Post on 19-Apr-2018
transcript
Cigna Medicare Rx Secure (PDP)
2014 Formulary(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN
Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.
When the drug list (formulary) refers to we,us, or our it means Cigna Health and Life Insurance Company. When it refers to plan or our plan it means Cigna Medicare Rx.
This document includes a list of drugs (formulary) for our plan which is current as of 08/2013. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.
The formulary was updated on 08/2013. For more recent information or other questions, please contact Cigna Medicare Rx at 1-800-222-6700 or, for TTY users, 711, 8 am8 pm, local time, 7 days a week or visit www.cignamedicarerx.com.
You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2015.
Cigna Medicare Rx is a PDP plan with a Medicare contract. Enrollment in Cigna Medicare Rx depends on contract renewal.
This information is available for free in other languages. Please call our Customer Service number listed on the front and back cover pages. Customer Service also has free language interpreter services available for non-English speakers.
Esta informacin est disponible sin cargo en otros idiomas. Para obtener informacin adicional, comunquese con el Servicio de atencin al cliente al nmero antes mencionado. Los miembros tambin cuentan con servicios de interpretacin gratuitos para aquellas personas que no hablan ingls.
This information is available for free in a different format, Braille or Large Print.
Please call Customer Service at the number listed on the front and back cover pages if you need plan information in another format.
Last Updated 08/2013
S5617_14_9552 Accepted 823099 f 09/13 HPMS Approved Formulary File Submission ID Version Number 14313.v07
http:www.cignamedicarerx.com
2014 Comprehensive Formulary Cigna Medicare Rx Secure
What is the Cigna Medicare Rx Formulary?
A formulary is a list of covered drugs selected by
Cigna Medicare Rx in consultation with a team
of health care providers, which represents the
prescription therapies believed to be a necessary
part of a quality treatment program. Cigna
Medicare Rx will generally cover the drugs listed
in our formulary as long as the drug is medically
necessary, the prescription is filled at a Cigna
Medicare Rx network pharmacy, and other plan
rules are followed. For more information on how
to fill your prescriptions, please review your
Evidence of Coverage.
Can the Formulary (drug list) change?
Generally, if you are taking a drug on our 2014
formulary that was covered at the beginning
of the year, we will not discontinue or reduce
coverage of the drug during the 2014 coverage
year except when a new, less expensive generic
drug becomes available or when new adverse
information about the safety or effectiveness
of a drug is released. Other types of formulary
changes, such as removing a drug from our
formulary, will not affect members who are
currently taking the drug. It will remain available
at the same cost-sharing for those members
taking it for the remainder of the coverage year.
We feel it is important that you have continued
access for the remainder of the coverage year to
the formulary drugs that were available when
you chose our plan, except for cases in which
you can save additional money or we can ensure
your safety.
If we remove drugs from our formulary, or
add prior authorization, quantity limits and/
or step therapy restrictions on a drug or move
a drug to a higher cost-sharing tier, we must
notify affected members of the change at least
60 days before the change becomes effective, or
at the time the member requests a refill of the
drug, at which time the member will receive a
60-day supply of the drug. If the Food and Drug
Administration deems a drug on our formulary
to be unsafe or the drugs manufacturer removes
the drug from the market, we will immediately
remove the drug from our formulary and provide
notice to members who take the drug. The
enclosed formulary is current as of January 1,
2014. To get updated information about the
drugs covered by Cigna Medicare Rx, please
contact us. Our contact information appears on
the front and back cover pages.
Our plans printed formulary document will be
updated for any mid-year, non maintenance
changes via errata sheets in the event that
we 1) remove a drug from our formulary,
2) increase the cost share of a formulary drug,
or 3) add utilization management edits to a
formulary drug and no new alternate drug is
offered by our plan as a possible replacement
for any of the previously described formulary
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2014 Comprehensive Formulary Cigna Medicare Rx Secure
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What are generic drugs?
Cigna Medicare Rx covers both brand name
drugs and generic drugs. A generic drug is
approved by the FDA as having the same active
ingredient as the brand name drug. Generally,
generic drugs cost less than brand name drugs.
Are there any restrictions on my coverage?
Some covered drugs may have additional
requirements or limits on coverage. These
requirements and limits may include:
Prior Authorization: Cigna Medicare Rx requires you or your physician to get prior
authorization for certain drugs. This means
that you will need to get approval from Cigna
Medicare Rx before you fill your prescriptions.
If you dont get approval, Cigna Medicare Rx
may not cover the drug.
Quantity Limits: For certain drugs, Cigna Medicare Rx limits the amount of the drug
that Cigna Medicare Rx will cover. For example,
Cigna Medicare Rx provides coverage for up
to 1 tablet per day per prescription for Crestor
10mg tablets. This may be in addition to a
standard one-month or three-month supply.
Step Therapy: In some cases, Cigna Medicare Rx requires you to first try certain
drugs to treat your medical condition before
we will cover another drug for that condition.
changes. All affected members currently taking
a formulary drug which will have one or more of
the previously described formulary changes will
be exempt from the formulary change(s) for the
remainder of the coverage year.
How do I use the Formulary?
There are two ways to find your drug within
the formulary:
Medical Condition
The formulary begins on page 13. The drugs
in this formulary are grouped into categories
depending on the type of medical conditions
that they are used to treat. For example, drugs
used to treat a heart condition are listed under
the category, Cardiovascular Agents. If you know
what your drug is used for, look for the category
name in the list that begins on page 13. Then
look under the category name for your drug.
Alphabetical Listing
If you are not sure what category to look under,
you should look for your drug in the Index
that begins on page 76. The Index provides an
alphabetical list of all of the drugs included in
this document. Both brand name drugs and
generic drugs are listed in the Index. Look in the
Index and find your drug. Next to your drug, you
will see the page number where you can find
coverage information. Turn to the page listed in
the Index and find the name of your drug in the
first column of the list.
2014 Comprehensive Formulary Cigna Medicare Rx Secure
3
YoucanaskCignaMedicareRxtomakean
exception and cover your drug. See below
for information about how to request
an exception.
How do I request an exception to the Cigna Medicare Rx Formulary?
You can ask Cigna Medicare Rx to make an
exception to our coverage rules. There are
several types of exceptions that you can ask us
to make.
Youcanaskustocoveryourdrugevenif
it is not on our formulary. If approved, this
drug will be covered at a pre-determined
cost-sharing level, and you would not be
able to ask up to provide the drug at a lower
cost-sharing level.
Youcanaskustowaivecoveragerestrictions
or limits on your drug. For example, for certain
drugs, Cigna Medicare Rx limits the amount
of the drug that we will cover. If your drug has
a quantity limit, you can ask us to waive the
limit and cover the greater amount.
Youcanaskustoprovideahigherlevel
of coverage for your drug. If your drug
is contained in our Non-Preferred Brand
Drugs Tier 4, you can ask us to cover it at the
cost-sharing amount that applies to drugs
in the Preferred Brand Drugs Tier 3 instead.
This would lower the amount you must pay
for your drug. Please note, if we grant your
request to cover a drug that is not on our
For example, if Drug A and Drug B both treat
your medical condition, Cigna Medicare Rx
may not cover Drug B unless you try Drug A
first. If Drug A does not work for you, Cigna
Medicare Rx will then cover Drug B.
You can find out if your drug has any additional
requirements or limits by looking in the
formulary that begins on page 13. You can also
get more information about the restrictions
applied to specific covered drugs by visiting our
Web site. Our contact information, along with
the date we last updated the formulary, appears
on the front and back cover pages.
You can ask Cigna Medicare Rx to make an
exception to these restrictions or limits. See the
section, How do I request an exception to the
Cigna Medicare Rx formulary? on page 3 for
information about how to request an exception.
What if my drug is not on the Formulary?
If your drug is not included in this formulary
(list of covered drugs), you should first contact
Customer Service and ask if your drug is covered.
If you learn that Cigna Medicare Rx does not
cover your drug, you have two options:
YoucanaskCustomerServiceforalistof
similar drugs that are covered by Cigna
Medicare Rx. When you receive the list,
show it to your doctor and ask him or her
to prescribe a similar drug that is covered by
Cigna Medicare Rx.
2014 Comprehensive Formulary Cigna Medicare Rx Secure
formulary, you may not ask us to provide a
higher level of coverage for the drug. Also,
you may not ask us to provide a higher level
of coverage for drugs that are in the Specialty
Tier 5. Generally, Cigna Medicare Rx will
only approve your request for an exception
if the alternative drugs included on the
plans formulary, the lower-tiered drug or
additional utilization restrictions would not
be as effective in treating your condition
and/or would cause you to have adverse
medical effects.
You should contact us to ask us for an initial
coverage decision for a formulary, tiering or
utilization restriction exception. When you are requesting a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting
your prescribers supporting statement. You can
request an expedited (fast) exception if you or
your doctor believe that your health could be
seriously harmed by waiting up to 72 hours for a
decision. If your request to expedite is granted,
we must give you a decision no later than
24 hours after we get your supporting statement
from your doctor or other prescriber.
What do I do before I can talk to my doctor about changing my drugs or requesting an exception?
As a new or continuing member in our plan,
you may be taking drugs that are not on our
formulary. Or, you may be taking a drug that
is on our formulary but your ability to get it
is limited. For example, you may need a prior
authorization from us before you can fill your
prescription. You should talk to your doctor to
decide if you should switch to an appropriate
drug that we cover or request a formulary
exception so that we will cover the drug you
take. While you talk to your doctor to determine
the right course of action for you, we may cover
your drug in certain cases during the first 90 days
you are a member of our plan.
For each of your drugs that is not on our
formulary or if your ability to get your drugs is
limited, we will cover a temporary 31-day supply
(unless you have a prescription written for fewer
days) when you go to a network pharmacy. After
your first 31-day supply, we will not pay for these
drugs, even if you have been a member of the
plan less than 90 days.
If you are a resident of a long-term care facility,
we will allow you to refill your prescription until
we have provided you with a 102-day transition
supply, consistent with dispensing increment,
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2014 Comprehensive Formulary Cigna Medicare Rx Secure
(unless you have a prescription written for fewer
days). We will cover more than one refill of these
drugs for the first 90 days you are a member of
our plan. If you need a drug that is not on our
formulary or if your ability to get your drugs
is limited, but you are past the first 90 days of
membership in our plan, we will cover a 31-day
emergency supply of that drug (unless you have
a prescription for fewer days) while you pursue a
formulary exception.
An extended transition process is provided to
circumstances involving level of care changes
in which a beneficiary is changing from one
treatment setting to another. An override for
refill-too-soon edit would be provided to allow
appropriate coverage. Since there may exist
some period of time in which beneficiaries with
level of care changes have a temporary gap in
coverage while going through a process, our
transition policy would allow coverage for one
fill with up to 31-day supply of medication.
For more information
For more detailed information about your Cigna
Medicare Rx prescription drug coverage, please
review your Evidence of Coverage and other
plan materials.
If you have questions about Cigna Medicare Rx,
please contact us. Our contact information,
along with the date we last updated the
formulary, appears on the front and back
cover pages.
If you have general questions about Medicare
prescription drug coverage, please call Medicare
at 1-800-MEDICARE (1-800-633-4227) 24 hours
a day/7 days a week. TTY users should call
1-877-486-2048. Or, visit www.medicare.gov.
Cigna Medicare Rx Formulary
The formulary that begins on page 13 provides
coverage information about some of the drugs
covered by Cigna Medicare Rx. If you have
trouble finding your drug in the list, turn to the
Index that begins on page 76.
The first column of the chart lists the drug name.
Brand name drugs are capitalized (e.g., NEXIUM)
and generic drugs are listed in lower-case italics
(e.g., omeprazole).
The information in the Requirements/Limits
column tells you if Cigna Medicare Rx has any
special requirements for coverage of your drug.
