Insured by Cigna Health and Life Insurance Company
2015 Cigna
RX ESSENTIAL
prescription drug list
The Cigna Rx Essential 4-Tier Prescription Drug List is applicable to plans
in California, effective 1/1/2015.
This cover page is for brokers only. Please discard if
providing the list to customers.
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Tel-Drug, Inc. and
Tel-Drug of Pennsylvania, L.L.C. “Cigna Home Delivery Pharmacy” refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C. The Cigna name, logo, and other Cigna marks are owned by Cigna
Intellectual Property, Inc.
863932 b 12/14 ©2014 Cigna
Insured by Cigna Health and Life Insurance Company
2015 Cigna
RX ESSENTIAL
prescription drug list
4-Tier
Choosing the medication that is right for you is between you and your doctor. This prescription drug
list offers you an extensive list of generic and brand name medications that are covered under your
pharmacy plan.
Choosing where to fill your medication should be easy, too. With access to a broad network of national,
regional and local retail pharmacies, as well as Cigna Home Delivery PharmacySM, you have convenient
access to your medications – whether you pick them up or have them delivered to your home.
Within this document you will find a list of medications covered under your plan, in an easy-to-read
format. You will see:
1. Medications split into four categories (generic, preferred brand, non-preferred brand and
specialty medications)
2. Medications listed in alphabetical order
3. Symbols to let you know if there are any important details related to coverage
Offered by: Cigna Health and Life Insurance Company
Your four-tier prescription drug list
A four-tier prescription drug list splits medications into four categories (or tiers):
Tier 1: Generic medications. Generic medications have the same quality, strength, purity and stability as their brand name
counterparts. On a four-tier plan, generic medications are available at the lowest cost sharing to you.
Tier 2: Preferred Brand Medications. This tier typically includes preferred brand medications and some high cost generic
medications. On a four-tier plan, these medications will usually cost you more than a Tier 1 generic, but less than
a Tier 3 medication.
Tier 3: Non-Preferred Brand Medications. This tier typically includes non-preferred brand medications and high cost generic
medications. Non-preferred brand medications generally have generic alternatives and/or one or more preferred brand option
within the same drug class. On a 4-Tier plan, these medications will usually cost you more than those in tiers 1 and 2.
Tier 4: Specialty Medications. This tier includes a mix of high cost generic and brand name Specialty medications. “Specialty
Medications” are medications that are used to treat an underlying disease which is considered to be rare and chronic and
includes, but is not limited to, multiple sclerosis, hepatitis C or rheumatoid arthritis. Specialty medications may include high cost
medications as well as medications that may require special handling and close supervision when being administered.
Understanding Cigna’s prescription drug list
Every medication available on Cigna’s prescription drug list has been approved by the U.S. Food and Drug Administration (FDA).
This list represents the medications covered under your plan. If you do not see a specific medication on this list, please check
myCigna.com to see a current listing of all of the medications covered under your plan.
The symbols on the list mean
If a medication on the list has one of the following symbols, your doctor may have to get an authorization
(approval) for coverage of that medication.
PA:
Prior Authorization may be required for different reasons. To learn the requirements needed for
coverage of a specific medication, feel free to give us a call.
QL:
Quantity Limit means you may have coverage for a limited amount of a specific medication.
AGE:
ST:
Age Requirement means that a person must be within a specific age group for a specific medication
to be covered.
Step Therapy is a prior authorization program that requires you to try other medications available
to treat the same condition before the medication with the “ST” is covered.
2
myCigna.com
Our customer website that can help you manage your prescription coverage:
When you visit myCigna.com, you can:
• Look up the details of your specific pharmacy plan
• Research thousands of available medications
• Compare medication prices using the Prescription Drug Price Quote tool
• Ask a pharmacist questions
• And much, much more!
Medications delivered right to your home
Cigna Home Delivery Pharmacy is designed for people who take prescription medications on a regular
basis (including specialty medications). The benefits of Cigna Home Delivery Pharmacy include:
• QuickFill, our automatic refill reminder service, makes it simple for
you to fill prescriptions through email or phone
• Up to a 90-day supply of medications in one fill
• Specialty medications for more complex conditions, including those
that require refrigeration and overnight delivery
• Delivery of medications to your door at no additional charge
• Licensed pharmacists available to help 24/7
• CoachRx: a free tool that can help with reminders, coaching and information.
Visit Cigna.com/coachrx to learn more
• It’s easy to switch! Just call
1.800.285.4812
For more information, visit the Cigna Home Delivery Pharmacy page on myCigna.com.
3
Save time and
money with the
convenience
of Cigna
Home Delivery
Pharmacy
Health care reform and you
The Patient Protection and Affordable Care Act (PPACA), commonly referred to as “health care reform,” was signed into law
on March 23, 2010. This important legislation will result in changes to every American’s health coverage. Some of the changes
took effect in 2010, and most of the law’s effects will be felt by 2014. Cigna will comply with all provisions of the law including
those that impact your pharmacy coverage plan. For example, coverage of medications that have not traditionally been included
in pharmacy plans, such as specific over-the-counter (OTC) medications, is available at no cost-share to you. As with all covered
medications, we require a prescription from your doctor to process the claim under your pharmacy plan (including OTC
