PRESCRIPTION DRUG LIST CHANGES - Cigna

PRESCRIPTION DRUG LIST CHANGES

Cigna Pharmacy Management?

2021

To help make sure you have access to coverage for safe, clinically effective and low-cost medications, we regularly review and update the Cigna Prescription Drug List. You can see a list of these changes below. Changes are listed by drug list name, the date the change starts and by the type of change that's taking place. Medications are then listed alphabetically by drug class.

If you have Cigna-administered pharmacy benefits and you're affected by one of these changes, we'll send you a letter with specific information on next steps.

STANDARD PRESCRIPTION DRUG LIST

Start date of change*,**

Drug class

Medications moving to preferred brand

June 22, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Reditrex

May 15, 2021 EYE CONDITIONS

Eysuvis

GASTROINTESTINAL/HEARTBURN

Sutab

January 1, 2021 AIDS/HIV

Juluca

ASTHMA/COPD/RESPIRATORY

Bevespi

DIABETES

Baqsimi

GASTROINTESTINAL/HEARTBURN

Pancreaze

INFECTIONS

Epclusa, Harvoni

PAIN RELIEF AND INFLAMMATORY DISEASE Taltz

Start date of change*,** Drug class

June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS

Medications becoming non-preferred brand

Orladeyo1

Generic and/or preferred brand alternatives

Lupron Depot

June 22, 2021 CANCER

Orgovyx1

No preferred formulary drug alternatives.

June 15, 2021 GASTROINTESTINAL/HEARTBURN

Lubiprostone 8 mcg, 24 mcg capsule

Amitiza

June 1, 2021 SKIN CONDITIONS

Winlevi 1% cream Wynzora 0.005%-0.064% cream

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

Generic products (e.g. adapalene; tretinoin; clindamycin-benzoyl peroxide)

betamethasone DP, fluocinolone, fluticasone, mometasone, trimacinolone, calcipotriene, calcipotriene-betamethasone DP

951712UPDATED_05/21/2021

STANDARD PRESCRIPTION DRUG LIST (cont)

Start date of change*,**

Drug class

June 1, 2021 URINARY TRACT CONDITIONS

May 15, 2021 May 2, 2021 May 1, 2021

EYE CONDITIONS PAIN RELIEF AND INFLAMMATORY DISEASE SKIN PREPS

April 18, 2021 HORMONAL AGENTS March 28, 2021 BLOOD PRESSURE/HEART MEDICATIONS

January 1, 2021

AIDS/HIV BLOOD MODIFIERS/BLEEDING DISORDERS BLOOD PRESSURE/HEART MEDICATIONS CANCER ERECTILE DYSFUNCTION EYE CONDITIONS HORMONAL AGENTS INFECTIONS SEIZURE DISORDERS SUBSTANCE ABUSE

WEIGHT MANAGEMENT

Start date of change*,** Drug class

June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS

June 22, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE

June 1, 2021 ASTHMA/COPD/RESPIRATORY

March 14, 2021 CANCER

January 1, 2021 BLOOD THINNERS/ANTI-CLOTTING

PAIN RELIEF AND INFLAMMATORY DISEASE

Start date of change*,**

Drug class

June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS

June 1, 2021 ASTHMA/COPD/RESPIRATORY

May 15, 2021 EYE CONDITIONS

May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE

Medications becoming non-preferred brand

Vesicare LS 5 mg/5 mL suspension

Lacrisert Qdolo Impeklo

Alkindi Sprinkle Conjupri

Intelence1 Amicar 0.25 g/ml oral solution1 Multaq, Norpace CR 150mg Tabloid Caverject Impulse Syringe Lotemax 0.5% drops Armour Thyroid, Synthroid, Unithroid Kitabis Pak1 Lyrica 20mg/ml oral solution Bunavail

Megace ES 625mg/5ml oral suspension

Generic and/or preferred brand alternatives

oxybutynin chloride, oxybutynin chloride ER, darifenacin ER, solifenacin, tolterodine, tolterodine ER, tropsium Restasis, Restasis Multi-dose, Xiidra

tramadol

topical betamethasone dipropionate (augmented) 0.05%, clobetasol propionate 0.05%, halobetasol propionate 0.05%, fluocinolide 0.1%

hydrocortisone 5mg tablet

amlodipine, felodipine, nifedipine, nicardipine

Talk to your doctor about other alternatives

aminocaproic acid 0.25g/ml oral solution

Talk to your doctor about other alternatives

Talk to your doctor about other alternatives

MUSE

loteprednol 0.5% drops levothyroxine

tobramycin pak 300mg/5ml

pregabalin 20mg/ml oral solution

buprenorphine/naloxone film or sublingual tablet, Zubsolv

megestrol 625ml/5ml oral suspension

Medications that will need approval (prior authorization)^

Orladeyo1 Reditrex Zokinvy Gavreto Eliquis4, Pradaxa4, Savaysa4, Xarelto4 diclofenac 1.3% patch, Flector 1.3% patch5, Voltaren 1% gel5

