Post on 29-May-2018
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
909016 UPDATED_6/27/2018
Start date of change*
Drug class Medication not covered^ Generic and/or preferred brand alternatives
September 1, 2018
SKIN CONDITIONS Doxepin 5% Cream generic topical steroid (e.g. betamethasone) or topical tacrolimus
July 1, 2018 DIABETES Segluromet Synjardy, Synjardy XR, Xigduo XRSteglatro Farxiga, JardianceSteglujan Glyxambi, QTERN
GASTROINTESTINAL/HEARTBURN OmePPI omeprazoleINFECTIONS Mycobutin rifabutinMULTIPLE SCLEROSIS Copaxone Aubagio, Avonex, Betaseron, Extavia,
Gilenya, glatiramer, Glatopa, Plegridy, Rebif, Tecfidera
SEIZURE DISORDERS Lyrica CR duloxetine, gabapentin, lidocaine 5% topical patch, Lyrica
SKIN CONDITIONS diclofenac 3% gel, Solaraze Fluoroplex, fluorouracil, imiquimod, PicatoMay 15, 2018 EYE CONDITIONS Vyzulta bimatoprost, latanoprost, Travatan ZApril 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE Duzallo allopurinol, probenecid, UloricMarch 1, 2018 DIABETES Fiasp Humalog
PARKINSON’S DISEASE Gocovri amantadineFebruary 1, 2018 ASTHMA/COPD/RESPIRATORY ArmonAir QVAR, Pulmicort FlexhalerJanuary 13, 2018 GASTROINTESTINAL/HEARTBURN Syndros dronabinolJanuary 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipramine
Pamelor nortriptylineParnate tranylcypromineTofranil imipramine
ASTHMA/COPD/RESPIRATORY Zyflo montelukast, zafirlukast, zileuton ERZyflo CR zileuton ER
ATTENTION DEFICIT HYPERACTIVITY DISORDER
Desoxyn methamphetamineDexedrine dextroamphetamine, dextroamphetamine ER
PRESCRIPTION DRUG LIST CHANGES
Cigna Pharmacy Management® 2018
The medications listed below are changing coverage (or cost levels) on Cigna’s Prescription Drug List. Changes are listed by drug list name and by the date they begin.
STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST
STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont)
Start date of change*
Drug class Medication not covered^ Generic and/or preferred brand alternatives
January 1, 2018 BLOOD PRESSURE/HEART MEDICATIONS Betapace sotalol tabletsCANCER Nilandron nilutamideDIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR
Invokana Farxiga, JardianceLantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba Novolin, Novolog Humalog, Humulin
GASTROINTESTINAL/HEARTBURN Cortifoam, Uceris rectal foam Anucort-HC, Colocort, Hemmorex-HC, hydrocortisone, Procto-Med HC, Procto-Pak, Proctosol-HC, Proctozone-HC
Lotronex alosetronMarinol dronabinolomeprazole bicarbonate packets, 40-1100mg capsules
omeprazole
Rowasa mesalamine enemaUceris tablet budesonide EC capsuleZegerid omeprazoleZofran ondansetronZofran ODT ondansetron ODT
HORMONAL AGENTS DDAVP desmopressinHectorol doxercalciferol capsule
INFECTIONS Augmentin, Augmentin ES, Augmentin XR amoxicillin-clavulanate ER, amoxicillin-clavulanate
Diflucan fluconazoleE.E.S. 200, Eryped 400 erythromycin ethylsuccinateMepron atovaquoneSporanox itraconazole
Targadox Avidoxy tablet, doxycycline hyclate, Morgidox capsule
Valcyte valganciclovir
Vancocin vancomycin capsule
Zovirax acyclovir
MISCELLANEOUS Gralise, Horizant gabapentin
PAIN RELIEF AND INFLAMMATORY DISEASE Cambia diclofenac, diclofenac ER, etodolac, etodolac ER, fenoprofen, Fenortho, flurbiprofen, ibuprofen, indomethacin, indomethacin ER, ketoprofen, Ketorolac, meclofenamate, mefenamic acid, meloxicam, nabumetone
D.H.E. 45, Migranal dihydroergotamine
Imitrex, Sumavel DosePro sumatriptan
Lorzone chlorzoxazone
OxyContin Embeda, Hysingla ER, Xtampza ER
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont)
Start date of change*
Drug class Medication not covered^ Generic and/or preferred brand alternatives
January 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE (cont)
Roxicodone oxycodone
Tivorbex indomethacin
Vanatol LQ butalbital/acetaminophen/caffeine tabs or caps
Vivlodex meloxicam
Zomig sumatriptan, zolmitriptan
Zorvolex diclofenac, diclofenac ER
PARKINSON'S DISEASE Lodosyn carbidopa
Requip XL ropinirole ER
SCHIZOPHRENIA/ANTI-PSYCHOTICS Geodon ziprasidoneZyprexa olanzapineZyprexa Zydis olanzapine ODT
SKIN CONDITIONS Cutivate fluticasone creamKenalog triamcinolone sprayLocoid lotion hydrocortisone butyrateLuzu ketoconazole creamSoriatane acitretinZiana clindamycin-tretinoin
SLEEP DISORDERS/SEDATIVES Nuvigil armodafinilProvigil modafinilRestoril temazepam
URINARY TRACT CONDITIONS Detrol tolterodineDetrol LA tolterodine ERDitropan XL oxybutynin EREnablex darifenacin ERGelnique darifenacin ER, oxybutynin ER, tolterodine
ER, trospium ER
Start date of change*
Drug classNon-preferred brand medication
Generic and/or preferred brand alternatives
August 15, 2018 ASTHMA/COPD/RESPIRATORY Symdeko+ Please work with your patient to prescribe a lower-cost option, if appropriate.
July 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Arixtra+ fondaparinux
Lovenox+ enoxaparin
Reopro+ Please work with your patient to prescribe a lower-cost option, if appropriate.
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
Start date of change*
Drug class Preferred brand medication
October 1, 2018 GASTROINTESTINAL/HEARTBURN Entyvio+
Nexium Powder PackJune 1, 2018 DIABETES Ozempic
VictozaApril 1, 2018 DIABETES QTERNJanuary 1, 2018 MISCELLANEOUS Nityr+
STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont)
Start date of change*
Drug classNon-preferred brand medication
Generic and/or preferred brand alternatives
July 1, 2018 CANCER dexrazoxane+, Evomela+, Hycamtin capsule+, Nilandron+, nilutamide+, Zinecard
Please work with your patient to prescribe a lower-cost option, if appropriate.
CONTRACEPTION PRODUCTS Depo-Provera 150mg/ml medroxyprogesterone
LoSeasonique Amethia Lo, Camrese Lo, levonorg-eth estradiol 0.1/0.02/0.01mg
Nexplanon+, Paragard T 380-a+ Please work with your patient to prescribe a lower-cost option, if appropriate.
Seasonique Amethia, Ashlyna, Camrese, Daysee, levonorg-eth estradiol 0.15/0.03/0.01mg
DENTAL PRODUCTS Arestin+ Please work with your patient to prescribe a lower-cost option, if appropriate.
DIABETES Korlym+ Please work with your patient to prescribe a lower-cost option, if appropriate.
EYE CONDITIONS Cystaran+, Ozurdex+, Retisert+ Please work with your patient to prescribe a lower-cost option, if appropriate.
GASTROINTESTINAL/HEARTBURN alosetron+, Buphenyl+, Chenodal+, Ravicti+, sodium phenylbutyrate
Please work with your patient to prescribe a lower-cost option, if appropriate.
HORMONAL AGENTS Aveed+, hydroxyprogesterone caproate+ Please work with your patient to prescribe a lower-cost option, if appropriate.
Depo-Provera 400mg/ml medroxyprogesterone
INFECTIONS Daraprim+, Sirturo+ Please work with your patient to prescribe a lower-cost option, if appropriate.
INFERTILITY Makena+ Please work with your patient to prescribe a lower-cost option, if appropriate.
MISCELLANEOUS Asclera+, Carbaglu+, Ferriprox+, Flebogamma DIF+, Keveyis+, Varithena+
Please work with your patient to prescribe a lower-cost option, if appropriate.
Orfadin+ Nityr
PAIN RELIEF AND INFLAMMATORY DISEASE (NON-NARCOTIC)
Colcrys colchicine
PARKINSON’S DISEASE Azilect rasagiline
SEIZURE DISORDERS Lamictal ODT lamotrigine ODT
SKIN CONDITIONS Ameluz+, Levulan+ Please work with your patient to prescribe a lower-cost option, if appropriate.
Tazorac 0.1% cream tazarotene
SLEEP DISORDERS/SEDATIVES Hetlioz+ Please work with your patient to prescribe a lower-cost option, if appropriate.
TRANSPLANT MEDICATIONS Cellcept+ mycophenolate
Neoral 25mg capsule, solution+ cyclosporine modified, Gengraf
Sandimmune 100mg capsule+ cyclosporine
URINARY TRACT CONDITIONS Thiola+ Please work with your patient to prescribe a lower-cost option, if appropriate.
March 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic Please work with your patient to prescribe a lower-cost option, if appropriate.
HORMONAL AGENTS Depo-Testosterone testosterone cypionate
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont)
Start date of change*
Drug classNon-preferred brand medication
Generic and/or preferred brand alternatives
February 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Bevyxxa enoxaparin, Fragmin
January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal spray
ATTENTION DEFICIT HYPERACTIVITY DISORDER
Adderall XR dextroamphetamine-amphetamine ER
Focalin XR dexmethylphenidate ER
SKIN CONDITIONS Ala-Scalp hydrocortisone
Analpram HC lotion hydrocortisone-pramoxine
Capex shampoo fluocinolone
Cordran flurandrenolide
Differin adapalene
Metrogel metronidazole gel
Naftin naftifine
Nucort, Texacort hydrocortisone
Start date of change*
Drug class Medication requiring prior authorization^^
July 1, 2018 CANCER Hycamtin++, Targretin++, tretinoin capsule++, Xeloda++
MISCELLANEOUS Nityr, Orfadin++
PAIN RELIEF AND INFLAMMATORY DISEASE (NARCOTIC)
Diskets, Dolophine, methadone++, Methadose
March 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic
January 1, 2018 GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi
HORMONAL AGENTS Androderm, Androgel, Striant, testosterone
MISCELLANEOUS NityrStart date of change*
Drug class Medication with quantity limits^^
September 1, 2018
SKIN CONDITIONS Prudoxin, Zonalon
August 15, 2018 ASTHMA/COPD/RESPIRATORY Symdeko
July 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER bupropion ER#, Celexa#, citalopram#, desvenlafaxiner ER#, duloxetine#, Effexor XR#, Effexor#, Emsam#, escitalopram#, Fetzima#, fluoxetine#, fluvoxamine ER#, fluvoxamine#, Forfivo XL#, Khedezla, paroxetine CR#, paroxetine#, Paxil CR#, Pexeva#, Prozac, sertraline#, venlafaxine ER#, Wellbutrin SR, Wellbutrin XL, Zoloft
BLOOD PRESSURE/HEART MEDICATIONS BiDil 20-37.5mg#, captopril-HCTZ, dofetilide#, Tikosyn
CHOLESTEROL MEDICATIONS simvastatin, Zocor
GASTROINTESTINAL/HEARTBURN Aciphex, Dexilant, esomeprazole, lansoprazole DR, Nexium DR, Nexium, omeprazole DR, omeprazole, omeprazole bicarbonate, pantoprazole, Prevacid SoluTab, Prilosec, prilosec 2.5mg, Protonix, rabeprazole
NUTRITIONAL/DIETARY Auryxia
PAIN RELIEF AND INFLAMMATORY DISEASE (NON-NARCOTIC)
Cafergot, ergotamine-caffeine, diclofenac 1%, Voltaren
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont)
Start date of change*
Drug class Medication with quantity limits^^
July 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE (NARCOTIC)
acetaminophen-caffeine-dihyrocodeine, acetaminophen-codeine, Arymo, asa-butalb-caff-codeine, aspirin-caff-dihydrocodeine, belladonna-opium, buprenorphine, butalb-acetaminoph-caff-codeine, butorphanol, carisoprodol-asa-codeine, codeine sulfate, Embeda, Exalgo, Fentanyl (all dosage forms), Flowtuss, Hycofenix, hydrocodone-acetaminophen, hydrocodone-ibuprofen, Hydromet, hydromorphone, Hysingla ER, Kadian, Lorcet, Lortab, meperidine, Morphabond ER, morphine, morphine ER, nalbuphine, Nucynta, Nucynta ER, Obredon, Opana ER, opium tincture, Oxecta, oxycodone, oxycodone ER, oxycodone-acetaminophen, oxycodone-aspirin, oxycodone-ibuprofen, OxyContin, oxymorphone, oxymorphone ER, pentazocine-acetaminophen, pentazocine-naloxone, Primlev, promethazine-codeine, Talwin, tramadol ER, tramadol-acetaminophen, Trezix, Tussigon, Tussionex, Xtampza ER, Zohydro ER, Zutripro
SEIZURE DISORDERS Banzel#
SKIN CONDITIONS calcitriol, Vectical
SLEEP DISORDERS/SEDATIVES RozeremFebruary 1, 2018 BLOOD THINNERS/ANTI-CLOTTING BevyxxaJanuary 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone
ALZHEIMER'S DISEASE Namenda XR, NamzaricANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine 25mg, 100mg, Marplan, PristiqASTHMA/COPD/RESPIRATORY PerforomistBLOOD PRESSURE/HEART MEDICATIONS RanexaCANCER Fareston, nilutamideEYE CONDITIONS bimatoprost eye drops, Cystaran, ZioptanHORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafemMISCELLANEOUS NuedextaOSTEOPOROSIS PRODUCTS alendronatePAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, MitigareSCHIZOPHRENIA/ANTI-PSYCHOTICS FanaptSEIZURE DISORDERS Gabitril, PotigaSKIN CONDITIONS Denavir, Regranex, Santyl, VecticalSLEEP DISORDERS/SEDATIVES Hetlioz
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
Start date of change*
Drug class Step Therapy medication^^Generic and/or preferred brand alternatives
April 1, 2018 ASTHMA/COPD/RESPIRATORY Trelegy Ellipta## Advair, Anoro Ellipta, Breo Ellipta, Stiolto Respimat, Symbicort
January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER
Focalin XR## dexmethylphenidate ER
SCHIZOPHRENIA/ANTI-PSYCHOTICS Orap## pimozide
SKIN CONDITIONS Ala-Scalp## hydrocortisoneCapex shampoo## fluocinoloneCordran## flurandrenolideNucort, Texacort## hydrocortisone
STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont)
Start date of change*
Drug class
Medication strength with limitations** (Your plan doesn’t cover 2 capsules/tablets per day of this strength)
Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)
January 1, 2018 ALLERGY/NASAL SPRAYS desloratadine ODT 2.5mg desloratadine ODT 5mg
ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg
Fetzima ER 40mg Fetzima ER 80mg
Trintellix 5mg Trintellix 10mg
Trintellix 10mg Trintellix 20mg
BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg
Benicar 20mg Benicar 40mg
Benicar HCT 20-12.5mg Benicar HCT 40-25mg
Bystolic 10mg Bystolic 20mg
Tekturna 150mg Tekturna 300mg
Tekturna HCT 150-12.5mg Tekturna HCT 300-25mg CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg
Livalo 2mg Livalo 4mg DIABETES Farxiga 5mg Farxiga 10mg PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg
Aptiom 400mg Aptiom 800mg
Fycompa 4mg Fycompa 8mg
Fycompa 6mg Fycompa 12mg
Trokendi XR 25mg Trokendi XR 50mg
Trokendi XR 100mg Trokendi XR 200mg SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
LEGACY (PERFORMANCE) PRESCRIPTION DRUG LIST
Start date of change*
Drug class Preferred brand medication
October 1, 2018 GASTROINTESTINAL/HEARTBURN Entyvio+
June 1, 2018 DIABETES Ozempic
Victoza
April 1, 2018 DIABETES QTERN
March 1, 2018 DIABETES Fiasp
January 1, 2018 MISCELLANEOUS Nityr+
Start date of change*
Drug classNon-preferred brand medication
Generic and/or preferred brand alternatives
August 15, 2018 ASTHMA/COPD/RESPIRATORY Symdeko+ Please work with your patient to prescribe a lower-cost option, if appropriate.
