Insured by Cigna Health and Life Insurance Company
2015 Cigna
RX ESSENTIAL
prescription drug list
The Cigna Rx Essential 5-Tier Prescription Drug List is applicable to plans
in California and Colorado, 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.
863933 b 12/14 ©2014 Cigna
1
Insured by Cigna Health and Life Insurance Company
2015 Cigna
RX ESSENTIAL
prescription drug list
5-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 five categories (preferred generic, non-preferred 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
1
Your five-tier prescription drug list
A five-tier prescription drug list splits medications into five categories (or tiers):
Tier 1: Preferred Generic Medications. Preferred generic medications have the same quality, strength, purity and stability as their
brand name counterparts. Preferred generic medications are available at the lowest cost sharing to you.
Tier 2: Non-Preferred Generic Medications. This tier typically includes non-preferred generic medications and some low cost
brand medications. Non-preferred generic medications have the same quality, strength, purity and stability as their brand name
counterparts. These medications are available at a higher cost to you than Tier 1 preferred generic medications.
Tier 3: Preferred Brand Medications. This tier typically includes preferred brand medications and some high cost generic
medications. On a five-tier plan, these medications will usually cost you more than a preferred generic, but less than
a Tier 4 medication.
Tier 4: Non-Preferred Brand Medications. This tier includes a mix of non-preferred brands and high cost generic medications.
These medications are available at a higher cost to you than Tier 3 medications.
Tier 5: 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 non-specialty medications in one fill
• Specialty medications for more complex conditions, including those
that require refrigeration and overnight delivery (limited to a 30-day
supply in one fill, unless not allowed by state law)
• 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.
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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
2
ALENDRONATE SODIUM 70 MG TABLET
2
ACARBOSE
2
2
ACEBUTOLOL HCL
2
ALENDRONATE SODIUM 70 MG/75ML
SOLUTION, ORAL
ACETAMINOPHEN-BUTALBITAL
2
ALFUZOSIN HCL ER
2
ACETAMINOPHEN-CODEINE
2
ALINIA
4
ACETASOL HC
2
ALLOPURINOL
1
ACETAZOLAMIDE
2
ALPRAZOLAM
2
ACETIC ACID
2
ALPRAZOLAM ER
2
ACETIC ACID-ALUMINUM
2
ALPRAZOLAM INTENSOL
2
ACETYLCYSTEINE
2
ALPRAZOLAM ODT
2
ACITRETIN
4
ALPRAZOLAM XR
2
ACYCLOVIR 200 MG CAPSULE
1
ALTAVERA
1
ACYCLOVIR 200 MG/5ML SUSPENSION,
ORAL (FINAL DOSE FORM)
2
ALYACEN
1
AMANTADINE
2
ACYCLOVIR 400 MG TABLET
2
AMCINONIDE
2
ACYCLOVIR 5 % OINTMENT (GRAM)
2
AMETHIA
1
ACYCLOVIR 800 MG TABLET
2
AMETHIA LO
1
ADAPALENE
2
AMETHYST
1
ADDERALL XR
2
AMILORIDE HCL
2
AFEDITAB CR
2
AMILORIDE-HYDROCHLOROTHIAZIDE
2
AGGRENOX
4
AMIODARONE HCL
2
AK-POLY-BAC
2
AMITIZA
4
ALAGESIC LQ
2
AMITRIPTYLINE HCL
1
ALBUTEROL SULFATE 0.63MG/3ML VIAL,
NEBULIZER (ML)
2
AMLODIPINE BESYLATE
2
AMLODIPINE BESYLATE-BENAZEPRIL
2
ALBUTEROL SULFATE 1.25MG/3ML VIAL,
NEBULIZER (ML)
2
AMLODIPINE-ATORVASTATIN
2
ALBUTEROL SULFATE 2 MG TABLET
2
AMLODIPINE-VALSARTAN
2
ALBUTEROL SULFATE 2 MG/5 ML SYRUP
2
AMMONIUM LACTATE
2
ALBUTEROL SULFATE 2.5 MG/0.5 VIAL,
NEBULIZER (EA)
2
AMNESTEEM
2
AMOX TR-POTASSIUM CLAVULANATE
2
ALBUTEROL SULFATE 2.5 MG/3ML VIAL,
NEBULIZER (ML)
1
AMOXAPINE
2
AMOXICILLIN
1
ALBUTEROL SULFATE 4 MG TABLET
2
AMOXICILLIN-CLAVULANATE ER
2
ALBUTEROL SULFATE 4 MG TABLET,
EXTENDED RELEASE 12 HR
2
AMPHETAMINE SALT COMBO
2
AMPICILLIN TRIHYDRATE
2
ALBUTEROL SULFATE 5 MG/ML SOLUTION,
NON-ORAL
2
ANA-LEX
2
ALBUTEROL SULFATE 8 MG TABLET,
EXTENDED RELEASE 12 HR
2
ANASTROZOLE
2
ANTIPYRINE-BENZOCAINE
2
ALCLOMETASONE DIPROPIONATE
2
ANUCORT-HC
2
ALENDRONATE SODIUM 10 MG TABLET
1
APEXICON E
2
ALENDRONATE SODIUM 35 MG TABLET
1
APRACLONIDINE HCL
2
ALENDRONATE SODIUM 40 MG TABLET
1
APRI
1
ALENDRONATE SODIUM 5 MG TABLET
1
APRISO
3
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
2
ARBINOXA
2
BPO
2
ARMOUR THYROID
2
BREVICON
4
ASCOMP WITH CODEINE
2
BRIELLYN
1
ASPIRIN-CAFFEINE-DIHYDROCODEIN
2
BRIMONIDINE TARTRATE
2
ATENOLOL
1
BROMFED DM
2
ATENOLOL-CHLORTHALIDONE
1
BROMFENAC SODIUM
2
ATORVASTATIN CALCIUM
2
BROMOCRIPTINE MESYLATE
2
ATOVAQUONE
2
BROMPHENIRAMINE-PSEUDOEPHED-DM
2
ATOVAQUONE-PROGUANIL HCL
2
BRONCOTRON PED
1
ATROPINE CARE
2
BRONCOTRON-S
1
ATROPINE SULFATE
2
BUDESONIDE
2
AUBRA
1
BUDESONIDE EC
4
AVAR
2
BUMETANIDE
1
AVAR-E
2
BUPRENORPHINE HCL
2
AVAR-E GREEN
2
BUPRENORPHINE-NALOXONE
2
AVIANE
1
BUPROBAN
2
AZELASTINE HCL
2
BUPROPION HCL
2
AZILECT
4
BUPROPION HCL SR
2
AZITHROMYCIN
2
BUPROPION XL
2
AZOPT
3
BUSPIRONE HCL
2
AZURETTE
1
BUTALB-ACETAMINOPH-CAFF-CODEIN
2
BACITRACIN
2
BUTALB-CAFF-ACETAMINOPH-CODEIN
2
BACITRACIN-POLYMYXIN
2
BUTALBITAL COMPOUND-CODEINE
2
BACLOFEN
1
BUTALBITAL-ACETAMINOPHEN-CAFFE
