December 2018

Brand Drug Additions

BRAND
NAME

STRENGTH

COMMON
USE

CLINICAL EDITS

Copay TIER

Standard
formulary

Value
formulary

Performance
formulary

Advantage
formulary

Legacy
formulary

AJOVY

225 MG/1.5

Prevention of migraine

 

NC

NC

NC

NC

3

ALTRENO

0.05%

Acne

PA

3

3

3

3

3

ARIKAYCE

590 MG/8.4

Antibiotic

PA

3

3

3

3

3

COPIKTRA

15, 25 MG

Leukemia, lymphoma

PA

3

3

3

3

3

DELSTRIGO

100–300 MG

HIV/AIDS

 

3

3

3

3

3

DUPIXENT

200 MG/1.14

Eczema, asthma

PA

3

3

3

3

3

EMGALITY

120 MG/ML

Prevention of migraine

 

NC

NC

NC

NC

3

EPIDIOLEX

100 MG/ML

Seizures

PA

3

3

3

3

3

GALAFOLD

123 MG

Fabry's disease

PA

3

3

3

3

3

ILARIS

150 MG/ML

Cryopyrin-associated periodic syndromes (CAPS), other rare inflammatory conditions

PA

3

3

3

3

3

KAPSPARGO SPRINKLE           

25, 50, 100, 200 MG    

Hypertension

 

3

3

3

3

3

LENVIMA

4, 12 MG

Thyroid, kidney, liver cancer

PA

3

3

3

3

3

MACRILEN                     

0.5 MG/ML

Diagnostic for adult growth hormone deficiency

 

3

3

3

3

3

MINOLIRA ER

105, 135 MG

Antibiotic

 

NC

NC

NC

NC

3

MULPLETA

3 MG

Increase platelet count in chronic liver disease

PA

3

3

3

3

3

NIVESTYM

300, 480 MCG

Increase white blood cell count in cancer

PA

3

3

3

3

3

NOCDURNA

25, 50 MCG

Nocturnal polyuria

 

NC

NC

NC

NC

3

NUPLAZID                     

10, 34 MG    

Psychosis in Parkinson's disease

PA

3

3

3

3

3

ORKAMBI

100–125, 150–188 MG

Cystic fibrosis

PA, QL

3

3

3

3

3

PIFELTRO

100 MG

HIV/AIDS

 

3

3

3

3

3

QBREXZA

2.40%

Excessive sweating

 

NC

NC

NC

NC

3

SIGNIFOR LAR

10,30 MG

Acromegaly, Cushing's disease

PA

3

3

3

3

3

SOMAVERT

10 MG

Acromegaly

PA

2

2

2

3

2

SYMTUZA

800-150 MG

HIV/AIDS

 

3

3

3

3

3

TAKHZYRO

300 MG/2 ML

Hereditary angioedema

PA

3

3

3

3

3

TALZENNA

0.25,1.0 MG

Breast cancer

PA

3

3

3

3

3

TEGSEDI

284 MG

Hereditary amyloidosis

PA

3

3

3

3

3

TIBSOVO                      

250 MG   

Acute myeloid leukemia

PA

3

3

3

3

3

TIGLUTIK

50 MG/10 ML

Amyotrophic lateral sclerosis (ALS)

PA

3

3

3

3

3

VIZIMPRO

15,30,45 MG

Lung cancer

PA

3

3

3

3

3

XARELTO

2.5 MG

Prevention or treatment of blood clots

 

2

2

2

2

2

XEPI

1%

Impetigo

 

NC

NC

NC

NC

3

XOFLUZA

20,40 MG

Seasonal influenza

QL

3

3

3

3

3

ZORTRESS

1 MG

Prevent organ rejection after transplant

 

3

3

3

3

3

ZTLIDO

1.80%

Pain due to postherpetic neuraligia

 

NC

NC

NC

NC

3

PA: Prior authorization
QL: Quantity limit
ST: Step Therapy
T1/Tier 1: Generic
T2/Tier 2: Brand
T3/Tier 3: Non-preferred
NC: Not Covered: This drug is not covered. However, if the covered alternative is not appropriate for the customer, there is a process where his/her provider can request approval of this drug.

Legal Disclaimer | Privacy | Product Disclosures | Cigna Company Names

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. Some plans require you to use an in-network pharmacy for prescriptions to be covered. Coverage is subject to any plan deductible, copayment and/or coinsurance requirements. Product availability may vary by location and plan type and is subject to change. All group health insurance policies and health benefit plans contain exclusions and limitations. For costs and details of coverage, contact a Cigna representative. Group medical and pharmacy plans are insured and/or administered by Cigna Health and Life Insurance Company or its affiliates. Policy forms: OK - HP-APP-1 et al., OR - HP-POL38 02-13, TN - HP-POL43/HC-CER1V1 et al. All pictures are used for illustrative purposes only. This website is not intended for residents of New Mexico.

© 2019 Cigna. All rights reserved