26 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 SMOKING CESSATION Medication Tier Notes APO-VARENICLINE 3 OC bupropion sr 150 mg tablet 1 PPACA, OC NICOTROL 2 PPACA, OC NICOTROL NS 2 PPACA, OC varenicline 1 PPACA, OC SUBSTANCE ABUSE Medication Tier Notes buprenorphine-naloxone 1 KLOXXADO 2 QL LUCEMYRA 2 QL naltrexone 1 QL NARCAN 2 QL OPVEE 3 QL SUBOXONE 3 ZIMHI 3 QL ZUBSOLV 2 TRANSPLANT MEDICATIONS Medication Tier Notes ENVARSUS XR 4 SP everolimus 0.25 mg, 0.5 mg, 0.75 mg, 1 mg tablet 4 SP LUPKYNIS 4 SP, PA, QL mycophenolate capsule, oral suspension, tablet 4 SP mycophenolic acid 4 SP REZUROCK 4 SP, PA sirolimus 4 SP tacrolimus capsule 4 SP URINARY TRACT CONDITIONS Medication Tier Notes alfuzosin er 1 cevimeline 1 dutasteride 1 URINARY TRACT CONDITIONS (cont.) Medication Tier Notes ELMIRON 2 finasteride 5 mg tablet 1 K-PHOS NO.2 2 K-PHOS ORIGINAL 2 mirabegron er 1 QL oxybutynin er 1 phenazopyridine 100 mg, 200 mg tablet 1 potassium citrate er 1 solifenacin 1 QL tamsulosin 1 tolterodine er 1 QL trospium er 1 VANRAFIA 4 SP, PA, QL VACCINES 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 ABRYSVO 3 PPACA ACTHIB 2 PPACA ADACEL TDAP 2 PPACA AFLURIA 2 PPACA AREXVY 3 PPACA BEXSERO 2 PPACA BOOSTRIX TDAP 2 PPACA CAPVAXIVE 2 PPACA COMIRNATY 2 PPACA DAPTACEL DTAP 2 PPACA DENGVAXIA 2 PPACA ENGERIX-B 2 PPACA FLUAD 2 PPACA FLUAD QUAD 2 PPACA FLUARIX 2 PPACA