2023 CIGNA PLUS NORTH CAROLINA 5-TIER PRESCRIPTION DRUG LIST - Coverage as of January 1, 2023
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Cigna HealthCare of North Carolina, Inc. 2023 CIGNA PLUS NORTH CAROLINA 5-TIER PRESCRIPTION DRUG LIST Coverage as of January 1, 2023 xxxxxx 07/22 © 2022 Cigna
What’s inside?
About this drug list 3
How to read this drug list 3
How to find your medication 5
Frequently Asked Questions (FAQs) 33
Exclusions and limitations: What’s not covered by this policy 35
View the drug list online
The myCigna® App* or myCigna.com®**. Click on the Find Care & Costs tab. Then select
Price a Medication, and type in your medication name.
Cigna.com/ifp-drug-list. Select North Carolina 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.
*App/online store terms and mobile phone carrier/data charges apply.
**Customers under age 13 (and/or their parent/guardian) will not be able to register at myCigna.com.
Next planned update: 07/01/2023,
Drug list originally created: 10/21/2013 Last updated: 07/01/2022, for changes starting 01/01/2023 for changes starting 01/01/2024
2About this drug list
This is a list of the prescription medications covered on the Cigna Plus North Carolina 5-Tier Prescription Drug List as
of January 1, 2023. 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 2023 Cigna Plus North Carolina 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 column
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 column
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 2023 Cigna Plus North Carolina 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, some medications 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.
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.
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.
AGE ge Requirements – Certain medications will only be covered 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 very hard to manage and require special
handling, 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. 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 or product 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 14–18
H–J 18–20
K–L 20–21
M–N 21–25
0–P 25–28
Q–S 28–30
T–U 30–32
V–Z 32–34
52023 Cigna Plus North Carolina 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 AFLURIA QUAD 2021-22 (3YR UP) 3
ABACAVIR-LAMIVUDINE 2 AFLURIA QUAD 2021-22 (6-35MO) 3
ABACAVIR-LAMIVUDINE-ZIDOVUDINE 2 AFTERA 4
ABIRATERONE 500 MG TABLET 5 PA, LDD AK-POLY-BAC 2
ABIRATERONE ACETATE 250 MG TAB 5 PA, LDD AKYNZEO 300-0.5 MG CAPSULE 5 PA, QL
ACAMPROSATE CALCIUM 3 ALBENDAZOLE 200 MG TABLET 4 PA
ACARBOSE 2 ALBUTEROL HFA 90 MCG INHALER 2 QL
ACEBUTOLOL HCL 2 ALBUTEROL SULFATE 2
ACETAMIN-CODEIN 300-30 MG/12.5 2 ALCAINE 2
ACETAMINOP-CODEINE 120-12 MG/5 2 ALCLOMETASONE DIPROPIONATE 2
ACETAMINOPHEN-COD #2 TABLET 2
ALCOHOL PADS 3
ACETAMINOPHEN-COD #3 TABLET 2
ALCOHOL PREP PADS 3
ACETAMINOPHEN-COD #4 TABLET 2
ALCOHOL SWAB 3
ACETAMN-CAF-DIHYDRCODEIN 320.5 2
ALCOHOL SWABS 3
ACETAZOLAMIDE 2
ALCOHOL WIPES 3
ACETAZOLAMIDE ER 2
ALDACTAZIDE 4
ACETIC ACID 2
ALECENSA 5 PA, QL, LDD
ACETYLCYSTEINE 10% VIAL 2
ALENDRONATE SOD 70 MG/75 ML 2
ACETYLCYSTEINE 20% VIAL 2
ALENDRONATE SODIUM 10 MG TAB 1
ACITRETIN 4
ALENDRONATE SODIUM 35 MG TAB 1
ACTEMRA 162 MG/0.9 ML SYRINGE 5 PA, ST, QL
ACTEMRA ACTPEN 5 PA, ST, QL ALENDRONATE SODIUM 5 MG TABLET 1
ACTHIB 3 ALENDRONATE SODIUM 70 MG TAB 2
ACTIMMUNE 5 PA, LDD ALFUZOSIN HCL ER 2
ACYCLOVIR 200 MG CAPSULE 1 ALINIA 4
ACYCLOVIR 200 MG/5 ML SUSP 2 ALISKIREN 4 QL
ACYCLOVIR 400 MG TABLET 1 ALLOPURINOL 1
ACYCLOVIR 5% OINTMENT 4 PA, QL ALMOTRIPTAN MALATE 2 QL
ACYCLOVIR 800 MG TABLET 1 ALOCRIL 4
ADACEL TDAP 3 ALOMIDE 4
ADAPALENE 0.1% CREAM 2 PA ALOSETRON HCL 4
ADAPALENE 0.1% GEL 2 PA ALPRAZOLAM 2
ADAPALENE 0.1% LOTION 2 PA ALPRAZOLAM ER 2
ADAPALENE 0.1% SOLUTION 2 PA ALPRAZOLAM INTENSOL 2
ADAPALENE 0.3% GEL 2 PA ALPRAZOLAM ODT 2
ADAPALENE 0.3% GEL PUMP 2 PA ALPRAZOLAM XR 2
ADAPALENE-BENZOYL PEROXIDE 4 ALTABAX 4
ADEFOVIR DIPIVOXIL 4 ALTACAINE 2
ADEK GUMMIES PLUS ZINC 2 ALTAVERA 1
ADEMPAS 5 PA, LDD ALVESCO 4 ST
AFIRMELLE 1 ALYACEN 1
AFLURIA 2018-2019 SYRINGE 3 ALYQ 5 PA
AFLURIA QUAD 2018-2019 3 AMABELZ 2
AFLURIA QUAD 2019-20 (3YR UP) 3 AMANTADINE 2
AFLURIA QUAD 2019-20 (6-35MO) 3 AMBRISENTAN 5 PA, LDD
AMCINONIDE 2
AFLURIA QUAD 2019-2020 3
AMETHIA 1
AFLURIA QUAD 2020-2021 3
AMETHYST 1
AFLURIA QUAD 2020-21 (3YR UP) 3
AMILORIDE HCL 2
AFLURIA QUAD 2020-21 (6-35MO) 3
AMILORIDE-HYDROCHLOROTHIAZIDE 2
AFLURIA QUAD 2021-2022 3
Go to Cigna.com/ifp-drug-list to see the full list of medications your plan covers.
62023 Cigna Plus North Carolina 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)
AMINOCAPROIC ACID 0.25 GRAM/ML 4 PA ANUCORT-HC 2
AMINOCAPROIC ACID 1,000 MG TAB 4 PA APEXICON E 4
AMINOCAPROIC ACID 500 MG TAB 4 PA APIDRA 4 ST, QL
AMIODARONE HCL 100 MG TABLET 2 APIDRA SOLOSTAR 4 ST, QL
AMIODARONE HCL 200 MG TABLET 2 APRACLONIDINE HCL 2
AMIODARONE HCL 400 MG TABLET 2 APREPITANT 125 MG CAPSULE 2 QL
AMITRIPTYLINE HCL 10 MG TAB 1 APREPITANT 125-80-80 MG PACK 2 QL
AMITRIPTYLINE HCL 100 MG TAB 2 APREPITANT 40 MG CAPSULE 2 QL
AMITRIPTYLINE HCL 150 MG TAB 2 APREPITANT 80 MG CAPSULE 2 QL
AMITRIPTYLINE HCL 25 MG TAB 1 APRI 1
AMITRIPTYLINE HCL 50 MG TAB 1 APTIOM 4 PA, QL
AMITRIPTYLINE HCL 75 MG TAB 1 APTIVUS 3
AMLODIPINE BESYLATE 2 AQUA CARE SODIUM CHLORIDE 2
AMLODIPINE BESYLATE-BENAZEPRIL 2 AQUA CARE STERILE WATER IRRIG 2
AMLODIPINE-ATORVASTATIN 2 ARANELLE 1
AMLODIPINE-OLMESARTAN 2 ARANESP 5 PA
AMLODIPINE-VALSARTAN 2 ARCALYST 5 PA, LDD
AMLODIPINE-VALSARTAN-HCTZ 2 ARFORMOTEROL TARTRATE 4 QL
AMMONIUM LACTATE 12% CREAM 2 ARIPIPRAZOLE 1 MG/ML SOLUTION 3
AMMONIUM LACTATE 12% LOTION 2 ARIPIPRAZOLE 10 MG TABLET 2
AMNESTEEM 4 ARIPIPRAZOLE 15 MG TABLET 2
AMOXAPINE 2
ARIPIPRAZOLE 2 MG TABLET 2
AMOX-CLAV 200-28.5 MG TAB CHEW 2
ARIPIPRAZOLE 20 MG TABLET 2
AMOX-CLAV 200-28.5 MG/5 ML SUS 2
ARIPIPRAZOLE 30 MG TABLET 2
AMOX-CLAV 250-125 MG TABLET 1
ARIPIPRAZOLE 5 MG TABLET 2
AMOX-CLAV 250-62.5 MG/5 ML SUS 2
ARIPIPRAZOLE ODT 4
AMOX-CLAV 400-57 MG TAB CHEW 2
ARMODAFINIL 150 MG TABLET 2 PA
AMOX-CLAV 400-57 MG/5 ML SUSP 2
ARMODAFINIL 200 MG TABLET 2 PA
AMOX-CLAV 500-125 MG TABLET 1 ARMODAFINIL 250 MG TABLET 2 PA
AMOX-CLAV 600-42.9 MG/5 ML SUS 2 ARMODAFINIL 50 MG TABLET 2 PA
AMOX-CLAV 875-125 MG TABLET 1 ARMOUR THYROID 3
AMOXICILLIN 125 MG TAB CHEW 1 ARNUITY ELLIPTA 3
AMOXICILLIN 125 MG/5 ML SUSP 1 ASA-BUTALB-CAFFEINE-CODEINE 2
AMOXICILLIN 200 MG/5 ML SUSP 1 ASCOMP WITH CODEINE 2
AMOXICILLIN 250 MG CAPSULE 1 ASENAPINE MALEATE 4 QL
AMOXICILLIN 250 MG TAB CHEW 2 ASHLYNA 1
AMOXICILLIN 250 MG/5 ML SUSP 1 ASMANEX HFA 4 ST, QL
AMOXICILLIN 400 MG/5 ML SUSP 1 ASMANEX TWISTHALER 110 MCG #30 4 ST, QL
AMOXICILLIN 500 MG CAPSULE 1 ASMANEX TWISTHALER 220 MCG #14 4 ST, QL
AMOXICILLIN 500 MG TABLET 1 ASMANEX TWISTHALER 220 MCG #30 4 ST, QL
AMOXICILLIN 875 MG TABLET 1 ASMANEX TWISTHALER 220 MCG 4 ST, QL
#60
AMOXICILLIN-CLAVULANATE POT ER 2
ASMANEX TWISTHALR 220 MCG #120 4 ST, QL
AMPHETAMINE SULFATE 10 MG TAB 2 QL
ASPIRIN-DIPYRIDAMOLE ER 2
AMPHETAMINE SULFATE 5 MG TAB 2 QL
ASTAGRAF XL 5
AMPICILLIN TRIHYDRATE 2
ATAZANAVIR SULFATE 2
ANAGRELIDE HCL 4
ATENOLOL 1
ANALPRAM HC 4
ATENOLOL-CHLORTHALIDONE 2
ANASTROZOLE 2
ANORO ELLIPTA 3 QL ATOMOXETINE HCL 10 MG CAPSULE 2 QL
Go to Cigna.com/ifp-drug-list to see the full list of medications your plan covers.
