prescription drug list changes - cigna · 2021. 1. 25. · fluticasone, halobetasol. start date of...
TRANSCRIPT
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
951712 UPDATED_05/21/2021
PRESCRIPTION DRUG LIST CHANGESCigna 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 classMedications becoming non-preferred brand
Generic and/or preferred brand alternatives
June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1 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 Generic products (e.g. adapalene; tretinoin; clindamycin-benzoyl peroxide)
Wynzora 0.005%-0.064% cream betamethasone DP, fluocinolone, fluticasone, mometasone, trimacinolone, calcipotriene, calcipotriene-betamethasone DP
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 classMedications becoming non-preferred brand
Generic and/or preferred brand alternatives
June 1, 2021 URINARY TRACT CONDITIONS Vesicare LS 5 mg/5 mL suspension oxybutynin chloride, oxybutynin chloride ER, darifenacin ER, solifenacin, tolterodine, tolterodine ER, tropsium
May 15, 2021 EYE CONDITIONS Lacrisert Restasis, Restasis Multi-dose, Xiidra
May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo tramadol
May 1, 2021 SKIN PREPS Impeklo topical betamethasone dipropionate (augmented) 0.05%, clobetasol propionate 0.05%, halobetasol propionate 0.05%, fluocinolide 0.1%
April 18, 2021 HORMONAL AGENTS Alkindi Sprinkle hydrocortisone 5mg tablet
March 28, 2021 BLOOD PRESSURE/HEART MEDICATIONS Conjupri amlodipine, felodipine, nifedipine, nicardipine
January 1, 2021 AIDS/HIV Intelence1 Talk to your doctor about other alternatives
BLOOD MODIFIERS/BLEEDING DISORDERS Amicar 0.25 g/ml oral solution1 aminocaproic acid 0.25g/ml oral solution
BLOOD PRESSURE/HEART MEDICATIONS Multaq, Norpace CR 150mg Talk to your doctor about other alternatives
CANCER Tabloid Talk to your doctor about other alternatives
ERECTILE DYSFUNCTION Caverject Impulse Syringe MUSE
EYE CONDITIONS Lotemax 0.5% drops loteprednol 0.5% drops
HORMONAL AGENTS Armour Thyroid, Synthroid, Unithroid levothyroxine
INFECTIONS Kitabis Pak1 tobramycin pak 300mg/5ml
SEIZURE DISORDERS Lyrica 20mg/ml oral solution pregabalin 20mg/ml oral solution
SUBSTANCE ABUSE Bunavail buprenorphine/naloxone film or sublingual tablet, Zubsolv
WEIGHT MANAGEMENT Megace ES 625mg/5ml oral suspension megestrol 625ml/5ml oral suspensionStart date of change*,**
Drug class Medications that will need approval (prior authorization)^
June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1
June 22, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Reditrex
June 1, 2021 ASTHMA/COPD/RESPIRATORY Zokinvy
March 14, 2021 CANCER Gavreto
January 1, 2021 BLOOD THINNERS/ANTI-CLOTTING Eliquis4, Pradaxa4, Savaysa4, Xarelto4
PAIN RELIEF AND INFLAMMATORY DISEASE diclofenac 1.3% patch, Flector 1.3% patch5, Voltaren 1% gel5
Start date of change*,**
Drug class Medications that will have a quantity limit
June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1
June 1, 2021 ASTHMA/COPD/RESPIRATORY Zokinvy
May 15, 2021 EYE CONDITIONS Eysuvis
May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE 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 Medications that will have a quantity limit
March 14, 2021 CANCER GavretoStart date of change*,**
Drug classMedications that will no longer be covered^^
Generic and/or preferred brand alternatives
June 29, 2021 SKIN CONDITIONS Klisyri topical fluorouracil, imiquimod 5% cream
June 22, 2021 GASTROINTESTINAL/HEARTBURN Reltone ursodiol
HORMONAL AGENTS Thyquidity levothyroxine, levoxyl, Levo-T, Unithroid, Euthyrox
June 15, 2021 GASTROINTESTINAL/HEARTBURN Lubiprostone 8 mcg, 24 mcg capsule Amitiza
June 1, 2021 SKIN CONDITIONS Winlevi 1% cream Generic products (e.g. adapalene; tretinoin; clindamycin-benzoyl peroxide)
June 1, 2021 SKIN CONDITIONS (cont) Wynzora 0.005%-0.064% cream betamethasone DP, fluocinolone, fluticasone, mometasone, trimacinolone, calcipotriene, calcipotriene-betamethasone DP
URINARY TRACT CONDITIONS Vesicare LS 5 mg/5 mL suspension oxybutynin chloride, oxybutynin chloride ER, darifenacin ER, solifenacin, tolterodine, tolterodine ER, tropsium
May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo tramadol
May 1, 2021 SKIN PREPS Impeklo topical betamethasone dipropionate (augmented) 0.05%, clobetasol propionate 0.05%, halobetasol propionate 0.05%, fluocinolide 0.1%
April 18, 2021 HORMONAL AGENTS Alkindi Sprinkle hydrocortisone 5mg tablet
March 28, 2021 BLOOD PRESSURE/HEART MEDICATIONS Conjupri amlodipine, felodipine, nifedipine, nicardipine
January 1, 2021 ASTHMA/COPD/RESPIRATORY ProAir HFA7, ProAir RespiClick7, Ventolin HFA7
albuterol HFA
DIABETES Kombiglyze XR8, Onglyza8 metformin, Janumet, Janumet XR, Januvia
EYE CONDITIONS Lumigan7, Travatan Z, Xalatan, Xelpros, Zioptan9
bimatoprost, latanoprost, travoprost
GASTROINTESTINAL/HEARTBURN Creon7, Pertzye, Zenpep7 Pancreaze
Motegrity, Trulance7, Zelnorm Amitiza, Linzess
Sensipar cinacalcet
HORMONAL AGENTS TaperDex dexamethasone 1.5mg tablet
INFECTIONS Baraclude entecavir tablet
Noxafil tablet posaconazole DR 100mg tablet
MULTIPLE SCLEROSIS Ampyra ER7 dalfampridine ER
NUTRITIONAL/DIETARY PreGenna, Trinaz Any generic prenatal vitamin
PAIN RELIEF AND INFLAMMATORY DISEASE Amerge generic triptans (e.g. naratriptan; sumatriptan)
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 classMedications that will no longer be covered^^
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 lamotrigine, lamotrigine ER, lamotrigine ODT
Qudexy XR11, Trokendi XR11 topiramate ER
Sabril11 vigabatrin, vigadrone
Topamax11 topiramate
Trileptal11 oxcarbazepine
Zonegran11 zonisamideSKIN CONDITIONS Apexicon E5, diflorasone, Impoyz5, Olux5,
Olux-E5, psorconbetamethasone, clobetasol, halobetasol
Condylox imiquimod 5% cream packet, podofilox 0.5% topical solution
Cordran5 betamethasone, clobetasol, fluocinolone, fluticasone, halobetasol
Finacea Foam7, Finacea Gel, MetroCream, MetroGel, MetroLotion, Soolantra12
azelaic acid, topical metronidazole
flurandrenolide, hydrocortisone butyrate lipid cream, lotion5, Pandel5
betamethasone, fluocinolone, fluticasone
Sorilux calcitriol, tazarotene, topical calcipotriene
Tridesilon5 alclometasone, desonide, triamcinolone
Xolegel ciclopirox 0.77% gel, ciclopirox 1% shampoo, ketoconazole 2% cream, ketoconazole 2% foam, selenium 2.5% lotion, sodium sulfacetamide 10% shampoo
SLEEP DISORDERS/SEDATIVES Belsomra8 DayvigoURINARY TRACT CONDITIONS Procysbi4 Cystagon
Start date of change*,**
Drug classMedications that will be excluded from coverage
Additional information
January 1, 2021 SKIN CONDITIONS Rosadan Kits 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 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
DIABETES Baqsimi
GASTROINTESTINAL/HEARTBURN Pancreaze
INFECTIONS Epclusa, Harvoni
PAIN RELIEF AND INFLAMMATORY DISEASE Ajovy13, Emgality13, Taltz
SEIZURE DISORDERS Vimpat
URINARY TRACT CONDITIONS Cystagon
Start date of change*,**
Drug classMedications becoming non-preferred brand
Generic and/or preferred brand alternatives
June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1 No preferred formulary drug alternatives
June 22, 2021 CANCER Orgovyx1 Lupron Depot
June 15, 2021 GASTROINTESTINAL/HEARTBURN Lubiprostone 8 mcg, 24 mcg capsule Amitiza
June 1, 2021 SKIN CONDITIONS Winlevi 1% cream Generic products (e.g. adapalene; tretinoin; clindamycin-benzoyl peroxide)
Wynzora 0.005%-0.064% cream betamethasone DP, fluocinolone, fluticasone, mometasone, trimacinolone, calcipotriene, calcipotriene-betamethasone DP
URINARY TRACT CONDITIONS Vesicare LS 5 mg/5 mL suspension oxybutynin chloride, oxybutynin chloride ER, darifenacin ER, solifenacin, tolterodine, tolterodine ER, tropsium
May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo tramadol
May 1, 2021 SKIN PREPS Impeklo topical betamethasone dipropionate (augmented) 0.05%, clobetasol propionate 0.05%, halobetasol propionate 0.05%, fluocinolide 0.1%
April 18, 2021 HORMONAL AGENTS Alkindi Sprinkle hydrocortisone 5mg tablet
March 28, 2021 BLOOD PRESSURE/HEART MEDICATIONS Conjupri amlodipine, felodipine, nifedipine, nicardipine
January 1, 2021 AIDS/HIV Intelence1 Talk to your doctor about other alternatives
ERECTILE DYSFUNCTION Caverject Impulse Syringe MUSE
HORMONAL AGENTS Unithroid 75mcg tablet levothyroxine
INFECTIONS Kitabis Pak1 tobramycin pak 300mg/5ml
