CIGNA NATIONAL PREFERRED 3-TIER PRESCRIPTION DRUG LIST

Oﬀered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, or their aﬃliates.

948519 d CNPF 5/22

Coverage as of July 1, 2022

CIGNA NATIONAL

PREFERRED 3-TIER

PRESCRIPTION DRUG LIST

About this drug list

This is a list of the most commonly prescribed

preferred medications covered on the Cigna National

Preferred 3-Tier Prescription Drug List as of July 1,

2022.

1,2

Medications are listed by the condition they

treat. Generic medications are listed in all lowercase

letters and brand-name medications are listed in all

capital letters.

The drug list is updated often so it isn’t a complete list

of the medications your plan covers. Also, your speciﬁc

plan may not cover all of these medications. Log in

to the myCigna App or myCigna.com, or check your

plan materials, to see all of the medications your plan

covers.

Abbreviations next to medications

In this drug list, medications that have limits and/or

extra coverage requirements have an abbreviation

listed next to them.* Here’s what they mean.

›

Prior authorization: Certain medications need

approval from Cigna before your plan will cover

them. These medications have a (PA) next to them.

Your plan won’t cover these medications unless

your doctor requests, and receives, approval from

Cigna.

›

Quantity limits: Some medications have a quantity

limit - meaning, your plan will only cover up to a

certain amount over a certain length of time. These

medications have a (QL) next to them. Your plan will

only cover a larger amount if your doctor requests,

and receives, approval from Cigna.

›

Step Therapy: Certain high-cost medications aren’t

covered until you try one or more lower-cost

alternatives ﬁrst.** These medications have a (ST)

next to them. You have many covered options to

choose from, and they’re used to treat the same

condition.

›

Age requirements: Certain medications will only be

covered if you’re within a speciﬁc age range. These

medications have (AGE) next to them. If you’re not

within the allowed age range, your plan will only

cover the medication if your doctor requests, and

receives, approval from Cigna.

* These coverage requirements may not apply to your speciﬁc plan. Log in to the myCigna

App or myCigna.com, or check your plan materials, to ﬁnd out if your plan includes prior

authorization, quantity limits, Step Therapy, and/or age requirements.

** If your doctor feels an alternative isn’t right for you, he or she can ask Cigna to consider

approving coverage of your medication.

Go generic and save

Ask your doctor if a preventive generic

medication may be right for you. Generics

have the same strength and active

ingredients as brand-name medications,

but often cost much less – in some cases,

up to 85% less.

3

2

Cigna National Preferred 3-Tier Prescription Drug List

AIDS/HIV

APRETUDE ER (PA)

BIKTARVY

CIMDUO

DESCOVY

emtricitabine/tenofovir

disoproxil fumarate

GENVOYA

JULUCA

ODEFSEY

SYMFI

SYMFI LO

SYMTUZA

TEMIXYS

TRIUMEQ

ALLERGY/NASAL

SPRAYS

AUVI-Q (ST, QL)

azelastine nasal spray

desloratadine

DYMISTA (ST, QL)

epinephrine auto-injector

(QL) (by MYLAN, TEVA)

EPIPEN (PA, QL), EPIPEN

JR (PA, QL)

fluticasone nasal spray (QL)

GRASTEK (PA)

hydroxyzine

hydroxyzine pamoate

levocetirizine

ODACTRA (PA)

ORALAIR (PA)

promethazine

RAGWITEK (PA)

SYMJEPI

ALZHEIMER’S DISEASE

donepezil (ST)

NAMZARIC (ST)

ANXIETY/

DEPRESSION/

BIPOLAR DISORDER

alprazolam

amitriptyline

bupropion

bupropion er

buspirone

citalopram (QL)

desvenlafaxine er (ST, QL)

diazepam

duloxetine dr (QL)

escitalopram (QL)

FETZIMA (ST, QL)

fluoxetine (QL)

lorazepam

mirtazapine

nortriptyline

paroxetine (QL)

trazodone

venlafaxine (ST, QL)

venlafaxine er (ST, QL)

ASTHMA/COPD/

RESPIRATORY

ADEMPAS (PA)

ADVAIR HFA (PA, QL)

AIRDUO DIGIHALER 113-14,

232-14, 55-14 MCG (PA,

QL)

albuterol hfa (by

CIPLA, PAR, PERRIGO,

PROFICIENT RX & TEVA)

albuterol nebulization

solution

ANORO ELLIPTA (QL)

ARNUITY ELLIPTA (QL)

ASMANEX HFA (QL)

ASMANEX TWISTHALER

(QL)

BEVESPI AEROSPHERE

(QL)

BREO ELLIPTA (PA, QL)

BREZTRI AEROSPHERE

(QL)

budesonide nebulization

suspension

COMBIVENT RESPIMAT

(QL)

DULERA (PA, QL)

FASENRA (PA)

FLOVENT DISKUS (QL)

FLOVENT HFA (QL)

INCRUSE ELLIPTA (QL)

montelukast

NUCALA (PA, QL)

OFEV (PA, QL)

OPSUMIT (PA)

PERFOROMIST (QL)

QVAR REDIHALER (QL)

SEREVENT DISKUS (QL)

sildenafil

SPIRIVA HANDIHALER

(QL)

SPIRIVA RESPIMAT (QL)

STIOLTO RESPIMAT (QL)

SYMBICORT (PA, QL)

tadalafil 20mg

TRACLEER SUSPENSION

(PA)

TRELEGY ELLIPTA (QL)

TRIKAFTA (PA, QL)

UPTRAVI (PA)

XOLAIR (PA, QL)

YUPELRI (QL)

ATTENTION DEFICIT

HYPERACTIVITY

DISORDER

atomoxetine

AZSTARYS (ST)

DAYTRANA (ST)

dexmethylphenidate er

dextroamphetamine/

amphetamine

dextroamphetamine/

amphetamine er

DYANAVEL XR

Generic medications are listed in all lowercase letters and brand-name medications are listed in all capital letters.

^ Not all plans cover this medication. Log in to the myCigna App or myCigna.com, or check your plan materials, to see if your plan covers it.

View the drug list online

This document was last updated on 05/01/2022.* You can go online to see the current list of

medications your plan covers.

Questions?

›

myCigna.com: Click to Chat - Monday-Friday, 9:00 am-8:00 pm EST.

›

By phone: Call the toll-free number on your Cigna ID card. We’re here 24/7/365.

myCigna

®

App or myCigna.com. Click on the Find Care & Costs tab. Then select

Price a Medication, and type in your medication name.

Cigna.com/PDL. Scroll down until you see a pdf of the Cigna National Preferred

3-Tier Prescription Drug List (Abridged).

33

Cigna National Preferred 3-Tier Prescription Drug List

ATTENTION DEFICIT

HYPERACTIVITY

DISORDER (cont.)

guanfacine er

methylphenidate

methylphenidate er (ST)

MYDAYIS

QUILLICHEW ER (ST)

QUILLIVANT XR (ST)

VYVANSE (ST)

BLOOD MODIFIERS/

BLEEDING DISORDERS

EMPAVELI (PA)

FULPHILA (PA, QL)

TAVALISSE (PA, QL)

ZIEXTENZO (PA)

BLOOD PRESSURE/

HEART MEDICATIONS

amiodarone

amlodipine

amlodipine/benazepril

amlodipine/valsartan

atenolol

atenolol/chlorthalidone

benazepril

bisoprolol/hctz

carvedilol

clonidine

digoxin

diltiazem er

doxazosin (QL)

droxidopa (PA)

enalapril

ENTRESTO (QL)

hydralazine

irbesartan

isosorbide er

isosorbide mononitrate er

labetalol

lisinopril

lisinopril/hctz

losartan

losartan/hctz

metoprolol succinate er

(ST)

metoprolol tartrate

nifedipine er

olmesartan

olmesartan/hctz

propranolol

propranolol er

quinapril

ramipril

TAKHZYRO (PA, ST)

TEKTURNA HCT

telmisartan

terazosin (QL)

valsartan

valsartan/hctz

verapamil er (ST)

VERQUVO (QL)

BLOOD THINNERS/

ANTI-CLOTTING

AGGRENOX 25 MG-200

MG CAPSULE

BEVYXXA CAPSULES

BRILINTA

clopidogrel

ELIQUIS (PA)

enoxaparin

FRAGMIN

warfarin

XARELTO (PA)

CANCER

ALECENSA (PA, QL)

ALUNBRIG (PA, QL)

anastrozole

ARRANON

BOSULIF (PA, QL)

CABOMETYX (PA, QL)

CALQUENCE (PA, QL)

COMETRIQ (PA, QL)

ERIVEDGE (PA, QL)

ERLEADA (PA)

EXKIVITY (PA, QL)

GILOTRIF (PA, QL)

IBRANCE (PA, QL)

IMBRUVICA (PA, QL)

INLYTA (PA, QL)

