2019 CIGNA RX PREMIERE 5-TIER PRESCRIPTION DRUG LIST - Starting January 1, 2019 - Cigna Health and Life Insurance Company
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Cigna Health and Life Insurance Company 2019 CIGNA RX PREMIERE 5-TIER PRESCRIPTION DRUG LIST Starting January 1, 2019 924126 11/18 © 2018 Cigna
Table of Contents
Getting started
Your prescription drug list 3
How to read your drug list 3
How to find your medication 5
Specialty medications 33
Prescription drug list FAQs 35
2019 Exclusions and Limitations 37
View your drug list online
The myCigna® website – Once you’re registered, log in and select Estimate
Health Care Costs, then select Get drug costs.
Cigna.com/druglist – Select your state from the drop down menu, then choose your search
method. You can either search for a medication name or view the full drug list.
Questions? – Call the toll-free number on the back of your Cigna ID card, or 866.494.2111.
We’re here to help.
* Drug list originally created: 10/21/2013 Last updated: 08/01/2018 Next planned update: 08/01/19
2Your prescription drug list
This document shows the prescription medications covered on the 2019 Cigna Rx Premiere Prescription Drug List as
of January 1, 2019.1 All of these medications are approved by the U.S. Food and Drug Administration (FDA).
Medications are listed alphabetically by medication name. If you don’t see a specific medication on this list, please
check myCigna.com to view the most current list of medications your plan covers.
How to read your drug list
Use the sample chart below to help you understand this drug list. This chart is just an example. It may not show
how these medications are actually covered on the 2019 Cigna Rx Premiere Prescription Drug List.
Medications are listed in alphabetical
order
DRUG NAME Tier NOTES (PA, ST, QL, AGE)
8-MOP 4
ABACAVIR 2
ABACAVIR-LAMIVUDINE 2 Tier (cost-share level) gives you an
idea of how much you may pay for
ABACAVIR-LAMIVUDINE-ZIDOVUDINE 2
a medication
ABSORICA 4 QL
ACAMPROSATE CALCIUM 2
ACARBOSE 2
ACEBUTOLOL HCL 2
ACETAMIN-CAFF-DIHYDROCOD 320.5 2
ACETAMINOPHEN-CODEINE 2
ACETASOL HC 2
ACETAZOLAMIDE 2
ACETIC ACID 2 Medications that have extra coverage
requirements will have an abbreviation
ACETIC ACID-ALUMINUM 2
in the Notes section
ACETYLCYSTEINE 10% VIAL 2
ACETYLCYSTEINE 20% VIAL 2
ACITRETIN 2
ACYCLOVIR 200 MG CAPSULE 1
ACYCLOVIR 200 MG/5 ML SUSP 2
ACYCLOVIR 400 MG TABLET 2
ACYCLOVIR 5% OINTMENT 2
ACYCLOVIR 800 MG TABLET 2
ADAPALENE 2 AGE
This chart is just a sample. It may not show how these medications are actually covered on the 2019 Cigna Rx Premiere Prescription Drug List.
3Tiers
Covered medications are divided into tiers or cost-share levels. Typically, the higher the tier, the higher the price
you’ll pay to fill the prescription.
Tier 1 – Preferred Generic Medications. This tier typically includes preferred (Lower-cost medication) $
generic medications. These medications have the same strength, and active
ingredients as brand name medications, but often cost much less. Preferred
generic medications are covered at your plan’s lowest cost share.
Tier 2 – Generic Medications. This tier typically includes most generic (Medium-cost medication) $$
medications and some low cost brand name medications. Generic
medications have the same strength and active ingredients as brand name
medications, but often cost much less.
Tier 3 – Preferred Brand Medications. This tier typically includes preferred (Higher-cost medication) $$$
brand name medications and some high cost generic medications.
Tier 4 – Non-Preferred Medications. This tier typically includes non- $$$$
preferred brand name medications and some high cost generic medications.
Tier 5 – Specialty and Other High Cost Medications. This tier typically $$$$$
includes Specialty medications and high cost generic and brand
name medications.
Abbreviations next to medications
Some medications on your drug list have extra requirements before your plan will cover them. This helps to make
sure you’re receiving coverage for the right medication, at the right cost, in the right amount and for the right
situation. These medications will have an abbreviation next to them in the Notes column in the drug list. Here’s
what each of the abbreviations mean.
PA
Prior Authorization – Cigna will review information provided by your doctor to make sure you
meet coverage guidelines for the medication. If approved, your plan will cover the medication.
ST tep Therapy – Step Therapy is a prior authorization program that requires you to try other
S
medications available to treat the same condition before the medication with the “ST” is covered.
QL uantity Limits – For some medications, your plan will only cover up to a certain amount over a
Q
certain length of time. For example, 30mg per day for 30 days. Your plan will only cover a larger
amount if your doctor requests and receives approval from Cigna.
AGE ge Requirements – You must be within a specific age range for your plan to cover the
A
medication.
LDD imited Distribution Drugs are medications that are only available at specific pharmacies in the
L
United States because of manufacturer restrictions.
Brand name medications are capitalized
In this drug list, brand name medications are capitalized and generic medications are lowercase.
Specialty medications are listed on page 33
Specialty medications are used to treat complex conditions like multiple sclerosis, hepatitis C and rheumatoid
arthritis. In this drug list, specialty medications are listed on page 33. Specialty medications are limited to a 30-day
supply. Please log in to the myCigna website or app, or check your plan materials, to learn more about how your
plan covers specialty medications.
4Plan exclusions
Your plan excludes certain types of medications or products from coverage. This is known as a “plan (or benefit)
exclusion.” This means that your plan doesn’t cover any prescription medications in the drug class or to treat the
specific condition. There’s also no option to receive coverage through a medication review process. Please log in
to the myCigna website or app, or check your plan materials, to find out if your plan excludes your medication
from coverage.
How to find your medication
Find your medication using the alphabetical list below. Then go to that page to see how your plan covers
the medication.
Medication name Page
A–B 6–10
C–D 10–14
E–G 14–16
H–J 16–18
K–L 18–20
M–N 20–24
0–P 24–26
Q–S 26–28
T–U 28–30
V–Z 30–32
52019 Cigna Rx Premiere Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
8-MOP 4 ALDACTAZIDE 4
ABACAVIR 2 ALENDRONATE SOD 70 MG/75 ML 2
ABACAVIR-LAMIVUDINE 2 ALENDRONATE SODIUM 10 MG TAB 1
ABACAVIR-LAMIVUDINE-ZIDOVUDINE 2 ALENDRONATE SODIUM 35 MG TAB 1
ACAMPROSATE CALCIUM 3 ALENDRONATE SODIUM 40 MG TAB 1
ACARBOSE 2 ALENDRONATE SODIUM 5 MG TABLET 1
ACEBUTOLOL HCL 2 ALENDRONATE SODIUM 70 MG TAB 2
ACETAMIN-CAFF-DIHYDROCOD 320.5 2 ALFUZOSIN HCL ER 2
ACETAMINOPHEN-CODEINE 2 ALINIA 4
ACETAZOLAMIDE 2 ALLOPURINOL 1
ACETIC ACID 2 ALMOTRIPTAN MALATE 2 QL
ACETIC ACID-ALUMINUM 2 ALOCRIL 4
ACETYLCYSTEINE 10% VIAL 2 ALOGLIPTIN 2 QL
ACETYLCYSTEINE 20% VIAL 2 ALOGLIPTIN-METFORMIN 2 QL
ACITRETIN 4 ALOGLIPTIN-PIOGLITAZONE 2 QL
ACYCLOVIR 200 MG CAPSULE 1 ALOMIDE 4
ACYCLOVIR 200 MG/5 ML SUSP 2 ALOSETRON HCL 4
ACYCLOVIR 400 MG TABLET 2 ALPRAZOLAM 2
ACYCLOVIR 5% OINTMENT 2 ALPRAZOLAM ER 2
ACYCLOVIR 800 MG TABLET 2 ALPRAZOLAM INTENSOL 2
ADAPALENE 2 AGE ALPRAZOLAM ODT 2
ADAPALENE-BENZOYL PEROXIDE 2 ALPRAZOLAM XR 2
ADEFOVIR DIPIVOXIL 2 ALTABAX 4
ADRENALIN CHLORIDE 4 ALTACAINE 2
ADVAIR DISKUS 3 ALTAVERA 1
ADVAIR HFA 3 ALYACEN 1
AFEDITAB CR 2 AMABELZ 2
AFTERA 4 AMANTADINE 2
AK-POLY-BAC 2 AMCINONIDE 2
ALA-CORT 2.5% CREAM 1 AMETHIA 1
ALBENZA 4 AMETHIA LO 1
ALBUTEROL 2.5 MG/0.5 ML SOL 2 AMETHYST 1
ALBUTEROL 5 MG/ML SOLUTION 2 AMILORIDE HCL 2
ALBUTEROL SUL 0.63 MG/3 ML SOL 2 AMILORIDE-HYDROCHLOROTHIAZIDE 2
ALBUTEROL SUL 1.25 MG/3 ML SOL 2 AMIODARONE HCL 100 MG TABLET 2
ALBUTEROL SUL 2.5 MG/3 ML SOLN 1 AMIODARONE HCL 200 MG TABLET 2
ALBUTEROL SULF 2 MG/5 ML SYRUP 2 AMIODARONE HCL 400 MG TABLET 2
ALBUTEROL SULFATE 2 MG TAB 2 AMITIZA 4
ALBUTEROL SULFATE 4 MG TAB 2 AMITRIPTYLINE HCL 1
ALBUTEROL SULFATE ER 4 MG TAB 2 AMLODIPINE BESYLATE 2
ALBUTEROL SULFATE ER 8 MG TAB 2 AMLODIPINE BESYLATE-BENAZEPRIL 2
ALCLOMETASONE DIPROPIONATE 2 AMLODIPINE-ATORVASTATIN 2
ALCOHOL PADS 3 AMLODIPINE-OLMESARTAN 2
ALCOHOL PREP PADS 3 AMLODIPINE-VALSARTAN 2
ALCOHOL PREP SWABS 3 AMLODIPINE-VALSARTAN-HCTZ 2
ALCOHOL SWAB 3 AMMONIUM LACTATE 12% CREAM 2
ALCOHOL SWABS 3 AMMONIUM LACTATE 12% LOTION 2
ALCOHOL WIPES 3 AMNESTEEM 2 QL
Please visit Cigna.com/ifp-drug-list to see a complete listing.
62019 Cigna Rx Premiere Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
AMOXAPINE 2 ATORVASTATIN CALCIUM 2
AMOX-CLAV 200-28.5 MG TAB CHEW 2 ATOVAQUONE 2
AMOX-CLAV 200-28.5 MG/5 ML SUS 2 ATOVAQUONE-PROGUANIL HCL 2
AMOX-CLAV 250-125 MG TABLET 2 ATRIPLA 3
AMOX-CLAV 250-62.5 MG/5 ML SUS 2 ATROPINE 1% EYE DROPS 2
AMOX-CLAV 400-57 MG TAB CHEW 2 ATROPINE 1% EYE OINTMENT 2
AMOX-CLAV 400-57 MG/5 ML SUSP 2 AUBRA 1
AMOX-CLAV 500-125 MG TABLET 2 AVANDIA 4
AMOX-CLAV 600-42.9 MG/5 ML SUS 2 AVIANE 1
AMOX-CLAV 875-125 MG TABLET 2 AZASITE 4
AMOXICILLIN 1 AZATHIOPRINE 2
AMOXICILLIN-CLAVULANATE POT ER 2 AZELASTINE HCL 2
AMPICILLIN TRIHYDRATE 2 AZITHROMYCIN 1 GM PWD PACKET 2
ANADROL-50 4 PA AZITHROMYCIN 100 MG/5 ML SUSP 2
ANAGRELIDE HCL 2 AZITHROMYCIN 200 MG/5 ML SUSP 2
ANALPRAM HC 4 AZITHROMYCIN 250 MG TABLET 2
ANASTROZOLE 2 AZITHROMYCIN 500 MG TABLET 2
ANDROXY 2 AZITHROMYCIN 600 MG TABLET 2
ANORO ELLIPTA 3 AZOPT 3
ANUCORT-HC 2 AZUPHEN MB 2
APEXICON E 2 AZURETTE 1
APIDRA 4 ST BACITRACIN 500 UNIT/GM OPHTH 2
APIDRA SOLOSTAR 4 ST BACITRACIN-POLYMYXIN EYE OINT 2
APRACLONIDINE HCL 2 BACLOFEN 10 MG TABLET 1
APREPITANT 2 QL BACLOFEN 20 MG TABLET 1
APRI 1 BACLOFEN 5 MG TABLET 2
APRISO 3 BAL-CARE DHA 1
APTIOM 4 QL BALCOLTRA 4
APTIVUS 3 BALSALAZIDE DISODIUM 2
ARANELLE 1 BALZIVA 1
ARBINOXA 2 BANZEL 4 QL
ARCAPTA NEOHALER 4 ST BASAGLAR KWIKPEN U-100 3
ARIPIPRAZOLE 2 BD 3 ML SYRINGE 18GX1-1/2" 3
ARIPIPRAZOLE ODT 2 BD 3 ML SYRINGE 20GX1-1/2" 3
ARMODAFINIL 2 PA BD 3 ML SYRINGE 25GX1" 3
ARMOUR THYROID 2 BD 3 ML SYRINGE 25GX1-1/2" 3
ARNUITY ELLIPTA 3 BD 3 ML SYRINGE WITH NEEDLE 3
ASA-BUTALB-CAFFEINE-CODEINE 2 BD AUTO INJECTOR 3
ASCOMP WITH CODEINE 2 BD AUTOSHIELD DUO NDL 5MMX30G 3
ASHLYNA 1 BD AUTOSHIELD NEEDLE 5MMX29G 3
ASMANEX 4 ST BD AUTOSHIELD NEEDLE 8MMX29G 3
ASMANEX HFA 4 ST BD BLUNT NEEDLE 18GX1-1/2" 3
ASPIRIN-CAFFEINE-DIHYDROCODEIN 2 BD ECLIPSE 30GX1/2" SYRINGE 3
ASPIRIN-DIPYRIDAMOLE ER 2 BD ECLIPSE LUER-LOK SYR 3 ML 3
ATAZANAVIR SULFATE 2 BD ECLIPSE NEEDLE 18GX1 1/2" 3
ATENOLOL 1 BD ECLIPSE NEEDLE 21GX1" 3
ATENOLOL-CHLORTHALIDONE 1 BD ECLIPSE NEEDLE 22GX1" 3
ATOMOXETINE HCL 2 BD ECLIPSE NEEDLE 23GX1" 3
Please visit Cigna.com/ifp-drug-list to see a complete listing.