SEIZURE DISORDERS Lyrica 20mg/ml oral solution pregabalin 20mg/ml oral solution
SUBSTANCE ABUSE Bunavail buprenorphine/naloxone film or sublingual tablet, Zubsolv
WEIGHT MANAGEMENT Megace ES 625mg/5ml oral suspension megestrol 625ml/5ml oral suspension
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
VALUE PRESCRIPTION DRUG LIST (cont)
Start date of change*,**
Drug class Medications that will need approval (prior authorization)^
June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1
June 22, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Reditrex
June 1, 2021 ASTHMA/COPD/RESPIRATORY Zokinvy
March 14, 2021 CANCER Gavreto
January 1, 2021 BLOOD THINNERS/ANTI-CLOTTING Eliquis4, Pradaxa4, Savaysa4, Xarelto4
HORMONAL AGENTS Tirosint, Tirosint-Sol
Start date of change*,**
Drug class Medications that will have a quantity limit
June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1
June 1, 2021 ASTHMA/COPD/RESPIRATORY Zokinvy
May 15, 2021 EYE CONDITIONS Eysuvis
May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo
March 14, 2021 CANCER Gavreto
Start date of change*,**
Drug classMedications that will no longer be covered^^
Generic and/or preferred brand alternatives
June 29, 2021 SKIN CONDITIONS Klisyri topical fluorouracil, imiquimod 5% cream
June 22, 2021 GASTROINTESTINAL/HEARTBURN Reltone ursodiol
HORMONAL AGENTS Thyquidity levothyroxine, levoxyl, Levo-T, Unithroid, Euthyrox
June 15, 2021 GASTROINTESTINAL/HEARTBURN Lubiprostone 8 mcg, 24 mcg capsule Amitiza
June 1, 2021 SKIN CONDITIONS Winlevi 1% cream Generic products (e.g. adapalene; tretinoin; clindamycin-benzoyl peroxide)
Wynzora 0.005%-0.064% cream betamethasone DP, fluocinolone, fluticasone, mometasone, trimacinolone, calcipotriene, calcipotriene-betamethasone DP
URINARY TRACT CONDITIONS Vesicare LS 5 mg/5 mL suspension oxybutynin chloride, oxybutynin chloride ER, darifenacin ER, solifenacin, tolterodine, tolterodine ER, tropsium
May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo tramadol
May 1, 2021 SKIN PREPS Impeklo topical betamethasone dipropionate (augmented) 0.05%, clobetasol propionate 0.05%, halobetasol propionate 0.05%, fluocinolide 0.1%
April 18, 2021 HORMONAL AGENTS Alkindi Sprinkle hydrocortisone 5mg tablet
March 28, 2021 BLOOD PRESSURE/HEART MEDICATIONS Conjupri amlodipine, felodipine, nifedipine, nicardipine
January 1, 2021 ASTHMA/COPD/RESPIRATORY Advair HFA7, Breo Ellipta7 Dulera, fluticasone-salmeterol (generic Advair Diskus), fluticasone-salmeterol (generic Airduo), Symbicort, Wixela Inhub
ProAir HFA7, ProAir RespiClick7 albuterol HFA
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
VALUE PRESCRIPTION DRUG LIST (cont)
Start date of change*,**
Drug classMedications that will no longer be covered^^
Generic and/or preferred brand alternatives
April 18, 2021 HORMONAL AGENTS Alkindi Sprinkle hydrocortisone 5mg tablet
January 1, 2021 CONTRACEPTION PRODUCTS Balcoltra, Natazia, Slynd, Taytulla Generic oral contraceptives (e.g. levonorgestrel-ethinyl estradiol)
DIABETES GlucaGen HypoKit7, Gvoke Baqsimi, Glucagon Emergency Kit
EYE CONDITIONS Cequa, Restasis MultiDose7, Xiidra7 Restasis
Travatan Z, Xalatan, Xelpros, Zioptan9 bimatoprost, latanoprost, travoprost
GASTROINTESTINAL/HEARTBURN Creon7, Pertzye, Zenpep7 Pancreaze
Linzess7, Motegrity, Trulance7, Zelnorm Amitiza
Sensipar cinacalcet
HORMONAL AGENTS TaperDex dexamethasone 1.5mg tablet
INFECTIONS Baraclude entecavir tablet
Noxafil tablet posaconazole DR 100mg tablet
MULTIPLE SCLEROSIS Ampyra ER7 dalfampridine ER
NUTRITIONAL/DIETARY PreGenna, Trinaz Any generic prenatal vitamin
PAIN RELIEF AND INFLAMMATORY DISEASE Amerge generic triptans (e.g. naratriptan; sumatriptan)
butalbital-acetaminophen 50-300mg tablet butalbital-acetaminophen 50-325mg tablet
Cosentyx10 Enbrel, Humira, Otezla, Skyrizi, Stelara, Taltz
diclofenac 1.3% patch, Flector 1.3% patch5, Voltaren 1% gel5
diclofenac 1% gel, generic oral NSAIDs (e.g. celecoxib; meloxicam)
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 lamotrigine, lamotrigine ER, lamotrigine ODT
Qudexy XR11, Trokendi XR11 topiramate ER
Sabril11 vigabatrin, vigadrone
Topamax11 topiramate
Trileptal11 oxcarbazepine
Zonegran11 zonisamide
SKIN CONDITIONS Apexicon E5, diflorasone, Impoyz5, Olux5, Olux-E5, Psorcon
betamethasone, clobetasol, halobetasol
Condylox imiquimod 5% cream packet, podofilox 0.5% topical solution
Cordran5 betamethasone, clobetasol, fluocinolone, fluticasone, halobetasol
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
LEGACY (STANDARD) PRESCRIPTION DRUG LIST
VALUE PRESCRIPTION DRUG LIST (cont)
Start date of change*,**
Drug classMedications that will no longer be covered^^
Generic and/or preferred brand alternatives
January 1, 2021 SKIN CONDITIONS Finacea foam, Finacea gel, MetroCream, MetroGel, MetroLotion, Soolantra12
azelaic acid, topical metronidazole
flurandrenolide, hydrocortisone butyrate lipid cream, lotion5, Pandel5
betamethasone, fluocinolone, fluticasone
Tridesilon5 alclometasone, desonide, triamcinolone
Xolegel ciclopirox 0.77% gel, ciclopirox 1% shampoo, ketoconazole 2% cream, ketoconazole 2% foam, selenium 2.5% lotion, sodium sulfacetamide 10% shampoo
SLEEP DISORDERS/SEDATIVES Belsomra8 DayvigoURINARY TRACT CONDITIONS Procysbi4 Cystagon
Start date of change*,**
Drug classMedications that will be excluded from coverage
Additional information
January 1, 2021 ALLERGY/NASAL SPRAYS Beconase AQ, flunisolide, mometasone, Nasonex, Omnaris, Qnasl, Qnasl Children, Xhance, Zetonna
generics products available over-the-counter (e.g. budesonide, fluticasone)
fluticasone 50 mcg spray generics products available over-the-counter (e.g. budesonide)
EYE CONDITIONS azelastine, Bepreve, epinastine, Lastacaft, Pazeo, Zerviate
products available over-the-counter (e.g. Alaway, Pataday)
SKIN CONDITIONS Rosadan Kits azelaic acid, topical metronidazole
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 classMedications becoming non-preferred brand
Generic and/or preferred brand alternatives
June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1 No preferred formulary drug alternatives
SKIN CONDITIONS Klisyri topical fluorouracil, imiquimod 5% cream, Fluoroplex
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
LEGACY (STANDARD) PRESCRIPTION DRUG LIST (cont)
Start date of change*,**
Drug classMedications becoming non-preferred brand
Generic and/or preferred brand alternatives
June 22, 2021 CANCER Orgovyx1 Lupron Depot
HORMONAL AGENTS Thyquidity levothyroxine, levoxyl, Levo-T, Unithroid, Euthyrox
GASTROINTESTINAL/HEARTBURN Reltone ursodiol
June 15, 2021 GASTROINTESTINAL/HEARTBURN Lubiprostone 8 mcg, 24 mcg capsule Amitiza
June 1, 2021 SKIN CONDITIONS Winlevi 1% cream Generic products (e.g. adapalene; tretinoin; clindamycin-benzoyl peroxide)
Wynzora 0.005%-0.064% cream betamethasone DP, fluocinolone, fluticasone, mometasone, trimacinolone, calcipotriene, calcipotriene-betamethasone DP
URINARY TRACT CONDITIONS Vesicare LS 5 mg/5 mL suspension oxybutynin chloride, oxybutynin chloride ER, darifenacin ER, solifenacin, tolterodine, tolterodine ER, tropsium
May 15, 2021 EYE CONDITIONS Lacrisert Restasis, Restasis Multi-dose, Xiidra
May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo tramadol
May 1, 2021 SKIN PREPS Impeklo topical betamethasone dipropionate (augmented) 0.05%, clobetasol propionate 0.05%, halobetasol propionate 0.05%, fluocinolide 0.1%
April 18, 2021 HORMONAL AGENTS Alkindi Sprinkle hydrocortisone 5mg tablet
March 28, 2021 BLOOD PRESSURE/HEART MEDICATIONS Conjupri amlodipine, felodipine, nifedipine, nicardipine
January 1, 2021 AIDS/HIV Intelence1 Talk to your doctor about other alternatives
ASTHMA/COPD/RESPIRATORY ProAir HFA, ProAir RespiClick, Ventolin HFA albuterol HFA
BLOOD MODIFIERS/BLEEDING DISORDERS Amicar 0.25 g/ml oral solution1 aminocaproic acid 0.25g/ml oral solution
BLOOD PRESSURE/HEART MEDICATIONS MULTAQ, Norpace CR 150mg Talk to your doctor about other alternatives
CANCER Tabloid Talk to your doctor about other alternatives
DIABETES Kombiglyze XR14, Onglyza14 metformin, Janumet, Janumet XR, Januvia
ERECTILE DYSFUNCTION Caverject Impulse Syringe1 MUSE
EYE CONDITIONS Lotemax 0.5% drops loteprednol 0.5% drops
Lumigan bimatoprost, latanoprost, travoprost
GASTROINTESTINAL/HEARTBURN Creon, Zenpep Pancreaze
Trulance Amitiza, Linzess
HORMONAL AGENTS Armour Thyroid, Synthroid, Unithroid levothyroxine
