27 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 VACCINES (cont.) Not all plans cover vaccines in the same way. Log in to the myCigna App or myCigna.com, or check your plan materials, to see how your plan covers them. Medication Tier Notes FLUBLOK 2 PPACA FLUCELVAX 2 PPACA FLULAVAL 2 PPACA FLUMIST 3 PPACA FLUZONE 2 PPACA FLUZONE HIGH-DOSE 2 PPACA GARDASIL 9 2 PPACA HEPLISAV-B 2 PPACA HIBERIX 2 PPACA INFANRIX DTAP 2 PPACA IPOL 2 PPACA JANSSEN COVID 2 PPACA KINRIX 2 PPACA MENQUADFI 2 PPACA MENVEO A-C-Y-W-135-DIP 2 PPACA M-M-R II VACCINE 2 PPACA MODERNA COVID 2 PPACA MRESVIA 3 PPACA NOVAVAX COVID 2 PPACA PEDIARIX 2 PPACA PEDVAXHIB 2 PPACA PENBRAYA 2 PPACA PENMENVY MEN A-B-C-W-Y 2 PPACA PENTACEL 2 PPACA PENTACEL ACTHIB COMPONENT 2 PPACA PFIZER COVID 2 PPACA PNEUMOVAX 23 2 PPACA PREHEVBRIO 2 PPACA PREVNAR 20 2 PPACA PRIORIX 2 PPACA PROQUAD 2 PPACA QUADRACEL DTAP-IPV 2 PPACA VACCINES (cont.) Not all plans cover vaccines in the same way. Log in to the myCigna App or myCigna.com, or check your plan materials, to see how your plan covers them. Medication Tier Notes RECOMBIVAX HB 2 PPACA ROTARIX 3 PPACA ROTATEQ 3 PPACA SHINGRIX 2 QL, PPACA SPIKEVAX COVID 2 PPACA TDVAX 2 PPACA TENIVAC 2 PPACA TRUMENBA 2 PPACA TWINRIX 2 PPACA VARIVAX 2 PPACA VAXELIS 2 PPACA VAXNEUVANCE 2 PPACA VITAMINS Medication Tier Notes CITRANATAL MEDLEY 3 OC POLY-VI-FLOR CHEWABLE TABLET 2 PPACA POLY-VI-FLOR WITH IRON CHEWABLE TABLET 2 PPACA WEIGHT MANAGEMENT Not all plans cover prescription weight management medications. Log in to the myCigna App or myCigna.com, or check your plan materials, to see if your plan covers them. Medication Tier Notes CONTRAVE 3 PA, OC IMCIVREE 4 SP, PA, QL, OC phentermine 1 OC QSYMIA 3 PA, OC SAXENDA 2 PA, OC WEGOVY 2 PA, QL, OC ZEPBOUND PEN 2 PA, QL, OC