Generic Drug Additions

Generic Name Strength Corresponding Brand Name Common Use Clinical Edits Prescription Drug List Tier
Standard Formulary Value Formulary Performance Formulary Advantage Formulary Legacy Formulary
orphenadrine/aspirin/caffeine 50/770/60 mg Norgesic Forte Pain   1 1 1 1 1
metyrosine 250 mg Demser Pheochromocytoma   1 1 1 1 1
deferasirox 90, 180, 360 mg Jadenu Sprinkle Treatment of chronic iron overload   1 1 1 1 1
ciproflox-dexameth otic susp 0.3%/0.1% Ciprodex Otic suspension Ear infection   1 1 1 1 1
pantoprazole sodium susp 40 mg Protonix suspension Acid reflux QL 1 1 (buy-up) 1 1 (buy-up) 1
dimethyl fumarate 120, 240 mg Tecfidera Multiple Sclerosis PA 1 1 1 1 1

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.

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.

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