INFECTIONS Kitabis Pak1 tobramycin pak 300mg/5ml
MULTIPLE SCLEROSIS Ampyra ER dalfampridine ER
PAIN RELIEF AND INFLAMMATORY DISEASE Cosentyx5 Enbrel, Humira, Otezla, Skyrizi, Stelara, Taltz
SEIZURE DISORDERS Lamictal XR Start Kit lamotrigine ER
Lyrica 20mg/ml oral solution pregabalin 20mg/ml oral solution
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
LEGACY (STANDARD) PRESCRIPTION DRUG LIST (cont)
Start date of change*,**
Drug classMedications becoming non-preferred brand
Generic and/or preferred brand alternatives
January 1, 2021 SEIZURE DISORDERS (cont) Qudexy XR, Trokendi XR topiramate ER
Sabril vigabatrin, vigadrone
SKIN CONDITIONS Finacea foam, Soolantra14 azelaic acid, topical metronidazole
Psorcon betamethasone, clobetasol, halobetasol
SLEEP DISORDERS/SEDATIVES Belsomra8 Dayvigo
SUBSTANCE ABUSE Bunavail buprenorphine/naloxone film or sublingual tablet, Zubsolv
WEIGHT MANAGEMENT Megace ES 625mg/5ml oral suspension megestrol 625ml/5ml oral suspension
Start date of change*,**
Drug class Medications that will need approval (prior authorization)^
June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1
June 22, 2021 GASTROINTESTINAL/HEARTBURN Reltone
HORMONAL AGENTS Thyquidity
PAIN RELIEF AND INFLAMMATORY DISEASE Reditrex
June 15, 2021 URINARY TRACT CONDITIONS Lubiprostone 8 mcg, 24 mcg capsule
June 1, 2021 ASTHMA/COPD/RESPIRATORY Zokinvy
SKIN CONDITIONS Winlevi 1% cream
Wynzora 0.005%-0.064% cream
May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo
May 1, 2021 SKIN PREPS Impeklo
April 18, 2021 HORMONAL AGENTS Alkindi Sprinkle
March 28, 2021 BLOOD PRESSURE/HEART MEDICATIONS Conjupri
March 14, 2021 CANCER Gavreto
January 1, 2021 ALLERGY/NASAL SPRAYS carbinoxamine, EpiPen, EpiPen Jr, RyVent
ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil, Aplenzin, Ativan, Cymbalta, Lexapro, Pamelor, Parnate, Pexeva, Tofranil, Wellbutrin XL
ASTHMA/COPD/RESPIRATORY Elixophyllin, Proventil HFA, Zyflo, Zyflo CR
ATTENTION DEFICIT HYPERACTIVITY DISORDER Desoxyn, Dexedrine
BLOOD PRESSURE/HEART MEDICATIONS Betapace, Cardizem, Cardizem CD, Consensi, Isordil, Isordil Titradose, Lanoxin
BLOOD THINNERS/ANTI-CLOTTING Eliquis, Pradaxa, Savaysa, Xarelto, Yosprala
CANCER Nilandron
CHOLESTEROL MEDICATIONS Antara, Fenoglide, Lipitor
COUGH/COLD MEDICATIONS benzonatate, TussiCaps
DIABETES Fortamet, Glumetza, metformin ER Gastric, metformin ER Osmotic
DIURETICS Edecrin
EYE CONDITIONS Travatan Z, Vyzulta, Xalatan, Xelpros, Zioptan9
GASTROINTESTINAL/HEARTBURN Anusol-HC suppository, Cortifoam, Librax, Lotronex, Marinol, Motegtrity, Nexium, Omeclamox-Pak, omeprazole, Pepcid suspension, tablet, Pertzye, Prevacid SoluTab, Pylera, Rowasa, Sensipar, Uceris rectal foam, Zegerid capsule, packet, Zelnorm, Zofran, Zuplenz
HORMONAL AGENTS DDAVP nasal spray, solution, tablet, Dexpak, Rayos, TaperDex, Uceris tablet
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
LEGACY (STANDARD) PRESCRIPTION DRUG LIST (cont)
Start date of change*,**
Drug class Medications that will need approval (prior authorization)^
January 1, 2021 INFECTIONS Augmentin, Baraclude, Diflucan, Doryx, E.E.S. 200, EryPed 400, Mepron, Minocin, Mycobutin, Noxafil tablet, Oracea, Sitavig, Solodyn, Sporanox, Targadox, Valcyte, Vancocin, Vibramycin, Zovirax capsule, suspension, tablet
MISCELLANEOUS Horizant
NUTRITIONAL/DIETARY PreGenna, Trinaz
PAIN RELIEF AND INFLAMMATORY DISEASE Allzital, Amerge, Amrix, BUPAP, Butalbital-acetaminophen 50-300mg tablet, Cambia, chlorzoxazone, ConZip, D.H.E.45, diclofenac 1.3% patch5, 1.5% topical solution, Duexis, Ergomar, Fenortho 200 mg capsule, Flector 1.3 % patch5, Frova, Gralise, Imitrex, Indocin, levorphanol, Lorzone, Maxalt, Maxalt MLT, Migranal, Naprelan, naproxen CR, Onzetra Xsail, Pennsaid, Relpax, roxicodone, Soriatane, Sprix, Tivorbex, Treximet, Vanatol LQ, Vimovo , Vivlodex, Voltaren 1% gel5, Zembrace Symtouch, Zipsor, Zomig, Zomig ZMT, Zorvolex
PARKINSON’S DISEASE Lodosyn, Requip XL, Zelapar
SCHIZOPHRENIA/ANTI-PSYCHOTICS FazaClo, Geodon, Versacloz, Zyprexa, Zyprexa Zydis
SEIZURE DISORDERS Mysoline
SKIN CONDITIONS Aldara, Anusol-HC cream, Apexicon E5, Bensal HP, Benzaclin, Carac, Clindage, Clobex shampoo, spray, topical lotion, Condylox, Cordran5, Cutivate, diclofenac 3% gel, diflorasone, Ertaczo, Exelderm, Extina, Finacea gel, flurandrenolide, Halog cream, ointment, hydrocortisone butyrate lipid cream, lotion5, Impoyz5, Jublia, Kenalog 0.147 mg/gm spray, Kerydin, Locoid, Loprox 0.77% cream, 1% shampoo, Luzu, MetroCream, MetroGel, MetroLotion, Noritate, Olux5, Olux-E5, Oxistat, Pandel5, Penlac, Prudoxin, Sernivo, Sorilux, Trainex, Tridesilon5, Ultravate, Vanos, Verdeso, Vusion, Xerese, Xolegel, Ziana, Zonalon, Zovirax cream, ointment, Zyclara
SLEEP DISORDERS/SEDATIVES Ambien, Ambien CR, Edular, Intermezzo, Nuvigil, Provigil, Restoril, Zolpimist
SUBSTANCE ABUSE EvzioStart date of change*,**
Drug class Medications that will have a quantity limit
June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1
June 1, 2021 ASTHMA/COPD/RESPIRATORY Zokinvy
May 15, 2021 EYE CONDITIONS Eysuvis
May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo
March 14, 2021 CANCER GavretoStart date of change*,**
Drug classMedications being added to Step Therapy Program^,^^
Generic and/or preferred brand alternatives
June 29, 2021 SKIN CONDITIONS Klisyri topical fluorouracil, imiquimod 5% cream, Fluoroplex
June 1, 2021 URINARY TRACT CONDITIONS Vesicare LS 5 mg/5 mL suspension oxybutynin chloride, oxybutynin chloride ER, darifenacin ER, solifenacin, tolterodine, tolterodine ER, tropsium
Start date of change*,**
Drug classMedications that will be excluded from coverage
Additional information
January 1, 2021 SKIN CONDITIONS Rosadan Kits azelaic acid, topical metronidazole
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
PERFORMANCE 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
April 1, 2021 CANCER Riabni
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 classMedications becoming non-preferred brand
Generic and/or preferred brand alternatives
June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1 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 Generic products (e.g. adapalene; tretinoin; clindamycin-benzoyl peroxide)
Wynzora 0.005%-0.064% cream betamethasone DP, fluocinolone, fluticasone, mometasone, trimacinolone, calcipotriene, calcipotriene-betamethasone DP
URINARY TRACT CONDITIONS Vesicare LS 5 mg/5 mL suspension oxybutynin chloride, oxybutynin chloride ER, darifenacin ER, solifenacin, tolterodine, tolterodine ER, tropsium
May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo tramadol
May 1, 2021 SKIN PREPS Impeklo topical betamethasone dipropionate (augmented) 0.05%, clobetasol propionate 0.05%, halobetasol propionate 0.05%, fluocinolide 0.1%
April 18, 2021 HORMONAL AGENTS Alkindi Sprinkle hydrocortisone 5mg tablet
March 28, 2021 BLOOD PRESSURE/HEART MEDICATIONS Conjupri amlodipine, felodipine, nifedipine, nicardipine
January 1, 2021 AIDS/HIV Intelence1 Talk to your doctor about other alternatives
BLOOD PRESSURE/HEART MEDICATIONS MULTAQ Talk to your doctor about other alternatives
EYE CONDITIONS Lotemax 0.5% drops loteprednol 0.5% drops
HORMONAL AGENTS Armour Thyroid, Synthroid, Unithroid levothyroxine
INFECTIONS Kitabis Pak1 tobramycin pak 300mg/5ml
SEIZURE DISORDERS Lyrica 20mg/ml oral solution pregabalin 20mg/ml oral solution
SUBSTANCE ABUSE Bunavail buprenorphine/naloxone film or sublingual tablet, Zubsolv
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
PERFORMANCE PRESCRIPTION DRUG LIST (cont)
Start date of change*,**
Drug classMedications becoming non-preferred brand
Generic and/or preferred brand alternatives
January 1, 2021 SUBSTANCE ABUSE Probuphine Talk to your doctor about other alternativesStart date of change*,**
Drug class Medications that will need approval (prior authorization)^
June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1
June 22, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Reditrex
June 1, 2021 ASTHMA/COPD/RESPIRATORY Zokinvy
March 14, 2021 CANCER Gavreto
January 1, 2021 BLOOD THINNERS/ANTI-CLOTTING Eliquis4, Pradaxa4, Savaysa4, Xarelto4
PAIN RELIEF AND INFLAMMATORY DISEASE diclofenac 1.3% patch, Flextor 1.3% patch5, Voltaren 1% gel5
Start date of change*,**
Drug class Medications that will have a quantity limit
