four-tier plan 2012 cignabenefits.brevardschools.org/hr/benefits 2013... · some pharmacy plans...

2012 Cigna prescription drug list

Four-Tier Plan

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Choosing the medication that is right for you is between you and your doctor. This prescription drug list offers you an extensive list of brand-name and generic medications that are covered under your pharmacy plan.

Choosing where to fill your medication should be easy, too. With over 61,000 pharmacies and Cigna Home Delivery Pharmacy in our network, you have convenient access to your medications – whether you pick them up or have them delivered to your home.

Within this document you will find a list of medications covered under your plan, in an easy-to-read format. You will see:

1. Medications split into four categories (generic, preferred brand, non-preferred brand and specialty injectable medications)

2. Health conditions and medications listed in alphabetical order

3. Symbols to let you know if there are any important details related to coverage

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Your four-tier prescription drug listA four-tier prescription drug list splits medications into four categories (or tiers):

1st Tier – Generic Medications: Generic medications have the same active ingredients, safety, dosage, quality and strength as their brand-name counterparts. You will usually pay less for generic medications under a four-tier plan.

2nd Tier – Preferred Brand Medications: Preferred brand medications will usually cost more than a generic, but may cost less than a non-preferred brand on a four-tier plan.

3rd Tier – Non-Preferred Brand Medications: Non-preferred brand medications generally have generic alternatives and/or one or more preferred brand options within the same drug class. You will usually pay more for non-preferred medications on a four-tier plan.

4th Tier – Specialty Injectable Medications: Specialty Injectable medications that are usually covered under the fourth tier include, but are not limited to, injectables to treat arthritis, multiple sclerosis and hepatitis C. Please see the list of medications covered under this tier on page 21.

Preventive prescription drug optionPreventive medications are described as medications that are used to prevent a disease or condition in people with risk factors such as: high blood pressure, high cholesterol, diabetes, asthma, osteoporosis, heart attack and stroke, or to prevent the recurrence of the disease or condition in people who have recovered.

Preventive medications do not include drugs used to treat an existing illness, injury or condition. Some pharmacy plans require you to pay a certain amount (deductible) before the plan coverage begins, but preventive medications may be covered before you reach that amount. To be sure, you can read your enrollment materials to see how preventive

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medications are covered specific to your plan. Also, a list of all covered preventive medications is available on myCigna.com. Preventive medications are identified by a “PM” symbol within the drug list search.

Understanding Cigna’s prescription drug listEvery medication available on Cigna’s prescription drug list has been approved by the U.S. Food and Drug Administration (FDA). This list represents the most commonly prescribed medications. If you do not see a specific medication on this list, please check myCigna.com to see all of the medications covered under your plan.

The symbols on the list mean …

If your medication has one of the following symbols, your doctor may have to get an authorization (approval) for coverage of that medication.

PA: Prior Authorization may be required for different reasons. To learn the requirements needed for coverage of a specific medication, please feel free to give us a call.

QL: Quantity Limit means you may have coverage for a limited amount of a specific medication.

AGE: Age Requirement means a person must be within a specific age group for a specific medication to be covered.

ST: Step Therapy is a prior authorization program that requires you to try other medications available to treat the same condition before the medication with the “ST” is covered.

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myCigna.comOur customer website that can help you manage your prescription coverage:

When you visit myCigna.com, you can:

• Lookupthedetailsofyourspecific pharmacy plan

• Researchthousandsofavailablemedications

• ComparemedicationpricesusingthePrescription Drug Price Quote Tool

• Askapharmacistquestions

• Andmuch,muchmore!

Medications delivered right to your homeCigna Home Delivery Pharmacy is designed for people who take prescription medications on a regular basis (including specialty medications). The benefits of Cigna Home Delivery Pharmacy include:

• Gettinguptoa90-daysupplyofyour medications in one fill

• Deliveryofmedicationstoyourdoor at no additional charge

• Licensedpharmacistsavailableto help 24/7

• CoachRx:afreetoolthatcanhelp with reminders, coaching and information. Visit Cigna.com/coachrx to learn more

• It’seasytoswitch!Justcall1.800.835.3784

For more information, visit the Cigna Home Delivery Pharmacy page on myCigna.com.