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http:www.medicare.gov
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2014 Comprehensive Formulary Cigna Medicare Rx Secure
Initial Coverage Level Copays/Coinsurance
State(s) Tiers
30-Day Preferred
Retail
30-Day Preferred
Mail Order
90-Day Preferred
Retail
90-Day Preferred
Mail Order
30-Day Non-Preferred
Retail
30-Day Non-Preferred
Mail Order
90-Day Non-Preferred
Retail
90-Day Non-Preferred
Mail Order
10-Day Out-of-
Network31-Day
LTC
AK
1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00
2 $6.00 $15.00 $5.00 $33.00 $99.00 $33.00 $33.00
3 $33.00 $82.50 $72.50 $45.00 $135.00 $45.00 $45.00
4 $84.00 $210.00 $200.00 $95.00 $285.00 $95.00 $95.00
5 25% 25% 25% 25% 25% 25% 25%
AL, TN
1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00
2 $3.00 $7.50 $0.00 $33.00 $99.00 $33.00 $33.00
3 $31.00 $77.50 $67.50 $44.00 $132.00 $44.00 $44.00
4 $59.00 $147.50 $137.50 $91.00 $273.00 $91.00 $91.00
5 25% 25% 25% 25% 25% 25% 25%
AR
1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00
2 $4.00 $10.00 $0.00 $33.00 $99.00 $33.00 $33.00
3 $32.00 $80.00 $70.00 $45.00 $135.00 $45.00 $45.00
4 $67.00 $167.50 $157.50 $95.00 $285.00 $95.00 $95.00
5 25% 25% 25% 25% 25% 25% 25%
AZ
1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00
2 $9.00 $22.50 $12.50 $33.00 $99.00 $33.00 $33.00
3 $38.00 $95.00 $85.00 $45.00 $135.00 $45.00 $45.00
4 $89.00 $222.50 $212.50 $95.00 $285.00 $95.00 $95.00
5 25% 25% 25% 25% 25% 25% 25%
CA
1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00
2 $9.00 $22.50 $12.50 $33.00 $99.00 $33.00 $33.00
3 $42.00 $105.00 $95.00 $45.00 $135.00 $45.00 $45.00
4 $90.00 $225.00 $215.00 $95.00 $285.00 $95.00 $95.00
5 25% 25% 25% 25% 25% 25% 25%
7
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Initial Coverage Level Copays/Coinsurance
State(s) Tiers
30-Day Preferred
Retail
30-Day Preferred
Mail Order
90-Day Preferred
Retail
90-Day Preferred
Mail Order
30-Day Non-Preferred
Retail
30-Day Non-Preferred
Mail Order
90-Day Non-Preferred
Retail
90-Day Non-Preferred
Mail Order
10-Day Out-of-
Network31-Day
LTC
CO
1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00
2 $9.00 $22.50 $12.50 $33.00 $99.00 $33.00 $33.00
3 $36.00 $90.00 $80.00 $45.00 $135.00 $45.00 $45.00
4 $85.00 $212.50 $202.50 $95.00 $285.00 $95.00 $95.00
5 25% 25% 25% 25% 25% 25% 25%
CT, MA, RI, VT
1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00
2 $5.00 $12.50 $2.50 $33.00 $99.00 $33.00 $33.00
3 $38.00 $95.00 $85.00 $45.00 $135.00 $45.00 $45.00
4 $89.00 $222.50 $212.50 $95.00 $285.00 $95.00 $95.00
5 25% 25% 25% 25% 25% 25% 25%
DE, DC, MD
1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00
2 $4.00 $10.00 $0.00 $33.00 $99.00 $33.00 $33.00
3 $35.00 $87.50 $77.50 $45.00 $135.00 $45.00 $45.00
4 $85.00 $212.50 $202.50 $95.00 $285.00 $95.00 $95.00
5 25% 25% 25% 25% 25% 25% 25%
FL
1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00
2 $9.00 $22.50 $12.50 $33.00 $99.00 $33.00 $33.00
3 $43.00 $107.50 $97.50 $45.00 $135.00 $45.00 $45.00
4 $91.00 $227.50 $217.50 $95.00 $285.00 $95.00 $95.00
5 25% 25% 25% 25% 25% 25% 25%
GA
1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00
2 $3.00 $7.50 $0.00 $33.00 $99.00 $33.00 $33.00
3 $31.00 $77.50 $67.50 $45.00 $135.00 $45.00 $45.00
4 $85.00 $212.50 $202.50 $95.00 $285.00 $95.00 $95.00
5 25% 25% 25% 25% 25% 25% 25%
8
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Initial Coverage Level Copays/Coinsurance
State(s) Tiers
30-Day Preferred
Retail
30-Day Preferred
Mail Order
90-Day Preferred
Retail
90-Day Preferred
Mail Order
30-Day Non-Preferred
Retail
30-Day Non-Preferred
Mail Order
90-Day Non-Preferred
Retail
90-Day Non-Preferred
Mail Order
10-Day Out-of-
Network31-Day
LTC
HI
1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00
2 $9.00 $22.50 $12.50 $33.00 $99.00 $33.00 $33.00
3 $40.00 $100.00 $90.00 $45.00 $135.00 $45.00 $45.00
4 $90.00 $225.00 $215.00 $95.00 $285.00 $95.00 $95.00
5 25% 25% 25% 25% 25% 25% 25%
IA, MN, MT, ND,
NE, SD, WY
1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00
2 $3.00 $7.50 $0.00 $23.00 $69.00 $23.00 $23.00
3 $36.00 $90.00 $80.00 $40.00 $120.00 $40.00 $40.00
4 $66.00 $165.00 $155.00 $81.00 $243.00 $81.00 $81.00
5 25% 25% 25% 25% 25% 25% 25%
ID, UT
1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00
2 $4.00 $10.00 $0.00 $33.00 $99.00 $33.00 $33.00
3 $36.00 $90.00 $80.00 $45.00 $135.00 $45.00 $45.00
4 $79.00 $197.50 $187.50 $95.00 $285.00 $95.00 $95.00
5 25% 25% 25% 25% 25% 25% 25%
IL
1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00
2 $3.00 $7.50 $0.00 $27.00 $81.00 $27.00 $27.00
3 $30.00 $75.00 $65.00 $40.00 $120.00 $40.00 $40.00
4 $65.00 $162.50 $152.50 $87.00 $261.00 $87.00 $87.00
5 25% 25% 25% 25% 25% 25% 25%
IN, KY
1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00
2 $3.00 $7.50 $0.00 $27.00 $81.00 $27.00 $27.00
3 $30.00 $75.00 $65.00 $43.00 $129.00 $43.00 $43.00
4 $83.00 $207.50 $197.50 $84.00 $252.00 $84.00 $84.00
5 25% 25% 25% 25% 25% 25% 25%
9
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Initial Coverage Level Copays/Coinsurance
State(s) Tiers
30-Day Preferred
Retail
30-Day Preferred
Mail Order
90-Day Preferred
Retail
90-Day Preferred
Mail Order
30-Day Non-Preferred
Retail
30-Day Non-Preferred
Mail Order
90-Day Non-Preferred
Retail
90-Day Non-Preferred
Mail Order
10-Day Out-of-
Network31-Day
LTC
KS
1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00
2 $3.00 $7.50 $0.00 $30.00 $90.00 $30.00 $30.00
3 $32.00 $80.00 $70.00 $40.00 $120.00 $40.00 $40.00
4 $65.00 $162.50 $152.50 $87.00 $261.00 $87.00 $87.00
5 25% 25% 25% 25% 25% 25% 25%
LA
1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00
2 $6.00 $15.00 $5.00 $33.00 $99.00 $33.00 $33.00
3 $36.00 $90.00 $80.00 $45.00 $135.00 $45.00 $45.00
4 $82.00 $205.00 $195.00 $95.00 $285.00 $95.00 $95.00
5 25% 25% 25% 25% 25% 25% 25%
MI
1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00
2 $3.00 $7.50 $0.00 $26.00 $78.00 $26.00 $26.00
3 $30.00 $75.00 $65.00 $35.00 $105.00 $35.00 $35.00
4 $65.00 $162.50 $152.50 $70.00 $210.00 $70.00 $70.00
5 25% 25% 25% 25% 25% 25% 25%
MO
1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00
2 $6.00 $15.00 $5.00 $25.00 $75.00 $25.00 $25.00
3 $30.00 $75.00 $65.00 $43.00 $129.00 $43.00 $43.00
4 $75.00 $187.50 $177.50 $91.00 $273.00 $91.00 $91.00
5 25% 25% 25% 25% 25% 25% 25%
MS
1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00
2 $3.00 $7.50 $0.00 $25.00 $75.00 $25.00 $25.00
3 $30.00 $75.00 $65.00 $40.00 $120.00 $40.00 $40.00
4 $65.00 $162.50 $152.50 $82.00 $246.00 $82.00 $82.00
5 25% 25% 25% 25% 25% 25% 25%
10
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Initial Coverage Level Copays/Coinsurance
State(s) Tiers
30-Day Preferred
Retail
30-Day Preferred
Mail Order
90-Day Preferred
Retail
90-Day Preferred
Mail Order
30-Day Non-Preferred
Retail
30-Day Non-Preferred
Mail Order
90-Day Non-Preferred
Retail
90-Day Non-Preferred
Mail Order
10-Day Out-of-
Network31-Day
LTC
NC
1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00
2 $3.00 $7.50 $0.00 $33.00 $99.00 $33.00 $33.00
3 $29.00 $72.50 $62.50 $45.00 $135.00 $45.00 $45.00
4 $65.00 $162.50 $152.50 $87.00 $261.00 $87.00 $87.00
5 25% 25% 25% 25% 25% 25% 25%
NH, ME
1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00
2 $3.00 $7.50 $0.00 $32.00 $96.00 $32.00 $32.00
3 $30.00 $75.00 $65.00 $43.00 $129.00 $43.00 $43.00
4 $65.00 $162.50 $152.50 $95.00 $285.00 $95.00 $95.00
5 25% 25% 25% 25% 25% 25% 25%
NJ
1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00
2 $9.00 $22.50 $12.50 $33.00 $99.00 $33.00 $33.00
3 $45.00 $112.50 $102.50 $45.00 $135.00 $45.00 $45.00
4 $90.00 $225.00 $215.00 $95.00 $285.00 $95.00 $95.00
5 25% 25% 25% 25% 25% 25% 25%
NM
1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00
2 $9.00 $22.50 $12.50 $33.00 $99.00 $33.00 $33.00
3 $32.00 $80.00 $70.00 $45.00 $135.00 $45.00 $45.00
4 $83.00 $207.50 $197.50 $95.00 $285.00 $95.00 $95.00
5 25% 25% 25% 25% 25% 25% 25%
NV
1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00
2 $9.00 $22.50 $12.50 $33.00 $99.00 $33.00 $33.00
3 $44.00 $110.00 $100.00 $45.00 $135.00 $45.00 $45.00
4 $90.00 $225.00 $215.00 $95.00 $285.00 $95.00 $95.00
5 25% 25% 25% 25% 25% 25% 25%
