260125_Chapter_1B_-_PBM_Standard-4-Tier_PDL_(2025).pdf

595201 w Standard 4-Tier 06/25 © 2025 Cigna Healthcare.

Cigna Healthcare Standard 4-Tier Prescription Drug List Coverage as of July 1, 2025

* Drug list originally created: 01/01/2004 Last updated: 04/01/2025, for changes starting 07/01/2025

Next planned update: 09/01/2025, for changes starting 01/01/2026

What's Inside? Page

About this drug list 3

How to read this drug list 3

How to find your medication 5

List of medications 6

Frequently Asked Questions (FAQs) 28

Exclusions and limitations for coverage 32

View your drug list online, 24/7 This document was last updated on 04/01/2025.*

• You can use the Price a Medication tool on the myCigna® App1 or myCigna.com® to see the most up-to-date list of the medications your plan covers.

• You can also see a pdf of this document on Cigna.com/PDL. Click on the dropdown next to "Drug Lists for Employer Plans." Scroll down until you see Cigna Standard Prescription Drug List;

then click on the 4-Tier (injectable specialty medications covered on Tier 4) [PDF].

Questions?

• By phone: Call the toll-free number on your Cigna Healthcare® ID card. We’re here 24/7/365.

• myCigna.com: Click to Chat - Monday-Friday, 9:00 am-8:00 pm EST.

About this drug list This is a list of the most commonly prescribed medications covered on the Cigna Healthcare Standard 4-Tier Prescription Drug List as of July 1, 2025. Medications are listed in alphabetical order (A-Z) by the condition they treat.

The drug list is updated on a regular basis; so, this document may not show all of the medications your plan covers. Also, your plan may not cover every medication on this list. Log in to the myCigna App or myCigna.com to see the most up-to-date list of medications your plan covers.

How to read this drug list Use the table below to understand how medications are covered on the Cigna Healthcare Standard 4-Tier Prescription Drug List.*

BLOOD PRESSURE/HEART MEDICATIONS

Medication Tier Notes amlodipine 1 amlodipine-benazepril 1 amlodipine-olmesartan 1 QL amlodipine-valsartan 1 atenolol 1 bisoprolol-hctz 1

CALAN SR 3

CAMZYOS 3 SP, PA, QL

candesartan 1 cartia xt 1 carvedilol 1 carvedilol er 1 QL

CATAPRES-TTS 1 3

CATAPRES-TTS 2 3

CATAPRES-TTS 3 3

clonidine patch, tablet 1

CORLANOR ORAL SOLUTION 2 SP, PA

CORLANOR TABLET 2 PA

dilt xr 1 diltiazem tablet 1 diltiazem 12hr er 1 diltiazem 24hr er 1 diltiazem 24hr er (cd) 1 diltiazem 24hr er (la) 1 QL diltiazem 24hr er (xr) 1

DIOVAN 3 ST

DIOVAN HCT 3 ST

* This table is just an example. It may not show how these medications are currently covered on this drug list.

Medications are grouped by the condition they treat

Medications that may have extra coverage requirements have letters (acronyms) listed next to them in the Notes column

Medications are listed in alphabetical order (A-Z) within each column

Brand-name medications are in all CAPITAL letters

Generic medications are in all lowercase letters

Tier (cost-share level) gives you an idea of how much you may pay for a medication

Specialty medications have SP listed next to them in the Notes column

PA

Prior Authorization* – This medication needs approval from Cigna Healthcare before your plan will cover it. Your doctor’s office will have to send us information to review to make sure you meet coverage requirements.

QL

Quantity Limit* – Your plan will only cover so much of this medication at one time. If your doctor wants you to fill more than what’s allowed, your doctor’s office can ask us to cover more.

ST

Step Therapy* – This is a high-cost medication that has a lower-cost alternative(s) that treats the same condition. Your plan won’t cover it until you try at least one preferred medication first (usually a generic or preferred brand) and can show that it didn’t work for you. If your doctor feels a preferred medication isn’t right for you, your doctor’s office can ask us to cover the higher-cost medication.

AGE

Age Requirement* – Your plan will only cover this medication if you’re a certain age or within a certain age range. If you’re not within the allowed age range and your doctor wants you to use the medication, your doctor’s office can ask us to cover it.

SP

This is a specialty medication, which is used to treat a rare and/or complex medical condition.

Some plans may only cover up to a 30-day supply and/or require you to fill it at a preferred specialty pharmacy.

Brand-name medications are in all capital letters In this drug list, generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters.

Tiers We put covered medications into tiers (or cost-share levels). Usually, the higher the tier, the higher the price you’ll pay for the medication.

* Not all plans have extra coverage requirements on medications. Log in to the myCigna App or myCigna.com, or check your plan materials, to see if yours does.

Tier 1 Generics. These medications are covered at your plan’s lowest cost-share. A generic works in the same way and provides the same clinical benefits as the brand-name medication – and usually cost much less.3

Tier 2 Preferred Brands. These medications usually have one or more lower-cost generic that treats the same condition.

Tier 3 Non-Preferred Brands. These medications are covered at your plan’s highest cost-share.

Non-preferred brands usually have a generic and/or preferred brand alternative(s) that treats the same condition.

Tier 4 Specialty (Injectables only). These medications are covered at your plan’s highest cost-share. Oral specialty medications (those you take by mouth) are covered on a lower tier.

Letters (acronyms) in the Notes column In this drug list, some medications have letters (acronyms) next to them in the Notes column.

Here’s what they mean.

How to find your medication Medications are listed in alphabetical order (A-Z) by condition. Conditions are also listed in alphabetical order (A-Z). To see which page your medication is on, find your condition in the table below. Then, go to the page listed next to it to see which medications are covered.

Letters (acronyms) in the Notes column (cont.)

Condition Page

AIDS/HIV 6

ALLERGY/NASAL SPRAYS 6

ALZHEIMER’S DISEASE 6

ANXIETY/DEPRESSION/BIPOLAR DISORDER 6, 7

ASTHMA/COPD/RESPIRATORY 7, 8

ATTENTION DEFICIT HYPERACTIVITY

DISORDER

BLOOD MODIFIERS/BLEEDING DISORDERS 8, 9

BLOOD PRESSURE/HEART MEDICATIONS 9, 10

BLOOD THINNERS/ANTI-CLOTTING 10

CANCER 10, 11

CHOLESTEROL MEDICATIONS 11, 12

CONTRACEPTION PRODUCTS 12-14

COUGH/COLD MEDICATIONS 14

DENTAL PRODUCTS 14

DIABETES 14, 15

DIURETICS 15, 16

EAR MEDICATIONS 16

ERECTILE DYSFUNCTION 16

EYE CONDITIONS 16, 17

FEMININE PRODUCTS 17

Condition Page

GASTROINTESTINAL/HEARTBURN 17, 18

HORMONAL AGENTS 18, 19

INFECTIONS 19, 20

INFERTILITY 20

MISCELLANEOUS 20, 21

MULTIPLE SCLEROSIS 21

NUTRITIONAL/DIETARY 21, 22

OSTEOPOROSIS PRODUCTS 22

PAIN RELIEF AND INFLAMMATORY DISEASE 22, 23

PARKINSON’S DISEASE 23

SCHIZOPHRENIA/ANTI-PSYCHOTICS 24

SEIZURE DISORDERS 24

SKIN CONDITIONS 24, 25

SLEEP DISORDERS/SEDATIVES 25

SMOKING CESSATION 25

SUBSTANCE ABUSE 25

TRANSPLANT MEDICATIONS 26

URINARY TRACT CONDITIONS 26

VACCINES 26, 27

VITAMINS 27

WEIGHT MANAGEMENT 27

PPACA

Health care reform under the Patient Protection and Affordable Care Act (PPACA) requires plans to cover the full cost of this preventive medication or product. This means it costs you $0 – you won’t pay a cost-share to fill it.