72019 Cigna Rx Premiere Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
BD ECLIPSE NEEDLE 25GX1" 3 BD LUER-LOK SYRINGE 1 ML 3
BD ECLIPSE NEEDLE 25GX1.5" 3 BD MAGNI-GUIDE MAGNIFIER 3
BD ECLIPSE NEEDLE 25GX5/8" 3 BD MEDSAVER SYRINGE 3
BD ECLIPSE NEEDLE 27GX1/2" 3 BD NEEDLE 18GX1 1/2" 3
BD ECLIPSE NEEDLE 30GX1/2" 3 BD NEEDLE 19GX1 1/2" 3
BD ECLIPSE NEEDLES 21GX1.5" 3 BD NEEDLE 20GX1 1/2" 3
BD FILTER NEEDLE 3 BD NEEDLE 21GX1 1/2" 3
BD INS SYR 0.3 ML 8MMX31G(1/2) 3 BD NEEDLE 21GX1" 3
BD INS SYR U-500 1/2ML 6MMX31G 3 BD NEEDLE 22GX1 1/2" 3
BD INS SYR UF 0.3ML 12.7MMX30G 3 BD NEEDLE 22GX1" 3
BD INS SYR UF 0.5ML 12.7MMX30G 3 BD NEEDLE 22GX3/4" 3
BD INS SYRN UF 1 ML 12.7MMX30G 3 BD NEEDLE 23GX1 1/2" 3
BD INS SYRNG 0.3 ML 29GX12.7MM 3 BD NEEDLE 23GX1" 3
BD INS SYRNG 0.5 ML 29GX12.7MM 3 BD NEEDLE 24GX1" 3
BD INS SYRNG UF 0.3 ML 8MMX31G 3 BD NEEDLE 25GX1" 3
BD INS SYRNG UF 0.5 ML 8MMX31G 3 BD NEEDLE 25GX5/8" 3
BD INSUL SYR 0.3 ML 31GX15/64" 3 BD NEEDLE 26GX0.625" 3
BD INSUL SYR 0.5 ML 31GX15/64" 3 BD NEEDLES 16GX1" 3
BD INSULIN SYR 0.3 ML 28GX1/2" 3 BD NEEDLES 16GX1.5" 3
BD INSULIN SYR 0.3 ML 29GX1/2" 3 BD NEEDLES 18GX1" 3
BD INSULIN SYR 0.3 ML 31GX5/16 3 BD NEEDLES 18GX1.5" 3
BD INSULIN SYR 0.3 ML 8MMX31G 3 BD NEEDLES 19GX1" 3
BD INSULIN SYR 0.5 ML 28GX1/2" 3 BD NEEDLES 19GX1.5" 3
BD INSULIN SYR 0.5 ML 29GX1/2" 3 BD NEEDLES 20GX1" 3
BD INSULIN SYR 0.5 ML 30GX1/2" 3 BD NEEDLES 20GX1.5" 3
BD INSULIN SYR 0.5 ML 8MMX31G 3 BD NEEDLES 21GX1" 3
BD INSULIN SYR 0.5ML 31GX5/16" 3 BD NEEDLES 21GX1.5" 3
BD INSULIN SYR 1 ML 12.7MMX30G 3 BD NEEDLES 21GX2" 3
BD INSULIN SYR 1 ML 25GX1" 3 BD NEEDLES 22GX1" 3
BD INSULIN SYR 1 ML 25GX5/8" 3 BD NEEDLES 22GX1.5" 3
BD INSULIN SYR 1 ML 26GX1/2" 3 BD NEEDLES 23GX0.75" 3
BD INSULIN SYR 1 ML 27GX12.7MM 3 BD NEEDLES 23GX1.25" 3
BD INSULIN SYR 1 ML 27GX5/8" 3 BD NEEDLES 25GX0.625" 3
BD INSULIN SYR 1 ML 28GX1/2" 3 BD NEEDLES 25GX0.875" 3
BD INSULIN SYR 1 ML 29GX1/2" 3 BD NEEDLES 25GX1.5" 3
BD INSULIN SYR 1 ML 29GX12.7MM 3 BD NEEDLES 26GX0.375" 3
BD INSULIN SYR 1 ML 30GX1/2" 3 BD NEEDLES 26GX0.5" 3
BD INSULIN SYR 1 ML 31GX15/64" 3 BD NEEDLES 27GX0.5" 3
BD INSULIN SYR 1 ML 31GX5/16" 3 BD NEEDLES 27GX1X1.25" 3
BD INSULIN SYR 1 ML 8MMX31G 3 BD NEEDLES 30GX0.5" 3
BD INSULIN SYR UF 1 ML 8MMX31G 3 BD NEEDLES 30GX1" 3
BD INSULIN SYRINGE 1 ML 3 BD NOKOR ADMIX NEEDLE 18GX1.5" 3
BD INSULIN U100-3/10 ML SYR 3 BD NOKOR NEEDLE 16GX1" 3
BD INTEGRA NEEDLE 25G X 5/8" 3 BD NOKOR NEEDLE 18GX1" 3
BD INTEGRA RETRA NEEDLE 23GX1" 3 BD PEN NEEDLE 29GX1/2" 3
BD INTEGRA SYR 1 ML 29GX1/2" 3 BD PRECISIONGLI 27GX1-1/2" NDL 3
BD INTEGRA SYR 3 ML 21GX1 1/2" 3 BD PRECISIONGLIDE 3 ML 22GX3/4 3
BD LUER-LOK SYR 3 ML 25GX5/8" 3 BD PRECISIONGLIDE NEEDLE 25G 3
Please visit Cigna.com/ifp-drug-list to see a complete listing.
82019 Cigna Rx Premiere Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
BD SAFETGLD INS 0.3 ML 8MMX31G 3 BETHANECHOL CHLORIDE 2
BD SAFETGLD INS 0.3ML 13MMX29G 3 BEXAROTENE 4 PA
BD SAFETGLD INS 0.5 ML 8MMX30G 3 BEYAZ 3
BD SAFETYGLID INS 1 ML 6MMX31G 3 BICALUTAMIDE 2
BD SAFETYGLIDE 3 ML SYRINGE 3 BILTRICIDE 4
BD SAFETYGLIDE NEEDLE 3 BIMATOPROST 0.03% EYE DROPS 2
BD SAFETYGLIDE NEEDLE 18GX1.5" 3 BINOSTO 4
BD SAFETYGLIDE NEEDLE 21GX1" 3 BISOPROLOL FUMARATE 2
BD SAFETYGLIDE NEEDLE 21GX1.5" 3 BISOPROLOL-HYDROCHLOROTHIAZIDE 1
BD SAFETYGLIDE NEEDLE 22GX1.5" 3 BLISOVI 24 FE 1
BD SAFETYGLIDE NEEDLE 25GX1" 3 BLISOVI FE 1
BD SAFETYGLIDE NEEDLE 27GX5/8" 3 BP WASH 7% LIQUID 2
BD SAFETYGLIDE SYRINGE 27GX5/8 3 BP WASH ACNE 4% TREATMENT PACK 2
BD SAFTYGLD INS 0.3 ML 6MMX31G 3 BPO 4% CREAMY WASH PACK 2
BD SAFTYGLD INS 0.5 ML 6MMX31G 3 BPO 4% GEL 2
BD SYR 0.3 ML 6MMX31G (1/2) 3 BPO 6% FOAMING CLOTHS 2
BD SYR 0.3 ML 8MMX31G (1/2) 3 BPO 8% GEL 2
BD SYRINGE 0.3 ML 12.7MMX30G 3 BREO ELLIPTA 3
BD SYRINGE 0.5 ML 12.7MMX30G 3 BREVICON 4
BD SYRINGE-SAFETY GLIDE 3 BRIELLYN 1
BD UF MICRO PEN NEEDLE 6MMX32G 3 BRILINTA 4
BD UF MINI PEN NEEDLE 5MMX31G 3 BRIMONIDINE TARTRATE 2
BD UF NANO PEN NEEDLE 4MMX32G 3 BROMFED DM 2
BD UF ORIG PEN NDL 12.7MMX29G 3 BROMFENAC SODIUM 2
BD UF SHORT PEN NEEDLE 8MMX31G 3 BROMOCRIPTINE MESYLATE 2
BD VEO INS 0.3ML 6MMX31G (1/2) 3 BROMPHENIRAMINE-PSEUDOEPHED- 2
BD VEO INS SYRING 1 ML 6MMX31G 3 DM
BD VEO INS SYRN 0.3 ML 6MMX31G 3 BROVANA 4
BD VEO INS SYRN 0.5 ML 6MMX31G 3 BUDESONIDE 0.25 MG/2 ML SUSP 4
BECONASE AQ 4 ST BUDESONIDE 0.5 MG/2 ML SUSP 4
BEKYREE 1 BUDESONIDE 1 MG/2 ML INH SUSP 4
BELLADONNA-OPIUM 2 BUDESONIDE 32 MCG NASAL SPRAY 2
BELSOMRA 4 ST, QL BUDESONIDE EC 3 MG CAPSULE 4
BENAZEPRIL HCL 1 BUMETANIDE 0.5 MG TABLET 1
BENAZEPRIL-HYDROCHLOROTHIAZIDE 2 BUMETANIDE 1 MG TABLET 1
BENZEPRO 6% FOAMING CLOTHS 2 BUMETANIDE 2 MG TABLET 1
BENZEPRO 7% CREAMY WASH 2 BUPRENORPHINE PATCH 2 QL
BENZONATATE 2 BUPRENORPHINE 2 MG TABLET SL 2
BENZTROPINE MES 0.5 MG TAB 2 BUPRENORPHINE 8 MG TABLET SL 2
BENZTROPINE MES 1 MG TABLET 2 BUPRENORPHINE-NALOXONE 2
BENZTROPINE MES 2 MG TABLET 2 BUPROPION HCL 2 QL
BEPREVE 4 BUPROPION HCL SR 2 QL
BESIVANCE 4 BUPROPION XL 2 QL
BETADINE 4 BUSPIRONE HCL 2
BETAMETHASONE DIPROP AUGMENTED 2 BUTALB-ACETAMINOPH-CAFF-CODEIN 2
BETAMETHASONE DIPROPIONATE 2 BUTALB-CAFF-ACETAMINOPH-CODEIN 2
BETAMETHASONE VALERATE 2 BUTALBITAL COMPOUND-CODEINE 2
BETAXOLOL HCL 2 BUTALBITAL-ACETAMINOPHEN-CAFFE 2
Please visit Cigna.com/ifp-drug-list to see a complete listing.