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2014 Comprehensive Formulary Cigna Medicare Rx Secure
Initial Coverage Level Copays/Coinsurance
State(s) Tiers
30-Day Preferred
Retail
30-Day Preferred
Mail Order
90-Day Preferred
Retail
90-Day Preferred
Mail Order
30-Day Non-Preferred
Retail
30-Day Non-Preferred
Mail Order
90-Day Non-Preferred
Retail
90-Day Non-Preferred
Mail Order
10-Day Out-of-
Network31-Day
LTC
NY
1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00
2 $3.00 $7.50 $0.00 $32.00 $96.00 $32.00 $32.00
3 $30.00 $75.00 $65.00 $35.00 $105.00 $35.00 $35.00
4 $65.00 $162.50 $152.50 $80.00 $240.00 $80.00 $80.00
5 25% 25% 25% 25% 25% 25% 25%
OH
1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00
2 $9.00 $22.50 $12.50 $33.00 $99.00 $33.00 $33.00
3 $40.00 $100.00 $90.00 $45.00 $135.00 $45.00 $45.00
4 $90.00 $225.00 $215.00 $95.00 $285.00 $95.00 $95.00
5 25% 25% 25% 25% 25% 25% 25%
OK
1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00
2 $3.00 $7.50 $0.00 $33.00 $99.00 $33.00 $33.00
3 $32.00 $80.00 $70.00 $45.00 $135.00 $45.00 $45.00
4 $82.00 $205.00 $195.00 $95.00 $285.00 $95.00 $95.00
5 25% 25% 25% 25% 25% 25% 25%
OR, WA
1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00
2 $6.00 $15.00 $5.00 $33.00 $99.00 $33.00 $33.00
3 $35.00 $87.50 $77.50 $45.00 $135.00 $45.00 $45.00
4 $70.00 $175.00 $165.00 $95.00 $285.00 $95.00 $95.00
5 25% 25% 25% 25% 25% 25% 25%
PA, WV
1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00
2 $5.00 $12.50 $2.50 $33.00 $99.00 $33.00 $33.00
3 $29.00 $72.50 $62.50 $45.00 $135.00 $45.00 $45.00
4 $63.00 $157.50 $147.50 $95.00 $285.00 $95.00 $95.00
5 25% 25% 25% 25% 25% 25% 25%
12
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Initial Coverage Level Copays/Coinsurance
State(s) Tiers
30-Day Preferred
Retail
30-Day Preferred
Mail Order
90-Day Preferred
Retail
90-Day Preferred
Mail Order
30-Day Non-Preferred
Retail
30-Day Non-Preferred
Mail Order
90-Day Non-Preferred
Retail
90-Day Non-Preferred
Mail Order
10-Day Out-of-
Network31-Day
LTC
SC
1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00
2 $5.00 $12.50 $2.50 $33.00 $99.00 $33.00 $33.00
3 $38.00 $95.00 $85.00 $45.00 $135.00 $45.00 $45.00
4 $86.00 $215.00 $205.00 $95.00 $285.00 $95.00 $95.00
5 25% 25% 25% 25% 25% 25% 25%
TX
1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00
2 $5.00 $12.50 $2.50 $33.00 $99.00 $33.00 $33.00
3 $38.00 $95.00 $85.00 $45.00 $135.00 $45.00 $45.00
4 $88.00 $220.00 $210.00 $95.00 $285.00 $95.00 $95.00
5 25% 25% 25% 25% 25% 25% 25%
VA
1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00
2 $5.00 $12.50 $2.50 $33.00 $99.00 $33.00 $33.00
3 $29.00 $72.50 $62.50 $45.00 $135.00 $45.00 $45.00
4 $62.00 $155.00 $145.00 $95.00 $285.00 $95.00 $95.00
5 25% 25% 25% 25% 25% 25% 25%
WI
1 $0.00 $0.00 $0.00 $10.00 $30.00 $10.00 $10.00
2 $3.00 $7.50 $0.00 $19.00 $57.00 $19.00 $19.00
3 $30.00 $75.00 $65.00 $35.00 $105.00 $35.00 $35.00
4 $65.00 $162.50 $152.50 $83.00 $249.00 $83.00 $83.00
5 25% 25% 25% 25% 25% 25% 25%
13
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Cost-Sharing Tier DescriptionTier 1: Preferred Generic Drugs. This grouping of prescription drugs represents the lowest cost sharing.
Tier 2: Non-Preferred Generic Drugs.
Tier 3: Preferred Brand Drugs.
Tier 4: Non-Preferred Brand Drugs.
Tier 5: Specialty Tier. This grouping of prescription drugs represents the highest cost sharing.
Symbol Key Utilization Management Requirements/LimitsB vs D: Coverage determination for Part B or Part D required. Note: Inhalant solutions used in a nebulizer are
only covered under Part D when the member is located in a long term care (LTC) setting.
PA: Prior authorization is required.
QL: Quantity limits apply.
RA : Restricted Access. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Customer Service at 1-800-222-6700, 8 am8 pm, local time, 7 days a week. TTY users should call 711.
ST: Step therapy is required.
Generally all medications on the formulary are available through mail order except when special circumstances or situations prohibit mailing a particular medication to your home.
Drug Name Drug Tier Requirements/Limits
Analgesics
acetaminophen/codeine solution 2 QL (5000 ML per 30 days)
acetaminophen/codeine tablet 300mg/15mg, 300mg/30mg 2 QL (360 EA per 30 days)
acetaminophen/codeine tablet 300mg/60mg 2 QL (240 EA per 30 days)
ascomp/codeine 2 QL (180 EA per 30 days) PA
butalbital/acetaminophen/caffeine/codeine 2 QL (180 EA per 30 days) PA
butorphanol tartrate injection 2
butorphanol tartrate nasal solution 2 QL (5 ML per 30 days)
BUTRANS PATCH 3 QL (4 EA per 28 days)
co-gesic 2 QL (240 EA per 30 days)
codeine sulfate tablet 15mg 2 QL (720 EA per 30 days)
codeine sulfate tablet 30mg 2 QL (360 EA per 30 days)
codeine sulfate tablet 60mg 2 QL (180 EA per 30 days)
DEMEROL INJECTION 25MG/ML, 50MG/ML, 75MG/ML, 100MG/ML
4 PA
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2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
DURAMORPH 4
endocet tablet 325mg/5mg, 325mg/7.5mg, 325mg/10mg 2 QL (360 EA per 30 days)
endocet tablet 500mg/7.5mg 2 QL (240 EA per 30 days)
endocet tablet 650mg/10mg 2 QL (180 EA per 30 days)
fentanyl patch 2 QL (20 EA per 30 days)
fentanyl citrate injection 2 BvsD
fentanyl citrate oral transmucosal lollipop 200mcg 2 QL (120 EA per 30 days) PA
fentanyl citrate oral transmucosal lollipop 400mcg, 600mcg, 800mcg, 1200mcg, 1600mcg
5 QL (120 EA per 30 days) PA
hydrocodone bitartrate/acetaminophen solution 7.5mg & 325mg/15ml
2 QL (5400 ML per 30 days)
hydrocodone bitartrate/acetaminophen tablet 10mg/750mg 2 QL (150 EA per 30 days)
hydrocodone/acetaminophen solution 7.5mg & 500mg/15ml 2 QL (3600 ML per 30 days)
hydrocodone/acetaminophen tablet 5mg/325mg, 7.5mg/325mg, 10mg/325mg
2 QL (360 EA per 30 days)
hydrocodone/acetaminophen tablet 2.5mg/500mg, 5mg/500mg, 7.5mg/500mg, 10mg/500mg
2 QL (240 EA per 30 days)
hydrocodone/acetaminophen tablet 7.5mg/650mg,10mg/ 650mg, 10mg/660mg
2 QL (180 EA per 30 days)
hydrocodone/acetaminophen tablet 7.5mg/750mg 2 QL (150 EA per 30 days)
hydrocodone/ibuprofen tablet 7.5mg/200mg 2 QL (180 EA per 30 days)
hydromorphone hcl tablet 2 QL (240 EA per 30 days)
hydromorphone hcl injection 500mg/50ml 2
LAZANDA 4 QL (43.96 GM per 28 days) PA
levorphanol tartrate 2 QL (180 EA per 30 days)
maxidone 2 QL (150 EA per 30 days)
meperidine hcl injection 2 PA
meperidine hcl oral solution 2 QL (900 ML per 30 days) PA
meperitab 2 QL (180 EA per 30 days) PA
methadone hcl concentrate 2 QL (500 ML per 30 days)
methadone hcl injection 2
methadone hcl tablet 5mg, 10mg 2 QL (360 EA per 30 days)
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
15
Drug Name Drug Tier Requirements/Limits
methadone hcl tablet soluble 40mg 2 QL (90 EA per 30 days)
methadone hcl oral solution 5mg/5ml 2 QL (4000 ML per 30 days)
methadone hcl oral solution 10mg/5ml 2 QL (2000 ML per 30 days)
methadose concentrate 2 QL (500 ML per 30 days)
methadose tablet soluble 40mg 2 QL (90 EA per 30 days)
morphine sulfate er capsule 20mg, 30mg, 50mg, 60mg, 80mg, 100mg 2 QL (60 EA per 30 days)
morphine sulfate er tablet 15mg, 30mg 2 QL (180 EA per 30 days)
morphine sulfate er tablet 60mg, 100mg, 200mg 2 QL (120 EA per 30 days)
morphine sulfate injection 0.5mg/ml, 1mg/ml, 4mg/ml, 10mg/ml, 15mg/ml
2
morphine sulfate oral solution 10mg/5ml 2 QL (5400 ML per 30 days)
morphine sulfate oral solution 20mg/5ml 2 QL (2700 ML per 30 days)
morphine sulfate oral solution 20mg/ml 2 QL (540 ML per 30 days)
morphine sulfate tablet 15mg, 30mg 2 QL (360 EA per 30 days)
nalbuphine hcl 2 BvsD
ONSOLIS 5 QL (120 EA per 30 days) PA
OPANA ER TABLET 5MG, 7.5MG, 10MG, 15MG, 20MG, 30MG 3 QL (60 EA per 30 days)
OPANA ER TABLET 40MG 3 QL (120 EA per 30 days)
oxycodone hcl capsule, tablet 2 QL (300 EA per 30 days)
oxycodone hcl concentrate 2 QL (360 ML per 30 days)
oxycodone/acetaminophen capsule 2 QL (240 EA per 30 days)
oxycodone/acetaminophen tablet 2.5mg/325mg, 5mg/325mg, 7.5mg/325mg, 10/325mg
2 QL (360 EA per 30 days)
oxycodone/acetaminophen tablet 7.5mg/500mg 2 QL (240 EA per 30 days)
oxycodone/acetaminophen tablet 10mg /650mg 2 QL (180 EA per 30 days)
oxycodone/aspirin 2 QL (360 EA per 30 days)