June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1
June 1, 2021 ASTHMA/COPD/RESPIRATORY Zokinvy
May 15, 2021 EYE CONDITIONS Eysuvis
May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo
March 14, 2021 CANCER GavretoStart date of change*,**
Drug classMedications that will no longer be covered^^
Generic and/or preferred brand alternatives
June 29, 2021 SKIN CONDITIONS Klisyri topical fluorouracil, imiquimod 5% cream
June 22, 2021 GASTROINTESTINAL/HEARTBURN Reltone ursodiol
HORMONAL AGENTS Thyquidity levothyroxine, levoxyl, Levo-T, Unithroid, Euthyrox
June 15, 2021 GASTROINTESTINAL/HEARTBURN Lubiprostone 8 mcg, 24 mcg capsule Amitiza
June 1, 2021 SKIN CONDITIONS Winlevi 1% cream Generic products (e.g. adapalene; tretinoin; clindamycin-benzoyl peroxide)
Wynzora 0.005%-0.064% cream betamethasone DP, fluocinolone, fluticasone, mometasone, trimacinolone, calcipotriene, calcipotriene-betamethasone DP
URINARY TRACT CONDITIONS Vesicare LS 5 mg/5 mL suspension oxybutynin chloride, oxybutynin chloride ER, darifenacin ER, solifenacin, tolterodine, tolterodine ER, tropsium
May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo tramadol
May 1, 2021 SKIN PREPS Impeklo topical betamethasone dipropionate (augmented) 0.05%, clobetasol propionate 0.05%, halobetasol propionate 0.05%, fluocinolide 0.1%
April 18, 2021 HORMONAL AGENTS Alkindi Sprinkle hydrocortisone 5mg tablet
March 28, 2021 BLOOD PRESSURE/HEART MEDICATIONS Conjupri amlodipine, felodipine, nifedipine, nicardipine
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
PERFORMANCE PRESCRIPTION DRUG LIST (cont)
Start date of change*,**
Drug classMedications that will no longer be covered^^
Generic and/or preferred brand alternatives
January 1, 2021 ASTHMA/COPD/RESPIRATORY ProAir HFA7, ProAir RespiClick7, Ventolin HFA7
albuterol HFA
DIABETES Kombiglyze XR8, Onglyza8 metformin, Janumet, Janumet XR, Januvia
EYE CONDITIONS Lumigan7, Travatan Z, Xalatan, Xelpros, Zioptan9
bimatoprost, latanoprost, travoprost
GASTROINTESTINAL/HEARTBURN Creon7, Pertzye7, Zenpep7 Pancreaze
Motegrity, Trulance7, Zelnorm Amitiza, Linzess
Sensipar cinacalcet
HORMONAL AGENTS TaperDex dexamethasone 1.5mg tablet
INFECTIONS Baraclude entecavir tablet
Noxafil tablet posaconazole DR 100mg tablet
MULTIPLE SCLEROSIS Ampyra ER7 dalfampridine ER
NUTRITIONAL/DIETARY PreGenna, Trinaz Any generic prenatal vitamin
PAIN RELIEF AND INFLAMMATORY DISEASE Amerge, Frova, Maxalt, Maxalt MLT, Relpax generic triptans (e.g. naratriptan; sumatriptan)
butalbital-acetaminophen 50-300mg tablet butalbital-acetaminophen 50-325mg tablet
Cosentyx10 Enbrel, Humira, Otezla, Skyrizi, Stelara, Taltz
SEIZURE DISORDERS Felbatol11 felbamate
Keppra/Keppra XR11 levetiracetam/levetiracetam ER
Lamictal XR Start Kit11 lamotrigine ER
Lamictal/ODT/XR11 lamotrigine, lamotrigine ER, lamotrigine ODT
Qudexy XR6, Trokendi XR11 topiramate ER
Sabril11 vigabatrin, vigadrone
Topamax11 topiramate
Trileptal11 oxcarbazepine
Zonegran11 zonisamide
SKIN CONDITIONS Apexicon E5, diflorasone, Impoyz5, Olux5, Olux-E5, Psorcon
betamethasone, clobetasol, halobetasol
Condylox imiquimod 5% cream packet, podofilox 0.5% topical solution
Cordran5 betamethasone, clobetasol, fluocinolone, fluticasone, halobetasol
Finacea7, MetroCream, MetroGel, MetroLotion, Soolantra12
azelaic acid, topical metronidazole
flurandrenolide, Pandel5 betamethasone, fluocinolone, fluticasone
hydrocortisone butyrate lipid cream, lotion5 betamethasone, fluocinolone, fluticasone
Sorilux calcitriol, tazarotene, topical calcipotriene
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
ADVANTAGE PRESCRIPTION DRUG LIST
PERFORMANCE PRESCRIPTION DRUG LIST (cont)
Start date of change*,**
Drug classMedications that will no longer be covered^^
Generic and/or preferred brand alternatives
January 1, 2021 SKIN CONDITIONS (cont) Tridesilon5 alclometasone, desonide, triamcinolone
Xolegel ciclopirox 0.77% gel, ciclopirox 1% shampoo, ketoconazole 2% cream, ketoconazole 2% foam, selenium 2.5% lotion, sodium sulfacetamide 10% shampoo
SLEEP DISORDERS/SEDATIVES Belsomra8 Dayvigo
URINARY TRACT CONDITIONS Procysbi4 CystagonStart date of change*,**
Drug classMedications that will be excluded from coverage
Additional information
January 1, 2021 SKIN CONDITIONS Rosadan Kits azelaic acid, topical metronidazole
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
April 1, 2021 CANCER Riabni
January 1, 2021 AIDS/HIV Juluca
DIABETES Baqsimi
GASTROINTESTINAL/HEARTBURN Pancreaze
INFECTIONS Epclusa, Harvoni
PAIN RELIEF AND INFLAMMATORY DISEASE Ajovy13, Emgality13, Taltz
SEIZURE DISORDERS VIMPAT
URINARY TRACT CONDITIONS Cystagon
Start date of change*,**
Drug classMedications becoming non-preferred brand
Generic and/or preferred brand alternatives
June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1 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 Generic products (e.g. adapalene; tretinoin; clindamycin-benzoyl peroxide)
Wynzora 0.005%-0.064% cream betamethasone DP, fluocinolone, fluticasone, mometasone, trimacinolone, calcipotriene, calcipotriene-betamethasone DP
URINARY TRACT CONDITIONS Vesicare LS 5 mg/5 mL suspension oxybutynin chloride, oxybutynin chloride ER, darifenacin ER, solifenacin, tolterodine, tolterodine ER, tropsium
May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo tramadol
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
ADVANTAGE PRESCRIPTION DRUG LIST (cont)
Start date of change*,**
Drug classMedications becoming non-preferred brand
Generic and/or preferred brand alternatives
June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1 Lupron Depot
May 1, 2021 SKIN PREPS Impeklo topical betamethasone dipropionate (augmented) 0.05%, clobetasol propionate 0.05%, halobetasol propionate 0.05%, fluocinolide 0.1%
April 18, 2021 HORMONAL AGENTS Alkindi Sprinkle hydrocortisone 5mg tablet
March 28, 2021 BLOOD PRESSURE/HEART MEDICATIONS Conjupri amlodipine, felodipine, nifedipine, nicardipine
January 1, 2021 AIDS/HIV Intelence1 Talk to your doctor about other alternatives
HORMONAL AGENTS Unithroid 75mcg tablet levothyroxine
INFECTIONS Kitabis Pak1 tobramycin pak 300mg/5ml
SEIZURE DISORDERS Lyrica 20mg/ml oral solution pregabalin 20mg/ml oral solution
SUBSTANCE ABUSE Bunavail buprenorphine/naloxone film or sublingual tablet, Zubsolv
Probuphine Talk to your doctor about other alternatives
WEIGHT MANAGEMENT Megace ES 625mg/5ml oral suspension megestrol 625ml/5ml oral suspension
Start date of change*,**
Drug class Medications that will need approval (prior authorization)^
June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1
June 22, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Reditrex
June 1, 2021 ASTHMA/COPD/RESPIRATORY Zokinvy
March 14, 2021 CANCER Gavreto
January 1, 2021 BLOOD THINNERS/ANTI-CLOTTING Eliquis4, Pradaxa4, Savaysa4, Xarelto4
HORMONAL AGENTS Tirosint, Tirosint-SOL
Start date of change*,**
Drug class Medications that will have a quantity limit
June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1
June 1, 2021 ASTHMA/COPD/RESPIRATORY Zokinvy
May 15, 2021 EYE CONDITIONS Eysuvis
May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo
March 14, 2021 CANCER Gavreto
Start date of change*,**
Drug classMedications that will no longer be covered^^
Generic and/or preferred brand alternatives
June 29, 2021 SKIN CONDITIONS Klisyri topical fluorouracil, imiquimod 5% cream
June 22, 2021 GASTROINTESTINAL/HEARTBURN Reltone ursodiol
HORMONAL AGENTS Thyquidity levothyroxine, levoxyl, Levo-T, Unithroid, Euthyrox
June 15, 2021 GASTROINTESTINAL/HEARTBURN Lubiprostone 8 mcg, 24 mcg capsule Amitiza
June 1, 2021 SKIN CONDITIONS Winlevi 1% cream Generic products (e.g. adapalene; tretinoin; clindamycin-benzoyl peroxide)
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
ADVANTAGE PRESCRIPTION DRUG LIST (cont)
Start date of change*,**
Drug classMedications that will no longer be covered^^
Generic and/or preferred brand alternatives
June 1, 2021 SKIN CONDITIONS (cont) Wynzora 0.005%-0.064% cream betamethasone DP, fluocinolone, fluticasone, mometasone, trimacinolone, calcipotriene, calcipotriene-betamethasone DP
URINARY TRACT CONDITIONS Vesicare LS 5 mg/5 mL suspension oxybutynin chloride, oxybutynin chloride ER, darifenacin ER, solifenacin, tolterodine, tolterodine ER, tropsium
May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo tramadol
