17 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 EYE CONDITIONS (cont.) Medication Tier Notes OXERVATE 4 SP, PA polymyxin b-trimethoprim 1 prednisolone eye drops 1 PROLENSA 3 RESTASIS EYE EMULSION 2 RHOPRESSA 3 ROCKLATAN 3 SIMBRINZA 3 timolol drops, gel-solution 1 TOBRADEX 3 tobramycin drops 1 tobramycin-dexamethasone 1 travoprost 1 TYRVAYA 2 QL XDEMVY 4 SP, PA, QL XIIDRA 2 ZIRGAN 3 FEMININE PRODUCTS Medication Tier Notes fem ph 1 GYNAZOLE 1 1 miconazole 3 vaginal suppository 1 terconazole 1 TRIMO-SAN 3 GASTROINTESTINAL/HEARTBURN Medication Tier Notes alosetron 4 SP aprepitant 1 QL APRISO 3 balsalazide 1 BONJESTA 3 CHOLBAM 4 SP, PA dexlansoprazole dr 1 QL dicyclomine capsule, oral solution; 20 mg tablet 1 GASTROINTESTINAL/HEARTBURN (cont.) Medication Tier Notes doxylamine-pyridoxine 1 QL ENTYVIO VIAL 4 SP, PA, OC esomeprazole 20 mg, 40 mg capsule; packet 1 QL famotidine oral suspension; 20 mg, 40 mg tablet 1 GATTEX 4 SP, PA gavilyte-c 1 PPACA gavilyte-g 1 PPACA gavilyte-n 1 PPACA hydrocortisone enema, suppository 1 IQIRVO 4 SP, PA lansoprazole 1 QL LINZESS 2 LITHOSTAT 2 lubiprostone 1 mesalamine 1 mesalamine dr 1 metoclopramide oral solution, tablet 1 MOTOFEN 3 MOVANTIK 2 PA OCALIVA 4 SP, PA OLPRUVA 4 SP, PA omeprazole 10 mg, 20 mg, 40 mg capsule 1 QL ondansetron 1 ondansetron odt 4 mg, 8 mg tablet 1 PANCREAZE 2 pantoprazole packet, tablet 1 QL peg 3350-electrolyte 1 PPACA peg-prep 1 PPACA PHEBURANE 4 SP, PA, QL rabeprazole tablet 1 QL RECTIV 3 RELISTOR SYRINGE, VIAL 3 PA REZDIFFRA 4 SP, PA, QL