2
BAL-CARE DHA
1
BUTALBITAL-ASPIRIN-CAFFEINE
2
BALSALAZIDE DISODIUM
2
BUTORPHANOL TARTRATE
2
QL
BALZIVA
1
BYDUREON
3
QL
BELLADONNA-OPIUM
2
BYDUREON PEN
3
QL
BENAZEPRIL HCL
1
BYETTA
3
BENAZEPRIL-HYDROCHLOROTHIAZIDE
2
CABERGOLINE
2
BENZONATATE
2
CAFFEINE CITRATE
2
BENZOYL PEROXIDE
2
CALCIPOTRIENE
2
BENZTROPINE MESYLATE
2
CALCIPOTRIENE-BETAMETHASONE DP
2
BETAMETHASONE DIPROPIONATE
2
CALCITONIN-SALMON
2
BETAMETHASONE VALERATE
2
CALCITRENE
2
BETAXOLOL HCL
2
CALCITRIOL
2
BETHANECHOL CHLORIDE
2
CALCIUM ACETATE
2
BEYAZ
3
CAMILA
1
BILTRICIDE
4
CAMRESE
1
BISOPROLOL FUMARATE
2
CAMRESE LO
1
BISOPROLOL-HYDROCHLOROTHIAZIDE
1
CANDESARTAN CILEXETIL
2
BP 10-1
2
CANDESARTAN-HYDROCHLOROTHIAZID
2
BP WASH
2
CANTIL
4
BP WASH ACNE TREATMENT
2
CAPACET
2
6
PA
QL
DRUG NAME
Tier
NOTES (PA, ST, QL, AGE)
DRUG NAME
Tier
CAPTOPRIL
1
CEPHALEXIN 500 MG TABLET
1
CAPTOPRIL-HYDROCHLOROTHIAZIDE
2
CEPHALEXIN 750 MG CAPSULE
2
CARBAMAZEPINE 100 MG CAPSULE,
EXTENDED RELEASE MULTIPHASE 12HR
2
CETIRIZINE HCL
2
CEVIMELINE HCL
2
CARBAMAZEPINE 100 MG TABLET,
CHEWABLE
1
CHATEAL
1
CARBAMAZEPINE 100 MG/5ML
SUSPENSION, ORAL (FINAL DOSE FORM)
2
CHERATUSSIN AC
2
CHERATUSSIN DAC
2
CARBAMAZEPINE 200 MG CAPSULE,
EXTENDED RELEASE MULTIPHASE 12HR
2
CHLORDIAZEPOXIDE HCL
2
CHLORDIAZEPOXIDE-AMITRIPTYLINE
2
CARBAMAZEPINE 200 MG TABLET
1
CHLORDIAZEPOXIDE-CLIDINIUM
2
CARBAMAZEPINE 300 MG CAPSULE,
EXTENDED RELEASE MULTIPHASE 12HR
2
CHLORHEXIDINE GLUCONATE
2
CHLOROQUINE PHOSPHATE
2
CARBAMAZEPINE ER
2
CHLOROTHIAZIDE
2
CARBAMAZEPINE XR
2
CHLORPROMAZINE HCL
2
CARBIDOPA
2
CHLORPROPAMIDE
1
CARBIDOPA-LEVODOPA
2
CHLORTHALIDONE
2
CARBIDOPA-LEVODOPA ER
2
CHLORZOXAZONE
2
CARBIDOPA-LEVODOPA-ENTACAPONE
2
CHOLESTYRAMINE
2
CARBINOXAMINE MALEATE
2
CHOLESTYRAMINE LIGHT
2
CARISOPRODOL
2
CHOLINE MAG TRISALICYLATE
2
CARISOPRODOL COMPOUND
2
CICLODAN
2
CARISOPRODOL COMPOUND-CODEINE
2
CICLOPIROX
2
CARISOPRODOL-ASPIRIN
2
CILOSTAZOL
2
CARISOPRODOL-ASPIRIN-CODEINE
2
CIMETIDINE 200 MG TABLET
1
CARTEOLOL HCL
2
CIMETIDINE 300 MG TABLET
1
CARTIA XT
2
CIMETIDINE 300 MG/5ML SOLUTION, ORAL
2
CARVEDILOL
1
CIMETIDINE 400 MG TABLET
1
CAZIANT
1
CIMETIDINE 800 MG TABLET
1
CEFACLOR
2
CIPROFLOXACIN
2
CEFACLOR ER
2
CIPROFLOXACIN ER
2
CEFADROXIL
2
2
CIPROFLOXACIN HCL 0.2 % DROPPERETTE,
SINGLE-USE DROP DISPENSER
2
CEFDINIR
CEFDITOREN PIVOXIL
2
CIPROFLOXACIN HCL 0.3 % DROPS
2
CEFPODOXIME PROXETIL
2
CIPROFLOXACIN HCL 100 MG TABLET
1
CEFPROZIL
2
CIPROFLOXACIN HCL 250 MG TABLET
1
CEFTIBUTEN
2
CIPROFLOXACIN HCL 500 MG TABLET
1
CEFUROXIME
2
CIPROFLOXACIN HCL 750 MG TABLET
1
CENTERGY
2
CITALOPRAM HBR 10 MG TABLET
1
CENTERGY DM
2
2
CEPHALEXIN 125 MG/5ML SUSPENSION,
RECONSTITUTED, ORAL (ML)
1
CITALOPRAM HBR 10 MG/5 ML
SOLUTION, ORAL
CITALOPRAM HBR 20 MG TABLET
1
CEPHALEXIN 250 MG CAPSULE
1
CITALOPRAM HBR 40 MG TABLET
1
CEPHALEXIN 250 MG TABLET
1
CLARAVIS
2
CEPHALEXIN 250 MG/5ML SUSPENSION,
RECONSTITUTED, ORAL (ML)
1
CLARIS
2
CLARITHROMYCIN
2
CEPHALEXIN 500 MG CAPSULE
1
CLARITHROMYCIN ER
2
7
NOTES (PA, ST, QL, AGE)
QL
DRUG NAME
Tier
NOTES (PA, ST, QL, AGE)
DRUG NAME
Tier
CLEANSING WASH
2
CORTISPORIN-TC
4
CLEMASTINE FUMARATE
2
COVARYX
2
CLINDACIN ETZ
2
COVARYX H.S.
2
CLINDACIN P
2
CROMOLYN SODIUM
2
CLINDAMYCIN HCL
2
CRYSELLE
1
CLINDAMYCIN PALMITATE HCL
2
CUPRIMINE
4
CLINDAMYCIN PEDIATRIC
2
CYANOCOBALAMIN INJECTION
2
CLINDAMYCIN PHOS-BENZOYL PEROX
2
CYCLAFEM
1
CLINDAMYCIN PHOSPHATE
2
CYCLESSA
1
CLINDAMYCIN-BENZOYL PEROXIDE
2
CYCLOBENZAPRINE HCL 10 MG TABLET
1
CLOBETASOL EMOLLIENT
2
CYCLOBENZAPRINE HCL 5 MG TABLET
1
CLOBETASOL EMULSION
2
CYCLOBENZAPRINE HCL 7.5 MG TABLET
2
CLOBETASOL PROPIONATE
2
CYCLOPENTOLATE HCL
2
CLOCORTOLONE PIVALATE
2
CYCLOSERINE
2
CLODAN
2
CYPROHEPTADINE HCL
2
CLOMIPHENE CITRATE
2
CYTRA-2
2
CLOMIPRAMINE HCL
2
CYTRA-3
2
CLONAZEPAM
2
CYTRA-K
2
CLONIDINE
2
DANAZOL
2
CLONIDINE HCL
2
DANTROLENE SODIUM
2
CLONIDINE HCL ER
2
DAPSONE
4
CLOPIDOGREL
2
DASETTA
1
CLORAZEPATE DIPOTASSIUM
2
DAYSEE
1
CLORPRES
2
DEBLITANE
1
CLOTRIMAZOLE
2
DELYLA
1
CLOTRIMAZOLE-BETAMETHASONE
2
DEMECLOCYCLINE HCL
2
CLOZAPINE
2
DENTA 5000 PLUS
2
CLOZAPINE ODT
2
DENTAGEL
2
C-NATE DHA
1
DEPADE
2
COARTEM
4
DEPEN
4
CODEINE SULFATE
2
DERMAZENE
2
CODEINE-GUAIFENESIN
2
DESIPRAMINE HCL
2
COLCRYS
4
DESMOPRESSIN ACETATE
2
COLESTIPOL HCL
2
DESOGEN
4
COLOCORT
2
DESOGESTREL-ETHINYL ESTRADIOL
1
COMPLETE FORMULATION D3000
2
DESOGESTR-ETH ESTRAD ETH ESTRA
1
COMPLETE FORMULATION MULTIVIT
2
DESONIDE
2
COMPLETE FORMULATION PEDIATRIC
2
DESOXIMETASONE
2
COMPLETE NATAL DHA
1
DEXAMETHASONE
1
COMPLETENATE
1
DEXAMETHASONE INTENSOL
1
COMPRO
2
DEXAMETHASONE SODIUM PHOSPHATE
2
CONSTULOSE
2
DEXILANT
3
CORMAX
2
DEXMETHYLPHENIDATE HCL
2
CORTANE-B
2
DEXMETHYLPHENIDATE HCL ER
2
CORTISONE ACETATE
2
DEXTROAMPHETAMINE SULFATE
2
QL
8
NOTES (PA, ST, QL, AGE)
ST
DRUG NAME
Tier
NOTES (PA, ST, QL, AGE)
DRUG NAME
Tier
NOTES (PA, ST, QL, AGE)
DEXTROAMPHETAMINE SULFATE ER
2
ECONAZOLE NITRATE
2
DIAZEPAM
2
ED-SPAZ
1
DIBENZYLINE
4
EEMT
2
DICLOFENAC POTASSIUM
2
EEMT H.S.
