22 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 NUTRITIONAL/DIETARY (cont.) Medication Tier Notes PRENATE DHA, ELITE, ENHANCE, MINI, PIXIE, RESTORE, STAR 2 PRIMACARE 2 QUFLORA PEDIATRIC DROPS; 1 MG CHEWABLE TABLET 2 PPACA sevelamer 1 sodium fluoride chewable tablet, drops 1 PPACA, OC soluvita 1 PPACA, OC TRI-VI-FLOR 2 PPACA tri-vitamin with fluoride 1 PPACA VELPHORO 2 VELTASSA 2 VITAFOL CAPLET, GUMMIES, NANO, OB+DHA, ULTRA 2 VITAFOL-ONE 2 vitamin d2 1.25 mg (50,000 unit) 1 OC vitamins a,c,d and fluoride 0.25 mg/ml 1 PPACA OSTEOPOROSIS PRODUCTS Medication Tier Notes alendronate 1 BINOSTO 3 ST ibandronate tablet 1 raloxifene 1 PPACA teriparatide 4 SP, PA, QL PAIN RELIEF AND INFLAMMATORY DISEASE Medication Tier Notes acetaminophen-codeine 1 PA ACTEMRA ACTPEN, SYRINGE 4 SP, PA, QL ADALIMUMAB-ADBM (CF) 4 SP, PA, QL AIMOVIG 2 PA AJOVY 2 PA ARCALYST 4 SP, PA AVSOLA 4 SP, PA, OC PAIN RELIEF AND INFLAMMATORY DISEASE (cont.) Medication Tier Notes BELBUCA 2 QL BENLYSTA AUTO-INJECTOR, SYRINGE 4 SP, PA BIMZELX 4 SP, PA, QL buprenorphine patch 1 QL butalbital-acetaminophen-caffeine capsule, tablet 1 QL celecoxib 1 QL CIMZIA 4 SP, PA, QL colchicine 1 COSENTYX PEN, SYRINGE 4 SP, PA, QL cyclobenzaprine tablet 1 CYLTEZO (CF) 4 SP, PA, QL diclofenac 1% gel, tablet 1 QL DUPIXENT 4 SP, PA eletriptan 1 QL EMGALITY 2 PA ENBREL 4 SP, PA, QL ENSPRYNG 4 SP, PA febuxostat 1 QL fentanyl lozenge, patch, effervescent tablet 1 PA FLECTOR 2 PA, QL HUMIRA (by AbbVie) 4 SP, PA, QL hydrocodone-acetaminophen 1 PA hydromorphone oral solution, suppository, tablet 1 PA HYSINGLA ER 2 PA ibuprofen oral suspension; 300 mg, 400 mg, 600 mg, 800 mg tablet 1 ILARIS 4 SP, PA, OC ILUMYA 4 SP, PA, QL indomethacin 25 mg, 50 mg capsule; oral suspension, 50 mg suppository 1 INFLECTRA 4 SP, PA, OC INFLIXIMAB 4 SP, PA, OC