Save time and money with the convenience of Cigna Home Delivery Pharmacy

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Health care reform and youThe Patient Protection and Affordable Care Act (PPACA), commonly referred to as “health care reform,” was signed into law on March 23, 2010. This important legislation will result in changes to every American’s health coverage. Some of the changes took effect in 2010, and most of the law’s effects will be felt by 2014. Cigna will comply with all provisions of the law including those that impact your pharmacy coverage plan. For example, depending upon the final government regulations, coverage of medications that have not traditionally been included in pharmacy plans, such as specific over-the-counter (OTC) medications, may be made available at no cost-share to you. As with all covered medications, we would require a prescription from your doctor to process the claim under your pharmacy plan (including OTC medications). To get the most current information, visit www.informedonreform.com or Cigna.com andlookforthe“InformedonReform”link.

If you have questions Please call the toll-free number on the back of your Cigna ID card. We’re here to help.

NoN-Preferred GeNerics Preferred BraNds BraNds

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ADD/ADHD and Stimulants

amphetamine/ dextroamphetaminedexmethylphenidatemethamphetaminemethylphenidate/ER/ 24 HR ER

Adderall XRFocalinFocalin XRIntunivMetadate ER Ritalin LARitalin SRStratteraVyvanse

Adderall (PA, ST)Amphetamine/ Dextroamphetamine XR (PA, ST)Concerta (PA, ST)Daytrana (PA, ST)Desoxyn (PA, ST)Kapvay Metadate CD (PA, ST) Methylin (PA, ST)Nuvigil Provigil Ritalin (PA, ST)

AIDS/HIV

didanosinestavudinezidovudine

AgeneraseAptivusCombivirCrixivanEmtrivaEpivirEpzicomInviraseIsentressKaletraLexivaNorvirPrezistaRescriptorReyatazSelzentrySustivaTrizivirTruvadaViraceptViramune, XRVireadZiagen

AtriplaEdurantIntelenceRetrovirVidexZerit

Allergy

azelastine nasalclemastine fumaratecyproheptadineepinastineepinephrine (inj.)flunisolide nasal

Adrenaclick (QL) AsteproEpipen (QL)Epipen Jr. (QL)NasonexSingulair

Atrovent (nasal)Beconase AQ (PA, ST)ClarinexFlonase (PA, ST)Nasacort AQ (PA, ST)Nasarel

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Asthma and Respiratory

albuterol solution (nebulizer solution)albuterol sulfate (syrup, tabs)aminophyllinebudesonidecaffeine citratecromolyn sodium (nebulizer solution)Dylixdyphyllineguaifenesin/dyphyllineguaifenesin/theophyllineipratropium bromide (nebulizer solution)levalbuterol (nebulizer solution)metaproterenol sulfate (syrup, tabs)Myci-Bron Gterbutaline sulfatetheophylline anhydrouszafirlukast

Advair Diskus/HFAAsmanexAtrovent HFACombiventFlovent Diskus/HFAMaxairProAir HFAPulmicortPulmozyme (PA)QvarRevatio (PA)SereventSingulairSpirivaSymbicortVentolin HFA

AccolateAccuneb nebulizer (PA, ST)Adcirca (PA)AlvescoArcaptaBrovana nebulizer (PA, ST) DalirespDuleraForadilLetairisPerforomist (PA, ST) Proventil HFATracleerVentavisXopenex HFAXopenex nebulizer (PA, ST)

Alzheimer Disease

donepezilgalantamine hydrobomiderivastigmine (caps)

Aricept 23mgNamenda

Aricept (5 mg and 10 mg)Aricept ODTCognexExelonRazadyneRazadyne ER

Allergy (Continued)

fluticasone nasal hydroxyzineipratropium nasallevocetirizinetriamcinolone nasal

Veramyst Omnaris (PA, ST)PatanaseRhinocort AQ (PA, ST) Semprex-DXyzal

Anxiety

alprazolambuspironelorazepamoxazepam

Lorazepam Intensol


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Birth Control*

AmeithiaApriAvianeBalzivaCamilaCamreseErrinGianviJolessaJunel FEKarivaLevoraLow-OgestrelMicrogestinNeconNortrelOcellaOgestrelPrevifemQuasenseSoliaSprintecTrinessaTri-SprintecZenchentZovia

BeYazLoestrin 24 FELo Loestrin FELoSeasoniqueNuvaRingOrtho EvraOrtho TriCyclen LoOvcon 50Plan B One-StepSeasoniqueYaz

AngeliqDesogenEllaEstrostep FELevlenLo/Ovral-28LoestrinLoestrin FELybrelNataziaNordetteOrtho-CeptOrtho-Novum 7-7-7Ovcon 35SafyralSeasonaleTri-NorinylTriphasil

* Please check your enrollment materials to determine whether these medications are covered under your specific plan.

