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 $$ TIER 3 $$$ DENTAL PRODUCTS (cont.)
TIER 1 $
TIER 2 $$
TIER 3 $$$
DIABETES (cont.) LYUMJEV (QL) MOUNJARO (PA, QL) OMNIPOD 5 G6 (GEN 5) (QL) OMNIPOD CLASSIC (GEN 3) (QL) OMNIPOD DASH (GEN 4) (QL) ONETOUCH ULTRA TEST STRIP ONETOUCH VERIO TEST STRIP OZEMPIC (PA, QL) QTERN (QL, ST) RYBELSUS (PA, QL) SOLIQUA 100-33 SYMLINPEN SYNJARDY (QL, ST) SYNJARDY XR (QL, ST) TRESIBA (QL) TRIJARDY XR (ST, QL) TRULICITY (PA,QL) V-GO 20 V-GO 30 V-GO 40 XIGDUO XR (QL, ST) XULTOPHY ZEGALOGUE (QL)
sodium fluoride sodium fluoride 5000 dry mouth sodium fluoride 5000 plus triamcinolone acetonide
PREVIDENT 5000 BOOSTER PLUS PREVIDENT 5000 DRY MOUTH PREVIDENT 5000 ENAMEL PROTECT PREVIDENT 5000 ORTHO DEFENSE PREVIDENT 5000 PLUS PREVIDENT 5000 SENSITIVE CEQUR CYCLOSET GLUCAGON EMERGENCY KIT (QL) GVOKE (QL) HUMALOG 100 UNIT/ML VIAL (QL) KORLYM* (PA) KETONE-GLUC KIT METFORMIN HCL 625 MG TABLET RIOMET RIOMET ER ULTIGUARD SAFE 1ML 30G 12.7MM ULTIGUARD SAFE 0.3ML 30G 12.7MM ULTIGUARD SAFEPACK 1ML 31G 8MM ULTIGUARD SAFEPACK- INSULIN SYRINGE ULTIGUARD SAFEPK 0.3ML 31G 8MM
EASY TOUCH EASY TOUCH FLIPLOCK
INSULIN, INSULIN SAFETY, INSULIN SYRINGE, LUER LOCK INSULIN, SHEATHLOCK INSULIN, UNI-SLIP, INSULIN SYRINGE glimepiride glipizide glipizide er glipizide xl GUARDIAN RT CHARGER GUARDIAN TEST PLUG HEALTHWISE INSULIN SYRINGE INPEN INSULIN SYRINGE U-500 LITE TOUCH LITETOUCH INSULIN SYRINGE MAGELLAN INSULIN SYRINGE MAGELLAN INSULIN SAFETY SYRINGE MAXI-COMFORT MAXICOMFORT II INSULIN SYRINGE metformin metformin er metformin 1,000 mg tablet metformin 500 mg tablet metformin 500 mg/5 ml solution metformin 850 mg tablet
DIABETES
ACCU-CHEK ADVOCATE SYRINGES ASSURE ID PEN NEEDLE BD INSULIN SYRINGE BD LANCETS BD PEN NEEDLE CARETOUCH INSULIN SYRINGE CEQUR SIMPLICITY INSERTER COMFORT EZ INSULIN SYRINGE CONTOUR SOLUTION CONTOUR NEXT LEV 1 CONTROL SOLUTION CONTOUR NEXT LEV 2 CONTROL SOLUTION DROPLET GENTEEL LANCING DEVICE DROPLET INSULIN SYRINGE DROPLET GENTEEL LANCING DEVICE DROPLET INSULIN SYRINGE EASY COMFORT INSULIN SYRINGE EASY GLIDE INSULIN SYRINGE
BAQSIMI (QL) BYDUREON (PA, QL) BYETTA (PA, QL) DEXCOM G6 RECEIVER (PA, QL) DEXCOM G6 SENSOR (PA, QL) DEXCOM G6 TRANSMITTER (PA, QL) DROPLET DROPSAFE FARXIGA (QL, ST) FREESTYLE LIBRE 14 DAY SENSOR (PA, QL) FREESTYLE LIBRE 2 SENSOR (PA, QL) GLUCAGEN (QL) GLYXAMBI (QL, ST) HUMALOG (QL) HUMALOG 100 UNIT/ML CARTRIDGE (QL) HUMULIN (QL) HUMULIN R (QL) INSULIN GLARGINE- YFGN (QL) INSULIN LISPRO (QL) JANUMET (QL, ST) JANUMET XR (QL, ST) JANUVIA (QL, ST) JARDIANCE (QL, ST)
metformin 850 mg/8.5ml cup microlet MINIMED RESERVOIR
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