Prescription Drug List Changes

PRESCRIPTION DRUG LIST CHANGES

For Providers 2021

Changes are being made to Cigna’s Prescription Drug List (formulary) that may affect some of your patients. These changes are listed by formulary name and by effective date. Below is the list of medications that are changing coverage levels. Please note that the coverage status of medications under our Prescription Drug Lists are always subject to the cost-share requirements, exclusions and coverage limitations of particular benefit plans. Drug lists used by patients who have coverage through their employer STANDARD FORMULARY Start date of Drug class Medications moving to preferred brand change*,** June 22, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Reditrex May 15, 2021 EYE CONDITIONS Eysuvis GASTROINTESTINAL/HEARTBURN Sutab January 1, 2021 AIDS/HIV Juluca ASTHMA/COPD/RESPIRATORY Bevespi DIABETES Baqsimi GASTROINTESTINAL/HEARTBURN Pancreaze INFECTIONS Epclusa, Harvoni PAIN RELIEF AND INFLAMMATORY DISEASE Taltz Start date of Medications becoming Generic and/or preferred Drug class change*,** non-preferred brand brand alternatives June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1 Lupron Depot June 22, 2021 CANCER Orgovyx1 No preferred formulary drug alternatives. June 15, 2021 GASTROINTESTINAL/HEARTBURN Lubiprostone 8 mcg, 24 mcg capsule Amitiza June 1, 2021 SKIN CONDITIONS Winlevi 1% cream Generic products (e.g. adapalene; tretinoin; clindamycin-benzoyl peroxide) Wynzora 0.005%-0.064% cream betamethasone DP, fluocinolone, fluticasone, mometasone, trimacinolone, calcipotriene, calcipotriene-betamethasone DP Generic medications start with a lowercase letter and brand name medications start with a capital letter.

951714 UPDATED_05/21/2021 STANDARD FORMULARY (cont)

Start date of Medications becoming Generic and/or preferred Drug class change*,** non-preferred brand brand alternatives June 1, 2021 URINARY TRACT CONDITIONS Vesicare LS 5 mg/5 mL suspension oxybutynin chloride, oxybutynin chloride ER, darifenacin ER, solifenacin, tolterodine, tolterodine ER, tropsium May 15, 2021 EYE CONDITIONS Lacrisert Restasis, Restasis Multi-dose, Xiidra May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo tramadol May 1, 2021 SKIN PREPS Impeklo topical betamethasone dipropionate (augmented) 0.05%, clobetasol propionate 0.05%, halobetasol propionate 0.05%, fluocinolide 0.1% April 18, 2021 HORMONAL AGENTS Alkindi Sprinkle hydrocortisone 5mg tablet March 28, 2021 BLOOD PRESSURE/HEART MEDICATIONS Conjupri amlodipine, felodipine, nifedipine, nicardipine January 1, 2021 AIDS/HIV Intelence1 Talk to your doctor about other alternatives BLOOD MODIFIERS/BLEEDING DISORDERS Amicar 0.25 g/ml oral solution1 aminocaproic acid 0.25g/ml oral solution BLOOD PRESSURE/HEART MEDICATIONS Multaq, Norpace CR 150mg Talk to your doctor about other alternatives CANCER Tabloid Talk to your doctor about other alternatives ERECTILE DYSFUNCTION Caverject Impulse Syringe MUSE EYE CONDITIONS Lotemax 0.5% drops loteprednol 0.5% drops HORMONAL AGENTS Armour Thyroid, Synthroid, Unithroid levothyroxine INFECTIONS Kitabis Pak1 tobramycin pak 300mg/5ml SEIZURE DISORDERS Lyrica 20mg/ml oral solution pregabalin 20mg/ml oral solution SUBSTANCE ABUSE Bunavail buprenorphine/naloxone film or sublingual tablet, Zubsolv WEIGHT MANAGEMENT Megace ES 625mg/5ml oral suspension megestrol 625ml/5ml oral suspension Start date of Drug class Medications that will need approval (prior authorization)^ change*,** June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1 June 22, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Reditrex June 1, 2021 ASTHMA/COPD/RESPIRATORY Zokinvy March 14, 2021 CANCER Gavreto January 1, 2021 BLOOD THINNERS/ANTI-CLOTTING Eliquis4, Pradaxa4, Savaysa4, Xarelto4 PAIN RELIEF AND INFLAMMATORY DISEASE diclofenac 1.3% patch, Flector 1.3% patch5, Voltaren 1% gel5 Start date of Drug class Medications that will have a quantity limit change*,** June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1 June 1, 2021 ASTHMA/COPD/RESPIRATORY Zokinvy May 15, 2021 EYE CONDITIONS Eysuvis May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo

Generic medications start with a lowercase letter and brand name medications start with a capital letter. STANDARD FORMULARY (cont)

