2022 CIGNA PLUS KANSAS 5-TIER PRESCRIPTION DRUG LIST - Coverage as of January 1, 2022
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Cigna Health and Life Insurance Company 2022 CIGNA PLUS KANSAS 5-TIER PRESCRIPTION DRUG LIST Coverage as of January 1, 2022 958298 08/21 © 2021 Cigna
What’s inside?
About this drug list 3
How to read this drug list 3
How to find your medication 5
Prescription drug list frequently asked questions (FAQs) 33
Exclusions and limitations: What’s not covered by this policy 35
View the drug list online
The myCigna® App and/or myCigna.com. Click on the “Find Care & Costs” tab and select
“Price a Medication.” Then type in your medication name to see how it’s covered.
Cigna.com/ifp-drug-list. Select Kansas from the drop down menu, and choose your search
method. Then type in your medication name or view the full list.
Questions? We’re here to help.
Call 866.494.2111, or the toll-free number on your Cigna ID card. We’re here 24/7/365.
Next planned update: 07/01/2022,
Drug list originally created: 10/21/2013 Last updated: 07/01/2021, for changes starting 01/01/2022 for changes starting 01/01/2023
2About this drug list
This is a list of the prescription medications covered on the Cigna Plus Kansas 5-Tier Prescription Drug List
as of January 1, 2022. All of these medications are approved by the U.S. Food and Drug Administration (FDA).
Medications are listed alphabetically. If you don’t see a specific medication on this list, log in to the
myCigna App or myCigna.com to see all of the medications your plan covers.
How to read this drug list
Use the chart below to help you read this drug list. This chart is just an example. It may not show how these
medications are actually covered on the 2022 Cigna Plus Kansas 5-Tier Prescription Drug List.
Medications are listed in
alphabetical order
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE, SRX, LDD)
ABACAVIR 2
ABACAVIR-LAMIVUDINE 2
ABACAVIR-LAMIVUDINE-ZIDOVUDINE 2
Tier (cost-share level) gives you an
ACYCLOVIR 200 MG CAPSULE 1 idea of how much you may pay for
ACYCLOVIR 200 MG/5 ML SUSPENSION 2 a medication
ACYCLOVIR 400 MG TABLET 2
ACYCLOVIR 800 MG TABLET 2
ADACEL TDAP 3
ADAPALENE 0.1% CREAM 2 AGE Medications that have extra
coverage requirements will
ALINIA 4
have an abbreviation in the
ALISKIREN 4 QL Notes section
ALLOPURINOL 100 MG TABLET 1
ALLOPURINOL 300 MG TABLET 1
AMCINONIDE 2
AMETHIA 1
AMETHIA LO 1
AMETHYST 1
AMILORIDE 2
AMILORIDE-HCTZ 2
AMINOCAPROIC ACID 0.25 GRAM/ML 4 Specialty medications have
AMINOCAPROIC ACID 1,000 MG TABLET 4 SRX SRX listed next to them in the
AMIODARONE 100 MG TABLET 2 Notes section
AMIODARONE 200 MG TABLET 2
AMIODARONE 400 MG TABLET 2
AMITIZA 4
AMITRIPTYLINE 1
This chart is just a sample. It may not show how these medications are actually covered on the 2022 Cigna Plus Kansas 5-Tier 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 Lowest-cost medication $
preferred 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 Lower-cost medication $$
medications and some low cost brand-name medications. Generic
medications have the same strength and active ingredients as brand-
name medications, but often cost much less.
Tier 3 – Preferred Brand Medications. This tier typically includes Medium-cost medication $$$
preferred brand-name medications and some high-cost generic
medications.
Tier 4 – Non-Preferred Medications. This tier typically includes Higher-cost medication $$$$
non-preferred brand-name medications and some high-cost generic
medications.
Tier 5 – Specialty and Other High-Cost Medications. This tier typically Highest-cost medication $$$$$
includes specialty medications and high-cost generic and brand-name
medications.
Abbreviations next to medications
In this drug list, medications that have limits and/or extra coverage requirements have an abbreviation listed next to
them in the Notes column. Here’s what they mean.
PA
Prior Authorization – Certain medications need approval from Cigna before your plan will cover
them. These medications have PA next to them. Your plan won’t cover these medications unless
your doctor requests, and receives, approval from Cigna.
ST tep Therapy – This is a prior authorization program. Your plan doesn’t cover certain high-cost
S
medications until you try one or more lower-cost alternatives first.* These medications have ST
next to them. You have many covered options to choose from, and they’re used to treat the same
condition.
QL uantity Limits – Some medications have a quantity limit. This means your plan will only cover up
Q
to a certain amount over a certain length of time. These medications have QL next to them. Your
plan will only cover a larger amount if your doctor requests, and receives, approval from Cigna.
AGE ge Requirements – Your plan will only cover certain medications if you’re within a specific age
A
range. These medications have AGE next to them. If you’re not within the allowed age range, your
plan will only cover the medication if your doctor requests, and receives, approval from Cigna.
SRX
Specialty Medications – These medications are used to treat complex medical conditions. They’re
typically injected or infused and may require refrigeration. These medications have SRX next to
them.
LDD imited Distribution Drugs – These medications are only available at specific pharmacies in the
L
United States. They’re used to treat conditions that are extremely hard to manage, require special
handling, and patient support and monitoring. These medications have LDD next to them.
* If your doctor feels an alternative isn’t right for you, he or she can ask Cigna to consider approving coverage of your medication.
4Specialty medications
Specialty medications are used to treat complex medical conditions. They’re typically injected or infused and may
require refrigeration. In this drug list, specialty medications have SRX listed next to them in the Notes section. Your
plan limits specialty medications to a 30-day supply. Log in to the myCigna App or myCigna.com, or check your
plan materials, to learn more about how your plan covers these medications.
Plan exclusions
Your plan doesn’t cover certain medications and products because they’re considered plan/benefit exclusions. This
means there’s no option to receive coverage through Cigna’s review process by showing that you need the
medication for your treatment. Log in to the myCigna App or myCigna.com, or check your plan materials, to see
which medications your plan excludes.
How to find your medication
Use the table below to find the page your medication is listed on.
Letter your medication starts with Page
A–B 6–10
C–D 10–14
E–G 14–17
H–J 17–19
K–L 19–21
M–N 21–24
0–P 24–27
Q–S 27–29
T–U 29–31
V–Z 31–32
52022 Cigna Plus Kansas 5-Tier Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE, SRX, LDD) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE, SRX, LDD)
ABACAVIR 2 ALCLOMETASONE 2
ABACAVIR-LAMIVUDINE 2 ALCOHOL PREP PADS 3
ABACAVIR-LAMIVUDINE-ZIDOVUDINE 2 ALDACTAZIDE 50-50 TABLET 4
ABIRATERONE 500 MG TABLET 5 SRX, PA, LDD ALECENSA 5 PA, LDD, SRX
ABIRATERONE 250 MG TABLET 5 SRX, PA, LDD ALENDRONATE 70 MG/75 ML 2
ACAMPROSATE DR 333 MG TABLET 3 ALENDRONATE 10 MG TABLET 1
ACARBOSE 2 ALENDRONATE 35 MG TABLET 1
ACEBUTOLOL 2 ALENDRONATE 40 MG TABLET 1
ACETAMINOPHEN-CODEINE 300-30 2 ALENDRONATE 5 MG TABLET 1
MG/12.5 ALENDRONATE 70 MG TABLET 2
ACETAMINOPHEN-CODEINE 120-12 2 ALFUZOSIN ER 2
MG/5 ALINIA 4
ACETAMINOPHEN-COD #2 TABLET 2
ALISKIREN 4 QL
ACETAMINOPHEN-COD #3 TABLET 2
ALLOPURINOL 1
ACETAMINOPHEN-COD #4 TABLET 2
ALMOTRIPTAN 2 QL
ACETAMINOPHEN-CAFFEINE- 2
ALOCRIL 4
DIHYDRCODEINE 320.5
ALOMIDE 4
ACETAZOLAMIDE TABLET 2
ALOSETRON 4
ACETAZOLAMIDE ER 2
ALPRAZOLAM 2
ACETIC ACID 2
ALPRAZOLAM ER 2
ACETYLCYSTEINE 10% VIAL 2
ALPRAZOLAM INTENSOL 2
ACETYLCYSTEINE 20% VIAL 2
ALPRAZOLAM ODT 2
ACITRETIN 4
ACTEMRA 162 MG/0.9 ML SYRINGE 5 SRX, PA, ST, QL ALPRAZOLAM XR 2
ACTEMRA ACTPEN 5 SRX, PA, ST, QL ALTABAX 4
ACTHIB 3 ALTACAINE 2
ACTIMMUNE 5 SRX, PA, LDD ALTAVERA 1
ACYCLOVIR 200 MG CAPSULE 1 ALYACEN 1
ACYCLOVIR 200 MG/5 ML 2 ALYQ 5 SRX, PA
SUSPENSION AMABELZ 2
ACYCLOVIR 400 MG TABLET 1 AMANTADINE 2
ACYCLOVIR 800 MG TABLET 1 AMBRISENTAN 5 SRX, PA, LDD
ADACEL TDAP 3 AMCINONIDE 2
ADAPALENE 0.1% CREAM 2 AGE AMETHIA 1
ADAPALENE 0.1% GEL 2 AGE AMETHIA LO 1
ADAPALENE 0.1% LOTION 2 AGE AMETHYST 1
ADAPALENE 0.1% SOLUTION 2 AGE AMILORIDE 5 MG TABLET 2
ADAPALENE 0.3% GEL 2 AGE AMILORIDE-HCTZ 2
ADAPALENE 0.3% GEL PUMP 2 AGE AMINOCAPROIC ACID 4
ADEFOVIR DIPIVOXIL 4 AMIODARONE 100 MG TABLET 2
ADEMPAS 5 SRX, PA, LDD AMIODARONE 200 MG TABLET 2
AFINITOR DISPERZ 5 SRX, PA AMIODARONE 400 MG TABLET 2
AFIRMELLE 1 AMITRIPTYLINE 10 MG TABLET 1
AFLURIA QUAD 3 AMITRIPTYLINE 100 MG TABLET 2
AFTERA 4 AMITRIPTYLINE 150 MG TABLET 2
AK-POLY-BAC 2 AMITRIPTYLINE 25 MG TABLET 1
AKYNZEO 300-0.5 MG CAPSULE 5 PA, QL, SRX AMITRIPTYLINE 50 MG TABLET 1
ALBENDAZOLE 4 AMITRIPTYLINE 75 MG TABLET 1
ALBUTEROL HFA 90 MCG INHALER 2 QL AMLODIPINE 2
ALBUTEROL 2 AMLODIPINE-BENAZEPRIL 2
ALCAINE 2 AMLODIPINE-ATORVASTATIN 2
Go to Cigna.com/ifp-drug-list to see the full list of medications your plan covers.
62022 Cigna Plus Kansas 5-Tier Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE, SRX, LDD) MEDICATION
MEDICATIONNAME
NAME Tier
Tier NOTES
NOTES(PA,(PA,ST,
ST,QL,
QL,AGE,
AGE,SRX,
SRX,LDD)
LDD)
AMLODIPINE-OLMESARTAN 2 APIDRA SOLOSTAR 4 ST, QL
AMLODIPINE-VALSARTAN 2 APOKYN 5 SRX, PA, LDD
AMLODIPINE-VALSARTAN-HCTZ 2 APRACLONIDINE 2
AMMONIUM LACTATE 12% CREAM 2 APREPITANT 125 MG CAPSULE 2 QL
AMMONIUM LACTATE 12% LOTION 2 APREPITANT 125-80-80 MG PACK 2 QL
AMNESTEEM 4 APREPITANT 40 MG CAPSULE 2 QL
AMOXAPINE 2 APREPITANT 80 MG CAPSULE 2 QL
AMOXICILLIN-CLAVULANATE 200- 2 APRI 1
28.5 MG TABLET CHEWABLE APTIOM 4 PA, QL
AMOXICILLIN-CLAVULANATE 200- 2 APTIVUS 3
28.5 MG SUSPENSION AQUA CARE 0.9% NACL IRRIGATION 2
AMOXICILLIN-CLAVULANATE 250- 1 AQUA CARE STERILE WATER 2
125 MG TABLET IRRIGATION
AMOXICILLIN-CLAVULANATE 250- 2 ARANELLE 1
62.5 MG/5 ML SUSPENSION ARANESP 5 SRX, PA
AMOXICILLIN-CLAVULANATE 400-57 2 ARCALYST 5 PA, LDD, SRX
MG TABLET CHEWABLE
ARCAPTA NEOHALER 4 ST
AMOXICILLIN-CLAVULANATE 400-57 2
ARIPIPRAZOLE 1 MG/ML SOLUTION 3
MG/5 ML SUSPENSION
ARIPIPRAZOLE 10 MG TABLET 2
AMOXICILLIN-CLAVULANATE 500- 1
125 MG TABLET ARIPIPRAZOLE 15 MG TABLET 2
AMOXICILLIN-CLAVULANATE 600- 2 ARIPIPRAZOLE 2 MG TABLET 2
42.9 MG/5 ML SUSPENSION ARIPIPRAZOLE 20 MG TABLET 2
AMOXICILLIN-CLAVULANATE 875- 1 ARIPIPRAZOLE 30 MG TABLET 2
125 MG TABLET ARIPIPRAZOLE 5 MG TABLET 2
AMOXICILLIN 125 MG TABLET 1 ARIPIPRAZOLE ODT 4
CHEWABLE ARMODAFINIL 2 PA
AMOXICILLIN 125 MG/5 ML 1 ARMOUR THYROID 3
SUSPENSION ARNUITY ELLIPTA 3
AMOXICILLIN 200 MG/5 ML 1 ASPIRIN-BUTALBITAL-CAFFEINE- 2
SUSPENSION CODEINE #3 CAPSULE
AMOXICILLIN 250 MG CAPSULE 1 ASCOMP WITH CODEINE 2
AMOXICILLIN 250 MG TABLET 2 ASENAPINE 4 QL
CHEWABLE ASHLYNA 1
AMOXICILLIN 250 MG/5 ML 1 ASMANEX TWISTHALER 4 ST
SUSPENSION
ASMANEX HFA 4 ST
AMOXICILLIN 400 MG/5 ML 1
ASPIRIN-DIPYRIDAMOLE ER 2
SUSPENSION
ASTAGRAF XL 5 SRX
AMOXICILLIN 500 MG CAPSULE 1
ATAZANAVIR 2
AMOXICILLIN 500 MG TABLET 1
ATENOLOL 1
AMOXICILLIN 875 MG TABLET 1
ATENOLOL-CHLORTHALIDONE 2
AMOXICILLIN-CLAVULANATE ER 2
ATOMOXETINE 2
AMPHETAMINE 2
ATORVASTATIN 2
AMPICILLIN CAPSULE 2
ATOVAQUONE 4
ANADROL-50 4 PA
ATOVAQUONE-PROGUANIL 2
ANAGRELIDE 4
ATROPINE 1% EYE DROPS 2
ANALPRAM HC 2.5%-1% LOTION 4
ATROPINE 1% EYE OINTMENT 2
ANASTROZOLE 2
AUBRA 1
ANORO ELLIPTA 3
AUBRA EQ 1
ANUCORT-HC 2
AUROVELA 1
APEXICON E 4
AUROVELA 24 FE 1
APIDRA 4 ST, QL
Go to Cigna.com/ifp-drug-list to see the full list of medications your plan covers.
