July 2017 Non-Medicare Formulary Changes

July 1, 2017 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]

Drug Coverage Changes by Class

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 classNon-preferred brand** medication**Generic and/or preferred brand alternatives
Infections Daklinza+ Epclusa+, Harvoni+, Sovaldi+
Drug classMedication not covered^Generic and/or preferred brand alternatives
Blood Pressure/ Heart Medications Cardizem Diltiazem
Isordil Titradose digitek, digox, digoxin
Lanoxin isosorbide dinitrate
Cholesterol Medications Antara, Fenoglide fenofibrate
Cough/Cold Medications Tussicaps hydrocodone-chlorpheniramne ER, promethazine-codeine
Diuretics Edecrin, ethacrynic acid bumetanide,furosemide, torsemide
Gastrointestinal/ Heartburn Anusol-HC suppository anucort-HC, Grx Hicort 25, hemmorex-HC, hydrocortisone, rectacort HC
Omeclamox- pak, Prevpac, Pylera lansoprazole-amoxicilin-clarithromycin (combo pak)
Hormonal Agents Dexpak dexamethasone
Infections Onmel itraconazole, terbinafine
Pain Relief and Inflammatory Disease Conzip tramadol, tramadol ER
Levorphanol tartate acetaminophen-codeine, hydrocodone acetaminophen, hydromorphone ER, hydromorphone, lorcet, lorcet HD, lorcet plus, oxycodone, oxycodone ER, tramadol, verdrocet, vicodin, vicodin ES, vicodin HP
Naprelan, naproxen CR, naproxen ER, Zipsor diclofenac, diclofenac ER, etodolac, etodolac ER, fenoprofen, flurbiprofen, ibuprofen, indomethacin, ketoprofen, ketorolac, meclofenamate, mefenamic acid, meloxicam, nabumetone, naproxen, naproxen DS, oxaprozin, piroxicam, sulindac, tolmentin
Zomig ZMT zolmitriptan ODT
Skin Conditions Aldara Imiquimod
Anusol-HC cream hydrocortisone, protco-med HC proctosol-HC, proctozone-HC
Clobex clobetasol, clodan shampoo
Ertaczo ketoconazole
Extina ketoconazole, ketodan
Halog clobetasol propionate, halobetasol propionate
Locoid lipocream hydrocortisone butyrate
Loprox ciclodan, ciclopriox
Oxistat clotrimazole econazole nitrate, ketoconazole, oxiconazole nitrate
Penlac Ciclodan, ciclopirox
Prudoxin doxepin
Salex salicylic acid
Trianex Triamcinolone acetonide, triderm
Ultravate Ala-cort, alclometasone dipropionate, aminonide, apexicon, betamethasone dipropinate, betamethasone valerate, clobetasol emollient, clobetaslon emulsion, clobetasol propionate, clocortonlone pivalate, clodan, cormax, desonide, desoximetasone, diflorasone diacetate, fluocinolene acetonide, fluocinonide, fluocinonide-E, flurandrenolide, fluticasone propionate, halobetasol propionate, hydrocortisone, hydrocortisone butyrate, hydrocortisone valerate, micort-HC, mometasone furoate, prednicarbate, psorcon, scalacort, tacrolimus, triamcinolone acetonide, trianex, triderm
Ultravate X clobetasol propionate, halobetasol propionate
Verdeso desonide
Vusion ketoconazole
Zonalon doxepin, prudoxin
Sleep Disorders/ Sedatives Ambien
Ambien CR
Zolpidem
zolpidem ER
Drug classMedication requiring prior authorizationAdditional information
Miscellaneous Syprine  