May 1, 2021 SKIN PREPS Impeklo topical betamethasone dipropionate (augmented) 0.05%, clobetasol propionate 0.05%, halobetasol propionate 0.05%, fluocinolide 0.1%
April 18, 2021 HORMONAL AGENTS Alkindi Sprinkle hydrocortisone 5mg tablet
March 28, 2021 BLOOD PRESSURE/HEART MEDICATIONS Conjupri amlodipine, felodipine, nifedipine, nicardipine
January 1, 2021 ASTHMA/COPD/RESPIRATORY Advair HFA7, Breo Ellipta7 Dulera, fluticasone-salmeterol (generic Advair Diskus), fluticasone-salmeterol (generic Airduo), Symbicort, Wixela Inhub
ProAir HFA7, ProAir RespiClick7 albuterol HFA
CONTRACEPTION PRODUCTS Balcoltra, Natazia, Slynd, Taytulla Generic oral contraceptives (e.g. levonorgestrel-ethinyl estradiol)
DIABETES GlucaGen HypoKit7, Gvoke Baqsimi, Glucagon Emergency Kit
EYE CONDITIONS Cequa, Restasis MultiDose7, Xiidra7 Restasis
Travatan Z, Xalatan, Xelpros, Zioptan9 bimatoprost, latanoprost, travoprost
GASTROINTESTINAL/HEARTBURN Creon7, Pertzye, Zenpep7 Pancreaze
Linzess7, Motegrity, Trulance7, Zelnorm Amitiza
Sensipar cinacalcet
HORMONAL AGENTS TaperDex dexamethasone 1.5mg tablet
INFECTIONS Baraclude entecavir tablet
Noxafil tablet posaconazole DR 100mg tablet
MULTIPLE SCLEROSIS Ampyra ER7 dalfampridine ER
NUTRITIONAL/DIETARY PreGenna, Trinaz Any generic prenatal vitamin
PAIN RELIEF AND INFLAMMATORY DISEASE Amerge generic triptans (e.g. naratriptan; sumatriptan)
butalbital-acetaminophen 50-300mg tablet butalbutal-acetaminophen 50-325mg tablet
Cosentyx10 Enbrel, Humira, Otezla, Skyrizi, Stelara, Taltz
diclofenac 1.3% patch, Flector 1.3% patch5, Voltaren 1% gel5
diclofenac 1% gel, generic oral NSAIDs (e.g. celecoxib; meloxicam)
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
ADVANTAGE PRESCRIPTION DRUG LIST (cont)
Start date of change*,**
Drug classMedications that will no longer be covered^^
Generic and/or preferred brand alternatives
January 1, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE (cont)
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 lamotrigine, lamotrigine ER, lamotrigine ODT
Qudexy XR5, Trokendi XR11 topiramate ER
Sabril11 vigabatrin, vigadrone
Topamax11 topiramate
Trileptal11 oxcarbazepine
Zonegran11 zonisamide
SKIN CONDITIONS Apexicon E5, diflorasone, Impoyz5, Olux5, Olux-E5, Psorcon
betamethasone, clobetasol, halobetasol
Condylox imiquimod 5% cream packet, podofilox 0.5% topical solution
Cordran5 betamethasone, clobetasol, fluocinolone, fluticasone, halobetasol
Finacea, MetroCream, MetroGel, MetroLotion, Soolantra12
azelaic acid, topical metronidazole
flurandrenolide, hydrocortisone butyrate lipid cream, lotion5, Pandel5
betamethasone, fluocinolone, fluticasone
Tridesilon5 alclometasone, desonide, triamcinolone
Xolegel ciclopirox 0.77% gel, ciclopirox 1% shampoo, ketoconazole 2% cream, ketoconazole 2% foam, selenium 2.5% lotion, sodium sulfacetamide 10% shampoo
SLEEP DISORDERS/SEDATIVES Belsomra8 Dayvigo
URINARY TRACT CONDITIONS Procysbi4 CystagonStart date of change*,**
Drug classMedications that will be excluded from coverage
Additional information
January 1, 2021 ALLERGY/NASAL SPRAYS Beconase AQ, flunisolide, mometasone, Nasonex, Omnaris, Qnasl, Qnasl Children, Xhance, Zetonna
generics products available over-the-counter (e.g. budesonide, fluticasone)
EYE CONDITIONS azelastine, Bepreve, epinastine, Lastacaft, Pazeo, Zerviate
products available over-the-counter (e.g. Alaway, Pataday)
SKIN CONDITIONS Rosadan Kits azelaic acid, topical metronidazole
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
LEGACY (PERFORMANCE) 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
April 1, 2021 CANCER Riabni
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 classMedications becoming non-preferred brand
Generic and/or preferred brand alternatives
June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1 No preferred formulary drug alternatives
SKIN CONDITIONS Klisyri topical fluorouracil, imiquimod 5% cream, Fluoroplex
June 22, 2021 CANCER Orgovyx1 Lupron Depot
HORMONAL AGENTS Thyquidity levothyroxine, levoxyl, Levo-T, Unithroid, Euthyrox
GASTROINTESTINAL/HEARTBURN Reltone ursodiol
June 15, 2021 GASTROINTESTINAL/HEARTBURN Lubiprostone 8 mcg, 24 mcg capsule Amitiza
June 1, 2021 SKIN CONDITIONS Winlevi 1% cream Generic products (e.g. adapalene; tretinoin; clindamycin-benzoyl peroxide)
Wynzora 0.005%-0.064% cream betamethasone DP, fluocinolone, fluticasone, mometasone, trimacinolone, calcipotriene, calcipotriene-betamethasone DP
URINARY TRACT CONDITIONS Vesicare LS 5 mg/5 mL suspension oxybutynin chloride, oxybutynin chloride ER, darifenacin ER, solifenacin, tolterodine, tolterodine ER, tropsium
May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo tramadol
May 1, 2021 SKIN PREPS Impeklo topical betamethasone dipropionate (augmented) 0.05%, clobetasol propionate 0.05%, halobetasol propionate 0.05%, fluocinolide 0.1%
April 18, 2021 HORMONAL AGENTS Alkindi Sprinkle hydrocortisone 5mg tablet
March 28, 2021 BLOOD PRESSURE/HEART MEDICATIONS Conjupri amlodipine, felodipine, nifedipine, nicardipine
January 1, 2021 AIDS/HIV Intelence1 Talk to your doctor about other alternatives
ASTHMA/COPD/RESPIRATORY ProAir HFA, ProAir RespiClick, Ventolin HFA albuterol HFA
BLOOD PRESSURE/HEART MEDICATIONS MULTAQ Talk to your doctor about other alternatives
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
LEGACY (PERFORMANCE) PRESCRIPTION DRUG LIST (cont)
Start date of change*,**
Drug classMedications becoming non-preferred brand
Generic and/or preferred brand alternatives
January 1, 2021 DIABETES Kombiglyze XR14, Onglyza14 metformin, Janumet, Janumet XR, Januvia
EYE CONDITIONS Lotemax 0.5% drops loteprednol 0.5% drops
Lumigan bimatoprost, latanoprost, travoprost
GASTROINTESTINAL/HEARTBURN Creon, Zenpep Pancreaze
Trulance Amitiza, Linzess
HORMONAL AGENTS Armour Thyroid, Synthroid, Unithroid 75mcg tablet
levothyroxine
INFECTIONS Kitabis Pak1 tobramycin pak 300mg/5ml
MULTIPLE SCLEROSIS Ampyra ER dalfampridine ER
PAIN RELIEF AND INFLAMMATORY DISEASE Cosentyx1,4 Enbrel, Humira, Otezla, Skyrizi, Stelara, Taltz
SEIZURE DISORDERS Lamictal XR Start Kit lamotrigine ER
Lyrica 20mg/ml oral solution pregabalin 20mg/ml oral solution
Qudexy XR, Trokendi XR topiramate ER
Sabril1 vigabatrin, vigadrone
SKIN CONDITIONS Finacea foam, Soolantra14 azelaic acid, topical metronidazole
Psorcon betamethasone, clobetasol, halobetasol
SLEEP DISORDERS/SEDATIVES Belsomra8 Dayvigo
SUBSTANCE ABUSE Bunavail buprenorphine/naloxone film or sublingual tablet, Zubsolv
Probuphine Talk to your doctor about other alternatives
WEIGHT MANAGEMENT Megace ES 625mg/5ml oral suspension megestrol 625ml/5ml oral suspension
Start date of change*,**
Drug class Medications that will need approval (prior authorization)^
June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1
June 22, 2021 GASTROINTESTINAL/HEARTBURN Reltone
HORMONAL AGENTS Thyquidity
PAIN RELIEF AND INFLAMMATORY DISEASE Reditrex
June 15, 2021 GASTROINTESTINAL/HEARTBURN Lubiprostone 8 mcg, 24 mcg capsule
June 1, 2021 ASTHMA/COPD/RESPIRATORY Zokinvy
SKIN CONDITIONS Winlevi 1% cream
Wynzora 0.005%-0.064% cream
May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo
May 1, 2021 SKIN PREPS Impeklo
April 18, 2021 HORMONAL AGENTS Alkindi Sprinkle
March 28, 2021 BLOOD PRESSURE/HEART MEDICATIONS Conjupri
March 14, 2021 CANCER Gavreto
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
LEGACY (PERFORMANCE) PRESCRIPTION DRUG LIST (cont)
Start date of change*,**
Drug class Medications that will need approval (prior authorization)^
January 1, 2021 ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil, Aplenzin, Ativan, Cymbalta, Lexapro, Pamelor, Parnate, Pexeva, Tofranil, Wellbutrin XL
ASTHMA/COPD/RESPIRATORY Elixophyllin, Proventil HFA, Zyflo, Zyflo CR
ATTENTION DEFICIT HYPERACTIVITY DISORDER Desoxyn, Dexedrine
BLOOD PRESSURE/HEART MEDICATIONS Betapace, Cardizem, Cardizem CD, Consensi, Isordil, Isordil Titradose, Lanoxin
BLOOD THINNERS/ANTI-CLOTTING Eliquis, Pradaxa, Savaysa, Xarelto, Yosprala
CANCER Aldara, Nilandron, Zyclara
CHOLESTEROL MEDICATIONS Antara, Fenoglide, Lipitor
COUGH/COLD MEDICATIONS benzonatate, TussiCaps
DIABETES Fortamet, Glumetza, metformin ER Gastric, metformin ER Osmotic
DIURETICS Edecrin
EYE CONDITIONS Travatan Z, Vyzulta, Xalatan, Xelpros, Zioptan9