72022 Cigna Plus Kansas 5-Tier Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE, SRX, LDD) MEDICATION
MEDICATIONNAME
NAME Tier
Tier NOTES
NOTES(PA,
(PA,ST,
ST,QL,
QL,AGE,
AGE,SRX,
SRX,LDD)
LDD)
AUROVELA FE 1 BD ECLIPSE NEEDLE 25GX1" 3
AVANDIA 4 BD ECLIPSE NEEDLE 25GX1.5" 3
AVIANE 1 BD ECLIPSE NEEDLE 25GX5/8" 3
AVONEX 5 PA, SRX BD ECLIPSE NEEDLE 27GX1/2" 3
AVONEX PEN 5 PA, SRX BD ECLIPSE NEEDLE 30GX1/2" 3
AYUNA 1 BD ECLIPSE NEEDLES 21GX1.5" 3
AZASITE 4 BD FILTER NEEDLE 3
AZATHIOPRINE 2 BD INSULIN SYRINGE 0.3 ML 3
AZELAIC ACID 2 8MMX31G(1/2)
AZELASTINE 2 BD INSULIN SYRINGE U-500 1/2 ML 3
AZELASTINE-FLUTICASONE 3 6MMX31G
AZITHROMYCIN 1 GM POWDER 2 QL BD INSULIN SYRINGE UF 0.3 ML 3
PACKET 12.7MMX30G
AZITHROMYCIN 100 MG/5 ML 2 QL BD INSULIN SYRINGE UF 0.5 ML 3
SUSPENSION 12.7MMX30G
AZITHROMYCIN 200 MG/5 ML 2 QL BD INSULIN SYRINGE UF 1 ML 3
SUSPENSION 12.7MMX30G
AZITHROMYCIN 250 MG TABLET 1 QL BD INSULIN SYRINGE 0.3 ML 3
AZITHROMYCIN 500 MG TABLET 1 QL 29GX12.7MM
AZITHROMYCIN 600 MG TABLET 2 QL BD INSULIN SYRINGE 0.5 ML 3
29GX12.7MM
AZOPT 3
BD INSULIN SYRINGE UF 0.3 ML 3
AZURETTE 1
8MMX31G
BACITRACIN 500 UNIT/GM 2
BD INSULIN SYRINGE UF 0.5 ML 3
OPHTHALMIC
8MMX31G
BACITRACIN-POLYMYXIN EYE 2
BD INSULIN SYRINGE 0.5 ML 3
OINTMENT
28GX1/2"
BACLOFEN 10 MG TABLET 2
BD INSULIN SYRINGE 0.5 ML 3
BACLOFEN 20 MG TABLET 2 29GX1/2"
BACLOFEN 5 MG TABLET 2 BD INSULIN SYRINGE 1 ML 25GX1" 3
BAL-CARE DHA COMBO PACK 1 BD INSULIN SYRINGE 1 ML 25GX5/8" 3
BALCOLTRA 4 BD INSULIN SYRINGE 1 ML 26GX1/2" 3
BALSALAZIDE 2 BD INSULIN SYRINGE 1 ML 3
BALZIVA 1 27GX12.7MM
BANZEL 200 MG TABLET 4 QL BD INSULIN SYRINGE 1 ML 27GX5/8" 3
BANZEL 400 MG TABLET 4 QL BD INSULIN SYRINGE 1 ML 28GX1/2" 3
BARACLUDE 0.05 MG/ML SOLUTION 5 SRX BD INSULIN SYRINGE 1 ML 29GX1/2" 3
BASAGLAR 100 UNIT/ML KWIKPEN 3 QL BD INSULIN SYRINGE 1 ML 3
BD 3 ML SYRINGE 18GX1-1/2" 3 29GX12.7MM
BD 3 ML SYRINGE 20GX1-1/2" 3 BD INSULIN SYRINGE UF 1 ML 3
BD 3 ML SYRINGE 25GX1" 3 8MMX31G
BD 3 ML SYRINGE 25GX1-1/2" 3 BD INSULIN SYRINGE 1 ML 3
BD 3 ML SYRINGE WITH NEEDLE 3 BD INTEGRA NEEDLE 25G X 5/8" 3
BD AUTOSHIELD DUO NEEDLE 3 BD INTEGRA RETRACTING NEEDLE 3
5MMX30G 23GX1"
BD BLUNT NEEDLE 18GX1-1/2" 3 BD INTEGRA SYRINGE 3 ML 21GX1 3
BD ECLIPSE 30GX1/2" SYRINGE 3 1/2"
BD ECLIPSE LUER-LOK SYRINGE 3 ML 3 BD LUER-LOK SYRINGE 3 ML 3
BD ECLIPSE NEEDLE 18GX1 1/2" 3 25GX5/8"
BD ECLIPSE NEEDLE 21GX1" 3 BD LUER-LOK SYRINGE 1 ML 3
BD ECLIPSE NEEDLE 22GX1" 3 BD MAGNI-GUIDE MAGNIFIER 3
BD ECLIPSE NEEDLE 23GX1" 3
Go to Cigna.com/ifp-drug-list to see the full list of medications your plan covers.
82022 Cigna Plus Kansas 5-Tier Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE, SRX, LDD) MEDICATION
MEDICATIONNAME
NAME Tier
Tier NOTES
NOTES(PA,(PA,ST,
ST,QL,
QL,AGE,
AGE,SRX,
SRX,LDD)
LDD)
BD SAFETYGLIDE
NANO 2 GEN PENINSULIN 1 ML
NEEDLE 3 BISOPROLOL
BD SAFETYGLIDE INSULIN 0.5 ML 32
13MMX29G
32GX4MM 8MMX30G
BISOPROLOL-HCTZ 1
BD SAFETYGLIDE
NEEDLE 18GX1NEEDLE
1/2" 3 BD SAFETYGLIDE
BLISOVI 24 FE INSULIN 0.5ML 31
BD SYRINGE-SAFETY
NEEDLE 19GX1 1/2" GLIDE 3 13MMX29G
BLISOVI FE 1
BD ULTRAFINE MICRO
NEEDLE 20GX1 1/2"PEN NEEDLE 3 BD SAFETYGLIDE
BOOSTRIX TDAP INSULIN 1 ML 33
6MMX32G
BD NEEDLE 21GX1 1/2" 3 13MMX29G
BOSENTAN 5 PA, SRX
BD
BD ULTRAFINE MINI PEN NEEDLE
NEEDLE 21GX1" 33 BD SAFETYGLIDE
BREO ELLIPTA INSULIN 1 ML 33
5MMX31G
BD NEEDLE 22GX1 1/2" 3 6MMX31G
BRIELLYN 1
BD
BD ULTRAFINE NANO PEN NEEDLE
NEEDLE 22GX3/4" 33 BD SAFETYGLIDE 3 ML SYRINGE 3
BRILINTA 4
4MMX32G BD SAFETYGLIDE NEEDLE 3
BD NEEDLE 23GX1 1/2" 3 BRIMONIDINE 2
BD ULTRAFINE ORIG PEN NDL 3 BD SAFETYGLIDE NEEDLE 18GX1.5" 3
BD NEEDLE 23GX1" 3 BRIVIACT 10 MG TABLET 4 PA, QL
12.7MMX29G BD SAFETYGLIDE NEEDLE 21GX1" 3
BD NEEDLE 25GX1" 3 BRIVIACT 10 MG/ML ORAL SOLUTION 4 PA, QL
BD ULTRAFINE SHORT PEN NEEDLE 3 BD SAFETYGLIDE NEEDLE 21GX1.5" 3
BD NEEDLE 25GX5/8" 3 BRIVIACT 100 MG TABLET 4 PA, QL
8MMX31G BD SAFETYGLIDE NEEDLE 22GX1.5" 3
BD NEEDLE 26GX0.625" 3 BRIVIACT 25 MG TABLET 4 PA, QL
BD VEO INSULIN 0.3ML 6MMX31G 3 BD SAFETYGLIDE NEEDLE 25GX1" 3
BD NEEDLES 16GX1"
(1/2) 3 BRIVIACT 50 MG TABLET 4 PA, QL
BD NEEDLES 16GX1.5" 33 BD SAFETYGLIDE NEEDLE 27GX5/8" 3
BD VEO INSULIN SYRINGE 0.3 ML BRIVIACT 75 MG TABLET 4 PA, QL
BD BD SAFETYGLIDE SYRINGE 27GX5/8 3
6MMX31G 18GX1"
NEEDLES 3 BROMFED DM 2
NEEDLES 18GX1.5" 3 BD SAFETYGLIDE INS 0.3 ML 3
BD VEO INSULIN SYRINGE 0.5 ML BROMFENAC 2
6MMX31G
BD NEEDLES 19GX1"
6MMX31G 3 BROMOCRIPTINE 2
BD SAFETYGLIDE INS 0.5 ML 3
BD VEO
NEEDLES 19GX1.5"
INSULIN SYRINGE 1 ML 3 BROMPHENIRAMINE-PSEUDOEPHED- 2
6MMX31G
6MMX31G
BD NEEDLES 20GX1" 3 DM
BD SYRINGE-SAFETY GLIDE 3
BECONASE
BD NEEDLESAQ20GX1.5" 34 ST BROVANA 4
BD UF MICRO PEN NEEDLE 6MMX32G 3
BEKYREE
BD NEEDLES 21GX1" 31 BUDESONIDE 0.25 MG/2 ML 4
BD UF MINI PEN NEEDLE 5MMX31G 3
BELLADONNA-OPIUM
BD NEEDLES 21GX1.5" 32 SUSPENSION
BD UF NANO PEN NEEDLE 4MMX32G 3
BENAZEPRIL
BD NEEDLES 21GX2" 13 BUDESONIDE 0.5 MG/2 ML 4
BDSUSPENSION
UF ORIGINAL PEN NEEDLE 3
BENAZEPRIL-HCTZ
BD NEEDLES 22GX1" 32 12.7MMX29G
BENZONATATE
BD 100 MG CAPSULE
NEEDLES 22GX1.5" 32 BUDESONIDE 1 MG/2 ML INH 4
BDSUSPENSION
UF SHORT PEN NEEDLE 8MMX31G 3
BENZONATATE 200 MG CAPSULE
BD NEEDLES 23GX0.75" 23
BD VEO INSULINEC0.3ML 6MMX31G
BUDESONIDE 34
BENZONATATE
BD PERLE 100 MG
NEEDLES 23GX1.25" 32 (1/2)
CAPSULE BUDESONIDE ER 5 PA, QL, SRX
BD NEEDLES 25GX0.625" 3 BD VEO INSULIN SYRINGE 1 ML 3
BENZTROPINE 0.5 MG TABLET 23 BUMETANIDE 0.5 MG TABLET 1
BD NEEDLES 25GX0.875" 6MMX31G
BENZTROPINE 1 MG TABLET BUMETANIDE 1 MG TABLET 1
BD NEEDLES 25GX1.5" 32 BD VEO INSULIN SYRINGE 0.3 ML 3
BENZTROPINE 2 MG TABLET 23 BUMETANIDE 2 MG TABLET 1
BD NEEDLES 26GX0.375" 6MMX31G
BEPREVE 43 BUPRENORPHINE 2 MG TABLET SL 2
BD NEEDLES 26GX0.5" BD VEO INSULIN SYRINGE 0.5 ML 3
BESER 0.05%27GX0.5"
LOTION 23 BUPRENORPHINE
6MMX31G 8 MG TABLET SL 2
BD NEEDLES
BESIVANCE 43 BUPRENORPHINE
BECONASE AQ PATCH 42 STQL
BD NEEDLES 27GX1X1.25"
BETADINE 5%30GX0.5"
EYE SOLUTION 43 BUPRENORPHINE-NALOXONE
BEKYREE 12
BD NEEDLES
BETAMETHASONE DIPROPIONATE 23 BUPROPION
BELLADONNA-OPIUM 22 QL
BD NEEDLES 30GX1"
BETAMETHASONE BUPROPION SR 100 MG TABLET 12 QL
BD NOKOR ADMIX DIPROPIONATE
NEEDLE 18GX1.5" 23 BENAZEPRIL
AUGMENTED BUPROPION SR
BENAZEPRIL-HCTZ 150 MG TABLET 22 QL
BD NOKOR NEEDLE 16GX1" 3
BETAMETHASONE BUPROPION SR 200 MG TABLET 2 QL
BD NOKOR NEEDLEVALERATE
18GX1" 23 BENZONATATE 100 MG CAPSULE 2
BETAXOLOL 23 BUPROPION XL200
BENZONATATE 150MGMGCAPSULE
TABLET 22 QL
BD PEN NEEDLE 29GX1/2"
BETHANECHOL CHLORIDE 23 BUPROPION XL 300 MG
BENZONATATE PERLE 100 MGTABLET 22 QL
BD PRECISIONGLIDE 27GX1-1/2"
BEXAROTENE
NEEDLE 4 PA BUSPIRONE
CAPSULE 2
BEXSERO
BD PRECISIONGLIDE 3 ML 22GX3/4 33 BUTALBITAL COMPOUND-CODEINE
BENZTROPINE 0.5 MG TABLET 22
BEYAZ
BD PRECISIONGLIDE NEEDLE 25G 33 BUTALBITAL-ACETAMINOPHEN-CAFFE
BENZTROPINE 1 MG TABLET 22 QL
BICALUTAMIDE
BD SAFETYGLIDE INSULIN 0.3 ML 23 BUTALBITAL-ACETAMINOPHEN-
BENZTROPINE 2 MG TABLET 22
BIKTARVY
8MMX31G 3 CAFFEINE-CODEINE
BEPREVE 4
BIMATOPROST
BD SAFETYGLIDE0.03% EYE 0.3ML
INSULIN DROPS 32 QL BUTALBITAL-ACETAMINOPHN 50-325 22
BESER
13MMX29G
BINOSTO 4 BUTALBITAL-ASPIRIN-CAFFEINE
BESIVANCE 42 QL
BETADINE 4
Go to Cigna.com/ifp-drug-list to see the full list of medications your plan covers.
