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Comprehensive Drug List (Formulary) Cigna-HealthSpring

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2016 CignaCOMPREHENSIVE DRUG LIST(Formulary)Please read: This document contains information aboutall of the drugs we cover in this plan.Plans coveredCigna-HealthSpring Preferred (HMO)Cigna-HealthSpring Preferred Plus (HMO)Cigna-HealthSpring Achieve Plus (HMO SNP)This drug list was updated on November 1, 2016. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice whennecessary. For more recent information or other questions, please contact Cigna Customer Service, at 1-800-627-7534 or, for TTY users, 711, 7 days a week, 8 a.m. – 8 p.m.,hours apply Monday – Friday, February 15 – September 30, or visit www.CignaHealthSpring.com. Cigna-HealthSpring is contracted with Medicare for PDP plans, HMO andPPO plans in select states, and with select State Medicaid programs. Enrollment in Cigna-HealthSpring depends on contract renewal.HPMS Approved Formulary File Submission ID 16158, Version Number 18 Y0036 16 32224c Final 3j Approved 08102015

Note to existing customers: This drug list has changed since last year. Please review this document to make surethat it still contains the drugs you take.When this drug list (formulary) refers to “we,” “us”, or “our,” it means Cigna. When it refers to “plan” or “our plan,”it means Cigna-HealthSpring Preferred (HMO), Cigna-HealthSpring Preferred Plus (HMO) and Cigna-HealthSpringAchieve Plus (HMO SNP).This document includes a list of the drugs (formulary) for our plans, which is current as of November 2016. For anupdated formulary, please contact us. Our contact information, along with the date we last updated the formulary,appears on the front and back cover pages.You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacynetwork, and/or copayments/coinsurance may change on January 1, 2017, and from time to time during the year.What is the Cigna Comprehensive Drug List?A drug list is a list of covered drugs selected by Cigna inconsultation with a team of health care providers, whichrepresents the prescription therapies believed to be a necessarypart of a quality treatment program. Cigna will generallycover the drugs listed in our drug list as long as the drugis medically necessary, the prescription is filled at a Cignanetwork pharmacy, and other plan rules are followed. For moreinformation on how to fill your prescriptions, please review yourEvidence of Coverage.of the drug, at which time the customer will receive a 60-daysupply of the drug. If the Food and Drug Administration deemsa drug on our drug list to be unsafe or the drug’s manufacturerremoves the drug from the market, we will immediately removethe drug from our drug list and provide notice to customers whotake the drug. The enclosed drug list is current as of November2016. To get updated information about the drugs covered byCigna, please contact us. Our contact information appears onthe front and back cover pages. If there are significant changesmade to the printed drug list within the covered year, you maybe notified by mail identifying the changes. Drug lists located onour website are reviewed and updated on a monthly basis.Can the Drug List (formulary) change?Generally, if you are taking a drug on our 2016 drug list that wascovered at the beginning of the year, we will not discontinueor reduce coverage of the drug during the 2016 coverage yearexcept when a new, less expensive generic drug becomesavailable or when new adverse information about the safetyor effectiveness of a drug is released. Other types of drug listchanges, such as removing a drug from our drug list, will notaffect customers who are currently taking the drug. It will remainavailable at the same cost-sharing for those customers takingit for the remainder of the coverage year. We feel it is importantthat you have continued access for the remainder of thecoverage year to the drugs that were available when you choseour plan, except for cases in which you can save additionalmoney or we can ensure your safety.How do I use the Drug List?There are two ways to find your drug within the drug list:Medical ConditionThe drug list begins on page 7. The drugs in this drug list aregrouped into categories depending on the type of medicalconditions that they are used to treat. For example, drugsused to treat a heart condition are listed under the category,“CARDIOVASCULAR AGENTS”. If you know what your drugis used for, look for the category name in the list that begins onpage 7. Then look under the category name for your drug.Covered Drug IndexIf you are not sure what category to look under, you should lookfor your drug in the Covered Drugs Index section that begins onpage 50. The Covered Drugs Index provides a list of all of thedrugs included in this document. Both brand name drugs andgeneric drugs are in the Drug List.If we remove drugs from our drug list, add prior authorization,quantity limits and/or step therapy restrictions on a drug or movea drug to a higher cost-sharing tier, we must notify affectedcustomers of the change at least 60 days before the changebecomes effective, or at the time the customer requests a refill1

