20 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 INFECTIONS (cont.) Medication Tier Notes hydroxychloroquine 1 IMPAVIDO 3 PA itraconazole 1 KITABIS PAK 3 SP, PA, QL LAGEVRIO (EUA) 2 QL levofloxacin oral solution, tablet, vial 1 LIKMEZ 3 PA LIVTENCITY 3 SP, PA, QL MACROBID 3 methenamine 1 metronidazole capsule, intravenous solution; 250 mg, 500 mg tablet; vaginal gel 1 minocycline 1 mondoxyne nl 1 morgidox capsule 1 nitazoxanide 1 nitrofurantoin capsule; 25 mg/5 ml oral suspension 1 NUZYRA 3 SP, PA, QL nystatin oral suspension, tablet 1 oseltamivir 1 QL PAXLOVID 2 QL PEGASYS 2 SP, PA penicillin v potassium 1 permethrin 1 posaconazole 1 PREVYMIS 3 SP PRIFTIN 3 pruradik 1 pyrimethamine 1 PA SIVEXTRO 3 PA sulfamethoxazole-tmp oral suspension, tablet, vial 1 SYNAGIS 3 SP, PA INFECTIONS (cont.) Medication Tier Notes terbinafine tablet 1 THALOMID 2 SP, PA TOBI PODHALER 2 SP, PA, QL tobramycin ampule 1 SP, PA, QL valacyclovir 1 valganciclovir 1 VALTREX 3 vancomycin capsule, oral solution; 750 mg, 1.25 gm, 1.5 gm, 5 gm, 10 gm vial 1 VANCOMYCIN 1.75 GM, 2 GM VIAL 3 vandazole 1 VEMLIDY 2 SP VIVJOA 3 SP, PA VOSEVI 2 SP, PA, QL XENLETA 3 PA, QL XIFAXAN 2 QL XOFLUZA 3 QL ZEPATIER 2 SP, PA, QL ZITHROMAX 3 ZYVOX ORAL SUSPENSION, TABLET 3 PA INFERTILITY Medication Tier Notes clomiphene 1 OC CRINONE 8% GEL 2 OC ENDOMETRIN 2 OC FOLLISTIM AQ 3 SP, PA, OC GONAL-F 2 SP, PA, OC GONAL-F RFF REDI-JECT 2 SP, PA, OC MAKENA 3 PA MENOPUR 3 SP, PA, OC NOVAREL 2 SP, PA, OC OVIDREL 2 SP, PA, OC PREGNYL 2 SP, PA, OC