92019 Cigna Rx Premiere Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
BUTALBITAL-ACETAMINOPHN 50-325 2 CARISOPRODOL-ASPIRIN 2
BUTALBITAL-ASPIRIN-CAFFEINE 2 CARISOPRODOL-ASPIRIN-CODEINE 2
BUTISOL SODIUM 4 CARNITOR SF 4
BUTORPHANOL 10 MG/ML SPRAY 2 QL CARTEOLOL HCL 2
BYDUREON 3 QL CARTIA XT 2
BYDUREON BCISE 3 QL CARVEDILOL 1
BYDUREON PEN 3 QL CAZIANT 1
BYETTA 3 QL CEFACLOR 2
BYSTOLIC 4 QL CEFACLOR ER 2
CABERGOLINE 2 QL CEFADROXIL 2
CAFFEINE CIT 60 MG/3 ML ORAL 2 CEFDINIR 2
CALCIPOTRIENE 2 CEFDITOREN PIVOXIL 2
CALCIPOTRIENE-BETAMETHASONE DP 2 CEFIXIME 2
CALCITONIN-SALMON 2 CEFPODOXIME PROXETIL 2
CALCITRENE 2 CEFPROZIL 2
CALCITRIOL 0.25 MCG CAPSULE 2 CEFTIBUTEN 2
CALCITRIOL 0.5 MCG CAPSULE 2 CEFUROXIME 2
CALCITRIOL 1 MCG/ML SOLUTION 2 CELECOXIB 2 QL
CALCITRIOL 3 MCG/G OINTMENT 2 QL CELONTIN 4
CALCIUM ACETATE 667 MG CAPSULE 2 CENTERGY 2
CALCIUM ACETATE 667 MG GELCAP 2 CENTERGY DM 2
CALCIUM ACETATE 667 MG TABLET 2 CEPHALEXIN 125 MG/5 ML SUSP 1
CAMBIA 4 CEPHALEXIN 250 MG CAPSULE 1
CAMILA 1 CEPHALEXIN 250 MG TABLET 1
CAMRESE 1 CEPHALEXIN 250 MG/5 ML SUSP 1
CAMRESE LO 1 CEPHALEXIN 500 MG CAPSULE 1
CANDESARTAN CILEXETIL 2 CEPHALEXIN 500 MG TABLET 1
CANDESARTAN-HYDROCHLOROTHIAZID 2 CEPHALEXIN 750 MG CAPSULE 2
CAPACET 2 CESAMET 4
CAPCOF 4 CETIRIZINE HCL 1 MG/ML SOLN 2
CAPECITABINE 4 CETIRIZINE HCL 1 MG/ML SYRUP 2
CAPTOPRIL 1 CEVIMELINE HCL 2
CAPTOPRIL-HYDROCHLOROTHIAZIDE 2 QL CHANTIX 4
CARBAGLU 4 PA CHATEAL 1
CARBAMAZEPINE 100 MG TAB CHEW 1 CHEMET 4
CARBAMAZEPINE 100 MG/5 ML SUSP 2 CHENODAL 4 LDD
CARBAMAZEPINE 200 MG TABLET 1 CHERATUSSIN AC 2
CARBAMAZEPINE ER 2 CHLORDIAZEPOXIDE HCL 2
CARBIDOPA 2 CHLORDIAZEPOXIDE-AMITRIPTYLINE 2
CARBIDOPA-LEVODOPA 2 CHLORDIAZEPOXIDE-CLIDINIUM 2
CARBIDOPA-LEVODOPA ER 2 CHLORHEXIDINE 0.12% RINSE 2
CARBIDOPA-LEVODOPA-ENTACAPONE 2 CHLOROQUINE PHOSPHATE 2
CARBINOXAMINE 4 MG/5 ML LIQUID 2 CHLOROTHIAZIDE 2
CARBINOXAMINE MALEATE 4 MG TAB 2 CHLORPROMAZINE 10 MG TABLET 2
CARETOUCH ALCOHOL PREP PAD 3 CHLORPROMAZINE 100 MG TABLET 2
CARISOPRODOL 2 CHLORPROMAZINE 200 MG TABLET 2
CARISOPRODOL COMPOUND 2 CHLORPROMAZINE 25 MG TABLET 2
CARISOPRODOL COMPOUND-CODEINE 2 CHLORPROMAZINE 50 MG TABLET 2
Please visit Cigna.com/ifp-drug-list to see a complete listing.
102019 Cigna Rx Premiere Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
CHLORPROPAMIDE 1 CLINDAMYCIN PH 1% SOLUTION 2
CHLORTHALIDONE 2 CLINDAMYCIN PHOS 1% PLEDGET 2
CHLORZOXAZONE 500 MG TABLET 2 CLINDAMYCIN PHOS-BENZOYL PEROX 2
CHOLESTYRAMINE 2 CLINDAMYCIN PHOSP 1% LOTION 2
CHOLESTYRAMINE LIGHT 2 CLINDAMYCIN PHOSPHATE 1% FOAM 2
CHOLINE MAG TRISALICYLATE 2 CLINDAMYCIN PHOS-TRETINOIN 2
CHORIONIC GONADOTROPIN 2 PA CLINDAMYCIN-BENZOYL PEROXIDE 2
CIALIS 4 PA, QL CLINDESSE 4
CICLODAN 0.77% CREAM 2 CLOBETASOL 0.05% CREAM 2
CICLODAN 8% SOLUTION 2 CLOBETASOL 0.05% GEL 2
CICLOPIROX 0.77% CREAM 2 CLOBETASOL 0.05% OINTMENT 2
CICLOPIROX 0.77% GEL 2 CLOBETASOL 0.05% SHAMPOO 2
CICLOPIROX 0.77% TOPICAL SUSP 2 CLOBETASOL 0.05% SOLUTION 2
CICLOPIROX 1% SHAMPOO 2 CLOBETASOL 0.05% TOPICAL LOTN 2
CICLOPIROX 8% SOLUTION 2 CLOBETASOL EMOLLIENT 2
CILOSTAZOL 2 CLOBETASOL EMULSION 2
CILOXAN 4 CLOBETASOL PROP 0.05% FOAM 2
CIMETIDINE 200 MG TABLET 1 CLOBETASOL PROP 0.05% SPRAY 2
CIMETIDINE 300 MG TABLET 1 CLOCORTOLONE PIVALATE 2
CIMETIDINE 300 MG/5 ML SOLN 2 CLODAN 0.05% SHAMPOO 2
CIMETIDINE 400 MG TABLET 1 CLOMIPRAMINE HCL 4
CIMETIDINE 800 MG TABLET 1 CLONAZEPAM 2
CIPRO HC 4 CLONIDINE 2
CIPRODEX 4 CLONIDINE HCL 0.1 MG TABLET 2
CIPROFLOXACIN 0.2% OTIC SOLN 2 CLONIDINE HCL 0.2 MG TABLET 2
CIPROFLOXACIN 0.3% EYE DROP 2 CLONIDINE HCL 0.3 MG TABLET 2
CIPROFLOXACIN 250 MG/5 ML SUSP 2 CLONIDINE HCL ER 2
CIPROFLOXACIN 500 MG/5 ML SUSP 2 CLOPIDOGREL 2
CIPROFLOXACIN ER 2 CLORAZEPATE DIPOTASSIUM 2
CIPROFLOXACIN HCL 100 MG TAB 1 CLORPRES 2
CIPROFLOXACIN HCL 250 MG TAB 1 CLOTRIMAZOLE 1% CREAM 2
CIPROFLOXACIN HCL 500 MG TAB 1 CLOTRIMAZOLE 1% SOLUTION 2
CIPROFLOXACIN HCL 750 MG TAB 1 CLOTRIMAZOLE 10 MG TROCHE 2
CITALOPRAM HBR 10 MG TABLET 1 QL CLOTRIMAZOLE-BETAMETHASONE 2
CITALOPRAM HBR 10 MG/5 ML SOLN 2 QL CLOZAPINE 2
CITALOPRAM HBR 20 MG TABLET 1 QL CLOZAPINE ODT 100 MG TABLET 4
CITALOPRAM HBR 40 MG TABLET 1 QL CLOZAPINE ODT 12.5 MG TABLET 4
CLARAVIS 2 QL CLOZAPINE ODT 150 MG TABLET 4
CLARITHROMYCIN 2 CLOZAPINE ODT 200 MG TABLET 4
CLARITHROMYCIN ER 2 CLOZAPINE ODT 25 MG TABLET 4
CLEMASTINE FUMARATE 2 C-NATE DHA 1
CLINDACIN ETZ 1% PLEDGET 2 COARTEM 4 QL
CLINDACIN P 2 CODEINE SULFATE 2
CLINDAMYCIN 2% VAGINAL CREAM 2 CODEINE-GUAIFEN 10-100 MG/5 ML 2
CLINDAMYCIN HCL 2 COLCHICINE 2
CLINDAMYCIN PALMITATE HCL 2 COLESEVELAM HCL 2
CLINDAMYCIN PEDIATRIC 2 COLESTIPOL HCL 2
CLINDAMYCIN PH 1% GEL 2 COLOCORT 2
Please visit Cigna.com/ifp-drug-list to see a complete listing.
112019 Cigna Rx Premiere Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
COLY-MYCIN S 4 DANTROLENE SODIUM 2
COMBIGAN 4 DAPSONE 4
COMPLERA 3 DARAPRIM 4 PA
COMPLETE NATAL DHA 1 DARIFENACIN ER 2
COMPLETENATE 1 DASETTA 1
COMPRO 2 DAYSEE 1
CONSTULOSE 2 DEBLITANE 1
CORDRAN 4 DECADRON 0.5 MG/5 ML ELIXIR 1
COREMINO 2 DECARA 25,000 UNIT VEGICAP 4 QL
CORMAX 2 DECARA 50,000 UNIT SOFTGEL 4 QL
CORTISONE ACETATE 2 DELYLA 1
CORTISPORIN 4 DEMECLOCYCLINE HCL 2
COVARYX 2 DEMSER 4
COVARYX H.S. 2 DENAVIR 4
CREON 4 DENTA 5000 PLUS 2
CRESEMBA 186 MG CAPSULE 4 PA DENTAGEL 2
CRIXIVAN 3 DEPADE 2
CROMOLYN 100 MG/5 ML ORAL CONC 2 DEPEN 4
CROMOLYN 20 MG/2 ML NEB SOLN 2 DESCOVY 3
CROMOLYN 4% EYE DROPS 2 DESIPRAMINE HCL 2
CRYSELLE 1 DESLORATADINE 2 QL
CUPRIMINE 4 DESMOPRESSIN 0.01% SOLUTION 2
CURITY ALCOHOL PREPS 3 DESMOPRESSIN 0.01% SPRAY 2
CYANOCOBALAMIN INJECTION 2 DESMOPRESSIN 0.1 MG/ML SOL 2
CYCLAFEM 1 DESMOPRESSIN 10 MCG/0.1 ML SPR 2
CYCLESSA 1 DESMOPRESSIN ACETATE 0.1 MG TB 2
CYCLOBENZAPRINE 10 MG TABLET 1 DESMOPRESSIN ACETATE 0.2 MG TB 2
CYCLOBENZAPRINE 5 MG TABLET 1 DESOGEN 4
CYCLOBENZAPRINE 7.5 MG TABLET 3 DESOGESTREL-ETHINYL ESTRADIOL 1
CYCLOMYDRIL 4 DESOGESTR-ETH ESTRAD ETH ESTRA 1
CYCLOPENTOLATE HCL 2 DESONIDE 2
CYCLOPHOSPHAMIDE 25 MG CAPSULE 3 DESOXIMETASONE 2
CYCLOPHOSPHAMIDE 50 MG CAPSULE 3 DESVENLAFAXINE SUCCINATE ER 2 QL
CYCLOSERINE 2 DEXAMETHASONE 1
CYCLOSET 4 DEXAMETHASONE 0.1% EYE DROP 2
CYCLOSPORINE 100 MG CAPSULE 2 DEXAMETHASONE INTENSOL 1
CYCLOSPORINE 25 MG CAPSULE 2 DEXILANT 3 ST, QL
CYCLOSPORINE MODIFIED 2 DEXMETHYLPHENIDATE ER 10 MG CP 2
CYPROHEPTADINE 2 MG/5 ML SYRUP 2 DEXMETHYLPHENIDATE ER 15 MG CP 2
CYPROHEPTADINE 4 MG TABLET 2 DEXMETHYLPHENIDATE ER 20 MG CP 2
CYRED 1 DEXMETHYLPHENIDATE ER 25 MG CP 2
CYSTARAN 4 LDD DEXMETHYLPHENIDATE ER 30 MG CP 2
CYTRA-2 2 DEXMETHYLPHENIDATE ER 35 MG CP 2
CYTRA-3 2 DEXMETHYLPHENIDATE ER 40 MG CP 2
CYTRA-K 2 DEXMETHYLPHENIDATE ER 5 MG CAP 2
DALIRESP 250 MCG TABLET 4 QL DEXMETHYLPHENIDATE HCL 2
DALIRESP 500 MCG TABLET 4 DEXTROAMPHETAMINE SULFATE 2
DANAZOL 2 DEXTROAMPHETAMINE SULFATE ER 2
Please visit Cigna.com/ifp-drug-list to see a complete listing.
