|
BRAND |
STRENGTH |
COMMON |
CLINICAL EDITS |
Copay TIER |
||||
|
Standard |
Value |
Performance |
Advantage |
Legacy |
||||
| ABILIFY MYCITE | 2,5,10,15,20,30 MG | Schizophrenia and bipolar disorder | NC | NC | NC | NC | 3 | |
| ACTEMRA ACTPEN | 162 MG/0.9 ML | Inflammatory conditions | PA | 2 | 2 | 2 | 2 | 2 |
| AEMCOLO | 194 MG | Traveler's diarrhea | QL | 3 | 3 | 3 | 3 | 3 |
| BRYHALI | 0.01% | Psoriasis | NC | NC | NC | NC | 3 | |
| CEQUA | 0.09% | Dry eye | NC | NC | NC | NC | 3 | |
| DAURISMO | 25,100 MG | Leukemia | PA | 3 | 3 | 3 | 3 | 3 |
| FIRDAPSE | 10 MG | Lambert-Eaton myasthenic syndrome | PA, QL | 3 | 3 | 3 | 3 | 3 |
| GRANIX | 300 MCG/ML | Neutropenia (low white blood cell count) | 2 | 2 | 2 | 2 | 2 | |
| INVELTYS | 1% | Ophthalmic inflammation following surgery | NC | NC | NC | NC | 3 | |
| LORBRENA | 25,100 MG | Lung cancer | PA | 3 | 3 | 3 | 3 | 3 |
| NUZYRA | 150 MG | Bacterial pneumonia and skin infections | PA | 3 | 3 | 3 | 3 | 3 |
| OXERVATE | 0.002% | Neurotrophic keratitis | PA | 3 | 3 | 3 | 3 | 3 |
| SEYSARA | 60,100,150 MG | Acne | NC | NC | NC | NC | 3 | |
| SIKLOS | 1000 MG | Sickle cell anemia | PA | 3 | 3 | 3 | 3 | 3 |
| SYMPAZAN | 5,10,20 MG | Lennox-Gastault syndrome | NC | NC | NC | NC | 3 | |
| TIROSINT | 175,200 MCG | Hypothyroidism | 3 | 3 | 3 | 3 | 3 | |
| TOLSURA | 65 MG | Systemic fungal infections | NC | NC | NC | NC | 3 | |
| TRESIBA | 100/ML | Diabetes | 2 | 2 | 2 | 2 | 2 | |
| UDENYCA | 6 MG/0.6ML | Neutropenia (low white blood cell count) | NC | NC | NC | NC | 3 | |
| VITRAKVI | 25 MG,100 MG,20 MG/ML | Solid tumors | PA | 3 | 3 | 3 | 3 | 3 |
| XELPROS | 0.005% | Glaucoma | 3 | 3 | 3 | 3 | 3 | |
| XOLAIR | 75MG/0.5ML,150MG/ML | Asthma | PA | 2 | 2 | 2 | 3 | 2 |
| XOSPATA | 40 MG | Leukemia | PA | 3 | 3 | 3 | 3 | 3 |
| XYOSTED | 50MG/0.5ML, 75 MG/0.5 ML, 100 MG/0.5 ML | Testosterone replacement | NC | NC | NC | NC | 3 | |
| YUPELRI | 175MCG/3ML | Chronic obstructive pulmonary disease (COPD) | NC | NC | NC | NC | 3 | |
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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