6 Cigna Healthcare Standard 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 AIDS/HIV Medication Tier Notes APRETUDE 4 SP, PA, PPACA BIKTARVY 4 SP, QL CABENUVA 4 SP, PA, OC CIMDUO 4 SP, PA darunavir 4 SP DESCOVY 120-15 MG TABLET 4 SP DESCOVY 200-25 MG TABLET 4 SP, PPACA DOVATO 4 SP, QL efavirenz-emtricitabine-tenofovir 4 SP, QL emtricitabine-tenofovir 200 mg-300 mg tablet 4 SP, PPACA GENVOYA 4 SP, QL ISENTRESS HD 4 SP, PA JULUCA 4 SP, QL ODEFSEY 4 SP, PA, QL PIFELTRO 4 SP, PA PREZCOBIX 4 SP, PA PREZISTA 100 MG/ML ORAL SUSPENSION; 75 MG, 150 MG TABLET 4 SP ritonavir 4 SP RUKOBIA 4 SP, PA, QL STRIBILD 4 SP, PA, QL SYMTUZA 4 SP, QL tenofovir 4 SP, PA TIVICAY 4 SP TRIUMEQ 4 SP, QL TRIUMEQ PD 4 SP, QL ALLERGY/NASAL SPRAYS Medication Tier Notes azelastine 0.1% (137 mcg) spray 1 azelastine-fluticasone 1 cromolyn oral concentrate 1 desloratadine 1 QL ALLERGY/NASAL SPRAYS (cont.) Medication Tier Notes epinephrine 0.15 mg, 0.3 mg auto- injector (by Mylan SP-Viatris, Teva USA); nasal solution 1 QL fluticasone spray 1 GRASTEK 2 PA, QL hydroxyzine oral solution, syrup, tablet 1 hydroxyzine pamoate 1 ipratropium spray 1 levocetirizine 1 mometasone spray 1 QL NEFFY 2 QL ODACTRA 3 PA, QL olopatadine spray 1 ORALAIR 2 PA, QL promethazine oral solution, syrup, tablet 1 RAGWITEK 3 PA, QL ALZHEIMER’S DISEASE Medication Tier Notes ADLARITY 2 PA, QL donepezil 1 EXELON 3 memantine 1 memantine er 1 QL NAMENDA 5-10 MG TITRATION PACK 2 pyridostigmine oral solution; 60 mg tablet 1 pyridostigmine er 180 mg tablet 1 rivastigmine 1 ANXIETY/DEPRESSION/BIPOLAR DISORDER2 Medication Tier Notes alprazolam 1 amitriptyline 1