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Prescription Drug List January 2014
PERFORMANCE
FOUR TIER
prescription drug list
The Performance Four Tier Prescription Drug List lets you
and your doctor choose medications that work best for
you. The following is a list of the most commonly used
medications covered under your plan.
This list is designed to cover your prescription medications at four
levels. The amount you pay depends on the tier from which you
and your doctor select your medication. If there is more than one
medication appropriate for your condition, we suggest that you talk
to your doctor about lower-cost choices like generic medications and
preferred brand medications to see if they could be right for you.
Offered by: Connecticut General Life Insurance Company or Cigna Health
and Life Insurance Company.
827363 i 12/13
1st Tier – Preventive Generic Medications: Preventive generic medications
for certain conditions such as diabetes, asthma, heart disease and cholesterol
are available on the first tier. You will usually pay less for preventive generic
medications under your plan.
2nd Tier – Other Generics and Preferred Brand Medications: All other
generics aside from preventive generics and preferred brand medications are
available on the second tier. These medications will usually cost more than
preventive generics, but less than non-preferred brand medications under
your plan.
3rd Tier – Non-Preferred Brand Medications: Non-preferred brand
medications are those that generally have generic alternatives and/or a
preferred brand medication within the same drug class. You will usually pay
more for a non-preferred brand under your plan.
4th Tier – Specialty Medications: Specialty medications covered on the
fourth tier are higher cost medications that may require special handling
and authorization, and typically treat conditions such as multiple sclerosis,
hepatitis C and rheumatoid arthritis.
The symbols on the list mean
If a medication on the list has one of the following symbols, your doctor may
need to get an authorization 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: Age Requirement means an individual must be within a
specific age group for a specific medication to be covered.
ST:
Step Therapy is a prior authorization program that requires
you to try other medications available to treat the same
condition before the “ST” medication is covered.
*Medications marked with an asterisk are considered to be
specialty medications. These medications must be obtained
from a preferred specialty pharmacy. Some plans may cover
specialty medications at different benefit levels. Refer to the
Specialty Pharmacy Drug List for more information.
2
Important note
The Performance Four Tier Drug List may not cover medications that have
over-the-counter (OTC) alternatives (e.g., drugs that treat stomach acid
conditions and non-sedating antihistamines to treat allergies) depending
on your plan. In these cases, the prescription available class alternatives
may be excluded from coverage. Examples* include allergy medications
such as Allegra, Clarinex, Xyzal and any generics; and heartburn/ulcer
medications such as Nexium, Prilosec, Zantac and any generics (*Examples
only, not an all-inclusive list).
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, depending upon the final government regulations, coverage
for medications that have not traditionally been included in pharmacy
plans, such as specific over-the-counter (OTC) medications, may be made
available at no cost-share to you. As with all covered medications, we
would require a prescription from your doctor to process the claim under
your pharmacy plan (including OTC medications).
To get the most current information, visit InformedonReform.com or
Cigna.com and look for the “Informed on Reform” link.
If you have any questions
Remember, this list is just a sample of the most commonly used
medications. You can use the Prescription Drug Price Quote tool available
on myCigna.com to see and compare the prices of all medications covered
under your plan. Or, you can call the number on the back of your ID card to
speak with a customer service representative at any time.
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Performance Four Tier Prescription Drug List
4
PREVENTIVE
GENERICS OTHER GENERICS AND
PREFERRED BRANDS
NON-PREFERRED
BRANDS
ADD/ADHD AND STIMULANTS
Adderall XR
amphetamine/
dextroamphetamine
clonidine hcl
dexmethylphenidate
Metadate ER/
methylphenidate hcl
Focalin XR
Intuniv
methamphetamine
methylphenidate/ER/
ER 24 HR
methylphenidate hcl
modafanil
Strattera
Vyvanse
Adderall (PA, ST)
Concerta (PA, ST)
Daytrana (PA, ST)
Desoxyn (PA, ST)
Dexedrine (PA, ST)
Focalin (PA, ST)
Kapvay
Metadate CD (PA, ST)
Methylin (PA, ST)
Nuvigil
Provigil
Quillivant XR (PA, ST)
Ritalin (PA, ST)
Ritalin ER
Ritalin LA (PA, ST)
Ritalin SR (PA, ST)
Zenzedi (PA, ST)
ALLERGY*
* These drugs may not
be covered under your
plan. Please use the
Prescription Drug
Price Quote Tool on
myCigna.com for more
information.
Astepro
azelastine nasal
clemastine fumarate
cyproheptadine
cyproheptadine hcl
desloratadine
epinastine
epinephrine
Epipen
Epipen Jr.
flunisolide nasal
fluticasone nasal
hydroxyzine
ipratropium nasal
levocetirizine
montelukast
Nasonex
triamcinolone nasal
Veramyst
Adrenaclick (QL)
Astelin
Atrovent (nasal)
Auvi-Q (QL)
Beconase AQ (PA, ST)
Clarinex
Dymista (PA, ST)
Flonase (PA, ST)
Nasacort AQ (PA, ST)
Omnaris (PA, ST)
Patanase
QNASL (PA, ST)
Rhinocort AQ (PA, ST)
Semprex-D
Singulair
Xyzal
Zetonna (PA, ST)
ALZHEIMER’S DISEASE
Aricept (23 MG)
donepezil
donepezil hcl
galantamine hydrobomide
Namenda
rivastigmine caps
Aricept (5 and 10 MG)
Aricept ODT
Exelon
Namenda XR
Razadyne
Razadyne ER
ANXIETY
alprazolam
buspirone
diazepam
lorazepam
oxazepam
Lorazepam Intensol
Niravam
PREVENTIVE
GENERICS OTHER GENERICS AND
PREFERRED BRANDS
NON-PREFERRED
BRANDS
ASTHMA AND RESPIRATORY
albuterol solution
(nebulizer solution)
albuterol sulfate
(syrup, tabs)
budesonide
caffeine citrate
cromolyn sodium
(nebulizer solution)
dyphylline
guaifenesin/theophylline
ipratropium bromide
(nebulizer solution)
levalbuterol
(nebulizer solution)
metaproterenol sulfate
(syrup, tabs)
montelukast
terbutaline sulfate
theophylline anhydrous
zafirlukast
Advair Diskus/HFA
Asmanex
Atrovent HFA
Combivent
Combivent Respimat
Flovent Diskus/HFA
ProAir HFA
Pulmicort
Qvar
Serevent
Spiriva
Symbicort
Ventolin HFA
Accolate
Accuneb nebulizer (PA, ST)
Alvesco
Arcapta
Breo Ellipta (ST)
Brovana nebulizer (PA, ST)
Daliresp
Dulera
Foradil
Lufyllin
Perforomist (PA, ST)
Proventil HFA
Singulair
Tudorza Pressair (ST)
Xopenex HFA
Xopenex nebulizer (PA, ST)
BIRTH CONTROL
Amethia
Angeliq
Apri
Desogen
Aviane
Ella
Balziva
Estrostep FE
BeYaz
Femcon FE
Camila
Loestrin
Camrese
Loestrin FE
Daysee
Mircette
Errin
Natazia
Estarylla
Nordette
Gianvi
Ortho-Cept
Jolessa
Ortho-Cyclen
Junel FE
Ortho-Novum 7-7-7
Kariva
Ortho-Tri-Cyclen
Kurvelo
Quartette
levonorgestrel
Safyral
Levora
Seasonale
Lo Loestrin FE
Seasonique
Lo Minastin FE
Tri-Norinyl
Loryna
Yaz
LoSeasonique
Low-Ogestrel
Microgestin
Minastrin 24 FE
Mono-Linyah
Necon
noreth-ethinyl estradiol/iron
Nortrel
NuvaRing
Ocella
Ogestrel
Ortho Evra
5
Please check your enrollment
materials to determine
whether these medications
are covered under your
specific plan.
