLarin FELeenaLessinaLevonestlevonorgestrellevonorgestrel-ethestralevonorgestrel-ethin estradiolLevoral-norgest-eth estr/ethin estraLorynaLow-OgestrelLuteraLyzaMarlissaMicrogestinMicrogestin FEMono-LinyahMononessaMyzilraNeconNext ChoiceNora-Benoreth a-et estra/fe fumaratenorethindronenorgestimate-ethinyl estradiolnorgestrel-ethinyl estradiolNortrelOcellaOgestrelOrsythiaPhilithPimtreaPirmellaPortia
Please check your Summary Plan Description to determine whether these medications are covered under your specific plan.
8
NoN-Preferred GeNerics Preferred BraNds BraNds
Perfo
rman
ce P
resc
riptio
n Dr
ug L
ist BIRTH CONTROL (CONTINUED)
PrevifemQuasenseReclipsenSprintecSronyxSyedaTilia FETri-EstaryllaTri-Legest FETri-LinyahTrinessaTri-PrevifemTri-SprintecTrivoraVelivetVesturaVioreleVyfemlaWeraWymzya FEZarahZenchentZeosaZovia
BLADDER PROBLEMS
flavoxateoxybutynin/XLpotassium citrate ERtolterodine tartratetrospium chloride
Detrol LAElmironToviazVESIcare
Detrol (PA,ST)Ditropan, Ditropan XL (PA,ST)Enablex (PA,ST)Gelnique (PA,ST)Myrbetriq (PA,ST)Oxytrol (PA,ST) (men only)Sanctura, Sanctura XR (PA,ST)
CANCER
anastrozoleazacitidine*bicalutamide*capecitabineexemestaneflutamide*letrozolelomustinetamoxifen citratetemozolomide* (PA)
Gleevec* (PA)Granix*Hexalen*LeukeranLupron Depot* (PA)LysodrenMatulane*MyleranNeulasta* (PA)Neupogen* (PA)
Afinitor* (PA)Afinitor Disperz* (PA)ArimidexAromasinBosulif* (PA)Caprelsa* (PA)Casodex*Cometriq* (PA)DroxiaErivedge* (PA)
Please check your Summary Plan Description to determine whether these medications are covered under your specific plan.
9 8
NoN-Preferred GeNerics Preferred BraNds BraNds
HIGH BLOOD PRESSURE/HEART MEDICATIONS
acebutolol HClacetazolamideamiloride HClamlodipine/atorvastatin
calciumamlodipine besylateamlodipine besylate/
benazeprilapresolineatenolol
BenicarBenicar HCTBystolicCoreg CRDiovanExforgeExforge HCTTarkaTekturnaTekturna HCT
Accupril (PA,ST)Accuretic (PA,ST)Aceon (PA,ST)Altace (PA,ST)AmturnideAtacand (PA, ST)Avalide (PA, ST)Avapro (PA, ST)AzorBetapace AF
CANCER (CONTINUED)
Nexavar* (PA)Revlimid* (PA)Sprycel* (PA)Sutent* (PA)Tarceva* (PA)Thalomid* (PA)Xeloda*Zolinza* (PA)
FarestonFemaraGilotrif (PA)Imbruvica* (PA)Inlyta* (PA)Jakafi* (PA)Mekinist* (PA)PanretinPomalyst (PA)Stivarga* (PA)Sylatron* (PA)Tafinlar* (PA)Targretin* (PA)Tasigna* (PA)Tykerb* (PA) ValchlorVotrient* (PA)Xalkori* (PA)Xtandi* (PA)Zelboraf* (PA)Zytiga* (PA)
CARDIOVASCULARBLOOD THINNER/ANTI-CLOTTING
anagrelide*cilostazolclopidogreldipyridamoleenoxaparin*fondaparinux*heparinJantoventiclopidinewarfarin
AggrenoxArixtraEffientFragminXarelto
Agrylin*BrillintaCoumadinEliquis (ST)LovenoxPlavixPletalPradaxa (ST)
10
NoN-Preferred GeNerics Preferred BraNds BraNds
Perfo
rman
ce P
resc
riptio
n Dr
ug L
ist CARDIOVASCULAR (CONTINUED)
HIGH BLOOD PRESSURE/HEART MEDICATIONS
