15 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 DIABETES (cont.) Medication Tier Notes BAQSIMI 2 QL BD INSULIN PEN NEEDLE 1 BD NANO 2 PEN NEEDLE 1 BD SAFETYGLIDE INSULIN SYRINGE 1 BD ULTRA-FINE PEN NEEDLE 1 BYDUREON BCISE 2 PA, QL CEQUR SIMPLICITY 2 CEQUR SIMPLICITY INSERTER 2 CYCLOSET 3 DEXCOM G6 2 PA, QL DEXCOM G7 2 PA, QL DROPLET GENTEEL LANCING DEVICE 1 FARXIGA 2 QL, ST FREESTYLE INSULINX TEST STRIP 2 FREESTYLE LIBRE 2 READER, SENSOR 2 PA, QL FREESTYLE LIBRE 2 PLUS SENSOR 2 PA, QL FREESTYLE LIBRE 3 READER, SENSOR 2 PA, QL FREESTYLE LIBRE 3 PLUS SENSOR 2 PA, QL FREESTYLE LIBRE 14 DAY READER, SENSOR 2 PA, QL FREESTYLE LITE TEST STRIP 2 FREESTYLE TEST STRIP 2 glimepiride 1 mg, 2 mg, 4 mg tablet 1 GLIMEPIRIDE 3 MG TABLET 3 glipizide 5 mg, 10 mg tablet 1 glipizide xl 1 GLYXAMBI 2 QL, ST GUARDIAN RT REPLACE CHARGER, TEST PLUG 1 GVOKE 2 QL HUMALOG 2 QL HUMULIN N, HUMULIN R, HUMULIN 70/30 2 QL INPEN (FOR HUMALOG, NOVOLOG, FIASP) 1 INSULIN GLARGINE-YFGN 2 QL DIABETES (cont.) Medication Tier Notes INSULIN LISPRO 2 QL JANUMET 2 QL, ST JANUMET XR 2 QL, ST JANUVIA 2 QL, ST JARDIANCE 2 QL, ST LANTUS 2 QL LYUMJEV 2 QL metformin oral solution; 500 mg, 750 mg, 850 mg, 1,000 mg tablet 1 metformin er 500 mg, 750 mg tablet 1 MICROLET 2 LANCING DEVICE 1 MICROLET NEXT LANCING DEVICE 1 MOUNJARO 2 PA, QL OMNIPOD 5 G6-LIBRE 2 PLUS 2 QL OMNIPOD 5 G6-G7 INTRO KIT, PODS (GEN5) 2 QL OMNIPOD 5 INTRO (G6-LIBRE 2 PLUS) 2 QL OMNIPOD DASH INTRO KIT, PODS (GEN 4) 2 QL OZEMPIC 2 PA, QL PARADIGM RESERVOIR 1 pioglitazone 1 PRECISION XTRA TEST STRIP 2 RYBELSUS 2 PA, QL SEMGLEE (YFGN) 2 QL SOLIQUA 100-33 2 SYMLINPEN 2 SYNJARDY 2 QL, ST SYNJARDY XR 2 QL, ST TOUJEO MAX SOLOSTAR 2 QL TOUJEO SOLOSTAR 2 QL TRESIBA 2 QL TRIJARDY XR 2 QL, ST TRUE METRIX GLUCOSE TEST STRIP 2 TRULICITY 2 PA, QL