Performance Four Tier Prescription Drug List
6
PREVENTIVE
GENERICS OTHER GENERICS AND
PREFERRED BRANDS
NON-PREFERRED
BRANDS
BIRTH CONTROL (CONTINUED)
Please check your enrollment
materials to determine
whether these medications
are covered under your
specific plan.
Ortho TriCyclen Lo
Plan B One-Step
Previfem
Quasense
Sprintec
Tri-Estarylla
Tri-Linyah
Trinessa
Tri-Sprintec
Vestura
Zenchent
Zeosa
Zovia
BLADDER PROBLEMS
Detrol LA
Elmiron
oxybutynin/XL
Oxytrol
tolterodine tartrate
Toviaz
trospium chloride
VESIcare
Detrol (PA, ST)
Ditropan
Ditropan XL (PA, ST)
Enablex (PA, ST)
Gelnique (PA, ST)
Myrbetriq (PA, ST)
Sanctura (PA, ST)
Sanctura XR (PA, ST)
Urocit-K
CANCER
anastrozole
exemestane
letrozole
Leukeran
lomustine
Lysodren
Myleran
tamoxifen citrate
Arimidex
Aromasin
Droxia
Fareston
Femara
CARDIOVASCULAR
BLOOD THINNER/ANTI-CLOTTING
cilostazol
clopidogrel
dipyridamole
Jantoven
ticlopidine
warfarin
Aggrenox
Arixtra
Effient
heparin
Xarelto
Brillinta
Coumadin
Eliquis (ST)
Plavix
Pletal
Pradaxa (ST)
HIGH BLOOD PRESSURE/HEART MEDICATIONS
acebutolol HCl
acetazolamide
amiloride HCl
amlodipine/atorvastatin
calcium
amlodipine besylate
amlodipine besylate/
benazepril
atenolol
Benicar
Benicar HCT
Bystolic
Coreg CR
Diovan
Diovan HCT
Exforge
Exforge HCT
Tarka
Accupril (PA, ST)
Accuretic (PA, ST)
Aceon (PA, ST)
Altace (PA, ST)
Amturnide
Atacand (PA, ST)
Atacand HCT (PA, ST)
Avalide (PA, ST)
Avapro (PA, ST)
PREVENTIVE
GENERICS OTHER GENERICS AND
PREFERRED BRANDS
NON-PREFERRED
BRANDS
CARDIOVASCULAR (CONTINUED)
HIGH BLOOD PRESSURE/HEART MEDICATIONS
benazepril HCl
Tekturna
Azor
benazepril HCl/amlodipine
Tekturna HCT
Betapace AF
benazepril HCl/HCTZ
Cardura
bendroflumethiazide/
Cardura XL
nadolol
Catapres, Catapres TTS
betaxolol HCl
Coreg
bisoprolol fumarate
Corgard
bisoprolol/HCTZ
Cozaar (PA, ST)
bumetanide
Dutoprol
candesartan cilexetil
Edarbi (PA, ST)
candesartan HCTZ
Edarbychlor (PA, ST)
captopril
Hyzaar (PA, ST)
captopril/HCTZ
Inderal LA
carvedilol
Innopran XL
chlorothiazide
Levatol
chlorthalidone
Lotensin (PA, ST)
chlorthalidone/atenolol
Lotensin HCT (PA, ST)
clonidine
Lotrel
clonidine HCl
Mavik (PA, ST)
Clorpres
Micardis (PA, ST)
diltiazem
Micardis HCT (PA, ST)
diltiazem 24HR ER
Norpace
doxazosin mesylate
Norpace CR
enalapril maleate
Norvasc
enalapril maleate/HCTZ
Nymalize
eplerenone
Prinivil (PA, ST)
eprosartan mesylate
Prinzide (PA, ST)
felodipine
Sular
fosinopril sodium
Tekamlo
furosemide
Teveten (PA, ST)
guanfacine
Teveten HCT (PA, ST)
hydralazine HCl
Toprol XL
hydrochlorothiazide
Tribenzor (ST)
hydrochlorothiazide/
Uniretic (PA, ST)
amilor HCl
Univasc (PA, ST)
indapamide
Vaseretic (PA, ST)
irbesartan
Vasotec (PA, ST)
irbesartan/HCTZ
Verelan
isradipine
Zestoretic (PA, ST)
labetalol HCl
Zestril (PA, ST)
lisinopril
lisinopril/HCTZ
losartan potassium
losartan potassium/ HCTZ
methazolamide
methyldopa
methyldopa/HCTZ
metolazone
metoprolol succinate
metoprolol tartrate
metoprolol/HCTZ
minoxidil
7
Performance Four Tier Prescription Drug List
8
PREVENTIVE
GENERICS OTHER GENERICS AND
PREFERRED BRANDS
NON-PREFERRED
BRANDS
CARDIOVASCULAR (CONTINUED)
HIGH BLOOD PRESSURE/HEART MEDICATIONS
moexipril HCl
moexipril HCl/HCTZ
nadolol
nicardipine HCl
nifedipine
nimodipine
perindopril erbumine
pindolol
prazosin HCl
propranolol HCl
propranolol/HCTZ
quinapril
quinapril HCl/HCTZ
ramipril
reserpine
sotalol HCl
spironolactone
spironolactone/HCTZ
terazosin HCl
timolol maleate
torsemide
trandolapril
trandolapril/verapamil HCl
valsartan
valsartan/HCTZ
Vecamyl-mecamylamine hcl
verapamill
OTHER
amiodarone
digoxin
disopyramide
flecainide
isosorbide dinitrate
isosorbide mononitrate
Multaq
nitroglycerin
propafenone SR
Tikosyn
Lanoxin
Nitrolingual spray
Nitromist
Ranexa (ST)