benazepril HClbenazepril HCl/amlodipinebenazepril HCl/HCTZbendroflumethiazide/nadololbetaxolol HClbisoprolol fumaratebisoprolol/HCTZbumetanidecandesartancandesartan cilexetilcandesartan HCTZcaptoprilcaptopril/HCTZcarvedilolchlorothiazidechlorthalidonechlorthalidone/atenololclonidineclonidine HClClorpresdiltiazemdiltiazem 24HR ERdoxazosin mesylateenalapril maleateenalapril maleate/HCTZeplerenoneeprosartan mesylatefelodipinefosinopril sodiumfosinopril sodium/HCTZfurosemideguanfacinehydralazine HClhydrochlorothiazidehydrochlorothiazide/
amilor HClhydroflumethiazideindapamideirbesartanirbesartan/HCTZisradipinelabetalol HCllisinoprillisinopril/HCTZlosartan potassiumlosartan potassium/HCTZ
CarduraCardura XLCatapres, Catapres TTSCoregCorgardCovera-HSCozaar (PA, ST)Diovan HCT (PA, ST)DutoprolDynacirc CREdarbi (PA,ST)Edarbychlor (PA, ST)Hyzaar (PA, ST)Inderal LAInnopran XLLevatolLotensin (PA,ST)Lotensin HCT (PA,ST)LotrelMavik (PA,ST)Micardis (PA, ST)Micardis HCT (PA, ST)MonoprilMonopril HCTNexiclon XRNorpaceNorpace CRNorvascPrinivil (PA,ST)Prinzide (PA,ST)SularTekamloTeveten (PA, ST)Teveten HCT (PA, ST)Toprol XLTribenzor (ST)TwynstaUniretic (PA,ST)Univasc (PA,ST)Vaseretic (PA,ST)Vasotec (PA,ST)VerelanZestoretic (PA,ST)Zestril (PA,ST)
11 10
NoN-Preferred GeNerics Preferred BraNds BraNds
CARDIOVASCULAR (CONTINUED)
HIGH BLOOD PRESSURE/HEART MEDICATIONS
methazolamidemethyldopamethyldopa/HCTZmetolazonemetoprolol/HCTZmetoprolol succinatemetoprolol tartrateminoxidilmoexipril HClmoexipril HCl/HCTZnadololnicardipine HClnifedipinenimodipineperindopril erbuminepindololprazosin HClpropranolol HClpropranolol/HCTZquinaprilquinapril HCl/HCTZramiprilreserpinereserpine/HCTZsotalol HClspironolactonespironolactone/HCTZtelmisartantelmisartan/amlodipinetelmisartan/HCTZterazosin HCltimolol maleatetorsemidetrandolapriltriamterene/HCTZvalsartanvalsartan/HCTZVecamyl-mecamylamine HClverapamilverapamil SR
12
NoN-Preferred GeNerics Preferred BraNds BraNds
Perfo
rman
ce P
resc
riptio
n Dr
ug L
ist
CHOLESTEROL LOWERING
atorvastatincholestyraminecholestyramine/aspartamecholestyramine powdercholestyramine/sucrosecolestipolfenofibratefenofibric acidfluvastatin/XLgemfibrozillovastatinniacinomega-3-acid ethyl esterspravastatin sodiumsimvastatin
Crestor (5 & 10 MG) (PA,ST)Crestor (20 & 40 MG)LovazaNiaspanSimcorWelcholZetia
AdvicorAltoprev (PA,ST)AntaraCaduetColestidFenoglideJuxtapid* (PA)Kynamro* (PA)LescolLescol XRLipitor (PA,ST)LiptruzetLivalo (PA, ST)LofibraMevacor (PA,ST)Pravachol (PA,ST)TriCorTrilipixVascepa (ST)Vytorin (PA,ST)Zocor (PA,ST)
CARDIOVASCULAR (CONTINUED)
OTHER
amiodaronedigoxindisopyramideflecainideisosorbide dinitrateisosorbide mononitratenitroglycerinprocainamidepropafenone SR
MultaqNitrolingual sprayTikosyn
LanoxinNitromistRanexa (ST)Rythmol SRSamsca (PA)
13 12
NoN-Preferred GeNerics Preferred BraNds BraNds
DIABETES
acarbosechlorpropamideglimepirideglipizideglipizide/metforminglucagonglyburideglyburide micronizedglyburide/metforminmetformin/ERnateglinidepioglitazonepioglitazone/glimepiridepioglitazone/metforminrepaglinidetolazamidetolbutamide
ACCU-CHEK test stripsApidraApidra SoloStarBD Insulin Syringes/
Pen NeedlesBydureon (QL)ByettaFortametGlucaGen HypoKitGlucagon Emergency Kit (QL)HumalogHumulinJanumetJanumet XRJanuviaKombiglyze XRLantusLantus SoloStar