122019 Cigna Rx Premiere Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
DEXTROAMPHETAMINE-AMPHET ER 2 DILT-XR 2
DEXTROAMPHETAMINE-AMPHETAMINE 2 DIPENTUM 4
DIAZEPAM 10 MG RECTAL GEL SYST 2 DIPHENHYDRAMINE 12.5 MG/5 ML 2
DIAZEPAM 10 MG TABLET 2 DIPHENHYDRAMINE 25 MG/10 ML 2
DIAZEPAM 2 MG TABLET 2 DIPHENOXYLATE-ATROPINE 2
DIAZEPAM 2.5 MG RECTAL GEL SYS 2 DIPYRIDAMOLE 25 MG TABLET 2
DIAZEPAM 20 MG RECTAL GEL SYST 2 DIPYRIDAMOLE 50 MG TABLET 2
DIAZEPAM 5 MG TABLET 2 DIPYRIDAMOLE 75 MG TABLET 2
DIAZEPAM 5 MG/5 ML ORAL SOLN 2 DISKETS 2 PA
DIAZEPAM 5 MG/5 ML SOLUTION 2 DISOPYRAMIDE PHOSPHATE 2
DIAZEPAM 5 MG/ML ORAL CONC 2 DISULFIRAM 2
DICLOFENAC 0.1% EYE DROPS 2 DIVALPROEX SODIUM 2
DICLOFENAC 1.5% TOPICAL SOLN 2 DIVALPROEX SODIUM ER 2
DICLOFENAC POTASSIUM 2 DOFETILIDE 4 QL
DICLOFENAC SOD DR 25 MG TAB 2 DONEPEZIL HCL 2
DICLOFENAC SOD DR 50 MG TAB 2 DONEPEZIL HCL ODT 2
DICLOFENAC SOD DR 75 MG TAB 2 DORZOLAMIDE HCL 2
DICLOFENAC SOD EC 25 MG TAB 2 DORZOLAMIDE-TIMOLOL 2
DICLOFENAC SOD EC 50 MG TAB 2 DOTHELLE DHA 1
DICLOFENAC SOD EC 75 MG TAB 2 DOXAZOSIN MESYLATE 1
DICLOFENAC SODIUM 1% GEL 2 QL DOXEPIN 10 MG CAPSULE 2
DICLOFENAC SODIUM ER 2 DOXEPIN 10 MG/ML ORAL CONC 2
DICLOFENAC SODIUM-MISOPROSTOL 2 DOXEPIN 100 MG CAPSULE 2
DICLOXACILLIN SODIUM 2 DOXEPIN 150 MG CAPSULE 2
DICYCLOMINE 10 MG CAPSULE 1 DOXEPIN 25 MG CAPSULE 2
DICYCLOMINE 10 MG/5 ML SOLN 2 DOXEPIN 5% CREAM 4
DICYCLOMINE 20 MG TABLET 1 DOXEPIN 50 MG CAPSULE 2
DIDANOSINE 2 DOXEPIN 75 MG CAPSULE 2
DIFICID 4 PA DOXERCALCIFEROL 0.5 MCG CAP 2
DIFLORASONE DIACETATE 2 DOXERCALCIFEROL 1 MCG CAPSULE 2
DIFLUNISAL 2 DOXERCALCIFEROL 2.5 MCG CAP 2
DIGITEK 1 DOXYCYCLINE HYC DR 100 MG TAB 2
DIGOX 1 DOXYCYCLINE HYC DR 150 MG TAB 2
DIGOXIN 0.05 MG/ML SOLUTION 2 DOXYCYCLINE HYC DR 200 MG TAB 2
DIGOXIN 0.125 MG TABLET 1 DOXYCYCLINE HYC DR 50 MG TAB 2
DIGOXIN 0.25 MG TABLET 1 DOXYCYCLINE HYC DR 75 MG TAB 2
DIGOXIN 125 MCG TABLET 1 DOXYCYCLINE HYCLATE 100 MG CAP 2
DIGOXIN 250 MCG TABLET 1 DOXYCYCLINE HYCLATE 100 MG TAB 2
DIHYDROERGOTAMINE MESYLATE 4 QL DOXYCYCLINE HYCLATE 20 MG TAB 2
DILATRATE-SR 4 DOXYCYCLINE HYCLATE 50 MG CAP 2
DILTIAZEM 120 MG TABLET 1 DOXYCYCLINE MONOHYDRATE 2
DILTIAZEM 12HR ER 2 DRONABINOL 4
DILTIAZEM 24HR CD 2 DROSPIRENONE-EE 3-0.02 MG TAB 1
DILTIAZEM 24HR ER 2 DROSPIRENONE-EE 3-0.03 MG TAB 1
DILTIAZEM 30 MG TABLET 1 DROSPIRENONE-ETH ESTRA-LEVOMEF 1
DILTIAZEM 60 MG TABLET 1 DUAVEE 4
DILTIAZEM 90 MG TABLET 1 DULERA 4 ST
DILTIAZEM ER 2 DULOXETINE HCL 2 QL
Please visit Cigna.com/ifp-drug-list to see a complete listing.
132019 Cigna Rx Premiere Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
DUREZOL 4 EPITOL 1
DUTASTERIDE 2 EPLERENONE 2
DUTASTERIDE-TAMSULOSIN 2 EPROSARTAN MESYLATE 2
DYMISTA 4 ERGOLOID MESYLATES 1
DYRENIUM 4 ERGOMAR 4
EASY TOUCH ALCOHOL PREP PADS 3 ERRIN 1
ECONAZOLE NITRATE 2 ERTACZO 4
ECONTRA EZ 4 ERY 2
EDARBI 4 ST, QL ERYTHROCIN STEARATE 2
EDARBYCLOR 4 ST, QL ERYTHROMYCIN 2
ED-SPAZ 1 ERYTHROMYCIN ETHYLSUCCINATE 2
EDURANT 3 ERYTHROMYCIN-BENZOYL PEROXIDE 2
EEMT 2 ESCITALOPRAM OXALATE 2 QL
EEMT H.S. 2 ESOMEPRAZOLE MAG DR 20 MG CAP 2 QL
EFAVIRENZ 2 ESOMEPRAZOLE MAG DR 40 MG CAP 2 QL
EFFER-K 4 ESOMEPRAZOLE STRONTIUM 2 QL
ELETRIPTAN HBR 2 QL ESTARYLLA 1
ELIDEL 4 ESTAZOLAM 2
ELINEST 1 ESTRADIOL 0.025 MG PATCH 2
ELIPHOS 2 ESTRADIOL 0.0375 MG PATCH 2
ELITE OB DHA 1 ESTRADIOL 0.0375 MG/DAY PATCH 2
ELITE-OB 1 ESTRADIOL 0.05 MG PATCH 2
ELITE-OB 400 1 ESTRADIOL 0.06 MG/DAY PATCH 2
ELLA 4 ESTRADIOL 0.075 MG PATCH 2
ELMIRON 4 ESTRADIOL 0.075 MG/DAY PATCH 2
EMADINE 4 ESTRADIOL 0.1 MG PATCH 2
EMBEDA 4 ST, QL ESTRADIOL 0.5 MG TABLET 1
EMOQUETTE 1 ESTRADIOL 1 MG TABLET 1
EMSAM 4 QL ESTRADIOL 10 MCG VAGINAL INSRT 2
EMTRIVA 3 ESTRADIOL 2 MG TABLET 1
EMVERM 2 ESTRADIOL TDS 0.025 MG/DAY 2
ENALAPRIL MALEATE 1 ESTRADIOL TDS 0.0375 MG/DAY 2
ENALAPRIL-HYDROCHLOROTHIAZIDE 2 ESTRADIOL TDS 0.05 MG/DAY 2
ENDOCET 2 ESTRADIOL TDS 0.06 MG/DAY 2
ENDOMETRIN 4 PA ESTRADIOL TDS 0.075 MG/DAY 2
ENLYTE 4 ESTRADIOL TDS 0.1 MG/DAY 2
ENOXAPARIN SODIUM 4 QL ESTRADIOL-NORETHINDRONE ACETAT 2
ENPRESSE 1 ESTROGEN-METHYLTESTOSTERONE 2
ENSKYCE 1 ESTROPIPATE 2
ENTACAPONE 2 ESTROSTEP FE 4
ENTECAVIR 0.5 MG TABLET 4 ESZOPICLONE 2
ENTECAVIR 1 MG TABLET 4 ETHACRYNIC ACID 2
ENTRESTO 3 PA ETHAMBUTOL HCL 2
ENULOSE 2 ETHOSUXIMIDE 2
EPIFOAM 4 ETHYL CHLORIDE 2
EPINASTINE HCL 2 ETHYNODIOL-ETHINYL ESTRADIOL 1
EPINEPHRINE 0.15 MG AUTO-INJCT 2 QL ETIDRONATE DISODIUM 2
EPINEPHRINE 0.3 MG AUTO-INJECT 2 QL ETODOLAC 2
Please visit Cigna.com/ifp-drug-list to see a complete listing.
142019 Cigna Rx Premiere Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
ETODOLAC ER 2 FLOVENT DISKUS 3
ETOPOSIDE 4 FLOVENT HFA 3
EURAX 4 FLOWTUSS 4
EVOTAZ 3 FLUCONAZOLE 10 MG/ML SUSP 2
EXELDERM 4 FLUCONAZOLE 100 MG TABLET 2
EXEMESTANE 2 FLUCONAZOLE 150 MG TABLET 1
EXTRA-VIRT PLUS DHA 1 FLUCONAZOLE 200 MG TABLET 2
EZETIMIBE 2 FLUCONAZOLE 40 MG/ML SUSP 2
EZETIMIBE-SIMVASTATIN 2 FLUCONAZOLE 50 MG TABLET 2
FACTIVE 4 FLUCYTOSINE 4
FALLBACK SOLO 4 FLUDROCORTISONE ACETATE 2
FALMINA 1 FLUNISOLIDE 2
FAMCICLOVIR 2 FLUOCINOLONE ACETONIDE 2
FAMOTIDINE 20 MG TABLET 1 FLUOCINOLONE ACETONIDE OIL 2
FAMOTIDINE 40 MG TABLET 1 FLUOCINONIDE 0.05% CREAM 2
FAMOTIDINE 40 MG/5 ML SUSP 2 FLUOCINONIDE 0.05% GEL 2
FANAPT 4 ST, QL FLUOCINONIDE 0.05% OINTMENT 2
FARESTON 4 FLUOCINONIDE 0.05% SOLUTION 2
FARXIGA 3 QL FLUOCINONIDE 0.1% CREAM 2
FAYOSIM 1 FLUOCINONIDE-E 2
FELBAMATE 400 MG TABLET 4 FLUORABON 2
FELBAMATE 600 MG TABLET 4 FLUOR-A-DAY 4
FELBAMATE 600 MG/5 ML SUSP 4 FLUORIDE 2
FELODIPINE ER 2 FLUORIDEX 2
FEM PH 2 FLUORIDEX DAILY DEFENSE 2
FEMCON FE 4 FLUORITAB 2
FEMYNOR 1 FLUOROMETHOLONE 2
FENOFIBRATE 2 FLUOROURACIL 0.5% CREAM 2
FENOFIBRIC ACID 2 FLUOROURACIL 2% TOPICAL SOLN 2
FENOPROFEN 600 MG TABLET 2 FLUOROURACIL 5% CREAM 2
FENTANYL PATCH 2 PA, QL FLUOROURACIL 5% TOPICAL SOLN 2
FENTANYL CIT OTFC 1,200 MCG 4 PA FLUOXETINE 20 MG/5 ML SOLUTION 2 QL
FENTANYL CIT OTFC 1,600 MCG 4 PA FLUOXETINE DR 2 QL
FENTANYL CITRATE OTFC 200 MCG 4 PA FLUOXETINE HCL 10 MG CAPSULE 1 QL
FENTANYL CITRATE OTFC 400 MCG 4 PA FLUOXETINE HCL 10 MG TABLET 1 QL
FENTANYL CITRATE OTFC 600 MCG 4 PA FLUOXETINE HCL 20 MG CAPSULE 1 QL
FENTANYL CITRATE OTFC 800 MCG 4 PA FLUOXETINE HCL 20 MG TABLET 1 QL
FERRIPROX 4 LDD FLUOXETINE HCL 40 MG CAPSULE 1 QL
FETZIMA 4 ST, QL FLUOXETINE HCL 60 MG TABLET 1 QL
FEXOFENADINE HCL 180 MG TABLET 2 FLUPHENAZINE 1 MG TABLET 2
FEXOFENADINE HCL 30 MG TABLET 2 FLUPHENAZINE 10 MG TABLET 2
FEXOFENADINE HCL 60 MG TABLET 2 FLUPHENAZINE 2.5 MG TABLET 2
FINACEA 4 FLUPHENAZINE 2.5 MG/5 ML ELIX 2
FINASTERIDE 5 MG TABLET 2 FLUPHENAZINE 5 MG TABLET 2
FIORICET 2 FLUPHENAZINE 5 MG/ML CONC 2
FLAVOXATE HCL 2 FLURA-DROPS 2
FLECAINIDE ACETATE 2 FLURANDRENOLIDE 2
FLECTOR 4 QL FLURAZEPAM HCL 2
Please visit Cigna.com/ifp-drug-list to see a complete listing.
