CHANGES TO YOUR DRUG LIST

More generics and lower-cost brands to help you stay healthy and save money

At Cigna, it’s our goal to offer you access to coverage for safe, effective and affordable medications. To do this, we regularly review and update our drug list. Starting July 1, 2017,* some of the medications on the Standard Prescription Drug List will change coverage (or cost) levels. These changes affect how much you pay for your medications. Medications where you may pay more Starting July 1, 2017, the medications listed below will be “non-preferred” on your plan’s drug list. “Non-preferred” means this medication may cost you more than similar medications. If you fill a prescription for any of these medications on or after this date, you may pay more at the pharmacy. We’ve also listed some lower-cost generic and/or preferred brand alternatives to talk about with your doctor.

GENERIC AND/OR PREFERRED DRUG CLASS NON-PREFERRED BRAND MEDICATION BRAND ALTERNATIVES INFECTIONS Daklinza+ Epclusa+, Harvoni+, Sovaldi+ + This is a specialty medication. Specialty medications are used to treat complex or chronic conditions like multiple sclerosis, hepatitis C and rheumatoid arthritis. Some plans cover specialty medications on a specialty tier. For plans with a specialty tier, this change will not affect the cost of your medication. To find out how your plan covers these medications, please check your enrollment materials or log into myCigna.com. Medications not covered on your drug list^ Starting July 1, 2017, the medications listed below will not be covered on your plan’s drug list.^ If you fill a prescription for any of these medications on or after this date, you’ll have to pay the full cost of the medication. We’ve also listed some lower-cost generic and/or preferred brand alternatives to talk about with your doctor.

GENERIC AND/OR PREFERRED DRUG CLASS BRAND MEDICATION NOT COVERED^ BRAND ALTERNATIVES BLOOD PRESSURE/HEART MEDICATIONS Cardizem diltiazem Isordil Titradose isosorbide dinitrate Lanoxin digitek, digox, digoxin CHOLESTEROL MEDICATIONS Antara, Fenoglide fenofibrate COUGH/COLD MEDICATIONS Tussicaps hydrocodone-chlorpheniramne ER, promethazine-codeine DIURETICS Edecrin, ethacrynic acid bumetanide, furosemide, torsemide GASTROINTESTINAL/HEARTBURN Anusol-HC suppository anucort-HC, hemmorex-HC, hydrocortisone, procto-med HC, proctosol-HC, proctozone-HC Omeclamox-pak, Prevpac, Pylera lansoprazole-amoxicillin-clarithromycin (combo pak)

891538 a Standard 04/17 GENERIC AND/OR PREFERRED DRUG CLASS BRAND MEDICATION NOT COVERED^ BRAND ALTERNATIVES HORMONAL AGENTS Dexpak dexamethasone INFECTIONS Onmel itraconazole, terbinafine PAIN RELIEF AND INFLAMMATORY DISEASE Conzip tramadol, tramadol ER levorphanol acetaminophen-codeine, hydrocodone- acetaminophen, hydromorphone ER, hydromorphone, lorcet, lorcet HD, lorcet plus, oxycodone, oxycodone ER, tramadol, verdrocet, Vicodin, Vicodin ES, Vicodin HP Naprelan, naproxen CR, naproxen ER, Zipsor diclofenac, diclofenac ER, etodolac, etodolac ER, fenoprofen, flurbiprofen, ibuprofen, indomethacin, ketoprofen, ketorolac, meclofenamate, mefenamic acid, meloxicam, nabumetone, naproxen Zomig ZMT zolmitriptan ODT SKIN CONDITIONS Aldara imiquimod Anusol-HC cream anucort-HC, hemmorex-HC, hydrocortisone, hydrocortisone acetate, procto-med HC, proctosol-HC, proctozone-HC Clobex clobetasol, clodan shampoo Ertaczo, Extina, Vusion ketoconazole Halog clobetasol propionate, halobetasol propionate Locoid lipocream hydrocortisone butyrate Loprox ciclodan, ciclopirox Oxistat Clotrimazole, econazole nitrate, ketoconazole, oxiconazole nitrate Penlac Ciclodan, ciclopirox Plexion sulfacetamide-sulfur, SS 10-2, Zencia Prudoxin, Zonalon doxepin Salex salicylic acid trianex triamcinolone, triderm Ultravate Ala-cort, alclometasone dipropionate, aminonide, apexicon, betamethasone dipropinate, betamethasone valerate, clobetasol emollient, clobetaslon emulsion, clobetasol propionate, clocortonlone pivalate, clodan, cormax, desonide, desoximetasone, diflorasone diacetate, fluocinolene acetonide, fluocinonide, fluocinonide-E, flurandrenolide, fluticasone propionate, halobetasol propionate, hydrocortisone, hydrocortisone butyrate, hydrocortisone valerate, micort-HC, mometasone furoate, prednicarbate, psorcon, scalacort, tacrolimus, triamcinolone acetonide, trianex, triderm GENERIC AND/OR PREFERRED DRUG CLASS BRAND MEDICATION NOT COVERED^ BRAND ALTERNATIVES SKIN CONDITIONS (cont) Ultravate X clobetasol propionate, halobetasol propionate Verdeso desonide SLEEP DISORDERS/SEDATIVES Ambien zolpidem Ambien CR zolpidem ER ^ These medications aren’t covered on your drug list. Your prescription drug plan requires approval from Cigna for these medications to be covered. If your doctor feels that an alternative medication isn’t right for you, he or she can ask Cigna to consider approving coverage of your medication.

Medications that need approval for coverage Starting July 1, 2017, the medications listed below will require approval from Cigna before they’re covered under your plan.