Actoplus MetActoplus Met XRActosAmarylAvandametAvandarylAvandiaCyclosetDuetactFarxiga (PA,ST)Glucophage XRGlysetInvokana (ST)Jentadueto (ST)Kazano (ST)Nesina (ST)Oseni (ST)Prandin
DEPRESSION
amitriptylinebupropionbupropion SRcitalopramdesipraminedesvenlafaxineduloxetine HClescitalopramfluoxetinefluvoxamineimipraminemirtazapinenortriptylineparoxetineparoxetine CRprotriptylinesertralinetrazodonetrimipraminetrimipramine maleatevenlafaxinevenlafaxine XR
CymbaltaPristiqWellbutrin XL
Aplenzin (PA,ST)Brintellix (PA,ST)Celexa (PA,ST)Desvenlafaxine ER (PA,ST)Desvenlafaxine Fumarate
(PA,ST)Effexor XR (PA,ST)EmsamFetzima (PA,ST)Forfivo XL (PA,ST)Khedezla (PA,ST)Lexapro (PA,ST)Luvox CRMarplanPaxil (PA,ST)Paxil CR (PA,ST)Pexeva (PA,ST)Prozac (PA,ST)RemeronSarafem (PA,ST)TofranilVenlafaxine HCl ER (PA,ST)Viibryd (PA,ST)VivactilWellbutrin (PA,ST)Wellbutrin SR (PA,ST)Zoloft (PA,ST)
14
NoN-Preferred GeNerics Preferred BraNds BraNds
Perfo
rman
ce P
resc
riptio
n Dr
ug L
ist
ENDOCRINE AND METABOLIC – OTHER
allopurinolcabergoline (QL)desmopressin*fluoxymesteroneoctreotide* (PA)
ColcrysIncrelex* (PA)LupronDepot-PED* (PA)Megace ESNilandronSandostatin* (PA)Sandostatin LAR* (PA)Somavert* (PA)Uloric
Egrifta* (PA)Signifor* (PA)Somatuline Depot* (PA)
EYE CONDITIONS
apraclonidine HClatropineazelastinebrimonidinebromfenacbromfenac sodiumciprofloxacindiclofenacdorzolamidedorzolamide/timololepinastineflurbiprofengatifloxacinketorolaclatanoprostlevobunolollevofloxacinpilocarpinetimololtobramycin/dexamethasonetravoprosttrifluridine
AlomideAlphagan P (0.10%)AzaSiteAzoptBetoptic SCiloxan (ointment)IopidineLotemax (drops & gel)MaxidexMoxezaPatadayPatanolRestasisTobradex ointmentTravatan ZVexolVigamox
Acular LSAlocrilAlrexBepreveBesivanceCiloxan (drops)CosoptCystaranDurezolElestatEmadineIlevroIquixLastacaftLotemax (ointment)OptivarProlensaResculaSimbrinza (ST)TimopticTobradex (drops)Tobradex STTrusoptVoltarenZioptan (ST)Zymaxid
DIABETES (CONTINUED)
LevemirNovoFine/NovoTwist needlesNovolinNovologOne Touch test stripsOnglyzaPrandimetSymlinPenVictoza
PrecoseStarlixTradjenta (ST)
15 14
NoN-Preferred GeNerics Preferred BraNds BraNds
GASTROINTESTINAL (NOT HEARTBURN/ULCER)
balsalazidebudesonidecromolyn sodium (solution)PEG 3350/potassium/ sodium bicarb/saltPEG 3350/potassium/ sodium bicarb/salt/ sodium sulf
AprisoAsacol HDCanasaCreonDelzicolGoLytelyHumira* (PA)LialdaPentasaUrso/Urso ForteZenpep
AmitizaCimzia* (PA)ColazalColyteEntocort ECGiazoLinzessNuLytelyPancreazePertzyePrepopikRelistor (PA)Remicade* (PA)Simponi* (PA)SuclearSucraid*UcerisUltresaViokace
GROWTH HORMONES
Humatrope* (PA)Saizen* (PA))
Genotropin* (PA)Nordiflex* (PA)Norditropin* (PA)Nutropin* (PA)Nutropin AQ* (PA)Omnitrope* (PA)Serostim* (PA)Tev-Tropin* (PA)
HEARTBURN/ULCER
cimetidinefamotidinelansoprazolelansoprazole/amoxicillin/
clarithromycinmetoclopramidemetoclopramide HClmisoprostolnizatidineomeprazoleomeprazole/sodium bicarbonatepantoprazolerabeprazole HClranitidinesucralfate
Nexium Aciphex (PA, ST)Aciphex Sprinkle (PA,ST)Dexilant (PA, ST)Esomeprazole Strontium
(PA,ST)Prevacid (PA, ST)PrevpacPrilosec (PA, ST)Protonix (PA, ST)Zantac EffertabZantac SyrupZegerid (PA, ST)