GASTROINTESTINAL/HEARTBURN Anusol-HC suppository, Cortifoam, Librax, Lotronex, Marinol, Motegrity, Nexium, Omeclamox-Pak, omeprazole, Pepcid suspension, tablet, Pertzye, Prevacid SoluTab, Pylera, Rowasa, Sensipar, Uceris rectal foam, Zegerid capsule, packet, Zelnorm, Zofran, Zuplenz
HORMONAL AGENTS DDAVP nasal spray, solution, tablet, Dexpak, Rayos, TaperDex, Uceris tablet
INFECTIONS Augmentin, Baraclude, Diflucan, Doryx, E.E.S. 200 EryPed 400, Mepron, Minocin, Mycobutin, Noxafil tablet, Oracea, Sitavig, Solodyn, Sporanox, Targadox, Valcyte, Vancocin, Vibramycin, Zovirax capsule, suspension, tablet
MISCELLANEOUS Horizant
NUTRITIONAL/DIETARY PreGenna, Trinaz
PAIN RELIEF AND INFLAMMATORY DISEASE Allzital, Amerge, Amrix, BUPAP, butalbital-acetaminophen 50-300mg tablet, Cambia, chlorzoxazone, ConZip, D.H.E.45, diclofenac 1.3% patch5, 1.5% topical solution, Duexis, Ergomar, Fenortho 200 mg capsule, Flector 1.3% patch5, Frova, Gralise, Imitrex, Indocin, levorphanol, Lorzone, Maxalt, Maxalt MLT, Migranal, Naprelan, naproxen CR, Onzetra Xsail, Pennsaid, Relpax, Roxicodone, Soriatane, Sprix, Tivorbex, Treximet, Vanatol LQ, Vimovo, Vivlodex, Votaren 1% gel5, Zembrace Symtouch, Zipsor, Zomig, Zomig ZMT, Zorvolex
PARKINSON'S DISEASE Lodosyn, Requip XL, Zelapar
SCHIZOPHRENIA/ANTI-PSYCHOTICS FazaClo, Geodon, Versacloz, Zyprexa, Zyprexa Zydis
SEIZURE DISORDERS Mysoline
SKIN CONDITIONS Anusol-HC cream, Apexicon E5, Bensal HP, Benzaclin, Carac, Clindagel, Clobex shampoo, spray, topical lotion, Condylox, Cordran5, Cutivate, diclofenac 3% gel, diflorasone, Ertaczo, Exelderm, Extina, Finacea gel, flurandrenolide, Halog cream, ointment, hydrocortisone butyrate lipid cream, lotion5, Impoyz5, Jublia, Kenalog 0.147mg/gm spray, Kerydin, Locoid, Loprox 0.77% cream, 1% shampoo, Luzu, MetroCream, MetroGel, MetroLotion, Noritate, Olux5, Olux-E5, Oxistat, Pandel5, Penlac, Prudoxin, Sernivo, Sorilux, Trainex, Tridesilon2, Ultravate, Vanos, Verdeso, Vusion, Xerese, Xolegel, Ziana, Zonalon, Zovirax cream, ointment
SLEEP DISORDERS/SEDATIVES Ambien, Ambien CR, Edular, Intermezzo, Nuvigil, Provigil, Restoril, Zolpimist
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
CIGNA TOTAL SAVINGS PRESCRIPTION DRUG LIST
LEGACY (PERFORMANCE) PRESCRIPTION DRUG LIST (cont)
Start date of change*,**
Drug class Medications that will need approval (prior authorization)^
January 1, 2021 SUBSTANCE ABUSE Evzio
Start date of change*,**
Drug class Medications that will have a quantity limit
June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1
June 1, 2021 ASTHMA/COPD/RESPIRATORY Zokinvy
May 15, 2021 EYE CONDITIONS Eysuvis
May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo
March 14, 2021 CANCER Gavreto
Start date of change*,**
Drug classMedications being added to Step Therapy Program^,^^
Generic and/or preferred brand alternatives
June 29, 2021 SKIN CONDITIONS Klisyri topical fluorouracil, imiquimod 5% cream, Fluoroplex
June 1, 2021 URINARY TRACT CONDITIONS Vesicare LS 5 mg/5 mL suspension oxybutynin chloride, oxybutynin chloride ER, darifenacin ER, solifenacin, tolterodine, tolterodine ER, tropsium
Start date of change*,**
Drug classMedications that will be excluded from coverage
Additional information
January 1, 2021 SKIN CONDITIONS Rosadan Kits azelaic acid, topical metronidazole
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
DIABETES Baqsimi
Jentadueto15, Jentadueto XR15, Tradjenta15
GASTROINTESTINAL/HEARTBURN Pancreaze
HORMONAL AGENTS Imvexxy, Intrarosa
INFECTIONS Epclusa, Harvoni
PAIN RELIEF AND INFLAMMATORY DISEASE Ajovy13, Cimzia, Emgality13, Olumiant
SEIZURE DISORDERS VIMPAT
URINARY TRACT CONDITIONS Cystagon
Start date of change*,**
Drug classMedications becoming non-preferred brand
Generic and/or preferred brand alternatives
June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1 Lupron Depot
June 22, 2021 CANCER Orgovyx1 No preferred formulary drug alternatives.
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
CIGNA TOTAL SAVINGS PRESCRIPTION DRUG LIST (cont)
Start date of change*,**
Drug classMedications becoming non-preferred brand
Generic and/or preferred brand alternatives
June 15, 2021 GASTROINTESTINAL/HEARTBURN Lubiprostone 8 mcg, 24 mcg capsule Amitiza
June 1, 2021 SKIN CONDITIONS Winlevi 1% cream Generic products (e.g. adapalene; tretinoin; clindamycin-benzoyl peroxide)
Wynzora 0.005%-0.064% cream betamethasone DP, fluocinolone, fluticasone, mometasone, trimacinolone, calcipotriene, calcipotriene-betamethasone DP
URINARY TRACT CONDITIONS Vesicare LS 5 mg/5 mL suspension oxybutynin chloride, oxybutynin chloride ER, darifenacin ER, solifenacin, tolterodine, tolterodine ER, tropsium
May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo tramadol
May 1, 2021 SKIN PREPS Impeklo topical betamethasone dipropionate (augmented) 0.05%, clobetasol propionate 0.05%, halobetasol propionate 0.05%, fluocinolide 0.1%
April 18, 2021 HORMONAL AGENTS Alkindi Sprinkle hydrocortisone 5mg tablet
March 28, 2021 BLOOD PRESSURE/HEART MEDICATIONS Conjupri amlodipine, felodipine, nifedipine, nicardipine
January 1, 2021 AIDS/HIV Atripla1, Descovy1, Intelence1, Selzentry1, Symtuza1, Truvada1
Talk to your doctor about other alternatives
ERECTILE DYSFUNCTION Caverject Impulse Syringe Talk to your doctor about other alternatives
INFECTIONS Kitabis Pak1 tobramycin pak 300mg/5ml
SEIZURE DISORDERS Lyrica 20mg/ml oral solution pregabalin 20mg/ml oral solution
SUBSTANCE ABUSE Bunavail buprenorphine/naloxone film or sublingual tablet, Zubsolv
WEIGHT MANAGEMENT Megace ES 625mg/5ml oral suspension megestrol 625ml/5ml oral suspension
Start date of change*,**
Drug class Medications that will need approval (prior authorization)^
June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1
June 22, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Reditrex
June 1, 2021 ASTHMA/COPD/RESPIRATORY Zokinvy
March 14, 2021 CANCER Gavreto
January 1, 2021 BLOOD THINNERS/ANTI-CLOTTING Eliquis4, Pradaxa4, Savaysa4, Xarelto4
Start date of change*,**
Drug class Medications that will have a quantity limit
June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1
June 1, 2021 ASTHMA/COPD/RESPIRATORY Zokinvy
May 15, 2021 EYE CONDITIONS Eysuvis
May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo
March 14, 2021 CANCER Gavreto
Start date of change*,**
Drug classMedications being added to Step Therapy Program^,^^
Generic and/or preferred brand alternatives
July 1, 2021 DIABETES Jentadueto, Jentadueto XR, Tradjenta metformin
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
CIGNA TOTAL SAVINGS PRESCRIPTION DRUG LIST (cont)
Start date of change*,**
Drug classMedications that will no longer be covered^^
Generic and/or preferred brand alternatives
June 29, 2021 SKIN CONDITIONS Klisyri topical fluorouracil, imiquimod 5% cream, Fluoroplex
June 22, 2021 GASTROINTESTINAL/HEARTBURN Reltone ursodiol
HORMONAL AGENTS Thyquidity levothyroxine, levoxyl, Levo-T, Unithroid, Euthyrox
June 15, 2021 GASTROINTESTINAL/HEARTBURN Lubiprostone 8 mcg, 24 mcg capsule Amitiza
June 1, 2021 SKIN CONDITIONS Winlevi 1% cream Generic products (e.g. adapalene; tretinoin; clindamycin-benzoyl peroxide)
Wynzora 0.005%-0.064% cream betamethasone DP, fluocinolone, fluticasone, mometasone, trimacinolone, calcipotriene, calcipotriene-betamethasone DP
URINARY TRACT CONDITIONS Vesicare LS 5 mg/5 mL suspension oxybutynin chloride, oxybutynin chloride ER, darifenacin ER, solifenacin, tolterodine, tolterodine ER, tropsium
May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo tramadol
May 1, 2021 SKIN PREPS Impeklo topical betamethasone (augmented) 0.05%, clobetasol 0.05%, halobetasol propionate 0.05%, fluocinolide 0.1%
April 18, 2021 HORMONAL AGENTS Alkindi Sprinkle hydrocortisone 5mg tablet
March 28, 2021 BLOOD PRESSURE/HEART MEDICATIONS Conjupri amlodipine, felodipine, nifedipine, nicardipine
January 1, 2021 ANXIETY/DEPRESSION/BIPOLAR DISORDER Forfivo XL bupropion XL tablet
Paxil CR paroxetine ER
ASTHMA/COPD/RESPIRATORY Advair HFA7, Breo Ellipta7 Dulera, fluticasone-salmeterol (generic Advair Diskus), fluticasone-salmeterol (generic Airduo), Symbicort, Wixela Inhub
Kalydeco5, Orkambi5, Symdeko5 Trikafta3
ProAir HFA7, ProAir RespiClick7 albuterol HFA
ATTENTION DEFICIT HYPERACTIVITY DISORDER Intuniv guanfacine ER
Strattera atomoxetine capsule
BLOOD PRESSURE/HEART MEDICATIONS Ranexa ranolazine ER
CANCER Pomalyst5 Revlimid
CHOLESTEROL MEDICATIONS Lovaza omega-3 acid ethyl esters capsule