92022 Cigna Plus Kansas 5-Tier Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE, SRX, LDD) MEDICATION
MEDICATIONNAME
NAME Tier
Tier NOTES
NOTES(PA,(PA,ST,
ST,QL,
QL,AGE,
AGE,SRX,
SRX,LDD)
LDD)
BUTORPHANOL 10DP
BETAMETHASONE MG/ML SPRAY
AUGMENTED 2 QL CARTEOLOL XL 300 MG TABLET
BUPROPION 22 QL
BYDUREON
BETAMETHASONE DP 23 QL CARTIA XT 10MG TABLET
BUSPIRONE 12
BYDUREON BCISE
BETAMETHASONE 23 QL CARVEDILOL15MG TABLET
BUSPIRONE 21
BYDUREON PEN
BETAXOLOL 23 QL CAYSTON 30MG TABLET
BUSPIRONE 25 PA, QL, LDD, SRX
BYETTA
BETHANECHOL 23 QL CAZIANT 5MG TABLET
BUSPIRONE 11
BYSTOLIC
BEXAROTENE 4 QL
PA CEFACLOR 7.5MG TABLET
BUSPIRONE 22
C-NATE DHA
BEXSERO 31 CEFACLOR ER
BUTALBITAL-ACETAMINOPHEN- 22
CABERGOLINE
BICALUTAMIDE 2 QL CAFFEINE-CODEINE
CEFADROXIL 2
CABOMETYX
BIKTARVY 35 PA, LDD, SRX BUTALBITAL
CEFDINIR COMPOUND-CODEINE 22
CAFFEINE CIT 60 MG/3 ML ORAL
BIMATOPROST 2 QL BUTALBITAL-ACETAMINOPHEN-
CEFDITOREN PIVOXIL 22 QL
CALCIPOTRIENE
BINOSTO 0.005% CREAM 24 CAFFEINE
CEFIXIME 100 MG/5 ML SUSPENSION 2
CALCIPOTRIENE 0.005% OINTMENT 2
BISOPROLOL BUTALBITAL-ACETAMINOPHEN
CEFIXIME 200 MG/5 ML SUSPENSION 22
CALCIPOTRIENE 0.005% SOLUTION 12
BISOPROLOL-HCTZ 50-325
CEFIXIME 400 MG CAPSULE 3
CALCIPOTRIENE-BETAMETHASONE
BLISOVI 24 FE 14 BUTALBITAL-ASPIRIN-CAFFEINE
CEFPODOXIME 22 QL
OINTMENT
BLISOVI FE 1 BUTORPHANOL
CEFPROZIL 10 MG/ML SPRAY 22 QL
CALCITONIN-SALMON
BOOSTRIX TDAP 32 BYDUREON
CEFUROXIME BCISE 32 QL
CALCITRIOL
BOSENTAN 0.25 MCG CAPSULE 25 SRX, PA, LDD BYDUREON
CELECOXIBPEN 32 QLQL
CALCITRIOL 0.5 MCG CAPSULE
BOSULIF 25 PA, LDD, SRX BYETTA
CELONTIN 34 QL
CALCITRIOL 1
BREO ELLIPTA MCG/ML SOLUTION 23 BYSTOLIC
CEPHALEXIN 125 MG/5 ML 41 QL
CALCITRIOL
BRIELLYN 3 MCG/G OINTMENT 21 QL CABERGOLINE
SUSPENSION 2 QL
CALCIUM 667 MG CAPSULE
BRILINTA 24 CABOMETYX
CEPHALEXIN 250 MG CAPSULE 51 SRX, PA, LDD
CALCIUM 667
BRIMONIDINE MG GEL CAPSULE 22 CAFFEINE 60 MG/3
CEPHALEXIN MLTABLET
250 MG ORAL 21
CALCIUM 667 MG TABLET
BRINZOLAMIDE 23 CALCIPOTRIENE
CEPHALEXIN 250 MG/5 CREAM
0.005% ML 21
CAMBIA
BRIVIACT 10 MG TABLET 44 PA, QL CALCIPOTRIENE
SUSPENSION 0.005% OINTMENT 2
CAMILA
BRIVIACT 10 MG/ML ORAL SOLUTION 14 PA, QL CALCIPOTRIENE
CEPHALEXIN 500 0.005% SOLUTION
MG CAPSULE 21
CAMRESE 100 MG TABLET
BRIVIACT 14 PA, QL CALCIPOTRIENE-BETAMETHASONE
CEPHALEXIN 500 MG TABLET 41
CAMRESE LO 14 DP
CEPHALEXIN 750 MG CAPSULE 2
BRIVIACT 25 MG TABLET PA, QL
CANDESARTAN CALCITONIN-SALMON
CETIRIZINE 1 MG/ML SOLUTION 22
BRIVIACT 50 MGCILEXETIL
TABLET 24 PA, QL
CANDESARTAN-HCTZ 24 CALCITRENE
CETIRIZINE 1 MG/ML SYRUP 22
BRIVIACT 75 MG TABLET PA, QL
CAPECITABINE 42 PA CALCITRIOL
CEVIMELINE0.25 MCG CAPSULE 22
BROMFED DM
CAPRELSA 52 PA, LDD, SRX CALCITRIOL
CHANTIX 0.5 MCG CAPSULE 23
BROMFENAC
CAPTOPRIL 12 CALCITRIOL
CHATEAL 1 MCG/ML SOLUTION 21
BROMOCRIPTINE
CAPTOPRIL-HCTZ 22 QL CALCITRIOL
CHATEAL EQ3 MCG/G OINTMENT 21 QL
BROMPHENIRAMINE-
CARBAGLU
PSEUDOEPHEDRINE-DM 4 PA CALCIUM
CHEMET ACETATE 667 MG CAPSULE 24
CARBAMAZEPINE 100 MG CHEWABLE 41
BROVANA CALCIUM
CHENODAL ACETATE 667 MG GELCAP 24 LDD
TABLET
BUDESONIDE 4 CALCIUM ACETATE 667 MG TABLET
CHLORDIAZEPOXIDE 22
CARBAMAZEPINE
BUDESONIDE EC 100 MG/5 ML 42 CAMBIA
CHLORDIAZEPOXIDE-AMITRIPTYLINE 42
SUSPENSION
BUDESONIDE ER 5 PA, QL, SRX CAMILA
CHLORDIAZEPOXIDE-CLIDINIUM 12
CARBAMAZEPINE
BUMETANIDE 0.5 MG200TABLET
MG TABLET 12 CAMRESE
CHLORHEXIDINE 0.12% RINSE 12
CARBAMAZEPINE ER
BUMETANIDE 1 MG TABLET 22 CAMRESE LO
CHLOROQUINE 12 QL
CARBIDOPA
BUMETANIDE 2 MG TABLET 42 CANDESARTAN
CHLORPROMAZINE 10 MG TABLET 22
CARBIDOPA-LEVODOPA
BUPRENORPHINE 2 MG TABLET SL 22 CANDESARTAN-HCTZ
CHLORPROMAZINE 100 MG TABLET 22
CARBIDOPA-LEVODOPA ER
BUPRENORPHINE 8 MG TABLET SL 22 CAPECITABINE
CHLORPROMAZINE 200 MG TABLET 42 PA
CARBIDOPA-LEVODOPA-ENTACAPONE
BUPRENORPHINE PATCH 22 QL CAPRELSA
CHLORPROMAZINE 25 MG TABLET 52 PA, LDD, SRX
CARBINOXAMINE 4 MG
BUPRENORPHINE-NALOXONETABLET 22 CAPTOPRIL
CHLORPROMAZINE 50 MG TABLET 22
CARBINOXAMINE
BUPROPION 4 MG/5 ML LIQUID 22 QL CAPTOPRIL-HCTZ
CHLORTHALIDONE 22 QL
CARETOUCH
BUPROPION SR 100 MGPREP
ALCOHOL PAD
TABLET 32 QL CARBAGLU
CHLORZOXAZONE 500 MG TABLET 42 PA, LDD
CARISOPRODOL
BUPROPION SR 150 MG TABLET 22 QL CARBAMAZEPINE
CHOLBAM 100 MG TABLET 25 PA, LDD, SRX
CARISOPRODOL-ASPIRIN 22 CHEWABLE
CHOLESTYRAMINE 2
BUPROPION SR 200 MG TABLET QL
CARISOPRODOL-ASPIRIN-CODEINE 22 CARBAMAZEPINE 100
CHOLESTYRAMINE LIGHT MG/5 ML 2 2
BUPROPION XL 150 MG TABLET QL
SUSPENSION
Go to Cigna.com/ifp-drug-list to see the full list of medications your plan covers.
