Exhibit 57a - Cal Yr 2025 City of Miami CIGNA Rx - Standard 3-Tier Prescription Drug List.pdf

Offered by: Cigna Health and Life Insurance Company or its affiliates.

595200 v Standard 3-Tier 02/2025 © 2025 Cigna Healthcare.

Cigna Healthcare Standard 3-Tier Prescription Drug List Coverage as of January 1, 2025

EXHIBIT 57a

* Drug list originally created: 01/01/2004 Last updated: 02/01/2025, for changes starting 01/01/2025

Next planned update: 03/01/2025, for changes starting 07/01/2025

What's Inside? Page

About this drug list 3

How to read this drug list 3

View your drug list online

• Cigna.com/druglist. Standard 3 Tier

• myCigna® App1 or myCigna.com®.

Questions?

• By phone:

• myCigna.com:

BLOOD PRESSURE/HEART MEDICATIONS

Medication Tier Notes amlodipine 1 amlodipine-valsartan 1 atenolol 1

AVAPRO 3 ST

BIDIL 3 QL

CARDIZEM LA 3 QL

cartia xt 1 carvedilol 1 carvedilol er 1 QL clonidine 1

CORLANOR 5MG/5ML ORAL SOLUTION 2 SP, PA

COZAAR 3 ST

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 dilt xr 1

DIOVAN 3 ST

DIOVAN HCT 3 ST

ENTRESTO 2 QL

flecainide 1

HYZAAR 3 ST

irbesartan 1 labetalol tablet 1 lisinopril 1

* This chart is just a sample. It may not show how these medications are actually covered on the Cigna Healthcare Standard 3-Tier Prescription Drug List.

About this drug list myCigna App or myCigna.com

How to read this drug list condition abbreviation alphabetical all capital letters lowercase letters

Tier

PA

Prior Authorization* –

QL

Quantity Limit* –

ST

Step Therapy* –

AGE

Age Requirement* –

SP

This is a specialty medication

Brand-name medications are in all capital letters

Tiers

Abbreviations next to medications

* These coverage requirements may not apply to your specific plan. Log in to the myCigna App or myCigna.com, or check your plan materials, to find out if your plan includes prior authorization, quantity limits, Step Therapy and/or age requirements.

Tier 1 Generic Medications.

These medications are covered at your plan’s lowest cost-share.

Tier 2 Preferred Brand Medications. $$

Tier 3 Non-Preferred Brand Medications. $$$

Letters (acronyms) in the Notes column letters (acronyms)

Condition Page

DIABETES

DIURETICS

Condition Page

PPACA

requires

OC

OC

myCigna App or myCigna.com

Letters (acronyms) in the Notes column cont.

Cigna Healthcare Standard 3-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 AGE – Age Requirement OC – Optional Coverage

Tier 2 – Preferred Brands QL – Quantity Limit SP – Specialty Medication

Tier 3 – Non-Preferred Brands ST – Step Therapy PPACA – No Cost-Share Preventive Medication

AIDS/HIV

Medication Tier Notes abacavir-lamivudine 1 SP, PA

APRETUDE 3 SP, PA, PPACA

BIKTARVY 2 SP, QL

CABENUVA 3 SP, PA, OC

CIMDUO 3 SP, PA

DESCOVY 200-25 MG TABLET SP, PPACA

DOVATO 2 SP, QL

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

GENVOYA 2 SP, QL

ISENTRESS 2 SP

ISENTRESS HD 2 SP, PA

JULUCA 2 SP, QL

ODEFSEY 3 SP, PA, QL

PREZCOBIX 3 SP, PA

PREZISTA 100 MG/ML SUSPENSION, 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

TIVICAY PD 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, spray

1 QL

fluticasone spray 1

GASTROCROM 3

GRASTEK 3 PA, QL

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

ODACTRA 3 PA, QL

olopatadine spray 1

ORALAIR 3 PA, QL

PATANASE 3

RAGWITEK 3 PA, QL

VISTARIL 3

ALZHEIMER’S DISEASE

Medication Tier Notes

ADLARITY 2 PA, QL

ARICEPT 3

donepezil 1 donepezil odt 1

EXELON

memantine 1 memantine er 1 QL

NAMENDA 5-10 MG TITRATION PACK 2

NAMENDA XR 3 QL

NAMZARIC 3 QL

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

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

Tier 1 – Generics PA – Prior Authorization AGE – Age Requirement OC – Optional Coverage

Tier 2 – Preferred Brands QL – Quantity Limit SP – Specialty Medication

Tier 3 – Non-Preferred Brands ST – Step Therapy PPACA – No Cost-Share Preventive Medication

ANXIETY/DEPRESSION/BIPOLAR DISORDER2

Medication Tier Notes alprazolam 1 alprazolam er 1 alprazolam intensol 1 alprazolam odt 1 alprazolam xr 1 amitriptyline 1 bupropion 1 QL bupropion sr 1 QL bupropion xl 150 mg, 300 mg tablet 1 QL buspirone 1 citalopram solution, tablet 1 QL clomipramine 1 desvenlafaxine er 25 mg, 50 mg, 100 mg tablet

1 QL

duloxetine 1 QL

EMSAM 3 QL

escitalopram 1 QL

FETZIMA 3 QL, ST

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

NUPLAZID 3 SP, PA

paroxetine 1 QL paroxetine cr 1 QL paroxetine er 1 QL sertraline oral concentrate, tablet 1 QL

SPRAVATO 3 SP, PA

trazodone 1

TRINTELLIX 2 QL

ANXIETY/DEPRESSION/BIPOLAR DISORDER cont. 2

Medication Tier Notes venlafaxine 1 QL venlafaxine er 1 QL

ZURZUVAE 3 SP, PA, QL

ASTHMA/COPD/RESPIRATORY

Medication Tier Notes

ADEMPAS 2 SP, PA

ADVAIR HFA 2 QL

AIRDUO DIGIHALER 3 QL, ST

AIRSUPRA 2 QL

albuterol 1 albuterol hfa 90 mcg inhaler 1 QL

ALVESCO 2

ambrisentan 1 SP, PA

ANORO ELLIPTA 2 QL

ASMANEX, ASMANEX HFA 2 QL

ATROVENT HFA 2 QL

BREO ELLIPTA 2 QL

breyna 1 QL

BREZTRI AEROSPHERE 2 QL

BRONCHITOL 3 SP, PA

budesonide inhalation suspension 1 QL budesonide-formoterol 1 QL

COMBIVENT RESPIMAT 2 QL

DULERA 2 QL

FASENRA PEN 2 SP, PA

fluticasone-salmeterol 100-50, 250-50, 500-50

1 QL

INCRUSE ELLIPTA 2

KALYDECO 3 SP, PA, QL

LETAIRIS 3 SP, PA

montelukast 1

NUCALA AUTO-INJECTOR, SYRINGE 2 SP, PA

OFEV 2 SP, PA

OPSUMIT 2 SP, PA

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

Tier 1 – Generics PA – Prior Authorization AGE – Age Requirement OC – Optional Coverage

Tier 2 – Preferred Brands QL – Quantity Limit SP – Specialty Medication

Tier 3 – Non-Preferred Brands ST – Step Therapy PPACA – No Cost-Share Preventive Medication

ASTHMA/COPD/RESPIRATORY cont.

