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. 826973 i 05/14 © 2014 Cigna. Some content provided under license.
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