16
NoN-Preferred GeNerics Preferred BraNds BraNds
Perfo
rman
ce P
resc
riptio
n Dr
ug L
ist HORMONE REPLACEMENT
estradiolestradiol/norethindrone acetateestropipateethinyl estradiollevothroidlevothyroxineLevoxylliothyroninemedroxyprogesteroneprogesterone, micronizedtestosterone cypionatetestosterone enanthatethyroidUnithroid
AloraAnadrol-50AndrodermAndroGelArmour ThyroidDivigelEnjuviaEstradermPremarinPremphasePremproSynthroidTestimVivelle-Dot
ActivellaAxiron (ST)CenestinCombipatchCytomelDepot TestosteroneEstraceFemhrtFemringFortesta (ST)MenestMinivellePrefestPrometriumVagifem
INFECTIONS
acycloviradefovir dipivoxil*amantadineamoxicillinamoxicillin/clavulanateatovaquoneazithromycincefaclor ERcefadroxilcefdinircefprozilceftibuten dihydrateceftriaxonecefuroxime axetilcephalexinciclopiroxciprofloxacinclarithromycinclindamycinclindamycin phosphatecycloserinedoxycyclineerythromycinfamciclovirfluconazoleflucytosineganciclovir*gentamicin sulfategriseofulvin microsizegriseofulvin ultramicrosize
Baraclude*Cipro HC OticCiprodexEpivir HBV*Gris-PegIncivek* (PA)Intron-A* (PA)Mycostatin (tabs)Pegasys* (PA)Peg Intron* (PA)PrimsolTamiflu (QL)Tobi*Valcyte
AncobonAugmentinAugmentin ES 600Augmentin XRAveloxBactrobanBethkis*BiaxinBiaxin XLCayston* (ST)CedaxCefzilCetraxalCiclodanCipro XRCoartem (QL)Copegus*Dificid (PA)Ery-TabFamvirFlagyl 375Flagyl ERFloxin OticGaramycin*Grifulvin VHepsera*Infergen* (PA)KeflexKeftabLamisil (QL)
17 16
NoN-Preferred GeNerics Preferred BraNds BraNds
INFECTIONS (CONTINUED)
itraconazole (QL) ketoconazolelamivudine*metronidazoleminocyclineminocycline SRModeriba*moxifloxacin HClmupirocinnitrofurantoinnystatinofloxacinpenicillin v potassiumribavirin*rifabutinrifampinrimantadinesulfamethoxazole/trimethoprimterbinafine (QL)terconazoletetracyclinetobramycinvalacyclovirvancomycinvoriconazole (PA)
Levaquin MalaroneMonurolMoxatagNoxafilOlysio* (PA)OmnicefOnmel (QL,ST)PenlacPriftinRebetol*Relenza (QL)RocephinSirturoSolodyn (ST)Sovaldi* (PA)Sporanox (QL)SupraxTobi Podhaler*Tyzeka*ValtrexVfend (PA)Victrelis* (PA)ZithromaxZyvox (PA)
MIGRAINE
acetaminophen/caffeine butalbitaldihydroergotamine (QL)mesylate (QL)naratriptan (QL)rizatriptan (QL)sumatriptan (QL)sumatriptan succinate (QL)zolmitriptan (QL)
Treximet (QL) Alsuma (QL)Amerge (QL)Axert (QL)DHE 45 (QL)Frova (QL)Imitrex (QL)Maxalt (QL)Maxalt MLT (QL)Migranal (QL)Relpax (QL)Sumavel DosePro (QL)Zomig/Zomig ZMT (QL)
MULTIPLE SCLEROSIS
Ampyra* (PA)Avonex/Avonex Pen* (PA)Copaxone* (PA)Rebif* (PA)Rebif Rebidose* (PA)Tecfidera* (PA)
Aubagio* (PA)Betaseron* (PA)Extavia* (PA)Gilenya* (PA)
18
NoN-Preferred GeNerics Preferred BraNds BraNds
Perfo
rman
ce P
resc
riptio
n Dr
ug L
ist
PAIN RELIEF AND INFLAMMATORY DISEASE
buprenorphinebutalbit/acetamin/caff/ codeinebutorphanol nasal (QL)codeine phos/carisoprodol/ asacodeine phosphatecodeine phosphate/aspirincodeine sulfatecyclophosphamide*dexamethasonediclofenacdiclofenac-misoprostoldihy-cod tt/apap/caffeinedihydrocodeine/aspirinetodolacfenoprofenfentanyl citrate (lozenge on stick) (PA)fentanyl transdermal (QL)flurbiprofenhydrocodone bitartrate/apaphydrocodone bitartrate/ aspirinhydromorphone HCl