2
DICLOFENAC SODIUM
2
EFFER-K 25 MEQ TABLET, EFFERVESCENT
2
DICLOFENAC SODIUM ER
2
ELIMITE
2
DICLOFENAC SODIUM-MISOPROSTOL
2
ELINEST
1
DICLOXACILLIN SODIUM
2
ELIPHOS
2
DICYCLOMINE HCL 10 MG CAPSULE
1
ELITE OB DHA
1
DICYCLOMINE HCL 10 MG/5 ML
SOLUTION ORAL
2
ELITE-OB
1
ELITE-OB 400
1
DICYCLOMINE HCL 20 MG TABLET
1
ELLA
4
DIFLORASONE DIACETATE
2
ELMIRON
4
DIFLUNISAL
2
EMOQUETTE
1
DIGOX
1
EMSAM
4
DIGOXIN 125 MCG TABLET
1
ENALAPRIL MALEATE
1
DIGOXIN 250 MCG TABLET
1
ENALAPRIL-HYDROCHLOROTHIAZIDE
2
DIGOXIN 50 MCG/ML SOLUTION, ORAL
2
ENDACOF-C
2
DIHYDROERGOTAMINE MESYLATE
2
ENDOCET
2
DILTIAZEM 24HR CD
2
ENDODAN
2
DILTIAZEM 24HR ER
2
ENPRESSE
1
DILTIAZEM ER
2
ENSKYCE
1
DILTIAZEM HCL
1
ENTACAPONE
2
DILT-XR
2
ENULOSE
2
DIPHENHYDRAMINE HCL
2
EPINASTINE HCL
2
DIPHENOXYLATE-ATROPINE
2
EPINEPHRINE
2
QL
DIPYRIDAMOLE
2
EPIPEN 2-PAK
3
QL
DISKETS
2
EPIPEN JR 2-PAK
3
QL
DISOPYRAMIDE PHOSPHATE
2
EPITOL
1
DISULFIRAM
2
EPLERENONE
2
DIVALPROEX SODIUM
2
EPROSARTAN MESYLATE
2
DIVALPROEX SODIUM ER
2
ERGOLOID MESYLATES
1
DONEPEZIL HCL
2
ERRIN
1
DONEPEZIL HCL ODT
2
ERY
2
DORZOLAMIDE HCL
2
ERYGEL
2
DORZOLAMIDE-TIMOLOL
2
ERYTHROCIN STEARATE
2
DOXAZOSIN MESYLATE
1
ERYTHROMYCIN
2
DOXEPIN HCL
2
ERYTHROMYCIN ETHYLSUCCINATE
2
DOXERCALCIFEROL
2
ERYTHROMYCIN-BENZOYL PEROXIDE
2
DOXYCYCLINE HYCLATE
2
ESCITALOPRAM OXALATE
2
DOXYCYCLINE MONOHYDRATE
2
ESTARYLLA
1
DRONABINOL
2
ESTAZOLAM
2
DROSPIRENONE-ETHINYL ESTRADIOL
1
3
ESTRADIOL .025MG/24H PATCH,
TRANSDERMAL WEEKLY
2
DULERA
DULOXETINE HCL
2
ESTRADIOL .0375MG/24 PATCH,
TRANSDERMAL WEEKLY
2
QL
9
DRUG NAME
Tier
ESTRADIOL .075MG/24H PATCH,
TRANSDERMAL WEEKLY
2
ESTRADIOL 0.05MG/24H PATCH,
TRANSDERMAL WEEKLY
2
ESTRADIOL 0.06MG/24H PATCH,
TRANSDERMAL WEEKLY
2
ESTRADIOL 0.1MG/24HR PATCH,
TRANSDERMAL WEEKLY
NOTES (PA, ST, QL, AGE)
DRUG NAME
Tier
FENTANYL CITRATE
4
FEXOFENADINE HCL
2
FINASTERIDE
2
FLAVOXATE HCL
2
FLECAINIDE ACETATE
2
2
FLUCONAZOLE 10 MG/ML SUSPENSION,
RECONSTITUTED, ORAL (ML)
2
ESTRADIOL 0.5 MG TABLET
1
FLUCONAZOLE 100 MG TABLET
2
ESTRADIOL 1 MG TABLET
1
FLUCONAZOLE 150 MG TABLET
1
ESTRADIOL 2 MG TABLET
1
FLUCONAZOLE 200 MG TABLET
2
ESTRADIOL-NORETHINDRONE ACETAT
2
2
ESTROGEN & METHYLTESTOSTERONE
2
FLUCONAZOLE 40 MG/ML SUSPENSION,
RECONSTITUTED, ORAL (ML)
ESTROGEN-METHYLTESTOSTERONE
2
FLUCONAZOLE 50 MG TABLET
2
ESTROPIPATE
2
FLUCYTOSINE
2
ESTROSTEP FE
4
FLUDROCORTISONE ACETATE
2
ESZOPICLONE
2
FLUNISOLIDE
2
ETHAMBUTOL HCL
2
FLUOCINOLONE ACETONIDE
2
ETHOSUXIMIDE
2
FLUOCINOLONE ACETONIDE OIL
2
ETHYL CHLORIDE
2
FLUOCINONIDE
2
ETIDRONATE DISODIUM
2
FLUOCINONIDE-E
2
ETODOLAC
2
FLUORABON
2
ETODOLAC ER
2
FLUORIDE
2
EVISTA
4
FLUORIDEX DAILY DEFENSE
2
EVZIO
4
FLUORITAB
2
EXALGO
4
FLUOROMETHOLONE
2
EXEMESTANE
2
FLUOROURACIL
2
EXOTIC-HC
2
FLUOXETINE DR
2
EXTRA-VIRT PLUS DHA
1
FLUOXETINE HCL 10 MG CAPSULE
1
FALMINA
1
FLUOXETINE HCL 10 MG TABLET
1
FAMCICLOVIR
2
FLUOXETINE HCL 20 MG CAPSULE
1
FAMOTIDINE 20 MG TABLET
1
FLUOXETINE HCL 20 MG TABLET
1
FAMOTIDINE 40 MG TABLET
1
FLUOXETINE HCL 20 MG/5 ML
SOLUTION, ORAL
2
FAMOTIDINE 40MG/5ML SUSPENSION,
ORAL (FINAL DOSE FORM)
2
FLUOXETINE HCL 40 MG CAPSULE
1
FARESTON
4
FLUOXETINE HCL 60 MG TABLET
1
FELBAMATE 400 MG TABLET
2
FLUPHENAZINE HCL
2
FELBAMATE 600 MG TABLET
2
FLURA-DROPS
2
FELBAMATE 600 MG/5ML SUSPENSION,
ORAL (FINAL DOSE FORM)
4
FLURAZEPAM HCL
2
FLURBIPROFEN
2
FELODIPINE ER
2
FLURBIPROFEN SODIUM
2
FEM PH
2
FLUTICASONE PROPIONATE
2
FEMCON FE
4
FLUVASTATIN SODIUM
2
FENOFIBRATE
2
FLUVOXAMINE MALEATE
2
FENOFIBRIC ACID
2
FLUVOXAMINE MALEATE ER
2
FENOPROFEN CALCIUM
2
FOCALGIN-B
1
FENTANYL
2
FOLBECAL
1
QL
QL
10
NOTES (PA, ST, QL, AGE)
PA
DRUG NAME
Tier
NOTES (PA, ST, QL, AGE)
DRUG NAME
Tier
FOLIC ACID
2
GUAIFENESIN AC
2
FOLINATAL PLUS B
1
GUAIFENESIN DAC
2
FOLIVANE-OB
1
GUAIFENESIN-CODEINE
2
FOLIVANE-PRX DHA NF
1
GUANFACINE HCL
1
FORADIL
3
GUANIDINE HCL
2
FORMADON
2
GYNAZOLE 1
2
FORTICAL
2
HALOBETASOL PROPIONATE