What are generic drugs?Cigna covers both brand name drugs and generic drugs. Ageneric drug is approved by the FDA as having the same activeingredient as the brand name drug. Generally, generic drugscost less than brand name drugs.helping you take your medications at least 80% of the time.There are several ways we can work together to accomplishthis goal: Talk with your doctor about whether a 90 day supply of yourongoing, stable medications may be appropriate. Takingthese medications every day as prescribed is important foryour overall health, and getting 90 day prescriptions of thesemedications can ensure that you don’t miss a dose.Are there any restrictions on my coverage?Some covered drugs may have additional requirements or limitson coverage. These requirements and limits may include: You can receive a 90-day supply at most retail pharmacies orthrough one of our mail-order pharmacies. Prior Authorization: Cigna requires you or your doctor toget prior authorization for certain drugs. This means thatyou will need to get approval from Cigna before you fill yourprescriptions. If you don’t get approval, Cigna may not coverthe drug. Talk to your pharmacist if you are experiencing any newchallenges with your maintenance medications.How can I use my prescription drug coverage to savemoney on my medications?There may be opportunities for you to save money on yourmedications using your Cigna coverage. Quantity Limits: For certain drugs, Cigna limits the amountof the drug that Cigna will cover. For example, Cigna allowsfor 1 tablet per day for CRESTOR. This applies to standardone-month supply (for total quantity of 30 per 30 days) orthree-month supply (for total quantity of 90 per 90 days). Ask your doctor (or other prescriber) if there are any lowercost generic alternatives available for any of your currentmedications. Step Therapy: In some cases, Cigna requires you to first trycertain drugs to treat your medical condition before we willcover another drug for that condition. For example, if Drug Aand Drug B both treat your medical condition, Cigna may notcover Drug B unless you try Drug A first. If Drug A does notwork for you, Cigna will then cover Drug B. Explore whether the ‘CMS extra help’ program may offeradditional financial support for your medications. If your medication is not covered on the Cigna drug list, talkwith your doctor about alternative medications which arecovered in the drug list.You can find out if your drug has any additional requirementsor limits by looking in the drug list that begins on page 7. Youcan also get more information about the restrictions applied tospecific covered drugs by visiting our Web site. We have postedonline documents that explain our prior authorization and steptherapy restrictions. You may also ask us to send you a copy.Our contact information, along with the date we last updated thedrug list, appears on the front and back cover pages.What if my drug is not in the Drug List?If your drug is not included in this drug list, you should firstcontact Customer Service and ask if your drug is covered. Ifyou learn that Cigna does not cover your drug, you have twooptions: You can ask Customer Service for a list of similar drugs thatare covered by Cigna. When you receive the list, show it toyour doctor and ask him or her to prescribe a similar drug thatis covered by Cigna.You can ask Cigna to make an exception to these restrictionsor limits or for a list of other, similar drugs that may treatyour health condition. See the section, “How do I request anexception to the Cigna drug list?” on this page for informationabout how to request an exception. You can ask Cigna to make an exception and cover yourdrug. See below for information about how to request anexception.Options for Maintenance MedicationsTaking the medications prescribed by your doctor (or otherprescriber) is important to your health.How do I request an exception to the Cigna Drug List?You can ask Cigna to make an exception to our coverage rules.There are several types of exceptions that you can ask us tomake.We are committed to helping you achieve control ofchronic conditions by making it easy for you to receive yourmaintenance medications. As part of our commitment tocoordinating your healthcare needs, we have set a goal of You can ask us to cover a drug even if it is not in our druglist. If approved, this drug will be covered at a pre-determined2