medications). To get the most current information, visit www.informedonreform.com or Cigna.com and look for the “Informed
on Reform” link.
If you have questions
Please call the toll-free number on the back of your Cigna ID card. We’re here to help.
4
Cigna prescription drug list
DRUG NAME
Tier
NOTES (PA, ST, QL, AGE)
DRUG NAME
Tier
ACAMPROSATE CALCIUM
1
ALENDRONATE SODIUM 70 MG TABLET
1
ACARBOSE
1
1
ACEBUTOLOL HCL
1
ALENDRONATE SODIUM 70 MG/75ML
SOLUTION, ORAL
ACETAMINOPHEN-BUTALBITAL
1
ALFUZOSIN HCL ER
1
ACETAMINOPHEN-CODEINE
1
ALINIA
3
ACETASOL HC
1
ALLOPURINOL
1
ACETAZOLAMIDE
1
ALPRAZOLAM
1
ACETIC ACID
1
ALPRAZOLAM ER
1
ACETIC ACID-ALUMINUM
1
ALPRAZOLAM INTENSOL
1
ACETYLCYSTEINE
1
ALPRAZOLAM ODT
1
ACITRETIN
3
ALPRAZOLAM XR
1
ACYCLOVIR 200 MG CAPSULE
1
ALTAVERA
1
ACYCLOVIR 200 MG/5ML SUSPENSION,
ORAL (FINAL DOSE FORM)
1
ALYACEN
1
AMANTADINE
1
ACYCLOVIR 400 MG TABLET
1
AMCINONIDE
1
ACYCLOVIR 5 % OINTMENT (GRAM)
1
AMETHIA
1
ACYCLOVIR 800 MG TABLET
1
AMETHIA LO
1
ADAPALENE
1
AMETHYST
1
ADDERALL XR
1
AMILORIDE HCL
1
AFEDITAB CR
1
AMILORIDE-HYDROCHLOROTHIAZIDE
1
AGGRENOX
3
AMIODARONE HCL
1
AK-POLY-BAC
1
AMITIZA
3
ALAGESIC LQ
1
AMITRIPTYLINE HCL
1
ALBUTEROL SULFATE 0.63MG/3ML VIAL,
NEBULIZER (ML)
1
AMLODIPINE BESYLATE
1
AMLODIPINE BESYLATE-BENAZEPRIL
1
ALBUTEROL SULFATE 1.25MG/3ML VIAL,
NEBULIZER (ML)
1
AMLODIPINE-ATORVASTATIN
1
ALBUTEROL SULFATE 2 MG TABLET
1
AMLODIPINE-VALSARTAN
1
ALBUTEROL SULFATE 2 MG/5 ML SYRUP
1
AMMONIUM LACTATE
1
ALBUTEROL SULFATE 2.5 MG/0.5 VIAL,
NEBULIZER (EA)
1
AMNESTEEM
1
AMOX TR-POTASSIUM CLAVULANATE
1
ALBUTEROL SULFATE 2.5 MG/3ML VIAL,
NEBULIZER (ML)
1
AMOXAPINE
1
AMOXICILLIN
1
ALBUTEROL SULFATE 4 MG TABLET
1
AMOXICILLIN-CLAVULANATE ER
1
ALBUTEROL SULFATE 4 MG TABLET,
EXTENDED RELEASE 12 HR
1
AMPHETAMINE SALT COMBO
1
AMPICILLIN TRIHYDRATE
1
ALBUTEROL SULFATE 5 MG/ML SOLUTION,
NON-ORAL
1
ANA-LEX
1
ALBUTEROL SULFATE 8 MG TABLET,
EXTENDED RELEASE 12 HR
1
ANASTROZOLE
1
ANTIPYRINE-BENZOCAINE
1
ALCLOMETASONE DIPROPIONATE
1
ANUCORT-HC
1
ALENDRONATE SODIUM 10 MG TABLET
1
APEXICON E
1
ALENDRONATE SODIUM 35 MG TABLET
1
APRACLONIDINE HCL
1
ALENDRONATE SODIUM 40 MG TABLET
1
APRI
1
ALENDRONATE SODIUM 5 MG TABLET
1
APRISO
2
AGE
5
NOTES (PA, ST, QL, AGE)
QL
DRUG NAME
Tier
NOTES (PA, ST, QL, AGE)
DRUG NAME
Tier
NOTES (PA, ST, QL, AGE)
ARANELLE
1
BPM-DM-PHEN
1
ARBINOXA
1
BPO
1
ARMOUR THYROID
1
BREVICON
3
ASCOMP WITH CODEINE
1
BRIELLYN
1
ASPIRIN-CAFFEINE-DIHYDROCODEIN
1
BRIMONIDINE TARTRATE
1
ATENOLOL
1
BROMFED DM
1
ATENOLOL-CHLORTHALIDONE
1
BROMFENAC SODIUM
1
ATORVASTATIN CALCIUM
1
BROMOCRIPTINE MESYLATE
1
ATOVAQUONE
1
BROMPHENIRAMINE-PSEUDOEPHED-DM
1
ATOVAQUONE-PROGUANIL HCL
1
BRONCOTRON PED
1
ATROPINE CARE
1
BRONCOTRON-S
1
ATROPINE SULFATE
1
BUDESONIDE
1
AUBRA
1
BUDESONIDE EC
3
AVAR
1
BUMETANIDE
1
AVAR-E
1
BUPRENORPHINE HCL
1
AVAR-E GREEN
1
BUPRENORPHINE-NALOXONE
1
AVIANE
1
BUPROBAN
1
AZELASTINE HCL
1
BUPROPION HCL
1
AZILECT
3
BUPROPION HCL SR
1
AZITHROMYCIN
1
BUPROPION XL
1
AZOPT
2
BUSPIRONE HCL
1
AZURETTE
1
BUTALB-ACETAMINOPH-CAFF-CODEIN
1
BACITRACIN
1
BUTALB-CAFF-ACETAMINOPH-CODEIN
1
BACITRACIN-POLYMYXIN
1
BUTALBITAL COMPOUND-CODEINE
1
BACLOFEN
1
BUTALBITAL-ACETAMINOPHEN-CAFFE
1
BAL-CARE DHA
1
BUTALBITAL-ASPIRIN-CAFFEINE
1
BALSALAZIDE DISODIUM
1
BUTORPHANOL TARTRATE
1
QL
BALZIVA
1
BYDUREON
2
QL
BELLADONNA-OPIUM
1
BYDUREON PEN
2
QL
BENAZEPRIL HCL
1
BYETTA
2
BENAZEPRIL-HYDROCHLOROTHIAZIDE
1
CABERGOLINE
1
BENZONATATE
1
CAFFEINE CITRATE
1
BENZOYL PEROXIDE
1
CALCIPOTRIENE
1
BENZTROPINE MESYLATE
1
CALCIPOTRIENE-BETAMETHASONE DP
1
BETAMETHASONE DIPROPIONATE
1
CALCITONIN-SALMON
1
BETAMETHASONE VALERATE
1
CALCITRENE
1
BETAXOLOL HCL
1
CALCITRIOL
1
BETHANECHOL CHLORIDE
1
CALCIUM ACETATE
1
BEYAZ
2
CAMILA
1
BILTRICIDE
3
CAMRESE
1
BISOPROLOL FUMARATE
1
CAMRESE LO
1
BISOPROLOL-HYDROCHLOROTHIAZIDE
1
CANDESARTAN CILEXETIL
1
BP 10-1
1
CANDESARTAN-HYDROCHLOROTHIAZID
1
BP WASH
1
CANTIL
3
BP WASH ACNE TREATMENT
1
CAPACET
1
6
PA
QL
DRUG NAME
Tier
NOTES (PA, ST, QL, AGE)
DRUG NAME
Tier
CAPTOPRIL
1
CEPHALEXIN 500 MG CAPSULE
1
CAPTOPRIL-HYDROCHLOROTHIAZIDE
1
CEPHALEXIN 500 MG TABLET
1
CARBAMAZEPINE 100 MG CAPSULE,
EXTENDED RELEASE MULTIPHASE 12HR
1
CEPHALEXIN 750 MG CAPSULE
1
CETIRIZINE HCL
1
CARBAMAZEPINE 100 MG TABLET,
CHEWABLE
1
CEVIMELINE HCL
1
CARBAMAZEPINE 100 MG/5ML
SUSPENSION, ORAL (FINAL DOSE FORM)
1
CHATEAL
1
CHERATUSSIN AC
1
CARBAMAZEPINE 200 MG CAPSULE,
EXTENDED RELEASE MULTIPHASE 12HR
1
CHERATUSSIN DAC
1
CHLORDIAZEPOXIDE HCL
1
CARBAMAZEPINE 200 MG TABLET
1
CHLORDIAZEPOXIDE-AMITRIPTYLINE
1
CARBAMAZEPINE 300 MG CAPSULE,
EXTENDED RELEASE MULTIPHASE 12HR
1
CHLORDIAZEPOXIDE-CLIDINIUM
1
CHLORHEXIDINE GLUCONATE
1
CARBAMAZEPINE ER
1
CHLOROQUINE PHOSPHATE
1
CARBAMAZEPINE XR
1
CHLOROTHIAZIDE
1
CARBIDOPA
1
CHLORPROMAZINE HCL
1
CARBIDOPA-LEVODOPA
1
CHLORPROPAMIDE
1
CARBIDOPA-LEVODOPA ER
1
CHLORTHALIDONE
1
CARBIDOPA-LEVODOPA-ENTACAPONE
1
CHLORZOXAZONE
1
CARBINOXAMINE MALEATE
1
CHOLESTYRAMINE
1
CARISOPRODOL
1
CHOLESTYRAMINE LIGHT
1
CARISOPRODOL COMPOUND
1
CHOLINE MAG TRISALICYLATE
1
CARISOPRODOL COMPOUND-CODEINE
1
CICLODAN
1
CARISOPRODOL-ASPIRIN
1
CICLOPIROX
1
CARISOPRODOL-ASPIRIN-CODEINE
1
CILOSTAZOL
1
CARTEOLOL HCL
1
CIMETIDINE 200 MG TABLET
1
CARTIA XT
1
CIMETIDINE 300 MG TABLET
1
CARVEDILOL
1
1
CIMETIDINE 300 MG/5ML SOLUTION,
ORAL
1
CAZIANT
CEFACLOR
1
CIMETIDINE 400 MG TABLET
1
CEFACLOR ER
1
CIMETIDINE 800 MG TABLET
1
CEFADROXIL
1
CIPROFLOXACIN
1
CEFDINIR
1
CIPROFLOXACIN ER
1
CEFDITOREN PIVOXIL
1
1
CEFPODOXIME PROXETIL
1
CIPROFLOXACIN HCL 0.2 % DROPPERETTE,
SINGLE-USE DROP DISPENSER
CEFPROZIL
1
CIPROFLOXACIN HCL 0.3 % DROPS
1
CEFTIBUTEN
1
CIPROFLOXACIN HCL 100 MG TABLET
1
CEFUROXIME
1
CIPROFLOXACIN HCL 250 MG TABLET
1
CENTERGY
1
CIPROFLOXACIN HCL 500 MG TABLET
1
CENTERGY DM
1
CIPROFLOXACIN HCL 750 MG TABLET
1
CEPHALEXIN 125 MG/5ML SUSPENSION,
RECONSTITUTED, ORAL (ML)
1
CITALOPRAM HBR 10 MG TABLET
1
1
CEPHALEXIN 250 MG CAPSULE
1
CITALOPRAM HBR 10 MG/5 ML SOLUTION,
ORAL
CEPHALEXIN 250 MG TABLET
1
CITALOPRAM HBR 20 MG TABLET
1
CEPHALEXIN 250 MG/5ML SUSPENSION,
RECONSTITUTED, ORAL (ML)
1
CITALOPRAM HBR 40 MG TABLET
1
CLARAVIS
1
CLARIS
1
7
NOTES (PA, ST, QL, AGE)
QL
DRUG NAME
Tier
NOTES (PA, ST, QL, AGE)
DRUG NAME
Tier
CLARITHROMYCIN
1
CORTANE-B
1
CLARITHROMYCIN ER
1
CORTISONE ACETATE
1
CLEANSING WASH
1
CORTISPORIN-TC
3
CLEMASTINE FUMARATE
1
COVARYX
1
CLINDACIN ETZ
1
COVARYX H.S.
