20 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 INFECTIONS (cont.) Medication Tier Notes PREVYMIS PELLET PACKET, TABLET 4 SP PRIFTIN 3 pruradik 1 pyrimethamine 4 SP, PA SIVEXTRO TABLET 3 PA sulfamethoxazole-tmp oral suspension, tablet 1 terbinafine tablet 1 THALOMID 4 SP, PA TOBI PODHALER 4 SP, PA, QL tobramycin ampule 4 SP, PA, QL valacyclovir 1 valganciclovir 1 VALTREX 3 vancomycin capsule, oral solution 1 vandazole 1 VEMLIDY 4 SP VIVJOA 4 SP, PA VOSEVI 4 SP, PA, QL XENLETA TABLET 3 PA, QL XIFAXAN 2 QL XOFLUZA 3 QL ZEPATIER 4 SP, PA, QL ZITHROMAX PACKET, ORAL SUSPENSION, TABLET, TRI-PAK 3 ZYVOX ORAL SUSPENSION, TABLET 3 PA INFERTILITY Medication Tier Notes clomiphene 1 OC CRINONE 8% GEL 2 OC ENDOMETRIN 2 OC FOLLISTIM AQ 4 SP, PA, OC GONAL-F 4 SP, PA, OC INFERTILITY (cont.) Medication Tier Notes GONAL-F RFF REDI-JECT 4 SP, PA, OC MENOPUR 4 SP, PA, OC NOVAREL 4 SP, PA, OC OVIDREL 4 SP, PA, OC PREGNYL 4 SP, PA, OC PREGNYL 4 SP, PA, OC MISCELLANEOUS Medication Tier Notes acamprosate 1 ACCU-CHEK FASTCLIX LANCET DRUM 1 ADDYI 3 PA, QL, OC AUSTEDO 4 SP, PA AUSTEDO XR 4 SP, PA, QL AUSTEDO XR TITRATION KIT 4 SP, PA, QL CARBAGLU 4 SP CERDELGA 4 SP, PA cinacalcet 4 SP CINRYZE 4 SP, PA, OC deferasirox 4 SP deferiprone 4 SP, PA DROPLET LANCET 1 EVRYSDI 4 SP, PA FILSPARI 4 SP, PA, QL GALAFOLD 4 SP, PA HAEGARDA 4 SP, PA INGREZZA 4 SP, PA, QL MICROLET LANCET 1 MYALEPT 4 SP, PA NITYR 4 SP, PA NUEDEXTA 3 QL ONETOUCH DELICA PLUS LANCET 1 ONETOUCH ULTRASOFT 2 LANCET 1 ORFADIN 4 SP, PA