18 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 GASTROINTESTINAL/HEARTBURN (cont.) Medication Tier Notes mesalamine 1 mesalamine dr 1 metoclopramide 1 MOTOFEN 3 MOVANTIK 2 PA OCALIVA 3 SP, PA OLPRUVA 3 SP, PA omeprazole 10 mg, 20 mg, 40 mg capsule 1 QL, OC PANCREAZE 2 pantoprazole 1 QL, OC peg 3350-electrolyte 1 PPACA peg-prep 1 PPACA PHEBURANE 2 SP, PA, QL rabeprazole tablet 1 QL OC RECTIV 3 RELISTOR SYRINGE, VIAL 3 PA REZDIFFRA 3 SP, PA, QL SANCUSO 3 PA, QL scopolamine 1 SFROWASA 3 sodium sulfate-potassium sulfate- magnesium sulfate 1 PPACA SUCRAID 3 SP, PA sucralfate 1 SYMPROIC 2 PA TRULANCE 2 VARUBI 3 PA, QL VIBERZI 2 VIOKACE 3 VOQUEZNA 3 PA, QL VOWST 3 SP, PA, QL ZENPEP 2 HORMONAL AGENTS Medication Tier Notes ACTHAR VIAL 3 SP, PA ANGELIQ 3 BIJUVA 3 budesonide dr 1 budesonide ec 1 cetrorelix 1 SP, PA, OC CETROTIDE 2 SP, PA, OC COMBIPATCH 2 CORTROPHIN VIAL 3 SP, PA CRINONE 4% GEL 3 PA CYTOMEL 3 DEPO-TESTOSTERONE 3 desmopressin ampule, vial 1 SP desmopressin nasal solution; 10 mcg/0.1 ml spray; tablet 1 DUAVEE 2 EGRIFTA SV 3 SP, PA estradiol cream, gel packet, gel pump, patch, tablet, vaginal insert 1 QL EVAMIST 3 FENSOLVI 2 SP, PA fyremadel 1 SP, PA, OC ganirelix 1 SP, PA, OC GENOTROPIN 2 SP, PA INTRAROSA 3 QL levoxyl 1 liothyronine 1 LUPRON DEPOT 3.75 MG KIT, 11.25 MG KIT 2 SP, PA lyllana 1 QL medroxyprogesterone tablet 1 MENOSTAR 3 QL methylprednisolone 1