July 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Reopro+ Please work with your patient to prescribe a lower-cost option, if appropriate.
CANCER dexrazoxane+, Evomela+, Hycamtin capsule+, Nilandron+, nilutamide+, Zinecard
Please work with your patient to prescribe a lower-cost option, if appropriate.
Fusilev+ leucovorin
CONTRACEPTION PRODUCTS LoSeasonique Amethia Lo, Camrese Lo, levonorg-eth estradiol 0.1/0.02/0.01mg
Nexplanon+, Paragard T 380-a+ Please work with your patient to prescribe a lower-cost option, if appropriate.
Seasonique Amethia, Ashlyna, Camrese, Daysee, levonorg-eth estradiol 0.15/0.03/0.01mg
DENTAL PRODUCTS Arestin+ Please work with your patient to prescribe a lower-cost option, if appropriate.
DIABETES Korlym+ Please work with your patient to prescribe a lower-cost option, if appropriate.
Segluromet Invokamet, Synjardy, Synjardy XR, Xigduo XR
Steglatro Farxiga, Invokana, JardianceSteglujan Glyxambi, QTERN
EYE CONDITIONS Cystaran+, Ozurdex+, Retisert+ Please work with your patient to prescribe a lower-cost option, if appropriate.
GASTROINTESTINAL/HEARTBURN alosetron+, Buphenyl+, Chenodal+, Ravicti+, sodium phenylbutyrate
Please work with your patient to prescribe a lower-cost option, if appropriate.
HORMONAL AGENTS Aveed+, hydroxyprogesterone caproate+ Please work with your patient to prescribe a lower-cost option, if appropriate.
Saizen+ Humatrope
INFECTIONS Daraprim+, Sirturo+ Please work with your patient to prescribe a lower-cost option, if appropriate.
INFERTILITY Makena+ Please work with your patient to prescribe a lower-cost option, if appropriate.
MISCELLANEOUS Asclera+, Carbaglu+, Ferriprox+,
Flebogamma DIF+, Keveyis+, Varithena+
Please work with your patient to prescribe a lower-cost option, if appropriate.
Orfadin+ Nityr
MULTIPLE SCLEROSIS Copaxone+ Aubagio, Avonex, Betaseron, Extavia, Gilenya, glatiramer, Glatopa, Plegridy, Rebif, Tecfidera
PAIN RELIEF AND INFLAMMATORY DISEASE (NON-NARCOTIC)
Colcrys colchicine
PARKINSON’S DISEASE Azilect rasagiline
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
LEGACY (PERFORMANCE) PRESCRIPTION DRUG LIST (cont)
LEGACY (PERFORMANCE) PRESCRIPTION DRUG LIST (cont)
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
Start date of change*
Drug classNon-preferred brand medication
Generic and/or preferred brand alternatives
July 1, 2018 SEIZURE DISORDERS Lamictal ODT lamotrigine ODT
Lyrica CR duloxetine, gabapentin, lidocaine 5% topical patch, Lyrica
SKIN CONDITIONS Ameluz+, Levulan+ Please work with your patient to prescribe a lower-cost option, if appropriate.
Tazorac 0.1% cream tazarotene
SLEEP DISORDERS/SEDATIVES Hetlioz+ Please work with your patient to prescribe a lower-cost option, if appropriate.
TRANSPLANT MEDICATIONS Cellcept tablet, capsule, suspension+ mycophenolate tablet, capsule, suspension
Neoral 25mg capsule, solution+ cyclosporine modified, Gengraf
Sandimmune 100mg capsule+ cyclosporine
URINARY TRACT CONDITIONS Thiola+ Please work with your patient to prescribe a lower-cost option, if appropriate.
May 15, 2018 EYE CONDITIONS Vyzulta bimatoprost, latanoprost, Travatan Z
April 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE Duzallo allopurinol, probenecid, Uloric
March 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic Please work with your patient to prescribe a lower-cost option, if appropriate.
PARKINSON’S DISEASE Gocovri amantadine
February 1, 2018 ASTHMA/COPD/RESPIRATORY ArmonAir QVAR, Pulmicort Flexhaler
BLOOD THINNERS/ANTI-CLOTTING Bevyxxa enoxaparin, Fragmin
January 13, 2018 GASTROINTESTINAL/HEARTBURN Syndros dronabinol
January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal spray
ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER
DIABETES Lantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Tresiba, Levemir
GASTROINTESTINAL/HEARTBURN omeprazole bicarbonate packet, 40mg-1100mg capsule, 20mg-1100mg
omeprazole
INFECTIONS Eryped 400 erythromycin
PAIN RELIEF AND INFLAMMATORY DISEASE OxyContin Embeda, Hysingla ER, Xtampza ER
Vanatol LQ butalbital/acetaminophen/caffeine tabs or caps
SKIN CONDITIONS Ala-Scalp hydrocortisone topical
Capex shampoo fluocinolone scalp
Cordran flurandrenolide topical
Differin adapalene
Kenalog spray triamcinolone spray
Locoid lotion hydrocortisone butyrate
Metrogel metronidazole gel
Naftin naftifine
Nucort, Texacort hydrocortisone
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
LEGACY (PERFORMANCE) PRESCRIPTION DRUG LIST (cont)
Start date of change*
Drug class Medication requiring prior authorization^^
July 1, 2018 CANCER Hycamtin++, Targretin++, tretinoin capsule++, Xeloda++
MISCELLANEOUS Nityr, Orfadin++
MULTIPLE SCLEROSIS Copaxone
PAIN RELIEF AND INFLAMMATORY DISEASE (NARCOTIC)
Diskets, Dolophine, methadone tablet, solution++, methadone intensol++, Methadose
April 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE Duzallo
March 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic
January 13, 2018 GASTROINTESTINAL/HEARTBURN Syndros
January 1, 2018 DIABETES Lantus, Lantus SoloStar, Toujeo SoloStar
GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi
HORMONAL AGENTS Androderm, Androgel, Axiron, Fortesta, Natesto, Striant, Testim, Testopel, testosterone, Vogelxo
MISCELLANEOUS Nityr
PAIN RELIEF AND INFLAMMATORY DISEASE RoxicodoneStart date of change*
Drug class Medication with quantity limits^^
September 1, 2018
SKIN CONDITIONS Doxepin 5% Cream, Prudoxin, Zonalon
August 15, 2018 ASTHMA/COPD/RESPIRATORY SymdekoJuly 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Aplenzin#, bupropion ER#, Celexa#, citalopram#, Cymbalta#, desvenlafaxiner ER#, duloxetine#,
Effexor XR#, Effexor#, Emsam#, escitalopram#, Fetzima#, fluoxetine#, fluvoxamine ER#,
fluvoxamine#, Forfivo XL#, Khedezla, Lexapro, paroxetine CR#, paroxetine#, Paxil CR#, Pexeva#,
Prozac, sertraline#, venlafaxine ER#, Wellbutrin SR, Wellbutrin XL, Zoloft
BLOOD PRESSURE/HEART MEDICATIONS BiDil 20-37.5mg#, captopril-HCTZ, dofetilide#, Tikosyn
CHOLESTEROL MEDICATIONS simvastatin, Zocor
DIABETES Jentadueto XR
GASTROINTESTINAL/HEARTBURN Aciphex, Dexilant, esomeprazole, lansoprazole DR, lansoprazole, Nexium DR, Nexium, OmePPI, omeprazole DR, omeprazole, omeprazole bicarbonate, pantoprazole, Prevacid Solutab, Prilosec, prilosec 2.5mg, Protonix, rabeprazole, Zegerid
NUTRITIONAL/DIETARY Auryxia
PAIN RELIEF AND INFLAMMATORY DISEASE (NON-NARCOTIC)
Cafergot, ergotamine-caffeine, diclofenac 1%, Voltaren
PAIN RELIEF AND INFLAMMATORY DISEASE (NARCOTIC)
acetaminophen-caffeine-dihyrocodeine, acetaminophen-codeine, Arymo, asa-butalb-caff-codeine, aspirin-caff-dihydrocodeine, belladonna-opium, buprenorphine, butalb-acetaminoph-caff-codeine, butorphanol, carisoprodol-asa-codeine, codeine sulfate, Embeda, Exalgo, Fentanyl (all dosage forms), Flowtuss, Hycofenix, hydrocodone-acetaminophen, hydrocodone-ibuprofen, Hydromet, hydromorphone, Hysingla ER, Kadian, Lorcet, Lortab, meperidine, Morphabond ER, morphine, morphine ER, nalbuphine, Nucynta, Nucynta ER, Obredon, Opana ER, opium tincture, Oxecta, oxycodone, oxycodone ER, oxycodone-acetaminophen, oxycodone-aspirin, oxycodone-ibuprofen, OxyContin, oxymorphone, oxymorphone ER, pentazocine-acetaminophen, pentazocine-naloxone, Primlev, promethazine-codeine, Talwin, tramadol ER, tramadol-acetaminophen, Trezix, Tussigon, Tussionex, Xtampza ER, Zohydro ER, Zutripro
LEGACY (PERFORMANCE) PRESCRIPTION DRUG LIST (cont)
Start date of change*
Drug class Medication with quantity limits^^
July 1, 2018 SCHIZOPHRENIA/ANTI-PSYCHOTICS Invega Sustenna#
SEIZURE DISORDERS Banzel#
SKIN CONDITIONS calcitriol, Vectical
SLEEP DISORDERS/SEDATIVES Rozerem
February 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Bevyxxa
January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone, Nasonex
ALZHEIMER'S DISEASE Namenda XR, Namzaric
ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine 25mg, 100mg, Marplan, Pristiq
ASTHMA/COPD/RESPIRATORY Perforomist
BLOOD PRESSURE/HEART MEDICATIONS Ranexa
CANCER Fareston, Nilandron, nilutamide
DIABETES Jentadueto, Tradjenta
EYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan
HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle Dot, yuvafem
INFECTIONS Zovirax
MISCELLANEOUS Nuedexta
OSTEOPOROSIS PRODUCTS alendronate
PAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, Mitigare
SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify Maintena, Aristada, Fanapt, Invega Trinza, Risperdal Consta, Zyprexa Relprevv
SEIZURE DISORDERS Gabitril, Potiga
SKIN CONDITIONS Denavir, Regranex, Santyl, Vectical, Zyclara
SLEEP DISORDERS/SEDATIVES Hetlioz
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
Start date of change*
Drug class Step Therapy medication^^Generic and/or Preferred Brand Alternatives
July 1, 2018 ERECTILE DYSFUNCTION Cialis## Please work with your patient to prescribe a lower-cost option, if appropriate.