IRESSA (PA, QL)

LENVIMA (PA, QL)

LORBRENA (PA, QL)

LYNPARZA (PA)

methotrexate

NINLARO (PA, QL)

NUBEQA

ODOMZO (PA, QL)

POMALYST (PA)

REVLIMID (PA)

ROZLYTREK (PA, QL)

RUBRACA (PA, QL)

RYDAPT (PA, QL)

SPRYCEL (PA, QL)

STIVARGA (PA, QL)

SUTENT (PA, QL)

TABRECTA (PA)

TAGRISSO (PA, QL)

TALZENNA (PA, QL)

tamoxifen

TASIGNA (PA, QL)

VENCLEXTA (PA, QL)

VERZENIO (PA)

VISTOGARD (PA, QL)

VITRAKVI (PA, QL)

VIZIMPRO (PA, QL)

VONJO (PA)

WELIREG

XALKORI (PA, QL)

XELODA (PA)

XOSPATA (PA, QL)

XTANDI (PA, QL)

YONSA (PA)

ZEJULA (QL)

ZOLINZA (PA, QL)

CHOLESTEROL

MEDICATIONS

atorvastatin (QL)

ezetimibe (ST)

ezetimibe/simvastatin (QL)

fenofibrate (ST)

fenofibrate micronized

fenofibrate acid delayed

release

fenofibric acid dr

gemfibrozil

LIPOFEN

LIVALO (ST, QL)

lovastatin (QL)

NEXLETOL

NEXLIZET

niacin er

omega-3 acid ethyl esters

pravastatin (QL)

PRAVACHOL (ST, QL)

REPATHA (PA)

rosuvastatin (QL)

simvastatin (QL)

VASCEPA

CONTRACEPTION

PRODUCTS

BLISOVI FE

ethinyl estradiol/

drospirenone

ethinyl estradiol/

drospirenone/levomefolate

ethinyl estradiol/

etonogestrel vaginal ring

ethinyl estradiol/

levonorgestrel

ethinyl estradiol/

norelgestromin patches

ethinyl estradiol/

norethindrone acetate

ethinyl estradiol/

norethindrone/iron

ethinyl estradiol/

norgestimate

EUFLEXXA

etonogestrel-ethinyl

estradiol vaginal ring (QL)

JUNEL

JUNEL FE

KYLEENA

MICROGESTIN FE

MIRENA

SKYLA

SPRINTEC

TRI-LO-MARZIA

TRINESSA

TRI-SPRINTEC

COUGH/COLD

MEDICATIONS

benzonatate

hydrocodone/

chlorpheniramine er

hydrocodone/

chlorpheiramine polistirex

er

promethazine/

dextromethorphan

DENTAL PRODUCTS

chlorhexidine

DIABETES

ACCU-CHEK LANCETS

BAQSIMI

BD AUTOSHIELD DUO

NEEDLES

Generic medications are listed in all lowercase letters and brand-name medications are listed in all capital letters.

^ Not all plans cover this medication. Log in to the myCigna App or myCigna.com, or check your plan materials, to see if your plan covers it.

4

DiABETES (cont.)

BD INSULIN SYRINGE

BD PEN NEEDLE

BD ULTRAFINE INSULIN

SYRINGES

BD ULTRAFINE PEN

NEEDLES

BYDUREON (PA, QL)

BYETTA (PA, QL)

DEXCOM SENSOR

DEXCOM G6 RECEIVER

(PA)

DEXCOM G6

TRANSMITTER (PA, QL)

DROPLET LANCETS

FARXIGA (ST, QL)

FREESTYLE FREEDOM,

FREESTYLE FREEDOM

LITE,

FREESTYLE INSULINX,

FREESTYLE LITE

FREESTYLE LIBRE

READER (PA)

FREESTYLE LIBRE

SENSOR (PA, QL)

FREESTYLE LIBRE 2

SENSOR

FREESTYLE TEST STRIPS:

FREESTYLE, FREESTYLE

INSULINX, FREESTYLE

LITE

glimepiride

glipizide

glipizide er

GLUCAGEN (QL)

GLUCAGON

GLUCOPHAGE (ST)

GLUCOPHAGE XR (ST, QL)

glyburide

GLYXAMBI (ST, QL)

GVOKE

HUMALOG

HUMULIN

JANUMET (ST, QL)

JANUMET XR (ST, QL)

JANUVIA (ST, QL)

JARDIANCE (ST, QL)

LEVEMIR

LYUMJEV

metformin (ST)

metformin er (QL)

MICROLET LANCETS

NOVOFINE AUTOSHIELD

NEEDLES

NOVOFINE NEEDLES

NOVOTWIST NEEDLES

OMNIPOD

OMNIPOD DASH

ONETOUCH TEST STRIPS:

ULTRA, VERIO

ONETOUCH ULTRA 2,

ULTRAMINI, VERIO, VERIO

FLEX

OZEMPIC (PA, QL)

pioglitazone (QL)

PRECISION XTRA TEST

STRIPS, B-KETONE STRIPS

RYBELSUS

SEGLUROMET

SEMGLEE

SOLIQUA (QL)

STEGLATRO

STEGLUJAN

SYMLINPEN (QL)

SYNJARDY (ST, QL)

SYNJARDY XR (ST, QL)

TECHLITE LANCETS

TOUJEO

TRESIBA

TRIJARDY XR

TRULICITY (PA, QL)

V-GO

XIGDUO XR (ST, QL)

XULTOPHY (QL)

ZEGALOGUE (QL)

DiURETICS

chlorthalidone

furosemide

hydrochlorothiazide

KERENDIA (PA)

spironolactone

triamterene/hctz

EAR MEDICATIONS

neomycin/polymyxin/

hydrocortisone ear

solution

ERECTILE

DYSFUNCTION

MUSE^ (PA, QL)

tadalafil^ (PA, QL) 2.5mg,

5mg, 10mg, 20mg

EYE CONDITIONS

AZASITE

erythromycin eye ointment

latanoprost eye solution

(PA)

loteprednol eye drops

loteprednol eye suspension

moxifloxacin eye solution

PATADAY

polymyxin/trimethoprim

eye solution

prednisolone eye

suspension

RESTASIS (PA, QL)

timolol eye solution

tobramycin eye solution

tobramycin/dexamethasone

eye suspension

travoprost eye solution (PA)

TYRVAYA 0.03 MG NASAL

SPRAY (PA)

XIIDRA (PA, QL)

FEMININE PRODUCTS

terconazole vaginal

GASTROINTESTINAL/

HEARTBURN

BYLVAY (PA, QL)

CREON

dicyclomine

diphenoxylate/atropine

esomeprazole dr (QL)

famotidine

lansoprazole dr (QL)

LINZESS (QL)

LIVMARLI (PA)

meclizine

metoclopramide

MOVANTIK (QL)

omeprazole dr (ST)

ondansetron

ondansetron ODT

PANCREAZE

pantoprazole dr (QL)

PENTASA

rabeprazole dr

RECTIV

RELISTOR (ST)

RELISTOR TABLETS (ST)

SYMPROIC

TALICIA (QL)

TRULANCE

UCERIS FOAM

VARUBI (QL)

VIBERZI

VIOKACE

ZENPEP

HORMONAL AGENTS

ANDRODERM (PA, QL)

BYNFEZIA PEN (PA, ST)

CETROTIDE

COMBIPATCH

dexamethasone

DUAVEE

estradiol (QL)

estradiol patches (QL)

estradiol/norethindrone

(QL)

estradiol vaginal inserts

(QL)

GENOTROPIN (PA)

levothyroxine sodium

liothyronine

LUPRON DEPOT 3.75 MG,

11.25 MG (PA)

LUPRON DEPOT-PED (PA)

medroxyprogesterone

methimazole

methylprednisolone

MYFEMBREE (PA)

ethylprednisolone

NATESTO (PA)

NORDITROPIN (PA)

ORIAHNN (PA)

ORILISSA (PA)

prednisolone sodium

phosphate

prednisone

PREMARIN CREAM

SANDOSTATIN (PA, ST)

SOMATULINE DEPOT (PA)

SOMAVERT (PA)

SYNAREL (PA)

TARPEYO DR (PA)

testosterone cypionate (PA)

XYOSTED (PA, QL)

YUVAFEM

INFECTIONS

acyclovir (PA, QL)

amoxicillin

amoxicillin/potassium

clavulanate

ARIKAYCE (PA)

azithromycin

BARACLUDE SOLUTION

BAXDELA (QL)

cefdinir

Generic medications are listed in all lowercase letters and brand-name medications are listed in all capital letters.

^ Not all plans cover this medication. Log in to the myCigna App or myCigna.com, or check your plan materials, to see if your plan covers it.

