24 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 PAIN RELIEF AND INFLAMMATORY DISEASE (cont.) Medication Tier Notes oxycodone ir capsule, oral concentrate, oral solution, ir tablet 1 PA PROCTOFOAM-HC 3 prolate 1 PA QULIPTA 2 PA, QL RENFLEXIS 3 SP, PA RINVOQ 2 SP, PA, QL RINVOQ LQ 2 SP, PA, QL rizatriptan 1 QL ROXYBOND 3 PA SAVELLA 3 SELARSDI SYRINGE, VIAL 2 SP, PA, QL SILIQ 3 SP, PA, QL SIMLANDI (CF) 2 SP, PA, QL SIMPONI 100 MG/ML PEN INJECTOR, SYRINGE 2 SP, PA, QL SIMPONI ARIA 2 SP, PA SKYRIZI 2 SP, PA, QL SOTYKTU 2 SP, PA, QL STELARA SYRINGE; 45 MG/0.5 ML VIAL 2 SP, PA, QL sumatriptan 1 QL SUPARTZ FX 3 SP, PA SYNVISC 3 SP, PA SYNVISC-ONE 3 SP, PA TALTZ 2 SP, PA, QL tanlor 1 tramadol 50 mg, 100 mg tablet 1 QL TREMFYA 2 SP, PA, QL TRILURON 3 SP, PA TYENNE 2 SP, PA, QL UBRELVY 2 PA, QL vanadom 1 VELSIPITY 2 SP, PA, QL VISCO-3 3 SP, PA XELJANZ 2 SP, PA, QL PAIN RELIEF AND INFLAMMATORY DISEASE (cont.) Medication Tier Notes XELJANZ XR 2 SP, PA, QL XIAFLEX 3 SP, PA XTAMPZA ER 2 PA YESINTEK 2 SP, PA, QL ZAVZPRET 2 QL zebutal 3 QL ZEPOSIA 2 SP, PA ZTLIDO 2 PARKINSON’S DISEASE Medication Tier Notes APOKYN 3 SP, PA benztropine 1 carbidopa-levodopa 1 CREXONT 3 ST DUOPA 3 SP INBRIJA 3 SP, PA NEUPRO 3 NOURIANZ 3 SP, PA, QL pramipexole 1 QL ropinirole 1 RYTARY 3 ST XADAGO 3 ST SCHIZOPHRENIA/ANTI-PSYCHOTICS2 Medication Tier Notes ABILIFY ASIMTUFII 2 QL ABILIFY MAINTENA 2 QL aripiprazole 1 QL ARISTADA 2 QL ARISTADA INITIO 2 asenapine 1 CAPLYTA 3 QL, ST ERZOFRI 2 QL INVEGA HAFYERA 2 QL INVEGA SUSTENNA 2 QL