cost-sharing level, and you would not be able to ask us toprovide the drug at a lower cost-sharing level.you can fill your prescription. You should talk to your doctorto decide if you should switch to an appropriate drug that wecover or request a drug list exception so that we will cover thedrug you take. While you talk to your doctor to determine theright course of action for you, we may cover your drug in certaincases during the first 90 days you are a customer of our plan. You can ask us to waive coverage restrictions or limits onyour drug. For example, for certain drugs, Cigna limits theamount of the drug that we will cover. If your drug has aquantity limit, you can ask us to waive the limit and cover agreater amount.For each of your drugs that is not on our drug list or if yourability to get your drugs is limited, we will cover a temporary30-day supply (unless you have a prescription written for fewerdays) when you go to a network pharmacy. After your first 30day supply, we will not pay for these drugs, even if you havebeen a customer of the plan less than 90 days. You can ask us to provide a tiering exception for a highercost sharing drug to be covered at a lower cost-sharing tier.If your drug is contained in the Non-Preferred Brand tier orthe Generic tier, you can ask us to cover it at the cost-sharingamount that applies to drugs in the respective PreferredBrand or Preferred Generic tier instead. This would lower theamount you must pay for your drug. If your drug is containedin our Brand tier you can ask to cover it at the cost-sharingamount that applies to drugs in the respective Generic tier ifall generic alternatives in the lower cost tier used to treat thesame condition/disease are determined to be not as effectiveas the Brand. Please note, if we grant your request to cover adrug that is not in our drug list, you may not ask us to providea higher level of coverage for the drug. Also, you may not askus to provide a higher level of coverage for drugs that are inthe Specialty tier.If you are a resident of a long-term care facility, we will allow youto refill your prescription until we have provided you with a 91- to98-day transition supply, consistent with dispensing increment,(unless you have a prescription written for fewer days). We willcover more than one refill of these drugs for the first 90 daysyou are a customer of our plan. If you need a drug that is notin our drug list or if your ability to get your drugs is limited, butyou are past the first 90 days of membership in our plan, wewill cover a 31-day emergency supply of that drug (unless youhave a prescription for fewer days) while you pursue a drug listexception.Generally, Cigna will only approve your request for an exceptionif the alternative drugs included on the plan’s drug list, the lowercost-sharing drug or additional utilization restrictions would notbe as effective in treating your condition and/or would cause youto have adverse medical effects.In order to accommodate unexpected transitions of ourcustomers that do not leave time for advanced planning, suchas level-of-care changes due to discharge from a hospital to anursing facility or to a home, Cigna will allow a one-time 31-daysupply (unless the prescription is written for fewer days).You should contact us to ask us for an initial coverage decisionfor a drug list, tiering or utilization restriction exception. Whenyou request a drug list, tiering or utilization restrictionexception you should submit a statement from yourprescriber or doctor supporting your request. Generally,we must make our decision within 72 hours of getting yourprescriber’s supporting statement. You can request anexpedited (fast) exception if you or your doctor believe that yourhealth could be seriously harmed by waiting up to 72 hours fora decision. If your request to expedite is granted, we must giveyou a decision no later than 24 hours after we get a supportingstatement from your doctor or other prescriber.Cigna’s Drug ListThe comprehensive drug list provides coverage informationabout all of the drugs covered by Cigna. If you have troublefinding your drug in the list, turn to the Covered Drug Index thatbegins on page 50.The first column of the chart lists the drug name. Brand namedrugs are capitalized (e.g., CRESTOR) and generic drugs arelisted in lower-case italics (e.g., simvastatin).The information in the Requirements/Limits column tells you ifCigna has any special requirements for coverage of your drug.We provide quantity limits on certain drugs which are indicatedwith a QL in the Covered Drugs by Category list on page 7along with the amount dispensed per the days supplied. (Forexample: CRESTOR 30/30; this means the drug CRESTORis limited to 30 tablets per 30 days. For 90-day supplies, thisquantity limit would be expanded to 90 tablets per 90 days).What do I do before I can talk to my doctor about changingmy drugs or requesting an exception?As a new or continuing customer in our plan you may be takingdrugs that are not in our drug list. Or, you may be taking a drugthat is on our drug list but your ability to get it is limited. Forexample, you may need a prior authorization from us before3

For more informationFor more detailed information about your Cigna prescription drug coverage, please review your Evidence of Coverage andother plan materials.If you have questions about Cigna, please contact us. Our contact information, along with the date we last updated the druglist, appears on the front and back cover pages.If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE(1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.Key:B/D – This prescription drug has a Part B versus Dadministrative prior authorization requirement. This drugmay be covered under Medicare Part B or D depending oncircumstances.QL – This drug has quantity limitsST – This drug has step therapy requirementsGenerally all medications in the drug list are availablethrough mail order, except when special circumstancesor situations prohibit mailing a particular medication toyour home.HI (Home Infusion) – This prescription drug may becovered under our medical benefit. For more information,contact Customer Service.PA – This drug requires prior authorizationDrug Tier and Cost-Share TableThe following table represents the plan name, plan service area,the drug tier number as it appears in the drug list, and the costshare amount for that tier number. Tier 1 is for Preferred Genericdrugs. Tier 2 is for Generic drugs. Tier number 3 is for PreferredBrand drugs. Tier number 4 is for Non-Preferred Brand drugs.Tier 5 is for Specialty tier drugs. You may also refer to yourEvidence of Coverage document for additional details.Note for customers receiving Extra Help: Your LIS copay levelwill be based on how the Food and Drug Administration (FDA)classifies certain drugs. Due to this, a generic drug may receivea preferred brand copay, or a preferred brand drug may receivea generic drug copay. Please see your LIS Rider for additionalinformation on these copay levels. Or call Customer Service forfurther clarification regarding a specific drug.4