OC

Plans can choose to cover certain medications, products and/or drug classes that aren’t usually covered. If a medication has OC next to it, log in to the myCigna App or myCigna.com to see if your plan covers it.

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.

AIDS/HIV

Medication Tier Notes

APRETUDE 3 SP, PA, PPACA

BIKTARVY 2 SP, QL

CABENUVA 4 SP, PA, OC

CIMDUO 3 SP, PA

COMPLERA 3 SP, PA, QL

darunavir 1 SP

DESCOVY 120-15 MG TABLET 2 SP

DESCOVY 200-25 MG TABLET 2 SP, PPACA

DOVATO 2 SP, QL

efavirenz-emtricitabine-tenofovir 1 SP, QL emtricitabine-tenofovir 200 mg-300 mg tablet

1 SP, PPACA

GENVOYA 2 SP, QL

ISENTRESS HD 2 SP, PA

JULUCA 2 SP, QL

ODEFSEY 3 SP, PA, QL

PIFELTRO 3 SP, PA

PREZCOBIX 3 SP, PA

PREZISTA 100 MG/ML ORAL SUSPEN-

SION; 75 MG, 150 MG TABLET

2 SP

ritonavir 1 SP

RUKOBIA 3 SP, PA, QL

STRIBILD 3 SP, PA, QL

SYMTUZA 2 SP, QL

tenofovir 1 SP, PA

TIVICAY 2 SP

TRIUMEQ 2 SP, QL

TRIUMEQ PD 2 SP, QL

ALLERGY/NASAL SPRAYS

Medication Tier Notes azelastine 0.1% (137 mcg) spray 1 azelastine-fluticasone 1 cromolyn oral concentrate 1 desloratadine 1 QL

ALLERGY/NASAL SPRAYS (cont.)

Medication Tier Notes epinephrine 0.15 mg, 0.3 mg auto-injector (by Mylan SP-Viatris, Teva USA); nasal solution

1 QL

fluticasone spray 1

GRASTEK 3 PA, QL

hydroxyzine oral solution, syrup, tablet 1 hydroxyzine pamoate capsule 1 ipratropium spray 1 levocetirizine 1 mometasone spray 1 QL

NEFFY 2 QL

ODACTRA 3 PA, QL

olopatadine spray 1

ORALAIR 3 PA, QL

promethazine oral solution, syrup, tablet

RAGWITEK 3 QL

ALZHEIMER’S DISEASE

Medication Tier Notes

ADLARITY 2 PA, QL

donepezil 1 memantine 1 memantine er 1 QL

NAMENDA 5-10 MG TITRATION PACK 2

NAMZARIC 3 QL

pyridostigmine oral solution, 60 mg tablet pyridostigmine er 1 rivastigmine 1

ANXIETY/DEPRESSION/BIPOLAR DISORDER2

Medication Tier Notes alprazolam 1 amitriptyline 1 bupropion sr 1 QL

Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters.

ANXIETY/DEPRESSION/BIPOLAR DISORDER (cont.)2

Medication Tier Notes bupropion xl 150 mg, 300 mg tablet 1 QL buspirone 1 citalopram oral solution, tablet 1 QL clomipramine 1 desvenlafaxine succinate er 1 QL duloxetine 1 QL

EMSAM 3 QL

escitalopram 1 QL

FETZIMA 3 QL ST

fluoxetine 1 QL fluvoxamine 1 QL fluvoxamine er 1 QL lorazepam oral concentrate, tablet 1 mirtazapine 1

NUPLAZID 3 SP, PA

paroxetine oral suspension, tablet 1 QL paroxetine er 1 QL sertraline oral concentrate, tablet 1 QL trazodone 1

TRINTELLIX 2 QL

venlafaxine er capsule; 37.5 mg, 75 mg, 150 mg, 225 mg tablet

1 QL

vilazodone 1 QL

ZURZUVAE 3 SP, PA, QL

ASTHMA/COPD/RESPIRATORY

Medication Tier Notes

ADEMPAS 2 SP, PA

ADVAIR HFA 2 QL

AIRSUPRA 2 QL

albuterol 1

ASTHMA/COPD/RESPIRATORY (cont.)

Medication Tier Notes albuterol hfa 90 mcg inhaler 1 QL

ALYFTREK 3 SP, PA, QL

ambrisentan 1 SP, PA

ANORO ELLIPTA 2 QL

ARNUITY ELLIPTA 2

ASMANEX, ASMANEX HFA 2 QL

ATROVENT HFA 2 QL

BREO ELLIPTA 2 QL

breyna 1 QL

BREZTRI AEROSPHERE 2 QL

budesonide inhalation suspension 1 QL budesonide-formoterol 1 QL

COMBIVENT RESPIMAT 2 QL

DULERA 2 QL

FASENRA PEN 4 SP, PA

INCRUSE ELLIPTA 2

KALYDECO 3 SP, PA, QL

montelukast 1

NUCALA AUTO-INJECTOR, SYRINGE 4 SP, PA

OFEV 2 SP, PA

OPSUMIT 2 SP, PA

OPSYNVI 2 SP, PA, QL

ORENITRAM ER 3 SP, PA

ORENITRAM TITRATION KIT 3 SP, PA, QL

PULMOZYME 2 SP, PA

QVAR REDIHALER 2

SPIRIVA RESPIMAT 2 QL

STIOLTO RESPIMAT 2 QL

STRIVERDI RESPIMAT 2 QL

SYMDEKO 3 SP, PA, QL

Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters.

ASTHMA/COPD/RESPIRATORY (cont.)

Medication Tier Notes tadalafil 20 mg tablet 1 SP, PA

TEZSPIRE 4 SP, PA, QL

TRACLEER 32 MG TABLET FOR

SUSPENSION

2 SP, PA

TRELEGY ELLIPTA 2 QL

TRIKAFTA 3 SP, PA, QL

TYVASO DPI 2 SP, PA

TYVASO 3 SP, PA

UPTRAVI TABLET, TITRATION PACK 2 SP, PA

VIJOICE 3 SP, PA, QL

wixela inhub 1 QL

XOLAIR 4 SP, PA

ATTENTION DEFICIT HYPERACTIVITY DISORDER2

Medication Tier Notes

ADDERALL 3 PA, ST

ADZENYS XR-ODT 3 PA, QL

atomoxetine 1 QL

AZSTARYS 3 PA, QL, ST

DAYTRANA 3 PA, QL

dexmethylphenidate er 1 PA, QL dextroamphetamine-amphetamine 1 PA dextroamphetamine-amphetamine er 1 PA, QL

DYANAVEL XR 3 PA, QL

guanfacine er 1 lisdexamfetamine 1 PA, QL methylphenidate 1 PA, QL methylphenidate er (cd) 1 PA, QL methylphenidate er (la) 1 PA, QL methylphenidate er capsule; 10 mg, 18 mg, 20 mg, 27 mg, 36 mg, 54 mg, 72 mg tablet

1 PA, QL

MYDAYIS 3 PA, QL

QUILLICHEW ER 3 PA, QL

ATTENTION DEFICIT HYPERACTIVITY DISORDER (cont.) 2

Medication Tier Notes

QUILLIVANT XR 3 PA, QL

XELSTRYM 3 PA, QL

BLOOD MODIFIERS/BLEEDING DISORDERS

Medication Tier Notes

ADVATE 4 SP, PA, OC

ADYNOVATE 4 SP, PA, OC

AFSTYLA 4 SP, PA, OC

ALTUVIIIO 4 SP, PA, OC

aminocaproic acid oral solution, tablet 1 SP

ARANESP 4 SP, PA, OC

DOPTELET 2 SP, PA

DROXIA 2

ELOCTATE 4 SP, PA, OC

EMPAVELI 4 SP, PA

ESPEROCT 4 SP, PA, OC

FABHALTA 2 SP, PA, QL

FULPHILA 4 SP, PA

GRANIX 4 SP, PA

HEMLIBRA 4 SP, PA

JIVI 4 SP, PA, OC

KOGENATE FS 4 SP, PA, OC

KOVALTRY 4 SP, PA, OC

NEULASTA 4 SP, PA

NEULASTA ONPRO 4 SP, PA, OC

NEUPOGEN 4 SP, PA

NIVESTYM 4 SP

NOVOEIGHT 4 SP, PA, OC

NYVEPRIA 4 SP, PA

PROCRIT 4 SP, PA, OC

PROMACTA 2 SP, PA

RETACRIT 4 SP, PA, OC

STIMUFEND 4 SP, PA

Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters.