1
CLINDACIN P
1
CROMOLYN SODIUM
1
CLINDAMYCIN HCL
1
CRYSELLE
1
CLINDAMYCIN PALMITATE HCL
1
CUPRIMINE
3
CLINDAMYCIN PEDIATRIC
1
CYANOCOBALAMIN INJECTION
1
CLINDAMYCIN PHOS-BENZOYL PEROX
1
CYCLAFEM
1
CLINDAMYCIN PHOSPHATE
1
CYCLESSA
1
CLINDAMYCIN-BENZOYL PEROXIDE
1
CYCLOBENZAPRINE HCL 10 MG TABLET
1
CLOBETASOL EMOLLIENT
1
CYCLOBENZAPRINE HCL 5 MG TABLET
1
CLOBETASOL EMULSION
1
CYCLOBENZAPRINE HCL 7.5 MG TABLET
1
CLOBETASOL PROPIONATE
1
CYCLOPENTOLATE HCL
1
CLOCORTOLONE PIVALATE
1
CYCLOSERINE
1
CLODAN
1
CYPROHEPTADINE HCL
1
CLOMIPHENE CITRATE
1
CYTRA-2
1
CLOMIPRAMINE HCL
1
CYTRA-3
1
CLONAZEPAM
1
CYTRA-K
1
CLONIDINE
1
DANAZOL
1
CLONIDINE HCL
1
DANTROLENE SODIUM
1
CLONIDINE HCL ER
1
DAPSONE
3
CLOPIDOGREL
1
DASETTA
1
CLORAZEPATE DIPOTASSIUM
1
DAYSEE
1
CLORPRES
1
DEBLITANE
1
CLOTRIMAZOLE
1
DELYLA
1
CLOTRIMAZOLE-BETAMETHASONE
1
DEMECLOCYCLINE HCL
1
CLOZAPINE
1
DENTA 5000 PLUS
1
CLOZAPINE ODT
1
DENTAGEL
1
C-NATE DHA
1
DEPADE
1
COARTEM
3
DEPEN
3
CODEINE SULFATE
1
DERMAZENE
1
CODEINE-GUAIFENESIN
1
DESIPRAMINE HCL
1
COLCRYS
3
DESMOPRESSIN ACETATE
1
COLESTIPOL HCL
1
DESOGEN
3
COLOCORT
1
DESOGESTREL-ETHINYL ESTRADIOL
1
COMPLETE FORMULATION D3000
1
DESOGESTR-ETH ESTRAD ETH ESTRA
1
COMPLETE FORMULATION MULTIVIT
1
DESONIDE
1
COMPLETE FORMULATION PEDIATRIC
1
DESOXIMETASONE
1
COMPLETE NATAL DHA
1
DEXAMETHASONE
1
COMPLETENATE
1
DEXAMETHASONE INTENSOL
1
COMPRO
1
DEXAMETHASONE SODIUM PHOSPHATE
1
CONSTULOSE
1
DEXILANT
2
CORMAX
1
DEXMETHYLPHENIDATE HCL
1
QL
8
NOTES (PA, ST, QL, AGE)
ST
DRUG NAME
Tier
NOTES (PA, ST, QL, AGE)
DRUG NAME
Tier
DEXMETHYLPHENIDATE HCL ER
1
DULERA
2
DEXTROAMPHETAMINE SULFATE
1
DULOXETINE HCL
1
DEXTROAMPHETAMINE SULFATE ER
1
ECONAZOLE NITRATE
1
DIAZEPAM
1
DIBENZYLINE
3
DICLOFENAC POTASSIUM
1
DICLOFENAC SODIUM
1
DICLOFENAC SODIUM ER
1
DICLOFENAC SODIUM-MISOPROSTOL
1
DICLOXACILLIN SODIUM
1
DICYCLOMINE HCL 10 MG CAPSULE
1
DICYCLOMINE HCL 10 MG/5 ML
SOLUTION, ORAL
1
DICYCLOMINE HCL 20 MG TABLET
1
DIFLORASONE DIACETATE
1
DIFLUNISAL
1
DIGOX
1
DIGOXIN 125 MCG TABLET
1
DIGOXIN 250 MCG TABLET
1
DIGOXIN 50 MCG/ML SOLUTION, ORAL
1
DIHYDROERGOTAMINE MESYLATE
1
DILTIAZEM 24HR CD
1
DILTIAZEM 24HR ER
1
DILTIAZEM ER
1
DILTIAZEM HCL
1
DILT-XR
1
DIPHENHYDRAMINE HCL
1
DIPHENOXYLATE-ATROPINE
1
DIPYRIDAMOLE
1
DISKETS
1
DISOPYRAMIDE PHOSPHATE
1
DISULFIRAM
1
DIVALPROEX SODIUM
1
DIVALPROEX SODIUM ER
1
DONEPEZIL HCL
1
DONEPEZIL HCL ODT
1
DORZOLAMIDE HCL
1
DORZOLAMIDE-TIMOLOL
1
DOXAZOSIN MESYLATE
1
DOXEPIN HCL
1
DOXERCALCIFEROL
1
DOXYCYCLINE HYCLATE
1
DOXYCYCLINE MONOHYDRATE
1
1
1
1
1
1
1
1
1
1
1
3
3
1
3
1
1
1
1
1
1
1
1
1
1
1
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
DRONABINOL
1
ED-SPAZ
EEMT
EEMT H.S.
EFFER-K 25 MEQ TABLET, EFFERVESCENT
ELIMITE
ELINEST
ELIPHOS
ELITE OB DHA
ELITE-OB
ELITE-OB 400
ELLA
ELMIRON
EMOQUETTE
EMSAM
ENALAPRIL MALEATE
ENALAPRIL-HYDROCHLOROTHIAZIDE
ENDACOF-C
ENDOCET
ENDODAN
ENPRESSE
ENSKYCE
ENTACAPONE
ENULOSE
EPINASTINE HCL
EPINEPHRINE
EPIPEN 2-PAK
EPIPEN JR 2-PAK
EPITOL
EPLERENONE
EPROSARTAN MESYLATE
ERGOLOID MESYLATES
ERRIN
ERY
ERYGEL
ERYTHROCIN STEARATE
ERYTHROMYCIN
ERYTHROMYCIN ETHYLSUCCINATE
ERYTHROMYCIN-BENZOYL PEROXIDE
ESCITALOPRAM OXALATE
ESTARYLLA
ESTAZOLAM
ESTRADIOL .025MG/24H PATCH,
TRANSDERMAL WEEKLY
DROSPIRENONE-ETHINYL ESTRADIOL
1
ESTRADIOL .0375MG/24 PATCH,
TRANSDERMAL WEEKLY
1
QL
9
NOTES (PA, ST, QL, AGE)
QL
QL
QL
DRUG NAME
ESTRADIOL .075MG/24H PATCH,
TRANSDERMAL WEEKLY
ESTRADIOL 0.05MG/24H PATCH,
TRANSDERMAL WEEKLY
ESTRADIOL 0.06MG/24H PATCH,
TRANSDERMAL WEEKLY
ESTRADIOL 0.1MG/24HR PATCH,
TRANSDERMAL WEEKLY
ESTRADIOL 0.5 MG TABLET
ESTRADIOL 1 MG TABLET
ESTRADIOL 2 MG TABLET
ESTRADIOL-NORETHINDRONE ACETAT
ESTROGEN & METHYLTESTOSTERONE
ESTROGEN-METHYLTESTOSTERONE
ESTROPIPATE
ESTROSTEP FE
ESZOPICLONE
ETHAMBUTOL HCL
ETHOSUXIMIDE
ETHYL CHLORIDE
ETIDRONATE DISODIUM
ETODOLAC
ETODOLAC ER
EVISTA
EVZIO
EXALGO
EXEMESTANE
EXOTIC-HC
EXTRA-VIRT PLUS DHA
FALMINA
FAMCICLOVIR
FAMOTIDINE 20 MG TABLET
FAMOTIDINE 40 MG TABLET
FAMOTIDINE 40MG/5ML SUSPENSION,
ORAL (FINAL DOSE FORM)
FARESTON
FELBAMATE 400 MG TABLET
FELBAMATE 600 MG TABLET
FELBAMATE 600 MG/5ML SUSPENSION,
ORAL (FINAL DOSE FORM)
FELODIPINE ER
FEM PH
FEMCON FE
FENOFIBRATE
FENOFIBRIC ACID
FENOPROFEN CALCIUM
FENTANYL
Tier
1
NOTES (PA, ST, QL, AGE)
DRUG NAME
Tier
FINASTERIDE
1
FLAVOXATE HCL
1
FLECAINIDE ACETATE
1
1
FLUCONAZOLE 10 MG/ML SUSPENSION,
RECONSTITUTED, ORAL (ML)
1
1
FLUCONAZOLE 100 MG TABLET
1
FLUCONAZOLE 150 MG TABLET
1
1
1
1
1
1
1
1
3
1
1
1
1
1
1
1
3
3
3
1
1
1
1
1
1
1
1
FLUCONAZOLE 200 MG TABLET
1
FLUCONAZOLE 40 MG/ML SUSPENSION,
RECONSTITUTED, ORAL (ML)
1
FLUCONAZOLE 50 MG TABLET
1
FLUCYTOSINE
1
FLUDROCORTISONE ACETATE
1
FLUNISOLIDE
1
FLUOCINOLONE ACETONIDE
1
FLUOCINOLONE ACETONIDE OIL
1
FLUOCINONIDE
1
FLUOCINONIDE-E
1
FLUORABON
1
FLUORIDE
1
FLUORIDEX DAILY DEFENSE
1
FLUORITAB
1
FLUOROMETHOLONE
1
FLUOROURACIL
1
FLUOXETINE DR
1
FLUOXETINE HCL 10 MG CAPSULE
1
FLUOXETINE HCL 10 MG TABLET
1
FLUOXETINE HCL 20 MG CAPSULE
1
FLUOXETINE HCL 20 MG TABLET
1
FLUOXETINE HCL 20 MG/5 ML SOLUTION,
ORAL
1
FLUOXETINE HCL 40 MG CAPSULE
1
FLUOXETINE HCL 60 MG TABLET
1
FLUPHENAZINE HCL
1
FLURA-DROPS
1
FLURAZEPAM HCL
1
FLURBIPROFEN
1
FLURBIPROFEN SODIUM
1
FLUTICASONE PROPIONATE
1
FLUVASTATIN SODIUM
1
FLUVOXAMINE MALEATE