To locate your drug cost, please refer to the table(s) below to find your service area and the Medicare Advantageplan in which you are currently enrolled or would like to enroll.Service Area: ArizonaH0354-001Cigna-HealthSpring Preferred (HMO)H0354-027Cigna-HealthSpring Achieve Plus (HMO SNP)Maricopa county and select zip codes in Pinal county (85117,85118, 85119, 85120, 85140, 85143, 85178), ArizonaStandard RetailCost-SharingStandard Mail OrderCost-Sharing30/60/90 Days30/90 Days 0/ 0/ 0 0/ 0Tier 2: Generic Drugs 15/ 30/ 45 15/ 45Tier 3: Preferred Brand Drugs 45/ 90/ 135 45/ 135 100/ 200/ 300 100/ 30033%33%Standard RetailCost-SharingStandard Mail OrderCost-Sharing30/60/90 Days30/90 Days 0/ 0/ 0 0/ 0Tier 2: Generic Drugs 10/ 20/ 30 10/ 30Tier 3: Preferred Brand Drugs 45/ 90/ 135 45/ 135Tier 4: Non-Preferred Brand Drugs 95/ 190/ 285 95/ 28533%33%Tier 1: Preferred Generic DrugsTier 4: Non-Preferred Brand DrugsTier 5: Specialty TierService Area: ArizonaH0354-023Cigna-HealthSpring Preferred Plus (HMO)Maricopa county and select zip codes in Pinal county (85117,85118, 85119, 85120, 85140, 85143, 85178), ArizonaH0354-024Cigna-HealthSpring Preferred (HMO)Pima County, ArizonaTier 1: Preferred Generic DrugsTier 5: Specialty Tier5

Service Area: ArizonaStandard RetailCost-SharingStandard Mail OrderCost-Sharing30/60/90 Days30/90 DaysTier 1: Preferred Generic Drugs 0/ 0/ 0 0/ 0Tier 2: Generic Drugs 5/ 10/ 15 5/ 15Tier 3: Preferred Brand Drugs 45/ 90/ 135 45/ 135Tier 4: Non-Preferred Brand Drugs 95/ 190/ 285 95/ 28533%33%H0354-026Cigna-HealthSpring Preferred Plus (HMO)Pima County, ArizonaTier 5: Specialty TierMy MedicationsIn this section, you can write down all of the medications you are currently taking. You can then find your drug in the following drug listpages. Look and see what tier your drug is on. Once you find out what tier your drug is on, you can look at the charts before this pageand locate your cost-share for that drug. If you need help locating your drugs and cost-share, please call Customer Service at 1-800627-7534, 7 days a week, 8 a.m. – 8 p.m., hours apply Monday – Friday, February 15 – September 30. TTY users can call 711.My MedicationsPage Numberin the Drug List6Cost-Sharethrough CignaGenericAvailable?GenericCost-Share

