7 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 ANXIETY/DEPRESSION/BIPOLAR DISORDER2 (cont.) Medication Tier Notes EMSAM 3 QL escitalopram 1 QL fluoxetine 1 QL fluvoxamine 1 QL fluvoxamine er 1 QL lorazepam oral concentrate, tablet 1 mirtazapine 1 NUPLAZID 3 SP, PA paroxetine 1 QL paroxetine er 1 QL sertraline 1 QL trazodone 1 TRINTELLIX 2 QL venlafaxine hcl er 1 QL vilazodone 1 QL ZURZUVAE 3 SP, PA, QL ASTHMA/COPD/RESPIRATORY Medication Tier Notes ADEMPAS 2 SP, PA AIRSUPRA 2 QL albuterol 1 albuterol hfa 1 QL ALVESCO 2 ALYFTREK 3 SP, PA, QL ambrisentan 1 SP, PA ANORO ELLIPTA 2 QL ASMANEX, ASMANEX HFA 2 QL ATROVENT HFA 2 QL breyna 1 QL BREZTRI AEROSPHERE 2 QL BRONCHITOL 3 SP, PA ASTHMA/COPD/RESPIRATORY (cont.) Medication Tier Notes budesonide inhalation suspension 1 QL budesonide-formoterol 1 QL COMBIVENT RESPIMAT 2 QL DULERA 2 QL FASENRA 2 SP, PA GLASSIA 3 SP, PA INCRUSE ELLIPTA 2 KALYDECO 3 SP, PA, QL montelukast 1 NUCALA 2 SP, PA OFEV 2 SP, PA OPSUMIT 2 SP, PA OPSYNVI 2 SP, PA, QL ORENITRAM ER 3 SP, PA ORENITRAM TITRATION KIT 3 SP, PA, QL PROLASTIN C 3 SP, PA PULMOZYME 3 SP, PA QVAR REDIHALER 2 SPIRIVA RESPIMAT 2 QL STIOLTO RESPIMAT 2 QL STRIVERDI RESPIMAT 2 QL SYMDEKO 3 SP, PA, QL TEZSPIRE 2 SP, PA, QL TRACLEER 32 MG TABLET FOR SUSPENSION 2 SP, PA TRELEGY ELLIPTA 2 QL treprostinil 1 SP, PA TRIKAFTA 3 SP, PA, QL TYVASO DPI 2 SP, PA TYVASO 3 SP, PA UPTRAVI TABLET, TITRATION PACK 2 SP, PA UPTRAVI VIAL 3 SP, PA