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]

7/1/18 COVERAGE CHANGE TO ALL Prescription OPIOIDS: Cigna COMMERCIAL CUSTOMERS

Effective 7/1/18, Cigna will be changing Opioid coverage determinations for both short acting and long acting Opioids. We will be following the FDA calculation guidelines (attached). Please note: This change does not affect opioid utilizers currently being treated for cancer or sickle cell disease, or in hospice. These customers will continue to receive coverage for their opioid medication(s). 

What does this mean for NEW opioid utilizers under Cigna’s Non-Medicare plans?

120-199 MME

On 7/1/18, customers filling an opioid prescription(s) for the first time in a total daily dose of 120+ MME will require a Prior Authorization (PA) for coverage of their medication(s). Cigna has an expedited prior authorization review process in place, and will make a coverage decision within 24-hours after receiving the provider’s request.

Below is the criteria new utilizers (120-199 MME) must satisfy to receive coverage. They must meet ALL criteria:
  • Quarterly reassessment of opioid therapy benefits and risks specific to the individuals diagnosis and treatment goals
  • Consideration of additional precautions intended to reduce the risk of serious harm associated with high dose opioids (for example, education and provision of naloxone)
  • Prescriber of therapy is (or prescribed in coordination with) a board certified pain management specialist.
200+ MME

On 7/1/18, customers filling an opioid prescription(s) for the first time in a total daily dose of 200+ MME will require a Prior Authorization (PA) for coverage of their medication(s). Cigna has an expedited prior authorization review process in place, and will make a coverage decision within 24-hours after receiving the provider’s request.

Below is the criteria new utilizers (200+ MME) must satisfy to receive coverage. They must meet ALL criteria:
  • Quarterly reassessment of opioid therapy benefits and risks specific to the individuals diagnosis and treatment goals
  • Consideration of additional precautions intended to reduce the risk of serious harm associated with high dose opioids (for example, education and provision of naloxone)
  • Prescriber of therapy is (or prescribed in coordination with) a board certified pain management specialist
  • The provider has performed an individualized behavioral health screening to assess the risks and benefits of the opioid dose (for example, PHQ-9, GAD-7, PC-PTSD)
  • The provider has screened for substance abuse risk to assess the risks and benefits of the opioid dose (for example, DIRE, ORT, PDUQ, PMQ)

What does this mean for CURRENT opioid utilizers under Cigna’s Non-Medicare plans?

120-199 MME

Customers, and their provider(s), were notified by mail that their opioid medication(s) would require PA as of July 1st.

  • If the customer and his/her provider satisfy the PA requirement prior to July 1st, Cigna will approve coverage of their opioid medication(s) for one year (as long as they don’t exceed 199 MME).
  • If the customer and his/her provider do not attempt to satisfy requirements prior to July 1st, Cigna will approve temporary coverage of their opioid medication(s) – until October 1st (as long as they don’t exceed 199 MME). This gives customers three months to meet criteria.
  • If the customer does not satisfy all of the PA requirements prior to July 1st, Cigna will not approve coverage of their opioid medication, and the medication will be denied for prior authorization. Beginning 7/1, Cigna will mail denial letters to the customer.
Below is the criteria current utilizers (120-199 MME) must satisfy prior to October 1st. They must meet ALL criteria:
  • Dual signed pain contract/consent form
  • Safe use attestation signed by Prescriber
  • Documentation of a consultation with a pain management specialist

Starting October 1st, if the customer still has not satisfied all of the PA requirements, the medication will be denied for prior authorization.

200+ MME

At this time, Cigna will continue to cover opioid prescriptions for current utilizers filling a total daily dose of 200+ MME.

The below reject messages will alert you to the above scenarios:

NCPDP Reject code NCPDP Message What to Do?
76 PLAN LIMIT EXCEEDED Urge customers to talk with their prescriber

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

Effective 1/1/18, Cigna is making changes to our formularies that may impact medication coverage for customers at your pharmacy. 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.