2
FOSINOPRIL SODIUM
1
HALONATE PAC
2
FOSINOPRIL-HYDROCHLOROTHIAZIDE
2
HALOPERIDOL
2
FUROSEMIDE
1
HALOPERIDOL LACTATE
2
GABAPENTIN
2
HEATHER
1
GALANTAMINE HBR
2
HEMENATAL OB
1
GALANTAMINE HYDROBROMIDE
2
HEMENATAL OB + DHA
1
GARAMYCIN
2
HEPARIN SODIUM
2
GASTRACE
1
HOMATROPAIRE
2
GATIFLOXACIN
2
HOMATROPINE HYDROBROMIDE
2
GAVILYTE-C
2
HUMALOG
3
GAVILYTE-G
2
HUMALOG MIX 50-50
3
GAVILYTE-N
2
HUMALOG MIX 75-25
3
GEMFIBROZIL
2
HUMULIN 70/30 KWIKPEN
3
GENERESS FE
4
HUMULIN 70-30
3
GENERLAC
2
HUMULIN N
3
GENTAK
2
HUMULIN N KWIKPEN
3
GENTAMICIN SULFATE
2
HUMULIN R
3
GIANVI
1
HYDRALAZINE HCL
2
GILDAGIA
1
HYDROCHLOROTHIAZIDE
1
GILDESS
1
HYDROCOD-CPM-PSEUDOEPHEDRINE
2
GILDESS FE
1
HYDROCODONE BT-HOMATROPINE MBR
2
GLIMEPIRIDE
1
HYDROCODONE-ACETAMINOPHEN
2
GLIPIZIDE
1
HYDROCODONE-CHLORPHENIRAMINE
2
GLIPIZIDE ER
1
HYDROCODONE-HOMATROPINE MBR
2
GLIPIZIDE XL
1
HYDROCODONE-IBUPROFEN
2
GLIPIZIDE-METFORMIN
2
HYDROCORTISONE 1 % CREAM (GRAM)
1
GLYBURIDE
1
HYDROCORTISONE 1 % OINTMENT (GRAM)
2
GLYBURIDE MICRONIZED
1
HYDROCORTISONE 10 MG TABLET
2
GLYBURIDE-METFORMIN HCL
2
2
GLYCINE
2
HYDROCORTISONE 100MG/60ML ENEMA
(ML)
GLYCOPYRROLATE
2
HYDROCORTISONE 2.5 % CREAM (GRAM)
1
GLYDO
2
HYDROCORTISONE 2.5 % LOTION (ML)
2
GRANISETRON HCL
2
HYDROCORTISONE 2.5 % OINTMENT (GRAM)
2
GRANISOL
2
HYDROCORTISONE 20 MG TABLET
2
GRISEOFULVIN
2
HYDROCORTISONE 5 MG TABLET
2
GRISEOFULVIN ULTRAMICROSIZE
2
HYDROCORTISONE ACETATE
2
GRX HICORT 25
2
HYDROCORTISONE BUTYRATE
2
GUAIATUSSIN AC
2
HYDROCORTISONE VALERATE
2
11
NOTES (PA, ST, QL, AGE)
DRUG NAME
Tier
NOTES (PA, ST, QL, AGE)
DRUG NAME
Tier
NOTES (PA, ST, QL, AGE)
HYDROCORTISONE-ACETIC ACID
2
ISOMETHEPT-DICHLORALP-ACETAMIN
2
HYDROCORTISONE-IODOQUINOL
2
ISONIAZID 100 MG TABLET
1
HYDROCORTISONE-PRAMOXINE
2
ISONIAZID 300 MG TABLET
1
HYDROCORTISONE-PRAMOXINE HCL
2
ISONIAZID 50 MG/5 ML SOLUTION, ORAL
2
HYDROMET
2
ISOSORBIDE DINITRATE
2
HYDROMORPHONE ER
2
ISOSORBIDE MONONITRATE
1
HYDROMORPHONE HCL
2
ISOSORBIDE MONONITRATE ER
1
HYDROXYCHLOROQUINE SULFATE
2
ISOXSUPRINE HCL
2
HYDROXYUREA
2
ISRADIPINE
2
HYDROXYZINE HCL
2
ITRACONAZOLE
2
HYDROXYZINE PAMOATE
2
JANTOVEN
1
HYOPHEN
2
JENCYCLA
1
HYOSCYAMINE SULFATE 0.125 MG TABLET
1
JENTADUETO
3
HYOSCYAMINE SULFATE 0.125 MG TABLET,
SUBLINGUAL
1
JINTELI
2
JOLESSA
1
HYOSCYAMINE SULFATE 0.125 MG
TABLET,DISINTEGRATING
1
JOLIVETTE
1
HYOSCYAMINE SULFATE 0.125MG/ML DROPS
2
JUNEL
1
HYOSCYAMINE SULFATE 125MCG/5ML ELIXIR
2
JUNEL FE
1
HYOSCYAMINE SULFATE ER
1
K EFFERVESCENT
2
HYOSCYAMINE SULFATE SR
1
KARIVA
1
HYOSYNE
2
KELNOR 1-35
1
HYPERCARE
2
KETOCONAZOLE
2
IBANDRONATE SODIUM
2
KETODAN
2
IBUDONE
2
KETOPROFEN
2
IBUPROFEN
1
KETOROLAC TROMETHAMINE 0.4 % DROPS
2
IMIPRAMINE HCL
2
KETOROLAC TROMETHAMINE 0.5 % DROPS
2
IMIPRAMINE PAMOATE
2
KETOROLAC TROMETHAMINE 10 MG TABLET
2
QL
IMIQUIMOD
2
KETOROLAC TROMETHAMINE 15 MG/ML
CARTRIDGE (ML)
2
QL
INATAL ADVANCE
1
QL
1
KETOROLAC TROMETHAMINE 15 MG/ML
VIAL (ML)
2
INATAL ULTRA
INDAPAMIDE
1
2
QL
INDOMETHACIN
2
KETOROLAC TROMETHAMINE 30 MG/ML
SYRINGE (ML)
INTROVALE
1
2
QL
IOPHEN-C NR
2
KETOROLAC TROMETHAMINE 60 MG/2 ML
VIAL (ML)
IPRATROPIUM BROMIDE 0.2 MG/ML
SOLUTION, NON-ORAL
1
KIONEX
2
KLOR-CON 10
2
IPRATROPIUM BROMIDE 21 MCG
AEROSOL, SPRAY (ML)
2
KLOR-CON 8
2
KLOR-CON M10
2
IPRATROPIUM BROMIDE 42MCG AEROSOL,
SPRAY (ML)
2
KLOR-CON M20
2
KLOR-CON-EF
2
IPRATROPIUM-ALBUTEROL
2
KURVELO
1
IRBESARTAN
2
LABETALOL HCL
2
IRBESARTAN-HYDROCHLOROTHIAZIDE
2
LACTATED RINGERS
2
ISOCHRON
2
LACTULOSE
2
ISOMETHEPT-CAFF-ACETAMINOPHEN
2
LAMOTRIGINE
2
QL
12
QL
DRUG NAME
Tier
LAMOTRIGINE ER
2
LITHIUM CARBONATE 300 MG TABLET
1
LANSOPRAZOL-AMOXICIL-CLARITHRO
2
2
LANSOPRAZOLE
2
LITHIUM CARBONATE 450 MG TABLET,
EXTENDED RELEASE
LARIN
1
LITHIUM CARBONATE 600 MG CAPSULE
1
LARIN FE
1
LITHIUM CARBONATE ER
2
LATANOPROST
2
L-METHYLFOLATE
2
LEENA
1
L-METHYLFOLATE CALCIUM
2
LEFLUNOMIDE
2
L-METHYLFOLATE FORMULA
2
LESSINA