Viagra## sildenafil, Cialis
April 1, 2018 ASTHMA/COPD/RESPIRATORY Trelegy Ellipta## Advair, Anoro Ellipta, Breo Ellipta, Stiolto Respimat, Symbicort
February 1, 2018 ASTHMA/COPD/RESPIRATORY ArmonAir## QVAR, Pulmicort Flexhaler
January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR## dextroamphetamine-amphetamine ER
Focalin XR## dexmethylphenidate ER
SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify## aripiprazole
Orap## pimozide
SKIN CONDITIONS Locoid lotion## hydrocortisone butyrate
SLEEP DISORDERS/SEDATIVES Silenor## eszopiclone, zolpidem
LEGACY (PERFORMANCE) PRESCRIPTION DRUG LIST (cont)
Start date of change*
Drug class
Medication strength with limitations** (Your plan doesn’t cover 2 capsules/tablets per day of this strength)
Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)
January 1, 2018 ALLERGY/NASAL SPRAYS desloratadine ODT 2.5mg desloratadine ODT 5mg
ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg
Fetzima ER 40mg Fetzima ER 80mg
Trintellix 5mg Trintellix 10mg
Trintellix 10mg Trintellix 20mg
BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg
Benicar 20mg Benicar 40mg
Benicar HCT 20-12.5mg Benicar HCT 40-25mg
Bystolic 10mg Bystolic 20mg
Tekturna 150mg Tekturna 300mg
Tekturna HCT 150-12.5mg Tekturna HCT 300-25mg
CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg
Livalo 2mg Livalo 4mg
DIABETES Farxiga 5mg Farxiga 10mg
PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg
SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg
SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg
Aptiom 400mg Aptiom 800mg
Fycompa 4mg Fycompa 8mg
Fycompa 6mg Fycompa 12mg
Trokendi XR 25mg Trokendi XR 50mg
Trokendi XR 100mg Trokendi XR 200mg
SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
LEGACY (STANDARD) PRESCRIPTION DRUG LIST
Start date of change*
Drug class Preferred brand medication
October 1, 2018 GASTROINTESTINAL/HEARTBURN Entyvio+
Nexium Powder PackJune 1, 2018 DIABETES Ozempic
VictozaApril 1, 2018 DIABETES QTERN
March 1, 2018 DIABETES FiaspJanuary 1, 2018 MISCELLANEOUS Nityr+
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
Start date of change*
Drug classNon-preferred brand medication
Generic and/or preferred brand alternatives
August 15, 2018 ASTHMA/COPD/RESPIRATORY Symdeko+ Please work with your patient to prescribe a lower-cost option, if appropriate.
July 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Arixtra+ fondaparinuxLovenox+ enoxaparinReopro+ Please work with your patient to prescribe
a lower-cost option, if appropriate.CANCER dexrazoxane+, Evomela+, Hycamtin
capsule+, Nilandron+, nilutamide+, ZinecardPlease work with your patient to prescribe a lower-cost option, if appropriate.
CONTRACEPTION PRODUCTS Depo-Provera 150mg/ml medroxyprogesteroneLoSeasonique Amethia Lo, Camrese Lo, levonorg-eth
estradiol 0.1/0.02/0.01mgNexplanon+, Paragard T 380-a+ Please work with your patient to prescribe
a lower-cost option, if appropriate.Seasonique Amethia, Ashlyna, Camrese, Daysee,
levonorg-eth estradiol 0.15/0.03/0.01mgDENTAL PRODUCTS Arestin+ Please work with your patient to prescribe
a lower-cost option, if appropriate.DIABETES Korlym+ Please work with your patient to prescribe
a lower-cost option, if appropriate.Segluromet Invokamet, Synjardy, Synjardy XR,
Xigduo XRSteglatro Farxiga, Invokana, JardianceSteglujan Glyxambi, QTERN
EYE CONDITIONS Cystaran+, Ozurdex+, Retisert+ Please work with your patient to prescribe a lower-cost option, if appropriate.
GASTROINTESTINAL/HEARTBURN alosetron+, Buphenyl+, Chenodal+, Lotronex+, Ravicti+, sodium phenylbutyrate
Please work with your patient to prescribe a lower-cost option, if appropriate.
HORMONAL AGENTS Aveed+, hydroxyprogesterone caproate+ Please work with your patient to prescribe a lower-cost option, if appropriate.
Depo-Provera 400mg/ml medroxyprogesteroneSaizen Humatrope
INFECTIONS Daraprim+, Sirturo+ Please work with your patient to prescribe a lower-cost option, if appropriate.
INFERTILITY Makena+ Please work with your patient to prescribe a lower-cost option, if appropriate.
MISCELLANEOUS Asclera+, Carbaglu+, Ferriprox+, Flebogamma DIF+, Keveyis+, Varithena+
Please work with your patient to prescribe a lower-cost option, if appropriate.
Orfadin+ NityrMULTIPLE SCLEROSIS Copaxone+ Aubagio, Avonex, Betaseron, Extavia,
Gilenya, glatiramer, Glatopa, Plegridy, Rebif, Tecfidera
PAIN RELIEF AND INFLAMMATORY DISEASE (NON-NARCOTIC)
Colcrys colchicine
PARKINSON’S DISEASE Azilect rasagiline
SEIZURE DISORDERS Lamictal ODT lamotrigine ODTLyrica CR duloxetine, gabapentin, lidocaine 5%
topical patch, Lyrica
LEGACY (STANDARD) PRESCRIPTION DRUG LIST (cont)
Start date of change*
Drug classNon-preferred brand medication
Generic and/or preferred brand alternatives
July 1, 2018 SKIN CONDITIONS Ameluz+, Levulan+ Please work with your patient to prescribe a lower-cost option, if appropriate.
Tazorac 0.1% cream tazaroteneSLEEP DISORDERS/SEDATIVES Hetlioz+ Please work with your patient to prescribe
a lower-cost option, if appropriate.TRANSPLANT MEDICATIONS Cellcept capsule, tablet, suspension+ mycophenolate
Neoral 25mg capsule, solution+ cyclosporine modified, GengrafSandimmune 100mg capsule+ cyclosporine
URINARY TRACT CONDITIONS Thiola+ Please work with your patient to prescribe a lower-cost option, if appropriate.
May 15, 2018 EYE CONDITIONS Vyzulta bimatoprost, latanoprost, Travatan ZApril 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE Duzallo allopurinol, probenecid, UloricMarch 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic Please work with your patient to prescribe
a lower-cost option, if appropriate.HORMONAL AGENTS Depo-Testosterone testosterone cypionatePARKINSON’S DISEASE Gocovri amantadine
February 1, 2018 ASTHMA/COPD/RESPIRATORY ArmonAir QVAR, Pulmicort Flexhaler
BLOOD THINNERS/ANTI-CLOTTING Bevyxxa enoxaparin, FragminJanuary 13, 2018 GASTROINTESTINAL/HEARTBURN Syndros dronabinolJanuary 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal spray
ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ERFocalin XR dexmethylphenidate ER
CANCER Nilandron nilutamide
DIABETES Apidra Humalog, NovologLantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba
GASTROINTESTINAL/HEARTBURN omeprazole bicarbonate packet, 40mg-1100mg capsule, 20mg-1100 mg capsule
omeprazole
INFECTIONS Eryped 400 erythromycinPAIN RELIEF AND INFLAMMATORY DISEASE D.H.E. 45 dihydroergotamine
Imitrex sumatriptanOxyContin Embeda, Hysingla ER, Xtampza ERVanatol LQ butalbital/acetaminophen/caffeine tabs
or capsSKIN CONDITIONS Ala-Scalp hydrocortisone
Analpram HC hydrocortisone-pramoxineCapex shampoo fluocinoloneCordran flurandrenolideDifferin adapaleneKenalog triamcinolone sprayLocoid lotion hydrocortisone butyrateMetrogel metronidazole gelNaftin naftifineNucort, Texacort hydrocortisone
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
LEGACY (STANDARD) PRESCRIPTION DRUG LIST (cont)
Start date of change*
Drug class Medication requiring prior authorization^^
July 1, 2018 CANCER Hycamtin++, Targretin++, tretinoin capsule++, Xeloda++
MISCELLANEOUS Nityr, Orfadin++
MULTIPLE SCLEROSIS CopaxonePAIN RELIEF AND INFLAMMATORY DISEASE (NARCOTIC)
Diskets, Dolophine, methadone++, Methadose
April 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE Duzallo
March 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic
January 13, 2018 GASTROINTESTINAL/HEARTBURN Syndros
January 1, 2018 DIABETES Lantus, Lantus SoloStar, Toujeo SoloStarGASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend capsule, powder packet, tripack, Sancuso, Varubi
HORMONAL AGENTS Androderm, Androgel, Axiron, Fortesta, Natesto, Striant, Testim, testosterone, Vogelxo
MISCELLANEOUS Nityr
PAIN RELIEF AND INFLAMMATORY DISEASE Roxicodone
LEGACY (STANDARD) PRESCRIPTION DRUG LIST (cont)
Start date of change*
Drug class Medication with quantity limits^^
September 1, 2018
SKIN CONDITIONS Doxepin 5% Cream, Prudoxin, Zonalon
August 15, 2018 ASTHMA/COPD/RESPIRATORY Symdeko
July 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Aplenzin#, bupropion ER#, Celexa#, citalopram#, Cymbalta#, desvenlafaxiner ER#, duloxetine#, Effexor XR#, Effexor#, Emsam#, escitalopram#, Fetzima#, fluoxetine#, fluvoxamine ER#, fluvoxamine#, Forfivo XL#, Khedezla, Lexapro, paroxetine CR#, paroxetine#, Paxil CR#, Pexeva#, Prozac, sertraline#, venlafaxine ER#, Wellbutrin SR, Wellbutrin XL, Zoloft
BLOOD PRESSURE/HEART MEDICATIONS BiDil 20-37.5mg#, captopril-HCTZ, dofetilide#, Tikosyn
CHOLESTEROL MEDICATIONS simvastatin, Zocor
DIABETES Jentadueto XR
GASTROINTESTINAL/HEARTBURN Aciphex, Dexilant, esomeprazole, lansoprazole DR, lansoprazole, Nexium DR, Nexium, OmePPI, omeprazole DR, omeprazole, omeprazole bicarbonate, pantoprazole, Prevacid SoluTab, Prilosec, prilosec 2.5mg, Protonix, rabeprazole, Zegerid
NUTRITIONAL/DIETARY Auryxia
PAIN RELIEF AND INFLAMMATORY DISEASE (NON-NARCOTIC)
Cafergot, ergotamine-caffeine, diclofenac 1%, Voltaren
PAIN RELIEF AND INFLAMMATORY DISEASE (NARCOTIC)
acetaminophen-caffeine-dihyrocodeine, acetaminophen-codeine, Arymo, asa-butalb-caff-codeine, aspirin-caff-dihydrocodeine, belladonna-opium, buprenorphine, butalb-acetaminoph-caff-codeine, butorphanol, carisoprodol-asa-codeine, codeine sulfate, Embeda, Exalgo, Fentanyl (all dosage forms), Flowtuss, Hycofenix, hydrocodone-acetaminophen, hydrocodone-ibuprofen, Hydromet, hydromorphone, Hysingla ER, Kadian, Lorcet, Lortab, meperidine, Morphabond ER, morphine, morphine ER, nalbuphine, Nucynta, Nucynta ER, Obredon, Opana ER, opium tincture, Oxecta, oxycodone, oxycodone ER, oxycodone-acetaminophen, oxycodone-aspirin, oxycodone-ibuprofen, OxyContin, oxymorphone, oxymorphone ER, pentazocine-acetaminophen, pentazocine-naloxone, Primlev, promethazine-codeine, Talwin, tramadol ER, tramadol-acetaminophen, Trezix, Tussigon, Tussionex, Xtampza ER, Zohydro ER, Zutripro
SEIZURE DISORDERS Banzel#
SKIN CONDITIONS calcitriol, VecticalSLEEP DISORDERS/SEDATIVES Rozerem
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
LEGACY (STANDARD) PRESCRIPTION DRUG LIST (cont)
Start date of change*
Drug class Medication with quantity limits^^
February 1, 2018 BLOOD THINNERS/ANTI-CLOTTING BevyxxaJanuary 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, Nasonex, mometasone
