21 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 MISCELLANEOUS Medication Tier Notes acamprosate 1 ACCU-CHEK FASTCLIX LANCET DRUM 1 ADDYI 3 QL, OC AUSTEDO 3 SP, PA AUSTEDO XR 3 SP, PA, QL AUSTEDO XR TITRATION KIT 3 SP, PA, QL BOTOX 3 SP, PA CARBAGLU 3 SP CERDELGA 2 SP, PA CEREZYME 3 SP, PA cinacalcet 1 SP CINRYZE 3 SP, PA deferasirox 1 SP deferiprone 1 SP, PA DROPLET LANCET 1 DYSPORT 3 SP, PA ELFABRIO 3 SP, PA EVRYSDI 3 SP, PA FABRAZYME 3 SP, PA FILSPARI 2 SP, PA, QL GALAFOLD 3 SP, PA HAEGARDA 3 SP, PA INGREZZA 3 SP, PA, QL MICROLET LANCET 1 MYALEPT 3 SP, PA NITYR 2 SP, PA NUEDEXTA 3 QL ONETOUCH DELICA PLUS LANCET 1 ONETOUCH ULTRASOFT 2 LANCET 1 ORFADIN 3 SP, PA PALYNZIQ 3 SP, PA POGO AUTOMATIC TEST CARTRIDGE 3 PRECISION XTRA B-KETONE STRIP 3 MISCELLANEOUS (cont.) Medication Tier Notes RADICAVA ORS 3 SP, PA, QL RUCONEST 3 SP, PA sapropterin 1 SP, PA sodium chloride irrigation solution, inhalation vial 1 SPINRAZA 3 SP, PA STRENSIQ 2 SP, PA TECHLITE LANCET 1 TEGLUTIK 3 SP, PA TEGSEDI 3 SP, PA TIGLUTIK 3 SP, PA TRUEPLUS KETONE TEST STRIP 3 VIVITROL 3 SP VOXZOGO 3 SP, PA VYLEESI 3 SP, PA, QL, OC VYNDAMAX 3 SP, PA, QL VYNDAQEL 3 SP, PA, QL VYVGART HYTRULO 3 SP, PA MULTIPLE SCLEROSIS Medication Tier Notes AVONEX 2 SP, PA BAFIERTAM 2 SP, PA BETASERON 2 SP, PA dalfampridine er 1 SP, PA dimethyl 1 SP fingolimod 1 SP FIRDAPSE 3 SP, PA, QL glatopa 1 SP KESIMPTA PEN 2 SP, PA MAVENCLAD 3 SP, PA MAYZENT 2 SP, PA OCREVUS 2 SP, PA OCREVUS ZUNOVO 2 SP, PA