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 $$
TIER 3 $$$
TIER 1 $
TIER 2 $$
TIER 3 $$$
DIABETES (cont.)
DIURETICS
ACETAZOLAMIDE TABLET ACETAZOLAMIDE ER CAPSULE BUMETANIDE TABLET chlorthalidone eplerenone furosemide solution, tablet hydrochloro- thiazide spironolactone triamterene-hctz ciprofloxacin- dexamethasone neomycin- polymyxin b-hydrocortisone ofloxacin
CAROSPIR (PA) DIURIL KERENDIA (PA, QL)
JYNARQUE* (PA) MAXZIDE
MONOJECT MONOJECT
INSULIN SAFETY SYRINGE, INSULIN SYRINGE PARADIGM PRODIGY INSULIN SYRINGE PRO COMFORT INSULIN SYRINGE PURE COMFORT PEN NEEDLE SAFETYGLIDE INSULIN SYRINGE, SYRINGE SURE COMFORT SURE COMFORT INSULIN SYRINGE TOPCARE ULTRA COMFORT TRUE COMFORT INSULIN SYRINGE TRUE COMFORT PRO INS SYRINGE TRUE METRIX LEVEL 1, 2, 3 CONTROL SOULTION TRUEPLUS SYRINGE TRUETRACK BLOOD GLUCOSE SYSTEM ULTICARE ULTIGUARD SAFE0.5ML 30G 12.7MM ULTIGUARD SAFEPK 0.5ML 31G 8MM ULTRACARE INSULIN SYRINGE ULTRA COMFORT ULTRA FLO INSULIN SYRINGE ULTRA-THIN II VANISHPOINT VANISHPOINT INSULIN SYRINGE VEO INSULIN SYRINGE
EAR MEDICATIONS
CIPRO HC
CIPRODEX CIPROFLOXACIN HCL- FLUOCINOLONE CORTISPORIN-TC DERMOTIC OTOVEL
ERECTILE DYSFUNCTION
sildenafil^ (QL) tadalafil^ (QL) vardenafil^ (QL)
MUSE^ (PA, QL)
CIALIS^ (QL, ST) STENDRA^ (QL, ST) VIAGRA^ (QL, ST)
EYE CONDITIONS AZASITE BESIVANCE BETOPTIC S BROMSITE COMBIGAN EYSUVIS (QL) INVELTYS FLAREX FML FORTE 0.25% EYE DROPS FML S.O.P. 0.1% OINTMENT LOTEMAX 0.5% EYE OINTMENT LOTEMAX SM 0.38% OPHTHALMIC GEL LOTEMAX SM SIMBRINZA
bepotastine bimatoprost (QL) brimonidine brimonidine tartrate- timolol brinzolamide ciprofloxacin cyclosporine difluprednate dorzolamide- timolol erythromycin fluorometholone ketorolac ketorolac solution latanoprost loteprednol moxifloxacin eye drops
ACUVAIL ALREX CEQUA CYSTADROPS* (PA, QL) CYSTARAN* (PA, QL) ILEVRO LOTEMAX NEVANAC OXERVATE* (PA) PROLENSA
RHOPRESSA ROCKLATAN TRUSOPT ZIRGAN ZYLET
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