CONTRACEPTION PRODUCTS Balcoltra, Loseasonique, Natazia, Quartette, Slynd, Taytulla7
Generic oral contraceptives (e.g. levonorgestrel-ethinyl estradiol)
Beyaz, Safyral, Yasmin 28, Yaz Generic oral contraceptives (e.g. drospirenone-ethinyl estradiol-levomefolate)
Depo-Provera medroxyprogesterone
Estrostep FE Generic oral contraceptives (e.g. Tilia FE, Tri-Legest FE)
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
CIGNA TOTAL SAVINGS PRESCRIPTION DRUG LIST (cont)
Start date of change*,**
Drug classMedications that will no longer be covered^^
Generic and/or preferred brand alternatives
January 1, 2021 CONTRACEPTION PRODUCTS Generess FE, Layolis FE, Loestrin FE, Miastrin 24 FE
Generic oral contraceptives (e.g. norethindrone-ethinyl estradiol-FE)
Loestrin Generic oral contraceptives (e.g. norethindrone-ethinyl estradiol)
Mirapex ER 4.5mg tablet pramipexole ER 4.5mg tablet
NuvaRing etonogestrel-ethinyl estradiol vaginal ring
Ortho Micronor Generic oral contraceptives (e.g. norethindrone 0.35mg)
Prenatabas FA Pretab 29mg-1mg tablet
DIABETES GlucaGen HypoKit7, Gvoke Baqsimi, Glucagon Emergency Kit
Janumet8, Janumet XR8, Januvia8 metformin, Jentadueto, Jentadueto XR, Tradjenta
EYE CONDITIONS Cequa, Restasis MultiDose7, Xiidra7 Restasis
FML Liquifilm fluorometholone eye drops
Lotemax drops loteprednol 0.5% drops
Travatan Z, Xalatan, Xelpros, Zioptan9 bimatoprost, latanoprost, travoprost
GASTROINTESTINAL/HEARTBURN Apriso mesalamine ER capsule
Carafate7 sucralfate
Creon7, Pertzye, Zenpep7 Pancreaze
Linzess7, Motegrity, Trulance7, Zelnorm Amitiza
Sensipar cinacalcet
HORMONAL AGENTS Armour Thyroid, Synthroid7, Tirosint, Tirosint Sol, Unithroid7
levothyroxine
Cortef hydrocortisone tablet
Minivelle estradiol patch
TaperDex dexamethasone 1.5mg tablet
Vivelle-Dot estradiol patch
INFECTIONS Baraclude entecavir tablet
Noxafil tablet posaconazole DR 100mg tablet
Sulfatrim sulfamethoxazole-TMP suspension
Tamiflu oseltamivir
MULTIPLE SCLEROSIS Ampyra ER7 dalfampridine ER
Avonex7, Extavia7, Plegridy7, Rebif7 Betaseron, glatiramer, Glatopa
Gilenya7, Mavenclad, Mayzent7, Tecfidera7, Zeposia7
Vumerity
NUTRITIONAL/DIETARY PreGenna, Trinaz Any generic prenatal vitamin
VitaTrue Combo Pack Prena1 True Combo Pack
PAIN RELIEF AND INFLAMMATORY DISEASE Amerge, Frova, Maxalt, Maxalt MLT, Relpax generic triptans (e.g. naratriptan; sumatriptan)
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
CIGNA TOTAL SAVINGS PRESCRIPTION DRUG LIST (cont)
Start date of change*,**
Drug classMedications that will no longer be covered^^
Generic and/or preferred brand alternatives
January 1, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE (cont)
butalbital-acetaminophen 50-300mg tablet butalbutal-acetaminophen 50-325mg tablet
diclofenac 1.3% patch, Flector 1.3% patch3,5, Voltaren 1% gel5
diclofenac 1% gel, oral generic Rx NSAIDs (e.g. celecoxib; meloxicam)
Humira7 Actemra, Cimzia, Cosentyx, Enbrel, Simponi 100mg, Stelara, Tremfya
Ilumya7, Otezla7, Skyrizi7 Cimzia, Cosentyx, Enbrel, Olumiant, Stelara, Tremfya
Kevzara, Rinvoq7 Actemra, Cimzia, Enbrel, Olumiant
Orencia Actemra, Cimzia, Cosentyx, Enbrel, Olumiant, Stelara
Uloric febuxostat
Xeljanz7, Xeljanz XR7 Actemra, Cimzia, Cosentyx, Enbrel, Olumiant, Simponi 100mg, Stelara
SEIZURE DISORDERS Carbatrol, Tegretol XR carbamazepine ER capsule
Depakote divalproex
Depakote ER divalproex ER
Depakote Sprinkle divalproex DR sprinkle capsule
Felbatol11 felbamate
Keppra/Keppra X11 levetiracetam/levetiracetam ER
Lamictal XR Start Kit11 lamotrigine ER
Lamictal/ODT/XR11 lamotrigine, lamotrigine ER, lamotrigine ODT
Onfi clobazam
Qudexy XR11, Trokendi XR11 topiramate ER
Sabril11 vigabatrin, vigadrone
Topamax11 topiramate
Trileptal11 oxcarbazepine
Zonegran11 zonisamide
SKIN CONDITIONS Apexicon E5, diflorasone, Impoyz5, Olux5, Olux-E5, Psorcon7
betamethasone, clobetasol, halobetasol
Condylox imiquimod 5% cream packet, podofilox 0.5% topical solution
Cordran5 betamethasone, clobetasol, fluocinolone, fluticasone, halobetasol
Elidel pimecrolimus cream
Finacea, MetroCream, MetroGel, MetroLotion, Soolantra12
azelaic acid, topical metronidazole
flurandrenolide, hydrocortisone butyrate lipid cream, lotion5, Pandel5
betamethasone, fluocinolone, fluticasone
CIGNA NATIONAL PRESCRIPTION DRUG LIST
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
Start date of change*,**
Drug classMedications that will no longer be covered^^
Generic and/or preferred brand alternatives
January 1, 2021 SKIN CONDITIONS (cont) Tridesilon5 alclometasone, desonide, triamcinolone
Xolegel ciclopirox 0.77% gel, ciclopirox 1% shampoo, ketoconazole 2% cream, ketoconazole 2% foam, selenium 2.5% lotion, sodium sulfacetamide 10% shampoo
SLEEP DISORDERS/SEDATIVES Belsomra8 Dayvigo
TRANSPLANT MEDICATIONS Myfortic mycophenolic acid
Prograf tacrolimus
URINARY TRACT CONDITIONS Procysbi4 CystagonStart date of change*,**
Drug classMedications that will be excluded from coverage
Additional information
January 1, 2021 ALLERGY/NASAL SPRAYS Beconase AQ, Nasonex, Omnaris, Qnasl, Qnasl Children, Xhance, Zetonna,
flunisolide, fluticasone, mometasone
flunisolide, mometasone spray generics products available over-the-counter (e.g. budesonide, fluticasone)
fluticasone 50 mcg spray generics products available over-the-counter (e.g. budesonide)
EYE CONDITIONS azelastine, epinastine products available over-the-counter (e.g. Alaway, Pataday)
Bepreve, Lastacaft, Pazeo, Zerviate azelastine, epinastine eye drops
SKIN CONDITIONS Rosadan Kits azelaic acid, topical metronidazole
CIGNA TOTAL SAVINGS PRESCRIPTION DRUG LIST (cont)
Start date of change*,**
Drug class Medications moving to preferred brand
May 7, 2021 CANCER Tabrecta1
April 16, 2021 BLOOD PRESSURE/HEART MEDICATIONS Verquvo
April 2, 2021 CANCER Xtandi
MULTIPLE SCLEROSIS Plegridy1
March 19, 2021 MULTIPLE SCLEROSIS Mayzent 0.25 MG Starter Pack
February 19, 2021 MULTIPLE SCLEROSIS Aubagio1
Start date of change*,**
Drug classMedications becoming non-preferred brand
Generic and/or preferred brand alternatives
April 2, 2021 URINARY TRACT CONDITIONS Gemtesa 75mg tablet darifenacin er, oxybutynin chloride er, tolterodine tartrate er, trospium chloride, Myrbetriq, Toviaz ER
March 19, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1 Takhzyro
INFECTIONS Dificid 40mg/ml suspension vancomycin hcl
February 5, 2021 EYE CONDITIONS Eysuvis 0.25% Eye Drops loteprednol etabonate, artificial tears
January 22, 2021 INFECTIONS Alinia 500mg Tablet nitazoxanide
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
CIGNA NATIONAL PRESCRIPTION DRUG LIST cont.
Start date of change*,**
Drug classMedications becoming non-preferred brand
Generic and/or preferred brand alternatives
January 16, 2021 HORMONAL AGENTS Mycapssa DR 20 mg capsule1 Somatuline Depot
PARKINSON’S DISEASE Ongentys 50 mg capsule entacapone
Start date of change*,**
Drug class Medications that will need approval (prior authorization)^
May 17, 2021 BLOOD MODIFIERS/BLEEDING DISORDERS Nyvepria1
April 1, 2021 EYE CONDITIONS Eysuvis 0.25% ophthalmic suspension
Lacrisert
HORMONAL AGENTS Synarel1
January 16, 2021 HORMONAL AGENTS Mycapssa DR 20 mg capsule1
PARKINSON’S DISEASE Ongentys 50 mg capsule
January 15, 2021 ASTHMA/COPD/RESPIRATORY Zokinvy1
Start date of change*,**
Drug class Medications that will have a quantity limit
May 17, 2021 CANCER Vitrakvi1
HORMONAL AGENTS Xyosted
NUTRITIONAL/DIETARY Nascobal 500mcg/0.1ml nasal spray device
PAIN RELIEF AND INFLAMMATORY DISEASE Humira 80mg/0.8ml pen1
SKIN CONDITIONS Condylox 0.5% gel
May 17, 2021 SLEEP DISORDERS/SEDATIVES Hetlioz LQ 4mg/ml oral suspension1
May 3, 2021 NUTRITIONAL/DIETARY Calcium 667mg
Phoslyra 667mg/5ml oral solution
Renvela
April 15, 2021 DIABETES Ozempic 4mg/3ml (1.34mg/ml) pre-filled pen
April 1, 2021 ANXIETY/DEPRESSION/BIPOLAR DISORDER Pexeva
PAIN RELIEF AND INFLAMMATORY DISEASE Xeljanz 1 mg/ml oral solution1
SKIN CONDITIONS Gentamicin 0.1% cream, ointment
March 15, 2021 ASTHMA/COPD/RESPIRATORY Trikafta 100/50/75 mg-150 mg tablets1
BLOOD PRESSURE/HEART MEDICATIONS Verquvo
NUTRITIONAL/DIETARY Velphoro 500 mg tablets
SLEEP DISORDERS/SEDATIVES Xyrem1
Xywav1
March 2, 2021 ANTIPARKINSON DRUGS Inbrija 42 mg capsules1
ASTHMA/COPD/RESPIRATORY Trelegy Ellipta 200/62.5/25 mcg
Zokinvy1
HORMONAL AGENTS Divigel 1.25 gram
PARKINSON’S DISEASE Ongentys 25 mg, 50 mg capsules
CIGNA NATIONAL PRESCRIPTION DRUG LIST cont.