oxycodone/ibuprofen 2 QL (150 EA per 30 days)
OXYCONTIN ER TABLET 10MG, 15MG, 20MG, 30MG, 40MG, 60MG 3 QL (90 EA per 30 days)
OXYCONTIN ER TABLET 80MG 3 QL (120 EA per 30 days)
oxymorphone hydrochloride 2 QL (180 EA per 30 days)
oxymorphone hydrochloride er tablet 5mg, 7.5mg, 10mg, 15mg, 20mg, 30mg
2 QL (60 EA per 30 days)
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2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
oxymorphone hydrochloride er tablet 40mg 2 QL (120 EA per 30 days)
pentazocine/acetaminophen 2 QL (180 EA per 30 days) PA
pentazocine/naloxone hcl 2 QL (360 EA per 30 days) PA
reprexain 2 QL (180 EA per 30 days)
roxicet solution 2 QL (1800 ML per 30 days)
roxicet tablet 2 QL (360 EA per 30 days)
stagesic 2 QL (240 EA per 30 days)
TALWIN 4 PA
tramadol hcl 2 QL (240 EA per 30 days)
Anesthetics
lidocaine hcl external solution 2
lidocaine hcl injection 0.5%, 1% 2
lidocaine hcl jelly gel 2% 2
lidocaine ointment 2 BvsD
lidocaine viscous 2
lidocaine/prilocaine cream 2 BvsD
LIDODERM 4 QL (90 EA per 30 days)
Anti-Addiction/Substance Abuse Treatment Agents
buprenorphine hcl injection 2
buprenorphine hcl tablet sublingual 2 QL (24 EA per 30 days)
buprenorphine hcl/naloxone hcl 2
buproban 2 QL (60 EA per 30 days)
CAMPRAL 4 QL (180 EA per 30 days)
CHANTIX TABLET 0.5MG, 1MG 3 QL (336 EA per 365 days)
CHANTIX TABLET STARTING MONTH 3 QL (106 EA per 365 days)
depade 2
disulfiram 2
naloxone hcl 2
naltrexone hcl 2
NICOTROL INHALER 4
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2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
REVIA 4
SUBOXONE 3
VIVITROL 5 PA
Anti-inflammatory Agents
CAMBIA 4
CELEBREX 3 QL (60 EA per 30 days)
diflunisal 2
etodolac 2
etodolac er 2
fenoprofen calcium 2
flurbiprofen 2
ibuprofen suspension 2
ibuprofen tablet 400mg, 600mg, 800mg 2
indomethacin & indomethacin er 2 PA
ketorolac tromethamine injection 2 PA
ketorolac tromethamine tablet 10mg 2 QL (20 EA per 30 days) PA
meclofenamate sodium 2
meloxicam 2
nabumetone 2
naproxen 2
naproxen dr 2
naproxen sodium tablet 275mg, 550mg 2
oxaprozin 2
piroxicam 2
salsalate 2
sulindac 2
tolmetin sodium 2
Antibacterials
ALTABAX 4
amikacin sulfate 2
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2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
amoxicillin 2
amoxicillin/potassium clavulanate 2
ampicillin 2
ampicillin sodium injection 2
ampicillin-sulbactam injection 2
AVELOX INJECTION 3
AVELOX TABLET 3 QL (30 EA per 30 days)
AZACTAM 1GM, 2GM 4
AZACTAM IN ISO-OSMOTIC DEXTROSE 1GM 4
AZACTAM IN ISO-OSMOTIC DEXTROSE 2GM 5
AZASITE 3
azithromycin 2
aztreonam 2
baciim 2
bacitracin 2
bacitracin/polymyxin b 2
bactocill in dextrose 2
BICILLIN C-R 4
BICILLIN L-A 4
BLEPH-10 4
CAYSTON 5
CEDAX CAPSULE 4
cefaclor & cefaclor er 2
cefadroxil 2
cefazolin sodium 2
cefdinir 2
cefepime 2
cefotaxime sodium 2
cefotetan 2
cefoxitin sodium 2
cefpodoxime proxetil 2
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2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
cefprozil 2
ceftazidime 2
ceftriaxone sodium 2
cefuroxime axetil tablet 2
cefuroxime sodium 2
cephalexin 2
chloramphenicol sodium succinate 2
CIPRO I.V. 4
CIPRODEX 3
ciprofloxacin er 2
ciprofloxacin hcl 2
ciprofloxacin i.v. 2
CLAFORAN 4
clarithromycin & clarithromycin er 2
CLEOCIN PHOSPHATE INJECTION 4
clindamycin hcl 2
clindamycin phosphate 2
colistimethate sodium 2
COLY-MYCIN M 4
CUBICIN 5 BvsD
demeclocycline hcl 2
dicloxacillin sodium 2
DIFICID 3 QL (20 EA per 30 days) PA
DORIBAX 4
doxycycline hyclate 2
doxycycline monohydrate 2
e.e.s. 2
ery 2
ery-tab 2
ERYPED 3
erythrocin lactobionate 2
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2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
erythrocin stearate 2
erythromycin base 2
erythromycin ethylsuccinate 2
erythromycin gel, ointment, solution 2
gentak ointment 2
gentamicin sulfate 2
imipenem/cilastatin 2
INVANZ 4
KETEK 4
levofloxacin injection, ophthalmic solution, oral solution 2
levofloxacin tablet 2 QL (30 EA per 30 days)
LINCOCIN 3
MACRODANTIN CAPSULE 25MG 4 PA
meropenem 2
MERREM 4
methenamine hippurate 2
metronidazole cream, lotion, tablet 2
metronidazole gel 0.75% 2
metronidazole injection 2
metronidazole vaginal 2
minocycline hcl 2
MOXEZA 3
mupirocin 2
nafcillin sodium 2
NALLPEN/DEXTROSE 3
neomycin sulfate tablet 2
neomycin/bacitracin/polymyxin 2
neomycin/polymyxin b sulfates 2
neomycin/polymyxin/bacitracin/hydrocortisone 2
neomycin/polymyxin/gramicidin 2
neomycin/polymyxin/hydrocortisone ophthalmic suspension 2
21
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
nitrofurantoin 2 PA
nitrofurantoin macrocrystalline 2 PA
nitrofurantoin monohydrate 2 PA
NOROXIN 4
ofloxacin 2
ORACEA 4
oxacillin sodium 2
paromomycin sulfate 2
PCE 3
penicillin g potassium 2
penicillin g procaine 2
penicillin g sodium 2
penicillin v potassium 2
pfizerpen-g 2
PHISOHEX 4
piperacillin sodium/tazobactam sodium 2
polymyxin b sulfate 2
PRIMAXIN IV 4
PRIMSOL 4
RELAGARD 4
SILVADENE 4
silver sulfadiazine 2
sodium sulfacetamide 2
ssd 2
streptomycin sulfate 2
sulfacetamide sodium ointment 10% 2
sulfadiazine 2
sulfamethoxazole/trimethoprim 2
sulfamethoxazole/trimethoprim ds 2
SUPRAX 4
SYNERCID 5
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2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
tazicef 2
TEFLARO 4
TIMENTIN 4
TOBI 5 BvsD
TOBI PODHALER 5
tobramycin sulfate 2
trimethoprim 2
trimethoprim sulfate/polymyxin b sulfate 2
TYGACIL 4
vancomycin hcl capsule 125mg 5 QL (40 EA per 10 days)
vancomycin hcl capsule 250mg 5 QL (80 EA per 10 days)
vancomycin hcl injection 2 BvsD
VANDAZOLE 4
VIGAMOX 3
XIFAXAN TABLET 200MG 4 QL (90 EA per 30 days) PA
XIFAXAN TABLET 550MG 5 QL (60 EA per 30 days) PA
ZMAX 4 QL (120 ML per 30 days)
ZOSYN 3
ZYVOX INJECTION 5
ZYVOX SUSPENSION 5 QL (1680 ML per 60 days)
ZYVOX TABLET 5 QL (56 EA per 60 days)
Anticonvulsants
BANZEL SUSPENSION 4
BANZEL TABLET 200MG 4
BANZEL TABLET 400MG 5
carbamazepine & carbamazepine er 2
CARBATROL 4
CELONTIN 4
clonazepam odt 0.125mg, 0.25mg, 0.5mg, 1mg 2 QL (120 EA per 30 days)
clonazepam odt 2mg 2 QL (300 EA per 30 days)
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2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
clonazepam tablet 0.5mg, 1mg 2 QL (120 EA per 30 days)
clonazepam tablet 2mg 2 QL (300 EA per 30 days)
clorazepate dipotassium tablet 3.75mg, 7.5mg 2 QL (90 EA per 30 days)
clorazepate dipotassium tablet 15mg 2 QL (120 EA per 30 days)
DEPACON 4
diazepam gel 2.5mg 2 QL (10 ML per 30 days)
diazepam gel 10mg 2 QL (20 ML per 30 days)
diazepam gel 20mg 2 QL (40 ML per 30 days)
DILANTIN 4
DILANTIN INFATABS 4
divalproex sodium & divalproex sodium er 2
epitol 2
ethosuximide 2
felbamate suspension 5
felbamate tablet 2
FELBATOL 5
fosphenytoin sodium 2
gabapentin 2
LAMICTAL ODT 3
lamotrigine & lamotrigine er 2
levetiracetam & levetiracetam er 2
LYRICA CAPSULE 25MG, 225MG, 300MG 3 QL (60 EA per 30 days)
LYRICA CAPSULE 50MG, 75MG, 100MG, 150MG, 200MG 3 QL (90 EA per 30 days)
LYRICA SOLUTION 3 QL (900 ML per 30 days)
magnesium sulfate injection 2
NEURONTIN SOLUTION 4
ONFI TABLET 5MG, 10MG 4 QL (60 EA per 30 days)
ONFI TABLET 20MG 4 QL (120 EA per 30 days)
oxcarbazepine 2
PEGANONE 4
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2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
phenobarbital 2 PA
PHENYTEK 4
phenytoin & phenytoin sodium extended 2
POTIGA TABLET 50MG 4 QL (270 EA per 30 days)
POTIGA TABLET 200MG, 300MG, 400MG 4 QL (90 EA per 30 days)
primidone 2
SABRIL PACKET 5 QL (200 EA per 30 days)
SABRIL TABLET 5 QL (180 EA per 30 days)
tiagabine hydrochloride 2
topiramate 2
valproate sodium 2
valproic acid 2
VIMPAT INJECTION 3
VIMPAT ORAL SOLUTION 3 QL (1200 ML per 30 days)
VIMPAT TABLET 3 QL (60 EA per 30 days)
zonisamide 2
Antidementia Agents
donepezil hcl odt & tablet 5mg 1 QL (30 EA per 30 days)
donepezil hcl odt & tablet 10mg 1 QL (60 EA per 30 days)
ergoloid mesylates 2 PA
EXELON PATCH 3 QL (30 EA per 30 days)
EXELON SOLUTION 4 QL (180 ML per 30 days)
galantamine hydrobromide solution 2 QL (200 ML per 30 days)
galantamine hydrobromide er capsule 2 QL (30 EA per 30 days)
galantamine hydrobromide tablet 2 QL (60 EA per 30 days)
NAMENDA SOLUTION 3 QL (300 ML per 30 days)