1
L-METHYLFOLATE FORTE
2
LETROZOLE
2
LO LOESTRIN FE
3
LEUKERAN
4
LODOSYN
4
LEVALBUTEROL CONCENTRATE
2
LOESTRIN
4
LEVALBUTEROL HCL
2
LOESTRIN FE
4
LEVEMIR
3
LOHIST-DM
2
LEVEMIR FLEXTOUCH
3
LOMEDIA 24 FE
1
LEVETIRACETAM
2
LOMUSTINE
2
LEVETIRACETAM ER
2
LOPERAMIDE
2
LEVLEN 28
1
LORAZEPAM
2
LEVOBUNOLOL HCL
2
LORAZEPAM INTENSOL
2
LEVOCARNITINE
2
LORCET
2
LEVOCETIRIZINE DIHYDROCHLORIDE
2
LORCET HD
2
LEVOFLOXACIN
2
LORCET PLUS
2
LEVOMEFOLATE CALCIUM-ALGAL
2
LORTUSS EX
2
LEVOMEFOLATE DHA
1
LORYNA
1
LEVONEST
1
LOSARTAN POTASSIUM
1
LEVONORGESTREL
1
LOSARTAN-HYDROCHLOROTHIAZIDE
1
LEVONORGESTREL-ETH ESTRADIOL
1
LOSEASONIQUE
4
LEVONORG-ETH ESTRAD ETH ESTRAD
1
LOVASTATIN
1
LEVORA-28
1
LOW-OGESTREL
1
LEVORPHANOL TARTRATE
2
LOXAPINE
2
LEVOTHYROXINE SODIUM
1
LUDENT FLUORIDE
2
LEVOXYL
1
LUGOL'S
2
LIDOCAINE
2
LUTERA
1
LIDOCAINE HCL
2
LYRICA
4
LIDOCAINE HCL VISCOUS
1
LYSODREN
4
LIDOCAINE-HYDROCORTISONE
2
LYZA
1
LIDOCAINE-PRILOCAINE
2
MACNATAL CN DHA
1
LIDOPIN
2
MALATHION
2
LINDANE
2
MAPROTILINE HCL
2
LIOTHYRONINE SODIUM
2
MARGESIC
2
LISINOPRIL
1
MARLEXATE
2
LISINOPRIL-HYDROCHLOROTHIAZIDE
1
MARLISSA
1
LITHIUM
2
MARTEN-TAB
2
LITHIUM CARBONATE 150 MG CAPSULE
1
MATERNITY
1
LITHIUM CARBONATE 300 MG CAPSULE
1
MATZIM LA
2
NOTES (PA, ST, QL, AGE)
DRUG NAME
13
Tier
NOTES (PA, ST, QL, AGE)
DRUG NAME
Tier
NOTES (PA, ST, QL, AGE)
DRUG NAME
Tier
MAXITROL
2
METHYLPHENIDATE HCL CD
2
M-CLEAR WC
2
METHYLPHENIDATE LA
2
MECLIZINE HCL
2
METHYLPHENIDATE SR
2
MECLOFENAMATE SODIUM
2
METHYLPREDNISOLONE
2
MEDROL
4
METIPRANOLOL
2
MEDROXYPROGESTERONE ACETATE
1
METOCLOPRAMIDE HCL
1
MEFENAMIC ACID
2
METOLAZONE
2
MEFLOQUINE HCL
2
METOPROLOL SUCCINATE
2
MEGESTROL ACETATE
2
METOPROLOL TARTRATE
1
MELOXICAM 15 MG TABLET
1
METOPROLOL-HYDROCHLOROTHIAZIDE
2
MELOXICAM 7.5 MG TABLET
1
METRONIDAZOLE
2
MELOXICAM 7.5 MG/5ML SUSPENSION,
ORAL (FINAL DOSE FORM)
2
MEXILETINE HCL
2
MICONAZOLE 3
1
MENEST
4
MICROGESTIN
1
ME-PB-HYOS 16.2 MG TABLET
1
MICROGESTIN FE
1
ME-PB-HYOS 16.2MG/5ML ELIXIR
2
MIDAZOLAM HCL
2
MEPERIDINE HCL
2
MIDODRINE HCL
2
MEPERITAB
2
MIGERGOT
2
MEPHYTON
4
MIGRAGESIC IDA
2
MEPROBAMATE
2
MILLIPRED
2
MERCAPTOPURINE
2
MILLIPRED DP
2
MESALAMINE
2
MIMVEY
2
METADATE ER
2
MIMVEY LO
2
METAPROTERENOL SULFATE
2
MINASTRIN 24 FE
3
METAXALONE
2
MINITRAN
2
METFORMIN HCL
1
MINOCYCLINE HCL
2
METFORMIN HCL ER
2
MINOXIDIL
2
METHADONE HCL
2
MIRCETTE
4
METHADONE INTENSOL
2
MIRTAZAPINE
2
METHADOSE
2
MISOPROSTOL
2
METHAMPHETAMINE HCL
2
MODAFINIL
2
METHAZOLAMIDE
2
MODICON
4
METHENAMINE HIPPURATE
2
MOEXIPRIL HCL
2
METHENAMINE MANDELATE
2
MOEXIPRIL-HYDROCHLOROTHIAZIDE
2
METHIMAZOLE
2
MOMETASONE FUROATE
2
METHITEST
2
MONO-LINYAH
1
METHOCARBAMOL
2
MONONESSA
1
METHOXSALEN
2
MONTELUKAST SODIUM
2
METHSCOPOLAMINE BROMIDE
2
MORGIDOX
2
METHYCLOTHIAZIDE
2
MORPHINE SULFATE
2
METHYLDOPA
1
MORPHINE SULFATE ER
2
METHYLDOPA-HYDROCHLOROTHIAZIDE
2
MOXEZA
3
METHYLERGONOVINE MALEATE
2
MOXIFLOXACIN HCL
2
METHYLPHENIDATE ER
2
MULTAQ
4
METHYLPHENIDATE HCL
2
MULTIVITAMIN AND FLUORIDE
2
QL
14
NOTES (PA, ST, QL, AGE)
PA
QL
DRUG NAME
Tier
NOTES (PA, ST, QL, AGE)
DRUG NAME
Tier
MULTI-VITAMIN W-FLUORIDE
2
NEOMYCIN-BACITRACIN-POLYMYXIN
2
MULTI-VITAMIN W-FLUORIDE-IRON
2
NEOMYCIN-POLYMYXIN B
2
MULTIVITAMIN WITH FLUORIDE
2
NEOMYCIN-POLYMYXIN-DEXAMETH
2
MULTI-VITAMIN WITH FLUORIDE
2
NEOMYCIN-POLYMYXIN-GRAMICIDIN
2
MULTI-VITAMIN-FLUOR-IRON
2
NEOMYCIN-POLYMYXIN-HC
2
MULTIVITAMINS W-FLUORIDE-IRON
2
NEOMYCIN-POLYMYXIN-HYDROCORT
2
MULTIVITAMINS WITH FLUORIDE
2
NEO-POLYCIN
2
MULTIVITAMINS-A,B,D,E,K,ZN
2
NEO-POLYCIN HC
2
MUPIROCIN
2
NEUAC
2
MYNATAL
1
NEWGEN
1
MYNATAL ADVANCE
1
NIACIN ER
2
MYNATAL PLUS
1
NICARDIPINE HCL
2
MYNATAL-Z
1
NIFEDICAL XL
2
MYNATE 90 PLUS
1
NIFEDIPINE
2
MYORISAN
2
NIFEDIPINE ER
2
MYZILRA
1
NIKKI
1
NABUMETONE
2
NIMODIPINE
2
NADOLOL
1
NISOLDIPINE
2
NADOLOL-BENDROFLUMETHIAZIDE
2
NITRO-BID
2
NALTREXONE HCL
2
NITRO-DUR
4
NAMENDA
4
NITROFURANTOIN
