PRESCRIPTION DRUG LIST CHANGES Cigna Pharmacy Management® 2021 To help make sure you have access to coverage for safe, clinically effective and low-cost medications, we regularly review and update the Cigna Prescription Drug List. You can see a list of these changes below. Changes are listed by drug list name, the date the change starts and by the type of change that’s taking place. Medications are then listed alphabetically by drug class. If you have Cigna-administered pharmacy benefits and you’re affected by one of these changes, we’ll send you a letter with specific information on next steps. STANDARD PRESCRIPTION DRUG LIST Start date of Drug class Medications moving to preferred brand change*,** June 22, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Reditrex May 15, 2021 EYE CONDITIONS Eysuvis GASTROINTESTINAL/HEARTBURN Sutab January 1, 2021 AIDS/HIV Juluca ASTHMA/COPD/RESPIRATORY Bevespi DIABETES Baqsimi GASTROINTESTINAL/HEARTBURN Pancreaze INFECTIONS Epclusa, Harvoni PAIN RELIEF AND INFLAMMATORY DISEASE Taltz Start date of Medications becoming Generic and/or preferred Drug class change*,** non-preferred brand brand alternatives June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1 Lupron Depot June 22, 2021 CANCER Orgovyx1 No preferred formulary drug alternatives. June 15, 2021 GASTROINTESTINAL/HEARTBURN Lubiprostone 8 mcg, 24 mcg capsule Amitiza June 1, 2021 SKIN CONDITIONS Winlevi 1% cream Generic products (e.g. adapalene; tretinoin; clindamycin-benzoyl peroxide) Wynzora 0.005%-0.064% cream betamethasone DP, fluocinolone, fluticasone, mometasone, trimacinolone, calcipotriene, calcipotriene-betamethasone DP Generic medications start with a lowercase letter and brand name medications start with a capital letter. 951712 UPDATED_05/21/2021 STANDARD PRESCRIPTION DRUG LIST (cont) Start date of Medications becoming Generic and/or preferred Drug class change*,** non-preferred brand brand alternatives June 1, 2021 URINARY TRACT CONDITIONS Vesicare LS 5 mg/5 mL suspension oxybutynin chloride, oxybutynin chloride ER, darifenacin ER, solifenacin, tolterodine, tolterodine ER, tropsium May 15, 2021 EYE CONDITIONS Lacrisert Restasis, Restasis Multi-dose, Xiidra May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo tramadol May 1, 2021 SKIN PREPS Impeklo topical betamethasone dipropionate (augmented) 0.05%, clobetasol propionate 0.05%, halobetasol propionate 0.05%, fluocinolide 0.1% April 18, 2021 HORMONAL AGENTS Alkindi Sprinkle hydrocortisone 5mg tablet March 28, 2021 BLOOD PRESSURE/HEART MEDICATIONS Conjupri amlodipine, felodipine, nifedipine, nicardipine January 1, 2021 AIDS/HIV Intelence1 Talk to your doctor about other alternatives BLOOD MODIFIERS/BLEEDING DISORDERS Amicar 0.25 g/ml oral solution1 aminocaproic acid 0.25g/ml oral solution BLOOD PRESSURE/HEART MEDICATIONS Multaq, Norpace CR 150mg Talk to your doctor about other alternatives CANCER Tabloid Talk to your doctor about other alternatives ERECTILE DYSFUNCTION Caverject Impulse Syringe MUSE EYE CONDITIONS Lotemax 0.5% drops loteprednol 0.5% drops HORMONAL AGENTS Armour Thyroid, Synthroid, Unithroid levothyroxine INFECTIONS Kitabis Pak1 tobramycin pak 300mg/5ml SEIZURE DISORDERS Lyrica 20mg/ml oral solution pregabalin 20mg/ml oral solution SUBSTANCE ABUSE Bunavail buprenorphine/naloxone film or sublingual tablet, Zubsolv WEIGHT MANAGEMENT Megace ES 625mg/5ml oral suspension megestrol 625ml/5ml oral suspension Start date of Drug class Medications that will need approval (prior authorization)^ change*,** June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1 June 22, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Reditrex June 1, 2021 ASTHMA/COPD/RESPIRATORY Zokinvy March 14, 2021 CANCER Gavreto January 1, 2021 BLOOD THINNERS/ANTI-CLOTTING Eliquis4, Pradaxa4, Savaysa4, Xarelto4 PAIN RELIEF AND INFLAMMATORY DISEASE diclofenac 1.3% patch, Flector 1.3% patch5, Voltaren 1% gel5 Start date of Drug class Medications that will have a quantity limit change*,** June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1 June 1, 2021 ASTHMA/COPD/RESPIRATORY Zokinvy May 15, 2021 EYE CONDITIONS Eysuvis May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo Generic medications start with a lowercase letter and brand name medications start with a capital letter. STANDARD PRESCRIPTION DRUG LIST (cont) Start date of Drug class Medications that will have a quantity limit change*,** March 14, 2021 CANCER Gavreto Start date of Medications that will no longer Generic and/or preferred Drug class change*,** be covered^^ brand alternatives June 29, 2021 SKIN CONDITIONS Klisyri topical fluorouracil, imiquimod 5% cream June 22, 2021 GASTROINTESTINAL/HEARTBURN Reltone ursodiol HORMONAL AGENTS Thyquidity levothyroxine, levoxyl, Levo-T, Unithroid, Euthyrox June 15, 2021 GASTROINTESTINAL/HEARTBURN