Bladder Problems

oxybutynin/XLtrospium chloride

Detrol Detrol LA ElmironOxytrol Toviaz VESIcare

Ditropan (PA, ST)Ditropan XL (PA, ST) Enablex (PA, ST) Gelnique (PA, ST) Sanctura (PA, ST)Sanctura XR (PA, ST)

Cancer

anastrozolebicalutamideexemestaneflutamideletrozoletamoxifen citrate

CeeNUGleevec (PA)HexalenLeukeranLysodrenMatulaneMyleranNexavar (PA)Revlimid (PA)

Afinitor (PA)ArimidexAromasinCaprelsa (PA)CasodexDroxiaFarestonFemaraTargretin

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Cancer (Continued)

Sprycel (PA)Sutent (PA)Tarceva (PA)Temodar (PA)Thalomid (PA)XelodaZolinza (PA)

Tasigna (PA)Tykerb (PA)Votrient (PA)Zelboraf (PA)Zytiga (PA)

CardiovascularBLood THiNNer/aNTi-cLoTTiNG

anagrelidecilostazoldipyridamoleenoxaparin (QL)fondaparinux (QL)heparin (QL) ticlopidinewarfarin

AggrenoxArixtra (QL)EffientFragmin (QL)Innohep (QL)Plavix

Agrylin (PA)BrilintaJantovenLovenox (QL)PletalPradaxa (PA)Xarelto (QL)

HiGH BLood PressUre/HearT MedicaTioNs

acebutolol HCl acetazolamideamiloride HCl amlodipine besylateapresolineatenololbenazepril HCl benazepril HCl/amlodipine benazepril HCl/HCTZbendroflumethiazide/ nadololbetaxolol HCl bisoprolol fumaratebisoprolol/HCTZbumetanidecaptoprilcaptopril/HCTZcarvedilolchlorothiazidechlorthalidonechlorthalidone/atenololclonidineclonidine HCl Clorpresdiltiazemdiltiazem 24HR ERdoxazosin mesylateenalapril maleate

Altace (caps)BystolicCoreg CRDiovan Diovan HCT ExforgeExforge HCTLanoxinMultaqProcanbidTarkaTekturna Tekturna HCTTikosynValturna

Accupril (PA, ST)Accuretic (PA, ST) Aceon (PA, ST)AmturnideAtacand (PA, ST)Avalide (PA, ST)Avapro (PA, ST)AzorBenicar (PA, ST)Benicar HCT (PA, ST)Betapace AFCarduraCardura XLCatapres, Catapres TTSCoregCorgardCovera-HSCozaar (PA, ST)Dynacirc CREdarbi (PA, ST)Hyzaar (PA, ST)Inderal LAInnopran XLLevatolLotensin (PA, ST) Lotensin HCT (PA, ST)LotrelMavik (PA, ST)


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Cardiovascular (Continued)


enalapril maleate/HCTZeplerenonefelodipinefosinopril sodiumfosinopril sodium/HCTZfurosemideguanabenz acetateguanfacinehydralazine HCl hydralazine/HCTZhydralazine/reserpine/HCTZhydrochlorothiazidehydrochlorothiazide/ amilor HCl hydroflumethiazideindapamideisradipinelabetalol HCl lisinoprillisinopril/HCTZlosartan potassiumlosartan potassium/HCTZmethazolamidemethyldopamethyldopa/HCTZmetolazonemetoprolol succinatemetoprolol tartratemetoprolol/HCTZminoxidilmoexipril HCl moexipril HCl/HCTZnadololnicardipine HCl nifedipinenimodipineperindopril erbuminepindololprazosin HCl propranolol HCl propranolol/HCTZquinaprilquinapril HCl/HCTZramipril (caps only)rauwolfia serpentina/ BFMTZreserpinereserpine/HCTZ

Micardis (PA, ST)Micardis HCT (PA, ST)Monopril (PA, ST) Monopril HCT (PA, ST)Nexiclon XRNitromistNorpaceNorpace CRNorvascPrinivil (PA, ST)Prinzide (PA, ST)Ranexa (PA)Rythmol SRSularTekamloTeveten (PA, ST)Teveten HCT (PA, ST)Toprol XLTribenzorUniretic (PA, ST) Univasc (PA, ST) Vaseretic (PA, ST) Vasotec (PA, ST) VerelanZestoretic (PA, ST) Zestril (PA, ST)

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Cardiovascular (Continued)


sotalol HCl spironolactonespironolactone/HCTZterazosin HCl timolol maleatetorsemidetrandolapriltrandolapril/verapamil HCl triamterene/HCTZverapamilverapamil SR

