22 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 MULTIPLE SCLEROSIS (cont.) Medication Tier Notes PLEGRIDY 2 SP, PA REBIF 2 SP, PA REBIF REBIDOSE 2 SP, PA teriflunomide 1 SP TYSABRI 3 SP, PA VUMERITY 2 SP, PA NUTRITIONAL/DIETARY Medication Tier Notes ACCRUFER 3 AURYXIA 3 QL betaine 1 gram/scoop powder 1 SP calcitriol ampule, capsule, oral solution, vial 1 cyanocobalamin 1 CYSTADANE 3 SP dodex 1 EFFER-K 10 MEQ, 20 MEQ TABLET 3 FLORIVA CHEWABLE TABLET 3 PPACA flotrex 1 PPACA fluoride 1 PPACA folic acid 1000 mcg, 1 mg tablet; vial 1 INJECTAFER 3 PA lanthanum 1 LOKELMA 2 ludent fluoride 1 PPACA MONOFERRIC 3 PA multi-vitamin w-fluoride-iron 1 PPACA multivitamin with fluoride drops, chewable tablet 1 PPACA multivitamin-iron-fluoride 1 PPACA mvc-fluoride 3 PPACA NEEVODHA 3 OB COMPLETE CAPLET 3 OB COMPLETE DHA, ONE, PETITE, PREMIER 2 POLY-VI-FLOR 3 PPACA NUTRITIONAL/DIETARY (cont.) Medication Tier Notes potassium chloride capsule, liquid, packet, intravenous solution, tablet, vial 1 PRENATE AM, CHEWABLE, ENHANCE, ESSENTIAL, MINI, PIXIE, RESTORE, STAR 3 PRENATE DHA, ELITE 2 PRIMACARE 3 QUFLORA PEDIATRIC DROPS; 1 MG CHEWABLE TABLET 3 PPACA sevelamer 1 sodium fluoride chewable tablet, drops 1 PPACA soluvita 1 PPACA soluvita a,c,d with fluoride 1 PPACA SOLUVITA MULTIVITAMIN FLUORIDE 3 PPACA TRI-VI-FLOR 3 PPACA tri-vitamin with fluoride 1 PPACA VELPHORO 2 VELTASSA 2 VITAFOL GUMMIES, ULTRA 3 VITAFOL-ONE 3 vitamin d2 1.25 mg (50,000 unit) 1 vitamins a,c,d and fluoride 1 PPACA OSTEOPOROSIS PRODUCTS Medication Tier Notes alendronate 1 BINOSTO 3 ST EVENITY 3 SP, PA, QL ibandronate syringe, vial 1 SP ibandronate tablet 1 JUBBONTI 2 SP, PA PROLIA 3 SP, PA raloxifene 1 PPACA teriparatide 1 SP, PA, QL WYOST 2 SP, PA