25 Cigna Healthcare Advantage 3-Tier Prescription Drug List Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization AGE – Age Requirement OC – Optional Coverage Tier 2 – Preferred Brands QL – Quantity Limit SP – Specialty Medication Tier 3 – Non-Preferred Brands ST – Step Therapy PPACA – No Cost-Share Preventive Medication SCHIZOPHRENIA/ANTI-PSYCHOTICS2 (cont.) Medication Tier Notes INVEGA TRINZA 2 QL lurasidone 1 QL olanzapine 1 paliperidone er 1 QL PERSERIS 3 QL quetiapine 25 mg, 50 mg, 100 mg, 200 mg, 300 mg, 400 mg tablet 1 quetiapine er 1 REXULTI 2 QL, ST risperidone 1 RYKINDO 3 QL SECUADO 3 ST UZEDY 3 QL VRAYLAR 3 QL, ST ziprasidone 1 VRAYLAR 3 QL, ST SEIZURE DISORDERS Medication Tier Notes BRIVIACT 3 PA carbamazepine er 1 clonazepam 1 DILANTIN 30 MG CAPSULE 2 PA DILANTIN 100 MG CAPSULE; INFATAB, ORAL SUSPENSION 3 PA divalproex 1 divalproex er 1 EPIDIOLEX 3 SP, PA FINTEPLA 3 SP, PA FYCOMPA ORAL SUSPENSION 2 PA gabapentin 1 lacosamide 1 lamotrigine er 1 lamotrigine odt 1 levetiracetam er 1 LYRICA ORAL SOLUTION 3 PA SEIZURE DISORDERS (cont.) Medication Tier Notes NAYZILAM 2 PA, QL oxcarbazepine 1 OXTELLAR XR 3 PA PHENYTEK 3 PA pregabalin 1 roweepra 1 SPRITAM 3 PA subvenite 1 TEGRETOL XR 3 PA topiramate 1 topiramate er 1 QL TROKENDI XR 3 QL VALTOCO 2 PA, QL vigpoder 1 SP VIMPAT ORAL SOLUTION 2 VIMPAT VIAL 3 XCOPRI 3 PA, QL SKIN CONDITIONS Medication Tier Notes ABSORICA 3 ACZONE 7.5% GEL PUMP 3 adapalene-benzoyl peroxide 1 ADBRY 2 SP, PA azelaic acid 1 BRYHALI 3 ST CAPEX SHAMPOO 3 ST CIBINQO 2 SP, PA, QL clindamycin foam, gel, lotion, pledget, solution 1 clobetasol 0.05% cream; foam, gel, lotion, ointment, shampoo, topical solution, topical spray 1 CLODERM 3 ST clotrimazole-betamethasone 1 dapsone 5% gel 1