72023 Cigna Plus North Carolina 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)
ATOMOXETINE HCL 100 MG CAPSULE 2 QL BD AUTOSHIELD DUO NDL 5MMX30G 3
ATOMOXETINE HCL 18 MG CAPSULE 2 QL BD BLUNT NEEDLE 18GX1-1/2" 3
ATOMOXETINE HCL 25 MG CAPSULE 2 QL BD ECLIPSE 30GX1/2" SYRINGE 3
ATOMOXETINE HCL 40 MG CAPSULE 2 QL BD ECLIPSE LUER-LOK SYR 3 ML 3
ATOMOXETINE HCL 60 MG CAPSULE 2 QL BD ECLIPSE NEEDLE 18GX1 1/2" 3
ATOMOXETINE HCL 80 MG CAPSULE 2 QL BD ECLIPSE NEEDLE 21GX1" 3
ATORVASTATIN CALCIUM 2 BD ECLIPSE NEEDLE 22GX1" 3
ATOVAQUONE 4 BD ECLIPSE NEEDLE 23GX1" 3
ATOVAQUONE-PROGUANIL HCL 2 BD ECLIPSE NEEDLE 25GX1" 3
ATRIPLA TABLET 4 QL BD ECLIPSE NEEDLE 25GX1.5" 3
ATROPINE 1% EYE DROPS 2 BD ECLIPSE NEEDLE 25GX5/8" 3
ATROPINE 1% EYE OINTMENT 2 BD ECLIPSE NEEDLE 27GX1/2" 3
AUBRA 1 BD ECLIPSE NEEDLE 30GX1/2" 3
AUBRA EQ 1 BD ECLIPSE NEEDLES 21GX1.5" 3
AUROVELA 1 BD FILTER NEEDLE 3
AUROVELA 24 FE 1 BD INS SYR 0.3 ML 8MMX31G(1/2) 3
AUROVELA FE 1 BD INS SYR U-500 1/2ML 6MMX31G 3
AVIANE 1 BD INS SYR UF 0.3ML 12.7MMX30G 3
BD INS SYR UF 0.5ML 12.7MMX30G 3
AVONEX 5 PA
BD INS SYRN UF 1 ML 12.7MMX30G 3
AVONEX PEN 5 PA
BD INS SYRNG 0.3 ML 29GX12.7MM 3
AYUNA 1
BD INS SYRNG 0.5 ML 29GX12.7MM 3
AZASITE 4
BD INS SYRNG UF 0.3 ML 8MMX31G 3
AZATHIOPRINE 50 MG TABLET 2
BD INS SYRNG UF 0.5 ML 8MMX31G 3
AZELAIC ACID 2
BD INSULIN SYR 0.5 ML 28GX1/2" 3
AZELASTINE HCL 2
BD INSULIN SYR 0.5 ML 29GX1/2" 3
AZELASTINE-FLUTICASONE 3
BD INSULIN SYR 1 ML 25GX1" 3
AZITHROMYCIN 1 GM PWD PACKET 2
BD INSULIN SYR 1 ML 25GX5/8" 3
AZITHROMYCIN 100 MG/5 ML SUSP 2
BD INSULIN SYR 1 ML 26GX1/2" 3
AZITHROMYCIN 200 MG/5 ML SUSP 2
BD INSULIN SYR 1 ML 27GX12.7MM 3
AZITHROMYCIN 250 MG TABLET 1
BD INSULIN SYR 1 ML 27GX5/8" 3
AZITHROMYCIN 500 MG TABLET 1
BD INSULIN SYR 1 ML 28GX1/2" 3
AZITHROMYCIN 600 MG TABLET 2
BD INSULIN SYR 1 ML 29GX1/2" 3
AZURETTE 1
BD INSULIN SYR 1 ML 29GX12.7MM 3
BACITRACIN 500 UNIT/GM OPHTH 2
BD INSULIN SYR UF 1 ML 8MMX31G 3
BACITRACIN-POLYMYXIN EYE OINT 2
BD INSULIN SYRINGE 1 ML 3
BACLOFEN 10 MG TABLET 2
BD INTEGRA NEEDLE 25G X 5/8" 3
BACLOFEN 20 MG TABLET 2
BD INTEGRA RETRA NEEDLE 23GX1" 3
BACLOFEN 5 MG TABLET 2
BD INTEGRA SYR 3 ML 21GX1 1/2" 3
BAL-CARE DHA 1
BD LANCETS 33G 3
BALCOLTRA 4
BD LUER-LOK SYR 3 ML 25GX5/8" 3
BALSALAZIDE DISODIUM 2
BD LUER-LOK SYRINGE 1 ML 3
BALZIVA 1
BD MAGNI-GUIDE MAGNIFIER 3
BAQSIMI 3 QL
BD MICROTAINER 21G LANCETS 3
BARACLUDE 0.05 MG/ML SOLUTION 5
BD MICROTAINER 30G LANCETS 3
BASAGLAR KWIKPEN U-100 3 QL
BD NANO 2 GEN PEN NDL 32GX4MM 3
BD 3 ML SYRINGE 18GX1-1/2" 3
BD NEEDLE 18GX1 1/2" 3
BD 3 ML SYRINGE 20GX1-1/2" 3
BD NEEDLE 19GX1 1/2" 3
BD 3 ML SYRINGE 25GX1" 3
BD NEEDLE 20GX1 1/2" 3
BD 3 ML SYRINGE 25GX1-1/2" 3
BD NEEDLE 21GX1 1/2" 3
BD 3 ML SYRINGE WITH NEEDLE 3
Go to Cigna.com/ifp-drug-list to see the full list of medications your plan covers.
82023 Cigna Plus North Carolina 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)
BD NEEDLE 21GX1" 3 BD SAFETYGLIDE NEEDLE 25GX1" 3
BD NEEDLE 22GX1 1/2" 3 BD SAFETYGLIDE NEEDLE 27GX5/8" 3
BD NEEDLE 22GX3/4" 3 BD SAFETYGLIDE SYRINGE 27GX5/8 3
BD NEEDLE 23GX1 1/2" 3 BD SAFTYGLD INS 0.3 ML 6MMX31G 3
BD NEEDLE 23GX1" 3 BD SAFTYGLD INS 0.5 ML 6MMX31G 3
BD NEEDLE 25GX1" 3 BD SYRINGE-SAFETY GLIDE 3
BD NEEDLE 25GX5/8" 3 BD UF INS SYR 1 ML 30GX1/2" 3
BD NEEDLE 26GX0.625" 3 BD UF MICRO PEN NEEDLE 6MMX32G 3
BD NEEDLES 16GX1" 3 BD UF MINI PEN NEEDLE 5MMX31G 3
BD NEEDLES 16GX1.5" 3 BD UF NANO PEN NEEDLE 4MMX32G 3
BD NEEDLES 18GX1" 3 BD UF ORIG PEN NDL 12.7MMX29G 3
BD NEEDLES 18GX1.5" 3 BD UF SHORT PEN NEEDLE 8MMX31G 3
BD NEEDLES 19GX1" 3 BD ULTRA-FINE 33G LANCETS 3
BD NEEDLES 19GX1.5" 3 BD ULTRA-FINE II 30G LANCETS 3
BD NEEDLES 20GX1" 3 BD VEO INS 0.3ML 6MMX31G (1/2) 3
BD NEEDLES 20GX1.5" 3 BD VEO INS SYRING 1 ML 6MMX31G 3
BD NEEDLES 21GX1" 3 BD VEO INS SYRN 0.3 ML 6MMX31G 3
BD NEEDLES 21GX1.5" 3 BD VEO INS SYRN 0.5 ML 6MMX31G 3
BD NEEDLES 21GX2" 3 BECONASE AQ 4 ST
BD NEEDLES 22GX1" 3 BEKYREE 1
BD NEEDLES 22GX1.5" 3 BELLADONNA-OPIUM 2
BD NEEDLES 23GX0.75" 3 BELSOMRA 4 ST, QL
BD NEEDLES 23GX1.25" 3 BENAZEPRIL HCL 1
BD NEEDLES 25GX0.625" 3 BENAZEPRIL- 2
BD NEEDLES 25GX0.875" 3 HYDROCHLOROTHIAZIDE
BD NEEDLES 25GX1.5" 3 BENZONATATE 100 MG CAPSULE 2
BD NEEDLES 26GX0.375" 3 BENZONATATE 200 MG CAPSULE 2
BD NEEDLES 26GX0.5" 3
BENZONATATE PERLE 100 MG CAP 2
BD NEEDLES 27GX0.5" 3
BENZTROPINE MES 0.5 MG TAB 2
BD NEEDLES 27GX1X1.25" 3
BD NEEDLES 30GX0.5" 3 BENZTROPINE MES 1 MG TABLET 2
BD NEEDLES 30GX1" 3 BENZTROPINE MES 2 MG TABLET 2
BD NOKOR ADMIX NEEDLE 18GX1.5" 3 BEPOTASTINE BESILATE 4
BD NOKOR NEEDLE 16GX1" 3 BESER 2
BD NOKOR NEEDLE 18GX1" 3 BETADINE 4
BD PRECISIONGLI 27GX1-1/2" NDL 3 BETAINE ANHYDROUS 5 PA, LDD
BD PRECISIONGLIDE 3 ML 22GX3/4 3 BETAMETHASONE DIPROPIONATE 2
BD PRECISIONGLIDE NEEDLE 25G 3 BETAMETHASONE DP AUG 0.05% 2
BD SAFETGLD INS 0.3 ML 8MMX31G 3 CRM
BD SAFETGLD INS 0.3ML 13MMX29G 3 BETAMETHASONE DP AUG 0.05% GEL 2
BD SAFETGLD INS 0.5 ML 8MMX30G 3 BETAMETHASONE DP AUG 0.05% LOT 2
BD SAFETGLD INS 0.5ML 13MMX29G 3 BETAMETHASONE DP AUG 0.05% OIN 2
BD SAFETYGLD INS 1 ML 13MMX29G 3 BETAMETHASONE VALERATE 2
BD SAFETYGLID INS 1 ML 6MMX31G 3 BETAXOLOL HCL 2
BD SAFETYGLIDE 3 ML SYRINGE 3 BETHANECHOL CHLORIDE 2
BD SAFETYGLIDE NEEDLE 3 BEXAROTENE 4 PA
BD SAFETYGLIDE NEEDLE 18GX1.5" 3 BEXSERO 3
BD SAFETYGLIDE NEEDLE 21GX1" 3 BICALUTAMIDE 2
BD SAFETYGLIDE NEEDLE 21GX1.5" 3 BIKTARVY 3 QL
BD SAFETYGLIDE NEEDLE 22GX1.5" 3 BIMATOPROST 2 QL
Go to Cigna.com/ifp-drug-list to see the full list of medications your plan covers.
