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 $$ TIER 3 $$$ ASTHMA/COPD/RESPIRATORY (cont.)
ALLERGY/NASAL SPRAYS
azelastine 0.1% (137 mcg) spray azelastine- fluticasone epinephrine (QL) fluticasone hydroxyzine capsule, syrup, tablet
GRASTEK (PA, QL) ODACTRA (PA, QL) ORALAIR (PA, QL) RAGWITEK (PA, QL)
budesonide- formoterol (QL) fluticasone- salmeterol 100-50, 250-50, 500-50 (QL) montelukast wixela inhub (QL)
ASMANEX (QL) ASMANEX HFA (QL) ATROVENT HFA (QL) BREO ELLIPTA (QL) BREZTRI AEROSPHERE (QL) COMBIVENT RESPIMAT (QL) DULERA (QL) INCRUSE ELLIPTA QVAR REDIHALER SPIRIVA
ALZHEIMER’S DISEASE
donepezil donepezil odt memantine memantine er (QL) pyridostigmine pyridostigmine er
ADLARITY (PA, QL) ARICEPT NAMENDA
NAMENDA XR (QL) NAMZARIC (QL)
HANDIHALER (QL) SPIRIVA RESPIMAT (QL) STIOLTO RESPIMAT (QL) STRIVERDI RESPIMAT (QL) TRELEGY ELLIPTA (QL) ATTENTION DEFICIT HYPERACTIVITY DISORDER 2 atomoxetine (QL) dexmethyl- phenidate (PA) dexmethyl- phenidate er (PA, QL) dextro- amphetamine- amphetamine (PA) dextro- amphetamine- amphetamine er (PA, QL) guanfacine er methylphenidate (PA, QL) methylphenidate cd (PA, QL) methylphenidate er (cd) (PA, QL) methylphenidate er (la) (PA, QL) ADDERALL (PA, ST) ADZENYS XR-ODT (PA, QL) AZSTARYS (PA, ST, QL) DAYTRANA (PA, QL) DYANAVEL XR (PA, QL) EVEKEO ODT (PA) FOCALIN (PA, ST) METHYLIN (PA) MYDAYIS (PA, QL) QUILLICHEW ER (PA, QL) QUILLIVANT XR (PA, QL) RITALIN (PA, ST) VYVANSE (PA, QL) XELSTRYM (PA, QL)
ANXIETY/DEPRESSION/BIPOLAR DISORDER 2
bupropion (QL) bupropion sr 150 mg (QL) bupropion xl 150 mg, 300 mg tablet (QL) buspirone citalopram tab (QL) citalopram 10 mg/ 5 ml solution (QL) desvenlafaxine er (QL) duloxetine (QL) escitalopram (QL) fluoxetine (QL) fluoxetine dr (QL) sertraline tablet (QL) sertraline 20 mg/ml oral concentrate (QL) trazodone venlafaxine (QL) venlafaxine er (QL)
TRINTELLIX (QL)
EMSAM (QL) FETZIMA (QL, ST)
ASTHMA/COPD/RESPIRATORY
albuterol albuterol hfa 90 mcg inhaler (QL) breyna (QL)
ADVAIR HFA (QL) ALVESCO ANORO ELLIPTA (QL)
AIRDUO DIGIHALER (QL, ST) SINGULAIR
methylphenidate er 10 mg capsule, tablet (PA, QL)
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