1
FLUVOXAMINE MALEATE ER
1
FOCALGIN-B
1
1
QL
3
1
1
3
1
1
3
1
1
1
1
QL
FOLBECAL
1
FENTANYL CITRATE
3
PA
FOLIC ACID
1
FEXOFENADINE HCL
1
FOLINATAL PLUS B
1
10
NOTES (PA, ST, QL, AGE)
DRUG NAME
Tier
NOTES (PA, ST, QL, AGE)
DRUG NAME
Tier
FOLIVANE-OB
1
GUANIDINE HCL
1
FOLIVANE-PRX DHA NF
1
GYNAZOLE 1
1
FORADIL
2
HALOBETASOL PROPIONATE
1
FORMADON
1
HALONATE PAC
1
FORTICAL
1
HALOPERIDOL
1
FOSINOPRIL SODIUM
1
HALOPERIDOL LACTATE
1
FOSINOPRIL-HYDROCHLOROTHIAZIDE
1
HEATHER
1
FUROSEMIDE
1
HEMENATAL OB
1
GABAPENTIN
1
HEMENATAL OB + DHA
1
GALANTAMINE HBR
1
HEPARIN SODIUM
1
GALANTAMINE HYDROBROMIDE
GARAMYCIN
GASTRACE
GATIFLOXACIN
GAVILYTE-C
GAVILYTE-G
GAVILYTE-N
GEMFIBROZIL
GENERESS FE
GENERLAC
GENTAK
GENTAMICIN SULFATE
GIANVI
GILDAGIA
GILDESS
GILDESS FE
GLIMEPIRIDE
GLIPIZIDE
GLIPIZIDE ER
GLIPIZIDE XL
GLIPIZIDE-METFORMIN
GLYBURIDE
GLYBURIDE MICRONIZED
GLYBURIDE-METFORMIN HCL
GLYCINE
GLYCOPYRROLATE
GLYDO
GRANISETRON HCL
GRANISOL
GRISEOFULVIN
GRISEOFULVIN ULTRAMICROSIZE
GRX HICORT 25
GUAIATUSSIN AC
GUAIFENESIN AC
GUAIFENESIN DAC
GUAIFENESIN-CODEINE
1
1
1
1
1
1
1
1
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
HOMATROPAIRE
1
HOMATROPINE HYDROBROMIDE
1
HUMALOG
2
HUMALOG MIX 50-50
2
HUMALOG MIX 75-25
2
HUMULIN 70/30 KWIKPEN
2
HUMULIN 70-30
2
HUMULIN N
2
HUMULIN N KWIKPEN
2
HUMULIN R
2
HYDRALAZINE HCL
1
HYDROCHLOROTHIAZIDE
1
HYDROCOD-CPM-PSEUDOEPHEDRINE
1
HYDROCODONE BT-HOMATROPINE MBR
1
HYDROCODONE-ACETAMINOPHEN
1
HYDROCODONE-CHLORPHENIRAMINE
1
HYDROCODONE-HOMATROPINE MBR
1
HYDROCODONE-IBUPROFEN
1
HYDROCORTISONE 1 % CREAM (GRAM)
1
HYDROCORTISONE 1 % OINTMENT (GRAM)
1
HYDROCORTISONE 10 MG TABLET
1
HYDROCORTISONE 100MG/60ML ENEMA
(ML)
1
HYDROCORTISONE 2.5 % CREAM (GRAM)
1
HYDROCORTISONE 2.5 % LOTION (ML)
1
HYDROCORTISONE 2.5 % OINTMENT (GRAM)
1
HYDROCORTISONE 20 MG TABLET
1
HYDROCORTISONE 5 MG TABLET
1
HYDROCORTISONE ACETATE
1
HYDROCORTISONE BUTYRATE
1
HYDROCORTISONE VALERATE
1
HYDROCORTISONE-ACETIC ACID
1
HYDROCORTISONE-IODOQUINOL
1
HYDROCORTISONE-PRAMOXINE
1
GUANFACINE HCL
1
HYDROCORTISONE-PRAMOXINE HCL
1
11
NOTES (PA, ST, QL, AGE)
DRUG NAME
Tier
HYDROMET
1
HYDROMORPHONE ER
1
HYDROMORPHONE HCL
NOTES (PA, ST, QL, AGE)
DRUG NAME
Tier
NOTES (PA, ST, QL, AGE)
ISOXSUPRINE HCL
1
ISRADIPINE
1
1
ITRACONAZOLE
1
HYDROXYCHLOROQUINE SULFATE
1
JANTOVEN
1
HYDROXYUREA
1
JENCYCLA
1
HYDROXYZINE HCL
1
JENTADUETO
2
HYDROXYZINE PAMOATE
1
JINTELI
1
HYOPHEN
HYOSCYAMINE SULFATE 0.125 MG TABLET
HYOSCYAMINE SULFATE 0.125 MG TABLET,
SUBLINGUAL
HYOSCYAMINE SULFATE 0.125 MG TABLET,
DISINTEGRATING
HYOSCYAMINE SULFATE 0.125MG/ML DROPS
HYOSCYAMINE SULFATE 125MCG/5ML ELIXIR
HYOSCYAMINE SULFATE ER
HYOSCYAMINE SULFATE SR
HYOSYNE
HYPERCARE
IBANDRONATE SODIUM
IBUDONE
IBUPROFEN
IMIPRAMINE HCL
IMIPRAMINE PAMOATE
IMIQUIMOD
INATAL ADVANCE
INATAL ULTRA
INDAPAMIDE
INDOMETHACIN
INTROVALE
IOPHEN-C NR
IPRATROPIUM BROMIDE 0.2 MG/ML
SOLUTION, NON-ORAL
IPRATROPIUM BROMIDE 21 MCG
AEROSOL, SPRAY (ML)
IPRATROPIUM BROMIDE 42MCG AEROSOL,
SPRAY (ML)
IPRATROPIUM-ALBUTEROL
IRBESARTAN
IRBESARTAN-HYDROCHLOROTHIAZIDE
ISOCHRON
ISOMETHEPT-CAFF-ACETAMINOPHEN
ISOMETHEPT-DICHLORALP-ACETAMIN
ISONIAZID 100 MG TABLET
ISONIAZID 300 MG TABLET
ISONIAZID 50 MG/5 ML SOLUTION, ORAL
ISOSORBIDE DINITRATE
ISOSORBIDE MONONITRATE
ISOSORBIDE MONONITRATE ER
1
1
1
JOLESSA
1
JOLIVETTE
1
JUNEL
1
JUNEL FE
1
K EFFERVESCENT
1
KARIVA
1
KELNOR 1-35
1
KETOCONAZOLE
1
KETODAN
1
KETOPROFEN
1
KETOROLAC TROMETHAMINE 0.4 % DROPS
1
KETOROLAC TROMETHAMINE 0.5 % DROPS
1
KETOROLAC TROMETHAMINE 10 MG TABLET
1
QL
KETOROLAC TROMETHAMINE 15 MG/ML
CARTRIDGE (ML)
1
QL
KETOROLAC TROMETHAMINE 15 MG/ML
VIAL (ML)
1
QL
KETOROLAC TROMETHAMINE 30 MG/ML
SYRINGE (ML)
1
QL
KETOROLAC TROMETHAMINE 60 MG/2 ML
VIAL (ML)
1
QL
KIONEX
1
KLOR-CON 10
1
KLOR-CON 8
1
KLOR-CON M10
1
KLOR-CON M20
1
KLOR-CON-EF
1
KURVELO
1
LABETALOL HCL
1
LACTATED RINGERS
1
LACTULOSE
1
LAMOTRIGINE
1
LAMOTRIGINE ER
1
LANSOPRAZOL-AMOXICIL-CLARITHRO
1
LANSOPRAZOLE
1
LARIN
1
LARIN FE
1
LATANOPROST
1
LEENA
1
QL
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
12
QL
DRUG NAME
Tier
LEFLUNOMIDE
1
LODOSYN
3
LESSINA
1
LOESTRIN
3
LETROZOLE
1
LOESTRIN FE
3
LEUKERAN
3
LOHIST-DM
1
LEVALBUTEROL CONCENTRATE
1
LOMEDIA 24 FE
1
LEVALBUTEROL HCL
1
LOMUSTINE
1
LEVEMIR
2
LOPERAMIDE
1
LEVEMIR FLEXTOUCH
2
LORAZEPAM
1
LEVETIRACETAM
1
LORAZEPAM INTENSOL
1
LEVETIRACETAM ER
1
LORCET
1
LEVLEN 28
1
LORCET HD
1
LEVOBUNOLOL HCL
LEVOCARNITINE
LEVOCETIRIZINE DIHYDROCHLORIDE
LEVOFLOXACIN
LEVOMEFOLATE CALCIUM-ALGAL
LEVOMEFOLATE DHA
LEVONEST
LEVONORGESTREL
LEVONORGESTREL-ETH ESTRADIOL
LEVONORG-ETH ESTRAD ETH ESTRAD
LEVORA-28
LEVORPHANOL TARTRATE
LEVOTHYROXINE SODIUM
LEVOXYL
LIDOCAINE
LIDOCAINE HCL
LIDOCAINE HCL VISCOUS
LIDOCAINE-HYDROCORTISONE
LIDOCAINE-PRILOCAINE
LIDOPIN
LINDANE
LIOTHYRONINE SODIUM
LISINOPRIL
LISINOPRIL-HYDROCHLOROTHIAZIDE
LITHIUM
LITHIUM CARBONATE 150 MG CAPSULE
LITHIUM CARBONATE 300 MG CAPSULE
LITHIUM CARBONATE 300 MG TABLET
LITHIUM CARBONATE 450 MG TABLET,
EXTENDED RELEASE
LITHIUM CARBONATE 600 MG CAPSULE
LITHIUM CARBONATE ER
L-METHYLFOLATE
L-METHYLFOLATE CALCIUM
L-METHYLFOLATE FORMULA
L-METHYLFOLATE FORTE
LO LOESTRIN FE
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
LORCET PLUS
1
LORTUSS EX
1
LORYNA
1
LOSARTAN POTASSIUM