152019 Cigna Rx Premiere Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
FLURBIPROFEN 2 GAVILYTE-H AND BISACODYL 2
FLURBIPROFEN SODIUM 2 GAVILYTE-N 2
FLUTAMIDE 2 GEMFIBROZIL 2
FLUTICASONE PROP 0.005% OINT 2 GENERESS FE 4
FLUTICASONE PROP 0.05% CREAM 2 GENERLAC 2
FLUTICASONE PROP 0.05% LOTION 2 GENGRAF 2
FLUTICASONE PROP 50 MCG SPRAY 2 GENTAK 2
FLUTICASONE-SALMETEROL 2 GENTAMICIN 0.1% CREAM 2
FLUVASTATIN ER 2 GENTAMICIN 0.1% OINTMENT 2
FLUVASTATIN SODIUM 2 GENTAMICIN 0.3% EYE DROPS 2
FLUVOXAMINE MALEATE 2 QL GENTAMICIN 0.3% EYE OINTMENT 2
FLUVOXAMINE MALEATE ER 2 QL GENTAMICIN 3 MG/ML EYE DROPS 2
FOCALGIN 90 DHA 1 GENVOYA 3
FOCALGIN CA 1 GIANVI 1
FOLIC ACID 1 MG TABLET 2 GILDAGIA 1
FOLIVANE-OB 1 GILDESS 1
FONDAPARINUX SODIUM 4 QL GILDESS 24 FE 1
FORMADON 2 GILDESS FE 1
FORMALDEHYDE 2 GLEOSTINE 4
FORMA-RAY 4 GLIMEPIRIDE 1
FORTICAL 2 GLIPIZIDE 1
FOSAMAX PLUS D 4 QL GLIPIZIDE ER 1
FOSAMPRENAVIR CALCIUM 2 GLIPIZIDE XL 1
FOSINOPRIL SODIUM 1 GLIPIZIDE-METFORMIN 2
FOSINOPRIL-HYDROCHLOROTHIAZIDE 2 GLUCAGEN 1 MG HYPOKIT 3
FOSRENOL 4 GLUCAGON EMERGENCY KIT 3
FROVATRIPTAN SUCCINATE 2 QL GLYBURIDE 1
FULYZAQ 4 GLYBURIDE MICRONIZED 1
FUROSEMIDE 10 MG/ML SOLUTION 1 GLYBURIDE-METFORMIN HCL 2
FUROSEMIDE 20 MG TABLET 1 GLYCINE 1.5% IRRIGATION 2
FUROSEMIDE 40 MG TABLET 1 GLYCOPYRROLATE 1 MG TABLET 2
FUROSEMIDE 40 MG/5 ML SOLN 1 GLYCOPYRROLATE 2 MG TABLET 2
FUROSEMIDE 80 MG TABLET 1 GLYDO 2
FYAVOLV 2 GRANISETRON HCL 0.1 MG/ML VIAL 2
FYCOMPA 10 MG TABLET 4 QL GRANISETRON HCL 1 MG TABLET 2
FYCOMPA 12 MG TABLET 4 QL GRANISETRON HCL 1 MG/ML VIAL 2
FYCOMPA 2 MG TABLET 4 QL GRANISETRON HCL 4 MG/4 ML VIAL 2
FYCOMPA 4 MG TABLET 4 QL GRISEOFULVIN 2
FYCOMPA 6 MG TABLET 4 QL GRISEOFULVIN ULTRAMICROSIZE 2
FYCOMPA 8 MG TABLET 4 QL GUAIATUSSIN AC 2
GABAPENTIN 2 GUAIFEN-CODEINE 100-10 MG/5 ML 2
GALANTAMINE ER 2 QL GUAIFENESIN AC 2
GALANTAMINE HBR 2 GUAIFENESIN-CODEINE SYRUP 2
GALANTAMINE HYDROBROMIDE 2 GUANFACINE HCL 1
GALZIN 4 GUANFACINE HCL ER 2
GATIFLOXACIN 2 GUANIDINE HCL 2
GAVILYTE-C 2 GYNAZOLE 1 2
GAVILYTE-G 2 HALOBETASOL PROPIONATE 2
Please visit Cigna.com/ifp-drug-list to see a complete listing.
162019 Cigna Rx Premiere Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
HALOG 4 HYDROCODONE-CHLORPHENIRAMNE ER 2
HALOPERIDOL 0.5 MG TABLET 2 HYDROCODONE-HOMATROPINE MBR 2
HALOPERIDOL 1 MG TABLET 2 HYDROCODONE-IBUPROFEN 2
HALOPERIDOL 10 MG TABLET 2 HYDROCORTISONE 1% ABSORBASE 2
HALOPERIDOL 2 MG TABLET 2 HYDROCORTISONE 1% CREAM 2
HALOPERIDOL 20 MG TABLET 2 HYDROCORTISONE 1% OINTMENT 2
HALOPERIDOL 5 MG TABLET 2 HYDROCORTISONE 10 MG TABLET 2
HALOPERIDOL LAC 2 MG/ML CONC 2 HYDROCORTISONE 100 MG/60 ML 2
HEATHER 1 HYDROCORTISONE 2.5% CREAM 2
HEMANGEOL 4 LDD HYDROCORTISONE 2.5% LOTION 2
HEMENATAL OB 1 HYDROCORTISONE 2.5% OINTMENT 2
HEMENATAL OB + DHA 1 HYDROCORTISONE 20 MG TABLET 2
HEMMOREX-HC 2 HYDROCORTISONE 5 MG TABLET 2
HEPARIN SOD 5,000 UNIT/ 0.5 ML 2 HYDROCORTISONE AC 25 MG SUPP 2
HEPARIN SOD 5,000 UNIT/0.5 ML 2 HYDROCORTISONE AC 30 MG SUPP 2
HOMATROPAIRE 2 HYDROCORTISONE BUTYRATE 2
HOMATROPINE HYDROBROMIDE 2 HYDROCORTISONE VALERATE 2
HUMALOG 3 HYDROCORTISONE-ACETIC ACID 2
HUMALOG JUNIOR KWIKPEN 3 HYDROCORTISONE-PRAMOXINE 2
HUMALOG KWIKPEN U-100 3 HYDROMET 2
HUMALOG KWIKPEN U-200 3 HYDROMORPHONE 1 MG/ML SOLUTION 2
HUMALOG MIX 50-50 3 HYDROMORPHONE 2 MG TABLET 2
HUMALOG MIX 50-50 KWIKPEN 3 HYDROMORPHONE 3 MG SUPPOS 2
HUMALOG MIX 75-25 3 HYDROMORPHONE 4 MG TABLET 2
HUMALOG MIX 75-25 KWIKPEN 3 HYDROMORPHONE 5 MG/5 ML SOLN 2
HUMULIN 70/30 KWIKPEN 3 HYDROMORPHONE 8 MG TABLET 2
HUMULIN 70-30 3 HYDROMORPHONE ER 2 QL
HUMULIN N 3 HYDROXYCHLOROQUINE SULFATE 2
HUMULIN N KWIKPEN 3 HYDROXYUREA 2
HUMULIN R 3 HYDROXYZINE 10 MG/5 ML SOLN 2
HUMULIN R U-500 3 HYDROXYZINE 10 MG/5 ML SYRUP 2
HUMULIN R U-500 KWIKPEN 3 HYDROXYZINE HCL 10 MG TABLET 2
HYDRALAZINE 10 MG TABLET 2 HYDROXYZINE HCL 25 MG TABLET 2
HYDRALAZINE 100 MG TABLET 2 HYDROXYZINE HCL 50 MG TABLET 2
HYDRALAZINE 25 MG TABLET 2 HYDROXYZINE PAMOATE 2
HYDRALAZINE 50 MG TABLET 2 HYOPHEN 2
HYDROCHLOROTHIAZIDE 1 HYOSCYAMINE 0.125 MG ODT 1
HYDROCOD-CPM-PSEUDOEPHEDRINE 2 HYOSCYAMINE 0.125 MG TAB SL 1
HYDROCODONE-ACETAMIN 10-300 MG 2 HYOSCYAMINE 0.125 MG/5 ML ELIX 2
HYDROCODONE-ACETAMIN 10-325 MG 2 HYOSCYAMINE 0.125 MG/ML DROP 2
HYDROCODONE-ACETAMIN 2.5-108/5 2 HYOSCYAMINE SULF 0.125 MG TAB 1
HYDROCODONE-ACETAMIN 2.5-325 2 HYOSCYAMINE SULFATE ER 1
HYDROCODONE-ACETAMIN 5-217/10 2 HYOSCYAMINE SULFATE SR 1
HYDROCODONE-ACETAMIN 5-300 MG 2 HYOSYNE 2
HYDROCODONE-ACETAMIN 5-325 MG 2 HYSINGLA ER 4 ST, QL
HYDROCODONE-ACETAMIN 7.5-300 2 IBANDRONATE SODIUM 150 MG TAB 2
HYDROCODONE-ACETAMIN 7.5-325 2 IBU 1
HYDROCODONE-ACETAMN 7.5-325/15 2 IBUDONE 2
Please visit Cigna.com/ifp-drug-list to see a complete listing.
172019 Cigna Rx Premiere Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
IBUPROFEN 100 MG/5 ML SUSP 1 JINTELI 2
IBUPROFEN 400 MG TABLET 1 JOLESSA 1
IBUPROFEN 600 MG TABLET 1 JOLIVETTE 1
IBUPROFEN 800 MG TABLET 1 JUBLIA 4 PA, ST
ILEVRO 4 JULEBER 1
IMATINIB MESYLATE 4 PA JULUCA 4
IMIPRAMINE HCL 2 JUNEL 1
IMIPRAMINE PAMOATE 2 JUNEL FE 1
IMIQUIMOD 2 JUNEL FE 24 1
IMPAVIDO 4 PA KAITLIB FE 1
INCONTROL ALCOHOL PADS 3 KALETRA 100-25 MG TABLET 3
INCRUSE ELLIPTA 3 KALETRA 200-50 MG TABLET 3
INDAPAMIDE 1 KARIVA 1
INDOMETHACIN 25 MG CAPSULE 2 KELNOR 1-35 1
INDOMETHACIN 50 MG CAPSULE 2 KELNOR 1-50 1
INDOMETHACIN ER 2 KERYDIN 4
INTELENCE 200 MG TABLET 3 KETEK 4
INTELENCE 25 MG TABLET 3 KETOCONAZOLE 2
INTROVALE 1 KETOPROFEN 2
IODOSORB 2 KETOROLAC 0.4% OPHTH SOLUTION 2
IOPHEN-C NR 2 KETOROLAC 0.5% OPHTH SOLUTION 2
IPRATROPIUM 0.03% SPRAY 2 KETOROLAC 10 MG TABLET 2 QL
IPRATROPIUM 0.06% SPRAY 2 KETOROLAC 15 MG/ML CARPUJECT 2 QL
IPRATROPIUM BR 0.02% SOLN 1 KETOROLAC 15 MG/ML ISECURE SYR 2 QL
IPRATROPIUM-ALBUTEROL 2 KETOROLAC 15 MG/ML SYRINGE 2 QL
IRBESARTAN 2 KETOROLAC 15 MG/ML VIAL 2 QL
IRBESARTAN-HYDROCHLOROTHIAZIDE 2 KETOROLAC 30 MG/ML CARPUJECT 2 QL
ISENTRESS 3 KETOROLAC 30 MG/ML ISECURE SYR 2 QL
ISENTRESS HD 3 KETOROLAC 30 MG/ML SYRINGE 2 QL
ISIBLOOM 1 KETOROLAC 30 MG/ML VIAL 2 QL
ISOCHRON 2 KETOROLAC 300 MG/10 ML VIAL 2 QL
ISONIAZID 100 MG TABLET 1 KETOROLAC 60 MG/2 ML CARPUJECT 2 QL
ISONIAZID 300 MG TABLET 1 KETOROLAC 60 MG/2 ML SYRINGE 2 QL
ISONIAZID 50 MG/5 ML SOLUTION 2 KETOROLAC 60 MG/2 ML VIAL 2 QL
ISOSORBIDE DINITRATE 2 KIMIDESS 1
ISOSORBIDE DINITRATE ER 2 KIONEX 2
ISOSORBIDE MONONITRATE 1 KLOR-CON 10 2
ISOSORBIDE MONONITRATE ER 1 KLOR-CON 20 MEQ PACKET 2
ISOTRETINOIN 2 QL KLOR-CON 25 MEQ PACKET 4
ISOXSUPRINE HCL 2 KLOR-CON 8 2
ISRADIPINE 2 KLOR-CON M10 2
ITRACONAZOLE 3 KLOR-CON M15 4
IV ANTISEPTIC WIPES 3 KLOR-CON M20 2
IV PREP WIPES 3 KLOR-CON SPRINKLE 2
IVERMECTIN 2 KOMBIGLYZE XR 3 QL
JANTOVEN 1 K-PHOS NO.2 4
JENCYCLA 1 K-PHOS ORIGINAL 4
JEVANTIQUE LO 2 KRISTALOSE 4
Please visit Cigna.com/ifp-drug-list to see a complete listing.