Actimmune* (PA)AvinzaCelebrexDilaudid-5DipentumEnbrel* (PA)Fentora (PA)Humira* (PA)Indocin (suppository)KadianLidodermLyricaNucynta (ST)Nucynta ER (QL)OxyContin (QL)PonstelRoxicetSavellaTrexall*Vimovo
Abstral (PA)Actemra* (PA)Actiq (PA)Ansaid (PA,ST)Arthrotec (PA, ST)Butrans (QL)Cambia (PA, ST)Cimzia* (PA)Conzip (PA,ST)Demerol (PA,ST)Dilaudid (PA,ST)Duexis (PA, ST)Duragesic (QL)Exalgo (QL)Fioricet w/codeineFlector (PA, ST)Horizant (ST)Hycet (PA,ST)Kineret* (PA)Lazanda (PA)Lortab (PA,ST)Mobic (PA, ST)Nalfon (PA,ST)Naprelan (PA, ST)Norco (PA,ST)
NAUSEA AND VOMITING
dronabinolgranisetronondansetronprochlorperazinepromethazinetrimethobenzamide
Emend (QL) Anzemet* (QL)DiclegisKytrilMarinolSancuso (QL)ScopaceZofranZuplenz (QL, ST)
OSTEOPOROSIS
alendronate sodiumcalcitonin-salmonetidronate disodiumForticalibandronate sodium*raloxifene HCl
EvistaForteo*Miacalcin
Actonel (PA,ST)Atelvia (PA,ST)Binosto (PA,ST)Boniva* (inj)Boniva (tab) (PA,ST)Fosamax (PA,ST)Fosamax Plus D (PA,ST)Skelid (PA,ST)
19 18
NoN-Preferred GeNerics Preferred BraNds BraNds
PAIN RELIEF AND INFLAMMATORY DISEASE (CONTINUED)
ibuprofenibuprofen/hydrocod bitindomethacinketoprofenketorolac (QL)leflunamidelevorphanol tartratelidocainelidocaine-prilocainemeclofenamatemefenamic acidmeloxicammeperidine HClmetaxalonemethotrexate*methylprednisolonemorphine SRmorphine sulfatenabumetonenaproxenopiumopium/belladonna alkaloidsorphenadrine/aspirin/caffeineoxaprozinoxycodone HCloxycodone HCl/
acetaminophenoxycodone/aspirinoxymorphoneOxymorphone HClpentazocine HCl/
acetaminophenpentazocine HCl/naloxone HClpiroxicamprednisonesulindactolmetintramadol HCl/acetaminophentramadol HCl/ER
Onsolis (PA)Opana (QL)Opana ER (QL)Otrexup* (PA)Oxecta (PA,ST)Pennsaid (PA, ST)Percocet (PA,ST)Percodan (PA,ST)Primalev (PA,ST)ProdrinQufloraRayos (ST)Remicade* (PA)Rheumatrex*Roxicodone (PA,ST)RyzoltSimponi* (PA)Simponi Aria* (PA)SkelaxinSprix (QL)SuboxoneSubsys (PA)Synalgos (PA,ST)Ultracet (PA,ST)Ultram (PA,ST)Ultram ER (PA,ST)Vicodin (PA,ST)Vicoprofen (PA,ST)Voltaren Gel (PA, ST)Voltaren XR (PA,ST)Xartemis XR (QL)Xeljanz* (PA)Xodol (PA,ST)Zamicet (PA,ST)Zohydro (QL)Zolvit (PA,ST)Zorvolex (PA,ST)
20
NoN-Preferred GeNerics Preferred BraNds BraNds
Perfo
rman
ce P
resc
riptio
n Dr
ug L
ist
SCHIzOPHRENIA
clozapinehaloperidolloxapineolanzapineolanzapine/fluoxetine HClquetiapinerisperidonethiothixeneziprasidone
Seroquel XR AbilifyAbilify DiscmeltClozaril (PA, ST)Fanapt (PA, ST)Fazaclo (PA, ST)Geodon (PA, ST)Invega (PA, ST)Latuda (PA, ST)MobanOrapRisperdal/ Risperdal M (PA, ST)Saphris (PA, ST)Seroquel (PA,ST)Versacloz (PA,ST)Zyprexa/Zyprexa Zydis (PA, ST)
PROSTATE
alfuzosindoxazosinfinasterideleuprolide acetate* (PA)prazosintamsulosinterazosin
AvodartCialis (PA,QL)JalynUroxatral
Firmagon* (PA)FlomaxProscarRapafloZoladex* (PA)
PARkINSON’S DISEASE
amantadinebenztropinebromocriptinecarbidopacarbidopa/levodopacarbidopa/levodopa CRcarbidopa/levodopa/
entacaponeentacaponepramipexoleropiniroleropinirole XLselegiline
Apokyn* (PA)AzilectRequip XL
