16 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 DIABETES (cont.) Medication Tier Notes TWIIST REFILL, REFILL KIT, STARTER KIT 2 QL V-GO 2 XIGDUO XR 2 QL, ST DIURETICS Medication Tier Notes acetazolamide tablet 1 bumetanide tablet 1 CAROSPIR 2 PA chlorthalidone 1 DIURIL 2 eplerenone 1 furosemide oral solution, tablet 1 hydrochlorothiazide 1 KERENDIA 2 PA, QL spironolactone 1 tolvaptan 4 SP, PA EAR MEDICATIONS Medication Tier Notes ciprofloxacin-dexamethasone 1 CORTISPORIN-TC 3 DERMOTIC 3 neomycin-polymyxin-hc otic solution, suspension 1 ofloxacin 0.3% ear drops 1 OTOVEL 3 ERECTILE DYSFUNCTION Medication Tier Notes CAVERJECT 3 PA_AGE, QL, OC CIALIS 3 QL, ST, OC EDEX 3 PA_AGE, QL, OC MUSE 2 PA_AGE, QL, OC ERECTILE DYSFUNCTION (cont.) Medication Tier Notes sildenafil 25 mg, 50 mg, 100 mg tablet 1 QL, OC STENDRA 3 QL, ST, OC tadalafil 1 QL, OC vardenafil 1 QL, OC VIAGRA 3 QL, ST, OC EYE CONDITIONS Medication Tier Notes AZASITE 2 BESIVANCE 2 BETOPTIC S 3 bimatoprost drops 1 QL brimonidine drops 1 brimonidine-timolol 1 brinzolamide 1 bromfenac drops 1 CEQUA 2 ciprofloxacin drops 1 cyclosporine eye emulsion 1 CYSTARAN 4 SP, PA, QL difluprednate 1 dorzolamide-timolol 1 erythromycin eye ointment 1 EYSUVIS 2 QL fluorometholone 1 ILEVRO 3 INVELTYS 3 ST latanoprost 1 LOTEMAX 0.5% EYE OINTMENT 3 ST LOTEMAX SM 3 ST loteprednol 1 MIEBO 2 QL moxifloxacin drops 1 neomycin-polymyxin-dexamethasone 1 ofloxacin eye drops 1