Covered Drugs By CategoryDRUG NAMEDRUG REQUIREMENTS/TIER LIMITSDRUG NAMEibuprofen tabs 400mg, 600mg,800mgketoprofenketoprofen erketorolac tromethamine inj15mg/ml, 30mg/mlketorolac tromethamine tabsmeclofenamate sodiummeloxicamnabumetonenaproxennaproxen drnaproxen sodium tabs indactolmetin sodiumOpioid Analgesics, Long-actingBUTRANSDURAMORPHfentanylINFUMORPH 200INFUMORPH 500levorphanol tartratemethadone hcl concmethadone hcl injmethadone hcl intensolmethadone hcl oral soln10mg/5mlmethadone hcl oral soln5mg/5mlmethadone hcl A QL(180/30)butalbital/acetaminophen/2PA QL(180/30)caffeine caps2PA QL(180/30)butalbital/acetaminophen/caffeine tabs 325mg; 50mg;40mgbutalbital/aspirin/caffeine2PA QL(180/30)esgic caps2PA QL(180/30)margesic2PA QL(180/30)marten-tab2PA QL(180/30)PRIALT5B/D PAtencon tabs 325mg; 50mg2PA QL(180/30)zebutal caps 325mg; 50mg;2PA QL(180/30)40mgNonsteroidal Anti-inflammatory DrugsCAMBIA4celecoxib2QL(60/30)choline magnesium trisalicylate2liqddiclofenac potassium2diclofenac sodium dr2diclofenac sodium er2diclofenac sodium/misoprostol2diflunisal2etodolac2etodolac er2fenoprofen calcium caps2400mgfenoprofen calcium tabs2flurbiprofen2ibuprofen lysine2ibuprofen susp2CAPITALIZED BRAND NAME DRUGQL Quantity Limits listed as (qty/days)PA Prior Authorization may be requiredHI Home InfusionDRUG REQUIREMENTS/TIER LIMITS22222222222PA QL(20/30)PA 00/30)Lower case italic Generic drugST Step Therapy rules applyB/D Drugs covered under Medicare Part B or Part DYou can find more information on the symbols by going to page 4.7

Covered Drugs By CategoryDRUG NAMEDRUG REQUIREMENTS/TIER LIMITSmethadone hcl tbsomethadose concmethadose sugar-freemethadose tbsomorphine sulfate er cp24morphine sulfate er tbcrmorphine sulfate inj 0.5mg/ml,10mg/0.7ml, 1mg/mlmorphine sulfate suppOPANA ER (CRUSHRESISTANT) T12A 40MGOPANA ER (CRUSHRESISTANT) T12A 10MG,15MG, 20MG, 30MG, 5MG,7.5MGoxymorphone hydrochloride ertramadol hcl er tb24Opioid Analgesics, Short-actingacetaminophen/codeine #2acetaminophen/codeine #3acetaminophen/codeine #4acetaminophen/codeine oralsolnacetaminophen/codeinephosphate tabs 300mg; 60mgacetaminophen/codeine tabs300mg; 60mgacetaminophen/codeine tabs300mg; utalbital/aspirin/caffeine/codeinebutorphanol tartrate injbutorphanol tartrate nasal solnCAPITAL/CODEINEcodeine sulfate tabs 60mgcodeine sulfate tabs 30mgcodeine sulfate tabs 15mgendocetfentanyl citrate inj 100mcg/2ml2222222DRUG (240/30)2QL(240/30)2QL(360/30)222PA QL(180/30)QL(330/30)PA 360/30)QL(720/30)QL(360/30)B/D PAfentanyl citrate oraltransmucosal lpop 200mcgfentanyl citrate oraltransmucosal lpop 1200mcg,1600mcg, 400mcg, 600mcg,800mcghydrocodone bitartrate/acetaminophen oral soln325mg/15ml; 7.5mg/15mlhydrocodone bitartrate/acetaminophen tabs 325mg;2.5mghydrocodone bitartrate/acetaminophen tabs 300mg;10mg, 300mg; 5mg, 300mg;7.5mghydrocodone/acetaminophentabs 325mg; 10mg, 325mg;5mg, 325mg; 7.5mghydrocodone/ibuprofen tabs5mg; 200mg, 7.5mg; 200mghydrocodone/ibuprofen tabs10mg; 200mghydromorphone hcl dosettehydromorphone hcl inj 1mg/ml,2mg/ml, 4mg/ml, 500mg/50mlhydromorphone hcl liqdhydromorphone hcl supphydromorphone hcl tabsibudone tabs 5mg; 200mgLAZANDAlorcetlorcet hdlorcet plus tabs 325mg; 7.5mglortab tabsmorphine sulfate add-vantagemorphine sulfate inj 10mg/ml,150mg/30ml, 15mg/ml, 1mg/ml, 25mg/ml, 2mg/ml, 4mg/ml,50mg/ml, 5mg/ml, 8mg/mlmorphine sulfate oral soln100mg/5mlmorphine sulfate oral soln20mg/5ml8DRUG REQUIREMENTS/TIER LIMITS2PA QL(120/30)5PA )2QL(540/30)2QL(2700/30)QL(240/30)QL(150/30)PA QL(44/28)QL(360/30)QL(360/30)QL(360/30)QL(360/30)

