6 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 AIDS/HIV Medication Tier Notes APRETUDE 3 SP, PA, PPACA BIKTARVY 2 SP, QL CABENUVA 3 SP, PA CIMDUO 3 SP, PA darunavir 1 SP DESCOVY 200-25 MG TABLET 2 SP, PPACA DOVATO 2 SP, QL efavirenz-emtricitabine-tenofovir 1 SP, QL emtricitabine-tenofovir 200 mg-300 mg tablet 1 SP, PPACA GENVOYA 2 SP, QL ISENTRESS HD 2 SP, PA JULUCA 2 SP, QL ODEFSEY 3 SP, PA, QL PIFELTRO 3 SP, PA PREZCOBIX 3 SP, PA PREZISTA ORAL SUSPENSION; 75 MG, 150 MG TABLET 2 SP ritonavir 1 SP RUKOBIA 3 SP, PA, QL STRIBILD 3 SP, PA, QL SYMTUZA 2 SP, QL tenofovir 1 SP, PA TIVICAY 2 SP TRIUMEQ 2 SP, QL TRIUMEQ PD 2 SP, QL ALLERGY/NASAL SPRAYS Medication Tier Notes azelastine 0.1% (137 mcg) spray 1 azelastine-fluticasone 1 cromolyn oral concentrate 1 desloratadine 1 QL, OC epinephrine 0.15 mg, 0.3 mg auto- injector (by Mylan SP-Viatris, Teva USA); nasal solution 1 QL ALLERGY/NASAL SPRAYS (cont.) Medication Tier Notes fluticasone spray 1 OC hydroxyzine oral solution, syrup, tablet 1 hydroxyzine pamoate 1 ipratropium spray 1 levocetirizine 1 OC mometasone spray 1 QL, OC olopatadine spray 1 ORALAIR 3 PA, QL promethazine ampule, oral solution, syrup, tablet, vial 1 RAGWITEK 3 PA, QL ALZHEIMER’S DISEASE Medication Tier Notes ADLARITY 2 PA, QL donepezil 1 EXELON 3 memantine 1 memantine er 1 QL NAMENDA 3 pyridostigmine oral solution; 60 mg tablet 1 pyridostigmine er 180 mg tablet 1 rivastigmine 1 ANXIETY/DEPRESSION/BIPOLAR DISORDER2 Medication Tier Notes alprazolam 1 amitriptyline 1 bupropion sr 1 QL bupropion xl 150 mg, 300 mg tablet 1 QL buspirone 1 citalopram oral solution, tablet 1 QL clomipramine 1 desvenlafaxine succinate er 1 QL duloxetine 1 QL