BLOOD MODIFIERS/BLEEDING DISORDERS (cont.)

Medication Tier Notes

TAVALISSE 2 SP, PA

TAVNEOS 3 SP, PA, QL

tranexamic acid 650 mg tablet 1 SP

UDENYCA AUTO-INJECTOR, SYRINGE 4 SP, PA

UDENYCA ONBODY 4 SP, PA, OC

VOYDEYA 2 SP, PA, QL

WILATE 4 SP, PA, OC

XYNTHA 4 SP, PA, OC

XYNTHA SOLOFUSE 4 SP, PA, OC

ZARXIO 4 SP

ZIEXTENZO 4 SP, PA

BLOOD PRESSURE/HEART MEDICATIONS

Medication Tier Notes amlodipine 1 amlodipine-benazepril 1 amlodipine-olmesartan 1 QL amlodipine-valsartan 1 amlodipine-valsartan-hctz 1 atenolol 1 bisoprolol 1 bisoprolol-hctz 1

CAMZYOS 3 SP, PA, QL

candesartan 1 carvedilol 1 carvedilol er 1 QL clonidine patch, tablet 1

CORLANOR ORAL SOLUTION 2 SP, PA

CORLANOR TABLET 2 PA

diltiazem 24hr er (cd) 1 dofetilide 1 QL droxidopa 1 SP enalapril 1

ENTRESTO 2 QL

BLOOD PRESSURE/HEART MEDICATIONS (cont.)

Medication Tier Notes

ENTRESTO SPRINKLE 2

flecainide 1 guanfacine 1 hydralazine tablet 1 irbesartan 1 labetalol 100 mg, 200 mg, 300 mg tablet lisinopril 1 lisinopril-hctz 1 losartan 1 losartan-hctz 1 metoprolol tablet 1 metoprolol er 1 metyrosine 1 PA midodrine 1 minoxidil tablet 1

MULTAQ 2

nadolol 1 nebivolol 1 QL nifedipine er 1

NITROSTAT 3

NORLIQVA 2 PA, QL

olmesartan 1 QL olmesartan-amlodipine-hctz 1 olmesartan-hctz 1 QL

ORLADEYO 3 SP, PA, QL

prazosin 1 propranolol solution, tablet 1 propranolol er 1 ranolazine er 1 QL sajazir 4 SP, PA

TAKHZYRO 4 SP, PA

telmisartan 1 QL

Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters.

BLOOD PRESSURE/HEART MEDICATIONS (cont.)

Medication Tier Notes telmisartan-hctz 1 QL

VALSARTAN ORAL SOLUTION 3 ST

valsartan tablet 1 valsartan-hctz 1 verapamil sr 1

VERQUVO 2 PA, QL

ZESTORETIC 3 ST

BLOOD THINNERS/ANTI-CLOTTING

Medication Tier Notes

BRILINTA 2

clopidogrel 1 dabigatran 1

ELIQUIS 2

enoxaparin 1 SP, QL fondaparinux 1 SP, QL

FRAGMIN 2 SP, QL

prasugrel 1 warfarin 1

XARELTO 2

ZONTIVITY 3

CANCER

Medication Tier Notes abirtega 1 PA

AKEEGA 3 SP, PA, QL

ALECENSA 2 SP, PA, QL

anastrozole 1 PPACA

AYVAKIT 3 SP, PA, QL

BOSULIF 3 SP, PA, QL

BRUKINSA 2 SP, PA, QL

CABOMETYX 2 SP, PA

CALQUENCE 2 SP, PA

capecitabine 1 SP, PA

COMETRIQ 3 SP, PA, QL

CANCER (cont.)

Medication Tier Notes

COTELLIC 2 SP, PA

DANZITEN 2 SP, PA

ERIVEDGE 2 SP, PA

ERLEADA 2 SP, PA

exemestane 1 PPACA

GAVRETO 3 SP, PA, QL

GLEOSTINE 2

hydroxyurea 1

IBRANCE 3 SP, PA, QL

imatinib 1 SP, QL

IMBRUVICA 2 SP, PA, QL

IMKELDI 2 SP, PA

INLYTA 3 SP, PA

JAKAFI 3 SP, PA, QL

JYLAMVO 3

KISQALI 2 SP, PA, QL

KOSELUGO 3 SP, PA, QL

lenalidomide 1 SP, PA, QL

LENVIMA 2 SP, PA

letrozole 1 leucovorin tablet 1

LONSURF 3 SP, PA

LORBRENA 3 SP, PA, QL

LUMAKRAS 3 SP, PA, QL

LUPRON DEPOT 7.5 MG KIT, 22.5 MG

3 MONTH KIT, 45 MG 6 MONTH KIT, 4

MONTH KIT

4 SP, PA, OC

LYNPARZA 2 SP, PA, QL

MEKINIST 2 SP, PA, QL

mercaptopurine 1 methotrexate tablet; 25 mg/ml, 50 mg/2 ml, 250 mg/10 ml, 1 gram/40 ml vial

NERLYNX 3 SP, PA

NINLARO 3 SP, PA, QL

Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters.

CANCER (cont.)

Medication Tier Notes

NUBEQA 2 SP, PA

ODOMZO 2 SP, PA

OGSIVEO 3 SP, PA, QL

ORGOVYX 3 SP, PA

ORSERDU 3 SP, PA, QL

PHESGO 4 SP, PA, OC

PIQRAY 2 SP, PA

POMALYST 2 SP, PA, QL

PURIXAN 3 SP

RETEVMO 3 SP, PA, QL

REVLIMID 2 SP, PA, QL

ROZLYTREK 3 SP, PA

RUBRACA 2 SP, PA, QL

RYDAPT 3 SP, PA

SCEMBLIX 2 SP, PA, QL

STIVARGA 2 SP, PA, QL

sunitinib 1 SP, PA, QL

TABRECTA 3 SP, PA, QL

TAFINLAR 2 SP, PA, QL

TAGRISSO 3 SP, PA

TALZENNA 3 SP, PA, QL

tamoxifen 1 PPACA

TASIGNA 2 SP, PA, QL

temozolomide 1 SP, PA

TIBSOVO 3 SP, PA

torpenz 1 SP, PA, QL

TREXALL 2

TRUQAP 2 SP, PA, QL

TUKYSA 3 SP, PA

VANFLYTA 3 SP, PA, QL

VENCLEXTA STARTING PACK, TABLET 2 SP, PA

VERZENIO 2 SP, PA, QL

VITRAKVI 3 SP, PA

CANCER (cont.)

Medication Tier Notes

VIZIMPRO 3 SP, PA

WELIREG 3 SP, PA, QL

XALKORI 3 SP, PA, QL

XATMEP 3

XOSPATA 3 SP, PA

XTANDI 2 SP, PA

ZEJULA 2 SP, PA, QL

ZELBORAF 2 SP, PA

CHOLESTEROL MEDICATIONS

Medication Tier Notes atorvastatin 10 mg, 20 mg tablet 1 PPACA atorvastatin 40 mg, 80 mg tablet 1

CADUET 3 QL

colesevelam 1

DOJOLVI 3 SP, PA

ezetimibe 1 fenofibrate 43 mg, 50 mg, 67 mg, 130 mg, 134 mg, 150 mg, 200 mg capsule; tablet 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 PA

Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters.