102022 Cigna Plus Kansas 5-Tier Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE, SRX, LDD) MEDICATION
MEDICATIONNAME
NAME Tier
Tier NOTES
NOTES(PA,(PA,ST,
ST,QL,
QL,AGE,
AGE,SRX,
SRX,LDD)
LDD)
CHORIONIC GONADOTROPIN
CARBAMAZEPINE 10,000
200 MG TABLET 2 PA CLOBAZAM 2.5 MG/ML SUSPENSION
CESAMET 44 PA
UNIT VIAL
CARBAMAZEPINE ER 100 MG 2 CLOBAZAM120
CETIRIZINE MG TABLET
MG/ML SOLUTION 24 PA
CICLODAN
CAPSULE 8% SOLUTION 2 CLOBETASOL
CETIRIZINE 1 MG/ML SYRUP 22
CICLOPIROX 0.77%ERCREAM
CARBAMAZEPINE 100 MG TABLET 2 CLOBETASOL EMOLLIENT
CEVIMELINE 22
CICLOPIROX 0.77%ERGEL
CARBAMAZEPINE 200 MG 2 CLOBETASOL24EMULSION
CHARLOTTE FE 12
CAPSULE 0.77% TOPICAL
CICLOPIROX 2 CLOCORTOLONE
CHATEAL 12
SUSPENSION ER 200 MG TABLET
CARBAMAZEPINE 2 CLODAN EQ
CHATEAL 0.05% SHAMPOO 12
CICLOPIROX
CARBAMAZEPINE1% SHAMPOO
ER 300 MG 2 CLOMIPRAMINE
CHEMET 44
CICLOPIROX
CAPSULE 8% SOLUTION 2 CLONAZEPAM
CHENODAL 42
CILOSTAZOL
CARBAMAZEPINE ER 400 MG TABLET 2 CLONIDINE 0.1 MG TABLET
CHLORDIAZEPOXIDE 22
CILOXAN 0.3% OINTMENT
CARBIDOPA 4 CLONIDINE 0.2 MG TABLET
CHLORDIAZEPOXIDE-AMITRIPTYLINE 22
CIMETIDINE 200 MG TABLET
CARBIDOPA-LEVODOPA 21 CLONIDINE 0.3 MG TABLET
CHLORDIAZEPOXIDE-CLIDINIUM 22
CIMETIDINE 300 MG TABLET
CARBIDOPA-LEVODOPA ER 21 CLONIDINE ER 0.12% RINSE
CHLORHEXIDINE 22
CIMETIDINE
CARBIDOPA-LEVODOPA- SOLUTION
300 MG/5 ML 2 CLONIDINE PATCH
CHLOROQUINE 22
ENTACAPONE
CIMETIDINE 400 MG TABLET 1 CLOPIDOGREL 10 MG TABLET
CHLORPROMAZINE 22
CARBINOXAMINE
CIMETIDINE 800 MG 4 MG/5 ML LIQUID
TABLET 21
CLORAZEPATE 100 MG TABLET
CHLORPROMAZINE 22
CARBINOXAMINE
CINACALCET MALEATE 4 MG 25 SRX
CLOTRIMAZOLE 1%200
CHLORPROMAZINE SOLUTION
MG TABLET 22
TABLETHC
CIPRO 4
CLOTRIMAZOLE 1%25TOPICAL
CHLORPROMAZINE CREAM
MG TABLET 22
CARETOUCH
CIPRODEX ALCOHOL 70% PREP 34
CLOTRIMAZOLE 10 MG TROCHE
CHLORPROMAZINE 50 MG TABLET 22
PAD
CIPROFLOXACIN 2
CLOTRIMAZOLE-BETAMETHASONE
CHLORPROPAMIDE 12
CARISOPRODOL
CIPROFLOXACIN 0.2% OTIC SOLUTION 22
CLOVIQUE
CHLORTHALIDONE 14 PA
CARISOPRODOL
CIPROFLOXACIN COMPOUND
0.3% EYE DROP 22
CLOZAPINE
CHLORZOXAZONE 500 MG TABLET 22
CARISOPRODOL-ASPIRIN
CIPROFLOXACIN 100 MG TABLET 21
CLOZAPINE ODT
CHOLBAM 54 SRX, PA, LDD
CARISOPRODOL-ASPIRIN-CODEINE
CIPROFLOXACIN 250 MG TABLET 21
COARTEM
CHOLESTYRAMINE 24 QL
CARTEOLOL
CIPROFLOXACIN 500 MG TABLET 21
CODEINE
CHOLESTYRAMINE LIGHT 22
CARTIA XT
CIPROFLOXACIN 750 MG TABLET 21
COLCHICINE
CHOLINE TRISALICYLATE 22
CARVEDILOL
CIPROFLOXACIN-FLUOCINOLONE 13
COLESEVELAM
CHORIONIC GONADOTROPIN 10,000 22 PA
CAYSTON
CITALOPRAM HBR 10 MG TABLET 51 SRX,
QL PA, QL, LDD
COLESTIPOL
UNIT VIAL 2
CAZIANT
CITALOPRAM HBR 10 MG/5 ML 12 QL
COLOCORT0.77% CREAM
CICLODAN 22
CEFACLOR
SOLUTION 2
CITALOPRAM COMBIGAN8% SOLUTION
CICLODAN 24
CEFACLOR ER HBR 20 MG TABLET 21 QL
CITALOPRAM HBR 40 MG TABLET COMETRIQ 0.77% CREAM
CICLOPIROX 25 PA, LDD, SRX
CEFADROXIL 21 QL
CLARAVIS COMPLERA 0.77% GEL
CICLOPIROX 23
CEFDINIR 24 QL
CLARITHROMYCIN COMPLETE NATAL
CICLOPIROX 0.77% DHA
TOPICAL 21
CEFDITOREN PIVOXIL 2
CLARITHROMYCIN COMPLETENATE
SUSPENSION 1
CEFIXIME 100 MG/5ERML SUSPENSION 2
CLEMASTINE COMPRO 1% SHAMPOO
CICLOPIROX 22
CEFIXIME 200 MG/5 ML SUSPENSION 2
CLINDACIN400ETZMG
1%CAPSULE
PLEDGET CONSTULOSE8% SOLUTION
CICLOPIROX 22
CEFIXIME 32
CLINDACIN P 2 CORDRAN 4 MCG/SQ CM TAPE LARGE
CILOSTAZOL 24
CEFPODOXIME
CLINDAMYCIN COREMINO
CILOXAN 42
CEFPROZIL 2
CLINDAMYCIN 1% FOAM CORTISONE200 MG TABLET
CIMETIDINE 22
CEFUROXIME 2
CLINDAMYCIN CORTISPORIN
CIMETIDINE 300 MG TABLET 24
CELECOXIB 1% LOTION 2 QL
CLINDAMYCIN 1% PLEDGET CORTISPORIN-TC
CIMETIDINE 300 MG/5 ML SOLUTION 24
CELONTIN 42
CLINDAMYCIN COSENTYX PEN
CIMETIDINE 400 MG TABLET 25 PA, QL, LDD, SRX
CENTERGY 1% SOLUTION 2
CLINDAMYCIN COSENTYX SYRINGE
CIMETIDINE 800 MG TABLET 25 PA, QL, LDD, SRX
CENTERGY DM 2% VAGINAL CREAM 2
CLINDAMYCIN125 PEDIATRIC 22 COTELLIC
CINACALCET 55 SRX PA, LDD, SRX
CEPHALEXIN MG/5 ML
CLINDAMYCIN-BENZOYL
SUSPENSION PEROXIDE 2 COVARYX
CIPRO HC 42
CLINDAMYCIN-BENZOYL
CEPHALEXIN PEROXIDE
250 MG CAPSULE 12 COVARYX H.S.
CIPROFLOXACIN 22
1.2-5% 250 MG/5 ML
CEPHALEXIN 2 CREON
CIPROFLOXACIN 0.2% OTIC SOLUTION 24
CLINDAMYCIN-TRETINOIN
SUSPENSION 2 CRIXIVAN
CIPROFLOXACIN 0.3% EYE DROP 23
CLINDESSE
CEPHALEXIN 500 MG CAPSULE 41 CROMOLYN 100ER
CIPROFLOXACIN MG/5 ML ORAL 22
CLOBAZAM 10750
CEPHALEXIN MGMGTABLET
CAPSULE 24 PA CONCENTRATE
CIPROFLOXACIN 100 MG TABLET 2
Go to Cigna.com/ifp-drug-list to see the full list of medications your plan covers.
112022 Cigna Plus Kansas 5-Tier Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE, SRX, LDD) MEDICATION
MEDICATIONNAME
NAME Tier
Tier NOTES
NOTES(PA,
(PA,ST,
ST,QL,
QL,AGE,
AGE,SRX,
SRX,LDD)
LDD)
CROMOLYN 20 MG/2
CIPROFLOXACIN ML NEB
250 MG TABLET 12 QL DESIPRAMINE 10 MG TROCHE
CLOTRIMAZOLE 22
SOLUTION
CIPROFLOXACIN 500 MG TABLET 1 DESLORATADINE
CLOTRIMAZOLE-BETAMETHASONE 22 QL
CROMOLYN 4% EYE
CIPROFLOXACIN 750DROPS
MG TABLET 12 DESMOPRESSIN 0.01% SOLUTION
CLOVIQUE 42 PA
CROTAN
CIPROFLOXACIN-FLUOCINOLONE 33 DESMOPRESSIN 0.01% SPRAY
CLOZAPINE 22
CRYSELLE
CIPROFLOXACIN-DEXAMETHASONE 13 DESMOPRESSIN
CLOZAPINE ODT 0.1 MG TABLET 42
CURITY ALCOHOL PREPS
CITALOPRAM 10 MG TABLET 31 QL DESMOPRESSIN
C-NATE DHA 0.2 MG TABLET 12
CYANOCOBALAMIN
CITALOPRAM 10 MG/5ML SOLUTION 22
INJECTION QL DESMOPRESSIN 10 MCG/0.1 ML
COARTEM 42 QL
CYCLAFEM 20 MG TABLET
CITALOPRAM 11 QL SPRAY
CODEINE 2
CYCLOBENZAPRINE 10 MG
CITALOPRAM 40 MG TABLET TABLET 11 QL DESOGESTREL-ETHINYL ESTRADIOL 1
COLCHICINE 2
CYCLOBENZAPRINE 5 MG TABLET
CLARAVIS 14 DESONIDE 0.05% CREAM 2
COLESEVELAM 2
CYCLOBENZAPRINE
CLARITHROMYCIN 7.5 MG TABLET 32 DESONIDE 0.05% LOTION 2
COLESTIPOL 2
CYCLOMYDRIL
CLARITHROMYCIN ER 42 DESONIDE 0.05% OINTMENT 2
COLOCORT 2
CYCLOPENTOLATE
CLEMASTINE 22 DESOXIMETASONE 0.05% CREAM 2
COLY-MYCIN S 4
CYCLOPHOSPHAMIDE
CLINDAMYCIN-BENZOYL PEROXIDE 32
25 MG DESOXIMETASONE 0.05% GEL 2
COMBIGAN 4
CAPSULE
1.2-5% DESOXIMETASONE 0.05% OINTMENT 2
COMETRIQ 5 PA, LDD, SRX
CYCLOPHOSPHAMIDE
CLINDACIN 50 MG
ETZ 1% PLEDGET 23 DESOXIMETASONE 0.25% CREAM 2
COMPLERA 3
CAPSULE DESOXIMETASONE 0.25% OINTMENT 2
CLINDACIN P 1% PLEDGETS 2 COMPLETE NATAL DHA 1
CYCLOSERINE 2 DESVENLAFAXINE ER 2 QL
CLINDAMYCIN (PEDIATRIC) 2 COMPLETENATE 1
CYCLOSET 4 DEXAMETHASONE 0.1% EYE DROP 2
CLINDAMYCIN 2% VAGINAL CREAM 2 COMPRO 2
CYCLOSPORINE 100 MG CAPSULE 2 DEXAMETHASONE 0.5 MG TABLET 1
CLINDAMYCIN HCL 2 CONSTULOSE 2
CYCLOSPORINE 25 MG CAPSULE 2 DEXAMETHASONE 0.5 MG/5 ML 1
CLINDAMYCIN 1% GEL 2 CORMAX 2
CYCLOSPORINE MODIFIED 2 ELIXIR
CLINDAMYCIN 1% SOLUTION 2 CORTISONE 25 MG TABLET 2
CYPROHEPTADINE 2 MG/5 ML 2 DEXAMETHASONE 0.5 MG/5 ML 1
CLINDAMYCIN 1% PLEDGET 2 CORTISPORIN 4
SOLUTION LIQUID
CLINDAMYCIN 1% LOTION 2 CORTISPORIN-TC 41
CYPROHEPTADINE 2 MG/5 ML SYRUP 2 DEXAMETHASONE 0.75 MG TABLET
CLINDAMYCIN 1% FOAM 2 COTELLIC 51 SRX, PA, LDD
CYPROHEPTADINE 4 MG TABLET 2 DEXAMETHASONE 1 MG TABLET
CLINDAMYCIN-TRETINOIN 2 COVARYX 21
CYRED 1 DEXAMETHASONE 1.5 MG TABLET
CLINDAMYCIN-BENZOYL PEROXIDE 2
CYRED EQ 1 COVARYX H.S.
DEXAMETHASONE 10 DAY 1.5 MG 21
1-5%
CYSTADANE 5 LDD, SRX CRIXIVAN
TABLET 3
CLINDAMYCIN-BENZOYL PEROXIDE 2
CYSTAGON
1-5% PUMP 5 LDD, SRX CROMOLYN 100 MG/5
DEXAMETHASONE 13 ML
DAYORAL
1.5 MG 41
CYSTARAN 44 QL, LDD CONCENTRATE
TABLET
CLINDESSE
DALFAMPRIDINE ER 54 PA, CROMOLYN 20 MG/22 ML
DEXAMETHASONE MGNEBULIZER
TABLET 41 QL
CLOBAZAM PA SRX
DALIRESP 42 QL SOLUTION
DEXAMETHASONE 4 MG TABLET 1
CLOBETASOL EMOLLIENT
DANAZOL 2 CROMOLYN 4% EYE6DROPS
DEXAMETHASONE DAY 1.5 MG 21
CLOBETASOL EMULSION 2
DANTROLENE 100 MG CAPSULE 2 TABLET
CROTAN 3
CLOBETASOL 2
DANTROLENE 25 MG CAPSULE 2 DEXAMETHASONE 6 MG TABLET
CRYSELLE 11
CLOCORTOLONE 2
DANTROLENE 50 MG CAPSULE 2 DEXAMETHASONE
CURITY INTENSOL
ALCOHOL PREPS 31
CLODAN 0.05% SHAMPOO 2
DAPSONE TABLET 4 DEXCOM G6 SENSOR
CYANOCOBALAMIN 23 PA, QL
CLOMIPRAMINE 4
DAPTACEL DTAP 3 DEXILANT
CYCLAFEM 14 ST, QL
CLONAZEPAM 2
DARAPRIM 4 PA DEXMETHYLPHENIDATE
CYCLOBENZAPRINE 10 MGERTABLET
10 MG 12 QL
CLONIDINE 0.1 MG TABLET 1 CAPSULE
DARIFENACIN ER 2 CYCLOBENZAPRINE 5 MG TABLET 1
CLONIDINE 0.2 MG TABLET 1 DEXMETHYLPHENIDATE
DASETTA 1 CYCLOBENZAPRINE 7.5 MGERTABLET
15 MG 32 QL
CLONIDINE 0.3 MG TABLET 1 CAPSULE
DAYSEE 1 CYCLOMYDRIL 4
CLONIDINE ER 2 DEXMETHYLPHENIDATE ER 20 MG
DEBLITANE 1 CYCLOPENTOLATE 22 QL
CLONIDINE PATCH 2 CAPSULE
DEFERASIROX 5 PA, SRX CYCLOPHOSPHAMIDE 25 MG 3
CLOPIDOGREL 300 MG TABLET 2 DEXMETHYLPHENIDATE
CAPSULE ER 25 MG 2 QL
DEMECLOCYCLINE 2 CAPSULE
CLOPIDOGREL 75 MG TABLET 1 CYCLOPHOSPHAMIDE 25 MG TABLET 3
DEMSER 4 DEXMETHYLPHENIDATE ER 30 MG 2 QL
CLORAZEPATE 2 CYCLOPHOSPHAMIDE 50 MG 3
DENTA 5000 PLUS 2 CAPSULE
CLORPRES 2 CAPSULE
DENTAGEL 2 DEXMETHYLPHENIDATE ER 35 MG 2 QL
CLOTRIMAZOLE 1% SOLUTION 2 CYCLOPHOSPHAMIDE 50 MG TABLET 3
DESCOVY 4 PA CAPSULE
CLOTRIMAZOLE 1% TOPICAL CREAM 2 CYCLOSERINE 2
Go to Cigna.com/ifp-drug-list to see the full list of medications your plan covers.
