16 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 DIABETES (cont.) Medication Tier Notes ONETOUCH ULTRA2 LANCET 3 ONETOUCH VERIO FLEX METER 3 ONETOUCH VERIO REFLECT METER 3 OZEMPIC 2 PA, QL PARADIGM RESERVOIR 1.8 ML 1 PARADIGM RESERVOIR 3 ML 3 pioglitazone 1 POGO AUTOMATIC BLOOD GLUCOSE SYSTEM 3 PRECISION XTRA KETONE-GLUCOSE KIT, MONITOR, MONITOR NFRS 3 PRECISION XTRA METER 2 PRECISION XTRA TEST STRIP 2 REZVOGLAR 2 QL RYBELSUS 2 PA, QL SOLIQUA 100-33 2 SYMLINPEN 2 SYNJARDY 2 QL, ST SYNJARDY XR 2 QL, ST TRESIBA 2 QL TRIJARDY XR 2 QL, ST TRUE METRIX AIR GLUCOSE METER 2 TRUE METRIX BLOOD GLUCOSE METER 2 TRUE METRIX GLUCOSE TEST STRIP 2 TRULICITY 2 PA, QL TWIIST REFILL, REFILL KIT, STARTER KIT 2 QL V-GO 2 XIGDUO XR 2 QL, ST ZEGALOGUE 2 QL DIURETICS Medication Tier Notes acetazolamide 1 bumetanide 1 CAROSPIR 2 PA DIURETICS (cont.) Medication Tier Notes chlorthalidone 1 DIURIL 3 eplerenone 1 furosemide 1 hydrochlorothiazide 1 KERENDIA 2 PA, QL spironolactone 1 tolvaptan 1 SP, PA EAR MEDICATIONS Medication Tier Notes ciprofloxacin-dexamethasone 1 CORTISPORIN-TC 3 DERMOTIC 3 neomycin-polymyxin-hc otic solution, suspension 1 ofloxacin 0.3% ear drops 1 OTOVEL 3 EYE CONDITIONS Medication Tier Notes AZASITE 2 BESIVANCE 2 BETOPTIC S 2 bimatoprost drops 1 QL brimonidine drops 1 brimonidine-timolol 1 brinzolamide 1 bromfenac drops 1 BYOOVIZ 3 SP, PA CEQUA 2 CIMERLI 3 SP, PA ciprofloxacin drops 1 cyclosporine eye emulsion 1 CYSTARAN 3 SP, PA, QL difluprednate 1