Four-Tier Prescription Drug List

Cigna Healthcare Advantage 4-Tier Prescription Drug List Coverage as of July 1, 2025 965173 b Advantage 4-Tier 04/25 © 2025 Cigna Healthcare. What's Inside? Page About this drug list 3 How to read this drug list 3 How to find your medication 5 List of medications 6 Frequently Asked Questions (FAQs) 29 Exclusions and limitations for coverage 33 View your drug list online, 24/7 This document was last updated on 04/01/2025.* • You can use the Price a Medication tool on the myCigna® App1 or myCigna.com® to see the most up-to-date list of the medications your plan covers. • You can also see a pdf of this document on Cigna.com/PDL. Click on the dropdown next to "Drug Lists for Employer Plans." Scroll down until you see Cigna Advantage Prescription Drug List; then click on the 4-Tier (all specialty medications covered on Tier 4) [PDF]. Questions? ­• By phone: Call the toll-free number on your Cigna Healthcare® ID card. We’re here 24/7/365. ­• myCigna.com: Click to Chat - Monday-Friday, 9:00 am-8:00 pm EST. * Drug list originally created: 01/01/2004 Last updated: 04/01/2025, for changes Next planned update: 09/01/2025, for starting 07/01/2025 changes starting 01/01/2026 2 About this drug list This is a list of the most commonly prescribed medications covered on the Cigna Healthcare Advantage 4-Tier Prescription Drug List as of July 1, 2025. Medications are listed in alphabetical order (A-Z) by the condition they treat. The drug list is updated on a regular basis; so, this document may not show all of the medications your plan covers. Also, your plan may not cover every medication on this list. Log in to the myCigna App or myCigna.com to see the most up-to-date list of medications your plan covers. Important: Your plan doesn’t cover prescription medications that treat allergies (ex. Allegra®, Clarinex®, Xyzal® and generics) and heartburn/stomach acid conditions (ex. Nexium®, Prilosec OTC® and generics). You can buy them at the store without a prescription. How to read this drug list Use the table below to understand how medications are covered on the Cigna Healthcare Advantage 4-Tier Prescription Drug List.* Medications are grouped by the condition they treat BLOOD PRESSURE/HEART MEDICATIONS Medication Tier Notes amlodipine 1 Tier (cost-share level) gives you amlodipine-benazepril 1 an idea of how much you may amlodipine-olmesartan 1 QL pay for a medication amlodipine-valsartan 1 atenolol 1 Medications are listed in bisoprolol-hctz 1 alphabetical order (A-Z) within each column CALAN SR 3 CAMZYOS 3 SP, PA, QL Specialty medications have candesartan 1 SP listed next to them in the cartia xt 1 Notes column carvedilol 1 carvedilol er 1 QL CATAPRES-TTS 1 3 Brand-name medications are in CATAPRES-TTS 2 3 all CAPITAL letters CATAPRES-TTS 3 3 clonidine patch, tablet 1 CORLANOR ORAL SOLUTION 2 SP, PA CORLANOR TABLET 2 PA Generic medications are in all dilt xr 1 lowercase letters diltiazem 12hr er 1 diltiazem 24hr er 1 Medications that may have extra diltiazem 24hr er (cd) 1 coverage requirements have diltiazem 24hr er (la) 1 QL letters (acronyms) listed next to them in the Notes column diltiazem 24hr er (xr) 1 * This table is just an example. It may not show how these medications are currently covered on this drug list. 3 Brand-name medications are in all capital letters In this drug list, generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tiers We put covered medications into tiers (or cost-share levels). Usually, the higher the tier, the higher the price you’ll pay for the medication. Generics. These medications are covered at your plan’s lowest cost-share. A generic works $ Tier 1 in the same way and provides the same clinical benefits as the brand-name medication – and usually cost much less.3 Preferred Brands. These medications usually have one or more lower-cost generic that $$ Tier 2 treats the same condition. Non-Preferred Brands. These medications are covered at your plan’s highest cost-share. $$$ Tier 3 Non-preferred brands usually have a generic and/or preferred brand alternative(s) that treats the same condition. Specialty. These medications are covered at your plan’s highest cost-share. This tier $$$$ Tier 4 includes both injectable and oral (those you take by mouth) specialty medications. Letters (acronyms) in the Notes column In this drug list, some medications have letters (acronyms) next to them in the Notes column. Here’s what they mean. Prior Authorization* – This medication needs approval from Cigna Healthcare before your plan PA will cover it. Your doctor’s office will have to send us information to review to make sure you meet coverage requirements. Quantity Limit* – Your plan will only cover so much of this medication at one time. If your doctor QL wants you to fill more than what’s allowed, your doctor’s office can ask us to cover more. Step Therapy* – This is a high-cost medication that has a lower-cost alternative(s) that treats the same condition. Your plan won’t cover it until you try at least one preferred medication first ST (usually a generic or preferred brand) and can show that it didn’t work for you. If your doctor feels a preferred medication isn’t right for you, your doctor’s office can ask us to cover the higher-cost medication. Age Requirement* – Your plan will only cover this medication if you’re a certain age or within a AGE certain age range. If you’re not within the allowed age range and your doctor wants you to use the medication, your doctor’s office can ask us to cover it. This is a specialty medication, which is used to treat a rare and/or complex medical condition. SP Some plans may only cover up to a 30-day supply and/or require you to fill it at a preferred specialty pharmacy. * Not all plans have extra coverage requirements on medications. Log in to the myCigna App or myCigna.com, or check your plan materials, to see if yours does. 4 Letters (acronyms) in the Notes column (cont.) Health care reform under the Patient Protection and Affordable Care Act (PPACA) requires PPACA plans to cover the full cost of this preventive medication or product. This means it costs you $0 – you won’t pay a cost-share to fill it. Plans can choose to cover certain medications, products and/or drug classes that aren’t usually OC covered. If a medication has OC next to it, log in to the myCigna App or myCigna.com to see if your plan covers it. How to find your medication Medications are listed in alphabetical order (A-Z) by condition. Conditions are also listed in alphabetical order (A-Z). To see which page your medication is on, find your condition in the table below. Then, go to the page listed next to it to see which medications are covered. Condition Page Condition Page AIDS/HIV 6 GASTROINTESTINAL/HEARTBURN 17, 18 ALLERGY/NASAL SPRAYS 6 HORMONAL AGENTS 18, 19 ALZHEIMER’S DISEASE 6 INFECTIONS 19, 20 ANXIETY/DEPRESSION/BIPOLAR DISORDER 6, 7 INFERTILITY 20 ASTHMA/COPD/RESPIRATORY 7, 8 MISCELLANEOUS 20, 21 ATTENTION DEFICIT HYPERACTIVITY 8 MULTIPLE SCLEROSIS 21 DISORDER NUTRITIONAL/DIETARY 21, 22 BLOOD MODIFIERS/BLEEDING DISORDERS 8, 9 OSTEOPOROSIS PRODUCTS 22 BLOOD PRESSURE/HEART MEDICATIONS 9 PAIN RELIEF AND INFLAMMATORY DISEASE 22-24 BLOOD THINNERS/ANTI-CLOTTING 10 PARKINSON’S DISEASE 24 CANCER 10, 11 SCHIZOPHRENIA/ANTI-PSYCHOTICS 24, 25 CHOLESTEROL MEDICATIONS 11 SEIZURE DISORDERS 25 CONTRACEPTION PRODUCTS 12-14 SKIN CONDITIONS 25, 26 COUGH/COLD MEDICATIONS 14 SLEEP DISORDERS/SEDATIVES 26 DENTAL PRODUCTS 14 SUBSTANCE ABUSE 26 DIABETES 14-16 TRANSPLANT MEDICATIONS 26 DIURETICS 16 URINARY TRACT CONDITIONS 27 VACCINES 27, 28 EAR MEDICATIONS 16 VITAMINS 28 EYE CONDITIONS 16, 17 FEMININE PRODUCTS 17 5 Cigna Healthcare Advantage 4-Tier Prescription Drug List AIDS/HIV ALLERGY/NASAL SPRAYS (cont.) Medication Tier Notes Medication Tier Notes APRETUDE 4 SP, PA, PPACA epinephrine 0.15 mg, 0.3 mg auto- 1 QL BIKTARVY 4 SP, QL injector (by Mylan SP-Viatris, Teva USA); nasal solution CABENUVA 4 SP, PA fluticasone spray 1 OC CIMDUO 4 SP, PA GRASTEK 3 PA, QL COMPLERA 4 SP, PA, QL hydroxyzine oral solution, syrup, tablet 1 darunavir 4 SP hydroxyzine pamoate capsule 1 DESCOVY 120-15 MG TABLET 4 SP ipratropium spray 1 DESCOVY 200-25 MG TABLET 4 SP, PPACA levocetirizine 1 OC DOVATO 4 SP, QL mometasone spray 1 QL, OC