Medication Tier Notes

OPSYNVI 2 SP, PA, QL

ORENITRAM ER 3 SP, PA

ORENITRAM TITRATION KIT 3 SP, PA, QL

PULMICORT 3 QL

PULMOZYME 2 SP, PA

QVAR REDIHALER 2

SINGULAIR 3

SPIRIVA HANDIHALER 2 QL

SPIRIVA RESPIMAT 2 QL

STIOLTO RESPIMAT 2 QL

STRIVERDI RESPIMAT 2 QL

SYMDEKO 3 SP, PA, QL

TEZSPIRE 210 MG/1.91 ML PEN 2 SP, PA, QL

TEZSPIRE 210 MG/1.91 ML SYRINGE 2 SP, PA

TRACLEER 32 MG TABLET FOR

SUSPENSION

2 SP, PA

TRELEGY ELLIPTA 2 QL

TRIKAFTA 3 SP, PA, QL

TYVASO DPI 2 SP, PA

TYVASO SOLUTION, KIT 3 SP, PA

UPTRAVI TABLET, TITRATION PACK 2 SP, PA

VIJOICE 3 SP, PA, QL

wixela inhub 1 QL

XOLAIR 2 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 1 PA dexmethylphenidate er 1 PA, QL dextroamphetamine-amphetamine 1 PA

ATTENTION DEFICIT HYPERACTIVITY DISORDER cont. 2

Medication Tier Notes dextroamphetamine-amphetamine er 1 PA, QL

DYANAVEL XR 3 PA, QL

EVEKEO ODT 3 PA

FOCALIN 3 PA, ST

guanfacine er 1

METHYLIN 3 PA

methylphenidate chewable tablet, solution, tablet

1 PA

methylphenidate cd 1 PA, QL methylphenidate er (cd) 1 PA, QL methylphenidate er (la) 1 PA, QL methylphenidate er 10 mg, 18 mg, 20 mg, 27 mg, 36 mg, 54 mg tablet

1 PA, QL

methylphenidate er capsule 1 PA, QL methylphenidate la 1 PA, QL

MYDAYIS 3 PA, QL

QUILLICHEW ER 3 PA, QL

QUILLIVANT XR 3 PA, QL

RITALIN 3 PA, ST

VYVANSE 3 PA, QL

XELSTRYM 3 PA, QL

BLOOD MODIFIERS/BLEEDING DISORDERS

Medication Tier Notes

ADVATE 3 SP, PA, OC

ADYNOVATE 2 SP, PA, OC

AFSTYLA 2 SP, PA, OC

ALPHANATE 3 SP, PA, OC

ALTUVIIIO 2 SP, PA, OC

aminocaproic acid solution, tablet 1 SP

ARANESP 2 SP, PA, OC

DOPTELET 2 SP, PA

ELOCTATE 2 SP, PA, OC

EMPAVELI 2 SP, PA

EPOGEN 2 SP, PA, OC

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

Tier 1 – Generics PA – Prior Authorization AGE – Age Requirement OC – Optional Coverage

Tier 2 – Preferred Brands QL – Quantity Limit SP – Specialty Medication

Tier 3 – Non-Preferred Brands ST – Step Therapy PPACA – No Cost-Share Preventive Medication

BLOOD MODIFIERS/BLEEDING DISORDERS cont.

Medication Tier Notes

ESPEROCT 2 SP, PA, OC

FABHALTA 2 SP, PA, QL

FULPHILA 3 SP, PA

GRANIX 3 SP, PA

HEMLIBRA 3 SP, PA

HUMATE-P 3 SP, PA, OC

JIVI 2 SP, PA, OC

KOGENATE FS 2 SP, PA, OC

KOVALTRY 2 SP, PA, OC

NEULASTA 2 SP, PA

NEULASTA ONPRO 2 SP, PA, OC

NIVESTYM 2 SP

NOVOEIGHT 2 SP, PA, OC

NYVEPRIA 2 SP, PA

PROCRIT 2 SP, PA, OC

PROMACTA 2 SP, PA

RETACRIT 2 SP, PA, OC

STIMUFEND 3 SP, PA

TAVALISSE 2 SP, PA

tranexamic acid 650 mg tablet 1 SP

UDENYCA AUTO-INJECTOR, SYRINGE 2 SP, PA

UDENYCA ONBODY 2 SP, PA, OC

VOYDEYA 2 SP, PA, QL

WILATE 3 SP, PA, OC

XYNTHA 3 SP, PA, OC

XYNTHA SOLOFUSE 3 SP, PA, OC

ZARXIO 2 SP

ZIEXTENZO 3 SP, PA

BLOOD PRESSURE/HEART MEDICATIONS

Medication Tier Notes amlodipine 1 amlodipine-benazepril 1 amlodipine-olmesartan 1 QL amlodipine-valsartan 1

BLOOD PRESSURE/HEART MEDICATIONS cont.

Medication Tier Notes 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

dofetilide 1 QL droxidopa 1 SP

ENTRESTO 2 QL

flecainide 1 guanfacine 1 hydralazine tablet 1

HYZAAR 3 ST

icatibant 1 SP, PA irbesartan 1 labetalol tablet 1 lisinopril 1 lisinopril-hctz 1

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

Tier 1 – Generics PA – Prior Authorization AGE – Age Requirement OC – Optional Coverage

Tier 2 – Preferred Brands QL – Quantity Limit SP – Specialty Medication

Tier 3 – Non-Preferred Brands ST – Step Therapy PPACA – No Cost-Share Preventive Medication

BLOOD PRESSURE/HEART MEDICATIONS cont.

Medication Tier Notes losartan 1 losartan-hctz 1 matzim la 1 metoprolol er 1 metoprolol tablet 1 metyrosine 1 PA

MICARDIS 3 QL, ST

MICARDIS HCT 3 QL, ST

MINIPRESS 3

minoxidil tablet 1

MULTAQ 2

nadolol 1 nebivolol 1 QL nifedipine 1 nifedipine er 1

NITROSTAT 3

NORLIQVA 2 PA, QL

NORVASC 3

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

ORLADEYO 3 SP, PA, QL

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

TAKHZYRO 3 SP, PA

taztia xt 1

TEKTURNA HCT 2

telmisartan 1 QL telmisartan-hctz 1 QL tiadylt er 1

BLOOD PRESSURE/HEART MEDICATIONS cont.

Medication Tier Notes

TIAZAC 3

TIKOSYN 3 PA, QL

VALSARTAN SOLUTION 3 ST

valsartan tablet 1 valsartan-hctz 1 verapamil er 1 verapamil er pm 1 verapamil sr 1 verapamil tablet 1

VERELAN 3

VERELAN PM 3

VERQUVO 2 PA, QL

ZESTORETIC 3 ST

Medication Tier Notes

ARIXTRA 3 SP, QL

BRILINTA 2

clopidogrel 1

ELIQUIS 2 PA

enoxaparin 1 SP, QL fondaparinux 1 SP, QL

FRAGMIN 2 SP, QL

jantoven 1

LOVENOX 3 SP, QL

PLAVIX 3

prasugrel 1 warfarin 1

XARELTO 2 PA

ZONTIVITY 3

CANCER

Medication Tier Notes abiraterone 1 SP, PA

AKEEGA 3 SP, PA, QL

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

Tier 1 – Generics PA – Prior Authorization AGE – Age Requirement OC – Optional Coverage

Tier 2 – Preferred Brands QL – Quantity Limit SP – Specialty Medication

Tier 3 – Non-Preferred Brands ST – Step Therapy PPACA – No Cost-Share Preventive Medication

CANCER cont.

Medication Tier Notes

ALECENSA 2 SP, PA, QL

anastrozole 1 PPACA

ARIMIDEX 3

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

COTELLIC 2 SP, PA

ERIVEDGE 2 SP, PA

ERLEADA 2 SP, PA

everolimus 2.5 mg, 5 mg, 7.5 mg, 10 mg tablet, tablet for suspension

1 SP, PA, QL

exemestane 1 PPACA

EXKIVITY 3 SP, PA

GAVRETO 3 SP, PA, QL

GLEOSTINE 2

hydroxyurea 1

IBRANCE 3 SP, PA, QL

imatinib 1 SP, QL

IMBRUVICA 2 SP, PA, QL

INLYTA 3 SP, PA

JAKAFI 3 SP, PA, QL

JYLAMVO 3

KISQALI 2 SP, PA, QL

KISQALI FEMARA CO-PACK 2 SP, PA, QL

lenalidomide 1 SP, PA, QL

LENVIMA 2 SP, PA

letrozole 1

LONSURF 3 SP, PA

LORBRENA 3 SP, PA, QL

LUMAKRAS 3 SP, PA, QL

CANCER cont.

