Cigna Healthcare Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 17-20).
TIER 1 $
TIER 2 $$ TIER 3 $$$ CHOLESTEROL MEDICATIONS (cont.)
TIER 1 $
TIER 2 $$ TIER 3 $$$ CONTRACEPTION PRODUCTS (cont.)
lovastatin 20 mg, 40 mg+ lovastatin 10 mg pitavastatin+ (QL) pravastatin+ rosuvastatin 20 mg, 40 mg (QL) rosuvastatin 5 mg, 10 mg+ (QL) simvastatin 5mg, 80mg (QL) simvastatin 10 mg, 20 mg, 40 mg+ (QL)
deblitane+ desogestrel-ethinyl estradiol+ desogestrel-ethinyl estradiol ethinyl estradiol+ dolishale+ drospirenone- ethinyl estradiol- levomefolate+ drospirenone- ethinyl estradiol+ enilloring+ enpresse+ enskyce+ errin+ estarylla+ ethynodiol-ethinyl estradiol+ etonogestrel- ethinyl estradiol+ falmina+ FEMCAP+ finzala+ gemmily+ hailey 24 fe+ hailey fe+ hailey+ celinest+ eluryng+ emzahh+
CONTRACEPTION PRODUCTS
afirmelle+ altavera+ alyacen+ amethia+ amethyst+ apri+
LO LOESTRIN FE
ANNOVERA BALCOLTRA
BEYAZ ELLA+ layolis fe+ LOESTRIN FE MINASTRIN 24 FE NATAZIA NEXTSTELLIS NUVARING SAFYRAL SLYND
aranelle+ ashlyna+ aubra eq+ aubra+ aurovela 24 fe+ aurovela fe+ aurovela+ aviane+ ayuna+ azurette+ balziva+ blisovi 24 fe+ blisovi fe+ briellyn+ camila+ camrese lo+ camrese+ CAYA CONTOURED+ caziant+ charlotte 24 fe+ chateal eq+
TAYTULLA TWIRLA+ TYBLUME YASMIN 28 YAZ
haloette+ heather+ iclevia+ incassia+ isibloom+ jaimiess+ jasmiel+ jencycla+ jolessa+ joyeaux+ juleber+ junel fe 24+ junel fe+ junel+ kaitlib fe+
chateal+ cryselle+ cyred eq+ dasetta+ daysee+
kalliga+ kariva+
kelnor 1-35+ kelnor 1-50+
8
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