January 1, 2018 Non-Medicare Formulary Change

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.

^ 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.

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.

^ 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.

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