CHOLESTEROL MEDICATIONS (cont.)

Medication Tier Notes 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 simvastatin 10 mg, 20 mg, 40 mg tablet

1 QL, PPACA

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 ashlyna 1 PPACA aubra 1 PPACA aubra eq 1 PPACA aurovela 1 PPACA aurovela fe 1 PPACA aviane 1 PPACA ayuna 1 PPACA azurette 1 PPACA balziva 1 PPACA blisovi fe 1 PPACA briellyn 1 PPACA camila 1 PPACA camrese 1 PPACA camrese lo 1 PPACA

CAYA CONTOURED 2 PPACA

caziant 1 PPACA charlotte 24 fe 1 PPACA

CONTRACEPTION PRODUCTS (cont.)

Medication Tier Notes chateal eq 1 PPACA cryselle 1 PPACA cyred 1 PPACA cyred eq 1 PPACA dasetta 1 PPACA daysee 1 PPACA deblitane 1 PPACA

DEPO-PROVERA 3 PPACA

DEPO-SUBQ PROVERA 104 SYRINGE 3 PPACA

desogestrel-ethinyl estradiol ethinyl estradiol

1 PPACA

dolishale 1 PPACA drospirenone-ethinyl estradiol 1 PPACA drospirenone-ethinyl estradiol-levomefolate

1 PPACA

elinest 1 PPACA

ELLA 3 PPACA

eluryng 1 PPACA emzahh 1 PPACA enilloring 1 PPACA enpresse 1 PPACA enskyce 1 PPACA errin 1 PPACA estarylla 1 PPACA ethynodiol-ethinyl estradiol 1 PPACA etonogestrel-ethinyl estradiol 1 PPACA falmina 1 PPACA feirza 1 PPACA

FEMCAP 2 PPACA

finzala 1 PPACA gemmily 1 PPACA hailey 1 PPACA hailey fe 1 PPACA haloette 1 PPACA

Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters.

CONTRACEPTION PRODUCTS (cont.)

Medication Tier Notes heather 1 PPACA iclevia 1 PPACA incassia 1 PPACA isibloom 1 PPACA jaimiess 1 PPACA jasmiel 1 PPACA jencycla 1 PPACA jolessa 1 PPACA joyeaux 1 PPACA juleber 1 PPACA junel 1 PPACA junel fe 1 PPACA kaitlib fe 1 PPACA kalliga 1 PPACA kariva 1 PPACA kelnor 1-35 1 PPACA kelnor 1-50 1 PPACA kurvelo 1 PPACA

KYLEENA 3 SP, PPACA

larin 1 PPACA larin fe 1 PPACA layolis fe 3 PPACA leena 1 PPACA lessina 1 PPACA levonest 1 PPACA levonorgestrel-ethinyl estradiol 1 PPACA levonorgestrel-ethinyl estradiol ethinyl estradiol

1 PPACA

levonorgestrel-ethinyl estradiol-fe bisglycinate

1 PPACA

levora-28 1 PPACA

LILETTA 3 SP, PPACA

lojaimiess 1 PPACA

CONTRACEPTION PRODUCTS (cont.)

Medication Tier Notes loryna 1 PPACA low-ogestrel 1 PPACA lo-zumandimine 1 PPACA lutera 1 PPACA lyleq 1 PPACA lyza 1 PPACA marlissa 1 PPACA medroxyprogesterone syringe, vial 1 PPACA merzee 1 PPACA mibelas 24 fe 1 PPACA microgestin 1 PPACA microgestin fe 1 PPACA mili 1 PPACA minzoya 1 PPACA

MIRENA 3 SP, PPACA

mono-linyah 1 PPACA necon 1 PPACA

NEXPLANON 2 SP, PPACA

nikki 1 PPACA nora-be 1 PPACA norelgestromin-ethinyl estradiol 1 PPACA norethindrone 0.35 mg tablet 1 PPACA norethindrone-ethinyl estradiol 1-0.02 mg, 1.5-0.03 mg (21) tablet

1 PPACA

norethindrone-ethinyl estradiol-fe 1 PPACA norgestimate-ethinyl estradiol 1 PPACA nortrel 1 PPACA nylia 1 PPACA ocella 1 PPACA

PARAGARD T 380-A 3 SP, PPACA

philith 1 PPACA pimtrea 1 PPACA portia 1 PPACA

Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters.

CONTRACEPTION PRODUCTS (cont.)

Medication Tier Notes reclipsen 1 PPACA rivelsa 1 PPACA setlakin 1 PPACA sharobel 1 PPACA simliya 1 PPACA simpesse 1 PPACA

SKYLA 3 SP, PPACA

sprintec 1 PPACA sronyx 1 PPACA syeda 1 PPACA tarina fe 1 PPACA tarina fe 1-20 eq 1 PPACA tilia fe 1 PPACA tri-estarylla 1 PPACA tri-legest fe 1 PPACA tri-linyah 1 PPACA tri-lo-estarylla 1 PPACA tri-lo-marzia 1 PPACA tri-lo-mili 1 PPACA tri-lo-sprintec 1 PPACA tri-mili 1 PPACA tri-sprintec 1 PPACA trivora-28 1 PPACA tri-vylibra 1 PPACA tri-vylibra lo 1 PPACA tulana 1 PPACA turqoz 1 PPACA valtya 1 PPACA velivet 1 PPACA vestura 1 PPACA vienva 1 PPACA viorele 1 PPACA volnea 1 PPACA

CONTRACEPTION PRODUCTS (cont.)

Medication Tier Notes vyfemla 1 PPACA vylibra 1 PPACA wera 1 PPACA

WIDE SEAL DIAPHRAGM 3 PPACA

wymzya fe 1 PPACA xarah fe 1 PPACA xulane 1 PPACA zafemy 1 PPACA zarah 1 PPACA zovia 1-35 1 PPACA zumandimine 1 PPACA

COUGH/COLD MEDICATIONS

Medication Tier Notes brompheniramine-pseudoephedrine-dm promethazine-dm 1

DENTAL PRODUCTS

Medication Tier Notes doxycycline hyclate 20 mg tablet 1

FLORIVA 0.25 MG/ML DROPS 3 PPAC, OC

periogard 1

PREVIDENT 5000 SENSITIVE 3

PREVIDENT KIDS 3

sodium fluoride 5000 plus 1 triamcinolone 0.1% paste 1

DIABETES

Medication Tier Notes

ACCU-CHEK CONTROL SOLUTION 1

ACCU-CHEK FASTCLIX LANCING

DEVICE

ACCU-CHEK SOFTCLIX LANCET KIT 1

BAQSIMI 2 QL

Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters.

DIABETES (cont.)

Medication Tier Notes

BD INSULIN PEN NEEDLE, SYRINGE 1

BD NANO 2 PEN NEEDLE 1

BD SAFETYGLIDE INSULIN SYRINGE 1

BD ULTRA-FINE PEN NEEDLE 1

BYDUREON BCISE 2 PA, QL

CEQUR SIMPLICITY 2

CEQUR SIMPLICITY INSERTER 2

CYCLOSET 3

DEXCOM G6 2 PA, QL

DEXCOM G7 RECEIVER, SENSOR 2 PA, QL

DROPLET GENTEEL LANCING DEVICE 1

FARXIGA 2 QL, ST

FREESTYLE LIBRE 2 READER, SENSOR 2 PA, QL

FREESTYLE LIBRE 2 PLUS SENSOR 2 PA, QL

FREESTYLE LIBRE 3 READER, SENSOR 2 PA, QL

FREESTYLE LIBRE 3 PLUS SENSOR 2 PA, QL

FREESTYLE LIBRE 14 DAY READER,

SENSOR

2 PA, QL

GLIMEPIRIDE 3 MG TABLET 3

glimepiride 1 mg, 2 mg, 4 mg tablet 1 glipizide 5 mg, 10 mg tablet 1 glipizide xl 1

GLYXAMBI 2 QL, ST

GVOKE 2 QL

HUMALOG 2 QL

HUMULIN N, HUMULIN R, HUMULIN

70/30

2 QL

INPEN (FOR HUMALOG, NOVOLOG OR

FIASP)

JANUMET XR 2 QL, ST

JANUVIA 2 QL, ST

JARDIANCE 2 QL, ST

LYUMJEV 2 QL

metformin oral solution; 500 mg, 750 mg, 850 mg, 1000 mg tablet

DIABETES (cont.)