Medications that will have a quantity limit

Orladeyo1 Zokinvy Eysuvis Qdolo

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

STANDARD PRESCRIPTION DRUG LIST (cont)

Start date of change*,**

Drug class

March 14, 2021 CANCER

Start date of change*,**

Drug class

June 29, 2021 SKIN CONDITIONS

June 22, 2021 GASTROINTESTINAL/HEARTBURN

Medications that will have a quantity limit

Gavreto

Medications that will no longer Generic and/or preferred

be covered^^

brand alternatives

Klisyri

topical fluorouracil, imiquimod 5% cream

Reltone

ursodiol

HORMONAL AGENTS

June 15, 2021 June 1, 2021

GASTROINTESTINAL/HEARTBURN SKIN CONDITIONS

June 1, 2021 SKIN CONDITIONS (cont)

Thyquidity

Lubiprostone 8 mcg, 24 mcg capsule Winlevi 1% cream Wynzora 0.005%-0.064% cream

URINARY TRACT CONDITIONS

Vesicare LS 5 mg/5 mL suspension

May 2, 2021 May 1, 2021

PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo

SKIN PREPS

Impeklo

April 18, 2021 HORMONAL AGENTS March 28, 2021 BLOOD PRESSURE/HEART MEDICATIONS

Alkindi Sprinkle Conjupri

January 1, 2021 ASTHMA/COPD/RESPIRATORY DIABETES EYE CONDITIONS GASTROINTESTINAL/HEARTBURN

HORMONAL AGENTS INFECTIONS

MULTIPLE SCLEROSIS NUTRITIONAL/DIETARY PAIN RELIEF AND INFLAMMATORY DISEASE

ProAir HFA7, ProAir RespiClick7, Ventolin HFA7 Kombiglyze XR8, Onglyza8 Lumigan7, Travatan Z, Xalatan, Xelpros, Zioptan9 Creon7, Pertzye, Zenpep7 Motegrity, Trulance7, Zelnorm Sensipar TaperDex Baraclude Noxafil tablet Ampyra ER7 PreGenna, Trinaz Amerge

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

levothyroxine, levoxyl, Levo-T, Unithroid, Euthyrox

Amitiza

Generic products (e.g. adapalene; tretinoin; clindamycin-benzoyl peroxide) betamethasone DP, fluocinolone, fluticasone, mometasone, trimacinolone, calcipotriene, calcipotriene-betamethasone DP oxybutynin chloride, oxybutynin chloride ER, darifenacin ER, solifenacin, tolterodine, tolterodine ER, tropsium tramadol topical betamethasone dipropionate (augmented) 0.05%, clobetasol propionate 0.05%, halobetasol propionate 0.05%, fluocinolide 0.1% hydrocortisone 5mg tablet amlodipine, felodipine, nifedipine, nicardipine albuterol HFA

metformin, Janumet, Janumet XR, Januvia bimatoprost, latanoprost, travoprost

Pancreaze Amitiza, Linzess cinacalcet dexamethasone 1.5mg tablet entecavir tablet posaconazole DR 100mg tablet dalfampridine ER Any generic prenatal vitamin generic triptans (e.g. naratriptan; sumatriptan)

SSTtaArtNdDatAe RofD

change*,**

PRESCRIPTION

Drug class

DRUG

LISTM(ecdoicnatti)ons that

be covered^^

will

no

longer

Generic and/or preferred brand alternatives

January 1, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE butalbital-acetaminophen 50-300mg tablet butalbutal-acetaminophen 50-325mg tablet

Cosentyx10

Enbrel, Humira, Otezla, Skyrizi, Stelara, Taltz

Frova, Maxalt, Maxalt MLT, Relpax

generic triptans (e.g. naratriptan; sumatriptan)