efavirenz-emtricitabine-tenofovir 4 SP, QL ODACTRA 3 PA, QL emtricitabine-tenofovir 200 mg-300 4 SP, PPACA mg tablet olopatadine spray 1 GENVOYA 4 SP, QL ORALAIR 3 PA, QL ISENTRESS HD 4 SP, PA promethazine ampule, syrup, tablet, 1 vial JULUCA 4 SP, QL RAGWITEK 3 PA, QL ODEFSEY 4 SP, PA, QL PIFELTRO 4 SP, PA ALZHEIMER’S DISEASE PREZCOBIX 4 SP, PA Medication Tier Notes PREZISTA 100 MG/ML ORAL 4 SP ADLARITY 2 PA, QL SUSPENSION, 75 MG, 150 MG TABLET donepezil 1 ritonavir 4 SP memantine 1 RUKOBIA 4 SP, PA, QL memantine er 1 QL STRIBILD 4 SP, PA, QL NAMENDA 3 SYMTUZA 4 SP, QL NAMZARIC 3 QL tenofovir 4 SP, PA pyridostigmine oral solution; 60 mg 1 TIVICAY 4 SP tablet TRIUMEQ 4 SP, QL pyridostigmine er 1 TRIUMEQ PD 4 SP, QL rivastigmine 1 ALLERGY/NASAL SPRAYS ANXIETY/DEPRESSION/BIPOLAR DISORDER2 Medication Tier Notes Medication Tier Notes azelastine 0.1% (137 mcg) spray 1 alprazolam 1 azelastine-fluticasone 1 amitriptyline 1 cromolyn oral concentrate 1 bupropion sr 1 QL desloratadine 1 QL, OC bupropion xl 150 mg, 300 mg tablet 1 QL Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement 6 Cigna Healthcare Advantage 4-Tier Prescription Drug List ANXIETY/DEPRESSION/BIPOLAR DISORDER2 (cont.) ASTHMA/COPD/RESPIRATORY (cont.) Medication Tier Notes Medication Tier Notes buspirone 1 ANORO ELLIPTA 2 QL citalopram oral solution, tablet 1 QL ASMANEX 2 QL clomipramine 1 ASMANEX HFA 2 QL desvenlafaxine succinate er 1 QL ATROVENT HFA 2 QL duloxetine 1 QL breyna 1 QL EMSAM 3 QL BREZTRI AEROSPHERE 2 QL escitalopram 1 QL budesonide inhalation suspension 1 QL FETZIMA 3 QL, ST budesonide-formoterol 1 QL fluoxetine 1 QL COMBIVENT RESPIMAT 2 QL fluvoxamine 1 QL DULERA 2 QL fluvoxamine er 1 QL FASENRA 4 SP, PA lorazepam oral concentrate, tablet 1 GLASSIA 4 SP, PA mirtazapine 1 INCRUSE ELLIPTA 2 NUPLAZID 4 SP, PA KALYDECO 4 SP, PA, QL paroxetine oral suspension, tablet 1 QL montelukast 1 paroxetine er 1 QL NUCALA AUTO-INJECTOR, SYRINGE 4 SP, PA sertraline oral concentrate, tablet 1 QL OFEV 4 SP, PA trazodone 1 OPSUMIT 4 SP, PA TRINTELLIX 2 QL OPSYNVI 4 SP, PA, QL venlafaxine er capsule; 37.5 mg, 75 1 QL ORENITRAM ER 4 SP, PA mg, 150 mg, 225 mg tablet ORENITRAM TITRATION KIT 4 SP, PA, QL vilazodone 1 QL PROLASTIN C 4 SP, PA ZURZUVAE 4 SP, PA, QL PULMOZYME 4 SP, PA ASTHMA/COPD/RESPIRATORY QVAR REDIHALER 2 Medication Tier Notes SPIRIVA RESPIMAT 2 QL ADEMPAS 4 SP, PA STIOLTO RESPIMAT 2 QL AIRSUPRA 2 QL STRIVERDI RESPIMAT 2 QL albuterol 1 SYMDEKO 4 SP, PA, QL albuterol hfa 90 mcg inhaler 1 QL tadalafil 20 mg tablet 4 SP, PA ALVESCO 2 TEZSPIRE PEN, SYRINGE 4 SP, PA, QL ALYFTREK 4 SP, PA, QL TRELEGY ELLIPTA 2 QL ambrisentan 4 SP, PA treprostinil 4 SP, PA Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement 7 Cigna Healthcare Advantage 4-Tier Prescription Drug List ASTHMA/COPD/RESPIRATORY (cont.) BLOOD MODIFIERS/BLEEDING DISORDERS (cont.) Medication Tier Notes Medication Tier Notes TRIKAFTA 4 SP, PA, QL ALTUVIIIO 4 SP, PA TYVASO DPI 4 SP, PA aminocaproic acid 4 SP TYVASO 4 SP, PA ARANESP 4 SP, PA UPTRAVI TABLET, TITRATION PACK 4 SP, PA DOPTELET 4 SP, PA UPTRAVI VIAL 4 SP, PA DROXIA 2 VIJOICE 4 SP, PA, QL ELOCTATE 4 SP, PA wixela inhub 1 QL EMPAVELI 4 SP, PA XOLAIR 4 SP, PA ESPEROCT 4 SP, PA ATTENTION DEFICIT HYPERACTIVITY DISORDER2 FABHALTA 4 SP, PA, QL FULPHILA 4 SP, PA Medication Tier Notes GRANIX 4 SP, PA ADDERALL 3 PA, ST HEMLIBRA 4 SP, PA atomoxetine 1 QL JIVI 4 SP, PA DAYTRANA 3 PA, QL KOGENATE FS 4 SP, PA dexmethylphenidate er 1 PA, QL KOVALTRY 4 SP, PA dextroamphetamine-amphetamine 1 PA NEULASTA 4 SP, PA dextroamphetamine-amphetamine er 1 PA, QL NEULASTA ONPRO 4 SP, PA guanfacine er 1 NEUPOGEN 4 SP, PA lisdexamfetamine 1 PA, QL NIVESTYM 4 SP methylphenidate chewable tablet, oral 1 PA solution, tablet NOVOEIGHT 4 SP, PA methylphenidate er (cd) 1 PA, QL NYVEPRIA 4 SP, PA methylphenidate er (la) 1 PA, QL PROCRIT 4 SP, PA methylphenidate er capsule; 10 mg, 1 PA, QL PROMACTA 4 SP, PA 18 mg, 20 mg, 27 mg, 36 mg, 54 mg, RETACRIT 4 SP, PA 72 mg tablet SOLIRIS 4 SP, PA QUILLIVANT XR 3 PA, QL STIMUFEND 4 SP, PA XELSTRYM 3 PA, QL TAVALISSE 4 SP, PA BLOOD MODIFIERS/BLEEDING DISORDERS TAVNEOS 4 SP, PA, QL Medication Tier Notes tranexamic acid 4 SP ADVATE 4 SP, PA UDENYCA ONBODY, AUTO-INJECTOR, 4 SP, PA ADYNOVATE 4 SP, PA SYRINGE AFSTYLA 4 SP, PA ULTOMIRIS 4 SP, PA VOYDEYA 4 SP, PA, QL Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement 8 Cigna Healthcare Advantage 4-Tier Prescription Drug List BLOOD MODIFIERS/BLEEDING DISORDERS (cont.) BLOOD PRESSURE/HEART MEDICATIONS (cont.) Medication Tier Notes Medication Tier Notes WILATE 4 SP, PA lisinopril 1 XYNTHA 4 SP, PA lisinopril-hctz 1 XYNTHA SOLOFUSE 4 SP, PA losartan 1 ZARXIO 4 SP losartan-hctz 1 BLOOD PRESSURE/HEART MEDICATIONS metoprolol er 1 metoprolol 1 Medication Tier Notes metyrosine 1 PA amlodipine 1 midodrine 1 amlodipine-benazepril 1 minoxidil tablet 1 amlodipine-olmesartan 1 QL MULTAQ 2 amlodipine-valsartan 1 nadolol 1 amlodipine-valsartan-hctz 1 nebivolol 1 QL atenolol 1 nifedipine er 1 bisoprolol 1 NITROSTAT 3 bisoprolol-hctz 1 NORLIQVA 2 PA, QL CAMZYOS 4 SP, PA, QL olmesartan 1 QL candesartan 1 olmesartan-amlodipine-hctz 1 carvedilol 1 olmesartan-hctz 1 QL carvedilol er 1 QL ORLADEYO 4 SP, PA, QL clonidine patch, tablet 1 prazosin 1 CORLANOR ORAL SOLUTION 4 SP, PA propranolol er 1 CORLANOR TABLET 2 PA propranolol 1 diltiazem 24hr er (cd) 1 ranolazine er 1 QL dofetilide 1 QL sajazir 4 SP, PA droxidopa 4 SP TAKHZYRO 4 SP, PA enalapril 1 telmisartan 1 QL ENTRESTO 2 QL telmisartan-hctz 1 QL ENTRESTO SPRINKLE 2 valsartan 1 flecainide 1 valsartan-hctz 1 guanfacine 1 verapamil sr 1 hydralazine 1 VERQUVO 2 PA, QL irbesartan 1 labetalol carpuject; 20 mg/4ml 1 syringe; 100 mg, 200 mg, 300 mg tablet; vial Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement 9 Cigna Healthcare Advantage 4-Tier Prescription Drug List BLOOD THINNERS/ANTI-CLOTTING CANCER (cont.) Medication Tier Notes Medication Tier Notes BRILINTA 2 IBRANCE 4 SP, PA, QL clopidogrel 1 imatinib 4 SP, QL dabigatran 1 IMBRUVICA 4 SP, PA, QL ELIQUIS 2 INLYTA 4 SP, PA enoxaparin 4 SP, QL JAKAFI 4 SP, PA, QL fondaparinux 4 SP, QL JYLAMVO 3 FRAGMIN 4 SP, QL KANJINTI 4 SP, PA prasugrel 1 KISQALI 4 SP, PA, QL warfarin 1 KOSELUGO 4 SP, PA, QL XARELTO 2 lenalidomide 4 SP, PA, QL ZONTIVITY 3 LENVIMA 4 SP, PA CANCER letrozole 1 leucovorin 1 Medication Tier Notes LONSURF 4 SP, PA abirtega 4 SP, PA LORBRENA 4 SP, PA, QL AKEEGA 4 SP, PA, QL LUMAKRAS 4 SP, PA, QL ALECENSA 4 SP, PA, QL LYNPARZA 4 SP, PA, QL anastrozole 1 PPACA MEKINIST 4 SP, PA, QL AYVAKIT 4 SP, PA, QL mercaptopurine 1 BOSULIF 4 SP, PA, QL methotrexate 1 BRUKINSA 4 SP, PA, QL MVASI 4 SP, PA CABOMETYX 4 SP, PA NERLYNX 4 SP, PA CALQUENCE 4 SP, PA NINLARO 4 SP, PA, QL capecitabine 4 SP, PA NUBEQA 4 SP, PA COMETRIQ 4 SP, PA, QL ODOMZO 4 SP, PA COTELLIC 4 SP, PA OGIVRI 4 SP, PA ELIGARD 4 SP OGSIVEO 4 SP, PA, QL ERIVEDGE 4 SP, PA ONTRUZANT 4 SP, PA ERLEADA 4 SP, PA ORGOVYX 4 SP, PA exemestane 1 PPACA ORSERDU 4 SP, PA, QL GAVRETO 4 SP, PA, QL PHESGO 4 SP, PA GLEOSTINE 2 PIQRAY 4 SP, PA HERCESSI 4 SP, PA POMALYST 4 SP, PA, QL hydroxyurea 1 Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement 10 Cigna Healthcare Advantage 4-Tier Prescription Drug List CANCER (cont.) CANCER (cont.) Medication Tier Notes Medication Tier Notes PURIXAN 4 SP ZEJULA 4 SP, PA, QL RETEVMO 4 SP, PA, QL ZELBORAF 4 SP, PA REVLIMID 4 SP, PA, QL ZIRABEV 4 SP, PA RIABNI 4 SP, PA CHOLESTEROL MEDICATIONS ROZLYTREK 4 SP, PA Medication Tier Notes RUBRACA 4 SP, PA, QL atorvastatin 10 mg, 20 mg tablet 1 PPACA RUXIENCE 4 SP, PA atorvastatin 40 mg, 80 mg tablet 1 RYDAPT 4 SP, PA CADUET 3 QL SCEMBLIX 4 SP, PA, QL colesevelam 1 STIVARGA 4 SP, PA, QL DOJOLVI 4 SP, PA sunitinib 4 SP, PA, QL ezetimibe 1 TABRECTA 4 SP, PA, QL fenofibrate 43 mg, 50 mg, 67 mg, 1 TAFINLAR 4 SP, PA, QL 130 mg, 134 mg, 150 mg, 200 mg TAGRISSO 4 SP, PA capsule; tablet TALZENNA 4 SP, PA, QL fluvastatin 1 PPACA tamoxifen 1 PPACA fluvastatin er 1 PPACA TASIGNA 4 SP, PA, QL icosapent ethyl 1 temozolomide 4 SP, PA LIPOFEN 3 ST TIBSOVO 4 SP, PA lovastatin 10 mg tablet 1 torpenz 4 SP, PA, QL lovastatin 20 mg, 40 mg, tablet 1 PPACA TRAZIMERA 4 SP, PA omega-3 acid ethyl esters 1 TREXALL 2 pitavastatin 1 QL, PPACA TRUQAP 4 SP, PA, QL pravastatin 1 PPACA TUKYSA 4 SP, PA REPATHA PUSHTRONEX, SURECLICK, 