12 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 CONTRACEPTION PRODUCTS (cont.) Medication Tier Notes ashlyna 1 PPACA aubra 1 PPACA aubra eq 1 PPACA aurovela 1 PPACA aurovela fe 1 PPACA aurovela 24 fe 1 PPACA aviane 1 PPACA ayuna 1 PPACA azurette 1 PPACA balziva 1 PPACA blisovi fe 1 PPACA blisovi 24 fe 1 PPACA briellyn 1 PPACA camila 1 PPACA camrese 1 PPACA camrese lo 1 PPACA CAYA CONTOURED 2 PPACA caziant 1 PPACA charlotte 24 fe 1 PPACA chateal eq 1 PPACA cryselle 1 PPACA cyred 1 PPACA cyred eq 1 PPACA dasetta 1 PPACA daysee 1 PPACA deblitane 1 PPACA DEPO-PROVERA 3 PPACA DEPO-SUBQ PROVERA 104 SYRINGE 3 PPACA desogestrel-ethinyl estradiol 1 PPACA desogestrel-ethinyl estradiol ethinyl estradiol 1 PPACA dolishale 1 PPACA drospirenone-ethinyl estradiol 1 PPACA CONTRACEPTION PRODUCTS (cont.) Medication Tier Notes drospirenone-ethinyl estradiol- levomefolate 1 PPACA elinest 1 PPACA ELLA 3 PPACA eluryng 1 PPACA emzahh 1 PPACA enilloring 1 PPACA enpresse 1 PPACA enskyce 1 PPACA errin 1 PPACA estarylla 1 PPACA ethynodiol-ethinyl estradiol 1 PPACA etonogestrel-ethinyl estradiol 1 PPACA falmina 1 PPACA feirza 1 PPACA FEMCAP 2 PPACA finzala 1 PPACA galbriela 1 PPACA gemmily 1 PPACA hailey 1 PPACA hailey fe 1 PPACA hailey 24 fe 1 PPACA haloette 1 PPACA heather 1 PPACA iclevia 1 PPACA incassia 1 PPACA introvale 1 PPACA isibloom 1 PPACA jaimiess 1 PPACA jasmiel 1 PPACA jencycla 1 PPACA jolessa 1 PPACA joyeaux 1 PPACA