Cigna National Preferred 3-Tier Prescription Drug List

5

INFECTIONS (cont.)

cefuroxime

cephalexin

ciprofloxacin

clarithromycin

clindamycin oral

doxycycline hyclate (ST)

doxycycline monohydrate

EMVERM

EPCLUSA (QL)

fluconazole

HARVONI (PA, QL)

hydroxychloroquine

KITABIS PAK (PA, QL)

levofloxacin

LIVTENCITY (PA)

metronidazole

metronidazole vaginal

minocycline

MOLNUPIRAVIR

nitrofurantoin macrocrystal

nystatin (QL)

ofloxacin

oseltamivir

PAXLOVID

PEGASYS (QL)

PEGINTRON (QL)

penicillin vk

SOLOSEC

sulfamethoxazole/

trimethoprim

THALOMID (PA)

TOBI PODHALER (PA, QL)

valacyclovir (QL)

VOSEVI (PA)

XIFAXAN (QL)

ZEPATIER (PA, QL)

INFERTILITY

ENDOMETRIN^

GONAL-F^ (PA), GONAL-F

RFF^ (PA), GONAL-F RFF

REDI-JECT^ (PA)

NOVAREL^ (QL)

OVIDREL^

MISCELLANEOUS

COVID AT-HOME TESTS

AUSTEDO (PA, QL)

CERDELGA (ST)

ESBRIET (PA, QL)

NITYR

NUEDEXTA (PA)

STRENSIQ (PA)

TEGSEDI (PA)

VOXZOGO (PA)

MULTIPLE SCLEROSIS

AUBAGIO (PA, QL)

AVONEX (PA, QL)

BAFIERTAM (PA, QL)

BETASERON (PA, QL)

dimethyl fumarate

FIRDAPSE (PA)

FIRDAPSE 10 MG TABLET

(PA, ST)

GILENYA

GLATOPA (PA, QL)

KESIMPTA (PA, QL)

MAYZENT (PA)

PLEGRIDY (PA, QL)

PONVORY (PA, QL)

REBIF (PA, QL)

VUMERITY

ZEPOSIA (PA, QL)

NUTRITIONAL/

DIETARY

calcium 667mg (QL)

cyanocobalamin injectable

ergocalciferol

folic acid

LOKELMA (QL)

NASCOBAL (QL)

PHOSLYRA (QL)

potassium chloride er

VELPHORO (QL)

VELTASSA (ST, QL)

OSTEOPOROSIS

PRODUCTS

alendronate (QL)

FORTEO (PA, QL)

ibandronate (QL)

raloxifene

TYMLOS (PA)

PAIN RELIEF AND

INFLAMMATORY

DISEASE

acetaminophen/codeine

(PA, QL)

ACTEMRA (PA, QL)

AIMOVIG (PA, QL)

AJOVY (PA, QL)

allopurinol

baclofen

BACLOFEN ORAL

SOLUTION (BRAND) (ST)

BELBUCA (ST, PA, QL)

butalbital/acetaminophen/

caffeine

celecoxib

colchicine tablets

cyclobenzaprine

CYCLOBENZAPRINE ER

(ST)

diclofenac dr

DUPIXENT (PA, QL)

DURAGESIC 12, 25, 50, 75,

100 MCG/HR PATCH (QL)

EMGALITY (PA)

ENBREL (PA, QL)

fentanyl patches (QL)

FLECTOR (ST, QL)

HUMIRA (PA, QL)

hydrocodone/

acetaminophen

hydromorphone

HYSINGLA ER (PA, ST, QL)

ibuprofen (ST)

indomethacin

ketorolac (QL)

LICART PATCHES

lidocaine patches

meloxicam (QL)

metaxalone

methocarbamol

MITIGARE

MORPHABOND ER (QL)

morphine er (QL)

morphine sulfate er (PA, ST,

QL)

nabumetone

naproxen (ST)

NORCO

OTEZLA (PA)

oxycodone (PA)

oxycodone/acetaminophen

OXYCONTIN (PA, ST, QL)

QULIPTA (PA)

RASUVO (ST)

RINVOQ ER (PA, ST, QL)

rizatriptan (QL)

SAPHNELO (PA)

SAVELLA (ST, QL)

SIMPONI 100 MG (PA, QL)

(ONLY FOR ULCERATIVE

COLITIS)

SKYRIZI (PA, QL)

STELARA (PA)

sumatriptan ( QL)

TALTZ (PA)

tizanidine

tramadol (PA, QL)

TREMFYA (PA)

TRUDHESA NASAL SPRAY

(ST)

XELJANZ (PA, QL)

XELJANZ XR (PA, QL)

ZOMIG NASAL (ST, QL)

ZTLIDO

PARKINSON’S

DISEASE

carbidopa/levodopa

INBRIJA (PA, QL)

KYNMOBI (PA, QL)

pramipexole

ropinirole

SCHIZOPHRENIA/

ANTI-PSYCHOTICS

aripiprazole

CAPLYTA (QL)

LATUDA (QL)

olanzapine

quetiapine

risperidone (QL)

SEIZURE DISORDERS

clonazepam

DILANTIN

divalproex dr

divalproex er

EPIDIOLEX (PA)

FYCOMPA

gabapentin

lamotrigine

levetiracetam

NAYZILAM

oxcarbazepine

pregabalin

QUDEXY XR (ST)

topiramate

VALTOCO (PA, QL)

VIMPAT

Generic medications are listed in all lowercase letters and brand-name medications are listed in all capital letters.

^ Not all plans cover this medication. Log in to the myCigna App or myCigna.com, or check your plan materials, to see if your plan covers it.

Cigna National Preferred 3-Tier Prescription Drug List

6

SKIN CONDITIONS

ABSORICA (ST)

ADBRY (PA)

clindamycin 1% gel

clindamycin topical (ST)

clindamycin/benzoyl

peroxide

clobetasol (ST, QL)

clotrimazole/betamethasone

(QL)

dapsone topical

ENSTILAR (QL, ST)

EPIDUO FORTE GEL PUMP

(ST)

FINACEA FOAM (ST)

gentamicin (QL)

fluocinonide (QL)

hydrocortisone topical (ST,

QL)

isotretinoin (ST)

ketoconazole topical (QL)

metronidazole topical

MIRVASO (PA)

mometasone (ST, QL)

mupirocin (ST, QL)

nystatin topical (QL)

ONEXTON

PICATO

tacrolimus topical (ST, QL)

tretinoin (PA)

triamcinolone topical (QL)

WYNZORA 0.005%-0.064%

CREAM (ST, QL)

Generic medications are listed in all lowercase letters and brand-name medications are listed in all capital letters.

^ Not all plans cover this medication. Log in to the myCigna App or myCigna.com, or check your plan materials, to see if your plan covers it.

Cigna National Preferred 3-Tier Prescription Drug List

SLEEP DISORDERS/

SEDATIVES

eszopiclone (QL)

SUNOSI

XYREM (PA, QL)

XYWAV (PA, QL)

zolpidem (QL)

zolpidem er (QL)

SMOKING CESSATION

CHANTIX (QL)

SUBSTANCE ABUSE

BUPRENORPHINE/

NALOXONE (QL)

KLOXXADO (QL)

NARCAN (QL)

ZUBSOLV (QL)

TRANSPLANT

MEDICATIONS

REZUROCK TABLET (PA,

QL)

ZORTRESS 1 MG TABLET

URINARY TRACT

CONDITIONS

finasteride

GELNIQUE (QL)

MYRBETRIQ

oxybutynin er

tamsulosin er

TOVIAZ

VACCINES

FLUMIST QUAD

PFIZER COVID VACCINE

TICOVAC 2.4 MCG/0.5 ML

SYRINGE

VAXNEUVANCE 0.5 ML

SYRINGE

WEIGHT MANAGEMENT

WEGOVY^ (PA, QL)

77

Medications that aren’t covered - and their covered alternative(s)

These medications aren’t covered on the Cigna National Preferred 3-Tier Prescription Drug List.

^^

However, there are

other medications available that are used to treat the same condition. They’re listed below.

DRUG CLASS

MEDICATION NAME

^^

(Not covered)

GENERIC AND/OR PREFERRED

BRAND ALTERNATIVE(S)

AIDS/HIV

ATRIPLA efavirenz-emtric-tenofov disop

CABENUVA SUSP atazanavir, lamivudine, DOVATO, EDURANT,

JULUCA, PREZISTA, TIVICAY

COMPLERA Odefsey

DELSTRIGO BIKTARVY, GENVOYA, ODEFSEY, SYMFI,

SYMTUZA, TRIUMEQ

PIFELTRO efavirenz, EDURANT

PREZCOBIX atazanavir, lopinavir-ritonavir, ritonavir,

PREZISTA

STRIBILD BIKTARVY, GENVOYA

TRUVADA emtricitabine/tenofovir (tdf )

ALLERGY/NASAL SPRAYS

epinephrine generic epinephrine auto-injector, EPIPEN,

EPIPEN JR.

