PRESCRIPTION DRUG LIST CHANGES

PRESCRIPTION DRUG LIST CHANGES

Cigna Pharmacy Management?

2018

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

If you're enrolled with Cigna, you can log into to find out how these changes may affect your specific plan.

STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST

Start date of change*

Drug class

January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER

ASTHMA/COPD/RESPIRATORY

ATTENTION DEFICIT HYPERACTIVITY DISORDER

Medication not covered^

Anafranil Pamelor Parnate Tofranil Zyflo Zyflo CR Desoxyn Dexedrine

BLOOD PRESSURE/HEART MEDICATIONS CANCER DIABETES

GASTROINTESTINAL/HEARTBURN

Betapace Nilandron Invokamet, Invokamet XR Invokana Lantus, Lantus SoloStar, Toujeo SoloStar Novolin, Novolog Cortifoam, Uceris rectal foam

Lotronex Marinol omeprazole bicarbonate packets, 40-1100mg capsules Rowasa Uceris tablet

Generic and/or preferred brand alternatives

clomipramine nortriptyline tranylcypromine imipramine montelukast, zafirlukast, zileuton ER zileuton ER methamphetamine dextroamphetamine, dextroamphetamine ER sotalol tablets nilutamide Synjardy, Synjardy XR, Xigduo XR Farxiga, Jardiance Basaglar, Levemir, Tresiba Humalog, Humulin Anucort-HC, Colocort, Hemmorex-HC, hydrocortisone, Procto-Med HC, ProctoPak, Proctosol-HC, Proctozone-HC alosetron dronabinol omeprazole

mesalamine enema budesonide EC capsule

909015UPDATED_10/17/2017

STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont)

Start date of change*

Drug class

January 1, 2018 GASTROINTESTINAL/HEARTBURN (cont)

HORMONAL AGENTS INFECTIONS

MISCELLANEOUS PAIN RELIEF AND INFLAMMATORY DISEASE

PARKINSON'S DISEASE SCHIZOPHRENIA/ANTI-PSYCHOTICS

Medication not covered^

Zegerid Zofran Zofran ODT DDAVP Hectorol Augmentin, Augmentin ES, Augmentin XR

Diflucan E.E.S. 200, Eryped 400 Mepron Sporanox Targadox

Valcyte Vancocin Zovirax Gralise, Horizant Cambia

D.H.E. 45, Migranal Imitrex, Sumavel DosePro Lorzone OxyContin Roxicodone Tivorbex Vanatol LQ

Vivlodex Zomig Zorvolex Lodosyn Requip XL Geodon Zyprexa Zyprexa Zydis

Generic and/or preferred brand alternatives

omeprazole ondansetron ondansetron ODT desmopressin doxercalciferol capsule amoxicillin-clavulanate ER, amoxicillinclavulanate fluconazole erythromycin ethylsuccinate atovaquone itraconazole

Avidoxy tablet, doxycycline hyclate, Morgidox capsule valganciclovir

vancomycin capsule

acyclovir

gabapentin

diclofenac, diclofenac ER, etodolac, etodolac ER, fenoprofen, Fenortho, flurbiprofen, ibuprofen, indomethacin, indomethacin ER, ketoprofen, Ketorolac, meclofenamate, mefenamic acid, meloxicam, nabumetone dihydroergotamine

sumatriptan

chlorzoxazone

Embeda, Hysingla ER, Xtampza ER

oxycodone

indomethacin

butalbital/acetaminophen/caffeine tabs or caps meloxicam

sumatriptan, zolmitriptan

diclofenac, diclofenac ER

carbidopa

ropinirole ER

ziprasidone

olanzapine

olanzapine ODT

STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont)