NAMENDA TABLET 5MG 3 QL (90 EA per 30 days)
NAMENDA TABLET 10MG 3 QL (60 EA per 30 days)
NAMENDA TITRATION PAK 3 QL (49 EA per 30 days)
rivastigmine tartrate 2 QL (60 EA per 30 days)
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2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
Antidepressants
amitriptyline hcl 2 PA
amoxapine 2
budeprion sr tablet 100mg 2 QL (60 EA per 30 days)
budeprion sr tablet 150mg 2 QL (90 EA per 30 days)
bupropion hcl 2
bupropion hcl sr tablet 100mg, 200mg 2 QL (60 EA per 30 days)
bupropion hcl sr tablet 150mg 2 QL (90 EA per 30 days)
bupropion hcl xl tablet 150mg 2 QL (90 EA per 30 days)
bupropion hcl xl tablet 300mg 2 QL (30 EA per 30 days)
chlordiazepoxide/amitriptyline 2 PA
citalopram hydrobromide solution 2 QL (600 ML per 30 days)
citalopram hydrobromide tablet 10mg, 20mg 2 QL (60 EA per 30 days)
citalopram hydrobromide tablet 40mg 2 QL (30 EA per 30 days)
clomipramine hcl 2 PA
CYMBALTA 4 QL (60 EA per 30 days)
desipramine hcl 2
doxepin hcl 2 PA
EMSAM 5
escitalopram oxalate solution 2 QL (600 ML per 30 days)
escitalopram oxalate tablet 2 QL (60 EA per 30 days)
fluoxetine hcl capsule 10mg, 20mg, 40mg 2
fluoxetine hcl tablet 10mg, 20mg, 60mg 2
fluoxetine hcl solution 20mg/5ml 2
fluvoxamine maleate 2
imipramine hcl 2 PA
maprotiline hcl 2
MARPLAN 4
mirtazapine & mirtazapine odt 2
nefazodone hcl 2
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2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
nortriptyline hcl capsule 2
olanzapine/fluoxetine 2 QL (30 EA per 30 days)
paroxetine hcl 2 QL (60 EA per 30 days)
PAXIL SUSPENSION 4 QL (900 ML per 30 days)
perphenazine/amitriptyline 2 PA
phenelzine sulfate 2
PRISTIQ 3 QL (30 EA per 30 days)
protriptyline hcl 2
sertraline hcl concentrate 2 QL (300 ML per 30 days)
sertraline hcl tablet 25mg, 50mg 2 QL (90 EA per 30 days)
sertraline hcl tablet 100mg 2 QL (60 EA per 30 days)
tranylcypromine sulfate 2
trazodone hcl 2
trimipramine maleate 2 PA
venlafaxine hcl er capsule 37.5mg 2 QL (30 EA per 30 days)
venlafaxine hcl er capsule 75mg 2 QL (90 EA per 30 days)
venlafaxine hcl er capsule 150mg 2 QL (60 EA per 30 days)
venlafaxine hcl tablet 2
VIIBRYD 3 QL (30 EA per 30 days)
Antiemetics
dronabinol capsule 2.5mg, 5mg 2 BvsD
dronabinol capsule 10mg 5 BvsD
EMEND CAPSULE 40MG 3 QL (2 EA per 30 days) BvsD
EMEND CAPSULE 80MG 3 QL (8 EA per 30 days) BvsD
EMEND CAPSULE 125MG 3 QL (4 EA per 30 days) BvsD
EMEND CAPSULE TRIFOLD PACK 3 QL (12 EA per 30 days) BvsD
meclizine hcl tablet rx 2
ondansetron hcl injection 2 BvsD
ondansetron hcl oral solution 2 QL (900 ML per 30 days) BvsD
ondansetron hcl tablet 4mg, 8mg 2 QL (90 EA per 30 days) BvsD
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2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
ondansetron hcl tablet 24mg 2 QL (5 EA per 30 days) BvsD
ondansetron odt tablet 4mg, 8mg 2 QL (90 EA per 30 days) BvsD
phenadoz suppository 12.5mg, 25mg 2 PA
promethazine hcl suppository 12.5mg, 25mg 2 PA
promethegan suppository 12.5mg, 25mg, 50mg 2 PA
SANCUSO 4 QL (4 EA per 30 days) PA
TRANSDERM-SCOP 4
trimethobenzamide hcl 2 PA
Antifungals
ABELCET 5 BvsD
AMBISOME 5 BvsD
amphotericin b 2 BvsD
ANCOBON 5
CANCIDAS 5 PA
ciclopirox gel, suspension 2
ciclopirox nail lacquer 2
ciclopirox olamine 2
clotrimazole rx 2
clotrimazole/betamethasone dipropionate 2
econazole nitrate 2
ERAXIS 3
fluconazole 2
flucytosine 5
GRIFULVIN V 3
GRIS-PEG 3
griseofulvin microsize 2
griseofulvin ultramicrosize 2
itraconazole 2
ketoconazole cream, shampoo, tablet 2
miconazole 3 rx 2
28
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
MYCAMINE 5
NAFTIN 4
NATACYN 4
NOXAFIL 5
nyamyc 2
nystatin 2
nystatin/triamcinolone 2
nystop 2
pedi-dri 2
SPORANOX SOLUTION 5
terbinafine hcl tablet 2
terconazole 2
VFEND 5
VFEND IV 4
voriconazole injection 2
voriconazole tablet 5
zazole cream 2
Antigout Agents
allopurinol 1
allopurinol sodium 2
ALOPRIM 4
COLCRYS 3
probenecid 2
probenecid/colchicine 2
ULORIC 3 QL (30 EA per 30 days) ST
Antimigraine Agents
D.H.E. 45 5
dihydroergotamine mesylate injection 2
ERGOMAR 4
migergot 2
29
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
MIGRANAL 4 QL (8 ML per 30 days)
rizatriptan benzoate odt & tablet 5mg 2 QL (27 EA per 30 days)
rizatriptan benzoate odt & tablet 10mg 2 QL (18 EA per 30 days)
sumatriptan nasal spray 5mg 2 QL (36 ML per 30 days)
sumatriptan nasal spray 20mg 2 QL (12 ML per 30 days)
sumatriptan succinate injection 4mg/0.5ml 2 QL (4 ML per 30 days)
sumatriptan succinate injection 6mg/0.5ml 2 QL (8 ML per 30 days)
sumatriptan succinate tablet 25mg 2 QL (36 EA per 30 days)
sumatriptan succinate tablet 50mg 2 QL (18 EA per 30 days)
sumatriptan succinate tablet 100mg 2 QL (9 EA per 30 days)
Antimyasthenic Agents
guanidine hcl 2
MESTINON SYRUP 3
MESTINON TIMESPAN 3
pyridostigmine bromide 2
REGONOL 4
Antimycobacterials
CAPASTAT SULFATE 3
dapsone 2
ethambutol hcl 2
isoniazid 2
MYCOBUTIN 3
PASER 4
PRIFTIN 4
pyrazinamide 2
rifampin 2
RIFATER 4
SEROMYCIN 3
SIRTURO 5
TRECATOR 3
30
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
Antineoplastics
ABRAXANE 5 BvsD
ADRIAMYCIN 4 BvsD
AFINITOR TABLET 2.5MG, 5MG, 7.5MG 5 QL (30 EA per 30 days)
AFINITOR TABLET 10MG 5 QL (60 EA per 30 days)
ALIMTA 5 BvsD
ALKERAN INJECTION 4 BvsD
amifostine 5 BvsD
anastrozole 2 QL (30 EA per 30 days)
ARRANON 5 BvsD
ARZERRA 5 BvsD
AVASTIN 5 BvsD
BICNU 3 BvsD
bleomycin sulfate 2 BvsD
BOSULIF 5
BUSULFEX 3 BvsD
CAMPTOSAR 4 BvsD
CAPRELSA 5
carboplatin 2 BvsD
CEENU 3
CERUBIDINE 4 BvsD
cisplatin 2 BvsD
cladribine 5 BvsD
CLOLAR 5 BvsD
COMETRIQ 5
COSMEGEN 5 BvsD
cyclophosphamide tablet 2 BvsD
cytarabine 2 BvsD
cytarabine aqueous 2 BvsD
dacarbazine 2 BvsD
31
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
DACOGEN 5 BvsD
daunorubicin hcl 2 BvsD
DAUNOXOME 4 BvsD
dexrazoxane 5 BvsD
DOCEFREZ 5 BvsD
docetaxel 5 BvsD
DOXIL 5 BvsD
doxorubicin hcl 2 BvsD
DROXIA 3
ELITEK 5
ELLENCE 5 BvsD
ELOXATIN 5 BvsD
ELSPAR 3 BvsD
EMCYT 3
epirubicin hcl 2 BvsD
ERBITUX 5 BvsD
ERIVEDGE 5
ETOPOPHOS 4 BvsD
etoposide injection 2 BvsD
exemestane 2
FARESTON 5
FASLODEX 5 BvsD
FLUDARA 5 BvsD
fludarabine phosphate 2 BvsD
fluorouracil 2 BvsD
gemcitabine hcl 5 BvsD
GEMZAR 5 BvsD
GLEEVEC 5
HALAVEN 5
HERCEPTIN 5 BvsD
32
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
HEXALEN 5
HYCAMTIN INJECTION 5 BvsD
hydroxyurea 2
ICLUSIG 5
IDAMYCIN PFS 5 BvsD
idarubicin hcl 5 BvsD
IFEX 4 BvsD
ifosfamide 2 BvsD
ifosfamide/mesna 5 BvsD
INLYTA 5
irinotecan 5 BvsD
ISTODAX 5 BvsD
IXEMPRA 5 BvsD
JAKAFI 5
JEVTANA 5 BvsD
KADCYLA 5 BvsD
letrozole 2
leucovorin calcium injection 2 BvsD
leucovorin calcium tablet 2
LEUKERAN 3
MATULANE 5
MEKINIST 5
melphalan hydrochloride 2 BvsD
mercaptopurine 2
mesna 2 BvsD
MESNEX INJECTION 4 BvsD
MESNEX TABLET 5
mitomycin 2 BvsD
mitoxantrone hcl 2 BvsD
MUSTARGEN 3 BvsD
NAVELBINE 5 BvsD
33
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
NEXAVAR 5 RA
NIPENT 5 BvsD
ONTAK 5 BvsD
oxaliplatin 5 BvsD
paclitaxel 2 BvsD
PANRETIN 5
pentostatin 5 BvsD
PERJETA 5 BvsD
POMALYST 5
PROLEUKIN 5
REVLIMID 5 QL (28 EA per 28 days) RA
RITUXAN 5 PA
SOLTAMOX 4
SPRYCEL 5
STIVARGA 5
SUTENT 5
SYLATRON 5 PA
SYNRIBO 5 BvsD
TABLOID 4
TAFINLAR 5
tamoxifen citrate 2
TARCEVA 5
TARGRETIN 5
TASIGNA 5
TAXOTERE 5 BvsD
THALOMID 5
thiotepa 2 BvsD
toposar 2 BvsD
topotecan hcl 5 BvsD
TREANDA 5 BvsD
tretinoin capsule 10mg 5
34
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
TRISENOX 4 BvsD
TYKERB 5
VECTIBIX 5 BvsD
VELCADE 5 BvsD
VIDAZA 3
vinblastine sulfate 2 BvsD
vincasar pfs 2 BvsD
vincristine sulfate 2 BvsD
vinorelbine tartrate 2 BvsD
VOTRIENT 5
VUMON 4 PA
XALKORI 5
YERVOY 5 BvsD
ZALTRAP 5 BvsD
ZANOSAR 4 BvsD
ZELBORAF 5
ZINECARD 5 BvsD
ZOLINZA 5
ZYTIGA 5
Antiparasitics
ALBENZA 4
ALINIA 4
atovaquone/proguanil hcl 2
chloroquine phosphate 2
DARAPRIM 4
EURAX 4
hydroxychloroquine sulfate 2
lindane 2
malathion 2
mefloquine hcl 2
MEPRON 5
35
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
NEBUPENT 4 BvsD
PENTAM 300 4
permethrin cream rx 2
PRIMAQUINE PHOSPHATE 4
QUALAQUIN 4 PA
quinine sulfate 2 PA
SKLICE 4
STROMECTOL 3
tinidazole 2
Antiparkinson Agents
APOKYN 5
AZILECT 3
benztropine mesylate injection 2
benztropine mesylate tablet 2 PA
bromocriptine mesylate 2