1
LOSARTAN-HYDROCHLOROTHIAZIDE
1
LOSEASONIQUE
3
LOVASTATIN
1
LOW-OGESTREL
1
LOXAPINE
1
LUDENT FLUORIDE
1
LUGOL'S
1
LUTERA
1
LYRICA
3
LYSODREN
3
LYZA
1
MACNATAL CN DHA
1
MALATHION
1
MAPROTILINE HCL
1
MARGESIC
1
MARLEXATE
1
MARLISSA
1
MARTEN-TAB
1
MATERNITY
1
MATZIM LA
1
MAXITROL
1
M-CLEAR WC
1
MECLIZINE HCL
1
MECLOFENAMATE SODIUM
1
1
1
1
1
1
1
2
MEDROL
3
MEDROXYPROGESTERONE ACETATE
1
MEFENAMIC ACID
1
MEFLOQUINE HCL
1
MEGESTROL ACETATE
1
MELOXICAM 15 MG TABLET
1
NOTES (PA, ST, QL, AGE)
DRUG NAME
13
Tier
NOTES (PA, ST, QL, AGE)
QL
DRUG NAME
Tier
NOTES (PA, ST, QL, AGE)
DRUG NAME
Tier
MELOXICAM 7.5 MG TABLET
1
METRONIDAZOLE
1
MELOXICAM 7.5 MG/5ML SUSPENSION,
ORAL (FINAL DOSE FORM)
1
MEXILETINE HCL
1
MICONAZOLE 3
1
MENEST
3
MICROGESTIN
1
ME-PB-HYOS 16.2 MG TABLET
1
MICROGESTIN FE
1
ME-PB-HYOS 16.2MG/5ML ELIXIR
1
MIDAZOLAM HCL
1
MEPERIDINE HCL
1
MIDODRINE HCL
1
MEPERITAB
1
MIGERGOT
1
MEPHYTON
3
MIGRAGESIC IDA
1
MEPROBAMATE
1
MILLIPRED
1
MERCAPTOPURINE
1
MILLIPRED DP
1
MESALAMINE
1
MIMVEY
1
METADATE ER
1
MIMVEY LO
1
METAPROTERENOL SULFATE
1
MINASTRIN 24 FE
2
METAXALONE
1
MINITRAN
1
METFORMIN HCL
1
MINOCYCLINE HCL
1
METFORMIN HCL ER
1
MINOXIDIL
1
METHADONE HCL
1
MIRCETTE
3
METHADONE INTENSOL
1
MIRTAZAPINE
1
METHADOSE
1
MISOPROSTOL
1
METHAMPHETAMINE HCL
1
MODAFINIL
1
METHAZOLAMIDE
1
MODICON
3
METHENAMINE HIPPURATE
1
MOEXIPRIL HCL
1
METHENAMINE MANDELATE
1
MOEXIPRIL-HYDROCHLOROTHIAZIDE
1
METHIMAZOLE
1
MOMETASONE FUROATE
1
METHITEST
1
MONO-LINYAH
1
METHOCARBAMOL
1
MONONESSA
1
METHOXSALEN
1
MONTELUKAST SODIUM
1
METHSCOPOLAMINE BROMIDE
1
MORGIDOX
1
METHYCLOTHIAZIDE
1
MORPHINE SULFATE
1
METHYLDOPA
1
MORPHINE SULFATE ER
1
METHYLDOPA-HYDROCHLOROTHIAZIDE
1
MOXEZA
2
METHYLERGONOVINE MALEATE
1
MOXIFLOXACIN HCL
1
METHYLPHENIDATE ER
1
MULTAQ
3
METHYLPHENIDATE HCL
1
MULTIVITAMIN AND FLUORIDE
1
METHYLPHENIDATE HCL CD
1
MULTI-VITAMIN W-FLUORIDE
1
METHYLPHENIDATE LA
1
MULTI-VITAMIN W-FLUORIDE-IRON
1
METHYLPHENIDATE SR
1
MULTIVITAMIN WITH FLUORIDE
1
METHYLPREDNISOLONE
1
MULTI-VITAMIN WITH FLUORIDE
1
METIPRANOLOL
1
MULTI-VITAMIN-FLUOR-IRON
1
METOCLOPRAMIDE HCL
1
MULTIVITAMINS W-FLUORIDE-IRON
1
METOLAZONE
1
MULTIVITAMINS WITH FLUORIDE
1
METOPROLOL SUCCINATE
1
MULTIVITAMINS-A,B,D,E,K,ZN
1
METOPROLOL TARTRATE
1
MUPIROCIN
1
METOPROLOL-HYDROCHLOROTHIAZIDE
1
MYNATAL
1
14
NOTES (PA, ST, QL, AGE)
PA
QL
DRUG NAME
Tier
MYNATAL ADVANCE
1
MYNATAL PLUS
1
MYNATAL-Z
1
MYNATE 90 PLUS
1
MYORISAN
1
MYZILRA
1
NABUMETONE
1
NADOLOL
1
NADOLOL-BENDROFLUMETHIAZIDE
1
NALTREXONE HCL
1
NAMENDA
3
NAPHAZOLINE HCL
NAPROXEN 125 MG/5ML SUSPENSION,
ORAL (FINAL DOSE FORM)
NAPROXEN 250 MG TABLET
NAPROXEN 375 MG TABLET
NAPROXEN 375 MG TABLET, DELAYED
RELEASE (ENTERIC COATED)
NAPROXEN 500 MG TABLET
NAPROXEN 500 MG TABLET, DELAYED
RELEASE (ENTERIC COATED)
NAPROXEN SODIUM
NARATRIPTAN
NARATRIPTAN HCL
NATALVIRT 90 DHA
NATALVIRT CA
NATALVIT
NATAZIA
NATEGLINIDE
NATROBA
NATURE-THROID
NEBUPENT
NECON
NEFAZODONE HCL
NEOMYCIN SULFATE
NEOMYCIN-BACITRACIN-POLY-HC
NEOMYCIN-BACITRACIN-POLYMYXIN
NEOMYCIN-POLYMYXIN B
NEOMYCIN-POLYMYXIN-DEXAMETH
NEOMYCIN-POLYMYXIN-GRAMICIDIN
NEOMYCIN-POLYMYXIN-HC
NEOMYCIN-POLYMYXIN-HYDROCORT
NEO-POLYCIN
NEO-POLYCIN HC
1
1
NEUAC
1
NEWGEN
NIACIN ER
NICARDIPINE HCL
1
1
1
Tier
NIFEDICAL XL
1
NIFEDIPINE
1
NIFEDIPINE ER
1
NIKKI
1
NIMODIPINE
1
NISOLDIPINE
1
NITRO-BID
1
NITRO-DUR
3
NITROFURANTOIN
1
NITROFURANTOIN MONO-MACRO
1
NITROGLYCERIN
1
NITROGLYCERIN PATCH
1
NITROSTAT
2
NITRO-TIME
1
NIZATIDINE 150 MG CAPSULE
1
NIZATIDINE 150MG/10ML SOLUTION, ORAL 1
NIZATIDINE 300 MG CAPSULE
1
NODOLOR
1
NORA-BE
1
NORETHINDRONE
1
NORETHINDRONE ACETATE
1
NORETHINDRON-ETHINYL ESTRADIOL
1
NORETHIN-ETH ESTRA FERROUS FUM
1
NORGESTIMATE-ETHINYL ESTRADIOL
1
NORINYL 1+35
3
NORINYL 1+50
3
NORLYROC
1
NOROXIN
3
NOR-Q-D
3
NORTREL
1
NORTRIPTYLINE HCL 10 MG CAPSULE
1
NORTRIPTYLINE HCL 10 MG/5 ML
1
SOLUTION, ORAL
NORTRIPTYLINE HCL 25 MG CAPSULE
1
NORTRIPTYLINE HCL 50 MG CAPSULE
1
NORTRIPTYLINE HCL 75 MG CAPSULE
1
NP THYROID
1
NULEV
1
NUVARING
2
NYAMYC
1
NYDAMAX
1
NYSTATIN 100000/G CREAM (GRAM)
1
NOTES (PA, ST, QL, AGE)
DRUG NAME
QL
1
1
1
1
1
1
1
1
1
1
3
3
1
1
1
3
1
1
1
1
1
1
1
1
1
1
1
1
QL
QL
15
NYSTATIN 100000/G OINTMENT (GRAM)
1
NYSTATIN 100000/G POWDER (GRAM)
1
NYSTATIN 100000/ML SUSPENSION, ORAL
(FINAL DOSE FORM)
1
NYSTATIN 500K UNIT TABLET
1
NYSTATIN 50MM UNIT POWDER (EA)
1
NOTES (PA, ST, QL, AGE)
DRUG NAME
Tier
NOTES (PA, ST, QL, AGE)
DRUG NAME
Tier
NYSTATIN-TRIAMCINOLONE
1
OXYCODONE HCL
1
NYSTOP
1
OXYCODONE HCL-ACETAMINOPHEN
1
OBSTETRIX DHA
1
OXYCODONE HCL-ASPIRIN
1
O-CAL FA
3
OXYCODONE HCL-IBUPROFEN
1
O-CAL PRENATAL
3
OXYCODONE-ACETAMINOPHEN
1
OCELLA
1
OXYMORPHONE HCL
1
OFLOXACIN
1
OXYMORPHONE HCL ER
1
OGESTREL
1
PACERONE
1
OLANZAPINE
1
PAIRE OB PLUS DHA
1
OLANZAPINE ODT
1
PANATUSS PED
1
OLANZAPINE-FLUOXETINE HCL
1
PANCRELIPASE 5,000
3
OLOPATADINE HCL
1
PANTOPRAZOLE SODIUM
1
OMEGA-3 ACID ETHYL ESTERS
1
PAPAVERINE HCL
1
OMEPRAZOLE
ONDANSETRON HCL
ONDANSETRON ODT
OPIUM TINCTURE
ORALONE
ORAP
ORPHENADRINE CITRATE
ORPHENADRINE COMPOUND FORTE
ORSYTHIA
ORTHO EVRA
ORTHO MICRONOR
ORTHO TRI-CYCLEN
ORTHO TRI-CYCLEN LO
ORTHO-CEPT
ORTHO-CYCLEN
ORTHO-NOVUM
OSCIMIN 0.125 MG TABLET
OSCIMIN 0.125 MG
TABLET,DISINTEGRATING
OSCIMIN SL
OSCIMIN SR
OTICIN