Rythmol SR
Samsca (PA)
CHOLESTEROL LOWERING
atorvastatin
cholestyramine
cholestyramine powder
cholestyramine/aspartame
cholestyramine/sucrose
colestipol
fenofibrate
fenofibric acid
fluvastatin/XL
gemfibrozil
lovastatin
niacin
pravastatin
Crestor (5 & 10 MG) (PA, ST)
Crestor (20 & 40 MG)
Lovaza
Niaspan
Simcor
Welchol
Zetia
Advicor
Altoprev (PA, ST)
Antara
Caduet
Colestid
Fenoglide
Lescol (PA, ST)
Lescol XR (PA, ST)
Lipitor (PA, ST)
Liptruzet (PA, ST)
Livalo (PA, ST)
Lofibra
Mevacor (PA, ST)
PREVENTIVE
GENERICS OTHER GENERICS AND
PREFERRED BRANDS
NON-PREFERRED
BRANDS
CHOLESTEROL LOWERING (CONTINUED)
simvastatin
Pravachol (PA, ST)
TriCor
Trilipix
Vascepa (ST)
Vytorin (PA, ST)
Zocor (PA, ST)
DEPRESSION
amitriptyline
bupropion
bupropion SR
citalopram
Cymbalta
desipramine
escitalopram
fluoxetine
fluvoxamine
imipramine
mirtazapine
nortriptyline
paroxetine
paroxetine CR
Pristiq
protriptyline
sertraline
trazodone
trimipramine maleate
venlafaxine
venlafaxine XR
Wellbutrin XL
Aplenzin (PA, ST)
Brintellix (PA, ST)
Celexa (PA, ST)
Desvenlafaxine ER (PA, ST)
Effexor XR (PA, ST)
Emsam
Fetzima (PA, ST)
Forfivo XL (PA, ST)
Lexapro (PA, ST)
Luvox CR
Marplan
Paxil (PA, ST)
Paxil CR (PA, ST)
Pexeva (PA, ST)
Prozac (PA, ST)
Remeron
Sarafem (PA, ST)
Tofranil
Venlafaxine HCl ER (PA, ST)
Viibryd (PA, ST)
Vivactil
Wellbutrin (PA, ST)
Wellbutrin SR (PA, ST)
Zoloft (PA, ST)
DIABETES
acarbose
chlorpropamide
glimepiride
glipizide
glipizide/metformin
glyburide
glyburide micronized
glyburide/metformin
metformin hcl
metformin/ER
nateglinide
pioglitazone
pioglitazone hcl
pioglitazone/glimiperide
pioglitazone/metformin
repaglinide
tolazamide
tolbutamide
ACCU-CHEK test strips
Actoplus Met
Apidra
Actoplus Met XR
Apidra SoloStar
Actos
BD Insulin Syringes/
Amaryl
Pen Needles
Avandamet
Bydureon (QL)
Avandaryl
Byetta
Avandia
GlucaGen HypoKit
Cycloset
Humalog
Duetact
Humulin
Fortamet
Janumet
Glucophage XR
Janumet XR
Glyset
Januvia
Invokana (ST)
Kombiglyze XR
Jentadueto (ST)
Lantus
Kazano (ST)
Lantus SoloStar
Nesina (ST)
Levemir
Oseni (ST)
NovoFine needles
Prandin
Novolin
Precose
Novolog
Starlix
9
Performance Four Tier Prescription Drug List
10
PREVENTIVE
GENERICS OTHER GENERICS AND
PREFERRED BRANDS
NON-PREFERRED
BRANDS
DIABETES (CONTINUED)
One Touch test strips
Onglyza
Prandimet
SymlinPen
Victoza
Tradjenta (ST)
ENDOCRINE AND METABOLIC – OTHER
allopurinol
cabergoline (QL)
Colcrys
fluoxymesterone
Megace ES
Nilandron
Uloric
EYE CONDITIONS
Alomide
Alphagan P (0.10%)
apraclonidine hcl
atropine
AzaSite
azelastine
Azopt
Betimol
Betoptic S
brimonidine
bromfenac
Ciloxan (oint)
ciprofloxacin
diclofenac
dorzolamide
dorzolamide/timolol
epinastine
flurbiprofen
gatifloxacin
Iopidine
ketorolac
latanoprost
levobunolol
levofloxacin
Lotemax (drops)
Maxidex
Moxeza
Pataday
Patanol
pilocarpine
Restasis
timolol
Tobradex (oint)
tobramycin/dexamethasone
Travatan Z
trifluridine
Vexol
Vigamox
Acular LS
Alocril
Alrex
Bepreve
Besivance
Ciloxan (drops)
Cosopt
Cystaran
Durezol
Elestat
Emadine
Lastacaft
Lotemax (ointment)
Optivar
Rescula
Simbrinza (ST)
Timoptic
Tobradex (drops)
Tobradex ST
Tobrex
Trusopt
Voltaren
Xalatan
Zioptan (ST)
Zymaxid
PREVENTIVE
GENERICS OTHER GENERICS AND
PREFERRED BRANDS
NON-PREFERRED
BRANDS
GASTROINTESTINAL (NOT HEARTBURN/ULCER)
Apriso
Asacol
Asacol HD
balsalazide
budesonide
Canasa
Creon
cromolyn sodium (solution)
Delzicol
GoLytely
Lialda
PEG 3350/potassium/
sodium bicarb/salt
PEG 3350/potassium/sodium
bicarb/salt/sodium sulf
Pentasa
Urso/Urso Forte
Zenpep
Amitiza
Colazal
Colyte
Entocort EC
Giazo
NuLytely
Pancreaze
Pertzye
Prepopik
Rayos (ST)
Relistor (PA)
Simponi Aria (PA)
Suclear
Uceris
Ultresa
Viokace
HEARTBURN/ULCER*
*These drugs may not be
covered under your plan.