ALZHEIMER'S DISEASE Namenda XR, NamzaricANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine 25mg, 100mg, Marplan, PristiqASTHMA/COPD/RESPIRATORY PerforomistBLOOD PRESSURE/HEART MEDICATIONS RanexaCANCER Fareston, Nilandron, nilutamideDIABETES Jentadueto, TradjentaEYE CONDITIONS bimatoprost eye drops, Cystaran, ZioptanHORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafemINFECTIONS ZoviraxMISCELLANEOUS NuedextaOSTEOPOROSIS PRODUCTS alendronatePAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, MitigareSCHIZOPHRENIA/ANTI-PSYCHOTICS FanaptSEIZURE DISORDERS Gabitril, PotigaSKIN CONDITIONS Denavir, Regranex, Santyl, Vectical, ZyclaraSLEEP DISORDERS/SEDATIVES Hetlioz
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
Start date of change*
Drug class Step Therapy medication^^Generic and/or preferred brand alternatives
April 1, 2018 ASTHMA/COPD/RESPIRATORY Trelegy Ellipta## Advair, Anoro Ellipta, Breo Ellipta, Stiolto Respimat, Symbicort
February 1, 2018 ASTHMA/COPD/RESPIRATORY ArmonAir## QVAR, Pulmicort Flexhaler
January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR## dextroamphetamine-amphetamine ER
Focalin XR## dexmethylphenidate ER
SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify## aripiprazole
Orap## pimozide
SKIN CONDITIONS Locoid lotion## hydrocortisone butyrate
SLEEP DISORDERS/SEDATIVES Silenor## eszopiclone, zolpidem
Start date of change*
Drug class
Medication strength with limitations** (Your plan doesn’t cover 2 capsules/tablets per day of this strength)
Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)
January 1, 2018 ALLERGY/NASAL SPRAYS desloratadine ODT 2.5mg desloratadine ODT 5mgANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg
Fetzima ER 40mg Fetzima ER 80mg Trintellix 5mg Trintellix 10mg Trintellix 10mg Trintellix 20mg
BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg Benicar 20mg Benicar 40mg Benicar HCT 20-12.5mg Benicar HCT 40-25mg
LEGACY (STANDARD) PRESCRIPTION DRUG LIST (cont)
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
Start date of change*
Drug class
Medication strength with limitations** (Your plan doesn’t cover 2 capsules/tablets per day of this strength)
Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)
January 1, 2018 BLOOD PRESSURE/HEART MEDICATIONS (cont)
Bystolic 10mg Bystolic 20mg Tekturna 150mg Tekturna 300mg Tekturna HCT 150-12.5mg Tekturna HCT 300-25mg
CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg Livalo 2mg Livalo 4mg
DIABETES Farxiga 5mg Farxiga 10mg PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg
Aptiom 400mg Aptiom 800mg Fycompa 4mg Fycompa 8mg Fycompa 6mg Fycompa 12mg Trokendi XR 25mg Trokendi XR 50mg Trokendi XR 100mg Trokendi XR 200mg
SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg
PERFORMANCE PRESCRIPTION DRUG LIST
Start date of change*
Drug class Medication not covered^ Generic and/or preferred brand alternatives
September 1, 2018
SKIN CONDITIONS Doxepin 5% Cream generic topical steroid (e.g. betamethasone) or topical tacrolimus
July 1, 2018 DIABETES Segluromet Synjardy, Synjardy XR, Xigduo XR
Steglatro Farxiga, Invokana, Jardiance
Steglujan Glyxambi, QTERN
GASTROINTESTINAL/HEARTBURN OmePPI omeprazole
INFECTIONS Mycobutin rifabutin
MULTIPLE SCLEROSIS Copaxone Aubagio, Avonex, Betaseron, Extavia, Gilenya, glatiramer, Glatopa, Plegridy, Rebif, Tecfidera
SEIZURE DISORDERS Lyrica CR duloxetine, gabapentin, lidocaine 5% topical patch, Lyrica
SKIN CONDITIONS diclofenac 3% gel, Solaraze Fluoroplex, fluorouracil topical, imiquimod cream, Picato
May 15, 2018 EYE CONDITIONS Vyzulta bimatoprost, latanoprost, Travatan Z
April 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE Duzallo allopurinol, probenecid, Uloric
March 1, 2018 DIABETES Fiasp Humalog
PARKINSON’S DISEASE Gocovri amantadine
February 1, 2018 ASTHMA/COPD/RESPIRATORY ArmonAir QVAR, Pulmicort Flexhaler
PERFORMANCE PRESCRIPTION DRUG LIST (cont)
Start date of change*
Drug class Medication not covered^ Generic and/or preferred brand alternatives
January 13, 2018 GASTROINTESTINAL/HEARTBURN Syndros dronabinolJanuary 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipramine
Pamelor nortriptylineParnate tranylcypromineTofranil imipramine
ASTHMA/COPD/RESPIRATORY Zyflo montelukast, zafirlukast, zileuton ERZyflo CR zileuton ER
ATTENTION DEFICIT HYPERACTIVITY DISORDER
Desoxyn methamphetamineDexedrine dextroamphetamine,
dextroamphetamine ERBLOOD PRESSURE/HEART MEDICATIONS Betapace sotalolCANCER Nilandron nilutamideDIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR
Invokana Farxiga, JardianceLantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba Novolin, Novolog Humalog, Humulin
GASTROINTESTINAL/HEARTBURN Cortifoam, Uceris rectal foam Colocort, Hemmorex-HC, hydrocortisone, Procto-Med HC, Procto-Pak, Proctosol-HC, Proctozone-HC
Marinol dronabinolomeprazole bicarbonate packet, 40mg-1100mg capsule, 20mg-1100mg
omeprazole
OmePPI omeprazole Rowasa mesalamine enemaUceris tablet budesonide EC capsuleZegerid omeprazoleZofran ondansetronZofran ODT ondansetron ODT
HORMONAL AGENTS Cortrosyn cosyntropinDDAVP desmopressinHectorol doxercalciferol
INFECTIONS Augmentin, Augmentin ES, Augmentin XR amoxicillin-clavulanate ER, amoxicillin-clavulanate
Diflucan fluconazoleE.E.S. 200, Eryped 400 erythromycinMepron atovaquoneSporanox itraconazoleTargadox Avidoxy, demeclocycline, doxycycline,
doxycycline IR-DR, minocycline, minocycline ER, mondoxyne NL, Morgidox capsule, tetracycline
Valcyte valganciclovir
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
Start date of change*
Drug class Medication not covered^ Generic and/or preferred brand alternatives
January 1, 2018 INFECTIONS (cont) Vancocin vancomycin capsule
Zovirax acyclovir
PAIN RELIEF AND INFLAMMATORY DISEASE Cambia diclofenac, diclofenac ER, etodolac, etodolac ER, fenoprofen, Fenortho, flurbiprofen, ibuprofen, indomethacin, indomethacin ER, ketoprofen, Ketorolac, meclofenamate, mefenamic acid, meloxicam, nabumetone
D.H.E. 45, Migranal dihydroergotamine
Gralise, Horizant gabapentin
Imitrex, Sumavel DosePro sumatriptan
Lorzone chlorzoxazone
OxyContin Embeda, Hysingla ER, Xtampza ER
Roxicodone oxycodone
Tivorbex indomethacin
Vanatol LQ butalbital/acetaminophen/caffeine tabs or caps
Vivlodex meloxicam
Zomig sumatriptan, zolmitriptan
Zorvolex diclofenac, diclofenac ER
PARKINSON'S DISEASE Lodosyn carbidopa
Requip XL ropinirole ER
SCHIZOPHRENIA/ANTI-PSYCHOTICS Geodon capsule ziprasidone
Zyprexa tablet olanzapine
Zyprexa Zydis olanzapine ODT
SKIN CONDITIONS Cutivate fluticasone
Kenalog topical spray triamcinolone
Locoid hydrocortisone
Luzu ketoconazole
Soriatane acitretin
Ziana clindamycin-tretinoin
SLEEP DISORDERS/SEDATIVES Nuvigil armodafinil
Provigil modafinil
Restoril temazepam
URINARY TRACT CONDITIONS Detrol tolterodine
Detrol LA tolterodine ER
Ditropan XL oxybutynin ER
Enablex darifenacin ER
Gelnique darifenacin ER, oxybutynin ER, tolterodine ER, trospium ER
PERFORMANCE PRESCRIPTION DRUG LIST (cont)
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
PERFORMANCE PRESCRIPTION DRUG LIST (cont)
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
Start date of change*
Drug class Preferred brand medication
October 1, 2018 GASTROINTESTINAL/HEARTBURN Entyvio+
June 1, 2018 DIABETES OzempicVictoza
April 1, 2018 DIABETES QTERNJanuary 1, 2018 MISCELLANEOUS Nityr+
Start date of change*
Drug classNon-preferred brand medication
Generic and/or preferred brand alternatives
August 15, 2018 ASTHMA/COPD/RESPIRATORY Symdeko+ Please work with your patient to prescribe a lower-cost option, if appropriate.
July 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Reopro+ Please work with your patient to prescribe a lower-cost option, if appropriate.
CANCER dexrazoxane+, Evomela+, Hycamtin capsule+, Nilandron+, nilutamide+, Zinecard
Please work with your patient to prescribe a lower-cost option, if appropriate.
Fusilev+ leucovorin
CONTRACEPTION PRODUCTS LoSeasonique Amethia Lo, Camrese Lo, levonorg-eth estradiol 0.1/0.02/0.01mg
Nexplanon+, Paragard T 380-a+ Please work with your patient to prescribe a lower-cost option, if appropriate.
Seasonique Amethia, Ashlyna, Camrese, Daysee, levonorg-eth estradiol 0.15/0.03/0.01mg
DENTAL PRODUCTS Arestin+ Please work with your patient to prescribe a lower-cost option, if appropriate.
DIABETES Korlym+ Please work with your patient to prescribe a lower-cost option, if appropriate.
EYE CONDITIONS Cystaran+, Ozurdex+, Retisert+ Please work with your patient to prescribe a lower-cost option, if appropriate.
GASTROINTESTINAL/HEARTBURN alosetron+, Buphenyl, Chenodal+, Ravicti+, sodium phenylbutyrate
Please work with your patient to prescribe a lower-cost option, if appropriate.
HORMONAL AGENTS Aveed+, hydroxyprogesterone caproate+ Please work with your patient to prescribe a lower-cost option, if appropriate.
INFECTIONS Daraprim+, Sirturo+ Please work with your patient to prescribe a lower-cost option, if appropriate.
INFERTILITY Makena+ Please work with your patient to prescribe a lower-cost option, if appropriate.
MISCELLANEOUS Asclera+, Carbaglu+, Ferriprox+, Flebogamma DIF+, Keveyis+, Varithena+
Please work with your patient to prescribe a lower-cost option, if appropriate.
Orfadin+ NityrPAIN RELIEF AND INFLAMMATORY DISEASE (NON-NARCOTIC)
Colcrys colchicine
PARKINSON’S DISEASE Azilect rasagiline
SEIZURE DISORDERS Lamictal ODT lamotrigine ODT
SKIN CONDITIONS Ameluz+, Levulan+ Please work with your patient to prescribe a lower-cost option, if appropriate.
Tazorac 0.1% cream tazaroteneSLEEP DISORDERS/SEDATIVES Hetlioz+ Please work with your patient to prescribe a
lower-cost option, if appropriate.
PERFORMANCE PRESCRIPTION DRUG LIST (cont)
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
Start date of change*
Drug classNon-preferred brand medication
Generic and/or preferred brand alternatives
July 1, 2018 TRANSPLANT MEDICATIONS Cellcept+ mycophenolateNeoral 25mg capsule, solution+ cyclosporine modified, GengrafSandimmune 100mg capsule+ cyclosporine
URINARY TRACT CONDITIONS Thiola+ Please work with your patient to prescribe a lower-cost option, if appropriate.
March 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic Please work with your patient to prescribe a lower-cost option, if appropriate.