Cholesterol Lowering

atorvastatin (12/1/2011)cholestyramine powdercolestipolfenofibratefenofibric acidgemfibrozillovastatinpravastatinsimvastatin

Lescol Lescol XLLovazaNiaspanSimcorTrilipixVytorinWelcholZetia

AdvicorAltoprev (PA, ST)Caduet (1/1/2012)Cholestyramine LightColestidCrestor (PA, ST)FenoglideLipitor (PA, ST) (1/1/2012)Livalo (PA, ST)LofibraMevacor (PA, ST)Pravachol (PA, ST)TriCorZocor (PA, ST)

Depression

amitriptylinebupropionbupropion SRcitalopramdesipraminefluoxetinefluvoxamine

Cymbalta Lexapro PristiqWellbutrin XL

Aplenzin (PA, ST) Celexa (PA, ST)Effexor XR (PA, ST) EmsamLuvox CR MarplanPaxil (PA, ST)

oTHer

amiodarone digoxin disopyramide flecainide isosorbide dinitrate isosorbide mononitrate nitroglycerin procainamide propafenone SR

Nitrolingual spray


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Endocrine and Metabolic – Other

allopurinolcabergoline (QL)desmopressinfluoxymesterone

ColcrysMegace ESNilandron

Egrifta (PA)Somatuline Depot (PA)

Depression (Continued)

mirtazapinenortriptylineparoxetineparoxetine CRprotriptylinesertralinetrazodonevenlafaxinevenlafaxine XR

Paxil CR (PA, ST)Prozac (PA, ST)RemeronSarafem (PA, ST)Selfemra (PA, ST)TofranilViibryd (PA, ST)VivactilWellbutrin (PA, ST)Wellbutrin SR (PA, ST)Zoloft (PA, ST)

Diabetes

acarboseacetohexamidechlorpropamideglimepirideglipizideglipizide/metforminglucagon (QL)glyburideglyburide/metforminglyburide micronizedmetforminnateglinidetolazamidetolbutamide

ACCU-CHEK Test StripsActoplus metActosApidraApidra SoloStarBD Insulin Syringes/Pen NeedlesByettaDuetactFortametGlucaGen HypoKit (QL)HumalogHumulinJanumetJanuviaKombiglyze XRLantusLantus SoloStarLevemirNovoFine needlesNovolinNovologOne Touch test stripsOnglyzaPrandimetPrandinSymlinPenVictoza

AmarylAvandametAvandarylAvandiaCyclosetGlucophage XRGlycronGlysetMetaglipPrecoseStarlixTradjenta

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Eye Conditions

atropine azelastinebrimonidinebromfenacciprofloxacindiclofenacdorzolamidedorzolamide/timololflurbiprofenketorolaclatanoprostlevobunolollevofloxacinpilocarpinetimololtobramycin/dexamethasonetrifluridine

AlomideAlphagan P 0.10%AzaSiteAzoptBetimolBetoptic SCiloxan (ointment)IopidineLotemaxMaxidexMoxezaPatadayPatanolRestasisTobradex (ointment)Travatan ZVexolVigamox

Acular LSAlamastAlocrilAlrexBepreveBesivance (ST)Ciloxan (drops)CosoptDurezolElestatEmadineIquixLastacaftOptivarTimopticTobradex (drops)Tobradex STTrusoptVoltarenXalatan

Gastrointestinal (Not Heartburn/Ulcer)

balsalazide PEG 3350/potassium/ sodium bicarb/salt PEG 3350/potassium/sodium bicarb/salt/sodium sulf

AprisoAsacolAsacol HDCanasaCreonEntocort ECGoLytelyLialdaPentasaUrso/Urso Forte

AmitizaColazalColyteNuLytelyPancreazeSucraidZenpep

Heartburn/Ulcer

cimetidinefamotidinelansoprazolemetoclopramidemisoprostolnizatidineomeprazoleomeprazole/sodium bicarbonatepantoprazoleranitidinesucralfate

Dexilant Prevpac

Aciphex (PA, ST) HelidacNexium (PA, ST)Prevacid (PA, ST)Prilosec (PA, ST)Protonix (PA, ST)Zantac EffertabZantac SyrupZegerid (PA, ST)


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Hormone Replacement

estradiolestropipateethinyl estradiollevothroidlevothyroxineLevoxylliothyroninemedroxyprogesteronethyroidUnithroid

AloraAnadrol-50AndrodermAndroGelArmour ThyroidDivigelEnjuviaEstradermMenestPremarinPremphasePremproPrometriumSynthroidTestimVivelle-Dot