Covered Drugs By CategoryDRUG NAMEmorphine sulfate oral soln10mg/5mlmorphine sulfate tabsnalbuphine hclOPIUMOPIUM TINCTUREoxycodone hcl capsoxycodone hcl concoxycodone hcl oral solnoxycodone hcl tabsoxycodone/acetaminophen oralsolnoxycodone/acetaminophen tabs325mg; 10mg, 325mg; 2.5mg,325mg; 5mg, 325mg; ne hydrochloridereprexain tabs 10mg; 200mgroxicetSYNALGOS-DCTALWINtramadol hcltramadol hydrochloride/acetaminophenxylonDRUG REQUIREMENTS/TIER L(360/30)QL(330/30)2QL(180/30)DRUG NAMElidocaine hcl viscouslidocaine ointlidocaine ptchlidocaine viscouslidocaine/prilocaine creapremium lidocaineSYNERAAlcohol Deterrents/Anti-cravingacamprosate calcium drdisulfiramVIVITROLOpioid Dependence Treatmentsbuprenorphine hcl injbuprenorphine hcl sublbuprenorphine hcl/naloxone hclnaltrexone hclSUBOXONEOpioid Reversal Agentsnaloxone hcl inj 0.4mg/ml,2mg/2mlNARCANSmoking Cessation Agentsbupropion hcl sr tb12 150mgCHANTIXCHANTIX CONTINUINGMONTH PAKCHANTIX STARTING MONTHPAKNICOTROL INHALERNICOTROL NSQL(240/30)QL(240/30)2222PA QL(90/30)B/D ALIZED BRAND NAME DRUGQL Quantity Limits listed as (qty/days)PA Prior Authorization may be requiredHI Home Infusion2222224Anti-Addiction/Substance Abuse Treatment AgentsAnestheticsLocal Anestheticsglydolidocaine hcl external solnlidocaine hcl gellidocaine hcl inj 0.5%, 1%,1.5%, 2%, 4%lidocaine hcl jellylidocaine hcl mouth/throat solnDRUG REQUIREMENTS/TIER LIMITSAminoglycosidesamikacin sulfate2HILower case italic Generic drugST Step Therapy rules applyB/D Drugs covered under Medicare Part B or Part DYou can find more information on the symbols by going to page 4.9

Covered Drugs By CategoryDRUG NAMEgentakgentamicin sulfategentamicin sulfate pediatricgentamicin sulfate/0.9% sodiumchloride inj 0.9mg/ml; 0.9%,1.2mg/ml; 0.9%, 1.4mg/ml;0.9%, 1.6mg/ml; 0.9%, 1mg/ml;0.9%, 2mg/ml; 0.9%isotonic gentamicin inj 0.8mg/ml; 0.9%neomycin sulfateneomycin/polymyxin b sulfatesparomomycin sulfatestreptomycin sulfatetobramycin sulfateTOBREX OINTZYLETAntibacterials, OtherALCOHOL PREP PADSALTABAXbaciimbacitracin injbacitracin ophthalmic ointbacitracin/polymyxin bchloramphenicol sodiumsuccinateCLEOCIN SUPPclindacin etz pledgetsclindacin-pclindamaxclindamycin hclclindamycin palmitate hclclindamycin phosphate addvantageclindamycin phosphate creaclindamycin phosphate externalsolnclindamycin phosphate foamclindamycin phosphate gelclindamycin phosphate in d5wDRUG REQUIREMENTS/TIER LIMITSDRUG NAME2222clindamycin phosphate inj300mg/2ml, 600mg/4ml,900mg/6mlclindamycin phosphate lotnclindamycin phosphatepharmacy bulk packageclindamycin phosphate swabCLINDESSEcolistimethate sodiumCORTISPORIN CREACORTISPORIN OINTCUBICINdaptomycinFEM PHFLAGYL incomycin hcllinezolid inj 600mg/300mllinezolid susrlinezolid tabsmethenamine hippuratemethenamine mandelateMETRO IVmetronidazole capsmetronidazole creametronidazole gelmetronidazole in nacl 0.79%metronidazole injmetronidazole lotnmetronidazole tabsmetronidazole ortisone2222223434222224222222HI22222HI10DRUG REQUIREMENTS/TIER L(224/30)QL(1680/28)QL(56/28)HIHIHI

