25 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 SKIN CONDITIONS (cont.) Medication Tier Notes BRYHALI 3 ST CAPEX SHAMPOO 3 ST CIBINQO 4 SP, PA, QL clindamycin foam, gel, lotion, pledget, topical solution 1 clobetasol 0.05% cream; foam, gel, lotion, ointment, shampoo, topical solution, topical spray 1 CLODERM 3 ST clotrimazole-betamethasone 1 dapsone 5% gel 1 DROPSAFE PREP PAD 1 DRYSOL 2 EBGLYSS 4 SP, PA EUCRISA 2 ST fluorouracil cream, topical solution 1 halobetasol 1 isotretinoin 1 ketoconazole cream, foam, shampoo 1 LITFULO 4 SP, PA, QL mupirocin 2% ointment 1 NAFTIN 2 NEMLUVIO 4 SP, PA neuac gel 1 ONEXTON 3 OPZELURA 3 PA pimecrolimus 1 PRAMOSONE 1%-1% CREAM, OINTMENT; 1% LOTION; 2.5%-1% OINTMENT 2 QBREXZA 3 PA RETIN-A MICRO PUMP 0.08% GEL 3 PA_AGE rosadan cream, gel 1 SKIN CONDITIONS (cont.) Medication Tier Notes SANTYL 2 QL sodium sulfacetamide-sulfur 9.8-4.8%, 10-2%, 10-5% cleanser; cream; lotion; pad; 8-4%, 10-5% topical suspension; wash 1 SOOLANTRA 3 sulfacleanse 8-4 1 tacrolimus ointment 1 tazarotene cream, gel 1 tretinoin cream, gel 1 PA_AGE triderm 1 TWYNEO 3 VALCHLOR 4 SP VECTICAL 3 QL XEPI 3 zenatane 1 ZORYVE 0.15% CREAM 2 QL, ST SLEEP DISORDERS/SEDATIVES Medication Tier Notes DAYVIGO 2 QL, ST doxepin tablet 1 QL eszopiclone 1 LUMRYZ 4 SP, PA, QL modafinil 1 PA SODIUM OXYBATE (by Hikma) 4 SP, PA, QL SUNOSI 2 PA, QL temazepam 1 WAKIX 4 SP, PA, QL XYWAV 4 SP, PA, QL zolpidem sublingual tablet, tablet 1 zolpidem er 1 QL