2 PA VENCLEXTA STARTING PACK, TABLET 4 SP, PA SYRINGE VERZENIO 4 SP, PA, QL rosuvastatin 5 mg, 10 mg tablet 1 QL, PPACA VITRAKVI 4 SP, PA rosuvastatin 20 mg, 40 mg tablet 1 QL VIZIMPRO 4 SP, PA simvastatin 5 mg, 80 mg tablet 1 QL WELIREG 4 SP, PA, QL simvastatin 10 mg, 20 mg, 40 mg 1 QL, PPACA tablet XALKORI 4 SP, PA, QL TRICOR 3 ST XATMEP 3 VASCEPA 2 PA XOSPATA 4 SP, PA XTANDI 4 SP, PA Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement 11 Cigna Healthcare Advantage 4-Tier Prescription Drug List CONTRACEPTION PRODUCTS CONTRACEPTION PRODUCTS (cont.) Medication Tier Notes Medication Tier Notes afirmelle 1 PPACA desogestrel-ethinyl estradiol ethinyl 1 PPACA altavera 1 PPACA estradiol alyacen 1 PPACA dolishale 1 PPACA amethia 1 PPACA drospirenone-ethinyl estradiol 1 PPACA amethyst 1 PPACA drospirenone-ethinyl estradiol- 1 PPACA levomefolate apri 1 PPACA elinest 1 PPACA aranelle 1 PPACA ELLA 3 PPACA ashlyna 1 PPACA eluryng 1 PPACA aubra 1 PPACA emzahh 1 PPACA aubra eq 1 PPACA enilloring 1 PPACA aurovela 1 PPACA enpresse 1 PPACA aurovela fe 1 PPACA enskyce 1 PPACA aviane 1 PPACA errin 1 PPACA ayuna 1 PPACA estarylla 1 PPACA azurette 1 PPACA ethynodiol-ethinyl estradiol 1 PPACA balziva 1 PPACA etonogestrel-ethinyl estradiol 1 PPACA blisovi fe 1 PPACA falmina 1 PPACA briellyn 1 PPACA feirza 1 PPACA camila 1 PPACA FEMCAP 3 PPACA camrese 1 PPACA finzala 1 PPACA camrese lo 1 PPACA gemmily 1 PPACA CAYA CONTOURED 3 PPACA hailey 1 PPACA caziant 1 PPACA hailey fe 1 PPACA charlotte 24 fe 1 PPACA haloette 1 PPACA chateal eq 1 PPACA heather 1 PPACA cryselle 1 PPACA iclevia 1 PPACA cyred 1 PPACA incassia 1 PPACA cyred eq 1 PPACA isibloom 1 PPACA dasetta 1 PPACA jaimiess 1 PPACA daysee 1 PPACA jasmiel 1 PPACA deblitane 1 PPACA jencycla 1 PPACA DEPO-PROVERA 3 PPACA jolessa 1 PPACA DEPO-SUBQ PROVERA 104 SYRINGE 3 PPACA Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement 12 Cigna Healthcare Advantage 4-Tier Prescription Drug List CONTRACEPTION PRODUCTS (cont.) CONTRACEPTION PRODUCTS (cont.) Medication Tier Notes Medication Tier Notes joyeaux 1 PPACA merzee 1 PPACA juleber 1 PPACA mibelas 24 fe 1 PPACA junel 1 PPACA microgestin 1 PPACA junel fe 1 PPACA microgestin fe 1 PPACA kaitlib fe 1 PPACA mili 1 PPACA kalliga 1 PPACA minzoya 1 PPACA kariva 1 PPACA MIRENA 4 SP, PPACA kelnor 1-35 1 PPACA mono-linyah 1 PPACA kelnor 1-50 1 PPACA necon 1 PPACA kurvelo 1 PPACA NEXPLANON 4 SP, PPACA KYLEENA 4 SP, PPACA nikki 1 PPACA larin 1 PPACA nora-be 1 PPACA larin fe 1 PPACA norelgestromin-ethinyl estradiol 1 PPACA layolis fe 3 PPACA norethindrone 0.35 mg tablet 1 PPACA leena 1 PPACA norethindrone-ethinyl estradiol 1-0.02 1 PPACA lessina 1 PPACA mg, 1.5-0.03 mg (21) tablet levonest 1 PPACA norethindrone-ethinyl estradiol-fe 1 PPACA levonorgestrel-ethinyl estradiol 1 PPACA norgestimate-ethinyl estradiol 1 PPACA levonorgestrel-ethinyl estradiol ethinyl 1 PPACA nortrel 1 PPACA estradiol nylia 1 PPACA levonorgestrel-ethinyl estradiol-fe 1 PPACA ocella 1 PPACA bisglycinate PARAGARD T 380-A 4 SP, PPACA levora-28 1 PPACA philith 1 PPACA LILETTA 4 SP, PPACA pimtrea 1 PPACA lojaimiess 1 PPACA portia 1 PPACA loryna 1 PPACA reclipsen 1 PPACA low-ogestrel 1 PPACA rivelsa 1 PPACA lo-zumandimine 1 PPACA setlakin 1 PPACA lutera 1 PPACA sharobel 1 PPACA lyleq 1 PPACA simliya 1 PPACA lyza 1 PPACA simpesse 1 PPACA marlissa 1 PPACA SKYLA 4 SP, PPACA medroxyprogesterone 150 mg/ml 1 PPACA sprintec 1 PPACA syringe, vial Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement 13 Cigna Healthcare Advantage 4-Tier Prescription Drug List CONTRACEPTION PRODUCTS (cont.) COUGH/COLD MEDICATIONS Medication Tier Notes Medication Tier Notes sronyx 1 PPACA brompheniramine-pseudoephedrine- 1 syeda 1 PPACA dm tarina fe 1 PPACA promethazine-dm 1 tilia fe 1 PPACA DENTAL PRODUCTS tri-estarylla 1 PPACA Medication Tier Notes tri-legest fe 1 PPACA doxycycline hyclate 20 mg tablet 1 tri-linyah 1 PPACA FLORIVA 0.25 MG/ML DROPS 3 PPACA tri-lo-estarylla 1 PPACA periogard 1 tri-lo-marzia 1 PPACA PREVIDENT 5000 SENSITIVE 3 tri-lo-mili 1 PPACA PREVIDENT KIDS 3 tri-lo-sprintec 1 PPACA sodium fluoride 5000 dry mouth 1 tri-mili 1 PPACA triamcinolone 0.1% paste 1 tri-sprintec 1 PPACA DIABETES trivora-28 1 PPACA Medication Tier Notes tri-vylibra 1 PPACA ACCU-CHEK CONTROL SOLUTION 1 tri-vylibra lo 1 PPACA ACCU-CHEK FASTCLIX LANCING 1 tulana 1 PPACA DEVICE turqoz 1 PPACA ACCU-CHEK GUIDE CONTROL 1 valtya 1 PPACA SOLUTION velivet 1 PPACA ACCU-CHEK GUIDE ME GLUCOSE 3 vestura 1 PPACA METER vienva 1 PPACA ACCU-CHEK GUIDE MONITOR SYSTEM 3 viorele 1 PPACA ACCU-CHEK SMARTVIEW CONTROL 1 SOLUTION volnea 1 PPACA ACCU-CHEK SOFTCLIX LANCET KIT 1 vyfemla 1 PPACA BAQSIMI 2 QL vylibra 1 PPACA BD INSULIN PEN NEEDLE, SYRINGE 1 wera 1 PPACA BD NANO PEN NEEDLE 1 WIDE SEAL DIAPHRAGM 3 PPACA BD ULTRA-FINE PEN NEEDLE 1 wymzya fe 1 PPACA BYDUREON BCISE 2 PA, QL xarah fe 1 PPACA CEQUR SIMPLICITY 2 xulane 1 PPACA CEQUR SIMPLICITY INSERTER 2 zafemy 1 PPACA CONTOUR METER 3 zarah 1 PPACA CONTOUR NEXT METER 3 zovia 1-35 1 PPACA zumandimine 1 PPACA Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement 14 Cigna Healthcare Advantage 4-Tier Prescription Drug List DIABETES (cont.) DIABETES (cont.) Medication Tier Notes Medication Tier Notes CONTOUR NEXT EZ METER, METER 3 HUMULIN N, HUMULIN R, HUMULIN 2 QL SYSTEM 70/30 CONTOUR NEXT GEN METER 3 INPEN (FOR HUMALOG, NOVOLOG OR 1 CONTOUR NEXT ONE METER 3 FIASP) CONTOUR PLUS BLUE METER 3 INSULIN LISPRO 2 QL CYCLOSET 3 JANUMET 2 QL, ST DEXCOM G6 2 PA, QL JANUMET XR 2 QL, ST DEXCOM G7 RECEIVER, SENSOR 2 PA, QL JANUVIA 2 QL, ST DROPLET GENTEEL LANCING DEVICE 1 JARDIANCE 2 QL, ST FARXIGA 2 QL, ST LYUMJEV 2 QL FREESTYLE FREEDOM LITE 3 metformin oral solution; 500 mg, 750 1 mg, 850 mg, 1000 mg tablet FREESTYLE INSULINX GLUCOSE 3 SYSTEM metformin er 500 mg, 750 mg tablet 1 FREESTYLE LIBRE 2 READER, SENSOR 2 PA, QL MICROLET 2 1 FREESTYLE LIBRE 2 PLUS SENSOR 2 PA, QL MICROLET NEXT LANCING DEVICE 1 FREESTYLE LIBRE 3 READER, SENSOR 2 PA, QL MOUNJARO 2 PA, QL FREESTYLE LIBRE 3 PLUS SENSOR 2 PA, QL OMNIPOD 5 G6-LIBRE 2 PLUS 2 QL FREESTYLE LIBRE 14 DAY READER, 2 PA, QL OMNIPOD 5 G6-G7 INTRO KIT, PODS 2 QL SENSOR (GEN 5) FREESTYLE LITE METER 3 OMNIPOD 5 INTRO (G6-LIBRE 2 PLUS) 2 QL glimepiride 1 mg, 2 mg, 4 mg tablet 1 OMNIPOD DASH INTRO KIT, PODS 2 QL (GEN 4) glipizide 5 mg, 10 mg tablet 1 ONETOUCH ULTRA TEST STRIP 2 glipizide xl 1 ONETOUCH VERIO FLEX METER 2 GLUCAGON EMERGENCY KIT 3 QL ONETOUCH VERIO REFLECT METER 2 GLUCOCARD EXPRESSION METER, 3 METER KIT ONETOUCH VERIO TEST STRIP 2 GLUCOCARD SHINE CONNEX METER 3 OZEMPIC 2 PA, QL GLUCOCARD SHINE EXPRESS METER 3 PARADIGM RESERVOIR 1.8 ML 1 GLUCOCARD SHINE METER, METER KIT 3 PARADIGM RESERVOIR 3 ML 3 GLUCOCARD SHINE XL METER 3 pioglitazone 1 GLUCOCARD VITAL METER KIT 3 PRECISION XTRA KETONE-GLUCOSE 3 KIT, MONITOR, MONITOR NFRS GLYXAMBI 2 QL, ST REZVOGLAR 2 QL HUMALOG 2 QL RYBELSUS 2 PA, QL Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement 15 Cigna Healthcare Advantage 4-Tier Prescription Drug List DIABETES (cont.) EAR MEDICATIONS (cont.) Medication Tier Notes Medication Tier Notes saxagliptin 1 QL DERMOTIC 3 SOLIQUA 100-33 2 neomycin-polymyxin-hc otic solution, 1 SYMLINPEN 2 suspension SYNJARDY 2 QL, ST ofloxacin 0.3% ear drops 1 SYNJARDY XR 2 QL, ST OTOVEL 3 TRESIBA 2 QL EYE CONDITIONS TRIJARDY XR 2 QL, ST Medication Tier Notes TRUE METRIX AIR GLUCOSE METER 3 AZASITE 2 TRUE METRIX BLOOD GLUCOSE METER 3 BESIVANCE 2 TRULICITY 2 PA, QL BETOPTIC S 2 TWIIST REFILL, REFILL KIT, STARTER KIT 2 QL bimatoprost drops 1 QL V-GO 2 brimonidine drops 1 XIGDUO XR 2 QL, ST brimonidine-timolol 1 ZEGALOGUE 2 QL brinzolamide 1 DIURETICS bromfenac drops 1 Medication Tier Notes BYOOVIZ 4 SP, PA acetazolamide 1 CEQUA 2 bumetanide 1 CIMERLI 4 SP, PA CAROSPIR 2 PA ciprofloxacin drops 1 chlorthalidone 1 cyclosporine 0.05% eye emulsion 1 DIURIL 3 CYSTARAN 4 SP, PA, QL eplerenone 1 difluprednate 1 furosemide 1 dorzolamide-timolol 1 hydrochlorothiazide 1 erythromycin ointment 1 JYNARQUE 4 SP, PA EYSUVIS 2 QL KERENDIA 2 PA, QL fluorometholone 1 spironolactone 1 ILEVRO 3 tolvaptan 4 SP latanoprost 1 triamterene-hctz 1 loteprednol 1 MIEBO 2 QL EAR MEDICATIONS moxifloxacin drops 1 Medication Tier Notes neomycin-polymyxin-dexamethasone 1 ciprofloxacin-dexamethasone 1 ofloxacin drops 1 