11 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 CANCER (cont.) Medication Tier Notes STIVARGA 2 SP, PA, QL TABRECTA 3 SP, PA, QL TAFINLAR 2 SP, PA, QL TAGRISSO 3 SP, PA TALZENNA 3 SP, PA, QL tamoxifen 1 PPACA temozolomide 1 SP, PA TIBSOVO 3 SP, PA torpenz 1 SP, PA, QL TRAZIMERA 2 SP, PA TREXALL 2 TRUQAP 2 SP, PA, QL TUKYSA 3 SP, PA VANFLYTA 3 SP, PA, QL VENCLEXTA STARTING PACK, TABLET 2 SP, PA VERZENIO 2 SP, PA, QL VITRAKVI 3 SP, PA VIZIMPRO 3 SP, PA WELIREG 3 SP, PA, QL XALKORI 3 SP, PA, QL XATMEP 3 XOSPATA 3 SP, PA XTANDI 2 SP, PA ZEJULA 2 SP, PA, QL ZELBORAF 2 SP, PA ZIRABEV 2 SP, PA CHOLESTEROL MEDICATIONS Medication Tier Notes atorvastatin 10 mg, 20 mg tablet 1 PPACA atorvastatin 40 mg, 80 mg tablet 1 CADUET 3 QL colesevelam 1 DOJOLVI 3 SP, PA ezetimibe 1 CHOLESTEROL MEDICATIONS (cont.) Medication Tier Notes fenofibrate 43 mg, 50 mg, 67 mg, 130 mg, 134 mg, 150 mg, 200 mg capsule; tablet 1 fluvastatin 1 PPACA fluvastatin er 1 PPACA icosapent ethyl 1 LIPOFEN 3 ST lovastatin 10 mg tablet 1 lovastatin 20 mg, 40 mg tablet 1 PPACA omega-3 acid ethyl esters 1 pitavastatin 1 QL, PPACA pravastatin 1 PPACA REPATHA PUSHTRONEX, SURECLICK, SYRINGE 2 rosuvastatin 5 mg, 10 mg tablet 1 QL, PPACA rosuvastatin 20 mg, 40 mg tablet 1 QL simvastatin 5 mg, 80 mg tablet 1 QL TRICOR 3 ST VASCEPA 2 PA CONTRACEPTION PRODUCTS Medication Tier Notes afirmelle 1 PPACA altavera 1 PPACA alyacen 1 PPACA amethia 1 PPACA amethyst 1 PPACA apri 1 PPACA aranelle 1 PPACA ashlyna 1 PPACA aubra 1 PPACA aubra eq 1 PPACA aurovela 1 PPACA aurovela fe 1 PPACA aurovela 24 fe 1 PPACA aviane 1 PPACA