2019 CIGNA RX PREMIERE 5-TIER PRESCRIPTION DRUG LIST...aldactazide 4 alendronate sod 70 mg/75 ml 2 alendronate sodium 10 mg tab 1 alendronate sodium 35 mg tab 1 alendronate sodium

2019 CIGNA RX PREMIERE 5-TIER PRESCRIPTION DRUG LIST

Starting January 1, 2019

924126 11/18 © 2018 Cigna

Cigna Health and Life Insurance Company

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View your drug list online

Questions? – Call the toll-free number on the back of your Cigna ID card, or 866.494.2111. We’re here to help.

The myCigna® website – Once you’re registered, log in and select Estimate Health Care Costs, then select Get drug costs.

Cigna.com/druglist – Select your state from the drop down menu, then choose your search method. You can either search for a medication name or view the full drug list.

Table of Contents

Your prescription drug list 3

How to read your drug list 3

How to find your medication 5

Specialty medications 33

Prescription drug list FAQs 35

2019 Exclusions and Limitations 37

Getting started

* Drug list originally created: 10/21/2013 Last updated: 08/01/2018 Next planned update: 08/01/19

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DRUG NAME Tier NOTES (PA, ST, QL, AGE)

8-MOP 4

ABACAVIR 2

ABACAVIR-LAMIVUDINE 2

ABACAVIR-LAMIVUDINE-ZIDOVUDINE 2

ABSORICA 4 QL

ACAMPROSATE CALCIUM 2

ACARBOSE 2

ACEBUTOLOL HCL 2

ACETAMIN-CAFF-DIHYDROCOD 320.5 2

ACETAMINOPHEN-CODEINE 2

ACETASOL HC 2

ACETAZOLAMIDE 2

ACETIC ACID 2

ACETIC ACID-ALUMINUM 2

ACETYLCYSTEINE 10% VIAL 2

ACETYLCYSTEINE 20% VIAL 2

ACITRETIN 2

ACYCLOVIR 200 MG CAPSULE 1

ACYCLOVIR 200 MG/5 ML SUSP 2

ACYCLOVIR 400 MG TABLET 2

ACYCLOVIR 5% OINTMENT 2

ACYCLOVIR 800 MG TABLET 2

ADAPALENE 2 AGE

Your prescription drug list

Tier (cost-share level) gives you an idea of how much you may pay for a medication

Medications that have extra coverage requirements will have an abbreviation in the Notes section

Medications are listed in alphabetical order

This document shows the prescription medications covered on the 2019 Cigna Rx Premiere Prescription Drug List as of January 1, 2019.1 All of these medications are approved by the U.S. Food and Drug Administration (FDA). Medications are listed alphabetically by medication name. If you don’t see a specific medication on this list, please check myCigna.com to view the most current list of medications your plan covers.

How to read your drug listUse the sample chart below to help you understand this drug list. This chart is just an example. It may not show how these medications are actually covered on the 2019 Cigna Rx Premiere Prescription Drug List.

This chart is just a sample. It may not show how these medications are actually covered on the 2019 Cigna Rx Premiere Prescription Drug List.

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Tiers Covered medications are divided into tiers or cost-share levels. Typically, the higher the tier, the higher the price you’ll pay to fill the prescription.

Abbreviations next to medicationsSome medications on your drug list have extra requirements before your plan will cover them. This helps to make sure you’re receiving coverage for the right medication, at the right cost, in the right amount and for the right situation. These medications will have an abbreviation next to them in the Notes column in the drug list. Here’s what each of the abbreviations mean.

PA Prior Authorization – Cigna will review information provided by your doctor to make sure you meet coverage guidelines for the medication. If approved, your plan will cover the medication.

ST Step Therapy – Step Therapy is a prior authorization program that requires you to try other medications available to treat the same condition before the medication with the “ST” is covered.

QL Quantity Limits – For some medications, your plan will only cover up to a certain amount over a certain length of time. For example, 30mg per day for 30 days. Your plan will only cover a larger amount if your doctor requests and receives approval from Cigna.

AGE Age Requirements – You must be within a specific age range for your plan to cover the medication.

LDD Limited Distribution Drugs are medications that are only available at specific pharmacies in the United States because of manufacturer restrictions.

Brand name medications are capitalized

In this drug list, brand name medications are capitalized and generic medications are lowercase.

Specialty medications are listed on page 33

Specialty medications are used to treat complex conditions like multiple sclerosis, hepatitis C and rheumatoid arthritis. In this drug list, specialty medications are listed on page 33. Specialty medications are limited to a 30-day supply. Please log in to the myCigna website or app, or check your plan materials, to learn more about how your plan covers specialty medications.

Tier 1 – Preferred Generic Medications. This tier typically includes preferred generic medications. These medications have the same strength, and active ingredients as brand name medications, but often cost much less. Preferred generic medications are covered at your plan’s lowest cost share.

Tier 2 – Generic Medications. This tier typically includes most generic medications and some low cost brand name medications. Generic medications have the same strength and active ingredients as brand name medications, but often cost much less.

Tier 3 – Preferred Brand Medications. This tier typically includes preferred brand name medications and some high cost generic medications.

Tier 4 – Non-Preferred Medications. This tier typically includes non-preferred brand name medications and some high cost generic medications.

Tier 5 – Specialty and Other High Cost Medications. This tier typically includes Specialty medications and high cost generic and brand name medications.

(Lower-cost medication) $

(Medium-cost medication) $$

(Higher-cost medication) $$$

$$$$

$$$$$

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Plan exclusions

Your plan excludes certain types of medications or products from coverage. This is known as a “plan (or benefit) exclusion.” This means that your plan doesn’t cover any prescription medications in the drug class or to treat the specific condition. There’s also no option to receive coverage through a medication review process. Please log in to the myCigna website or app, or check your plan materials, to find out if your plan excludes your medication from coverage.

How to find your medication Find your medication using the alphabetical list below. Then go to that page to see how your plan covers the medication.

Medication name Page

A–B 6–10

C–D 10–14

E–G 14–16

H–J 16–18

K–L 18–20

M–N 20–24

0–P 24–26

Q–S 26–28

T–U 28–30

V–Z 30–32

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MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)ALDACTAZIDE 4ALENDRONATE SOD 70 MG/75 ML 2ALENDRONATE SODIUM 10 MG TAB 1ALENDRONATE SODIUM 35 MG TAB 1ALENDRONATE SODIUM 40 MG TAB 1ALENDRONATE SODIUM 5 MG TABLET 1ALENDRONATE SODIUM 70 MG TAB 2ALFUZOSIN HCL ER 2ALINIA 4ALLOPURINOL 1ALMOTRIPTAN MALATE 2 QLALOCRIL 4ALOGLIPTIN 2 QLALOGLIPTIN-METFORMIN 2 QLALOGLIPTIN-PIOGLITAZONE 2 QLALOMIDE 4ALOSETRON HCL 4ALPRAZOLAM 2ALPRAZOLAM ER 2ALPRAZOLAM INTENSOL 2ALPRAZOLAM ODT 2ALPRAZOLAM XR 2ALTABAX 4ALTACAINE 2ALTAVERA 1ALYACEN 1AMABELZ 2AMANTADINE 2AMCINONIDE 2AMETHIA 1AMETHIA LO 1AMETHYST 1AMILORIDE HCL 2AMILORIDE-HYDROCHLOROTHIAZIDE 2AMIODARONE HCL 100 MG TABLET 2AMIODARONE HCL 200 MG TABLET 2AMIODARONE HCL 400 MG TABLET 2AMITIZA 4AMITRIPTYLINE HCL 1AMLODIPINE BESYLATE 2AMLODIPINE BESYLATE-BENAZEPRIL 2AMLODIPINE-ATORVASTATIN 2AMLODIPINE-OLMESARTAN 2AMLODIPINE-VALSARTAN 2AMLODIPINE-VALSARTAN-HCTZ 2AMMONIUM LACTATE 12% CREAM 2AMMONIUM LACTATE 12% LOTION 2AMNESTEEM 2 QL

2019 Cigna Rx Premiere Prescription Drug List

Please visit Cigna.com/ifp-drug-list to see a complete listing.

MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)8-MOP 4ABACAVIR 2ABACAVIR-LAMIVUDINE 2ABACAVIR-LAMIVUDINE-ZIDOVUDINE 2ACAMPROSATE CALCIUM 3ACARBOSE 2ACEBUTOLOL HCL 2ACETAMIN-CAFF-DIHYDROCOD 320.5 2ACETAMINOPHEN-CODEINE 2ACETAZOLAMIDE 2ACETIC ACID 2ACETIC ACID-ALUMINUM 2ACETYLCYSTEINE 10% VIAL 2ACETYLCYSTEINE 20% VIAL 2ACITRETIN 4ACYCLOVIR 200 MG CAPSULE 1ACYCLOVIR 200 MG/5 ML SUSP 2ACYCLOVIR 400 MG TABLET 2ACYCLOVIR 5% OINTMENT 2ACYCLOVIR 800 MG TABLET 2ADAPALENE 2 AGEADAPALENE-BENZOYL PEROXIDE 2ADEFOVIR DIPIVOXIL 2ADRENALIN CHLORIDE 4ADVAIR DISKUS 3ADVAIR HFA 3AFEDITAB CR 2AFTERA 4AK-POLY-BAC 2ALA-CORT 2.5% CREAM 1ALBENZA 4ALBUTEROL 2.5 MG/0.5 ML SOL 2ALBUTEROL 5 MG/ML SOLUTION 2ALBUTEROL SUL 0.63 MG/3 ML SOL 2ALBUTEROL SUL 1.25 MG/3 ML SOL 2ALBUTEROL SUL 2.5 MG/3 ML SOLN 1ALBUTEROL SULF 2 MG/5 ML SYRUP 2ALBUTEROL SULFATE 2 MG TAB 2ALBUTEROL SULFATE 4 MG TAB 2ALBUTEROL SULFATE ER 4 MG TAB 2ALBUTEROL SULFATE ER 8 MG TAB 2ALCLOMETASONE DIPROPIONATE 2ALCOHOL PADS 3ALCOHOL PREP PADS 3ALCOHOL PREP SWABS 3ALCOHOL SWAB 3ALCOHOL SWABS 3ALCOHOL WIPES 3

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MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)AMOXAPINE 2AMOX-CLAV 200-28.5 MG TAB CHEW 2AMOX-CLAV 200-28.5 MG/5 ML SUS 2AMOX-CLAV 250-125 MG TABLET 2AMOX-CLAV 250-62.5 MG/5 ML SUS 2AMOX-CLAV 400-57 MG TAB CHEW 2AMOX-CLAV 400-57 MG/5 ML SUSP 2AMOX-CLAV 500-125 MG TABLET 2AMOX-CLAV 600-42.9 MG/5 ML SUS 2AMOX-CLAV 875-125 MG TABLET 2AMOXICILLIN 1AMOXICILLIN-CLAVULANATE POT ER 2AMPICILLIN TRIHYDRATE 2ANADROL-50 4 PAANAGRELIDE HCL 2ANALPRAM HC 4ANASTROZOLE 2ANDROXY 2ANORO ELLIPTA 3ANUCORT-HC 2APEXICON E 2APIDRA 4 STAPIDRA SOLOSTAR 4 STAPRACLONIDINE HCL 2APREPITANT 2 QLAPRI 1APRISO 3APTIOM 4 QLAPTIVUS 3ARANELLE 1ARBINOXA 2ARCAPTA NEOHALER 4 STARIPIPRAZOLE 2ARIPIPRAZOLE ODT 2ARMODAFINIL 2 PAARMOUR THYROID 2ARNUITY ELLIPTA 3ASA-BUTALB-CAFFEINE-CODEINE 2ASCOMP WITH CODEINE 2ASHLYNA 1ASMANEX 4 STASMANEX HFA 4 STASPIRIN-CAFFEINE-DIHYDROCODEIN 2ASPIRIN-DIPYRIDAMOLE ER 2ATAZANAVIR SULFATE 2ATENOLOL 1ATENOLOL-CHLORTHALIDONE 1ATOMOXETINE HCL 2

MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)ATORVASTATIN CALCIUM 2ATOVAQUONE 2ATOVAQUONE-PROGUANIL HCL 2ATRIPLA 3ATROPINE 1% EYE DROPS 2ATROPINE 1% EYE OINTMENT 2AUBRA 1AVANDIA 4AVIANE 1AZASITE 4AZATHIOPRINE 2AZELASTINE HCL 2AZITHROMYCIN 1 GM PWD PACKET 2AZITHROMYCIN 100 MG/5 ML SUSP 2AZITHROMYCIN 200 MG/5 ML SUSP 2AZITHROMYCIN 250 MG TABLET 2AZITHROMYCIN 500 MG TABLET 2AZITHROMYCIN 600 MG TABLET 2AZOPT 3AZUPHEN MB 2AZURETTE 1BACITRACIN 500 UNIT/GM OPHTH 2BACITRACIN-POLYMYXIN EYE OINT 2BACLOFEN 10 MG TABLET 1BACLOFEN 20 MG TABLET 1BACLOFEN 5 MG TABLET 2BAL-CARE DHA 1BALCOLTRA 4BALSALAZIDE DISODIUM 2BALZIVA 1BANZEL 4 QLBASAGLAR KWIKPEN U-100 3BD 3 ML SYRINGE 18GX1-1/2" 3BD 3 ML SYRINGE 20GX1-1/2" 3BD 3 ML SYRINGE 25GX1" 3BD 3 ML SYRINGE 25GX1-1/2" 3BD 3 ML SYRINGE WITH NEEDLE 3BD AUTO INJECTOR 3BD AUTOSHIELD DUO NDL 5MMX30G 3BD AUTOSHIELD NEEDLE 5MMX29G 3BD AUTOSHIELD NEEDLE 8MMX29G 3BD BLUNT NEEDLE 18GX1-1/2" 3BD ECLIPSE 30GX1/2" SYRINGE 3BD ECLIPSE LUER-LOK SYR 3 ML 3BD ECLIPSE NEEDLE 18GX1 1/2" 3BD ECLIPSE NEEDLE 21GX1" 3BD ECLIPSE NEEDLE 22GX1" 3BD ECLIPSE NEEDLE 23GX1" 3



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MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)BD ECLIPSE NEEDLE 25GX1" 3BD ECLIPSE NEEDLE 25GX1.5" 3BD ECLIPSE NEEDLE 25GX5/8" 3BD ECLIPSE NEEDLE 27GX1/2" 3BD ECLIPSE NEEDLE 30GX1/2" 3BD ECLIPSE NEEDLES 21GX1.5" 3BD FILTER NEEDLE 3BD INS SYR 0.3 ML 8MMX31G(1/2) 3BD INS SYR U-500 1/2ML 6MMX31G 3BD INS SYR UF 0.3ML 12.7MMX30G 3BD INS SYR UF 0.5ML 12.7MMX30G 3BD INS SYRN UF 1 ML 12.7MMX30G 3BD INS SYRNG 0.3 ML 29GX12.7MM 3BD INS SYRNG 0.5 ML 29GX12.7MM 3BD INS SYRNG UF 0.3 ML 8MMX31G 3BD INS SYRNG UF 0.5 ML 8MMX31G 3BD INSUL SYR 0.3 ML 31GX15/64" 3BD INSUL SYR 0.5 ML 31GX15/64" 3BD INSULIN SYR 0.3 ML 28GX1/2" 3BD INSULIN SYR 0.3 ML 29GX1/2" 3BD INSULIN SYR 0.3 ML 31GX5/16 3BD INSULIN SYR 0.3 ML 8MMX31G 3BD INSULIN SYR 0.5 ML 28GX1/2" 3BD INSULIN SYR 0.5 ML 29GX1/2" 3BD INSULIN SYR 0.5 ML 30GX1/2" 3BD INSULIN SYR 0.5 ML 8MMX31G 3BD INSULIN SYR 0.5ML 31GX5/16" 3BD INSULIN SYR 1 ML 12.7MMX30G 3BD INSULIN SYR 1 ML 25GX1" 3BD INSULIN SYR 1 ML 25GX5/8" 3BD INSULIN SYR 1 ML 26GX1/2" 3BD INSULIN SYR 1 ML 27GX12.7MM 3BD INSULIN SYR 1 ML 27GX5/8" 3BD INSULIN SYR 1 ML 28GX1/2" 3BD INSULIN SYR 1 ML 29GX1/2" 3BD INSULIN SYR 1 ML 29GX12.7MM 3BD INSULIN SYR 1 ML 30GX1/2" 3BD INSULIN SYR 1 ML 31GX15/64" 3BD INSULIN SYR 1 ML 31GX5/16" 3BD INSULIN SYR 1 ML 8MMX31G 3BD INSULIN SYR UF 1 ML 8MMX31G 3BD INSULIN SYRINGE 1 ML 3BD INSULIN U100-3/10 ML SYR 3BD INTEGRA NEEDLE 25G X 5/8" 3BD INTEGRA RETRA NEEDLE 23GX1" 3BD INTEGRA SYR 1 ML 29GX1/2" 3BD INTEGRA SYR 3 ML 21GX1 1/2" 3BD LUER-LOK SYR 3 ML 25GX5/8" 3

MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)BD LUER-LOK SYRINGE 1 ML 3BD MAGNI-GUIDE MAGNIFIER 3BD MEDSAVER SYRINGE 3BD NEEDLE 18GX1 1/2" 3BD NEEDLE 19GX1 1/2" 3BD NEEDLE 20GX1 1/2" 3BD NEEDLE 21GX1 1/2" 3BD NEEDLE 21GX1" 3BD NEEDLE 22GX1 1/2" 3BD NEEDLE 22GX1" 3BD NEEDLE 22GX3/4" 3BD NEEDLE 23GX1 1/2" 3BD NEEDLE 23GX1" 3BD NEEDLE 24GX1" 3BD NEEDLE 25GX1" 3BD NEEDLE 25GX5/8" 3BD NEEDLE 26GX0.625" 3BD NEEDLES 16GX1" 3BD NEEDLES 16GX1.5" 3BD NEEDLES 18GX1" 3BD NEEDLES 18GX1.5" 3BD NEEDLES 19GX1" 3BD NEEDLES 19GX1.5" 3BD NEEDLES 20GX1" 3BD NEEDLES 20GX1.5" 3BD NEEDLES 21GX1" 3BD NEEDLES 21GX1.5" 3BD NEEDLES 21GX2" 3BD NEEDLES 22GX1" 3BD NEEDLES 22GX1.5" 3BD NEEDLES 23GX0.75" 3BD NEEDLES 23GX1.25" 3BD NEEDLES 25GX0.625" 3BD NEEDLES 25GX0.875" 3BD NEEDLES 25GX1.5" 3BD NEEDLES 26GX0.375" 3BD NEEDLES 26GX0.5" 3BD NEEDLES 27GX0.5" 3BD NEEDLES 27GX1X1.25" 3BD NEEDLES 30GX0.5" 3BD NEEDLES 30GX1" 3BD NOKOR ADMIX NEEDLE 18GX1.5" 3BD NOKOR NEEDLE 16GX1" 3BD NOKOR NEEDLE 18GX1" 3BD PEN NEEDLE 29GX1/2" 3BD PRECISIONGLI 27GX1-1/2" NDL 3BD PRECISIONGLIDE 3 ML 22GX3/4 3BD PRECISIONGLIDE NEEDLE 25G 3



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MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)BD SAFETGLD INS 0.3 ML 8MMX31G 3BD SAFETGLD INS 0.3ML 13MMX29G 3BD SAFETGLD INS 0.5 ML 8MMX30G 3BD SAFETYGLID INS 1 ML 6MMX31G 3BD SAFETYGLIDE 3 ML SYRINGE 3BD SAFETYGLIDE NEEDLE 3BD SAFETYGLIDE NEEDLE 18GX1.5" 3BD SAFETYGLIDE NEEDLE 21GX1" 3BD SAFETYGLIDE NEEDLE 21GX1.5" 3BD SAFETYGLIDE NEEDLE 22GX1.5" 3BD SAFETYGLIDE NEEDLE 25GX1" 3BD SAFETYGLIDE NEEDLE 27GX5/8" 3BD SAFETYGLIDE SYRINGE 27GX5/8 3BD SAFTYGLD INS 0.3 ML 6MMX31G 3BD SAFTYGLD INS 0.5 ML 6MMX31G 3BD SYR 0.3 ML 6MMX31G (1/2) 3BD SYR 0.3 ML 8MMX31G (1/2) 3BD SYRINGE 0.3 ML 12.7MMX30G 3BD SYRINGE 0.5 ML 12.7MMX30G 3BD SYRINGE-SAFETY GLIDE 3BD UF MICRO PEN NEEDLE 6MMX32G 3BD UF MINI PEN NEEDLE 5MMX31G 3BD UF NANO PEN NEEDLE 4MMX32G 3BD UF ORIG PEN NDL 12.7MMX29G 3BD UF SHORT PEN NEEDLE 8MMX31G 3BD VEO INS 0.3ML 6MMX31G (1/2) 3BD VEO INS SYRING 1 ML 6MMX31G 3BD VEO INS SYRN 0.3 ML 6MMX31G 3BD VEO INS SYRN 0.5 ML 6MMX31G 3BECONASE AQ 4 STBEKYREE 1BELLADONNA-OPIUM 2BELSOMRA 4 ST, QLBENAZEPRIL HCL 1BENAZEPRIL-HYDROCHLOROTHIAZIDE 2BENZEPRO 6% FOAMING CLOTHS 2BENZEPRO 7% CREAMY WASH 2BENZONATATE 2BENZTROPINE MES 0.5 MG TAB 2BENZTROPINE MES 1 MG TABLET 2BENZTROPINE MES 2 MG TABLET 2BEPREVE 4BESIVANCE 4BETADINE 4BETAMETHASONE DIPROP AUGMENTED 2BETAMETHASONE DIPROPIONATE 2BETAMETHASONE VALERATE 2BETAXOLOL HCL 2

MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)BETHANECHOL CHLORIDE 2BEXAROTENE 4 PABEYAZ 3BICALUTAMIDE 2BILTRICIDE 4BIMATOPROST 0.03% EYE DROPS 2BINOSTO 4BISOPROLOL FUMARATE 2BISOPROLOL-HYDROCHLOROTHIAZIDE 1BLISOVI 24 FE 1BLISOVI FE 1BP WASH 7% LIQUID 2BP WASH ACNE 4% TREATMENT PACK 2BPO 4% CREAMY WASH PACK 2BPO 4% GEL 2BPO 6% FOAMING CLOTHS 2BPO 8% GEL 2BREO ELLIPTA 3BREVICON 4BRIELLYN 1BRILINTA 4BRIMONIDINE TARTRATE 2BROMFED DM 2BROMFENAC SODIUM 2BROMOCRIPTINE MESYLATE 2BROMPHENIRAMINE-PSEUDOEPHED-DM

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BROVANA 4BUDESONIDE 0.25 MG/2 ML SUSP 4BUDESONIDE 0.5 MG/2 ML SUSP 4BUDESONIDE 1 MG/2 ML INH SUSP 4BUDESONIDE 32 MCG NASAL SPRAY 2BUDESONIDE EC 3 MG CAPSULE 4BUMETANIDE 0.5 MG TABLET 1BUMETANIDE 1 MG TABLET 1BUMETANIDE 2 MG TABLET 1BUPRENORPHINE PATCH 2 QLBUPRENORPHINE 2 MG TABLET SL 2BUPRENORPHINE 8 MG TABLET SL 2BUPRENORPHINE-NALOXONE 2BUPROPION HCL 2 QLBUPROPION HCL SR 2 QLBUPROPION XL 2 QLBUSPIRONE HCL 2BUTALB-ACETAMINOPH-CAFF-CODEIN 2BUTALB-CAFF-ACETAMINOPH-CODEIN 2BUTALBITAL COMPOUND-CODEINE 2BUTALBITAL-ACETAMINOPHEN-CAFFE 2



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MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)BUTALBITAL-ACETAMINOPHN 50-325 2BUTALBITAL-ASPIRIN-CAFFEINE 2BUTISOL SODIUM 4BUTORPHANOL 10 MG/ML SPRAY 2 QLBYDUREON 3 QLBYDUREON BCISE 3 QLBYDUREON PEN 3 QLBYETTA 3 QLBYSTOLIC 4 QLCABERGOLINE 2 QLCAFFEINE CIT 60 MG/3 ML ORAL 2CALCIPOTRIENE 2CALCIPOTRIENE-BETAMETHASONE DP 2CALCITONIN-SALMON 2CALCITRENE 2CALCITRIOL 0.25 MCG CAPSULE 2CALCITRIOL 0.5 MCG CAPSULE 2CALCITRIOL 1 MCG/ML SOLUTION 2CALCITRIOL 3 MCG/G OINTMENT 2 QLCALCIUM ACETATE 667 MG CAPSULE 2CALCIUM ACETATE 667 MG GELCAP 2CALCIUM ACETATE 667 MG TABLET 2CAMBIA 4CAMILA 1CAMRESE 1CAMRESE LO 1CANDESARTAN CILEXETIL 2CANDESARTAN-HYDROCHLOROTHIAZID 2CAPACET 2CAPCOF 4CAPECITABINE 4CAPTOPRIL 1CAPTOPRIL-HYDROCHLOROTHIAZIDE 2 QLCARBAGLU 4 PACARBAMAZEPINE 100 MG TAB CHEW 1CARBAMAZEPINE 100 MG/5 ML SUSP 2CARBAMAZEPINE 200 MG TABLET 1CARBAMAZEPINE ER 2CARBIDOPA 2CARBIDOPA-LEVODOPA 2CARBIDOPA-LEVODOPA ER 2CARBIDOPA-LEVODOPA-ENTACAPONE 2CARBINOXAMINE 4 MG/5 ML LIQUID 2CARBINOXAMINE MALEATE 4 MG TAB 2CARETOUCH ALCOHOL PREP PAD 3CARISOPRODOL 2CARISOPRODOL COMPOUND 2CARISOPRODOL COMPOUND-CODEINE 2

MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)CARISOPRODOL-ASPIRIN 2CARISOPRODOL-ASPIRIN-CODEINE 2CARNITOR SF 4CARTEOLOL HCL 2CARTIA XT 2CARVEDILOL 1CAZIANT 1CEFACLOR 2CEFACLOR ER 2CEFADROXIL 2CEFDINIR 2CEFDITOREN PIVOXIL 2CEFIXIME 2CEFPODOXIME PROXETIL 2CEFPROZIL 2CEFTIBUTEN 2CEFUROXIME 2CELECOXIB 2 QLCELONTIN 4CENTERGY 2CENTERGY DM 2CEPHALEXIN 125 MG/5 ML SUSP 1CEPHALEXIN 250 MG CAPSULE 1CEPHALEXIN 250 MG TABLET 1CEPHALEXIN 250 MG/5 ML SUSP 1CEPHALEXIN 500 MG CAPSULE 1CEPHALEXIN 500 MG TABLET 1CEPHALEXIN 750 MG CAPSULE 2CESAMET 4CETIRIZINE HCL 1 MG/ML SOLN 2CETIRIZINE HCL 1 MG/ML SYRUP 2CEVIMELINE HCL 2CHANTIX 4CHATEAL 1CHEMET 4CHENODAL 4 LDDCHERATUSSIN AC 2CHLORDIAZEPOXIDE HCL 2CHLORDIAZEPOXIDE-AMITRIPTYLINE 2CHLORDIAZEPOXIDE-CLIDINIUM 2CHLORHEXIDINE 0.12% RINSE 2CHLOROQUINE PHOSPHATE 2CHLOROTHIAZIDE 2CHLORPROMAZINE 10 MG TABLET 2CHLORPROMAZINE 100 MG TABLET 2CHLORPROMAZINE 200 MG TABLET 2CHLORPROMAZINE 25 MG TABLET 2CHLORPROMAZINE 50 MG TABLET 2



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MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)CHLORPROPAMIDE 1CHLORTHALIDONE 2CHLORZOXAZONE 500 MG TABLET 2CHOLESTYRAMINE 2CHOLESTYRAMINE LIGHT 2CHOLINE MAG TRISALICYLATE 2CHORIONIC GONADOTROPIN 2 PACIALIS 4 PA, QLCICLODAN 0.77% CREAM 2CICLODAN 8% SOLUTION 2CICLOPIROX 0.77% CREAM 2CICLOPIROX 0.77% GEL 2CICLOPIROX 0.77% TOPICAL SUSP 2CICLOPIROX 1% SHAMPOO 2CICLOPIROX 8% SOLUTION 2CILOSTAZOL 2CILOXAN 4CIMETIDINE 200 MG TABLET 1CIMETIDINE 300 MG TABLET 1CIMETIDINE 300 MG/5 ML SOLN 2CIMETIDINE 400 MG TABLET 1CIMETIDINE 800 MG TABLET 1CIPRO HC 4CIPRODEX 4CIPROFLOXACIN 0.2% OTIC SOLN 2CIPROFLOXACIN 0.3% EYE DROP 2CIPROFLOXACIN 250 MG/5 ML SUSP 2CIPROFLOXACIN 500 MG/5 ML SUSP 2CIPROFLOXACIN ER 2CIPROFLOXACIN HCL 100 MG TAB 1CIPROFLOXACIN HCL 250 MG TAB 1CIPROFLOXACIN HCL 500 MG TAB 1CIPROFLOXACIN HCL 750 MG TAB 1CITALOPRAM HBR 10 MG TABLET 1 QLCITALOPRAM HBR 10 MG/5 ML SOLN 2 QLCITALOPRAM HBR 20 MG TABLET 1 QLCITALOPRAM HBR 40 MG TABLET 1 QLCLARAVIS 2 QLCLARITHROMYCIN 2CLARITHROMYCIN ER 2CLEMASTINE FUMARATE 2CLINDACIN ETZ 1% PLEDGET 2CLINDACIN P 2CLINDAMYCIN 2% VAGINAL CREAM 2CLINDAMYCIN HCL 2CLINDAMYCIN PALMITATE HCL 2CLINDAMYCIN PEDIATRIC 2CLINDAMYCIN PH 1% GEL 2

MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)CLINDAMYCIN PH 1% SOLUTION 2CLINDAMYCIN PHOS 1% PLEDGET 2CLINDAMYCIN PHOS-BENZOYL PEROX 2CLINDAMYCIN PHOSP 1% LOTION 2CLINDAMYCIN PHOSPHATE 1% FOAM 2CLINDAMYCIN PHOS-TRETINOIN 2CLINDAMYCIN-BENZOYL PEROXIDE 2CLINDESSE 4CLOBETASOL 0.05% CREAM 2CLOBETASOL 0.05% GEL 2CLOBETASOL 0.05% OINTMENT 2CLOBETASOL 0.05% SHAMPOO 2CLOBETASOL 0.05% SOLUTION 2CLOBETASOL 0.05% TOPICAL LOTN 2CLOBETASOL EMOLLIENT 2CLOBETASOL EMULSION 2CLOBETASOL PROP 0.05% FOAM 2CLOBETASOL PROP 0.05% SPRAY 2CLOCORTOLONE PIVALATE 2CLODAN 0.05% SHAMPOO 2CLOMIPRAMINE HCL 4CLONAZEPAM 2CLONIDINE 2CLONIDINE HCL 0.1 MG TABLET 2CLONIDINE HCL 0.2 MG TABLET 2CLONIDINE HCL 0.3 MG TABLET 2CLONIDINE HCL ER 2CLOPIDOGREL 2CLORAZEPATE DIPOTASSIUM 2CLORPRES 2CLOTRIMAZOLE 1% CREAM 2CLOTRIMAZOLE 1% SOLUTION 2CLOTRIMAZOLE 10 MG TROCHE 2CLOTRIMAZOLE-BETAMETHASONE 2CLOZAPINE 2CLOZAPINE ODT 100 MG TABLET 4CLOZAPINE ODT 12.5 MG TABLET 4CLOZAPINE ODT 150 MG TABLET 4CLOZAPINE ODT 200 MG TABLET 4CLOZAPINE ODT 25 MG TABLET 4C-NATE DHA 1COARTEM 4 QLCODEINE SULFATE 2CODEINE-GUAIFEN 10-100 MG/5 ML 2COLCHICINE 2COLESEVELAM HCL 2COLESTIPOL HCL 2COLOCORT 2



