Cigna Healthcare Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 17-20).
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TIER 2 $$ TIER 3 $$$ CONTRACEPTION PRODUCTS (cont.)
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DIABETES (cont.) DEXCOM G7 SENSOR (PA, QL) FARXIGA (QL, ST) FREESTYLE LIBRE 14 DAY READER, SENSOR (PA, QL) FREESTYLE LIBRE 2 READER, SENSOR (PA, QL) FREESTYLE LIBRE 3 READER, SENSOR (PA, QL) GLUCAGEN VIAL GLUCAGEN HYPOKIT (QL) GLYXAMBI (QL, ST) HUMALOG QL) HUMULIN 70/30 KWIKPEN (QL) HUMULIN 70/30, HUMULIN N, HUMULIN R (QL) INSULIN GLARGINE- YFGN (QL) INSULIN LISPRO (QL) INSULIN LISPRO JUNIOR KWIKPEN (QL) INSULIN LISPRO KWIKPEN (QL) INSULIN LISPRO PROTAMINE MIX (QL) JANUMET (QL, ST) JANUMET XR (QL, ST) JANUVIA (QL, ST) JARDIANCE (QL, ST) LYUMJEV (QL) LYUMJEV KWIKPEN (QL) LYUMJEV TEMPO PEN U-100 (QL) MOUNJARO (PA, QL) OMNIPOD 5 G6 INTRO KIT (GEN 5) (QL)
vyfemla+ vylibra+ wera+ WIDE SEAL DIAPHRAGM+ wymzya fe+ xulane+ zafemy+ zarah+ zovia 1-35+ zumandimine+
ADVOCATE SYRINGE ASSURE ID INSULIN SAFETY BD AUTOSHIELD DUO PEN NEEDLE BD ECLIPSE 30GX1/2" SYRINGE BD INSULIN PEN NEEDLE, SYRINGE BD LUER-LOK SYRINGE 1 ML CARETOUCH INSULIN SYRINGE COMFORT EZ INSULIN SYRINGE DROPLET GENTEEL LANCING DEVICE DROPLET INSULIN SYRINGE EASY COMFORT INSULIN SYRINGE EASY GLIDE INSULIN SYRINGE EASY TOUCH EASY TOUCH FLIPLOCK INSULIN EASY TOUCH INSULIN SAFETY EASY TOUCH INSULIN SYRINGE EASY TOUCH LUER LOCK INSULIN EASY TOUCH SHEATHLOCK INSULIN EASY TOUCH UNI- SLIP SYRINGE 1 ML EASY-TOUCH INSULIN SYRINGE ECLIPSE SYRINGE FREESTYLE PRECISION GUARDIAN RT CHARGER GUARDIAN TEST PLUG HEALTHWISE INSULIN SYRINGE
COUGH/COLD MEDICATIONS
brompheniramine- pseudoephedrine -dm hydrocodone- chlorpheniramine er (PA) promethazine-dm chlorhexidine doxycycline hyclate FLUORIDEX DAILY DEFENSE 1.1% oralone periogard triamcinolone
TUZISTRA XR (PA, QL)
DENTAL PRODUCTS
PREVIDENT 0.2% RINSE
CLINPRO 5000 FLORIVA 0.25 MG/ ML DROPS+^ FLUORIDEX SENSITIVITY RELIEF JUST RIGHT 5000 PERIDEX PREVIDENT 1.1% GEL PREVIDENT 5000 CYCLOSET GLUCAGON EMERGENCY KIT (QL) GVOKE (QL) GVOKE HYPOPEN (QL) GVOKE PFS SYRINGE (QL) ULTIGUARD SAFEPACK SYRINGE
DIABETES
ACCU-CHEK ACCU-CHEK
BAQSIMI (QL) BYDUREON BCISE (PA, QL) BYETTA (PA, QL) CEQUR SIMPLICITY CEQUR SIMPLICITY INSERTER DEXCOM G6 RECEIVER (PA, QL) DEXCOM G6 SENSOR (PA, QL) DEXCOM G6 TRANSMITTER (PA, QL) DEXCOM G7 RECEIVER (PA, QL)
CONTROL SOLUTION ACCU-CHEK FASTCLIX LANCING DEVICE ACCU-CHEK GUIDE CONTROL SOLUTION ACCU-CHEK SMARTVIEW
CONTROL SOLUTION ACCU-CHEK SOFTCLIX
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