ACG-Cigna Demonstration Project

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Actimmune® (interferon gamma1b)

Acthar® Gel (repository corticotropin)

Actiq® (transmucosal fentanyl)

Addyi™ (flibanserin)

Advantage Prescription Drug List - (1602)

Afrezza®

Alpha1-Proteinase Inhibitors

Ampyra® (dalfampridine)

Anadrol® (oxymetholone)

Antiemetic Therapy

Antifungals, Topical

Antivirals, Topical

Apokyn®

(apomorphine)

Arcalyst™ (rilonacept)

Austedo™ (deutetrabenazine)

Baxdela™ (delafloxacin)

Benlysta® (belimumab)

Botulinum Therapy

Brineura® (cerliponase alfa)

Ceprotin® (protein C concentrate)

Chimeric Antigen Receptor T-Cell (CAR-T) & Advanced Cellular/Immune Effector Cell Therapy

Cholbam® (cholic acid)

Clotting Factors & Antithrombin

Compounded Medications

Controlled Substance Analgesic & Narcotic Antagonist Quantity Limitations

Corlanor® (ivabradine)

Cresemba® (isavuconazonium)

Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Modulators

Daraprim® (pyrimethamine)

Denosumab

Depen® (penicillamine & trientine hydrochloride)

Dimercaprol & Edetate Calcium Disodium

Dose Optimization

Duopa®

(carbidopa & levodopa enteral suspension)

Dupixent® (dupilumab)

Egrifta® (tesamorelin)

Emflaza™ (deflazacort)

Endometrin® (progesterone)

Entresto™ (sacubitril/valsartan)

Epinephrine

Erythropoiesis Stimulating Agents (ESA)

Evzio® (naloxone)

Exondys 51™ (eteplirsen)

Filgrastim

Gattex® (teduglutide)

Glycopyrrolate Inhalation Solution

Hepatitis C Therapy

Hereditary Angioedema (HAE) Therapy

Hetlioz® (tasimelteon)

HIV/AIDS

HMG-CoA Reductase Inhibitors (Statins)

Human Papillomavirus Vaccine

Idiopathic Pulmonary Fibrosis Therapy

Ilaris® (canakinumab)

Immune Globulin (IVIG)

Immunomodulators

Impavido® (miltefosine)

Increlex® (mecasermin)

Infertility Injectables

Ingrezza™ (valbenazine)

Insulin

glargine

Interferon Therapy

Interleukin (IL)-5 Antagonists: Mepolizumab

&

Reslizumab

Jakafi® (ruxolitinib)

Jetrea® (ocriplasmin)

Korlym® (mifepristone)

Krystexxa® (pegloticase)

Kuvan® (sapropterin)

Lesinurad

Luxturna™ (voretigene neparvovec)

Lysosomal Storage Disorders Therapy

Makena® (hydroxyprogesterone caproate Injection)

Medication Administration Site of Care

Modafinil/Armodafinil

Mozobil®

(plerixafor)

Multiple Sclerosis Therapy

Neulasta® (pegfilgrastim

Nplate® (romiplostim)

Ocaliva® (obeticholic acid)

Oncology Medications

Opioid Therapy

Oral Phosphodiesterase-5 (PDE5) Inhibitors

Otezla® (apremilast)

PCSK9

Inhibitors

Performance Prescription Drug List

Pharmacy

Prior Authorization

Promacta® (eltrombopag)

Pulmonary Hypertension (PH) Therapy

Quantity Limitations

Radicava™ (edaravone)

Rituxan® (rituximab for Non-Oncology Indications)

Routine Immunizations

Sandostatin®, Sandostatin LAR ® Depot (octreotide)

Soliris® (eculizumab)

Somatropin

Spinraza™ (nusinersen)

Standard Prescription Drug List

Step

Therapy

Step Therapy Individual & Family Plan

Step Therapy – Legacy Prescription Drug Lists (Employer Group Plans

Step Therapy - Standard Prescription Drug Lists (Employer Group Plans)

Step Therapy – Value Prescription Drug Lists (Employer Group Plans)

Supprelin® LA (histrelin acetate subcutaneous implant)

Synagis® (palivizumab)

Testopel® (implantable hormone pellets)

Testosterone Therapy

Topical Alpha Adrenergic Agonists

Topical Doxepin

Unassigned Drug or Biologic Code Medical Precertification

Value

Prescription

Drug List

Vascular Endothelial Growth Factor (VEGF) Inhibitors for Ocular Use

Vfend® voriconazole

Visco-supplementation

for Osteoarthritis

Xiaflex® (collagenase clostridium histolyticum)

Xolair® (omalizumab)

Zilretta® (triamcinolone acetonide extended-release injection)

Zyvox® (oxazolidinone) Antibiotics

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