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 CLASS | DRUG(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.
OxyContin | Xtampza 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 CLASS | DRUG(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 CLASS | DRUG(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.