SEIZURE DISORDERS

Felbatol11

felbamate

Keppra/Keppra XR11

levetiracetam/levetiracetam ER

Lamictal XR Start Kit11

lamotrigine ER

Lamictal/ODT/XR11 Qudexy XR11, Trokendi XR11

lamotrigine, lamotrigine ER, lamotrigine ODT topiramate ER

Sabril11

vigabatrin, vigadrone

Topamax11

topiramate

Trileptal11

oxcarbazepine

SKIN CONDITIONS

Zonegran11

Apexicon E5, diflorasone, Impoyz5, Olux5, Olux-E5, psorcon

zonisamide betamethasone, clobetasol, halobetasol

Condylox

imiquimod 5% cream packet, podofilox 0.5% topical solution

Cordran5

betamethasone, clobetasol, fluocinolone, fluticasone, halobetasol

Finacea Foam7, Finacea Gel, MetroCream, azelaic acid, topical metronidazole MetroGel, MetroLotion, Soolantra12

flurandrenolide, hydrocortisone butyrate betamethasone, fluocinolone, fluticasone lipid cream, lotion5, Pandel5

Sorilux

calcitriol, tazarotene, topical calcipotriene

Tridesilon5

alclometasone, desonide, triamcinolone

SLEEP DISORDERS/SEDATIVES URINARY TRACT CONDITIONS

Xolegel

Belsomra8 Procysbi4

ciclopirox 0.77% gel, ciclopirox 1% shampoo, ketoconazole 2% cream, ketoconazole 2% foam, selenium 2.5% lotion, sodium sulfacetamide 10% shampoo

Dayvigo

Cystagon

Start date of change*,**

Drug class

January 1, 2021 SKIN CONDITIONS

Medications that will be excluded from coverage

Rosadan Kits

Additional information

azelaic acid, topical metronidazole

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

VALUE PRESCRIPTION DRUG LIST

Start date of change*,**

Drug class

June 22, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE

May 15, 2021 EYE CONDITIONS

GASTROINTESTINAL/HEARTBURN

January 1, 2021 AIDS/HIV

DIABETES

GASTROINTESTINAL/HEARTBURN

INFECTIONS

PAIN RELIEF AND INFLAMMATORY DISEASE

SEIZURE DISORDERS

URINARY TRACT CONDITIONS

Start date of change*,**

Drug class

June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS

June 22, 2021 CANCER

June 15, 2021 GASTROINTESTINAL/HEARTBURN

June 1, 2021 SKIN CONDITIONS

URINARY TRACT CONDITIONS

May 2, 2021 May 1, 2021

PAIN RELIEF AND INFLAMMATORY DISEASE SKIN PREPS

April 18, 2021 HORMONAL AGENTS March 28, 2021 BLOOD PRESSURE/HEART MEDICATIONS

January 1, 2021

AIDS/HIV ERECTILE DYSFUNCTION HORMONAL AGENTS INFECTIONS SEIZURE DISORDERS SUBSTANCE ABUSE

WEIGHT MANAGEMENT

Medications moving to preferred brand

Reditrex Eysuvis Sutab Juluca Baqsimi Pancreaze Epclusa, Harvoni Ajovy13, Emgality13, Taltz Vimpat Cystagon

Medications becoming non-preferred brand

Orladeyo1 Orgovyx1 Lubiprostone 8 mcg, 24 mcg capsule Winlevi 1% cream

Wynzora 0.005%-0.064% cream

Vesicare LS 5 mg/5 mL suspension

Qdolo Impeklo

Alkindi Sprinkle Conjupri

Intelence1 Caverject Impulse Syringe Unithroid 75mcg tablet Kitabis Pak1 Lyrica 20mg/ml oral solution Bunavail

Megace ES 625mg/5ml oral suspension

Generic and/or preferred brand alternatives

No preferred formulary drug alternatives

Lupron Depot

Amitiza

Generic products (e.g. adapalene; tretinoin; clindamycin-benzoyl peroxide) betamethasone DP, fluocinolone, fluticasone, mometasone, trimacinolone, calcipotriene, calcipotriene-betamethasone DP oxybutynin chloride, oxybutynin chloride ER, darifenacin ER, solifenacin, tolterodine, tolterodine ER, tropsium tramadol

topical betamethasone dipropionate (augmented) 0.05%, clobetasol propionate 0.05%, halobetasol propionate 0.05%, fluocinolide 0.1% hydrocortisone 5mg tablet

amlodipine, felodipine, nifedipine, nicardipine Talk to your doctor about other alternatives MUSE

levothyroxine tobramycin pak 300mg/5ml

pregabalin 20mg/ml oral solution

buprenorphine/naloxone film or sublingual tablet, Zubsolv megestrol 625ml/5ml oral suspension

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

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