Tier Changes

Brand Name Strength Common Use Tier Change Clinical Edits Prescription Drug List Tier
Standard Formulary Value Formulary Performance Formulary Advantage Formulary Legacy Formulary
DOVATO TABLET  50-300 MG  HIV/AIDS POSITIVE    2 2 2 2 2
DULERA INHALER 100 MCG/5 MCG AND 200 MCG/5 MCG ASTHMA POSITIVE    2 2 2 2 2
ERIVEDGE CAPSULE 150 MG  CANCER POSITIVE  PA 2 2 2 2 2
FIRVANQ SOLUTION 25, 50 MG/ML ANTIBIOTIC POSITIVE    2 2 2 2 2
FYCOMPA ORAL SUSP 0.5 MG/ML  SEIZURES POSITIVE  PA 2 2 2 2 2
FYCOMPA TABLET 2, 4 , 6 , 8, 10, 12 MG SEIZURES POSITIVE  PA 2 2 2 2 2
IBRANCE  75, 100, 125 MG CANCER POSITIVE   2 2 2 2 2
MAYZENT TABLET 0.25, 2 MG  MULTIPLE SCLEROSIS POSITIVE  PA 2 2 2 2 2
MESALAMINE DR 800 MG INFLAMMATORY BOWEL DISEASE POSITIVE    1 1 1 1 1
NUVARING VAGINAL RING   CONTRACEPTIVE POSITIVE    2 (no change) 2 2 (no change) 2 2 (no change)
SIMPONI ARIA VIAL  50 MG/4 ML INFLAMMATORY CONDITIONS POSITIVE PA 2 2 2 2 2
SYMFI TABLET 600-300-300 MG  HIV/AIDS POSITIVE    2 2 2 2 2
SYMFI LO TABLET 400-300-300 MG HIV/AIDS POSITIVE    2 2 2 2 2
TRULANCE TABLET 3 MG  INFLAMMATORY BOWEL DISEASE POSITIVE    2 2 2 2 2
VERZENIO  50, 100, 150, 200 MG CANCER POSITIVE   2 2 2 2 2
XOLAIR VIAL 150 MG ASTHMA POSITIVE  PA 2 (no change) 2 (no change) 2 (no change) 2 2 (no change)
XOLAIR SYRINGE 75 MG/0.5 ML AND 150 MG/ML  ASTHAM POSITIVE  PA 2 (no change) 2 (no change) 2 (no change) 2 2 (no change)

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 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 complete details of prescription drug coverage, contact a Cigna representative.

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