CIGNA PERFORMANCE 3-TIER PRESCRIPTION DRUG LIST For California Health Maintenance Organization, Point of Service, Network, Preferred Provider Organization, Exclusive Provider Organization, Open Access Plus, Open Access Plus IN Network, LocalPlus, LocalPlus IN Coverage as of July 1, 2021 View your drug list online: View your coverage info online: Cigna.com/druglist myCigna® App or myCigna.com 24/7 Customer Service: 800.Cigna24 (800.244.6224) Offered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, or their affiliates. 927838 c CA Performance 3-Tier 05/21 Last updated: 06/01/2021. This drug list is subject to change and all prior versions are no longer in effect. What’s inside? Information about the drug list 3 Frequently asked questions (FAQs) 3 Words you may need to know 9 About this drug list 10 How to read this drug list 11 How to find your medication 14 List of prescription medications 16 Exclusions and limitations for coverage 192 Index of medications 193 View the drug list online This document was last updated 06/01/2021.* You can go online to see the current list of medications your plan covers. myCigna® App and/or myCigna.com. Click on the “Find Care & Costs” tab and select “Price a Medication.” Then type in your medication name to see how it’s covered. Cigna.com/druglist. Select Performance 3 Tier from the drop down menu. Then type in your medication name or view the full list. Questions? › Click to chat: myCigna website, Monday–Friday, 9:00 am–8:00 pm EST. › By phone: Call the toll-free number on your Cigna ID card. We’re here 24/7/365. * Drug list created: originally created 01/01/2004 Last updated: 06/01/2021, for changes Next planned update: 09/15/2021, for starting 07/01/2021 changes starting 01/01/2022 2 Information about the drug list Frequently asked questions (FAQs) Understanding your prescription medication coverage can be confusing. Here are answers to some commonly asked questions. Q. How often is the drug list updated? How do I know (P&T) Committee, which is a group of practicing if my medication coverage changed? doctors and pharmacists, most of whom work outside of Cigna. The group meets regularly to A. Cigna reviews and updates the prescription drug list every month. We make changes for many reasons – review medical evidence and information provided like when new medications become available or are by federal agencies, drug manufacturers, medical no longer available, or when medication prices professional associations, national organizations and change. We try to give you many options to choose peer-reviewed journals medications about the safety from to treat your health condition. These changes and effectiveness of medications that are newly may include:1,2 approved by the FDA and medications already on the market. The Cigna Pharmacy Management® › Moving a medication to a lower cost tier. This Business Decision Team then looks at the results of can happen at any time during the year. the P&T Committee’s clinical review, as well as the › Moving a brand medication to a higher cost tier medication’s overall value and other factors before when a generic becomes available. This can adding it to, or removing it from, the drug list. happen at any time during the year. Q. Why do certain medications need approval › Moving a medication to a higher cost tier and/or before my plan will cover them? no longer covering a medication. This typically A. The review process helps to make sure you’re happens twice a year on January 1st and July 1st. receiving coverage for the right medication, at › Adding extra coverage requirements to the right cost, in the right amount and for the a medication. right situation. When we make a change that affects the coverage Q. How do I know if I’m taking a medication that of a medication you’re taking, we let you know needs approval? before it happens. This way, you have time to talk A. Log in to the myCigna App or myCigna.com, or with your doctor about your options. check your plan materials, to learn more about Q. Why doesn’t my plan cover certain medications? how your plan covers your medications. If your medication has a (PA) or (ST) next to it, your A. To help lower your overall health care costs, your medication needs approval before your plan plan doesn’t cover certain high-cost brand will cover it. If it has a (QL) next to it, you may medications because they have lower-cost, covered need approval depending on the amount you’re alternatives which are used to treat the same filling. If it has (AGE) next to it, you may need condition. Meaning, the alternative works the same approval depending on the covered age range or similar to the non-covered medication. If you’re for the medication. taking a medication that your plan doesn’t cover and your doctor feels an alternative isn’t right Q. What types of medications typically need for you, he or she can ask Cigna to consider approval? approving coverage. A. Medications that: Your plan may also exclude certain medications or › May be unsafe when combined with other products from coverage. This is known as a “plan (or medications benefit) exclusion.” For example, your plan excludes medications that aren’t approved by the U.S. Food › Have lower-cost, equally effective alternatives and Drug Administration (FDA). With excluded available medications, there’s no option to receive coverage › Should only be used for certain health through Cigna’s coverage review process. conditions Q. How do you decide which medications to cover? › Are often misused or abused A. The Cigna Prescription Drug List is developed with the help of Cigna’s Pharmacy and Therapeutics 3 Q. What types of medications typically have doctor continues to prescribe it to treat your quantity limits? condition (as long as the medication is appropriately prescribed and is safe and effective in treating your A. Medications that: condition). › Are often taken in amounts larger than, or for longer than, may be appropriate Q. My plan doesn’t cover my medication. I need to take it because it’s medically necessary for my › Are often misused or abused treatment. How do I get approval (prior Q. What types of medications require Step Therapy? authorization) for my medication? A. The medications are used to treat many conditions, A. If your doctor feels that your medication is including, but not limited to: necessary for your treatment and an alternative isn’t right for you, he or she can ask Cigna to consider › ADD/ADHD › High cholesterol approving coverage of your medication. Ask your › Allergies › Osteoporosis doctor’s office to contact Cigna so we can start the › Bladder problems › Pain coverage review process. They know how the review process works and will take care of everything for Breathing problems Skin conditions › › you. In case the office asks, they can download a › Depression › Sleep disorders request form from Cigna’s provider portal at › High blood pressure cignaforhcp.com. Cigna will review information your doctor provides to make sure your medication Q. Why does my medication have an age meets coverage guidelines. If it does, you’ll be requirement? approved for coverage of the medication. If it A. Some medications are only considered clinically doesn’t meet guidelines, you and your doctor can appropriate if you’re within a certain age range. appeal the decision. We’ll send you information either way. Q. How do I get approval (prior authorization) for my medication? For non-urgent requests, Cigna will let you and your doctor know within 72 hours of the decision. If A. Ask your doctor’s office to contact Cigna so we can approved, coverage will be provided until the start the coverage review process. They know how prescription runs out (including refills). For urgent the review process works and will take care of requests based on exigent circumstances, Cigna will everything for you. In case the office asks, they can let you and your doctor know within 24 hours of the download a request form from Cigna’s provider decision. If approved, coverage will be provided for portal at cignaforhcp.com. Cigna will review the duration of the exigency. It’s important to know information your doctor provides to make sure your that when medications are approved, it’s typically medication meets coverage guidelines. If it does, for one year of coverage. If your medication is you’ll be approved for coverage of the medication. If approved for less time, it’s because there’s a clinical it doesn’t meet guidelines, you and your doctor can reason based on Cigna’s coverage guidelines for the appeal the decision. We’ll send you information medication and/or the reviewing doctor. either way. Q. My medication is part of the Step Therapy For non-urgent requests, Cigna will let you and your program. I don’t want to try an alternative. doctor know within 72 hours of the decision. If How do I get approval (prior authorization) for approved, coverage will be provided until the my medication? prescription runs out (including refills). For urgent requests based on exigent circumstances, Cigna will A. If you and your doctor feel an alternative medication let you and your doctor know within 24 hours of the won’t work for you, your doctor can ask Cigna to decision. If approved, coverage will be provided for consider approving coverage of your current the duration of the exigency.