Brand Drug Additions

Brand Name Strength Common Use Clinical Edits Prescription Drug List Tier
Standard Formulary Value Formulary Performance Formulary Advantage Formulary Legacy Formulary
Tazverik 200 mg Epithelioid sarcoma PA 3 3 3 3 3
Procysbi Granules 75, 300 mg Treatment of nephropathic cystinosis PA 3 3 3 3 3
Nexletol 180 mg Hypercholesterolemia PA, QL 3 NC 3 NC 3
Xcopri 50, 100, 150, 200, 250, 350 mg + titration packs Treatment of partial onset seizures PA, QL 3 3 3 3 3
Ubrelvy 50, 100 mg Treatment of acute migraine PA, QL 2 2 2 2 2
Nurtec ODT 75 mg Treatment of acute migraine PA, QL 2 2 2 2 2
Pemazyre 4.5, 9, 13.5 mg Treatment of metastatic cholangiocarcinoma PA, QL 3 3 3 3 3
Tukysa 50, 150 mg Used in combination for HER2-positive breast cancer PA 3 3 3 3 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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