Medication Tier Notes

LUPRON DEPOT 7.5 MG KIT, 22.5 MG

3 MONTH KIT, 45 MG 6 MONTH KIT, 4

MONTH KIT

3 SP, PA, OC

LYNPARZA 2 SP, PA, QL

MEKINIST 2 SP, PA, QL

mercaptopurine 1 methotrexate 2.5 mg 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

NUBEQA 2 SP, PA

ODOMZO 2 SP, PA

ORGOVYX 3 SP, PA

PHESGO 3 SP, PA, OC

PIQRAY 2 SP, PA

POMALYST 2 SP, PA, QL

RETEVMO 3 SP, PA, QL

REVLIMID 2 SP, PA, QL

ROZLYTREK 3 SP, PA

RUBRACA 2 SP, PA, QL

SCEMBLIX 2 SP, PA, QL

STIVARGA 2 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

TREXALL 2

TUKYSA 3 SP, PA

VENCLEXTA STARTING PACK, TABLET 2 SP, PA

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

Tier 1 – Generics PA – Prior Authorization AGE – Age Requirement OC – Optional Coverage

Tier 2 – Preferred Brands QL – Quantity Limit SP – Specialty Medication

Tier 3 – Non-Preferred Brands ST – Step Therapy PPACA – No Cost-Share Preventive Medication

CANCER cont.

Medication Tier Notes

VERZENIO 2 SP, PA, QL

VITRAKVI 3 SP, PA

VIZIMPRO 3 SP, PA

WELIREG 3 SP, PA, QL

XALKORI 3 SP, PA, QL

XELODA 3 SP, PA

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

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

rosuvastatin 20 mg, 40 mg tablet 1 QL

CHOLESTEROL MEDICATIONS cont.

Medication Tier Notes rosuvastatin 5 mg, 10 mg tablet 1 QL, PPACA simvastatin 5 mg, 80 mg tablet 1 QL simvastatin 10 mg, 20 mg, 40 mg tablet

1 PPACA

TRICOR 3 ST

VASCEPA 2 PA

ZETIA 3

CONTRACEPTION PRODUCTS

Medication Tier Notes afirmelle 1 PPACA altavera 1 PPACA alyacen 1 PPACA amethia 1 PPACA amethyst 1 PPACA

ANNOVERA 3

apri 1 PPACA aranelle 1 PPACA ashlyna 1 PPACA aubra 1 PPACA aubra eq 1 PPACA aurovela 1 PPACA aurovela 24 fe 1 PPACA aurovela fe 1 PPACA aviane 1 PPACA ayuna 1 PPACA azurette 1 PPACA

BALCOLTRA 3

balziva 1 PPACA

BEYAZ 3

blisovi 24 fe 1 PPACA blisovi fe 1 PPACA briellyn 1 PPACA camila 1 PPACA camrese 1 PPACA

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

Tier 1 – Generics PA – Prior Authorization AGE – Age Requirement OC – Optional Coverage

Tier 2 – Preferred Brands QL – Quantity Limit SP – Specialty Medication

Tier 3 – Non-Preferred Brands ST – Step Therapy PPACA – No Cost-Share Preventive Medication

CONTRACEPTION PRODUCTS cont.

Medication Tier Notes camrese lo 1 PPACA

CAYA CONTOURED 1 PPACA

caziant 1 PPACA charlotte 24 fe 1 PPACA chateal 1 PPACA chateal eq 1 PPACA cryselle 1 PPACA cyred 1 PPACA cyred eq 1 PPACA dasetta 1 PPACA daysee 1 PPACA deblitane 1 PPACA desogestrel-ethinyl estradiol 1 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

FEMCAP 1 PPACA

finzala 1 PPACA gemmily 1 PPACA

CONTRACEPTION PRODUCTS cont.

Medication Tier Notes hailey 1 PPACA hailey 24 fe 1 PPACA hailey fe 1 PPACA haloette 1 PPACA 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 junel fe 24 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 24 fe 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

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

Tier 1 – Generics PA – Prior Authorization AGE – Age Requirement OC – Optional Coverage

Tier 2 – Preferred Brands QL – Quantity Limit SP – Specialty Medication

Tier 3 – Non-Preferred Brands ST – Step Therapy PPACA – No Cost-Share Preventive Medication

CONTRACEPTION PRODUCTS cont.

Medication Tier Notes levonorgestrel-ethinyl estradiol-fe bisglycinate

1 PPACA

levora-28 1 PPACA

LILETTA 3 SP, PPACA

LOESTRIN FE 3

lojaimiess 1 PPACA loryna 1 PPACA low-ogestrel 1 PPACA lo-zumandimine 1 PPACA lutera 1 PPACA lyleq 1 PPACA lyza 1 PPACA marlissa 1 PPACA medroxyprogesterone 150mg/ml syringe, vial

1 PPACA

merzee 1 PPACA mibelas 24 fe 1 PPACA microgestin 1 PPACA microgestin 24 fe 1 PPACA microgestin fe 1 PPACA mili 1 PPACA

MIRENA 3 SP, PPACA

mono-linyah 1 PPACA

NATAZIA 3

necon 1 PPACA

NEXPLANON 2 SP, PPACA

NEXTSTELLIS 3

nikki 1 PPACA nora-be 1 PPACA norelgestromin-ethinyl estradiol 1 PPACA norethindrone 1 PPACA norethindrone-ethinyl estradiol 1 PPACA norethindrone-ethinyl estradiol-fe 1 PPACA norgestimate-ethinyl estradiol 1 PPACA

CONTRACEPTION PRODUCTS cont.

Medication Tier Notes nortrel 1 PPACA

NUVARING 3

nylia 1 PPACA nymyo 1 PPACA ocella 1 PPACA

PARAGARD T 380-A 3 SP, PPACA

philith 1 PPACA pimtrea 1 PPACA pirmella 1 PPACA portia 1 PPACA previfem 1 PPACA reclipsen 1 PPACA rivelsa 1 PPACA

SAFYRAL 3

setlakin 1 PPACA sharobel 1 PPACA simliya 1 PPACA simpesse 1 PPACA

SKYLA 3 SP, PPACA

SLYND 3

sprintec 1 PPACA sronyx 1 PPACA syeda 1 PPACA tarina 24 fe 1 PPACA tarina fe 1 PPACA tarina fe 1-20 eq 1 PPACA taysofy 1 PPACA

TAYTULLA 3

tilia fe 1 PPACA tri femynor 1 PPACA tri-estarylla 1 PPACA tri-legest fe 1 PPACA tri-linyah 1 PPACA

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

Tier 1 – Generics PA – Prior Authorization AGE – Age Requirement OC – Optional Coverage

Tier 2 – Preferred Brands QL – Quantity Limit SP – Specialty Medication

Tier 3 – Non-Preferred Brands ST – Step Therapy PPACA – No Cost-Share Preventive Medication

CONTRACEPTION PRODUCTS cont.

Medication Tier Notes 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-nymyo 1 PPACA tri-previfem 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

TWIRLA 3 PPACA

tydemy 1 PPACA velivet 1 PPACA vestura 1 PPACA vienva 1 PPACA viorele 1 PPACA volnea 1 PPACA vyfemla 1 PPACA vylibra 1 PPACA wera 1 PPACA

WIDE SEAL DIAPHRAGM 1 PPACA

wymzya fe 1 PPACA xulane 1 PPACA

YASMIN 28 3

YAZ 3

zafemy 1 PPACA zarah 1 PPACA zovia 1-35 1 PPACA zumandimine 1 PPACA

COUGH/COLD MEDICATIONS

Medication Tier Notes brompheniramine-pseudoephedrine-dm

HYCODAN 3 PA, QL

promethazine-dm 1

DENTAL PRODUCTS

Medication Tier Notes chlorhexidine 0.12% cup, rinse 1

CLINPRO 5000 3

denta 5000 plus 1 dentagel 1 doxycycline hyclate 20 mg tablet 1

FLORIVA 3 PPACA, OC

FLUORIDEX DAILY DEFENSE 1.1% 1

FLUORIDEX SENSITIVITY RELIEF 3

JUST RIGHT 5000 3

oralone 1

PERIDEX 3

periogard 1

PREVIDENT 0.2% RINSE 2

PREVIDENT 1.1% GEL 3

PREVIDENT 5000 3

sodium fluoride 1 triamcinolone 0.1% paste 1

DIABETES

Medication Tier Notes

ACCU-CHEK MULTICLIX LANCET KIT 1

ACCU-CHEK CONTROL SOLUTION 1

ACCU-CHEK FASTCLIX LANCING

DEVICE

ACCU-CHEK SOFTCLIX LANCET KIT 1

BAQSIMI 2 QL

BD AUTOSHIELD DUO PEN NEEDLE 1

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

Tier 1 – Generics PA – Prior Authorization AGE – Age Requirement OC – Optional Coverage

Tier 2 – Preferred Brands QL – Quantity Limit SP – Specialty Medication

Tier 3 – Non-Preferred Brands ST – Step Therapy PPACA – No Cost-Share Preventive Medication

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

BD VEO INSULIN SYRINGE 1

BYDUREON BCISE 2 PA, QL

BYETTA 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 INSULIN SYRINGE 1

DROPLET LANCET 1

DROPLET GENTEEL LANCING DEVICE 1

FARXIGA 2 QL, ST

FREESTYLE LIBRE 2 READER, 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 1

GLIPIZIDE 2.5 MG TABLET 3

glipizide 5 mg, 10 mg tablet 1 glipizide er 1 glipizide xl 1

GLUCAGEN HYPOKIT 2 QL

GLUCAGON EMERGENCY KIT 3 QL

GLYXAMBI 2 QL, ST

GUARDIAN RT CHARGER 1

GUARDIAN TEST PLUG 1

GVOKE 2 QL

HUMALOG 2 QL

HUMULIN N, HUMULIN R, HUMULIN

70/30

2 QL

DIABETES cont.