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
Start date of change*,**
Drug class Medications that will have a quantity limit
March 2, 2021 SEIZURE DISORDERS Fintepla 2.2 mg/ml oral solution1
February 15, 2021 CONTRACEPTION PRODUCTS Phexxi
February 5, 2021 EYE CONDITIONS Eysuvis 0.25% ophthalmic suspension
Start date of change*,**
Drug classMedications being added to Step Therapy Program^,^^
Generic and/or preferred brand alternatives
April 15, 2021 INFECTIONS Vibramycin cap, suspension, and syrup Doxycycline, Minocycline
SKIN CONDITIONS Kerydin generic (Tavaborale) Ciclodan 8% topical solution (branded generic), ciclopirox 8% topical solution, ciclopirox 8% treatment kit
Start date of change*,**
Drug classMedications that will no longer be covered^^
Generic and/or preferred brand alternatives
May 16, 2021 AIDS/HIV Cabenuva suspension atazanavir, lamivudine, Dovato, Edurant, Juluca, Prezista, Tivicay
CANCER Tepmetko1 Tabrecta
CONTRACEPTION PRODUCTS Tyblume altavera, aviane, falmina, lessina, levonor-eth etrad, portia, vienva
PAIN RELIEF AND INFlAMMATORY DISEASE Reditrex methotrexage inj, Rasuvo
SKIN CONDITIONS Tazarotene 0.1% foam tazarotene cream, Tazorac gel
TRANSPLANT MEDICATIONS Lupkynis1 mycophenolate, prednisone
April 16, 2021 CANCER Orgovyx1 Eligard, Firmagon
Riabni 100mg/10ml, 500mg/50ml vial1 Ruxience
GASTROINTESTINAL/HEARTBURN Reltone 200 mg, 400 mg capsule ursodiol
HORMONAL AGENTS Thyquidity euthyrox, levo-t, levothyroxine, levoxyl
SKIN CONDITIONS Impeklo 0.05% Lotion betamethasone dipropionate, clobetasol, desonide, desoximetasone, diflorasone, fluocinonide, halcinonide
Klisyri 1% ointment packet diclofenac 3% gel, fluorouracil 5% cream, solution, imiquimod 5% cream
April 1, 2021 ANXIETY/DEPRESSION/BIPOLAR DISORDER Pexeva, Viibryd citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline
BLOOD PRESSURE/HEART MEDICATIONS Bystolic atenolol, carvedilol, metoprolol succinate
Edarbi candesartan, irbesartan, losartan, olmesartan, telmisartan, valsartan
Edarbyclor candesartan-HCTZ, irbesartan-HCTZ, losartan-HCTZ, olmesartan-HCTZ, telmisartan-HCTZ, valsartan-HCTZ, chlorthalidone plus valsartan
CONTRACEPTION PRODUCTS Annovera generic oral contraceptives, Xulane patches
Balcoltra Aviane, Larissia, Lessina, levonorgestrel-eth estradiol, Sronyx, Vienva
Lo Loestrin FE Blisolvi FE, Blisolvi 24 FE, Hailey FE, Junel FE, Larin FE, Melodetta 24 FE, norethindrone-eth estradiol FE
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
CIGNA NATIONAL PRESCRIPTION DRUG LIST cont.
Start date of change*,**
Drug classMedications that will no longer be covered^^
Generic and/or preferred brand alternatives
April 1, 2021 CONTRACEPTION PRODUCTS Natazia Blisolvi FE, drospirenone-ethinyl estradiol, Estarylla, Junel FE, Sprintec, Tri-Sprintec
Slynd generic progestin-only oral contraceptives
Taytulla Gemmily, norethindrone-eth estradiol FE
DIABETES Afrezza Humalog, Lyumjev
GASTROINTESTINAL/HEARTBURN Clenpiq Gavilyte-G, peg-electrolyte solution, peg-3350, Trilyte with Flavor packets.
Golytely Packets Gavilyte-G, peg-electrolyte solution, peg-3350, Trilyte with Flavor packets.
Plenvu Gavilyte-G, peg-electrolyte solution, peg-3350, Trilyte with Flavor packets.
Suprep Gavilyte-G, peg-electrolyte solution, peg-3350, Trilyte with Flavor packets.
HORMONAL AGENTS Osphena estradiol (cream), Yuvafem, Estring, Premarin (cream)
Premarin Tablets estradiol tablets
Premphase Amabelz, estradiol-norethindrone acetate, Fyavolv, Jinteli, Mimvey, norethindrone-ethinyl estradiol
Prempro Amabelz, estradiol-norethindrone acetate, Fyavolv, Jinteli, Mimvey, norethindrone-ethinyl estradiol
SKIN CONDITIONS Drysol Over the counter alternatives.
March 16, 2021 GASTROINTESTINAL/HEARTBURN Lubiprostone 8 mcg, 24 mcg capsule Linzess, Trulance
PAIN RELIEF AND INFLAMMATORY DISEASE Zolmitriptan 2.5 mg, 5 mg Nasal Spray sumatriptan nasal, Zomig nasal
SKIN CONDITIONS Wynzora 0.005%-0.064% Cream betamethasone dipropionate, calcipotriene-betamethasone dipropionate, clobetasol propionate, diflorasone diacetate, calcipotriene (generic), Enstilar
URINARY TRACT CONDITIONS Vesicare LS 5 MG/5 ML supension oxybutynin, oxybutynin ER
March 12, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo 5 MG/ML Solution tramadol (generic tablet)
March 2, 2021 BLOOD PRESSURE/HEART MEDICATIONS Conjupri amlodipine, felodipine, nifedipine, nicardipine
GASTROINTESTINAL/HEARTBURN Sutab 1.479-0.225-0.188 GM tab Gavilyte-G, peg-electrolyte solution, peg-3350, Trilyte with Flavor packets.
SKIN CONDITIONS Winlevi 1% cream clindamycin topical, clindamycin-tretionin, erythromycin topical, tretinoin, Amzeeq, Onexton
February 5, 2021 EYE CONDITIONS Eysuvis 0.25% Eye Drops loteprednol etabonate, artificial tears
Cigna reserves the right to make changes to the Drug List without notice. Your plan may cover additional medications; please refer to your enrollment materials for details. Cigna does not take responsibility for any medication decisions made by the doctor or pharmacist. Cigna may receive payments from manufacturers of certain preferred brand medications, and in limited instances, certain non-preferred brand medications, that may or may not be shared with your plan depending on its arrangement with Cigna. Depending upon plan design, market conditions, the extent to which manufacturer payments are shared with your plan and other factors as of the date of service, the preferred brand medication may or may not represent the lowest-cost brand medication within its class for you and/or your plan. Health benefit plans vary, but in general to be eligible for coverage a drug must be approved by the Food and Drug Administration (FDA), prescribed by a health care professional, purchased from a licensed pharmacy and medically necessary. If your plan provides coverage for certain prescription drugs with no cost-share, you may be required to use an in-network pharmacy to fill the prescription. If you use a pharmacy that does not participate in your plan’s network, your prescription may not be covered, or reimbursement may be limited by your plan’s copayment, coinsurance or deductible requirements. Certain features described in this document may not be applicable to your specific health plan, and plan features may vary by location and plan type. Refer to your plan documents for costs and complete details of your plan’s prescription drug coverage.
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, and HMO or service company subsidiaries of Cigna Health Corporation. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.
951712 © 2021 Cigna. Some content provided under license. CRP2012_007122.1 UPDATED_05/21/2021
* State laws in 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.
** 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.
^ These changes may not apply to your specific plan. That’s because some plans don’t have prior authorization, quantity limits and/or Step Therapy. Log in to the myCigna App or website, or check your plan materials, to find out if your plan includes these extra coverage requirements.
^^ These medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving coverage of your medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy and the cost can’t be applied to your annual deductible or out-of-pocket maximum.
1. This is a specialty medication. For plans that cover specialty medications on a specialty tier, this change won’t affect the cost of the medication. Please log in to the myCigna App or website, or check your plan materials, to learn more about how your plan covers specialty medications.
2. Please log in to the myCigna App or website, or check your plan materials, to learn more about how your plan covers brand name medications that have a generic equivalent available. Depending on your plan, you may have to pay an additional charge (on top of your plan’s cost-share) for filling the brand name medication.
3. These changes may not apply to your specific plan. That’s because some plans don’t have prior authorization, quantity limits and/or Step Therapy. Log in to the myCigna App or website, or check your plan materials, to find out if your plan includes these extra coverage requirements.
4. If you’re currently taking this medication, this change won’t affect you.5. If you currently have approval for your plan to cover this medication, it’s important to know that your approval will end on 1/1/21. If your doctor wants you to continue taking this medication,
ask his or her office to contact Cigna to start the coverage review process.6. This medication needs approval from Cigna before your plan will cover it. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving coverage
of your medication. If you don’t get approval and you continue to fill this prescription on or after January 1st, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy and the cost can’t be applied to your annual deductible or out-of-pocket maximum.
7. If Cigna approves coverage of this medication through a review process, it may cost you more as of January 1st. You’ll pay your tier 3 (non-preferred brand) copay or coinsurance when you fill it.8. This medication will no longer be part of Step Therapy as of 1/1/21. If you currently have approval for your plan to cover this medication, your approval will end on 1/1/21. If your doctor wants
you to continue taking this medication, ask his or her office to contact Cigna to start the coverage review process. If Cigna approves coverage of this medication through a review process, it may cost you more as of January 1st. You’ll pay your tier 3 (non-preferred brand) copay or coinsurance when you fill it.
9. This medication will no longer be part of Step Therapy as of 1/1/21. If you currently have approval for your plan to cover this medication, it’s important to know that your approval will end on 1/1/21. If your doctor wants you to continue taking this medication, ask his or her office to contact Cigna to start the coverage review process.
10. If you currently have approval for your plan to cover this medication, it’s important to know that your approval will end on 1/1/21. If your doctor wants you to continue taking this medication, ask his or her office to contact Cigna to start the coverage review process. If Cigna re-approves coverage, it may cost you more as of January 1st. You’ll pay your tier 3 (non-preferred brand) copay or coinsurance when you fill it.
11. This change will only affect you if you’re taking this medication to treat a seizure condition. Also, it’s important to know that your current approval to receive coverage for this medication will end on 1/1/21. If your doctor wants you to continue taking this medication, ask his or her office to contact Cigna to start the coverage review process.
12. If Cigna approves coverage of this medication through a review process, it may cost you more as of January 1st. You’ll pay your tier 3 (non-preferred brand) copay or coinsurance when you fill it. Also, because this medication has a generic equivalent available, you may have to pay an additional charge on top of your non-preferred brand cost-share. Please check your plan materials to find out how your plan covers brand name medications.
13. If you currently have approval for your plan to cover this medication, you can continue to receive coverage until your approval ends.14. Starting 1/1/21, this medication will also need approval from Cigna before your plan will cover it.15. Starting 1/1/21, this medication will also be part of the Step Therapy program. If you currently have approval for your plan to cover this medication, it’s important to know that your approval
will end on 1/1/21. If your doctor wants you to continue taking this medication, ask his or her office to contact Cigna to start the coverage review process.16. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving coverage of your medication. If you don’t get approval and you continue to fill this
prescription on or after January 1st, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy and the cost can’t be applied to your annual deductible or out-of-pocket maximum.