ComtanEldeprylLodosynMirapexMirapex ERNeuproParcopaRequipSinemet CRStalevoTasmarZelapar
21 20
NoN-Preferred GeNerics Preferred BraNds BraNds
SEIzURE
carbamazepineclonazepamdiazepamdivalproexfelbamategabapentinlamotriginelevetiracetamoxcarbazepinephenytointiagabine HCltopiramatevalproatevalproate sodiumzonisamide
CelontinDiastatDiastat AcudialFelbatolGabitrilKeppraLamictal ODTLyricaPeganoneVimpat
AptiomBanzelCarbatrolDepakote (all forms)FycompaKeppra XRLamictalLamictal/ XRNeurontinOxtellar XRPotigaSaphrisStavzorTegretol XRTopamaxTrileptalZonegran
SEXUAL DYSFUNCTION
* Please check yourSummary Plan Description to determine whether thismedication is coveredunder your plan.
Cialis (PA,QL)Muse (PA, QL)Viagra (PA, QL)
Caverject (PA, QL)Edex (PA, QL)Levitra (PA, QL)OsphenaStaxyn (PA, QL)Stendra (PA, QL)
22
NoN-Preferred GeNerics Preferred BraNds BraNds
Perfo
rman
ce P
resc
riptio
n Dr
ug L
ist SkIN CONDITIONS
acitretinadapalene (AGE)alclometasone dipropionateamcinonideamnesteem (QL)Apexicon E (diflorasone
diacetate)betamethasonebetamethasone dipropionatebetamethasone dipropionate/
propylene glycolbetamethasone valeratecalcipotrienecalcitriol ointmentClaravis (QL)clinicamycinphosphate/
benzoyl peroxide gelclobetasol propionateclobetasol propionate/emollclocortolone pivalatedesonidedesoximetasonediclofenac sodiumdiflorasone diacetatefluocinolone acetonidefluocinonidefluocinonide/emollientfluorouracil topicalfluticasone propionatehalobetasol prop/ammonium
lachalobetasol propionatehydrocortisonehydrocortisone acetate/aloe
verahydrocortisone acetate/ureahydrocortisone butyratehydrocortisone valerateimiquimodIsotretinoin (QL)mafenide acetatemetronidazolemometasonepodofiloxprednicarbatesalicylic acidSotret (QL)
Benzaclin (Gel w/pump)Benzamycin PakCapex Shampoo (PA, ST)CaracCarmol HC (PA,ST)Cloderm (PA,ST)Cordran (PA, ST)Cordran SP (PA, ST)Derma-Smoothe/FS (PA, ST)Differin (AGE)Dovonex creamEnbrel* (PA)ExeldermFluoroplexFuracinHumira* (PA)Kenalog spray (PA, ST)KlaronLocoid (lotion)Locoid LipocreamLoprox shampooMetrogel 1%NaftinNoritateNucort (PA, ST)OraceaRetin-A Micro (AGE)SoriataneTazoracTexacort (PA, ST)
Absorica (QL)AcanyaAclovate (PA, ST)Ala-Scalp HP (PA, ST)AldaraAphthasolAqua Glycolic HC (PA, ST)Atralin (AGE)AvarAvar LSBenzaclinBenzefoamClindacin PacClobex (PA, ST) Cloderm (PA, ST)CondyloxCutivate (PA, ST)Delos AcneDermasorb AFDermasorb HC (PA,ST)Dermasorb TA (PA,ST)Dermasorb XMDermatop (PA, ST)Desonate (PA, ST)Desowen (PA, ST)Diprolene (PA, ST)Diprolene AF (PA, ST)DovonexDuac CSEcozaElidel (PA, ST)Elocon (PA, ST)Epiduo (AGE)First Hydrocortisone (PA, ST)Halog (PA, ST)Kenalog (PA, ST)Luxiq (PA, ST)LuzuMetrogelMetrolotionMomexin (PA, ST)NuzonOlux (PA, ST)Olux-e (PA, ST)Otezla* (PA)Pandel (PA, ST)Panretin* (PA)Pediaderm HC (PA, ST)
23 22
NoN-Preferred GeNerics Preferred BraNds BraNds
SLEEP
eszopiclonezaleplonzolpidemzolpidem ER
Silenor Ambien (PA, ST)Ambien CR (PA, ST)Edluar (PA, ST)Intermezzo (PA, ST)Lunesta (PA, ST)Rozerem (PA, ST)Sonata (PA, ST)Zolpimist (PA, ST)
SkIN CONDITIONS (CONTINUED)
