9 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 BLOOD MODIFIERS/BLEEDING DISORDERS (cont.) Medication Tier Notes UDENYCA ONBODY 4 SP, PA, OC VOYDEYA 4 SP, PA, QL WILATE 4 SP, PA, OC XYNTHA 4 SP, PA, OC XYNTHA SOLOFUSE 4 SP, PA, OC ZARXIO 4 SP ZIEXTENZO 4 SP, PA BLOOD PRESSURE/HEART MEDICATIONS Medication Tier Notes amlodipine 1 amlodipine-benazepril 1 amlodipine-olmesartan 1 QL amlodipine-valsartan 1 atenolol 1 bisoprolol 5 mg, 10 mg tablet 1 bisoprolol-hctz 1 CAMZYOS 4 SP, PA, QL candesartan 1 carvedilol 1 carvedilol er 1 QL clonidine patch, tablet 1 CORLANOR ORAL SOLUTION 4 SP, PA diltiazem 24hr er (cd) 1 dofetilide 1 QL droxidopa 4 SP enalapril 1 ENTRESTO SPRINKLE 2 flecainide 1 guanfacine 1 hydralazine tablet 1 irbesartan 1 labetalol 100 mg, 200 mg, 300 mg tablet 1 lisinopril 1 BLOOD PRESSURE/HEART MEDICATIONS (cont.) Medication Tier Notes lisinopril-hctz 1 losartan 1 losartan-hctz 1 metoprolol tablet 1 metoprolol er 1 metyrosine 1 PA midodrine 1 minoxidil tablet 1 MULTAQ 2 nadolol 1 nebivolol 1 QL nifedipine er 1 NITROSTAT 3 NORLIQVA 2 PA, QL olmesartan 1 QL olmesartan-amlodipine-hctz 1 olmesartan-hctz 1 QL ORLADEYO 4 SP, PA, QL prazosin 1 propranolol solution, tablet 1 propranolol er 1 ranolazine er 1 QL TAKHZYRO 4 SP, PA TEKTURNA HCT 2 telmisartan 1 QL telmisartan-hctz 1 QL VALSARTAN ORAL SOLUTION 3 ST valsartan 1 valsartan-hctz 1 verapamil er 1 verapamil sr 1 VERQUVO 2 PA, QL ZESTORETIC 3 ST