12

MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)COLY-MYCIN S 4COMBIGAN 4COMPLERA 3COMPLETE NATAL DHA 1COMPLETENATE 1COMPRO 2CONSTULOSE 2CORDRAN 4COREMINO 2CORMAX 2CORTISONE ACETATE 2CORTISPORIN 4COVARYX 2COVARYX H.S. 2CREON 4CRESEMBA 186 MG CAPSULE 4 PACRIXIVAN 3CROMOLYN 100 MG/5 ML ORAL CONC 2CROMOLYN 20 MG/2 ML NEB SOLN 2CROMOLYN 4% EYE DROPS 2CRYSELLE 1CUPRIMINE 4CURITY ALCOHOL PREPS 3CYANOCOBALAMIN INJECTION 2CYCLAFEM 1CYCLESSA 1CYCLOBENZAPRINE 10 MG TABLET 1CYCLOBENZAPRINE 5 MG TABLET 1CYCLOBENZAPRINE 7.5 MG TABLET 3CYCLOMYDRIL 4CYCLOPENTOLATE HCL 2CYCLOPHOSPHAMIDE 25 MG CAPSULE 3CYCLOPHOSPHAMIDE 50 MG CAPSULE 3CYCLOSERINE 2CYCLOSET 4CYCLOSPORINE 100 MG CAPSULE 2CYCLOSPORINE 25 MG CAPSULE 2CYCLOSPORINE MODIFIED 2CYPROHEPTADINE 2 MG/5 ML SYRUP 2CYPROHEPTADINE 4 MG TABLET 2CYRED 1CYSTARAN 4 LDDCYTRA-2 2CYTRA-3 2CYTRA-K 2DALIRESP 250 MCG TABLET 4 QLDALIRESP 500 MCG TABLET 4DANAZOL 2

MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)DANTROLENE SODIUM 2DAPSONE 4DARAPRIM 4 PADARIFENACIN ER 2DASETTA 1DAYSEE 1DEBLITANE 1DECADRON 0.5 MG/5 ML ELIXIR 1DECARA 25,000 UNIT VEGICAP 4 QLDECARA 50,000 UNIT SOFTGEL 4 QLDELYLA 1DEMECLOCYCLINE HCL 2DEMSER 4DENAVIR 4DENTA 5000 PLUS 2DENTAGEL 2DEPADE 2DEPEN 4DESCOVY 3DESIPRAMINE HCL 2DESLORATADINE 2 QLDESMOPRESSIN 0.01% SOLUTION 2DESMOPRESSIN 0.01% SPRAY 2DESMOPRESSIN 0.1 MG/ML SOL 2DESMOPRESSIN 10 MCG/0.1 ML SPR 2DESMOPRESSIN ACETATE 0.1 MG TB 2DESMOPRESSIN ACETATE 0.2 MG TB 2DESOGEN 4DESOGESTREL-ETHINYL ESTRADIOL 1DESOGESTR-ETH ESTRAD ETH ESTRA 1DESONIDE 2DESOXIMETASONE 2DESVENLAFAXINE SUCCINATE ER 2 QLDEXAMETHASONE 1DEXAMETHASONE 0.1% EYE DROP 2DEXAMETHASONE INTENSOL 1DEXILANT 3 ST, QLDEXMETHYLPHENIDATE ER 10 MG CP 2DEXMETHYLPHENIDATE ER 15 MG CP 2DEXMETHYLPHENIDATE ER 20 MG CP 2DEXMETHYLPHENIDATE ER 25 MG CP 2DEXMETHYLPHENIDATE ER 30 MG CP 2DEXMETHYLPHENIDATE ER 35 MG CP 2DEXMETHYLPHENIDATE ER 40 MG CP 2DEXMETHYLPHENIDATE ER 5 MG CAP 2DEXMETHYLPHENIDATE HCL 2DEXTROAMPHETAMINE SULFATE 2DEXTROAMPHETAMINE SULFATE ER 2



13

MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)DEXTROAMPHETAMINE-AMPHET ER 2DEXTROAMPHETAMINE-AMPHETAMINE 2DIAZEPAM 10 MG RECTAL GEL SYST 2DIAZEPAM 10 MG TABLET 2DIAZEPAM 2 MG TABLET 2DIAZEPAM 2.5 MG RECTAL GEL SYS 2DIAZEPAM 20 MG RECTAL GEL SYST 2DIAZEPAM 5 MG TABLET 2DIAZEPAM 5 MG/5 ML ORAL SOLN 2DIAZEPAM 5 MG/5 ML SOLUTION 2DIAZEPAM 5 MG/ML ORAL CONC 2DICLOFENAC 0.1% EYE DROPS 2DICLOFENAC 1.5% TOPICAL SOLN 2DICLOFENAC POTASSIUM 2DICLOFENAC SOD DR 25 MG TAB 2DICLOFENAC SOD DR 50 MG TAB 2DICLOFENAC SOD DR 75 MG TAB 2DICLOFENAC SOD EC 25 MG TAB 2DICLOFENAC SOD EC 50 MG TAB 2DICLOFENAC SOD EC 75 MG TAB 2DICLOFENAC SODIUM 1% GEL 2 QLDICLOFENAC SODIUM ER 2DICLOFENAC SODIUM-MISOPROSTOL 2DICLOXACILLIN SODIUM 2DICYCLOMINE 10 MG CAPSULE 1DICYCLOMINE 10 MG/5 ML SOLN 2DICYCLOMINE 20 MG TABLET 1DIDANOSINE 2DIFICID 4 PADIFLORASONE DIACETATE 2DIFLUNISAL 2DIGITEK 1DIGOX 1DIGOXIN 0.05 MG/ML SOLUTION 2DIGOXIN 0.125 MG TABLET 1DIGOXIN 0.25 MG TABLET 1DIGOXIN 125 MCG TABLET 1DIGOXIN 250 MCG TABLET 1DIHYDROERGOTAMINE MESYLATE 4 QLDILATRATE-SR 4DILTIAZEM 120 MG TABLET 1DILTIAZEM 12HR ER 2DILTIAZEM 24HR CD 2DILTIAZEM 24HR ER 2DILTIAZEM 30 MG TABLET 1DILTIAZEM 60 MG TABLET 1DILTIAZEM 90 MG TABLET 1DILTIAZEM ER 2

MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)DILT-XR 2DIPENTUM 4DIPHENHYDRAMINE 12.5 MG/5 ML 2DIPHENHYDRAMINE 25 MG/10 ML 2DIPHENOXYLATE-ATROPINE 2DIPYRIDAMOLE 25 MG TABLET 2DIPYRIDAMOLE 50 MG TABLET 2DIPYRIDAMOLE 75 MG TABLET 2DISKETS 2 PADISOPYRAMIDE PHOSPHATE 2DISULFIRAM 2DIVALPROEX SODIUM 2DIVALPROEX SODIUM ER 2DOFETILIDE 4 QLDONEPEZIL HCL 2DONEPEZIL HCL ODT 2DORZOLAMIDE HCL 2DORZOLAMIDE-TIMOLOL 2DOTHELLE DHA 1DOXAZOSIN MESYLATE 1DOXEPIN 10 MG CAPSULE 2DOXEPIN 10 MG/ML ORAL CONC 2DOXEPIN 100 MG CAPSULE 2DOXEPIN 150 MG CAPSULE 2DOXEPIN 25 MG CAPSULE 2DOXEPIN 5% CREAM 4DOXEPIN 50 MG CAPSULE 2DOXEPIN 75 MG CAPSULE 2DOXERCALCIFEROL 0.5 MCG CAP 2DOXERCALCIFEROL 1 MCG CAPSULE 2DOXERCALCIFEROL 2.5 MCG CAP 2DOXYCYCLINE HYC DR 100 MG TAB 2DOXYCYCLINE HYC DR 150 MG TAB 2DOXYCYCLINE HYC DR 200 MG TAB 2DOXYCYCLINE HYC DR 50 MG TAB 2DOXYCYCLINE HYC DR 75 MG TAB 2DOXYCYCLINE HYCLATE 100 MG CAP 2DOXYCYCLINE HYCLATE 100 MG TAB 2DOXYCYCLINE HYCLATE 20 MG TAB 2DOXYCYCLINE HYCLATE 50 MG CAP 2DOXYCYCLINE MONOHYDRATE 2DRONABINOL 4DROSPIRENONE-EE 3-0.02 MG TAB 1DROSPIRENONE-EE 3-0.03 MG TAB 1DROSPIRENONE-ETH ESTRA-LEVOMEF 1DUAVEE 4DULERA 4 STDULOXETINE HCL 2 QL



14

MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)DUREZOL 4DUTASTERIDE 2DUTASTERIDE-TAMSULOSIN 2DYMISTA 4DYRENIUM 4EASY TOUCH ALCOHOL PREP PADS 3ECONAZOLE NITRATE 2ECONTRA EZ 4EDARBI 4 ST, QLEDARBYCLOR 4 ST, QLED-SPAZ 1EDURANT 3EEMT 2EEMT H.S. 2EFAVIRENZ 2EFFER-K 4ELETRIPTAN HBR 2 QLELIDEL 4ELINEST 1ELIPHOS 2ELITE OB DHA 1ELITE-OB 1ELITE-OB 400 1ELLA 4ELMIRON 4EMADINE 4EMBEDA 4 ST, QLEMOQUETTE 1EMSAM 4 QLEMTRIVA 3EMVERM 2ENALAPRIL MALEATE 1ENALAPRIL-HYDROCHLOROTHIAZIDE 2ENDOCET 2ENDOMETRIN 4 PAENLYTE 4ENOXAPARIN SODIUM 4 QLENPRESSE 1ENSKYCE 1ENTACAPONE 2ENTECAVIR 0.5 MG TABLET 4ENTECAVIR 1 MG TABLET 4ENTRESTO 3 PAENULOSE 2EPIFOAM 4EPINASTINE HCL 2EPINEPHRINE 0.15 MG AUTO-INJCT 2 QLEPINEPHRINE 0.3 MG AUTO-INJECT 2 QL

MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)EPITOL 1EPLERENONE 2EPROSARTAN MESYLATE 2ERGOLOID MESYLATES 1ERGOMAR 4ERRIN 1ERTACZO 4ERY 2ERYTHROCIN STEARATE 2ERYTHROMYCIN 2ERYTHROMYCIN ETHYLSUCCINATE 2ERYTHROMYCIN-BENZOYL PEROXIDE 2ESCITALOPRAM OXALATE 2 QLESOMEPRAZOLE MAG DR 20 MG CAP 2 QLESOMEPRAZOLE MAG DR 40 MG CAP 2 QLESOMEPRAZOLE STRONTIUM 2 QLESTARYLLA 1ESTAZOLAM 2ESTRADIOL 0.025 MG PATCH 2ESTRADIOL 0.0375 MG PATCH 2ESTRADIOL 0.0375 MG/DAY PATCH 2ESTRADIOL 0.05 MG PATCH 2ESTRADIOL 0.06 MG/DAY PATCH 2ESTRADIOL 0.075 MG PATCH 2ESTRADIOL 0.075 MG/DAY PATCH 2ESTRADIOL 0.1 MG PATCH 2ESTRADIOL 0.5 MG TABLET 1ESTRADIOL 1 MG TABLET 1ESTRADIOL 10 MCG VAGINAL INSRT 2ESTRADIOL 2 MG TABLET 1ESTRADIOL TDS 0.025 MG/DAY 2ESTRADIOL TDS 0.0375 MG/DAY 2ESTRADIOL TDS 0.05 MG/DAY 2ESTRADIOL TDS 0.06 MG/DAY 2ESTRADIOL TDS 0.075 MG/DAY 2ESTRADIOL TDS 0.1 MG/DAY 2ESTRADIOL-NORETHINDRONE ACETAT 2ESTROGEN-METHYLTESTOSTERONE 2ESTROPIPATE 2ESTROSTEP FE 4ESZOPICLONE 2ETHACRYNIC ACID 2ETHAMBUTOL HCL 2ETHOSUXIMIDE 2ETHYL CHLORIDE 2ETHYNODIOL-ETHINYL ESTRADIOL 1ETIDRONATE DISODIUM 2ETODOLAC 2



15

MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)ETODOLAC ER 2ETOPOSIDE 4EURAX 4EVOTAZ 3EXELDERM 4EXEMESTANE 2EXTRA-VIRT PLUS DHA 1EZETIMIBE 2EZETIMIBE-SIMVASTATIN 2FACTIVE 4FALLBACK SOLO 4FALMINA 1FAMCICLOVIR 2FAMOTIDINE 20 MG TABLET 1FAMOTIDINE 40 MG TABLET 1FAMOTIDINE 40 MG/5 ML SUSP 2FANAPT 4 ST, QLFARESTON 4FARXIGA 3 QLFAYOSIM 1FELBAMATE 400 MG TABLET 4FELBAMATE 600 MG TABLET 4FELBAMATE 600 MG/5 ML SUSP 4FELODIPINE ER 2FEM PH 2FEMCON FE 4FEMYNOR 1FENOFIBRATE 2FENOFIBRIC ACID 2FENOPROFEN 600 MG TABLET 2FENTANYL PATCH 2 PA, QLFENTANYL CIT OTFC 1,200 MCG 4 PAFENTANYL CIT OTFC 1,600 MCG 4 PAFENTANYL CITRATE OTFC 200 MCG 4 PAFENTANYL CITRATE OTFC 400 MCG 4 PAFENTANYL CITRATE OTFC 600 MCG 4 PAFENTANYL CITRATE OTFC 800 MCG 4 PAFERRIPROX 4 LDDFETZIMA 4 ST, QLFEXOFENADINE HCL 180 MG TABLET 2FEXOFENADINE HCL 30 MG TABLET 2FEXOFENADINE HCL 60 MG TABLET 2FINACEA 4FINASTERIDE 5 MG TABLET 2FIORICET 2FLAVOXATE HCL 2FLECAINIDE ACETATE 2FLECTOR 4 QL

MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)FLOVENT DISKUS 3FLOVENT HFA 3FLOWTUSS 4FLUCONAZOLE 10 MG/ML SUSP 2FLUCONAZOLE 100 MG TABLET 2FLUCONAZOLE 150 MG TABLET 1FLUCONAZOLE 200 MG TABLET 2FLUCONAZOLE 40 MG/ML SUSP 2FLUCONAZOLE 50 MG TABLET 2FLUCYTOSINE 4FLUDROCORTISONE ACETATE 2FLUNISOLIDE 2FLUOCINOLONE ACETONIDE 2FLUOCINOLONE ACETONIDE OIL 2FLUOCINONIDE 0.05% CREAM 2FLUOCINONIDE 0.05% GEL 2FLUOCINONIDE 0.05% OINTMENT 2FLUOCINONIDE 0.05% SOLUTION 2FLUOCINONIDE 0.1% CREAM 2FLUOCINONIDE-E 2FLUORABON 2FLUOR-A-DAY 4FLUORIDE 2FLUORIDEX 2FLUORIDEX DAILY DEFENSE 2FLUORITAB 2FLUOROMETHOLONE 2FLUOROURACIL 0.5% CREAM 2FLUOROURACIL 2% TOPICAL SOLN 2FLUOROURACIL 5% CREAM 2FLUOROURACIL 5% TOPICAL SOLN 2FLUOXETINE 20 MG/5 ML SOLUTION 2 QLFLUOXETINE DR 2 QLFLUOXETINE HCL 10 MG CAPSULE 1 QLFLUOXETINE HCL 10 MG TABLET 1 QLFLUOXETINE HCL 20 MG CAPSULE 1 QLFLUOXETINE HCL 20 MG TABLET 1 QLFLUOXETINE HCL 40 MG CAPSULE 1 QLFLUOXETINE HCL 60 MG TABLET 1 QLFLUPHENAZINE 1 MG TABLET 2FLUPHENAZINE 10 MG TABLET 2FLUPHENAZINE 2.5 MG TABLET 2FLUPHENAZINE 2.5 MG/5 ML ELIX 2FLUPHENAZINE 5 MG TABLET 2FLUPHENAZINE 5 MG/ML CONC 2FLURA-DROPS 2FLURANDRENOLIDE 2FLURAZEPAM HCL 2



16

MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)FLURBIPROFEN 2FLURBIPROFEN SODIUM 2FLUTAMIDE 2FLUTICASONE PROP 0.005% OINT 2FLUTICASONE PROP 0.05% CREAM 2FLUTICASONE PROP 0.05% LOTION 2FLUTICASONE PROP 50 MCG SPRAY 2FLUTICASONE-SALMETEROL 2FLUVASTATIN ER 2FLUVASTATIN SODIUM 2FLUVOXAMINE MALEATE 2 QLFLUVOXAMINE MALEATE ER 2 QLFOCALGIN 90 DHA 1FOCALGIN CA 1FOLIC ACID 1 MG TABLET 2FOLIVANE-OB 1FONDAPARINUX SODIUM 4 QLFORMADON 2FORMALDEHYDE 2FORMA-RAY 4FORTICAL 2FOSAMAX PLUS D 4 QLFOSAMPRENAVIR CALCIUM 2FOSINOPRIL SODIUM 1FOSINOPRIL-HYDROCHLOROTHIAZIDE 2FOSRENOL 4FROVATRIPTAN SUCCINATE 2 QLFULYZAQ 4FUROSEMIDE 10 MG/ML SOLUTION 1FUROSEMIDE 20 MG TABLET 1FUROSEMIDE 40 MG TABLET 1FUROSEMIDE 40 MG/5 ML SOLN 1FUROSEMIDE 80 MG TABLET 1FYAVOLV 2FYCOMPA 10 MG TABLET 4 QLFYCOMPA 12 MG TABLET 4 QLFYCOMPA 2 MG TABLET 4 QLFYCOMPA 4 MG TABLET 4 QLFYCOMPA 6 MG TABLET 4 QLFYCOMPA 8 MG TABLET 4 QLGABAPENTIN 2GALANTAMINE ER 2 QLGALANTAMINE HBR 2GALANTAMINE HYDROBROMIDE 2GALZIN 4GATIFLOXACIN 2GAVILYTE-C 2GAVILYTE-G 2

MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)GAVILYTE-H AND BISACODYL 2GAVILYTE-N 2GEMFIBROZIL 2GENERESS FE 4GENERLAC 2GENGRAF 2GENTAK 2GENTAMICIN 0.1% CREAM 2GENTAMICIN 0.1% OINTMENT 2GENTAMICIN 0.3% EYE DROPS 2GENTAMICIN 0.3% EYE OINTMENT 2GENTAMICIN 3 MG/ML EYE DROPS 2GENVOYA 3GIANVI 1GILDAGIA 1GILDESS 1GILDESS 24 FE 1GILDESS FE 1GLEOSTINE 4GLIMEPIRIDE 1GLIPIZIDE 1GLIPIZIDE ER 1GLIPIZIDE XL 1GLIPIZIDE-METFORMIN 2GLUCAGEN 1 MG HYPOKIT 3GLUCAGON EMERGENCY KIT 3GLYBURIDE 1GLYBURIDE MICRONIZED 1GLYBURIDE-METFORMIN HCL 2GLYCINE 1.5% IRRIGATION 2GLYCOPYRROLATE 1 MG TABLET 2GLYCOPYRROLATE 2 MG TABLET 2GLYDO 2GRANISETRON HCL 0.1 MG/ML VIAL 2GRANISETRON HCL 1 MG TABLET 2GRANISETRON HCL 1 MG/ML VIAL 2GRANISETRON HCL 4 MG/4 ML VIAL 2GRISEOFULVIN 2GRISEOFULVIN ULTRAMICROSIZE 2GUAIATUSSIN AC 2GUAIFEN-CODEINE 100-10 MG/5 ML 2GUAIFENESIN AC 2GUAIFENESIN-CODEINE SYRUP 2GUANFACINE HCL 1GUANFACINE HCL ER 2GUANIDINE HCL 2GYNAZOLE 1 2HALOBETASOL PROPIONATE 2



17

MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)HALOG 4HALOPERIDOL 0.5 MG TABLET 2HALOPERIDOL 1 MG TABLET 2HALOPERIDOL 10 MG TABLET 2HALOPERIDOL 2 MG TABLET 2HALOPERIDOL 20 MG TABLET 2HALOPERIDOL 5 MG TABLET 2HALOPERIDOL LAC 2 MG/ML CONC 2HEATHER 1HEMANGEOL 4 LDDHEMENATAL OB 1HEMENATAL OB + DHA 1HEMMOREX-HC 2HEPARIN SOD 5,000 UNIT/ 0.5 ML 2HEPARIN SOD 5,000 UNIT/0.5 ML 2HOMATROPAIRE 2HOMATROPINE HYDROBROMIDE 2HUMALOG 3HUMALOG JUNIOR KWIKPEN 3HUMALOG KWIKPEN U-100 3HUMALOG KWIKPEN U-200 3HUMALOG MIX 50-50 3HUMALOG MIX 50-50 KWIKPEN 3HUMALOG MIX 75-25 3HUMALOG MIX 75-25 KWIKPEN 3HUMULIN 70/30 KWIKPEN 3HUMULIN 70-30 3HUMULIN N 3HUMULIN N KWIKPEN 3HUMULIN R 3HUMULIN R U-500 3HUMULIN R U-500 KWIKPEN 3HYDRALAZINE 10 MG TABLET 2HYDRALAZINE 100 MG TABLET 2HYDRALAZINE 25 MG TABLET 2HYDRALAZINE 50 MG TABLET 2HYDROCHLOROTHIAZIDE 1HYDROCOD-CPM-PSEUDOEPHEDRINE 2HYDROCODONE-ACETAMIN 10-300 MG 2HYDROCODONE-ACETAMIN 10-325 MG 2HYDROCODONE-ACETAMIN 2.5-108/5 2HYDROCODONE-ACETAMIN 2.5-325 2HYDROCODONE-ACETAMIN 5-217/10 2HYDROCODONE-ACETAMIN 5-300 MG 2HYDROCODONE-ACETAMIN 5-325 MG 2HYDROCODONE-ACETAMIN 7.5-300 2HYDROCODONE-ACETAMIN 7.5-325 2HYDROCODONE-ACETAMN 7.5-325/15 2

MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)HYDROCODONE-CHLORPHENIRAMNE ER 2HYDROCODONE-HOMATROPINE MBR 2HYDROCODONE-IBUPROFEN 2HYDROCORTISONE 1% ABSORBASE 2HYDROCORTISONE 1% CREAM 2HYDROCORTISONE 1% OINTMENT 2HYDROCORTISONE 10 MG TABLET 2HYDROCORTISONE 100 MG/60 ML 2HYDROCORTISONE 2.5% CREAM 2HYDROCORTISONE 2.5% LOTION 2HYDROCORTISONE 2.5% OINTMENT 2HYDROCORTISONE 20 MG TABLET 2HYDROCORTISONE 5 MG TABLET 2HYDROCORTISONE AC 25 MG SUPP 2HYDROCORTISONE AC 30 MG SUPP 2HYDROCORTISONE BUTYRATE 2HYDROCORTISONE VALERATE 2HYDROCORTISONE-ACETIC ACID 2HYDROCORTISONE-PRAMOXINE 2HYDROMET 2HYDROMORPHONE 1 MG/ML SOLUTION 2HYDROMORPHONE 2 MG TABLET 2HYDROMORPHONE 3 MG SUPPOS 2HYDROMORPHONE 4 MG TABLET 2HYDROMORPHONE 5 MG/5 ML SOLN 2HYDROMORPHONE 8 MG TABLET 2HYDROMORPHONE ER 2 QLHYDROXYCHLOROQUINE SULFATE 2HYDROXYUREA 2HYDROXYZINE 10 MG/5 ML SOLN 2HYDROXYZINE 10 MG/5 ML SYRUP 2HYDROXYZINE HCL 10 MG TABLET 2HYDROXYZINE HCL 25 MG TABLET 2HYDROXYZINE HCL 50 MG TABLET 2HYDROXYZINE PAMOATE 2HYOPHEN 2HYOSCYAMINE 0.125 MG ODT 1HYOSCYAMINE 0.125 MG TAB SL 1HYOSCYAMINE 0.125 MG/5 ML ELIX 2HYOSCYAMINE 0.125 MG/ML DROP 2HYOSCYAMINE SULF 0.125 MG TAB 1HYOSCYAMINE SULFATE ER 1HYOSCYAMINE SULFATE SR 1HYOSYNE 2HYSINGLA ER 4 ST, QLIBANDRONATE SODIUM 150 MG TAB 2IBU 1IBUDONE 2



18

MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)IBUPROFEN 100 MG/5 ML SUSP 1IBUPROFEN 400 MG TABLET 1IBUPROFEN 600 MG TABLET 1IBUPROFEN 800 MG TABLET 1ILEVRO 4IMATINIB MESYLATE 4 PAIMIPRAMINE HCL 2IMIPRAMINE PAMOATE 2IMIQUIMOD 2IMPAVIDO 4 PAINCONTROL ALCOHOL PADS 3INCRUSE ELLIPTA 3INDAPAMIDE 1INDOMETHACIN 25 MG CAPSULE 2INDOMETHACIN 50 MG CAPSULE 2INDOMETHACIN ER 2INTELENCE 200 MG TABLET 3INTELENCE 25 MG TABLET 3INTROVALE 1IODOSORB 2IOPHEN-C NR 2IPRATROPIUM 0.03% SPRAY 2IPRATROPIUM 0.06% SPRAY 2IPRATROPIUM BR 0.02% SOLN 1IPRATROPIUM-ALBUTEROL 2IRBESARTAN 2IRBESARTAN-HYDROCHLOROTHIAZIDE 2ISENTRESS 3ISENTRESS HD 3ISIBLOOM 1ISOCHRON 2ISONIAZID 100 MG TABLET 1ISONIAZID 300 MG TABLET 1ISONIAZID 50 MG/5 ML SOLUTION 2ISOSORBIDE DINITRATE 2ISOSORBIDE DINITRATE ER 2ISOSORBIDE MONONITRATE 1ISOSORBIDE MONONITRATE ER 1ISOTRETINOIN 2 QLISOXSUPRINE HCL 2ISRADIPINE 2ITRACONAZOLE 3IV ANTISEPTIC WIPES 3IV PREP WIPES 3IVERMECTIN 2JANTOVEN 1JENCYCLA 1JEVANTIQUE LO 2

MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)JINTELI 2JOLESSA 1JOLIVETTE 1JUBLIA 4 PA, STJULEBER 1JULUCA 4JUNEL 1JUNEL FE 1JUNEL FE 24 1KAITLIB FE 1KALETRA 100-25 MG TABLET 3KALETRA 200-50 MG TABLET 3KARIVA 1KELNOR 1-35 1KELNOR 1-50 1KERYDIN 4KETEK 4KETOCONAZOLE 2KETOPROFEN 2KETOROLAC 0.4% OPHTH SOLUTION 2KETOROLAC 0.5% OPHTH SOLUTION 2KETOROLAC 10 MG TABLET 2 QLKETOROLAC 15 MG/ML CARPUJECT 2 QLKETOROLAC 15 MG/ML ISECURE SYR 2 QLKETOROLAC 15 MG/ML SYRINGE 2 QLKETOROLAC 15 MG/ML VIAL 2 QLKETOROLAC 30 MG/ML CARPUJECT 2 QLKETOROLAC 30 MG/ML ISECURE SYR 2 QLKETOROLAC 30 MG/ML SYRINGE 2 QLKETOROLAC 30 MG/ML VIAL 2 QLKETOROLAC 300 MG/10 ML VIAL 2 QLKETOROLAC 60 MG/2 ML CARPUJECT 2 QLKETOROLAC 60 MG/2 ML SYRINGE 2 QLKETOROLAC 60 MG/2 ML VIAL 2 QLKIMIDESS 1KIONEX 2KLOR-CON 10 2KLOR-CON 20 MEQ PACKET 2KLOR-CON 25 MEQ PACKET 4KLOR-CON 8 2KLOR-CON M10 2KLOR-CON M15 4KLOR-CON M20 2KLOR-CON SPRINKLE 2KOMBIGLYZE XR 3 QLK-PHOS NO.2 4K-PHOS ORIGINAL 4KRISTALOSE 4



19

MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)K-SOL 2K-TAB ER 8 MEQ TABLET 2KURVELO 1LABETALOL HCL 100 MG TABLET 2LABETALOL HCL 200 MG TABLET 2LABETALOL HCL 300 MG TABLET 2LACRISERT 4LACTATED RINGERS IRRIGATION 2LACTULOSE 2LAMICTAL XR (BLUE) 4LAMICTAL XR (GREEN) 4LAMICTAL XR (ORANGE) 4LAMIVUDINE 2LAMIVUDINE HBV 2LAMIVUDINE-ZIDOVUDINE 2LAMOTRIGINE 2LAMOTRIGINE (BLUE) 2LAMOTRIGINE (GREEN) 2LAMOTRIGINE (ORANGE) 2LAMOTRIGINE ER 2LAMOTRIGINE ODT 2LAMOTRIGINE ODT (BLUE) 2LAMOTRIGINE ODT (GREEN) 2LAMOTRIGINE ODT (ORANGE) 2LANSOPRAZOL-AMOXICIL-CLARITHRO 2LANSOPRAZOLE DR 15 MG CAPSULE 2 QLLANSOPRAZOLE DR 30 MG CAPSULE 2 QLLANTHANUM CARBONATE 2LARIN 1LARIN 24 FE 1LARIN FE 1LARISSIA 1LASTACAFT 4LATANOPROST 0.005% EYE DROPS 2LATUDA 4 ST, QLLAYOLIS FE 4LEENA 1LEFLUNOMIDE 2LESSINA 1LETROZOLE 2LEUCOVORIN CALCIUM 10 MG TAB 2LEUCOVORIN CALCIUM 15 MG TAB 2LEUCOVORIN CALCIUM 25 MG TAB 2LEUCOVORIN CALCIUM 5 MG TAB 2LEUKERAN 4LEUPROLIDE 2WK 1 MG/0.2 ML KIT 2 PALEUPROLIDE 2WK 14 MG/2.8 ML KT 2 PALEVALBUTEROL CONCENTRATE 2

MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)LEVALBUTEROL HCL 2LEVALBUTEROL TARTRATE HFA 2LEVATOL 4LEVEMIR 4 STLEVEMIR FLEXTOUCH 4 STLEVETIRACETAM 1,000 MG TABLET 2LEVETIRACETAM 100 MG/ML SOLN 2LEVETIRACETAM 250 MG TABLET 2LEVETIRACETAM 500 MG TABLET 2LEVETIRACETAM 500 MG/5 ML SOLN 2LEVETIRACETAM 750 MG TABLET 2LEVETIRACETAM ER 2LEVLEN 28 1LEVOBUNOLOL HCL 2LEVOCARNITINE 1 G/10 ML SOLN 2LEVOCARNITINE 200 MG/ML VIAL 2LEVOCARNITINE 330 MG TABLET 2LEVOCETIRIZINE 2.5 MG/5 ML SOL 2LEVOCETIRIZINE 5 MG TABLET 2LEVOFLOXACIN 0.5% EYE DROPS 2LEVOFLOXACIN 25 MG/ML SOLUTION 2LEVOFLOXACIN 250 MG TABLET 2LEVOFLOXACIN 250 MG/10 ML SOLN 2LEVOFLOXACIN 500 MG TABLET 2LEVOFLOXACIN 500 MG/20 ML SOLN 2LEVOFLOXACIN 750 MG TABLET 2LEVOMEFOLATE DHA 1LEVOMEFOLATE-ALGAL 15 MG CAP 2LEVOMEFOLATE-ALGAL 7.5 MG CAP 2LEVONEST 1LEVONORGESTREL-ETH ESTRADIOL 1LEVONORG-ETH ESTRAD ETH ESTRAD 1LEVORA-28 1LEVORPHANOL TARTRATE 2LEVOTHYROXINE 100 MCG TABLET 1LEVOTHYROXINE 112 MCG TABLET 1LEVOTHYROXINE 125 MCG TABLET 1LEVOTHYROXINE 137 MCG TABLET 1LEVOTHYROXINE 150 MCG TABLET 1LEVOTHYROXINE 175 MCG TABLET 1LEVOTHYROXINE 200 MCG TABLET 1LEVOTHYROXINE 25 MCG TABLET 1LEVOTHYROXINE 300 MCG TABLET 1LEVOTHYROXINE 50 MCG TABLET 1LEVOTHYROXINE 75 MCG TABLET 1LEVOTHYROXINE 88 MCG TABLET 1LEVOXYL 1LEVULAN 4 LDD



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MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)LEXIVA 50 MG/ML SUSPENSION 3LIDOCAINE 5% OINTMENT 2 QLLIDOCAINE 5% PATCH 2LIDOCAINE HCL 2% JELLY 2LIDOCAINE HCL 4% SOLUTION 2LIDOCAINE HCL VISCOUS 1LIDOCAINE-HC 2.8-0.55% GEL 2LIDOCAINE-HC 3-0.5% CREAM 2LIDOCAINE-HC 3-0.5% CREAM KIT 2LIDOCAINE-HYDROCORT 3-2.5% GEL 2LIDOCAINE-PRILOCAINE 2LILLOW 1LINDANE 2LINEZOLID 100 MG/5 ML SUSP 4 PALINEZOLID 600 MG TABLET 2 PALINZESS 4LIOTHYRONINE SOD 25 MCG TAB 2LIOTHYRONINE SOD 5 MCG TAB 2LIOTHYRONINE SOD 50 MCG TAB 2LISINOPRIL 1LISINOPRIL-HYDROCHLOROTHIAZIDE 1LITHIUM 2LITHIUM CARBONATE 150 MG CAP 1LITHIUM CARBONATE 300 MG CAP 1LITHIUM CARBONATE 300 MG TAB 1LITHIUM CARBONATE 600 MG CAP 1LITHIUM CARBONATE ER 2LITHIUM ER 450 MG TABLET 2LITHOSTAT 4LIVALO 4 ST, QLL-METHYLFOLATE 2L-METHYLFOLATE CALCIUM 2L-METHYLFOLATE FORTE 2LO LOESTRIN FE 3LOESTRIN 4LOESTRIN FE 4LOMEDIA 24 FE 1LOPERAMIDE 2 MG CAPSULE 2LOPINAVIR-RITONAVIR 2LOPREEZA 2LORAZEPAM 0.5 MG TABLET 2LORAZEPAM 1 MG TABLET 2LORAZEPAM 2 MG TABLET 2LORAZEPAM 2 MG/ML ORAL CONCENT 2LORAZEPAM INTENSOL 2LORCET 2LORCET HD 2LORCET PLUS 2

MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)LORTAB 10 MG-300 MG/15 ML ELXR 2LORYNA 1LOSARTAN POTASSIUM 1LOSARTAN-HYDROCHLOROTHIAZIDE 1LOSEASONIQUE 4LOTEMAX 4LOVASTATIN 1LOW-OGESTREL 1LOXAPINE 2LUDENT FLUORIDE 2LUGOL'S SOLUTION 2LUMIGAN 4LUTERA 1LYRICA 4 QLLYSODREN 4LYZA 1MACNATAL CN DHA 1MALATHION 2MAPROTILINE HCL 2MARGESIC 2MARLISSA 1MARPLAN 4MARTEN-TAB 2MATERNITY 1MATZIM LA 2MECLIZINE 12.5 MG TABLET 2MECLIZINE 25 MG TABLET 2MECLOFENAMATE SODIUM 2MEDROL 4MEDROXYPROGESTERONE ACETATE 1MEFENAMIC ACID 2MEFLOQUINE HCL 2 QLMEGESTROL ACETATE 2MELODETTA 24 FE 1MELOXICAM 15 MG TABLET 1MELOXICAM 7.5 MG TABLET 1MELOXICAM 7.5 MG/5 ML SUSP 2MELPHALAN 2MEMANTINE HCL 2MENEST 4MENTAX 4MEPERIDINE 100 MG TABLET 2MEPERIDINE 50 MG TABLET 2MEPERIDINE 50 MG/5 ML SOLUTION 2MEPHYTON 4MEPROBAMATE 2MERCAPTOPURINE 2MESALAMINE 4



21Please visit Cigna.com/ifp-drug-list to see a complete listing.


MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)METADATE ER 2METAPROTERENOL SULFATE 2METAXALL 2METAXALONE 2METFORMIN HCL 1METFORMIN HCL ER 500 MG TABLET 2METFORMIN HCL ER 750 MG TABLET 2METHADONE 10 MG/5 ML SOLUTION 2 PAMETHADONE 10 MG/ML ORAL CONC 2 PAMETHADONE 40 MG TABLET DISPR 2 PAMETHADONE 5 MG/5 ML SOLUTION 2 PA

METHADONE HCL 10 MG TABLET 2 PAMETHADONE HCL 5 MG TABLET 2 PAMETHADONE INTENSOL 2 PAMETHADOSE 40 MG TABLET DISPR 2 PAMETHAMPHETAMINE HCL 2METHAZOLAMIDE 2METHENAMINE HIPPURATE 2METHENAMINE MANDELATE 2METHERGINE 2METHIMAZOLE 2METHITEST 2METHOCARBAMOL 500 MG TABLET 2METHOCARBAMOL 750 MG TABLET 2METHOTREXATE 2.5 MG TABLET 2METHOXSALEN 4METHSCOPOLAMINE BROMIDE 2METHYCLOTHIAZIDE 2METHYLDOPA 1METHYLDOPA-HYDROCHLOROTHIAZIDE 2METHYLERGONOVINE 0.2 MG TABLET 2METHYLPHENIDATE ER 10 MG CAP 2METHYLPHENIDATE ER 10 MG TAB 2METHYLPHENIDATE ER 18 MG TAB 2METHYLPHENIDATE ER 20 MG CAP 2METHYLPHENIDATE ER 20 MG TAB 2METHYLPHENIDATE ER 27 MG TAB 2METHYLPHENIDATE ER 30 MG CAP 2METHYLPHENIDATE ER 36 MG TAB 2METHYLPHENIDATE ER 40 MG CAP 2METHYLPHENIDATE ER 54 MG TAB 2METHYLPHENIDATE HCL 2METHYLPHENIDATE HCL CD 2METHYLPHENIDATE HCL ER 2METHYLPHENIDATE LA 2METHYLPREDNISOLONE 2METHYLTESTOSTERONE 2METIPRANOLOL 2

MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)

METOCLOPRAMIDE 10 MG TABLET 1METOCLOPRAMIDE 10 MG/10 ML SOL 1METOCLOPRAMIDE 5 MG TABLET 1METOCLOPRAMIDE 5 MG/5 ML SOLN 1METOCLOPRAMIDE HCL ODT 2METOLAZONE 2METOPROLOL SUCCINATE 2METOPROLOL TARTRATE 100 MG TAB 1METOPROLOL TARTRATE 25 MG TAB 1METOPROLOL TARTRATE 37.5 MG TB 2METOPROLOL TARTRATE 50 MG TAB 1METOPROLOL TARTRATE 75 MG TAB 2METOPROLOL-HYDROCHLOROTHIAZIDE 2METRONIDAZOLE 0.75% CREAM 2METRONIDAZOLE 0.75% LOTION 2METRONIDAZOLE 250 MG TABLET 2METRONIDAZOLE 375 MG CAPSULE 2METRONIDAZOLE 500 MG TABLET 2METRONIDAZOLE TOP 1% GEL PUMP 2METRONIDAZOLE TOPICAL 0.75% GL 2METRONIDAZOLE TOPICAL 1% GEL 2METRONIDAZOLE VAGINAL 0.75% GL 2MEXILETINE HCL 2MIBELAS 24 FE 1MICONAZOLE 3 200 MG VAG SUPP 1MICORT-HC 2MICROGESTIN 1MICROGESTIN 24 FE 3MICROGESTIN FE 1.5-30 TAB 1MICROGESTIN FE 1-20 TABLET 4MIDAZOLAM HCL 2 MG/ML SYRUP 2MIDODRINE HCL 2MIGERGOT 2MIGLITOL 2MILI 1MIMVEY 2MIMVEY LO 2MINASTRIN 24 FE 3MINITRAN 2MINOCYCLINE ER 135 MG TABLET 2MINOCYCLINE ER 45 MG TABLET 2MINOCYCLINE ER 90 MG TABLET 2MINOCYCLINE HCL 2MINOXIDIL 10 MG TABLET 2MINOXIDIL 2.5 MG TABLET 2MIRCETTE 4MIRTAZAPINE 2MIRVASO 4

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MISOPROSTOL 2MODAFINIL 4 PAMODERIBA 2MODICON 4MOEXIPRIL HCL 2MOEXIPRIL-HYDROCHLOROTHIAZIDE 2MOLINDONE HCL 2MOMETASONE FUROATE 2MONDOXYNE NL 2MONO-LINYAH 1MONONESSA 1MONTELUKAST SODIUM 2MONUROL 4MORGIDOX 100 MG CAPSULE 2MORGIDOX 50 MG CAPSULE 2MORPHINE SULF 10 MG SUPPOS 2MORPHINE SULF 10 MG/5 ML SOLN 2MORPHINE SULF 100 MG/5 ML SOLN 2MORPHINE SULF 20 MG SUPPOS 2MORPHINE SULF 20 MG/5 ML SOLN 2MORPHINE SULF 30 MG SUPPOS 2MORPHINE SULF 5 MG SUPPOS 2MORPHINE SULFATE ER 2 QLMORPHINE SULFATE IR 15 MG TAB 2MORPHINE SULFATE IR 30 MG TAB 2MOVIPREP 4MOXEZA 3MOXIFLOXACIN 0.5% EYE DROPS 2MOXIFLOXACIN HCL 400 MG TABLET 2MULTAQ 4MULTIVITAMIN AND FLUORIDE 2MULTI-VITAMIN W-FLUORIDE 2MULTI-VITAMIN WITH FLUORIDE 2MULTI-VITAMIN-FLUOR-IRON 2MULTIVITAMIN-IRON-FLUORIDE 2MULTIVITAMINS CHEWABLES TABLET 2MULTIVITAMINS W-FLUORIDE-IRON 2MULTIVITAMINS WITH FLUORIDE 2MULTIVIT-FLUOR 0.25 MG TAB CHW 2MULTIVIT-FLUOR 0.25 MG/ML DROP 2MULTIVIT-FLUOR 0.5 MG TAB CHEW 2MULTIVIT-FLUOR 0.5 MG/ML DROP 2MULTIVIT-FLUORIDE 1 MG TAB CHW 2MULTIVIT-FLUOR-IRON 0.25 MG/ML 2MULTIVIT-IRON-FL 0.25 MG/ML 2MUPIROCIN 2MVW COMPLETE FORMLTN PEDIATRIC 2MVW COMPLETE FORMULATION D3000 2


MVW COMPLETE FORMULATION D5000 2MVW COMPLETE FORMULTN MULTIVIT 2MY WAY 4MYCOPHENOLATE 200 MG/ML SUSP 2MYCOPHENOLATE 250 MG CAPSULE 2MYCOPHENOLATE 500 MG TABLET 2MYCOPHENOLIC ACID 2MYLERAN 4MYNATAL 1MYNATAL ADVANCE 1MYNATAL PLUS 1MYNATAL-Z 1MYNATE 90 PLUS 1MYORISAN 2 QLMYRBETRIQ 4 ST, QLMYTESI 4MYZILRA 1NABUMETONE 2NADOLOL 1NADOLOL-BENDROFLUMETHIAZIDE 2NAFTIFINE HCL 2NAFTIN 4NALOXONE 0.4 MG/ML CARPUJECT 2NALOXONE 2 MG/2 ML SYRINGE 2NALTREXONE HCL 2NAPROXEN 125 MG/5 ML SUSPEN 2NAPROXEN 250 MG TABLET 1NAPROXEN 375 MG TABLET 1NAPROXEN 500 MG KIT 1NAPROXEN 500 MG TABLET 1NAPROXEN DR 375 MG TABLET 1NAPROXEN DR 500 MG TABLET 1NAPROXEN SOD ER 375 MG TABLET 2NAPROXEN SODIUM 275 MG TAB 1NAPROXEN SODIUM 550 MG TAB 1NAPROXEN SODIUM DS 1NARATRIPTAN 2 QLNARATRIPTAN HCL 2 QLNARCAN 4 MG NASAL SPRAY 3NASCOBAL 4NATACYN 4NATAZIA 4NATEGLINIDE 2NATURE-THROID 1NEBUPENT 4NEBUSAL 3% VIAL 2NECON 1NEFAZODONE HCL 2



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NEOMYCIN SULFATE 2NEOMYCIN-BACITRACIN-POLY-HC 2NEOMYCIN-BACITRACIN-POLYMYXIN 2NEOMYCIN-POLYMYXIN B 2NEOMYCIN-POLYMYXIN-DEXAMETH 2NEOMYCIN-POLYMYXIN-GRAMICIDIN 2NEOMYCIN-POLYMYXIN-HC 2NEOMYCIN-POLYMYXIN-HYDROCORT 2NEO-POLYCIN 2NEO-POLYCIN HC 2NEO-SYNALAR 4NEUAC GEL 2NEUPRO 4NEVANAC 4NEVIRAPINE 2NEVIRAPINE ER 2NEWGEN 1NEXT CHOICE ONE DOSE 4NIACIN ER 2NICARDIPINE 20 MG CAPSULE 2NICARDIPINE 30 MG CAPSULE 2NICOTROL 4NICOTROL NS 4NIFEDICAL XL 2NIFEDIPINE 2NIFEDIPINE ER 2NIKKI 1NILUTAMIDE 2NIMODIPINE 2NISOLDIPINE 2 QLNITRO-BID 2NITRO-DUR 4NITROFURANTOIN 2NITROFURANTOIN MONO-MACRO 2NITROGLYCERIN 0.3 MG TABLET SL 2NITROGLYCERIN 0.4 MG TABLET SL 2NITROGLYCERIN 0.6 MG TABLET SL 2NITROGLYCERIN 400 MCG SPRAY 2NITROGLYCERIN ER 2.5 MG CAP 2NITROGLYCERIN ER 6.5 MG CAP 2NITROGLYCERIN ER 9 MG CAPSULE 2NITROGLYCERIN LINGUAL 0.4 MG 2NITROGLYCERIN PATCH 2NITRO-TIME 2NIVA-PLUS 1NIZATIDINE 15 MG/ML SOLUTION 2NIZATIDINE 150 MG CAPSULE 1NIZATIDINE 300 MG CAPSULE 1


NOLIX 2NORA-BE 1NORETHIND-ETH ESTRAD 0.5-2.5 2NORETHIND-ETH ESTRAD 1-0.02 MG 1NORETHINDRONE 1NORETHINDRONE ACETATE 2NORETHIN-ETH ESTRAD 1 MG-5 MCG 2NORETHIN-ETH ESTRA-FERROUS FUM 1NORGESTIMATE-ETHINYL ESTRADIOL 1NORINYL 1-35 4NORITATE 4NORLYDA 1NORLYROC 1NORPACE CR 4NOR-Q-D 4NORTREL 1NORTRIPTYLINE 10 MG/5 ML SOLN 2NORTRIPTYLINE HCL 10 MG CAP 1NORTRIPTYLINE HCL 25 MG CAP 1NORTRIPTYLINE HCL 50 MG CAP 1NORTRIPTYLINE HCL 75 MG CAP 1NORVIR 3NOVOFINE 30G X 1/3" NEEDLES 3NOVOFINE 32G NEEDLES 3NOVOFINE AUTOCOVER 30G NEEDLE 3NOVOFINE PLUS PEN NDL 32GX1/6" 3NOVOLOG 4 STNOVOLOG FLEXPEN 4 STNOVOLOG MIX 70-30 4 STNOVOLOG MIX 70-30 FLEXPEN 4 STNOVOTWIST NEEDLE 30G 8MM 3NOVOTWIST NEEDLE 32G 5MM 3NOXAFIL 4NP THYROID 1NUCYNTA 4 QLNUCYNTA ER 4 ST, QLNUEDEXTA 4NULEV 1NUVARING 3NYAMYC 2NYATA 100,000 UNIT/GM POWDER 2NYSTATIN 100,000 UNIT/GM CREAM 1NYSTATIN 100,000 UNIT/GM POWD 2NYSTATIN 100,000 UNIT/ML SUSP 2NYSTATIN 100,000 UNITS/GM OINT 1NYSTATIN 150,000,000 UNITS PWD 2NYSTATIN 500,000 UNIT ORAL TAB 2NYSTATIN 500,000 UNIT/5 ML SUS 2



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NYSTATIN 500,000,000 UNITS PWD 2NYSTATIN-TRIAMCINOLONE 1NYSTOP 2OBSTETRIX DHA 1OBSTETRIX ONE 1O-CAL FA 4O-CAL PRENATAL 4OCELLA 1OCTREOTIDE ACETATE 2 PAODEFSEY 3OFLOXACIN 2OGESTREL 1OKEBO 2OLANZAPINE 10 MG TABLET 2OLANZAPINE 15 MG TABLET 2OLANZAPINE 2.5 MG TABLET 2OLANZAPINE 20 MG TABLET 2OLANZAPINE 5 MG TABLET 2OLANZAPINE 7.5 MG TABLET 2OLANZAPINE ODT 2OLANZAPINE-FLUOXETINE HCL 2OLMESARTAN MEDOXOMIL 2OLMESARTAN-AMLODIPINE-HCTZ 2OLMESARTAN-HYDROCHLOROTHIAZIDE 2OLOPATADINE HCL 2OMEGA-3 ACID ETHYL ESTERS 2OMEPRAZOLE DR 10 MG CAPSULE 2 QLOMEPRAZOLE DR 20 MG CAPSULE 2 QLOMEPRAZOLE DR 40 MG CAPSULE 2 QLONDANSETRON HCL 2ONDANSETRON ODT 2ONETOUCH DELICA 30G LANCETS 3ONETOUCH DELICA 33G LANCETS 3ONETOUCH DELICA LANCING DEV 3ONETOUCH SURESOFT 18G LANC DEV 3ONETOUCH SURESOFT 21G LANC DEV 3ONETOUCH SURESOFT 28G LANC DEV 3ONETOUCH ULTRA BLUE TEST STRP 3ONETOUCH ULTRA2 1ONETOUCH ULTRAMINI 1ONETOUCH ULTRASOFT LANCETS 3ONETOUCH VERIO FLEX 1ONETOUCH VERIO IQ 1ONETOUCH VERIO METER SYSTEM 1ONETOUCH VERIO TEST STRIP 3ONGLYZA 3 QLONMEL 4 QLOPCICON ONE-STEP 1