Medication Tier Notes metformin er 500 mg, 750 mg tablet 1

MICROLET 2 LANCING DEVICE 1

MICROLET NEXT LANCING DEVICE 1

MOUNJARO 2 PA, QL

OMNIPOD 5 G6-LIBRE 2 PLUS 2 QL

OMNIPOD 5 G6-G7 INTRO KIT, PODS

(GEN5)

2 QL

OMNIPOD 5 INTRO (G6-LIBRE 2 PLUS) 2 QL

OMNIPOD DASH INTRO KIT, PODS

(GEN 4)

2 QL

ONETOUCH ULTRA TEST STRIP 2

ONETOUCH VERIO TEST STRIP 2

OZEMPIC 2 PA, QL

PARADIGM RESERVOIR 1

pioglitazone 1

RYBELSUS 2 PA, QL

saxagliptin 1 QL

SEMGLEE (YFGN) 2 QL

SOLIQUA 100-33 2

SYMLINPEN 2

SYNJARDY 2 QL, ST

SYNJARDY XR 2 QL, ST

TRESIBA 2 QL

TRIJARDY XR 2 QL, ST

TRULICITY 2 PA, QL

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

Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters.

DIURETICS (cont.)

Medication Tier Notes chlorthalidone 1

DIURIL 2

eplerenone 1 furosemide oral solution, tablet 1 hydrochlorothiazide 1

JYNARQUE 3 SP, PA

KERENDIA 2 PA, QL

spironolactone 1 tolvaptan 1 SP triamterene-hctz 1

EAR MEDICATIONS

Medication Tier Notes ciprofloxacin-dexamethasone 1 QL, OC

CORTISPORIN-TC 3 QL, OC

DERMOTIC 3 QL, OC

neomycin-polymyxin-hc otic solution, suspension

1 QL, OC

ofloxacin 0.3% ear drops 1 QL, OC

OTOVEL 3 QL, OC

ERECTILE DYSFUNCTION

Medication Tier Notes

CAVERJECT 3 PA, AGE, QL, OC

CIALIS 3 QL, ST, OC

EDEX 3 PA, AGE, QL, OC

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

EYE CONDITIONS (cont.)

Medication Tier Notes

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 3 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 drops 1

OXERVATE 3 SP, PA

polymyxin b-trimethoprim 1 prednisolone eye drops 1

PROLENSA 3

RHOPRESSA 3

ROCKLATAN 3

SIMBRINZA 3

tafluprost 1 QL timolol drops, gel-solution 1

Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters.

EYE CONDITIONS (cont.)

Medication Tier Notes

TOBRADEX EYE OINTMENT 3

TOBRADEX ST 3

tobramycin drops 1 tobramycin-dexamethasone 1 travoprost 1

TYRVAYA 2 QL

XDEMVY 2 SP, PA, QL

XIIDRA 2

ZIRGAN 3

FEMININE PRODUCTS

Medication Tier Notes fem ph 1

GYNAZOLE 1 1

miconazole 3 200 mg vaginal suppository terconazole 1

TRIMO-SAN 3

GASTROINTESTINAL/HEARTBURN

Medication Tier Notes alosetron 1 SP aprepitant 1 QL

APRISO 3

balsalazide 1 bismuth-metronidazole-tetracycline 1

BONJESTA 3

CHOLBAM 3 SP, PA

dexlansoprazole dr 1 QL dicyclomine capsule, oral solution, tablet doxylamine-pyridoxine 1 QL

ENTYVIO VIAL 4 SP, PA, OC

esomeprazole 20 mg, 40 mg capsule;

packet

1 QL

GASTROINTESTINAL/HEARTBURN (cont.)

Medication Tier Notes famotidine oral suspension; 20 mg, 40 mg tablet

GATTEX 4 SP, PA

gavilyte-c 1 PPACA gavilyte-g 1 PPACA gavilyte-n 1 PPACA hydrocortisone enema, suppository 1

IQIRVO 2 SP, PA

lansoprazole 1 QL

LINZESS 2

LITHOSTAT 2

lubiprostone 1 mesalamine 1 mesalamine dr 1 mesalamine er 1 metoclopramide oral solution, tablet 1

MOTOFEN 3

MOVANTIK 2 PA

NEXIUM DR 2.5 MG, 5 MG PACKET 2 QL

OCALIVA 3 SP, PA

OLPRUVA 3 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

PENTASA 500 MG CAPSULE 3

PHEBURANE 2 SP, PA, QL

prochlorperazine suppository, tablet 1

PROTONIX ORAL SUSPENSION, TABLET 3 QL, ST

rabeprazole tablet 1 QL

RECTIV 3

RELISTOR SYRINGE, VIAL 3 PA

Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters.

GASTROINTESTINAL/HEARTBURN (cont.)

Medication Tier Notes

REZDIFFRA 3 SP, PA, QL

SANCUSO 3 PA, QL

scopolamine 1

SFROWASA 3

sodium sulfate-potassium sulfate-magnesium sulfate

1 PPACA

SUCRAID 3 SP, PA

sucralfate 1

SYMPROIC 2 PA

TRULANCE 2

VARUBI 3 PA, QL

VIBERZI 2

VIOKACE 3

VOQUEZNA TABLET 3 PA, QL

VOWST 3 SP, PA, QL

ZENPEP 2

HORMONAL AGENTS

Medication Tier Notes

ANGELIQ 3

BIJUVA 3

budesonide ec 1 cetrorelix 1 SP, PA, OC

CETROTIDE 2 SP, PA, OC

COMBIPATCH 2

CRINONE 4% GEL 3 PA

CYTOMEL 3

DEPO-TESTOSTERONE 3

desmopressin ampule, vial 1 SP desmopressin nasal solution, 10 mcg/0.1 ml spray, tablet

DUAVEE 2

EGRIFTA SV 4 SP, PA

HORMONAL AGENTS (cont.)

Medication Tier Notes estradiol cream, gel packet, patch, pump, tablet, vaginal insert

1 QL

EVAMIST 3

FENSOLVI 4 SP, PA, OC

fyremadel 1 SP, PA, OC ganirelix 1 SP, PA, OC

GENOTROPIN 4 SP, PA, PPACA

INTRAROSA 3 QL

levoxyl 1 liothyronine tablet 1

LUPRON DEPOT 3.75 MG, 11.25 MG KIT 4 SP, PA, OC

LUPRON DEPOT-PED 4 SP, PA, OC

lyllana 1 QL medroxyprogesterone tablet 1

MENOSTAR 3 QL

methimazole 1 methylprednisolone dosepack, tablet 1 mimvey 1

MYFEMBREE 2 PA, QL

NGENLA 4 SP, PA

norethindrone 5 mg tablet 1

OMNITROPE 4 SP, PA

ORIAHNN 2 PA, QL

ORILISSA 2 PA, QL

OSPHENA 3 QL

prednisolone oral solution, tablet 1 prednisone 1

PREMARIN VAGINAL CREAM, TABLET 2

PREMPHASE 2

PREMPRO 2

progesterone capsule 1

RAYALDEE 3

Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters.