Start date of Drug class Medications that will have a quantity limit change*,** March 14, 2021 CANCER Gavreto Start date of Medications that will no longer Generic and/or preferred Drug class change*,** be covered^^ brand alternatives June 29, 2021 SKIN CONDITIONS Klisyri topical fluorouracil, imiquimod 5% cream June 22, 2021 GASTROINTESTINAL/HEARTBURN Reltone ursodiol HORMONAL AGENTS Thyquidity levothyroxine, levoxyl, Levo-T, Unithroid, Euthyrox June 15, 2021 GASTROINTESTINAL/HEARTBURN Lubiprostone 8 mcg, 24 mcg capsule Amitiza June 1, 2021 SKIN CONDITIONS Winlevi 1% cream Generic products (e.g. adapalene; tretinoin; clindamycin-benzoyl peroxide) June 1, 2021 SKIN CONDITIONS (cont) Wynzora 0.005%-0.064% cream betamethasone DP, fluocinolone, fluticasone, mometasone, trimacinolone, calcipotriene, calcipotriene-betamethasone DP URINARY TRACT CONDITIONS Vesicare LS 5 mg/5 mL suspension oxybutynin chloride, oxybutynin chloride ER, darifenacin ER, solifenacin, tolterodine, tolterodine ER, tropsium May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo tramadol May 1, 2021 SKIN PREPS Impeklo topical betamethasone dipropionate (augmented) 0.05%, clobetasol propionate 0.05%, halobetasol propionate 0.05%, fluocinolide 0.1% April 18, 2021 HORMONAL AGENTS Alkindi Sprinkle hydrocortisone 5mg tablet March 28, 2021 BLOOD PRESSURE/HEART MEDICATIONS Conjupri amlodipine, felodipine, nifedipine, nicardipine January 1, 2021 ASTHMA/COPD/RESPIRATORY ProAir HFA7, ProAir RespiClick7, albuterol HFA Ventolin HFA7 DIABETES Kombiglyze XR8, Onglyza8 metformin, Janumet, Janumet XR, Januvia EYE CONDITIONS Lumigan7, Travatan Z, Xalatan, Xelpros, bimatoprost, latanoprost, travoprost Zioptan9 GASTROINTESTINAL/HEARTBURN Creon7, Pertzye, Zenpep7 Pancreaze Motegrity, Trulance7, Zelnorm Amitiza, Linzess Sensipar cinacalcet HORMONAL AGENTS TaperDex dexamethasone 1.5mg tablet INFECTIONS Baraclude entecavir tablet Noxafil tablet posaconazole DR 100mg tablet MULTIPLE SCLEROSIS Ampyra ER7 dalfampridine ER NUTRITIONAL/DIETARY PreGenna, Trinaz Any generic prenatal vitamin PAIN RELIEF AND INFLAMMATORY DISEASE Amerge generic triptans (e.g. naratriptan; sumatriptan) Generic medications start with a lowercase letter and brand name medications start with a capital letter. STANDARD FORMULARY (cont)

Start date of Medications that will no longer Generic and/or preferred Drug class change*,** be covered^^ brand alternatives January 1, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE butalbital-acetaminophen 50-300mg tablet butalbutal-acetaminophen 50-325mg tablet Cosentyx10 Enbrel, Humira, Otezla, Skyrizi, Stelara, Taltz Frova, Maxalt, Maxalt MLT, Relpax generic triptans (e.g. naratriptan; sumatriptan) SEIZURE DISORDERS Felbatol11 felbamate Keppra/Keppra XR11 levetiracetam/levetiracetam ER Lamictal XR Start Kit11 lamotrigine ER Lamictal/ODT/XR11 lamotrigine, lamotrigine ER, lamotrigine ODT Qudexy XR11, Trokendi XR11 topiramate ER Sabril11 vigabatrin, vigadrone Topamax11 topiramate Trileptal11 oxcarbazepine Zonegran11 zonisamide SKIN CONDITIONS Apexicon E5, diflorasone, Impoyz5, Olux5, betamethasone, clobetasol, halobetasol Olux-E5, psorcon Condylox imiquimod 5% cream packet, podofilox 0.5% topical solution Cordran5 betamethasone, clobetasol, fluocinolone, fluticasone, halobetasol Finacea Foam7, Finacea Gel, MetroCream, azelaic acid, topical metronidazole MetroGel, MetroLotion, Soolantra12 flurandrenolide, hydrocortisone butyrate betamethasone, fluocinolone, fluticasone lipid cream, lotion5, Pandel5 Sorilux calcitriol, tazarotene, topical calcipotriene Tridesilon5 alclometasone, desonide, triamcinolone Xolegel ciclopirox 0.77% gel, ciclopirox 1% shampoo, ketoconazole 2% cream, ketoconazole 2% foam, selenium 2.5% lotion, sodium sulfacetamide 10% shampoo SLEEP DISORDERS/SEDATIVES Belsomra8 Dayvigo URINARY TRACT CONDITIONS Procysbi4 Cystagon Start date of Medications that will be Drug class Additional information change*,** excluded from coverage January 1, 2021 SKIN CONDITIONS Rosadan Kits azelaic acid, topical metronidazole

Generic medications start with a lowercase letter and brand name medications start with a capital letter. VALUE FORMULARY

Start date of Drug class Medications moving to preferred brand change*,** June 22, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Reditrex May 15, 2021 EYE CONDITIONS Eysuvis GASTROINTESTINAL/HEARTBURN Sutab January 1, 2021 AIDS/HIV Juluca DIABETES Baqsimi GASTROINTESTINAL/HEARTBURN Pancreaze INFECTIONS Epclusa, Harvoni PAIN RELIEF AND INFLAMMATORY DISEASE Ajovy13, Emgality13, Taltz SEIZURE DISORDERS Vimpat URINARY TRACT CONDITIONS Cystagon Start date of Medications becoming Generic and/or preferred Drug class change*,** non-preferred brand brand alternatives June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1 No preferred formulary drug alternatives June 22, 2021 CANCER Orgovyx1 Lupron Depot June 15, 2021 GASTROINTESTINAL/HEARTBURN Lubiprostone 8 mcg, 24 mcg capsule Amitiza June 1, 2021 SKIN CONDITIONS Winlevi 1% cream Generic products (e.g. adapalene; tretinoin; clindamycin-benzoyl peroxide) Wynzora 0.005%-0.064% cream betamethasone DP, fluocinolone, fluticasone, mometasone, trimacinolone, calcipotriene, calcipotriene-betamethasone DP URINARY TRACT CONDITIONS Vesicare LS 5 mg/5 mL suspension oxybutynin chloride, oxybutynin chloride ER, darifenacin ER, solifenacin, tolterodine, tolterodine ER, tropsium May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo tramadol May 1, 2021 SKIN PREPS Impeklo topical betamethasone dipropionate (augmented) 0.05%, clobetasol propionate 0.05%, halobetasol propionate 0.05%, fluocinolide 0.1% April 18, 2021 HORMONAL AGENTS Alkindi Sprinkle hydrocortisone 5mg tablet March 28, 2021 BLOOD PRESSURE/HEART MEDICATIONS Conjupri amlodipine, felodipine, nifedipine, nicardipine January 1, 2021 AIDS/HIV Intelence1 Talk to your doctor about other alternatives ERECTILE DYSFUNCTION Caverject Impulse Syringe MUSE HORMONAL AGENTS Unithroid 75mcg tablet levothyroxine INFECTIONS Kitabis Pak1 tobramycin pak 300mg/5ml SEIZURE DISORDERS Lyrica 20mg/ml oral solution pregabalin 20mg/ml oral solution SUBSTANCE ABUSE Bunavail buprenorphine/naloxone film or sublingual tablet, Zubsolv WEIGHT MANAGEMENT Megace ES 625mg/5ml oral suspension megestrol 625ml/5ml oral suspension