182019 Cigna Rx Premiere Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
K-SOL 2 LEVALBUTEROL HCL 2
K-TAB ER 8 MEQ TABLET 2 LEVALBUTEROL TARTRATE HFA 2
KURVELO 1 LEVATOL 4
LABETALOL HCL 100 MG TABLET 2 LEVEMIR 4 ST
LABETALOL HCL 200 MG TABLET 2 LEVEMIR FLEXTOUCH 4 ST
LABETALOL HCL 300 MG TABLET 2 LEVETIRACETAM 1,000 MG TABLET 2
LACRISERT 4 LEVETIRACETAM 100 MG/ML SOLN 2
LACTATED RINGERS IRRIGATION 2 LEVETIRACETAM 250 MG TABLET 2
LACTULOSE 2 LEVETIRACETAM 500 MG TABLET 2
LAMICTAL XR (BLUE) 4 LEVETIRACETAM 500 MG/5 ML SOLN 2
LAMICTAL XR (GREEN) 4 LEVETIRACETAM 750 MG TABLET 2
LAMICTAL XR (ORANGE) 4 LEVETIRACETAM ER 2
LAMIVUDINE 2 LEVLEN 28 1
LAMIVUDINE HBV 2 LEVOBUNOLOL HCL 2
LAMIVUDINE-ZIDOVUDINE 2 LEVOCARNITINE 1 G/10 ML SOLN 2
LAMOTRIGINE 2 LEVOCARNITINE 200 MG/ML VIAL 2
LAMOTRIGINE (BLUE) 2 LEVOCARNITINE 330 MG TABLET 2
LAMOTRIGINE (GREEN) 2 LEVOCETIRIZINE 2.5 MG/5 ML SOL 2
LAMOTRIGINE (ORANGE) 2 LEVOCETIRIZINE 5 MG TABLET 2
LAMOTRIGINE ER 2 LEVOFLOXACIN 0.5% EYE DROPS 2
LAMOTRIGINE ODT 2 LEVOFLOXACIN 25 MG/ML SOLUTION 2
LAMOTRIGINE ODT (BLUE) 2 LEVOFLOXACIN 250 MG TABLET 2
LAMOTRIGINE ODT (GREEN) 2 LEVOFLOXACIN 250 MG/10 ML SOLN 2
LAMOTRIGINE ODT (ORANGE) 2 LEVOFLOXACIN 500 MG TABLET 2
LANSOPRAZOL-AMOXICIL-CLARITHRO 2 LEVOFLOXACIN 500 MG/20 ML SOLN 2
LANSOPRAZOLE DR 15 MG CAPSULE 2 QL LEVOFLOXACIN 750 MG TABLET 2
LANSOPRAZOLE DR 30 MG CAPSULE 2 QL LEVOMEFOLATE DHA 1
LANTHANUM CARBONATE 2 LEVOMEFOLATE-ALGAL 15 MG CAP 2
LARIN 1 LEVOMEFOLATE-ALGAL 7.5 MG CAP 2
LARIN 24 FE 1 LEVONEST 1
LARIN FE 1 LEVONORGESTREL-ETH ESTRADIOL 1
LARISSIA 1 LEVONORG-ETH ESTRAD ETH ESTRAD 1
LASTACAFT 4 LEVORA-28 1
LATANOPROST 0.005% EYE DROPS 2 LEVORPHANOL TARTRATE 2
LATUDA 4 ST, QL LEVOTHYROXINE 100 MCG TABLET 1
LAYOLIS FE 4 LEVOTHYROXINE 112 MCG TABLET 1
LEENA 1 LEVOTHYROXINE 125 MCG TABLET 1
LEFLUNOMIDE 2 LEVOTHYROXINE 137 MCG TABLET 1
LESSINA 1 LEVOTHYROXINE 150 MCG TABLET 1
LETROZOLE 2 LEVOTHYROXINE 175 MCG TABLET 1
LEUCOVORIN CALCIUM 10 MG TAB 2 LEVOTHYROXINE 200 MCG TABLET 1
LEUCOVORIN CALCIUM 15 MG TAB 2 LEVOTHYROXINE 25 MCG TABLET 1
LEUCOVORIN CALCIUM 25 MG TAB 2 LEVOTHYROXINE 300 MCG TABLET 1
LEUCOVORIN CALCIUM 5 MG TAB 2 LEVOTHYROXINE 50 MCG TABLET 1
LEUKERAN 4 LEVOTHYROXINE 75 MCG TABLET 1
LEUPROLIDE 2WK 1 MG/0.2 ML KIT 2 PA LEVOTHYROXINE 88 MCG TABLET 1
LEUPROLIDE 2WK 14 MG/2.8 ML KT 2 PA LEVOXYL 1
LEVALBUTEROL CONCENTRATE 2 LEVULAN 4 LDD
Please visit Cigna.com/ifp-drug-list to see a complete listing.
192019 Cigna Rx Premiere Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
LEXIVA 50 MG/ML SUSPENSION 3 LORTAB 10 MG-300 MG/15 ML ELXR 2
LIDOCAINE 5% OINTMENT 2 QL LORYNA 1
LIDOCAINE 5% PATCH 2 LOSARTAN POTASSIUM 1
LIDOCAINE HCL 2% JELLY 2 LOSARTAN-HYDROCHLOROTHIAZIDE 1
LIDOCAINE HCL 4% SOLUTION 2 LOSEASONIQUE 4
LIDOCAINE HCL VISCOUS 1 LOTEMAX 4
LIDOCAINE-HC 2.8-0.55% GEL 2 LOVASTATIN 1
LIDOCAINE-HC 3-0.5% CREAM 2 LOW-OGESTREL 1
LIDOCAINE-HC 3-0.5% CREAM KIT 2 LOXAPINE 2
LIDOCAINE-HYDROCORT 3-2.5% GEL 2 LUDENT FLUORIDE 2
LIDOCAINE-PRILOCAINE 2 LUGOL'S SOLUTION 2
LILLOW 1 LUMIGAN 4
LINDANE 2 LUTERA 1
LINEZOLID 100 MG/5 ML SUSP 4 PA LYRICA 4 QL
LINEZOLID 600 MG TABLET 2 PA LYSODREN 4
LINZESS 4 LYZA 1
LIOTHYRONINE SOD 25 MCG TAB 2 MACNATAL CN DHA 1
LIOTHYRONINE SOD 5 MCG TAB 2 MALATHION 2
LIOTHYRONINE SOD 50 MCG TAB 2 MAPROTILINE HCL 2
LISINOPRIL 1 MARGESIC 2
LISINOPRIL-HYDROCHLOROTHIAZIDE 1 MARLISSA 1
LITHIUM 2 MARPLAN 4
LITHIUM CARBONATE 150 MG CAP 1 MARTEN-TAB 2
LITHIUM CARBONATE 300 MG CAP 1 MATERNITY 1
LITHIUM CARBONATE 300 MG TAB 1 MATZIM LA 2
LITHIUM CARBONATE 600 MG CAP 1 MECLIZINE 12.5 MG TABLET 2
LITHIUM CARBONATE ER 2 MECLIZINE 25 MG TABLET 2
LITHIUM ER 450 MG TABLET 2 MECLOFENAMATE SODIUM 2
LITHOSTAT 4 MEDROL 4
LIVALO 4 ST, QL MEDROXYPROGESTERONE ACETATE 1
L-METHYLFOLATE 2 MEFENAMIC ACID 2
L-METHYLFOLATE CALCIUM 2 MEFLOQUINE HCL 2 QL
L-METHYLFOLATE FORTE 2 MEGESTROL ACETATE 2
LO LOESTRIN FE 3 MELODETTA 24 FE 1
LOESTRIN 4 MELOXICAM 15 MG TABLET 1
LOESTRIN FE 4 MELOXICAM 7.5 MG TABLET 1
LOMEDIA 24 FE 1 MELOXICAM 7.5 MG/5 ML SUSP 2
LOPERAMIDE 2 MG CAPSULE 2 MELPHALAN 2
LOPINAVIR-RITONAVIR 2 MEMANTINE HCL 2
LOPREEZA 2 MENEST 4
LORAZEPAM 0.5 MG TABLET 2 MENTAX 4
LORAZEPAM 1 MG TABLET 2 MEPERIDINE 100 MG TABLET 2
LORAZEPAM 2 MG TABLET 2 MEPERIDINE 50 MG TABLET 2
LORAZEPAM 2 MG/ML ORAL CONCENT 2 MEPERIDINE 50 MG/5 ML SOLUTION 2
LORAZEPAM INTENSOL 2 MEPHYTON 4
LORCET 2 MEPROBAMATE 2
LORCET HD 2 MERCAPTOPURINE 2
LORCET PLUS 2 MESALAMINE 4
Please visit Cigna.com/ifp-drug-list to see a complete listing.
202019 Cigna Rx Premiere Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
METADATE ER 2 METOCLOPRAMIDE 10 MG TABLET 1
METAPROTERENOL SULFATE 2 METOCLOPRAMIDE 10 MG/10 ML SOL 1
METAXALL 2 METOCLOPRAMIDE 5 MG TABLET 1
METAXALONE 2 METOCLOPRAMIDE 5 MG/5 ML SOLN 1
METFORMIN HCL 1 METOCLOPRAMIDE HCL ODT 2
METFORMIN HCL ER 500 MG TABLET 2 METOLAZONE 2
METFORMIN HCL ER 750 MG TABLET 2 METOPROLOL SUCCINATE 2
METHADONE 10 MG/5 ML SOLUTION 2 PA METOPROLOL TARTRATE 100 MG TAB 1
METHADONE 10 MG/ML ORAL CONC 2 PA METOPROLOL TARTRATE 25 MG TAB 1
METHADONE 40 MG TABLET DISPR 2 PA METOPROLOL TARTRATE 37.5 MG TB 2
METHADONE 5 MG/5 ML SOLUTION 2 PA METOPROLOL TARTRATE 50 MG TAB 1
METHADONE HCL 10 MG TABLET 2 PA METOPROLOL TARTRATE 75 MG TAB 2
METHADONE HCL 5 MG TABLET 2 PA METOPROLOL-HYDROCHLOROTHIAZIDE 2
METHADONE INTENSOL 2 PA METRONIDAZOLE 0.75% CREAM 2
METHADOSE 40 MG TABLET DISPR 2 PA METRONIDAZOLE 0.75% LOTION 2
METHAMPHETAMINE HCL 2 METRONIDAZOLE 250 MG TABLET 2
METHAZOLAMIDE 2 METRONIDAZOLE 375 MG CAPSULE 2
METHENAMINE HIPPURATE 2 METRONIDAZOLE 500 MG TABLET 2
METHENAMINE MANDELATE 2 METRONIDAZOLE TOP 1% GEL PUMP 2
METHERGINE 2 METRONIDAZOLE TOPICAL 0.75% GL 2
METHIMAZOLE 2 METRONIDAZOLE TOPICAL 1% GEL 2
METHITEST 2 METRONIDAZOLE VAGINAL 0.75% GL 2
METHOCARBAMOL 500 MG TABLET 2 MEXILETINE HCL 2
METHOCARBAMOL 750 MG TABLET 2 MIBELAS 24 FE 1
METHOTREXATE 2.5 MG TABLET 2 MICONAZOLE 3 200 MG VAG SUPP 1
METHOXSALEN 4 MICORT-HC 2
METHSCOPOLAMINE BROMIDE 2 MICROGESTIN 1
METHYCLOTHIAZIDE 2 MICROGESTIN 24 FE 3
METHYLDOPA 1 MICROGESTIN FE 1.5-30 TAB 1
METHYLDOPA-HYDROCHLOROTHIAZIDE 2 MICROGESTIN FE 1-20 TABLET 4
METHYLERGONOVINE 0.2 MG TABLET 2 MIDAZOLAM HCL 2 MG/ML SYRUP 2
METHYLPHENIDATE ER 10 MG CAP 2 MIDODRINE HCL 2
METHYLPHENIDATE ER 10 MG TAB 2 MIGERGOT 2
METHYLPHENIDATE ER 18 MG TAB 2 MIGLITOL 2
METHYLPHENIDATE ER 20 MG CAP 2 MILI 1
METHYLPHENIDATE ER 20 MG TAB 2 MIMVEY 2
METHYLPHENIDATE ER 27 MG TAB 2 MIMVEY LO 2
METHYLPHENIDATE ER 30 MG CAP 2 MINASTRIN 24 FE 3
METHYLPHENIDATE ER 36 MG TAB 2 MINITRAN 2
METHYLPHENIDATE ER 40 MG CAP 2 MINOCYCLINE ER 135 MG TABLET 2
METHYLPHENIDATE ER 54 MG TAB 2 MINOCYCLINE ER 45 MG TABLET 2
METHYLPHENIDATE HCL 2 MINOCYCLINE ER 90 MG TABLET 2
METHYLPHENIDATE HCL CD 2 MINOCYCLINE HCL 2
METHYLPHENIDATE HCL ER 2 MINOXIDIL 10 MG TABLET 2
METHYLPHENIDATE LA 2 MINOXIDIL 2.5 MG TABLET 2
METHYLPREDNISOLONE 2 MIRCETTE 4
METHYLTESTOSTERONE 2 MIRTAZAPINE 2
METIPRANOLOL 2 MIRVASO 4
Please visit Cigna.com/ifp-drug-list to see a complete listing.