122022 Cigna Plus Kansas 5-Tier Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE, SRX, LDD) MEDICATION
MEDICATIONNAME
NAME Tier
Tier NOTES
NOTES(PA,
(PA,ST,
ST,QL,
QL,AGE,
AGE,SRX,
SRX,LDD)
LDD)
DEXMETHYLPHENIDATE ER 40 MG
CYCLOSET 42 QL DIGOXIN 0.25 MG TABLET
DESOXIMETASONE 0.25% CREAM 21
CAPSULE
CYCLOSPORINE 100 MG CAPSULE 2 DIGOXIN 125 MCG0.25%
DESOXIMETASONE TABLETOINTMENT 21
DEXMETHYLPHENIDATE
CYCLOSPORINE ER 5 MG
25 MG CAPSULE 22 QL DIGOXIN 250 MCGERTABLET
DESVENLAFAXINE 21 QL
CAPSULE
CYCLOSPORINE MODIFIED 2 DIHYDROERGOTAMINE
DEXAMETHASONE 0.1% EYE DROP 24 QL
DEXMETHYLPHENIDATE
CYPROHEPTADINE 2 MG/5 TABLET
ML 22 DILATRATE-SR 4
DEXAMETHASONE 0.5 MG TABLET 2
DEXTROAMPHETAMINE 2 DILT-XR
SOLUTION DEXAMETHASONE 0.5 MG/5 ML 22
DEXTROAMPHETAMINE
CYPROHEPTADINE 2 MG/5 ER ML SYRUP 22 QL DILTIAZEM 120 MG TABLET
ELIXIR 1
DEXTROAMPHETAMINE-
CYPROHEPTADINE 4 MG TABLET 22 DILTIAZEM 12HR ER
DEXAMETHASONE 0.5 MG/5 ML 22
AMPHETAMINE
CYRED 1 DILTIAZEM 24HR ER
LIQUID 2
DEXTROAMPHETAMINE-
CYRED EQ 21 QL DILTIAZEM 24HR ER
DEXAMETHASONE (CD)
0.75 MG TABLET 22
AMPHETAMINE ER DILTIAZEM 24HR ER (LA)TABLET
CYSTADANE 5 LDD, SRX DEXAMETHASONE 1 MG 22
DIAZEPAM 10 MG RECTAL GEL 2 DILTIAZEM 24HR ER
CYSTAGON 5 LDD, SRX DEXAMETHASONE 1.5(XR)
MG TABLET 22
SYSTEM
CYSTARAN 4 PA, QL, LDD DILTIAZEM 30 MG 2TABLET
DEXAMETHASONE MG TABLET 21
DIAZEPAM 10 MG TABLET 2
CYTRA-K CRYSTALS PACKET 2 DILTIAZEM 60 MG 4TABLET
DEXAMETHASONE MG TABLET 21
DIAZEPAM 2 MG TABLET 2
DALFAMPRIDINE ER 5 PA, LDD, SRX DILTIAZEM 90 MG TABLET
DEXAMETHASONE 6 MG TABLET 21
DIAZEPAM 2.5 MG RECTAL GEL 2
DALIRESP 4 QL DIPHEN 12.5 MG/5INTENSOL
DEXAMETHASONE ML ELIXIR 24
SYSTEM
DANAZOL 22 DIPHEN G6
DEXCOM 12.5READER,
MG/5 ML ELIXIR&
SENSOR 34 PA, QL
DIAZEPAM 20 MG RECTAL GEL
DANTROLENE 100 MG CAPSULE 2 DIPHENHYDRAMINE 12.5 MG/5 ML
TRANSMITTER 2
SYSTEM
DANTROLENE 25 TABLET
MG CAPSULE 2 DIPHENHYDRAMINE 25 MG/10 ML
DEXILANT 42 ST, QL
DIAZEPAM 5 MG
DIPHENOXYLATE-ATROPINE
DEXMETHYLPHENIDATE ER 10 MG 22 QL
DANTROLENE
DIAZEPAM 5 MG/5 MLCAPSULE
50 MG ORAL 2
CAPSULE
DIPHTHERIA-TETANUS TOXOIDS- 3
SOLUTION
DAPSONE 4
PEDIATRIC
DEXMETHYLPHENIDATE ER 15 MG 2 QL
DIAZEPAM DTAP
DAPTACEL 5 MG/5 ML SOLUTION 32
CAPSULE
DIPYRIDAMOLE 25 MG TABLET 2
DIAZEPAM 5 MG/ML
DARIFENACIN ER ORAL 2
DEXMETHYLPHENIDATE ER 20 MG
DIPYRIDAMOLE 50 MG TABLET 22 QL
CONCENTRATE
DASETTA 1 CAPSULE
DIPYRIDAMOLE 75 MG TABLET 2
DIAZOXIDE
DAYSEE 14 DEXMETHYLPHENIDATE
DISOPYRAMIDE ER 25 MG 22 QL
DICLOFENAC
DEBLITANE 21
CAPSULE
DIVALPROEX 2
DICLOFENAC
DECADRON 0.50.1% EYEML
MG/5 DROPS
ELIXIR 22
DEXMETHYLPHENIDATE
DIVALPROEX ER ER 30 MG 22 QL
DICLOFENAC
DEFERASIROX 1.5% TOPICAL SOLUTION 25 PA, LDD, SRX CAPSULE
DOFETILIDE 4 QL
DICLOFENAC
DEFERIPRONE 1% GEL 24 QL
PA DEXMETHYLPHENIDATE ER 35 MG 22 QL
DONEPEZIL
DICLOFENAC DR 25 MG TABLET
DEMECLOCYCLINE 22 CAPSULE
DONEPEZIL ODT 2
DICLOFENAC
DENTA 5000 DR 50 MG TABLET
PLUS 22 DEXMETHYLPHENIDATE ER 40 MG 2 QL
DORZOLAMIDE 2
DICLOFENAC
DENTAGEL DR 75 MG TABLET 22 CAPSULE
DORZOLAMIDE-TIMOLOL EYE DROPS 2
DICLOFENAC
DESCOVY EC 25 MG TABLET 24 PA DEXMETHYLPHENIDATE ER 5 MG 2 QL
DOTTI 2 QL
DICLOFENAC
DESIPRAMINEEC 50 MG TABLET 22 CAPSULE
DOXAZOSIN 1
DICLOFENAC EC 75 MG TABLET 2 DEXMETHYLPHENIDATE 2
DESLORATADINE 2 QL DOXEPIN 10 MG CAPSULE 2
DICLOFENAC EPOLAMINE 4 QL DEXTROAMPHETAMINE 2
DESMOPRESSIN 0.01% SOLUTION 2 DOXEPIN 10 MG/ML ORAL 2
DICLOFENAC ER 2 DEXTROAMPHETAMINE ER 2 QL
DESMOPRESSIN 0.01% SPRAY 2 CONCENTRATE
DICLOFENAC-MISOPROSTOL 2 DEXTROAMPHETAMINE- 22 QL
DESMOPRESSIN 10 MCG/0.1 ML 2 DOXEPIN 100 MG CAPSULE
DICLOXACILLIN 2 AMPHETAMINE ER
SPRAY DOXEPIN 150 MG CAPSULE 2
DICYCLOMINE 10 MG CAPSULE 1 DEXTROAMPHETAMINE- 2
DESMOPRESSIN 0.1 MG TABLET 2 DOXEPIN 25 MG CAPSULE 2
DICYCLOMINE 10 MG/5 ML SOLUTION 2 AMPHETAMINE
DESMOPRESSIN 0.2 MG TABLET 2 DOXEPIN 3 MG TABLET 3 QL
DICYCLOMINE 20 MG TABLET 1 DIAZEPAM 10 MG RECTAL GEL 2
DESOGESTREL-ETHINYL ESTRADIOL 1 DOXEPIN 5% CREAM
SYSTEM 4
DIDANOSINE 2 DOXEPIN 50
DESOGESTR-ETHINYL ESTRADIOL
DIFICID
1
4 PA, QL DIAZEPAM 10MG
MGCAPSULE
TABLET 22
ETHINYL ESTRADIOL
DIFLORASONE 42 DIAZEPAM 2 MGTABLET
DOXEPIN 6 MG TABLET 23 QL
DESONIDE 0.05% CREAM DOXEPIN 75 MG CAPSULE 2
DIFLUNISAL 22 DIAZEPAM 2.5 MG RECTAL GEL 2
DESONIDE 0.05% LOTION DOXERCALCIFEROL 0.5 MCG CAPSULE
SYSTEM 2
DIGITEK
DESONIDE 0.05% OINTMENT 12 DOXERCALCIFEROL 1 MCGGELCAPSULE
DIAZEPAM 20 MG RECTAL 22
DIGOX
DESOXIMETASONE 0.05% CREAM 12 DOXERCALCIFEROL 2.5 MCG CAPSULE 2
SYSTEM
DIGOXIN 0.05 MG/ML SOLUTION 22 DOXYCYCLINE
DESOXIMETASONE 0.05% GEL DIAZEPAM 5 MG25TABLET
MG/5 ML 22
DIGOXIN 0.125 MG TABLET
DESOXIMETASONE 0.05% OINTMENT 12 SUSPENSION
Go to Cigna.com/ifp-drug-list to see the full list of medications your plan covers.
