8 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 ASTHMA/COPD/RESPIRATORY (cont.) Medication Tier Notes VIJOICE 3 SP, PA, QL wixela inhub 1 QL XOLAIR 2 SP, PA ATTENTION DEFICIT HYPERACTIVITY DISORDER2 Medication Tier Notes atomoxetine 1 QL DAYTRANA 3 PA, QL dexmethylphenidate er 1 PA, QL dextroamphetamine-amphetamine 1 PA dextroamphetamine-amphetamine er 1 PA, QL guanfacine er 1 lisdexamfetamine 1 PA, QL methylphenidate 1 PA, QL methylphenidate er (cd) 1 PA, QL methylphenidate er (la) 1 PA, QL methylphenidate er capsule; 10 mg, 18 mg, 20 mg, 27 mg, 36 mg, 54 mg, 72 mg tablet 1 PA, QL QUILLIVANT XR 3 PA, QL XELSTRYM 3 PA, QL BLOOD MODIFIERS/BLEEDING DISORDERS Medication Tier Notes ADVATE 3 SP, PA ADYNOVATE 2 SP, PA AFSTYLA 2 SP, PA ALTUVIIIO 2 SP, PA aminocaproic acid 1 SP ARANESP 2 SP, PA DOPTELET 2 SP, PA DROXIA 2 ELOCTATE 2 SP, PA EMPAVELI 2 SP, PA ESPEROCT 2 SP, PA FABHALTA 2 SP, PA, QL BLOOD MODIFIERS/BLEEDING DISORDERS (cont.) Medication Tier Notes FULPHILA 3 SP, PA GRANIX 3 SP, PA HEMLIBRA 2 SP, PA HYMPAVZI PEN 2 SP, PA JIVI 2 SP, PA KOGENATE FS 2 SP, PA KOVALTRY 2 SP, PA LEUKINE 2 SP NEULASTA 2 SP, PA NEULASTA ONPRO 2 SP, PA NEUPOGEN 3 SP, PA NIVESTYM 2 SP NOVOEIGHT 2 SP, PA NYVEPRIA 2 SP, PA PROCRIT 2 SP, PA RETACRIT 2 SP, PA SOLIRIS 2 SP, PA STIMUFEND 3 SP, PA TAVALISSE 2 SP, PA TAVNEOS 3 SP, PA, QL tranexamic acid 1 SP UDENYCA 2 SP, PA ULTOMIRIS 3 SP, PA VOYDEYA 2 SP, PA, QL WILATE 3 SP, PA XYNTHA 3 SP, PA XYNTHA SOLOFUSE 3 SP, PA ZARXIO 2 SP ZIEXTENZO 3 SP, PA BLOOD PRESSURE/HEART MEDICATIONS Medication Tier Notes amlodipine 1 amlodipine-benazepril 1 amlodipine-olmesartan 1 QL