Medication Tier Notes

INPEN (FOR HUMALOG, NOVOLOG OR

FIASP)

INSULIN GLARGINE-YFGN 2 QL

INSULIN LISPRO 2 QL

JANUMET 2 QL, ST

JANUMET XR 2 QL, ST

JANUVIA 2 QL, ST

JARDIANCE 2 QL, ST

LYUMJEV 2 QL

metformin cup, solution, 500 mg, 850 mg, 1000 mg tablet metformin er 500 mg, 750 mg tablet 1

MICROLET LANCET 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 PODS (GEN 5) 2 QL

OMNIPOD 5 G6-G7 INTRO KIT (GEN 5) 2 QL

OMNIPOD 5 G6-G7 PODS (GEN 5) 2 QL

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

OMNIPOD CLASSIC PDM KIT (GEN 3) 2 QL

OMNIPOD CLASSIC PODS (GEN 3) 2 QL

OMNIPOD DASH INTRO KIT (GEN 4) 2 QL

OMNIPOD DASH PODS (GEN 4) 2 QL

OMNIPOD GO PODS 2 QL

ONETOUCH ULTRA TEST STRIP 2

ONETOUCH VERIO TEST STRIP 2

OZEMPIC 2 PA, QL

PARADIGM RESERVOIR 1

pioglitazone 1

RIOMET 3

RYBELSUS 2 PA, QL

SEMGLEE (YFGN) 2 QL

SEMGLEE (YFGN) PEN 2 QL

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

Tier 1 – Generics PA – Prior Authorization AGE – Age Requirement OC – Optional Coverage

Tier 2 – Preferred Brands QL – Quantity Limit SP – Specialty Medication

Tier 3 – Non-Preferred Brands ST – Step Therapy PPACA – No Cost-Share Preventive Medication

DIABETES cont.

Medication Tier Notes

SOLIQUA 100-33 2

SYMLINPEN 2

SYNJARDY 2 QL, ST

SYNJARDY XR 2 QL, ST

TECHLITE INSULIN SYRINGE 1

TRESIBA 2 QL

TRIJARDY XR 2 QL, ST

TRUEPLUS INSULIN SYRINGE 1

TRULICITY 2 PA, QL

V-GO 2

XIGDUO XR 2 QL, ST

ZEGALOGUE 2 QL

DIURETICS

Medication Tier Notes acetazolamide tablet 1 acetazolamide er 1 bumetanide tablet 1

CAROSPIR 2 PA

chlorthalidone 1

DIURIL 2

eplerenone 1 furosemide solution, tablet 1 hydrochlorothiazide 1

JYNARQUE 3 SP, PA

KERENDIA 2 PA, QL

spironolactone 1 tolvaptan 1 SP

EAR MEDICATIONS

Medication Tier Notes

CIPRO HC 2

ciprofloxacin-dexamethasone 1

CIPROFLOXACIN-FLUOCINOLONE 3

DERMOTIC 3

neomycin-polymyxin-hc 1

EAR MEDICATIONS cont.

Medication Tier Notes 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

sildenafil 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

ACUVAIL 3

ALREX 3

AZASITE 2

BESIVANCE 2

BETOPTIC S 2

bimatoprost drops 1 QL brimonidine drops 1 brimonidine-timolol 1 brinzolamide 1 bromfenac drops 1

BROMSITE 2

CEQUA 2

ciprofloxacin drops 1 cyclosporine 0.05% eye emulsion 1

CYSTADROPS 3 SP, PA, QL

CYSTARAN 3 SP, PA, QL

difluprednate 1 dorzolamide-timolol 1 erythromycin ointment 1

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

Tier 1 – Generics PA – Prior Authorization AGE – Age Requirement OC – Optional Coverage

Tier 2 – Preferred Brands QL – Quantity Limit SP – Specialty Medication

Tier 3 – Non-Preferred Brands ST – Step Therapy PPACA – No Cost-Share Preventive Medication

EYE CONDITIONS cont.

Medication Tier Notes

EYSUVIS 2 QL

FLAREX 2

fluorometholone 1

ILEVRO 3

INVELTYS 2

latanoprost 1

LOTEMAX 0.5% EYE OINTMENT 2

LOTEMAX SM 2

loteprednol 1

MIEBO 2 QL

moxifloxacin drops 1 neomycin-polymyxin-dexamethasone 1 ofloxacin drops 1

OXERVATE 3 SP, PA

polymyxin b sulfate-trimethoprim 1 prednisolone 1% eye drops 1

PROLENSA 3

RHOPRESSA 3

ROCKLATAN 3

SIMBRINZA 2

timolol gel-solution, drops 1

TOBRADEX EYE OINTMENT 2

TOBRADEX ST 2

tobramycin drops 1 tobramycin-dexamethasone 1 travoprost 1

TYRVAYA 2 QL

XDEMVY 2 SP, PA, QL

XIIDRA 2

ZERVIATE 2

ZIRGAN 3

ZYLET 3

FEMININE PRODUCTS

Medication Tier Notes fem ph 1

FEMININE PRODUCTS cont.

Medication Tier Notes

GYNAZOLE 1 1

miconazole 3 200 mg suppository 1 terconazole 1

GASTROINTESTINAL/HEARTBURN

Medication Tier Notes alosetron 1 SP anucort-hc 1 aprepitant 1 QL

APRISO 3

BONJESTA 3

CHOLBAM 3 SP, PA

constulose 1

CUVPOSA 3

dexlansoprazole dr 1 QL dicyclomine capsule, solution, tablet 1

ENTYVIO VIAL 2 SP, PA, OC

esomeprazole capsule, packet 1 QL famotidine suspension, 20 mg, 40 mg tablet

GATTEX 3 SP, PA

gavilyte-c 1 PPACA gavilyte-g 1 PPACA gavilyte-n 1 PPACA hemmorex-hc 1 hydrocortisone enema, suppository 1 lansoprazole 1 QL

LEVBID 3

LEVSIN 3

LEVSIN-SL 3

LINZESS 2

LITHOSTAT 2

lubiprostone 1 mesalamine 1 mesalamine dr 1 mesalamine er 1

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

Tier 1 – Generics PA – Prior Authorization AGE – Age Requirement OC – Optional Coverage

Tier 2 – Preferred Brands QL – Quantity Limit SP – Specialty Medication

Tier 3 – Non-Preferred Brands ST – Step Therapy PPACA – No Cost-Share Preventive Medication

GASTROINTESTINAL/HEARTBURN cont.

Medication Tier Notes metoclopramide cup, solution, tablet 1 misoprostol 1

MOTOFEN 3

MOVANTIK 2 PA

NEXIUM DR 2.5 MG, 5 MG PACKET 2 QL

NULEV 3

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 1

PANCREAZE 2

pantoprazole packet, tablet 1 QL peg 3350-electrolyte 1 PPACA

PENTASA 500 MG CAPSULE 3

PHEBURANE 2 SP, PA, QL

PREVACID DR CAPSULE 3 QL, ST

PROTONIX SUSPENSION, TABLET 3 QL, ST

rabeprazole tablet 1 QL

RECTIV 3

RELISTOR SYRINGE, VIAL 3 PA

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

TRANSDERM-SCOP 3

TRULANCE 2

URSO 3

URSO FORTE 3

GASTROINTESTINAL/HEARTBURN cont.