212019 Cigna Rx Premiere Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
MISOPROSTOL 2 MVW COMPLETE FORMULATION D5000 2
MODAFINIL 4 PA MVW COMPLETE FORMULTN MULTIVIT 2
MODERIBA 2 MY WAY 4
MODICON 4 MYCOPHENOLATE 200 MG/ML SUSP 2
MOEXIPRIL HCL 2 MYCOPHENOLATE 250 MG CAPSULE 2
MOEXIPRIL-HYDROCHLOROTHIAZIDE 2 MYCOPHENOLATE 500 MG TABLET 2
MOLINDONE HCL 2 MYCOPHENOLIC ACID 2
MOMETASONE FUROATE 2 MYLERAN 4
MONDOXYNE NL 2 MYNATAL 1
MONO-LINYAH 1 MYNATAL ADVANCE 1
MONONESSA 1 MYNATAL PLUS 1
MONTELUKAST SODIUM 2 MYNATAL-Z 1
MONUROL 4 MYNATE 90 PLUS 1
MORGIDOX 100 MG CAPSULE 2 MYORISAN 2 QL
MORGIDOX 50 MG CAPSULE 2 MYRBETRIQ 4 ST, QL
MORPHINE SULF 10 MG SUPPOS 2 MYTESI 4
MORPHINE SULF 10 MG/5 ML SOLN 2 MYZILRA 1
MORPHINE SULF 100 MG/5 ML SOLN 2 NABUMETONE 2
MORPHINE SULF 20 MG SUPPOS 2 NADOLOL 1
MORPHINE SULF 20 MG/5 ML SOLN 2 NADOLOL-BENDROFLUMETHIAZIDE 2
MORPHINE SULF 30 MG SUPPOS 2 NAFTIFINE HCL 2
MORPHINE SULF 5 MG SUPPOS 2 NAFTIN 4
MORPHINE SULFATE ER 2 QL NALOXONE 0.4 MG/ML CARPUJECT 2
MORPHINE SULFATE IR 15 MG TAB 2 NALOXONE 2 MG/2 ML SYRINGE 2
MORPHINE SULFATE IR 30 MG TAB 2 NALTREXONE HCL 2
MOVIPREP 4 NAPROXEN 125 MG/5 ML SUSPEN 2
MOXEZA 3 NAPROXEN 250 MG TABLET 1
MOXIFLOXACIN 0.5% EYE DROPS 2 NAPROXEN 375 MG TABLET 1
MOXIFLOXACIN HCL 400 MG TABLET 2 NAPROXEN 500 MG KIT 1
MULTAQ 4 NAPROXEN 500 MG TABLET 1
MULTIVITAMIN AND FLUORIDE 2 NAPROXEN DR 375 MG TABLET 1
MULTI-VITAMIN W-FLUORIDE 2 NAPROXEN DR 500 MG TABLET 1
MULTI-VITAMIN WITH FLUORIDE 2 NAPROXEN SOD ER 375 MG TABLET 2
MULTI-VITAMIN-FLUOR-IRON 2 NAPROXEN SODIUM 275 MG TAB 1
MULTIVITAMIN-IRON-FLUORIDE 2 NAPROXEN SODIUM 550 MG TAB 1
MULTIVITAMINS CHEWABLES TABLET 2 NAPROXEN SODIUM DS 1
MULTIVITAMINS W-FLUORIDE-IRON 2 NARATRIPTAN 2 QL
MULTIVITAMINS WITH FLUORIDE 2 NARATRIPTAN HCL 2 QL
MULTIVIT-FLUOR 0.25 MG TAB CHW 2 NARCAN 4 MG NASAL SPRAY 3
MULTIVIT-FLUOR 0.25 MG/ML DROP 2 NASCOBAL 4
MULTIVIT-FLUOR 0.5 MG TAB CHEW 2 NATACYN 4
MULTIVIT-FLUOR 0.5 MG/ML DROP 2 NATAZIA 4
MULTIVIT-FLUORIDE 1 MG TAB CHW 2 NATEGLINIDE 2
MULTIVIT-FLUOR-IRON 0.25 MG/ML 2 NATURE-THROID 1
MULTIVIT-IRON-FL 0.25 MG/ML 2 NEBUPENT 4
MUPIROCIN 2 NEBUSAL 3% VIAL 2
MVW COMPLETE FORMLTN PEDIATRIC 2 NECON 1
MVW COMPLETE FORMULATION D3000 2 NEFAZODONE HCL 2
Please visit Cigna.com/ifp-drug-list to see a complete listing.
222019 Cigna Rx Premiere Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
NEOMYCIN SULFATE 2 NOLIX 2
NEOMYCIN-BACITRACIN-POLY-HC 2 NORA-BE 1
NEOMYCIN-BACITRACIN-POLYMYXIN 2 NORETHIND-ETH ESTRAD 0.5-2.5 2
NEOMYCIN-POLYMYXIN B 2 NORETHIND-ETH ESTRAD 1-0.02 MG 1
NEOMYCIN-POLYMYXIN-DEXAMETH 2 NORETHINDRONE 1
NEOMYCIN-POLYMYXIN-GRAMICIDIN 2 NORETHINDRONE ACETATE 2
NEOMYCIN-POLYMYXIN-HC 2 NORETHIN-ETH ESTRAD 1 MG-5 MCG 2
NEOMYCIN-POLYMYXIN-HYDROCORT 2 NORETHIN-ETH ESTRA-FERROUS FUM 1
NEO-POLYCIN 2 NORGESTIMATE-ETHINYL ESTRADIOL 1
NEO-POLYCIN HC 2 NORINYL 1-35 4
NEO-SYNALAR 4 NORITATE 4
NEUAC GEL 2 NORLYDA 1
NEUPRO 4 NORLYROC 1
NEVANAC 4 NORPACE CR 4
NEVIRAPINE 2 NOR-Q-D 4
NEVIRAPINE ER 2 NORTREL 1
NEWGEN 1 NORTRIPTYLINE 10 MG/5 ML SOLN 2
NEXT CHOICE ONE DOSE 4 NORTRIPTYLINE HCL 10 MG CAP 1
NIACIN ER 2 NORTRIPTYLINE HCL 25 MG CAP 1
NICARDIPINE 20 MG CAPSULE 2 NORTRIPTYLINE HCL 50 MG CAP 1
NICARDIPINE 30 MG CAPSULE 2 NORTRIPTYLINE HCL 75 MG CAP 1
NICOTROL 4 NORVIR 3
NICOTROL NS 4 NOVOFINE 30G X 1/3" NEEDLES 3
NIFEDICAL XL 2 NOVOFINE 32G NEEDLES 3
NIFEDIPINE 2 NOVOFINE AUTOCOVER 30G NEEDLE 3
NIFEDIPINE ER 2 NOVOFINE PLUS PEN NDL 32GX1/6" 3
NIKKI 1 NOVOLOG 4 ST
NILUTAMIDE 2 NOVOLOG FLEXPEN 4 ST
NIMODIPINE 2 NOVOLOG MIX 70-30 4 ST
NISOLDIPINE 2 QL NOVOLOG MIX 70-30 FLEXPEN 4 ST
NITRO-BID 2 NOVOTWIST NEEDLE 30G 8MM 3
NITRO-DUR 4 NOVOTWIST NEEDLE 32G 5MM 3
NITROFURANTOIN 2 NOXAFIL 4
NITROFURANTOIN MONO-MACRO 2 NP THYROID 1
NITROGLYCERIN 0.3 MG TABLET SL 2 NUCYNTA 4 QL
NITROGLYCERIN 0.4 MG TABLET SL 2 NUCYNTA ER 4 ST, QL
NITROGLYCERIN 0.6 MG TABLET SL 2 NUEDEXTA 4
NITROGLYCERIN 400 MCG SPRAY 2 NULEV 1
NITROGLYCERIN ER 2.5 MG CAP 2 NUVARING 3
NITROGLYCERIN ER 6.5 MG CAP 2 NYAMYC 2
NITROGLYCERIN ER 9 MG CAPSULE 2 NYATA 100,000 UNIT/GM POWDER 2
NITROGLYCERIN LINGUAL 0.4 MG 2 NYSTATIN 100,000 UNIT/GM CREAM 1
NITROGLYCERIN PATCH 2 NYSTATIN 100,000 UNIT/GM POWD 2
NITRO-TIME 2 NYSTATIN 100,000 UNIT/ML SUSP 2
NIVA-PLUS 1 NYSTATIN 100,000 UNITS/GM OINT 1
NIZATIDINE 15 MG/ML SOLUTION 2 NYSTATIN 150,000,000 UNITS PWD 2
NIZATIDINE 150 MG CAPSULE 1 NYSTATIN 500,000 UNIT ORAL TAB 2
NIZATIDINE 300 MG CAPSULE 1 NYSTATIN 500,000 UNIT/5 ML SUS 2
Please visit Cigna.com/ifp-drug-list to see a complete listing.
232019 Cigna Rx Premiere Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
NYSTATIN 500,000,000 UNITS PWD 2 OPIUM TINCTURE 2
NYSTATIN-TRIAMCINOLONE 1 ORACIT 4
NYSTOP 2 ORALONE 2
OBSTETRIX DHA 1 ORPHENADRINE ER 100 MG TABLET 2
OBSTETRIX ONE 1 ORSYTHIA 1
O-CAL FA 4 ORTHO MICRONOR 4
O-CAL PRENATAL 4 ORTHO TRI-CYCLEN 4
OCELLA 1 ORTHO TRI-CYCLEN LO 4
OCTREOTIDE ACETATE 2 PA ORTHO-CYCLEN 4
ODEFSEY 3 ORTHO-NOVUM 4
OFLOXACIN 2 OSCIMIN 0.125 MG ODT 1
OGESTREL 1 OSCIMIN 0.125 MG TABLET 2
OKEBO 2 OSCIMIN SL 1
OLANZAPINE 10 MG TABLET 2 OSCIMIN SR 2
OLANZAPINE 15 MG TABLET 2 OSELTAMIVIR PHOSPHATE 2 QL
OLANZAPINE 2.5 MG TABLET 2 OSMOPREP 4
OLANZAPINE 20 MG TABLET 2 OSPHENA 4
OLANZAPINE 5 MG TABLET 2 OTOVEL 4
OLANZAPINE 7.5 MG TABLET 2 OVCON-35 1
OLANZAPINE ODT 2 OXANDROLONE 2 PA
OLANZAPINE-FLUOXETINE HCL 2 OXAPROZIN 2
OLMESARTAN MEDOXOMIL 2 OXAZEPAM 2
OLMESARTAN-AMLODIPINE-HCTZ 2 OXCARBAZEPINE 2
OLMESARTAN-HYDROCHLOROTHIAZIDE 2 OXICONAZOLE NITRATE 2
OLOPATADINE HCL 2 OXISTAT 4
OMEGA-3 ACID ETHYL ESTERS 2 OXTELLAR XR 4 QL
OMEPRAZOLE DR 10 MG CAPSULE 2 QL OXYBUTYNIN 5 MG TABLET 1
OMEPRAZOLE DR 20 MG CAPSULE 2 QL OXYBUTYNIN 5 MG/5 ML SYRUP 2
OMEPRAZOLE DR 40 MG CAPSULE 2 QL OXYBUTYNIN CHLORIDE ER 2
ONDANSETRON HCL 2 OXYCODON-ACETAMINOPHEN 2.5-325 2
ONDANSETRON ODT 2 OXYCODON-ACETAMINOPHEN 7.5-325 2
ONETOUCH DELICA 30G LANCETS 3 OXYCODONE HCL 2
ONETOUCH DELICA 33G LANCETS 3 OXYCODONE HCL-ASPIRIN 2
ONETOUCH DELICA LANCING DEV 3 OXYCODONE HCL-IBUPROFEN 2
ONETOUCH SURESOFT 18G LANC DEV 3 OXYCODONE-ACETAMINOPHEN 10-325 2
ONETOUCH SURESOFT 21G LANC DEV 3 OXYCODONE-ACETAMINOPHEN 5-325 2
ONETOUCH SURESOFT 28G LANC DEV 3 OXYMORPHONE HCL 2
ONETOUCH ULTRA BLUE TEST STRP 3 OXYMORPHONE HCL ER 2 QL
ONETOUCH ULTRA2 1 PACERONE 200 MG TABLET 2
ONETOUCH ULTRAMINI 1 PALIPERIDONE ER 2
ONETOUCH ULTRASOFT LANCETS 3 PANCREAZE 4
ONETOUCH VERIO FLEX 1 PANTOPRAZOLE SOD DR 20 MG TAB 2 QL
ONETOUCH VERIO IQ 1 PANTOPRAZOLE SOD DR 40 MG TAB 2 QL
ONETOUCH VERIO METER SYSTEM 1 PAREGORIC 2
ONETOUCH VERIO TEST STRIP 3 PARICALCITOL 1 MCG CAPSULE 2
ONGLYZA 3 QL PARICALCITOL 2 MCG CAPSULE 2
ONMEL 4 QL PARICALCITOL 4 MCG CAPSULE 2
OPCICON ONE-STEP 1 PAROEX 2
Please visit Cigna.com/ifp-drug-list to see a complete listing.
242019 Cigna Rx Premiere Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
PAROMOMYCIN SULFATE 2 PILOCARPINE HCL 2
PAROXETINE CR 2 QL PIMOZIDE 2
PAROXETINE ER 2 QL PIMTREA 1
PAROXETINE HCL 1 QL PINDOLOL 2
PASER 4 PIOGLITAZONE HCL 2
PCE 4 PIOGLITAZONE-GLIMEPIRIDE 2
PEG 3350-ELECTROLYTE 2 PIOGLITAZONE-METFORMIN 2
PEG-3350 AND ELECTROLYTES 2 PIRMELLA 1
PEG-3350 WITH FLAVOR PACKS 2 PIROXICAM 2
PEGANONE 4 PLAN B ONE-STEP 4
PEG-PREP 2 PNV 29-1 1
PENICILLIN V POTASSIUM 1 PNV OB+DHA 1
PENTAZOCINE-NALOXONE HCL 2 PNV-DHA 1
PENTOXIFYLLINE 2 PNV-DHA + DOCUSATE 1
PERFOROMIST 4 PNV-FERROUS FUMARATE-DOCU-FA 1
PERINDOPRIL ERBUMINE 2 PNV-OMEGA 1
PERMETHRIN 5% CREAM 2 PNV-SELECT 1
PERPHENAZINE 2 PNV-VP-U 1
PERPHENAZINE-AMITRIPTYLINE 2 PODOFILOX 2
PERTZYE 4 LDD POLYCIN 2
PEXEVA 4 ST, QL POLYETHYLENE GLYCOL 3350 POWD 2
PHENADOZ 2 POLYMYXIN B SUL-TRIMETHOPRIM 2
PHENAZOPYRIDINE HCL 1 PORTIA 1
PHENELZINE SULFATE 2 POTASS CIT-SOD CIT-CITRIC ACID 2
PHENOBARBITAL 100 MG TABLET 2 POTASSIUM CITRATE ER 2
PHENOBARBITAL 15 MG TABLET 2 POTASSIUM CITRATE-CITRIC ACID 2
PHENOBARBITAL 16.2 MG TABLET 2 POTASSIUM CL 10% (20 MEQ/15 ML 2
PHENOBARBITAL 20 MG/5 ML ELIX 2 POTASSIUM CL 10% (40 MEQ/30 ML 2
PHENOBARBITAL 20 MG/5 ML SOLN 2 POTASSIUM CL 20 MEQ PACKET 2
PHENOBARBITAL 30 MG TABLET 2 POTASSIUM CL 20% (40 MEQ/15 ML 2
PHENOBARBITAL 32.4 MG TABLET 2 POTASSIUM CL 25 MEQ TAB EFF 2
PHENOBARBITAL 60 MG TABLET 2 POTASSIUM CL ER 10 MEQ CAPSULE 2
PHENOBARBITAL 64.8 MG TABLET 2 POTASSIUM CL ER 10 MEQ TABLET 2
PHENOBARBITAL 97.2 MG TABLET 2 POTASSIUM CL ER 20 MEQ TABLET 2
PHENOXYBENZAMINE HCL 10 MG CAP 2 POTASSIUM CL ER 8 MEQ CAPSULE 2
PHENYLEPHRINE 10% EYE DROPS 2 POTASSIUM CL ER 8 MEQ TABLET 2
PHENYLEPHRINE 2.5% EYE DROP 2 POTIGA 4
PHENYTOIN 2 PR BENZOYL PEROXIDE 2
PHENYTOIN SODIUM EXTENDED 2 PR BENZOYL PEROXIDE 7% WASH 2
PHILITH 1 PR NATAL 400 1
PHOSLYRA 4 PR NATAL 400 EC 1
PHOSPHA 250 NEUTRAL 2 PR NATAL 430 1
PHOSPHASAL 2 PR NATAL 430 EC 1
PHOSPHOLINE IODIDE 4 PRADAXA 4 ST, QL
PHRENILIN FORTE 2 PRAMCORT 2
PHYSIOSOL 4 PRAMIPEXOLE DIHYDROCHLORIDE 2
PHYTONADIONE 5 MG TABLET 2 PRAMIPEXOLE ER 2
PICATO 4 PRAMOSONE 4
Please visit Cigna.com/ifp-drug-list to see a complete listing.