MEDICATION REQUIRING PRIOR DRUG CLASS ADDITIONAL INFORMATION AUTHORIZATION MISCELLANEOUS Syprine PAIN RELIEF AND INFLAMMATORY DISEASE acetaminophen-codeine, ascomp with codeine, aspirin-caffeine-dihydrocodeine, belladonna-opium, butalbital-acetaminophen caffeine-codeine, butalbital- caffeine-acetaminophen codeine, butalbital compound- codeine, butorphanol, carisoprodol compound-codeine, carisoprodol-aspirin-codeine, codeine, Demerol, dihydrocodeine-acetaminophen-caffeine, Dilaudid, Duragesic, Embeda, Endocet, Exalgo, fentanyl patch, Fioricet with Codeine, Hycet, hydrocodone- acetaminophen, hydrocodone ibuprofen, hydromorphone, Ask your doctor to call us. Your plan will only hydromorphone ER, Hysingla ER, Ibudone, Kadian ER, cover this medication if your doctor requests levorphanol tartrate, Lorcet, Lorcet HD, Lorcet Plus, Lortab, and receives approval from Cigna. meperidine, morphine sulfate, morphine sulfate ER, MS Contin, norco, Nucynta, Nucynta ER, Opana, Opana ER, Oxaydo, oxycodone acetaminophen, oxycodone- aspirin, oxycodone-ibuprofen, oxycodone, oxycodone ER, oxymorphone ER, oxymorphone, Oxycontin, pentazocine- naloxone, Percocet, Primlev, Reprexain, Roxicodone, Synalgos-DC, trezix, Tylenol-codeine, Verdrocet, Vicodin, Vicodin ES, Vicodin HP, Xartemis XR, Xodol, Xtampza ER, Xylon 10, Zamicet, Zohydro ER Cuprimine, Depen Titratab

DRUG CLASS MEDICATION WITH QUANTITY LIMITS ADDITIONAL INFORMATION

COUGH/COLD MEDICATIONS Flowtuss, hycofenix, Hydrocod-cpm-pseudoephedrine, Hydrocodone BT-homatropine, Hydrocodone- Your plan only covers a certain amount of chlorpheniramne ER, Hydrocodone-homatropine, hydromet, this medication. If your doctor writes a obredon, Promethazine VC-codeine, Promethazine-codeine, prescription for an amount more than what’s Promethazine-phenyleph-codeine, Rezira, Tussicaps, allowed, it will only be covered in that amount Tussigon, Tussionex, Tuzistra XR, Vituz, Zutripro if your doctor requests and receives approval GASTROINTESTINAL/HEARTBURN Opium Tincture from Cigna. MISCELLANEOUS Evzio, Naltrexone DRUG CLASS MEDICATION WITH QUANTITY LIMITS ADDITIONAL INFORMATION

PAIN RELIEF AND INFLAMMATORY DISEASE Abstral, acetaminophen-codeine, actiq, alfentanil, ascomp with codeine, aspirin-caffeine-dihydocodeine, belladonna- opium, butalbital-acetaminophen-caffeine-codeine, butalbital-caffeine-acetaminophen-codeine, butalbital compound-codeine, butalbital-acetaminophen-caffeine, butalbital-aspirin-caffeine, butorphanol, capacet, carisoprodol compound-codeine, carisoprodol-aspirin- codeine, codeine, Demerol, dihydrocodeine-acetaminophen- caffeine, Dilaudid, duramorph, Endocet, esgic, fentanyl Your plan only covers a certain amount of patch, fentanyl-bupivacacaine, fentora, fioricet, fioricet with this medication. If your doctor writes a codeine, fiorinal, finorinal with codeine, hycet, hydrocodone- prescription for an amount more than what’s acetaminophen, hydrocodone-ibuprofen, hydromorphone, allowed, it will only be covered in that amount Ibudone, infumorph, ionsys, lazanda, levorphanol, Lorcet, if your doctor requests and receives approval Lorcet HD, Lorcet Plus, Lortab, meperidine, morphine, from Cigna. nalbuphine, norco, Nucynta, Nucynta ER, Opana, Oxaydo, oxycodone, oxycodone-aspirin, oxycodone-ibuprofen, oxycodone-acetaminophen, oxymorphone, pentazocine- naloxone, Percocet, Primlev, Reprexain, Roxicodone, subsys, sufentanil, Synalgos- DC, talwin, trezix, Tylenol-codeine, ultiva, Verdrocet, Vicodin, Vicodin ES, Vicodin HP, Xodol 10- 300, xodol 5-300, xodol 7.5-300, Xylon 10, zamicet, zebutal Fentora

Narcotic pain medications (opioids) As opioid-related deaths continue to increase in the U.S.,** we want to make sure you’re using these medications safely and effectively. Because of this, we’re making changes to the coverage of opioids (narcotic pain medications). Depending on your plan, if you fill a prescription for an opioid for the first time, it may need approval for coverage and/or you may be limited in the amount of medication you can fill at one time.

What you should do next › Talk with your doctor. Switching to a generic or preferred brand alternative may help save you money. You should ask your doctor if one of these medications may be right for you. › Review your coverage on myCigna.com. Starting July 1, 2017, log into myCigna.com to view your plan’s drug list and/or use the Drug Cost tool to see how these changes may affect the cost of your medication.

If you have questions We know how important your pharmacy benefits are and we’re here to help. Please call us at the toll-free number on the back of your Cigna ID card. * In accordance with Texas and Louisiana state law, customers with affected benefit plans who receive coverage for medications that are removed from the prescription drug list during the plan year will continue to have those medications covered at the same benefit level until their plan renewal date. To find out if these state mandates apply to your plan, please call Customer Service. ** American Society of Addiction Medicine, “Opioid Addiction: 2016 Facts & Figures,” 2016.

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