26 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 SKIN CONDITIONS (cont.) Medication Tier Notes DROPSAFE PREP PAD 1 DRYSOL 3 EBGLYSS 2 SP, PA EUCRISA 2 ST fluorouracil cream, topical solution 1 halobetasol 1 isotretinoin 1 ketoconazole cream, foam, shampoo 1 LITFULO 3 SP, PA, QL mupirocin 2% ointment 1 NAFTIN 3 NEMLUVIO 2 SP, PA neuac gel 1 ONEXTON 3 OPZELURA 3 PA pimecrolimus 1 PRAMOSONE 3 RETIN-A MICRO PUMP 0.08% GEL 3 PA_AGE rosadan cream, gel 1 SANTYL 3 QL sodium sulfacetamide-sulfur 9.8-4.8%, 10-2%, 10-5% cleanser; cream; lotion; pad; 8-4%, 10-5% topical suspension; wash 1 SOOLANTRA 3 sulfacleanse 8-4 1 tacrolimus ointment 1 tazarotene cream, gel 1 tretinoin cream, gel 1 PA_AGE triderm 1 TWYNEO 3 VALCHLOR 3 SP XEPI 3 zenatane 1 ZORYVE 0.15% CREAM 2 QL ST SLEEP DISORDERS/SEDATIVES Medication Tier Notes DAYVIGO 2 QL, ST doxepin tablet 1 QL eszopiclone 1 LUMRYZ 3 SP, PA, QL modafinil 1 PA SODIUM OXYBATE (by Hikma) 3 SP, PA, QL SUNOSI 2 PA, QL temazepam 1 WAKIX 3 SP, PA, QL XYWAV 3 SP, PA, QL zolpidem sublingual tablet, tablet 1 zolpidem er 1 QL SUBSTANCE ABUSE Medication Tier Notes BRIXADI 3 SP buprenorphine-naloxone 1 KLOXXADO 2 QL LUCEMYRA 2 QL naltrexone 1 QL NARCAN 2 QL OPVEE 3 QL SUBLOCADE 3 SP SUBOXONE 3 ZIMHI 3 QL ZUBSOLV 2 TRANSPLANT MEDICATIONS Medication Tier Notes ENVARSUS XR 3 SP everolimus 0.25 mg, 0.5 mg, 0.75 mg, 1 mg tablet 1 SP LUPKYNIS 3 SP, PA, QL mycophenolate 1 SP mycophenolic acid 1 SP PROGRAF AMPULE 2 SP