BECONASE AQ, OMNARIS, ZETONNA ﬂunisolide, ﬂuticasone, mometasone

NASONEX mometasone

PALFORZIA No alternatives recommended.

QNASL, QNASL CHILDREN’S ﬂunisolide, ﬂuticasone, mometasone

ALZHEIMER'S DISEASE

MESTINON pyridostigmine

NAMENDA XR memantine er

ANXIETY/DEPRESSION/BIPOLAR DISORDER

BUPROPION HCL XL 450 MG TABLET ,

FORFIVO XL 450 MG TABLET, WELLBUTRIN XL

bupropion xl

CELEXA, citalopram 30mg capsules citalopram hbr

CYMBALTA duloxetine

DRIZALMA SPRINKLE desvenlafaxine er, duloxetine, venlafaxine er,

FETZIMA

EFFEXOR XR venlafaxine er

LEXAPRO escitalopram

LOREEV XR lorazepam tablets

PEXEVA, VIIBRYD citalopram, escitalopram, ﬂuoxetine,

ﬂuvoxamine, paroxetine, sertraline

PRISTIQ desvenlafaxine er

PROZAC ﬂuoxetine

SERTRALINE 150MG, 200MG CAPSULES sertraline tablets

SPRAVATO olanzapine/ﬂuoxetine, bupropion,

desvenlafaxine er, duloxetine, escitalopram,

mirtazapine, sertraline

VALIUM diazepam

WELLBUTRIN SR bupropion sr

XANAX alprazolam

XANAX XR alprazolam er

ZOLOFT sertraline

ASTHMA/COPD/RESPIRATORY

ADCIRCA tadalaﬁl

AIRDUO DIGIHALER, AIRDUO RESPICLICK,

budesonide-formoterol

ﬂuticasone-salmeterol (by PRASCO,

PROFICIENT RX,WIXELA INHUB, ADVAIR HFA,

BREO ELLIPTA, DULERA, SYMBICORT

^^

This medication isn’t covered on this drug list. If your doctor feels a diﬀerent medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the non-covered medication. If you

don’t get approval and you continue to ﬁll a prescription for a medication that isn’t covered, you’ll pay its full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t

be applied to your annual deductible or out-of-pocket maximum.

88

DRUG CLASS

MEDICATION NAME

^^

(Not covered)

GENERIC AND/OR PREFERRED

BRAND ALTERNATIVE(S)

ASTHMA/COPD/RESPIRATORY (cont)

albuterol sulfate hfa (by A-S Medication,

Prasco), levalbuterol hfa, PROAIR DIGIHALER,

PROAIR RESPICLICK, PROAIR HFA, PROVENTIL

HFA, VENTOLIN HFA, XOPENEX HFA

albuterol hfa (by CIPLA, PAR, PERRIGO,

PROFICIENT RX & TEVA

ARMONAIR DIGIHALER, PULMICORT

FLEXHALER

ARNUITY ELLIPTA, ASMANEX, ASMANEX

HFA, FLOVENT DISKUS, FLOVENT HFA, QVAR

REDIHALER

CINQAIR DUPIXENT, FASENRA, NUCALA

DALIRESP ARNUITY ELLIPTA, ASMANEX HFA, FLOVENT

HFA, INCRUSE ELLIPTA, QVAR REDIHALER,

SEREVENT DISKUS, SPIRIVA RESPIMAT

DUAKLIR PRESSAIR ANORO ELLIPTA, BEVESPI AEROSPHERE,

STIOLTO RESPIMAT

ﬂuticasone-salmeterol (By AS MEDICATION,

TEVA

ﬂuticasone-salmeterol (by PRASCO,

PROFICIENT RX, ADVAIR HFA, BREO ELLIPTA,

DULERA, SYMBICORT

LETAIRIS ambrisentan

PULMICORT budesonide

SINGULAIR montelukast

STRIVERDI RESPIMAT SEREVENT DISKUS

TUDORZA PRESSAIR INCRUSE ELLIPTA, SPIRIVA RESPIMAT, SPIRIVA

TEZSPIRE HYDROXYUREA, DROXIA

ATTENTION DEFICIT HYPERACTIVITY DISORDER

ADDERALL, ADDERALL XR dextroamphetamine-amphetamine

AMPHETAMINE ER SUSPENSION dextroamphetamine er, dextroamphetamine-

amphetamine er, DYANAVEL XR, MYDAYIS,

VYVANSE

CONCERTA methylphenidate er

FOCALIN dexmethylphenidate

FOCALIN XR dexmethylphenidate er

INTUNIV guanfacine er

QELBREE atomoxetine, clonidine er, guanfacine er

STRATTERA atomoxetine

BLOOD MODIFIERS/BLEEDING DISORDERS

MULPLETA DOPTELET

NYVEPRIA, UDENYCA FULPHILA, ZIEXTENZO

OXBRYTA 300MG TABLET FOR SUSP hydroxyurea, ADAKVEO, DROXIA

SIKLOS DROXIA

TAVNEOS azathioprine, cyclophosphamide,

mycophenolate, RUXIENCE

BLOOD PRESSURE/HEART MEDICATIONS

ATACAND candesartan

ATACAND HCT candesartan-hctz

AVALIDE irbesartan-hctz

AVAPRO irbesartan

AZOR amlodipine-olmesartan

BENICAR olmesartan

BENICAR HCT olmesartan-hctz

BYSTOLIC atenolol, carvedilol, metoprolol succinate

CONJUPRI amlodipine, felodipine, nifedipine, nicardipine

COREG carvedilol

^^

This medication isn’t covered on this drug list. If your doctor feels a diﬀerent medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the non-covered medication. If you

don’t get approval and you continue to ﬁll a prescription for a medication that isn’t covered, you’ll pay its full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t

be applied to your annual deductible or out-of-pocket maximum.

9

DRUG CLASS

MEDICATION NAME

^^

(Not covered)

GENERIC AND/OR PREFERRED

BRAND ALTERNATIVE(S)

BLOOD PRESSURE/HEART MEDICATIONS (cont)

CORLANOR atenolol, bisoprolol, carvedilol, metoprolol

succinate, metoprolol tartrate, propranolol

COZAAR losartan

DIOVAN valsartan

DIOVAN HCT valsartan-hctz

DUTOPROL metoprolol tartrate-hctz, metoprolol succinate

er-hctz

EDARBI candesartan, irbesartan, losartan, olmesartan,

telmisartan, valsartan

EDARBYCLOR candesartan-hctz, irbesartan-hctz, losartan-

hctz, olmesartan-hctz, valsartan-hctz,

chlorthalidone plus valsartan

EPANED SOLUTION enalapril

EXFORGE amlodipine-valsartan

EXFORGE HCT amlodipine-valsartan-hctz

HEMANGEOL 4.28 MG/ML ORAL SOLN propranolol hcl (solution)

HYZAAR losartan-hctz

INDERAL LA, INDERAL XL, INNOPRAN XL propranolol er

KAPSPARGO SPRINKLE metoprolol succinate

KATERZIA amlodipine

LOTREL amlodipine-benazepril

MICARDIS telmisartan

MICARDIS HCT telmisartan-hctz

NEXICLON XR clonidine patches, tablets

NORTHERA desmopressin, ﬂudrocortisone,

indomethacin,midodrine, pyridostigmine

NORVASC amlodipine

QBRELIS lisinopril

RANEXA ranolazine er

TEKTURNA aliskiren

TIKOSYN dofetilide

TOPROL XL metoprolol succinate

TRIBENZOR olmesartan-amlodipine-hctz

BLOOD THINNERS/ANTI-CLOTTING AGGRENOX aspirin-dipyridamole er

aspirin-omeprazole, YOSPRALA aspirin plus omeprazole, esomepreazole,

lansoprazole, pantoprazole, rabeprazole

LOVENOX enoxaparin

PLAVIX clopidogrel

PRADAXA, SAVAYSA ELIQUIS, XARELTO

CANCER AFINITOR, AFINITOR DISPERZ everolimus

ARIMIDEX anastrozole

FOTIVDA everolimus, CABOMETYX, INLYTA, LENVIMA,

NEXAVAR, SUTENT, VOTRIENT

GLEEVEC imatinib

INQOVI decitabine

9

^^

This medication isn’t covered on this drug list. If your doctor feels a diﬀerent medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the non-covered medication. If you

don’t get approval and you continue to ﬁll a prescription for a medication that isn’t covered, you’ll pay its full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t

be applied to your annual deductible or out-of-pocket maximum.

