Cigna Healthcare Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 17-20).
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MISCELLANEOUS (cont.) COMPACT SPACE CHAMBER (QL)
INFECTIONS (cont.)
amoxicillin- clavulanate er azithromycin packet, suspension, tablet cefdinir cephalexin EMVERM fluconazole suspension, tablet hydroxy- chloroquine metronidazole tablet, vaginal gel nitrofurantoin oseltamivir (QL) posaconazole suspension, tablet praziquantel sulfamethoxazole suspension, tablet valacyclovir vandazole ACCU-CHEK FASTCLIX LANCET DRUM ACCU-CHEK SOFTCLIX DROPLET LANCET KETONE TEST STRIP KETOSTIX REAGENT MICROLET ONETOUCH LANCETS POGO AUTOMATIC TEST CARTRIDGE PRECISION XTRA sodium chloride SOFT TOUCH LANCET TRUEPLUS KETONE TEST STRIP
XIFAXAN (QL)
ERYPED 200 LIKMEZ (PA) MACROBID
EASIVENT (QL) FLEXICHAMBER (QL) MICROCHAMBER (QL) MICROSPACER (QL)
MACRODANTIN PLAQUENIL (PA) SIVEXTRO 200 MG TABLET (PA) sulfatrim TAMIFLU (QL) VALTREX VIVJOA (PA) XENLETA TABLET (PA, QL) XOFLUZA (QL) ZITHROMAX PACKET, SUSPENSION, TABLET ZITHROMAX TRI- PAK ZYVOX SUSPENSION, TABLET (PA)
OPTICHAMBER DIAMOND (QL) POCKET CHAMBER (QL) PROCARE SPACER WITH CHILD MASK (QL) RITEFLO (QL) SPACE CHAMBER (QL) SPACE CHAMBER- MEDIUM MASK (QL) VORTEX (QL) VORTEX VHC FROG MASK (QL) NUTRITIONAL/DIETARY
INFERTILITY
CRINONE^ ENDOMETRIN^ MISCELLANEOUS
ludent fluoride+^ multivitamin with fluoride+ sodium fluoride chewable tablet, drops+^ tri-vitamin with fluoride+ vitamin d2 1.25mg (50,000 unit)^ vitamins a,c,d and fluoride+
FLORIVA CHEWABLE TAB+ LOKELMA mvc-fluoride+ NEEVODHA^ OB COMPLETE SOFTGEL, TABLET POLY-VI-FLOR WITH IRON+ POLY-VI-FLOR+ PRENATE CHEWABLE^ PRENATE DHA PRENATE ELITE PRENATE ENHANCE PRENATE ESSENTIAL^ PRENATE MINI PRENATE PIXIE PRENATE RESTORE PRIMACARE
ACCRUFER^ AURYXIA (QL) DRISDOL^ EFFER-K OB COMPLETE CAPLET^ PHOSLYRA
ACE AEROSOL CLOUD
ADDYI^ (PA, QL) NUEDEXTA (QL) VEOZAH (QL)
ENHANCER (QL) AEROCHAMBER (QL) AEROCHAMBER MV (QL) AEROCHAMBER PLUS FLOW-VU (QL) AEROCHAMBER Z-STAT PLUS (QL) AEROTRACH PLUS (QL) AEROVENT PLUS (QL) BREATHRITE (QL) CLEVER CHOICE HOLDING CHAMBER (QL)
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