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 $$ TIER 3 $$$ ANXIETY/DEPRESSION/BIPOLAR DISORDER 2
AIDS/HIV
efavirenz- emtricitabine- tenofovir* (QL) emtricitabine- tenofovir 200-300 mg*+ etravirine* ritonavir* tenofovir* (PA)
BIKTARVY* (QL) DESCOVY 200-25 MG TABLET*+ (PA) DOVATO* (QL) GENVOYA* (QL) ISENTRESS HD* (PA) ISENTRESS* JULUCA* (QL) PREZISTA* SYMTUZA* (QL) TIVICAY PD* TIVICAY* TRIUMEQ* (QL) TRIUMEQ PD* (QL)
CIMDUO* (PA) COMPLERA* (PA, QL) DELSTRIGO* (PA,QL) ODEFSEY* (PA, QL) PIFELTRO* (PA) PREZCOBIX* (PA) RUKOBIA* (PA,QL) STRIBILD* (PA, QL)
alprazolam alprazolam er alprazolam intensol alprazolam odt alprazolam xr amitriptyline bupropion (QL) bupropion sr (QL) bupropion xl 150 mg tablet (QL) bupropion xl 300 mg tablet (QL) buspirone citalopram (QL) citalopram solution, tablet (QL) clomipramine duloxetine (QL) escitalopram (QL) fluoxetine dr (QL) fluoxetine (QL) fluvoxamine (QL) fluvoxamine er (QL) lorazepam lorazepam intensol mirtazapine paroxetine cr (QL) paroxetine er (QL) paroxetine (QL) sertraline (QL) trazodone venlafaxine (QL) venlafaxine er (QL)
DESVENLAFAXINE ER (QL, ST) EMSAM (QL) FETZIMA (QL, ST) NUPLAZID* (PA) SPRAVATO* (PA) TRINTELLIX (QL, ST) XANAX XANAX XR
ALLERGY/NASAL SPRAYS
azelastine azelastine- fluticasone cromolyn
CLARINEX GASTROCROM
GRASTEK (PA, QL) ODACTRA (PA, QL) ORALAIR (PA, QL) PATANASE RAGWITEK (PA, QL) VISTARIL
desloratadine (QL) epinephrine (QL) fluticasone hydroxyzine hcl solution, syrup, tablet hydroxyzine pamoate ipratropium levocetirizine dihydrochloride mometasone (QL) olopatadine phenylephrine hcl promethazine solution, syrup, tablet
ASTHMA/COPD/RESPIRATORY
albuterol alyq* (PA)
ADEMPAS* (PA) ADVAIR HFA (QL) ALVESCO ANORO ELLIPTA (QL) ASMANEX (QL) ASMANEX HFA (QL) ATROVENT HFA (QL) BREO ELLIPTA (QL) BREZTRI AEROSPHERE (QL)
ADCIRCA* (PA) AIRDUO DIGIHALER (QL, ST) BRONCHITOL* (PA) BUDESONIDE- FORMOTEROL (QL) DALIRESP (QL) FLUTICASONE- SALMETEROL (QL) KALYDECO* (PA, QL) LETAIRIS* (PA)
ALZHEIMER’S DISEASE
ambrisentan* (PA) budesonide (QL) fluticasone- salmeterol (QL) ipratropium- albuterol montelukast tadalafil 20mg tablet* (PA) wixela inhub (QL)
donepezil donepezil odt memantine
ARICEPT EXELON
MESTINON NAMENDA NAMENDA XR (QL) NAMZARIC (QL)
memantine er (QL) pyridostigmine 60 mg/5 ml, 60 mg pyridostigmine er rivastigmine
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