sulfacetamidesulfacetamide sodium/sulfursulfacetamidesulfursulfacetamide/sulfur/cleansertretinoin (AGE)triamcinolone acetonideurea
Plexion Protopic (PA, ST)Psorcon (PA, ST)Psorcon ERegranex (PA)Remicade* (PA)RiaxRosulaScalacort DK (PA, ST)Soriatane CKStelara* (PA)Sumadan XLTSynalar (PA, ST)TaclonexTemovate (PA, ST)Topicort (PA, ST)Topicort LP (PA, ST)Tretin-X (PA)Ultrasal-ERUltravate (PA, ST)Vanos (PA, ST)VecticalVerdeso (PA, ST)VytoneWestcort (PA, ST)XolegelXolegel CorepakZianaZyclara (PA, ST)
24
NoN-Preferred GeNerics Preferred BraNds BraNds
Perfo
rman
ce P
resc
riptio
n Dr
ug L
ist
VITAMINS
Available as generic where ^ is noted.
calcitriolcyanocobalaminfolic acid
Active OB^Bal-Care DHA EssentialCitranatalCitranatal Assure^Citranatal B-CalmCitranatal Harmony^Duet DHADuet DHA ECFocalgin-B^Gesticare DHAInfanate BalanceNatachewNatafortNeevoNeevo DHANestabsNestabs ABCNestabs DHA^Nexa PlusOB CompleteOB Complete DHAOB Complete OneOB Complete PetiteOB Complete PremierPNV Folic Acid-IronPNV-DHA PlusPrecare PremierPrefera-OB OnePreferaOB Prenatal VitaminPrenaissance Next-BPrenataPrenatal 19Prenate AMPrenate ChewablePrenate DHAPrenate ElitePrenate Enhance
TRANSPLANT
azathioprine*cyclosporine*mycophenolate moefetil*mycophenolate sodium*sirolimus*tacrolimus*
Azasan*Cellcept*Neoral*Prograf*Rapamune*Sandimmune*
Imuran*Myfortic*Zortress*
25 24
NoN-Preferred GeNerics Preferred BraNds BraNds
VITAMINS (CONTINUED)
Available as generic where ^ is noted.
Prenate MiniPrenate PlusPrenate RestoreProvida OBStuart PrenatalStuartnatal PlusStuartnatal Plus 3TL-Select DHATricareTricare Prenatal Compleat Tricare Prenatal DHA One^Vinate CareVinate DHAVita Fol-OB DHAVitafol-OneVitafol UltraVitapearlViva DHAVP-PNV-DHA
26
NoN-Preferred GeNerics Preferred BraNds BraNds
Perfo
rman
ce P
resc
riptio
n Dr
ug L
ist MISCELLANEOUS
aminocaproic acid*buprenorphinebuprenorphine HCl/
naloxone HCl Cyclobenzaprinedoxercalciferolhydrocodonehydrocodone/
chlorpheniramine suspension
hydrocortisoneleucovorin*levocarnitinelindanemegestrolmethocarbamolnaltrexoneparicalcitol*pentoxifyllinepramoxine/hydrocortisonepseudoephed/
hydrocodone/cpmriluzole*sodium phenylbutyratespinosadtizanidinetranexamic acid
Analpram AdvancedAnalpram-EAnalpram HCAnamantle HC ForteAranesp* (PA)BuphenylChantixEpogen* (PA)Follistim AQ* (PA)FosrenolPramosoneProcrit* (PA)Proctofoam-HCPulmuzyme* (PA)RenvelaRilutek*SuboxoneTussiCapsZavesca* (PA)
Arcalyst* (PA)Brisdelle (QL)CortifoamCuvposaEpifoamGattex* (PA)GlycateHectorolHetlioz (PA)Ilaris* (PA)Kuvan*Lupaneta Pack* (PA)LystedaNatrobaNimotopNuedextaPhosloPhoslyraProcysbi* (PA)Promacta* (PA)Ravicti* (PA)RectivRenagelReviaSkliceSubutexTussionexUlesfiaVituzZanaflexZemplar*Zubsolv (ST)Zutripro
26 27
ExCLUSIONS & LIMITATIONS
Plans typically do not provide coverage for the following, except as required by law or by the terms of your specific plan:
1. Any medications available over-the-counter (OTC) that do not require a prescription by federal or state law, and any medication that is a pharmaceutical alternative to an OTC medication other than insulin. [examples include OTC Benadryl, Maalox, Sudafed PE, etc.].
