Cigna Healthcare Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 17-20).
TIER 1 $
TIER 2 $$ TIER 3 $$$ NUTRITIONAL/DIETARY (cont.) QUFLORA PEDIATRIC 0.25 MG/ML DROPS, 0.5 MG/ ML DROPS, 1 MG CHEWABLE TABLET+ TRI-VI-FLOR+ VELPHORO VELTASSA OSTEOPOROSIS PRODUCTS
TIER 1 $ TIER 3 $$$ PAIN RELIEF AND INFLAMMATORY DISEASE (cont.) oxycodone- acetaminophen (PA) TIER 2 $$
prolate tablet (PA) sumatriptan (QL) sumatriptan (QL)
PARKINSON’S DISEASE
carbidopa- levodopa-
MIRAPEX ER (QL) NEUPRO RYTARY
entacapone pramipexole pramipexole er (QL) ropinirole ropinirole er
STALEVO XADAGO
alendronate ibandronate tablet
ACTONEL (ST) ATELVIA (ST) BINOSTO (ST) EVISTA FOSAMAX (ST) PAIN RELIEF AND INFLAMMATORY DISEASE
raloxifene+ risedronate risedronate dr
SCHIZOPHRENIA/ANTI-PSYCHOTICS 2
aripiprazole (QL) aripiprazole odt quetiapine quetiapine er clonazepam gabapentin lacosamide solution, tablet lamotrigine lamotrigine (blue, green, orange) lamotrigine er lamotrigine odt lamotrigine odt (orange) levetiracetam solution, tablet levetiracetam er oxcarbazepine pregabalin capsule, solution roweepra subvenite subvenite (blue, green orange) topiramate topiramate er (QL)
REXULTI (QL, ST)
CAPLYTA (QL, ST) FANAPT (QL, ST) SECUADO (ST) VRAYLAR (QL, ST) APTIOM (PA, QL) BRIVIACT TABLET, ORAL SOLUTION (PA) CARBATROL (PA) DILANTIN (PA) LYRICA SOLUTION (PA) NEURONTIN (PA) ONFI (PA) OXTELLAR XR (PA) PHENYTEK (PA) SPRITAM (PA) TEGRETOL (PA) TEGRETOL XR (PA) VALTOCO (PA, QL) XCOPRI (PA, QL)
allopurinol tablet buprenorphine film, patch (QL) celecoxib (QL) colchicine cyclobenzaprine diclofenac tablet diclofenac er ec-naproxen endocet (PA) hydrocodone- acetaminophen (PA) ibu 400 mg, 600 mg, 800 mg tablet ibuprofen suspension, 400 mg, 600 mg, 800 mg tablet lidocaine 5% patch, meloxicam tablet methocarbamol 500 mg, 700 mg tablet oxycodone (PA) OXYCODONE ER (PA) ointment, 2% solution (QL)
AIMOVIG AUTO- INJECTOR (PA) AJOVY AUTO- INJECTOR, SYRINGE (PA) BELBUCA (QL) EMGALITY PEN, SYRINGE (PA) FLECTOR (PA, QL) HYSINGLA ER (PA) LICART (PA, QL) MITIGARE NUCYNTA (PA) NURTEC ODT (PA, QL) OTREXUP (PA) PROCTOFOAM-HC QULIPTA (PA, QL) SAVELLA TRUDHESA (PA, QL) UBRELVY (PA, QL) XTAMPZA ER (PA) ZAVZPRET (PA, QL) ZTLIDO
BUTRANS (QL) CELEBREX (QL, ST) NUCYNTA ER (PA) OXAYDO (PA) ROXYBOND (PA)
SEIZURE DISORDERS
DILANTIN 30 MG CAPSULE (PA) FYCOMPA (PA, QL) NAYZILAM (PA, QL) VIMPAT 10 MG/ML SOLUTION
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