January 2018 Cigna Non-Medicare Formulary Change

January 1, 2018 Non-Medicare Formulary Change

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

Cigna may make changes to our drug lists which can affect customers at the pharmacy. We include a list of impacted drugs – by drug class – that will be considered non-covered, non-preferred brand or require approval from Cigna for coverage, as well as the covered alternatives.

We send letters to our customers who are impacted explaining the changes to their current medications. However, if a customer with Cigna pharmacy benefits does attempt to refill a medication that is not covered, when appropriate, they can be assisted 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
  • Help the customer fill out this simple form below to bring to their prescriber [PDF]

1/1/18 COVERAGE CHANGE TO OXYCONTIN (Non-Medicare)

Effective 1/1/18, Cigna will no longer cover the long-acting opioid, OxyContin. Please note: This change does not affect OxyContin users in hospice or active cancer treatment. These customers will continue to receive coverage for their medication.

We sent a letter to customers who have filled a prescription for OxyContin within the last 120 days. The letter explained the coverage change to their current medication and provided information on covered alternatives, including Xtampza ER. On Cigna's formularies, Xtampza ER is the only covered long-acting preferred brand oxycodone option available to customers. We are encouraging customers who would like to remain on an oxycodone product to talk with their physician about switching to Xtampza ER. We have included the U.S. Food and Drug Administration’s dosing chart on the next page which shows the conversion to Xtampza ER. This chart is designed to assist pharmacists and physicians with prescribing Xtampza ER to their patients currently on OxyContin.

OxyContin Coverage Change

Please note that the information below only applies to our non-Medicare Standard Prescription Drug List and does not reflect the entire list of covered and not-covered drugs for this or any other Cigna drug list.

DRUG CLASSDRUG(S) NOT COVERED IN DRUG CLASS^DRUG(S) COVERED IN DRUG CLASS
PAIN RELIEF AND INFLAMMATORY DISEASE OxyContin Embeda, Hysingla ER, Xtampza ER

^ This medication is not covered in our formularies; however, health care professionals can ask Cigna to consider approving coverage through a “medical necessity” review process. Through this process, health care professionals must show that covered alternatives failed to produce results for the patient and therefore a non-covered medication should be considered for coverage.

OxyContin to Xtampza ER dosing chart

When converting from OxyContin (oxycodone hydrochloride) extended release tablets to Xtampza ER (oxycodone base) extended release capsules, consider the below dose equivalency chart, but take into account the patient’s total daily dose when finalizing a new regimen. Xtampza ER should only be dosed every 12 hours with food. Every 8 hour dosing is not necessary, or permitted for Xtampza ER. The maximum daily dose of Xtampza ER is 288 mg per day (eight 36 mg capsules, equivalent to 320 mg oxycodone HCl per day) as the safety of the excipients in Xtampza ER for doses over 288 mg/day has not been established.

OxyContinXtampza ER
10mg tablet 9mg capsule
15mg tablet 13.5mg capsule
20mg tablet 18mg capsule
30mg tablet 27mg capsule
40mg tablet 36mg capsule
60mg tablet 2x 27mg capsule
80mg tablet 2x 36mg capsule

Drug Coverage Changes by Class – For Drugs Covered Under the Pharmacy Benefit

Please note that this list only applies to our non-Medicare Standard Prescription Drug List and does not reflect the entire list of covered and not-covered drugs for this or any other Cigna drug list.