132022 Cigna Plus Kansas 5-Tier Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE, SRX, LDD) MEDICATION
MEDICATIONNAME
NAME Tier
Tier NOTES
NOTES(PA,(PA,ST,
ST,QL,
QL,AGE,
AGE,SRX,
SRX,LDD)
LDD)
DOXYCYCLINE
DIAZEPAM HYC DR
5 MG/5 ML100
ORALMG 2 ELMIRON DR 120 MG CAPSULE
DIMETHYL 54 PA, LDD, SRX
TABLET
SOLUTION ELURYNG DR 240 MG CAPSULE
DIMETHYL 52 PA, LDD, SRX
DOXYCYCLINE
DIAZEPAM HYC DR
5 MG/5 ML150 MG
SOLUTION 2 EMCYT
DIPENTUM 45 SRX
TABLET 5 MG/ML ORAL
DIAZEPAM 2 EMEND 125 MG POWDER PACKET
DIPHEN 45 PA, QL, SRX
DOXYCYCLINE
CONCENTRATEHYC DR 200 MG 2 EMOQUETTE 1
DIPHENHYDRAMINE 12.5 MG/5 ML 2
TABLET
DIAZOXIDE 4 EMSAM
DIPHENHYDRAMINE 25 MG/10 ML 24 QL
DOXYCYCLINE0.1%
DICLOFENAC HYC EYE
DR 50 MG TABLET
DROPS 22 EMTRIVA
DIPHENOXYLATE-ATROPINE 23
DOXYCYCLINE HYC DR 75
DICLOFENAC 1.5% TOPICAL MG TABLET 22 EMVERM
DIPHTHERIA-TETANUS TOXOIDS- 34
DOXYCYCLINE
SOLUTION HYCLATE 100 MG 2 ENALAPRIL 1
PEDIATRIC
CAPSULE
DICLOFENAC 2 ENALAPRIL-HCTZ
DIPYRIDAMOLE 25 MG TABLET 22
DOXYCYCLINEDRHYCLATE
DICLOFENAC 100 MG
25 MG TABLET 22 ENBREL
DIPYRIDAMOLE 50 MG TABLET 25 PA, ST, QL, SRX
TABLET
DICLOFENAC DR 50 MG TABLET 2 ENBREL MINI 75 MG TABLET
DIPYRIDAMOLE 25 PA, ST, QL, SRX
DOXYCYCLINE
DICLOFENAC DRHYCLATE 20 MG
75 MG TABLET 22
TABLET ENBREL SURECLICK
DISOPYRAMIDE 25 PA, ST, QL, SRX
DICLOFENAC EC 25 MG TABLET 2 ENDOCET
DISULFIRAM 22
DOXYCYCLINE HYCLATE 50 MG 2
DICLOFENAC EC 50 MG TABLET 2 ENDOMETRIN
DIVALPROEX 24 PA
CAPSULE
DICLOFENAC EC 75 MG TABLET 2 ENGERIX-B ADULT
DIVALPROEX ER 23
DRONABINOL 4
DICLOFENAC 1% GEL 2 QL ENGERIX-B PEDIATRIC-ADOLESCENT 43 QL
DOFETILIDE
DROSPIRENONE-ETHINYL ESTRADIOL 1
DICLOFENAC ER 2 ENLYTE
DONEPEZIL 24
DROSPIRENONE-ETHINYL 1
DICLOFENAC-MISOPROSTOL
ESTRADIOL-LEVOMEFOLATE 2 ENOXAPARIN
DONEPEZIL ODT 24 QL
DICLOXACILLIN
DROXIA 24 ENPRESSE
DORZOLAMIDE 21
DICYCLOMINE
DUAVEE 10 MG CAPSULE 24 DORZOLAMIDE-TIMOLOL EYE DROPS 21
ENSKYCE
DICYCLOMINE
DULOXETINE 10 MG/5 ML SOLUTION 22 QL ENTACAPONE
DOTTI 22 QL
DICYCLOMINE 20 MG TABLET
DUPIXENT SYRINGE 25 PA, SRX ENTECAVIR
DOVATO 34
DIDANOSINE 24 ENTRESTO
DUREZOL DOXAZOSIN 23
DIFICID 200 MG TABLET 42 PA, QL ENULOSE10 MG CAPSULE
DUTASTERIDE DOXEPIN 22
DIFICID 40 MG/ML SUSPENSION 42 QL EPIDIOLEX
DUTASTERIDE-TAMSULOSIN DOXEPIN 10 MG/ML ORAL 24 PA
DIFLORASONE
DYMISTA 44 EPIFOAM
CONCENTRATE 4
DIFLUNISAL
EASY COMFORT ALCOHOL PAD 23 EPINASTINE
DOXEPIN 100 MG CAPSULE 22
DIGITEK
EASY TOUCH ALCOHOL PREP PADS 23 EPINEPHRINE
DOXEPIN 0.15
150 MG MG AUTO-
CAPSULE 22 QL
DIGOX
EC-NAPROXEN 21 INJECTOR
DOXEPIN 25 MG CAPSULE 2
DIGOXIN 0.05 MG/ML SOLUTION
ECONAZOLE 22 EPINEPHRINE 0.3
DOXEPIN 5% CREAM MG AUTO-INJECTOR 42 QL
DIGOXIN
ECONTRA0.125
EZ MG TABLET 24 EPITOL
DOXEPIN 50 MG CAPSULE 21
DIGOXIN 0.25 MG TABLET
ED-SPAZ 21 EPIVIR HBV
DOXEPIN 25 MG/5
75 MG ML SOLUTION 25
CAPSULE SRX
DIGOXIN
EDARBI 125 MCG TABLET 24 ST, QL EPLERENONE
DOXEPIN 3 MG TABLET 32 QL
DIGOXIN 250 MCG TABLET
EDARBYCLOR 24 ST, QL ERGOLOID6 MG
DOXEPIN S TABLET 31 QL
DIHYDROERGOTAMINE
EDURANT 43 QL ERIVEDGE
DOXERCALCIFEROL 0.5 MCG CAPSULE 25 PA, LDD, SRX
DILATRATE-SR
EEMT D.S. 42 ERLOTINIB 5 PA, SRX
DOXERCALCIFEROL 1 MCG CAPSULE 2
DILTIAZEM
EEMT H.S. 120 MG TABLET 12 ERRIN 1
DOXERCALCIFEROL 2.5 MCG CAPSULE 2
DILTIAZEM
EFAVIRENZ 12HR ER 120 MG CAPSULE 2 ERTACZO 4
DOXYCYCLINE 25 MG/5 ML 2
DILTIAZEM
EFFER-K 1012HR ER 60 MG CAPSULE
MEQ EFFERVESCENT 24 ERY
SUSPENSION 2
TABLET 12HR ER 90 MG CAPSULE
DILTIAZEM 2 ERYTHROCIN 100 MG CAPSULE
DOXYCYCLINE 12
EFFER-K 2024HR
DILTIAZEM MEQ EFFERVESCENT
ER 42 ERYTHROMYCIN 0.5% EYE
DOXYCYCLINE 100 MG TABLET OINTMENT 12
TABLET
DILTIAZEM 24HR ER (CD) 2 ERYTHROMYCIN 2% GEL
DOXYCYCLINE 20 MG TABLET 22
EGRIFTA 24HR ER (LA)
DILTIAZEM 25 PA, LDD, SRX ERYTHROMYCIN
DOXYCYCLINE 2% CAPSULE
50 MG SOLUTION 12
EGRIFTA SV24HR ER (XR)
DILTIAZEM 52 PA, SRX DOXYCYCLINE MONOHYDRATE 100 12
ERYTHROMYCIN 250 MG FILMTAB
ELETRIPTAN
DILTIAZEM 30 MG TABLET 21 QL ERYTHROMYCIN
MG CAPSULE 500 MG FILMTAB 2
ELINEST 60 MG TABLET
DILTIAZEM 11 ERYTHROMYCIN
DOXYCYCLINE DR 250 MG CAPSULE
MONONHYDRATE 100 12
ELIQUIS
DILTIAZEM 90 MG TABLET 31 QL ERYTHROMYCIN
MG TABLET ETHYLSUCCINATE 2
ELITE-OB
DILT-XR 12 ERYTHROMYCIN-BENZOYL
DOXYCYCLINE MONOHYDRATE PEROXIDE
150 22
ELLA
DIMETHYL 30 DAY STARTER PACK 45 PA, LDD, SRX MG CAPSULE
ESBRIET 5 PA, LDD, SRX
Go to Cigna.com/ifp-drug-list to see the full list of medications your plan covers.
142022 Cigna Plus Kansas 5-Tier Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE, SRX, LDD) MEDICATION
MEDICATIONNAME
NAME Tier
Tier NOTES
NOTES(PA,(PA,ST,
ST,QL,
QL,AGE,
AGE,SRX,
SRX,LDD)
LDD)
ESCITALOPRAMMONOHYDRATE 150 2
DOXYCYCLINE QL EZETIMIBE
EMADINE 42
MG TABLET DR 10 MG PACKET 3
ESOMEPRAZOLE QL EZETIMIBE-SIMVASTATIN
EMCYT 52 SRX
DOXYCYCLINE
ESOMEPRAZOLE MONOHYDRATE 50 MG 13
DR 20 MG PACKET QL FACTIVE125 MG POWDER PACKET
EMEND 54 PA, QL, SRX
CAPSULE
ESOMEPRAZOLE DR 40 MG PACKET 3 QL FALMINA
EMOQUETTE 11
DOXYCYCLINE
ESOMEPRAZOLE MONOHYDRATE
MAG DR 20 MG50 12 QL FAMCICLOVIR
EMSAM 42 QL
MG TABLET
CAPSULE FAMOTIDINE 20 MG TABLET
EMTRICITABINE 21
DOXYCYCLINE
ESOMEPRAZOLE MONOHYDRATE
MAG DR 40 MG75 MG 22 QL FAMOTIDINE 40 MG TABLET100-150 21
CAPSULE EMTRICITABINE-TENOFOVIR
CAPSULE FAMOTIDINE 40 MG/5 ML 2
MG
DOXYCYCLINE
ESOMEPRAZOLE MONOHYDRATE
STRONTIUM 75 22 QL SUSPENSION
MG TABLET EMTRICITABINE-TENOFOVIR 133-200 2
ESTARYLLA 1 FANAPT
MG 4 ST, QL
DRONABINOL
ESTAZOLAM 42
FARXIGA
EMTRICITABINE-TENOFOVIR 167-250 2 3 QL
DROSPIRENONE-ETHINYL
ESTRADIOL 0.025 MG PATCH 12 QL FARYDAK
MG 5 PA, SRX
ESTRADIOL-LEVOMEFOLATE
ESTRADIOL 0.0375 MG PATCH 2 QL FAYOSIM
EMTRICITABINE-TENOFOVIR 200-300 21
DROSPIRENONE-ETHINYL ESTRADIOL 1
ESTRADIOL 0.0375 MG/DAY PATCH 2 MG
FEBUXOSTAT 4 QL
DROXIA 4
ESTRADIOL 0.05 MG PATCH 2 QL EMTRIVA 10
FELBAMATE MG/ML SOLUTION 34
DUAVEE 4
ESTRADIOL 0.06 MG/DAY PATCH 2 EMVERM
FELODIPINE ER 42
DULOXETINE DR 20 MG CAPSULE 2 QL
ESTRADIOL 0.075 MG PATCH 2 QL ENALAPRIL
FEM PH 12
DULOXETINE DR 30 MG CAPSULE 2 QL
ESTRADIOL 0.075 MG/DAY PATCH 2 ENALAPRIL-HCTZ
FEMYNOR 11
DULOXETINE DR 60 MG CAPSULE 2 QL
ESTRADIOL 0.1 MG PATCH 2 QL ENBREL 25 MG 120
FENOFIBRATE KIT MG TABLET 52 PA, QL, SRX
DUPIXENT PEN 5 PA, SRX
ESTRADIOL 0.5 MG TABLET 1 ENBREL 25 MG/0.5
FENOFIBRATE ML SYRINGE
130 MG CAPSULE 52 PA, QL, SRX
DUPIXENT SYRINGE 5 PA, SRX
ESTRADIOL 1 MG TABLET 1 ENBREL 50 MG/ML
FENOFIBRATE SYRINGE
134 MG CAPSULE 52 PA, QL, SRX
DUREZOL 4
ESTRADIOL 10 MCG VAGINAL INSERT 2 QL ENBREL MINI 145 MG TABLET
FENOFIBRATE 52 PA, QL, SRX
DUTASTERIDE
ESTRADIOL 2 MG TABLET 21 ENBREL SURECLICK 52 PA, QL, SRX
FENOFIBRATE 150 MG CAPSULE
DUTASTERIDE-TAMSULOSIN
ESTRADIOL TDS 0.025 MG/DAY 22 ENDOCET 22
FENOFIBRATE 160 MG TABLET
EASY COMFORT ALCOHOL 70%
ESTRADIOL TDS 0.0375 MG/DAY PAD 32
FENOFIBRATE
ENDOMETRIN 200 MG CAPSULE 42 PA
EASY TOUCH ALCOHOL 70%
ESTRADIOL TDS 0.05 MG/DAY PADS 32
FENOFIBRATE
ENGERIX-B 40 MG TABLET
ADULT 32
EC-NAPROXEN
ESTRADIOL TDSDR0.06 MG/DAY 22
FENOFIBRATE 43
ENGERIX-B PEDIATRICMG CAPSULE 32
ECONAZOLE
ESTRADIOL TDS 0.075 MG/DAY 22
FENOFIBRATE 48 MG TABLET
ENLYTE 42
ECONTRA
ESTRADIOLEZTDS 0.1 MG/DAY 42
FENOFIBRATE 50 MG CAPSULE
ENOXAPARIN 42 QL
EDARBI
ESTRADIOL-NORETHINDRONE 42 ST, QL
FENOFIBRATE
ENPRESSE 54 MG TABLET 12
EDARBYCLOR
ESTROGEN-METHYLTESTOSTERONE 42 ST, QL
FENOFIBRATE 67 MG CAPSULE
ENSKYCE 12
ED-SPAZ
ESTROSTEP FE 24
FENOFIBRIC
ENTACAPONE ACID 22
EDURANT
ESZOPICLONE 32 FENOPROFEN 600 MG TABLET
ENTECAVIR 42
EEMT D.S.
ETHAMBUTOL 22 FENTANYL OTFC 1,200 MCG
ENTRESTO 34 PA
EEMT H.S.
ETHOSUXIMIDE 22 FENTANYL OTFC 1,600 MCG 4 PA
ENULOSE 2
EFAVIRENZ
ETHYL CHLORIDE 22 FENTANYL
EPCLUSA 200OTFC 200 MG
MG-50 MCGTABLET 54 PA, PA QL, SRX
EFAVIRENZ-EMTRICITABINE-
ETHYNODIOL-ETHINYL ESTRADIOL 21 FENTANYL OTFC 400 MCG 4 PA SRX
TENOFOVIR EPCLUSA 400 MG-100 MG TABLET 5 PA,
ETODOLAC 2 FENTANYL OTFC 600 MCG 4 PA LDD
EFAVIRENZ-LAMIVUDINE-TENOFOVIR 22 EPIDIOLEX 4 PA,
ETODOLAC ER FENTANYL OTFC 800 MCG
EFFER-K EPIFOAM 44 PA
ETONOGESTREL-ETHINYL ESTRADIOL 42 FENTANYL PATCH 2 PA
EGRIFTA 54 PA, LDD, SRX EPINASTINE 2
ETOPOSIDE 50 MG CAPSULE FERRIPROX 4 PA, LDD
EGRIFTA SV 52 PA, LDD, SRX EPINEPHRINE 0.15 MG AUTO- 2 QL
EUTHYROX FETZIMA 4 ST, QL
ELETRIPTAN 25 QL INJECTOR
EVEROLIMUS 0.25 MG TABLET SRX FINACEA 15% FOAM 4
ELINEST 15 EPINEPHRINE 0.3 MG AUTO- 2 QL
EVEROLIMUS 0.5 MG TABLET SRX FINASTERIDE 5 MG TABLET
INJECTOR 2
ELIQUIS
EVEROLIMUS 0.75 MG TABLET 35 PA,
SRXQL FIORICET
EPITOL 22 QL
ELITE OB DHA2.5 MG TABLET
EVEROLIMUS 15 PA, SRX FIRVANQ
EPIVIR HBV 25 MG/5 ML SOLUTION 53 SRX
ELITE-OB
EVEROLIMUS 5 MG TABLET 15 PA, SRX FLAC OTIC OIL
EPLERENONE 22
ELITE-OB
EVEROLIMUS4007.5 MG TABLET 15 PA, SRX FLAVOXATE
EPROSARTAN 22
ELLA
EVOTAZ 43 FLECAINIDE
ERGOLOID 12
ELMIRON
EXEMESTANE 42 FLOVENT DISKUS
ERIVEDGE 53 PA, LDD, SRX
ELURYNG 2
Go to Cigna.com/ifp-drug-list to see the full list of medications your plan covers.
