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The managed drug limitation program (MDL) helps us promote If you have any questions or concerns please contact Member safe, clinical y appropriate drug usage and simplify drug regimens Services at the number listed on your ID card. This list is for when clinical y appropriate. With this program there’s a limit on the informational purposes only and is subject to change. To confirm amount and days supply of certain medications such as sleeping coverage, please contact your plan administrator or cal the pil s. These limits were developed based on recommendations customer service number on your health plan ID card.
from a variety of medical experts, including the Food Drug Administration. Your physician may cal our Pharmacy Prior Authorization Department to request a medical necessity review.
Drug Name
retail QuaNtity
mail OrDer QuaNtity
Per 30 Days
Per 90 Days*
Anti-EmEtics
ondansetron hcl 4mg/8mg tablets and ODT 24 tablets Anti-inflAmmAtory AgEnts
AntivirAls
DiAbEtEs mEDicAtions
Drug Name
retail QuaNtity
mail OrDer QuaNtity
Per 30 Days
Per 90 Days*
DiAbEtic suppliEs pEr 365 DAys
ErEctilE Dysfunction AgEnts†
influEnzA
migrAinE AgEnts
Imitrex Injection kits/refills 6mg (12mg/ml) Drug Name
retail QuaNtity
mail OrDer QuaNtity
Per 30 Days
Per 90 Days*
nArcotic AgEnts (pAin)
sEDAtivEs/Hypnotics†
* Some medications aren’t clinical y appropriate for long-term use. In these instances, limitations for retail and mail-order are identical; therefore, the use of mail-order isn’t cost effective.
** Doses of Duragesic greater than 100 mcg will require using more than 10 patches per month because multiple patches will have to be applied simultaneously to achieve the desired dose.
† Certain therapeutic categories do not warrant a need to prescribe more than one drug from within that class of agents. The prescribing of medications from such drug classes should be limited to one drug per month. For example, Viagra and Cialis, erectile dysfunction agents, should not both be dispensed within the same month. Quantities will vary depending on disease being treated.
This list is for informational purposes only and is subject to change. To confirm coverage, please contact your plan administrator or customer service at the number on your health plan ID card. “CIGNA” and the “Tree of Life” logo are registered service marks of CIGNA Intellectual Property, Inc., licensed for use by CIGNA Corporation and its operating subsidiaries. All products and services are provided exclusively by such operating subsidiaries and not by CIGNA Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company (CGLIC), Tel-Drug, Inc. and its affiliates, CIGNA Behavioral Health, Inc., Intracorp, and HMO or service company subsidiaries of CIGNA Health Corporation and CIGNA Dental Health, Inc. In California, HMO plans are offered by CIGNA HealthCare of California, Inc. and Great-West Healthcare of California, Inc. All other medical plans in California are insured or administered by CGLIC. CGLIC has acquired the business of Great-West Healthcare.

Source: http://priorauthrx.ihcgroup.com/Cigna/MDL%207-2010.pdf