DRUG CLASSDRUG(S) NOT COVERED IN DRUG CLASS^DRUG(S) COVERED IN DRUG CLASS
ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipramine
Pamelor nortriptyline
Parnate tranylcypromine
Tofranil imipramine
ASTHMA/COPD/RESPIRATORY Zyflo montelukast, zafirlukast, zileuton ER
Zyflo CR zileuton ER
ATTENTION DEFICIT HYPERACTIVITY DISORDER Desoxyn methamphetamine
Dexedrine dextroamphetamine, dextroamphetamine ER
BLOOD PRESSURE/HEART MEDICATIONS Betapace sotalol tablets
CANCER Nilandron nilutamide
DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR
Invokana Farxiga, Jardiance
Lantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba
Novolin, Novolog Humalog, Humulin
GASTROINTESTINAL/HEARTBURN Cortifoam, Uceris rectal foam Anucort-HC, Colocort, Hemmorex-HC, hydrocortisone, Procto-Med HC, Procto-Pak, Proctosol-HC, Proctozone-HC
Lotronex alosetron
Marinol dronabinol
omeprazole bicarbonate packets, 40-1100mg capsules omeprazole
Rowasa mesalamine enema
Uceris tablet budesonide EC capsule
Zegerid omeprazole
Zofran ondansetron
Zofran ODT ondansetron ODT
HORMONAL AGENTS DDAVP desmopressin
Hectorol doxercalciferol capsule
INFECTIONS Augmentin, Augmentin ES, Augmentin XR amoxicillin-clavulanate ER, amoxicillin clavulanate
Diflucan fluconazole
E.E.S. 200, Eryped 400 erythromycin ethylsuccinate
Mepron atovaquone
Sporanox itraconazole
INFECTIONS Targadox Avidoxy tablet, doxycycline hyclate, Morgidox capsule
Valcyte valganciclovir
Vancocin vancomycin capsule
Zovirax acyclovir
MISCELLANEOUS Gralise, Horizant gabapentin
PAIN RELIEF AND INFLAMMATORY DISEASE Cambia diclofenac, diclofenac ER, etodolac, etodolac ER, fenoprofen, Fenortho, flurbiprofen, ibuprofen, indomethacin, indomethacin ER, ketoprofen, Ketorolac, meclofenamate, mefenamic acid, meloxicam, nabumetone
D.H.E. 45, Migranal dihydroergotamine
Imitrex, Sumavel DosePro sumatriptan
Lorzone chlorzoxazone
OxyContin Embeda, Hysingla ER, Xtampza ER
Roxicodone oxycodone
Tivorbex indomethacin
Vanatol LQ butalbital/acetaminophen/caffeine tabs or caps
Vivlodex meloxicam
Zomig sumatriptan, zolmitriptan
Zorvolex diclofenac, diclofenac ER
PARKINSON'S DISEASE Lodosyn carbidopa
Requip XL ropinirole ER
SCHIZOPHRENIA/ANTI-PSYCHOTICS Geodon ziprasidone
Zyprexa olanzapine
Zyprexa Zydis olanzapine ODT
SKIN CONDITIONS Cutivate fluticasone cream
Kenalog triamcinolone spray
Locoid lotion hydrocortisone butyrate
Luzu ketoconazole cream
Soriatane acitretin
Ziana clindamycin-tretinoin
SLEEP DISORDERS/SEDATIVES Nuvigil armodafinil
Provigil modafinil
Restoril temazepam
URINARY TRACT CONDITIONS Detrol tolterodine
Detrol LA tolterodine ER
Ditropan XL oxybutynin ER
Enablex darifenacin ER
Gelnique darifenacin ER, oxybutynin ER, tolterodine ER, trospium ER
DRUG CLASS NON-PREFERRED BRAND DRUG(S) GENERIC AND/OR PREFERRED BRAND ALTERNATIVES
ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER
Focalin XR dexmethylphenidate ER
SKIN CONDITIONS Ala-Scalp hydrocortisone
Analpram HC lotion hydrocortisone-pramoxine
Capex shampoo fluocinolone
Cordran flurandrenolide
Nucort, Texacort hydrocortisone
DRUG CLASS DRUG(S) REQUIRING PRIOR AUTHORIZATION ADDITIONAL INFORMATION
GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi Your plan will only cover this medication if the customer’s doctor requests and receives approval from Cigna.
HORMONAL AGENTS Androderm, Androgel, Striant, testosterone
DRUG CLASS DRUG(S) WITH QUANTITY LIMITS ADDITIONAL INFORMATION
ALLERGY/NASAL SPRAYS cromolyn oral, mometasone Your plan only covers a certain amount of this medication over a certain number of days.