CORTISPORIN-TC 3 OXERVATE 4 SP, PA Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement 16 Cigna Healthcare Advantage 4-Tier Prescription Drug List EYE CONDITIONS (cont.) GASTROINTESTINAL/HEARTBURN (cont.) Medication Tier Notes Medication Tier Notes polymyxin b-trimethoprim 1 balsalazide 1 prednisolone 1% eye drops 1 bismuth-metronidazole-tetracycline 1 PROLENSA 3 BONJESTA 3 RHOPRESSA 3 CHOLBAM 4 SP, PA ROCKLATAN 3 dexlansoprazole dr 1 QL, OC SIMBRINZA 2 dicyclomine 1 tafluprost 1 QL doxylamine-pyridoxine 1 QL TEPEZZA 4 SP, PA ENTYVIO VIAL 4 SP, PA timolol drops, gel-solution 1 esomeprazole 20 mg, 40 mg capsule; 1 QL, OC TOBRADEX EYE OINTMENT 3 packet TOBRADEX ST 2 famotidine oral suspension 1 tobramycin drops 1 GATTEX 4 SP, PA tobramycin-dexamethasone 1 gavilyte-c 1 PPACA travoprost 1 gavilyte-g 1 PPACA TYRVAYA 2 QL gavilyte-n 1 PPACA XDEMVY 4 SP, PA, QL hydrocortisone enema, suppository 1 XIIDRA 2 IQIRVO 4 SP, PA ZIRGAN 3 lansoprazole 1 QL, OC ZYLET 3 LINZESS 2 LITHOSTAT 3 FEMININE PRODUCTS lubiprostone 1 Medication Tier Notes mesalamine 1 fem ph 1 mesalamine dr 1 GYNAZOLE 1 1 mesalamine er 1 miconazole 3 200 mg vaginal 1 metoclopramide 1 suppository MOTOFEN 3 terconazole 1 MOVANTIK 2 PA TRIMO-SAN 3 NEXIUM DR 2.5 MG, 5 MG PACKET 2 QL GASTROINTESTINAL/HEARTBURN OCALIVA 4 SP, PA Medication Tier Notes OLPRUVA 4 SP, PA alosetron 4 SP omeprazole 10 mg, 20 mg, 40 mg 1 QL, OC aprepitant 1 QL capsule APRISO 3 Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement 17 Cigna Healthcare Advantage 4-Tier Prescription Drug List GASTROINTESTINAL/HEARTBURN (cont.) HORMONAL AGENTS (cont.) Medication Tier Notes Medication Tier Notes ondansetron 1 cetrorelix acetate 4 SP, PA, OC ondansetron odt 4 mg, 8 mg tablet 1 CETROTIDE 4 SP, PA, OC PANCREAZE 2 COMBIPATCH 2 pantoprazole 1 QL, OC CORTROPHIN 4 SP, PA peg 3350-electrolyte 1 PPACA CRINONE 4% GEL 3 PA PENTASA 500 MG CAPSULE 3 CYTOMEL 3 PHEBURANE 4 SP, PA, QL DEPO-TESTOSTERONE 3 prochlorperazine 1 desmopressin ampule, vial 4 SP rabeprazole tablet 1 QL, OC desmopressin nasal solution, 10 1 RECTIV 3 mcg/0.1 ml spray, tablet RELISTOR SYRINGE, VIAL 3 PA DUAVEE 2 REZDIFFRA 4 SP, PA, QL estradiol cream, gel packet, patch, 1 tablet SANCUSO 3 PA, QL EVAMIST 3 scopolamine 1 FENSOLVI 4 SP, PA SFROWASA 3 fyremadel 4 SP, PA, OC sodium sulfate-potassium sulfate- 1 PPACA magnesium sulfate ganirelix 4 SP, PA, OC SUCRAID 4 SP, PA GENOTROPIN 4 SP, PA sucralfate 1 INTRAROSA 3 QL SYMPROIC 2 PA levoxyl 1 TRULANCE 2 liothyronine 1 VARUBI 3 PA, QL LUPRON DEPOT 3.75 MG KIT, 11.25 MG 4 SP, PA 3 MO KIT VIBERZI 2 lyllana 1 QL VIOKACE 3 medroxyprogesterone tablet 1 VOQUEZNA TABLET 3 PA, QL MENOSTAR 3 QL VOWST 4 SP, PA, QL methimazole 1 ZENPEP 2 methylprednisolone 1 HORMONAL AGENTS mimvey 1 Medication Tier Notes MYFEMBREE 2 PA, QL ACTHAR VIAL 4 SP, PA norethindrone 5 mg tablet 1 ANGELIQ 3 OMNITROPE 4 SP, PA BIJUVA 3 ORIAHNN 2 PA, QL budesonide ec 1 ORILISSA 2 PA, QL Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement 18 Cigna Healthcare Advantage 4-Tier Prescription Drug List HORMONAL AGENTS (cont.) INFECTIONS (cont.) Medication Tier Notes Medication Tier Notes OSPHENA 3 QL BICILLIN L-A 3 prednisolone oral solution, tablet 1 CAYSTON 4 SP, PA, QL prednisone 1 cefdinir 1 PREMARIN 2 cefpodoxime 1 PREMPHASE 2 cefuroxime axetil 1 PREMPRO 2 cephalexin 1 progesterone capsule 1 CIPRO 3 RAYALDEE 3 ciprofloxacin 1 SANDOSTATIN LAR DEPOT 4 SP, PA clindamycin capsule, oral solution, 1 SOMATULINE DEPOT 4 SP, PA vaginal cream SOMAVERT 4 SP, PA CRESEMBA 3 PA testosterone gel, gel pump, packet 1 PA, QL crotan 1 testosterone cypionate 200 mg/ml, 1 DIFICID 3 QL 1,000 mg/10 ml, 2,000 mg/10 ml, doxycycline monohydrate 1 6,000 mg/30 ml EMVERM 1 thyroid 1 entecavir 4 SP, QL TRIPTODUR 4 SP, PA EPCLUSA 4 SP, PA, QL unithroid 3 erythromycin capsule, tablet 1 yuvafem 1 QL famciclovir 1 INFECTIONS fluconazole 1 Medication Tier Notes flucytosine 1 acyclovir capsule, oral suspension, 1 fosfomycin 1 tablet HARVONI 4 SP, PA, QL albendazole 1 hydroxychloroquine 1 amoxicillin 1 IMPAVIDO 3 PA amoxicillin-clavulanate 1 itraconazole 1 ARIKAYCE 4 SP, PA KITABIS PAK 4 SP, PA, QL atovaquone 1 LAGEVRIO (EUA) 2 QL atovaquone-proguanil 1 levofloxacin oral solution, tablet, vial 1 azithromycin 1 LIKMEZ 3 PA BARACLUDE ORAL SOLUTION 4 SP LIVTENCITY 4 SP, PA, QL BAXDELA 3 PA MACROBID 3 BEYFORTUS 3 PPACA methenamine 1 Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement 19 Cigna Healthcare Advantage 4-Tier Prescription Drug List INFECTIONS (cont.) INFECTIONS (cont.) Medication Tier Notes Medication Tier Notes metronidazole capsule, intravenous 1 VIVJOA 4 SP, PA solution, tablet, vaginal gel VOSEVI 4 SP, PA, QL minocycline 1 XENLETA 3 PA, QL mondoxyne nl 1 XIFAXAN 2 QL morgidox 1 XOFLUZA 3 QL nitazoxanide 1 ZEPATIER 4 SP, PA, QL nitrofurantoin capsule, 25 mg/5 ml 1 ZITHROMAX TRI-PAK 3 oral suspension ZYVOX ORAL SUSPENSION, TABLET 3 PA NUZYRA 4 SP, PA, QL INFERTILITY nystatin oral suspension, tablet 1 oseltamivir 1 QL Medication Tier Notes PAXLOVID 2 QL clomiphene 1 OC PEGASYS 4 SP, PA CRINONE 8% GEL 2 OC penicillin v potassium 1 ENDOMETRIN 2 OC posaconazole 1 FOLLISTIM AQ 4 SP, PA, OC PREVYMIS 4 SP GONAL-F 4 SP, PA, OC PRIFTIN 3 GONAL-F RFF 4 SP, PA, OC pyrimethamine 1 PA GONAL-F RFF REDI-JECT 4 SP, PA, OC SIVEXTRO 3 PA MENOPUR 4 SP, PA, OC sulfamethoxazole-tmp oral 1 NOVAREL 4 SP, PA, OC suspension, tablet OVIDREL 4 SP, PA, OC SYNAGIS 4 SP, PA PREGNYL 4 SP, PA, OC terbinafine tablet 1 MISCELLANEOUS TOBI PODHALER 4 SP, PA, QL Medication Tier Notes tobramycin ampule 4 SP, PA, QL acamprosate 1 valacyclovir 1 ACCU-CHEK FASTCLIX LANCET DRUM 1 valganciclovir 1 AUSTEDO 4 SP, PA VALTREX 3 AUSTEDO XR 4 SP, PA, QL vancomycin capsule, oral solution; 750 1 AUSTEDO XR TITRATION KIT 4 SP, PA, QL mg, 1.25 gm, 1.5 gm, 5 gm, 10 gm vial BOTOX 4 SP, PA VANCOMYCIN INTRAVENOUS 3 CARBAGLU 4 SP SOLUTION, 1.75 GM, 2 GM VIAL CERDELGA 4 SP, PA vandazole 1 CEREZYME 4 SP, PA VEMLIDY 4 SP cinacalcet 4 SP Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement 20 Cigna Healthcare Advantage 4-Tier Prescription Drug List MISCELLANEOUS (cont.) MISCELLANEOUS (cont.) Medication Tier Notes Medication Tier Notes CINRYZE 4 SP, PA VOXZOGO 4 SP, PA deferasirox 4 SP VYNDAMAX 4 SP, PA, QL deferiprone 4 SP, PA VYVGART HYTRULO 4 SP, PA DROPLET LANCET 1 MULTIPLE SCLEROSIS DYSPORT 4 SP, PA Medication Tier Notes ELFABRIO 4 SP, PA AVONEX 4 SP, PA EVRYSDI ORAL SOLUTION 4 SP, PA BAFIERTAM 4 SP, PA FABRAZYME 4 SP, PA BETASERON 4 SP, PA GALAFOLD 4 SP, PA dalfampridine er 4 SP, PA HAEGARDA 4 SP, PA dimethyl 4 SP INGREZZA CAPSULE, INITIATION PACK, 4 SP, PA, QL fingolimod 4 SP SPRINKLE CAPSULE FIRDAPSE 4 SP, PA, QL MICROLET 1 glatopa 4 SP MYALEPT 4 SP, PA KESIMPTA PEN 4 SP, PA NITYR 4 SP, PA MAVENCLAD 4 SP, PA NUEDEXTA 3 QL MAYZENT 4 SP, PA ONETOUCH DELICA PLUS LANCET 1 OCREVUS 4 SP, PA ONETOUCH ULTRASOFT 2 LANCET 1 OCREVUS ZUNOVO 4 SP, PA ORFADIN 4 SP, PA PLEGRIDY 4 SP, PA PALYNZIQ 4 SP, PA REBIF 4 SP, PA PRECISION XTRA KETONE-GLUCOSE 3 KIT REBIF REBIDOSE 4 SP, PA RADICAVA ORS 4 SP, PA, QL teriflunomide 4 SP RUCONEST 4 SP, PA TYSABRI 4 SP, PA sapropterin 4 SP, PA VUMERITY 4 SP, PA sodium chloride irrigation solution, 1 NUTRITIONAL/DIETARY vial Medication Tier Notes SPINRAZA 4 SP, PA ACCRUFER 3 STRENSIQ 4 SP, PA AURYXIA 3 QL TECHLITE LANCET 1 calcitriol ampule, capsule, oral 1 TEGLUTIK 4 SP, PA solution, vial TIGLUTIK 4 SP, PA cyanocobalamin 1 TRUEPLUS KETONE TEST STRIP 3 CYSTADANE 4 SP VIVITROL 4 SP dodex 1 Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement 21 Cigna Healthcare Advantage 4-Tier Prescription Drug List NUTRITIONAL/DIETARY (cont.) NUTRITIONAL/DIETARY (cont.) Medication Tier Notes Medication Tier Notes EFFER-K 10 MEQ, 20 MEQ 3 soluvita a,c,d with fluoride 1 PPACA FLORIVA CHEWABLE TABLET 3 PPACA SOLUVITA MULTIVITAMIN FLUORIDE 3 PPACA fluoride 1 PPACA tri-vitamin with fluoride 1 PPACA folic acid 1 mg, 1000 mcg tablet; 5 1 VELPHORO 2 mg/ml, 50 mg/10 ml vial VELTASSA 2 INJECTAFER 3 PA VITAFOL CAPSULE, GUMMIES, NANO, 3 lanthanum 1 OB+DHA, ULTRA LOKELMA 2 VITAFOL-ONE 3 ludent fluoride 1 PPACA vitamin d2 1.25 mg (50,000 unit) 1 MONOFERRIC 3 PA vitamins a,c,d and fluoride 1 PPACA multivitamin with fluoride-iron 1 PPACA OSTEOPOROSIS PRODUCTS multivitamin with fluoride drops, 1 PPACA Medication Tier Notes chewable