ActivellaAxironCenestinCombipatchCytomelFemhrtFemringFortestaPrefestVagifem

Infections

acycloviramantadineamoxicillinamoxicillin/clavulanateazithromycin (QL)cefaclor ERcefadroxilcefprozilcefuroxime axetilcephalexinciclopiroxciprofloxacinclarithromycinclindamycindoxycyclineerythromycinfamciclovir fluconazole (QL for 150mg only) ganciclovirgentamicin sulfategriseofulvinitraconazoleketoconazolemetronidazoleminocyclineminocycline SRmupirocinnitrofurantoinnystatinofloxacin

BaracludeCipro HC OticCiprodexEpivir HBVGris-PegHepseraMycostatin (tab)PrimsolTamiflu (QL)Tobi

AugmentinAugmentin ES 600Augmentin XRAveloxBiaxinBiaxin XLCedaxCefzilCipro XRCoartem (QL) CopegusDificid (PA)Ery-TabFamvir Flagyl ERFloxin OticGaramycinKeflexKeftabLamisil (QL)LevaquinMalarone (PA) MonurolMoxatagNoxafilOmnicefPenlac (PA) PriftinRebetolRelenza (QL)Rocephin (PA)

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Osteoporosis

alendronate(Fortical) calcitonin-salmon

BonivaEvista ForteoMiacalcin

Actonel (PA, ST) Atelvia (PA, ST) Fosamax (PA, ST) Fosamax Plus D (PA, ST) Skelid (PA, ST)

Nausea and Vomiting

dronabinolgranisetron (tabs, sol) (QL)ondansetron (tabs, sol) (QL)prochlorperazinepromethazinetrimethobenzamide

Emend (QL) Anzemet (tabs)(QL)Kytril (tabs, sol)(QL)MarinolSancuso (QL)ScopaceZofran (tabs, sol)(QL)Zuplenz (QL, ST)

Migraine

acetaminophen/ caffeine/butalbitalnaratriptan (QL)sumatriptan (QL)

Maxalt (QL)Maxalt MLT (QL)Treximet (QL)

Alsuma (QL)Amerge (QL)Axert (QL)DHE 45 (QL)Frova (QL)Imitrex (QL)Migranal (QL)Relpax (QL)Sumavel DosePro (QL)Zomig/Zomig ZMT (QL)

Multiple Sclerosis

Ampyra (PA) Betaseron (PA)Extavia (PA)Gilenya (PA)

Infections (Continued)

penicillin v potassiumribavirinrimantadinesulfamethoxazole/ trimethoprimterbinafineterconazoletetracyclinevalacyclovirvoriconazole

SolodynSporanox (QL) SupraxTyzekaValtrexVfend (PA)Zithromax (QL)Zyvox (PA)


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Pain Relief and Inflammatory Disease

buprenorphinebutorphanol nasal (QL)codeine phos/carisoprodol/ asacodeine phosphatecodeine phosphate/aspirincodeine sulfatediclofenacdihy-cod tt/apap/caffeineetodolacfenoprofenfentanyl transdermal (QL) fentanyl citrate (lozenge on stick) (PA)flurbiprofenhydrocodone/ acetaminophenhydrocodone bitartrate/ apaphydrocodone bitartrate/ aspirinhydromorphone HClibuprofenibuprofen/hydrocod bitindomethacinketoprofenketorolac oral (PA, QL)leflunamidelevorphanol tartratemeclofenamatemefenamic acidmeloxicammeperidine HClmethotrexatemorphine SRmorphine sulfatenabumetonenaproxenopiumopium/belladonna alkaloidsoxaprozinoxycodone HCloxycodone HCl/ acetaminophenoxycodone/aspirinoxymorphonepentazocine HCl/ acetaminophenpentazocine HCl/ naloxone HCl

AvinzaCelebrexDilaudid-5 DipentumIndocin (suppository)KadianLidodermLyricaNucynta (PA, ST)OxyContin (QL)Ponstel RheumatrexRoxicet (PA, ST)SavellaSkelaxinTrexallVimovo