92023 Cigna Plus North Carolina 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)
BINOSTO 4 BUTALB-ACETAMIN-CAFF 50-300-40 2 QL
BISOPROLOL FUMARATE 2 BUTALB-ACETAMIN-CAFF 50-325-40 2 QL
BISOPROLOL- 1 BUTALB-ACETAMINOPH-CAFF- 2
HYDROCHLOROTHIAZIDE CODEIN
BLISOVI 24 FE 1 BUTALBITAL COMPOUND-CODEINE 2
BLISOVI FE 1 BUTALBITAL-ACETAMINOPHN 50-325 2
BOOSTRIX TDAP 3 BUTALBITAL-ASPIRIN-CAFFEINE CP 2 QL
BOSENTAN 5 PA, LDD BUTALBITAL-ASPIRIN-CAFFEINE TB 2 QL
BOSULIF 5 PA, QL, LDD BUTORPHANOL 10 MG/ML SPRAY 2 PA, QL
BREO ELLIPTA 3 QL BYDUREON BCISE 3 QL
BRIELLYN 1 BYDUREON PEN 3 QL
BRILINTA 4 BYETTA 3 QL
BRIMONIDINE TARTRATE 2 CABERGOLINE 0.5 MG TABLET 2 QL
CAFFEINE CIT 60 MG/3 ML ORAL 2
BRIMONIDINE TARTRATE-TIMOLOL 4
CALCIPOTRIENE 0.005% CREAM 2
BRINZOLAMIDE 3
CALCIPOTRIENE 0.005% OINTMENT 2
BROMFED DM 2
CALCIPOTRIENE 0.005% SOLUTION 2
BROMFENAC SODIUM 2 CALCIPOTRIENE-BETAMETHASONE 4
BROMOCRIPTINE MESYLATE 2 DP
BROMPHENIRAMINE-PSEUDOEPHED- 2 CALCITONIN-SALMON 200 UNITS SP 2
DM CALCITRIOL 0.25 MCG CAPSULE 2
BUDESONIDE 0.25 MG/2 ML SUSP 4 QL CALCITRIOL 0.5 MCG CAPSULE 2
BUDESONIDE 0.5 MG/2 ML SUSP 4 QL CALCITRIOL 1 MCG/ML SOLUTION 2
BUDESONIDE 1 MG/2 ML INH SUSP 4 QL CALCITRIOL 3 MCG/G OINTMENT 2 QL
BUDESONIDE DR 4 CALCIUM ACETATE 667 MG CAPSULE 2
BUDESONIDE EC 4 CALCIUM ACETATE 667 MG GELCAP 2
BUDESONIDE ER 9 MG TABLET 5 PA, QL CALCIUM ACETATE 667 MG TABLET 2
BUMETANIDE 0.5 MG TABLET 2 CAMILA 1
BUMETANIDE 1 MG TABLET 2 CAMRESE 1
BUMETANIDE 2 MG TABLET 2 CAMRESE LO 1
BUPRENORPHINE 10 MCG/HR PATCH 2 QL CANDESARTAN CILEXETIL 2
BUPRENORPHINE 15 MCG/HR PATCH 2 QL CANDESARTAN- 2
BUPRENORPHINE 2 MG TABLET SL 2 HYDROCHLOROTHIAZID
BUPRENORPHINE 20 MCG/HR PATCH 2 QL CAPECITABINE 150 MG TABLET 4 PA
BUPRENORPHINE 5 MCG/HR PATCH 2 QL CAPECITABINE 500 MG TABLET 4 PA
BUPRENORPHINE 7.5 MCG/HR PATCH 2 QL CAPRELSA 5 PA, QL, LDD
BUPRENORPHINE 8 MG TABLET SL 2 CAPTOPRIL 2
BUPRENORPHINE-NALOXONE 2 CAPTOPRIL-HYDROCHLOROTHIAZIDE 2 QL
BUPROPION HCL 100 MG TABLET 2 QL CARBAGLU 4 PA, LDD
BUPROPION HCL 75 MG TABLET 2 QL CARBAMAZEPINE 100 MG TAB CHEW 2
BUPROPION HCL SR 100 MG TABLET 2 QL CARBAMAZEPINE 100 MG/5 ML SUSP 2
BUPROPION HCL SR 150 MG TABLET 2 QL CARBAMAZEPINE 200 MG TABLET 2
BUPROPION HCL SR 200 MG TABLET 2 QL CARBAMAZEPINE ER 2
BUPROPION HCL XL 150 MG TABLET 2 QL CARBIDOPA 4
BUPROPION HCL XL 300 MG TABLET 2 QL CARBIDOPA-LEVODOPA 2
BUSPIRONE HCL 10 MG TABLET 1 CARBIDOPA-LEVODOPA ER 2
BUSPIRONE HCL 15 MG TABLET 2 CARBIDOPA-LEVODOPA- 2
BUSPIRONE HCL 30 MG TABLET 2 ENTACAPONE
BUSPIRONE HCL 5 MG TABLET 1 CARBINOXAMINE 4 MG/5 ML LIQUID 2
BUSPIRONE HCL 7.5 MG TABLET 2 CARBINOXAMINE MALEATE 4 MG TAB 2
Go to Cigna.com/ifp-drug-list to see the full list of medications your plan covers.
102023 Cigna Plus North Carolina 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)
CARETOUCH ALCOHOL PREP PAD 3 CHLORZOXAZONE 500 MG TABLET 2
CARGLUMIC ACID 4 PA CHOLESTYRAMINE 2
CARISOPRODOL 2 CHOLESTYRAMINE LIGHT 2
CARISOPRODOL-ASPIRIN 2 CHOLINE MAG TRISALICYLATE 2
CARISOPRODOL-ASPIRIN-CODEINE 2 CHORIONIC GONAD 10,000 UNIT VL 2 PA
CARTEOLOL HCL 2 CICLODAN 0.77% CREAM 2
CARTIA XT 2
CICLODAN 8% SOLUTION 2
CARVEDILOL 1
CICLOPIROX 2
CAYSTON 5 PA, QL, LDD
CILOSTAZOL 2
CAZIANT 1
CILOXAN 4
CEFACLOR 2
CIMETIDINE 200 MG TABLET 2
CEFACLOR ER 2
CIMETIDINE 300 MG TABLET 2
CEFADROXIL 2
CIMETIDINE 300 MG/5 ML SOLN 2
CEFDINIR 2
CIMETIDINE 400 MG TABLET 2
CEFDITOREN PIVOXIL 2
CIMETIDINE 400 MG/6.67 ML SOLN 2
CEFIXIME 100 MG/5 ML SUSP 2
CIMETIDINE 800 MG TABLET 2
CEFIXIME 200 MG/5 ML SUSP 2
CINACALCET HCL 30 MG TABLET 5 PA
CEFIXIME 400 MG CAPSULE 3
CINACALCET HCL 60 MG TABLET 5 PA
CEFPODOXIME PROXETIL 2
CINACALCET HCL 90 MG TABLET 5 PA
CEFPROZIL 2
CIPRO HC 4
CEFUROXIME 2
CIPROFLOXACIN 2
CELECOXIB 100 MG CAPSULE 2 QL CIPROFLOXACIN 0.2% OTIC SOLN 2
CELECOXIB 200 MG CAPSULE 2 QL CIPROFLOXACIN 0.3% EYE DROP 2
CELECOXIB 400 MG CAPSULE 2 QL CIPROFLOXACIN ER 2
CELECOXIB 50 MG CAPSULE 2 QL CIPROFLOXACIN HCL 100 MG TAB 2
CELONTIN 4 CIPROFLOXACIN HCL 250 MG TAB 1
CEPHALEXIN 125 MG/5 ML SUSP 2 CIPROFLOXACIN HCL 500 MG TAB 1
CEPHALEXIN 250 MG CAPSULE 1 CIPROFLOXACIN HCL 750 MG TAB 1
CEPHALEXIN 250 MG/5 ML SUSP 2 CIPROFLOXACIN HCL-FLUOCINOLONE 3 PA
CEPHALEXIN 500 MG CAPSULE 1 CIPROFLOXACIN-DEXAMETHASONE 3
CEPHALEXIN 750 MG CAPSULE 2 CITALOPRAM HBR 10 MG TABLET 1 QL
CETIRIZINE HCL 1 MG/ML SOLN 2 CITALOPRAM HBR 10 MG/5 ML SOLN 2 QL
CETIRIZINE HCL 1 MG/ML SYRUP 2 CITALOPRAM HBR 20 MG TABLET 1 QL
CEVIMELINE HCL 2 CITALOPRAM HBR 40 MG TABLET 1 QL
CHARLOTTE 24 FE 1 CLARAVIS 4
CHATEAL 1 CLARITHROMYCIN 2
CHATEAL EQ 1 CLARITHROMYCIN ER 2
CHEMET 4 CLEMASTINE FUM 2.68 MG TAB 2
CHLORDIAZEPOXIDE HCL 2 CLIND PH-BENZOYL PEROX 1.2-5% 2
CHLORDIAZEPOXIDE-AMITRIPTYLINE 2 CLINDACIN ETZ 1% PLEDGET 2
CHLORDIAZEPOXIDE-CLIDINIUM 2 CLINDACIN P 2
CHLORHEXIDINE 0.12% RINSE 2 CLINDAMYCIN (PEDIATRIC) 2
CHLOROQUINE PHOSPHATE 2 CLINDAMYCIN 2% VAGINAL CREAM 2
CHLORPROMAZINE 10 MG TABLET 2 CLINDAMYCIN HCL 2
CHLORPROMAZINE 100 MG TABLET 2 CLINDAMYCIN PH 1% GEL 2
CHLORPROMAZINE 200 MG TABLET 2 CLINDAMYCIN PH 1% SOLUTION 2
CHLORPROMAZINE 25 MG TABLET 2 CLINDAMYCIN PHOS 1% PLEDGET 2
CHLORPROMAZINE 50 MG TABLET 2
CLINDAMYCIN PHOSP 1% LOTION 2
CHLORPROPAMIDE 1
CLINDAMYCIN PHOSPHATE 1% FOAM 2
CHLORTHALIDONE 1
Go to Cigna.com/ifp-drug-list to see the full list of medications your plan covers.
112023 Cigna Plus North Carolina 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)
CLINDAMYCIN PHOS-TRETINOIN 2 CROTAN 3
CLINDAMYCIN-BENZOYL PEROXIDE 2 CRYSELLE 1
CLINDESSE 4 CURITY ALCOHOL PREPS 3
CLOBAZAM 4 PA CYANOCOBALAMIN INJECTION 2
CLOBETASOL EMOLLIENT 2 CYCLAFEM 1
CLOBETASOL EMULSION 2 CYCLOBENZAPRINE 10 MG TABLET 1
CLOBETASOL PROPIONATE 2
CYCLOBENZAPRINE 5 MG TABLET 1
CLOCORTOLONE PIVALATE 2
CYCLOMYDRIL 4
CLODAN 0.05% SHAMPOO 2
CYCLOPENTOLATE HCL 2
CLOMIPRAMINE HCL 4
CYCLOPHOSPHAMIDE 25 MG 3
CLONAZEPAM 2 CAPSULE
CLONIDINE 2 CYCLOPHOSPHAMIDE 50 MG 3
CLONIDINE HCL 0.1 MG TABLET 1 CAPSULE
CLONIDINE HCL 0.2 MG TABLET 1 CYCLOSERINE 2
CLONIDINE HCL 0.3 MG TABLET 1 CYCLOSET 4
CLONIDINE HCL ER 2 CYCLOSPORINE 0.05% EYE EMULS 4
CLOPIDOGREL 300 MG TABLET 2 CYCLOSPORINE 100 MG CAPSULE 2
CLOPIDOGREL 75 MG TABLET 1 CYCLOSPORINE 25 MG CAPSULE 2
CLORAZEPATE DIPOTASSIUM 2 CYCLOSPORINE MODIFIED 2
CLOTRIMAZOLE 1% SOLUTION 2 CYPROHEPTADINE 2 MG/5 ML SOLN 2
CLOTRIMAZOLE 1% TOPICAL CREAM 2 CYPROHEPTADINE 2 MG/5 ML SYRUP 2
CLOTRIMAZOLE 10 MG TROCHE 2 CYPROHEPTADINE 4 MG TABLET 2
CLOTRIMAZOLE-BETAMETHASONE 2 CYRED 1
CLOZAPINE 2 CYRED EQ 1
CLOZAPINE ODT 4 CYSTADANE 5 PA, LDD
C-NATE DHA 1 CYSTAGON 5 PA, LDD
COARTEM 4 QL CYSTARAN 4 PA, QL, LDD
CODEINE SULFATE 2 DALFAMPRIDINE ER 10 MG TABLET 5 PA, LDD
COLCHICINE 2 DALIRESP 4 QL
COLESEVELAM HCL 2 DANAZOL 2
COLESTIPOL HCL 2 DANTROLENE SODIUM 100 MG CAP 2
COLOCORT 2 DANTROLENE SODIUM 25 MG CAP 2
COMBIVIR 4 DANTROLENE SODIUM 50 MG CAP 2
COMPLERA 3 QL DAPSONE 4
COMPLETE NATAL DHA 1 DAPTACEL DTAP 3
COMPLETENATE 1 DARIFENACIN ER 2
COMPRO 2 DASETTA 1
CONSTULOSE 2 DAYSEE 1
CORTISONE ACETATE 2 DEBLITANE 1
CORTISPORIN 4 DECADRON 0.5 MG/5 ML ELIXIR 2
CORTISPORIN-TC 4 DEFERASIROX 5 PA, LDD
COTELLIC 5 PA, LDD DEFERIPRONE (3 TIMES A DAY) 4 PA
COVARYX 2 DEFERIPRONE 500 MG TABLET 4 PA
COVARYX H.S. 2 DEMECLOCYCLINE HCL 2
CRESEMBA 186 MG CAPSULE 4 PA DENTA 5000 PLUS 2
CRIXIVAN 3 DENTAGEL 2
CROMOLYN 100 MG/5 ML ORAL CONC 4 DESCOVY 4 PA
CROMOLYN 20 MG/2 ML NEB SOLN 4 QL DESIPRAMINE HCL 2
CROMOLYN 4% EYE DROPS 2 DESLORATADINE 2.5 MG ODT 2 QL
Go to Cigna.com/ifp-drug-list to see the full list of medications your plan covers.
