17 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 EYE CONDITIONS (cont.) Medication Tier Notes dorzolamide-timolol 1 erythromycin eye ointment 1 EYSUVIS 2 QL fluorometholone 1 ILEVRO 3 latanoprost 1 loteprednol 1 MIEBO 2 QL moxifloxacin drops 1 neomycin-polymyxin-dexamethasone 1 ofloxacin eye drops 1 OXERVATE 3 SP, PA polymyxin b-trimethoprim 1 prednisolone eye drops 1 PROLENSA 3 RESTASIS EYE EMULSION 2 RHOPRESSA 3 ROCKLATAN 3 SIMBRINZA 2 TEPEZZA 3 SP, PA timolol drops, gel-solution 1 TOBRADEX 3 TOBRADEX ST 2 tobramycin drops 1 tobramycin-dexamethasone 1 travoprost 1 TYRVAYA 2 QL XDEMVY 2 SP, PA, QL XIIDRA 2 ZIRGAN 3 ZYLET 3 FEMININE PRODUCTS Medication Tier Notes fem ph 1 GYNAZOLE 1 1 miconazole 3 vaginal suppository 1 terconazole 1 TRIMO-SAN 3 GASTROINTESTINAL/HEARTBURN Medication Tier Notes alosetron 1 SP aprepitant 1 QL APRISO 3 balsalazide 1 BONJESTA 3 CHOLBAM 3 SP, PA dexlansoprazole dr 1 QL, OC dicyclomine ampule, capsule, oral solution; 20 mg tablet; vial 1 doxylamine-pyridoxine 1 QL ENTYVIO VIAL 2 SP, PA esomeprazole 20 mg, 40 mg capsule; packet, vial 1 QL, OC famotidine oral suspension 1 GATTEX 3 SP, PA gavilyte-c 1 PPACA gavilyte-g 1 PPACA gavilyte-n 1 PPACA hydrocortisone enema, suppository 1 IQIRVO 2 SP, PA lansoprazole 1 QL, OC LINZESS 2 LITHOSTAT 3 lubiprostone 1