Abstral (PA)Actiq (PA)Arthrotec (PA, ST)Butrans (QL)Cambia (PA, ST)Demerol (PA, ST) Dilaudid (PA, ST)Duragesic (QL)Exalgo (QL)Fentora (PA)Flector (PA, ST)Horizant (ST)Hycet (PA, ST) Lorcet (PA, ST) Lorcet Plus (PA, ST) Lortab (PA, ST) Magnacet (PA, ST) Maxidone (PA, ST) Mobic (PA, ST)Nalfon (PA, ST)Naprelan (PA, ST)Norco (PA, ST) Onsolis (PA)OpanaOpana ERPanlor SS (PA, ST) Pennsaid (PA, ST)Percocet (PA, ST) Percodan (PA, ST) Primalev (PA, ST) Roxicodone (PA, ST) Ryzolt (PA, ST) Sprix (QL)Synalgos-DC (PA, ST) Tylox (PA, ST) Ultracet (PA, ST) Ultram (PA, ST) Ultram ER (PA, ST) Vicodin (PA, ST) Vicodin ES (PA, ST) Vicodin HP (PA, ST) Vicoprofen (PA, ST) Voltaren (PA, ST) Voltaren Gel (PA, ST)Voltaren XR (PA, ST) Xodol (PA, ST) Xolox (PA, ST) Zamicet (PA, ST)

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Prostate

alfuzosindoxazosinfinasterideprazosintamsulosinterazosin

AvodartJalyn

FlomaxProscarRapafloUroxatralZytiga (PA)

Schizophrenia

clozapinehaloperidolloxapineolanzapinerisperidonethiothixene

SeroquelSeroquel XR

Abilify (PA, ST) Abilify Discmelt (PA, ST) Clozaril (PA, ST) Fanapt (PA, ST) Fazaclo (PA, ST) Geodon (PA, ST) Invega (PA, ST) Latuda (PA, ST) MobanOrapRisperdal (PA, ST) Saphris (PA, ST) Zyprexa (PA, ST)

Parkinson Disease

amantadinebenztropinebromocriptinecarbidopa/levodopacarbidopa/levodopa SApramipexoleropiniroleselegiline

AzilectRequipRequip XL

ComtanEldeprylLodosynMirapexMirapex ERStalevoTasmarZelapar

Pain Relief and Inflammatory Disease (Continued)

piroxicamsulindactramadol HCl/ERtramadol HCl/acetaminophentolmetin

Zolvit (PA, ST) Zydone (PA, ST)


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Seizure

carbamazepineclonazepamdiazepamdivalproexgabapentinlamotriginelevetiracetamtopiramatevalproatezonisamide

CelontinDiastatDiastat AcudialFelbatolGabitrilKeppraLamictalLyricaPeganone

BanzelCarbatrolDepakote (all forms)Keppra XRNeurontinStavzorTegretol XRTopamaxTrileptalVimpatZonegran

Sexual Dysfunction

Muse (PA, QL)Viagra (PA, QL)

Caverject (PA, QL)Cialis (PA, QL)Edex (PA, QL)Levitra (PA, QL)Staxyn (PA, QL)

Skin Conditions

adapalene (AGE)alclometasone dipropionateamcinonideAmnesteem (QL)Apexicon E (diflorasone diacetate)betamethasonebetamethasone dipropionatebetamethasone dipropionate/ propylene glycolbetamethasone valeratecalcipotrieneclobetasol propionateclobetasol propionate/emolldesonidedesoximetasonediflorasone diacetatefluocinolone acetonidefluocinonide/emollientfluorouracil topicalfluticasone propionatehalobetasol prop/ ammonium lachalobetasol propionatehydrocortisonehydrocortisone acetate/alo verhydrocortisone acetate/ureahydrocortisone butyratehydrocortisone valerate

BenzaclinBenzamycin PakCapex Shampoo (PA, ST)CaracCarmol 40Carmol HC (PA, ST)Carmol scalpCloderm (PA, ST)Cordran (PA, ST)Cordran SP (PA, ST)Derma-Smoothe/FS (PA, ST)Differin (AGE)Dovonex creamDuacExeldermFluoroplexFuracinKenalog spray (PA, ST)KlaronLocoid (lotion) (PA, ST)Locoid Lipocream (PA, ST)Loprox shampooMetrogel 1%NoritateNucort (PA,ST)OraceaRetin-A Micro (AGE)Soriatane Tazorac

AcanyaAclovate (PA, ST) AldaraApexicon (PA, ST)AphthasolAtralin (AGE)Benzefoam Clindacin PacClobex (PA, ST) CondyloxCutivate (PA, ST) DelosDermatop (PA, ST) Desonate (PA, ST) Desowen (PA, ST) Diprolene (PA, ST) Diprolene AF (PA, ST) Elidel (PA, ST) Elocon (PA, ST) Epiduo (AGE)First Hydrocort (PA, ST) Halog (PA, ST) Luxiq (PA, ST) MetrolotionMomexin (PA, ST) Nuzon (PA, ST)Olux (PA, ST) Olux-e (PA, ST) Pandel (PA, ST)

