19 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 HORMONAL AGENTS (cont.) Medication Tier Notes UCERIS TABLET 3 PA, QL unithroid 3 XYOSTED 3 PA, QL yuvafem 1 QL INFECTIONS Medication Tier Notes acyclovir capsule, oral suspension, tablet 1 AEMCOLO 3 QL albendazole 1 amoxicillin 1 amoxicillin-clavulanate 1 ARIKAYCE 4 SP, PA atovaquone 1 atovaquone-proguanil 1 azithromycin packet, oral suspension, tablet 1 BARACLUDE ORAL SOLUTION 4 SP BAXDELA 450 MG TABLET 3 PA BEYFORTUS 3 PPACA CAYSTON 4 SP, PA, QL cefdinir 1 cefpodoxime 1 cefuroxime tablet 1 cephalexin 1 CIPRO ORAL SUSPENSION 2 ciprofloxacin oral suspension, tablet 1 clarithromycin 1 clindamycin capsule, oral solution, vaginal cream 1 CRESEMBA CAPSULE 3 PA DIFICID 3 QL doxycycline monohydrate 1 EMVERM 1 INFECTIONS (cont.) Medication Tier Notes entecavir 4 SP, QL EPCLUSA 4 SP, PA, QL erythromycin capsule, tablet 1 famciclovir 1 fluconazole oral suspension, tablet 1 flucytosine 1 fosfomycin 1 HARVONI 4 SP, PA, QL hydroxychloroquine 1 IMPAVIDO 3 PA itraconazole 1 KITABIS PAK 4 SP, PA, QL LAGEVRIO (EUA) 2 QL levofloxacin oral solution, tablet 1 LIKMEZ 3 PA LIVTENCITY 4 SP, PA, QL MACROBID 3 methenamine 1 metronidazole capsule; 250 mg, 500 mg tablet; vaginal gel 1 minocycline 1 mondoxyne nl 1 morgidox capsule 1 nitazoxanide 1 nitrofurantoin capsule; 25 mg/5 ml oral suspension 1 NUZYRA 150 MG TABLET 4 SP, PA, QL nystatin oral suspension, tablet 1 oseltamivir 1 QL PAXLOVID 2 QL PEGASYS 4 SP, PA penicillin v potassium 1 permethrin cream 1 posaconazole oral suspension, tablet 1