Start date of change*

Drug class

January 1, 2018 SKIN CONDITIONS

SLEEP DISORDERS/SEDATIVES URINARY TRACT CONDITIONS

Start date of change*

January 1, 2018

Drug class

ALLERGY/NASAL SPRAYS ATTENTION DEFICIT HYPERACTIVITY DISORDER

SKIN CONDITIONS

Start date of change*

Drug class

January 1, 2018 GASTROINTESTINAL/HEARTBURN

HORMONAL AGENTS

Medication not covered^

Generic and/or preferred brand alternatives

Cutivate

fluticasone cream

Kenalog

triamcinolone spray

Locoid lotion

hydrocortisone butyrate

Luzu

ketoconazole cream

Soriatane

acitretin

Ziana

clindamycin-tretinoin

Nuvigil

armodafinil

Provigil

modafinil

Restoril

temazepam

Detrol

tolterodine

Detrol LA

tolterodine ER

Ditropan XL

oxybutynin ER

Enablex

darifenacin ER

Gelnique

darifenacin ER, oxybutynin ER, tolterodine ER, trospium ER

Non-preferred brand medication

Generic and/or preferred brand alternatives

Astepro

azelastine nasal spray

Adderall XR

dextroamphetamine-amphetamine ER

Focalin XR

dexmethylphenidate ER

Ala-Scalp

hydrocortisone

Analpram HC lotion

hydrocortisone-pramoxine

Capex shampoo

fluocinolone

Cordran

flurandrenolide

Differin

adapalene

Metrogel

metronidazole gel

Naftin

naftifine

Nucort, Texacort

hydrocortisone

Medication requiring prior authorization

Additional information

Akynzeo, Anzemet, Emend,

Your plan will only cover this medication if

Sancuso, Varubi

your doctor requests and receives approval

Androderm, Androgel, Striant, testosterone from Cigna.

Start date of change*

January 1, 2018

Drug class

ALLERGY/NASAL SPRAYS ALZHEIMER'S DISEASE ANXIETY/DEPRESSION/BIPOLAR DISORDER

ASTHMA/COPD/RESPIRATORY BLOOD PRESSURE/HEART MEDICATIONS CANCER EYE CONDITIONS

Medication with quantity limits Additional information

cromolyn oral, mometasone Namenda XR, Namzaric desvenlafaxine 25mg, 100mg, Marplan, Pristiq Perforomist Ranexa Fareston, nilutamide bimatoprost eye drops, Cystaran, Zioptan

Your plan only covers a certain amount of this medication over a certain number of days. Your plan will only cover a larger amount if your doctor requests and receives approval from Cigna.

STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont)

Start date of change*

January 1, 2018

Start date of change*

January 1, 2018

Drug class

HORMONAL AGENTS

MISCELLANEOUS OSTEOPOROSIS PRODUCTS PAIN RELIEF AND INFLAMMATORY DISEASE SCHIZOPHRENIA/ ANTI-PSYCHOTICS SEIZURE DISORDERS SKIN CONDITIONS SLEEP DISORDERS/SEDATIVES

Drug class

ATTENTION DEFICIT HYPERACTIVITY DISORDER SCHIZOPHRENIA/ANTI-PSYCHOTICS SKIN CONDITIONS

Medication with quantity limits Additional information

Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem Nuedexta alendronate Daliresp, Mitigare Fanapt

Your plan only covers a certain amount of this medication over a certain number of days. Your plan will only cover a larger amount if your doctor requests and receives approval from Cigna.

Gabitril, Potiga Denavir, Regranex, Santyl, Vectical Hetlioz

Step Therapy medication^^

Focalin XR

Generic and/or preferred brand alternatives

dexmethylphenidate ER

Orap Ala-Scalp Capex shampoo Cordran Nucort, Texacort

pimozide hydrocortisone fluocinolone flurandrenolide hydrocortisone

Start date of change*

Drug class

January 1, 2018 ALLERGY/NASAL SPRAYS

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

desloratadine ODT 2.5mg

Covered medication strength (Prescription must be for 1 capsule/tablet per day of this strength)

