23 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 PAIN RELIEF AND INFLAMMATORY DISEASE (cont.) Medication Tier Notes JOURNAVX 3 QL ketorolac syringe, tablet, vial 1 QL KEVZARA 4 SP, PA, QL KINERET 4 SP, PA, QL leflunomide 1 LICART 2 PA, QL lidocaine viscous 1 meloxicam tablet 1 metaxalone 400 mg, 800 mg tablet 1 MITIGARE 2 morphine er 1 PA nabumetone 1 NUCYNTA 2 PA NUCYNTA ER 3 PA NURTEC ODT 2 PA, QL OLUMIANT 4 SP, PA, QL OMVOH PEN, SYRINGE 4 SP, PA, QL ORENCIA CLICKJECT, SYRINGE 4 SP, PA, QL OTEZLA 4 SP, PA, QL OXAYDO 3 PA oxycodone ir capsule, oral concentrate, oral solution, ir tablet 1 PA PROCTOFOAM-HC 2 prolate 1 PA QULIPTA 2 PA, QL RASUVO 2 ST REMICADE 4 SP, PA, OC REYVOW 3 PA, QL RINVOQ 4 SP, PA, QL RINVOQ LQ 4 SP, PA, QL rizatriptan 1 QL ROXYBOND 3 PA SAVELLA 2 SELARSDI SYRINGE 4 SP, PA, QL PAIN RELIEF AND INFLAMMATORY DISEASE (cont.) Medication Tier Notes SILIQ 4 SP, PA, QL SIMLANDI (CF) 4 SP, PA, QL SIMPONI 50 MG/0.5 ML PEN INJECTOR, SYRINGE 4 SP, PA, QL SIMPONI 100 MG/ML PEN INJECTOR, SYRINGE 4 SP, PA, QL SIMPONI ARIA 4 SP, PA SKYRIZI ON-BODY, PEN, SYRINGE 4 SP, PA, QL SOTYKTU 4 SP, PA, QL STELARA SYRINGE; 45 MG/0.5 ML VIAL 4 SP, PA, QL sumatriptan 1 QL TALTZ 4 SP, PA, QL tanlor 1 tramadol 50 mg, 100 mg tablet 1 QL TREMFYA 4 SP, PA, QL TYENNE AUTO-INJECTOR, SYRINGE 4 SP, PA, QL UBRELVY 2 PA, QL vanadom 1 VELSIPITY 4 SP, PA, QL XELJANZ 4 SP, PA, QL XELJANZ XR 4 SP, PA, QL XTAMPZA ER 2 PA YESINTEK SYRINGE; 45 MG/0.5 ML VIAL 4 SP, PA, QL zebutal 3 QL ZEPOSIA 4 SP, PA ZTLIDO 2 PARKINSON’S DISEASE Medication Tier Notes APOKYN 4 SP, PA benztropine tablet 1 carbidopa-levodopa 1 CREXONT 3 ST DUOPA 4 SP