23 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 Medication Tier Notes acetaminophen-codeine 1 PA ACTEMRA ACTPEN, SYRINGE 2 SP, PA, QL ACTEMRA VIAL 2 SP, PA ADALIMUMAB-ADBM (CF) 2 SP, PA, QL AIMOVIG 2 PA AJOVY 2 PA ARCALYST 3 SP, PA AVSOLA 2 SP, PA BELBUCA 2 QL BENLYSTA 3 SP, PA BIMZELX 3 SP, PA, QL buprenorphine 1 QL butalbital-acetaminophen-caffeine capsule, tablet 1 QL celecoxib 1 QL CIMZIA 2 SP, PA, QL colchicine 1 COSENTYX PEN, SYRINGE 3 SP, PA, QL cyclobenzaprine tablet 1 CYLTEZO (CF) 2 SP, PA, QL diclofenac 1% gel, tablet 1 QL DUPIXENT 2 SP, PA DUROLANE 2 SP, PA eletriptan 1 QL EMGALITY 2 PA ENBREL 2 SP, PA, QL ENSPRYNG 3 SP, PA EUFLEXXA 2 SP, PA febuxostat 1 QL fentanyl 1 PA GEL-ONE 3 SP, PA GELSYN-3 2 SP, PA HUMIRA (by AbbVie) 2 SP, PA, QL HYALGAN 3 SP, PA PAIN RELIEF AND INFLAMMATORY DISEASE (cont.) Medication Tier Notes hydrocodone-acetaminophen 1 PA hydromorphone ampule, cartridge, oral solution, suppository, syringe, tablet; 2 mg/ml, 10 mg/ml, 40 mg/20 ml, 50 mg/5 ml, 500 mg/5 ml vial 1 PA HYMOVIS 3 SP, PA HYSINGLA ER 2 PA ibuprofen oral suspension; 300 mg, 400 mg, 600 mg, 800 mg tablet 1 ILARIS 3 SP, PA ILUMYA 3 SP, PA, QL indomethacin 25 mg, 50 mg capsule; oral suspension; 50 mg suppository 1 INFLECTRA 2 SP, PA ketorolac syringe, tablet, vial 1 QL KEVZARA 3 SP, PA, QL KRYSTEXXA 3 SP, PA leflunomide 1 lidocaine viscous 1 meloxicam tablet 1 metaxalone 400 mg, 800 mg tablet 1 MITIGARE 2 MONOVISC 3 SP, PA morphine er 1 PA nabumetone 1 NUCYNTA 3 PA NUCYNTA ER 3 PA NURTEC ODT 2 PA, QL OLUMIANT 3 SP, PA, QL OMVOH 2 SP, PA, QL ORENCIA CLICKJECT, SYRINGE 3 SP, PA, QL ORENCIA VIAL 3 SP, PA ORTHOVISC 3 SP, PA OTEZLA 2 SP, PA, QL OXAYDO 3 PA