2
NAPHAZOLINE HCL
2
NITROFURANTOIN MONO-MACRO
2
NAPROXEN 125 MG/5ML SUSPENSION,
ORAL (FINAL DOSE FORM)
2
NITROGLYCERIN
2
NITROGLYCERIN PATCH
2
NAPROXEN 250 MG TABLET
1
NITROSTAT
3
NAPROXEN 375 MG TABLET
1
NITRO-TIME
2
NAPROXEN 375 MG TABLET, DELAYED
RELEASE (ENTERIC COATED)
1
NIZATIDINE 150 MG CAPSULE
1
NAPROXEN 500 MG TABLET
1
NIZATIDINE 150MG/10ML SOLUTION, ORAL
2
NAPROXEN 500 MG TABLET, DELAYED
RELEASE (ENTERIC COATED)
1
NIZATIDINE 300 MG CAPSULE
1
NODOLOR
2
NAPROXEN SODIUM
1
NORA-BE
1
NARATRIPTAN
2
QL
NORETHINDRONE
1
NARATRIPTAN HCL
2
QL
NORETHINDRONE ACETATE
2
NATALVIRT 90 DHA
1
NORETHINDRON-ETHINYL ESTRADIOL
1
NATALVIRT CA
1
NORETHIN-ETH ESTRA FERROUS FUM
1
NATALVIT
4
NORGESTIMATE-ETHINYL ESTRADIOL
1
NATAZIA
4
NORINYL 1+35
4
NATEGLINIDE
2
NORINYL 1+50
4
NATROBA
2
NORLYROC
1
NATURE-THROID
1
NOROXIN
4
NEBUPENT
4
NOR-Q-D
4
NECON
1
NORTREL
1
NEFAZODONE HCL
2
NORTRIPTYLINE HCL 10 MG CAPSULE
1
NEOMYCIN SULFATE
2
2
NEOMYCIN-BACITRACIN-POLY-HC
2
NORTRIPTYLINE HCL 10 MG/5 ML
SOLUTION, ORAL
QL
15
NOTES (PA, ST, QL, AGE)
DRUG NAME
Tier
NOTES (PA, ST, QL, AGE)
DRUG NAME
Tier
NORTRIPTYLINE HCL 25 MG CAPSULE
1
OSCIMIN 0.125 MG TABLET, DISINTEGRATING
1
NORTRIPTYLINE HCL 50 MG CAPSULE
1
OSCIMIN SL
1
NORTRIPTYLINE HCL 75 MG CAPSULE
1
OSCIMIN SR
2
NP THYROID
1
OTICIN
2
NULEV
1
OTICIN HC
2
NUVARING
3
OTO-END 10
2
NYAMYC
2
OTOMAX-HC
2
NYDAMAX
2
OTOZIN
2
NYSTATIN 100000/G CREAM (GRAM)
1
OVCON-35
1
NYSTATIN 100000/G OINTMENT (GRAM)
1
OXANDROLONE
2
NYSTATIN 100000/G POWDER (GRAM)
2
OXAPROZIN
2
NYSTATIN 100000/ML SUSPENSION, ORAL
(FINAL DOSE FORM)
2
OXAZEPAM
2
OXCARBAZEPINE
2
NYSTATIN 500K UNIT TABLET
2
OXYBUTYNIN CHLORIDE 5 MG TABLET
1
NYSTATIN 50MM UNIT POWDER (EA)
2
OXYBUTYNIN CHLORIDE 5 MG/5 ML SYRUP
2
NYSTATIN-TRIAMCINOLONE
1
OXYBUTYNIN CHLORIDE ER
2
NYSTOP
2
OXYCODONE HCL
2
OBSTETRIX DHA
1
OXYCODONE HCL-ACETAMINOPHEN
2
O-CAL FA
4
OXYCODONE HCL-ASPIRIN
2
O-CAL PRENATAL
4
OXYCODONE HCL-IBUPROFEN
2
OCELLA
1
OXYCODONE-ACETAMINOPHEN
2
OFLOXACIN
2
OXYMORPHONE HCL
2
OGESTREL
1
OXYMORPHONE HCL ER
2
OLANZAPINE
2
PACERONE
2
OLANZAPINE ODT
2
PAIRE OB PLUS DHA
1
OLANZAPINE-FLUOXETINE HCL
2
PANATUSS PED
1
OLOPATADINE HCL
2
PANCRELIPASE 5,000
4
OMEGA-3 ACID ETHYL ESTERS
2
PANTOPRAZOLE SODIUM
2
OMEPRAZOLE
2
PAPAVERINE HCL
2
ONDANSETRON HCL
2
PAREGORIC
2
ONDANSETRON ODT
2
PAROEX
2
OPIUM TINCTURE
2
PAROMOMYCIN SULFATE
2
ORALONE
2
PAROXETINE HCL
1
ORAP
4
PASER
4
ORPHENADRINE CITRATE
2
PATADAY
3
ORPHENADRINE COMPOUND FORTE
2
PEG 3350-ELECTROLYTE
2
ORSYTHIA
1
PEG-3350
2
ORTHO EVRA
4
PEG-3350 AND ELECTROLYTES
2
ORTHO MICRONOR
4
PEG-3350 WITH FLAVOR PACKS
2
ORTHO TRI-CYCLEN
4
PEGANONE
4
ORTHO TRI-CYCLEN LO
4
PENICILLIN V POTASSIUM
1
ORTHO-CEPT
4
PENTAZOCINE-NALOXONE HCL
2
ORTHO-CYCLEN
4
PENTOXIFYLLINE
2
ORTHO-NOVUM
4
PERINDOPRIL ERBUMINE
2
OSCIMIN 0.125 MG TABLET
2
PERMETHRIN
2
16
NOTES (PA, ST, QL, AGE)
PA
QL
DRUG NAME
Tier
PERPHENAZINE
2
PRAMIPEXOLE DIHYDROCHLORIDE
2
PERPHENAZINE-AMITRIPTYLINE
2
PRAVASTATIN SODIUM
1
PHENADOZ
2
PRAZOSIN HCL
2
PHENAZOPYRIDINE HCL
1
PREDNICARBATE
2
PHENELZINE SULFATE
2
PREDNISOLONE
2
PHENOBARBITAL
2
PREDNISOLONE ACETATE
2
PHENYLEPHRINE HCL
2
PREDNISOLONE SODIUM PHOSPHATE
2
PHENYTOIN
2
PREDNISONE
2
PHENYTOIN SODIUM EXTENDED
2
PREDNISONE INTENSOL
2
PHILITH
1
PREFEST
2
PHOSPHA 250 NEUTRAL
2
PREFOL-DHA
1
PHOSPHASAL
2
PRENAISSANCE
1
PILOCARPINE HCL
2
PRENAISSANCE 90 DHA
1
PIMTREA
1
PRENAISSANCE BALANCE
1
PINDOLOL
2
PRENAISSANCE DHA
1
PINNACAINE
2
PRENAISSANCE NEXT
1
PIOGLITAZONE HCL
2
PRENAISSANCE NEXT-B
4
PIOGLITAZONE-GLIMEPIRIDE
2
PRENAISSANCE PLUS
1
PIOGLITAZONE-METFORMIN
2
PRENAISSANCE PROMISE
1
PIRMELLA
1
PRENAPLUS
1
PIROXICAM
2
PRENATAL 19
1
PLAN B ONE-STEP
4
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
2
PNV-SELECT
1
PREVIFEM
1
PNV-TOTAL
1
PRIFTIN
4
PODOFILOX
2
PRIMAQUINE
2
POLYCIN
2
PRIMIDONE
2
POLYETHYLENE GLYCOL 3350
2
PRIMLEV
2
POLYMYXIN B SUL-TRIMETHOPRIM