February 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Bevyxxa enoxaparin, FragminJanuary 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal spray
ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ERSKIN CONDITIONS Ala-Scalp hydrocortisone
Analpram HC lotion hydrocortisone-pramoxineCapex shampoo fluocinoloneCordran flurandrenolideDifferin adapaleneMetrogel metronidazole gelNaftin naftifineNucort, Texacort hydrocortisone
Start date of change*
Drug class Medication requiring prior authorization^^
July 1, 2018 CANCER Hycamtin++, Targretin++, tretinoin capsule++, Xeloda++
MISCELLANEOUS Nityr, Orfadin++
PAIN RELIEF AND INFLAMMATORY DISEASE (NARCOTIC)
Diskets, Dolophine, methadone++, Methadose
March 1, 2018 GASTROINTESTINAL/HEARTBURN SymproicJanuary 1, 2018 GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi
HORMONAL AGENTS Androderm, Androgel, Striant, Testopel, testosteroneMISCELLANEOUS Nityr
Start date of change*
Drug class Medication with quantity limits^^
September 1, 2018
SKIN CONDITIONS Prudoxin, Zonalon
August 15, 2018 ASTHMA/COPD/RESPIRATORY SymdekoJuly 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER bupropion ER#, Celexa#, citalopram#, desvenlafaxine ER#, duloxetine#, Effexor XR#,
Effexor#, Emsam#, escitalopram#, Fetzima#, fluoxetine#, fluvoxamine ER#, fluvoxamine#, Forfivo XL#, Khedezla, paroxetine CR#, paroxetine#, Paxil CR#, Pexeva#, Prozac, sertraline#, venlafaxine ER#, Wellbutrin SR, Wellbutrin XL, Zoloft
BLOOD PRESSURE/HEART MEDICATIONS BiDil 20-37.5mg#, captopril-HCTZ, dofetilide#, Tikosyn
CHOLESTEROL MEDICATIONS simvastatin, Zocor
GASTROINTESTINAL/HEARTBURN Aciphex, Dexilant, esomeprazole, lansoprazole DR, lansoprazole, Nexium DR, Nexium, omeprazole DR, omeprazole, omeprazole bicarbonate, pantoprazole, Prevacid SoluTab, Prilosec, prilosec 2.5mg, Protonix, rabeprazole
NUTRITIONAL/DIETARY Auryxia
PERFORMANCE PRESCRIPTION DRUG LIST (cont)
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
Start date of change*
Drug class Medication with quantity limits^^
July 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE (NON-NARCOTIC)
Cafergot, ergotamine-caffeine, diclofenac 1%, Voltaren
PAIN RELIEF AND INFLAMMATORY DISEASE (NARCOTIC)
acetaminophen-caffeine-dihyrocodeine, acetaminophen-codeine, Arymo, asa-butalb-caff-codeine, aspirin-caff-dihydrocodeine, belladonna-opium, buprenorphine, butalb-acetaminoph-caff-codeine, butorphanol, carisoprodol-asa-codeine, codeine sulfate, Embeda, Exalgo, Fentanyl (all dosage forms), Flowtuss, Hycofenix, hydrocodone-acetaminophen, hydrocodone-ibuprofen, Hydromet, hydromorphone, Hysingla ER, Kadian, Lorcet, Lortab, meperidine, Morphabond ER, morphine, morphine ER, nalbuphine, Nucynta, Nucynta ER, Obredon, Opana ER, opium tincture, Oxecta, oxycodone, oxycodone ER, oxycodone-acetaminophen, oxycodone-aspirin, oxycodone-ibuprofen, OxyContin, oxymorphone, oxymorphone ER, pentazocine-acetaminophen, pentazocine-naloxone, Primlev, promethazine-codeine, Talwin, tramadol ER, tramadol-acetaminophen, Trezix, Tussigon, Tussionex, Xtampza ER, Zohydro ER, Zutripro
SCHIZOPHRENIA/ANTI-PSYCHOTICS Invega Sustenna#
SEIZURE DISORDERS Banzel#
SKIN CONDITIONS calcitriol, VecticalSLEEP DISORDERS/SEDATIVES Rozerem
February 1, 2018 BLOOD THINNERS/ANTI-CLOTTING BevyxxaJanuary 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone
ALZHEIMER'S DISEASE Namenda XR, NamzaricANXIETY/DEPRESSION/BIPOLAR DISORDER desvanlafaxine 25mg, 100mg, Marplan, PristiqASTHMA/COPD/RESPIRATORY PerforomistBLOOD PRESSURE/HEART MEDICATIONS RanexaCANCER Fareston, nilutamideEYE CONDITIONS bimatoprost eye drops, Cystaran, ZioptanHORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafemMISCELLANEOUS NuedextaOSTEOPOROSIS PRODUCTS alendronatePAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, MitigareSCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify Maintena, Aristada, Fanapt, Invega Trinza, Risperdal Consta, Zyprexa RelprevvSEIZURE DISORDERS Gabitril, PotigaSKIN CONDITIONS Denavir, Regranex, Santyl, VecticalSLEEP DISORDERS/SEDATIVES Hetlioz
Start date of change*
Drug class Step Therapy medication^^Generic and/or preferred brand alternatives
July 1, 2018 ERECTILE DYSFUNCTION Cialis## Please work with your patient to prescribe a lower-cost option, if appropriate.
Viagra## sildenafil, CialisApril 1, 2018 ASTHMA/COPD/RESPIRATORY Trelegy Ellipta## Advair, Anoro Ellipta, Breo Ellipta, Stiolto
Respimat, SymbicortJanuary 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR## dextroamphetamine-amphetamine ER
Focalin XR## dexmethylphenidate ERSCHIZOPHRENIA/ANTI-PSYCHOTICS Orap## pimozideSLEEP DISORDERS/SEDATIVES Silenor## eszopiclone, zolpidem
PERFORMANCE PRESCRIPTION DRUG LIST (cont)
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
Start date of change*
Drug class
Medication strength with limitations** (Your plan doesn’t cover 2 capsules/tablets per day of this strength)
Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)
January 1, 2018 ALLERGY/NASAL SPRAYS desloratadine ODT 2.5mg desloratadine ODT 5mg
ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg
Fetzima ER 40mg Fetzima ER 80mg
Trintellix 5mg Trintellix 10mg
Trintellix 10mg Trintellix 20mg
BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg Benicar 20mg Benicar 40mg Benicar HCT 20-12.5mg Benicar HCT 40-25mg Bystolic 10mg Bystolic 20mg Tekturna 150mg Tekturna 300mg Tekturna HCT 150-12.5mg Tekturna HCT 300-25mg
CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg Livalo 2mg Livalo 4mg
DIABETES Farxiga 5mg Farxiga 10mg
PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg
SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg
SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg Aptiom 400mg Aptiom 800mg Fycompa 4mg Fycompa 8mg Fycompa 6mg Fycompa 12mg Trokendi XR 25mg Trokendi XR 50mg Trokendi XR 100mg Trokendi XR 200mg
SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg
VALUE PRESCRIPTION DRUG LIST
Start date of change*
Drug class Medication not covered^ Generic and/or preferred brand alternatives
September 1, 2018
SKIN CONDITIONS Doxepin 5% Cream generic topical steroid (e.g. betamethasone) or topical tacrolimus
July 1, 2018 DIABETES Segluromet Synjardy, Synjardy XR, Xigduo XRSteglatro Farxiga, JardianceSteglujan Glyxambi
INFECTIONS Mycobutin rifabutinMULTIPLE SCLEROSIS Copaxone Aubagio, Avonex, Betaseron, Extavia,
Gilenya, glatiramer, Glatopa, Plegridy, Rebif, Tecfidera
SEIZURE DISORDERS Lyrica CR duloxetine, gabapentin, lidocaine 5% topical patch, Lyrica
SKIN CONDITIONS diclofenac 3% gel, Solaraze Fluoroplex, fluorouracil topical, imiquimod cream, Picato
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
VALUE PRESCRIPTION DRUG LIST (cont)
Start date of change*
Drug class Medication not covered^ Generic and/or preferred brand alternatives
May 15, 2018 EYE CONDITIONS Vyzulta bimatoprost, latanoprost, Travatan Z
April 1, 2018 DIABETES QTERN GlyxambiPAIN RELIEF AND INFLAMMATORY DISEASE Duzallo allopurinol, probenecid
March 1, 2018 DIABETES Fiasp HumalogPARKINSON’S DISEASE Gocovri amantadine
February 1, 2018 ASTHMA/COPD/RESPIRATORY ArmonAir QVAR
January 13, 2018 GASTROINTESTINAL/HEARTBURN Syndros dronabinol
January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipraminePamelor nortriptyline
Parnate tranylcypromine
Tofranil imipramineASTHMA/COPD/RESPIRATORY Spiriva, Spiriva Respimat Incruse Ellipta
Stiolto Respimat Anoro Ellipta
Zyflo montelukast, zafirlukast, zileuton ER
Zyflo CR zileuton ER
ATTENTION DEFICIT HYPERACTIVITY DISORDER
Desoxyn methamphetamine
Dexedrine dextroamphetamine, dextroamphetamine ER
BLOOD PRESSURE/HEART MEDICATIONS Betapace sotalol tablet
CANCER Nilandron nilutamide
DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR
Invokana Farxiga, Jardiance
Kombiglyze XR, Onglyza alogliptin, alogliptin-metformin, Janumet, Janumet XR, Januvia
Lantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba
EYE CONDITIONS Alocril, Alomide cromolyn eye drops
Bepreve, Emadine, Lastacaft, Pataday, Patanol, Pazeo
azelastine, epinastine, olopatadine
Elestat epinastine
GASTROINTESTINAL/HEARTBURN Marinol dronabinol
Rowasa mesalamine enema
Zofran ondansetron
Zofran ODT ondansetron ODT
HORMONAL AGENTS DDAVP nasal spray, tablet desmopressin nasal spray, tablets
Hectorol doxercalciferol
INFECTIONS Augmentin, Augmentin ES, Augmentin XR amoxicillin-clavulanate ER, amoxicillin-clavulanate
Diflucan fluconazole
E.E.S. 200, Eryped 400 erythromycinMepron atovaquone
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
VALUE PRESCRIPTION DRUG LIST (cont)
Start date of change*
Drug class Medication not covered^ Generic and/or preferred brand alternatives
January 1, 2018 INFECTIONS (cont) Sporanox itraconazoleTargadox doxycycline
Valcyte valganciclovir
Vancocin vancomycin capsule
Zovirax acyclovirPAIN RELIEF AND INFLAMMATORY DISEASE D.H.E. 45, Migranal dihydroergotamine
Imitrex sumatriptanOxyContin Embeda, Hysingla ER, Xtampza ERRoxicodone oxycodoneVanatol LQ butalbital/acetaminophen/caffeine tabs
or capsZomig sumatriptan, zolmitriptan
PARKINSON'S DISEASE Lodosyn carbidopa
Requip XL ropinirole ER
SCHIZOPHRENIA/ANTI-PSYCHOTICS Geodon ziprasidone
Zyprexa tablet olanzapine tablet
Zyprexa Zydis olanzapine ODT
SKIN CONDITIONS Acanya, Atralin, Avita, Azelex, Differin, Epiduo, Epiduo Forte, Fabior, Onexton, Retin-A, Retin-A Micro, Tretin-X, Veltin
Aczone, adapalene, Ala-Cort, alclometasone, amcinonide, Apexicon E, Avar, Avar-E, BenzePRO, benzoyl peroxide, betamethasone, BP 10-1, BPO, Clindacin ETZ, Clindacin P, clindamycin, clindamycin-benzoyl peroxide, clindamycin-tretinoin, clobetasol, clocortolone, Clodan, Cormax, desonide, desoximetasone, fluocinolone, halobetasol, hydrocortisone, Micort-HC, mometasone, prednicarbate, Psorcon, Scalacort, tretinoin, triamcinolone, Trianex, Triderm
Cutivate fluticasone
Dovonex, Sorilux calcipotriene
Enstilar, Taclonex calcipotriene-betamethasone DP
Soriatane acitretin
Tazorac adapalene, Ala-Cort, alclometasone, amcinonide, Apexicon E, Avar, Benzepro, benzoyl peroxide, betamethasone, BP 10-1, BPO, Clindacin ETZ, Clindacin P, clindamycin, clobetasol, clocortolone, Clodan, Cormax, desonide, desoximetasone, fluocinolone, halobetasol, hydrocortisone, Micort-HC, mometasone, prednicarbate, Psorcon, Scalacort, triamcinolone, Trianex, Triderm
Vectical calcitriol ointment
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
VALUE PRESCRIPTION DRUG LIST (cont)
Start date of change*
Drug class Medication not covered^ Generic and/or preferred brand alternatives
January 1, 2018 SLEEP DISORDERS/SEDATIVES Nuvigil armodafinilProvigil modafinilRestoril temazepam
URINARY TRACT CONDITIONS Detrol, Detrol LA, Ditropan XL, Enablex, Gelnique
darifenacin ER, oxybutynin ER, tolterodine, tolterodine ER, trospium ER
Start date of change*
Drug class Preferred brand medication
October 1, 2018 GASTROINTESTINAL/HEARTBURN Entyvio+
Nexium Powder PackJune 1, 2018 DIABETES Ozempic
VictozaJanuary 1, 2018 MISCELLANEOUS Nityr+
Start date of change*
Drug classNon-preferred brand medication
Generic and/or preferred brand alternatives
August 15, 2018 ASTHMA/COPD/RESPIRATORY Symdeko+ Please work with your patient to prescribe a lower-cost option, if appropriate.
July 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Arixtra+ fondaparinux
Lovenox+ enoxaparin
Reopro+ Please work with your patient to prescribe a lower-cost option, if appropriate.