OTICIN HC
OTO-END 10
OTOMAX-HC
OTOZIN
OVCON-35
OXANDROLONE
OXAPROZIN
OXAZEPAM
OXCARBAZEPINE
1
1
1
1
1
3
1
1
1
3
3
3
3
3
3
3
1
1
PAREGORIC
1
PAROEX
1
PAROMOMYCIN SULFATE
1
PAROXETINE HCL
1
PASER
3
PATADAY
2
PEG 3350-ELECTROLYTE
1
PEG-3350
1
PEG-3350 AND ELECTROLYTES
1
PEG-3350 WITH FLAVOR PACKS
1
PEGANONE
3
PENICILLIN V POTASSIUM
1
PENTAZOCINE-NALOXONE HCL
1
PENTOXIFYLLINE
1
PERINDOPRIL ERBUMINE
1
PERMETHRIN
1
PERPHENAZINE
1
PERPHENAZINE-AMITRIPTYLINE
1
PHENADOZ
1
PHENAZOPYRIDINE HCL
1
PHENELZINE SULFATE
1
PHENOBARBITAL
1
PHENYLEPHRINE HCL
1
PHENYTOIN
1
PHENYTOIN SODIUM EXTENDED
1
PHILITH
1
PHOSPHA 250 NEUTRAL
1
PHOSPHASAL
1
PILOCARPINE HCL
1
OXYBUTYNIN CHLORIDE 5 MG TABLET
OXYBUTYNIN CHLORIDE 5 MG/5 ML SYRUP
1
1
PIMTREA
1
PINDOLOL
1
OXYBUTYNIN CHLORIDE ER
1
PINNACAINE
1
1
1
1
1
1
1
1
1
1
1
1
1
PA
16
NOTES (PA, ST, QL, AGE)
QL
DRUG NAME
Tier
NOTES (PA, ST, QL, AGE)
DRUG NAME
Tier
PIOGLITAZONE HCL
1
PRENAISSANCE NEXT-B
3
PIOGLITAZONE-GLIMEPIRIDE
1
PRENAISSANCE PLUS
1
PIOGLITAZONE-METFORMIN
1
PRENAISSANCE PROMISE
1
PIRMELLA
1
PRENAPLUS
1
PIROXICAM
1
PRENATAL 19
1
PLAN B ONE-STEP
3
PRENATAL LOW IRON
1
PNV 29-1
1
PRENATAL PLUS
1
PNV OB+DHA
1
PRENATAL VITAMINS LOW IRON
1
PNV-DHA
1
PRENATAL-U
1
PNV-DHA + DOCUSATE
1
PREPLUS
1
PNV-FERROUS FUMARATE-DOCU-FA
1
PRETAB
1
PNV-OMEGA
1
PREVALITE
1
PNV-SELECT
1
PREVIFEM
1
PNV-TOTAL
1
PRIFTIN
3
PODOFILOX
1
PRIMAQUINE
1
POLYCIN
1
PRIMIDONE
1
POLYETHYLENE GLYCOL 3350
1
PRIMLEV
1
POLYMYXIN B SUL-TRIMETHOPRIM
1
PROAIR HFA
2
PORTIA
1
PROBENECID
1
POTASS CIT-SOD CIT-CITRIC ACID
1
PROBENECID-COLCHICINE
1
POTASSIUM BICARBONATE
1
PROCENTRA
1
POTASSIUM CHLORIDE
1
PROCHLORPERAZINE MALEATE
1
POTASSIUM CITRATE ER
1
PROCTO-PAK
1
POTASSIUM CITRATE-CITRIC ACID
1
PROCTOSOL-HC
1
PR NATAL 400
1
PROCTOZONE-HC
1
PR NATAL 400 EC
1
PROGESTERONE
1
PR NATAL 430
1
PROMETHAZINE HCL
1
PR NATAL 430 EC
1
PROMETHAZINE VC
1
PRAMCORT
1
PROMETHAZINE VC-CODEINE
1
PRAMIPEXOLE DIHYDROCHLORIDE
1
PROMETHAZINE-CODEINE
1
PRAVASTATIN SODIUM
1
PROMETHAZINE-DM
1
PRAZOSIN HCL
1
PROMETHEGAN
1
PREDNICARBATE
1
PROPAFENONE HCL
1
PREDNISOLONE
1
PROPAFENONE HCL ER
1
PREDNISOLONE ACETATE
1
PROPANTHELINE BROMIDE
1
PREDNISOLONE SODIUM PHOSPHATE
1
PROPARACAINE HCL
1
PREDNISONE
1
PROPRANOLOL HCL
1
PREDNISONE INTENSOL
1
PROPRANOLOL HCL ER
1
PREFEST
1
PREFOL-DHA
1
PRENAISSANCE
1
PRENAISSANCE 90 DHA
1
PRENAISSANCE BALANCE
1
PRENAISSANCE DHA
1
PRENAISSANCE NEXT
1
PROPRANOLOL-HYDROCHLOROTHIAZID
PROPYLTHIOURACIL
PROTRIPTYLINE HCL
PRUDOXIN
PULMOSAL
PYRAZINAMIDE
PYRIDOSTIGMINE BROMIDE
QUARTETTE
1
1
1
1
1
1
1
3
17
NOTES (PA, ST, QL, AGE)
DRUG NAME
QUASENSE
QUETIAPINE FUMARATE
QUINAPRIL HCL
QUINAPRIL-HYDROCHLOROTHIAZIDE
QUINIDINE GLUCONATE
QUINIDINE SULFATE
QUININE SULFATE
QVAR
RABEPRAZOLE SODIUM
RALOXIFENE HCL
RAMIPRIL
RANITIDINE HCL 15 MG/ML SYRUP
RANITIDINE HCL 150 MG CAPSULE
RANITIDINE HCL 150 MG TABLET
RANITIDINE HCL 300 MG CAPSULE
RANITIDINE HCL 300 MG TABLET
REA LO 39
REA LO 40
RECLIPSEN
RECTACORT-HC
REGENECARE
RELCOF C
RELENZA
RELNATE DHA
REMEVEN
RENAGEL
REPAGLINIDE
REPREXAIN
RESERPINE
RIFABUTIN
RIFAMPIN
RIMANTADINE HCL
RISEDRONATE SODIUM
RISPERIDONE
RISPERIDONE ODT
RIVASTIGMINE
RIZATRIPTAN
R-NATAL OB
Tier NOTES (PA, ST, QL, AGE)
1
1
1
1
1
1
1
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
3 QL
1
1
3
1
1
1
1
1
1
1
1
1
1
1 QL
1
DRUG NAME
SEB-PREV
SECONAL SODIUM
SELEGILINE HCL
SELENIUM SULFIDE
SE-NATAL 19
SERTRALINE HCL 100 MG TABLET
SERTRALINE HCL 20 MG/ML
CONCENTRATE, ORAL
SERTRALINE HCL 25 MG TABLET
SERTRALINE HCL 50 MG TABLET
SE-TAN DHA
SETONET
SEVELAMER CARBONATE
SF
SF 5000 PLUS
SHAROBEL
SILVER NITRATE
SILVER SULFADIAZINE
SIMVASTATIN
SODIUM CHLORIDE
SODIUM CITRATE & CITRIC ACID
SODIUM FLUORIDE
SODIUM PHENYLBUTYRATE
SODIUM POLYSTYRENE SULFONATE
SODIUM SULFACETAMIDE
SODIUM SULFACETAMIDE-SULFUR
SOTALOL
SOTALOL AF
SPECTRACEF
SPINOSAD
SPIRONOLACTONE
SPIRONOLACTONE-HCTZ
SPRINTEC
SPS
SRONYX
SSS 10-5
STANNOUS FLUORIDE
STROMECTOL
Tier
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
3
ROPINIROLE HCL
1
STRONG IODINE
1
ROSADAN
1
SUCRALFATE
1
ROSANIL
ROXICET
SAFYRAL
SALICYLIC ACID
SALSALATE
SAMSCA
SAPHRIS
SEASONIQUE
1
1
3
1
1
3
3
3
SULFACETAMIDE SODIUM
1
SULFACETAMIDE-PREDNISOLONE
1
SULFACLEANSE 8-4
1
SULFADIAZINE
1
SULFAMETHOXAZOLE-TRIMETHOPRIM
1
SULFASALAZINE
1
SULFASALAZINE DR
1
SULFAZINE
1
PA
ST
18
NOTES (PA, ST, QL, AGE)
DRUG NAME
Tier
NOTES (PA, ST, QL, AGE)
DRUG NAME
Tier
NOTES (PA, ST, QL, AGE)
SULFAZINE EC
1
TILIA FE
1
SULINDAC
1
TIMOLOL MALEATE
1
SUMATRIPTAN
1
QL
TINIDAZOLE
1
SUMATRIPTAN SUCCINATE
1
QL
TIZANIDINE HCL
1
SUPERVITE EC
1
TL-CARE DHA
1
SUTTAR-2
1
TL-SELECT
1
SUTTAR-SF
1
TOBRAMYCIN 0.3 % DROPS
1
SYEDA
1
TOBRAMYCIN-DEXAMETHASONE
1
SYMAX
1
TOLAZAMIDE
1
SYMAX-SL
1
TOLBUTAMIDE
1
SYMAX-SR
1
TOLMETIN SODIUM
1
SYNTHROID
3
TOLTERODINE TARTRATE
1
TABLOID
3
TOLTERODINE TARTRATE ER
1
TAMIFLU
2
TOPIRAGEN
1
TAMOXIFEN CITRATE
1
TOPIRAMATE
1
TAMSULOSIN HCL
1
TORSEMIDE
1
TARINA FE
1
TRADJENTA
2
TARON-BC
1
TRAMADOL HCL
1
QL
TARON-C DHA
1
1
QL
TARON-CRYSTALS
1
TRAMADOL HCL ER 100 MG TABLET,
EXTENDED RELEASE 24 HR
TARON-PREX PRENATAL
1
1
TAZTIA XT
1
TRAMADOL HCL ER 100 MG TABLET,
EXTENDED RELEASE MULTIPHASE 24 HR
TELMISARTAN
1
1
TELMISARTAN-AMLODIPINE
1
TRAMADOL HCL ER 150 MG CAPSULE, EXT.