tablet alendronate 1 multivitamin-iron-fluoride 1 PPACA BINOSTO 3 ST mvc-fluoride 3 PPACA EVENITY 4 SP, PA, QL NEEVO DHA 3 ibandronate syringe, vial 4 SP OB COMPLETE CAPLET 3 ibandronate tablet 1 OB COMPLETE ONE, PETITE, PREMIER, 2 WITH DHA PROLIA 4 SP, PA POLY-VI-FLOR 3 PPACA raloxifene 1 PPACA POLY-VI-FLOR WITH IRON CHEWABLE 3 PPACA teriparatide 600 mcg/2.4 ml pen 4 SP, PA, QL TABLET PAIN RELIEF AND INFLAMMATORY DISEASE potassium chloride liquid, packet, 1 Medication Tier Notes intravenous solution, vial acetaminophen-codeine 1 PA PRENATE AM, CHEWABLE, ENHANCE, 3 ESSENTIAL, MINI, PIXIE, RESTORE, ACTEMRA ACTPEN, SYRINGE 4 SP, PA, QL STAR ACTEMRA VIAL 4 SP, PA PRENATE DHA, ELITE 2 ADALIMUMAB-ADAZ(CF) 4 SP, PA, QL PRIMACARE 3 ADALIMUMAB-ADBM(CF) 4 SP, PA, QL QUFLORA PEDIATRIC DROPS, 1 MG 3 PPACA AIMOVIG 2 PA CHEWABLE TABLET AJOVY 2 PA sevelamer 1 ARCALYST 4 SP, PA sodium fluoride chewable tablet, 1 PPACA AVSOLA 4 SP, PA drops BELBUCA 2 QL soluvita 0.5 mg/ml drops 1 PPACA BENLYSTA 4 SP, PA Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement 22 Cigna Healthcare Advantage 4-Tier Prescription Drug List PAIN RELIEF AND INFLAMMATORY DISEASE (cont.) PAIN RELIEF AND INFLAMMATORY DISEASE (cont.) Medication Tier Notes Medication Tier Notes BIMZELX 4 SP, PA, QL indomethacin 25 mg, 50 mg capsule, 1 buprenorphine 1 QL oral suspension, 50 mg suppository butalbital-acetaminophen-caffeine 1 QL INFLECTRA 4 SP, PA celecoxib 1 QL ketorolac syringe, tablet, vial 1 QL CIMZIA 4 SP, PA, QL KEVZARA 4 SP, PA, QL colchicine 1 KRYSTEXXA 4 SP, PA COSENTYX PEN, SYRINGE 4 SP, PA, QL leflunomide 1 cyclobenzaprine tablet 1 lidocaine viscous 1 CYLTEZO(CF) 4 SP, PA, QL lidocaine-prilocaine 1 diclofenac 1% gel, tablet 1 QL meloxicam tablet 1 DUPIXENT 4 SP, PA MITIGARE 2 DUROLANE 4 SP, PA MONOVISC 4 SP, PA eletriptan 1 QL morphine er 1 PA EMGALITY 2 PA NUCYNTA 3 PA ENBREL 4 SP, PA, QL NUCYNTA ER 3 PA ENSPRYNG 4 SP, PA NURTEC ODT 2 PA, QL EUFLEXXA 4 SP, PA OLUMIANT 4 SP, PA, QL febuxostat 1 QL OMVOH 4 SP, PA, QL fentanyl 1 PA ORENCIA CLICKJECT, SYRINGE 4 SP, PA, QL GEL-ONE 4 SP, PA ORENCIA VIAL 4 SP, PA GELSYN-3 4 SP, PA ORTHOVISC 4 SP, PA HUMIRA BY ABBVIE 4 SP, PA, QL OTEZLA 4 SP, PA, QL HYALGAN 4 SP, PA oxycodone 1 PA hydrocodone-acetaminophen 1 PA PROCTOFOAM-HC 3 hydromorphone ampule, cartridge, 1 PA prolate tablet 1 PA oral solution, suppository; 0.2 mg/ QULIPTA 2 PA, QL ml, 0.5 mg/0.5 ml, 1 mg/ml, 2 mg/ml RENFLEXIS 4 SP, PA syringe; tablet; 2 mg/ml, 10 mg/ml, 50 mg/5 ml, 500 mg/5 ml vial RINVOQ ER 4 SP, PA, QL HYMOVIS 4 SP, PA RINVOQ LQ 4 SP, PA, QL HYSINGLA ER 2 PA rizatriptan 1 QL ibuprofen 1 ROXYBOND 3 PA ILARIS 4 SP, PA SAVELLA 3 ILUMYA 4 SP, PA, QL SILIQ 4 SP, PA, QL Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement 23 Cigna Healthcare Advantage 4-Tier Prescription Drug List PAIN RELIEF AND INFLAMMATORY DISEASE (cont.) PARKINSON’S DISEASE (cont.) Medication Tier Notes Medication Tier Notes SIMLANDI(CF) 4 SP, PA, QL CREXONT 3 ST SIMPONI 100 MG/ML PEN INJECTOR, 4 SP, PA, QL DUOPA 4 SP SYRINGE INBRIJA 4 SP, PA SIMPONI ARIA 4 SP, PA NEUPRO 3 SKYRIZI 4 SP, PA, QL NOURIANZ 4 SP, PA, QL SOTYKTU 4 SP, PA, QL pramipexole 1 QL STELARA SYRINGE, VIAL 4 SP, PA, QL ropinirole 1 sumatriptan 1 QL RYTARY 3 ST SUPARTZ FX 4 SP, PA XADAGO 3 ST SYNVISC 4 SP, PA SCHIZOPHRENIA/ANTI-PSYCHOTICS2 SYNVISC-ONE 4 SP, PA Medication Tier Notes TALTZ 4 SP, PA, QL ABILIFY ASIMTUFII 2 QL tanlor 1 ABILIFY MAINTENA 2 QL tramadol 50 mg, 100 mg tablet 1 QL aripiprazole 1 QL TREMFYA 4 SP, PA, QL ARISTADA 2 QL TRILURON 4 SP, PA ARISTADA INITIO 2 TYENNE AUTO-INJECTOR, SYRINGE 4 SP, PA, QL asenapine 1 UBRELVY 2 PA, QL CAPLYTA 3 QL vanadom 1 chlorpromazine 1 VELSIPITY 4 SP, PA, QL ERZOFRI 2 QL VISCO-3 4 SP, PA INVEGA HAFYERA 2 QL XELJANZ 4 SP, PA, QL INVEGA SUSTENNA 2 QL XELJANZ XR 4 SP, PA, QL INVEGA TRINZA 2 QL XIAFLEX 4 SP, PA lurasidone 1 QL XTAMPZA ER 2 PA olanzapine 1 ZAVZPRET 2 QL paliperidone er 1 QL ZEPOSIA 4 SP, PA PERSERIS 3 QL ZTLIDO 2 quetiapine 25 mg, 50 mg, 100 mg, 200 1 PARKINSON’S DISEASE mg, 300 mg, 400 mg tablet Medication Tier Notes quetiapine er 1 APOKYN 4 SP, PA REXULTI 2 QL, ST benztropine 1 risperidone 1 carbidopa-levodopa 1 RYKINDO 3 QL Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement 24 Cigna Healthcare Advantage 4-Tier Prescription Drug List SCHIZOPHRENIA/ANTI-PSYCHOTICS2 (cont.) SEIZURE DISORDERS (cont.) Medication Tier Notes Medication Tier Notes SECUADO 3 ST SPRITAM 3 PA SEROQUEL 3 ST subvenite 1 UZEDY 3 QL TEGRETOL XR 3 PA VRAYLAR 3 QL, ST topiramate 1 ziprasidone 1 topiramate er 1 QL SEIZURE DISORDERS VALTOCO 3 PA, QL vigpoder 4 SP Medication Tier Notes VIMPAT ORAL SOLUTION 2 APTIOM 3 PA, QL VIMPAT VIAL 3 BRIVIACT 3 PA XCOPRI 3 PA, QL carbamazepine er 1 clonazepam 1 SKIN CONDITIONS DILANTIN 30 MG CAPSULE 2 PA Medication Tier Notes DILANTIN 100 MG CAPSULE, INFATAB, 3 PA adapalene-benzoyl peroxide 1 ORAL SUSPENSION ADBRY 4 SP, PA divalproex 1 azelaic acid 1 divalproex er 1 BRYHALI 3 ST EPIDIOLEX 4 SP, PA CAPEX SHAMPOO 3 ST FINTEPLA 4 SP, PA CIBINQO 4 SP, PA, QL FYCOMPA 2 PA, QL clindamycin foam, gel, lotion, pledget, 1 gabapentin 1 topical solution KLONOPIN 3 PA clobetasol cream, foam, gel, lotion, 1 lacosamide 1 ointment, shampoo, topical solution, spray lamotrigine er 1 clotrimazole-betamethasone 1 lamotrigine odt 1 dapsone gel, gel pump 1 levetiracetam er 1 DROPSAFE PREP PAD 1 LYRICA ORAL SOLUTION 3 PA DRYSOL 3 NAYZILAM 2 PA, QL EBGLYSS 4 SP, PA ONFI 3 PA EUCRISA 2 ST oxcarbazepine 1 fluorouracil 5% cream, topical solution 1 OXTELLAR XR 3 PA halobetasol 1 PHENYTEK 3 PA isotretinoin 1 pregabalin 1 ketoconazole cream, foam, shampoo 1 roweepra 1 LITFULO 4 SP, PA, QL Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement 25 Cigna Healthcare Advantage 4-Tier Prescription Drug List SKIN CONDITIONS (cont.) SLEEP DISORDERS/SEDATIVES (cont.) Medication Tier Notes Medication Tier Notes mupirocin 2% ointment 1 temazepam 1 NAFTIN 3 WAKIX 4 SP, PA, QL NEMLUVIO 4 SP, PA XYWAV 4 SP, PA, QL neuac gel 1 zolpidem sublingual tablet, tablet 1 OPZELURA 3 PA zolpidem er 1 QL pimecrolimus 1 SUBSTANCE ABUSE PRAMOSONE 3 Medication Tier Notes REGRANEX 3 PA, QL BRIXADI 4 SP rosadan cream, gel 1 buprenorphine-naloxone 1 SANTYL 3 QL KLOXXADO 2 QL sodium sulfacetamide-sulfur 9.8-4.8%, 1 LUCEMYRA 2 QL 10-2%, 10-5% cleanser; cream, lotion, pad; 8-4%, 10-5% topical suspension; naltrexone 1 QL wash NARCAN 2 QL SOOLANTRA 3 OPVEE 3 QL sulfacleanse 8-4 1 SUBLOCADE 4 SP tacrolimus ointment 1 SUBOXONE 3 tazarotene cream, gel 1 ZIMHI 3 QL tretinoin cream, gel 1 PA, AGE ZUBSOLV 2 triderm 1 TRANSPLANT MEDICATIONS TWYNEO 3 Medication Tier Notes XEPI 3 ENVARSUS XR 4 SP zenatane 1 everolimus 0.25mg, 0.5 mg, 0.75 mg, 1 4 SP SLEEP DISORDERS/SEDATIVES mg tablet Medication Tier Notes LUPKYNIS 4 SP, PA, QL DAYVIGO 2 QL, ST mycophenolate 4 SP doxepin tablet 1 QL mycophenolic acid 4 SP eszopiclone 1 PROGRAF AMPULE 4 SP LUMRYZ 4 SP, PA, QL PROGRAF GRANULE PACKET 4 SP modafinil 1 PA REZUROCK 4 SP, PA SODIUM OXYBATE (by Hikma) 4 SP, PA, QL sirolimus 4 SP SUNOSI 2 PA, QL tacrolimus capsule 4 SP Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement 26 Cigna Healthcare Advantage 4-Tier Prescription Drug List URINARY TRACT CONDITIONS VACCINES (cont.) Medication Tier Notes Not all plans cover vaccines in the same way. Log in to alfuzosin er 1 the myCigna App or myCigna.com, or check your plan materials, to see how your plan covers them. cevimeline 1 Medication Tier Notes dutasteride 1 ENGERIX-B 3 PPACA ELMIRON 3 FLUAD 3 PPACA finasteride 5 mg tablet 1 FLUARIX 3 PPACA K-PHOS NO.2 3 FLUBLOK 3 PPACA K-PHOS ORIGINAL 3 FLUCELVAX 3 PPACA mirabegron er 1 QL FLULAVAL 3 PPACA oxybutynin er 1 FLUMIST 3 PPACA phenazopyridine 100 mg, 200 mg 1 tablet FLUZONE 3 PPACA potassium er 1 FLUZONE HIGH-DOSE 3 PPACA RAPAFLO 3 QL GARDASIL 9 3 PPACA solifenacin 1 QL HEPLISAV-B 3 PPACA tamsulosin 1 HIBERIX 3 PPACA tolterodine er 1 QL INFANRIX DTAP 3 PPACA trospium er 1 IPOL 3 PPACA KINRIX 3 PPACA VACCINES MENQUADFI 3 PPACA Not all plans cover vaccines in the same way. Log in to MENVEO A-C-Y-W-135-DIP 3 PPACA the myCigna App or myCigna.com, or check your plan materials, to see how your plan covers them. M-M-R II VACCINE 3 PPACA Medication Tier Notes MODERNA COVID 3 PPACA ABRYSVO 3 PPACA MRESVIA 3 PPACA ACTHIB 3 PPACA NOVAVAX 3 PPACA ADACEL