Standard Prescription Drug List

Non-Preferred

Brand Medication

Drug Class

Non-Preferred

Brand Medication

Generic and/or Preferred Brand Alternatives

BLOOD THINNERS/ANTI-CLOTTING

Arixtra+

fondaparinux

Lovenox+

enoxaparin

Reopro+

Talk with your doctor to find out if there are lower-cost options available.

CANCER

dexrazoxane+, Evomela+, Hycamtin capsule, Nilandron+, nilutamide+, Zinecard

Talk with your doctor to find out if there are lower-cost options available

CONTRACEPTION PRODUCTS

Depo-Provera 150mg/ml

medroxyprogesterone

LoSeasonique

Amethia Lo, Camrese Lo, levonorg-eth estradiol 0.1/0.02/0.01mg

Nexplanon+, Paragard T 380-a+

Talk with your doctor to find out if there are lower-cost options available.

Seasonique

Amethia, Ashlyna, Camrese, Daysee, levonorg-eth estradiol 0.15/0.03/0.01mg

DENTAL PRODUCTS

Arestin+

Talk with your doctor to find out if there are lower-cost options available.

DIABETES

Korlym+

Talk with your doctor to find out if there are lower-cost options available.

EYE CONDITIONS

Cystaran+,Ozurdex+, Retisert+

Talk with your doctor to find out if there are lower-cost options available.

GASTROINTESTINAL/HEARTBURN

alosetron+, Buphenyl+, Chenodal+, Ravicti+, sodium phenylbutyrate

Talk with your doctor to find out if there are lower-cost options available.

HORMONAL AGENTS

Aveed+,hydroxyprogesterone caproate+

Talk with your doctor to find out if there are lower-cost options available

Depo-Provera 400mg/ml

medroxyprogesterone

Depo-Testosterone

testosterone cypionate

INFECTIONS

Daraprim+,Sirturo+

 

 

Talk with your doctor to find out if there are lower-cost options available.

INFERTILITY

Makena+

Talk with your doctor to find out if there are lower-cost options available.

MISCELLANEOUS

Asclera+, Carbaglu+, Ferriprox+, Flebogamma DIF+, Keveyis+,Varithena+

Talk with your doctor to find out if there are lower-cost options available.

Orfadin+

Nityr

PAIN RELIEF AND INFLAMMATORY DISEASE (NON-NARCOTIC)

 

 

Colcrys

colchicine

PARKINSON'S DISEASE

Azilect

rasagiline

SEIZURE DISORDERS

Lamictal ODT

lamotrigine ODT

SKIN CONDITIONS

Ameluz+, Levulan+

Talk with your doctor to find out if there are lower-cost options available.

Tazorac 0.1% cream

tazarotene

SLEEP DISORDERS/SEDATIVES

Hetlioz+

Talk with your doctor to find out if there are lower-cost options available

TRANSPLANT MEDICATIONS

Cellcept+

mycophenolate

Neoral 25mg capsule, solution+

cyclosporine modified, Gengraf

Sandimmune 100mg capsule+

cyclosporine

URINARY TRACT CONDITIONS

Thiola+

Talk with your doctor to find out if there are lower-cost options available.

Drug Class

Medication requiring Prior Authorization^

Additional Information

CANCER

Hycamtin++, Targretin++, tretinoin capsule++, Xeloda++

Your plan only covers this medication if your doctor requests and receives approval from Cigna. If you’re taking this medication, ask your doctor to call us soon so we can begin the review process.

MISCELLANEOUS

Nityr, Orfadin++

PAIN RELIEF AND INFLAMMATORY DISEASE (NARCOTIC)

Diskets, Dolophine, methadone++, Methadose

Drug Class

Medication with Quantity Limits^

Additional Information

ANXIETY/DEPRESSION/BIPOLAR DISORDER

bupropion ER#, Celexa#, citalopram#, desvenlafaxiner ER#, duloxetine#, Effexor XR#, Effexor#, Emsam#, escitalopram#, Fetzima#, fluoxetine#, fluvoxamine ER#, fluvoxamine#, Forfivo XL#, Khedezla, paroxetine CR#, paroxetine#, Paxil CR#, Pexeva#, Prozac, sertraline#, venlafaxine ER#, Wellbutrin SR, Wellbutrin XL, Zoloft

Your plan only covers up to a certain amount of this medication over a certain amount of time. If you’re taking this medication, you may need approval for your prescription to be covered.