RELEASE 24 HR BIPHASIC 25-75
TELMISARTAN-HYDROCHLOROTHIAZID
1
TRAMADOL HCL ER 200 MG TABLET,
EXTENDED RELEASE 24 HR
1
TEMAZEPAM
1
1
TRAMADOL HCL ER 200 MG TABLET,
EXTENDED RELEASE MULTIPHASE 24 HR
1
TENCON
TERAZOSIN HCL
1
1
TERBINAFINE HCL
1
TRAMADOL HCL ER 300 MG TABLET,
EXTENDED RELEASE 24 HR
TERBUTALINE SULFATE
1
1
TERCONAZOLE
1
TRAMADOL HCL ER 300 MG TABLET,
EXTENDED RELEASE MULTIPHASE 24 HR
TESTIM
2
TRAMADOL HCL-ACETAMINOPHEN
1
TESTOSTERONE CYPIONATE
1
TRANDOLAPRIL
1
TESTOSTERONE ENANTHATE
1
TRANEXAMIC ACID
1
TETCAINE
1
TRANYLCYPROMINE SULFATE
1
TETRACAINE HCL
1
TRAVATAN Z
2
TETRACYCLINE HCL
1
TRAZODONE HCL
1
THEOCHRON
1
TRECATOR
3
THEOPHYLLINE
1
TRETINOIN 0.01 % GEL (GRAM)
1
THEOPHYLLINE ANHYDROUS
1
TRETINOIN 0.025 % CREAM (GRAM)
1
THIORIDAZINE HCL
1
TRETINOIN 0.025 % GEL (GRAM)
1
THIOTHIXENE
1
TRETINOIN 0.05 % CREAM (GRAM)
1
AGE
TIAGABINE HCL
1
TRETINOIN 0.1 % CREAM (GRAM)
1
AGE
TICLOPIDINE HCL
1
TRETINOIN 10 MG CAPSULE
1
TIKOSYN
3
TRETINOIN MICROSPHERE
1
TRIADVANCE
1
QL
QL
QL
19
QL
QL
QL
AGE
AGE
DRUG NAME
Tier
NOTES (PA, ST, QL, AGE)
DRUG NAME
Tier
TRIAMCINOLONE ACETONIDE
1
USTELL
1
TRIAMTERENE-HCTZ
1
UTIRA-C
1
TRIAMTERENE-HYDROCHLOROTHIAZID
1
VAGIFEM
3
TRIANEX
1
VALACYCLOVIR
1
TRIAZOLAM
1
VALCYTE
3
TRICITRATES
1
VALPROIC ACID
1
TRIDERM
1
VALSARTAN
1
TRI-ESTARYLLA
1
VALSARTAN-HYDROCHLOROTHIAZIDE
1
TRIFLUOPERAZINE HCL
1
VANCOMYCIN HCL
1
TRIFLURIDINE
1
VANDAZOLE
1
TRIHEXYPHENIDYL HCL
1
VASOLEX
1
TRI-LEGEST FE
1
VELIVET
1
TRI-LINYAH
1
VEMAVITE-PRX 2
1
TRILYTE WITH FLAVOR PACKETS
1
VENA-BAL DHA
1
TRIMETHOBENZAMIDE HCL
1
VENATAL COMPLETE DHA
1
TRIMETHOPRIM
1
VENATAL-FA
1
TRINATAL GT
1
VENLAFAXINE HCL
1
TRINATAL RX 1
1
VENLAFAXINE HCL ER
1
TRINESSA
1
VERAPAMIL ER
1
TRI-NORINYL
3
VERAPAMIL ER PM
1
TRIPLE-VITAMIN W-FLUORIDE
1
VERAPAMIL HCL
1
TRI-PREVIFEM
1
VERAPAMIL SR
1
TRI-SPRINTEC
1
VESICARE
2
TRI-TABS DHA
1
VESTURA
1
TRIVEEN-DUO DHA
1
VIGAMOX
2
TRIVEEN-ONE
1
VINACAL
1
TRIVEEN-PRX RNF
1
VINATE GT
1
TRIVEEN-U
1
VINATE II
1
TRI-VI-FLORO
1
VINATE ONE
1
TRI-VIT WITH FLUORIDE-IRON
1
VINATE PN CARE
1
TRI-VITAMIN WITH FLUORIDE
1
VINATE ULTRA
1
TRIVORA-28
1
VINATE-M
1
TROPICAMIDE
1
VIORELE
1
TROSPIUM CHLORIDE
1
VIRT NATE
1
TROSPIUM CHLORIDE ER
1
VIRT-ADVANCE
1
TRUST NATAL DHA
1
VIRT-C DHA
1
TUDORZA PRESSAIR
2
VIRT-CARE ONE
1
TUSNEL C
1
VIRTI-SULF
1
U-CORT
1
VIRT-PHOS 250 NEUTRAL
1
ULTIMATECARE ONE
1
VIRT-PN
1
ULTIMATECARE ONE NF
1
VIRT-PN DHA
1
UNITHROID
1
UR N-C
1
URIN D.S.
1
URSODIOL
1
VIRT-PN PLUS
VIRTPREX
VIRT-SELECT
VIRTUSSIN AC
1
1
1
1
20
NOTES (PA, ST, QL, AGE)
ST
DRUG NAME
VIRT-VITE GT
VITAFOL-OB
VITAMIN D2
VITAMINS A,C,D & FLUORIDE
VITASPIRE
VOL-NATE
VOL-PLUS
VOL-TAB RX
VORICONAZOLE
VP-CH PLUS
VP-CH-PNV
VP-ERA OB PLUS
VP-GGR-B6
VP-HEME OB
VP-HEME OB + DHA
VP-HEME ONE
VYFEMLA
VYNATAL-FA
VYTORIN
WARFARIN SODIUM
WATER
WERA
WESTHROID
WP THYROID
WYMZYA FE
XULANE
X-VIATE
XYLON 10
YASMIN 28
YAZ
ZAFIRLUKAST
ZALEPLON
ZARAH
ZATEAN-CH
ZATEAN-PN
ZATEAN-PN DHA
ZATEAN-PN PLUS
ZAZOLE
ZEBUTAL
ZENATANE
ZENCHENT
ZENCHENT FE
Tier NOTES (PA, ST, QL, AGE)
1
1
1
1
1
1
1
1
1 PA
1
1
1
1
1
1
1
1
1
2 ST
1
1
1
1
1
1
1
1
1
3
3
1
1
1
1
1
1
1
1
1
1 QL
1
1
ZENCIA
1
ZENPEP
2
ZEOSA
1
ZETONNA
3
ZIPRASIDONE HCL
1
21
DRUG NAME
Tier
ZOLMITRIPTAN
1
QL
ZOLMITRIPTAN ODT
1
QL
ZOLPIDEM TARTRATE
1
ZOLPIDEM TARTRATE ER
1
ZONISAMIDE
1
ZOVIA 1-35E
1
ZOVIA 1-50E
1
NOTES (PA, ST, QL, AGE)
Specialty medications
The following specialty medications are typically covered under the fourth tier.