carbidopa/levodopa 2
carbidopa/levodopa er 2
carbidopa/levodopa odt 2
entacapone 2
LODOSYN 3
pramipexole dihydrochloride 2
ropinirole hcl 2
ropinirole hcl er 2
selegiline hcl 2
TASMAR 3
trihexyphenidyl hcl 2 PA
ZELAPAR 4
Antipsychotics
ABILIFY DISCMELT 3 QL (60 EA per 30 days)
ABILIFY INJECTION 4
36
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
ABILIFY MAINTENA 5
ABILIFY ORAL SOLUTION 3 QL (900 ML per 30 days)
ABILIFY TABLET 3 QL (30 EA per 30 days)
chlorpromazine hcl injection, tablet 2
clozapine 2
compro 2
FANAPT 4 QL (60 EA per 30 days)
FANAPT TITRATION PACK 4 QL (16 EA per 30 days)
FAZACLO 4
fluphenazine decanoate 2
fluphenazine hcl 2
GEODON INJECTION 4
haloperidol 2
haloperidol decanoate 2
haloperidol lactate 2
INVEGA SUSTENNA 39MG/0.25ML, 78MG/0.5ML 4
INVEGA SUSTENNA 117MG/0.75ML, 156MG/ML, 234MG/1.5ML 5
INVEGA TABLET ER 1.5MG, 3MG 4 QL (30 EA per 30 days)
INVEGA TABLET ER 6MG 4 QL (60 EA per 30 days)
INVEGA TABLET ER 9MG 5 QL (30 EA per 30 days)
LATUDA TABLET 20MG, 40MG, 120MG 3 QL (30 EA per 30 days)
LATUDA TABLET 80MG 3 QL (60 EA per 30 days)
loxapine succinate 2
olanzapine odt 2 QL (30 EA per 30 days)
olanzapine injection 2
olanzapine tablet 2 QL (60 EA per 30 days)
ORAP 4
perphenazine 2
prochlorperazine 2
prochlorperazine edisylate 2
prochlorperazine maleate 2
37
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
quetiapine fumarate tablet 25mg, 50mg, 100mg, 200mg 2 QL (120 EA per 30 days)
quetiapine fumarate tablet 300mg, 400mg 2 QL (90 EA per 30 days)
RISPERDAL CONSTA 12.5MG, 25MG 4
RISPERDAL CONSTA 37.5MG, 50MG 5
risperidone odt 0.25mg, 0.5mg, 1mg, 2mg, 3mg 2 QL (90 EA per 30 days)
risperidone odt 4mg 2 QL (120 EA per 30 days)
risperidone solution 2 QL (360 ML per 30 days)
risperidone tablet 0.25mg, 0.5mg, 1mg, 2mg, 3mg 2 QL (90 EA per 30 days)
risperidone tablet 4mg 2 QL (120 EA per 30 days)
SAPHRIS 3 QL (60 EA per 30 days)
SEROQUEL XR TABLET 50MG, 300MG, 400MG 3 QL (60 EA per 30 days)
SEROQUEL XR TABLET 150MG, 200MG 3 QL (30 EA per 30 days)
thioridazine hcl 2 PA
thiothixene 2
trifluoperazine hcl 2
ziprasidone hcl 2 QL (60 EA per 30 days)
Antispasticity Agents
baclofen 2
tizanidine hcl 2
Antivirals
abacavir 2
acyclovir capsule, suspension, tablet 2
acyclovir sodium injection 2 BvsD
amantadine hcl 2
APTIVUS 5
ATRIPLA 5
BARACLUDE 3
cidofovir 5
COMPLERA 5
COPEGUS 5 ST
38
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
CRIXIVAN 3
DENAVIR 4
didanosine 2
EDURANT 5
EMTRIVA 4
EPIVIR HBV 4
EPIVIR SOLUTION 4
EPZICOM 5
foscarnet sodium 2 BvsD
FUZEON 5
ganciclovir 2 BvsD
HEPSERA 5
INCIVEK 5 PA
INFERGEN 5 PA
INTELENCE TABLET 25MG 4
INTELENCE TABLET 100MG, 200MG 5
INTRON-A 4
INVIRASE CAPSULE 200MG 4
INVIRASE TABLET 500MG 5
ISENTRESS TABLET CHEWABLE 25MG, 100MG 3
ISENTRESS TABLET 400MG 5
KALETRA 5
lamivudine 2
lamivudine/zidovudine 5
LEXIVA SUSPENSION 4
LEXIVA TABLET 5
nevirapine tablet 2
NORVIR 4
PEG-INTRON 5 PA
PREZISTA SUSPENSION 4
PREZISTA TABLET 75MG, 150MG 4
39
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
PREZISTA TABLET 400MG, 600MG, 800MG 5
REBETOL CAPSULE 5 ST
REBETOL SOLUTION 4 ST
RELENZA DISKHALER 4 QL (120 EA per 365 days)
RESCRIPTOR 4
RETROVIR IV INFUSION 4
REYATAZ 3
ribapak tablet 5 ST
ribasphere capsule 200mg 2
ribasphere tablet 200mg 2
ribasphere tablet 400mg 2 ST
ribasphere tablet 600mg 5 ST
ribavirin capsule, tablet 200mg 2
rimantadine hcl 2
SELZENTRY 5
stavudine 2
STRIBILD 5
SUSTIVA 3
TAMIFLU CAPSULE 30MG 3 QL (120 EA per 365 days)
TAMIFLU CAPSULE 45MG 3 QL (60 EA per 365 days)
TAMIFLU CAPSULE 75MG 3 QL (56 EA per 365 days)
TAMIFLU SUSPENSION 3
trifluridine 2
TRIZIVIR 5
TRUVADA 5
TYZEKA 5
valacyclovir hcl 2
VICTRELIS 5 PA
VIDEX PEDIATRIC SOLUTION 3
VIRACEPT 5
VIRAMUNE 4
40
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
VIRAMUNE XR 4
VIREAD 5
VISTIDE 5
ZERIT SOLUTION 4
ZIAGEN SOLUTION 4
zidovudine 2
Anxiolytics
alprazolam er tablet 0.5mg, 1mg, 2mg, 3mg 2 QL (90 EA per 30 days)
alprazolam intensol 2 QL (300 ML per 30 days)
alprazolam odt 0.25mg, 0.5mg, 1mg 2 QL (120 EA per 30 days)
alprazolam odt 2mg 2 QL (150 EA per 30 days)
alprazolam tablet 0.25mg, 0.5mg, 1mg 2 QL (120 EA per 30 days)
alprazolam tablet 2mg 2 QL (150 EA per 30 days)
buspirone hcl 2
diazepam intensol 2 QL (240 ML per 30 days)
diazepam injection 2
diazepam oral solution 1mg/ml 2 QL (1200 ML per 30 days)
diazepam tablet 2mg, 5mg, 10mg 2 QL (120 EA per 30 days)
lorazepam injection 2mg/ml, 4mg/ml 2
lorazepam intensol 2 QL (150 ML per 30 days)
lorazepam tablet 2 QL (120 EA per 30 days)
meprobamate 2 PA
oxazepam 2 QL (120 EA per 30 days)
Bipolar Agents
EQUETRO 4
lithium carbonate 2
lithium carbonate er 2
lithium citrate 2
Blood Glucose Regulators
acarbose 2
41
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
ALCOHOL PREP PADS 3
AVANDIA TABLET 2MG, 4MG 4 QL (60 EA per 30 days)
AVANDIA TABLET 8MG 4 QL (30 EA per 30 days)
BD INSULIN SYRINGE 3
BD PEN NEEDLE 3
BYDUREON 3 QL (2.6 ML per 28 days)
BYETTA 3 QL (3 ML per 30 days)
chlorpropamide 1 PA
GAUZE PADS 2X2 3
glimepiride 1
glipizide 1
glipizide er 1
glipizide/metformin hcl 1
GLUCAGEN HYPOKIT 3
GLUCAGON EMERGENCY KIT 3
glyburide 1 PA
glyburide micronized 1 PA
glyburide/metformin hcl 1 PA
GLYSET 4
HUMALOG 3
HUMALOG MIX 50/50 3
HUMALOG MIX 75/25 3
HUMULIN 70/30 3
HUMULIN N 3
HUMULIN R 3
HUMULIN R U-500 (CONCENTRATED) 3
INSULIN SYRINGE & PEN NEEDLE 3
JANUMET 3 QL (60 EA per 30 days)
JANUMET XR TABLET 500MG/50MG, 1000MG/50MG 3 QL (60 EA per 30 days)
JANUMET XR TABLET 1000MG/100MG 3 QL (30 EA per 30 days)
JANUVIA 3 QL (30 EA per 30 days)
42
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
JENTADUETO 3 QL (60 EA per 30 days)
JUVISYNC 3 QL (30 EA per 30 days)
LANTUS 3
LANTUS SOLOSTAR 3
LEVEMIR 3
LEVEMIR FLEXPEN 3
metformin hcl 1
metformin hcl er 1
nateglinide 1
NOVOFINE & NOVOTWIST PEN NEEDLE 3
pioglitazone hcl 1 QL (30 EA per 30 days)
pioglitazone hcl/glimepiride 1 QL (30 EA per 30 days)
pioglitazone hcl/metformin hcl 1 QL (90 EA per 30 days)
PRANDIN 4
PROGLYCEM 4
RIOMET 3
SYMLINPEN 60 4 QL (12 ML per 30 days)
SYMLINPEN 120 4 QL (10.8 ML per 30 days)
tolazamide 1
tolbutamide 1
TRADJENTA 3 QL (30 EA per 30 days)
V-GO 4
VICTOZA 3 QL (9 ML per 30 days)
Blood Products/Modifiers/Volume Expanders
AGGRENOX 3 QL (60 EA per 30 days)
aminocaproic acid tablet 2
anagrelide hydrochloride 2
ARANESP 25MCG/0.42ML, 25MCG/ML, 40MCG/0.4ML, 40MCG/ML, 60MCG/0.3ML, 60MCG/ML
3 PA
ARANESP 100MCG/0.5ML, 100MCG/ML, 150MCG/0.3ML, 150MCG/0.75ML, 200MCG/0.4ML, 200MCG/ML, 300MCG/0.6ML, 300MCG/ML, 500MCG/ML
5 PA
43
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
BRILINTA 3 QL (60 EA per 30 days)
cilostazol 1
clopidogrel tablet 75mg 1
clopidogrel tablet 300mg 1 QL (1 EA per 30 days)
COUMADIN 4
CYKLOKAPRON 3
dipyridamole tablet 2 PA
EFFIENT TABLET 5MG 3 QL (42 EA per 30 days)
EFFIENT TABLET 10MG 3 QL (36 EA per 30 days)
ELIQUIS 3 QL (60 EA per 30 days)
enoxaparin sodium 30mg/0.3ml 2 QL (18 ML per 365 days)
enoxaparin sodium 40mg/0.4ml 2 QL (24 ML per 365 days)
enoxaparin sodium 60mg/0.6ml 2 QL (36 ML per 365 days)
enoxaparin sodium 80mg/0.8ml 2 QL (48 ML per 365 days)
enoxaparin sodium 100mg/ml 2 QL (60 ML per 365 days)
enoxaparin sodium 120mg/0.8ml 5 QL (48 ML per 365 days)
enoxaparin sodium 150mg/ml 5 QL (60 ML per 365 days)
enoxaparin sodium 300mg/3ml 2 QL (90 ML per 365 days)
EPOGEN 4 PA
fondaparinux sodium 2.5mg/0.5ml 2 QL (32 ML per 365 days)
fondaparinux sodium 5mg/0.4ml 5 QL (12 ML per 365 days)
fondaparinux sodium 7.5mg/0.6ml 5 QL (18 ML per 365 days)
fondaparinux sodium 10mg/0.8ml 5 QL (24 ML per 365 days)
heparin sodium 1000unit/ml 2 BvsD
heparin sodium 2000unit/ml, 2500unit/ml, 5000unit/ml, 10000unit/ml, 20000unit/ml
2
heparin sodium/d5w injection 5%/40unit/ml 2
heparin sodium/nacl 0.45% 2
heparin sodium/sodium chloride 0.9% premix 2
jantoven 1
LEUKINE 5
44
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
MOZOBIL 5
NEUMEGA 5 PA
NEUPOGEN 5
PRADAXA 4 QL (60 EA per 30 days)
PROCRIT 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML, 10000UNIT/ML
3 PA
PROCRIT 20000UNIT/ML, 40000UNIT/ML 5 PA
PROMACTA 5
ticlopidine hcl 2 PA
tranexamic acid injection 2
warfarin sodium 1
XARELTO TABLET 10MG, 20MG 3 QL (30 EA per 30 days)
XARELTO TABLET 15MG 3 QL (60 EA per 30 days)