152022 Cigna Plus Kansas 5-Tier Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE, SRX, LDD) MEDICATION
MEDICATIONNAME
NAME Tier
Tier NOTES
NOTES(PA,
(PA,ST,
ST,QL,
QL,AGE,
AGE,SRX,
SRX,LDD)
LDD)
FLOVENT HFA
ERLOTINIB 53 PA, LDD, SRX FLURANDRENOLIDE
EVEROLIMUS 2.5 MG TABLET 54 PA, SRX
FLUAD QUAD
ERRIN 13 FLURAZEPAM5 MG TABLET
EVEROLIMUS 52 PA, SRX
FLUARIX
ERTACZOQUAD 34 FLURBIPROFEN
EVEROLIMUS 7.5 MG TABLET 52 PA, SRX
FLUBLOK
ERY QUAD
2% PADS 32 FLUTAMIDE
EVOTAZ 32
FLUCELVAX
ERYTHROCINQUAD 34 FLUTICASONE PROP 0.005%
EXEMESTANE 22
FLUCONAZOLE
ERYTHROMYCIN 0.5% EYE OINTMENT 22
10 MG/ML OINTMENT PLUS DHA
EXTRA-VIRT 1
SUSPENSION 2% GEL
ERYTHROMYCIN 2 EZETIMIBE PROP 0.05% CREAM 22
FLUTICASONE
FLUCONAZOLE 100 MG TABLET
ERYTHROMYCIN 2% PLEDGETS 22 FLUTICASONE PROP 0.05% LOTION 22
EZETIMIBE-SIMVASTATIN
FLUCONAZOLE 150 MG TABLET
ERYTHROMYCIN 2% SOLUTION 12 FLUTICASONE PROP 50 MCG SPRAY 42
FACTIVE
FLUCONAZOLE
ERYTHROMYCIN200250MGMGTABLET
FILMTAB 22 FLUTICASONE-SALMETEROL 113-14 12
FALMINA
FLUCONAZOLE 40 MG/ML
ERYTHROMYCIN 500 MG FILMTAB 22 FLUTICASONE-SALMETEROL 232-14 22
FAMCICLOVIR
SUSPENSION FLUTICASONE-SALMETEROL
ERYTHROMYCIN DR 250 MG CAPSULE 2 FAMOTIDINE 20 MG TABLET 55-14 12
FLUCONAZOLE 50 MG TABLET 2 FLUVASTATIN40 MG TABLET
ERYTHROMYCIN ES 400 MG TABLET 2 FAMOTIDINE 12
FLUCYTOSINE 4 FLUVASTATIN ER
ERYTHROMYCIN-BENZOYL PEROXIDE 2 FAMOTIDINE 40 MG/5 ML 22
FLUDROCORTISONE 2 FLUVOXAMINE
SUSPENSION 2 QL
ESBRIET 5 PA, LDD, SRX
FLULAVAL QUAD 3 FLUVOXAMINE ER
FANAPT 42 ST, QLQL
ESCITALOPRAM 2 QL
FLUMIST QUAD 3 FLUZONE
FARXIGA HIGH-DOSE QUAD 3 3 QL
ESOMEPRAZOLE DR 10 MG PACKET 3 QL
FLUNISOLIDE 2 FLUZONE QUAD
FARYDAK 53 PA, SRX
ESOMEPRAZOLE DR 20 MG PACKET 3 QL
FLUOCINOLONE 2 FOLIC ACID 1 MG TABLET
FAYOSIM 12
ESOMEPRAZOLE DR 40 MG PACKET 3 QL
FLUOCINOLONE OIL 2 FOLIVANE-OB
ESOMEPRAZOLE MAG DR 20 MG 2 QL FEBUXOSTAT 41 QL
FLUOCINONIDE 2 FONDAPARINUX
CAPSULE FELBAMATE 44 QL
FLUOCINONIDE-E
ESOMEPRAZOLE MAG DR 40 MG 22 QL FOSAMPRENAVIR 2
FELODIPINE ER 2
FLUORABON
CAPSULE 2 FOSINOPRIL 1
FEM PH 2
FLUORIDE
ESOMEPRAZOLE DR 49.3 MG 22 QL FOSINOPRIL-HCTZ 2
FEMYNOR 1
FLUORIDEX
CAPSULE 2 FOSRENOL 1,000 MG POWDER PACK 4
FENOFIBRATE 120 MG TABLET 2
FLUORIDEX
ESTARYLLA SENSITIVITY RELIEF 21 FOSRENOL 750 MG POWDER PACKET 4
FENOFIBRATE 130 MG CAPSULE 2
FLUORITAB
ESTAZOLAM 22 FRAGMIN 5 QL, SRX
FENOFIBRATE 134 MG CAPSULE 2
FLUOROMETHOLONE
ESTRADIOL PATCH (ONCE WEEKLY) 22 FREESTYLE LIBRE 14 DAY SENSOR 3 PA, QL
FENOFIBRATE 145 MG TABLET 2
FLUOROURACIL
ESTRADIOL 0.5%
PATCH CREAM
(TWICE WEEKLY) 22 QL FROVATRIPTAN 2 QL
FENOFIBRATE 150 MG CAPSULE 2
FLUOROURACIL 2% TOPICAL
ESTRADIOL 0.5 MG TABLET 2
1 FULPHILA 5 PA, SRX
FENOFIBRATE 160 MG TABLET 2
SOLUTION FUROSEMIDE 10 MG/ML SOLUTION 1
ESTRADIOL 1 MG TABLET 1 FENOFIBRATE 200 MG CAPSULE 2
FLUOROURACIL 5% CREAM 2 FUROSEMIDE 20 MG TABLET 1
ESTRADIOL 10 MCG VAGINAL INSERT 2 QL FENOFIBRATE 40 MG TABLET 2
FLUOROURACIL 5% TOPICAL 2 FUROSEMIDE 40 MG TABLET 1
ESTRADIOL 2 MG TABLET 1 FENOFIBRATE 43 MG CAPSULE 2
SOLUTION FUROSEMIDE 40 MG/5 ML SOLUTION 1
ESTRADIOL-NORETHINDRONE 2 FENOFIBRATE 48 MG TABLET 2
FLUOXETINE 10 MG CAPSULE 1 QL FUROSEMIDE 80 MG TABLET 1
ESTROGEN-METHYLTESTOSTERONE 2 FENOFIBRATE 50 MG CAPSULE 2
FLUOXETINE 10 MG TABLET 1 QL FUZEON 5 LDD, SRX
ESZOPICLONE 2 FENOFIBRATE 54 MG TABLET 2
FLUOXETINE 20 MG CAPSULE 1 QL FYAVOLV 2
ETHAMBUTOL 2 FENOFIBRATE 67 MG CAPSULE 2
FLUOXETINE 20 MG TABLET 1 QL FYCOMPA 10 MG TABLET 4 PA, QL
ETHOSUXIMIDE 2 FENOFIBRIC ACID 2
FLUOXETINE 20 MG/5 ML SOLUTION 2 QL FYCOMPA 12 MG TABLET 4 PA, QL
ETHYL CHLORIDE 2 FENOPROFEN 600 MG TABLET 2
FLUOXETINE 40 MG CAPSULE 1 QL FYCOMPA 2 MG TABLET 4 PA, QL
ETHYNODIOL-ETHINYL ESTRADIOL 1 FENTANYL CITRATE OTFC 1,200 MCG 4 PA
FLUOXETINE 60 MG TABLET 1 QL FYCOMPA 4 MG TABLET 4 PA, QL
ETIDRONATE 2 FENTANYL CITRATE OTFC 1,600 MCG 4 PA
FLUOXETINE DR 2 QL FYCOMPA 6 MG TABLET 4 PA, QL
ETODOLAC 2 FENTANYL CITRATE OTFC 200 MCG 4 PA
FLUPHENAZINE 1 MG TABLET 2 FYCOMPA 8 MG TABLET 4 PA, QL
ETODOLAC ER 2 FENTANYL CITRATE OTFC 400 MCG 4 PA
FLUPHENAZINE 10 MG TABLET 2 GABAPENTIN 2
ETONOGESTREL-ETHINYL ESTRADIOL 2 FENTANYL CITRATE OTFC 600 MCG 4 PA
FLUPHENAZINE 2.5 MG TABLET 2 GALANTAMINE 2
ETOPOSIDE 50 MG CAPSULE 4 FENTANYL CITRATE OTFC 800 MCG 4 PA
FLUPHENAZINE 2.5 MG/5 ML ELIXIR 2 GALANTAMINE ER 2 QL
EURAX 10% CREAM 4 FENTANYL PATCH 2 PA
FLUPHENAZINE 5 MG TABLET 2 GALZIN 4
EUTHYROX 1 FETZIMA 4 ST, QL
FLUPHENAZINE 5 MG/ML 2 GARDASIL 9 3
EVEROLIMUS
CONCENTRATE0.25 MG TABLET 5 SRX FEXOFENADINE 180 MG TABLET 2
EVEROLIMUS GATIFLOXACIN 2
FLURA-DROPS0.5 MG TABLET 52 SRX FEXOFENADINE 30 MG TABLET 2
EVEROLIMUS 0.75 MG TABLET 5 SRX GATTEX 5 PA, LDD, SRX
FEXOFENADINE 60 MG TABLET 2
Go to Cigna.com/ifp-drug-list to see the full list of medications your plan covers.
162022 Cigna Plus Kansas 5-Tier Prescription Drug List
MEDICATION NAME Tier NOTES (PA, ST, QL, AGE, SRX, LDD) MEDICATION
MEDICATIONNAME
NAME Tier
Tier NOTES
NOTES(PA,(PA,ST,
ST,QL,
QL,AGE,
AGE,SRX,
SRX,LDD)
LDD)
GAVILYTE-C 5 MG TABLET
FINASTERIDE 2 HALOPERIDOL 0.03% EYE DROPS
FLURBIPROFEN 22
GAVILYTE-G
FIORICET 50-300-40 MG CAPSULE 2 QL HALOPERIDOL LACTATE
FLURBIPROFEN 2 MG/ML
100 MG TABLET 22
GAVILYTE-N
FIRVANQ 32 CONCENTRATE
FLUTAMIDE 2
GEMFIBROZIL
FLAC OTIC OIL 22 HAVRIX
FLUTICASONE 0.005% OINTMENT 23
GENERESS
FLAVOXATE FE 42 HEATHER 0.05% CREAM
FLUTICASONE 21
GENERLAC
FLECAINIDE 22 HEMMOREX-HC
FLUTICASONE 0.05% LOTION 22
GENGRAFDISKUS
FLOVENT 23 HEPARIN 5,000 UNIT/ 0.5
FLUTICASONE 50 MCG SPRAY ML 22
GENOTROPIN
FLOVENT HFA 53 PA, ST, SRX HEPARIN 5,000 UNIT/ML SYRINGE
FLUTICASONE-SALMETEROL 100-50 22
GENTAK
FLUAD 23 FLUTICASONE-SALMETEROL 113-14 23
HEPLISAV-B
GENTAMICIN
FLUAD QUAD 0.1% CREAM 23 HETLIOZ
FLUTICASONE-SALMETEROL 232-14 25 PA, SRX
GENTAMICIN
FLUARIX QUAD 0.1% OINTMENT 23 HIBERIX VACCINE WITH DILUENT
FLUTICASONE-SALMETEROL 250-50 2 3
GENTAMICIN
FLUBLOK QUAD0.3% EYE DROP 23 HOMATROPAIRE
FLUTICASONE-SALMETEROL 55-14 22
GENTAMICIN 3
FLUCELVAX QUAD MG/ML EYE DROP 23 HUMALOG ER
FLUVASTATIN 23 QL
GENVOYA
FLUCONAZOLE 32 HUMALOG
FLUVASTATINJUNIOR KWIKPEN 23 QL
GIANVI
FLUCYTOSINE 14 HUMALOG KWIKPEN U-100
FLUVOXAMINE 23 QLQL
GILOTRIF
FLUDROCORTISONE 52 PA, LDD, SRX HUMALOG KWIKPEN
FLUVOXAMINE ER U-200 23 QLQL
GLATIRAMER
FLULAVAL QUAD 53 PA, SRX HUMALOG MIX 50-50
FLUZONE HIGH-DOSE QUAD 33 QL
GLATOPA
FLUMIST QUAD 53 PA, SRX HUMALOG
FLUZONE MIX 50-50 KWIKPEN
QUAD 33 QL
GLEOSTINE
FLUNISOLIDE 0.025% SPRAY 42 HUMALOG MIX 75-25
FOLIC ACID 1 MG TABLET 13 QL
GLIMEPIRIDE
FLUOCINOLONE 12 HUMALOG
FOLIVANE-OBMIX 75-25 KWIKPEN 13 QL
GLIPIZIDE
FLUOCINOLONE OIL 12 HUMATROPE
FONDAPARINUX 45 QLPA, SRX
GLIPIZIDE ER
FLUOCINONIDE 12 HUMIRA
FORMADON 25 PA, QL, SRX
GLIPIZIDE XL
FLUOCINONIDE-E 12 HUMIRA PEDIATRIC CROHN'S 5 PA, QL, SRX
FORMA-RAY 4
GLIPIZIDE-METFORMIN
FLUORABON 22 HUMIRA PEN 5 PA, QL, SRX
FOSAMPRENAVIR 2
GLYBURIDE
FLUORIDE 12 HUMIRA PEN CROHN'S-UC-HS 5 PA, QL, SRX
FOSFOMYCIN 3
GLYBURIDE
FLUORIDEX MICRONIZED 12 HUMIRA PEN PSORIASIS-UVEITIS- 5 PA, QL, SRX
FOSINOPRIL 1
GLYBURIDE-METFORMIN 22 ADOLESCENT HS
