|Brand Name||Strength||Common Use||Clinical Edits||Prescription Drug List Tier|
|Standard Formulary||Value Formulary||Performance Formulary||Advantage Formulary||Legacy Formulary|
|EGRIFTA SV||2 MG||GROWTH HORMONE RELEASING HORMONE(GHRH) AND ANALOGS||PA||3||3||3||3||3|
|OLUMIANT||1 MG||JANUS KINASE (JAK) INHIBITORS||PA, QL||3||3||3||3||3|
|PRETOMANID||200 MG||ANTITUBERCULAR ANTIBIOTICS||PA, QL||3||3||3||3||3|
|ZIEXTENZO||6 MG/0.6ML||LEUKOCYTE (WBC) STIMULANTS||PA||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.
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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