Cigna Healthcare Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 17-20).
TIER 1 $
TIER 2 $$
TIER 3 $$$
TIER 1 $
TIER 2 $$
TIER 3 $$$
DIABETES (cont.) OMNIPOD 5 G6 PODS (GEN 5) (QL) OMNIPOD CLASSIC PDM KIT(GEN 3) (QL) OMNIPOD CLASSIC PODS (GEN 3) (QL) OMNIPOD DASH INTRO KIT (GEN 4) (QL) OMNIPOD DASH PODS (GEN 4) (QL) OMNIPOD GO PODS (QL) ONETOUCH ULTRA TEST STRIP ONETOUCH VERIO TEST STRIP OZEMPIC (PA, QL) RYBELSUS (PA, QL) SEMGLEE (YFGN) (QL) SEMGLEE (YFGN) PEN (QL) SOLIQUA 100-33 SYMLINPEN SYNJARDY (QL, ST) SYNJARDY XR (QL, ST) TRESIBA VIAL, FLEXTOUCH (QL) TRIJARDY XR (QL, ST) TRULICITY (PA, QL) V-GO 20, 30, 40 XIGDUO XR (QL, ST) ZEGALOGUE AUTO-INJECTOR, SYRINGE (QL)
DIABETES (cont.)
INPEN (FOR NOVOLOG OR FIASP)
TRUEPLUS INSULIN SYRINGE ULTICARE INSULIN SYRINGE ULTILET INSULIN SYRINGE ULTRA COMFORT ULTRA FLO INSULIN SYRINGE ULTRACARE INSULIN SYRINGE ULTRA-FINE PEN NEEDLE VANISHPOINT VANISHPOINT INSULIN SYRINGE VEO INSULIN SYRINGE chlorthalidone eplerenone furosemide solution, tablet spironolactone triamterene-hctz ciprofloxacin- dexamethasone neomycin- polymyxin-hc ofloxacin
INSULIN SYRINGE INSULIN SYRINGE U-500 LITETOUCH INSULIN SYRINGE MAGELLAN INSULIN SYRINGE MAXICOMFORT INSULIN SYRINGE metformin 500 mg, 850 mg, 1,000 mg tablet metformin 500 mg/5 ml, 850 mg/8.5 ml cup metformin 500 mg/5 ml solution metformin er MICROLET 2 MICROLET NEXT LANCING DEVICE MONOJECT INSULIN SYRINGE NANO 2 GEN PEN NEEDLE PARADIGM PRO COMFORT INSULIN SYRINGE PRODIGY INSULIN SYRINGE SAFESNAP INSULIN SYRINGE SAFETYGLIDE INSULIN SYRINGE SURE COMFORT INSULIN SYRINGE SURE-JECT INSULIN SYRINGE TECHLITE INSULIN SYRINGE TERUMO INSULIN SYRINGE THINPRO INSULIN SYRINGE TOPCARE ULTRA COMFORT TRUE COMFORT INSULIN SYRINGE
DIURETICS
CAROSPIR SUSP (PA) KERENDIA (PA, QL)
FUROSCIX (QL) MAXZIDE
EAR MEDICATIONS
CIPRO HC
CIPROFLOXACIN- FLUOCINOLONE OTOVEL
ERECTILE DYSFUNCTION
sildenafil^ (QL) tadalafil^ (QL)
MUSE^ (PA age, QL)
CIALIS^ (QL, ST) STENDRA^ (QL, ST) VIAGRA^ (QL, ST)
EYE CONDITIONS AZASITE BESIVANCE BETOPTIC S BROMSITE CEQUA EYSUVIS (QL) FLAREX INVELTYS LOTEMAX 0.5% EYE OINTMENT LOTEMAX SM SIMBRINZA
cyclosporine dorzolamide- timolol erythromycin latanoprost ofloxacin polymyxin b-trimethoprim tobramycin travoprost
ACUVAIL ALREX ILEVRO
MIEBO (QL) PROLENSA RHOPRESSA ROCKLATAN ZIRGAN ZYLET
11
Made with FlippingBook - professional solution for displaying marketing and sales documents online