252019 Cigna Rx Premiere Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
PRAMOSONE E 4 PROCTOSOL-HC 2
PRASUGREL HCL 2 PROCTOZONE-HC 2
PRAVASTATIN SODIUM 1 PROFENO 2
PRAZIQUANTEL 2 PROGESTERONE 100 MG CAPSULE 2
PRAZOSIN HCL 2 PROGESTERONE 200 MG CAPSULE 2
PRED-G 4 PROGLYCEM 4
PREDNICARBATE 2 PROMETHAZINE 12.5 MG SUPPOS 2
PREDNISOLONE 2 PROMETHAZINE 12.5 MG TABLET 2
PREDNISOLONE 15 MG/5 ML SOLN 2 PROMETHAZINE 25 MG SUPPOSITORY 2
PREDNISOLONE 5 MG/5 ML SOLN 2 PROMETHAZINE 25 MG TABLET 2
PREDNISOLONE ACETATE 2 PROMETHAZINE 50 MG SUPPOSITORY 2
PREDNISOLONE SOD 1% EYE DROP 2 PROMETHAZINE 50 MG TABLET 2
PREDNISOLONE SOD PH 25 MG/5 ML 2 PROMETHAZINE 6.25 MG/5 ML SOLN 2
PREDNISOLONE SODIUM PHOS ODT 2 PROMETHAZINE 6.25 MG/5 ML SYRP 2
PREDNISONE 2 PROMETHAZINE VC 2
PREDNISONE INTENSOL 2 PROMETHAZINE VC-CODEINE 2
PREFEST 2 PROMETHAZINE-CODEINE 2
PREMARIN 4 PROMETHAZINE-DM 2
PRENA1 TRUE 1 PROMETHAZINE-PHENYLEPH-CODEINE 2
PRENAISSANCE 1 PROMETHAZINE-PHENYLEPHRINE 2
PRENAISSANCE NEXT 1 PROMETHEGAN 2
PRENAISSANCE PLUS 1 PROPAFENONE HCL 2
PRENATAL 19 1 PROPAFENONE HCL ER 2
PRENATAL LOW IRON 1 PROPANTHELINE BROMIDE 2
PRENATAL PLUS 1 PROPARACAINE 0.5% EYE DROPS 2
PRENATAL PLUS-DHA COMBO PACK 1 PROPRANOLOL 10 MG TABLET 2
PRENATAL VITAMIN PLUS LOW IRON 1 PROPRANOLOL 20 MG TABLET 2
PRENATAL-U 1 PROPRANOLOL 20 MG/5 ML SOLN 2
PREPLUS 1 PROPRANOLOL 40 MG TABLET 2
PREPOPIK 4 PROPRANOLOL 40 MG/5 ML SOLN 2
PRETAB 1 PROPRANOLOL 60 MG TABLET 2
PREVALITE 2 PROPRANOLOL 80 MG TABLET 2
PREVIFEM 1 PROPRANOLOL HCL ER 2
PREZCOBIX 3 PROPRANOLOL-HYDROCHLOROTHIAZID 2
PREZISTA 3 PROPYLTHIOURACIL 2
PRIFTIN 4 PROTRIPTYLINE HCL 2
PRIMAQUINE 2 PRUDOXIN 2
PRIMIDONE 2 PSORCON 2
PRIMLEV 2 PULMOSAL 2
PRIMSOL 4 PYRAZINAMIDE 2
PRO COMFORT ALCOHOL PADS 3 PYRIDOSTIGMINE BROMIDE 2
PROBENECID 2 PYRIDOSTIGMINE BROMIDE ER 2
PROBENECID-COLCHICINE 2 QUARTETTE 4
PROCENTRA 2 QUASENSE 1
PROCHLORPERAZINE 2 QUAZEPAM 15 MG TABLET 2
PROCHLORPERAZINE MALEATE 2 QUETIAPINE FUMARATE 2
PROCTO-MED HC 2 QUETIAPINE FUMARATE ER 2
PROCTO-PAK 2 QUILLIVANT XR 4 ST
Please visit Cigna.com/ifp-drug-list to see a complete listing.
262019 Cigna Rx Premiere Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
QUINAPRIL HCL 2 RISPERIDONE ODT 2
QUINAPRIL-HYDROCHLOROTHIAZIDE 2 RITONAVIR 2
QUINIDINE GLUC ER 324 MG TAB 2 RIVASTIGMINE 2
QUINIDINE SULFATE 2 RIVELSA 1
QUININE SULFATE 2 RIZATRIPTAN 2 QL
QUTENZA 4 R-NATAL OB 1
RABEPRAZOLE SODIUM 2 QL ROPINIROLE ER 2
RAJANI 1 ROPINIROLE HCL 2
RALOXIFENE HCL 2 ROSADAN 0.75% CREAM 2
RAMIPRIL 2 ROSADAN 0.75% GEL 2
RANEXA 4 ST ROSUVASTATIN CALCIUM 2
RANITIDINE 15 MG/ML SYRUP 2 ROWEEPRA 2
RANITIDINE 150 MG CAPSULE 1 ROWEEPRA XR 2
RANITIDINE 150 MG TABLET 1 ROZEREM 4 ST, QL
RANITIDINE 150 MG/10 ML SYRUP 2 RULAVITE DHA 1
RANITIDINE 300 MG CAPSULE 1 SAFYRAL 4
RANITIDINE 300 MG TABLET 1 SALICYLIC ACID 27.5% LIQUID 2
RAPAFLO 4 QL SALSALATE 2
RASAGILINE MESYLATE 2 SANTYL 4
RECLIPSEN 1 SAPHRIS 4 ST, QL
RECTIV 4 SAVAYSA 4 ST, QL
REGRANEX 4 PA SAVELLA 4
RELENZA 4 QL SCOPOLAMINE 2
RELISTOR 4 PA SEASONIQUE 4
RELNATE DHA 1 SECONAL SODIUM 2
RENACIDIN 4 SELEGILINE HCL 2
RENAGEL 4 SELENIUM SULFIDE 2.25% SHAMPOO 2
REPAGLINIDE 2 SELENIUM SULFIDE 2.5% LOTION 2
REPAGLINIDE-METFORMIN HCL 2 SE-NATAL 19 1
REPREXAIN 2 SEREVENT DISKUS 3
RESPA A.R. 4 SERTRALINE 20 MG/ML ORAL CONC 2 QL
RESTASIS 4 SERTRALINE 20 MG/ML ORAL SOLN 2 QL
RESTASIS MULTIDOSE 4 SERTRALINE HCL 100 MG TABLET 1 QL
REYATAZ 3 SERTRALINE HCL 25 MG TABLET 1 QL
RIBASPHERE 2 SERTRALINE HCL 50 MG TABLET 1 QL
RIBAVIRIN 200 MG CAPSULE 2 SETLAKIN 1
RIBAVIRIN 200 MG TABLET 2 SEVELAMER CARBONATE 800 MG TAB 2
RIDAURA 4 SF 2
RIFABUTIN 2 SF 5000 PLUS 2
RIFAMATE 4 SHAROBEL 1
RIFAMPIN 150 MG CAPSULE 2 SILDENAFIL 2 PA
RIFAMPIN 300 MG CAPSULE 2 SILENOR 4 ST, QL
RIFATER 4 SILVER NITRATE 2
RILUZOLE 2 SILVER SULFADIAZINE 2
RIMANTADINE HCL 2 SIMBRINZA 3
RISEDRONATE SODIUM 2 SIMVASTATIN 10 MG TABLET 1
RISEDRONATE SODIUM DR 2 SIMVASTATIN 20 MG TABLET 1
RISPERIDONE 2 SIMVASTATIN 40 MG TABLET 1
Please visit Cigna.com/ifp-drug-list to see a complete listing.
272019 Cigna Rx Premiere Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE)
SIMVASTATIN 5 MG TABLET 1 SUMATRIPTAN 2 QL
SIMVASTATIN 80 MG TABLET 1 QL SUMATRIPTAN SUCCINATE 2 QL
SINGLE USE SWAB 3 SUPRAX 4
SIROLIMUS 2 SUPREP 4
SIRTURO 4 PA SURE COMFORT ALCOHOL 3
SIVEXTRO 200 MG TABLET 4 PA SURE-PREP ALCOHOL PREP PADS 3
SKLICE 4 SUSTIVA 3
SODIUM CHLORIDE 0.9% INHAL VL 2 SYEDA 1
SODIUM CHLORIDE 0.9% IRRIG. 2 SYMAX 1
SODIUM CHLORIDE 10% VIAL 2 SYMAX-SL 1
SODIUM CHLORIDE 3% VIAL 2 SYMAX-SR 2
SODIUM CHLORIDE 7% VIAL 2 SYMLINPEN 120 4 QL
SODIUM CITRATE-CITRIC ACID 2 SYMLINPEN 60 4 QL
SODIUM FLUORIDE 2 SYNERA 4
SODIUM PHENYLBUTYRATE 2 SYNTHROID 4
SODIUM POLYSTYRENE SULFONATE 2 SYPRINE 4
SOLOXIDE 2 TABLOID 4
SOLTAMOX 4 TACROLIMUS 2
SOTALOL 1 TAKE ACTION 4
SOTALOL AF 1 TAMIFLU 30 MG CAPSULE 4 QL
SPINOSAD 2 TAMIFLU 45 MG CAPSULE 4 QL
SPIRONOLACTONE 2 TAMIFLU 75 MG CAPSULE 4 QL
SPIRONOLACTONE-HCTZ 2 TAMOXIFEN CITRATE 2
SPRINTEC 1 TAMSULOSIN HCL 2
SPRIX 4 QL, LDD TANZEUM 4 ST, QL
SPS 2 TARINA FE 1
SRONYX 1 TARON-C DHA 1
SSKI 4 TARON-PREX PRENATAL 1
STAVUDINE 2 TAYTULLA 3
STERILE WATER FOR IRRIGATION 2 TAZAROTENE 2
STRIBILD 3 TAZORAC 4
STRIVERDI RESPIMAT 4 ST TAZTIA XT 2
STRONG IODINE 2 TEKTURNA 4 QL
SUBVENITE 2 TELMISARTAN 2
SUBVENITE (BLUE) 2 TELMISARTAN-AMLODIPINE 2
SUBVENITE (GREEN) 2 TELMISARTAN-HYDROCHLOROTHIAZID 2
SUBVENITE (ORANGE) 2 TEMAZEPAM 2
SUCRALFATE 2 TEMOZOLOMIDE 4 PA
SULFACETAMIDE SODIUM 2 TENCON 2
SULFACETAMIDE-PREDNISOLONE 2 TENOFOVIR DISOPROXIL FUMARATE 2
SULFADIAZINE 2 TERAZOSIN HCL 1
SULFAMETHOXAZOLE-TMP DS TABLET 2 TERBINAFINE HCL 1
SULFAMETHOXAZOLE-TMP SS TABLET 2 TERBUTALINE SULFATE 2.5 MG TAB 2
SULFAMETHOXAZOLE-TMP SUSP 2 TERBUTALINE SULFATE 5 MG TAB 2
SULFAMYLON 4 TERCONAZOLE 2
SULFASALAZINE 2 TESTOSTERONE 10 MG GEL PUMP 2 QL
SULFASALAZINE DR 2 TESTOSTERONE 12.5 MG/1.25 GRAM 2 QL
SULINDAC 2 TESTOSTERONE 25 MG/2.5 GM PKT 2 QL
Please visit Cigna.com/ifp-drug-list to see a complete listing.
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