2
PROAIR HFA
3
PORTIA
1
PROBENECID
2
POTASS CIT-SOD CIT-CITRIC ACID
2
PROBENECID-COLCHICINE
2
POTASSIUM BICARBONATE
2
PROCENTRA
2
POTASSIUM CHLORIDE
2
PROCHLORPERAZINE MALEATE
2
POTASSIUM CITRATE ER
2
PROCTO-PAK
2
POTASSIUM CITRATE-CITRIC ACID
2
PROCTOSOL-HC
2
PR NATAL 400
1
PROCTOZONE-HC
2
PR NATAL 400 EC
1
PROGESTERONE
2
PR NATAL 430
1
PROMETHAZINE HCL
2
PR NATAL 430 EC
1
PROMETHAZINE VC
2
PRAMCORT
2
PROMETHAZINE VC-CODEINE
2
NOTES (PA, ST, QL, AGE)
DRUG NAME
17
Tier
NOTES (PA, ST, QL, AGE)
DRUG NAME
Tier
NOTES (PA, ST, QL, AGE)
DRUG NAME
Tier
NOTES (PA, ST, QL, AGE)
PROMETHAZINE-CODEINE
2
RESERPINE
2
PROMETHAZINE-DM
2
RIFABUTIN
2
PROMETHEGAN
2
RIFAMPIN
2
PROPAFENONE HCL
2
RIMANTADINE HCL
2
PROPAFENONE HCL ER
2
RISEDRONATE SODIUM
2
PROPANTHELINE BROMIDE
2
RISPERIDONE
2
PROPARACAINE HCL
2
RISPERIDONE ODT
2
PROPRANOLOL HCL
2
RIVASTIGMINE
2
PROPRANOLOL HCL ER
2
RIZATRIPTAN
2
PROPRANOLOL-HYDROCHLOROTHIAZID
2
R-NATAL OB
1
PROPYLTHIOURACIL
2
ROPINIROLE HCL
2
PROTRIPTYLINE HCL
2
ROSADAN
2
PRUDOXIN
2
ROSANIL
2
PULMOSAL
2
ROXICET
2
PYRAZINAMIDE
2
SAFYRAL
4
PYRIDOSTIGMINE BROMIDE
2
SALICYLIC ACID
2
QUARTETTE
4
SALSALATE
2
QUASENSE
1
SAMSCA
4
PA
QUETIAPINE FUMARATE
2
SAPHRIS
4
ST
QUINAPRIL HCL
2
SEASONIQUE
4
QUINAPRIL-HYDROCHLOROTHIAZIDE
2
SEB-PREV
2
QUINIDINE GLUCONATE
2
SECONAL SODIUM
2
QUINIDINE SULFATE
2
SELEGILINE HCL
2
QUININE SULFATE
2
SELENIUM SULFIDE
2
QVAR
3
SE-NATAL 19
1
RABEPRAZOLE SODIUM
2
SERTRALINE HCL 100 MG TABLET
1
RALOXIFENE HCL
2
2
RAMIPRIL
2
SERTRALINE HCL 20 MG/ML
CONCENTRATE, ORAL
RANITIDINE HCL 15 MG/ML SYRUP
2
SERTRALINE HCL 25 MG TABLET
1
RANITIDINE HCL 150 MG CAPSULE
1
SERTRALINE HCL 50 MG TABLET
1
RANITIDINE HCL 150 MG TABLET
1
SE-TAN DHA
1
RANITIDINE HCL 300 MG CAPSULE
1
SETONET
1
RANITIDINE HCL 300 MG TABLET
1
SEVELAMER CARBONATE
2
REA LO 39
2
SF
2
REA LO 40
2
SF 5000 PLUS
2
RECLIPSEN
1
SHAROBEL
1
RECTACORT-HC
2
SILVER NITRATE
2
REGENECARE
2
SILVER SULFADIAZINE
2
RELCOF C
2
SIMVASTATIN
1
RELENZA
4
SODIUM CHLORIDE
2
2
QL
RELNATE DHA
1
SODIUM CITRATE & CITRIC ACID
REMEVEN
2
SODIUM FLUORIDE
2
RENAGEL
4
SODIUM PHENYLBUTYRATE
2
REPAGLINIDE
2
SODIUM POLYSTYRENE SULFONATE
2
REPREXAIN
2
SODIUM SULFACETAMIDE
2
18
QL
Tier
DRUG NAME
Tier
SODIUM SULFACETAMIDE-SULFUR
2
TELMISARTAN
2
SOTALOL
1
TELMISARTAN-AMLODIPINE
2
SOTALOL AF
1
TELMISARTAN-HYDROCHLOROTHIAZID
2
SPECTRACEF
2
TEMAZEPAM
2
SPINOSAD
2
TENCON
2
SPIRONOLACTONE
2
TERAZOSIN HCL
1
SPIRONOLACTONE-HCTZ
2
TERBINAFINE HCL
1
SPRINTEC
1
TERBUTALINE SULFATE
2
SPS
2
TERCONAZOLE
2
SRONYX
1
TESTIM
3
SSS 10-5
2
TESTOSTERONE CYPIONATE
2
STANNOUS FLUORIDE
2
TESTOSTERONE ENANTHATE
2
STROMECTOL
4
TETCAINE
2
STRONG IODINE
2
TETRACAINE HCL
2
SUCRALFATE
2
TETRACYCLINE HCL
1
SULFACETAMIDE SODIUM
2
THEOCHRON
2
SULFACETAMIDE-PREDNISOLONE
2
THEOPHYLLINE
2
SULFACLEANSE 8-4
2
THEOPHYLLINE ANHYDROUS
2
SULFADIAZINE
2
THIORIDAZINE HCL
2
SULFAMETHOXAZOLE-TRIMETHOPRIM
2
THIOTHIXENE
2
SULFASALAZINE
2
TIAGABINE HCL
2
SULFASALAZINE DR
2
TICLOPIDINE HCL
2
SULFAZINE
2
TIKOSYN
4
SULFAZINE EC
2
TILIA FE
1
SULINDAC
2
TIMOLOL MALEATE
2
SUMATRIPTAN
2
QL
TINIDAZOLE
2
SUMATRIPTAN SUCCINATE
2
QL
TIZANIDINE HCL
2
SUPERVITE EC
1
TL-CARE DHA
1
SUTTAR-2
2
TL-SELECT
1
SUTTAR-SF
2
TOBRAMYCIN 0.3 % DROPS
2
SYEDA
1
TOBRAMYCIN-DEXAMETHASONE
2
SYMAX
1
TOLAZAMIDE
2
SYMAX-SL
1
TOLBUTAMIDE
2
SYMAX-SR
2
TOLMETIN SODIUM
2
SYNTHROID
4
TOLTERODINE TARTRATE
2
TABLOID
4
TOLTERODINE TARTRATE ER
2
TAMIFLU
3
TOPIRAGEN
2
TAMOXIFEN CITRATE
2
TOPIRAMATE
2
TAMSULOSIN HCL
2
TORSEMIDE
2
TARINA FE
1
TRADJENTA
3
TARON-BC
1
TRAMADOL HCL
2
QL
TARON-C DHA
1
2
QL
TARON-CRYSTALS
2
TRAMADOL HCL ER 100 MG TABLET,
EXTENDED RELEASE 24 HR
TARON-PREX PRENATAL
1
2
TAZTIA XT
2
TRAMADOL HCL ER 100 MG TABLET,
EXTENDED RELEASE MULTIPHASE 24 HR
DRUG NAME
NOTES (PA, ST, QL, AGE)
QL
19
NOTES (PA, ST, QL, AGE)
QL
QL
DRUG NAME
Tier
TRAMADOL HCL ER 150 MG CAPSULE, EXT.