OPIUM TINCTURE 2ORACIT 4ORALONE 2ORPHENADRINE ER 100 MG TABLET 2ORSYTHIA 1ORTHO MICRONOR 4ORTHO TRI-CYCLEN 4ORTHO TRI-CYCLEN LO 4ORTHO-CYCLEN 4ORTHO-NOVUM 4OSCIMIN 0.125 MG ODT 1OSCIMIN 0.125 MG TABLET 2OSCIMIN SL 1OSCIMIN SR 2OSELTAMIVIR PHOSPHATE 2 QLOSMOPREP 4OSPHENA 4OTOVEL 4OVCON-35 1OXANDROLONE 2 PAOXAPROZIN 2OXAZEPAM 2OXCARBAZEPINE 2OXICONAZOLE NITRATE 2OXISTAT 4OXTELLAR XR 4 QLOXYBUTYNIN 5 MG TABLET 1OXYBUTYNIN 5 MG/5 ML SYRUP 2OXYBUTYNIN CHLORIDE ER 2OXYCODON-ACETAMINOPHEN 2.5-325 2OXYCODON-ACETAMINOPHEN 7.5-325 2OXYCODONE HCL 2OXYCODONE HCL-ASPIRIN 2OXYCODONE HCL-IBUPROFEN 2OXYCODONE-ACETAMINOPHEN 10-325 2OXYCODONE-ACETAMINOPHEN 5-325 2OXYMORPHONE HCL 2OXYMORPHONE HCL ER 2 QLPACERONE 200 MG TABLET 2PALIPERIDONE ER 2PANCREAZE 4PANTOPRAZOLE SOD DR 20 MG TAB 2 QLPANTOPRAZOLE SOD DR 40 MG TAB 2 QLPAREGORIC 2PARICALCITOL 1 MCG CAPSULE 2PARICALCITOL 2 MCG CAPSULE 2PARICALCITOL 4 MCG CAPSULE 2PAROEX 2



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PAROMOMYCIN SULFATE 2PAROXETINE CR 2 QLPAROXETINE ER 2 QLPAROXETINE HCL 1 QLPASER 4PCE 4PEG 3350-ELECTROLYTE 2PEG-3350 AND ELECTROLYTES 2PEG-3350 WITH FLAVOR PACKS 2PEGANONE 4PEG-PREP 2PENICILLIN V POTASSIUM 1PENTAZOCINE-NALOXONE HCL 2PENTOXIFYLLINE 2PERFOROMIST 4PERINDOPRIL ERBUMINE 2PERMETHRIN 5% CREAM 2PERPHENAZINE 2PERPHENAZINE-AMITRIPTYLINE 2PERTZYE 4 LDDPEXEVA 4 ST, QLPHENADOZ 2PHENAZOPYRIDINE HCL 1PHENELZINE SULFATE 2PHENOBARBITAL 100 MG TABLET 2PHENOBARBITAL 15 MG TABLET 2PHENOBARBITAL 16.2 MG TABLET 2PHENOBARBITAL 20 MG/5 ML ELIX 2PHENOBARBITAL 20 MG/5 ML SOLN 2PHENOBARBITAL 30 MG TABLET 2PHENOBARBITAL 32.4 MG TABLET 2PHENOBARBITAL 60 MG TABLET 2PHENOBARBITAL 64.8 MG TABLET 2PHENOBARBITAL 97.2 MG TABLET 2PHENOXYBENZAMINE HCL 10 MG CAP 2PHENYLEPHRINE 10% EYE DROPS 2PHENYLEPHRINE 2.5% EYE DROP 2PHENYTOIN 2PHENYTOIN SODIUM EXTENDED 2PHILITH 1PHOSLYRA 4PHOSPHA 250 NEUTRAL 2PHOSPHASAL 2PHOSPHOLINE IODIDE 4PHRENILIN FORTE 2PHYSIOSOL 4PHYTONADIONE 5 MG TABLET 2PICATO 4


PILOCARPINE HCL 2PIMOZIDE 2PIMTREA 1PINDOLOL 2PIOGLITAZONE HCL 2PIOGLITAZONE-GLIMEPIRIDE 2PIOGLITAZONE-METFORMIN 2PIRMELLA 1PIROXICAM 2PLAN B ONE-STEP 4PNV 29-1 1PNV OB+DHA 1PNV-DHA 1PNV-DHA + DOCUSATE 1PNV-FERROUS FUMARATE-DOCU-FA 1PNV-OMEGA 1PNV-SELECT 1PNV-VP-U 1PODOFILOX 2POLYCIN 2POLYETHYLENE GLYCOL 3350 POWD 2POLYMYXIN B SUL-TRIMETHOPRIM 2PORTIA 1POTASS CIT-SOD CIT-CITRIC ACID 2POTASSIUM CITRATE ER 2POTASSIUM CITRATE-CITRIC ACID 2POTASSIUM CL 10% (20 MEQ/15 ML 2POTASSIUM CL 10% (40 MEQ/30 ML 2POTASSIUM CL 20 MEQ PACKET 2POTASSIUM CL 20% (40 MEQ/15 ML 2POTASSIUM CL 25 MEQ TAB EFF 2POTASSIUM CL ER 10 MEQ CAPSULE 2POTASSIUM CL ER 10 MEQ TABLET 2POTASSIUM CL ER 20 MEQ TABLET 2POTASSIUM CL ER 8 MEQ CAPSULE 2POTASSIUM CL ER 8 MEQ TABLET 2POTIGA 4PR BENZOYL PEROXIDE 2PR BENZOYL PEROXIDE 7% WASH 2PR NATAL 400 1PR NATAL 400 EC 1PR NATAL 430 1PR NATAL 430 EC 1PRADAXA 4 ST, QLPRAMCORT 2PRAMIPEXOLE DIHYDROCHLORIDE 2PRAMIPEXOLE ER 2PRAMOSONE 4



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PRAMOSONE E 4PRASUGREL HCL 2PRAVASTATIN SODIUM 1PRAZIQUANTEL 2PRAZOSIN HCL 2PRED-G 4PREDNICARBATE 2PREDNISOLONE 2PREDNISOLONE 15 MG/5 ML SOLN 2PREDNISOLONE 5 MG/5 ML SOLN 2PREDNISOLONE ACETATE 2PREDNISOLONE SOD 1% EYE DROP 2PREDNISOLONE SOD PH 25 MG/5 ML 2PREDNISOLONE SODIUM PHOS ODT 2PREDNISONE 2PREDNISONE INTENSOL 2PREFEST 2PREMARIN 4PRENA1 TRUE 1PRENAISSANCE 1PRENAISSANCE NEXT 1PRENAISSANCE PLUS 1PRENATAL 19 1PRENATAL LOW IRON 1PRENATAL PLUS 1PRENATAL PLUS-DHA COMBO PACK 1PRENATAL VITAMIN PLUS LOW IRON 1PRENATAL-U 1PREPLUS 1PREPOPIK 4PRETAB 1PREVALITE 2PREVIFEM 1PREZCOBIX 3PREZISTA 3PRIFTIN 4PRIMAQUINE 2PRIMIDONE 2PRIMLEV 2PRIMSOL 4PRO COMFORT ALCOHOL PADS 3PROBENECID 2PROBENECID-COLCHICINE 2PROCENTRA 2PROCHLORPERAZINE 2PROCHLORPERAZINE MALEATE 2PROCTO-MED HC 2PROCTO-PAK 2


PROCTOSOL-HC 2PROCTOZONE-HC 2PROFENO 2PROGESTERONE 100 MG CAPSULE 2PROGESTERONE 200 MG CAPSULE 2PROGLYCEM 4PROMETHAZINE 12.5 MG SUPPOS 2PROMETHAZINE 12.5 MG TABLET 2PROMETHAZINE 25 MG SUPPOSITORY 2PROMETHAZINE 25 MG TABLET 2PROMETHAZINE 50 MG SUPPOSITORY 2PROMETHAZINE 50 MG TABLET 2PROMETHAZINE 6.25 MG/5 ML SOLN 2PROMETHAZINE 6.25 MG/5 ML SYRP 2PROMETHAZINE VC 2PROMETHAZINE VC-CODEINE 2PROMETHAZINE-CODEINE 2PROMETHAZINE-DM 2PROMETHAZINE-PHENYLEPH-CODEINE 2PROMETHAZINE-PHENYLEPHRINE 2PROMETHEGAN 2PROPAFENONE HCL 2PROPAFENONE HCL ER 2PROPANTHELINE BROMIDE 2PROPARACAINE 0.5% EYE DROPS 2PROPRANOLOL 10 MG TABLET 2PROPRANOLOL 20 MG TABLET 2PROPRANOLOL 20 MG/5 ML SOLN 2PROPRANOLOL 40 MG TABLET 2PROPRANOLOL 40 MG/5 ML SOLN 2PROPRANOLOL 60 MG TABLET 2PROPRANOLOL 80 MG TABLET 2PROPRANOLOL HCL ER 2PROPRANOLOL-HYDROCHLOROTHIAZID 2PROPYLTHIOURACIL 2PROTRIPTYLINE HCL 2PRUDOXIN 2PSORCON 2PULMOSAL 2PYRAZINAMIDE 2PYRIDOSTIGMINE BROMIDE 2PYRIDOSTIGMINE BROMIDE ER 2QUARTETTE 4QUASENSE 1QUAZEPAM 15 MG TABLET 2QUETIAPINE FUMARATE 2QUETIAPINE FUMARATE ER 2QUILLIVANT XR 4 ST



27


QUINAPRIL HCL 2QUINAPRIL-HYDROCHLOROTHIAZIDE 2QUINIDINE GLUC ER 324 MG TAB 2QUINIDINE SULFATE 2QUININE SULFATE 2QUTENZA 4RABEPRAZOLE SODIUM 2 QLRAJANI 1RALOXIFENE HCL 2RAMIPRIL 2RANEXA 4 STRANITIDINE 15 MG/ML SYRUP 2RANITIDINE 150 MG CAPSULE 1RANITIDINE 150 MG TABLET 1RANITIDINE 150 MG/10 ML SYRUP 2RANITIDINE 300 MG CAPSULE 1RANITIDINE 300 MG TABLET 1RAPAFLO 4 QLRASAGILINE MESYLATE 2RECLIPSEN 1RECTIV 4REGRANEX 4 PARELENZA 4 QLRELISTOR 4 PARELNATE DHA 1RENACIDIN 4RENAGEL 4REPAGLINIDE 2REPAGLINIDE-METFORMIN HCL 2REPREXAIN 2RESPA A.R. 4RESTASIS 4RESTASIS MULTIDOSE 4REYATAZ 3RIBASPHERE 2RIBAVIRIN 200 MG CAPSULE 2RIBAVIRIN 200 MG TABLET 2RIDAURA 4RIFABUTIN 2RIFAMATE 4RIFAMPIN 150 MG CAPSULE 2RIFAMPIN 300 MG CAPSULE 2RIFATER 4RILUZOLE 2RIMANTADINE HCL 2RISEDRONATE SODIUM 2RISEDRONATE SODIUM DR 2RISPERIDONE 2


RISPERIDONE ODT 2RITONAVIR 2RIVASTIGMINE 2RIVELSA 1RIZATRIPTAN 2 QLR-NATAL OB 1ROPINIROLE ER 2ROPINIROLE HCL 2ROSADAN 0.75% CREAM 2ROSADAN 0.75% GEL 2ROSUVASTATIN CALCIUM 2ROWEEPRA 2ROWEEPRA XR 2ROZEREM 4 ST, QLRULAVITE DHA 1SAFYRAL 4SALICYLIC ACID 27.5% LIQUID 2SALSALATE 2SANTYL 4SAPHRIS 4 ST, QLSAVAYSA 4 ST, QLSAVELLA 4SCOPOLAMINE 2SEASONIQUE 4SECONAL SODIUM 2SELEGILINE HCL 2SELENIUM SULFIDE 2.25% SHAMPOO 2SELENIUM SULFIDE 2.5% LOTION 2SE-NATAL 19 1SEREVENT DISKUS 3SERTRALINE 20 MG/ML ORAL CONC 2 QLSERTRALINE 20 MG/ML ORAL SOLN 2 QLSERTRALINE HCL 100 MG TABLET 1 QLSERTRALINE HCL 25 MG TABLET 1 QLSERTRALINE HCL 50 MG TABLET 1 QLSETLAKIN 1SEVELAMER CARBONATE 800 MG TAB 2SF 2SF 5000 PLUS 2SHAROBEL 1SILDENAFIL 2 PASILENOR 4 ST, QLSILVER NITRATE 2SILVER SULFADIAZINE 2SIMBRINZA 3SIMVASTATIN 10 MG TABLET 1SIMVASTATIN 20 MG TABLET 1SIMVASTATIN 40 MG TABLET 1



28


SIMVASTATIN 5 MG TABLET 1SIMVASTATIN 80 MG TABLET 1 QLSINGLE USE SWAB 3SIROLIMUS 2SIRTURO 4 PASIVEXTRO 200 MG TABLET 4 PASKLICE 4SODIUM CHLORIDE 0.9% INHAL VL 2SODIUM CHLORIDE 0.9% IRRIG. 2SODIUM CHLORIDE 10% VIAL 2SODIUM CHLORIDE 3% VIAL 2SODIUM CHLORIDE 7% VIAL 2SODIUM CITRATE-CITRIC ACID 2SODIUM FLUORIDE 2SODIUM PHENYLBUTYRATE 2SODIUM POLYSTYRENE SULFONATE 2SOLOXIDE 2SOLTAMOX 4SOTALOL 1SOTALOL AF 1SPINOSAD 2SPIRONOLACTONE 2SPIRONOLACTONE-HCTZ 2SPRINTEC 1SPRIX 4 QL, LDDSPS 2SRONYX 1SSKI 4STAVUDINE 2STERILE WATER FOR IRRIGATION 2STRIBILD 3STRIVERDI RESPIMAT 4 STSTRONG IODINE 2SUBVENITE 2SUBVENITE (BLUE) 2SUBVENITE (GREEN) 2SUBVENITE (ORANGE) 2SUCRALFATE 2SULFACETAMIDE SODIUM 2SULFACETAMIDE-PREDNISOLONE 2SULFADIAZINE 2SULFAMETHOXAZOLE-TMP DS TABLET 2SULFAMETHOXAZOLE-TMP SS TABLET 2SULFAMETHOXAZOLE-TMP SUSP 2SULFAMYLON 4SULFASALAZINE 2SULFASALAZINE DR 2SULINDAC 2


SUMATRIPTAN 2 QLSUMATRIPTAN SUCCINATE 2 QLSUPRAX 4SUPREP 4SURE COMFORT ALCOHOL 3SURE-PREP ALCOHOL PREP PADS 3SUSTIVA 3SYEDA 1SYMAX 1SYMAX-SL 1SYMAX-SR 2SYMLINPEN 120 4 QLSYMLINPEN 60 4 QLSYNERA 4SYNTHROID 4SYPRINE 4TABLOID 4TACROLIMUS 2TAKE ACTION 4TAMIFLU 30 MG CAPSULE 4 QLTAMIFLU 45 MG CAPSULE 4 QLTAMIFLU 75 MG CAPSULE 4 QLTAMOXIFEN CITRATE 2TAMSULOSIN HCL 2TANZEUM 4 ST, QLTARINA FE 1TARON-C DHA 1TARON-PREX PRENATAL 1TAYTULLA 3TAZAROTENE 2TAZORAC 4TAZTIA XT 2TEKTURNA 4 QLTELMISARTAN 2TELMISARTAN-AMLODIPINE 2TELMISARTAN-HYDROCHLOROTHIAZID 2TEMAZEPAM 2TEMOZOLOMIDE 4 PATENCON 2TENOFOVIR DISOPROXIL FUMARATE 2TERAZOSIN HCL 1TERBINAFINE HCL 1TERBUTALINE SULFATE 2.5 MG TAB 2TERBUTALINE SULFATE 5 MG TAB 2TERCONAZOLE 2TESTOSTERONE 10 MG GEL PUMP 2 QLTESTOSTERONE 12.5 MG/1.25 GRAM 2 QLTESTOSTERONE 25 MG/2.5 GM PKT 2 QL



