Cigna Healthcare Standard 4-Tier Prescription Drug List Injectable specialty medications are covered on Tier 4 (listed on pages 20-23).
TIER 1 $ TIER 3 $$$ BLOOD PRESSURE/HEART MEDICATIONS (cont.) prazosin propranolol tablet propranolol er ramipril ranolazine er (QL) sajazir* (PA) taztia xt TIER 2 $$
TIER 1 $
TIER 2 $$
TIER 3 $$$
CANCER (cont.)
NERLYNX* (PA) NINLARO* (PA, QL) ODOMZO* (PA) ORGOVYX* (PA) PIQRAY* (PA) POMALYST* (PA, QL) PURIXAN* RETEVMO* (PA,QL) ROZLYTREK* (PA) SCEMBLIX* (PA,QL) STIVARGA* (PA, QL) TAFINLAR* (PA, QL) TAGRISSO* (PA) TALZENNA* (PA,QL) TASIGNA* (PA, QL) TIBSOVO* (PA) TUKYSA* (PA) VITRAKVI* (PA) WELIREG* (PA, QL) XELODA* (PA) XOSPATA* (PA) ZELBORAF* (PA)
telmisartan (QL) telmisartan-hctz (QL) tiadylt er valsartan-hctz verapamil er verapamil er pm verapamil tablet verapamil sr
BLOOD THINNERS/ANTI-CLOTTING
clopidogrel jantoven prasugrel warfarin
BRILINTA ELIQUIS (PA) XARELTO (PA)
ARIXTRA (QL) PLAVIX PRADAXA (PA) SAVAYSA (PA,QL) ZONTIVITY ALUNBRIG* (PA, QL) ARIMIDEX AROMASIN AYVAKIT* (PA,QL) BOSULIF* (PA, QL) BRAFTOVI* (PA) COMETRIQ* (PA, QL) COTELLIC* (PA) EXKIVITY* (PA) GAVRETO* (PA,QL) IBRANCE* (PA, QL) ICLUSIG* (PA, QL) INLYTA* (PA) JAKAFI* (PA, QL) KISQALI* (PA,QL) KISQALI FEMARA CO-PACK* (PA,QL) LENVIMA* (PA) LONSURF* (PA) LUMAKRAS* (PA,QL) MEKINIST* (PA,QL) MEKTOVI* (PA)
CANCER
CHOLESTEROL MEDICATIONS
abiraterone* (PA) anastrozole+ capecitabine* (PA) everolimus* (PA, QL) sodium (QL) hydroxyurea imatinib* (QL) lenalidomide* (PA,QL) letrozole mercaptopurine methotrexate tamoxifen+ temozolomide* (PA) exemestane+ fondaparinux
ALECENSA* (PA, QL)
atorvastatin 10 mg, 20 mg+ colesevelam
NEXLETOL (PA, QL) NEXLIZET (PA, QL)
CADUET (QL) LIPOFEN (ST) ROSZET (PA) TRICOR (ST) TRILIPIX (ST) VYTORIN (ST) WELCHOL ZETIA
BRUKINSA* (PA, QL) CABOMETYX* (PA) ERIVEDGE* (PA) ERLEADA* (PA) GLEOSTINE IMBRUVICA* (PA, QL) LYNPARZA* (PA, QL) REVLIMID* (PA, QL) RUBRACA* (PA, QL) SPRYCEL* (PA, QL) TREXALL VENCLEXTA* (PA) VENCLEXTA STARTING PACK* (PA) VERZENIO* (PA) XTANDI* (PA) ZEJULA* (PA, QL)
REPATHA (PA) VASCEPA (PA)
ezetimibe ezetimibe- simvastatin fenofibrate fenofibric acid fluvastatin+
fluvastatin er+ icosapent ethyl lovastatin 10 mg lovastatin 20mg, 40mg tablet+ omega-3 acid ethyl esters pravastatin+ rosuvastatin 5mg, 10 mg+ (QL) simvastatin 80mg (QL) simvastatin 10 mg, 20 mg, 40 mg+ (QL)
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