TDAP 3 PPACA PEDIARIX 3 PPACA AFLURIA 3 PPACA PEDVAXHIB 3 PPACA AREXVY 3 PPACA PENBRAYA 3 PPACA BEXSERO 3 PPACA PENTACEL 3 PPACA BOOSTRIX TDAP 3 PPACA PFIZER COVID 3 PPACA CAPVAXIVE 3 PPACA PNEUMOVAX 23 3 PPACA COMIRNATY 3 PPACA PREVNAR 20 3 PPACA DAPTACEL DTAP 3 PPACA PRIORIX 3 PPACA DENGVAXIA 3 PPACA PROQUAD 3 PPACA Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement 27 Cigna Healthcare Advantage 4-Tier Prescription Drug List VACCINES (cont.) Not all plans cover vaccines in the same way. Log in to the myCigna App or myCigna.com, or check your plan materials, to see how your plan covers them. Medication Tier Notes QUADRACEL DTAP-IPV 3 PPACA RECOMBIVAX HB 3 PPACA ROTARIX 3 PPACA ROTATEQ 3 PPACA SHINGRIX 3 QL, PPACA SPIKEVAX 3 PPACA TDVAX 3 PPACA TENIVAC 3 PPACA TRUMENBA 3 PPACA TWINRIX 3 PPACA VARIVAX 3 PPACA VAXELIS 3 PPACA VAXNEUVANCE 3 PPACA VITAMINS Medication Tier Notes CITRANATAL MEDLEY 3 POLY-VI-FLOR 3 PPACA POLY-VI-FLOR-IRON 0.25 MG DROPS, 3 PPACA 0.5-10 MG CHEWABLE TABLET Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement 28 Frequently Asked Questions (FAQs) Here are answers to questions you may have about your drug list and prescription medication coverage. Q. Why do you make changes to the drug list? For example, your plan doesn’t cover (or "excludes”): A. We review and update the drug list on a regular • Prescription medications that treat allergies basis to make sure you have coverage for low-cost, (ex. Allegra, Clarinex, Xyzal and generics) and safe and effective medications. We make changes for heartburn/stomach acid conditions (ex. Nexium, many reasons; for example, when a new medication Prilosec OTC and generics). comes out or is no longer available, or when a • Medications that treat lifestyle conditions, such medication’s price changes. These changes may as infertility, erectile dysfunction and smoking include: cessation.4 ­• Moving a medication to a lower cost tier. This • Medications that the U.S. Food and Drug can happen at any time during the year. Administration (FDA) hasn’t approved. • Moving a brand medication to a higher cost tier when a generic comes out. This can happen at Q. How do you decide which medications to cover? any time during the year. A. The Cigna Healthcare Prescription Drug List is • Moving a medication to a higher cost tier and/ developed with the help of the Cigna Healthcare or no longer covering a medication. This usually Pharmacy and Therapeutics (P&T) Committee, which happens twice a year on January 1 and July 1. is a group of practicing doctors and pharmacists, • Adding extra coverage requirements to a most of whom work outside of Cigna Healthcare. The medication. This usually happens twice a year on group meets regularly to review medical evidence January 1 and July 1. and information provided by federal agencies, drug manufacturers, medical professional associations, When we make a change that affects your national organizations and peer-reviewed journals medication (for example, it’ll cost more, won’t be about the safety and effectiveness of medications covered, and/or has an extra coverage requirement), that are newly approved by the FDA and medications we let you know before it happens. This way, you have already on the market. time to talk with your doctor about your options. Only you and your doctor can decide what’s best for The Cigna Healthcare Health Plan Commercial Value your treatment. Assessment Committee (HVAC) then looks at the results of the P&T Committee’s clinical review, as well Q. Why doesn’t my plan cover certain medications? as the medication’s overall value and other factors A. To help lower your overall health care costs, your before adding it to, or removing it from, the drug list. plan doesn’t cover certain high-cost brand-name medications that have lower-cost alternatives that Q. Why do certain medications need approval can treat the same condition. If your medication isn’t before my plan will cover them? covered and your doctor feels a different medication A. The review process helps make sure you’re getting isn’t right for you, your doctor’s office can ask us to coverage for the right medication, at the right cost, cover it through our review process. in the right amount and for the right situation. There are some medications and products that Q. How do I know if a medication needs approval? your plan won't cover for any reason because A. Check your drug list or log in to the myCigna App they’re a “plan (or benefit) exclusion.” This means the or myCigna.com and use the Price a Medication tool. medication or product isn’t on your drug list, and If the medication has: there’s no option to ask us to cover it through our • PA (Prior Authorization) or ST (Step Therapy) review process. next to it, it needs approval before your plan will cover it. 29 Frequently Asked Questions (FAQs) (cont.) • QL (Quantity Limit) next to it, you may need Q. How do I get approval (prior authorization) for approval depending on how much you’re filling at my medication? one time. A. Ask your doctor’s office to contact us to start the • AGE (Age Requirement) next to it, you may need coverage review process. They know how the review approval depending on your age. process works and will take care of everything for you. In case the office asks, they can download a Q. What types of medications usually need request form from our provider portal approval? at cignaforhcp.com. A. Medications that: We’ll review the information your doctor sends us to • May not be safe when you take them with other make sure you meet coverage requirements for the medications. medication. We’ll send you and your doctor a letter • Have lower-cost alternatives that work just as with the decision and next steps. It can take up to well at treating the same condition. five (5) business days to hear from us. You can always check with your doctor’s office to find out if we’ve • Should only be used for certain health conditions. made a decision. You can also log in to the myCigna • Are often used in the wrong way or are abused App or myCigna.com to see where your medication (taken more often than you should). is in the review process. Q. What types of medications usually have Many times, we don’t get all of the information we quantity limits? need from the doctor’s office to approve coverage. If A. Medications that are often: we don’t approve your medication, your doctor can • Taken in a greater amount or used for a longer send us more information to review, using the same time than they should be. process as before. We’re happy to review the request again. Depending on what your doctor sends this • Used in the wrong way or are abused (taken time, we may be able to approve coverage. Or you more often than you should). and your doctor can appeal the decision by sending us a request, in writing, that explains why we should Q. What medications are part of Step Therapy? cover the medication. A. They’re usually high-cost medications that treat conditions such as: Q. What happens if I try to fill a prescription that ­• ADD/ADHD ­• High cholesterol needs approval, but I don’t get it ahead of time? ­• Allergies ­• Osteoporosis A. When your pharmacist tries to fill your ­• Bladder problems­ • Pain prescription, they’ll see that the medication needs ­• Breathing problems ­• Skin conditions our approval before it can be covered. Because you ­• Depression ­• Sleep disorders didn’t get approval ahead of time, your plan won’t ­• High blood pressure cover its cost. If that happens, ask your doctor to contact us to start the coverage review process. Q. Why does my medication have an age Or you can choose to pay the medication’s full cost requirement? out-of-pocket directly to the pharmacy. If you do this, A. Not all medications are right for all ages. Some the cost won’t count toward your annual deductible medications work best for people of a certain age or out-of-pocket maximum. or within a certain age range. As you get older, body changes can decrease the body’s ability to break Q. What happens if I try to fill a prescription that down or get rid of certain medications. This means has a quantity limit? that the medication may stay in your body longer. A. Your pharmacist will only fill the amount your plan So, an older adult may need a lower dose of the covers. If you want to fill more than what’s allowed, medication or a different medication that’s safer. 