Medication Tier Notes

VARUBI 3 PA, QL

VIBERZI 2

VIOKACE 3

VOQUEZNA TABLET 3 PA, QL

VOWST 3 SP, PA, QL

XERMELO 3 SP, PA

ZENPEP 2

HORMONAL AGENTS

Medication Tier Notes

ACTIVELLA 3

amabelz 1

ANDROGEL 3 PA, QL

ANGELIQ 3

BIJUVA 3

budesonide dr 1 budesonide ec 1 budesonide er 1 PA, QL cabergoline 1 QL

CETROTIDE 2 SP, PA, OC

COMBIPATCH 2

CRINONE 4% GEL 3 PA

CYTOMEL 3

DEPO-ESTRADIOL 3

DEPO-TESTOSTERONE 3

desmopressin ampule, vial 1 SP desmopressin solution, 10 mcg/0.1 ml spray, tablet dexamethasone intensol 1 dotti 1 QL

DUAVEE 2

EGRIFTA SV 3 SP, PA

EMFLAZA 3 SP, PA

estradiol cream, gel packet, patch, tablet

1 QL

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

Tier 1 – Generics PA – Prior Authorization AGE – Age Requirement OC – Optional Coverage

Tier 2 – Preferred Brands QL – Quantity Limit SP – Specialty Medication

Tier 3 – Non-Preferred Brands ST – Step Therapy PPACA – No Cost-Share Preventive Medication

HORMONAL AGENTS cont.

Medication Tier Notes estradiol-norethindrone 1

ESTRING 2 QL

ESTROGEL 2

euthyrox 1

EVAMIST 3

FENSOLVI 2 SP, PA, OC

fyremadel 1 SP, PA, OC

GENOTROPIN 2 SP, PA

INTRAROSA 3 QL

LANREOTIDE 3 SP, PA, OC

levo-t 1 levothyroxine tablet 1 levoxyl 1 liothyronine tablet 1

LUPRON DEPOT 3.75 MG, 11.25 MG KIT 2 SP, PA, OC

LUPRON DEPOT-PED 3 SP, PA, OC

lyllana 1 QL

MEDROL 4 MG DOSEPAK, 4 MG, 8 MG,

16 MG TABLET

MEDROL 4 MG DOSEPAK, 4 MG, 8 MG,

16 MG TABLET

MEDROL 2 MG TABLET 2

medroxyprogesterone 1

MENOSTAR 3 QL

methylprednisolone dosepack, tablet 1 mimvey 1

MYFEMBREE 2 PA, QL

NGENLA 2 SP, PA

norethindrone 1 np thyroid 1

OMNITROPE 2 SP, PA

ORIAHNN 2 PA, QL

ORILISSA 2 PA, QL

OSPHENA 3 QL

prednisone 1

HORMONAL AGENTS cont.

Medication Tier Notes prednisone intensol 1

PREMARIN VAGINAL CREAM, TABLET 2

PREMPHASE 2

PREMPRO 2

progesterone capsule 1

RAYALDEE 3

SANDOSTATIN LAR DEPOT 3 SP, PA, OC

SEROSTIM 2 SP, PA

SKYTROFA 2 SP, PA

SOMATULINE DEPOT 2 SP, PA, OC

SOMAVERT 2 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 unithroid 3

XYOSTED 3 PA, QL

yuvafem 1 QL

INFECTIONS

Medication Tier Notes acyclovir capsule, suspension, tablet 1

AEMCOLO 3 QL

albendazole 1

ALINIA 3

amoxicillin 1 amoxicillin-clavulanate 1 amoxicillin-clavulanate er 1

ANCOBON 3

ARIKAYCE 3 SP, PA

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

BACTRIM 3

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

Tier 1 – Generics PA – Prior Authorization AGE – Age Requirement OC – Optional Coverage

Tier 2 – Preferred Brands QL – Quantity Limit SP – Specialty Medication

Tier 3 – Non-Preferred Brands ST – Step Therapy PPACA – No Cost-Share Preventive Medication

INFECTIONS cont.

Medication Tier Notes

BACTRIM DS 3

BARACLUDE ORAL SOLUTION 2 SP

BAXDELA 450 MG TABLET 3 PA

BEYFORTUS 3 PPACA

CAYSTON 3 SP, PA, QL

cefdinir 1 cefpodoxime 1 cefuroxime axetil 1 cephalexin 1

CIPRO SUSPENSION 2

CIPRO TABLET 3

ciprofloxacin 1 clarithromycin 1 clarithromycin er 1

CLEOCIN 75 MG CAPSULE 2

CLEOCIN 150 MG, 300 MG CAPSULE 3

clindamycin capsule, vaginal cream, solution coremino 1 QL crotan 1

DIFICID 3 QL

doxycycline monohydrate 1 e.e.s. 400 2

EMVERM 1

entecavir 1 SP, QL

EPCLUSA 2 SP, PA, QL

ERYPED 200 3

ery-tab dr 250 mg tablet 3 ery-tab dr 333 mg tablet 2

ERY-TAB DR 500 MG TABLET 3

erythromycin 1 famciclovir 1

FLAGYL 3

fluconazole 1 flucytosine 1

INFECTIONS cont.

Medication Tier Notes 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 solution, tablet 1

LIKMEZ 3 PA

LIVTENCITY 3 SP, PA, QL

MACROBID 3

MACRODANTIN 3

MALARONE 3 PA

methenamine 1 metronidazole capsule, tablet, vaginal gel minocycline 1 minocycline er tablet 1 QL mondoxyne nl 1 nitazoxanide 1 nitrofurantoin capsule, 25 mg/5 ml suspension

NUZYRA 150 MG TABLET 3 SP, PA, QL

nystatin 1 oseltamivir 1 QL

PAXLOVID 2 QL

PEGASYS 2 SP, PA

penicillin v potassium 1 permethrin 1

PLAQUENIL 3 PA

posaconazole suspension, tablet 1

PREVYMIS TABLET 3 SP

PRIFTIN 3

SIVEXTRO TABLET 3 PA

SOVALDI 2 SP, PA, QL

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

Tier 1 – Generics PA – Prior Authorization AGE – Age Requirement OC – Optional Coverage

Tier 2 – Preferred Brands QL – Quantity Limit SP – Specialty Medication

Tier 3 – Non-Preferred Brands ST – Step Therapy PPACA – No Cost-Share Preventive Medication

INFECTIONS cont.

Medication Tier Notes sulfamethoxazole-tmp suspension, tablet sulfatrim 3

TAMIFLU 3 QL

terbinafine 1

THALOMID 2 SP, PA

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 3 SP, PA, QL

ZITHROMAX PACKET, SUSPENSION,

TABLET

ZITHROMAX TRI-PAK 3

ZYVOX ORAL SUSPENSION, TABLET 3 PA

INFERTILITY

Medication Tier Notes clomiphene 1 OC

CRINONE 8% GEL 2 OC

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

INFERTILITY cont.

Medication Tier Notes

OVIDREL 2 SP, PA, OC

PREGNYL 2 SP, PA, OC

MISCELLANEOUS

Medication Tier Notes

ACCU-CHEK FASTCLIX LANCET DRUM 1

ADDYI 3 PA, QL, OC

AEROCHAMBER MINI 2 QL

AEROCHAMBER MV HOLD CHAMBER 2 QL

AEROCHAMBER PLUS FLOW-VU 2 QL

AEROCHAMBER Z-STAT PLUS 2 QL

AEROTRACH HOLDING CHAMBER 2 QL

AEROVENT PLUS HOLDING CHAMBER 2 QL

AUSTEDO 3 SP, PA

AUSTEDO XR 3 SP, PA, QL

AUSTEDO XR TITRATION KIT 3 SP, PA, QL

BERINERT 3 SP, PA, OC

BREATHRITE 2 QL

CARBAGLU 3 SP

CERDELGA 2 SP, PA

cinacalcet 1 SP

CINRYZE 3 SP, PA, OC

CLEVER CHOICE HOLDING CHAMBER 2 QL

COMPACT SPACE CHAMBER 2 QL

CVS KETONE CARE TEST STRIP 1

deferiprone 1 SP, PA

DROPLET LANCET 1

EASIVENT 2 QL

EVRYSDI 3 SP, PA

FLEXICHAMBER 2 QL

GALAFOLD 3 SP, PA

HAEGARDA 3 SP, PA

INGREZZA CAPSULE, INITIATION PACK,

SPRINKLE CAPSULE

3 SP, PA, QL

KETOSTIX REAGENT 1

MICROCHAMBER 2 QL

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

Tier 1 – Generics PA – Prior Authorization AGE – Age Requirement OC – Optional Coverage

Tier 2 – Preferred Brands QL – Quantity Limit SP – Specialty Medication

Tier 3 – Non-Preferred Brands ST – Step Therapy PPACA – No Cost-Share Preventive Medication

MISCELLANEOUS cont.

