| Generic Name | Strength | Corresponding Brand Name | Common Use | Clinical Edits | Prescription Drug List Tier | ||||
| Standard Formulary | Value Formulary | Performance Formulary | Advantage Formulary | Legacy Formulary | |||||
| dimethyl fumarate | 120mg & 240mg | Tecfidera | Multiple Sclerosis | PA | T1 | T1 | T1 | T1 | T1 |
| emtricitabine | 200mg | Emtriva | HIV | PA | T1 | T1 | T1 | T1 | T1 |
| PEG3350/sod/sul/nacl/kcl/asb/c | powder | Moviprep | Bowel Prep | T1 | T1 | T1 | T1 | T1 | |
| sapropterin dihydrochloride | 100mg | Kuvan | Phenylketonuria | PA | T1 | T1 | T1 | T1 | T1 |
| tobramycin | 300mg/4ml | Bethkis | Cystic Fibrosis | PA, QL | T1 | T1 | T1 | T1 | T1 |
| diclofenac submicronized | 35mg | Zorvolex | Anti-inflammatory | NC | T3 | T3 | T3 | T3 | T3 |
| efavirenz/lamivu/tenofov disop | 400/300/300mg | Symfi Lo | HIV | T1 | T1 | T1 | T1 | T1 | |
| efavirenz/lamivu/tenofov disop | 600/300/300mg | Symfi | HIV | T1 | T1 | T1 | T1 | T1 | |
| deferiprone | 500mg | Ferriprox | Iron chelator | PA | T1 | T1 | T1 | T1 | T1 |
| lapatinib ditosylate | 250mg | Tykerb | Breast Cancer | PA | T1 | T1 | T1 | T1 | T1 |
| emtricitabine/tenofovir | 200/300mg | Truvada | HIV | T1 | T1 | T1 | T1 | T1 | |
| efavirenz/emtricit/tenofovr df | 600/200/300mg | Atripla | HIV | PA | T1 | T1 | T1 | T1 | T1 |
| fosfomycin | 3gm | Monurol | Antibiotic | T1 | T1 | T1 | T1 | T1 | |
| tavaborole | 5% | Kerydin | Antifungal | NC | T1 | T1 | T1 | T1 | T1 |
| rufinamide | 40mg/ml | Banzel | Anticonvulsant | PA, QL | T1 | T1 | T1 | T1 | T1 |
| icosapent ethyl | 1 gm | Vascepa | Hypertriglyceridemia | T1 | T1 | T1 | T1 | T1 | |
| timolol maleate/PF | 0.50% | Timoptic Ocudose | Glaucoma | T1 | T1 | T1 | T1 | T1 | |
| norethindrone-e.estradiol-iron | 1mg-20mcg/75mg | Taytulla | Contraception | T1 | T1 | T1 | T1 | T1 | |
| levothyroxine sodium | all | Tirosint | Thyroid | PA(Val/Adv) | T3 | T3 | T3 | T3 | T3 |
| ivermectin | 0.50% | Sklice | Head Lice | T1 | T1 | T1 | T1 | T1 | |
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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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, review your plan documents or contact a Cigna representative.
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