Tier Changes

Brand Name

Strength

Common Use

Tier Change

Clinical Edits

PDL Tier

Standard Formulary

Value Formulary

Performance Formulary

Advantage Formulary

Legacy Formulary

AIMOVIG

70 MG/ML AUTOINJECTOR

Migraine

From 3 to 2

PA

2

2

2

2

2

BELBUCA

75, 150, 300, 450, 600, 750, 900 MCG FILM

Moderate-to-severe pain

Remove ST

 

2

2

2

2

2

CARAFATE

1 GM/10 ML SUSPENSION

Gastrointestinal ulcer

From 3 to 2

 

2

2

2

2

 

COMBIGEN 

0.2%-.05% EYE DROPS

Glaucoma

From 3 to 2

 

2

2

2

2

2

ESBRIET

267 MG CAPSULE, 801 MG TABLET

Pulmonary fibrosis

From 3 to 2

PA

2

2

2

2

2

FLOVENT, FLOVENT HFA

50, 100, 250 MCG DISKUS; 44, 110, 220 MCG INHALER

Asthma, COPD

From 3 to 2

 

2

2

2

2

2

LATUDA

20, 40, 60, 80, 120 MG TABLET

Schizophrenia, bipolar disorder

From 3 to 2

 

2

2

2

2

2

LETAIRIS

5, 10MG TABLET

Pulmonary arterial hypertension

From 3 to 2

PA

2

2

2

2

2

LUMIGAN

0.01% EYE DROPS

Glaucoma

From 3 to 2

 

2

NC (no change)

2

NC (no change)

2

OFEV

100, 150 MG CAPSULE

Pulmonary fibrosis

From 3 to 2

PA

2

2

2

2

2

OPSUMIT

10 MG TABLET

Pulmonary arterial hypertension

From 3 to 2

PA

2

2

2

2

2

SOOLANTRA

1% CREAM

Rosacea

From 3 to 2

 

2

2

2

2

2

STRENSIQ 

18 MG/0.45 ML, 28 MG/0.7 ML, 40 MG/ML AND 80 MG/0.8 ML VIAL

Hypophosphatasia

From 3 to 2

PA

2

2

2

2

2

TOBI PODHALER 

28 MG INHALE CAP

Bacterial infection

From 3 to 2

 

2

2

2

2

2

TRACLEER

32, 62.5, 125 MG TABLET

Pulmonary arterial hypertension

From 3 to 2

PA

2

2

2

2

2

V-GO

20, 30 AND 40 DISPOSABLE DEVICE

Diabetes

From 3 to 2

 

2

2

2

2

2

XIFAXAN

200, 500 MG TABLET

Bacterial infection

From 3 to 2

 

2

2

2

2

2

TRACLEER

32 MG TABLET FOR SUSP

Pulmonary Anti-Htn, Endothelin Receptor Antagonist

 

PA

2

2

2

2

2

V-GO

20, 30 AND 40 DISPOSABLE DEVICE

Diabetic Supplies

 

 

2

2

2

2

2

XIFAXAN

200, 500 MG TABLET

Rifamycins and related Derivative Antiobiotics

 

 

2

2

2

2

2

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 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.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, (CHLIC), Cigna Behavioral Health, Inc., Cigna Health Management, Inc., Accredo Health Group, Inc., Express Scripts, Inc., ESI Mail Pharmacy Service, Inc., Express Scripts Pharmacy, Inc., Tel-Drug, Inc., Tel-Drug of Pennsylvania, L.L.C., Lynnfield Drug, Inc., and HMO or service company subsidiaries of Cigna Health Corporation. Policy forms: OK - HP-APP-1 et al., OR - HP-POL38 02-13, TN - HP-POL43/HC-CER1V1 et al. (CHLIC). The Cigna name, logo, and other Cigna marks are trademarks of Cigna Intellectual Property, Inc. "Express Scripts" is a trademark of Express Scripts Strategic Development, Inc. This newsletter is not intended for residents of New Mexico.

© 2020 Cigna. All rights reserved