11 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 CANCER (cont.) Medication Tier Notes RETEVMO 4 SP, PA, QL REVLIMID 4 SP, PA, QL ROZLYTREK 4 SP, PA RUBRACA 4 SP, PA, QL RYDAPT 4 SP, PA SCEMBLIX 4 SP, PA, QL STIVARGA 4 SP, PA, QL TABRECTA 4 SP, PA, QL TAFINLAR 4 SP, PA, QL TAGRISSO 4 SP, PA TALZENNA 4 SP, PA, QL tamoxifen 1 PPACA temozolomide 4 SP, PA TIBSOVO 4 SP, PA torpenz 4 SP, PA, QL TREXALL 2 TRUQAP 4 SP, PA, QL TUKYSA 4 SP, PA VANFLYTA 4 SP, PA, QL VENCLEXTA STARTING PACK, TABLET 4 SP, PA VERZENIO 4 SP, PA, QL VITRAKVI 4 SP, PA VIZIMPRO 4 SP, PA WELIREG 4 SP, PA, QL XALKORI 4 SP, PA, QL XATMEP 3 XOSPATA 4 SP, PA XTANDI 4 SP, PA ZEJULA 4 SP, PA, QL ZELBORAF 4 SP, PA CHOLESTEROL MEDICATIONS Medication Tier Notes atorvastatin 10 mg, 20 mg tablet 1 PPACA atorvastatin 40 mg, 80 mg tablet 1 CHOLESTEROL MEDICATIONS (cont.) Medication Tier Notes CADUET 3 QL colesevelam 1 DOJOLVI 4 SP, PA ezetimibe 1 fenofibrate 43 mg, 50 mg, 67 mg, 130 mg, 134 mg, 150 mg, 200 mg capsule; tablet 1 fluvastatin 1 PPACA fluvastatin er 1 PPACA icosapent ethyl 1 LIPOFEN 3 ST lovastatin 10 mg tablet 1 lovastatin 20 mg, 40 mg tablet 1 PPACA NEXLETOL 2 PA, QL NEXLIZET 2 PA, QL omega-3 acid ethyl esters 1 pitavastatin 1 QL, PPACA pravastatin 1 PPACA REPATHA PUSHTRONEX, SURECLICK, SYRINGE 2 rosuvastatin 5 mg, 10 mg tablet 1 QL, PPACA rosuvastatin 20 mg, 40 mg tablet 1 QL simvastatin 5 mg, 80 mg tablet 1 QL TRICOR 3 ST VASCEPA 2 PA CONTRACEPTION PRODUCTS Medication Tier Notes afirmelle 1 PPACA altavera 1 PPACA alyacen 1 PPACA amethia 1 PPACA amethyst 1 PPACA apri 1 PPACA aranelle 1 PPACA