1010

DRUG CLASS

MEDICATION NAME

^^

(Not covered)

GENERIC AND/OR PREFERRED

BRAND ALTERNATIVE(S)

CANCER (cont) INREBIC JAKAFI

KISQALI, KISQALI FEMARA COPACK, PIQRAY IBRANCE, VERZENIO

ONUREG azacitidine, decitabine

QINLOCK imatinib, NEXAVAR, SPRYCEL, STIVARGA,

SUTENT, TASIGNA, VOTRIENT

SCEMBLIX imatinib, BOSULIF, ICLUSIG, SPRYCEL, TASIGNA

TARGRETIN bexarotene

TEPMETKO TABRECTA

TRUSELTIQ PEMAZYRE

XATMEP methotrexate

XPOVIO DARZALEX, KYPROLIS, NINLARO, POMALYST,

REVLIMID, THALOMID, VELCADE

ZYTIGA abiraterone

CHOLESTEROL MEDICATIONS ALTOPREV, EZALLOR SPRINKLE atorvastatin, ﬂuvastatin er, lovastatin,

pravastatin, rosuvastatin, simvastatin tablets,

LIVALO

ANTARA 30MG, 90MG CAPSULE fenoﬁbrate, fenoﬁbric acid

CRESTOR rosuvastatin

LIPITOR atorvastatin

LEQVIO, PRALUENT REPATHA

ROSUVASTATINEZETIMIBE 510MG, 1010MG,

2010MG, 4010MG

ezetimibe, atorvastatin, rosuvastatin

TRICOR fenoﬁbrate

VYTORIN ezetimibe-simvastatin

WELCHOL 625MG TABLET colesevelam hcl

ZETIA ezetimibe

ZOCOR simvastatin

CONTRACEPTION PRODUCTS ANNOVERA generic oral contraceptives, XULANE PATCHES

BALCOLTRA AVIANE, LARISSIA, LESSINA, levonorgestrel-eth

estradiol, SRONYX, VIENVA

ESTROSTEP FE TRI-LEGEST FE, TILIA FE

GENERESS FE KAITLIB FE, LAYOLIS FE, norethindrone-

estradiol-iron

LO LOESTRIN FE BLISOLVI FE, BLISOLVI 24 FE, HAILEY FE,

JUNEL FE, LARIN FE, MELODETTA 24 FE,

norethindrone- eth estradiol fe

LOESTRIN AUROVELA, JUNEL, LARIN, MICROGESTIN,

norethindrone-ethinyl estradiol

LOESTRIN FE AUROVELA FE, BLISOLVI FE, JUNEL FE, LARIN

FE, MICROGESTIN FE, norethindrone-ethinyl

estradiol fe, TARINA FE

LOSEASONIQUE AMETHIA LO, CAMRESE LO, levonorg-estradiol,

LOJAIMIESS

MINASTRIN 24 FE MIBELAS, norethindrone-ethinyl estradiol fe

^^

This medication isn’t covered on this drug list. If your doctor feels a diﬀerent medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the non-covered medication. If you

don’t get approval and you continue to ﬁll a prescription for a medication that isn’t covered, you’ll pay its full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t

be applied to your annual deductible or out-of-pocket maximum.

11

DRUG CLASS

MEDICATION NAME

^^

(Not covered)

GENERIC AND/OR PREFERRED

BRAND ALTERNATIVE(S)

CONTRACEPTION PRODUCTS (cont) MIRCETTE AZURETTE, BEKYREE, desogestrone estradiol,

KARIVA, PIMTREA, SIMLIYA, VIORELE

NATAZIA BLISOLVI FE, drospirenone-ethinyl estradiol,

ESTARYLLA, JUNEL FE, TRISPRINTEC

NEXTSTELLIS AUROVELA FE, BLISOLVI FE, drospirenone

ethinyl estradiol, ESTARYLLA, JUNEL FE, TRI-

SPRINTEC, SPRINTEC

NUVARING eluryng, etonogestrel-ethinyl estradiol

PHEXXI FC2 FEMALE CONDOM, FEMCAP, GYNOL, VCF

QUARTETTE FAYOSIM, levonorg-estradiol, RIVELSA

SAYFRAL drospirenone-estradiol, TYDEMY

SEASONIQUE AMETHIA, ASHLYNA, CAMRESE, DAYSEE,

JAIMIESS, levonorg-esgtradiol, SIMPESSE

SLYND generic progestin-only oral contraceptives

TAYTULLA GEMMILY, norethindrone-eth estradiol fe

TWIRLA BLISOVI FE, etonogestrel-ethinyl estradiol,

HAILEY FE, JUNEL FE, XULANE

TYBLUME altavera, aviane, falmina, lessina, portia

YASMIN OCELLA, SYEDA, ZARAH

DIABETES

ADLYXIN, VICTOZA BYDUREON, BYETTA, OZEMPIC, TRULICITY

ADMELOG SOLOSTAR HUMALOG PEN

ADMELOG, AFREZZA HUMALOG VIAL

alogliptin, NESINA, ONGLYZA, TRADJENTA JANUVIA

alogliptin-metformin, JENTADUETO,

JENTADUETO XR, KAZANO, KOMBIGLYZE XR

JANUMET, JANUMET XR

alogliptin-pioglitazone pioglitazine, JANUVIA

APIDRA, APIDRA SOLOSTAR, INSULIN ASPART,

INSULIN LISPRO, NOVOLOG

HUMALOG

ASCENSIA BREEZE, CONTOUR

GLUCOGUARD, ROCHE ACCUCHEK,

TRIVIDIA TRUETEST, TRUETRACK

All other test strips that are not listed as

preferred

FREESTYLE FREEDOM, FREESTYLE INSULINX,

FREESTYLE LITE METER, PRECISION XTRA,

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO,

ONETOUCH VERIO FLEX

FIASP, FIASP FLEXTOUCH, FIASP PENFILL HUMALOG, LYUMJEV

GLUMETZA metformin

INSULIN GLARGINE U100 PEN, INSULIN

GLARGINE U100 VL

LANTUS, LEVEMIR, TOUJEO SOLOSTAR, TRESIBA

INVOKAMET, INVOKAMET XR SEGLUROMET, SYNJARDY, SYNJARDY XR,

XIGDUO XR

INVOKANA FARXIGA, JARDIANCE, STEGLATRO

KORLYM ketoconazole, LYSODREN

LANTUS SEMGLEE, TOUJEO, TRESIBA, LEVEMIR

NOVOLIN, RELION NOVOLIN HUMULIN

QTERN GLYXAMBI, STEGLUJAN

SEMGLEE 100 UNIT/ML PEN, SEMGLEE 100

UNIT/ML VIAL

LANTUS SOLOSTAR, LEVEMIR FLEXTOUCH,

TOUJEO SOLOSTAR, TRESIBA FLEXTOUCH

U100

11

^^

This medication isn’t covered on this drug list. If your doctor feels a diﬀerent medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the non-covered medication. If you

don’t get approval and you continue to ﬁll a prescription for a medication that isn’t covered, you’ll pay its full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t

be applied to your annual deductible or out-of-pocket maximum.

12

DRUG CLASS

MEDICATION NAME

^^

(Not covered)

GENERIC AND/OR PREFERRED

BRAND ALTERNATIVE(S)

DIURETICS

CAROSPIR spironolactone

THALITONE chlorthalidone

EAR MEDICATIONS

CIPRO HC, ciproﬂoxacin-ﬂuocinolone, OTOVEL ciproﬂoxacin-dexamethasone

CETRAXAL 0.2% EAR SOLUTION ciproﬂoxacin otic, oﬂoxacin otic

ERECTILE DYSFUNCTION

CIALIS tadalaﬁl

VIAGRA sildenaﬁl

EYE CONDITIONS

ACUVAIL, BROMSITE, NEVANAC bromfenac drops, diclofenac drops, ketorolac

drops

ALOCRIL, ALOMIDE, LASTACAFT, PAZEO,

ZERVIATE

azelastine drops, bepotastine, cromolyn drops,

epinastine drops, olopatadine drops

ALREX azelastine, bepotastine, cromolyn sodium,

dexamethasone, epinastine, ﬂuorometholone,

olopatadine

AZOPT brinzolamide

BEPREVE bepotastine besilate

BESIVANCE, CILOXAN OINTMENT ciproﬂoxacin drops, gatiﬂoxacin drops,

levoﬂoxacin drops, moxiﬂoxacin drops,

oﬂoxacin drops

BETIMOL timolol maleate, betaxolol, levobunolol

COSOPT, COSOPT PF dorzolamide-timolol

CYSTADROPS CYSTARAN

DUREZOL 0.05% EYE DROPS diﬂuprednate

DURYSTA, XELPROS, ZIOPTAN bimatoprost drops, latanoprost drops,

travoprost drops

FLAREX, FML FORTE, FMP SOP, MAXIDEX,

PRED MILD

dexamethasone drops, ﬂuorometholone drops,

loteprednol drops, prednisolone drops

ISTALOL timolol

RHOPRESSA, ROCKLATAN betaxolol hcl, bimatoprost, dorzolamide-

timolol, latanoprost, levobunolol hcl, timolol

maleate, travoprost

TIMOPTIC OCUDOSE betaxolol drops, brimonidine 0.15% drops,

brimonidine 0.2% drops, levobunolol drops,

timolol drops

TOBRADEX ST EYE DROPS, ZYLET tobramycin/dexamethasone (drops)

TRAVATAN Z travoprost

TYRVAYA RESTASIS, XIIDRA

XALATAN latanoprost drops

GASTROINTESTINAL/HEARTBURN ACIPHEX rabeprazole

ACIPHEX SPRINKLE, ESOMEPRAZOLE

STRONTIUM, PRILOSEC RX, RABEPRAZOLE DR

SPRINKLE, ZEGERID

esomeprazole, lansoprazole, omperazole,

pantoprazole, rabeprazole

AKYNZEO granistetron, ondansetron, aprepitant, VARUBI

TABLETS

AMITIZA, LUBIPROSTONE LINZESS, TRULANCE

ASACOL HD, CANASA mesalamine

BONJESTA ER 2020 MG TABLET doxylamine succ-pyridoxine hcl

12

^^

This medication isn’t covered on this drug list. If your doctor feels a diﬀerent medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the non-covered medication. If you

don’t get approval and you continue to ﬁll a prescription for a medication that isn’t covered, you’ll pay its full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t

be applied to your annual deductible or out-of-pocket maximum.

