13 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 juleber 1 PPACA junel 1 PPACA junel fe 1 PPACA junel fe 24 1 PPACA kaitlib fe 1 PPACA kalliga 1 PPACA kariva 1 PPACA kelnor 1-35 1 PPACA kelnor 1-50 1 PPACA kurvelo 1 PPACA KYLEENA 4 SP, PPACA larin 1 PPACA larin fe 1 PPACA larin 24 fe 1 PPACA layolis fe 3 PPACA leena 1 PPACA lessina 1 PPACA levonest 1 PPACA levonorgestrel-ethinyl estradiol 1 PPACA levonorgestrel-ethinyl estradiol ethinyl estradiol 1 PPACA levonorgestrel-ethinyl estradiol-fe bisglycinate 1 PPACA levora-28 1 PPACA LILETTA 4 SP, PPACA lojaimiess 1 PPACA loryna 1 PPACA low-ogestrel 1 PPACA lo-zumandimine 1 PPACA lutera 1 PPACA lyleq 1 PPACA lyza 1 PPACA marlissa 1 PPACA CONTRACEPTION PRODUCTS (cont.) Medication Tier Notes medroxyprogesterone syringe, vial 1 PPACA meleya 1 PPACA merzee 1 PPACA mibelas 24 fe 1 PPACA microgestin 1 PPACA microgestin fe 1 PPACA microgestin 24 fe 1 PPACA mili 1 PPACA minzoya 1 PPACA MIRENA 4 SP, PPACA MIUDELLA 4 SP, PPACA mono-linyah 1 PPACA necon 1 PPACA NEXPLANON 4 SP, PPACA nikki 1 PPACA nora-be 1 PPACA norelgestromin-ethinyl estradiol 1 PPACA norethindrone 0.35 mg tablet 1 PPACA norethindrone-ethinyl estradiol 1-0.02 mg, 1.5-0.03 mg (21) tablet 1 PPACA norethindrone-ethinyl estradiol-fe 1 PPACA norgestimate-ethinyl estradiol 1 PPACA nortrel 1 PPACA nylia 1 PPACA nymyo 1 PPACA ocella 1 PPACA orquidea 1 PPACA PARAGARD T 380-A 4 SP, PPACA philith 1 PPACA pimtrea 1 PPACA pirmella 1 PPACA portia 1 PPACA reclipsen 1 PPACA