Generic medications start with a lowercase letter and brand name medications start with a capital letter. VALUE FORMULARY (cont)

Start date of Drug class Medications that will need approval (prior authorization)^ change*,** June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1 June 22, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Reditrex June 1, 2021 ASTHMA/COPD/RESPIRATORY Zokinvy March 14, 2021 CANCER Gavreto January 1, 2021 BLOOD THINNERS/ANTI-CLOTTING Eliquis4, Pradaxa4, Savaysa4, Xarelto4 HORMONAL AGENTS Tirosint, Tirosint-Sol Start date of Drug class Medications that will have a quantity limit change*,** June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1 June 1, 2021 ASTHMA/COPD/RESPIRATORY Zokinvy May 15, 2021 EYE CONDITIONS Eysuvis May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo March 14, 2021 CANCER Gavreto Start date of Medications that will no longer Generic and/or preferred Drug class change*,** be covered^^ brand alternatives June 29, 2021 SKIN CONDITIONS Klisyri topical fluorouracil, imiquimod 5% cream June 22, 2021 GASTROINTESTINAL/HEARTBURN Reltone ursodiol HORMONAL AGENTS Thyquidity levothyroxine, levoxyl, Levo-T, Unithroid, Euthyrox June 15, 2021 GASTROINTESTINAL/HEARTBURN Lubiprostone 8 mcg, 24 mcg capsule Amitiza June 1, 2021 SKIN CONDITIONS Winlevi 1% cream Generic products (e.g. adapalene; tretinoin; clindamycin-benzoyl peroxide) Wynzora 0.005%-0.064% cream betamethasone DP, fluocinolone, fluticasone, mometasone, trimacinolone, calcipotriene, calcipotriene-betamethasone DP URINARY TRACT CONDITIONS Vesicare LS 5 mg/5 mL suspension oxybutynin chloride, oxybutynin chloride ER, darifenacin ER, solifenacin, tolterodine, tolterodine ER, tropsium May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo tramadol May 1, 2021 SKIN PREPS Impeklo topical betamethasone dipropionate (augmented) 0.05%, clobetasol propionate 0.05%, halobetasol propionate 0.05%, fluocinolide 0.1% April 18, 2021 HORMONAL AGENTS Alkindi Sprinkle hydrocortisone 5mg tablet March 28, 2021 BLOOD PRESSURE/HEART MEDICATIONS Conjupri amlodipine, felodipine, nifedipine, nicardipine January 1, 2021 ASTHMA/COPD/RESPIRATORY Advair HFA7, Breo Ellipta7 Dulera, fluticasone-salmeterol (generic Advair Diskus), fluticasone-salmeterol (generic Airduo), Symbicort, Wixela Inhub ProAir HFA7, ProAir RespiClick7 albuterol HFA Generic medications start with a lowercase letter and brand name medications start with a capital letter. VALUE FORMULARY (cont)

Start date of Medications that will no longer Generic and/or preferred Drug class change*,** be covered^^ brand alternatives April 18, 2021 HORMONAL AGENTS Alkindi Sprinkle hydrocortisone 5mg tablet January 1, 2021 CONTRACEPTION PRODUCTS Balcoltra, Natazia, Slynd, Taytulla Generic oral contraceptives (e.g. levonorgestrel-ethinyl estradiol) DIABETES GlucaGen HypoKit7, Gvoke Baqsimi, Glucagon Emergency Kit EYE CONDITIONS Cequa, Restasis MultiDose7, Xiidra7 Restasis Travatan Z, Xalatan, Xelpros, Zioptan9 bimatoprost, latanoprost, travoprost GASTROINTESTINAL/HEARTBURN Creon7, Pertzye, Zenpep7 Pancreaze Linzess7, Motegrity, Trulance7, Zelnorm Amitiza Sensipar cinacalcet HORMONAL AGENTS TaperDex dexamethasone 1.5mg tablet INFECTIONS Baraclude entecavir tablet Noxafil tablet posaconazole DR 100mg tablet MULTIPLE SCLEROSIS Ampyra ER7 dalfampridine ER NUTRITIONAL/DIETARY PreGenna, Trinaz Any generic prenatal vitamin PAIN RELIEF AND INFLAMMATORY DISEASE Amerge generic triptans (e.g. naratriptan; sumatriptan) butalbital-acetaminophen 50-300mg tablet butalbital-acetaminophen 50-325mg tablet Cosentyx10 Enbrel, Humira, Otezla, Skyrizi, Stelara, Taltz diclofenac 1.3% patch, Flector 1.3% patch5, diclofenac 1% gel, generic oral NSAIDs (e.g. Voltaren 1% gel5 celecoxib; meloxicam) Frova, Maxalt, Maxalt MLT, Relpax generic triptans (e.g. naratriptan; sumatriptan) SEIZURE DISORDERS Felbatol11 felbamate Keppra/Keppra XR11 levetiracetam/levetiracetam ER Lamictal XR Start Kit11 lamotrigine ER Lamictal/ODT/XR11 lamotrigine, lamotrigine ER, lamotrigine ODT Qudexy XR11, Trokendi XR11 topiramate ER Sabril11 vigabatrin, vigadrone Topamax11 topiramate Trileptal11 oxcarbazepine Zonegran11 zonisamide SKIN CONDITIONS Apexicon E5, diflorasone, Impoyz5, Olux5, betamethasone, clobetasol, halobetasol Olux-E5, Psorcon Condylox imiquimod 5% cream packet, podofilox 0.5% topical solution Cordran5 betamethasone, clobetasol, fluocinolone, fluticasone, halobetasol