122023 Cigna Plus North Carolina 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)
DESLORATADINE 5 MG ODT 2 QL DEXTROAMP-AMPHET ER 30 MG CAP 2 QL
DESLORATADINE 5 MG TABLET 2 QL DEXTROAMP-AMPHET ER 5 MG CAP 2 QL
DESMOPRESSIN 0.01% SOLUTION 2 DEXTROAMP-AMPHETAM 12.5 MG 2 QL
DESMOPRESSIN 10 MCG/0.1 ML SPR 2 TAB
DESMOPRESSIN ACETATE 0.1 MG TB 2 DEXTROAMP-AMPHETAM 7.5 MG TAB 2 QL
DESMOPRESSIN ACETATE 0.2 MG TB 2 DEXTROAMP-AMPHETAMIN 10 MG 2 QL
DESOGESTREL-ETHINYL ESTRADIOL 1 TAB
DESOGESTR-ETH ESTRAD ETH ESTRA 1 DEXTROAMP-AMPHETAMIN 15 MG 2 QL
TAB
DESONIDE 0.05% CREAM 2
DEXTROAMP-AMPHETAMIN 20 MG 2 QL
DESONIDE 0.05% LOTION 2 TAB
DESONIDE 0.05% OINTMENT 2 DEXTROAMP-AMPHETAMIN 30 MG 2 QL
DESOXIMETASONE 0.05% CREAM 2 TAB
DESOXIMETASONE 0.05% GEL 2 DEXTROAMP-AMPHETAMINE 5 MG 2 QL
TAB
DESOXIMETASONE 0.05% OINTMENT 2
DEXTROAMPHETAMINE 10 MG TAB 2 QL
DESOXIMETASONE 0.25% CREAM 2
DEXTROAMPHETAMINE 5 MG TAB 2 QL
DESOXIMETASONE 0.25% OINTMENT 2 DEXTROAMPHETAMINE 5 MG/5 ML 2 QL
DESVENLAFAXINE SUCCNT ER 100MG 2 QL DEXTROAMPHETAMINE SULFATE ER 2 QL
DESVENLAFAXINE SUCCNT ER 25 MG 2 QL DIAZEPAM 10 MG RECTAL GEL SYST 2
DESVENLAFAXINE SUCCNT ER 50 MG 2 QL DIAZEPAM 10 MG TABLET 2
DEXAMETHASONE 0.1% EYE DROP 2 DIAZEPAM 2 MG TABLET 2
DEXAMETHASONE 0.5 MG TABLET 2 DIAZEPAM 2.5 MG RECTAL GEL SYS 2
DEXAMETHASONE 0.5 MG/5 ML ELX 2 DIAZEPAM 20 MG RECTAL GEL SYST 2
DEXAMETHASONE 0.5 MG/5 ML LIQ 2 DIAZEPAM 5 MG TABLET 2
DEXAMETHASONE 0.75 MG TABLET 2 DIAZEPAM 5 MG/5 ML SOLUTION 2
DEXAMETHASONE 1 MG TABLET 2 DIAZEPAM 5 MG/ML ORAL CONC 2
DEXAMETHASONE 1.5 MG TABLET 2 DIAZOXIDE 4
DEXAMETHASONE 10 DAY 1.5 MG TB 2 DICLOFENAC 0.1% EYE DROPS 2
DEXAMETHASONE 13 DAY 1.5 MG TB 2 DICLOFENAC 1.5% TOPICAL SOLN 2
DEXAMETHASONE 2 MG TABLET 2 DICLOFENAC POT 50 MG TABLET 2
DEXAMETHASONE 4 MG TABLET 2 DICLOFENAC SOD DR 25 MG TAB 2
DEXAMETHASONE 6 DAY 1.5 MG TAB 2
DICLOFENAC SOD DR 50 MG TAB 2
DEXAMETHASONE 6 MG TABLET 2
DICLOFENAC SOD DR 75 MG TAB 2
DEXAMETHASONE INTENSOL 2
DEXMETHYLPHENIDATE 10 MG TAB 2 QL DICLOFENAC SOD EC 25 MG TAB 2
DEXMETHYLPHENIDATE 2.5 MG TAB 2 QL DICLOFENAC SOD EC 50 MG TAB 2
DEXMETHYLPHENIDATE 5 MG TAB 2 QL DICLOFENAC SOD EC 75 MG TAB 2
DEXMETHYLPHENIDATE ER 10 MG CP 2 QL DICLOFENAC SODIUM 1% GEL 2 QL
DEXMETHYLPHENIDATE ER 15 MG CP 2 QL DICLOFENAC SODIUM ER 2
DEXMETHYLPHENIDATE ER 20 MG CP 2 QL DICLOFENAC SODIUM-MISOPROSTOL 2
DEXMETHYLPHENIDATE ER 25 MG CP 2 QL DICLOXACILLIN SODIUM 2
DICYCLOMINE 10 MG CAPSULE 2
DEXMETHYLPHENIDATE ER 30 MG CP 2 QL
DICYCLOMINE 10 MG/5 ML SOLN 2
DEXMETHYLPHENIDATE ER 35 MG CP 2 QL
DICYCLOMINE 20 MG TABLET 2
DEXMETHYLPHENIDATE ER 40 MG CP 2 QL
DIDANOSINE 2
DEXMETHYLPHENIDATE ER 5 MG CAP 2 QL
DIFICID 200 MG TABLET 4 PA, QL
DEXTROAMP-AMPHET ER 10 MG CAP 2 QL
DIFICID 40 MG/ML SUSPENSION 4 QL
DEXTROAMP-AMPHET ER 15 MG CAP 2 QL
DIFLORASONE DIACETATE 4
DEXTROAMP-AMPHET ER 20 MG CAP 2 QL
DEXTROAMP-AMPHET ER 25 MG CAP 2 QL DIFLUNISAL 2
DIFLUPREDNATE 3
Go to Cigna.com/ifp-drug-list to see the full list of medications your plan covers.
132023 Cigna Plus North Carolina 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)
DIGITEK 2 DOXEPIN 5% CREAM 4
DIGOX 2 DOXEPIN 50 MG CAPSULE 2
DIGOXIN 0.05 MG/ML SOLUTION 2 DOXEPIN 75 MG CAPSULE 2
DIGOXIN 0.125 MG TABLET 2 DOXEPIN HCL 3 MG TABLET 3 QL
DIGOXIN 0.25 MG TABLET 2 DOXEPIN HCL 6 MG TABLET 3 QL
DIGOXIN 125 MCG TABLET 2 DOXERCALCIFEROL 0.5 MCG CAP 2
DIGOXIN 250 MCG TABLET 2 DOXERCALCIFEROL 1 MCG CAPSULE 2
DIHYDROERGOTAMINE 1 MG/ML 4 QL DOXERCALCIFEROL 2.5 MCG CAP 2
AMP DOXYCYCLINE 25 MG/5 ML SUSP 2
DILTIAZEM 120 MG TABLET 1 DOXYCYCLINE HYCLATE 100 MG CAP 1
DILTIAZEM 12HR ER 2 DOXYCYCLINE HYCLATE 100 MG TAB 1
DILTIAZEM 24HR ER 2 DOXYCYCLINE HYCLATE 20 MG TAB 2
DILTIAZEM 24HR ER (CD) 2
DOXYCYCLINE HYCLATE 50 MG CAP 1
DILTIAZEM 24HR ER (LA) 2
DOXYCYCLINE MONO 100 MG CAP 1
DILTIAZEM 24HR ER (XR) 2
DOXYCYCLINE MONO 100 MG TABLET 1
DILTIAZEM 30 MG TABLET 1
DOXYCYCLINE MONO 150 MG CAP 2
DILTIAZEM 60 MG TABLET 1
DOXYCYCLINE MONO 150 MG TABLET 2
DILTIAZEM 90 MG TABLET 1
DOXYCYCLINE MONO 50 MG CAP 1
DILT-XR 2
DOXYCYCLINE MONO 50 MG TABLET 1
DIMETHYL FUMARATE 30D START PK 5 PA, LDD
DOXYCYCLINE MONO 75 MG CAPSULE 2
DIMETHYL FUMARATE DR 120 MG CP 5 PA, LDD
DOXYCYCLINE MONO 75 MG TABLET 2
DIMETHYL FUMARATE DR 240 MG CP 5 PA, LDD
DRONABINOL 4
DIPENTUM 4
DROPSAFE PREP PADS 3
DIPHEN 4
DIPHENHYDRAMINE 12.5 MG/5 ML 2 DROSPIRENONE-ETH ESTRA- 1
LEVOMEF
DIPHENHYDRAMINE 25 MG/10 ML 2
DROSPIRENONE-ETHINYL ESTRADIOL 1
DIPHENOXYLATE-ATROPINE 2
DIPHTHERIA-TETANUS TOXOIDS-PED 3 DROXIA 4
DIPYRIDAMOLE 2 DUAVEE 4
DISOPYRAMIDE PHOSPHATE 2 DULERA 100 MCG-5 MCG INHALER 4 ST, QL
DISULFIRAM 2 DULERA 200 MCG-5 MCG INHALER 4 ST, QL
DIVALPROEX SODIUM 2 DULERA 50 MCG-5 MCG INHALER 4 ST, QL
DIVALPROEX SODIUM ER 2 DULOXETINE HCL DR 20 MG CAP 2 QL
DOFETILIDE 125 MCG CAPSULE 4 QL DULOXETINE HCL DR 30 MG CAP 2 QL
DOFETILIDE 250 MCG CAPSULE 4 QL DULOXETINE HCL DR 60 MG CAP 2 QL
DOFETILIDE 500 MCG CAPSULE 4 QL DUPIXENT 300 MG/2 ML PEN 5 PA
DOLISHALE 1 DUPIXENT SYRINGE 5 PA
DONEPEZIL HCL 2 DUTASTERIDE 2
DONEPEZIL HCL ODT 2 DUTASTERIDE-TAMSULOSIN 2
DORZOLAMIDE HCL 2 EASY COMFORT ALCOHOL PAD 3
DORZOLAMIDE-TIMOLOL EYE DROPS 2 EASY TOUCH ALCOHOL PREP PADS 3
DOTTI 2 QL EC-NAPROXEN 2
DOVATO 3 QL ECONAZOLE NITRATE 2
DOXAZOSIN MESYLATE 2 ECONTRA EZ 4
DOXEPIN 10 MG CAPSULE 2 ED-SPAZ 2
DOXEPIN 10 MG/ML ORAL CONC 2 EDURANT 3
DOXEPIN 100 MG CAPSULE 2 EEMT 2
DOXEPIN 150 MG CAPSULE 2 EEMT H.S. 2
DOXEPIN 25 MG CAPSULE 2
Go to Cigna.com/ifp-drug-list to see the full list of medications your plan covers.
