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 $$ TIER 3 $$$ NUTRITIONAL/DIETARY (cont.)
TIER 1 $ TIER 3 $$$ PAIN RELIEF AND INFLAMMATORY DISEASE (cont.) celecoxib (QL) colchicine 0.6 mg tablet TIER 2 $$
KLOR-CON 10 MEQ KLOR-CON M10 TABLET lanthanum MULTI-VITAMIN W-FLUORIDE- IRON+ potassium chloride 10%, capsule, packet, tablet sevelamer sodium fluoride+^ taron-prex prenatal^ vitamin d2 1.25 mg (50,000 unit)^ VITAMINS A,C,D AND FLUORIDE+
FOSRENOL 1,000 MG POWDER PACK FOSRENOL 750 MG POWDER PACKET LOKELMA NEEVO DHA^ OB COMPLETE ONE OB COMPLETE PETITE OB COMPLETE PREMIER OB COMPLETE WITH DHA POLY-VI-FLOR WITH IRON+ POLY-VI-FLOR+ PRENATE^ PRIMACARE QUFLORA PEDIATRIC 1 MG CHEWABLE TABLET+ QUFLORA PEDIATRIC 0.25 MG/ML DROP+ QUFLORA PEDIATRIC 0.5 MG/ ML DROP+
TRI-VI-FLOR+ VELPHORO VELTASSA
HYSINGLA ER (PA) LICART (PA, QL) MITIGARE NUCYNTA (PA) NURTEC ODT (PA, QL) OTEZLA* (PA, QL) OTREXUP (PA) PROCTOFOAM-HC QULIPTA (PA, QL) REDITREX (PA) RINVOQ* (PA, QL) SAVELLA TRUDHESA (PA,QL) UBRELVY (PA, QL) XELJANZ* (PA, QL) XELJANZ XR* (PA, QL) XTAMPZA ER (PA) ZTLIDO
BUTRANS (QL) CELEBREX (QL, ST) DEPEN* (PA, QL) EC-NAPROSYN (ST) FEXMID KEVZARA* (PA, QL) KINERET* (PA,QL) NAPROSYN (ST) NUCYNTA ER (PA) OLUMIANT* (PA, QL) OTREXUP (PA) PERCOCET (PA) PROCORT REMICADE*^ (PA) ROXYBOND (PA) ZANAFLEX ZEBUTAL (QL) ZOHYDRO ER (PA)
cyclobenzaprine diclofenac 1% gel, tablet (QL) diclofenac dr diclofenac ec EC-NAPROXEN ECOTRIN EC 81 MG TABLET+ eletriptan (QL) ENDOCET (PA) febuxostat (QL) fentanyl patch (PA) frovatriptan (QL) FIORICET (QL) GLYDO hydrocodone- acetaminophen (PA) hydromorphone (PA) hydromorphone er (PA) IBU ibuprofen indomethacin indomethacin er ketorolac tromethamine (QL) leflunomide lidocaine patch, ointment, solution (QL) meloxicam tablet metaxalone methocarbamol MORPHINE (PA) MORPHINE ER (PA) nabumetone NALOCET (PA) oxycodone (PA) oxycodone er (PA) oxycodone- acetaminophen (PA)
OSTEOPOROSIS PRODUCTS
alendronate ibandronate 150 mg tablet raloxifene+ risedronate risedronate dr
ACTONEL (ST) ATELVIA (ST) BINOSTO (ST) BONIVA (ST) EVISTA
PAIN RELIEF AND INFLAMMATORY DISEASE
acetaminophen- codeine (PA) allopurinol tablet baclofen tablet buprenorphine patch (QL) butalbital- acetaminophen-
AIMOVIG (PA) AJOVY (PA)
ANALPRAM HC ARAVA BUTRANS (QL) CELEBREX (QL, ST) DEPEN* (PA, QL) EC-NAPROSYN (ST) FEXMID KEVZARA* (PA, QL) ANALPRAM HC ARAVA
BELBUCA (QL) EMGALITY (PA) FLECTOR (PA, QL) AIMOVIG (PA) AJOVY (PA) BELBUCA (QL) EMGALITY (PA) FLECTOR (PA, QL)
caffeine (QL) carisoprodol
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