Generic medications start with a lowercase letter and brand name medications start with a capital letter. VALUE FORMULARY (cont)

Start date of Medications that will no longer Generic and/or preferred Drug class change*,** be covered^^ brand alternatives January 1, 2021 SKIN CONDITIONS Finacea foam, Finacea gel, MetroCream, azelaic acid, topical metronidazole MetroGel, MetroLotion, Soolantra12 flurandrenolide, hydrocortisone butyrate betamethasone, fluocinolone, fluticasone lipid cream, lotion5, Pandel5 Tridesilon5 alclometasone, desonide, triamcinolone Xolegel ciclopirox 0.77% gel, ciclopirox 1% shampoo, ketoconazole 2% cream, ketoconazole 2% foam, selenium 2.5% lotion, sodium sulfacetamide 10% shampoo SLEEP DISORDERS/SEDATIVES Belsomra8 Dayvigo URINARY TRACT CONDITIONS Procysbi4 Cystagon Start date of Medications that will be Drug class Additional information change*,** excluded from coverage January 1, 2021 ALLERGY/NASAL SPRAYS Beconase AQ, flunisolide, mometasone, generics products available over-the- Nasonex, Omnaris, Qnasl, Qnasl Children, counter (e.g. budesonide, fluticasone) Xhance, Zetonna fluticasone 50 mcg spray generics products available over-the- counter (e.g. budesonide) EYE CONDITIONS azelastine, Bepreve, epinastine, Lastacaft, products available over-the-counter (e.g. Pazeo, Zerviate Alaway, Pataday) SKIN CONDITIONS Rosadan Kits azelaic acid, topical metronidazole

LEGACY (STANDARD) FORMULARY

Generic medications start with a lowercase letter and brand name medications start with a capital letter. LEGACY (STANDARD) FORMULARY

Start date of Medications becoming Generic and/or preferred Drug class change*,** non-preferred brand brand alternatives June 22, 2021 CANCER Orgovyx1 Lupron Depot HORMONAL AGENTS Thyquidity levothyroxine, levoxyl, Levo-T, Unithroid, Euthyrox GASTROINTESTINAL/HEARTBURN Reltone ursodiol June 15, 2021 GASTROINTESTINAL/HEARTBURN Lubiprostone 8 mcg, 24 mcg capsule Amitiza June 1, 2021 SKIN CONDITIONS Winlevi 1% cream Generic products (e.g. adapalene; tretinoin; clindamycin-benzoyl peroxide) Wynzora 0.005%-0.064% cream betamethasone DP, fluocinolone, fluticasone, mometasone, trimacinolone, calcipotriene, calcipotriene-betamethasone DP URINARY TRACT CONDITIONS Vesicare LS 5 mg/5 mL suspension oxybutynin chloride, oxybutynin chloride ER, darifenacin ER, solifenacin, tolterodine, tolterodine ER, tropsium May 15, 2021 EYE CONDITIONS Lacrisert Restasis, Restasis Multi-dose, Xiidra May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo tramadol May 1, 2021 SKIN PREPS Impeklo topical betamethasone dipropionate (augmented) 0.05%, clobetasol propionate 0.05%, halobetasol propionate 0.05%, fluocinolide 0.1% April 18, 2021 HORMONAL AGENTS Alkindi Sprinkle hydrocortisone 5mg tablet March 28, 2021 BLOOD PRESSURE/HEART MEDICATIONS Conjupri amlodipine, felodipine, nifedipine, nicardipine January 1, 2021 AIDS/HIV Intelence1 Talk to your doctor about other alternatives ASTHMA/COPD/RESPIRATORY ProAir HFA, ProAir RespiClick, Ventolin HFA albuterol HFA BLOOD MODIFIERS/BLEEDING DISORDERS Amicar 0.25 g/ml oral solution1 aminocaproic acid 0.25g/ml oral solution BLOOD PRESSURE/HEART MEDICATIONS MULTAQ, Norpace CR 150mg Talk to your doctor about other alternatives CANCER Tabloid Talk to your doctor about other alternatives DIABETES Kombiglyze XR14, Onglyza14 metformin, Janumet, Janumet XR, Januvia ERECTILE DYSFUNCTION Caverject Impulse Syringe1 MUSE EYE CONDITIONS Lotemax 0.5% drops loteprednol 0.5% drops Lumigan bimatoprost, latanoprost, travoprost GASTROINTESTINAL/HEARTBURN Creon, Zenpep Pancreaze Trulance Amitiza, Linzess HORMONAL AGENTS Armour Thyroid, Synthroid, Unithroid levothyroxine INFECTIONS Kitabis Pak1 tobramycin pak 300mg/5ml MULTIPLE SCLEROSIS Ampyra ER dalfampridine ER PAIN RELIEF AND INFLAMMATORY DISEASE Cosentyx5 Enbrel, Humira, Otezla, Skyrizi, Stelara, Taltz SEIZURE DISORDERS Lamictal XR Start Kit lamotrigine ER Lyrica 20mg/ml oral solution pregabalin 20mg/ml oral solution

Generic medications start with a lowercase letter and brand name medications start with a capital letter. LEGACY (STANDARD) FORMULARY (cont)

