As part of Cigna’s ongoing commitment to provide affordable and quality health care coverage, we regularly review and update our formularies. Pharmacy costs are the number one driver of client expenses under both pharmacy and medical benefits,1 and we expect this trend to continue. That’s why helping our clients achieve optimal value for their pharmacy benefit spend is of the utmost importance. At the same time, we continue to focus on improving clinical outcomes (especially for those managing pain with opioids) and reducing the total cost of health care.
Summary of July 1, 2019 formulary changes (unless otherwise noted)2
- High-cost, low-value drug removals3
- Opioid use management
- Improving health for those with chronic heart failure
- Promote generic drugs when available
- Diabetes – expanded coverage of therapeutic Continuous Glucose Monitors (CGMs)
- Enhanced choice, access, and cost in several categories – especially those in anti-inflammatory drugs class
Below are details of the July 1, 2019 formulary changes you can expect
- High-cost, low-value drug removals
For the fourth year in a row, we will remove drugs from formularies1,3 that:
- Have low use and have experienced significant price inflation.
- Are inappropriately priced compared to identical/near-identical products.
Cigna uses a process to monitor egregious price practices. This includes weekly monitoring of branded drugs and generics, updated criteria that broadens our scope, and faster response when prices escalate.
In addition to the 156 very highly priced drugs4 currently managed by Cigna formularies, we will remove eight more starting July 2019.5,3
The drugs that will be removed have identical or near-identical covered alternatives:
- Allzital – Consistent tension headaches
- Onzetra Xsail – Acute migraines
- Zolpimist – Insomnia (sedative)
- Indocin oral suspension – Pain, swelling, and joint stiffness caused by arthritis, gout, bursitis, and tendonitis
- Fenortho – Pain, arthritis
- Benzonatate – Cough (cough medicine)
- Chlorzoxazone – Pain and stiffness caused by muscle spasm (muscle relaxant)
- Carbinoxamine (Ryvent) – Allergic reactions (antihistamine)
- Managing the use of opioids
To help protect members, Cigna will place quantity limits on certain narcotics.
As per U.S. Food and Drug Administration guidelines, quantity limits will apply to the following products:
- Buprenorphine (patch products)
- Butorphanol Tartrate
- Tramadol HCL and Tramadol HCL ER
- Belbuca (Additionally, Belbuca was added to the preferred brand tier on 2/1/19.)
- Improving health for those with chronic heart failure
- Entresto Prior Authorization (PA) was removed as of 11/15/18 in order to offer members fast access to coverage of this heart failure drug.
- Results of a Cigna study showed reduced hospitalizations after starting on Entresto, and a corresponding net reduction in total medical cost for clients.2
- This evidence, in conjunction with an assessment of the PA on Entresto where we determined that the vast majority of use was consistent with the PA criteria, led to the decision to remove the PA requirement.
- Promote generic drugs
Some clients adopt Member Pay the Difference logic to help manage utilization of branded drugs when generics are available. This means if the provider does not indicate Dispense As Written (DAW) on the prescription, and the member chooses a brand drug when a lower-cost generic is available, the member will pay a higher cost for choosing the brand.
Seven branded drugs will now be subject to this logic and penalty:
- Zonalon cream – Troublesome itching from certain skin conditions
- Avar LS cleanser – Acne and other skin conditions
- Hylatopicplus cream – Treats or prevents certain skin problems
- Vitatrue Combo Package – Vegan and kosher prenatal multivitamin
- Macrodantin capsule* – Treats or prevents urinary tract infections (antibiotic)
- Ryvent tablet – Allergic reactions (antihistamine)
- Prograf capsule** – Transplant rejection
* Also adding to non-preferred brand tier on all formularies.
**Tier change only.
- Diabetes
As previously announced, effective 4/1/19, Cigna will administer coverage for two therapeutic Continuous Glucose Monitor (CGM) sensors, Abbott Freestyle Libre and Dexcom G6® under the pharmacy benefit. Prior authorizations and quantity limits apply. Please refer to the communication sent on 3/28/19 for additional information.
- Positive additions to formularies
Starting in three waves (April 1, May 1, and July 1), Cigna will offer improved access to coverage for many drugs in several categories, including the anti-inflammatory drug class. We are excited to offer members more choices and reduced costs for coverage of drugs used to manage hypertension, glaucoma, breast cancer, and mental health issues, as well as those used to treat different types of inflammatory disease.
Member communications
Letters and emails are being sent to members affected by the July 2019 changes. A second letter will be sent in May. A third letter and reminder email will be sent in July.
Health care provider communications
To build awareness and help providers talk to their patients, we will:
- Send a letter to affected providers that outlines key formulary changes
- Post a notice on our provider web portal and our provider newsletter
During this time of rising drug costs, our priority is to maintain affordability for our clients and members now and in the future. We will continue to make enhancements to our formularies to help drive sustainable cost savings and improve member health outcomes. For your convenience, updated formulary overview lists are always available online in the Pharmacy section of our Digital Marketing Toolkit, and Drug List Changes summaries are attached to this email.
2019 Performance Drug List Changes
2019 Advantage Drug List Changes
2019 Performance Drug List Changes – Member Flyer
2019 Advantage Drug List Changes – Member Flyer
