Cigna Healthcare Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 17-20).
TIER 1 $ TIER 3 $$$ ATTENTION DEFICIT HYPERACTIVITY DISORDER 2 (cont.) TIER 2 $$
TIER 1 $ TIER 3 $$$ BLOOD PRESSURE/HEART MEDICATIONS (cont.) diltiazem 24hr er (xr) dilt xr TIER 2 $$ NORVASC TIAZAC
methylphenidate er 15 mg capsule (PA, QL) methylphenidate er 18 mg tablet (PA, QL) methylphenidate er 20 mg capsule, tablet (PA, QL) methylphenidate er 27mg tablet (PA, QL) methylphenidate er 30 mg capsule (PA, QL) methylphenidate er 36 mg tablet (PA, QL) methylphenidate er 40 mg capsule (PA, QL) methylphenidate er 50 mg capsule (PA, QL) methylphenidate er 54 mg tablet (PA, QL) methylphenidate er 60 mg capsule (PA, QL) methylphenidate la (PA, QL)
VALSARTAN 4 MG/ ML SOLUTION (ST) ZESTORETIC (ST) ZESTRIL (ST)
flecainide irbesartan labetalol tablet lisinopril lisinopril-hctz losartan losartan-hctz matzim la metoprolol tablet metoprolol er olmesartan (QL) olmesartan- amlodipine-hctz olmesartan-hctz (QL) propranolol solution, tablet propranolol er taztia xt telmisartan (QL) tiadylt er valsartan tablet valsartan-hctz
BLOOD THINNERS/ANTI-CLOTTING
clopidogrel
BRILINTA ELIQUIS (PA) XARELTO (PA)
SAVAYSA (PA, QL) ZONTIVITY
CANCER
BLOOD PRESSURE/HEART MEDICATIONS
anastrozole+ exemestane+ methotrexate methotrexate tamoxifen+
ARIMIDEX AROMASIN
amlodipine amlodipine- valsartan
CORLANOR TAB (PA) ENTRESTO (QL) NORLIQVA (PA, QL) TEKTURNA HCT VERQUVO (PA, QL)
AVAPRO (ST) BIDIL (QL) CARDIZEM LA (QL) COZAAR (ST) DIOVAN (ST) DIOVAN HCT (ST) HYZAAR (ST) MICARDIS (QL, ST) MICARDIS HCT 40- 12.5 MG TABLET (QL, ST) MICARDIS HCT 80-12.5 MG, 80-25 MG TABLET (ST) NITROSTAT
atenolol cartia xt carvedilol carvedilol er (QL) clonidine diltiazem tablet diltiazem 12hr er diltiazem 24hr er diltiazem 24hr er (cd) diltiazem 24hr er (la) (QL)
CHOLESTEROL MEDICATIONS
atorvastatin 40 mg, 80 mg atorvastatin 10 mg, 20 mg+ ezetimibe
NEXLETOL (PA, QL) NEXLIZET (PA, QL)
CADUET (QL) LIPOFEN (ST) TRICOR (ST) ZETIA
REPATHA (PA) VASCEPA (PA)
FENOFIBRATE fluvastatin er+ fluvastatin+ icosapent ethyl
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