Start date of Medications becoming Generic and/or preferred Drug class change*,** non-preferred brand brand alternatives January 1, 2021 SEIZURE DISORDERS (cont) Qudexy XR, Trokendi XR topiramate ER Sabril vigabatrin, vigadrone SKIN CONDITIONS Finacea foam, Soolantra14 azelaic acid, topical metronidazole Psorcon betamethasone, clobetasol, halobetasol SLEEP DISORDERS/SEDATIVES Belsomra8 Dayvigo SUBSTANCE ABUSE Bunavail buprenorphine/naloxone film or sublingual tablet, Zubsolv WEIGHT MANAGEMENT Megace ES 625mg/5ml oral suspension megestrol 625ml/5ml oral suspension Start date of Drug class Medications that will need approval (prior authorization)^ change*,** June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1 June 22, 2021 GASTROINTESTINAL/HEARTBURN Reltone HORMONAL AGENTS Thyquidity PAIN RELIEF AND INFLAMMATORY DISEASE Reditrex June 15, 2021 URINARY TRACT CONDITIONS Lubiprostone 8 mcg, 24 mcg capsule June 1, 2021 ASTHMA/COPD/RESPIRATORY Zokinvy SKIN CONDITIONS Winlevi 1% cream Wynzora 0.005%-0.064% cream May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo May 1, 2021 SKIN PREPS Impeklo April 18, 2021 HORMONAL AGENTS Alkindi Sprinkle March 28, 2021 BLOOD PRESSURE/HEART MEDICATIONS Conjupri March 14, 2021 CANCER Gavreto January 1, 2021 ALLERGY/NASAL SPRAYS carbinoxamine, EpiPen, EpiPen Jr, RyVent ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil, Aplenzin, Ativan, Cymbalta, Lexapro, Pamelor, Parnate, Pexeva, Tofranil, Wellbutrin XL ASTHMA/COPD/RESPIRATORY Elixophyllin, Proventil HFA, Zyflo, Zyflo CR ATTENTION DEFICIT HYPERACTIVITY DISORDER Desoxyn, Dexedrine BLOOD PRESSURE/HEART MEDICATIONS Betapace, Cardizem, Cardizem CD, Consensi, Isordil, Isordil Titradose, Lanoxin BLOOD THINNERS/ANTI-CLOTTING Eliquis, Pradaxa, Savaysa, Xarelto, Yosprala CANCER Nilandron CHOLESTEROL MEDICATIONS Antara, Fenoglide, Lipitor COUGH/COLD MEDICATIONS benzonatate, TussiCaps DIABETES Fortamet, Glumetza, metformin ER Gastric, metformin ER Osmotic DIURETICS Edecrin EYE CONDITIONS Travatan Z, Vyzulta, Xalatan, Xelpros, Zioptan9 GASTROINTESTINAL/HEARTBURN Anusol-HC suppository, Cortifoam, Librax, Lotronex, Marinol, Motegtrity, Nexium, Omeclamox-Pak, omeprazole, Pepcid suspension, tablet, Pertzye, Prevacid SoluTab, Pylera, Rowasa, Sensipar, Uceris rectal foam, Zegerid capsule, packet, Zelnorm, Zofran, Zuplenz HORMONAL AGENTS DDAVP nasal spray, solution, tablet, Dexpak, Rayos, TaperDex, Uceris tablet

Generic medications start with a lowercase letter and brand name medications start with a capital letter. LEGACY (STANDARD) FORMULARY (cont)

Start date of Drug class Medications that will need approval (prior authorization)^ change*,** January 1, 2021 INFECTIONS Augmentin, Baraclude, Diflucan, Doryx, E.E.S. 200, EryPed 400, Mepron, Minocin, Mycobutin, Noxafil tablet, Oracea, Sitavig, Solodyn, Sporanox, Targadox, Valcyte, Vancocin, Vibramycin, Zovirax capsule, suspension, tablet MISCELLANEOUS Horizant NUTRITIONAL/DIETARY PreGenna, Trinaz PAIN RELIEF AND INFLAMMATORY DISEASE Allzital, Amerge, Amrix, BUPAP, Butalbital-acetaminophen 50-300mg tablet, Cambia, chlorzoxazone, ConZip, D.H.E.45, diclofenac 1.3% patch5, 1.5% topical solution, Duexis, Ergomar, Fenortho 200 mg capsule, Flector 1.3 % patch5, Frova, Gralise, Imitrex, Indocin, levorphanol, Lorzone, Maxalt, Maxalt MLT, Migranal, Naprelan, naproxen CR, Onzetra Xsail, Pennsaid, Relpax, roxicodone, Soriatane, Sprix, Tivorbex, Treximet, Vanatol LQ, Vimovo , Vivlodex, Voltaren 1% gel5, Zembrace Symtouch, Zipsor, Zomig, Zomig ZMT, Zorvolex PARKINSON’S DISEASE Lodosyn, Requip XL, Zelapar SCHIZOPHRENIA/ANTI-PSYCHOTICS FazaClo, Geodon, Versacloz, Zyprexa, Zyprexa Zydis SEIZURE DISORDERS Mysoline SKIN CONDITIONS Aldara, Anusol-HC cream, Apexicon E5, Bensal HP, Benzaclin, Carac, Clindage, Clobex shampoo, spray, topical lotion, Condylox, Cordran5, Cutivate, diclofenac 3% gel, diflorasone, Ertaczo, Exelderm, Extina, Finacea gel, flurandrenolide, Halog cream, ointment, hydrocortisone butyrate lipid cream, lotion5, Impoyz5, Jublia, Kenalog 0.147 mg/gm spray, Kerydin, Locoid, Loprox 0.77% cream, 1% shampoo, Luzu, MetroCream, MetroGel, MetroLotion, Noritate, Olux5, Olux-E5, Oxistat, Pandel5, Penlac, Prudoxin, Sernivo, Sorilux, Trainex, Tridesilon5, Ultravate, Vanos, Verdeso, Vusion, Xerese, Xolegel, Ziana, Zonalon, Zovirax cream, ointment, Zyclara SLEEP DISORDERS/SEDATIVES Ambien, Ambien CR, Edular, Intermezzo, Nuvigil, Provigil, Restoril, Zolpimist SUBSTANCE ABUSE Evzio Start date of Drug class Medications that will have a quantity limit change*,** June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1 June 1, 2021 ASTHMA/COPD/RESPIRATORY Zokinvy May 15, 2021 EYE CONDITIONS Eysuvis May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo March 14, 2021 CANCER Gavreto Start date of Medications being added to Generic and/or preferred Drug class change*,** Step Therapy Program^,^^ brand alternatives June 29, 2021 SKIN CONDITIONS Klisyri topical fluorouracil, imiquimod 5% cream, Fluoroplex June 1, 2021 URINARY TRACT CONDITIONS Vesicare LS 5 mg/5 mL suspension oxybutynin chloride, oxybutynin chloride ER, darifenacin ER, solifenacin, tolterodine, tolterodine ER, tropsium Start date of Medications that will be Drug class Additional information change*,** excluded from coverage January 1, 2021 SKIN CONDITIONS Rosadan Kits azelaic acid, topical metronidazole Generic medications start with a lowercase letter and brand name medications start with a capital letter. PERFORMANCE FORMULARY