HORMONAL AGENTS (cont.)

Medication Tier Notes

SANDOSTATIN LAR DEPOT 4 SP, PA, OC

SOMATULINE DEPOT 4 SP, PA, OC

SOMAVERT 4 SP, PA

testosterone gel, gel pump, packet 1 PA, QL testosterone cypionate 200 mg/ml, 1,000 mg/10 ml, 2,000 mg/10 ml, 6,000 mg/30 ml thyroid 1 unithroid 3

XYOSTED 3 PA, QL

yuvafem 1 QL

INFECTIONS

Medication Tier Notes acyclovir capsule, oral suspension, tablet albendazole 1 amoxicillin 1 amoxicillin-clavulanate 1

ARIKAYCE 3 SP, PA

atovaquone 1 atovaquone-proguanil 1 azithromycin packet, oral suspension, tablet

BARACLUDE ORAL SOLUTION 2 SP

BAXDELA TABLET 3 PA

BEYFORTUS 3 PPACA

CAYSTON 3 SP, PA, QL

cefdinir 1 cefpodoxime 1 cefuroxime axetil 1 cephalexin 1

CIPRO ORAL SUSPENSION 2

ciprofloxacin oral suspension, tablet 1

INFECTIONS (cont.)

Medication Tier Notes clindamycin capsule, oral solution, vaginal cream

CRESEMBA CAPSULE 3 PA

crotan 1

DIFICID 3 QL

doxycycline monohydrate 1

EMVERM 1

entecavir 1 SP, QL

EPCLUSA 2 SP, PA, QL

erythromycin capsule, oral suspension, tablet famciclovir 1 fluconazole oral suspension, tablet 1 flucytosine 1 fosfomycin 1

HARVONI 2 SP, PA, QL

hydroxychloroquine 1

IMPAVIDO 3 PA

itraconazole 1

KITABIS PAK 3 SP, PA, QL

LAGEVRIO (EUA) 2 QL

levofloxacin oral solution, tablet 1

LIKMEZ 3 PA

LIVTENCITY 3 SP, PA, QL

MACROBID 3

methenamine 1 metronidazole capsule, tablet, vaginal gel minocycline 1 mondoxyne nl 1 morgidox capsule 1 nitazoxanide 1 nitrofurantoin capsule; 25 mg/5 ml oral suspension

Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters.

INFECTIONS (cont.)

Medication Tier Notes

NUZYRA 150 MG TABLET 3 SP, PA, QL

nystatin oral suspension, tablet 1 oseltamivir 1 QL

PAXLOVID 2 QL

PEGASYS 4 SP, PA

penicillin v potassium 1 posaconazole oral suspension, tablet 1

PREVYMIS PELLET PACKET, TABLET 3 SP

PRIFTIN 3

pyrimethamine 1 SP, PA

SIVEXTRO TABLET 3 PA

sulfamethoxazole-tmp oral suspension, tablet terbinafine tablet 1

TOBI PODHALER 2 SP, PA, QL

tobramycin ampule 1 SP, PA, QL valacyclovir 1 valganciclovir 1

VALTREX 3

vancomycin capsule, oral solution 1 vandazole 1

VEMLIDY 2 SP

VIVJOA 3 SP, PA

VOSEVI 2 SP, PA, QL

XENLETA TABLET 3 PA, QL

XIFAXAN 2 QL

XOFLUZA 3 QL

ZEPATIER 2 SP, PA, QL

ZITHROMAX TRI-PAK 3

ZYVOX ORAL SUSPENSION, TABLET 3 PA

INFERTILITY

Medication Tier Notes clomiphene 1 OC

CRINONE 8% GEL 2 OC

INFERTILITY (cont.)

Medication Tier Notes

ENDOMETRIN 2 OC

FOLLISTIM AQ 3 SP, PA, OC

GONAL-F 2 SP, PA, OC

GONAL-F RFF 2 SP, PA, OC

GONAL-F RFF REDI-JECT 2 SP, PA, OC

MENOPUR 2 SP, PA, OC

NOVAREL 2 SP, PA, OC

OVIDREL 2 SP, PA, OC

PREGNYL 2 SP, PA, OC

MISCELLANEOUS

Medication Tier Notes acamprosate 1

ACCU-CHEK FASTCLIX LANCET DRUM 1

ADDYI 3 PA, QL, OC

AUSTEDO 3 SP, PA

AUSTEDO XR 3 SP, PA, QL

AUSTEDO XR TITRATION KIT 3 SP, PA, QL

CARBAGLU 3 SP

CERDELGA 2 SP, PA

cinacalcet 1 SP

CINRYZE 4 SP, PA, OC

deferasirox 1 SP deferiprone 1 SP, PA

DROPLET LANCET 1

EVRYSDI ORAL SOLUTION 3 SP, PA

GALAFOLD 3 SP, PA

HAEGARDA 4 SP, PA

INGREZZA CAPSULE, INITIATION PACK,

SPRINKLE CAPSULE

3 SP, PA, QL

MYALEPT 4 SP, PA

NITYR 2 SP, PA

NUEDEXTA 3 QL

ONETOUCH DELICA PLUS LANCET 1

ONETOUCH ULTRASOFT 2 LANCET 1

Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters.

MISCELLANEOUS (cont.)

Medication Tier Notes

ORFADIN 3 SP, PA

PALYNZIQ 4 SP, PA

PRECISION XTR B-KETONE STRIP 1

RADICAVA ORS 3 SP, PA, QL

RUCONEST 4 SP, PA, OC

sapropterin 1 SP, PA sodium chloride 1

SPACE CHAMBER-LARGE MASK 2 QL

STRENSIQ 4 SP, PA

TECHLITE LANCET 1

TEGLUTIK 3 SP, PA

TEGSEDI 4 SP, PA

TIGLUTIK 3 SP, PA

TRUEPLUS KETONE TEST STRIP 1

VEOZAH 3 QL

VORTEX HOLDING CHAMBER 2 QL

VORTEX VHC MASK 2 QL

VOXZOGO 4 SP, PA

VYLEESI 3 SP, PA, QL, OC

VYNDAMAX 3 SP, PA, QL

VYNDAQEL 3 SP, PA, QL

MULTIPLE SCLEROSIS

Medication Tier Notes

AVONEX 4 SP, PA

BAFIERTAM 2 SP, PA

BETASERON 4 SP, PA

dalfampridine er 1 SP, PA dimethyl 1 SP fingolimod 1 SP

FIRDAPSE 3 SP, PA, QL

glatopa 4 SP

KESIMPTA PEN 4 SP, PA

MAVENCLAD 3 SP, PA

MULTIPLE SCLEROSIS (cont.)

Medication Tier Notes

MAYZENT 2 SP, PA

PLEGRIDY 4 SP, PA

REBIF 4 SP, PA

REBIF REBIDOSE 4 SP, PA

teriflunomide 1 SP

VUMERITY 2 SP, PA

NUTRITIONAL/DIETARY

Medication Tier Notes

ACCRUFER 3 OC

AURYXIA 3 QL

calcitriol capsule, oral solution 1 OC cyanocobalamin 1

CYSTADANE 3 SP

dodex 1

EFFER-K 10 MEQ, 20 MEQ TABLET 3

FLORIVA CHEWABLE TABLET 2 PPACA

fluoride 1 PPACA, OC folic acid 1 mg tablet 1 OC lanthanum 1

LOKELMA 2

ludent fluoride 1 PPACA, OC mvc-fluoride 2 PPACA

NEEVODHA 2 OC

OB COMPLETE CAPLET 3 OC

OB COMPLETE DHA, ONE, PETITE,

PREMIER

POLY-VI-FLOR 2 PPACA

POLY-VI-FLOR WITH IRON CHEWABLE

TABLET

2 PPACA

potassium chloride oral solution, packet

PRENATE CHEWABLE, ESSENTIAL 2 OC

PRENATE DHA, ELITE, ENHANCE, MINI,

PIXIE, RESTORE, STAR

Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters.