CANCER dexrazoxane+, Evomela+, Nilandron+, nilutamide+, Zinecard
Please work with your patient to prescribe a lower-cost option, if appropriate.
Targretin capsule+ bexarotene
CONTRACEPTION PRODUCTS Depo-Provera 150mg/ml medroxyprogesterone
LoSeasonique Amethia Lo, Camrese Lo, levonorg-eth estradiol 0.1/0.02/0.01mg
Nexplanon+, Paragard T 380-a+ Please work with your patient to prescribe a lower-cost option, if appropriate.
Seasonique Amethia, Ashlyna, Camrese, Daysee, levonorg-eth estradiol 0.15/0.03/0.01mg
DENTAL PRODUCTS Arestin+ Please work with your patient to prescribe a lower-cost option, if appropriate.
DIABETES Korlym+ Please work with your patient to prescribe a lower-cost option, if appropriate.
EYE CONDITIONS Cystaran+, Ozurdex+, Retisert+ Please work with your patient to prescribe a lower-cost option, if appropriate.
GASTROINTESTINAL/HEARTBURN alosetron+, Buphenyl+, Chenodal+, Ravicti+, sodium phenylbutyrate
Please work with your patient to prescribe a lower-cost option, if appropriate.
HORMONAL AGENTS Aveed+, hydroxyprogesterone caproate+ Please work with your patient to prescribe a lower-cost option, if appropriate.
Depo-Provera 400mg/ml medroxyprogesterone
INFECTIONS Daraprim+, Sirturo+ Please work with your patient to prescribe a lower-cost option, if appropriate.
INFERTILITY Makena+ Please work with your patient to prescribe a lower-cost option, if appropriate.
VALUE PRESCRIPTION DRUG LIST (cont)
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
Start date of change*
Drug classNon-preferred brand medication
Generic and/or preferred brand alternatives
July 1, 2018 MISCELLANEOUS Asclera+, Carbaglu+, Ferriprox+, Flebogamma DIF+, Keveyis+, Varithena+
Please work with your patient to prescribe a lower-cost option, if appropriate.
PARKINSON'S DISEASE Azilect rasagiline
SEIZURE DISORDERS Lamictal ODT lamotrigine ODT
SKIN CONDITIONS Ameluz+, Levulan+ Please work with your patient to prescribe a lower-cost option, if appropriate.
SLEEP DISORDERS/SEDATIVES Hetlioz+ Please work with your patient to prescribe a lower-cost option, if appropriate.
TRANSPLANT MEDICATIONS Cellcept+ mycophenolateNeoral 25mg capsule, solution+ cyclosporine modified, Gengraf
URINARY TRACT CONDITIONS Thiola+ Please work with your patient to prescribe a lower-cost option, if appropriate.
March 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic Please work with your patient to prescribe a lower-cost option, if appropriate.
HORMONAL AGENTS Depo-Testosterone testosterone cypionateFebruary 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Bevyxxa enoxaparin, FragminJanuary 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER
Start date of change*
Drug class Medication requiring prior authorization^^
July 1, 2018 CANCER Hycamtin++, Targretin++, tretinoin capsule++, Xeloda++
MISCELLANEOUS Nityr, Orfadin++
PAIN RELIEF AND INFLAMMATORY DISEASE (NARCOTIC)
Diskets, Dolophine, methadone++, Methadose
March 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic
January 1, 2018 GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend capsule, powder packet, tripack, Sancuso, Varubi
HORMONAL AGENTS Androderm, Androgel, Striant testosterone
MISCELLANEOUS Nityr
Start date of change*
Drug class Medication with quantity limits^^
September 1, 2018
SKIN CONDITIONS Prudoxin, Zonalon
August 15, 2018 ASTHMA/COPD/RESPIRATORY Symdeko
July 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER bupropion ER#, Celexa#, citalopram#, desvenlafaxine ER#, duloxetine#, Effexor XR#, Effexor#, Emsam#, escitalopram#, Fetzima#, fluoxetine#, fluvoxamine ER#, fluvoxamine#, Forfivo XL#, Khedezla, paroxetine CR#, paroxetine#, Paxil CR#, Pexeva#, Prozac, sertraline#, venlafaxine ER#, Wellbutrin SR, Wellbutrin XL, Zoloft
BLOOD PRESSURE/HEART MEDICATIONS BiDil 20-37.5mg#, captopril-HCTZ, dofetilide#, Tikosyn
CHOLESTEROL MEDICATIONS simvastatin
NUTRITIONAL/DIETARY Auryxia
PAIN RELIEF AND INFLAMMATORY DISEASE (NON-NARCOTIC)
Cafergot, ergotamine-caffeine
diclofenac 1% gel, Voltaren
VALUE PRESCRIPTION DRUG LIST (cont)
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
Start date of change*
Drug class Medication with quantity limits^^
July 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE (NARCOTIC)
acetaminophen-caffeine-dihyrocodeine, acetaminophen-codeine, Arymo, asa-butalb-caff-codeine, aspirin-caff-dihydrocodeine, belladonna-opium, buprenorphine, butalb-acetaminoph-caff-codeine, butorphanol, carisoprodol-asa-codeine, codeine sulfate, Embeda, Exalgo, Fentanyl (all dosage forms), Flowtuss, Hycofenix, hydrocodone-acetaminophen, hydrocodone-ibuprofen, Hydromet, hydromorphone, Hysingla ER, Kadian, Lorcet, Lortab, meperidine, Morphabond ER, morphine, morphine ER, nalbuphine, Nucynta, Nucynta ER, Obredon, Opana ER, opium tincture, Oxecta, oxycodone, oxycodone ER, oxycodone-acetaminophen, oxycodone-aspirin, oxycodone-ibuprofen, OxyContin, oxymorphone, oxymorphone ER, pentazocine-acetaminophen, pentazocine-naloxone, Primlev, promethazine-codeine, Talwin, tramadol ER, tramadol-acetaminophen, Trezix, Tussigon, Tussionex, Xtampza ER, Zohydro ER, Zutripro
SEIZURE DISORDERS Banzel#
SKIN CONDITIONS calcitriol
SLEEP DISORDERS/SEDATIVES Rozerem
February 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Bevyxxa
January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone
ALZHEIMER'S DISEASE Namenda XR, Namzaric
ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine ER, Marplan
ASTHMA/COPD/RESPIRATORY Perforomist
BLOOD PRESSURE/HEART MEDICATIONS Ranexa
CANCER Fareston, nilutamide
EYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan
HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem
MISCELLANEOUS Nuedexta
OSTEOPOROSIS PRODUCTS alendronate
PAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, Mitigare
SCHIZOPHRENIA/ANTI-PSYCHOTICS Fanapt
SEIZURE DISORDERS Gabitril, Potiga
SKIN CONDITIONS Denavir, Regranex, Santyl
SLEEP DISORDERS/SEDATIVES Hetlioz
Start date of change*
Drug class Step Therapy medication^^Generic and/or preferred brand alternatives
April 1, 2018 ASTHMA/COPD/RESPIRATORY Trelegy Ellipta## Advair, Anoro Ellipta, Breo Ellipta, Stiolto Respimat, Symbicort
January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR## dextroamphetamine-amphetamine ER
Focalin XR## dexmethylphenidate ER
SCHIZOPHRENIA/ANTI-PSYCHOTICS Orap## pimozide
SLEEP DISORDERS/SEDATIVES Silenor## zolpidem, eszopiclone
VALUE PRESCRIPTION DRUG LIST (cont)
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
Start date of change*
Drug class
Medication strength with limitations** (Your plan doesn’t cover 2 capsules/tablets per day of this strength)
Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)
January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg
Fetzima ER 40mg Fetzima ER 80mg
Trintellix 5mg Trintellix 10mg
Trintellix 10mg Trintellix 20mg DIABETES Farxiga 5mg Farxiga 10mg PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg
Aptiom 400mg Aptiom 800mg
Fycompa 4mg Fycompa 8mg
Fycompa 6mg Fycompa 12mg
Trokendi XR 25mg Trokendi XR 50mg
Trokendi XR 100mg Trokendi XR 200mg SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg
ADVANTAGE PRESCRIPTION DRUG LIST
Start date of change*
Drug class Medication not covered^ Generic and/or preferred brand alternatives
September 1, 2018
SKIN CONDITIONS Doxepin 5% Cream generic topical steroid (e.g. betamethasone) or topical tacrolimus
July 1, 2018 DIABETES Segluromet Synjardy, Synjardy XR, Xigduo XR
Steglatro Farxiga, Jardiance
Steglujan Glyxambi
INFECTIONS Mycobutin rifabutin
MULTIPLE SCLEROSIS Copaxone Aubagio, Avonex, Betaseron, Extavia, Gilenya, glatiramer, Glatopa, Plegridy, Rebif, Tecfidera
SEIZURE DISORDERS Lyrica CR duloxetine, gabapentin, lidocaine 5% topical patch, Lyrica
SKIN CONDITIONS diclofenac 3% gel, Solaraze Fluoroplex, fluorouracil, imiquimod, Picato
May 15, 2018 EYE CONDITIONS Vyzulta bimatoprost, latanoprost, Travatan Z
April 1, 2018 DIABETES QTERN Glyxambi
PAIN RELIEF AND INFLAMMATORY DISEASE Duzallo allopurinol, probenecid
March 1, 2018 DIABETES Fiasp Humalog
PARKINSON’S DISEASE Gocovri amantadine
February 1, 2018 ASTHMA/COPD/RESPIRATORY ArmonAir QVAR
January 13, 2018 GASTROINTESTINAL/HEARTBURN Syndros dronabinol
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
ADVANTAGE PRESCRIPTION DRUG LIST (cont)
Start date of change*
Drug class Medication not covered^ Generic and/or preferred brand alternatives
January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipramine
Pamelor nortriptyline
Parnate tranylcypromine
Tofranil imipramine
ASTHMA/COPD/RESPIRATORY Spiriva, Spiriva Respimat Incruse Ellipta
Stiolto Respimat Anoro Ellipta
Zyflo montelukast, zafirlukast, zileuton ER
Zyflo CR zileuton ER
ATTENTION DEFICIT HYPERACTIVITY DISORDER
Desoxyn methamphetamine
Dexedrine dextroamphetamine, dextroamphetamine ER
BLOOD PRESSURE/HEART MEDICATIONS Betapace sotalol tablet
CANCER Nilandron nilutamide
DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR
Invokana Farxiga, Jardiance
Kombiglyze XR, Onglyza alogliptin, alogliptin-metformin, Janumet, Janumet XR, Januvia
Lantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba
EYE CONDITIONS Alocril, Alomide cromolyn eye drops
Bepreve, Emadine, Lastacaft, Pataday, Patanol, Pazeo
azelastine, epinastine, olopatadine
Elestat epinastine
GASTROINTESTINAL/HEARTBURN Marinol dronabinol
Rowasa mesalamine enema
Zofran ondansetron
Zofran ODT ondansetron ODT
HORMONAL AGENTS Cortrosyn cosyntropin
DDAVP desmopressin
Hectorol doxercalciferol
INFECTIONS Augmentin, Augmentin ES, Augmentin XR amoxicillin-clavulanate ER, amoxicillin-clavulanate
Diflucan fluconazoleE.E.S. 200, Eryped 400 erythromycinMepron atovaquoneSporanox itraconazoleTargadox doxycyclineValcyte valganciclovirVancocin vancomycin capsuleZovirax acyclovir
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
ADVANTAGE PRESCRIPTION DRUG LIST (cont)
Start date of change*
Drug class Medication not covered^ Generic and/or preferred brand alternatives
January 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE D.H.E. 45, Migranal dihydroergotamine
Imitrex sumatriptan
OxyContin Embeda, Hysingla ER, Xtampza ER
Roxicodone oxycodone
Vanatol LQ butalbital/acetaminophen/caffeine tabs or caps
Zomig sumatriptan, zolmitriptan
PARKINSON'S DISEASE Lodosyn carbidopa
Requip XL ropinirole ER
SCHIZOPHRENIA/ANTI-PSYCHOTICS Geodon ziprasidone
Zyprexa tablet olanzapine
Zyprexa Zydis olanzapine ODT
SKIN CONDITIONS Acanya, Atralin, Avita, Azelex, Differin, Epiduo, Epiduo Forte, Fabior, Onexton, Retin-A, Retin-A Micro, Tretin-X, Veltin
Aczone, adapalene, Ala-Cort, alclometasone, amcinonide, Apexicon E, Avar, Avar-E, BenzePRO, benzoyl peroxide, betamethasone, BP 10-1, BPO, Clindacin ETZ, Clindacin P, clindamycin, clindamycin-benzoyl peroxide, clindamycin-tretinoin, clobetasol, clocortolone, Clodan, Cormax, desonide, desoximetasone, fluocinolone, halobetasol, hydrocortisone, Micort-HC, mometasone, prednicarbate, Psorcon, Scalacort, tretinoin, triamcinolone, Trianex, Triderm
Cutivate fluticasone
Dovonex, Sorilux calcipotriene
Enstilar, Taclonex calcipotriene-betamethasone DP
Soriatane acitretin
Tazorac adapalene, Ala-Cort, alclometasone, amcinonide, Apexicon E, Avar, Avar-E, Benzepro, benzoyl peroxide, betamethasone, BP 10-1, BPO, Clindacin ETZ, Clindacin P, clindamycin, clobetasol, clocortolone, Clodan, Cormax, desonide, desoximetasone, fluocinolone, halobetasol, hydrocortisone, Micort-HC, mometasone, prednicarbate, Psorcon, Scalacort, triamcinolone, Trianex, Triderm
Vectical calcitriol
SLEEP DISORDERS/SEDATIVES Nuvigil armodafinil
Provigil modafinil
Restoril temazepam
ADVANTAGE PRESCRIPTION DRUG LIST (cont)
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
Start date of change*
Drug class Preferred brand medication
October 1, 2018 GASTROINTESTINAL/HEARTBURN Entyvio+
Nexium Powder Pack June 1, 2018 DIABETES Ozempic
VictozaJanuary 1, 2018 MISCELLANEOUS Nityr+
Start date of change*
Drug class Medication not covered^ Generic and/or preferred brand alternatives
January 1, 2018 URINARY TRACT CONDITIONS Detrol tolterodineDetrol LA tolterodine ERDitropan XL oxybutynin EREnablex darifenacin ERGelnique darifenacin ER, oxybutynin ER, tolterodine
ER, trospium ER
Start date of change*
Drug classNon-preferred brand medication
Generic and/or preferred brand alternatives
August 15, 2018 ASTHMA/COPD/RESPIRATORY Symdeko+ Please work with your patient to prescribe a lower-cost option, if appropriate.
