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
ERLEADA 60mg Treats prostate cancer that has not spread to other parts of the body and no longer responds to a medical or surgical treatment that lowers testosterone Positive PA 2 2 2 2 2
INVOKANA 100mg and 300mg Sodium-glucose co-transporter 2 (SGLT2) inhibitor used to control blood sugar in people with type 2 diabetes mellitus, in addition to diet and exercise Positive   2 2 (no change) 2 2 (no change) 2 (no change)
PICATO 0.05% and 0.015% Gel treatment for actinic keratosis Positive   2 2 (no change) 2 2 (no change) 2
SYMTUZA 800-150-200-10mg Oral treatment to help control Human Immunodeficiency Virus-1 (HIV-1) infection Positive   2 2 2 2 2
UPTRAVI 200mg, 400mg, 600mg, 800mg, 1000mg, 1200mg, 1400mg and 1600mg Prostacyclin receptor agonist indicated for the
treatment of pulmonary arterial hypertension (PAH, WHO Group I) 
Positive PA 2 2 2 2 2
VELPHORO 500mg Phosphate binder that helps prevent hypocalcemia (low levels of calcium in the blood) caused by elevated phosphorus Positive   2 2 (no change) 2 2 (no change) 2
VIBERZI 75mg and 100mg Treats irritable bowel syndrome with diarrhea (IBS-D) Positive   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.

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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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