July 2014
Performance Drug List
PRESCRIPTION
DRUG LIST
CHANGES
This list includes representative changes only. For more information, please use myCigna.com to see all of
the medications covered under your plan.
Brands with generics
Preferred brand additions
These brand name drugs have
generic equivalents/alternatives,
and the brand is considered a
non-preferred brand
• Aciphex • Avelox • Evista • Flagyl 375 • Hectorol • Lodosyn • Loestrin • Lovaza • Lunesta
• Mepron • Micardis • Micardis HCT • Mycobutin • Myfortic • Twynsta • Vanos • Xeloda • Zutripro
These drugs have moved from nonpreferred brand status to preferred
brand status
• Prenaissance Next-B
• Tecfidera*(PA)
• Vitapearl
• Vinate DHA
Brand deletions
These brand name drugs have
preferred alternatives, and are
considered a non-preferred brand
• Oxytrol (for men)
Drugs requiring authorization
Prior Authorization (PA):
• Actemra* (PA)
• Adempas* (PA)
• Copaxone* 40 MG (PA)
• Hetlioz* (PA)
• Olysio* (PA)
• Opsumit* (PA)
• Orenitram ER* (PA)
• Otezla* (PA)
• Otrexup* (PA)
• Sovaldi* (PA) *medications marked with an asterisk are
considered to be specialty medications.
Quantity Limitations (QL):
• Xartemis XR (QL) • Zohydro (QL) Step Therapy (PA, ST or ST):
• Aciphex sprinkle (PA, ST) • Dermasorb HC (PA, ST) • Dermasorb TA (PA, ST) • Desvenlafaxine Fumarate (PA, ST) • Esomeprazole Strontium (PA, ST) • Farxiga (ST) • Khedezla (PA, ST)
Drugs excluded from the
prescription drug list
• Mirvaso (excluded for cosmetic status)
• Oxytrol [excluded for women^ as an overthe-counter (OTC) equivalent is available]
^ remains covered as a non-preferred brand
for men.
Offered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company or their affiliates.
“Cigna,” the “Tree of Life” logo, and “GO YOU” are registered service marks, and “Cigna Home Delivery Pharmacy” is a service mark of Cigna Intellectual Property, Inc.,
licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna
Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, Tel-Drug, Inc., Tel-Drug of
Pennsylvania, L.L.C., and HMO subsidiaries of Cigna Health Corporation. “Cigna Specialty Pharmacy Services” refers to the specialty drug division of Tel-Drug, Inc. and
Tel-Drug of Pennsylvania, L.L.C., doing business as Cigna Home Delivery Pharmacy. All models are used for illustrative purposes only.
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