Medication Tier Notes

MICROSPACER 2 QL

MYALEPT 3 SP, PA

NITYR 2 SP, PA

NUEDEXTA 3 QL

ONETOUCH DELICA PLUS LANCET 1

ONETOUCH ULTRASOFT LANCET 1

ONETOUCH ULTRASOFT 2 LANCET 1

OPTICHAMBER DIAMOND 2 QL

ORFADIN 3 SP, PA

PALYNZIQ 3 SP, PA

POCKET CHAMBER 2 QL

POGO AUTOMATIC TEST CARTRIDGE 1

PRECISION XTR B-KETONE STRIP 1

PRO COMFORT SPACER WITH MASK 3 QL

PROCARE SPACER WITH MASK 2 QL

RADICAVA ORS 3 SP, PA, QL

RELION KETONE TEST STRIP 1

RITEFLO SPACER 2 QL

RUCONEST 3 SP, PA, OC

sapropterin 1 SP, PA sodium chloride 1

SOFT TOUCH LANCET 1

SPACE CHAMBER 2 QL

SPACE CHAMBER WITH MASK 2 QL

STRENSIQ 2 SP, PA

TECHLITE LANCET 1

TEGLUTIK 3 SP, PA

TEGSEDI 3 SP, PA

TIGLUTIK 3 SP, PA

TRUEPLUS KETONE TEST STRIP 1

VEOZAH 3 QL

VORTEX HOLDING CHAMBER 2 QL

VORTEX VHC FROG MASK 2 QL

VORTEX VHC LADYBUG MASK 2 QL

VOXZOGO 3 SP, PA

MISCELLANEOUS cont.

Medication Tier Notes

VYLEESI 3 SP, PA, QL, OC

VYNDAMAX 3 SP, PA, QL

MULTIPLE SCLEROSIS

Medication Tier Notes

AVONEX 2 SP, PA

BAFIERTAM 2 SP, PA

BETASERON 2 SP, PA

dalfampridine er 1 SP, PA dimethyl 1 SP

FIRDAPSE 3 SP, PA, QL

glatiramer 1 SP glatopa 1 SP

KESIMPTA PEN 2 SP, PA

MAVENCLAD 2 SP, PA

MAYZENT 2 SP, PA

PLEGRIDY 2 SP, PA

PONVORY 2 SP, PA

REBIF 2 SP, PA

REBIF REBIDOSE 2 SP, PA

VUMERITY 2 SP, PA

NUTRITIONAL/DIETARY

Medication Tier Notes

ACCRUFER 3 OC

AURYXIA 3 QL

betaine anhydrous 1 SP calcitriol ampule, capsule 1 OC

CYSTADANE 3 SP

FLORIVA CHEWABLE TABLET 2 PPACA

fluoride 1 PPACA, OC folic acid 1 mg tablet 1 OC folic acid 1000 mcg tablet 1 klor-con 8 meq, 10 meq, 20 meq 1 klor-con m10, m20 1 klor-con m15 2

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

Tier 1 – Generics PA – Prior Authorization AGE – Age Requirement OC – Optional Coverage

Tier 2 – Preferred Brands QL – Quantity Limit SP – Specialty Medication

Tier 3 – Non-Preferred Brands ST – Step Therapy PPACA – No Cost-Share Preventive Medication

NUTRITIONAL/DIETARY cont.

Medication Tier Notes

K-TAB ER 3

lanthanum 1

LOKELMA 2

ludent fluoride 1 PPACA, OC multivitamin-fluoride chewable tablet 1 PPACA mvc-fluoride 2 PPACA

NEEVODHA 2 OC

OB COMPLETE CAPLET 3 OC

OB COMPLETE ONE, PETITE, PREMIER,

WITH DHA

PHOSLYRA 3

POLY-VI-FLOR 2 PPACA

POLY-VI-FLOR WITH IRON CHEWABLE

TABLET

2 PPACA

potassium chloride liquid, packet 1 potassium chloride er 1

PRENATE CHEWABLE, ESSENTIAL 2 OC

PRENATE DHA, ELITE, ENHANCE, MINI,

PIXIE, RESTORE

PRIMACARE 2

QUFLORA PED DROPS, 1 MG

CHEWABLE TABLET

2 PPACA

QUFLORA PED 0.25 MG, 0.5 MG

CHEWABLE TABLET

ROCALTROL 3 OC

sevelamer 1 sodium fluoride 1 PPACA, OC soluvita 1 PPACA, OC

TRI-VI-FLOR 2 PPACA

tri-vit-fluor 1 PPACA

VELPHORO 2

VELTASSA 2

vitamin d2 1.25mg (50,000 unit) 1 OC vit a,c,d-fluoride 1 PPACA

OSTEOPOROSIS PRODUCTS

Medication Tier Notes alendronate 1

BINOSTO 3 ST

EVISTA 3

FOSAMAX 3 ST

ibandronate tablet 1 raloxifene 1 PPACA

PAIN RELIEF AND INFLAMMATORY DISEASE

Medication Tier Notes acetaminophen-codeine 1 PA

ACTEMRA SYRINGE 2 SP, PA, QL

ACTEMRA ACTPEN 2 SP, PA, QL

ADALIMUMAB-ADAZ (CF) 2 SP, PA, QL

ADALIMUMAB-ADBM (CF) 2 SP, PA, QL

AIMOVIG 2 PA

AJOVY 2 PA

allopurinol 100 mg, 300 mg tablet 1

ARAVA 3

ARCALYST 3 SP, PA

AVSOLA 2 SP, PA, OC

baclofen tablet 1

BELBUCA 2 QL

BENLYSTA AUTO-INJECTOR, SYRINGE 3 SP, PA

BIMZELX 3 SP, PA, QL

buprenorphine film, patch 1 QL butalbital-acetaminophen-caffeine 1 QL

BUTRANS 3 QL

carisoprodol 1

CELEBREX 3 QL, ST

celecoxib 1 QL

CIMZIA 2 SP, PA, QL

colchicine 1

COSENTYX PEN, SYRINGE 3 SP, PA, QL

cyclobenzaprine 1

CYLTEZO (CF) 2 SP, PA, QL

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

Tier 1 – Generics PA – Prior Authorization AGE – Age Requirement OC – Optional Coverage

Tier 2 – Preferred Brands QL – Quantity Limit SP – Specialty Medication

Tier 3 – Non-Preferred Brands ST – Step Therapy PPACA – No Cost-Share Preventive Medication

PAIN RELIEF AND INFLAMMATORY DISEASE cont.

Medication Tier Notes diclofenac 1% gel, 50 mg tablet 1 QL diclofenac er 1

DUPIXENT 2 SP, PA

EC-NAPROSYN 3 ST

ec-naproxen 1 eletriptan 1 QL

EMGALITY 2 PA

ENBREL 2 SP, PA, QL

ENBREL MINI 2 SP, PA, QL

ENBREL SURECLICK 2 SP, PA, QL

endocet 1 PA

ENSPRYNG 3 SP, PA

febuxostat 1 QL

FEXMID 3

FLECTOR 2 PA, QL

glydo 1

HUMIRA 2 SP, PA, QL

hydrocodone-acetaminophen 1 PA hydromorphone solution, suppository, tablet

1 PA

hydromorphone er 1 PA

HYSINGLA ER 2 PA

ibu 400 mg, 600 mg, 800 mg tablet 1 ibuprofen suspension, 400 mg, 600 mg, 800 mg tablet

ILARIS 3 SP, PA, OC

ILUMYA 3 SP, PA, QL

indomethacin 25 mg, 50 mg capsule, suspension, 50 mg suppository indomethacin er 1

INFLECTRA 2 SP, PA, OC

INFLIXIMAB 3 SP, PA, OC

ketorolac carpuject, syringe, tablet, vial 1 QL

KEVZARA 3 SP, PA, QL

KINERET 3 SP, PA, QL

PAIN RELIEF AND INFLAMMATORY DISEASE cont.