Pain Relief and Inflammatory Disease acetaminophen-codeine, ascomp with codeine, aspirin-caffeine-dihydrocodeine, belladonna-opium, butalbital-acetaminophen caffeine-codeine, butalbital-caffeine-acetaminophen codeine, butalbital compound-codeine, butorphanol, carisoprodol compound-codeine, carisoprodol-aspirin-codeine, codeine, Demerol, dihydrocodeine-acetaminophen-caffeine, Dilaudid, Duragesic, Embeda, Endocet, Exalgo, fentanyl patch, Fioricet with Codeine, Hycet, hydrocodone-acetaminophen, hydrocodone ibuprofen,hydromorphone, hydromorphone ER, Hysingla ER, Ibudone, Kadian ER, levorphanol tartrate, Lorcet, Lorcet HD, Lorcet Plus, Lortab, meperidine, morphine sulfate, morphine sulfate ER, MS Contin, norco, Nucynta, Nucynta ER, Opana, Opana ER, Oxaydo, oxycodone acetaminophen, oxycodone-aspirin, oxycodone-ibuprofen, oxycodone, oxycodone ER, oxymorphone ER, oxymorphone, Oxycontin, pentazocine-naloxone, Percocet, Primlev, Reprexain, Roxicodone, Synalgos-DC, trezix, Tylenol-codeine, Verdrocet, Vicodin, Vicodin ES, Vicodin HP, Xartemis XR,Xodol, Xtampza ER, Xylon 10, Zamicet, Zohydro ER Ask your doctor to call us. Your plan will only cover your medication if your doctor requests and receives approval from Cigna.
Pain Relief and Inflammatory Disease Cuprimine, Depen Titratab  
Drug classMedication with quantity limitsAdditional information
Cough/ Cold Medications Flowtuss, hycofenix, Hydrocod-cpm-pseudoephedrine, Hydrocodone BT-homatropine, Hydrocodone-chlorpheniramne ER, Hydrocodone-homatropine, hydromet, obredon, Promethazine VC-codeine, Promethazine-codeine, Promethazine-phenyleph-codeine, Rezira, Tussicaps, Tussigon, Tussionex, Tuzistra XR, Vituz, Zutripro Your plan only covers a certain amount of this medication. If your doctor writes a prescription for an amount more than what’s allowed, it will only be covered in that amount if your doctor requests and receives approval from Cigna.
Gastrointestinal/ Heartburn Opium Tincture
Miscellaneous Evzio, Naltrexone  
Pain Relief and Inflammatory Disease Abstral, acetaminophen-codeine, actiq, alfentanil, ascomp with codeine, aspirin-caffeine- dihydocodeine, belladonna- opium, butalbital-acetaminophen-caffeine- codeine, butalbital-caffeine-acetaminophen-codeine, butalbital compound-codeine, butalbital-acetaminophen-caffeine, butalbital-aspirin-caffeine, butorphanol, capacet, carisoprodol compound-codeine, carisoprodol-aspirin-codeine, codeine, Demerol, dihydrocodeine-acetaminophen-caffeine, Dilaudid, duramorph, Endocet, esgic, fentanyl patch, fentanyl-bupivacacaine, fentora, fioricet, fioricet with codeine, fiorinal, finorinal with codeine, hycet, hydrocodone-acetaminophen, hydrocodone-ibuprofen, hydromorphone, Ibudone, infumorph, ionsys, lazanda, levorphanol, Lorcet, Lorcet HD, Lorcet Plus, Lortab, meperidine, morphine, nalbuphine, norco, Nucynta, Nucynta ER, Opana, Oxaydo, oxycodone, oxycodone-aspirin, oxycodone-ibuprofen, oxycodone-acetaminophen, oxymorphone, pentazocine-naloxone, Percocet, Primlev, Reprexain, Roxicodone, subsys, sufentanil, Synalgos- DC, talwin, trezix, Tylenol-codeine, ultiva, Verdrocet, Vicodin, Vicodin ES, Vicodin HP, Xodol,10-300, xodol 5-300, xodol 7.5-300, Xylon 10, zamicet, zebutal  

* Drug is not covered unless approved through a medical necessity review. Customers should speak with their provider about switching to a covered alternative drug.
^ In Step Therapy, customers must try the most cost-effective, appropriate drugs available before their plan approves more expensive brand name drugs.

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