1313

DRUG CLASS

MEDICATION NAME

^^

(Not covered)

GENERIC AND/OR PREFERRED

BRAND ALTERNATIVE(S)

GASTROINTESTINAL/HEARTBURN (cont) CLENPIQ, GOLYTELY, OSMOPREP, PLENVU,

SUPREP, SUTAB

gavilyte-g, peg 3350 electrolyte, trilyte with

ﬂavor packets

CORTIFOAM hydrocortisone enema, UCERIS FOAM

DARTISLA ODT 1.7 MG TABLET glycopyrrolate tablets

DELZICOL mesalamine dr

DEXLANSOPRAZOLE DR esomeprazole magnesium, lansoprazole,

omeprazole, pantoprazole, rabeprazole

DIPENTUM balsalazide, mesalamine dr, mesalamine er,

sulfasalazine, PENTASA

EMEND aprepitant

HELIDAC, PYLERA lansoprazole-amoxicillin-clarithromycin,

TALICIA

LIBRAX clidinium with chlordiazepoxide

LOTRONEX alosetron

MOVIPREP peg-electrolyte solution

MYTESI diphenoxylate/atropine, loperamide

NEXIUM PACKETS esomeprazole

PERTZYE CREON, ZENPEP

PREVACID RX lansoprazole

PROTONIX SUSPENSION pantoprazole

RELTONE ursodiol

SENSIPAR cinacalcet

HORMONAL AGENTS TRANSDERMSCOP scopolamine

ALKINDI SPRINKLE hydrocortisone

ANDROGEL, TESTIM, AVEED testosterone

BIJUVA, PREMPHASE, PREMPRO AMABELZ, estradiol-norethindrone acetate,

FYAVOLV, JINTELI, MIMVEY, norethindrone-

ethinyl estradiol

CLIMARA PRO COMBIPATCH

CORTROPHIN

CRINONE 4% medroxyprogesterone, megestrol,

norethindrone, progesterone

CYTOMEL liothyronine

DIVIGEL, EVAMIST estradiol patches

ELESTRIN, ESTRACE, ESTROGEL, MINIVELLE,

VIVELLE DOT

estradiol

EMFLAZA prednisone solution, prednisone tablets

ESTRING, IMVEXXY estradiol cream, estradiol tablets, yuvafem,

PREMARIN CREAM

FEMRING, INTRAROSA estradiol cream, estradiol patches, estradiol

tablets, yuvafem, PREMARIN CREAM,

HEMADY dexamethasone

HUMATROPE, NUTROPIN AQ NUSPIN,

OMNITROPE, SAIZEN, SAIZENPREP, SKYTROFA,

ZOMACTON

GENOTROPIN, NORDITROPIN

^^

This medication isn’t covered on this drug list. If your doctor feels a diﬀerent medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the non-covered medication. If you

don’t get approval and you continue to ﬁll a prescription for a medication that isn’t covered, you’ll pay its full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t

be applied to your annual deductible or out-of-pocket maximum.

14

DRUG CLASS

MEDICATION NAME

^^

(Not covered)

GENERIC AND/OR PREFERRED

BRAND ALTERNATIVE(S)

HORMONAL AGENTS (cont)

ISTURISA SIGNIFOR

MENEST, PREMARIN TABLETS estradiol tablets

MYCAPSSA somatuline depot

OSPHENA estradiol cream, yuvafem, PREMARIN CREAM

SYNTHROID euthyrox, levo-t, levothyroxine, levoxyl,

unithroid

THYQUIDITY, TIROSINT, TIROSINT SOL euthyrox, levo-t, levothyroxine sodium, levoxyl,

unithroid

VAGIFEM estradiol, YUVAFEM

INFECTIONS

BARACLUDE entecavir

BREXAFEMME ﬂuconazole

DORYX doxycycline hyclate

DORYX MPC, DOXYCYCLINE 40MG CAPSULES doxycycline hyclate, doxycycline monohydrate

FIRVANQ vancomycin capsules

LAMPIT benznidazole

LEDIPASVIRSOFOSBUVIR HARVONI

MAVYRET, SOVALDI EPCLUSA, HARVONI, VOSEVI, ZEPATIER

MINOCYCLINE ER CAPSULES, XIMINO minocycline er tablets

NATROBA spinosad

NOXAFIL posaconazole

ORACEA doxycycline hyclate, doxycycline monohydrate,

azelaic acid, ivermectin, metronidazole

PLAQUENIL hydroxychloroquine

SITAVIG acyclovir oral or cream, famciclovir, valacyclovir

SOFOSBUVIRVELPATASVIR EPCLUSA

TOBI tobramycin

TOLSURA itraconazole

VALTREX valacyclovir

MISCELLANEOUS

BRISDELLE paroxetine

EXJADE, JADENU, JADENU SPRINKLE deferasirox

FIRAZYR icatibant

NOCTIVA desmopressin

XENAZINE tetrabenazine

ZAVESCA miglustat

MULTIPLE SCLEROSIS AMPYRA dalfampridine er

EXTAVIA AVONEX, BETASERON, PLEGRIDY, REBIF

TECFIDERA dimethyl fumarate

NUTRITIONAL/DIETARY FOSRENOL POWDER PACKET lanthanum, sevelamer, Phoslyra, Velphoro

MONOFERRIC sodium ferric gluconate complex, VENOFER

PREGENNA, TRINAZ generic prenatal vitamins

RENAGEL sevelamer

OSTEOPOROSIS PRODUCTS EVENITY alendronate, ibandronate, risedonate,

zoledronic acid, FORTEO, TYMLOS

^^

This medication isn’t covered on this drug list. If your doctor feels a diﬀerent medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the non-covered medication. If you

don’t get approval and you continue to ﬁll a prescription for a medication that isn’t covered, you’ll pay its full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t

be applied to your annual deductible or out-of-pocket maximum.

15

DRUG CLASS

MEDICATION NAME

^^

(Not covered)

GENERIC AND/OR PREFERRED

BRAND ALTERNATIVE(S)

PAIN RELIEF AND INFLAMMATORY DISEASE AMRIX cyclobenzaprine

APADAZ, benzhydrocodone- acetaminophen hydrocodone-acetaminophen

BACLOFEN 5 MG/5 ML SOLUTION baclofen tablets

bupap acetaminophen-butalbital

BUTRANS buprenorphine

CELEBREX celecoxib

CIMZIA, ILUMYA, ORENCIA, SIMPONI 50mg/ml ENBREL, HUMIRA, OTEZLA, RINVOQ ER,

STELARA SC, TALTZ, XELJANZ

colchicine capsules, COLCRYS colchicine tablets, MITIGARE

COSENTYX, SILIQ TALTZ, ENBREL, HUMIRA, OTEZLA, SKYRIZI,

STELARA, TREMFYA

CUPRIMINE penicillamine

diclofenac epolamine patches FLECTOR PATCHES

DICLOFENAC POTASSIUM 25MG TABLET diclofenac potassium, etodolac, ﬂurbiprofen,

ibuprofen, ketoprofen, meloxicam,

nabumetone

ELYXYB celecoxib

fenoprofen capsules, FENORTHO, NALFON fenoprofen tablets, etodolac, ﬂurbiprofen,

ibuprofen, meloxicam, nabumetone

fentanyl buccal tablets, FENTORA, LAZANDA,

SUBSYS

fentanyl lozenges

Imitrex sumatriptan

INDOCIN 25 MG/5 ML SUSPENSION ibuprofen (suspension), naproxen (suspension)