Start date of Drug class Medications moving to preferred brand change*,** June 22, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Reditrex May 15, 2021 EYE CONDITIONS Eysuvis GASTROINTESTINAL/HEARTBURN Sutab April 1, 2021 CANCER Riabni January 1, 2021 AIDS/HIV Juluca ASTHMA/COPD/RESPIRATORY Bevespi DIABETES Baqsimi GASTROINTESTINAL/HEARTBURN Pancreaze INFECTIONS Epclusa, Harvoni PAIN RELIEF AND INFLAMMATORY DISEASE Taltz Start date of Medications becoming Generic and/or preferred Drug class change*,** non-preferred brand brand alternatives June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1 Lupron Depot June 22, 2021 CANCER Orgovyx1 No preferred formulary drug alternatives. June 15, 2021 GASTROINTESTINAL/HEARTBURN Lubiprostone 8 mcg, 24 mcg capsule Amitiza June 1, 2021 SKIN CONDITIONS Winlevi 1% cream Generic products (e.g. adapalene; tretinoin; clindamycin-benzoyl peroxide) Wynzora 0.005%-0.064% cream betamethasone DP, fluocinolone, fluticasone, mometasone, trimacinolone, calcipotriene, calcipotriene-betamethasone DP URINARY TRACT CONDITIONS Vesicare LS 5 mg/5 mL suspension oxybutynin chloride, oxybutynin chloride ER, darifenacin ER, solifenacin, tolterodine, tolterodine ER, tropsium May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo tramadol May 1, 2021 SKIN PREPS Impeklo topical betamethasone dipropionate (augmented) 0.05%, clobetasol propionate 0.05%, halobetasol propionate 0.05%, fluocinolide 0.1% April 18, 2021 HORMONAL AGENTS Alkindi Sprinkle hydrocortisone 5mg tablet March 28, 2021 BLOOD PRESSURE/HEART MEDICATIONS Conjupri amlodipine, felodipine, nifedipine, nicardipine January 1, 2021 AIDS/HIV Intelence1 Talk to your doctor about other alternatives BLOOD PRESSURE/HEART MEDICATIONS MULTAQ Talk to your doctor about other alternatives EYE CONDITIONS Lotemax 0.5% drops loteprednol 0.5% drops HORMONAL AGENTS Armour Thyroid, Synthroid, Unithroid levothyroxine INFECTIONS Kitabis Pak1 tobramycin pak 300mg/5ml SEIZURE DISORDERS Lyrica 20mg/ml oral solution pregabalin 20mg/ml oral solution SUBSTANCE ABUSE Bunavail buprenorphine/naloxone film or sublingual tablet, Zubsolv Generic medications start with a lowercase letter and brand name medications start with a capital letter. PERFORMANCE FORMULARY (cont)

Start date of Medications becoming Generic and/or preferred Drug class change*,** non-preferred brand brand alternatives January 1, 2021 SUBSTANCE ABUSE Probuphine Talk to your doctor about other alternatives Start date of Drug class Medications that will need approval (prior authorization)^ change*,** June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1 June 22, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Reditrex June 1, 2021 ASTHMA/COPD/RESPIRATORY Zokinvy March 14, 2021 CANCER Gavreto January 1, 2021 BLOOD THINNERS/ANTI-CLOTTING Eliquis4, Pradaxa4, Savaysa4, Xarelto4 PAIN RELIEF AND INFLAMMATORY DISEASE diclofenac 1.3% patch, Flextor 1.3% patch5, Voltaren 1% gel5 Start date of Drug class Medications that will have a quantity limit change*,** June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1 June 1, 2021 ASTHMA/COPD/RESPIRATORY Zokinvy May 15, 2021 EYE CONDITIONS Eysuvis May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo March 14, 2021 CANCER Gavreto Start date of Medications that will no longer Generic and/or preferred Drug class change*,** be covered^^ brand alternatives June 29, 2021 SKIN CONDITIONS Klisyri topical fluorouracil, imiquimod 5% cream June 22, 2021 GASTROINTESTINAL/HEARTBURN Reltone ursodiol HORMONAL AGENTS Thyquidity levothyroxine, levoxyl, Levo-T, Unithroid, Euthyrox June 15, 2021 GASTROINTESTINAL/HEARTBURN Lubiprostone 8 mcg, 24 mcg capsule Amitiza June 1, 2021 SKIN CONDITIONS Winlevi 1% cream Generic products (e.g. adapalene; tretinoin; clindamycin-benzoyl peroxide) Wynzora 0.005%-0.064% cream betamethasone DP, fluocinolone, fluticasone, mometasone, trimacinolone, calcipotriene, calcipotriene-betamethasone DP URINARY TRACT CONDITIONS Vesicare LS 5 mg/5 mL suspension oxybutynin chloride, oxybutynin chloride ER, darifenacin ER, solifenacin, tolterodine, tolterodine ER, tropsium May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo tramadol May 1, 2021 SKIN PREPS Impeklo topical betamethasone dipropionate (augmented) 0.05%, clobetasol propionate 0.05%, halobetasol propionate 0.05%, fluocinolide 0.1% April 18, 2021 HORMONAL AGENTS Alkindi Sprinkle hydrocortisone 5mg tablet March 28, 2021 BLOOD PRESSURE/HEART MEDICATIONS Conjupri amlodipine, felodipine, nifedipine, nicardipine

Generic medications start with a lowercase letter and brand name medications start with a capital letter. PERFORMANCE FORMULARY (cont)