Lubiprostone 8 mcg, 24 mcg capsule Amitiza June 1, 2021 SKIN CONDITIONS Winlevi 1% cream Generic products (e.g. adapalene; tretinoin; clindamycin-benzoyl peroxide) June 1, 2021 SKIN CONDITIONS (cont) Wynzora 0.005%-0.064% cream betamethasone DP, fluocinolone, fluticasone, mometasone, trimacinolone, calcipotriene, calcipotriene-betamethasone DP URINARY TRACT CONDITIONS Vesicare LS 5 mg/5 mL suspension oxybutynin chloride, oxybutynin chloride ER, darifenacin ER, solifenacin, tolterodine, tolterodine ER, tropsium May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo tramadol May 1, 2021 SKIN PREPS Impeklo topical betamethasone dipropionate (augmented) 0.05%, clobetasol propionate 0.05%, halobetasol propionate 0.05%, fluocinolide 0.1% April 18, 2021 HORMONAL AGENTS Alkindi Sprinkle hydrocortisone 5mg tablet March 28, 2021 BLOOD PRESSURE/HEART MEDICATIONS Conjupri amlodipine, felodipine, nifedipine, nicardipine January 1, 2021 ASTHMA/COPD/RESPIRATORY ProAir HFA7, ProAir RespiClick7, albuterol HFA Ventolin HFA7 DIABETES Kombiglyze XR8, Onglyza8 metformin, Janumet, Janumet XR, Januvia EYE CONDITIONS Lumigan7, Travatan Z, Xalatan, Xelpros, bimatoprost, latanoprost, travoprost Zioptan9 GASTROINTESTINAL/HEARTBURN Creon7, Pertzye, Zenpep7 Pancreaze Motegrity, Trulance7, Zelnorm Amitiza, Linzess Sensipar cinacalcet HORMONAL AGENTS TaperDex dexamethasone 1.5mg tablet INFECTIONS Baraclude entecavir tablet Noxafil tablet posaconazole DR 100mg tablet MULTIPLE SCLEROSIS Ampyra ER7 dalfampridine ER NUTRITIONAL/DIETARY PreGenna, Trinaz Any generic prenatal vitamin PAIN RELIEF AND INFLAMMATORY DISEASE Amerge generic triptans (e.g. naratriptan; sumatriptan) Generic medications start with a lowercase letter and brand name medications start with a capital letter. STANDARDStart date of PRESCRIPTION DRUG LISTMedications (cont) that will no longer Generic and/or preferred Drug class change*,** be covered^^ brand alternatives January 1, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE butalbital-acetaminophen 50-300mg tablet butalbutal-acetaminophen 50-325mg tablet Cosentyx10 Enbrel, Humira, Otezla, Skyrizi, Stelara, Taltz Frova, Maxalt, Maxalt MLT, Relpax generic triptans (e.g. naratriptan; sumatriptan) SEIZURE DISORDERS Felbatol11 felbamate Keppra/Keppra XR11 levetiracetam/levetiracetam ER Lamictal XR Start Kit11 lamotrigine ER Lamictal/ODT/XR11 lamotrigine, lamotrigine ER, lamotrigine ODT Qudexy XR11, Trokendi XR11 topiramate ER Sabril11 vigabatrin, vigadrone Topamax11 topiramate Trileptal11 oxcarbazepine Zonegran11 zonisamide SKIN CONDITIONS Apexicon E5, diflorasone, Impoyz5, Olux5, betamethasone, clobetasol, halobetasol Olux-E5, psorcon Condylox imiquimod 5% cream packet, podofilox 0.5% topical solution Cordran5 betamethasone, clobetasol, fluocinolone, fluticasone, halobetasol Finacea Foam7, Finacea Gel, MetroCream, azelaic acid, topical metronidazole MetroGel, MetroLotion, Soolantra12 flurandrenolide, hydrocortisone butyrate betamethasone, fluocinolone, fluticasone lipid cream, lotion5, Pandel5 Sorilux calcitriol, tazarotene, topical calcipotriene Tridesilon5 alclometasone, desonide, triamcinolone Xolegel ciclopirox 0.77% gel, ciclopirox 1% shampoo, ketoconazole 2% cream, ketoconazole 2% foam, selenium 2.5% lotion, sodium sulfacetamide 10% shampoo SLEEP DISORDERS/SEDATIVES Belsomra8 Dayvigo URINARY TRACT CONDITIONS Procysbi4 Cystagon Start date of Medications that will be Drug class Additional information change*,** excluded from coverage January 1, 2021 SKIN CONDITIONS Rosadan Kits azelaic acid, topical metronidazole Generic medications start with a lowercase letter and brand name medications start with a capital letter. VALUE PRESCRIPTION DRUG LIST Start date of Drug class Medications moving to preferred brand change*,** June 22, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Reditrex May 15, 2021 EYE CONDITIONS Eysuvis GASTROINTESTINAL/HEARTBURN Sutab January 1, 2021 AIDS/HIV Juluca DIABETES Baqsimi GASTROINTESTINAL/HEARTBURN Pancreaze INFECTIONS Epclusa, Harvoni PAIN RELIEF AND INFLAMMATORY DISEASE Ajovy13, Emgality13, Taltz SEIZURE DISORDERS Vimpat URINARY TRACT CONDITIONS Cystagon Start date of Medications becoming Generic and/or preferred Drug class change*,** non-preferred brand brand alternatives June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1 No preferred formulary drug alternatives June 22, 2021 CANCER Orgovyx1 Lupron Depot June 15, 2021 GASTROINTESTINAL/HEARTBURN Lubiprostone 8 mcg, 24 mcg capsule Amitiza June 1, 2021 SKIN CONDITIONS Winlevi 1% cream Generic products (e.g. adapalene; tretinoin; clindamycin-benzoyl peroxide) Wynzora 0.005%-0.064% cream betamethasone DP, fluocinolone, fluticasone, mometasone, trimacinolone, calcipotriene, calcipotriene-betamethasone DP URINARY TRACT CONDITIONS Vesicare LS 5 mg/5 mL suspension