 

BLOOD PRESSURE/HEART MEDICATIONS

BiDil 20-37.5mg#, captopril-HCTZ, dofetilide#, Tikosyn

CHOLESTEROL MEDICATIONS

simvastatin, Zocor

GASTROINTESTINAL/HEARTBURN

Aciphex, Dexilant, esomeprazole, lansoprazole DR, Nexium DR, Nexium, omeprazole DR, omeprazole, omeprazole bicarbonate, pantoprazole, Prevacid SoluTab, Prilosec, prilosec 2.5mg, Protonix, rabeprazole

NUTRITIONAL/DIETARY

Auryxia

PAIN RELIEF AND INFLAMMATORY DISEASE (NON-NARCOTIC)

Cafergot, ergotamine-caffeine, diclofenac 1%, Voltaren

PAIN RELIEF AND INFLAMMATORY DISEASE (NARCOTIC)

acetaminophen-caffeine-dihyrocodeine, acetaminophen-codeine, Arymo, asa-butalb-caff-codeine, aspirin-caff-dihydrocodeine, belladonna-opium, buprenorphine, butalb-acetaminoph-caff-codeine, butorphanol, carisoprodol-asa-codeine, codeine sulfate, Embeda, Exalgo, Fentanyl (all dosage forms), Flowtuss, Hycofenix, hydrocodone-acetaminophen, hydrocodone-ibuprofen, Hydromet, hydromorphone, Hysingla ER, Kadian, Lorcet, Lortab, meperidine, Morphabond ER, morphine, morphine ER, nalbuphine, Nucynta, Nucynta ER, Obredon, Opana ER, opium tincture, Oxecta, oxycodone, oxycodone ER, oxycodone-acetaminophen, oxycodone-aspirin, oxycodone-ibuprofen, OxyContin, oxymorphone, oxymorphone ER, pentazocine-acetaminophen, pentazocine-naloxone, Primlev, promethazine-codeine, Talwin, tramadol ER, tramadol-acetaminophen, Trezix, Tussigon, Tussionex, Xtampza ER, Zohydro ER, Zutripro

To promote safer opioid use, your plan may limit the amount, or day supply, of narcotic pain medications (opioids) it will cover. If you’re taking an opioid, you may need approval for your prescription to be covered.

 

SEIZURE DISORDERS

Banzel#

Your plan only covers up to a certain amount of this medication over a certain amount of time. If you’re taking this medication, you may need approval for your prescription to be covered.

SKIN CONDITIONS

calcitriol, Vectical

SLEEP DISORDERS/SEDATIVES

Rozerem

Drug Class

Medication Not Covered^^^

Generic and/or Preferred Brand Alternatives

GASTROINTESTINAL/HEARTBURN

OmePPI

omeprazole

INFECTIONS

Mycobutin

rifabutin

MULTIPLE SCLEROSIS

Copaxone

Aubagio, Avonex, Betaseron, Extavia, Gilenya, glatiramer, Glatopa, Plegridy, Rebif, Tecfidera

SKIN CONDITIONS

diclofenac 3% gel, Solaraze

Fluoroplex, fluorouracil, imiquimod, Picato

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

+ This is a specialty medication. Some plans cover these medications on a specialty tier, may limit you to a 30-day supply and/or require you to use Cigna Specialty Pharmacy (our home delivery pharmacy) to fill your prescription. For plans that cover specialty medications on a specialty tier, this change will not affect the cost of the medication. Log in to the myCigna website or app or check your plan materials to learn more about your plan’s coverage requirements for specialty medications.

^ These changes may not apply to your plan. Not all plans include requirements for prior authorization and/or quantity limits. Please check your plan materials or log in to the myCigna website or app starting July 1st to learn more about how your plan covers these medications.

++Approval may be required for new prescriptions filled on or after July 1st.

# Quantity limits may apply to new prescriptions filled on or after July 1st.

^^^ These medications require approval from Cigna before they may be covered by your plan. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving coverage of your medication.

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