30 Frequently Asked Questions (FAQs) (cont.) your doctor’s office can ask us to cover it through our Q. How can I find out how much my medication will review process. cost me? A. When you and your doctor are thinking about Q. Are all of the medications on this drug list the right medication for your treatment, knowing approved by the FDA? how much it costs, what lower-cost alternatives are A. Yes. available, and which pharmacies offer the best prices can help you avoid surprises. Log in to the myCigna Q. Does my plan cover medications that the FDA App or myCigna.com and use the Price a Medication recently approved? tool to see how much your medication costs before A. We review all recently approved medications and you get to the pharmacy counter – or even before products to see if they should be covered, and if you leave your doctor’s office.5 so, at what cost-share (tier). These include, but are not limited to, medications, medical supplies and/or Q. What’s a cost-share? devices covered under standard pharmacy benefits. A. It’s the amount you pay out of your own pocket for It can take up to six months from the date the FDA a covered prescription and/or an eligible health care approved them for us to make a decision. or related service. For some plans, the cost-share is a copay; for other plans, it’s a coinsurance. If your doctor wants you to use a recently approved medication, your doctor’s office can ask us to cover it Q. How can I save money on my prescription through our review process. medications? A. You should think about using a medication Q. What are preventive medications? that’s covered on a lower tier, such as a generic or A. Preventive medications help keep you from preferred brand medication, or by filling a 90-day getting certain health conditions or to keep them supply (if your plan allows). Ask your doctor if one of from coming back. These include, but are not limited these options may work for you. to, asthma, depression, diabetes, heart attack, high blood pressure, high cholesterol, osteoporosis Q. What's a generic medication? (a disease that causes bones to become weak), A. A generic medication is the same as (or equal to) prenatal nutrient deficiency (when a pregnant the brand-name medication. It has the same active person doesn't get enough of the nutrients they ingredient, strength and dosage form, treats the need) and stroke. same condition(s), and works in the same way – and usually costs less.3 Generics are usually sold under Q. Which medications are covered under the their chemical or scientific name, instead of the health care reform law? brand name. A. The Patient Protection and Affordable Care Act (PPACA), also known as “health care reform,” was Q. Do generics work the same as brand-name signed into law on March 23, 2010. This law requires medications? plans to cover the full cost of some prescription A. Yes. A generic medication works in the same way preventive medications and over-the-counter (OTC) and provides the same clinical benefit as the brand- products. This means it costs you $0 to fill them – you name medication.3 won’t pay any cost-share. Q. What are the differences between generic and Go to Cigna.com/PDL to see a list of $0 medications, brand-name medications? Click on the dropdown next to "Drug Lists for A. The generic and brand-name medication may3: Employer Plans." Under the Preventive Drug Lists section, click on the link for the PPACA No Cost-Share • Look different. For example, generics may have Preventive Drug List. For more information about a different shape, size or color than their brand- health care reform, go to CignaHealthcare.com. name versions. 31 Frequently Asked Questions (FAQs) (cont.) • Have a different flavor and/or different 2. By phone. preservatives, come in different packaging and/ • Call your doctor’s office. Ask them to send a or with different labeling and may expire at 90-day prescription (with refills) to Express different times. Scripts home delivery. Or, It's important to know that these differences don't • Call Express Scripts Pharmacy at affect how the generic works. 800.835.3784. They’ll contact your doctor’s office to get your prescription. Have your Q. My pharmacy isn’t in my plan’s network. Can I ID card, doctor’s contact information and continue to fill my prescriptions there? medication name(s) ready when you call. A. To get the most from your plan coverage, you should use an in-network pharmacy. If your plan Fill specialty medications through offers out-of-network coverage, you’ll pay your out- Accredo by Evernorth® of-network cost-share to fill a prescription there. If you’re using a specialty medication to treat a rare and/or complex medical condition, Accredo can help. Q. Can I fill my prescriptions by mail? They’ll give you the personalized care and support A. Yes, as long as your plan offers home delivery.6 you need. They’ll also fill and ship your specialty medication to you. To learn more, go to Fill maintenance medications through Cigna.com/specialty. Express Scripts Pharmacy by Evernorth® • Talk with specially-trained pharmacists and Express Scripts Pharmacy is a convenient option nurses, 24/7. when you’re using a medication on a regular basis to treat an ongoing health condition. It’s simple and • Get fast shipping at no extra cost.7 safe, and saves you trips to the pharmacy. To learn • Sign up for refills and reminders. Some refills can more, go to Cigna.com/homedelivery. be done by text.9 • Easily order, manage, track and pay for your • Get help paying for your medication (if you medications on your phone or online. need it). • Get standard shipping at no extra cost.7 • Manage and track your medications online. • Fill up to a 90-day supply at one time. To get started, call 877.826.7657, Monday–Friday, • Talk with a pharmacist, 24/7. 7:00 am–10:00 pm CST and Saturdays, 7:00 am– • Sign up for automatic refills or refill reminders so 4:00 pm CST. you don’t miss a dose.8 • Use their payment plan (if you need it). Q. Where can I find more information about my pharmacy benefits? Here are two easy ways to get started: A. Use the online tools and resources on the myCigna 1. Online. Log in to the myCigna App or App or myCigna.com. You can find out how much myCigna.com and click on the Prescriptions tab. your medication costs (and what lower-cost options Choose My Medications from the dropdown may be available), see which medications your menu. Then click the button next to your plan covers, find an in-network pharmacy, ask a medication name to move your prescription(s) pharmacist a question, see your pharmacy claims from your retail pharmacy to home delivery. Or, and coverage details, and more. You can also manage your home delivery orders. medications your plan covers, find an in-network pharmacy, ask a pharmacist a question, see your pharmacy claims and coverage details and more. You can also manage your Express Scripts® Pharmacy orders. 