142023 Cigna Plus North Carolina 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)
EFAVIRENZ 2 EPIVIR 4
EFAVIRENZ-EMTRIC-TENOFOV DISOP 2 QL EPIVIR HBV 25 MG/5 ML SOLN 5
EFAVIRENZ-LAMIVU-TENOFOV DISOP 2 QL EPLERENONE 2
EFFER-K 4 EPROSARTAN MESYLATE 2
ELETRIPTAN HBR 20 MG TABLET 2 QL EPZICOM 4
ELETRIPTAN HBR 40 MG TABLET 2 QL ERGOLOID MESYLATES 1
ELINEST 1 ERIVEDGE 5 PA, LDD
ELIQUIS 3 PA, QL ERLOTINIB HCL 5 PA, LDD
ELITE-OB 1 ERRIN 1
ELLA 4 ERTACZO 4
ELURYNG 2 ERY 2
EMCYT 5 ERYTHROCIN STEARATE 4
ERYTHROMYCIN 0.5% EYE OINTMENT 2
EMEND 125 MG POWDER PACKET 5 PA, QL
ERYTHROMYCIN 2% GEL 2
EMOQUETTE 1
ERYTHROMYCIN 2% PLEDGETS 2
EMTRICITABINE 2
ERYTHROMYCIN 2% SOLUTION 2
EMTRICITABINE-TENOFOVIR DISOP 2
ERYTHROMYCIN 250 MG FILMTAB 2
EMTRIVA 10 MG/ML SOLUTION 3
ERYTHROMYCIN 500 MG FILMTAB 2
EMTRIVA 200 MG CAPSULE 4
EMVERM 4 ERYTHROMYCIN DR 250 MG CAP 2
ENALAPRIL MALEATE 10 MG TAB 1 ERYTHROMYCIN ETHYLSUCCINATE 2
ENALAPRIL MALEATE 2.5 MG TAB 1 ERYTHROMYCIN-BENZOYL PEROXIDE 2
ENALAPRIL MALEATE 20 MG TAB 1 ESBRIET 5 PA, LDD
ENALAPRIL MALEATE 5 MG TABLET 1 ESCITALOPRAM 10 MG TABLET 2 QL
ENALAPRIL-HYDROCHLOROTHIAZIDE 1 ESCITALOPRAM 20 MG TABLET 2 QL
ENBREL 25 MG KIT 5 PA, QL ESCITALOPRAM 5 MG TABLET 2 QL
ENBREL 25 MG/0.5 ML SYRINGE 5 PA, QL ESCITALOPRAM OXALATE 5 MG/5 ML 2 QL
ENBREL 50 MG/ML SYRINGE 5 PA, QL ESOMEPRAZOLE DR 10 MG PACKET 3 QL
ENBREL MINI 5 PA, QL ESOMEPRAZOLE DR 20 MG PACKET 3 QL
ENBREL SURECLICK 5 PA, QL ESOMEPRAZOLE DR 40 MG PACKET 3 QL
ENDOCET 2 ESOMEPRAZOLE MAG DR 20 MG CAP 2 QL
ENDOMETRIN 4 PA ESOMEPRAZOLE MAG DR 40 MG CAP 2 QL
ENGERIX-B ADULT 3 ESOMEPRAZOLE STRONTIUM 2 QL
ENGERIX-B PEDIATRIC-ADOLESCENT 3 ESTARYLLA 1
ENLYTE 4 ESTAZOLAM 2
ENOXAPARIN SODIUM 4 QL ESTRADIOL (ONCE WEEKLY) 2
ENPRESSE 1 ESTRADIOL (TWICE WEEKLY) 2 QL
ENSKYCE 1 ESTRADIOL 0.5 MG TABLET 1
ENTACAPONE 2 ESTRADIOL 1 MG TABLET 1
ENTECAVIR 4 ESTRADIOL 10 MCG VAGINAL INSRT 2 QL
ENTRESTO 3 QL ESTRADIOL 2 MG TABLET 1
ENULOSE 2 ESTRADIOL-NORETHINDRONE ACETAT 2
EPCLUSA 5 PA, QL ESTROGEN-METHYLTESTOSTERONE 2
EPIDIOLEX 4 PA, LDD ESZOPICLONE 2
EPIFOAM 4 ETHAMBUTOL HCL 2
EPINASTINE HCL 2 ETHOSUXIMIDE 2
ETHYL CHLORIDE 2
EPINEPHRINE 0.15 MG AUTO-INJCT 2 QL
ETHYNODIOL-ETHINYL ESTRADIOL 1
EPINEPHRINE 0.3 MG AUTO-INJECT 2 QL
ETODOLAC 2
EPITOL 2
Go to Cigna.com/ifp-drug-list to see the full list of medications your plan covers.
152023 Cigna Plus North Carolina 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)
ETODOLAC ER 2 FENOFIBRIC ACID 2
ETONOGESTREL-ETHINYL ESTRADIOL 2 FENOPROFEN 600 MG TABLET 2
ETOPOSIDE 4 FENTANYL 100 MCG/HR PATCH 2 PA
ETRAVIRINE 2 FENTANYL 12 MCG/HR PATCH 2 PA
EURAX 4 FENTANYL 25 MCG/HR PATCH 2 PA
EUTHYROX 1 FENTANYL 37.5 MCG/HR PATCH 2 PA
EVEROLIMUS 0.25 MG TABLET 5 FENTANYL 50 MCG/HR PATCH 2 PA
EVEROLIMUS 0.5 MG TABLET 5 FENTANYL 62.5 MCG/HR PATCH 2 PA
EVEROLIMUS 0.75 MG TABLET 5 FENTANYL 75 MCG/HR PATCH 2 PA
EVEROLIMUS 1 MG TABLET 5 FENTANYL 87.5 MCG/HR PATCH 2 PA
EVEROLIMUS 10 MG TABLET 5 PA, QL FENTANYL CIT OTFC 1,200 MCG 4 PA
EVEROLIMUS 2 MG TAB FOR SUSP 5 PA, QL FENTANYL CIT OTFC 1,600 MCG 4 PA
EVEROLIMUS 2.5 MG TABLET 5 PA, QL FENTANYL CITRATE OTFC 200 MCG 4 PA
EVEROLIMUS 3 MG TAB FOR SUSP 5 PA, QL FENTANYL CITRATE OTFC 400 MCG 4 PA
EVEROLIMUS 5 MG TAB FOR SUSP 5 PA, QL FENTANYL CITRATE OTFC 600 MCG 4 PA
EVEROLIMUS 5 MG TABLET 5 PA, QL FENTANYL CITRATE OTFC 800 MCG 4 PA
EVEROLIMUS 7.5 MG TABLET 5 PA, QL FERRIPROX 100 MG/ML SOLUTION 4 PA, LDD
EVOTAZ 3 FETZIMA 4 ST, QL
EXEMESTANE 2 FINASTERIDE 2
EZ FLU 2018-2019 (FLUCELVAX) 3 FIRVANQ 3
EZETIMIBE 2 FLAC OTIC OIL 2
EZETIMIBE-SIMVASTATIN 2 FLAVOXATE HCL 2
FALMINA 1 FLECAINIDE ACETATE 2
FAMCICLOVIR 2 FLOVENT 100 MCG DISKUS 3 QL
FAMOTIDINE 40 MG TABLET 1 FLOVENT 250 MCG DISKUS 3 QL
FAMOTIDINE 40 MG/5 ML SUSP 2 FLOVENT 50 MCG DISKUS 3 QL
FANAPT 4 ST, QL FLOVENT HFA 110 MCG INHALER 3 QL
FARXIGA 3 QL FLOVENT HFA 220 MCG INHALER 3 QL
FARYDAK 5 PA FLOVENT HFA 44 MCG INHALER 3 QL
FAYOSIM 1 FLUAD 2019-2020 3
FEBUXOSTAT 40 MG TABLET 4 QL FLUAD 2020-2021 3
FEBUXOSTAT 80 MG TABLET 4 QL FLUAD QUAD 2020-2021 3
FELBAMATE 4 FLUAD QUAD 2021-2022 3
FELODIPINE ER 2 FLUARIX QUAD 2019-2020 3
FEM PH 2 FLUARIX QUAD 2020-2021 3
FEMYNOR 1 FLUARIX QUAD 2021-2022 3
FENOFIBRATE 120 MG TABLET 2 FLUBLOK QUAD 2019-2020 3
FENOFIBRATE 130 MG CAPSULE 2 FLUBLOK QUAD 2020-2021 3
FENOFIBRATE 134 MG CAPSULE 2
FLUBLOK QUAD 2021-2022 3
FENOFIBRATE 145 MG TABLET 2
FLUCELVAX QUAD 2019-2020 3
FENOFIBRATE 150 MG CAPSULE 2
FLUCELVAX QUAD 2020-2021 3
FENOFIBRATE 160 MG TABLET 2
FLUCELVAX QUAD 2021-2022 3
FENOFIBRATE 200 MG CAPSULE 2
FLUCONAZOLE 2
FENOFIBRATE 40 MG TABLET 2
FLUCYTOSINE 4
FENOFIBRATE 43 MG CAPSULE 2
FLUDROCORTISONE ACETATE 2
FENOFIBRATE 48 MG TABLET 2
FLULAVAL QUAD 2019-2020 3
FENOFIBRATE 50 MG CAPSULE 2
FENOFIBRATE 54 MG TABLET 2 FLULAVAL QUAD 2020-2021 3
FENOFIBRATE 67 MG CAPSULE 2 FLULAVAL QUAD 2021-2022 3
Go to Cigna.com/ifp-drug-list to see the full list of medications your plan covers.
162023 Cigna Plus North Carolina 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)
FLUMIST QUAD 2019-2020 3 FLUVOXAMINE MALEATE 25 MG TAB 2 QL
FLUMIST QUAD 2020-2021 3 FLUVOXAMINE MALEATE 50 MG TAB 2 QL
FLUMIST QUAD 2021-2022 3 FLUVOXAMINE MALEATE ER 2 QL
FLUNISOLIDE 2 FLUZONE HIGH-DOSE 2019-2020 3
FLUZONE HIGH-DOSE QUAD 2020-21 3
FLUOCINOLONE ACETONIDE 2
FLUZONE HIGH-DOSE QUAD 2021-22 3
FLUOCINOLONE ACETONIDE OIL 2
FLUZONE QUAD 2019-2020 3
FLUOCINONIDE 2
FLUZONE QUAD 2020-2021 3
FLUOCINONIDE-E 2
FLUZONE QUAD 2021-2022 3
FLUORABON 2
FLUZONE QUAD PEDI 2019-2020 3
FLUORIDE 2
FOLIC ACID 1 MG TABLET 1
FLUORIDEX 2 FONDAPARINUX SODIUM 4 QL
FLUORIDEX SENSITIVITY RELIEF 2 FORMADON 2
FLUORITAB 2 FORMA-RAY 4
FLUOROMETHOLONE 2 FORMOTEROL 20 MCG/2 ML NEB VL 4 QL
FLUOROURACIL 0.5% CREAM 4 FOSAMAX PLUS D 4 QL
FLUOROURACIL 2% TOPICAL SOLN 2 FOSAMPRENAVIR CALCIUM 2
FLUOROURACIL 5% CREAM 2 FOSFOMYCIN TROMETHAMINE 3
FLUOROURACIL 5% TOPICAL SOLN 2 FOSINOPRIL SODIUM 1
FLUOXETINE 20 MG/5 ML SOLUTION 2 QL FOSINOPRIL-HYDROCHLOROTHIAZIDE 2
FLUOXETINE DR 2 QL FOSRENOL 4
FLUOXETINE HCL 10 MG CAPSULE 1 QL FRAGMIN 5 QL
FLUOXETINE HCL 20 MG CAPSULE 1 QL FREESTYLE LIBRE 2 SENSOR 3 PA, QL
FLUOXETINE HCL 40 MG CAPSULE 1 QL FROVATRIPTAN SUCCINATE 2 QL
FLUPHENAZINE 1 MG TABLET 2 FUROSEMIDE 10 MG/ML SOLUTION 1
FLUPHENAZINE 10 MG TABLET 2 FUROSEMIDE 20 MG TABLET 1
FLUPHENAZINE 2.5 MG TABLET 2 FUROSEMIDE 40 MG TABLET 1
FLUPHENAZINE 2.5 MG/5 ML ELIX 2 FUROSEMIDE 40 MG/5 ML SOLN 1
FLUPHENAZINE 5 MG TABLET 2 FUROSEMIDE 80 MG TABLET 1
FLUPHENAZINE 5 MG/ML CONC 2 FUZEON 5 LDD
FLURA-DROPS 2 FYAVOLV 2
FLURANDRENOLIDE 4 FYCOMPA 10 MG TABLET 4 PA, QL
FLURAZEPAM HCL 2 FYCOMPA 12 MG TABLET 4 PA, QL
FLURBIPROFEN 2 FYCOMPA 2 MG TABLET 4 PA, QL
FLURBIPROFEN SODIUM 2 FYCOMPA 4 MG TABLET 4 PA, QL
FLUTAMIDE 2 FYCOMPA 6 MG TABLET 4 PA, QL
FLUTICASONE PROP 0.005% OINT 2 FYCOMPA 8 MG TABLET 4 PA, QL
FLUTICASONE PROP 0.05% CREAM 2 GABAPENTIN 2
FLUTICASONE PROP 0.05% LOTION 2 GALANTAMINE ER 16 MG CAPSULE 2 QL
FLUTICASONE PROP 50 MCG SPRAY 2 GALANTAMINE ER 24 MG CAPSULE 2 QL
FLUTICASONE-SALMETEROL 100-50 2 QL GALANTAMINE ER 8 MG CAPSULE 2 QL
FLUTICASONE-SALMETEROL 113-14 2 QL GALANTAMINE HBR 2
FLUTICASONE-SALMETEROL 232-14 2 QL GALANTAMINE HYDROBROMIDE 2
FLUTICASONE-SALMETEROL 250-50 2 QL GALZIN 4
FLUTICASONE-SALMETEROL 55-14 2 QL GARDASIL 9 3
FLUVASTATIN ER 2 GATIFLOXACIN 2
FLUVASTATIN SODIUM 2 GATTEX 5 PA, LDD
FLUVOXAMINE MALEATE 100 MG TAB 2 QL GAVILYTE-C 2
Go to Cigna.com/ifp-drug-list to see the full list of medications your plan covers.
