7 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 ANXIETY/DEPRESSION/BIPOLAR DISORDER (cont.)2 Medication Tier Notes AUVELITY 2 QL, ST bupropion sr 1 QL bupropion xl 150 mg, 300 mg tablet 1 QL buspirone 1 citalopram oral solution, tablet 1 QL clomipramine 1 desvenlafaxine succinate er 1 QL duloxetine 1 QL EMSAM 3 QL escitalopram 1 QL fluoxetine 1 QL fluvoxamine 1 QL fluvoxamine er 1 QL lorazepam oral concentrate, tablet 1 mirtazapine 1 NUPLAZID 4 SP, PA paroxetine 1 QL paroxetine er 1 QL sertraline 1 QL trazodone 1 TRINTELLIX 2 QL venlafaxine hcl er 1 QL vilazodone 1 QL ZURZUVAE 4 SP, PA, QL ASTHMA/COPD/RESPIRATORY Medication Tier Notes ADEMPAS 4 SP, PA ADVAIR HFA 2 QL AIRSUPRA 2 QL albuterol 1 albuterol hfa 1 QL ASTHMA/COPD/RESPIRATORY (cont.) Medication Tier Notes ALYFTREK 4 SP, PA, QL ambrisentan 4 SP, PA ANORO ELLIPTA 2 QL ARNUITY ELLIPTA 2 ASMANEX, ASMANEX HFA 2 QL ATROVENT HFA 2 QL BREO ELLIPTA 2 QL breyna 1 QL BREZTRI AEROSPHERE 2 QL BRONCHITOL 4 SP, PA budesonide inhalation suspension 1 QL budesonide-formoterol 1 QL COMBIVENT RESPIMAT 2 QL DULERA 2 QL FASENRA PEN 4 SP, PA INCRUSE ELLIPTA 2 KALYDECO 4 SP, PA, QL montelukast 1 NUCALA AUTO-INJECTOR, SYRINGE 4 SP, PA OFEV 4 SP, PA OPSUMIT 4 SP, PA OPSYNVI 4 SP, PA, QL ORENITRAM ER 4 SP, PA ORENITRAM TITRATION KIT 4 SP, PA, QL PULMOZYME 4 SP, PA QVAR REDIHALER 2 SPIRIVA RESPIMAT 2 QL STIOLTO RESPIMAT 2 QL STRIVERDI RESPIMAT 2 QL SYMDEKO 4 SP, PA, QL TEZSPIRE 4 SP, PA, QL