19 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 HORMONAL AGENTS (cont.) Medication Tier Notes mimvey 1 MYFEMBREE 2 PA, QL norethindrone 5 mg tablet 1 OMNITROPE 2 SP, PA ORIAHNN 2 PA, QL ORILISSA 2 PA, QL OSPHENA 3 QL prednisolone oral solution, syrup, tablet 1 prednisone 1 PREMARIN 2 PREMPHASE 2 PREMPRO 2 progesterone capsule 1 RAYALDEE 3 SANDOSTATIN LAR DEPOT 3 SP, PA SOMATULINE DEPOT 2 SP, PA SOMAVERT 2 SP, PA testosterone gel, gel pump, packet 1 PA, QL testosterone cypionate 200 mg/ml, 1,000 mg/10 ml, 2,000 mg/10 ml, 6,000 mg /30 ml 1 thyroid 1 TRIPTODUR 2 SP, PA UCERIS TABLET 3 PA, QL unithroid 3 yuvafem 1 QL INFECTIONS Medication Tier Notes acyclovir capsule, oral suspension, tablet 1 AEMCOLO 3 QL albendazole 1 INFECTIONS (cont.) Medication Tier Notes amoxicillin 1 amoxicillin-clavulanate 1 ARIKAYCE 3 SP, PA atovaquone 1 atovaquone-proguanil 1 azithromycin 1 BARACLUDE ORAL SOLUTION 2 SP BAXDELA 3 PA BEYFORTUS 3 PPACA BICILLIN L-A 3 CAYSTON 3 SP, PA, QL cefdinir 1 cefpodoxime 1 cefuroxime tablet 1 cephalexin 1 CIPRO ORAL SUSPENSION 3 ciprofloxacin oral suspension, tablet 1 clarithromycin 1 clindamycin capsule, oral solution, vaginal cream, vial 1 CRESEMBA 3 PA DIFICID 3 QL doxycycline monohydrate 1 EMVERM 1 ENFLONSIA 3 PPACA entecavir 1 SP, QL EPCLUSA 2 SP, PA, QL erythromycin capsule, tablet 1 famciclovir 1 fluconazole 1 flucytosine 1 fosfomycin 1 HARVONI 2 SP, PA, QL