July 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Reopro+ Please work with your patient to prescribe a lower-cost option, if appropriate.
CANCER dexrazoxane+, Evomela+, Hycamtin capsule+, Nilandron+, nilutamide+, Zinecard
Please work with your patient to prescribe a lower-cost option, if appropriate.
Fusilev+ leucovorin
Targretin capsule+ bexarotene
CONTRACEPTION PRODUCTS LoSeasonique Amethia Lo, Camrese Lo, levonorg-eth estradiol 0.1/0.02/0.01mg
Nexplanon+, Paragard T 380-a+ Please work with your patient to prescribe a lower-cost option, if appropriate.
Seasonique Amethia, Ashlyna, Camrese, Daysee, levonorg-eth estradiol 0.15/0.03/0.01mg
DENTAL PRODUCTS Arestin+ Please work with your patient to prescribe a lower-cost option, if appropriate.
DIABETES Korlym+ Please work with your patient to prescribe a lower-cost option, if appropriate.
EYE CONDITIONS Cystaran+, Ozurdex+, Retisert+ Please work with your patient to prescribe a lower-cost option, if appropriate.
GASTROINTESTINAL/HEARTBURN alosetron+, Buphenyl+, Chenodal+, Ravicti+, sodium phenylbutyrate
Please work with your patient to prescribe a lower-cost option, if appropriate.
HORMONAL AGENTS Aveed+, hydroxyprogesterone caproate+ Please work with your patient to prescribe a lower-cost option, if appropriate.
INFECTIONS Daraprim+, Sirturo+ Please work with your patient to prescribe a lower-cost option, if appropriate.
INFERTILITY Makena+ Please work with your patient to prescribe a lower-cost option, if appropriate.
ADVANTAGE PRESCRIPTION DRUG LIST (cont)
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
Start date of change*
Drug classNon-preferred brand medication
Generic and/or preferred brand alternatives
July 1, 2018 MISCELLANEOUS Asclera+, Carbaglu+, Ferriprox+, Flebogamma DIF+, Keveyis+, Varithena+
Please work with your patient to prescribe a lower-cost option, if appropriate.
PARKINSON'S DISEASE Azilect rasagiline
SEIZURE DISORDERS Lamictal ODT lamotrigine ODT
SKIN CONDITIONS Ameluz+, Levulan+ Please work with your patient to prescribe a lower-cost option, if appropriate.
SLEEP DISORDERS/SEDATIVES Hetlioz+ Please work with your patient to prescribe a lower-cost option, if appropriate.
TRANSPLANT MEDICATIONS Cellcept+ mycophenolate
URINARY TRACT CONDITIONS Thiola+ Please work with your patient to prescribe a lower-cost option, if appropriate.
March 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic Please work with your patient to prescribe a lower-cost option, if appropriate.
February 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Bevyxxa enoxaparin
January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER
Start date of change*
Drug class Medication requiring prior authorization^^
July 1, 2018 CANCER Hycamtin++, Targretin++, tretinoin capsule++, Xeloda++
MISCELLANEOUS Nityr, Orfadin++
PAIN RELIEF AND INFLAMMATORY DISEASE (NARCOTIC)
Diskets, Dolophine, methadone++, Methadose
March 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic
January 1, 2018 GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi
HORMONAL AGENTS Androderm, Androgel, Striant, Testopel, testosterone
MISCELLANEOUS Nityr
Start date of change*
Drug class Medication with quantity limits^^
September 1, 2018
SKIN CONDITIONS Prudoxin, Zonalon
August 15, 2018 ASTHMA/COPD/RESPIRATORY Symdeko
July 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER bupropion ER#, Celexa#, citalopram#, desvenlafaxine ER#, duloxetine#, Effexor XR#, Effexor#, Emsam#, escitalopram#, Fetzima#, fluoxetine#, fluvoxamine ER#, fluvoxamine#, Forfivo XL#, Khedezla, paroxetine CR#, paroxetine#, Paxil CR#, Pexeva#, Prozac#, sertraline#, venlafaxine ER#, Wellbutrin SR, Wellbutrin XL, Zoloft
BLOOD PRESSURE/HEART MEDICATIONS BiDil 20-37.5mg#, captopril-HCTZ, dofetilide#, Tikosyn
CHOLESTEROL MEDICATIONS simvastatin
NUTRITIONAL/DIETARY Auryxia
PAIN RELIEF AND INFLAMMATORY DISEASE (NON-NARCOTIC)
Cafergot, ergotamine-caffeine, diclofenac 1%, Voltaren
ADVANTAGE PRESCRIPTION DRUG LIST (cont)
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
Start date of change*
Drug class Medication with quantity limits^^
July 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE (NARCOTIC)
acetaminophen-caffeine-dihyrocodeine, acetaminophen-codeine, Arymo, asa-butalb-caff-codeine, aspirin-caff-dihydrocodeine, belladonna-opium, buprenorphine, butalb-acetaminoph-caff-codeine, butorphanol, carisoprodol-asa-codeine, codeine sulfate, Embeda, Exalgo, Fentanyl (all dosage forms), Flowtuss, Hycofenix, hydrocodone-acetaminophen, hydrocodone-ibuprofen, Hydromet, hydromorphone, Hysingla ER, Kadian, Lorcet, Lortab, meperidine, Morphabond ER, morphine, morphine ER, nalbuphine, Nucynta, Nucynta ER, Obredon, Opana ER, opium tincture, Oxecta, oxycodone, oxycodone ER, oxycodone-acetaminophen, oxycodone-aspirin, oxycodone-ibuprofen, OxyContin, oxymorphone, oxymorphone ER, pentazocine-acetaminophen, pentazocine-naloxone, Primlev, promethazine-codeine, Talwin, tramadol ER, tramadol-acetaminophen, Trezix, Tussigon, Tussionex, Xtampza ER, Zohydro ER, Zutripro
SCHIZOPHRENIA/ANTI-PSYCHOTICS Invega Sustenna#
SEIZURE DISORDERS Banzel#
SKIN CONDITIONS calcitriol
SLEEP DISORDERS/SEDATIVES Rozerem
February 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Bevyxxa
January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone
ALZHEIMER'S DISEASE Namenda XR, Namzaric
ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine ER, Marplan
ASTHMA/COPD/RESPIRATORY Perforomist
BLOOD PRESSURE/HEART MEDICATIONS Ranexa
CANCER Fareston, nilutamide
EYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan
HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem
MISCELLANEOUS Nuedexta
OSTEOPOROSIS PRODUCTS alendronate
PAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, Mitigare
SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify Maintena, Aristada, Fanapt, Invega Trinza, Risperdal Consta, Zyprexa Relprevv
SEIZURE DISORDERS Gabitril, Potiga
SKIN CONDITIONS Denavir, Regranex, Santyl
SLEEP DISORDERS/SEDATIVES HetliozStart date of change*
Drug class Step Therapy medication^^Generic and/or preferred brand alternatives
April 1, 2018 ASTHMA/COPD/RESPIRATORY Trelegy Ellipta## Advair, Anoro Ellipta, Breo Ellipta, Stiolto Respimat, Symbicort
January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR## dextroamphetamine-amphetamine ERFocalin XR## dexmethylphenidate ER
SCHIZOPHRENIA/ANTI-PSYCHOTICS Orap## pimozideSLEEP DISORDERS/SEDATIVES Silenor## eszopiclone, zaleplon, zolpidem,
zolpidem ER
ADVANTAGE PRESCRIPTION DRUG LIST (cont)
Start date of change*
Drug class
Medication strength with limitations** (Your plan doesn’t cover 2 capsules/tablets per day of this strength)
Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)
January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg
Fetzima ER 40mg Fetzima ER 80mg
Trintellix 5mg Trintellix 10mg
Trintellix 10mg Trintellix 20mg
DIABETES Farxiga 5mg Farxiga 10mg
PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg
SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg
SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg
Aptiom 400mg Aptiom 800mg
Fycompa 4mg Fycompa 8mg
Fycompa 6mg Fycompa 12mg
Trokendi XR 25mg Trokendi XR 50mg
Trokendi XR 100mg Trokendi XR 200mg
SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg
CIGNA RX ESSENTIAL 5-TIER PRESCRIPTION DRUG LIST
Start date of change*
MEDICATION NOT COVERED^GENERIC AND/OR PREFERRED BRAND ALTERNATIVES
January 1, 2018 Adderall XR dextroamphetamine-amphetamine ERAzilect rasagiline mesylateCimzia Humira (requires prior authorization), Enbrel (requires prior authorization),
Remicade (requires prior authorization)Combivir lamivudine/zidovudinediclofenac sodium 1.5% topical solution diclofenac sodium 1% gelEmend capsules aprepitant capsulesEpiPen and EpiPen Jr epinephrine auto-injectors Epivir lamivudineFuzeon Talk with your doctor about switching to a covered alternative.Glatopa Copaxone (requires prior authorization)Gleevec imatinib mesylate (requires prior authorization)Invirase Talk with your doctor about switching to a covered alternative.Maxitrol eye drops neomycin/polymyxin/dexamethasone eye dropsmetformin hcl ER (generic Fortamet) metformin hcl ER (generic Glucophage XR)Natroba spinosadNilandron nilutamideNitrostat nitroglycerin sublingual tabletsOrencia Actemra (requires prior authorization)Pennsaid 2% Pump diclofenac sodium 1% gel
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
Start date of change*
MEDICATION NOT COVERED^GENERIC AND/OR PREFERRED BRAND ALTERNATIVES
January 1, 2018 Rayos prednisone
Rescriptor Talk with your doctor about switching to a covered alternative.
Retrovir zidovudine
Selzentry Talk with your doctor about switching to a covered alternative.
Stelara Cosentyx (requires prior authorization)
Tamiflu capsules oseltamivir phosphate capsules
Tikosyn dofetilide
Trianex triamcinolone ointment
Trizivir abacavir/lamivudine/zidovudine
Vagifem yuvafem
Valcyte 50mg/ml solution valganciclovir hcl 50mg/ml solution
Videx EC didanosine DR
Viracept Talk with your doctor about switching to a covered alternative.
Viramune nevirapine
Viramune XR nevirapine ER
Zebutal 50-325-40mg capsule butalbital/acetaminophen/caffeine 50-325-40mg capsule
Zerit stavudine
Zetia ezetimibe
Ziagen 20mg/ml oral solution abacavir 20mg/ml oral solution
Ziagen 300mg tablet abacavir 300mg tablet
Start date of change*
EXCLUDED MEDICATION ADDITIONAL INFORMATION
January 1, 2018 lidocaine hcl 3% lotion This medication is not approved by the U.S. Food and Drug Administration (FDA). Talk with your doctor. There may be alternative FDA-approved prescription medications or over-the-counter medicines (those that don’t need a prescription) available to treat your condition.
Start date of change*
MEDICATION WITH QUANTITY LIMITS ADDITIONAL INFORMATION
January 1, 2018 epinephrine auto-injectors Your plan only covers this medication up to a certain amount over a certain number of days. Your plan will only cover larger amounts if your doctor requests and receives approval from Cigna.
lidocaine 5% ointment
Start date of change*
STEP THERAPY MEDICATION^^GENERIC AND/OR PREFERRED BRAND ALTERNATIVES
January 1, 2018 Saizen Humatrope (requires prior authorization)
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
CIGNA RX ESSENTIAL 5-TIER PRESCRIPTION DRUG LIST (cont.)
