27 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 TRANSPLANT MEDICATIONS (cont.) Medication Tier Notes PROGRAF GRANULE PACKET 3 SP REZUROCK 3 SP, PA sirolimus 1 SP tacrolimus capsule 1 SP URINARY TRACT CONDITIONS Medication Tier Notes alfuzosin er 1 cevimeline 1 dutasteride 1 ELMIRON 3 finasteride 5 mg tablet 1 K-PHOS NO.2 3 K-PHOS ORIGINAL 3 mirabegron er 1 QL oxybutynin er 1 phenazopyridine 100 mg, 200 mg tablet 1 potassium citrate er 1 solifenacin 1 QL tamsulosin 1 tolterodine er 1 QL trospium er 1 VANRAFIA 2 SP, PA, QL VACCINES Not all plans cover vaccines in the same way. Log in to the myCigna App or myCigna.com, or check your plan materials, to see how your plan covers them. Medication Tier Notes ABRYSVO 3 PPACA ACTHIB 3 PPACA ADACEL TDAP 3 PPACA AFLURIA 3 PPACA AREXVY 3 PPACA BEXSERO 3 PPACA VACCINES (cont.) Not all plans cover vaccines in the same way. Log in to the myCigna App or myCigna.com, or check your plan materials, to see how your plan covers them. Medication Tier Notes BOOSTRIX TDAP 3 PPACA CAPVAXIVE 3 PPACA COMIRNATY 3 PPACA DAPTACEL DTAP 3 PPACA DENGVAXIA 3 PPACA ENGERIX-B 3 PPACA FLUAD 3 PPACA FLUAD QUAD 3 PPACA FLUARIX 3 PPACA FLUBLOK 3 PPACA FLUCELVAX 3 PPACA FLULAVAL 3 PPACA FLUMIST 3 PPACA FLUZONE 3 PPACA FLUZONE HIGH-DOSE 3 PPACA GARDASIL 9 3 PPACA HEPLISAV-B 3 PPACA HIBERIX 3 PPACA INFANRIX DTAP 3 PPACA IPOL 3 PPACA JANSSEN COVID 3 PPACA KINRIX 3 PPACA MENQUADFI 3 PPACA MENVEO A-C-Y-W-135-DIP 3 PPACA M-M-R II VACCINE 3 PPACA MODERNA COVID 3 PPACA MRESVIA 3 PPACA NOVAVAX COVID 3 PPACA PEDIARIX 3 PPACA PEDVAXHIB 3 PPACA PENBRAYA 3 PPACA PENMENVY MEN A-B-C-W-Y 3 PPACA