10 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 BLOOD THINNERS/ANTI-CLOTTING Medication Tier Notes clopidogrel 1 dabigatran 1 ELIQUIS 2 enoxaparin 4 SP, QL fondaparinux 4 SP, QL FRAGMIN 4 SP, QL prasugrel 1 warfarin 1 XARELTO 2 ZONTIVITY 3 CANCER Medication Tier Notes abirtega 1 PA AKEEGA 4 SP, PA, QL ALECENSA 4 SP, PA, QL ALUNBRIG 4 SP, PA, QL anastrozole 1 PPACA AYVAKIT 4 SP, PA, QL BOSULIF 4 SP, PA, QL BRUKINSA CAPSULE 4 SP, PA, QL CABOMETYX 4 SP, PA CALQUENCE 4 SP, PA capecitabine 4 SP, PA COMETRIQ 4 SP, PA, QL COTELLIC 4 SP, PA DANZITEN 4 SP, PA ERIVEDGE 4 SP, PA ERLEADA 4 SP, PA exemestane 1 PPACA FRUZAQLA 4 SP, PA, QL GAVRETO 4 SP, PA, QL GLEOSTINE 2 hydroxyurea 1 CANCER (cont.) Medication Tier Notes IBRANCE 4 SP, PA, QL imatinib 4 SP, QL IMBRUVICA 4 SP, PA, QL IMKELDI 4 SP, PA INLYTA 4 SP, PA JAKAFI 4 SP, PA, QL JYLAMVO 3 KISQALI 4 SP, PA, QL KOSELUGO 4 SP, PA, QL lenalidomide 4 SP, PA, QL LENVIMA 4 SP, PA letrozole 1 leucovorin tablet 1 LONSURF 4 SP, PA LORBRENA 4 SP, PA, QL LUMAKRAS 4 SP, PA, QL LUPRON DEPOT 7.5 MG KIT, 22.5 MG 3 MONTH KIT, 4 MONTH KIT, 45 MG 6 MONTH KIT 4 SP, PA, OC LYNPARZA 4 SP, PA, QL MEKINIST 4 SP, PA, QL mercaptopurine tablet 1 methotrexate tablet; 50 mg/2 ml, 250 mg/10 ml, 1 gram/40 ml vial 1 NERLYNX 4 SP, PA NINLARO 4 SP, PA, QL NUBEQA 4 SP, PA ODOMZO 4 SP, PA OGSIVEO 4 SP, PA, QL ORGOVYX 4 SP, PA ORSERDU 4 SP, PA, QL PHESGO 4 SP, PA, OC PIQRAY 4 SP, PA POMALYST 4 SP, PA, QL PURIXAN 4 SP