ALZHEIMER'S DISEASE Namenda XR, Namzaric
ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine 25mg, 100mg, Marplan, Pristiq
ASTHMA/COPD/RESPIRATORY Perforomist
BLOOD PRESSURE/HEART MEDICATIONS Ranexa
CANCER Fareston, nilutamide
EYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan
HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem
MISCELLANEOUS Nuedexta
OSTEOPOROSIS PRODUCTS alendronate
PAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, Mitigare
SCHIZOPHRENIA/ANTI-PSYCHOTICS Fanapt
SEIZURE DISORDERS Gabitril, Potiga
SKIN CONDITIONS Denavir, Regranex, Santyl, Vectical
SLEEP DISORDERS/SEDATIVES Hetlioz
DRUG CLASS STEP THERAPY GENERIC AND/OR PREFERRED BRAND ALTERNATIVES
ATTENTION DEFICIT HYPERACTIVITY DISORDER Focalin XR dexmethylphenidate ER
SCHIZOPHRENIA/ANTI-PSYCHOTICS Orap pimozide
SKIN CONDITIONS Ala-Scalp hydrocortisone
Capex shampoo fluocinolone
Cordran flurandrenolide
Nucort, Texacort hydrocortisone
DRUG CLASS DOSE OPTIMIZATION - DRUG STRENGTH WITH LIMITATIONS^^
(Plan does not cover 2 capsules/tablets per day)
COVERED DRUG STRENGTH
(Prescription must be for this strength)
ALLERGY/NASAL SPRAYS desloratadine ODT 2.5mg desloratadine ODT 5mg
ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg
Fetzima ER 40mg Fetzima ER 80mg
Trintellix 5mg Trintellix 10mg
Trintellix 10mg Trintellix 20mg
BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg
Benicar 20mg Benicar 40mg
Benicar HCT 20-12.5mg Benicar HCT 40-25mg
Bystolic 10mg Bystolic 20mg
Tekturna 150mg Tekturna 300mg
Tekturna HCT 150-12.5mg Tekturna HCT 300-25mg
CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg
Livalo 2mg Livalo 4mg
DIABETES Farxiga 5mg Farxiga 10mg
PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg
SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg
SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg
Aptiom 400mg Aptiom 800mg
Fycompa 4mg Fycompa 8mg
Fycompa 6mg Fycompa 12mg
Trokendi XR 25mg Trokendi XR 50mg
Trokendi XR 100mg Trokendi XR 200mg
SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg
DRUG CLASS BENEFIT PLAN EXCLUSIONS*  
EAR MEDICATIONS Cortane-B Lotion  
GASTROINTESTINAL/HEARTBURN Donnatal Elixir, Gelclair Oral Gel Packet, Proctocort 30 Mg Suppository
INFECTIONS Benzodox 30 Kit, Benzodox 60 Kit, Urelle Tablet
NUTRITIONAL/DIETARY Feriva FA Capsule
PAIN RELIEF AND INFLAMMATORY DISEASE Analpram HC 2.5%-1% Crm Single, Prodrin Caplet
SEIZURE DISORDERS Smartrx Gabakit
DRUG CLASS BENEFIT PLAN EXCLUSIONS*
SKIN CONDITIONS Ala-Quin 3-0.5% Cream, Avar 9.5%-5% Foam, Avar 9.5-5% Cleansing Pads, Avar LS 10%-2% Foam, Avar LS 10-2% Cleansing Pads, Avar LS Cleanser, Avar-E LS Cream, Dermasorb AF Complete Kit, Inova 4% Easy Pad, Inova 4-1 Easy Pad, Inova 8-2 Easy Pad, Iodoflex Pad, Keralac 47% Cream, Neosalus Foam, Ovace 10% Wash, Ovace Plus 10% Shampoo, Ovace Plus 10% Wash, Ovace Plus 9.8% Foam, Ovace Plus 9.8% Lotion, Ovace Plus Wash 10% Clnsng Gel, Plexion 9.8-4.8% Cleanser, Plexion 9.8-4.8% Clnsing Cloth, Plexion 9.8-4.8% Cream, Plexion 9.8-4.8% Lotion, Rynoderm 37.5% Topical Cream, Salex 6% Cream Kit, Salex 6% Lotion Kit, Salex 6% Shampoo, Salvax 6% Foam, Selrx 2.3% Shampoo, Sumadan 9%-4.5% Wash, Sumadan Kit, Sumadan XLT Kit, Sumaxin Cleansing Pads, Sumaxin CP Kit, Sumaxin TS Topical Suspension, Sumaxin Wash, Ultrasal-ER 28.5% Solution, Uramaxin GT 45% Pre-Filled App, Urevaz 44% Cream, Vanoxide-HC Lotion, Virasal Antiviral Wart Remover, Vytone Cream Packet, Zithranol 1% Shampoo

