Cigna Healthcare Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 17-20).
TIER 1 $
TIER 2 $$ TIER 3 $$$ GASTROINTESTINAL/HEARTBURN (cont.)
TIER 1 $
TIER 2 $$
TIER 3 $$$
EYE CONDITIONS (cont.) TOBRADEX EYE OINTMENT TOBRADEX ST XIIDRA ZERVIATE FEMININE PRODUCTS
peg-prep+ sodium sulfate- potassium sulfate- magnesium sulfate+
HORMONAL AGENTS
desmopressin solution, spray, tablet dotti (QL) estradiol (QL) estradiol (once weekly) estradiol (twice weekly) (QL) euthyrox levo-t levothyroxine tablet levoxyl liothyronine tablet lyllana (QL) methyl- prednisolone dosepack, tablet np thyroid prednisone prednisone intensol progesterone capsule testosterone (PA, QL) testosterone
ANDRODERM (PA, QL) COMBIPATCH DUAVEE ESTRING (QL) ESTROGEL MYFEMBREE (PA, QL) ORIAHNN (PA, QL) ORILISSA (PA, QL) PREMARIN PREMPHASE PREMPRO
ACTIVELLA ANDROGEL (PA, QL) ANGELIQ BIJUVA CRINONE (PA) CYTOMEL DEPO- TESTOSTERONE EVAMIST INTRAROSA (QL) MEDROL MENOSTAR (QL) OSPHENA (QL) RAYALDEE unithroid XYOSTED (PA, QL)
GYNAZOLE 1 miconazole 3 200 mg suppository terconazole
GASTROINTESTINAL/HEARTBURN
dicyclomine capsule, solution, tablet esomeprazole capsule, packet (QL) famotidine suspension, 20 mg, 40 mg tablet
CLENPIQ+ LINZESS LITHOSTAT NEXIUM DR 2.5 MG, 5 MG PACKET (QL) PANCREAZE SUFLAVE+ SUTAB+ TRULANCE VIBERZI
APRISO BONJESTA CARAFATE CUVPOSA DICLEGIS MOTOFEN MOVANTIK (PA) PROTONIX SUSPENSION, TABLET (QL, ST) RECTIV RELISTOR (PA) RELISTOR (PA) SANCUSO (PA, QL) SFROWASA SYMPROIC (PA) VARUBI (PA, QL) VIOKACE
gavilyte-c+ gavilyte-g+ gavilyte-n+ lubiprostone mesalamine
mesalamine dr mesalamine er metoclopramide omeprazole capsule (QL) ondansetron ondansetron ondansetron odt pantoprazole packet, tablet (QL) pantoprazole (QL) peg 3350-electrolyte+ peg-3350 and electrolytes+ peg3350-sodium sulfate-sodium chloride- potassium chloride sodium ascorbate- ascorbic acid+
cypionate 200 mg/ml, 1,000
mg/10 ml, 2,000 mg/10 ml, 6,000 mg/30 ml yuvafem (QL)
INFECTIONS
acyclovir capsule, suspension, tablet
e.e.s. 400 LAGEVRIO (EUA) (QL) PAXLOVID (QL) PAXLOVID (EUA) (QL)
AEMCOLO (QL) BAXDELA 450 MG TABLET (PA) BEYFORTUS+ BILTRICIDE DIFICID (QL)
amoxicillin amoxicillin- clavulanate
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