Cigna Healthcare Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 17-20).
TIER 1 $
TIER 2 $$ TIER 3 $$$ CONTRACEPTION PRODUCTS (cont.)
TIER 1 $
TIER 2 $$ TIER 3 $$$ CONTRACEPTION PRODUCTS (cont.)
kurvelo+ larin 24 fe+ larin fe+ larin+ leena+ lessina+ levonest+ levonorgestrel- ethinyl estradiol+ levonorgestrel- ethinyl estradiol ethinyl estradiol+ levonorgestrel- ethinyl estradiol-fe bisglycinate+ levora-28+ lojaimiess+ loryna+ low-ogestrel+ lo-zumandimine+ lutera+ lyleq+ lyza+ marlissa+ medroxy- progesterone+ merzee+ mibelas 24 fe+ microgestin 24 fe+ microgestin fe+ microgestin+ mili+ mono-linyah+ necon+ nikki+ nora-be+ norelgestromin- ethinyl estradiol+ norethindrone+ norethindrone- ethinyl estradiol- fe+ norethindrone- ethinyl estradiol+ norethindrone- ethinyl estradiol+ norethindrone- ethinyl estradiol ferrous fumarate+
norgestimate- ethinyl estradiol+
norlyda+ nortrel+ nylia+ nymyo+ ocella+ philith+ pimtrea+ pirmella+ portia+
previfem+ reclipsen+ rivelsa+ setlakin+ sharobel+ simliya+ simpesse+ sprintec+ sronyx+ syeda+ tarina 24 fe+ tarina fe 1-20 eq+ tarina fe+ taysofy+ tilia fe+ tri femynor+ tri-estarylla+ tri-legest fe+ tri-linyah+ tri-lo-estarylla+ tri-lo-marzia+ tri-lo-mili+ tri-lo-sprintec+ tri-mili+ tri-nymyo+
tri-previfem+ tri-sprintec+ trivora-28+ tri-vylibra lo+ tri-vylibra+
tulana+ turqoz+ tydemy+ velivet+ vestura+ vienva+ viorele+ volnea+
9
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