Please use the Prescription
Drug Price Quote Tool on
myCigna.com for more
information.
cimetidine
famotidine
lansoprazole
lansoprazole/amoxicillin/
clarithromycin
metoclopramide
metoclopramide hcl
misoprostol
Nexium
nizatidine
pantoprazole
rabeprazole
rabeprazole sodium
ranitidine
sucralfate
Aciphex (PA, ST)
Dexilant (PA,ST)
Helidac
Omeclamox-Pak
Prevacid (PA,ST)
Prevpac
Prilosec (PA,ST)
Protonix (PA,ST)
Zantac Syrup
Zegerid (PA,ST)
HORMONE REPLACEMENT
Alora
Anadrol-50
Androderm
AndroGel
Armour Thyroid
Divigel
Enjuvia
Estraderm
estradiol
estradiol/norethindrone
acetate
estropipate
ethinyl estradiol
levothroid
Activella
Axiron (ST)
Cenestin
Combipatch
Cytomel
Delatestryl
Depot Testosterone
Estrace
Femhrt
Femring
Fortesta (ST)
Menest
Minivelle
Prefest
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Performance Four Tier Prescription Drug List
12
PREVENTIVE
GENERICS OTHER GENERICS AND
PREFERRED BRANDS
NON-PREFERRED
BRANDS
HORMONE REPLACEMENT (CONTINUED)
levothyroxine sodium
Prometrium
Levoxyl
Provera
liothyronine
Vagifem
medroxyprogesterone
medroxyprogesterone acetate
Premarin
Premphase
Prempro
progesterone
progesterone, micronized
Prometrium
Synthroid
Testim
testosterone cypionate
testosterone enanthate
thyroid
Unithroid
Vivelle-Dot
INFECTIONS
acyclovir
amantadine
amoxicillin
amoxicillin/clavulanate
azithromycin
cefaclor ER
cefadroxil
cefdinir
cefprozil
ceftibuten dihydrate
ceftriaxone
cefuroxime axetil
cephalexin
ciclopirox
Cipro HC Otic
Ciprodex
ciprofloxacin
clarithromycin
clindamycin
clindamycin phosphate
cycloserine
doxycycline
erythromycin
famciclovir
fluconazole
flucytosine
gentamicin sulfate
griseofulvin
Gris-Peg
itraconazole
ketoconazole
metronidazole
minocycline
minocycline hcl
mupirocin
Ancobon
Augmentin
Augmentin ES 600
Augmentin XR
Avelox
Biaxin
Biaxin XL
Cipro XR
CNL 8
Coartem (QL)
Dificid (PA)
Ery-Tab
Famvir
Flagyl ER
Keflex
Ketodan
Lamisil (QL)
Lariam
Levaquin
Malarone
Monurol
Moxatag
Noxafil
Penlac
Priftin
Relenza (QL)
Rocephin
Solodyn (ST)
Sporanox (QL)
Suprax
Valtrex
Vfend (PA)
Zithromax
Zyvox (PA)
PREVENTIVE
GENERICS OTHER GENERICS AND
PREFERRED BRANDS
NON-PREFERRED
BRANDS
INFECTIONS (CONTINUED)
Mycostatin (tab)
nitrofurantoin
nystatin
ofloxacin
penicillin v potassium
Primsol
rimantadine
sulfamethoxazole/
trimethoprim
Tamiflu (QL)
terbinafine
terconazole
tetracycline
valacyclovir
Valcyte
vancomycin
voriconazole (PA)
MIGRAINE
acetaminophen/caffeine/
butalbital
naratriptan (QL)
rizatriptan (QL)
sumatriptan (QL)
sumatriptan succinate (QL)
Treximet (QL)
zolmitriptan (QL)
Alsuma (QL)
Amerge (QL)
Axert (QL)
DHE 45 (QL)
Frova (QL)
Imitrex (QL)
Maxalt (QL)
Maxalt MLT (QL)
Migranal (QL)
Relpax (QL)
Sumavel DosePro (QL)
Zomig/Zomig ZMT (QL)
NAUSEA AND VOMITING
dronabinol
granisetron
ondansetron
prochlorperazine
promethazine
trimethobenzamide
Diclegis
Marinol
Sancuso (QL)
Zofran
Zuplenz (QL, ST)
OSTEOPOROSIS
alendronate sodium
calcitonin-salmon
Fortical
ibandronate sodium
Didronel
Evista
Miacalcin
Actonel (PA, ST)
Atelvia (PA, ST)
Binosto (PA, ST)
Boniva (PA, ST)
Fosamax (PA, ST)
Fosamax Plus D (PA, ST)
Skelid (PA, ST)
PAIN RELIEF AND INFLAMMATORY DISEASE
Avinza
Abstral (PA)
buprenorphine
Actiq (PA)
butalbit/acetamin/caff/
Arthrotec (PA, ST)
codeine
Butrans (QL)
13
Performance Four Tier Prescription Drug List
14
PREVENTIVE
GENERICS OTHER GENERICS AND
PREFERRED BRANDS
NON-PREFERRED
BRANDS
PAIN RELIEF AND INFLAMMATORY DISEASE (CONTINUED)
butorphanol nasal (QL)
Celebrex
