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 $$
TIER 3 $$$
INFECTIONS (cont.)
MISCELLANEOUS (cont.)
tobramycin ampule* (PA,QL) valacyclovir valganciclovir vancomycin capsule, solution vandazole voriconazole (PA)
KIMONO MAXX+ (QL) KIMONO MICROTHIN AQUA LUBE+ (QL) KIMONO MICROTHIN+ (QL) KIMONO TEXTURED+ (QL) MICROLET NOVAMAX PLUS ONETOUCH LANCETS POGO AUTOMATIC TEST CARTRIDGE PRECISION XTRA sapropterin* (PA) sodium chloride inhalation vial, irrigation solution vial TECHLITE LANCETS TRUEPLUS KETONE TEST STRIP TRUSTEX+ (QL) TRUSTEX CONDOM+ (QL) TRUSTEX LATEX CONDOM+ (QL) TRUSTEX-RIA+ (QL)
POCKET CHAMBER (QL) PROCARE SPACER WITH CHILD MASK (QL) RITEFLO (QL) SPACE CHAMBER (QL) SPACE CHAMBER- MEDIUM MASK (QL) SPACE CHAMBER- SMALL MASK (QL) VORTEX (QL) VORTEX VHC FROG MASK (QL) VORTEX VHC LADYBUG MASK (QL)
INFERTILITY clomiphene ^ ENDOMETRIN^ PREGNYL*^ (PA)
CHORIONIC GONADOTROPIN 10,000 UNIT VIAL*^ (PA) CRINONE 8%^ (PA)
MISCELLANEOUS
ACCU-CHEK FASTCLIX LANCET DRUM ACCU-CHEK MULTICLIX LANCETS ACCU-CHEK SAFE- T-PRO 23G LANCETS ACCU-CHEK CONDOMS+ (QL) deferiprone* (PA) disulfiram DROPLET LANCETS DUREX AVANTI BARE REAL FEEL+ (QL) FANTASY+ (QL) FORA GTEL KETONE TEST STRIP GOJJI BLOOD KETONE TEST STRIP KETONE CARE TEST STRIP SOFTCLIX LANCETS AIMSCO+ (QL) cinacalcet* KETONE TEST STRIP KETOSTIX REAGENT KIMONO+ (QL)
ACE AEROSOL CLOUD
ADDYI^ (PA, QL) AUSTEDO* (PA) BRISDELLE (QL) EVRYSDI* (PA) GALAFOLD* HYPER-SAL INGREZZA INITIATION PACK* (PA, QL) INGREZZA* (PA) NUEDEXTA (QL) ORFADIN* (PA) PALYNZIQ* (PA) PRO COMFORT SPACER WITH MASK (QL) RADICAVA ORS* (PA,QL) TIGLUTIK* (PA) VYNDAMAX* (PA, QL)
ENHANCER (QL) AEROCHAMBER MINI (QL) AEROCHAMBER MV (QL) AEROCHAMBER PLUS FLOW-VU (QL) AEROCHAMBER Z-STAT PLUS (QL) AEROTRACH PLUS (QL) AEROVENT PLUS (QL) BREATHRITE (QL) CERDELGA* (PA) CLEVER CHOICE HOLDING CHAMBER (QL) COMPACT SPACE CHAMBER (QL) EASIVENT (QL) ESBRIET* (PA) FLEXICHAMBER (QL) MICROCHAMBER (QL) NITYR* (PA) OPTICHAMBER DIAMOND (QL)
MULTIPLE SCLEROSIS
dalfampridine er* (PA) dimethyl fumarate*
BAFIERTAM* (PA) GILENYA* (PA) MAYZENT* (PA) VUMERITY* (PA) ZEPOSIA* (PA)
FIRDAPSE* (PA,QL) MAVENCLAD* (PA) PONVORY* (PA)
NUTRITIONAL/DIETARY
betaine anhydrous* cyanocobalamin injection dodex fluoride+^ folic acid+^ folic acid capsule, tablet+ folitab 500+ klor-con KLOR-CON 8 MEQ
CITRANATAL ASSURE CITRANATAL B-CALM CITRANATAL DHA CITRANATAL HARMONY CITRANATAL RX FLORIVA CHEWABLE TABLET+
ACCRUFER^ AURYXIA (QL) CITRANATAL BLOOM^ DRISDOL^ K-TAB ER OB COMPLETE^ PHOSLYRA PRENATAL FORMULA-DHA+ ROCALTROL^
15
Made with FlippingBook - professional solution for displaying marketing and sales documents online