Cardiovascular Agents
acebutolol hcl 2
acetazolamide sodium 2
afeditab cr 1
amiloride hcl 2
amiloride/hctz 2
amiodarone hcl injection 1
amiodarone hcl tablet 1
amlodipine besylate tablet 2.5mg 1 QL (90 EA per 30 days)
amlodipine besylate tablet 5mg , 10mg 1 QL (60 EA per 30 days)
amlodipine besylate/atorvastatin calcium 1 QL (30 EA per 30 days)
amlodipine besylate/benazepril hcl 2 QL (30 EA per 30 days)
AMTURNIDE 4 QL (30 EA per 30 days)
atenolol 1
atenolol/chlorthalidone 1
atorvastatin calcium 1 QL (30 EA per 30 days)
benazepril hcl 1
benazepril hcl/hctz 1
45
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
BENICAR 3 QL (30 EA per 30 days)
BENICAR HCT 3 QL (30 EA per 30 days)
betaxolol hcl tablet 10mg, 20mg 1
BIDIL 4
bisoprolol fumarate 1
bisoprolol fumarate/hctz 1
bumetanide 1
BYSTOLIC TABLET 2.5MG, 5MG 3 QL (90 EA per 30 days)
BYSTOLIC TABLET 10MG 3 QL (120 EA per 30 days)
BYSTOLIC TABLET 20MG 3 QL (60 EA per 30 days)
candesartan cilexetil/hctz 1 QL (30 EA per 30 days)
captopril 1
captopril/hctz 1
cartia xt 1
carvedilol 1
chlorothiazide 2
chlorothiazide sodium 2
chlorthalidone 1
clonidine hcl tablet 1
colestipol hcl 2
COREG CR 3 QL (30 EA per 30 days)
CRESTOR 3 QL (30 EA per 30 days)
digoxin 1 PA
dilacor xr 1
dilt-cd 1
dilt-xr 1
diltiazem cd 1
diltiazem hcl er 1
diltiazem hcl injection 1
diltiazem hcl tablet 1
diltzac 1
46
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
DIOVAN TABLET 40MG, 80MG, 160MG 4 QL (60 EA per 30 days)
DIOVAN TABLET 320MG 4 QL (30 EA per 30 days)
disopyramide phosphate 2 PA
doxazosin mesylate 2
DUTOPROL 4 QL (60 EA per 30 days)
enalapril maleate 1
enalapril maleate/hctz 1
eplerenone 2
EXFORGE 3 QL (30 EA per 30 days)
EXFORGE HCT 3 QL (30 EA per 30 days)
felodipine er 2 QL (60 EA per 30 days)
fenofibrate micronized 2 QL (30 EA per 30 days)
fenofibrate tablet 48mg, 54mg 2 QL (60 EA per 30 days)
fenofibrate tablet 145mg, 160mg 2 QL (30 EA per 30 days)
flecainide acetate 2
fluvastatin capsule 20mg 1 QL (30 EA per 30 days)
fluvastatin capsule 40mg 1 QL (60 EA per 30 days)
fosinopril sodium 1
fosinopril sodium/hctz 1
furosemide 1
gemfibrozil 1
guanfacine hcl 2 PA
hydralazine hcl 1
hydrochlorothiazide 1
indapamide 1
INNOPRAN XL 4
irbesartan 1 QL (30 EA per 30 days)
irbesartan/hctz 1 QL (30 EA per 30 days)
isosorbide dinitrate 2
isosorbide dinitrate er 2
isosorbide mononitrate 1
47
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
isosorbide mononitrate er 1
isradipine 2
JUXTAPID 5
KYNAMRO 5
labetalol hcl 1
LANOXIN 3 PA
LANOXIN PEDIATRIC 3 PA
LESCOL XL 4 QL (30 EA per 30 days)
lisinopril 1
lisinopril/hctz 1
losartan potassium/hctz tablet 50mg/12.5mg 1 QL (60 EA per 30 days)
losartan potassium/hctz tablet 100mg/12.5mg, 100mg/25mg 1 QL (30 EA per 30 days)
losartan potassium tablet 25mg 1 QL (90 EA per 30 days)
losartan potassium tablet 50mg 1 QL (60 EA per 30 days)
losartan potassium tablet 100mg 1 QL (30 EA per 30 days)
lovastatin tablet 10mg, 20mg 1 QL (90 EA per 30 days)
lovastatin tablet 40mg 1 QL (60 EA per 30 days)
LOVAZA 3
methazolamide 2
methyclothiazide 2
methyldopa 2 PA
methyldopa/hctz 2 PA
methyldopate hcl 2 PA
metolazone 2
metoprolol succinate er tablet 25mg, 50mg, 100mg 1 QL (90 EA per 30 days)
metoprolol succinate er tablet 200mg 1 QL (60 EA per 30 days)
metoprolol tartrate 1
metoprolol/hctz 2
mexiletine hcl 2
MICARDIS 4 QL (30 EA per 30 days)
MICARDIS HCT 4 QL (30 EA per 30 days)
48
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
midodrine hcl 2
minitran 2
minoxidil 2
moexipril hcl 1
moexipril/hctz 1
MULTAQ 3 QL (60 EA per 30 days)
nadolol 2
nadolol/bendroflumethiazide 2
NIASPAN TABLET ER 500MG 4 QL (30 EA per 30 days)
NIASPAN TABLET ER 750MG, 1000MG 4 QL (60 EA per 30 days)
nicardipine hcl 2
nifediac cc 1
nifedical xl 1
nifedipine 2 PA
nifedipine er 1
nimodipine 2
nisoldipine 2 QL (30 EA per 30 days)
nisoldipine er 2 QL (30 EA per 30 days)
NITRO-BID 4
NITRO-DUR PATCH 0.3MG/HR, 0.8MG/HR 4
nitroglycerin transdermal patch 1
nitroglycerin injection 2
NITROLINGUAL PUMPSPRAY 3
NITROSTAT 3
pacerone 1
pentoxifylline er 1
perindopril erbumine 1
pindolol 2
pravastatin sodium tablet 10mg, 20mg 1 QL (90 EA per 30 days)
pravastatin sodium tablet 40mg 1 QL (60 EA per 30 days)
pravastatin sodium tablet 80mg 1 QL (30 EA per 30 days)
49
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
prazosin hcl 2
procainamide hcl 2
propafenone hcl 2
propranolol hcl 2
propranolol hcl er 2
propranolol/hctz 2
quinapril hcl 1
quinapril/hctz 1
quinidine gluconate 2
quinidine gluconate cr 2
quinidine sulfate 2
quinidine sulfate er 2
ramipril 1
RANEXA 3
RECTIV 4
reserpine 2 PA
SIMCOR TABLET ER 500MG/20MG, 500MG/40MG, 1000MG/40MG 3 QL (30 EA per 30 days)
SIMCOR TABLET ER 750MG/20MG, 1000MG/20MG 3 QL (60 EA per 30 days)
simvastatin tablet 5mg, 10mg, 20mg 1 QL (90 EA per 30 days)
simvastatin tablet 40mg 1 QL (45 EA per 30 days)
simvastatin tablet 80mg 1 QL (30 EA per 30 days)
sorine 1
sotalol hcl 1
sotalol hcl af 1
spironolactone 1
spironolactone/hctz 1
taztia xt 1
TEKAMLO 4 QL (30 EA per 30 days)
TEKTURNA 4 QL (30 EA per 30 days)
TEKTURNA HCT 4 QL (30 EA per 30 days)
terazosin hcl 2
50
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
TIKOSYN 4
timolol maleate tablet 2
TOPROL XL TABLET ER 25MG, 50MG, 100MG 4 QL (90 EA per 30 days)
TOPROL XL TABLET ER 200MG 4 QL (60 EA per 30 days)
torsemide injection 1
torsemide tablet 1
trandolapril 1
triamterene/hctz 1
TRILIPIX CAPSULE 45MG 4 QL (60 EA per 30 days)
TRILIPIX CAPSULE 135MG 4 QL (30 EA per 30 days)
valsartan/hctz 1 QL (30 EA per 30 days)
verapamil hcl 1
verapamil hcl er 1
verapamil hcl sr 1
VYTORIN 4 QL (30 EA per 30 days)
WELCHOL 3
ZETIA 3 QL (30 EA per 30 days)
Central Nervous System Agents
amphetamine/dextroamphetamine capsule er 5mg, 10mg, 15mg 2 QL (30 EA per 30 days)
amphetamine/dextroamphetamine capsule er 20mg, 25mg, 30mg 2 QL (60 EA per 30 days)
amphetamine/dextroamphetamine tablet 2
AMPYRA 5 QL (60 EA per 30 days) PA
AUBAGIO 5 QL (30 EA per 30 days) PA
AVONEX 5 PA
COPAXONE 5 PA
dexmethylphenidate hcl 2
dextroamphetamine sulfate er 2
dextroamphetamine sulfate tablet 2
EXTAVIA 5 PA
GILENYA 5 QL (30 EA per 30 days) PA
INTUNIV 4 QL (30 EA per 30 days) PA
51
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
metadate er 2
METHYLIN TABLET CHEWABLE 4
methylphenidate hcl 2
methylphenidate hcl cd capsule 10mg, 20mg, 30mg, 40mg, 50mg, 60mg
2
methylphenidate hcl er capsule 20mg, 30mg, 40mg 2
methylphenidate hcl er tablet 10mg, 20mg 2
NUEDEXTA 3 QL (60 EA per 30 days)
procentra 2
REBIF 5 PA
REBIF TITRATION PACK 5 PA
riluzole 2
SAVELLA 3 QL (60 EA per 30 days)
SAVELLA TITRATION PACK 3 QL (55 EA per 30 days)
STRATTERA CAPSULE 10MG, 18MG, 25MG, 40MG 3 QL (60 EA per 30 days)
STRATTERA CAPSULE 60MG, 80MG, 100MG 3 QL (30 EA per 30 days)
XENAZINE 5 RA
Dental and Oral Agents
chlorhexidine gluconate oral rinse 2
KEPIVANCE 5
periogard 2
pilocarpine hcl tablet 2
triamcinolone in orabase 2
Dermatological Agents
8-MOP 3
ammonium lactate rx 2
amnesteem 2
calcipotriene 2
CARAC 4
claravis 2
clindamycin phosphate foam 1% 2
52
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
clindamycin phosphate gel 1% 2
clindamycin phosphate lotion 1% 2
clindamycin phosphate solution 1% 2
clindamycin phosphate swab 1% 2
ELIDEL 4
erythromycin/benzoyl peroxide 2
fluorouracil cream 5% 2
fluorouracil topical solution 2%, 5% 2
imiquimod 2
myorisan 2
OXSORALEN 4
OXSORALEN ULTRA 3
podofilox 2
PRUDOXIN 3
REGRANEX 5 QL (30 GM per 30 days) PA
SANTYL 3
selenium sulfide lotion 2
SOLARAZE 3
SORIATANE 5
sulfacetamide sodium suspension 10% 2
TAZORAC 4
tretinoin cream 0.025%, 0.05%, 0.1% 2 PA
tretinoin gel 0.01%, 0.025% 2 PA
UVADEX 3 BvsD
VOLTAREN 3
ZONALON 3
ZYCLARA 3
ZYCLARA PUMP 3
Enzyme Replacement/Modifiers
ADAGEN 5
ALDURAZYME 5
53
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
BUPHENYL 5
CEREZYME 5
CREON 3
CYSTADANE 5
CYSTAGON 3
ELAPRASE 5
ELELYSO 5
FABRAZYME 5
KUVAN 5
LUMIZYME 5
MYOZYME 5
NAGLAZYME 5
ORFADIN 5
PANCRELIPASE 4
RAVICTI 5
sodium phenylbutyrate 2
SUCRAID 5
VPRIV 5 BvsD
XIAFLEX 5 PA
ZAVESCA 5
ZENPEP 3
Gastrointestinal Agents
AMITIZA 3 QL (60 EA per 30 days)
atropine sulfate injection 2
CARAFATE SUSPENSION 4
CHENODAL 5
cimetidine 1