172023 Cigna Plus North Carolina 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)
GAVILYTE-G 2 HALOPERIDOL LAC 2 MG/ML CONC 2
GAVILYTE-N 2 HARVONI 5 PA, QL
GEMFIBROZIL 2 HAVRIX 3
GEMMILY 1 HEATHER 1
HEMANGEOL 4 LDD
GENERLAC 2
HEMENATAL OB + DHA 1
GENGRAF 2
HEMMOREX-HC 2
GENTAK 2 HEPARIN SOD 5,000 UNIT/0.5 ML 2
GENTAMICIN 0.1% CREAM 2 HEPARIN SOD 5,000 UNIT/ML SYRG 2
GENTAMICIN 0.1% OINTMENT 2 HEPLISAV-B 3
GENTAMICIN 0.3% EYE DROP 2 HETLIOZ 5 PA, LDD
GENVOYA TABLET 3 QL HETLIOZ LQ 5 PA, LDD
GIANVI 1 HIBERIX 3
GLATIRAMER ACETATE 5 PA HOMATROPAIRE 2
GLATOPA 20 MG/ML SYRINGE 5 PA HOMATROPINE HYDROBROMIDE 2
GLATOPA 40 MG/ML SYRINGE 5 PA HUMALOG 3 QL
GLEOSTINE 4 PA HUMALOG JUNIOR KWIKPEN 3 QL
GLIMEPIRIDE 1 HUMALOG KWIKPEN U-100 3 QL
GLIPIZIDE 1 HUMALOG KWIKPEN U-200 3 QL
HUMALOG MIX 50-50 3 QL
GLIPIZIDE ER 1
HUMALOG MIX 50-50 KWIKPEN 3 QL
GLIPIZIDE XL 1
HUMALOG MIX 75-25 3 QL
GLIPIZIDE-METFORMIN 2 HUMALOG MIX 75-25 KWIKPEN 3 QL
GLUCAGON EMERGENCY KIT 3 QL HUMIRA 5 PA, QL, LDD
GLYBURIDE 1 HUMIRA PEN 5 PA, QL, LDD
GLYBURIDE MICRONIZED 1 HUMIRA PEN CROHN'S-UC-HS 5 PA, QL, LDD
GLYBURIDE-METFORMIN HCL 2 HUMIRA PEN PSOR-UVEITS-ADOL HS 5 PA, QL, LDD
GLYCINE 1.5% IRRIGATION 2 HUMIRA(CF) 5 PA, QL
GLYCOPYRROLATE 1 MG TABLET 2 HUMIRA(CF) PEDIATRIC CROHN'S 5 PA, QL, LDD
GLYCOPYRROLATE 2 MG TABLET 2 HUMIRA(CF) PEN 5 PA, QL, LDD
GLYDO 2 HUMIRA(CF) PEN CROHN'S-UC-HS 5 PA, QL, LDD
GRANISETRON HCL 4 HUMIRA(CF) PEN PEDIATRIC UC 5 PA, QL, LDD
GRISEOFULVIN 2 HUMIRA(CF) PEN PSOR-UV-ADOL HS 5 PA, QL, LDD
GRISEOFULVIN ULTRAMICROSIZE 2 HUMULIN 70/30 KWIKPEN 3 QL
GUANFACINE HCL 2 HUMULIN 70-30 3 QL
HUMULIN N 3 QL
GUANFACINE HCL ER 1 MG TABLET 2 QL
HUMULIN N KWIKPEN 3 QL
GUANFACINE HCL ER 2 MG TABLET 2 QL
HUMULIN R 3 QL
GUANFACINE HCL ER 3 MG TABLET 2 QL
HUMULIN R U-500 3 QL
GUANFACINE HCL ER 4 MG TABLET 2 QL
HUMULIN R U-500 KWIKPEN 3 QL
GYNAZOLE 1 2
HYCAMTIN 0.25 MG CAPSULE 5 PA
HAILEY 1
HYCAMTIN 1 MG CAPSULE 5 PA
HAILEY 24 FE 1
HYDRALAZINE 10 MG TABLET 1
HAILEY FE 1
HYDRALAZINE 100 MG TABLET 2
HALCINONIDE 4
HYDRALAZINE 25 MG TABLET 1
HALOBETASOL PROP 0.05% CREAM 2
HYDRALAZINE 50 MG TABLET 1
HALOBETASOL PROP 0.05% 2
OINTMNT HYDROCHLOROTHIAZIDE 1
HALOPERIDOL 2 HYDROCODONE ER 100 MG TABLET 4 PA, ST
HALOPERIDOL LAC 10 MG/5 ML CUP 2 HYDROCODONE ER 120 MG TABLET 4 PA, ST
HYDROCODONE ER 20 MG TABLET 4 PA, ST
Go to Cigna.com/ifp-drug-list to see the full list of medications your plan covers.
182023 Cigna Plus North Carolina 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)
HYDROCODONE ER 30 MG TABLET 4 PA, ST HYOSCYAMINE SULFATE SR 2
HYDROCODONE ER 40 MG TABLET 4 PA, ST HYOSYNE 2
HYDROCODONE ER 60 MG TABLET 4 PA, ST IBANDRONATE SODIUM 150 MG TAB 2
HYDROCODONE ER 80 MG TABLET 4 PA, ST IBRANCE 5 PA, QL, LDD
HYDROCODONE-ACETAMINOPHEN 2 IBU 1
HYDROCODONE-CHLORPHENIRAMNE 2 IBUDONE 2
ER IBUPROFEN 100 MG/5 ML SUSP 2
HYDROCODONE-HOMATROPINE MBR 2 QL IBUPROFEN 400 MG TABLET 1
HYDROCODONE-IBUPROFEN 2 IBUPROFEN 600 MG TABLET 1
HYDROCORTISONE 1% CREAM 2 IBUPROFEN 800 MG TABLET 1
HYDROCORTISONE 1% OINTMENT 2 ICATIBANT 5 PA, LDD
HYDROCORTISONE 10 MG TABLET 2 ICLEVIA 1
HYDROCORTISONE 100 MG/60 ML 2 ICLUSIG 5 PA, QL, LDD
HYDROCORTISONE 2.5% CREAM 2 ICOSAPENT ETHYL 4 PA
HYDROCORTISONE 2.5% LOTION 2 ILARIS 5 PA, LDD
HYDROCORTISONE 2.5% OINTMENT 2 IMATINIB MESYLATE 100 MG TAB 4 PA, QL
HYDROCORTISONE 20 MG TABLET 2 IMATINIB MESYLATE 400 MG TAB 4 PA, QL
HYDROCORTISONE 5 MG TABLET 2 IMBRUVICA 5 PA, QL, LDD
HYDROCORTISONE AC 25 MG SUPP 2 IMIPRAMINE HCL 2
HYDROCORTISONE AC 30 MG SUPP 2 IMIPRAMINE PAMOATE 3
HYDROCORTISONE BUTY 0.1% 2 IMIQUIMOD 5% CREAM PACKET 2
CREAM
IMPAVIDO 4 PA
HYDROCORTISONE BUTYR 0.1% OINT 2
INCASSIA 1
HYDROCORTISONE BUTYR 0.1% SOLN 2
INCONTROL ALCOHOL PADS 3
HYDROCORTISONE VALERATE 2
INCRELEX 5 PA, LDD
HYDROCORTISONE-ACETIC ACID 2
INCRUSE ELLIPTA 3
HYDROMET 2 QL
INDAPAMIDE 1
HYDROMORPHONE 1 MG/ML 2
INDOMETHACIN 25 MG CAPSULE 2
SOLUTION
INDOMETHACIN 50 MG CAPSULE 2
HYDROMORPHONE 2 MG TABLET 2
INDOMETHACIN ER 2
HYDROMORPHONE 3 MG SUPPOS 2
INFANRIX DTAP 3
HYDROMORPHONE 4 MG TABLET 2
INLYTA 5 PA, LDD
HYDROMORPHONE 5 MG/5 ML SOLN 2
INSULIN ASPART 4 ST, QL
HYDROMORPHONE 8 MG TABLET 2
INSULIN ASPART FLEXPEN 4 ST, QL
HYDROMORPHONE ER 2 PA
INSULIN ASPART PENFILL 4 ST, QL
HYDROXYCHLOROQUINE 200 MG TAB 2
INSULIN ASPART PROT MIX 70-30 4 ST, QL
HYDROXYUREA 2
INTELENCE 3
HYDROXYZINE 10 MG/5 ML SOLN 2
INTRON A 5 PA
HYDROXYZINE 10 MG/5 ML SYRUP 2
INTROVALE 1
HYDROXYZINE HCL 10 MG TABLET 2
INVIRASE 4
HYDROXYZINE HCL 25 MG TABLET 2
IPOL 3
HYDROXYZINE HCL 50 MG TABLET 2
IPRATROPIUM BROMIDE 2
HYDROXYZINE PAMOATE 2
IPRATROPIUM-ALBUTEROL 2
HYOPHEN 2
IRBESARTAN 1
HYOSCYAMINE 0.125 MG ODT 2
IRBESARTAN- 1
HYOSCYAMINE 0.125 MG TAB SL 2 HYDROCHLOROTHIAZIDE
HYOSCYAMINE 0.125 MG/5 ML ELIX 2 IRESSA 5 PA, LDD
HYOSCYAMINE 0.125 MG/ML DROP 2 ISENTRESS 3
HYOSCYAMINE SULF 0.125 MG TAB 2
ISENTRESS HD 3
HYOSCYAMINE SULFATE ER 2
Go to Cigna.com/ifp-drug-list to see the full list of medications your plan covers.
192023 Cigna Plus North Carolina 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)
ISIBLOOM 1 KETOROLAC 0.4% OPHTH SOLUTION 2
ISONIAZID 100 MG TABLET 1 KETOROLAC 0.5% OPHTH SOLUTION 2
ISONIAZID 300 MG TABLET 1 KETOROLAC 10 MG TABLET 2 QL
ISONIAZID 50 MG/5 ML SOLUTION 2 KINERET 5 PA, ST, QL, LDD
ISOSORBIDE DINITRATE 10 MG TAB 2 KINRIX 3
ISOSORBIDE DINITRATE 20 MG TAB 2 KIONEX 2
ISOSORBIDE DINITRATE 30 MG TAB 2 KLOR-CON 2
ISOSORBIDE DINITRATE 5 MG TAB 2 KLOR-CON 10 2
ISOSORBIDE MONONIT ER 120 MG 2 KLOR-CON 8 2
ISOSORBIDE MONONIT ER 30 MG TB 1 KLOR-CON M10 2
ISOSORBIDE MONONIT ER 60 MG TB 1 KLOR-CON M15 4
ISOSORBIDE MONONITRATE 1 KLOR-CON M20 2
ISOTRETINOIN 4 KOMBIGLYZE XR 3 QL
ISOXSUPRINE HCL 2 K-PHOS NO.2 4
ISRADIPINE 2 K-PHOS ORIGINAL 4
ITRACONAZOLE 3 KURVELO 1
IV PREP WIPES 3 KYNMOBI 5 PA, QL
IVERMECTIN 0.5% LOTION 4 LABETALOL HCL 100 MG TABLET 2
IVERMECTIN 3 MG TABLET 2 PA LABETALOL HCL 200 MG TABLET 2
JAIMIESS 1 LABETALOL HCL 300 MG TABLET 2
JAKAFI 5 PA, QL, LDD LACRISERT 4
JANTOVEN 1 LACTATED RINGERS IRRIGATION 2
JANUMET 4 QL
LACTULOSE 10 GM/15 ML SOLUTION 2
JANUMET XR 4 QL
LACTULOSE 20 GM/30 ML SOLUTION 2
JASMIEL 1
LAMIVUDINE 2
JENCYCLA 1
JINTELI 2 LAMIVUDINE HBV 2
JOLESSA 1 LAMIVUDINE-ZIDOVUDINE 2
JUBLIA 4 PA, ST LAMOTRIGINE 2
JULEBER 1 LAMOTRIGINE (BLUE) 2
JULUCA 3 QL LAMOTRIGINE (GREEN) 2
JUNEL 1 LAMOTRIGINE (ORANGE) 2
JUNEL FE 1 LAMOTRIGINE ER 2
JUNEL FE 24 1 LAMOTRIGINE ODT 2
KAITLIB FE 1 LAMOTRIGINE ODT (BLUE) 2
KALETRA 100-25 MG TABLET 3 LAMOTRIGINE ODT (GREEN) 2
KALETRA 200-50 MG TABLET 3 LAMOTRIGINE ODT (ORANGE) 2
KALETRA 80 MG-20 MG/ML SOLN 4 LANSOPRAZOL-AMOXICIL- 2
CLARITHRO
KALLIGA 1
LANSOPRAZOLE DR 15 MG CAPSULE 2 QL
KARIVA 1
LANSOPRAZOLE DR 30 MG CAPSULE 2 QL
KELNOR 1-35 1 LANTHANUM CARBONATE 4
KELNOR 1-50 1 LAPATINIB 5 PA, QL
KETOCONAZOLE 2% CREAM 2 LARIN 1
KETOCONAZOLE 2% SHAMPOO 2 LARIN 24 FE 1
KETOCONAZOLE 200 MG TABLET 2 LARIN FE 1
KETOPROFEN 50 MG CAPSULE 2 LARISSIA 1
KETOPROFEN 75 MG CAPSULE 2 LASTACAFT 4
KETOPROFEN ER 200 MG CAPSULE 2 LATANOPROST 2
Go to Cigna.com/ifp-drug-list to see the full list of medications your plan covers.