A
ABACAVIR^
ABACAVIR-LAMIVUDINE-ZIDOVUDINE^
ACTIMMUNE^ (PA)
ADCIRCA^ (PA)
ADEFOVIR DIPIVOXIL^
AFINITOR^ (PA)
AFINITOR DISPERZ^ (PA)
ALKERAN
AMINOCAPROIC ACID^
ANAGRELIDE HCL^
ANZEMET 100 MG TABLET (PA, QL)
ANZEMET 100 MG/5ML VIAL (ML) (PA)
ANZEMET 12.5/0.625 VIAL (ML) (PA)
ANZEMET 20 MG/ML VIAL (ML) (PA)
ANZEMET 50 MG TABLET (PA, QL)
APOKYN^ (PA)
APTIVUS^
ARANESP (PA)
ARCALYST (PA)
ATRIPLA^
AVONEX^ (PA)
AVONEX ADMINISTRATION PACK^ (PA)
AVONEX PEN^ (PA)
AZATHIOPRINE^
B
BARACLUDE^
BICALUTAMIDE^
BOSULIF^ (PA)
C
CAPECITABINE^
CAPRELSA (PA)
CIMZIA^ (PA)
COMETRIQ (PA)
COMPLERA^
COPAXONE 20 MG/ML SYRINGE (ML)^
(PA)
COPAXONE 40 MG/ML SYRINGE (ML)^
(PA, ST)
CRIXIVAN^
CYCLOPHOSPHAMIDE^
CYCLOSPORINE^
CYCLOSPORINE MODIFIED^
CYSTADANE
CYSTAGON
D
DIDANOSINE^
H
N
HECORIA^
HEXALEN^
HUMATROPE^ (PA)
HYCAMTIN^
NEULASTA (PA)
NEUPOGEN
NEVIRAPINE^
NEVIRAPINE ER
NEXAVAR^ (PA)
NORDITROPIN FLEXPRO^ (PA, ST)
NORDITROPIN NORDIFLEX^ (PA, ST)
NORVIR^
NUTROPIN AQ^ (PA, ST)
NUTROPIN AQ NUSPIN^ (PA, ST)
I
E
ICLUSIG (PA)
ILARIS (PA)
INCIVEK^ (PA)
INCRELEX^ (PA)
INLYTA^ (PA)
INTELENCE^
INTRON A^ (PA)
INVIRASE^
ISENTRESS^
EDURANT^
EGRIFTA^ (PA)
EMCYT^
EMEND 125 MG CAPSULE (QL)
EMEND 125MG-80MG CAPSULE, DOSE
PACK (QL)
EMEND 150 MG VIAL (EA)
EMEND 40 MG CAPSULE (QL)
EMEND 80 MG CAPSULE (QL)
EMTRIVA^
ENOXAPARIN SODIUM (QL)
ENTECAVIR^
EPIVIR HBV^
EPOGEN (PA)
EPZICOM^
ERIVEDGE^ (PA)
ETOPOSIDE^
EXJADE
EXTAVIA^ (PA, ST)
J
JAKAFI (PA)
JUXTAPID (PA)
K
KALETRA^
KUVAN^
L
FIRAZYR^ (PA)
FIRMAGON (PA)
FLUTAMIDE^
FONDAPARINUX SODIUM (QL)
FORTEO^
FRAGMIN (QL)
FUZEON^
LAMIVUDINE^
LAMIVUDINE HBV^
LAMIVUDINE-ZIDOVUDINE^
LETAIRIS^
LEUCOVORIN CALCIUM^
LEUKINE
LEUPROLIDE ACETATE^ (PA)
LEXIVA^
LUPRON DEPOT^ (PA)
LUPRON DEPOT-PED^ (PA)
G
M
GATTEX (PA)
GENGRAF^
GENOTROPIN^ (PA, ST)
GLEEVEC^ (PA)
GRANIX
MATULANE
MESNEX
METHOTREXATE^
MODERIBA^
MYCOPHENOLATE MOFETIL^
MYCOPHENOLIC ACID
F
22
O
OCTREOTIDE ACETATE^ (PA)
OMNITROPE^ (PA, ST)
ORENCIA^ (PA)
ORFADIN
P
PANRETIN^
PARICALCITOL^
PEGINTRON^ (PA)
PEGINTRON REDIPEN^ (PA)
PREZISTA^
PROMACTA^ (PA)
PULMOZYME^ (PA)
R
RAPAMUNE^
REBETOL^
REBIF^ (PA)
REBIF REBIDOSE (PA)
RESCRIPTOR
REVLIMID^ (PA)
REYATAZ^
RIBASPHERE 200 MG CAPSULE^
RIBASPHERE 200 MG TABLET^
RIBASPHERE 400 MG TABLET
RIBASPHERE 600 MG TABLET
RIBAVIRIN^
RILUZOLE^
S
V
SABRIL
SAIZEN^ (PA)
SELZENTRY^
SENSIPAR
SEROSTIM^ (PA)
SILDENAFIL^ (PA)
SIROLIMUS^
SOMATULINE DEPOT (PA)
SOMAVERT 10 MG VIAL (EA) (PA)
SOMAVERT 15 MG VIAL (EA) (PA)
SOMAVERT 20 MG VIAL (EA) (PA)
SOMAVERT 25 MG VIAL (EA)^ (PA)
SOMAVERT 30 MG VIAL (EA)^ (PA)
SPRYCEL^ (PA)
STAVUDINE^
STELARA^ (PA, ST)
STIVARGA^ (PA)
STRIBILD
SUCRAID
SUSTIVA^
SUTENT^ (PA)
SYLATRON^ (PA)
SYLATRON 4-PACK^ (PA)
SYNAREL^
VALCHLOR
VENTAVIS
VICTRELIS^ (PA, ST)
VIDEX^
VIRACEPT^
VIRAZOLE^
VIREAD^
VOTRIENT^ (PA)
X
XALKORI^ (PA)
XELODA^
XENAZINE
XOLAIR^ (PA)
XTANDI^ (PA)
XYREM (PA)
Z
ZAVESCA (PA)
ZELBORAF^ (PA)
ZIDOVUDINE^
ZOLADEX^ (PA)
ZOLINZA (PA)
ZORTRESS^
ZYTIGA^ (PA)
T
TACROLIMUS^
TARCEVA^ (PA)
TARGRETIN^
TASIGNA^ (PA)
TECFIDERA (PA)
TEMOZOLOMIDE^ (PA)
THALOMID^ (PA)
TOBRAMYCIN 300 MG/5ML AMPUL FOR NEBULIZATION (ML)
TRACLEER^
TRUVADA^
TYKERB^ (PA)
TYVASO
TYZEKA^
23
Exclusions and limitations
Plans typically do not provide coverage for the following, except as required by law or by the terms of your specific plan:
1. Any medications available over-the-counter (OTC)
that do not require a prescription by federal or state law
except as specifically required by the Patient Protection and
Affordable Care Act (PPACA).
7. Implantable contraceptive products.
8. Prescription vitamins other than prenatal vitamins,
dietary supplements, herbal supplements and fluoride
other than supplements specifically designated as
preventive under the Patient Protection and Affordable
Care Act (PPACA).
2. Any medication that is a pharmaceutical alternative to an
OTC medication other than insulin [examples include OTC
Benadryl, Maalox, Sudafed PE, etc.].
9. Medications used for cosmetic purposes that have no
medically acceptable use; such as medications used to
reduce wrinkles, medications to promote hair growth,
medications used to control perspiration and fade
cream products.
3. Injectable infertility medications, and any injectable
medications that require health care professional
supervision and are not typically considered selfadministered medications are covered under the medical
benefits of the plan and require prior authorization.
The following are examples of health care professional
supervised medications: injectables used to treat
hemophilia and RSV (respiratory syncytial virus),
chemotherapy injectables and endocrine and
metabolic agents.
10. Injectable or infused immunization agents, biological
products for allergy immunization, biological sera, blood,
blood plasma and other blood products or fractions are
covered under the medical benefits of the plan.
11. Medications used for travel prophylaxis (the prevention of
travel-related diseases), except anti-malarial medications.
4. Any medications that are experimental or investigational
within the meaning set forth in the policy.
12. Replacement of prescription medications and related
supplies due to loss or theft, except in the case of
a natural disaster.
5. Food and Drug Administration (FDA) approved
medications used for purposes other than those approved
by the FDA unless the medication is recognized for the
treatment of the particular indication in one of the standard
reference compendia (The United States Pharmacopoeia
Drug Information or The American Hospital Formulary
Service Drug Information) or in medical literature.
Medical literature means scientific studies published in
a peer-reviewed national professional medical journal.
13. Medications used to enhance athletic performance.
14. Medications that are to be taken by, or administered to,
a customer while the customer is a patient in a licensed
hospital, skilled nursing facility, rest home or similar
institution which operates on its premises, or allows
to be operated on its premises, a facility for
dispensing pharmaceuticals.
6. Prescription and non-prescription supplies (such as ostomy
supplies), devices and appliances other than related
supplies, except for those pertaining to diabetic supplies
and equipment.
15. Prescriptions more than one year from the original
date of issue.
24
Cigna reserves the right to make changes to this drug list without notice. Your plan may cover additional
medications; please refer to your policy 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.
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Tel-Drug, Inc. and
Tel-Drug of Pennsylvania, L.L.C. “Cigna Home Delivery Pharmacy” refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C. The Cigna name, logo, and other Cigna marks are owned by Cigna
Intellectual Property, Inc.
863932 b 12/14 ©2014 Cigna
25