December 2018

Generic Drug Additions

GENERIC NAME

STRENGTH

CORRESPONDING BRAND NAME


COMMON USE

CLINICAL EDITS

Copay TIER

Standard formulary

Value
formulary

Performance formulary

Advantage formulary

Legacy formulary

ALBENDAZOLE

200 MG

ALBENZA

Parasitic infections

 

1

1

1

1

1

AMPHETAMINE SULFATE

5, 10 MG

EVEKEO

ADD/ADHD

 

1

1

1

1

1

BENOXINATE HCL/FLUORESCEIN SOD

0.4%–0.25%

FLURESS

Ophthalmic procedures

 

1

1

1

1

1

BUDESONIDE

9 MG

UCERIS

Ulcerative colitis

 

1

1

1

1

1

BUPROPION HCL

450 MG

FORFIVO XL

Anti-depressant

QL

1

1

1

1

1

BUTALBITAL/
ACETAMINOPHEN     

50 MG –
300 MG

BUTALBITAL-
ACETAMINOPHEN

Migraine headache

 

NC

NC

NC

NC

1

CLINDAMYCIN PHOS/BENZOYL PEROX

1.2%–2.5%

ACANYA

Acne

 

1

1

1

1

1

CLINDAMYCIN PHOSPHATE

1.00%

CLINDAGEL

Acne

 

1

1

1

1

1

CLOBAZAM

2.5, 10,
20 MG

ONFI

Seizures

 

1

1

1

1

1

COLESEVELAM HCI

3.75 G

WELCHOL

Hyper-

cholesterolemia

 

1

1

1

1

1

CROTAMITON

10%

EURAX

Scabies or pruritis

 

1

1

1

1

1

DALFAMPRIDINE

10 MG

AMPYRA

Multiple sclerosis

PA

1

1

1

1

1

DESOXIMETASONE

0.25%

TOPICORT

Topical inflammatory conditions

 

1

1

1

1

1

DEXAMETHASONE

1.5 MG

DEXPAK

Inflammatory or allergic conditions

 

NC

NC

NC

NC

1

DORZOLAMIDE/TIMOLOL

2 %–0.5 %

COSOPT PF

Glaucoma

 

1

1

1

1

1

GLYCOPYRROLATE

1.5 MG

GLYCATE

Peptic ulcer

 

1

1

1

1

1

ITRACONAZOLE

10 MG/ML

SPORANOX

Fungal infections

 

1

1

1

1

1

LACTULOSE

10 G

KRISTALOSE

Laxative

 

1

1

1

1

1

LIDOCAINE/EMOLLIENT CMB NO.102

5%

DERMACINRX PHN PAK

Topical inflammatory conditions

 

1

1

1

1

1

LULICONAZOLE

1%

LUZU

Topical antifungal

 

1

1

1

1

1

METFORMIN HCL

500 MG/
5 ML

RIOMET

Diabetes, type II

 

1

1

1

1

1

MORPHINE
SULFATE

40 MG

KADIAN

Severe pain

PA, QL

1

1

1

1

1

TADALAFIL

20 MG

ADCIRCA

Pulmonary arterial hypertension

 

1

1

1

1

1

TADALAFIL

2.5,5,10,
20 MG

CIALIS

Erectile dysfunction or benign prostatic hyperplasia

PA

1

1

1

1

1

TESTOSTERONE

20.25/1.25. 1.25G-1.62,2.5G-1.62

ANDROGEL

Testosterone deficiency

PA, QL

1

1

1

1

1

VARDENAFIL HCL

2.5,5,10,
20 MG

LEVITRA

Erectile dysfunction

PA, QL

1

1

1

1

1

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.

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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.

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