Start date of Medications that will no longer Generic and/or preferred Drug class change*,** be covered^^ brand alternatives January 1, 2021 ASTHMA/COPD/RESPIRATORY ProAir HFA7, ProAir RespiClick7, Ventolin albuterol HFA HFA7 DIABETES Kombiglyze XR8, Onglyza8 metformin, Janumet, Janumet XR, Januvia EYE CONDITIONS Lumigan7, Travatan Z, Xalatan, Xelpros, bimatoprost, latanoprost, travoprost Zioptan9 GASTROINTESTINAL/HEARTBURN Creon7, Pertzye7, Zenpep7 Pancreaze Motegrity, Trulance7, Zelnorm Amitiza, Linzess Sensipar cinacalcet HORMONAL AGENTS TaperDex dexamethasone 1.5mg tablet INFECTIONS Baraclude entecavir tablet Noxafil tablet posaconazole DR 100mg tablet MULTIPLE SCLEROSIS Ampyra ER7 dalfampridine ER NUTRITIONAL/DIETARY PreGenna, Trinaz Any generic prenatal vitamin PAIN RELIEF AND INFLAMMATORY DISEASE Amerge, Frova, Maxalt, Maxalt MLT, Relpax generic triptans (e.g. naratriptan; sumatriptan) butalbital-acetaminophen 50-300mg tablet butalbital-acetaminophen 50-325mg tablet Cosentyx10 Enbrel, Humira, Otezla, Skyrizi, Stelara, Taltz SEIZURE DISORDERS Felbatol11 felbamate Keppra/Keppra XR11 levetiracetam/levetiracetam ER Lamictal XR Start Kit11 lamotrigine ER Lamictal/ODT/XR11 lamotrigine, lamotrigine ER, lamotrigine ODT Qudexy XR6, Trokendi XR11 topiramate ER Sabril11 vigabatrin, vigadrone Topamax11 topiramate Trileptal11 oxcarbazepine Zonegran11 zonisamide SKIN CONDITIONS Apexicon E5, diflorasone, Impoyz5, Olux5, betamethasone, clobetasol, halobetasol Olux-E5, Psorcon Condylox imiquimod 5% cream packet, podofilox 0.5% topical solution Cordran5 betamethasone, clobetasol, fluocinolone, fluticasone, halobetasol Finacea7, MetroCream, MetroGel, azelaic acid, topical metronidazole MetroLotion, Soolantra12 flurandrenolide, Pandel5 betamethasone, fluocinolone, fluticasone hydrocortisone butyrate lipid cream, lotion5 betamethasone, fluocinolone, fluticasone Sorilux calcitriol, tazarotene, topical calcipotriene

Generic medications start with a lowercase letter and brand name medications start with a capital letter. PERFORMANCE FORMULARY (cont)

ADVANTAGE FORMULARY

Generic medications start with a lowercase letter and brand name medications start with a capital letter. ADVANTAGE FORMULARY (cont)

Start date of Medications becoming Generic and/or preferred Drug class change*,** non-preferred brand brand alternatives June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1 Lupron Depot May 1, 2021 SKIN PREPS Impeklo topical betamethasone dipropionate (augmented) 0.05%, clobetasol propionate 0.05%, halobetasol propionate 0.05%, fluocinolide 0.1% April 18, 2021 HORMONAL AGENTS Alkindi Sprinkle hydrocortisone 5mg tablet March 28, 2021 BLOOD PRESSURE/HEART MEDICATIONS Conjupri amlodipine, felodipine, nifedipine, nicardipine January 1, 2021 AIDS/HIV Intelence1 Talk to your doctor about other alternatives HORMONAL AGENTS Unithroid 75mcg tablet levothyroxine INFECTIONS Kitabis Pak1 tobramycin pak 300mg/5ml SEIZURE DISORDERS Lyrica 20mg/ml oral solution pregabalin 20mg/ml oral solution SUBSTANCE ABUSE Bunavail buprenorphine/naloxone film or sublingual tablet, Zubsolv Probuphine Talk to your doctor about other alternatives WEIGHT MANAGEMENT Megace ES 625mg/5ml oral suspension megestrol 625ml/5ml oral suspension Start date of Drug class Medications that will need approval (prior authorization)^ change*,** June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1 June 22, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Reditrex June 1, 2021 ASTHMA/COPD/RESPIRATORY Zokinvy March 14, 2021 CANCER Gavreto January 1, 2021 BLOOD THINNERS/ANTI-CLOTTING Eliquis4, Pradaxa4, Savaysa4, Xarelto4 HORMONAL AGENTS Tirosint, Tirosint-SOL Start date of Drug class Medications that will have a quantity limit change*,** June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1 June 1, 2021 ASTHMA/COPD/RESPIRATORY Zokinvy May 15, 2021 EYE CONDITIONS Eysuvis May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo March 14, 2021 CANCER Gavreto Start date of Medications that will no longer Generic and/or preferred Drug class change*,** be covered^^ brand alternatives June 29, 2021 SKIN CONDITIONS Klisyri topical fluorouracil, imiquimod 5% cream June 22, 2021 GASTROINTESTINAL/HEARTBURN Reltone ursodiol HORMONAL AGENTS Thyquidity levothyroxine, levoxyl, Levo-T, Unithroid, Euthyrox June 15, 2021 GASTROINTESTINAL/HEARTBURN Lubiprostone 8 mcg, 24 mcg capsule Amitiza June 1, 2021 SKIN CONDITIONS Winlevi 1% cream Generic products (e.g. adapalene; tretinoin; clindamycin-benzoyl peroxide) Generic medications start with a lowercase letter and brand name medications start with a capital letter. ADVANTAGE FORMULARY (cont)