29


TESTOSTERONE 50 MG/5 GRAM GEL 2 QLTESTOSTERONE 50 MG/5 GRAM PKT 2 QLTESTOSTERONE CYPIONATE 2TESTOSTERONE ENANTHATE 2TETCAINE 2TETRABENAZINE 2 PATETRACAINE 0.5% EYE DROPS 2TETRACAINE 0.5% STERI-UNIT SOL 2TETRACYCLINE HCL 1TETRAVISC 4TEXACORT 4THEOCHRON 2THEOPHYLLINE 2THEOPHYLLINE ANHYDROUS 2THIOLA 4 LDDTHIORIDAZINE HCL 2THIOTHIXENE 2THRIVITE 19 1THYROID 1THYROLAR-1 4THYROLAR-1/2 4THYROLAR-1/4 4THYROLAR-2 4THYROLAR-3 4TIAGABINE HCL 2TICLOPIDINE HCL 2TILIA FE 1TIMOLOL 0.25% GEL-SOLUTION 2TIMOLOL 0.25% GFS GEL-SOLUTION 2TIMOLOL 0.5% GEL-SOLUTION 2TIMOLOL 0.5% GFS GEL-SOLUTION 2TIMOLOL MALEATE 0.25% EYE DROP 2TIMOLOL MALEATE 0.5% EYE DROPS 2TIMOLOL MALEATE 10 MG TABLET 2TIMOLOL MALEATE 20 MG TABLET 2TIMOLOL MALEATE 5 MG TABLET 2TINIDAZOLE 2TIS-U-SOL PENTALYTE 4TIVICAY 3TIZANIDINE HCL 2TL-SELECT 1TOBRADEX 4TOBRADEX ST 4TOBRAMYCIN 2TOBRAMYCIN-DEXAMETHASONE 2TOBREX 4TOLAZAMIDE 2TOLBUTAMIDE 2


TOLCAPONE 2TOLMETIN SODIUM 2TOLTERODINE TARTRATE 2TOLTERODINE TARTRATE ER 2TOPIRAMATE 2TOPIRAMATE ER 2TORSEMIDE 2TOVIAZ 4 ST, QLTRAMADOL ER 100 MG TABLET 2 QLTRAMADOL ER 200 MG TABLET 2 QLTRAMADOL ER 300 MG TABLET 2 QLTRAMADOL HCL 2 QLTRAMADOL HCL ER 100 MG TABLET 2 QLTRAMADOL HCL ER 150 MG CAPSULE 2 QLTRAMADOL HCL ER 200 MG TABLET 2 QLTRAMADOL HCL ER 300 MG TABLET 2 QLTRAMADOL HCL-ACETAMINOPHEN 2 QLTRANDOLAPRIL 2TRANDOLAPRIL-VERAPAMIL ER 2TRANEXAMIC ACID 650 MG TABLET 2TRANYLCYPROMINE SULFATE 2TRAVATAN Z 3TRAZODONE HCL 1TRECATOR 4TRETINOIN 0.01% GEL 2 AGETRETINOIN 0.025% CREAM 2 AGETRETINOIN 0.025% GEL 2 AGETRETINOIN 0.05% CREAM 2 AGETRETINOIN 0.05% GEL 2 AGETRETINOIN 0.1% CREAM 2 AGETRETINOIN 10 MG CAPSULE 4 PATRETINOIN MICROSPHERE 2 AGETRETIN-X 4 AGETRI FEMYNOR 1TRIADVANCE 1TRIAMCINOLONE 0.025% CREAM 2TRIAMCINOLONE 0.025% LOTION 2TRIAMCINOLONE 0.025% OINT 2TRIAMCINOLONE 0.1% CREAM 2TRIAMCINOLONE 0.1% LOTION 2TRIAMCINOLONE 0.1% OINTMENT 2TRIAMCINOLONE 0.1% PASTE 2TRIAMCINOLONE 0.147 MG/G SPRAY 2TRIAMCINOLONE 0.5% CREAM 2TRIAMCINOLONE 0.5% OINTMENT 2TRIAMTERENE-HYDROCHLOROTHIAZID 2TRIAZOLAM 2TRICITRATES 2



30


TRIDERM 2TRIENTINE HCL 4TRI-ESTARYLLA 1TRIFLUOPERAZINE HCL 2TRIFLURIDINE 2TRIHEXYPHENIDYL HCL 2TRIKLO 2TRI-LEGEST FE 1TRI-LINYAH 1TRI-LO-ESTARYLLA 1TRI-LO-MARZIA 1TRI-LO-SPRINTEC 1TRILYTE WITH FLAVOR PACKETS 2TRIMETHOBENZAMIDE HCL 2TRIMETHOPRIM 2TRI-MILI 1TRIMIPRAMINE MALEATE 2TRIMPEX 4TRINATAL GT 1TRINATAL RX 1 1TRINESSA 1TRINESSA LO 1TRI-NORINYL 4TRINTELLIX 4 ST, QLTRIPLE-VITAMIN W-FLUORIDE 2TRI-PREVIFEM 1TRI-SPRINTEC 1TRI-TABS DHA 1TRIUMEQ 3TRIVEEN-DUO DHA 1TRIVEEN-ONE 1TRIVEEN-PRX RNF 1TRIVEEN-U 1TRI-VIT WITH FLUORIDE-IRON 2TRI-VITAMIN WITH FLUORIDE 2TRIVORA-28 1TRI-VYLIBRA 1TROPICAMIDE 2TROSPIUM CHLORIDE 2TROSPIUM CHLORIDE ER 2TRULICITY 3 QLTRUST NATAL DHA 1TRUVADA 3TUDORZA PRESSAIR 4 STTULANA 1TUSSIGON 2TYBOST 3TYDEMY 1


TYZINE 4ULESFIA 4ULORIC 4 QLULTILET ALCOHOL SWAB 3ULTIMATECARE ONE 1ULTIMATECARE ONE NF 1UNITHROID 1UR N-C 2URIN D.S. 2UROPHEN MB 2UROQID-ACID NO.2 4URSODIOL 2USTELL 2UTIRA-C 2VALACYCLOVIR 2VALGANCICLOVIR HCL 2VALPROIC ACID 2VALSARTAN 2VALSARTAN-HYDROCHLOROTHIAZIDE 2VANCOMYCIN HCL 125 MG CAPSULE 2VANCOMYCIN HCL 250 MG CAPSULE 2VANDAZOLE 2VASCAZEN 4VASCEPA 4VECAMYL 2 LDDVELIVET 1VELPHORO 4VEMAVITE-PRX 2 1VENA-BAL DHA 1VENATAL COMPLETE DHA 1VENLAFAXINE HCL 2 QLVENLAFAXINE HCL ER 2 QLVENTOLIN HFA 3VERAPAMIL 120 MG TABLET 2VERAPAMIL 360 MG CAP PELLET 2VERAPAMIL 40 MG TABLET 2VERAPAMIL 80 MG TABLET 2VERAPAMIL ER 2VERAPAMIL ER PM 2VERAPAMIL SR 2VERDROCET 2VEREGEN 4VESICARE 4 ST, QLVESTURA 1VEXOL 4VIDEX 3VIENVA 1VIGABATRIN 2 QL



31


VIIBRYD 4 ST, QLVIMPAT 10 MG/ML SOLUTION 4 QLVIMPAT 100 MG TABLET 4 QLVIMPAT 150 MG TABLET 4 QLVIMPAT 200 MG TABLET 4 QLVIMPAT 50 MG TABLET 4 QLVINACAL 1VINATE GT 1VINATE II 1VINATE ONE 1VINATE PN CARE 1VINATE ULTRA 1VINATE-M 1VIOKACE 4VIORELE 1VIREAD 3VIRT-ADVANCE 1VIRT-C DHA 1VIRT-NATE 1VIRT-NATE DHA 1VIRT-PHOS 250 NEUTRAL 2VIRT-PN 1VIRT-PN DHA 1VIRT-PN PLUS 1VIRTPREX 1VIRTRATE-2 2VIRTRATE-3 2VIRTRATE-K 2VIRT-SELECT 1VIRT-VITE GT 1VIT D2 1.25 MG (50,000 UNIT) 2VITAFOL-OB 1VITAMINS A,C,D AND FLUORIDE 2VITASPIRE 1VITEKTA 3VOL-NATE 1VOL-PLUS 1VOL-TAB RX 1VORICONAZOLE 200 MG TABLET 2 PAVORICONAZOLE 40 MG/ML SUSP 2 PAVORICONAZOLE 50 MG TABLET 2 PAVP-CH PLUS 1VP-CH-PNV 1VP-GGR-B6 1VP-HEME OB 1VP-HEME ONE 1VRAYLAR 4 ST, QLVYFEMLA 1


VYLIBRA 1VYNATAL-FA 1VYVANSE 10 MG CAPSULE 4 STVYVANSE 20 MG CAPSULE 4 STVYVANSE 30 MG CAPSULE 4 STVYVANSE 40 MG CAPSULE 4 STVYVANSE 50 MG CAPSULE 4 STVYVANSE 60 MG CAPSULE 4 STVYVANSE 70 MG CAPSULE 4 STWARFARIN SODIUM 1WEBCOL 3WELCHOL 4WERA 1WESTHROID 1WP THYROID 1WYMZYA FE 1XARELTO 3 QLXARTEMIS XR 4 ST, QLXERAC AC 4XERESE 4XIFAXAN 4XIGDUO XR 3 QLXTAMPZA ER 3 QLXULANE 1XYLON 10 2YASMIN 28 4YAZ 4YUVAFEM 2ZAFIRLUKAST 2ZALEPLON 2ZARAH 1ZATEAN-CH 1ZATEAN-PN DHA 1ZATEAN-PN PLUS 1ZAZOLE 2ZENATANE 2 QLZENCHENT 1ZENCHENT FE 1ZENPEP 3ZETONNA 4 STZIDOVUDINE 2ZILEUTON ER 2ZIOPTAN 4ZIPRASIDONE HCL 2ZIRGAN 4ZOLMITRIPTAN 2 QLZOLMITRIPTAN ODT 2 QLZOLPIDEM TARTRATE 2



32


ZOLPIDEM TARTRATE ER 2ZONISAMIDE 2ZONTIVITY 4ZOVIA 1-35E 1ZOVIA 1-50E 1ZUPLENZ 4 QLZYLET 4



33

Specialty medications

The following specialty medications are typically covered on Tier 5

A

ACTEMRA 162 MG/0.9 ML SYRINGE (PA, LDD)ACTIMMUNE (PA, LDD)ADCIRCA (PA)ADEMPAS (PA, LDD)AFINITOR (PA, LDD)AFINITOR DISPERZ (PA, LDD)AKYNZEO 300-0.5 MG CAPSULE (PA, QL)ALECENSA (PA, LDD)AMPYRA (PA, LDD)ANZEMET (PA, QL)APOKYN (PA)ARANESP (PA)ARCALYST (PA, LDD)ASTAGRAF XLAVONEX (PA)AVONEX PEN (PA)

B

BARACLUDE 0.05 MG/ML SOLUTIONBOSULIF (PA, LDD)

C

CABOMETYX (PA, LDD)CAPRELSA (PA, LDD)CAYSTON (PA, ST, LDD)CHOLBAM (PA, LDD)CIMZIA (PA, ST)COMETRIQ (PA, LDD)COSENTYX (2 SYRINGES) (PA, LDD)COSENTYX PEN (2 PENS) (PA, LDD)COSENTYX PEN (PA, LDD)COSENTYX SYRINGE (PA, LDD)COTELLIC (PA, LDD)CYSTADANE (LDD)CYSTAGON (LDD)

E

EGRIFTA (PA, LDD)EMCYTEMEND 125 MG POWDER PACKET (PA, QL)ENBREL (PA)ENBREL MINI (PA)ENBREL SURECLICK (PA)EPCLUSA (PA)EPIVIR HBV 25 MG/5 ML SOLNEPOGEN (PA)

ERIVEDGE (PA, LDD)ESBRIET (PA, LDD)EXJADE (LDD)

F

FARYDAK (PA, LDD)FIRAZYR (PA, LDD)FIRMAGON 2 X 120 MG KIT (PA)FIRMAGON 80 MG KIT (PA)FORTEOFRAGMIN (QL)FUZEON (LDD)

G

GATTEX (PA, LDD)GENOTROPIN (PA, ST)GILOTRIF (PA, LDD)GLATIRAMER ACETATE (PA)GLATOPA (PA)GRANIX

H

HARVONI (PA)HETLIOZ (PA)HEXALENHUMATROPE (PA)HUMIRA (PA)HUMIRA PEDIATRIC CROHN’S (PA)HUMIRA PEN (PA)HUMIRA PEN CROHN-UC-HS STARTER (PA)HUMIRA PEN PSORIASIS-UVEITIS (PA)HYCAMTIN 0.25 MG CAPSULE (PA)HYCAMTIN 1 MG CAPSULE (PA)

I

IBRANCE (PA, LDD)ICLUSIG (PA, LDD)ILARIS (PA, LDD)IMBRUVICA (PA, LDD)INCRELEX (PA)INLYTA (PA, LDD)INTRON A (PA)IRESSA (PA, LDD)

J

JADENU (LDD)JADENU SPRINKLE (LDD)JAKAFI (PA, LDD)

K

KALYDECO (PA, LDD)KINERET (PA, ST, LDD)KUVAN (PA, LDD)

L

LENVIMA (PA, LDD)LETAIRIS (PA, LDD)LEUKINELONSURF (PA, LDD)LUPANETA PACK (PA)LUPRON DEPOT (LUPANETA) (PA)LUPRON DEPOT (PA)LUPRON DEPOT-PED (PA)LYNPARZA (PA, LDD)

M

MATULANE (LDD)MEKINIST (PA)MESNEX 400 MG TABLETMIGLUSTAT (PA)MIRCERA (PA)MYALEPT (PA)

N

NATPARA (PA, LDD)NEULASTA (PA)NEUPOGEN (PA, ST)NEXAVAR (PA)NINLARO (PA, LDD)NORDITROPIN FLEXPRO (PA, ST)NORTHERA (PA, LDD)NUTROPIN AQ (PA, ST)NUTROPIN AQ NUSPIN (PA, ST)

O

ODOMZO (PA, LDD)OLYSIO (PA, ST)OMNITROPE (PA, ST)OPSUMIT (PA, LDD)ORENCIA 125 MG/ML SYRINGE (PA, ST, LDD)ORENCIA 50 MG/0.4 ML SYRINGE (PA, ST, LDD)ORENCIA 87.5 MG/0.7 ML SYRINGE (PA, ST, LDD)ORENCIA CLICKJECT (PA, ST, LDD)ORENITRAM ER (PA, LDD)ORKAMBI 200 MG-125 MG TABLET (PA, LDD)OTEZLA (PA, LDD)

Specialty medications are limited to a 30-day supply.

34

Specialty medications

The following specialty medications are typically covered on Tier 5

P

PANRETINPEGASYS (PA)PEGASYS PROCLICK (PA)PEGINTRON (PA)PEGINTRON REDIPEN (PA)PLEGRIDY (PA, ST, LDD)PLEGRIDY PEN (PA, ST, LDD)POMALYST (PA, LDD)PRALUENT PEN (PA, ST, LDD)PRALUENT SYRINGE (PA, ST, LDD)PROMACTA (PA)PULMOZYME (PA)

R

RAPAMUNE 1 MG/ML ORAL SOLNREBETOLREPATHA PUSHTRONEX (PA, ST)REPATHA SURECLICK (PA, ST)REPATHA SYRINGE (PA, ST)REVLIMID (PA, LDD)

S

SABRIL 500 MG TABLET (QL)SAIZEN (PA, ST)SAIZEN-SAIZENPREP (PA, ST)SAMSCA (LDD)SENSIPARSEROSTIM (PA, ST, LDD)SIGNIFOR (PA)SIMPONI (PA, ST, LDD)

SIMPONI ARIA (PA, ST, LDD)SOMATULINE DEPOT (PA, LDD)SOMAVERT (PA, LDD)SOVALDI (PA)SPRYCEL (PA)STELARA 45 MG/0.5 ML SYRINGE (PA, ST, LDD)STELARA 45 MG/0.5 ML VIAL (PA, ST, LDD)STELARA 90 MG/ML SYRINGE (PA, ST, LDD)STIVARGA (PA, LDD)SUCRAID (LDD)SUTENT (PA, LDD)SYLATRON (PA, LDD)SYNAREL

T

TAFINLAR (PA, LDD)TAGRISSO (PA)TARCEVA (PA, LDD)TARGRETIN 1% GELTASIGNA (PA, LDD)TECFIDERA (PA, LDD)TECHNIVIE (PA, ST)THALOMID (PA, LDD)TRACLEER (PA, LDD)TYKERB (PA)TYVASO (PA, LDD)TYVASO INSTITUTIONAL START KIT (PA, LDD)TYVASO REFILL KIT (PA, LDD)TYVASO STARTER KIT (PA, LDD)TYZEKA

V

VALCHLOR (LDD)VARUBI 90 MG TABLET (PA, QL)VENCLEXTA (PA)VENCLEXTA STARTING PACK (PA)VENTAVIS (PA)VIEKIRA PAK (PA, ST)VISTOGARD (LDD)VOTRIENT (PA)

X

XALKORI (PA, LDD)XELJANZ (PA, ST, LDD)XELJANZ XR (PA, ST, LDD)XOLAIR (PA, LDD)XTANDI (PA, ST, LDD)XURIDEN (PA)XYREM (PA, LDD)

Z

ZARXIO (LDD)ZAVESCA (PA, LDD)ZELBORAF (PA, LDD)ZOLADEX 10.8 MG IMPLANT SYRN (PA)ZOLADEX 3.6 MG IMPLANT SYRN (PA)ZOLINZA (PA)ZORTRESSZYDELIG (PA)ZYKADIA (PA, LDD)ZYTIGA (PA, LDD)

Specialty medications are limited to a 30-day supply.