codeine phos/carisoprodol/asa
codeine phosphate
codeine phosphate/aspirin
codeine sulfate
dexamethasone
diclofenac
dihy-cod tt/apap/caffeine
Dilaudid-5
Dipentum
etodolac
fenoprofen
fentanyl citrate
(lozenge on a stick ) (PA)
fentanyl transdermal (QL)
Fentora (PA)
flurbiprofen
hydrocodone bitartrate/apap
hydrocodone/acetaminophen
hydromorphone HCl
ibuprofen
ibuprofen/hydrocod bit
Indocin (suppository)
indomethacin
Kadian
ketoprofen
Ketorolac (QL)
leflunamide
levorphanol tartrate
lidocaine
Lidoderm
Lyrica
meclofenamate
mefenamic acid
meloxicam
meperidine HCl
metaxalone
methylprednisolone
morphine sulfate
nabumetone
naproxen
Nucynta (ST)
Nucynta ER (QL)
opium
opium/belladonna alkaloids
oxaprozin
oxycodone HCl
oxycodone HCl/acetaminophen
oxycodone/aspirin
OxyContin (QL)
oxymorphone
pentazocine HCl/
acetaminophen
Cambia (PA, ST)
Conzip (PA, ST)
Demerol (PA, ST)
Dilauded (PA, ST)
Duexis (PA, ST)
Duragesic (QL)
Exalgo (QL)
Fioricet w/codeine
Flector (PA, ST)
Horizant (ST)
Hycet (PA, ST)
Lazanda (PA)
Lorcet (PA, ST)
Lorcet Plus (PA, ST)
Lortab (PA, ST)
Lortab Solution (PA, ST)
Magnacet (PA, ST)
Maxidne (PA, ST)
Mobic (PA, ST)
Nalfon (PA, ST)
Naprelan (PA, ST)
Norco (PA, ST)
Onsolis (PA)
Opana
Opana ER (QL)
Oxecta (PA, ST)
Pennsaid (PA, ST)
Percocet (PA, ST)
Percodan (PA, ST)
Ponstel (PA, ST)
Primalev (PA, ST)
Roxicodone (PA, ST)
Skelaxin
Sprix (QL)
Synalgos-DC (PA, ST)
Tylox
Ultracet (PA, ST)
Ultram (PA, ST)
Ultram ER (PA, ST)
Vicodin (PA, ST)
Vicodin ES (PA, ST)
Vicodin HP (PA, ST)
Vicoprofen (PA, ST)
Voltaren (PA, ST)
Voltaren Gel (PA, ST)
Voltaren XR (PA, ST)
Xodol (PA, ST)
Zamicet (PA, ST)
Zolvit (PA, ST)
Zorvolex (PA, ST)
Zydone (PA, ST)
PREVENTIVE
GENERICS OTHER GENERICS AND
PREFERRED BRANDS
NON-PREFERRED
BRANDS
PAIN RELIEF AND INFLAMMATORY DISEASE (CONTINUED)
pentazocine HCl/naloxone HCl
piroxicam
prednisone
Roxicet
Savella
Suboxone
sulindac
tolmetin
tramadol HCl/acetaminophen
tramadol HCl/ER
Trexall
Vimovo
PARKINSON’S DISEASE
amantadine
Azilect
benztropine
bromocriptine
carbidopa/levodopa/
entacapone
carbidopa/levodopa
carbidopa/levodopa CR
pramipexole
ropinirole
ropinirole XL
selegiline
Comtan
Eldepryl
Lodosyn
Mirapex
Mirapex ER
Neupro
Parcopa
Requip
Requip XL
Sinemet CR
Stalevo
Tasmar
Zelapar
PROSTATE
alfuzosin
Avodart
Cialis (PA, QL)
doxazosin
finasteride
Jalyn
prazosin
tamsulosin
terazosin
Flomax
Proscar
Rapaflo
Uroxatral
SCHIZOPHRENIA
clozapine
haloperidol
loxapine
olanzapine
olanzapine/fluoxetine HCl
quetiapine
risperidone
Seroquel XR
thiothixene
ziprasidone
Abilify
Abilify Discmelt
Clozaril (PA, ST)
Fanapt (PA, ST)
Fazaclo (PA, ST)
Geodon (PA, ST)
Invega (PA, ST)
Latuda (PA, ST)
Orap
Risperdal (PA, ST)
Saphris (PA, ST)
Seroquel (PA, ST)
Symbax
Versacloz (PA, ST)
Zyprexa (PA, ST)
15
Performance Four Tier Prescription Drug List
16
PREVENTIVE
GENERICS OTHER GENERICS AND
PREFERRED BRANDS
NON-PREFERRED
BRANDS
SEIZURE
carbamazepine
Celontin
clonazepam
Diastat
Diastat Acudial
diazepam
Dilantin (30 MG only)
divalproex
felbamate
Felbatol
gabapentin
Gabitril
Keppra
Lamictal ODT
lamotrigine
levetiracetam
Lyrica
oxcarbazepine
Peganone
phenytoin
tiagabine hcl
topiramate
valproate
Vimpat
zonisamide
Banzel
Carbatrol
Depakote (all forms)
Dilantin
Keppra XR
Lamictal
Lamictal XR
Neurontin
Onfi
Oxtellar XR
Potiga
Saphris
Stavzor
Tegretol XR
Topamax
Trileptal
Zonegran
SEXUAL DYSFUNCTION*
*Please check your enrollment
materials to determine
whether this medication is
covered under your plan.
