Cigna Healthcare Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 17-20).
TIER 1 $
TIER 2 $$
TIER 3 $$$
TIER 1 $
TIER 2 $$
TIER 3 $$$
SKIN CONDITIONS
VACCINES Not all plans cover vaccines in the same way. Log in to the myCigna App or myCigna.com , or check your plan materials, to find out how your specific plan covers them. ACTHIB+
amnesteem azelaic acid claravis clindacin etz 1% pledget clindacin p 1% pledgets clindamycin DROPSAFE PREP PAD halobetasol isotretinoin mupirocin 2% ointment myorisan tretinoin (PA age) triderm zenatane
EUCRISA (ST) NAFTIN PRAMOSONE 1% LOTION SANTYL (QL)
ABSORICA ACZONE 7.5% GEL PUMP BRYHALI (ST) CAPEX SHAMPOO (ST) CLEOCIN T CLODERM (ST) EVOCLIN OPZELURA (PA) PRAMOSONE 2.5%- 1% LOTION QBREXZA (PA) REGRANEX (PA, QL) SOOLANTRA TACLONEX SUSPENSION TWYNEO VECTICAL (QL) XEPI
AREXVY+ FLUMIST QUAD+
ADACEL TDAP+ AFLURIA QUAD+ BEXSERO+ BOOSTRIX TDAP+ COMIRNATY+ DAPTACEL DTAP+ DENGVAXIA+ DIPHTHERIA- TETANUS TOXOIDS-PED+ ENGERIX-B ADULT+ ENGERIX-B PEDIATRIC- ADOLESCENT+ FLUAD QUAD+ FLUARIX QUAD+ FLUBLOK QUAD+ FLUCELVAX QUAD+ FLULAVAL QUAD+ FLUZONE HIGH- DOSE QUAD+ FLUZONE QUAD+ GARDASIL 9+ HEPLISAV-B+ HIBERIX+ INFANRIX DTAP+ IPOL+ JANSSEN COVID-19 VACCINE (EUA)+ KINRIX+ MENQUADFI+ MENVEO A-C-Y-W- 135-DIP+ M-M-R II VACCINE+ MODERNA COVID VAC(EUA)+ MODERNA COVID-19 BOOSTER (EUA)+ NOVAVAX COVID (EUA)+ NOVAVAX COVID-19 VACC,ADJ(EUA)+
ROTARIX+ ROTATEQ+
SLEEP DISORDERS/SEDATIVES
doxepin (QL) eszopiclone zolpidem zolpidem er (QL)
DAYVIGO (QL, ST) SUNOSI (PA, QL)
SMOKING CESSATION 2
bupropion sr 150 mg+^ varenicline+^
NICOTROL NS+^ NICOTROL+^
SUBSTANCE ABUSE
buprenorphine buprenorphine- naloxone naloxone (QL) naltrexone (QL)
KLOXXADO (QL) LUCEMYRA (QL) NARCAN (QL) ZUBSOLV
OPVEE (QL) SUBOXONE ZIMHI (QL)
URINARY TRACT CONDITIONS
finasteride oxybutynin 5 mg tablet, solution, tablet
FLOMAX PYRIDIUM UROCIT-K
oxybutynin er potassium er
tamsulosin tolterodine tolterodine er (QL)
15
Made with FlippingBook - professional solution for displaying marketing and sales documents online