Medication Tier Notes leflunomide 1

LICART 2 PA, QL

lidocaine jelly, ointment, 5% patch, solution

1 QL

lidocaine viscous 1 meloxicam tablet 1 methocarbamol tablet 1

MITIGARE 2

morphine concentrate, solution, suppository, tablet

1 PA

morphine er 1 PA

NAPROSYN TABLET 3 ST

NUCYNTA 2 PA

NUCYNTA ER 3 PA

NURTEC ODT 2 PA, QL

OLUMIANT 3 SP, PA, QL

OMVOH PEN 2 SP, PA, QL

ORENCIA CLICKJECT, SYRINGE 3 SP, PA, QL

OTEZLA 2 SP, PA, QL

OTREXUP 2 PA

OXAYDO 3 PA

oxycodone 1 PA

OXYCODONE ER 1 PA

oxycodone-acetaminophen 1 PA

PERCOCET 3 PA

PROCTOFOAM-HC 2

prolate tablet 1 PA

QULIPTA 2 PA, QL

REMICADE 3 SP, PA, OC

RINVOQ 2 SP, PA, QL

rizatriptan 1 QL

ROXYBOND 3 PA

SAVELLA 2

SIMLANDI(CF) 2 SP, PA, QL

SIMPONI 50 MG/0.5 ML PEN INJECTOR,

SYRINGE

3 SP, PA, QL

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

Tier 1 – Generics PA – Prior Authorization AGE – Age Requirement OC – Optional Coverage

Tier 2 – Preferred Brands QL – Quantity Limit SP – Specialty Medication

Tier 3 – Non-Preferred Brands ST – Step Therapy PPACA – No Cost-Share Preventive Medication

PAIN RELIEF AND INFLAMMATORY DISEASE cont.

Medication Tier Notes

SIMPONI 100 MG/ML PEN INJECTOR,

SYRINGE

2 SP, PA, QL

SIMPONI ARIA 2 SP, PA

SKYRIZI ON-BODY, PEN, SYRINGE 2 SP, PA, QL

SOTYKTU 2 SP, PA, QL

STELARA 45 MG/0.5 ML SYRINGE, VIAL,

90 MG/ML SYRINGE

2 SP, PA, QL

sumatriptan 1 QL

TALTZ 80 MG/ML AUTO-INJECTOR,

SYRINGE

2 SP, PA, QL

tramadol 50 mg tablet 1 QL tramadol er 1 QL

TREMFYA 2 SP, PA, QL

TYENNE AUTO-INJECTOR, SYRINGE 2 SP, PA, QL

UBRELVY 2 PA, QL

vanadom 1

XELJANZ 2 SP, PA, QL

XELJANZ XR 2 SP, PA, QL

XTAMPZA ER 2 PA

ZAVZPRET 2 PA, QL

ZANAFLEX 3

zebutal 3 QL

ZEPOSIA 2 SP, PA

ZTLIDO 2

PARKINSON’S DISEASE

Medication Tier Notes

APOKYN 3 SP, PA

AZILECT 3 QL

benztropine tablet 1 carbidopa-levodopa 1 carbidopa-levodopa er 1

DUOPA 3 SP

INBRIJA 3 SP, PA

NEUPRO 3

PARKINSON’S DISEASE cont.

Medication Tier Notes

NOURIANZ 3 SP, PA, QL

pramipexole 1 pramipexole er 1 QL ropinirole 1 ropinirole er 1

RYTARY 3

SINEMET 3

XADAGO 3 ST

Medication Tier Notes aripiprazole 1 QL aripiprazole odt 1 asenapine 1

CAPLYTA 3 QL, ST

chlorpromazine concentrate, tablet 1 clozapine 1 clozapine odt 1

INVEGA ER 3 QL, ST

olanzapine odt 1 olanzapine tablet 1 paliperidone er 1 QL quetiapine 1 quetiapine er 1

REXULTI 2 QL, ST

risperidone 1 risperidone odt 1

SAPHRIS 3 ST

SECUADO 3 ST

SEROQUEL 3 ST

SEROQUEL XR 3 ST

VRAYLAR 3 QL, ST

ziprasidone capsule 1

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

Tier 1 – Generics PA – Prior Authorization AGE – Age Requirement OC – Optional Coverage

Tier 2 – Preferred Brands QL – Quantity Limit SP – Specialty Medication

Tier 3 – Non-Preferred Brands ST – Step Therapy PPACA – No Cost-Share Preventive Medication

SEIZURE DISORDERS

Medication Tier Notes

APTIOM 3 PA, QL

BRIVIACT ORAL SOLUTION, TABLET 3 PA

carbamazepine 1 carbamazepine er 1

CARBATROL 3 PA

clonazepam 1

DIASTAT 3 PA

DILANTIN 30 MG CAPSULE 2 PA

DILANTIN 100 MG CAPSULE, 50 MG

INFATAB, 125 MG/5 ML SUSPENSION

3 PA

divalproex dr 1 divalproex er 1

EPIDIOLEX 1

epitol 1

FINTEPLA 1

FYCOMPA 1

gabapentin 1

KLONOPIN 3 PA

lacosamide solution, tablet 1 lamotrigine 1 lamotrigine (blue), (green), (orange) 1 lamotrigine er 1 lamotrigine odt 1 lamotrigine odt (blue), (green), (orange) levetiracetam oral solution, tablet 1 levetiracetam er 1

LYRICA 3 PA

NAYZILAM 2 PA, QL

NEURONTIN 3 PA

oxcarbazepine 1

OXTELLAR XR 3 PA

PHENYTEK 3 PA

pregabalin 1 roweepra 1

SEIZURE DISORDERS cont.

Medication Tier Notes

SPRITAM 3 PA

subvenite 1 subvenite (blue), (green), (orange) 1

TEGRETOL 3 PA

TEGRETOL XR 3 PA

topiramate 1 topiramate er 1 QL

VALTOCO 3 PA, QL

vigabatrin 1 SP vigadrone powder packet 1 SP

VIMPAT SOLUTION 2

XCOPRI 3 PA, QL

SKIN CONDITIONS

Medication Tier Notes

ABSORICA 3

adapalene-benzoyl peroxide 1

ADBRY AUTO-INJECTOR, SYRINGE 2 SP, PA

amnesteem 1 avar 1 azelaic acid 1 bp 10-1 1

BRYHALI 3 ST

CAPEX SHAMPOO 3 ST

CIBINQO 2 SP, PA, QL

claravis 1

CLEOCIN T 3

clindacin etz 1% pledget 1 clindacin p 1 clindamycin 1 clindamycin-benzoyl peroxide 1 clobetasol 1 clodan cream, shampoo, solution 1

CLODERM 3 ST

clotrimazole-betamethasone 1

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

Tier 1 – Generics PA – Prior Authorization AGE – Age Requirement OC – Optional Coverage

Tier 2 – Preferred Brands QL – Quantity Limit SP – Specialty Medication

Tier 3 – Non-Preferred Brands ST – Step Therapy PPACA – No Cost-Share Preventive Medication

SKIN CONDITIONS cont.

Medication Tier Notes dapsone 1

DROPSAFE PREP PAD 1

DRYSOL 2

EFUDEX 3

EUCRISA 2 ST

EVOCLIN 3

fluorouracil 1 isotretinoin 1 ketoconazole 1 ketodan foam 1

LITFULO 3 SP, PA, QL

metronidazole 1 mupirocin 2% ointment 1 myorisan 1

NAFTIN 2

neuac gel 1

OPZELURA 3 PA

pimecrolimus 1

PRAMOSONE 1% LOTION, 1%-1%

CREAM, OINTMENT, 2.5%-1%

OINTMENT

PRAMOSONE 2.5%-1% CREAM,

LOTION

QBREXZA 3 PA

REGRANEX 3 PA, QL

rosadan cream, gel 1

SANTYL 2 QL

sodium sulfacetamide-sulfur 1

SOOLANTRA 3

sss 10-5 1 sulfacleanse 8-4 1

TACLONEX SUSPENSION 3

tacrolimus 1 tazarotene cream, gel 1

TEMOVATE 3 ST

SKIN CONDITIONS cont.

