21 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 MISCELLANEOUS (cont.) Medication Tier Notes PALYNZIQ 4 SP, PA POGO AUTOMATIC TEST CARTRIDGE 1 PRECISION XTRA B-KETONE STRIP 1 RADICAVA ORS 4 SP, PA, QL RUCONEST 4 SP, PA, OC sapropterin 4 SP, PA sodium chloride irrigation solution, inhalation vial 1 SPACE CHAMBER-LARGE MASK 2 QL STRENSIQ 4 SP, PA TECHLITE LANCET 1 TEGLUTIK 4 SP, PA TEGSEDI 4 SP, PA TIGLUTIK 4 SP, PA TRUEPLUS KETONE TEST STRIP 1 VEOZAH 3 QL VORTEX HOLDING CHAMBER 2 QL VORTEX VHC LADYBUG MASK 2 QL VORTEX VHC PEDIATRIC MASK 2 QL VOXZOGO 4 SP, PA VYLEESI 4 SP, PA, QL, OC VYNDAMAX 4 SP, PA, QL VYNDAQEL 4 SP, PA, QL VYVGART HYTRULO 1,000 MG-10,000 UNITS/5 ML 4 SP, PA MULTIPLE SCLEROSIS Medication Tier Notes AVONEX 4 SP, PA BAFIERTAM 4 SP, PA BETASERON 4 SP, PA dalfampridine er 4 SP, PA dimethyl 4 SP fingolimod 4 SP FIRDAPSE 4 SP, PA, QL MULTIPLE SCLEROSIS (cont.) Medication Tier Notes glatopa 4 SP KESIMPTA PEN 4 SP, PA MAVENCLAD 4 SP, PA MAYZENT 4 SP, PA PLEGRIDY 4 SP, PA REBIF 4 SP, PA REBIF REBIDOSE 4 SP, PA teriflunomide 4 SP VUMERITY 4 SP, PA NUTRITIONAL/DIETARY Medication Tier Notes ACCRUFER 3 OC AURYXIA 3 QL betaine 1 gram/scoop powder 4 SP calcitriol capsule, oral solution 1 OC cyanocobalamin 1 CYSTADANE 4 SP dodex 1 EFFER-K 10 MEQ, 20 MEQ TABLET 3 FLORIVA CHEWABLE TABLET 2 PPACA fluoride 1 PPACA, OC folic acid 1000 mcg, 1 mg tablet 1 lanthanum 1 LOKELMA 2 ludent fluoride 1 PPACA, OC mvc-fluoride 2 PPACA NEEVODHA 2 OC OB COMPLETE CAPLET 3 OC OB COMPLETE DHA, ONE, PETITE, PREMIER 2 POLY-VI-FLOR 2 PPACA potassium chloride oral solution, packet 1 PRENATE AM, CHEWABLE, ESSENTIAL 2 OC