Cialis (PA, QL)
Muse (PA, QL)
Viagra (PA, QL)
Caverject (PA, QL)
Edex (PA, QL)
Levitra (PA, QL)
Osphena
Staxyn (PA, QL)
Stendra (PA, QL)
SKIN CONDITIONS
acitretin
adapalene (AGE)
alclometasone dipropionate
amcinonide
amnesteem (QL)
Apexicon E
(diflorasone diacetate)
Benzaclin
Benzamycin Pak
betamethasone
betamethasone dipropionate
betamethasone dipropionate/
propylene glycol
betamethasone valerate
calcipotriene
calcitriol ointment
Capex Shampoo (PA, ST)
Carac
Absorbica (QL)
Acanya
Aclovate (PA, ST)
Aldara
Aphthasol
Atralin (AGE)
Avita
Bactroban
Benzefoam
Bromday
Carmol HC (PA, ST)
Clindacin Pac
Clobex (PA, ST)
Condylox
Cutivate (PA, ST)
Dermatop (PA, ST)
Desonate (PA, ST)
Desowen (PA, ST)
PREVENTIVE
GENERICS OTHER GENERICS AND
PREFERRED BRANDS
NON-PREFERRED
BRANDS
SKIN CONDITIONS (CONTINUED)
Claravis (QL)
clinicamycinphosphate/
benzoyl peroxide gel
clobetasol propionate
clobetasol propionate/emoll
Cloderm (PA, ST)
Cordran (PA, ST)
Cordran SP (PA, ST)
Derma-Smooth/FS (PA, ST)
desonide
desoximetasone
Differin (AGE)
diflorasone diacetate
Exelderm
fluocinolone acetonide
fluocinonide/emollient
Fluoroplex
fluorouracil topical
fluticasone propionate
halobetasol prop/
ammonium lac
halobetasol propionate
hydrocortisone
hydrocortisone acetate/
aloe vera
hydrocortisone acetate/urea
hydrocortisone butyrate
hydrocortisone valerate
imiquimod
isotretinoin (QL)
Kenalog spray (PA, ST)
Klaron
Loprox shampoo
Lotemax
Metrogel 1%
metronidazole
mometasone furoate
Naftin
Noritate
Nucort (PA, ST)
Oracea
podofilox
prednicarbate
Retin-A Micro (AGE)
Soriatane
sulfacetamide
sulfacetamide sodium/sulfur
sulfacetamide sulfur
Tazorac
Texacort (PA, ST)
tretinoin (AGE)
triamcinolone acetonide
urea
Diprolene (PA, ST)
Diprolene AF (PA, ST)
Duac
Elidel (PA, ST)
Elocon (PA, ST)
Epiduo (AGE)
First Hydrocort
Halog (PA, ST)
Locoid (lotion)
Locoid Lipocream
Luxiq (PA, ST)
Metrolotion
Mirvaso (ST)
Momexin (PA, ST)
Olux (PA, ST)
Olux-E (PA, ST)
Pandel (PA, ST)
PB Wash
Pediaderm HC (PA, ST)
Prolensa
Protopic (PA, ST)
Regranex (PA)
Retin-A (AGE)
Riax
Rosula
Scalacort DK
Solaraze
Sorilux
Synalar (PA, ST)
Synalar TS (PA, ST)
Taclonex
Targretin gel
Temovate (PA ,ST)
Topicort (PA, ST)
Topicort LP (PA, ST)
Tretin-X (PA)
Ultravate (PA, ST)
Ultravate PAC (PA, ST)
Ultravate X (PA, ST)
Umecta
Vanos (PA, ST)
Vectical
Verdeso (PA, ST)
Vytone
Westcort (PA, ST)
Xolegel
Ziana
Zyclara (ST)
17
Performance Four Tier Prescription Drug List
18
PREVENTIVE
GENERICS OTHER GENERICS AND
PREFERRED BRANDS
NON-PREFERRED
BRANDS
SLEEP
Silenor
zaleplon
zolpidem
zolpidem ER
VITAMINS
All plans cover all generic
prescription prenatal vitamins,
even though not listed here.
Active OB
Bal-Care DHA Essential
calcitriol
Citranatal
Citranatal Assure
Citranatal B-Calm
Citranatal Harmony^
cyanocobalamin
Duet
Duet DHA
Duet DHA Balanced
Duet DHA EC
folic acid
Gesticare DHA
Infanate Balance
Natachew
Natafort
Neevo
Neevo DHA
Nestabs
Nestabs ABC
Nestabs DHA^
Nexa Plus
OB Complete
OB Complete DHA
OB Complete One
OB Complete Petite
PNV Folic Acid-Iron
PNV-DHA Plus
Precare Premier
Prefera-OB One
PreferaOB Prenatal Vitamin
Prenata
Prenatal 19
Prenate AM
Prenate Chewable
Prenate DHA
Prenate Elite
Prenate Enhance
Prenate Mini
Prenate Plus
Prenate Restore
Provida OB
Ambien (PA, ST)
Ambien CR (PA, ST)
Edluar (PA, ST)
Intermezzo (PA, ST)
Lunesta (PA, ST)
Rozerem (PA, ST)
Sonata (PA, ST)
Zolpimist (PA, ST)
PREVENTIVE
GENERICS OTHER GENERICS AND
PREFERRED BRANDS
NON-PREFERRED
BRANDS
VITAMINS (CONTINUED)
All plans cover all generic
prescription prenatal vitamins,
even though not listed here.
Stuart Prenatal
Stuartnatal Plus
Stuartnatal Plus 3
TL-Select DHA
Tricare
Tricare Prenatal Compleat
Tricare Prenatal DHA One^
Vinate Care
Vita Fol-OB DH
Vitafol Ultra
VIVA CT
Viva DHA
VP-PNV-DHA
MISCELLANEOUS
Analpram Advanced
Analpram HC
Analpram-E
Buphenyl
buprenorphine
Chantix
cyclobenzaprine
Fosrenol
hydrocodone/
chlorpheniramine
suspension
levocarnitine
lindane
megestrol
methocarbamol
naltrexone
naltrexone hcl
pentoxifylline
Pramosone
pramoxine/hydrocortisone
Proctofoam-HC
quinine sulfate
Renvela
sodium phenylbutarate
sodium polystyrene
sulfonate
spinosad
SPS
Suboxone
tizanidine
tranexamic acid
TussiCaps
Brisdelle (QL)
Cortifoam
Cuvposa
Epifoam
Glycate
Natroba
Nimotop
Nuedexta
Nymalize
Phoslo
Phoslyra
Rectiv
Renagel
Revia
Sklice
Tussionex
Ulesfia
Zanaflex
Zubsolv (ST)
Zutripro
19
Specialty Drugs
20
* These medications must be obtained from a preferred specialty pharmacy. Only your first
prescription can be obtained at a network retail pharmacy. All subsequent refills must be
obtained through a preferred specialty pharmacy. To maximize your benefits, all other
medications are available through one of our specialty pharmacies, at a network retail
pharmacy or through your physician’s office, if necessary.
^ Check your plan materials to determine if this Growth Hormone medication is covered
under your plan.
