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 $$ TIER 3 $$$ ASTHMA/COPD/RESPIRATORY (cont.) COMBIVENT RESPIMAT (QL) DULERA (QL) INCRUSE ELLIPTA OFEV* (PA) OPSUMIT* (PA)
TIER 1 $ TIER 3 $$$ BLOOD PRESSURE/HEART MEDICATIONS (cont.) amlodipine- olmesartan (QL) amlodipine- valsartan atenolol TIER 2 $$ TEKTURNA HCT (QL) VERQUVO (PA,QL)
LONHALA MAGNAIR (PA, QL) ORENITRAM ER* (PA) ORKAMBI* (PA, QL) PULMICORT RESPULES (QL) SINGULAIR TRIKAFTA* (PA, QL) TYVASO REFILL KIT* (PA)
CALAN SR CARDIZEM LA (QL) CARDURA CATAPRES-TTS 1 CATAPRES-TTS 2 CATAPRES-TTS 3 COZAAR (ST) DIOVAN (ST) DIOVAN HCT (ST) EPANED MICARDIS (QL, ST) MICARDIS HCT (QL, ST) MINIPRESS NITROSTAT NORTHERA* (PA) NORVASC ORLADEYO* (PA, QL) PACERONE 100 MG, 400 MG TABLET (PA) PROCARDIA XL SOTYLIZE TEKTURNA (QL) TEKTURNA HCT (QL) TIAZAC TIKOSYN (PA, QL) TRIBENZOR VALSARTAN (ST) VALSARTAN 4MG/ ML SOLUTION (ST) VERELAN VERELAN PM ZESTORETIC (ST) ZESTRIL (ST) EXFORGE HCT HYZAAR (ST) LOTENSIN (ST)
benazepril bisoprolol bisoprolol-hctz candesartan cartia xt carvedilol carvedilol er (QL) clonidine diltiazem 12hr er diltiazem 24hr er diltiazem 24hr er (cd) diltiazem 24hr er (la) diltiazem 24hr er (xr) diltiazem DILT-XR dofetilide (QL) doxazosin droxidopa* enalapril flecainide guanfacine hydralazine tablet irbesartan irbesartan- hctz labetalol tablet lisinopril lisinopril-hctz losartan metoprolol metyrosine (PA) nadolol nebivolol (QL) nifedipine nifedipine er olmesartan (QL) olmesartan- amlodipine-hctz olmesartan-hctz (QL) pacerone pacerone 200 mg tablet
PULMOZYME* (PA) QVAR REDIHALER SPIRIVA HANDIHALER (QL) STIOLTO RESPIMAT (QL) STRIVERDI RESPIMAT (QL) TRACLEER* (PA) TRELEGY ELLIPTA (QL)
ATTENTION DEFICIT HYPERACTIVITY DISORDER 2 amphetamine (PA) atomoxetine (QL) dexmethylph- enidate (PA, QL) dexmethylph- enidate er (PA, QL) guanfacine er methylphenidate (PA) methylphenidate capsule (PA,QL) methylphenidate cd (PA, QL) methylphenidate er (PA, QL) methylphenidate er (cd) (PA, QL) methylphenidate er (la) (PA, QL) methylphenidate la (PA, QL) MYDAYIS (PA, QL) VYVANSE (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) METHYL- PHENIDATE ER 72 MG TAB (QL) QUILLICHEW ER (PA, QL) QUILLIVANT XR (PA, QL) RITALIN (PA, ST)
BLOOD MODIFIERS/BLEEDING DISORDERS DOPTELET* (PA) SIKLOS (PA) TAVALISSE* (PA) BLOOD PRESSURE/HEART MEDICATIONS DROXIA
tranexamic acid 650 mg*
amiodarone tablet amlodipine amlodipine- benazepril
CORLANOR (PA) ENTRESTO (QL) NORLIQVA (PA,QL)
ALTACE (ST) AVALIDE (ST) AVAPRO (ST) BIDIL (QL)
7
Made with FlippingBook - professional solution for displaying marketing and sales documents online