NUTRITIONAL/DIETARY (cont.)

Medication Tier Notes

PRIMACARE 2

QUFLORA PEDIATRIC DROPS, 1 MG

CHEWABLE TABLET

2 PPACA

sevelamer 1 sodium fluoride chewable tablet, drops

1 PPACA, OC

soluvita 0.5 mg/ ml drops 1 PPACA, OC tri-vitamin with fluoride 1 PPACA

VELPHORO 2

VELTASSA 2

VITAFOL CAPLET, GUMMIES, NANO,

OB+DHA, ULTRA

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 600 mcg/2.4 ml pen 1 SP, PA, QL

PAIN RELIEF AND INFLAMMATORY DISEASE

Medication Tier Notes acetaminophen-codeine 1 PA

ACTEMRA ACTPEN, SYRINGE 4 SP, PA, QL

ADALIMUMAB-ADAZ(CF) 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

BELBUCA 2 QL

BENLYSTA AUTO-INJECTOR, SYRINGE 4 SP, PA

BIMZELX 4 SP, PA, QL

PAIN RELIEF AND INFLAMMATORY DISEASE (cont.)

Medication Tier Notes buprenorphine patch 1 QL butalbital-acetaminophen-caffeine 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 1 PA

FLECTOR 2 PA, QL

GRALISE ER 300 MG, 600 MG TABLET 3

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; 400 mg, 600 mg, 800 mg tablet

ILARIS 4 SP, PA, OC

ILUMYA 4 SP, PA, QL

indomethacin 25 mg, 50 mg capsule;

oral suspension, 50 mg susppository

INFLECTRA 4 SP, PA, OC

INFLIXIMAB 4 SP, PA, OC

JOURNAVX 3 QL

ketorolac syringe, tablet, vial 1 QL

KEVZARA 4 SP, PA, QL

KINERET 4 SP, PA, QL

Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters.

PAIN RELIEF AND INFLAMMATORY DISEASE (cont.)

Medication Tier Notes leflunomide 1

LICART 2 PA, QL

lidocaine viscous 1 lidocaine-prilocaine 1 meloxicam tablet 1

MITIGARE 2

morphine er 1 PA

NUCYNTA 2 PA

NUCYNTA ER 3 PA

NURTEC ODT 2 PA, QL

OLUMIANT 3 SP, PA, QL

OMVOH PEN, SYRINGE 4 SP, PA, QL

ORENCIA CLICKJECT, SYRINGE 4 SP, PA, QL

OTEZLA 2 SP, PA, QL

OXAYDO 3 PA

oxycodone 1 PA

PROCTOFOAM-HC 2

prolate tablet 1 PA

QULIPTA 2 PA, QL

RASUVO 2 ST

REMICADE 4 SP, PA, OC

REYVOW 3 PA, QL

RINVOQ 2 SP, PA, QL

RINVOQ LQ 2 SP, PA, QL

rizatriptan 1 QL

ROXYBOND 3 PA

SAVELLA 2

SELSARSDI SYRINGE 4 SP, PA, QL

SILIQ 4 SP, PA, QL

SIMLANDI(CF) 4 SP, PA, QL

SIMPONI 50 MG/0.5 ML PEN INJECTOR,

SYRINGE

4 SP, PA, QL

SIMPONI 100 MG/ML PEN INJECTOR,

SYRINGE

4 SP, PA, QL

SIMPONI ARIA 4 SP, PA

PAIN RELIEF AND INFLAMMATORY DISEASE (cont.)

Medication Tier Notes

SKYRIZI, ON-BODY, PEN, SYRINGE 4 SP, PA, QL

SOTYKTU 2 SP, PA, QL

STELARA 45 MG/0.5 ML SYRINGE, VIAL;

90 MG/ML SYRINGE

4 SP, PA, QL

sumatriptan 1 QL

TALTZ 4 SP, PA, QL

tanlor 1 tramadol 50 mg, 100 mg tablet 1 QL

TREMFYA AUTO-INJECTOR, PEN,

SYRINGE

4 SP, PA, QL

TYENNE AUTO-INJECTOR, SYRINGE 4 SP, PA, QL

UBRELVY 2 PA, QL

vanadom 1

VELSIPITY 2 SP, PA, QL

XELJANZ 2 SP, PA, QL

XELJANZ XR 2 SP, PA, QL

XTAMPZA ER 2 PA

YESINTEK SYRINGE, 45 MG/0.5 ML VIAL 4 SP, PA, QL

ZEPOSIA 2 SP, PA

ZTLIDO 2

PARKINSON’S DISEASE

Medication Tier Notes

APOKYN 4 SP, PA

benztropine tablet 1 carbidopa-levodopa 1

CREXONT 3 ST

DUOPA 3 SP

INBRIJA 3 SP, PA

NEUPRO 3

NOURIANZ 3 SP, PA, QL

pramipexole 1 QL ropinirole 1

RYTARY 3 ST

XADAGO 3 ST

Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters.

SCHIZOPHRENIA/ANTI-PSYCHOTICS

Medication Tier Notes aripiprazole 1 QL asenapine 1

CAPLYTA 3 QL

chlorpromazine oral concentrate, tablet lurasidone 1 QL

LYBALVI 3 QL

olanzapine tablet 1 paliperidone er 1 QL quetiapine 25 mg, 50 mg, 100 mg, 200 mg, 300 mg, 400 mg tablet quetiapine er 1

REXULTI 3 QL

risperidone 1

SECUADO 3 ST

SEROQUEL 3 ST

VRAYLAR 3 QL

ziprasidone capsule 1

SEIZURE DISORDERS

Medication Tier Notes

APTIOM 3 PA, QL

BRIVIACT ORAL SOLUTION, TABLET 3 PA

carbamazepine er 1 clonazepam 1

DILANTIN 30 MG CAPSULE 2 PA

DILANTIN 100 MG CAPSULE, INFATAB,

ORAL SUSPENSION

3 PA

divalproex 1 divalproex er 1

EPIDIOLEX 3 SP, PA

FINTEPLA 3 SP, PA

FYCOMPA 2 PA, QL

gabapentin 1

KLONOPIN 3 PA

lacosamide oral solution, tablet 1

SEIZURE DISORDERS (cont.)

Medication Tier Notes lamotrigine er 1 lamotrigine odt 1 levetiracetam er 1

LYRICA ORAL SOLUTION 3 PA

NAYZILAM 2 PA, QL

ONFI 3 PA

oxcarbazepine 1

OXTELLAR XR 3 PA

PHENYTEK 3 PA

pregabalin 1 roweepra 1

SPRITAM 3 PA

subvenite 1

TEGRETOL XR 3 PA

topiramate 15 mg, 25 mg sprinkle capsule; tablet topiramate er 1 QL

VALTOCO 3 PA, QL

vigpoder 1 SP

VIMPAT ORAL SOLUTION 2

XCOPRI 3 PA, QL

SKIN CONDITIONS

Medication Tier Notes

ABSORICA 3

adapalene-benzoyl peroxide 1

ADBRY AUTO-INJECTOR, SYRINGE 4 SP, PA

azelaic acid 1

BRYHALI 3 ST

CAPEX SHAMPOO 3 ST

CIBINQO 2 SP, PA, QL

clindamycin foam, gel, lotion, pledget, topical solution clobetasol cream, foam, gel, lotion, ointment, shampoo, topical solution, spray

Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters.

SKIN CONDITIONS (cont.)