Covered Drugs By CategoryDRUG NAMEnitrofurantoinnitrofurantoin macrocrystalscaps 100mg, 50mgnitrofurantoin monohydratenitrofurantoin monohydrate/macrocrystalspolymyxin b sulfatepolymyxin b sulfate/trimethoprim sulfatePRIMSOLRELAGARDrosadanSILVER NITRATE EXTERNALSOLNsilver thoprim sulfate/polymyxinb sulfateTYGACILvancomycinvancomycin hcl caps 125mgvancomycin hcl caps 250mgvancomycin hcl in dextrosevancomycin hcl inj 0.9%;1gm/200ml, 1000mg, 10gm,500mg, 750mgvancomycin hcl inj 5000mgvandazoleVIBATIV INJ 250MGXIFAXAN TABS 200MGXIFAXAN TABS 550MGZYVOX SUSRDRUG REQUIREMENTS/TIER LIMITS22QL(90/365)22QL(90/365)QL(90/365)DRUG NAMEBeta-lactam, CephalosporinsCEDAX CAPScefaclorcefaclor ercefadroxilcefazolincefazolin sodiumcefazolin sodium/dextrosecefdinircefditoren pivoxilcefepimecefepime/dextrosecefiximecefotaxime sodium inj 1gm,2gm, 500mgcefotetan/dextrosecefoxitin sodiumcefpodoxime ftibutenCEFTIN SUSRceftriaxone in iso-osmoticdextroseceftriaxone sodium inj 10gm,1gm, 250mg, 2gm, 500mgceftriaxone/dextrosecefuroxime axetilcefuroxime sodium inj 1.5gm,7.5gm, 750mg, 75gmcephalexinFORTAZ INJ 500MGMAXIPIMESPECTRACEF TABS 400MG224423224522525522224555CAPITALIZED BRAND NAME DRUGQL Quantity Limits listed as (qty/days)PA Prior Authorization may be requiredHI Home InfusionHIHIQL(40/10)QL(80/10)HIHIB/D PAHIPA QL(9/30)PA QL(60/30)QL(1680/28)DRUG REQUIREMENTS/TIER 44HILower case italic Generic drugST Step Therapy rules applyB/D Drugs covered under Medicare Part B or Part DYou can find more information on the symbols by going to page 4.11

Covered Drugs By CategoryDRUG NAMESUPRAX CAPSSUPRAX CHEWSUPRAX SUSR 500MG/5MLtazicefTEFLAROBeta-lactam, OtherAZACTAM IN ISO-OSMOTICDEXTROSE INJ 1GM; 0AZACTAM IN ISO-OSMOTICDEXTROSE INJ 2GM; 0AZACTAM INJ 1GMAZACTAM INJ ANZmeropenemmeropenem/sodium chlorideMERREMPRIMAXIN IVPRIMAXIN IV ADD-VANTAGEBeta-lactam, siumampicillinampicillin sodium inj 125mg,250mg, 500mgampicillin sodium inj 10gm,1gm, 2gmampicillin-sulbactambactocill in dextroseBICILLIN C-RBICILLIN L-Adicloxacillin sodiumNAFCILLINnafcillin sodiumoxacillin sodiumDRUG REQUIREMENTS/TIER LIMITS44424HI4HI5HI452242422444HIHIHIDRUG NAMEpenicillin g potassium in isoosmotic dextrosepenicillin g potassium inj20000000unit, 5000000unitpenicillin g procainepenicillin g sodiumpenicillin v potassiumpfizerpen-gpiperacillin sodium/ tazobactamsodiumpiperacillin YNUNASYN BULK PACKZOSYNMacrolidesAZASITEazithromycin injazithromycin packazithromycin susrazithromycin tabsclarithromycinclarithromycin erDIFICIDe.e.s. 400E.E.S. GRANULESeryERY-TABERYPED 200ERYPED 400ERYTHROCINLACTOBIONATEerythrocin stearateerythromycinerythromycin baseerythromycin 22HI22442322HIHIHIHIHI12DRUG REQUIREMENTS/TIER 3222224HIPA QL(20/30)

Covered Dru

Nov 01, 2016 · (Formulary) This drug list was updated on November 1, 2016. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. For more recent information or other questions, please contact Cigna Customer Service, at 1-800-627-753