202023 Cigna Plus North Carolina 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)
LATUDA 4 ST, QL LEVOTHYROXINE 137 MCG TABLET 1
LAYOLIS FE 4 LEVOTHYROXINE 150 MCG TABLET 1
LEDIPASVIR-SOFOSBUVIR 5 PA, QL LEVOTHYROXINE 175 MCG TABLET 1
LEENA 1 LEVOTHYROXINE 200 MCG TABLET 1
LEFLUNOMIDE 2 LEVOTHYROXINE 25 MCG TABLET 1
LENALIDOMIDE 5 PA, QL, LDD LEVOTHYROXINE 300 MCG TABLET 1
LENVIMA 5 PA, LDD LEVOTHYROXINE 50 MCG TABLET 1
LESSINA 1 LEVOTHYROXINE 75 MCG TABLET 1
LETROZOLE 2 LEVOTHYROXINE 88 MCG TABLET 1
LEUCOVORIN CALCIUM 10 MG TAB 2 LEVOXYL 1
LEUCOVORIN CALCIUM 15 MG TAB 2 LEVULAN 4 LDD
LEUCOVORIN CALCIUM 25 MG TAB 2 LEXIVA 50 MG/ML SUSPENSION 3
LEUCOVORIN CALCIUM 5 MG TAB 2 LEXIVA 700 MG TABLET 4
LEUKERAN 4 LIDOCAINE 2% VISCOUS SOLN 2
LEUKINE 5 LIDOCAINE 5% OINTMENT 2 QL
LEUPROLIDE 2WK 14 MG/2.8 ML KT 4 PA LIDOCAINE 5% PATCH 2
LEVALBUTEROL CONCENTRATE 2 LIDOCAINE HCL 2% JEL UROJET AC 2
LEVALBUTEROL HCL 2 LIDOCAINE HCL 2% JELLY 2
LEVALBUTEROL TAR HFA 45MCG INH 2 QL LIDOCAINE HCL 2% JELLY URO-JET 2
LEVEMIR 4 ST, QL LIDOCAINE HCL 4% SOLUTION 2
LEVEMIR FLEXTOUCH 4 ST, QL LIDOCAINE-PRILOCAINE 2
LEVETIRACETAM 1,000 MG TABLET 2 LILLOW 1
LEVETIRACETAM 100 MG/ML SOLN 2 LINDANE 2
LEVETIRACETAM 1000 MG/10 ML 2 LINEZOLID 100 MG/5 ML SUSP 4 PA
LEVETIRACETAM 250 MG TABLET 2 LINEZOLID 600 MG TABLET 2 PA
LEVETIRACETAM 500 MG TABLET 2 LINZESS 4
LEVETIRACETAM 500 MG/5 ML SOLN 2 LIOTHYRONINE SOD 25 MCG TAB 2
LEVETIRACETAM 750 MG TABLET 2 LIOTHYRONINE SOD 5 MCG TAB 2
LEVETIRACETAM ER 2 LIOTHYRONINE SOD 50 MCG TAB 2
LEVOBUNOLOL HCL 2 LISINOPRIL 1
LEVOCARNITINE 1 G/10 ML SOLN 2 LISINOPRIL-HYDROCHLOROTHIAZIDE 1
LEVOCARNITINE 330 MG TABLET 2 LITHIUM 2
LEVOCARNITINE SF 2 LITHIUM CARBONATE 1
LEVOCETIRIZINE 2.5 MG/5 ML SOL 2 LITHIUM CARBONATE ER 2
LEVOCETIRIZINE 5 MG TABLET 2 LITHOSTAT 4
LEVOFLOXACIN 0.5% EYE DROPS 2 LO LOESTRIN FE 3
LEVOFLOXACIN 25 MG/ML SOLUTION 2 LOJAIMIESS 1
LEVOFLOXACIN 250 MG TABLET 2 LOKELMA 4 PA
LEVOFLOXACIN 500 MG TABLET 2 LOPERAMIDE 2 MG CAPSULE 2
LEVOFLOXACIN 750 MG TABLET 2 LOPINAVIR-RITONAVIR 2
LEVONEST 1 LOPREEZA 2
LEVONORGESTREL-ETH ESTRADIOL 1 LORAZEPAM 0.5 MG TABLET 2
LEVONORG-ETH ESTRAD ETH ESTRAD 1 LORAZEPAM 1 MG TABLET 2
LEVORA-28 1 LORAZEPAM 2 MG TABLET 2
LEVORPHANOL TARTRATE 5 LORAZEPAM 2 MG/ML ORAL 2
LEVO-T 1 CONCENT
LEVOTHYROXINE 100 MCG TABLET 1 LORAZEPAM INTENSOL 2
LEVOTHYROXINE 112 MCG TABLET 1 LORCET 2
LEVOTHYROXINE 125 MCG TABLET 1 LORCET PLUS 2
Go to Cigna.com/ifp-drug-list to see the full list of medications your plan covers.
212023 Cigna Plus North Carolina 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)
LORTAB 2 MEPROBAMATE 2
LORYNA 1 MERCAPTOPURINE 2
LOSARTAN POTASSIUM 1 MERZEE 1
LOSARTAN-HYDROCHLOROTHIAZIDE 1 MESALAMINE 4
LOTEPREDNOL ETABONATE 3
MESALAMINE ER 3
LOVASTATIN 1
MESNEX 400 MG TABLET 5
LOW-OGESTREL 1
LOXAPINE 2 METAPROTERENOL SULFATE 2
LO-ZUMANDIMINE 1 METAXALL 4
LUBIPROSTONE 4 METAXALONE 4
LUCEMYRA 4 METFORMIN ER OSMOTIC 4
LUDENT FLUORIDE 2 METFORMIN HCL 1,000 MG TABLET 1
LULICONAZOLE 4 METFORMIN HCL 500 MG TABLET 1
LUTERA 1 METFORMIN HCL 850 MG TABLET 1
LYLLANA 2 QL METFORMIN HCL ER 2
LYZA 1 METHADONE 10 MG/5 ML SOLUTION 2 PA
MALATHION 2 METHADONE 10 MG/ML ORAL CONC 2 PA
MAPROTILINE HCL 2 METHADONE 5 MG/5 ML SOLUTION 2 PA
MARAVIROC 4 METHADONE HCL 10 MG TABLET 2 PA
MARLISSA 1 METHADONE HCL 5 MG TABLET 2 PA
MARPLAN 4 METHADONE INTENSOL 2 PA
MATZIM LA 2 METHAMPHETAMINE HCL 4 QL
MECLIZINE 12.5 MG TABLET 2 METHAZOLAMIDE 2
MECLIZINE 25 MG TABLET 2 METHENAMINE HIPPURATE 2
MECLOFENAMATE SODIUM 2 METHENAMINE MANDELATE 2
MEDROL 4 METHERGINE 4
MEDROXYPROGESTERONE ACETATE 1 METHIMAZOLE 2
MEFENAMIC ACID 2 METHITEST 5
METHOCARBAMOL 500 MG TABLET 2
MEFLOQUINE HCL 250 MG TABLET 2 QL
METHOCARBAMOL 750 MG TABLET 2
MEGESTROL 20 MG TABLET 2
METHOTREXATE 2.5 MG TABLET 2
MEGESTROL 40 MG TABLET 2
METHOXSALEN 4
MEGESTROL 625 MG/5 ML SUSP 4 METHSCOPOLAMINE BROMIDE 2
MEGESTROL ACET 40 MG/ML SUSP 2 METHYLDOPA 2
MEGESTROL ACET 400 MG/10 ML 2 METHYLDOPA- 2
MEKINIST 5 PA, QL HYDROCHLOROTHIAZIDE
MELODETTA 24 FE 1 METHYLERGONOVINE MALEATE 4
MELOXICAM 15 MG TABLET 1 METHYLPHENIDATE 10 MG CHEW 2 QL
MELOXICAM 7.5 MG TABLET 1 TAB
MELPHALAN 2 METHYLPHENIDATE 10 MG TABLET 2 QL
MEMANTINE HCL 2 METHYLPHENIDATE 10 MG/5 ML SOL 2 QL
MENACTRA 3 METHYLPHENIDATE 2.5 MG CHEW TB 2 QL
MENEST 4 METHYLPHENIDATE 20 MG TABLET 2 QL
MENQUADFI 3 METHYLPHENIDATE 5 MG CHEW TAB 2 QL
MENTAX 4 METHYLPHENIDATE 5 MG TABLET 2 QL
MENVEO A-C-Y-W-135-DIP 3 METHYLPHENIDATE 5 MG/5 ML SOLN 2 QL
MEPERIDINE 100 MG TABLET 2 METHYLPHENIDATE ER (LA) 2 QL
MEPERIDINE 50 MG TABLET 2 METHYLPHENIDATE ER 10 MG TAB 2 QL
MEPERIDINE 50 MG/5 ML SOLUTION 2 METHYLPHENIDATE ER 18 MG TAB 2 QL
METHYLPHENIDATE ER 20 MG TAB 2 QL
Go to Cigna.com/ifp-drug-list to see the full list of medications your plan covers.