35

Prescription drug list FAQs

Understanding your prescription medication coverage can be confusing. Below are answers to some commonly asked questions.

Why do you make changes to the drug list?

Cigna regularly reviews and updates the prescription drug list. We make changes for many reasons – like when new medications become available or are no longer available, or when medication prices change. We try to give you many options to choose from to treat your health condition. Here are some changes that typically take place:

› Moving a medication to a higher cost tier and/or no longer covering a medication.

› Adding requirements to a medication. For example, requiring approval from Cigna before a medication may be covered or adding a quantity limit to a medication.

› Moving a medication to a lower cost tier. › No longer covering a brand medication when

a generic becomes available.

When we make a change to the coverage of a medication you’re taking, we’ll send you a letter three months before the change takes place so you have time to prepare. It’s important to know that when a medication changes tiers or is no longer covered, you may pay a different amount to fill that medication.

Why doesn’t my plan cover certain medications?

To help lower your overall health care costs, your plan doesn’t cover certain high-cost brand medications because they have lower-cost, covered alternatives which are used to treat the same condition. Meaning, the alternative works the same or similar to the non-covered medication. If you’re taking a medication that isn’t covered by your plan and your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving coverage of your medication.

Your plan may also exclude certain medications or products from coverage. This is known as a “plan (or benefit) exclusion.” For example, your plan excludes medications that aren’t approved by the U.S. Food and Drug Administration (FDA).

How do you decide which medications are covered?

The Prescription Drug List is managed by the Business Decision Team, which makes, subject to the P&T Committee’s review and approval of the Prescription Drug List, coverage tier placement decisions of Prescription Drugs or Related Supplies and/or applies utilization management requirements to certain

Prescription Drugs or Related Supplies. Your Policy’s coverage tiers may contain Prescription Drugs or Related Supplies that are Generic Drugs, Brand Drugs or Specialty Medications. Placement of any Prescription Drug or Related Supplies in a specific tier, and application of utilization management requirements to a Prescription Drug, depends on a number of clinical and economic factors. Clinical factors include, without limitation, the P&T Committee’s evaluations of the place in therapy, or relative safety or relative efficacy of the Prescription Drug or Related Supplies, and economic factors include, without limitation, the cost and/or available rebates for Prescription Drugs or Related Supplies. Whether a particular Prescription Drug or Related Supplies is appropriate for You or any of Your Family Member(s), regardless of its eligibility coverage under Your Policy, is a determination that is made by You (or Your Family Member) and the prescribing Physician.

The coverage status of a Prescription Drug or Related Supply may change periodically during the Policy Year for various reasons. For example, a Prescription Drug or Related Supply may be removed from the market, a new Prescription Drug in the same therapeutic class may become available, or the cost of a Prescription Drug or Related Supply may increase.

As a result of coverage changes, You may be required to pay more or less for that Prescription Drug or Related Supply, or try another covered Prescription Drug or Related Supply. Please access www.mycigna.com or call Customer Service at the telephone number on Your ID card for the most up-to-date coverage tier status, utilization management, or other coverage limitations for Prescription Drugs or Related Supplies.

Which medications are covered under the health care reform law?The Patient Protection and Affordable Care Act (PPACA), commonly referred to as “health care reform,” was signed into law on March 23, 2010. Under this law, certain preventive medications (including some over-the-counter medicines) may be available to you at no cost-share ($0), depending on your plan. Log in to the myCigna website or app or check your plan materials to learn more about how your plan covers preventive medications. You can also view the PPACA No Cost-Share Preventive Medications drug list on Cigna.com/ifp-drug-list.

For more information about health care reform, visit www.informedonreform.com or Cigna.com.

36

Are medications newly approved by the FDA covered on my drug list?

All new Food and Drug Administration (FDA)-approved drug products are designated as not covered under your drug list until the Cigna business decision team makes a placement decision on the new drug (or new indication), which decision shall be based in part on the P&T Committee’s clinical review of the drug. The P&T Committee makes a reasonable effort to review all new FDA approved drug products (or new FDA approved indications) within 90 days of its release to the market. The business decision team must make a reasonable effort to review a new FDA approved drug product (or new indications) within 90 days, and make a decision on each new FDA approved drug product (or new FDA approved indication) within 180 days of its release onto the market, or a clinical justification must be documented if this timeframe is not met. If your doctor feels a currently covered medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the newly approved medication.

How can I find out how much I’ll pay for a specific medication?

Use the Drug Cost tool on the myCigna website or app to estimate how much your medication may cost and view lower cost1 alternatives, if available.

How can I save money on my prescription medications?

You may be able to save money by switching to a medication that’s on a lower tier (ex. preferred generic or generic) or by filling a 90-day supply, if your plan allows. Talk with your doctor to find out if one of these options may work for you.

What’s the difference between brand name and generic medications?

The FDA requires generic equivalent medications to have the same quality and performance as brand name medications. A generic equivalent medication is the same as a brand name medication in dosage form, active ingredient, strength, route of administration, quality, performance characteristics and intended use. Generics typically cost much less than brand name medications – in some cases, up to 85% less.2 Just because generics cost less than brands, it doesn’t mean they’re lower-quality medications.

How can I get help with my specialty medication?

Cigna Specialty PharmacySM can help you manage your health and prescription needs. Their team of medical condition experts provide personalized, 24/7 support. They’ll help you get approval for coverage of your medication, answer any questions you have about your medication and its cost, help you work through any side effects and make sure you have any supplies you need (at no extra cost). They’ll also give you information about financial assistance programs (if you need help paying for your medication). To learn more about the services they provide, please call 800.351.3606 or go to cigna.com/ specialty-pharmacyservices.

Can I fill my prescriptions by mail? If you take a medication every day to treat an ongoing health condition (like diabetes, high blood pressure, high cholesterol or asthma), you can order up to a 90-day supply through Cigna Home Delivery Pharmacy.SM To get started, call 800.835.3784. To learn more about the services they provide, go to cigna.com/home-delivery-pharmacy.

If you’re taking a specialty medication to treat a complex condition like multiple sclerosis, hepatitis C and rheumatoid arthritis, you can fill your prescription through Cigna Specialty Pharmacy (our home delivery pharmacy). To get started, call 800.351.3606. To learn more about the services they provide, go to cigna.com/specialty-pharmacy-services.

Where can I find more information about my prescription medication plan?

Use the online tools and resources on the myCigna website or app to help you better understand your pharmacy benefits. You can view your prescription drug list or search for a specific medication, use the Drug Cost tool to estimate how much your medication may cost, find an in-network pharmacy near you, review your pharmacy claims and payment history, and fill and track your home delivery orders.

Prescription drug list FAQs (cont)

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Virginia Exclusions And LimitationsExcluded Services

In addition to any other exclusions and limitations described in this Policy, there are no benefits provided for the following:

› Services obtained from an Out-of-Network (Non-Participating) Provider, except for Emergency Services (including Emergency Services provided by an Urgent Care facility), and specialty care, in the event that Medically Necessary specialist services are not available from an In-network Provider, as described under the “Special Circumstances” section of this Policy.

› Any amounts in excess of maximum amounts of Covered Expenses stated in this Policy.

› Services not specifically listed as Covered Services in this Policy in the sections titled “Comprehensive Services What The Policy Pays For”, “Prescription Drug Benefits”, “Pediatric Vision Benefits” and the “Benefit Schedule”.

› Services for treatment of complications of non-covered procedures or services.

› Services or supplies that are not Medically Necessary, except for Preventive Care Services as provided in this Policy.

› Services or supplies that are considered to be for Experimental Procedures or Investigative Procedures or Unproven Procedures, except as otherwise stated in this Policy under ‘Clinical Trials’.

› Services received before the Effective Date of coverage.

› Services received after coverage under this Policy ends.

› Services for which You have no legal obligation to pay or for which no charge would be made if You did not have health plan or insurance coverage.

› Any condition for which benefits are recovered or can be recovered, either by adjudication, settlement or otherwise, under any workers’ compensation, employer’s liability law or occupational disease law, except coverage for any medical condition pursuant to such exclusion if (i) an award of the Workers’ Compensation Commission denies compensation benefits relating to such medical condition and no request for review of such award is made pursuant to and within the time prescribed by applicable law; or (ii) an award of the Workers’ Compensation Commission, after review by the full Commission, denies compensation benefits

relating to such medical condition. Following the entry of a workers’ compensation award pursuant to clause (i) or (ii) having the effect of prohibiting the application of any such exclusion, Cigna shall immediately provide coverage for such medical condition to the extent otherwise covered under the contract, subscription contract or health services plan. If, upon appeal to the Court of Appeals or the Supreme Court, such medical condition is held to be compensable under the Virginia Workers’ Compensation Act (Title 65.2), Cigna may recover from the applicable employer or workers’ compensation insurance carrier the costs of coverage for medical conditions found to be compensable under the Act.

› Conditions caused by: (a) an act of war (declared or undeclared); (b) the inadvertent release of nuclear energy when government funds are available for treatment of Illness or Injury arising from such release of nuclear energy; however, benefits may not be able to be provided or may be delayed in the event of a major disaster. (c) an Insured Person participating in the military service of any country (note: for information about an Insured Person who becomes an active duty member of the military, please see “Cancellation by You”, under “Terms of the Policy” in the “General Provisions” section); (d) an Insured Person participating in an insurrection, rebellion, or riot.

› Any services provided by a local, state or federal government agency (except Medicaid), except when payment under this Policy is expressly required by federal or state law.

› Any services required by state or federal law to be supplied by a public school system or school district.

› Any services for which payment may be obtained from any local, state or federal government agency (except Medicaid). Veterans Administration Hospitals and Military Treatment Facilities, except for services rendered on an emergency basis where a legal liability exists for charges made to the Insured Person for such services.

› If the Insured Person is eligible for Medicare Part A, B or D, Cigna will provide claim payment according to this Policy minus any amount paid by Medicare, not to exceed the amount Cigna would have paid if it were the sole insurance carrier.

› Court-ordered treatment or hospitalization, unless such treatment is an involuntary hold or prescribed by a Physician and listed as covered in this Policy.

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› Professional services performed by a member of the covered person’s immediate family and services for which no charge is normally made in the absence of insurance.

› Supplies received or purchased directly or on Your behalf from any of the following:

– Yourself, or a company under Your partial or complete ownership;

– A person who is Your spouse, Domestic Partner, child, stepchild, parent, brother or sister.

– A facility or health care professional that provides remuneration to You, directly or indirectly, or to an organization from which You receive, directly or indirectly, remuneration.

› Services of a Hospital emergency room for any condition that is not an Emergency Medical Condition as defined in this Policy.

› Custodial Care. This exclusion does not apply to Hospice Care Services, or Occupational Therapy to restore activities such as walking, eating, drinking, dressing, toileting, transferring from wheelchair to bed, bathing, and job related activities.

› Private duty nursing in the inpatient setting, except when provided as part of the Hospice Services benefit in this Policy.

› Inpatient room and board charges in connection with a Hospital stay primarily for environmental change or physical therapy; Custodial Care or rest cures; services provided by a rest home, a home for the aged, a nursing home or any similar facility service.

› Services received during an inpatient stay when the stay is primarily related to behavioral, social maladjustment, lack of discipline or other antisocial actions which are not specifically the result of mental health.

› Complementary and alternative medicine services, including but not limited to: massage therapy; animal therapy, including but not limited to equine therapy or canine therapy; art therapy; meditation; visualization; acupuncture; acupressure; reflexology; rolfing; light therapy; aromatherapy; music or sound therapy; dance therapy; sleep therapy, except as stated in this Policy under “Sleep Testing and Treatment”; hypnosis; energy-balancing; breathing exercises; movement and/or exercise therapy including but not limited to yoga, pilates, tai-chi, walking, hiking, swimming, golf; and any other alternative treatment as defined by the National Center for Complementary and Alternative Medicine (NCCAM) of the National Institutes of

Health. Services specifically listed as covered under “Rehabilitative Therapy” and “Habilitative Therapy” are not subject to this exclusion.

› Any services or supplies provided by or at a place for the aged, a nursing home, or any facility where a significant portion of the activities of which include rest, recreation, leisure, or any other services that are not Covered Services.

› Assistance in activities of daily living, including but not limited to: bathing, eating, dressing, or other Custodial Care, self-care activities or homemaker services, and services primarily for rest, domiciliary or convalescent care.

› Services performed by unlicensed practitioners or services which do not require licensure to perform, for example meditation, breathing exercises, guided visualization.

› Inpatient room and board charges in connection with a Hospital stay primarily for diagnostic tests which could have been performed safely on an outpatient basis.

› Services which are self-directed to a free-standing or Hospital based diagnostic facility.

› Services ordered by a Physician or other who is an employee or representative of a free-standing or Hospital-based diagnostic facility, when that Physician or other Provider:

– Has not been actively involved in Your medical care prior to ordering the service, or

– Is not actively involved in Your medical care after the service is received.

This exclusion does not apply to mammography.

› Dental services, dentures, bridges, crowns, caps or other Dental Prostheses, extraction of teeth or treatment to the teeth or gums, except as specifically provided in this Policy.

› Orthodontic Services, braces and other orthodontic appliances including orthodontic services for Temporomandibular Joint Dysfunction, except for services as stated in this Policy under “Congenital Defects and Birth Anomolies for Newborns”.

› Dental Implants: Dental materials implanted into or on bone or soft tissue or any associated procedure as part of the implantation or removal of dental implants.

› Hearing aids including but not limited to semi-implantable hearing devices, audient bone conductors and Bone Anchored Hearing Aids (BAHAs). For the purposes of this exclusion, a hearing aid is any device that amplifies sound. Does not apply to cochlear implants.

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› Routine hearing tests except as provided under Preventive Care.

› Genetic screening, except as stated in this Policy under “Pregnancy and Maternity Care” and “Women’s Preventive Care”, or pre-implantations genetic screening: general population-based genetic screening is a testing method performed in the absence of any symptoms or any significant, proven risk factors for genetically linked inheritable disease.

› Optometric services, eye exercises including orthoptics, eyeglasses, contact lenses, routine eye exams, and routine eye refractions, except as specifically stated in this Policy under Pediatric Vision.

› An eye surgery solely for the purpose of correcting refractive defects of the eye, such as near-sightedness (myopia), astigmatism and/or farsightedness (presbyopia).

› Cosmetic surgery or other services for beautification, to improve or alter appearance or self-esteem. This exclusion shall not include Reconstructive Surgery when such service is incidental to or follows surgery resulting from trauma, infection or other diseases of the involved part, and Reconstructive Surgery because of congenital disease or anomaly of a covered dependent child which has resulted in a functional defect.

› Aids or devices that assist with nonverbal communication, including but not limited to communication boards, prerecorded speech devices, laptop computers, desktop computers, Personal Digital Assistants (PDAs), Braille typewriters, visual alert systems for the deaf and memory

Documents

2019 CIGNA RX PREMIERE 5-TIER PRESCRIPTION DRUG LIST...aldactazide 4 alendronate sod 70 mg/75 ml 2 alendronate sodium 10 mg tab 1 alendronate sodium 35 mg tab 1 alendronate sodium