24 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 PARKINSON’S DISEASE (cont.) Medication Tier Notes INBRIJA 4 SP, PA NEUPRO 3 NOURIANZ 4 SP, PA, QL pramipexole 1 QL ropinirole 1 RYTARY 3 ST XADAGO 3 ST SCHIZOPHRENIA/ANTI-PSYCHOTICS2 Medication Tier Notes aripiprazole 1 QL asenapine 1 CAPLYTA 3 QL lurasidone 1 QL LYBALVI 3 QL olanzapine tablet 1 paliperidone er 1 QL quetiapine 25 mg, 50 mg, 100 mg, 200 mg, 300 mg, 400 mg tablet 1 quetiapine er 1 REXULTI 3 QL risperidone 1 SECUADO 3 ST VRAYLAR 3 QL ziprasidone capsule 1 SEIZURE DISORDERS Medication Tier Notes BRIVIACT ORAL SOLUTION, TABLET 3 PA carbamazepine er 1 clonazepam 1 DILANTIN 30 MG CAPSULE 2 PA DILANTIN 100 MG CAPSULE; INFATAB, ORAL SUSPENSION 3 PA divalproex 1 SEIZURE DISORDERS (cont.) Medication Tier Notes divalproex er 1 EPIDIOLEX 4 SP, PA FINTEPLA 4 SP, PA FYCOMPA ORAL SUSPENSION 2 PA gabapentin 1 lacosamide oral solution, tablet 1 lamotrigine er 1 lamotrigine odt 1 levetiracetam er 1 LYRICA ORAL SOLUTION 3 PA NAYZILAM 2 PA, QL oxcarbazepine 1 OXTELLAR XR 3 PA PHENYTEK 3 PA pregabalin 1 roweepra 1 SPRITAM 3 PA subvenite 1 TEGRETOL XR 3 PA topiramate 1 topiramate er 1 QL TROKENDI XR 3 QL VALTOCO 2 PA, QL vigpoder 4 SP VIMPAT ORAL SOLUTION 2 XCOPRI 3 PA, QL SKIN CONDITIONS Medication Tier Notes ABSORICA 3 ACZONE 7.5% GEL PUMP 3 adapalene-benzoyl peroxide 1 ADBRY AUTO-INJECTOR, SYRINGE 4 SP, PA azelaic acid 1