cimetidine hcl 1
constulose 2
cromolyn sodium concentrate 100mg/5ml 2
54
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
CUVPOSA 4
DEXILANT 4 QL (60 EA per 30 days)
dicyclomine hcl 2
diphenoxylate/atropine 2
enulose 2
famotidine injection 1
famotidine tablet 20mg, 40mg rx 1
GATTEX 5 PA
gavilyte-c 2
gavilyte-g 2
gavilyte-n/flavor pack 2
generlac 2
glycopyrrolate injection 2
glycopyrrolate tablet 2
GOLYTELY 3
HALFLYTELY BOWEL PREP/FLAVOR PACKS 3
lactulose 2
loperamide hcl capsule rx 2
LOTRONEX 5 PA
methscopolamine bromide 2
metoclopramide hcl 2
misoprostol 2
MOVIPREP 4
NEXIUM 3 QL (60 EA per 30 days)
NEXIUM I.V. 3
NULYTELY/FLAVOR PACKS 3
omeprazole capsule delayed release rx 2 QL (60 EA per 30 days)
pantoprazole sodium injection 2
pantoprazole sodium tablet delayed release 2 QL (60 EA per 30 days)
polyethylene glycol 3350 powder 2
propantheline bromide 2
55
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
ranitidine hcl capsule, syrup 1
ranitidine hcl injection 150mg/6ml 1
ranitidine hcl tablet 150mg, 300mg rx 1
RELISTOR 3
sucralfate tablet 1
ursodiol capsule 300mg 2
Genitourinary Agents
alfuzosin hcl er 2 QL (30 EA per 30 days)
AVODART 3 QL (30 EA per 30 days)
bethanechol chloride 2
calcium acetate capsule 2
CIALIS TABLET 2.5MG, 5MG 3 QL (30 EA per 30 days) PA
eliphos 2
ELMIRON 4
finasteride tablet 5mg 2
flavoxate hcl 2
FOSRENOL 3
GELNIQUE GEL 3% 3 QL (92 GM per 30 days)
GELNIQUE GEL 10% 3 QL (30 GM per 30 days)
JALYN 3 QL (30 EA per 30 days)
MYRBETRIQ 4 QL (30 EA per 30 days)
oxybutynin chloride 2
oxybutynin chloride er tablet 5mg 2 QL (30 EA per 30 days)
oxybutynin chloride er tablet 10mg, 15mg 2 QL (60 EA per 30 days)
PHOSLO 3
PHOSLYRA 3
RAPAFLO 3 QL (30 EA per 30 days) ST
RENVELA 3
tamsulosin hcl 2
tolterodine tartrate 2 QL (60 EA per 30 days)
56
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
trospium chloride 2 QL (60 EA per 30 days)
trospium chloride er 2 QL (30 EA per 30 days)
VESICARE 3 QL (30 EA per 30 days)
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
a-hydrocort 2 BvsD
a-methapred 2 BvsD
ala cort 2
amcinonide 2
ARISTOSPAN INTRA-ARTICULAR 4
ARISTOSPAN INTRALESIONAL 4
augmented betamethasone dipropionate 2
betamethasone dipropionate 2
betamethasone valerate cream, lotion, ointment 2
clobetasol propionate gel, ointment, solution 2
clobetasol propionate e cream 2
cortisone acetate 2
DEPO-MEDROL 4 BvsD
desonide 2
dexamethasone elixir, tablet 2
dexamethasone intensol 2
dexamethasone sodium phosphate injection 2
fludrocortisone acetate 2
fluocinolone acetonide 2
fluocinolone acetonide body 2
fluocinonide 2
fluocinonide-e 2
fluticasone propionate cream 0.05% 2
fluticasone propionate lotion 0.05% 2
fluticasone propionate ointment 0.005% 2
halobetasol propionate 2
hydrocortisone butyrate 2
57
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
hydrocortisone valerate 2
hydrocortisone cream 1%, 2.5% 2
hydrocortisone lotion 2.5% 2
hydrocortisone ointment 1%, 2.5% 2
hydrocortisone tablet 2
lokara 2
methylprednisolone 2
methylprednisolone acetate 2 BvsD
methylprednisolone dose pack 2
methylprednisolone sodium succinate injection 2 BvsD
mometasone furoate cream, ointment, solution 2
prednicarbate 2
prednisolone sodium phosphate solution 5mg/5ml, 15mg/5ml 2
prednisone 2
prednisone intensol 2
procto-pak 2
PROCTOCORT CREAM 4
proctocream hc 2
proctosol hc 2
proctozone-hc 2
SOLU-CORTEF 3 BvsD
SOLU-MEDROL 3 BvsD
triamcinolone acetonide cream 0.025%, 0.1%, 0.5% 2
triamcinolone acetonide lotion 0.025%, 0.1% 2
triamcinolone acetonide ointment 0.025%, 0.1%, 0.5% 2
triderm 2
u-cort 2
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
ACTHAR HP 5 PA
desmopressin acetate 2
EGRIFTA INJECTION 1MG 5 QL (60 EA per 30 days) PA
58
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
EGRIFTA INJECTION 2MG 5 QL (30 EA per 30 days) PA
GENOTROPIN 5MG, 12MG 5 PA
GENOTROPIN MINIQUICK INJECTION 0.2MG 4 PA
GENOTROPIN MINIQUICK INJECTION 0.4MG, 0.6MG, 0.8MG, 1MG, 1.2MG, 1.4MG, 1.6MG, 1.8MG, 2MG
5 PA
HUMATROPE INJECTION 5MG, 6MG, 12MG, 24MG 5 PA
HUMATROPE INJECTION COMBO PACK 5 PA
INCRELEX 5 PA
NORDITROPIN FLEXPRO 5 PA
NORDITROPIN NORDIFLEX 5 PA
NUTROPIN 5 PA
NUTROPIN AQ 5 PA
OMNITROPE INJECTION 5MG/1.5ML, 10MG/1.5ML 4 PA
OMNITROPE INJECTION 5.8MG 5 PA
SAIZEN INJECTION 5MG, 8.8MG 5 PA
SAIZEN INJECTION CLICK.EASY 8.8MG 5 PA
SEROSTIM 5 PA
TEV-TROPIN 4 PA
ZORBTIVE 5 PA
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)
ALORA 4 PA
amethia 2
amethyst 2
ANADROL-50 5
ANDRODERM 3
ANDROGEL 3
ANDROGEL PUMP 3
ANDROXY 4
ANGELIQ 4 PA
apri 2
aranelle 2
59
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
aviane 2
balziva 2
briellyn 2
camila 2
cryselle 2
cyclafem 2
drospirenone/ethinyl estradiol 2
emoquette 2
ENJUVIA 3 PA
enpresse 2
errin 2
estradiol/norethindrone acetate 2 PA
estradiol tablet 2 PA
estropipate 2 PA
EVISTA 3
gianvi 2
gildagia 2
introvale 2
jinteli 2 PA
jolivette 2
junel 2
junel fe 2
kariva 2
kelnor 2
leena 2
lessina 2
levonest 2
levonorgestrel/ethinyl estradiol 2
levora 2
loryna 2
low-ogestrel 2
60
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
lutera 2
MAKENA 5 PA
marlissa 2
medroxyprogesterone acetate 2
MEGACE ES 3 PA
MEGACE ORAL 4 PA
megestrol acetate suspension 2 PA
megestrol acetate tablet 2 PA
MENEST 4 PA
methitest 2
microgestin 2
microgestin fe 2
mimvey 2 PA
mononessa 2
necon 2
nora-be 2
norethindrone acetate 2
nortrel 2
NUVARING 4
ocella 2
ogestrel 2
orsythia 2
ORTHO EVRA 4
OXANDRIN 5
oxandrolone tablet 2.5mg 2
oxandrolone tablet 10mg 5
PLAN B ONE-STEP 4
portia 2
PREFEST 4 PA
PREMARIN CREAM 3
PREMPRO 4 PA
61
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
previfem 2
progesterone capsule 2
quasense 2
reclipsen 2
sprintec 2
sronyx 2
TESTIM 3
testosterone cypionate 2
testosterone enanthate 2
tri-legest fe 2
tri-previfem 2
tri-sprintec 2
trinessa 2
trivora 2
velivet 2
zenchent fe 2
zovia 2
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
ARMOUR THYROID 3 PA
LEVOTHROID 3
levothyroxine sodium tablet 1
LEVOXYL 3
liothyronine sodium 2
nature-throid 2 PA
nature-throid nt 2 PA
np thyroid 2 PA
SYNTHROID 4
THYROLAR 4
UNITHROID 3
westhroid 2 PA
westhroid-p 2 PA
62
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
Hormonal Agents, Suppressant (Adrenal)
LYSODREN 3
Hormonal Agents, Suppressant (Parathyroid)
SENSIPAR TABLET 30MG 3 QL (60 EA per 30 days)
SENSIPAR TABLET 60MG 5 QL (60 EA per 30 days)
SENSIPAR TABLET 90MG 5 QL (120 EA per 30 days)
Hormonal Agents, Suppressant (Pituitary)
cabergoline 2
ELIGARD INJECTION 7.5MG 4 QL (1 EA per 30 days) PA
ELIGARD INJECTION 22.5MG 4 QL (1 EA per 90 days) PA
ELIGARD INJECTION 30MG 4 QL (1 EA per 120 days) PA
ELIGARD INJECTION 45MG 4 QL (1 EA per 180 days) PA
FIRMAGON 4 BvsD
leuprolide acetate 2 PA
LUPRON DEPOT 5 PA
LUPRON DEPOT-PED 5 PA
octreotide acetate injection 50mcg/ml, 100mcg/ml, 200mcg/ml 2
octreotide acetate injection 500mcg/ml, 1000mcg/ml 5
SANDOSTATIN INJECTION 50MCG/ML 4
SANDOSTATIN INJECTION 100MCG/ML, 200MCG/ML, 500MCG/ML, 1000MCG/ML
5
SANDOSTATIN LAR DEPOT 5
SIGNIFOR 5
SOMATULINE DEPOT 5
SOMAVERT 5
SYNAREL 5 PA
TRELSTAR DEPOT 3.75MG 3 QL (1 EA per 28 days) PA
TRELSTAR LA 11.25MG 3 QL (1 EA per 84 days) PA
TRELSTAR 22.5MG 3 QL (1 EA per 168 days) PA
ZOLADEX 4 PA
63
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
Hormonal Agents, Suppressant (Sex Hormones/Modifiers)
bicalutamide 2
flutamide 2
NILANDRON 4
XTANDI 5
Hormonal Agents, Suppressant (Thyroid)
methimazole 2
propylthiouracil 2
Immunological Agents
ACTEMRA 5 PA
ACTHIB 3
ACTIMMUNE 5
ADACEL 3
ARCALYST 5 PA RA
ATGAM 5
azathioprine 2
azathioprine sodium 2
BENLYSTA 5 PA
BOOSTRIX 3
CARIMUNE NF 5 PA
CELLCEPT CAPSULE 4 BvsD
CELLCEPT INTRAVENOUS 4 BvsD
CELLCEPT SUSPENSION, TABLET 5 BvsD
CERVARIX 3
COMVAX 3
CUPRIMINE 3
cyclosporine 2 BvsD
cyclosporine modified 2 BvsD
DAPTACEL 3
DEPEN TITRATABS 3
64
2014 Comprehensive Formulary Cigna Medicare Rx Secure
Covered Drugs By Category
Drug Name Drug Tier Requirements/Limits
ENBREL 5 PA
ENGERIX-B 3 BvsD
GAMASTAN S/D 3 PA
GAMMAGARD LIQUID 5 PA
GAMMAPLEX 5 PA
GAMUNEX-C 5 PA
GARDASIL 3
gengraf 2 BvsD
HAVRIX 3
HIZENTRA 5 PA
HUMIRA 5 PA
ILARIS 5 PA
IMOVAX RABIES (H.D.C.V.) 3
INFANRIX 3
IPOL INACTIVATED IPV 3
IXIARO 3
JE-VAX 3
leflunomide 2