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Skin Conditions (Continued)

imiquimodisotretinoin (QL)metronidazolemometasone furoatepodofiloxprednicarbateSotret (QL)sulfacetamidetretinoin (AGE)triamcinolone acetonide

Texacort (PA, ST) Panretin (PA)Pediaderm HC (PA, ST) Protopic (PA, ST) Regranex (PA) RosulaScalacort DK TaclonexTargretin gelTemovate (PA, ST) Topicort (PA, ST) Topicort LP (PA, ST) Ultravate (PA, ST) Ultravate PAC (PA, ST) Vanos (PA, ST) VecticalVerdeso (PA, ST) Westcort (PA, ST) XolegelXolegel CorepakZianaZyclara (ST)

Transplant

azathioprinecyclosporinemycophenolate moefetiltacrolimus

AzasanCellceptNeoralPrografRapamuneSandimmune

ImuranMyforticZortress

Sleep

zaleplon zolpidem zolpidem ER

Silenor Ambien (PA, ST) Ambien CR (PA, ST) Edluar (PA, ST) Lunesta (PA, ST) Rozerem (PA, ST) Sonata (PA, ST) Zolpimist (PA, ST)


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Miscellaneous

aminocaproic acidcyclobenzaprineleucovorinlevocarnitinelindanemegestrolmethocarbamolnaltrexone (QL)pentoxifyllinepramoxine/hydrocortisonetizanidine

Analpram AdvancedAnalpram HCAnalpram-EAnamantle HC ForteFollistim AQ* (PA)FosrenolPhoslyraPramosoneProctofoam-HCRenvelaRilutekTussiCapsTussionexUloricZavesca (PA)Zemplar

CortifoamCuvposaEpifoamKuvan NatrobaNimotopNuedextaPhosloPromacta (PA)RenagelUlesfiaZanaflexZutripro

Vitamins*

calcitriolcyanocobalaminfolic acid

*All plans cover all generic prescription prenatal vitamins, even though not listed here.

CitranatalDuetDuet DHADuet DHA EC StuartnaDuet DHA StuartnatalDuet StuartnatalFoltabs Prenatal Plus DGesticareGesticare DHANatachewNatafortNeevoOB CompleteOB Complete DHAPrecarePrecare ConceivePrecare PremierPreferaOBPrenatal VitaminStuart PrenatalStuartnatal PlusStuartnatal Plus 3Tricare DHAViva DHA

* Please check your enrollment materials to determine whether this medication is covered under your plan.

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rugs Specialty Injectable Drugs (All Require Prior Authorization)

The following injectable drugs are typically covered under the Fourth Tier and require prior authorization for coverage.

Drug name Condition treated

Actimmune Chronic granulomatous diseaseAnzemet Nausea and vomitingApokyn Parkinson diseaseAranesp AnemiaArcalyst Inflammatory disorderAvonex Multiple sclerosisBetaseron Multiple sclerosisCeftriaxone Infection Cimzia Crohn’s diseaseCopaxone Multiple sclerosisDelatestryl Hormone deficiencyDepo-Testosterone Hormone deficiencyEgrifta HIV-relatedEmend IV Nausea and vomitingEnbrel ArthritisEpogen AnemiaExtavia Multiple sclerosisFirazyr Hereditary angioedemiaFirmagon Prostate cancerFuzeon HIV infectionGaramycin InfectionGenotropin Growth hormone deficiencyGold Sodium Thiomalate ArthritisGranisetron Nausea and vomitingHumatrope Growth hormone deficiencyHumira ArthritisIlaris Inflammatory disorderIncrelex Growth failureInfergen Hepatitis CIntron A Hepatitis CKetorolac Tromethamine Pain and inflammationKineret ArthritisKytril Nausea and vomitingLeukine Low blood cell countLeuprolide Acetate Cancer, endocrineLupron, Lupron Depot Cancer, endocrineMyochrysine ArthritisNebcin InfectionNeulasta Low blood cell countNeumega Low platelet count

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rugs Specialty Injectable Drugs (Continued) (All Require Prior Authorization)

