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 $$ TIER 3 $$$ HORMONAL AGENTS (cont.)
TIER 1 $
TIER 2 $$
TIER 3 $$$
INFECTIONS (cont.)
fyremadel^ (PA) LEVO-T levothyroxine tablet LEVOXYL liothyronine LYLLANA (QL) medroxy- progesterone methyl- prednisolone millipred MIMVEY norethindrone NP THYROID prednisone prednisone intensol prednisolone solution prednisolone odt prednisolone sodium phosphate progesterone tablet testosterone cypionate YUVAFEM (QL)
PREMPRO
MENOSTAR (QL) PROMETRIUM RAYALDEE
cephalexin ciprofloxacin clarithromycin clarithromycin er clindamycin clindamycin (pediatric) coremino (QL) dapsone tablets doxycycline monohydrate EMVERM entecavir* (QL) erythromycin erythromycin ethylsuccinate chloroquine itraconazole levofloxacin solution, tablet methenamine metronidazole gel, capsule, tablet minocycline minocycline er tablet (QL) mondoxyne nl nitazoxanide nitrofurantoin nitrofurantoin monohydrate- macrocrystal nystatin suspension, tablet oseltamivir (QL) penicillin v potassium permethrin 5% cream posaconazole tablet sulfamethoxazole- trimethoprim suspension, tablet famciclovir fluconazole flucytosine fosfomycin hydroxy-
XIFAXAN (QL)
CLINDESSE DARAPRIM* (PA) DIFICID (QL) ELIMITE ERYPED 200 ERY-TAB DR 250 MG, 500 MG TABLET EURAX 10* LOTION FLAGYL HIPREX KITABIS PAK* (PA, QL) LIVTENCITY* (PA, QL) MACROBID MACRODANTIN MALARONE (PA) MONUROL NATROBA NUZYRA 150 MG TABLET* (PA,QL) PLAQUENIL (PA) posaconazole suspension PREVYMIS TABLET* PRIFTIN SIVEXTRO 200 MG TABLET (PA) SKLICE sulfatrim TAMIFLU (QL) URIBEL VALTREX VFEND (PA) VIEKIRA PAK* (PA,QL) XENLETA (PA, QL) XOFLUZA (QL) ZEPATIER* (PA, QL) ZITHROMAX ZITHROMAX TRI- PAK ZYVOX SUSPENSION, TABLET (PA)
teriparatide* UNITHROID
INFECTIONS
acyclovir capsule, suspension, tablet albendazole
BARACLUDE SOLUTION* e.e.s. 400
AEMCOLO (QL) ALINIA ANCOBON ARIKAYCE* (PA) BACTRIM BACTRIM DS BAXDELA 450 MG TABLET (PA) CAYSTON* (PA, QL) CIPRO 250MG, 500MG TABLET CIPRO TABLET CLEOCIN PEDIATRIC CLEOCIN 150, 300 MG CAPSULE CLEOCIN 100 MG VAGINAL OVULE CLEOCIN 2% VAGINAL CREAM
amoxicillin amoxicillin- clavulanate er
EPCLUSA* (PA, QL) EURAX 10% CREAM FIRVANQ HARVONI* (PA, QL) LAGEVRIO (EUA) (QL) SOVALDI* (PA, QL) THALOMID* (PA) TOBI PODHALER* (PA, QL) VEMLIDY* VIBRAMYCIN 50 MG/5 ML SYRUP VOSEVI* (PA, QL) PAXLOVID (QL) PEGASYS* (PA)
amoxicillin- clavulanate atovaquone atovaquone- proguanil AVIDOXY azithromycin packet, suspension, tablet cefadroxil cefdinir cefpodoxime cefuroxime tablet
terbinafine tetracycline
14
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