Cigna Healthcare Standard 4-Tier Prescription Drug List Injectable specialty medications are covered on Tier 4 (listed on pages 20-23).
TIER 1 $
TIER 2 $$ TIER 3 $$$ CONTRACEPTION PRODUCTS (cont.)
TIER 1 $
TIER 2 $$ TIER 3 $$$ CONTRACEPTION PRODUCTS (cont.)
MARLISSA+ MEDROXY- PROGESTERONE+ MERZEE+ MICROGESTIN FE+ MICROGESTIN+ microgestin 24 fe+ MILI+ MONO-LINYAH+ NECON+ NIKKI+ NORA-BE+ norethindrone+ norethindrone- ethinyl estradiol- iron+ norethindrone- ethinyl estradiol+ norethindrone- ethinyl estradiol- ferrous fumarate norgestimate- ethinyl estradiol+ NORTREL+ NYLIA+
TRI-LINYAH+ TRI-LO- ESTARYLLA+ TRI-LO-MARZIA+ TRI-LO-MILI+ TRI-LO-SPRINTEC+ TRI-MILI+ TRI-NYMYO+ TRI-SPRINTEC+ TRIVORA-28+ TRI-VYLIBRA LO+ TRI-VYLIBRA+
TULANA+ TYDEMY+ VELIVET+ VESTURA+ VIENVA+ VIORELE+ VOLNEA+ VYFEMLA+ VYLIBRA+ WERA+ wide seal
diaphragm+ WYMZYA FE+
NYMYO+ OCELLA+ PHILITH+ PIMTREA+ PIRMELLA+ PORTIA+ RECLIPSEN+ RIVELSA+ SETLAKIN+ SHAROBEL+ SIMLIYA+ SIMPESSE+ SPRINTEC+ SRONYX+ SYEDA+
XULANE+ ZAFEMY+ ZOVIA 1-35+ ZUMANDIMINE+
COUGH/COLD MEDICATIONS
brompheniramine- pseudoephedrine -dm hydrocodone- chlorpheniramne er (PA) promethazine-dm chlorhexidine DENTA 5000 PLUS DENTAGEL doxycycline hyclate FLUORIDEX DAILY DEFENSE 1.1% ORALONE
HYCODAN (PA, QL) TUXARIN ER (PA,QL) TUZISTRA XR (PA, QL)
DENTAL PRODUCTS
CLINPRO 5000 FLORIVA+^ FLUORIDEX SENSITIVITY RELIEF JUST RIGHT 5000 PERIDEX PREVIDENT 1.1% GEL PREVIDENT 0.2% PREVIDENT 5000
TARINA 24 FE+ TARINA FE 1-20 EQ+ TARINA FE+
taysofy+ TILIA FE+
TRI FEMYNOR+ TRI-ESTARYLLA+ TRI-LEGEST FE+
PERIOGARD SF 1.1% GEL SF 5000 PLUS
10
Made with FlippingBook - professional solution for displaying marketing and sales documents online