Medication Tier Notes tretinoin 1 PA, AGE triderm 1

TWYNEO 3

VALCHLOR 3 SP

VECTICAL 3 QL

XEPI 3

zenatane 1

SLEEP DISORDERS/SEDATIVES

Medication Tier Notes

DAYVIGO 2 QL, ST

doxepin 1 QL eszopiclone 1

HETLIOZ 3 SP, PA

HETLIOZ LQ 3 SP, PA

LUMRYZ ER 3 SP, PA, QL

modafinil 1 PA

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

SUNOSI 2 PA, QL

WAKIX 3 SP, PA, QL

XYWAV 3 SP, PA, QL

zolpidem sublingual tablet, tablet 1 zolpidem er 1 QL

SMOKING CESSATION2

Medication Tier Notes

APO-VARENICLINE 3 OC

bupropion sr 150 mg 1 PPACA, OC

NICOTROL 2 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

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

Tier 1 – Generics PA – Prior Authorization AGE – Age Requirement OC – Optional Coverage

Tier 2 – Preferred Brands QL – Quantity Limit SP – Specialty Medication

Tier 3 – Non-Preferred Brands ST – Step Therapy PPACA – No Cost-Share Preventive Medication

SUBSTANCE ABUSE cont.

Medication Tier Notes

NARCAN 2 QL

OPVEE 3 QL

SUBOXONE 3

ZIMHI 3 QL

ZUBSOLV 2

TRANSPLANT MEDICATIONS

Medication Tier Notes

ASTAGRAF XL 3 SP

ENVARSUS XR 3 SP

everolimus 1 SP

LUPKYNIS 3 SP, PA, QL

mycophenolate capsule, suspension, tablet

1 SP

mycophenolic acid 1 SP

REZUROCK 3 SP, PA

sirolimus 1 SP tacrolimus 1 SP

ZORTRESS 3 SP

URINARY TRACT CONDITIONS

Medication Tier Notes alfuzosin er 1

CYSTAGON 2 SP

dutasteride 1

ELMIRON 2

finasteride 1

K-PHOS NO. 2 2

K-PHOS ORIGINAL 2

oxybutynin solution, syrup, 5 mg tablet oxybutynin er 1 phenazopyridine 100 mg, 200 mg tablet potassium er 1

PROSCAR 3

URINARY TRACT CONDITIONS cont.

Medication Tier Notes

PYRIDIUM 3

RAPAFLO 3 QL

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

UROCIT-K 3

UROXATRAL 3

VACCINES

the myCigna App or myCigna.com

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

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

Tier 1 – Generics PA – Prior Authorization AGE – Age Requirement OC – Optional Coverage

Tier 2 – Preferred Brands QL – Quantity Limit SP – Specialty Medication

Tier 3 – Non-Preferred Brands ST – Step Therapy PPACA – No Cost-Share Preventive Medication

VACCINES cont.

the myCigna App or myCigna.com

Medication Tier Notes

FLUZONE HIGH-DOSE 2 PPACA

FLUZONE 2 PPACA

GARDASIL 9 2 PPACA

HEPLISAV-B 2 PPACA

HIBERIX 2 PPACA

INFANRIX DTAP 2 PPACA

IPOL 2 PPACA

JANSSEN COVID 2 PPACA

KINRIX 2 PPACA

MENACTRA 2

MENQUADFI 2 PPACA

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

PENTACEL ACTHIB COMPONENT 2 PPACA

PFIZER COVID 2 PPACA

PNEUMOVAX 23 2 PPACA

PREHEVBRIO 2 PPACA

PREVNAR 20 2 PPACA

PRIORIX 2 PPACA

PROQUAD 2 PPACA

VACCINES cont.

the myCigna App or myCigna.com

Medication Tier Notes

QUADRACEL DTAP-IPV 2 PPACA

RECOMBIVAX HB 2 PPACA

ROTARIX 3 PPACA

ROTATEQ 3 PPACA

SHINGRIX 2 QL, PPACA

SPIKEVAX COVID 2 PPACA

TDVAX 2 PPACA

TENIVAC 2 PPACA

TRUMENBA 2 PPACA

TWINRIX 2 PPACA

VARIVAX VACCINE 3 PPACA

VAXELIS 3 PPACA

VAXNEUVANCE 2 QL, PPACA

VITAMINS

Medication Tier Notes

POLY-VI-FLOR 2 PPACA

POLY-VI-FLOR WITH IRON 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 2 PA, QL, OC

Frequently Asked Questions (FAQs)

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

A.

• Moving a medication to a lower cost tier.

• Moving a brand medication to a higher cost tier when a generic becomes available.

• Moving a medication to a higher cost tier and/or no longer covering a medication.

st st

• Adding extra coverage requirements to

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

Q. How do you decide which medications to cover?

Q. Why do certain medications need approval before my plan will cover them?

Q. How do I know if I’m taking a medication that needs approval?

A. myCigna App or myCigna.com has a PA or ST

QL

AGE

Q. What types of medications typically need approval?

A.

Q. What types of medications typically have quantity limits?

A.

Q. What types of medications require Step Therapy?

A.

• Allergies •

Q. Why does my medication have an age requirement?

A.

Q. How do I get approval (prior authorization) for my medication?

A.

cignaforhcp.com the myCigna App or myCigna.com that needs approval but I don’t get approval ahead of time?

A.

has a quantity limit?

Q. Are all of the medications on this drug list approved by the FDA?

Q. Does my plan cover medications that the FDA recently approved?

A.

Q. Which medications are covered under the health care reform law?

A.

myCigna App or myCigna.com

Cigna.com/PDL www.informedonreform.com or

CignaHealthcare.com

Q. What are preventive medications?

myCigna

App or myCigna.com

Q. What’s a cost-share?

A.

Q. How can I save money on my prescription medications?

A.

Q. What's a generic medication?

A.

Q. Do generics work the same as brand-name medications?

A.

brand-name medications?

Q. My pharmacy isn’t in my plan’s network. Can I

A.

A. 5

Express Scripts® Pharmacy for maintenance medications go to Cigna.com/homedelivery

• 6

Here are three easy ways to get started.

myCigna App or myCigna.com to

800.835.3784

Accredo® for specialty medications

877.826.7657

Cigna.com/specialty

A.

myCigna App or myCigna.com

Exclusions and limitations for coverage

1. App/online store terms and mobile phone carrier/data charges apply. Customers under age 13 (and/or their parent/guardian) will not be able to register at myCigna.com.

2. For insured plans that must follow Delaware’s state insurance laws: Brand-name antidepressants, smoking cessation, attention deficit hyperactivity disorder (ADHD) and anti-psychotic medications that don’t have a generic equivalent available will be covered as Tier 2 (preferred brand). This is true even if the medication is listed as Tier 3 (non-preferred brand) on your plan’s drug list. To find out how your specific plans covers these medications, log in to the myCigna App or myCigna.com, or call Customer Service using the number on your ID card.

3. Prices shown on myCigna are not guaranteed and coverage is subject to your plan terms and conditions. Visit myCigna for more information.

4. U.S. Food and Drug Administration (FDA) website, “Generic Drugs: Questions and Answers.” Last updated 03/16/21. fda.gov/drugs/questions-answers/generic-drugs-questions-answers.

5. Not all plans offer Express Scripts® Pharmacy and Accredo as covered pharmacy options. Log in to the myCigna App or myCigna.com, or check your plan materials, to learn more about the pharmacies in your plan’s network. Cigna Healthcare maintains an ownership interest in Express Scripts® Pharmacy’s home delivery services and Accredo’s specialty pharmacy services.

However, you have the right to fill prescriptions at any pharmacy in your plan’s network. You won’t be penalized regardless of where you fill your prescriptions.

6. Standard shipping costs are included as part of your prescription plan.

7. Some medications aren’t available in a 90-day supply and may only be packaged in lesser amounts. For example, three packages of oral contraceptives equal an 84-day supply. Even though it’s not a “90-day supply,” it’s still considered a 90-day prescription.

8. As allowable by law. For medications administered by a health care provider, Accredo will ship the medication directly to your doctor’s office.

9. Costs and complete details of the plan’s prescription drug coverage are set forth in the plan documents.