INDOCIN 50 MG SUPPOSITORY etodolac, ﬂurbiprofen, ibuprofen,

indomethacin, ketoprofen, meloxicam,

naproxen sodium

INDOMETHACIN 20MG CAPSULES, ketorolac

nasal spray, TIVORBEX, VIVLODEX, ZIPSOR,

ZORVOLEX

diclofenac, indomethacin, ibuprofen,

meloxicam, naproxen, nabumetone

KEVZARA, KINERET, OLUMIANT ACTEMRA, ENBREL, HUMIRA, RINVOQ ER,

XELJANZ

lidocaine-tetracaine, PLIAGLIS lidocaine-prilocaine, lidocaine cream

LIDODERM lidocaine cream

MAXALT, MAXALT MLT rizatriptan

oxycodone er, XTAMPZA ER, NUCYNTA ER hydromorphone er, morphine er, oxymorphone

er, HYSINGLA ER, OXYCONTIN

NUCYNTA hydrocodone-acetaminophen, morphine,

oxycodone, trmadol, tramadol-acetaminophen

ONZETRA XSAIL sumatriptan, ZOMIG

OTREXUP RASUVO

OZOBAX oral baclofen tablets

PENNSAID diclofenac topical, FLECTOR PATCHES

PERCOCET, PRIMLEV oxycodone-acetaminophen

PROCTOFOAMHC pramoxine/hydrocortisone

QDOLO tramadol (generic tablet)

REDITREX methotrexate inj, RASUVO

^^

This medication isn’t covered on this drug list. If your doctor feels a diﬀerent medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the non-covered medication. If you

don’t get approval and you continue to ﬁll a prescription for a medication that isn’t covered, you’ll pay its full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t

be applied to your annual deductible or out-of-pocket maximum.

1616

DRUG CLASS

MEDICATION NAME

^^

(Not covered)

GENERIC AND/OR PREFERRED

BRAND ALTERNATIVE(S)

PAIN RELIEF AND INFLAMMATORY DISEASE (cont) RELAFEN DS nabumetone, etodolac, ﬂurbiprofen, ibuprofen,

ketoprofen, meloxicam, oxaprozin

RELPAX eletriptan

SEGLENTIS 56 MG-44 MG TABLET celecoxib, tramadol tablets

TRAMADOL HCL 25MG/5ML CUP tramadol tablets

TREXIMET sumatriptan-naproxen

ULORIC febuxostat

VIMOVO naproxen-esomeprazole

ZOHYDRO ER hydrocodone

ZOMIG zolmitriptan

ZOMIG ZMT zolmitriptan odt

PARKINSON’S DISEASE APOKYN KYNMOBI

DHIVY carbidopa-levodopa

GOCOVRI amantadine capsules, amantadine tablets,

amantadine oral solution

ONGENTYS entacapone

XADAGO, ZELAPAR rasagiline, selegiline

SCHIZOPHRENIA/ANTI-PSYCHOTICS ABILIFY aripiprazole

LYBALVI aripiprazole, asenapine, olanzapine,

paliperidone er, quetiapine, quetiapine er,

LATUDA

SAPRHIS asenapine

SEROQUEL quetiapine

SEROQUEL XR quetiapine er

SEIZURE DISORDERS APTIOM carbamazepine, oxcarbazepine, pregabalin,

topiramate, VIMPAT

EPRONTIA topiramate sprinkle caps

FINTEPLA DIACOMIT, EPIDIOLEX

KEPPRA, KEPPRA XR levetiracetam

LAMICTAL lamotrigine

LAMICTAL ODT lamotrigine odt

LAMICTAL XR lamotrigine er

LYRICA, LYRICA CR pregabalin

NEURONTIN gabapentin

TOPAMAX topiramate

TRILEPTAL oxcarbazepine

ZONEGRAN zonisamide

SKIN CONDITIONS ABSORICA accutane, amnesteem, claravis, isotretinoin,

myorisan, zenatane

ACANYA clindamycin-benzoyl peroxide

ALCORTIN A hydrocortisone, betamethasone, clobetasol,

ﬂuocinolone, ﬂuocinonide, mometasone,

mupirocin

ANUSOLHC hydrocortisone

ATRALIN tretinoin

^^

This medication isn’t covered on this drug list. If your doctor feels a diﬀerent medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the non-covered medication. If you

don’t get approval and you continue to ﬁll a prescription for a medication that isn’t covered, you’ll pay its full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t

be applied to your annual deductible or out-of-pocket maximum.

17

DRUG CLASS

MEDICATION NAME

^^

(Not covered)

GENERIC AND/OR PREFERRED

BRAND ALTERNATIVE(S)

SKIN CONDITIONS (cont) calcipotriene foam, SORILUX calipotriene, calcitriol

CARAC, imiquimod 3.75% cream pump,

KLISYRI

"diclofenac 3% gel, ﬂuorouracil 2% solution,

ﬂuorouracil 5% cream, imiquimod 5% cream"

CLENIA PLUS sodium sulfacetamide sulfure

CLINDAGEL clindamycin gel, erythromycin gel

clocortolone betamethasone, ﬂuocinolone, triamcinolone

DRYSOL over-the-counter alternatives

ECOZA, luliconazole, sulconazole nitrate,

XOLEGEL

ciclopirox, econazole, ketoconazole, naftiﬁne,

oxiconazole

ELIDEL pimecrolimus

EPIDUO, EPIDUO FORTE adapalene-benzoyl peroxide

ERTACZO ciclopirox, clotrimazole, econazole nitrate,

ketoconazole, naftiﬁne hcl, oxiconazole nitrate

FABIOR, TAZORAC GEL tazarotene, tretinoin

HALOBETASOL 0.05% FOAM, IMPEKLO,

IMPOYZ 0.025% CREAM, LEXETTE 0.05%

FOAM, ULTRAVATE 0.05% LOTION

betamethasone, clobetasol, desoximetasone,

diﬂorasone, ﬂuocinonide, halobetasol

propionate

KERYDIN tavaborole

LOCOID, LOCOID LIPOCREAM hydrocortisone

NORITATE 1% CREAM metronidazole

OPZELURA 1.5% CREAM pimecrolimus, tacrolimus, betamethasone

dipropionate, ﬂuocinonide, halcinonide,

triamcinolone

QBREXZA 2.4% CLOTH certain, BROMI-LOTION

RETINA MICRO 0.6% & 0.8% tretinoin microsphere 0.04% & 0.1%

SERNIVO 0.05% SPRAY betamethasone, betamethasone,

desoximetasone, ﬂuocinolone, ﬂuocinonide,

triamcinolone

TAZAROTENE 0.1% FOAM, TAZORAC 0.05%

CREAM,

tazarotene 0.1% cream

TAZORAC 0.05%. 1% GEL: tazarotene 0.1% cream, tretinoin

TOPICORT desoximetasone

TRILUMA ﬂuocinolone, hydroquinone, tretinoin

ULTRAVATE 0.05% CREAM, OINTMENT halobetasol propionate

VANOS ﬂuocinonide

VELTIN clindamycin-benzoyl peroxide, clindamycin-

tretinoin, erythromycin- benzoyl peroxide,

tretinoin, ONEXTON

VERDESO desonide

VEREGEN 15% OINTMENT imiquimod, podoﬁlox

WINLEVI clindamycin topical, clindamycin-tretionin,

erythromycin topical, tretinoin, ONEXTON

XERESE 5%1% CREAM acyclovir (cream), acyclovir (oral), famciclovir,

valacyclovir

ZILXI azelaic acid, metronidazole, ROSULA, FINACEA

ZOVIRAX acyclovir

^^

This medication isn’t covered on this drug list. If your doctor feels a diﬀerent medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the non-covered medication. If you

don’t get approval and you continue to ﬁll a prescription for a medication that isn’t covered, you’ll pay its full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t

be applied to your annual deductible or out-of-pocket maximum.

DRUG CLASS

MEDICATION NAME

^^

(Not covered)

GENERIC AND/OR PREFERRED

BRAND ALTERNATIVE(S)

SKIN CONDITIONS (cont) ZYCLARA imiquimod 5% cream

SLEEP DISORDERS/SEDATIVES AMBIEN zolpidem

AMBIEN CR zolpidem er

DORAL, QUAZEPAM estazolam, lorazepam

LUNESTA eszopiclone

NUVIGIL armodaﬁnil

PROVIGIL modaﬁnil

ROZEREM ramelteon

SUBSTANCE ABUSE BUNAVAIL buprenorphine/naloxone, ZUBSOLV

LUCEMYRA clonidine

SUBOXONE buprenorphine-naloxone

ZIMHI 5 MG/0.5 ML SYRINGE naloxone syringe (generic)

TRANSPLANT MEDICATIONS ENVARSUS XR tacrolimus

LUPKYNIS mycophenolate, prednisone

URINARY TRACT CONDITIONS DETROL LA tolterodine er

PROCYSBI CYSTAGON

RAPAFLO silodosin

UROXATRAL alfuzosin er

VESICARE solifenacin

VESICARE LS oxybutynin, oxbutynin er

^^

This medication isn’t covered on this drug list. If your doctor feels a diﬀerent medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the non-covered medication. If you

don’t get approval and you continue to ﬁll a prescription for a medication that isn’t covered, you’ll pay its full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t

be applied to your annual deductible or out-of-pocket maximum.

