14 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 rivelsa 1 PPACA rosyrah 1 PPACA setlakin 1 PPACA sharobel 1 PPACA simliya 1 PPACA simpesse 1 PPACA SKYLA 4 SP, PPACA sprintec 1 PPACA sronyx 1 PPACA syeda 1 PPACA tarina fe 1 PPACA tarina 24 fe 1 PPACA tarina fe 1-20 eq 1 PPACA taysofy 1 PPACA tilia fe 1 PPACA tri-estarylla 1 PPACA tri-legest fe 1 PPACA tri-linyah 1 PPACA tri-lo-estarylla 1 PPACA tri-lo-marzia 1 PPACA tri-lo-mili 1 PPACA tri-lo-sprintec 1 PPACA tri-mili 1 PPACA tri-nymyo 1 PPACA tri-sprintec 1 PPACA tri-vylibra 1 PPACA tri-vylibra lo 1 PPACA tulana 1 PPACA turqoz 1 PPACA valtya 1 PPACA velivet 1 PPACA vestura 1 PPACA vienva 1 PPACA viorele 1 PPACA volnea 1 PPACA CONTRACEPTION PRODUCTS (cont.) Medication Tier Notes vyfemla 1 PPACA vylibra 1 PPACA wera 1 PPACA WIDE SEAL DIAPHRAGM 3 PPACA wymzya fe 1 PPACA xarah fe 1 PPACA xelria fe 1 PPACA xulane 1 PPACA zafemy 1 PPACA zarah 1 PPACA zovia 1-35 1 PPACA zumandimine 1 PPACA COUGH/COLD MEDICATIONS Medication Tier Notes brompheniramine-pseudoephedrine- dm 1 hydrocodone-chlorpheniramine er 1 PA hydrocodone-homatropine 1 PA, QL promethazine-dm 1 DENTAL PRODUCTS Medication Tier Notes doxycycline hyclate 20 mg tablet 1 FLORIVA 0.25 MG/ML DROPS 3 PPACA, OC periogard 1 PREVIDENT 5000 SENSITIVE 3 PREVIDENT KIDS 3 sodium fluoride 5000 dry mouth 1 triamcinolone 0.1% paste 1 DIABETES Medication Tier Notes ACCU-CHEK FASTCLIX LANCING DEVICE 1 ACCU-CHEK CONTROL SOLUTION 1 ACCU-CHEK SOFTCLIX LANCET KIT 1