CIGNA RX PLUS PRESCRIPTION DRUG LISTStart date of change*
MEDICATION NOT COVERED^GENERIC AND/OR PREFERRED BRAND ALTERNATIVES
January 1, 2018 Adderall XR dextroamphetamine-amphetamine ERAzilect rasagiline mesylateBenicar olmesartan medoxomilBenicar HCT olmesartan medoxomil/hydrochlorothiazideCombivir lamivudine/zidovudineCordran 0.05% lotion flurandrenolide 0.05% lotiondiclofenac sodium 1.5% topical solution diclofenac sodium 1% gelDoral quazepamEdecrin ethacrynic acidEmend capsules aprepitant capsulesEpiPen and EpiPen Jr epinephrine auto-injectors Epivir lamivudineGlatopa Copaxone (requires prior authorization)Gleevec imatinib mesylate (requires prior authorization)
Invirase Talk with your doctor about switching to a covered alternative.
Maxitrol eye drops neomycin/polymyxin/dexamethasone eye drops
metformin hcl ER (generic Fortamet) metformin hcl ER (generic Glucophage XR)
Naftin 2% cream naftifine hcl 2% cream
Natroba spinosad
Nilandron nilutamide
Nitrostat nitroglycerin sublingual tablets
Orencia Actemra (requires prior authorization)
Pennsaid 2% Pump diclofenac sodium 1% gel
Rayos prednisone
Rescriptor Talk with your doctor about switching to a covered alternative.
Retrovir zidovudine
Selzentry Talk with your doctor about switching to a covered alternative.
Stelara Cosentyx (requires prior authorization)
Tamiflu capsules oseltamivir phosphate capsules
Tikosyn dofetilide
Trianex triamcinolone ointment
Trizivir abacavir/lamivudine/zidovudine
Vagifem yuvafem
Valcyte 50mg/ml solution valganciclovir hcl 50mg/ml solution
Videx EC didanosine DR
Viracept Talk with your doctor about switching to a covered alternative.
Viramune nevirapine
Viramune XR nevirapine ER
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
Start date of change*
MEDICATION NOT COVERED^GENERIC AND/OR PREFERRED BRAND ALTERNATIVES
January 1, 2018 Zebutal 50-325-40mg capsule butalbital/acetaminophen/caffeine 50-325-40mg capsule
Zerit stavudine
Zetia ezetimibe
Ziagen 300mg tablet abacavir 300mg tablet
Start date of change*
EXCLUDED MEDICATION ADDITIONAL INFORMATION
January 1, 2018 Lidocaine hcl 3% lotion This medication is not approved by the U.S. Food and Drug Administration (FDA). Talk with your doctor. There may be alternative FDA-approved prescription medications or over-the-counter medicines (those that don’t need a prescription) available to treat your condition.
Novacort
Start date of change*
MEDICATION WITH QUANTITY LIMITS ADDITIONAL INFORMATION
January 1, 2018 Epinephrine auto-injectors Your plan only covers this medication up to a certain amount over a certain number of days. Your plan will only cover larger amounts if your doctor requests and receives approval from Cigna.
Lidocaine 5% ointment
Start date of change*
STEP THERAPY MEDICATION^^GENERIC AND/OR PREFERRED BRAND ALTERNATIVES
January 1, 2018 Saizen Humatrope (requires prior authorization)
CIGNA RX PLUS PRESCRIPTION DRUG LIST (FLORIDA ONLY)
Start date of change*
MEDICATION NOT COVERED^GENERIC AND/OR PREFERRED BRAND ALTERNATIVES
January 1, 2018 Adderall XR dextroamphetamine-amphetamine ER
Azilect rasagiline mesylate
Benicar olmesartan medoxomil
Benicar HCT olmesartan medoxomil/hydrochlorothiazide
Cimzia Humira (requires prior authorization), Enbrel (requires prior authorization), Remicade (requires prior authorization)
Cordran 0.05% lotion flurandrenolide 0.05% lotion
diclofenac sodium 1.5% topical solution diclofenac sodium 1% gel
Doral quazepam
Edecrin ethacrynic acid
Emend capsules aprepitant capsules
EpiPen and EpiPen Jr epinephrine auto-injectors
Glatopa Copaxone (requires prior authorization)
Gleevec imatinib mesylate (requires prior authorization)
Maxitrol eye drops neomycin/polymyxin/dexamethasone eye drops
metformin hcl ER (generic Fortamet) metformin hcl ER (generic Glucophage XR)
Naftin 2% cream naftifine hcl 2% cream
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
CIGNA RX PLUS PRESCRIPTION DRUG LIST (cont.)
Start date of change*
MEDICATION NOT COVERED^GENERIC AND/OR PREFERRED BRAND ALTERNATIVES
January 1, 2018 Natroba spinosad
Nilandron nilutamide
Nitrostat nitroglycerin sublingual tablets
Orencia Actemra (requires prior authorization)
Pennsaid 2% Pump diclofenac sodium 1% gel
Rayos prednisone
Simponi Humira (requires prior authorization), Enbrel (requires prior authorization), Remicade (requires prior authorization)
Stelara Cosentyx (requires prior authorization)
Tamiflu capsules oseltamivir phosphate capsules
Tikosyn dofetilide
Trianex triamcinolone ointment
Vagifem yuvafem
Valcyte 50mg/ml solution valganciclovir hcl 50mg/ml solution
Zebutal 50-325-40mg capsule butalbital/acetaminophen/caffeine 50-325-40mg capsule
Zetia ezetimibe
Start date of change*
EXCLUDED MEDICATION ADDITIONAL INFORMATION
January 1, 2018 Lidocaine hcl 3% lotion This medication is not approved by the U.S. Food and Drug Administration (FDA). Talk with your doctor. There may be alternative FDA-approved prescription medications or over-the-counter medicines (those that don’t need a prescription) available to treat your condition.
Novacort
Start date of change*
MEDICATION WITH QUANTITY LIMITS ADDITIONAL INFORMATION
January 1, 2018 Epinephrine auto-injectors Your plan only covers this medication up to a certain amount over a certain number of days. Your plan will only cover larger amounts if your doctor requests and receives approval from Cigna.
Lidocaine 5% ointment
Start date of change*
STEP THERAPY MEDICATION^^GENERIC AND/OR PREFERRED BRAND ALTERNATIVES
January 1, 2018 Saizen Humatrope (requires prior authorization)
CIGNA RX PREMIERE PRESCRIPTION DRUG LIST
Start date of change*
MEDICATION NOT COVERED^GENERIC AND/OR PREFERRED BRAND ALTERNATIVES
January 1, 2018 Adderall XR dextroamphetamine-amphetamine ER
Azilect rasagiline mesylate
Benicar olmesartan medoxomil
Benicar HCT olmesartan medoxomil/hydrochlorothiazide
Combivir lamivudine/zidovudine
CIGNA RX PLUS PRESCRIPTION DRUG LIST (FLORIDA ONLY) (cont.)
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
Start date of change*
MEDICATION NOT COVERED^GENERIC AND/OR PREFERRED BRAND ALTERNATIVES
January 1, 2018 Cordran 0.05% lotion flurandrenolide 0.05% lotion
diclofenac sodium 1.5% topical solution diclofenac sodium 1% gel
Doral quazepam
Edecrin ethacrynic acid
Emend capsules aprepitant capsulesEpiPen and EpiPen Jr epinephrine auto-injectors Epivir lamivudineGlatopa Copaxone (requires prior authorization)Gleevec imatinib mesylate (requires prior authorization)Invirase Talk with your doctor about switching to a covered alternative.Maxitrol eye drops neomycin/polymyxin/dexamethasone eye dropsmetformin hcl ER (generic Fortamet) metformin hcl ER (generic Glucophage XR)Naftin 2% cream naftifine hcl 2% creamNatroba spinosadNilandron nilutamideNitrostat nitroglycerin sublingual tabletsPennsaid 2% Pump diclofenac sodium 1% gelRayos prednisoneRescriptor Talk with your doctor about switching to a covered alternative.Retrovir zidovudineSelzentry Talk with your doctor about switching to a covered alternative.Stelara Cosentyx (requires prior authorization)Tamiflu capsules oseltamivir phosphate capsulesTikosyn dofetilideTrianex triamcinolone ointmentTrizivir abacavir/lamivudine/zidovudineVagifem yuvafemValcyte 50mg/ml solution valganciclovir hcl 50mg/ml solutionVidex EC didanosine DR
Viracept Talk with your doctor about switching to a covered alternative.
Viramune nevirapine
Viramune XR nevirapine ER
Zebutal 50-325-40mg capsule butalbital/acetaminophen/caffeine 50-325-40mg capsule
Zerit stavudine
Zetia ezetimibe
Ziagen 300mg tablet abacavir 300mg tablet
Ziana clindamycin/tretinoin
CIGNA RX PREMIERE PRESCRIPTION DRUG LIST (cont.)
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
Start date of change*
EXCLUDED MEDICATION ADDITIONAL INFORMATION
January 1, 2018 Lidocaine hcl 3% lotion This medication is not approved by the U.S. Food and Drug Administration (FDA). Talk with your doctor. There may be alternative FDA-approved prescription medications or over-the-counter medicines (those that don’t need a prescription) available to treat your condition.
Novacort
Start date of change*
MEDICATION WITH QUANTITY LIMITS ADDITIONAL INFORMATION
January 1, 2018 Epinephrine auto-injectors Your plan only covers this medication up to a certain amount over a certain number of days. Your plan will only cover larger amounts if your doctor requests and receives approval from Cigna.
Lidocaine 5% ointment
Start date of change*
STEP THERAPY MEDICATION^^GENERIC AND/OR PREFERRED BRAND ALTERNATIVES
January 1, 2018 Saizen Humatrope (requires prior authorization)
Health benefit plans vary, but in general to be eligible for coverage a drug must be approved by the Food and Drug Administration (FDA), prescribed by a health care professional, purchased from a licensed pharmacy and medically necessary. If your plan provides coverage for certain prescription drugs with no cost-share, you may be required to use an in-network pharmacy to fill the prescription. If you use a pharmacy that does not participate in your plan’s network, your prescription may not be covered, or reimbursement may be limited by your plan’s copayment, coinsurance or deductible requirements. Certain features described in this document may not be applicable to your specific health plan, and plan features may vary by location and plan type. Refer to your plan documents for costs and complete details of your plan’s prescription drug coverage.
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Health Management, Inc., Tel-Drug, Inc., Tel-Drug of Pennsylvania, L.L.C., and HMO or service company subsidiaries of Cigna Health Corporation, including Cigna HealthCare of Arizona, Inc., Cigna HealthCare of California, Inc., Cigna HealthCare of Colorado, Inc., Cigna HealthCare of Connecticut, Inc., Cigna HealthCare of Florida, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Illinois, Inc., Cigna HealthCare of Indiana, Inc., Cigna HealthCare of St. Louis, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of New Jersey, Inc., Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of Tennessee, Inc., and Cigna HealthCare of Texas, Inc. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.
909016 © 2018 Cigna. Some content provided under license. UPDATED_6/27/2018
Generic medications start with a lowercase letter and brand name medications start with a capital letter.
* State laws in Texas and Louisiana require health insurance plans to cover your medications at your current benefit level until your plan renews. This means that if your medication is taken off the drug list, is moved to a higher cost-share tier or needs approval, your plan can’t make these changes until your renewal date. To find out if these state laws apply to your plan, please call Customer Service using the number on the back of your ID card.
+ This is a specialty medication. Some plans cover these medications on a specialty tier, may limit you to a 30-day supply and/or require you to use Cigna Specialty Pharmacy (our home delivery pharmacy) to fill your prescription. For plans that cover specialty medications on a specialty tier, this change will not affect the cost of the medication. If you’re enrolled with Cigna, log in to the myCigna website or app or check your plan materials to learn more about your plan’s coverage requirements for specialty medications.
++ Approval may be required for new prescriptions filled on or after July 1st.^ These medications require approval from Cigna before they may be covered by your plan. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider
approving coverage of your medication.^^ These changes may not apply to your plan. Not all plans include requirements for prior authorization, quantity limits and/or Step Therapy. If you’re enrolled with Cigna, please check your plan
materials or log in to the myCigna website or app starting July 1st to learn more about how your plan covers these medications.# Quantity limits may apply to new prescriptions filled on or after July 1st.
## This is a Step Therapy medication. Step Therapy medications aren’t covered by your plan without approval from Cigna. Your plan requires you to try a lower-cost alternative first. Typically, these are generics or lower-cost preferred brands.
** Your plan doesn’t cover more than one tablet/capsule in this strength a day. If your doctor feels a higher strength of this medication once each day isn’t right for you, he or she can ask Cigna to consider approving coverage of your current medication strength.
Cigna reserves the right to make changes to the Drug List without notice.
CIGNA RX PREMIERE PRESCRIPTION DRUG LIST (cont.)