2. Medications that are therapeutically equivalent as determined by the Cigna HealthCare Pharmacy and Therapeutics Committee in which at least one of the medications within the class is available over the counter [examples include Rx equivalents to OTC Allegra, Claritin and Zyrtec (Allegra D, Clarinex, Xyzal) and Rx equivalents to OTC Prevacid, Prilosec, Zantac (Aciphex, Kapidex, Nexium, Axid, Pepcid, Zantac)].
3. Any injectable infertility medications, and any injectable medications that require health care professional supervision and are not typically considered self-administered medications. The following are examples of health care professional-supervised medications: injectables used to treat hemophilia and RSV (respiratory syncytial virus), chemotherapy injectables and endocrine and metabolic agents.
4. Any medications that are experimental or investigational within the meaning set forth in the summary plan description.
5. Food and Drug Administration (FDA) approved medications used for purposes other than those approved by the FDA unless the medication is recognized for the treatment of the particular indication in one of the standard reference compendia (The United States Pharmacopoeia Drug Information or The American Hospital Formulary Service Drug Information) or in medical literature. Medical literature means scientific studies published in a peer-reviewed national professional medical journal.
6. Any prescription and non-prescription supplies (such as ostomy supplies), devices and appliances.
7. Any contraceptive medications and prescription appliances for contraception.
8. Implantable contraceptive products. 9. Any fertility medication. 10. Any prescription vitamins (other than
prenatal vitamins), dietary supplements and fluoride products.
11. Medications used for cosmetic purposes, such as medications used to reduce wrinkles, medications to promote hair growth, medications used to control perspiration and fade cream products.
12. Any diet pills or appetite suppressants (anorectics).
13. Immunization agents, biological products for allergy immunization, biological sera, blood, blood plasma and other blood products or fractions and medications used for travel prophylaxis (the prevention of travel-related diseases).
14. Replacement of prescription medications and related supplies due to loss or theft.
15. Medications used to enhance athletic performance.
16. Medications that are to be taken by, or administered to, a customer while the customer is a patient in a licensed hospital, skilled nursing facility, rest home or similar institution which operates on its premises, or allows to be operated on its premises, a facility for dispensing pharmaceuticals.
17. Prescriptions more than one year from the original date of issue.
Cigna reserves the right to make changes to this drug list without notice. Your plan may cover additional medications; please refer to your Summary Plan Description for details. Cigna does not take responsibility for any medication decisions made by the doctor or pharmacist. Cigna may receive payments from manufacturers of certain preferred brand medications, and in limited instances, certain non-preferred brand medications, that may or may not be shared with your plan depending on its arrangement with Cigna. Depending upon plan design, market conditions, the extent to which manufacturer payments are shared with your plan and other factors as of the date of service, the preferred brand medication may or may not represent the lowest-cost brand medication within its class for you and/or your plan.
874988 a 05/14 © 2014 Cigna. Some content provided under license.
“Cigna,” the “Tree of Life” logo and “GO YOU” are registered service marks, and “Cigna Home Delivery Pharmacy” is a service mark of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, Tel-Drug, Inc., Tel-Drug of Pennsylvania, L.L.C., and HMO subsidiaries of Cigna Health Corporation. “Cigna Specialty Pharmacy Services” refers to the specialty drug division of Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C., doing business as Cigna Home Delivery Pharmacy.
Recommended