19

1. State laws in Connecticut, Texas and Louisiana may require your plan to cover your medication at your current beneﬁt level until your plan renews. This means that if your medication is taken

oﬀ the drug list, is moved to a higher cost-share tier or needs approval from Cigna before your plan will cover it, these changes may not begin until your plan’s renewal date. To ﬁnd out if these

state laws apply to your plan, please call Customer Service using the number on your Cigna ID card.

2. State law in Illinois may require your plan to cover your medications at your current beneﬁt level until your plan renews. This means that if you currently have approval through a review process

for your plan to cover your medication, the drug list change(s) listed here may not aﬀect you until your plan renewal date. If you don’t currently have approval through a coverage review process,

you may continue to receive coverage at your current beneﬁt level if your doctor requests it. To ﬁnd out if this state law applies to your plan, please call Customer Service using the number on

your Cigna ID card.

3. U.S. Food and Drug Administration (FDA) website, “Generic Drugs: Questions and Answers.” Last updated 03/16/21. https://www.fda.gov/drugs/questions-answers/generic-drugs-questions-

answers.

Product availability may vary by location and plan type and is subject to change. All group health insurance policies and health beneﬁt plans contain exclusions and limitations. For costs and details

of coverage, review your plan documents or contact a Cigna representative.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company (CHLIC), Accredo Health Group,

Inc., Express Scripts, Inc., ESI Mail Pharmacy Service, Inc, Express Scripts Pharmacy, Inc., and HMO or service company subsidiaries of Cigna Health Corporation, including Cigna HealthCare of Arizona,

Inc., Cigna HealthCare of California, Inc., Cigna HealthCare of Colorado, Inc., Cigna HealthCare of Connecticut, Inc., Cigna HealthCare of Florida, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare

of Illinois, Inc., Cigna HealthCare of Indiana, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of New Jersey, Inc., Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of Tennessee,

Inc., (CHC-TN), and Cigna HealthCare of Texas, Inc. “Accredo” refers to Accredo Health Group, Inc. “Express Scripts Pharmacy” refers to ESI Mail Pharmacy, Inc. Policy forms: OK - HP-APP-1 et al., OR - HP-

POL38 02-13, TN - HP-POL43/HC-CER1V1 et al. (CHLIC); GSA-COVER, et al. (CHC-TN). The Cigna name, logo, “Together all the way.,” and “myCigna” are trademarks of Cigna Intellectual Property, Inc.

“Accredo” and “Express Scripts Pharmacy” are trademarks of Express Scripts Strategic Development, Inc.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna

Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company,

Evernorth Care Solutions, Inc., Evernorth Behavioral Health, Inc., Cigna Health Management, Inc., and HMO or

service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. The Cigna name, logos,

and other Cigna marks are owned by Cigna Intellectual Property, Inc. ATTENTION: If you speak languages other

than English, language assistance services, free of charge are available to you. For current Cigna customers,

call the number on the back of your ID card. Otherwise, call 1.800.244.6224 (TTY:Dial 711). ATENCIÓN: Si usted

habla un idioma que no sea inglés, tiene a su disposición servicios gratuitos de asistencia lingüística. Si es un

cliente actual de Cigna, llame al número que ﬁgura en el reverso de su tarjeta de identiﬁcación. Si no lo es, llame

al 1.800.244.6224 (losusuarios de TTY deben llamar al 711).

Cigna complies with applicable Federal civil rights laws and does not discriminate on the basis of race,

color, national origin, age, disability, or sex. Cigna does not exclude people or treat them differently

because of race, color, national origin, age, disability, or sex.

Cigna:

• Provides free aids and services to people with disabilities to communicate eectively with us,

suchas:

– Qualiﬁed sign language interpreters

– Written information in other formats (large print, audio, accessible electronic formats,

otherformats)

• Provides free language services to people whose primary language is not English, such as:

– Qualiﬁed interpreters

– Information written in other languages

If you need these services, contact customer service at the toll-free number shown on your IDcard, and

ask a Customer Service Associate for assistance.

If you believe that Cigna has failed to provide these services or discriminated in another way on the

basis of race, color, national origin, age, disability, or sex, you can file a grievance by sending an email

toACAGriev[email protected]om or by writing to the following address:

Cigna

Nondiscrimination Complaint Coordinator

PO Box 188016

Chattanooga, TN 37422

If you need assistance filing a written grievance, please call the number on the back of your ID card

or send an email to ACAGriev[email protected]om. You can also file a civil rights complaint with the

U.S.Department of Health and Human Services, Office for Civil Rights electronically through the

Officefor Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf,

or by mail orphone at:

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Room 509F, HHH Building

Washington, DC 20201

1.800.368.1019, 800.537.7697 (TDD)

Complaint forms are available at

http://www.hhs.gov/ocr/oce/ﬁle/index.html.

DISCRIMINATION IS AGAINST THE LAW

Medical coverage

Proﬁciency of Language Assistance Services

English – ATTENTION: Language assistance services, free of charge, are available to you. For current Cigna

customers, call the number on the back of your ID card. Otherwise, call 1.800.244.6224 (TTY: Dial 711).

Spanish – ATENCIÓN: Hay servicios de asistencia de idiomas, sin cargo, a su disposición. Si es un cliente

actual de Cigna, llame al número que figura en el reverso de su tarjeta de identificación. Si no lo es, llame

al 1.800.244.6224 (los usuarios de TTY deben llamar al 711).

Chinese – 注意：我們可為您免費提供語言協助服務。對於 Cigna 的現有客戶，請致電您的 ID 卡背面的號碼。其

他客戶請致電 1.800.244.6224 （聽障專線：請撥 711）。

Vietnamese



Korean – 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 현재 Cigna

가입자님들께서는 ID 카드 뒷면에 있는 전화번호로 연락해주십시오. 기타 다른 경우에는 1.800.244.6224

(TTY: 다이얼 711)번으로 전화해주십시오.

Tagalog – PAUNAWA: Makakakuha ka ng mga serbisyo sa tulong sa wika nang libre. Para sa mga

kasalukuyang customer ng Cigna, tawagan ang numero sa likuran ng iyong ID card. O kaya, tumawag sa

1.800.244.6224 (TTY: I-dial ang 711).

Russian









Cigna – Arabic

711

:TTY) 1.800.244.6224

French Creole – ATANSYON: Gen sèvis èd nan lang ki disponib gratis pou ou. Pou kliyan Cigna yo, rele

nimewo ki dèyè kat ID ou. Sinon, rele nimewo 1.800.244.6224 (TTY: Rele 711).

French – ATTENTION: Des services d’aide linguistique vous sont proposés gratuitement. Si vous êtes un

client actuel de Cigna, veuillez appeler le numéro indiqué au verso de votre carte d’identité. Sinon, veuillez

appeler le numéro 1.800.244.6224 (ATS: composez le numéro 711).

Portuguese – ATENÇÃO: Tem ao seu dispor serviços de assistência linguística, totalmente gratuitos. Para

clientes Cigna atuais, ligue para o número que se encontra no verso do seu cartão de identificação. Caso

contrário, ligue para 1.800.244.6224 (Dispositivos TTY: marque 711).

Polish – UWAGA: w celu skorzystania z dostępnej, bezpłatnej pomocy językowej, obecni klienci firmy

Cigna mogą dzwonić pod numer podany na odwrocie karty identyfikacyjnej. Wszystkie inne osoby

prosimy o skorzystanie z numeru 1 800 244 6224 (TTY: wybierz 711).

Japanese – 注意事項：日本語を話される場合、無料の言語支援サービスをご利用いただけます。現在のCignaの

お客様は、IDカード裏面の電話番号まで、お電話にてご連絡ください。その他の方は、1.800.244.6224（TTY: 711）

まで、お電話にてご連絡ください。

Italian – ATTENZIONE: Sono disponibili servizi di assistenza linguistica gratuiti. Per i clienti Cigna attuali,

chiamare il numero sul retro della tessera di identificazione. In caso contrario, chiamare il numero

1.800.244.6224 (utenti TTY: chiamare il numero 711).

German – ACHTUNG: Die Leistungen der Sprachunterstützung stehen Ihnen kostenlos zur Verfügung.

Wenn Sie gegenwärtiger Cigna-Kunde sind, rufen Sie bitte die Nummer auf der Rückseite Ihrer

Krankenversicherungskarte an. Andernfalls rufen Sie 1.800.244.6224 an (TTY: Wählen Sie 711).





Cigna– Persian (Farsi)

7111.800.244.6224



896375b 05/21