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January 2017 Cigna Non-Medicare Formulary Change

When Cigna makes formulary changes that may affect customers, we provide a list of the drugs that are affected.


Effective January 1, 2017, Cigna has made formulary changes that may affect customers at your pharmacy. Cigna has limited the number of preferred drugs in certain drug classes within our formularies. Some drug classes now feature one or a select set of preferred brand name drugs, and other brand name equivalent drugs are covered by going through Cigna’s medical necessity review process. We have included a list of drugs – by drug class – that are considered non-covered or non-preferred brand as of January 1, 2017 and their covered alternatives. We sent letters to the customers and prescribers explaining the effect, based on their current medications. However, if a customer with Cigna pharmacy benefits does come in and attempts to refill a medication that is not covered, when appropriate, we ask that you assist them in the following ways:

  • Mention the alternative covered drugs available in the chart below
  • Urge the customer to meet with the prescriber to discuss these alternatives or please call the prescriber to facilitate the new prescription

Please help the customer fill out this simple form to bring to their prescriber.

Drug classNon-preferred brand medicationGeneric and/or preferred brand alternatives
Blood Modifiers/Bleeding Disorders Neupogen+ Granix, Zarxio
Cancer Gleevec imatinib mesylate
Cholesterol Medications Lescol XL generic statins
Pain Relief & Inflammatory Disease Kadian, Nucynta ER, Xartemis XR Hysingla ER, OxyContin, Xtampza ER


Drug classMedication not covered^Generic and/or preferred brand alternatives
Allergy/Nasal Sprays Beconase AQ, Dymista, Nasonex, Omnaris, QNASL, Veramyst, Zetonna budesonide, flunisolide, fluticasone propionate, mometasone furoate, triamcinolone acetonide
QNASL Children fluticasone propionate, budesonide, triamcinolone acetonide
Anxiety/Depression/Bipolar Disorder Aplenzin bupropion XL
Ativan lorazepam
Pexeva paroxetine
Asthma/COPD/Respiratory Aerospan, Alvesco, Arnuity Ellipta, Asmanex, Asmanex HFA, Flovent Diskus, Flovent HFA QVAR, Pulmicort Flexhaler
Dulera Advair HFA, Advair Diskus, Breo Ellipta, Symbicort
Incruse Ellipta, Tudorza Pressair Spiriva, Spiriva Respimat
Proventil HFA, Xopenex HFA ProAir Respiclick, ProAir HFA, Ventolin HFA
Blood Pressure/Heart Medications Cardizem CD cartia XT, diltiazem 24hr CD, diltiazem 24hr ER
Isordil isosorbide
Diabetes Fortamet, metformin ER (when filled as generic to Glumetza) metformin ER (when filled as generic to Glucophage XR or generic to Fortamet)
Jardiance, Synjardy Invokamet, Invokana, Farxiga, Xigduo XR
Tanzeum, Victoza Trulicity, Bydureon, Byetta
Gastrointestinal/Heartburn Asacol HD, Colazal, Delzicol, Dipentum, Giazo Apriso, balsalazide, Lialda, mesalamine, Pentasa, sulfasalazine
Librax chlordiazepoxide-clidinium
Metozolv ODT metoclopramide, metoclopramide ODT
Nexium esomeprazole magnesium
Pepcid famotidine
Zegerid omeprazole-sodium bicarbonate, omeprazole, omeprazole+syrspend sf alka
Zuplenz ondansetron, ondansetron ODT
Hormonal Agents Rayos prednisone, prednisone intensol
Saizen Humatrope


Drug classMedication not covered^Generic and/or preferred brand alternatives
Infections Bethkis, Tobi Kitabis Pak, tobramycin
Sitavig acyclovir
Pain Relief and Inflammatory Disease Amrix baclofen, carisoprodol, cyclobenzaprine, methocarbamol, tizanidine
Belbuca Butrans
diclofenac 1.5% solution, klofensaid II, Pennsaid diclofenac 1% gel, generic oral NSAIDs (diclofenac, ibuprofen, meloxicam, naproxen)
Lido-K lidocaine, lidopin
Sprix ketorolac tromethamine
Treximet generic triptans (naratriptan, sumatriptan, zolmitriptan) plus a generic NSAID (ibuprofen, meloxicam, naproxen)
Zembrace Symtouch sumatriptan
Schizophrenia/Anti-Psychotics Abilify, Abilify ODT  
Fazaclo, Versacloz  
Seizure Disorders Mysoline  
Skin Conditions Absorica claravis, myorisan, zenatane
Benzaclin, Duac, Neuac kit clindamycin-benzoyl peroxide, neuac gel
Carac fluorouracil
Clindagel clindamycin phosphate
Jublia, Kerydin ciclodan, ciclopirox, itraconazole, terbinafine
Noritate metronidazole, rosadan
Novacort hydrocortisone
Vanos fluocinonide
Xerese acyclovir, hydrocortisone
Zovirax acyclovir
Zyclara imiquimod
Sleep Disorders/Sedatives Edluar, Intermezzo zolpidem tartrate, zolpidem tartrate ER
Substance Abuse Evzio naloxone vial & PFS, Narcan
Urinary Tract Conditions Myrbetriq, Toviaz, VESIcare darifenacin ER, oxybutynin chloride ER, tolterodine tartrate ER, trospium chloride ER


Drug classMedication with Quantity Limits
Pain Relief and Inflammatory Disease Lidocaine 5% ointment

Pharmacy Forms

Submit a Maximum Allowable Cost (MAC) review form for Cigna Preferred pharmacies to request a higher amount of pharmacy coverage for a patient.

Submit an Optum Maximum Allowable Cost (MAC) review form for Cigna Non-Preferred pharmacies to request a higher amount of pharmacy coverage for a patient.

View all Pharmacy forms at CignaforHCP