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 $$ TIER 3 $$$ CONTRACEPTION PRODUCTS
TIER 1 $
TIER 2 $$ TIER 3 $$$ CONTRACEPTION PRODUCTS (cont.)
AFIRMELLE+ ALTAVERA+ ALYACEN+ AMETHIA+ AMETHYST+ APRI+
LO LOESTRIN FE NEXPLANON*+
ANNOVERA BALCOLTRA
ENSKYCE+ ERRIN+ ESTARYLLA+ ethynodiol-ethinyl estradiol+ etonogestrel- ethinyl estradiol+
BEYAZ ELLA+
KYLEENA*+ LAYOLIS FE+ LILETTA*+ LOESTRIN FE MICROGESTIN 24 FE MINASTRIN 24 FE MIRENA*+ NATAZIA NEXTSTELLIS NUVARING PARAGARD T 380- A*+
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+ CHATEAL+ CRYSELLE+ CYRED EQ+ CYRED+ DASETTA+ DAYSEE+ DEBLITANE+ desogestrel-ethinyl estradiol+ desogestrel-ethinyl estradiol-ethinyl estradiol+ DOLISHALE+ drospirenone- ethinyl estradiol- levomefolate+ drospirenone- ethinyl estradiol+ ELINEST+
FALMINA+ FEMCAP+ FEMYNOR+ GEMMILY+ HAILEY 24 FE+ HAILEY FE+ HAILEY+ HEATHER+ ICLEVIA+ INCASSIA+ ISIBLOOM+ JAIMIESS+ JASMIEL+ JENCYCLA+ JOLESSA+ JULEBER+ JUNEL FE 24+ JUNEL FE+ JUNEL+ KAITLIB FE+ KALLIGA+ KARIVA+ KELNOR 1-35+ KELNOR 1-50+ KURVELO+ LARIN 24 FE+ LARIN FE+
SAFYRAL SKYLA*+ SLYND TAYTULLA TWIRLA+ TYBLUME VCF+ YASMIN 28 YAZ
LARIN+ LEENA+ LESSINA+ LEVONEST+ levonorgestrel- ethinyl estradiol+ LEVORA-28+ LOJAIMIESS+ LORYNA+ LOW-OGESTREL+ LO- ZUMANDIMINE+ LUTERA+ LYLEQ+ LYZA+
ELURYNG+ ENPRESSE+
9
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