18 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 GASTROINTESTINAL/HEARTBURN (cont.) Medication Tier Notes SANCUSO 3 PA, QL scopolamine 1 SFROWASA 3 sodium sulfate-potassium sulfate- magnesium sulfate 1 PPACA SUCRAID 4 SP, PA sucralfate 1 SYMPROIC 2 PA TRULANCE 2 VARUBI 3 PA, QL VIBERZI 2 VIOKACE 3 VOQUEZNA TABLET 3 PA, QL VOWST 4 SP, PA, QL ZENPEP 2 HORMONAL AGENTS Medication Tier Notes ANGELIQ 3 BIJUVA 3 budesonide dr 1 budesonide ec 1 cetrorelix 4 SP, PA, OC CETROTIDE 4 SP, PA, OC COMBIPATCH 2 CRINONE 4% GEL 3 PA CYTOMEL 3 DEPO-TESTOSTERONE 3 desmopressin ampule, vial 4 SP DUAVEE 2 EGRIFTA SV 4 SP, PA estradiol cream, gel packet, gel pump, patch, tablet, vaginal insert 1 QL EVAMIST 3 FENSOLVI 4 SP, PA, OC fyremadel 4 SP, PA, OC HORMONAL AGENTS (cont.) Medication Tier Notes ganirelix 4 SP, PA, OC GENOTROPIN 4 SP, PA INTRAROSA 3 QL levoxyl 1 liothyronine tablet 1 LUPRON DEPOT 3.75 MG, 11.25 MG KIT 4 SP, PA, OC LUPRON DEPOT-PED 4 SP, PA, OC lyllana 1 QL medroxyprogesterone tablet 1 MENOSTAR 3 QL methylprednisolone dosepack, tablet 1 mimvey 1 MYFEMBREE 2 PA, QL NGENLA 4 SP, PA norethindrone 5 mg tablet 1 OMNITROPE 4 SP, PA ORIAHNN 2 PA, QL ORILISSA 2 PA, QL OSPHENA 3 QL prednisolone oral solution, syrup, tablet 1 prednisone 1 PREMARIN VAGINAl CREAM, TABLET 2 PREMPHASE 2 PREMPRO 2 progesterone capsule 1 RAYALDEE 3 SANDOSTATIN LAR DEPOT 4 SP, PA, OC SOMATULINE DEPOT 4 SP, PA, OC SOMAVERT 4 SP, PA testosterone gel, gel pump, packet 1 PA, QL testosterone cypionate 200 mg/ml, 1,000 mg/10 ml, 2,000 mg/10 ml, 6,000 mg /30 ML 1 thyroid 1