^ These medications are not covered in our formularies; however, health care professionals can ask Cigna to consider approving coverage through a “medical necessity” review process. Through this process, health care professionals must show that covered alternatives failed to produce results for the patient and therefore a non-covered medication should be considered for coverage.

^^ These drugs are part of the Dose Optimization program. There is a “medical necessity” review process in place for customers who have proven a higher dose once per day is not clinically appropriate and require the use of a lower strength twice per day.

* This product’s eligibility for coverage varies by manufacturer because not all versions of the product have been approved by the FDA for marketing. Products not approved by the FDA for marketing are excluded from coverage under benefit plans.

Drug Coverage Changes by Class – For Drugs Covered Under the Medical Benefit

This list only applies to our non-Medicare Standard Prescription Drug List and does not reflect the entire list of covered and not-covered drugs for this or any other Cigna drug list. Please note that drugs are listed alphabetically by brand name, with the generic name in parenthesis.

DRUG CLASSDRUG(S) REQUIRING PRIOR AUTHORIZATION
GASTROINTESTINAL/HEARTBURN

Adriamycin (Doxorubicin Hcl), Adrucil (Fluorouracil), Alkeran (Melphalan Hcl), Aloxi (Palonosetron Hcl), Arranon (Nelarabine), Arzerra (Ofatumumab), Bleomycin (Bleomycin Sulfate), Camptosar (Irinotecan Hcl), Cerubidine (Daunorubicin Hcl), Clolar (Clofarabine), Cosmegen (Dactinomycin), Cytosar-U (Cytarabine), Dacogen (Decitabine), Depocyt (Cytarabine Liposome/Pf), Doxil (Doxorubicin Hcl Peg-Liposomal), Dtic-Dome (Dacarbazine), Ellence (Epirubicin Hcl), Eloxatin (Oxaliplatin), Emend (Fosaprepitant Dimeglumine), Faslodex (Fulvestrant), Fludara (Fludarabine Phosphate), Folotyn (Pralatrexate), Fudr (Floxuridine), Fusilev (Levoleucovorin Calcium), Gemzar (Gemcitabine Hcl), Hycamtin (Topotecan Hcl), Idamycin (Idarubicin Hcl), Ifex (Ifosfamide), Istodax (Romidepsin), Ixempra (Ixabepilone), Leustatin (Cladribine), Mustargen (Mechlorethamine Hcl), Mutamycin (Mitomycin), Navelbine (Vinorelbine Tartrate), Nipent (Pentostatin), Novantrone (Mitoxantrone Hcl), Oncaspar (Pegaspargase), Paraplatin (Carboplatin), Platinol (Cisplatin)

Proleukin (Aldesleukin), Taxol (Paclitaxel), Taxotere (Docetaxel), Temodar (Temozolomide), Tepadina (Thiotepa), Toposar (Etoposide), Torisel (Temsirolimus), Trisenox (Arsenic Trioxide), Velban (Vinblastine Sulfate), Velcade (Bortezomib)

Vidaza (Azacitidine), Vincasar (Vinblastine Sulfate), Vumon (Teniposide), Zanosar (Streptozocin)

Pharmacy Forms

Submit a Maximum Allowable Cost (MAC) review form [PDF] 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