32 Exclusions and limitations for coverage Health benefit plans vary, but in general to be eligible for coverage a drug must be approved by the Food and Drug Administration (FDA), prescribed by a health care professional, purchased from a licensed pharmacy and be medically necessary. If your plan provides coverage for certain preventive prescription drugs with no cost-share, you may be required to use an in-network pharmacy to fill the prescription. If you use a pharmacy that does not participate in your plan’s network, the prescription may not be covered. Certain drugs may require prior authorization, or be subject to step therapy, quantity limits or other utilization management requirements. Plans generally do not provide coverage for the following under the pharmacy benefit, except as required by state or federal law, or by the terms of your specific plan:10 • Over-the-counter (OTC) medicines (those that do fractions and medications used for travel not require a prescription) except insulin unless prophylaxis. state or federal law requires coverage of • Replacement of prescription medications and such medicines. related supplies due to loss or theft. • Prescription medications or supplies for which there • Medications which are to be taken by or is a prescription or OTC therapeutic equivalent or administered to a covered person while they are a therapeutic alternative. patient in a licensed hospital, skilled nursing facility, • Doctor-administered injectable medications rest home or similar institution which operates on its covered under the Plan’s medical benefit, unless premises or allows to be operated on its premises a otherwise covered under the Plan’s prescription facility for dispensing pharmaceuticals. drug list or approved by Cigna Healthcare. • Prescriptions more than one year from the date of • Implantable contraceptive devices covered under issue. the Plan’s medical benefit. • Coverage for prescription medication products for • Medications that are not medically necessary. the amount dispensed (days’ supply) which is more • Experimental or investigational medications, than the applicable supply limit, or is less than any including U.S. Food and Drug Administration (FDA)- applicable supply minimum set forth in The approved medications used for purposes other Schedule, or which is more than the quantity limit(s) than those approved by the FDA unless the or dosage limit(s) set by the P&T Committee. medication is recognized for the treatment of the • More than one prescription order or refill for particular indication. a given prescription supply period for the same • Medications that are not approved by the FDA. prescription medication product prescribed by one or more doctors and dispensed by one or • Prescription and non-prescription devices, supplies, more pharmacies. and appliances other than those supplies specifically listed as covered. • Prescription medication products dispensed outside the jurisdiction of the United States, • Medications used for fertility,11 sexual dysfunction, except as required for emergency or urgent cosmetic purposes, weight loss, smoking cessation,11 care treatment. or athletic enhancement. In addition to the plan’s standard pharmacy exclusions, • Prescription vitamins (other than prenatal vitamins) certain new FDA-approved medication products or dietary supplements unless state or federal law (including, but not limited to, medications, medical requires coverage of such products. supplies or devices that are covered under standard • Immunization agents, biological products pharmacy benefit plans) may not be covered for the for allergy immunization, biological sera, blood, first six months of market availability unless approved blood plasma and other blood products or by Cigna Healthcare as medically necessary. 33 Cigna Healthcare reserves the right to make changes to the drug list without notice. Your plan may cover additional medications; please refer to your enrollment materials for details. Cigna Healthcare does not take responsibility for any medication decisions made by the doctor or pharmacist. Cigna Healthcare may receive payments from manufacturers of certain preferred brand medications, and in limited instances, certain non-preferred brand medications, that may or may not be shared with your plan depending on its arrangement with Cigna Healthcare. Depending upon plan design, market conditions, the extent to which manufacturer payments are shared with your plan and other factors as of the date of service, the preferred brand medication may or may not represent the lowest-cost brand medication within its class for you and/or your plan. Health benefit plans vary, but in general to be eligible for coverage a drug must be approved by the U.S. Food and Drug Administration (FDA), prescribed by a health care professional, purchased from a licensed pharmacy and medically necessary. If your plan provides coverage for certain prescription drugs with no cost-share, you may be required to use an in-network pharmacy to fill the prescription. If you use a pharmacy that does not participate in your plan’s network, your prescription may not be covered, or reimbursement may be limited by your plan’s copayment, coinsurance or deductible requirements. Certain features described in this document may not be applicable to your specific health plan, and plan features may vary by location and plan type. Refer to your plan documents for costs and complete details of your plan’s prescription drug coverage. 1. App/online store terms and mobile phone carrier/data charges apply. Customers under age 13 (and/or their parent/guardian) will not be able to register at myCigna.com. 2. For insured plans that must follow Delaware’s state insurance laws: Brand-name antidepressants, smoking cessation, attention deficit hyperactivity disorder (ADHD) and anti-psychotic medications that don’t have a generic equivalent available will be covered as Tier 2 (preferred brand). This is true even if the medication is listed as Tier 3 (non-preferred brand) on your plan’s drug list. To find out how your specific plans covers these medications, log in to the myCigna App or myCigna.com, or call the number on your ID card. 3. U.S. Food and Drug Administration (FDA) website, “Generic Drug Facts.” Content current as of 11/01/21. fda.gov/drugs/generic-drugs/generic-drug-facts. 4. Smoking cessation medications are not usually covered under the plan, except as required by law or by the terms of your specific plan. Costs and complete details of the plan’s prescription drug coverage, including a full list of exclusions and limitations, are set forth in the plan documents. If there are any differences between the information provided here and the plan documents, the information in the plan documents takes complete precedence. 5. Prices shown on myCigna are not guaranteed and coverage is subject to your plan terms and conditions. Visit myCigna for more information. 6. Not all plans offer Express Scripts Pharmacy and Accredo as covered pharmacy options. Log in to the myCigna App or myCigna.com, or check your plan materials, to learn more about the pharmacies in your plan’s network. Cigna Healthcare, Evernorth, Express Scripts and Accredo are all part of The Cigna Group. This means we have an ownership interest in Express Scripts Pharmacy’s home delivery services and Accredo’s specialty pharmacy services. However, you have the right to fill prescriptions at any pharmacy in your plan’s network (as your plan allows). 7. Your plan pays the cost for standard shipping. 8. Express Scripts Pharmacy can automatically refill certain medications. Log in to the myCigna App or myCigna.com, or call 800.835.3784, to sign up. You can sign up to get emails and/or texts from Express Scripts Pharmacy. To get text messages, you’ll have to sign up for the Express Scripts texting service. You can do this online or when you call 800.835.3784 to refill your prescription. Once you sign up, just reply to their welcome text to get started. Standard text messaging rates apply. 9. You can only refill certain specialty medications by text. To get text messages, you’ll have to sign up for Accredo’s texting service. You can do this when you call Accredo to refill your prescription. Once you sign up, just reply to their welcome text to get started. Standard text messaging rates apply. 10 Costs and complete details of the plan’s prescription drug coverage are set forth in the plan documents. If there are any differences between the information provided here and the plan documents, the information in the plan documents takes complete precedence. 11. For plans that must follow state insurance laws, such as Delaware: Your plan may provide coverage for infertility medications and smoking cessation medications even if this drug list states that your plan may not cover them. To find out if your specific plan covers these medications, log in to the myCigna App or myCigna.com, or check your plan materials. Para obtener ayuda en español llame al número en su tarjeta de Cigna Healthcare. Cigna Healthcare products and services are provided exclusively by or through operating subsidiaries of The Cigna Group. 965173 b Advantage 4-Tier 04/25 © 2025 Cigna Healthcare. Cigna Healthcare Advantage 4-Tier Prescription Drug List Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement 35 Cigna Healthcare Advantage 4-Tier Prescription Drug List Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement 36