desloratadine ODT 5mg

ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg

Fetzima ER 40mg

Fetzima ER 40mg

Fetzima ER 80mg

Trintellix 5mg

Trintellix 10mg

Trintellix 10mg

Trintellix 20mg

BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg

Azor 10-40mg

Benicar 20mg

Benicar 40mg

Benicar HCT 20-12.5mg

Benicar HCT 40-25mg

Bystolic 10mg

Bystolic 20mg

Tekturna 150mg

Tekturna 300mg

Tekturna HCT 150-12.5mg

Tekturna HCT 300-25mg

CHOLESTEROL MEDICATIONS

Livalo 1mg

Livalo 2mg

Livalo 2mg

Livalo 4mg

DIABETES

Farxiga 5mg

Farxiga 10mg

PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg

Uloric 80mg

SCHIZOPHRENIA/ANTI-PSYCHOTICS

Latuda 60mg

Latuda 120mg

STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont)

Start date of change*

Drug class

January 1, 2018 SEIZURE DISORDERS

SLEEP DISORDERS/SEDATIVES

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

Aptiom 200mg Aptiom 400mg Fycompa 4mg Fycompa 6mg Trokendi XR 25mg Trokendi XR 100mg Silenor 3mg

Covered medication strength (Prescription must be for 1 capsule/tablet per day of this strength)

Aptiom 400mg Aptiom 800mg Fycompa 8mg Fycompa 12mg Trokendi XR 50mg Trokendi XR 200mg Silenor 6mg

PERFORMANCE PRESCRIPTION DRUG LIST

Start date of change*

January 1, 2018

Start date of change*

January 1, 2018

Start date of change*

January 1, 2018

Drug class

ALLERGY/NASAL SPRAYS ATTENTION DEFICIT HYPERACTIVITY DISORDER DIABETES GASTROINTESTINAL/HEARTBURN INFECTIONS PAIN RELIEF AND INFLAMMATORY DISEASE

SKIN CONDITIONS

Drug class

DIABETES GASTROINTESTINAL/HEARTBURN HORMONAL AGENTS

PAIN RELIEF AND INFLAMMATORY DISEASE

Drug class

ALLERGY/NASAL SPRAYS ALZHEIMER'S DISEASE ANXIETY/DEPRESSION/BIPOLAR DISORDER ASTHMA/COPD/RESPIRATORY

Non-preferred brand medication

Astepro Adderall XR Lantus, Lantus SoloStar, Toujeo SoloStar omeprazole bicarbonate packet, 40mg-1100mg capsule, 20mg-1100mg Eryped 400 OxyContin Vanatol LQ

Ala-Scalp Capex shampoo Cordran Differin Kenalog spray Locoid lotion Metrogel Naftin Nucort, Texacort

Medication requiring prior authorization

Lantus, Lantus SoloStar, Toujeo SoloStar Akynzeo, Anzemet, Emend, Sancuso, Varubi Androderm, Androgel, Axiron, Fortesta, Natesto, Striant, Testim, Testopel, testosterone, Vogelxo Roxicodone

Generic and/or preferred brand alternatives

azelastine nasal spray dextroamphetamine-amphetamine ER Basaglar, Tresiba, Levemir omeprazole

erythromycin Embeda, Hysingla ER, Xtampza ER butalbital/acetaminophen/caffeine tabs or caps hydrocortisone topical fluocinolone scalp flurandrenolide topical adapalene triamcinolone spray hydrocortisone butyrate metronidazole gel naftifine hydrocortisone

Additional information

Your plan will only cover this medication if your doctor requests and receives approval from Cigna.

Medication with quantity limits Additional information

cromolyn oral, mometasone, Nasonex Namenda XR, Namzaric desvenlafaxine 25mg, 100mg, Marplan, Pristiq Perforomist

Your plan only covers a certain amount of this medication over a certain number of days. Your plan will only cover a larger amount if your doctor requests and receives approval from Cigna.

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