222023 Cigna Plus North Carolina 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)
METHYLPHENIDATE ER 27 MG TAB 2 QL MIRCERA 4 PA
METHYLPHENIDATE ER 36 MG TAB 2 QL MIRTAZAPINE 2
METHYLPHENIDATE ER 54 MG TAB 2 QL MISOPROSTOL 2
METHYLPHENIDATE HCL CD 2 QL M-M-R II VACCINE 3
METHYLPHENIDATE HCL ER (CD) 2 QL M-NATAL PLUS 1
METHYLPHENIDATE LA 2 QL MODAFINIL 100 MG TABLET 4 PA
METHYLPREDNISOLONE 2 MODAFINIL 200 MG TABLET 4 PA
METHYLTESTOSTERONE 5 MODERNA COVID-19 VACCINE (EUA) 3
METOCLOPRAMIDE 10 MG TABLET 1 MOEXIPRIL HCL 2
METOCLOPRAMIDE 10 MG/10 ML SOL 2 MOLINDONE HCL 2
METOCLOPRAMIDE 5 MG TABLET 1 MOMETASONE FUROATE 0.1% CREAM 2
METOCLOPRAMIDE 5 MG/5 ML SOLN 2 MOMETASONE FUROATE 0.1% OINT 2
METOLAZONE 2 MOMETASONE FUROATE 0.1% SOLN 2
METOPROLOL SUCCINATE 2 MOMETASONE FUROATE 50 MCG 2 QL
METOPROLOL TARTRATE 100 MG TAB 1 SPRY
METOPROLOL TARTRATE 25 MG TAB 1 MONDOXYNE NL 100 MG CAPSULE 1
METOPROLOL TARTRATE 37.5 MG TB 2 MONDOXYNE NL 75 MG CAPSULE 2
METOPROLOL TARTRATE 50 MG TAB 1 MONO-LINYAH 1
METOPROLOL TARTRATE 75 MG TAB 2 MONTELUKAST SODIUM 2
METOPROLOL- 2 MORGIDOX 100 MG CAPSULE 1
HYDROCHLOROTHIAZIDE MORGIDOX 50 MG CAPSULE 1
METRONIDAZOLE 0.75% CREAM 2 MORPHINE SULF 10 MG SUPPOS 2
METRONIDAZOLE 0.75% LOTION 2 MORPHINE SULF 10 MG/5 ML SOLN 2
METRONIDAZOLE 250 MG TABLET 2 MORPHINE SULF 100 MG/5 ML CONC 2
METRONIDAZOLE 375 MG CAPSULE 2 MORPHINE SULF 20 MG SUPPOS 2
METRONIDAZOLE 500 MG TABLET 2 MORPHINE SULF 20 MG/5 ML SOLN 2
METRONIDAZOLE TOP 1% GEL PUMP 2 MORPHINE SULF 30 MG SUPPOS 2
METRONIDAZOLE TOPICAL 0.75% GL 2 MORPHINE SULF 5 MG SUPPOS 2
METRONIDAZOLE TOPICAL 1% GEL 2 MORPHINE SULF ER 100 MG TABLET 2 PA
METRONIDAZOLE VAGINAL 0.75% GL 2 MORPHINE SULF ER 15 MG TABLET 2 PA
METYROSINE 4 MORPHINE SULF ER 200 MG TABLET 2 PA
MEXILETINE HCL 2 MORPHINE SULF ER 30 MG TABLET 2 PA
MIBELAS 24 FE 1 MORPHINE SULF ER 60 MG TABLET 2 PA
MICONAZOLE 3 200 MG VAG SUPP 2 MORPHINE SULFATE ER 10 MG CAP 2 PA
MICROGESTIN 1 MORPHINE SULFATE ER 100 MG CAP 2 PA
MICROGESTIN 24 FE 1 MORPHINE SULFATE ER 120 MG CAP 2 PA
MICROGESTIN FE 1 MORPHINE SULFATE ER 20 MG CAP 2 PA
MIDAZOLAM HCL 10 MG/5 ML SYRUP 2 MORPHINE SULFATE ER 30 MG CAP 2 PA
MIDAZOLAM HCL 2 MG/ML SYRUP 2 MORPHINE SULFATE ER 40 MG CAP 2 PA
MIDAZOLAM HCL 5 MG/2.5 ML SYRP 2 MORPHINE SULFATE ER 45 MG CAP 2 PA
MIDODRINE HCL 2 MORPHINE SULFATE ER 50 MG CAP 2 PA
MIGERGOT 4 MORPHINE SULFATE ER 60 MG CAP 2 PA
MIGLITOL 2 MORPHINE SULFATE ER 75 MG CAP 2 PA
MIGLUSTAT 5 PA MORPHINE SULFATE ER 80 MG CAP 2 PA
MILI 1
MORPHINE SULFATE ER 90 MG CAP 2 PA
MIMVEY 2
MORPHINE SULFATE IR 15 MG TAB 2
MIMVEY LO 2
MORPHINE SULFATE IR 30 MG TAB 2
MINITRAN 2
MOXIFLOXACIN 0.5% EYE DROPS 2
MINOCYCLINE HCL 1
MOXIFLOXACIN HCL 2
MINOXIDIL 2
Go to Cigna.com/ifp-drug-list to see the full list of medications your plan covers.
232023 Cigna Plus North Carolina 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)
MULTI-VITAMIN W-FLUORIDE-IRON 2 NATPARA 5 PA, LDD
MULTIVITAMIN-IRON-FLUORIDE 2 NATURE-THROID 1
MULTIVIT-FLUOR 0.25 MG TAB CHW 2 NAYZILAM 5 PA, QL
MULTIVIT-FLUOR 0.25 MG/ML DROP 2 NEBUSAL 3% VIAL 2
MULTIVIT-FLUOR 0.5 MG TAB CHEW 2 NECON 1
MULTIVIT-FLUOR 0.5 MG/ML DROP 2 NEFAZODONE HCL 2
MULTIVIT-FLUORIDE 1 MG TAB CHW 2 NEOMYCIN SULFATE 2
MUPIROCIN 2% CREAM 2 NEOMYCIN-BACITRACIN-POLY-HC 2
MUPIROCIN 2% OINTMENT 2 NEOMYCIN-BACITRACIN-POLYMYXIN 2
MVW COMPLETE FORMLTN 2 NEOMYCIN-POLYMYXIN B 2
PEDIATRIC NEOMYCIN-POLYMYXIN-GRAMICIDIN 2
MVW COMPLETE FORMLTN 2 NEOMYCIN-POLYMYXIN-HC 2
PROBIOTIC NEOMYCIN-POLYMYXIN-HYDROCORT 2
MVW COMPLETE FORMULATION 2 NEOMYC-POLYM-DEXAMET EYE 2
D3000 OINTM
MVW COMPLETE FORMULATION 2 NEOMYC-POLYM-DEXAMETH EYE 2
D5000 DROP
MVW COMPLETE FORMULTN 2 NEO-POLYCIN 2
MULTIVIT NEO-POLYCIN HC 2
MYCOPHENOLATE 200 MG/ML SUSP 2 NEO-SYNALAR 4
MYCOPHENOLATE 250 MG CAPSULE 2 NEUAC GEL 2
MYCOPHENOLATE 500 MG TABLET 2 NEULASTA 5 PA
MYCOPHENOLIC ACID 2 NEULASTA ONPRO 5 PA
MYLERAN 4 NEUPRO 4
MYNATAL 1 NEVIRAPINE 2
MYNATAL PLUS 1 NEVIRAPINE ER 2
MYNATAL-Z 1 NEWGEN 1
MYORISAN 4 NEXAVAR 5 PA, QL, LDD
MYRBETRIQ ER 25 MG TABLET 4 ST, QL NIACIN ER 2
MYRBETRIQ ER 50 MG TABLET 4 ST, QL NICARDIPINE 20 MG CAPSULE 2
MYTESI 4 LDD NICARDIPINE 30 MG CAPSULE 2
NABUMETONE 2 NICOTROL 4
NADOLOL 2 NICOTROL NS 4
NAFTIFINE HCL 2 NIFEDIPINE 2
NALOXONE 0.4 MG/ML CARPUJECT 2 NIFEDIPINE ER 2
NALOXONE 2 MG/2 ML SYRINGE 2 NIKKI 1
NALOXONE HCL 4 MG NASAL SPRAY 2 QL NILUTAMIDE 5
NALTREXONE 50 MG TABLET 2 QL NIMODIPINE 4
NAPROXEN 250 MG TABLET 1 NINLARO 5 PA, QL, LDD
NAPROXEN 375 MG TABLET 1 NISOLDIPINE 2 QL
NAPROXEN 500 MG KIT 1 NITAZOXANIDE 4 PA
NAPROXEN 500 MG TABLET 1 NITRO-BID 2
NAPROXEN SOD CR 375 MG TABLET 2 NITRO-DUR 4
NAPROXEN SOD ER 375 MG TABLET 2
NITROFURANTOIN 25 MG/5 ML SUSP 4
NAPROXEN SODIUM 275 MG TAB 2
NITROFURANTOIN MCR 100 MG CAP 1
NAPROXEN SODIUM 550 MG TAB 2
NITROFURANTOIN MCR 25 MG CAP 2
NARATRIPTAN HCL 2 QL
NITROFURANTOIN MCR 50 MG CAP 1
NATACYN 4
NITROFURANTOIN MONO-MCR 100 1
NATAZIA 4 MG
NATEGLINIDE 2
Go to Cigna.com/ifp-drug-list to see the full list of medications your plan covers.
242023 Cigna Plus North Carolina 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)
NITROGLYCERIN 0.3 MG TABLET SL 2 NUEDEXTA 4 PA
NITROGLYCERIN 0.4 MG TABLET SL 2 NULEV 2
NITROGLYCERIN 0.6 MG TABLET SL 2 NYAMYC 2
NITROGLYCERIN 400 MCG SPRAY 2 NYLIA 1
NITROGLYCERIN ER 2.5 MG CAP 2 NYMYO 1
NITROGLYCERIN ER 6.5 MG CAP 2 NYSTATIN 2
NITROGLYCERIN ER 9 MG CAPSULE 2 NYSTATIN-TRIAMCINOLONE 2
NITROGLYCERIN PATCH 2 NYSTOP 2
NITRO-TIME 2 NYVEPRIA 5 PA
NIVA-PLUS 1 OBSTETRIX DHA 1
NIVESTYM 5 OBSTETRIX ONE 1
NIZATIDINE 2 O-CAL FA 4
NOLIX 4 OCELLA 1
NORA-BE 1 OCTREOTIDE 1,000 MCG/5 ML VIAL 2 PA
NORDITROPIN FLEXPRO 5 PA OCTREOTIDE 1,000 MCG/ML VIAL 2 PA
NORETHIND-ETH ESTRAD 0.5-2.5 2 OCTREOTIDE 5,000 MCG/5 ML VIAL 2 PA
NORETHIND-ETH ESTRAD 1-0.02 MG 1 OCTREOTIDE ACET 0.05 MG/ML VL 2 PA
NORETHINDRONE 1 OCTREOTIDE ACET 100 MCG/ML AMP 2 PA
OCTREOTIDE ACET 100 MCG/ML SYR 2 PA
NORETHINDRONE ACETATE 2
NORETHINDRONE-E.ESTRADIOL-IRON 1 OCTREOTIDE ACET 100 MCG/ML VL 2 PA
NORETHIN-EE 1.5-0.03 MG(21) TB 1 OCTREOTIDE ACET 200 MCG/ML VL 2 PA
OCTREOTIDE ACET 50 MCG/ML AMP 2 PA
NORETHIN-ETH ESTRAD 1 MG-5 MCG 2
OCTREOTIDE ACET 50 MCG/ML SYR 2 PA
NORETHIN-ETH ESTRA-FERROUS 1
FUM OCTREOTIDE ACET 50 MCG/ML VIAL 2 PA
NORGESTIMATE-ETHINYL ESTRADIOL 1 OCTREOTIDE ACET 500 MCG/ML AMP 2 PA
NORLYDA 1 OCTREOTIDE ACET 500 MCG/ML SYR 2 PA
NORPACE CR 4 OCTREOTIDE ACET 500 MCG/ML VL 2 PA
NORTREL 1 ODACTRA 4 PA, QL
NORTRIPTYLINE 10 MG/5 ML SOLN 2 ODEFSEY 3 QL
NORTRIPTYLINE HCL 10 MG CAP 1 ODOMZO 5 PA, LDD
OFEV 5 PA, LDD
NORTRIPTYLINE HCL 25 MG CAP 1
OFLOXACIN 2
NORTRIPTYLINE HCL 50 MG CAP 1
OKEBO 2
NORTRIPTYLINE HCL 75 MG CAP 1 OLANZAPINE 10 MG TABLET 2
NORVIR 100 MG POWDER PACKET 3 OLANZAPINE 15 MG TABLET 2
NORVIR 100 MG TABLET 4 OLANZAPINE 2.5 MG TABLET 2
NORVIR 80 MG/ML SOLUTION 3
OLANZAPINE 20 MG TABLET 2
NOVOFINE 32G NEEDLES 3
OLANZAPINE 5 MG TABLET 2
NOVOFINE AUTOCOVER 30G NEEDLE 3
OLANZAPINE 7.5 MG TABLET 2
NOVOFINE PLUS PEN NDL 32GX1/6" 3
OLANZAPINE ODT 2
NOVOLOG 100 UNIT/ML FLEXPEN 4 ST, QL
OLANZAPINE-FLUOXETINE HCL 2
NOVOLOG 100 UNIT/ML VIAL 4 ST, QL
OLMESARTAN MEDOXOMIL 2
NOVOLOG MIX 70-30 FLEXPEN 4 ST, QL
OLMESARTAN-AMLODIPINE-HCTZ 2
NOVOLOG MIX 70-30 VIAL 4 ST, QL
OLMESARTAN- 2
NOVOLOG PENFILL 4 ST, QL HYDROCHLOROTHIAZIDE
NOVOTWIST NEEDLE 32G 5MM 3 OLOPATADINE 665 MCG NASAL SPRY 2
NOXAFIL 4 OLOPATADINE HCL 0.1% EYE DROPS 2
NP THYROID 1 OLOPATADINE HCL 0.2% EYE DROP 2
NUCYNTA 4 OMEGA-3 ACID ETHYL ESTERS 2
NUCYNTA ER 4 PA, ST
Go to Cigna.com/ifp-drug-list to see the full list of medications your plan covers.
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