8 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 ASTHMA/COPD/RESPIRATORY (cont.) Medication Tier Notes TRACLEER 32 MG TABLET FOR SUSPENSION 4 SP, PA TRELEGY ELLIPTA 2 QL TRIKAFTA 4 SP, PA, QL TYVASO DPI 4 SP, PA TYVASO 4 SP, PA UPTRAVI TABLET, TITRATION PACK 4 SP, PA VIJOICE 4 SP, PA, QL wixela inhub 1 QL XOLAIR 4 SP, PA ATTENTION DEFICIT HYPERACTIVITY DISORDER2 Medication Tier Notes ADZENYS XR-ODT 3 PA, QL atomoxetine 1 QL AZSTARYS 3 PA, QL, ST DAYTRANA 3 PA, QL dexmethylphenidate er 1 PA, QL dextroamphetamine-amphetamine 1 PA dextroamphetamine-amphetamine er 1 PA, QL DYANAVEL XR 3 PA, QL EVEKEO ODT 3 PA guanfacine er 1 lisdexamfetamine 1 PA, QL methylphenidate 1 PA, QL methylphenidate er (cd) 1 PA, QL methylphenidate er (la) 1 PA, QL methylphenidate er capsule; 10 mg, 18 mg, 20 mg, 27 mg, 36 mg, 54 mg, 72 mg tablet 1 PA, QL MYDAYIS 3 PA, QL QUILLICHEW ER 3 PA, QL QUILLIVANT XR 3 PA, QL XELSTRYM 3 PA, QL BLOOD MODIFIERS/BLEEDING DISORDERS Medication Tier Notes ADVATE 4 SP, PA, OC ADYNOVATE 4 SP, PA, OC AFSTYLA 4 SP, PA, OC ALTUVIIIO 4 SP, PA, OC aminocaproic acid oral solution, tablet 4 SP ARANESP 4 SP, PA, OC DOPTELET 4 SP, PA DROXIA 2 ELOCTATE 4 SP, PA, OC EMPAVELI 4 SP, PA ESPEROCT 4 SP, PA, OC FABHALTA 4 SP, PA, QL FULPHILA 4 SP, PA GRANIX 4 SP, PA HEMLIBRA 4 SP, PA HYMPAVZI PEN 4 SP, PA JIVI 4 SP, PA, OC KOGENATE FS 4 SP, PA, OC KOVALTRY 4 SP, PA, OC LEUKINE 4 SP NEULASTA 4 SP, PA NEULASTA ONPRO 4 SP, PA, OC NEUPOGEN 4 SP, PA NIVESTYM 4 SP NOVOEIGHT 4 SP, PA, OC NYVEPRIA 4 SP, PA PROCRIT 4 SP, PA, OC RETACRIT 4 SP, PA, OC STIMUFEND 4 SP, PA TAVALISSE 4 SP, PA TAVNEOS 4 SP, PA, QL tranexamic acid tablet 4 SP UDENYCA AUTO-INJECTOR, SYRINGE 4 SP, PA