Drug Name
A
Abraxane
Actemra SC
Actemra*
Acthrel
Actimmune*
Adagen
Adcetris
Adcirca*
Adefovir Dipivoxil*
Adempas
Adriamycin
Adriamycin RDF
Adrucil
Advate H*
Advate L*
Advate M*
Advate SH*
Advate UH*
Advate*
Afinitor*
Afinitor Disperz*
Agrylin*
Aldurazyme*
Alferon N*
Alimta
Alkeran
Aloxi
Alphanate*
Alphanine SD*
Amifostine
Aminocaproic Acid
sol*
Aminocaproic Acid
tab*
Aminocaproic Acid
vial*
Ampyra*
Anagrelide HCl*
Anzemet Tablet
Anzemet Vial
Apokyn*
Aptivus
Aralast
Aralast NP
Aranesp*
Arcalyst
Argatroban
Arixtra
Arranon
Arzerra
Astagraf XL*
Atgam
Atripla*
Atryn
Aubagio*
Avastin
Avonex*
Avonex
Administration
Pack*
Avonex Pen*
Azacitidine
Azasan*
Azathioprine*
B
BAL in Oil
Baraclude*
Baygam*
BCG Vaccine
(Tice Strain)
Bebulin VH
Immuno*
Bebulin*
Benefix*
Benlysta
Berinert
Betaseron*
Bethkis
Bexxar
Bicalutamide*
BiCNU
Bivigam*
Bleomycin Sulfate
Boniva*
Bosulif*
Botox*
Bravelle*
Busulfex
C
Calcium Disodium
Versenate
Camptosar
Caprelsa
Carboplatin
Carimune NF
Nanofiltered*
Casodex*
Caverject
Cayston
Cellcept*
Ceprotin
Ceredase*
Cerezyme*
Cerubidine
Cetrotide*
Chorionic
Gonadotropin*
Cidofovir
Cimzia*
Cinryze
Cisplatin
Cladribine
Clolar
Combivir*
Cometriq*
Complera*
Copaxone*
Copegus*
Corifact
Cosmegen
Crixivan*
Cyclophosphamide*
Cyclosporine*
Cyklokapron
Cystadane
Cystagon
Cytarabine
Cytogam*
Cytovene
Cytoxan
D
Dacarbazine
Dacogen
Dactinomycin
Daunorubicin
Daunoxome
DDAVP
Decitabine
Depocyt
Desmopressin
Didanosine*
Docefrez
Docetaxel
Doxil
Doxorubicin
Dtic-Dome IV
Dysport*
E
Edex
Edurant*
Egrifta*
Elaprase*
Elelyso*
Eligard*
Elitek
Ellence
Eloxatin
Elspar
Emcyt*
Emend Capsule*
Emend Vial
Emtriva*
Enbrel*
Enoxaparin
Epirubicin
Epivir*
Epivir HBV*
Epogen*
Epoprostenol
Sodium*
Epzicom*
Erbitux
Erivedge*
Erwinaze
Ethyol
Etopophos
Etoposide*
Euflexxa*
Exjade
Extavia*
Eylea
F
Granisetron
K
Mylotarg
Fabrazyme*
Granisetron Vial
Kalbitor
Myobloc*
Faslodex
Granix
Kaletra*
Myozyme*
Feiba NF*
Kalydeco*
H
N
Feiba VH Immuno*
Kcentra Kit*
H.P. Acthar*
Nabi-HB
Fertinex
Kepivance
Halaven
Naglazyme*
Firazyr*
Kineret*
Hecoria*
Natrecor
Firmagon*
Koate-DVIi*
Helixate FS*
Navelbine
Flebogamma*
Kogenate FS*
Hemofil M*
Neoral*
Flebogamma Dif*
Krystexxa
Hepagam B*
Neulasta*
Flolan*
Kuvan*
Hepsera*
Neumega*
Floxuridine
Kynamro
Herceptin
Neupogen*
Fludara
Kyprolis
Hexalen*
Nevirapine*
Fluorouracil
Hizentra*
L
Nexavar*
Flutamide*
Humate-P*
Lamivudine*
Nexavir
Follistim AQ*
Humatrope*^
LamivudineNipent
Folotyn
Humira*
Zidovudine*
Norditropin*^
Fondaparinux
Hyalgan*
Letairis*
Norditropin Flexpro*
Sodium
Hycamtin
Leucovorin Calcium
Norditropin
Fragmin
Hylenex*
Leukine*
Nordiflex*^
FUDR
Hyperhep B S-D*
Leuprolide Acetate*
Norvir*
Fusilev*
Hyperrab S-D*
Leustatin
Novantrone*
Fuzeon*
Hyperrho S-D*
Lexiva*
Novarel*
G
Lipodox
Novoseven*
I
Gamastan S-D*
Lipodox 50
Novoseven RT*
Idamycin PFS
Gammagard Liquid*
Lovenox
Nplate*
Idarubicin HCl
Gammagard Liquid
Lucentis*
Nulojix
Ifex
Injection
Lumizyme*
Nutropin*^
Ifosfamide
Gammagard S-D*
Lupron Depot*
Nutropin AQ*^
Ifosfamide-Mesna
Gammagard*
Lupron Depot-Ped*
Nutropin AQ
Ilaris
Gammaked*
Lutrepulse
Nuspin*
Imbruvica*
Gammaplex*
Imogam Rabies-HT*
M
O
Gammaplex
Imuran*
Macugen
Octagam*
Injection
Incivek*
Marqibo Kit*
Octreotide Acetate*
Gamunex*
Increlex*
Matulane
Oforta*
Gamunex-C*
Infergen*
Mekinist*
Omnitrope*^
Gamunex-C
Inlyta*
Melphalan HCl
Omontys
Gammaked
Innohep
Menopur*
Oncaspar
Ganciclovir Sodium
Intelence*
Mesnex
Ontak
Ganirelix Acetate*
Intron A*
Methotrexate
Onxol
Garamycin inj
Invirase*
Micrhogam*
Opsumit
Gattex
Iprivask*
Micrhogam Plus*
Orencia Disp
Gel-One*
Iressa
Mithracin
Syringe*
Gemcitabine HCl
Irinotecan HCl
Mitomycin
Orencia Vial*
Gemzar
Isentress*
Mitoxantrone HCl*
Orfadin
Gengraf*
Istodax
Monoclate-P*
Orthoclone OKT3
Genotropin*^
Ixempra
Mononine*
Orthovisc*
Gilenya*
Mozobil*
Ovidrel*
J
Gilotrif
Mustargen
Oxaliplatin
Jakafi
Glassia
Mycophenolate*
Jetrea*
P
Gleevec*
Mycophenolate
Jevtana*
Paclitaxel
Gliadel
Mofetil*
Juxtapid*
Pamidronate
Gonal-F*
Myfortic*
Disodium*
Gonal-F Rff*
21
Specialty Drugs
22
Pamidronate*
Panretin*
Paraplatin
Paricalcitol*
Pegasys*
Pegasys Proclick*
Pegintron*
Pegintron
Redipen*
Pentostatin
Perjeta
Photofrin
Pomalyst
Pregnyl*
Prezista*
Prialt
Privigen*
Procrit*
Procysbi DR*
Profasi*
Profilnine SD*
Prograf
Prolastin
Prolastin C
Proleukin*
Prolia
Promacta*
Provenge
Provisc*
Pulmozyme*
R
Rapamune*
Rebetol*
Rebif*
Rebif Rebidose*
Reclast*
Recombinate*
Refludan
Relistor Disp
Syringe
Relistor Kit
Relistor Vial
Remicade*
Remodulin
Repronex*
Rescriptor
Retrovir
Revatio*
Revlimid*
Reyataz*
Rheumatrex
Rhogam*
Rhogam Plus*
Rhophylac
Riastap
Ribapak 400-400
MG Dosepack*
Ribapak 600-400
MG Dosepack*
Ribapak 600-600
MG Dosepack*
Ribapak*
Ribasphere*
Ribatab*
Ribavirin*
Rilutek*
Riluzole*
Rituxan