Medication Tier Notes clotrimazole-betamethasone 1 dapsone gel, gel pump 1

DROPSAFE PREP PAD 1

DRYSOL 2

EBGLYSS 4 SP, PA

EUCRISA 2 ST

fluorouracil 5% cream, topical solution 1 halobetasol 1 isotretinoin 1 ketoconazole cream, foam, shampoo 1

LITFULO 3 SP, PA, QL

mupirocin 2% ointment 1

NAFTIN 2

NEMLUVIO 4 SP, PA

neuac gel 1

OPZELURA 3 PA

pimecrolimus 1

PRAMOSONE 1%-1% CREAM,

OINTMENT; 1% LOTION; 2.5%-1%

OINTMENT

QBREXZA 3 PA

REGRANEX 3 PA, QL

rosadan cream, gel 1

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

SOOLANTRA 3

sulfacleanse 8-4 1 tacrolimus ointment 1 tazarotene cream, gel 1 tretinoin cream, gel 1 PA, AGE triderm 1

TWYNEO 3

VECTICAL 3 QL

SKIN CONDITIONS (cont.)

Medication Tier Notes

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 3 SP, PA, QL

modafinil 1 PA

SODIUM OXYBATE (by Hikma) 3 SP, PA, QL

SUNOSI 2 PA, QL

temazepam 1

WAKIX 3 SP, PA, QL

XYWAV 3 SP, PA, QL

zolpidem sublingual tablet, tablet 1 zolpidem er 1 QL

SMOKING CESSATION

Medication Tier Notes

APO-VARENICLINE 3 OC

bupropion sr 150 mg tablet 1 PPACA, OC

NICOTROL NS 2 PPACA, OC

varenicline 1 PPACA, OC

SUBSTANCE ABUSE

Medication Tier Notes buprenorphine-naloxone 1

KLOXXADO 2 QL

LUCEMYRA 2 QL

naltrexone 1 QL

NARCAN 2 QL

OPVEE 3 QL

SUBOXONE 3

ZIMHI 3 QL

ZUBSOLV 2

Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters.

TRANSPLANT MEDICATIONS

Medication Tier Notes

ENVARSUS XR 3 SP

everolimus 0.25 mg, 0.5 mg, 0.75 mg, 1 mg tablet

1 SP

LUPKYNIS 3 SP, PA, QL

mycophenolate capsule, oral suspension, tablet

1 SP

mycophenolic acid 1 SP

REZUROCK 3 SP, PA

sirolimus 1 SP tacrolimus capsule 1 SP

URINARY TRACT CONDITIONS

Medication Tier Notes alfuzosin er 1 cevimeline 1 dutasteride 1

ELMIRON 2

finasteride 5 mg tablet 1

K-PHOS NO.2 2

K-PHOS ORIGINAL 2

mirabegron er 1 QL oxybutynin er 1 phenazopyridine 100 mg, 200 mg tablet potassium er 1

RAPAFLO 3 QL

solifenacin 1 QL tamsulosin 1 tolterodine er 1 QL trospium er 1

VACCINES

Not all plans cover vaccines in the same way. Log in to the myCigna App or myCigna.com, or check your plan materials, to see how your plan covers them.

Medication Tier Notes

ABRYSVO 3 PPACA

ACTHIB 2 PPACA

ADACEL TDAP 2 PPACA

AFLURIA 2 PPACA

AREXVY 3 PPACA

BEXSERO 2 PPACA

BOOSTRIX TDAP 2 PPACA

CAPVAXIVE 2 PPACA

COMIRNATY 2 PPACA

DAPTACEL DTAP 2 PPACA

DENGVAXIA 2 PPACA

ENGERIX-B 2 PPACA

FLUAD 2 PPACA

FLUARIX 2 PPACA

FLUBLOK 2 PPACA

FLUCELVAX 2 PPACA

FLULAVAL 2 PPACA

FLUMIST 3 PPACA

FLUZONE 2 PPACA

FLUZONE HIGH-DOSE 2 PPACA

GARDASIL 9 2 PPACA

HEPLISAV-B 2 PPACA

HIBERIX 2 PPACA

INFANRIX DTAP 2 PPACA

IPOL 2 PPACA

KINRIX 2 PPACA

MENQUADFI 2 PPACA

Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters.

VACCINES (cont.)

Not all plans cover vaccines in the same way. Log in to the myCigna App or myCigna.com, or check your plan materials, to see how your plan covers them.

Medication Tier Notes

MENVEO A-C-Y-W-135-DIP 2 PPACA

M-M-R II VACCINE 2 PPACA

MODERNA COVID 2 PPACA

MRESVIA 3 PPACA

NOVAVAX COVID 2 PPACA

PEDIARIX 2 PPACA

PEDVAXHIB 2 PPACA

PENBRAYA 2 PPACA

PENTACEL 2 PPACA

PFIZER COVID 2 PPACA

PNEUMOVAX 23 2 PPACA

PREVNAR 20 2 PPACA

PRIORIX 2 PPACA

PROQUAD 2 PPACA

QUADRACEL DTAP-IPV 2 PPACA

RECOMBIVAX HB 2 PPACA

ROTARIX 3 PPACA

ROTATEQ 3 PPACA

SHINGRIX 2 QL, PPACA

SPIKEVAX 2 PPACA

TDVAX 2 PPACA

TENIVAC 2 PPACA

TRUMENBA 2 PPACA

TWINRIX 2 PPACA

VARIVAX 2 PPACA

VAXELIS 2 PPACA

VAXNEUVANCE 2 PPACA

VITAMINS

Medication Tier Notes

CITRANATAL MEDLEY 3 OC

POLY-VI-FLOR 2 PPACA

POLY-VI-FLOR WITH IRON CHEWABLE

TABLET

2 PPACA

WEIGHT MANAGEMENT

Medication Tier Notes

CONTRAVE 3 PA, OC

IMCIVREE 3 SP, PA, QL, OC

phentermine 1 OC

QSYMIA 3 PA, OC

SAXENDA 2 PA, OC

WEGOVY 2 PA, QL, OC

ZEPBOUND PEN 2 PA, QL, OC

Frequently Asked Questions (FAQs) Here are answers to questions you may have about your drug list and prescription medication coverage.

Q. Why do you make changes to the drug list?

A. We review and update the drug list on a regular basis to make sure you have coverage for low-cost, safe and effective medications. We make changes for many reasons; for example, when a new medication comes out or is no longer available, or when a medication’s price changes. These changes may include:

• Moving a medication to a lower cost tier. This can happen at any time during the year.

• Moving a brand medication to a higher cost tier when a generic comes out. This can happen at any time during the year.

• Moving a medication to a higher cost tier and/ or no longer covering a medication. This usually happens twice a year on January 1 and July 1.

• Adding extra coverage requirements to a medication. This usually happens twice a year on January 1 and July 1.

When we make a change that affects your medication (for example, it’ll cost more, won’t be covered, and/or has an extra coverage requirement), we let you know before it happens. This way, you have time to talk with your doctor about your options.

Only you and your doctor can decide what’s best for your treatment.

Q. Why doesn’t my plan cover certain medications?

A. To help lower your overall health care costs, your plan doesn’t cover certain high-cost brand-name medications that have lower-cost alternatives that can treat the same condition. If your medication isn’t covered and your doctor feels a different medication isn’t right for you, your doctor’s office can ask us to cover it through our review process.

There are some medications and products that your plan won't cover for any reason because they’re a “plan (or benefit) exclusion.” This means the medication or product isn’t on your drug list, and there’s no option to ask us to cover it through our review process. For example, your plan doesn’t cover (or “excludes”) medications that the U.S. Food and Drug Administration (FDA) hasn’t approved.

Q. How do you decide which medications to cover?

A. The Cigna Healthcare Prescription Drug List is developed with the help of the Cigna Healthcare Pharmacy and Therapeutics (P&T) Committee, which is a group of practicing doctors and…