FLUORIDEX SENSITIVITY RELIEF FOSINOPRIL-HCTZ 2
GLYCINE 1.5% IRRIGATION 22 HUMIRA(CF) 5 PA, QL, SRX
FLUORITAB FOSRENOL 4
GLYCOPYRROLATE 1 MG TABLET 22 HUMIRA(CF) PEDIATRIC CROHN'S 5 PA, QL, SRX
FLUOROMETHOLONE FRAGMIN 5 QL, SRX
GLYCOPYRROLATE 2 MG TABLET 24 HUMIRA(CF) PEN 5 PA, QL, SRX
FLUOROURACIL 0.5% CREAM FREESTYLE LIBRE 10 DAY READER & 3 PA, QL
GLYDO 22 HUMIRA(CF) PEN CROHN'S-UC-HS 5 PA, QL, SRX
FLUOROURACIL 2% TOPICAL SENSOR
GRANISETRON
SOLUTION 4 HUMIRA(CF) PEN PSORIASIS- 5 PA, QL, SRX
FREESTYLE LIBRE 14 DAY READER & 3 PA, QL
GRANIX UVEITIS-ADOLESCENT HS
FLUOROURACIL 5% CREAM 25 SRX SENSOR
GRISEOFULVIN 5% TOPICAL HUMULIN 70-30 3 QL
FLUOROURACIL 2 FREESTYLE LIBRE 2 READER & 3 PA, QL
SOLUTION
GRISEOFULVIN ULTRAMICROSIZE 2 HUMULIN 70/30 KWIKPEN
SENSOR 3 QL
FLUOXETINE
GUANFACINE20 MG/5 ML SOLUTION 21 QL HUMULIN N
FROVATRIPTAN 23 QLQL
FLUOXETINE
GUANFACINEDR ER 2 QL HUMULIN N KWIKPEN
FUROSEMIDE 10 MG/ML SOLUTION 1 3 QL
FLUOXETINE
GUANIDINE 10 MG CAPSULE 12 QL HUMULIN R 3 QL
FUROSEMIDE 20 MG TABLET 1
FLUOXETINE
GVOKE HYPOPEN20 MG CAPSULE
1-PACK 13 QL HUMULIN R U-500 3 QL
FUROSEMIDE 40 MG TABLET 1
FLUOXETINE 40 MG
GVOKE HYPOPEN 2-PACK CAPSULE 13 QL HUMULIN R U-500 KWIKPEN 3 QL
FUROSEMIDE 40 MG/5 ML SOLUTION 1
FLUPHENAZINE
GVOKE PFS 1-PACK1 MG TABLET
SYRINGE 23 QL HYCAMTIN 0.25 MG CAPSULE 5 PA, SRX
FUROSEMIDE 80 MG TABLET 1
GVOKE PFS 2-PACK SYRINGE 32 QL HYCAMTIN 1 MG CAPSULE 5 PA, SRX
FLUPHENAZINE 10 MG TABLET FUZEON 5 LDD, SRX
GYNAZOLE 1 2.5 MG TABLET HYDRALAZINE 10 MG TABLET 2
FLUPHENAZINE 2 FYAVOLV 2
HAILEY HYDRALAZINE 100 MG TABLET 2
FLUPHENAZINE 2.5 MG/5 ML ELIXIR 21 FYCOMPA 10 MG TABLET 4 PA, QL
HAILEY 24 FE 5 MG TABLET HYDRALAZINE 25 MG TABLET 2
FLUPHENAZINE 21 FYCOMPA 12 MG TABLET 4 PA, QL
HAILEY FE HYDRALAZINE 50 MG TABLET 2
FLUPHENAZINE 5 MG/ML 21 FYCOMPA 2 MG TABLET 4 PA, QL
CONCENTRATE
HALCINONIDE 4 HYDROCHLOROTHIAZIDE 1
FYCOMPA 4 MG TABLET 4 PA, QL
FLURA-DROPS
HALOBETASOL 0.05% CREAM 2 HYDROCODONE-ACETAMINOPHEN 2
FYCOMPA 6 MG TABLET 4 PA, QL
FLURANDRENOLIDE
HALOBETASOL 0.05% OINTMENT 42 HYDROCODONE-CHLORPHENIRAMINE 2
FYCOMPA 8 MG TABLET 4 PA, QL
ER
FLURAZEPAM
HALOG 0.1% OINTMENT 24 GABAPENTIN 2
Go to Cigna.com/ifp-drug-list to see the full list of medications your plan covers.
172022 Cigna Plus Kansas 5-Tier Prescription Drug List
MEDICATION NAME
MEDICATION NAME Tier
Tier NOTES (PA,
NOTES (PA, ST,
ST, QL,
QL, AGE,
AGE, SRX,
SRX, LDD)
LDD) MEDICATION NAME Tier NOTES (PA, ST, QL, AGE, SRX, LDD)
HYDROCODONE-HOMATROPINE
GALANTAMINE ER 22 QL
QL HYOSCYAMINE
HAILEY 24 FE SR 1
HYDROCODONE-IBUPROFEN
GALANTAMINE 22 HYOSYNE
HAILEY FE 21
HYDROCORTISONE 1% CREAM
GALZIN 24 IBANDRONATE
HALCINONIDE 150 MG TABLET 24
HYDROCORTISONE
GARDASIL 9 1% OINTMENT 23 IBRANCE
HALOBETASOL 0.05% CREAM 52 PA, LDD, SRX
HYDROCORTISONE
GATIFLOXACIN 10 MG TABLET 22 IBU
HALOBETASOL 0.05% OINTMENT 12
HYDROCORTISONE
GATTEX 100 MG/60 ML 25 PA, LDD, SRX IBUPROFEN 100 MG/5 ML
HALOG OINTMENT 14
HYDROCORTISONE 2.5% CREAM 22 SUSPENSION
HALOPERIDOL 2
GAVILYTE-C
HYDROCORTISONE 2.5% LOTION 22 IBUPROFEN
HALOPERIDOL 4002 MG TABLET
MG/ML 12
GAVILYTE-G
HYDROCORTISONE 2.5% OINTMENT 22 IBUPROFEN
CONCENTRATE600 MG TABLET 1
GAVILYTE-N
HYDROCORTISONE 20 MG TABLET 2 IBUPROFEN 800 MG TABLET
HARVONI 33.75-150 MG PELLET 15 PA, QL, SRX
GEMFIBROZIL 2
HYDROCORTISONE 5 MG TABLET 2 ICATIBANT
PACKET 5 PA, SRX
GEMMILY 1
HYDROCORTISONE AC 25 MG 2 ICLUSIG
HARVONI 45-200 MG PELLET PACKET 5 PA, LDD, SRX
QL, SRX
GENERLAC 2
SUPPOSITORY ILARIS
HARVONI 45-200 MG TABLET 5 PA, LDD,
SRX SRX
GENGRAF 2
HYDROCORTISONE AC 30 MG 2 ILEVRO
HARVONI 90-400 MG TABLET 45 PA, SRX
GENOTROPIN
SUPPOSITORY 5 PA, ST, SRX
IMATINIB
HAVRIX 43 PA
GENTAK
HYDROCORTISONE BUTYRATE 22
IMBRUVICA
HEATHER 51 PA, LDD, SRX
GENTAMICIN 0.1% VALERATE
HYDROCORTISONE CREAM 22
IMIPRAMINE
HEMENATAL OB + DHA 21
GENTAMICIN 0.1% OINTMENT
HYDROCORTISONE-ACETIC ACID 22
IMIPRAMINE 2
GENTAMICIN 0.3% EYE DROP 22 HEMMOREX-HC 2
HYDROCORTISONE-PRAMOXINE IMIQUIMOD 5% CREAM PACKET 2
GENTAMICIN
1%-1% CREAM 3 MG/ML EYE DROP 2 HEPARIN 5,000 UNIT/0.5 ML 2
INCASSIA 1
GENVOYA TABLET
HYDROCORTISONE-PRAMOXINE 32 HEPARIN 5,000 UNIT/ML SYRINGE 2
INCONTROL ALCOHOL PADS 3
GIANVI
2.5-1% CREAM 1 HEPLISAV-B 3
INCRELEX 5 PA, SRX
GILOTRIF
HYDROCORTISONE-PRAMOXINE 52 PA, LDD, SRX HETLIOZ 5 PA, LDD, SRX
INCRUSE ELLIPTA 3
2.5%-1% CREAM
GLATIRAMER 5 PA, SRX HETLIOZ LQ 5 PA, LDD, SRX
INDAPAMIDE 1
HYDROMET
GLATOPA 25 QL
PA, SRX HIBERIX VACCINE WITH DILUENT 3
INDOMETHACIN 25 MG CAPSULE 2
HYDROMORPHONE 1 MG/ML
GLEOSTINE 42 HOMATROPAIRE 2
INDOMETHACIN 50 MG CAPSULE 2
SOLUTION
GLIMEPIRIDE 1 HOMATROPINE 2
INDOMETHACIN ER 2
HYDROMORPHONE 2 MG TABLET 2 HUMALOG 33 QL
GLIPIZIDE 1 INFANRIX DTAP
HYDROMORPHONE 3 MG 2 HUMALOG
GLIPIZIDE ER
SUPPOSITORY 1 INLYTA JUNIOR KWIKPEN 35 QL
PA, LDD, SRX
GLIPIZIDE XL 12 HUMALOG KWIKPEN U-100
INSULIN ASPART 34 QL
ST, QL
HYDROMORPHONE 4 MG TABLET HUMALOG KWIKPEN U-200 34 QL
GLIPIZIDE-METFORMIN
HYDROMORPHONE 5 MG/5 ML 22 INSULIN ASPART FLEXPEN ST, QL
GLYBURIDE 1 HUMALOG MIX 50-50
INSULIN ASPART PENFILL 34 QL
ST, QL
SOLUTION
GLYBURIDE MICRONIZED 12 HUMALOG MIX 50-50
INSULIN ASPART KWIKPEN ASP
PROT-INSULIN 34 QL
ST, QL
HYDROMORPHONE 8 MG TABLET
GLYBURIDE-METFORMIN 22 HUMALOG
INTELENCE MIX 75-25 33 QL
HYDROMORPHONE ER
GLYCINE 1.5% IRRIGATION 22 HUMALOG
INTRON A MIX 75-25 KWIKPEN 35 QL
PA, SRX
HYDROXYCHLOROQUINE QL
GLYCOPYRROLATE HUMATROPE 51 PA, SRX
HYDROXYUREA 1 MG TABLET 22 INTROVALE
GLYCOPYRROLATE HUMIRA 53 PA, QL, LDD, SRX
HYDROXYZINE 2 MG TABLET 22 IPOL
GLYDO 22 HUMIRA PEDIATRIC
IPRATROPIUM 0.03%CROHN'S
SPRAY 52 PA, QL, SRX
HYDROXYZINE 10 MG TABLET
GRANISETRON 42 HUMIRA PEN
IPRATROPIUM 0.06% SPRAY 52 PA, QL, LDD, SRX
HYDROXYZINE 10 MG/5 ML
GRISEOFULVIN 2 HUMIRA PEN CROHN'S-UC-HS
IPRATROPIUM BR 0.02% SOLUTION 51 PA, QL, LDD, SRX
SOLUTION
GRISEOFULVIN ULTRAMICROSIZE 2 HUMIRA PEN PSORIASIS-UVEITIS-
IPRATROPIUM-ALBUTEROL 52 PA, QL, LDD, SRX
HYDROXYZINE 10 MG/5 ML SYRUP
ADOLESCENT HS
GUANFACINE
HYDROXYZINE 25 MG TABLET 2 IRBESARTAN 2
HUMIRA(CF) 5 PA, QL, SRX
GUANFACINE
HYDROXYZINEER50 MG TABLET 2 IRBESARTAN-HCTZ 2
HUMIRA(CF) PEDIATRIC CROHN'S 5 PA, QL, LDD, SRX
GUANIDINE
HYOPHEN 2 IRESSA 5 PA, LDD, SRX
HUMIRA(CF) PEN 40 MG/0.4 ML 5 PA, QL, LDD, SRX
GVOKE HYPOPEN
HYOSCYAMINE 1-PACK
0.125 MG ODT 31 QL ISENTRESS 3
HUMIRA(CF) PEN 80 MG/0.8 ML 5 PA, QL, LDD, SRX
GVOKE HYPOPEN
HYOSCYAMINE 2-PACK
0.125 MG TABLET 31 QL ISENTRESS HD 3
HUMIRA(CF) PEN CROHN'S-UC-HS 5 PA, QL, LDD, SRX
GVOKE PFS 1-PACK SYRINGE
HYOSCYAMINE 0.125 MG TABLET SL 31 QL ISIBLOOM 1
HUMIRA(CF) PEN PEDIATRIC UC 5 PA, QL, LDD, SRX
GVOKE PFS 2-PACK
HYOSCYAMINE 0.125SYRINGE
MG/5 ML ELIXIR 32 QL ISOCHRON 2
HUMIRA(CF) PEN PSORIASIS- 5 PA, QL, LDD, SRX
GYNAZOLE
HYOSCYAMINE1 0.125 MG/ML DROP 2 ISONIAZID 100 MG TABLET 1
UVEITIS-ADOLESCENT HS
HYOSCYAMINE ER
HAILEY 1 ISONIAZID 300 MG TABLET 1
HUMULIN 70/30 KWIKPEN 3 QL
Go to Cigna.com/ifp-drug-list to see the full list of medications your plan covers.
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