Rixubis*
S
Sabril
Saizen*^
Sandimmune*
Sandostatin*
Sandostatin Lar*
Selzentry*
Sensipar
Serostim^
Signifor
Sildenafil*
Simponi*
Simponi Aria*
Simulect
Soliris*
Somatuline Depot
Somavert
Sprycel*
Stavudine*
Stelara*
Stimate
Stivarga*
Stribild*
Sucraid
Supartz*
Supprelin
Supprelin LA*
Sustiva*
Sutent*
Sylatron*
Sylatron 4-Pack*
Synagis*
Synarel*
Synribo*
Synvisc*
Synvisc-One*
T
Tacrolimus*
Tafinlar*
Tarabine PFS
Tarceva*
Targretin*
Tasigna*
Taxol
Taxotere
Tecfidera*
Temodar
Temozolomide*
Teniposide
Tev-Tropin*^
Thalomid*
Theracys
Thiotepa
Thrombate III
Thymoglobulin
Thyrogen
Tivicay*
Tobi
Tobi Podhaler*
Toposar
Topotecan HCl*
Torisel
Tracleer*
Tranexamic Acid
Treanda
Trelstar*
Trelstar Depot
Trelstar LA
Trexall*
Trisenox
Trizivir*
Truvada*
Tykerb*
Tysabri*
Tyvaso
Tyzeka*
V
Valchlor
Valstar
Vantas*
Vectibix
Velcade
Veletri*
Ventavis*
Vepesid*
Victrelis*
Vidaza
Videx*
Videx EC*
Vinblastine
Sulfate
Vincasar PFS
Vincristine Sulfate
Vinorelbine
Vinorelbine
Tartrate
Viracept*
Viramune*
Viramune XR*
Virazole*
Viread*
Vistide
Visudyne
Vivitrol*
Voraxaze
Votrient*
Vpriv*
Vumon
W
Wilate*
Winrho SDF*
X
Xalkori*
Xeljanz*
Xeloda*
Xenazine
Xeomin*
Xgeva
Xiaflex*
Xofigo
Xolair*
Xtandi*
Xyntha*
Xyntha Solofuse*
Xyrem
Y
Yervoy
Z
Zaltrap
Zanosar
Zavesca*
Zelboraf*
Zemaira
Zemplar
Zerit*
Zevalin
Ziagen*
Zidovudine*
Zofran
Zoladex*
Zoledronic Acid*
Zolinza
Zometa*
Zorbtive*
Zortress*
Zytiga*
EXCLUSIONS & 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-thecounter (OTC) that do not require a
prescription by federal or state law, and
any medication that is a pharmaceutical
alternative to an OTC medication other
than insulin [examples include OTC
Benadryl, Maalox, Sudafed PE, etc.]
2. Medications that are therapeutically
equivalent as determined by the Cigna
HealthCare Pharmacy and Therapeutics
Committee in which at least one of the
medications within the class is available
over the counter. [examples include Rx
equivalents to OTC Allegra, Claritin and
Zyrtec (Allegra D, Clarinex, Xyzal) and Rx
equivalents to OTC Prevacid, Prilosec and
Zantac (Aciphex, Kapidex, Nexium, Axid,
Pepcid, Zantac)].
3. Any injectable infertility medications, and
any injectable medications that require
health care professional supervision
and are not typically considered selfadministered medications. The following
are examples of health care professionalsupervised medications: injectables used
to treat hemophilia and RSV (respiratory
syncytial virus), chemotherapy injectables
and endocrine and metabolic agents.
4. Any medications that are experimental or
investigational within the meaning set
forth in the summary plan description.
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.
6. Any prescription and non-prescription
supplies (such as ostomy supplies), devices
and appliances.
7. Any contraceptive medications and
prescription appliances for contraception.
8. Implantable contraceptive products.
9. Any fertility medication.
10. Any prescription vitamins (other than
prenatal vitamins), dietary supplements
and fluoride products.
11. Medications used for cosmetic purposes,
such as medications used to reduce
wrinkles, medications to promote hair
growth, medications used to control
perspiration and fade cream products.
12. Any diet pills or appetite suppressants
(anorectics).
13. Immunization agents, biological products
for allergy immunization, biological sera,
blood, blood plasma and other blood
products or fractions and medications used
for travel prophylaxis (the prevention of
travel-related diseases).
14. Replacement of prescription medications
and related supplies due to loss or theft.
15. Medications used to enhance athletic
performance.
16. 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.
17. Prescriptions more than one year from the
original date of issue.
23
Cigna reserves the right to make changes to this drug
list without notice. Your plan may cover additional
medications; please refer to your enrollment materials
for details. Cigna does not take responsibility for
any medication decisions made by the doctor or
pharmacist. Cigna may receive payments from
manufacturers of certain preferred brand medications,
and in limited instances, certain non-preferred brand
medications, that may or may not be shared with
your plan depending on its arrangement with Cigna.
Depending upon plan design, market conditions, the
extent to which manufacturer payments are shared with
your plan and other factors as of the date of service, the
preferred brand medication may or may not represent
the lowest-cost brand medication within its class for
you and/or your plan.
“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.
827363 i 12/13 © 2013 Cigna. Some content provided under license.