RELEASE 24 HR BIPHASIC 25-75
2
TRAMADOL HCL ER 200 MG TABLET,
EXTENDED RELEASE 24 HR
2
TRAMADOL HCL ER 200 MG TABLET,
EXTENDED RELEASE MULTIPHASE 24 HR
2
TRAMADOL HCL ER 300 MG TABLET,
EXTENDED RELEASE 24 HR
2
NOTES (PA, ST, QL, AGE)
DRUG NAME
QL
QL
Tier
TRI-SPRINTEC
1
TRI-TABS DHA
1
TRIVEEN-DUO DHA
1
TRIVEEN-ONE
1
TRIVEEN-PRX RNF
1
TRIVEEN-U
1
TRI-VI-FLORO
2
TRI-VIT WITH FLUORIDE-IRON
2
TRI-VITAMIN WITH FLUORIDE
2
TRIVORA-28
1
TRAMADOL HCL ER 300 MG TABLET,
EXTENDED RELEASE MULTIPHASE 24 HR
2
TRAMADOL HCL-ACETAMINOPHEN
2
TRANDOLAPRIL
2
TROPICAMIDE
2
TRANEXAMIC ACID
2
TROSPIUM CHLORIDE
2
TRANYLCYPROMINE SULFATE
2
TROSPIUM CHLORIDE ER
2
TRAVATAN Z
3
TRUST NATAL DHA
1
TRAZODONE HCL
1
TUDORZA PRESSAIR
3
TRECATOR
4
TUSNEL C
2
TRETINOIN 0.01 % GEL (GRAM)
2
U-CORT
2
TRETINOIN 0.025 % CREAM (GRAM)
2
ULTIMATECARE ONE
1
TRETINOIN 0.025 % GEL (GRAM)
2
ULTIMATECARE ONE NF
1
TRETINOIN 0.05 % CREAM (GRAM)
2
AGE
UNITHROID
1
TRETINOIN 0.1 % CREAM (GRAM)
2
AGE
UR N-C
2
TRETINOIN 10 MG CAPSULE
2
URIN D.S.
2
TRETINOIN MICROSPHERE
2
URSODIOL
2
TRIADVANCE
1
USTELL
2
TRIAMCINOLONE ACETONIDE
2
UTIRA-C
2
TRIAMTERENE-HCTZ
2
VAGIFEM
4
TRIAMTERENE-HYDROCHLOROTHIAZID
2
VALACYCLOVIR
2
TRIANEX
2
VALCYTE
4
TRIAZOLAM
2
VALPROIC ACID
2
TRICITRATES
2
VALSARTAN
2
TRIDERM
2
VALSARTAN-HYDROCHLOROTHIAZIDE
2
TRI-ESTARYLLA
1
VANCOMYCIN HCL
2
TRIFLUOPERAZINE HCL
2
VANDAZOLE
2
TRIFLURIDINE
2
VASOLEX
2
TRIHEXYPHENIDYL HCL
2
VELIVET
1
TRI-LEGEST FE
1
VEMAVITE-PRX 2
1
TRI-LINYAH
1
VENA-BAL DHA
1
TRILYTE WITH FLAVOR PACKETS
2
VENATAL COMPLETE DHA
1
TRIMETHOBENZAMIDE HCL
2
VENATAL-FA
1
TRIMETHOPRIM
2
VENLAFAXINE HCL
2
TRINATAL GT
1
VENLAFAXINE HCL ER
2
TRINATAL RX 1
1
VERAPAMIL ER
2
TRINESSA
1
VERAPAMIL ER PM
2
TRI-NORINYL
4
VERAPAMIL HCL
2
TRIPLE-VITAMIN W-FLUORIDE
2
VERAPAMIL SR
2
TRI-PREVIFEM
1
QL
AGE
AGE
20
NOTES (PA, ST, QL, AGE)
DRUG NAME
Tier
Tier
NOTES (PA, ST, QL, AGE)
DRUG NAME
ST
WESTHROID
1
NOTES (PA, ST, QL, AGE)
VESICARE
3
VESTURA
1
WP THYROID
1
VIGAMOX
3
WYMZYA FE
1
VINACAL
1
XULANE
1
VINATE GT
1
X-VIATE
2
VINATE II
1
XYLON 10
2
VINATE ONE
1
YASMIN 28
4
VINATE PN CARE
1
YAZ
4
VINATE ULTRA
1
ZAFIRLUKAST
2
VINATE-M
1
ZALEPLON
2
VIORELE
1
ZARAH
1
VIRT NATE
1
ZATEAN-CH
1
VIRT-ADVANCE
1
ZATEAN-PN
1
VIRT-C DHA
1
ZATEAN-PN DHA
1
VIRT-CARE ONE
1
ZATEAN-PN PLUS
1
VIRTI-SULF
2
ZAZOLE
2
VIRT-PHOS 250 NEUTRAL
2
ZEBUTAL
2
VIRT-PN
1
ZENATANE
2
VIRT-PN DHA
1
ZENCHENT
1
VIRT-PN PLUS
1
ZENCHENT FE
1
VIRTPREX
1
ZENCIA
2
VIRT-SELECT
1
ZENPEP
3
VIRTUSSIN AC
2
ZEOSA
1
VIRT-VITE GT
1
ZETONNA
4
VITAFOL-OB
1
ZIPRASIDONE HCL
2
VITAMIN D2
2
ZOLMITRIPTAN
2
QL
VITAMINS A,C,D & FLUORIDE
2
ZOLMITRIPTAN ODT
2
QL
VITASPIRE
1
ZOLPIDEM TARTRATE
2
VOL-NATE
1
ZOLPIDEM TARTRATE ER
2
VOL-PLUS
1
ZONISAMIDE
2
VOL-TAB RX
1
ZOVIA 1-35E
1
VORICONAZOLE
2
ZOVIA 1-50E
1
VP-CH PLUS
1
VP-CH-PNV
1
VP-ERA OB PLUS
1
VP-GGR-B6
1
VP-HEME OB
1
VP-HEME OB + DHA
1
VP-HEME ONE
1
VYFEMLA
1
VYNATAL-FA
1
VYTORIN
3
WARFARIN SODIUM
1
WATER
2
WERA
1
PA
ST
21
QL
Specialty medications
The following specialty medications are typically covered under the fifth tier.
A
D
I
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^
DIDANOSINE^
ICLUSIG (PA)
ILARIS (PA)
INCIVEK^ (PA)
INCRELEX^ (PA)
INLYTA^ (PA)
INTELENCE^
INTRON A^ (PA)
INVIRASE^
ISENTRESS^
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
E
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)
F
FIRAZYR^ (PA)
FIRMAGON (PA)
FLUTAMIDE^
FONDAPARINUX SODIUM (QL)
FORTEO^
FRAGMIN (QL)
FUZEON^
G
J
JAKAFI (PA)
JUXTAPID (PA)
K
KALETRA^
KUVAN^
L
LAMIVUDINE^
LAMIVUDINE HBV^
LAMIVUDINE-ZIDOVUDINE^
LETAIRIS^
LEUCOVORIN CALCIUM^
LEUKINE
LEUPROLIDE ACETATE^ (PA)
LEXIVA^
LUPRON DEPOT^ (PA)
LUPRON DEPOT-PED^ (PA)
M
MATULANE
MESNEX
METHOTREXATE^
MODERIBA^
MYCOPHENOLATE MOFETIL^
MYCOPHENOLIC ACID
GATTEX (PA)
GENGRAF^
GENOTROPIN^ (PA, ST)
GLEEVEC^ (PA)
GRANIX
H
HECORIA^
HEXALEN^
HUMATROPE^ (PA)
HYCAMTIN^
^If you live in Colorado, these specialty medications must be obtained through Cigna Home Delivery Pharmacy. Only your first prescription can be obtained at a network retail pharmacy.
All subsequent refills must be obtained through Cigna Home Delivery Pharmacy. To maximize your benefits, all other medications are available through one of our specialty pharmacies, at a
network retail pharmacy or through your doctor’s office, if necessary.
22
Specialty medications
The following specialty medications are typically covered under the fifth tier.
N
S
V
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)
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)
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^
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^
X
XALKORI^ (PA)
XELODA^
XENAZINE
XOLAIR^ (PA)
XTANDI^ (PA)
XYREM (PA)
Z
ZAVESCA (PA)
ZELBORAF^ (PA)
ZIDOVUDINE^
ZOLADEX^ (PA)
ZOLINZA (PA)
ZORTRESS^
ZYTIGA^ (PA)
^If you live in Colorado, these specialty medications must be obtained through Cigna Home Delivery Pharmacy. Only your first prescription can be obtained at a network retail pharmacy.
All subsequent refills must be obtained through Cigna Home Delivery Pharmacy. To maximize your benefits, all other medications are available through one of our specialty pharmacies, at a
network retail pharmacy or through your doctor’s office, if necessary.
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.
863933 b 12/14 ©2014 Cigna
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