The following injectable drugs are typically covered under the Fourth Tier and require prior authorization for coverage.Drug name Condition treatedNeupogen AnemiaNorditropin Growth hormone deficiencyNorditropin Nordiflex Growth hormone deficiencyNutropin Growth hormone deficiencyNutropin AQ, Nuspin Growth hormone deficiencyOctreotide Acetate EndocrineOmnitrope Growth hormone deficiencyOndansetron Nausea and vomitingOrencia (self-administered only) ArthritisPeg Intron Hepatitis CPegasys Hepatitis CProcrit AnemiaProleukin CancerRebif Multiple sclerosisRelistor Opioid-induced constipationRemicade Arthritis, colon diseaseRocephin InfectionSaizen Growth hormone deficiencySandostatin EndocrineSandostatin LAR EndocrineSerostim Growth hormone deficiencySimponi ArthritisSomatulin Depot AcromegalySomavert AcromegalyStelara PsoriasisSylatron CancerTestosterone Hormone deficiencyTev-Tropin Growth hormone deficiencyTobramycin Sulfate InfectionToradol IV/IM Pain and inflammationXolair AsthmaZofran Nausea and vomitingZoladex CancerZorbtive Growth hormone deficiency

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Exclusions and limitations Plans typically do not provide coverage for the following, except as required by law or by the terms of your specific plan: 1. Any medications available over the counter

that do not require a prescription by Federal or State Law, and any medication that is a pharmaceutical alternative to an over the counter medication other than insulin. [examples include OTC Benadryl, Maalox, Sudafed PE , etc.]

2. Medications that are therapeutically equivalent as determined by the Cigna HealthCare Pharmacy and Therapeutics Committee in which at least one of the medications within the class is available over the counter. [examples include Rx equivalents to OTC Allegra, Claritin and Zyrtec (Allegra D, Clarinex, Xyzal) and Rx equivalents to OTC Prevacid, Prilosec, Zantac (Aciphex, Kapidex, Nexium, Axid, Pepcid, Zantac)]

3. Any injectable infertility medications, and any injectable medications that require Health Care Professional supervision and are not typically considered self-administered medications. The following are examples of Health Care Professional-supervised medications: Injectables used to treat hemophilia and RSV (respiratory syncytial virus), chemotherapy injectables, and endocrine and metabolic agents.

4. Any medications that are experimental or investigational, within the meaning set forth in the summary plan description.

5. Food and Drug Administration (FDA)-approved medications used for purposes other than those approved by the FDA unless the medication is recognized for the treatment of the particular indication in one of the standard reference compendia (The United States Pharmacopoeia Drug Information or The American Hospital Formulary Service Drug Information) or in medical literature. Medical literature means scientific studies published in a peer-reviewed national professional medical journal.

6. Any prescription and non-prescription supplies (such as ostomy supplies), devices, and appliances.

7. Any contraceptive medications and prescription appliances for contraception.

8. Implantable contraceptive products. 9. Any fertility medication. 10. Any medications used for treatment of

sexual dysfunction, including but not limited to erectile dysfunction, delayed ejaculation, anorgasmia and decreased libido.

11. Any prescription vitamins (other than prenatal vitamins), dietary supplements and fluoride products.

12. Medications used for cosmetic purposes, such as medications used to reduce wrinkles, medications to promote hair growth, medications used to control perspiration and fade cream products.

13. Any diet pills or appetite suppressants (anorectics).

14. Prescription smoking cessation products. 15. Immunization agents, biological products

for allergy immunization, biological sera, blood, blood plasma and other blood products or fractions and medications used for travel prophylaxis.

16. Replacement of prescription medications and related supplies due to loss or theft.

17. Medications used to enhance athletic performance.

18. Medications that are to be taken by or administered to a Customer while the Customer is a patient in a licensed hospital, skilled nursing facility, rest home or similar institution which operates on its premises or allows to be operated on its premises a facility for dispensing pharmaceuticals.

19. Prescriptions more than one year from the original date of issue.

“Cigna” is a registered service mark, and the “Tree of Life” logo and ”Cigna Home Delivery Pharmacy” are service marks, of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, Tel-Drug, Inc., Tel-Drug of Pennsylvania, L.L.C., and HMO or service company subsidiaries of Cigna Health Corporation. “Cigna Home Delivery Pharmacy” refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C.

595201 n 12/11 © 2011 Cigna

Cigna reserves the right to make changes to this Drug List without notice. Your plan may cover additional medications; please refer to your enrollment materials for details. Cigna does not take responsibility for any medication decisions made by the prescriber or pharmacist. Cigna may receive payments from manufacturers of certain Preferred Brand medications, and in limited instances, certain Non-Preferred Brand medications, that may or may not be shared with your plan depending on its arrangement with Cigna. Depending upon plan design, market conditions, the extent to which manufacturer payments are shared with your plan, and other factors as of the date of service, the Preferred Brand medication may or may not represent the lowest-cost brand medication within its class for you and/or your plan.

four-tier plan 2012 cignabenefits.brevardschools.org/hr/benefits 2013... · some pharmacy plans...

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