Start date of Medications that will no longer Generic and/or preferred Drug class change*,** be covered^^ brand alternatives June 1, 2021 SKIN CONDITIONS (cont) Wynzora 0.005%-0.064% cream betamethasone DP, fluocinolone, fluticasone, mometasone, trimacinolone, calcipotriene, calcipotriene-betamethasone DP URINARY TRACT CONDITIONS Vesicare LS 5 mg/5 mL suspension oxybutynin chloride, oxybutynin chloride ER, darifenacin ER, solifenacin, tolterodine, tolterodine ER, tropsium May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo tramadol May 1, 2021 SKIN PREPS Impeklo topical betamethasone dipropionate (augmented) 0.05%, clobetasol propionate 0.05%, halobetasol propionate 0.05%, fluocinolide 0.1% April 18, 2021 HORMONAL AGENTS Alkindi Sprinkle hydrocortisone 5mg tablet March 28, 2021 BLOOD PRESSURE/HEART MEDICATIONS Conjupri amlodipine, felodipine, nifedipine, nicardipine January 1, 2021 ASTHMA/COPD/RESPIRATORY Advair HFA7, Breo Ellipta7 Dulera, fluticasone-salmeterol (generic Advair Diskus), fluticasone-salmeterol (generic Airduo), Symbicort, Wixela Inhub ProAir HFA7, ProAir RespiClick7 albuterol HFA CONTRACEPTION PRODUCTS Balcoltra, Natazia, Slynd, Taytulla Generic oral contraceptives (e.g. levonorgestrel-ethinyl estradiol) DIABETES GlucaGen HypoKit7, Gvoke Baqsimi, Glucagon Emergency Kit EYE CONDITIONS Cequa, Restasis MultiDose7, Xiidra7 Restasis Travatan Z, Xalatan, Xelpros, Zioptan9 bimatoprost, latanoprost, travoprost GASTROINTESTINAL/HEARTBURN Creon7, Pertzye, Zenpep7 Pancreaze Linzess7, Motegrity, Trulance7, Zelnorm Amitiza Sensipar cinacalcet HORMONAL AGENTS TaperDex dexamethasone 1.5mg tablet INFECTIONS Baraclude entecavir tablet Noxafil tablet posaconazole DR 100mg tablet MULTIPLE SCLEROSIS Ampyra ER7 dalfampridine ER NUTRITIONAL/DIETARY PreGenna, Trinaz Any generic prenatal vitamin PAIN RELIEF AND INFLAMMATORY DISEASE Amerge generic triptans (e.g. naratriptan; sumatriptan) butalbital-acetaminophen 50-300mg tablet butalbutal-acetaminophen 50-325mg tablet Cosentyx10 Enbrel, Humira, Otezla, Skyrizi, Stelara, Taltz diclofenac 1.3% patch, Flector 1.3% patch5, diclofenac 1% gel, generic oral NSAIDs (e.g. Voltaren 1% gel5 celecoxib; meloxicam)

Generic medications start with a lowercase letter and brand name medications start with a capital letter. ADVANTAGE FORMULARY (cont)

Start date of Medications that will no longer Generic and/or preferred Drug class change*,** be covered^^ brand alternatives January 1, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Frova, Maxalt, Maxalt MLT, Relpax generic triptans (e.g. naratriptan; (cont) sumatriptan) SEIZURE DISORDERS Felbatol11 felbamate Keppra/Keppra XR11 levetiracetam/levetiracetam ER Lamictal XR Start Kit11 lamotrigine ER Lamictal/ODT/XR11 lamotrigine, lamotrigine ER, lamotrigine ODT Qudexy XR5, Trokendi XR11 topiramate ER Sabril11 vigabatrin, vigadrone Topamax11 topiramate Trileptal11 oxcarbazepine Zonegran11 zonisamide SKIN CONDITIONS Apexicon E5, diflorasone, Impoyz5, Olux5, betamethasone, clobetasol, halobetasol Olux-E5, Psorcon Condylox imiquimod 5% cream packet, podofilox 0.5% topical solution Cordran5 betamethasone, clobetasol, fluocinolone, fluticasone, halobetasol Finacea, MetroCream, MetroGel, azelaic acid, topical metronidazole MetroLotion, Soolantra12 flurandrenolide, hydrocortisone butyrate betamethasone, fluocinolone, fluticasone lipid cream, lotion5, Pandel5 Tridesilon5 alclometasone, desonide, triamcinolone Xolegel ciclopirox 0.77% gel, ciclopirox 1% shampoo, ketoconazole 2% cream, ketoconazole 2% foam, selenium 2.5% lotion, sodium sulfacetamide 10% shampoo SLEEP DISORDERS/SEDATIVES Belsomra8 Dayvigo URINARY TRACT CONDITIONS Procysbi4 Cystagon Start date of Medications that will be Drug class Additional information change*,** excluded from coverage January 1, 2021 ALLERGY/NASAL SPRAYS Beconase AQ, flunisolide, mometasone, generics products available over-the- Nasonex, Omnaris, Qnasl, Qnasl Children, counter (e.g. budesonide, fluticasone) Xhance, Zetonna EYE CONDITIONS azelastine, Bepreve, epinastine, Lastacaft, products available over-the-counter (e.g. Pazeo, Zerviate Alaway, Pataday) SKIN CONDITIONS Rosadan Kits azelaic acid, topical metronidazole

Generic medications start with a lowercase letter and brand name medications start with a capital letter. LEGACY (PERFORMANCE) FORMULARY

Start date of Drug class Medications moving to preferred brand change*,** June 22, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Reditrex May 15, 2021 EYE CONDITIONS Eysuvis GASTROINTESTINAL/HEARTBURN Sutab April 1, 2021 CANCER Riabni January 1, 2021 AIDS/HIV Juluca ASTHMA/COPD/RESPIRATORY Bevespi DIABETES Baqsimi GASTROINTESTINAL/HEARTBURN Pancreaze INFECTIONS Epclusa, Harvoni PAIN RELIEF AND INFLAMMATORY DISEASE Taltz Start date of Medications becoming Generic and/or preferred Drug class change*,** non-preferred brand brand alternatives June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1 No preferred formulary drug alternatives SKIN CONDITIONS Klisyri topical fluorouracil, imiquimod 5% cream, Fluoroplex June 22, 2021 CANCER Orgovyx1 Lupron Depot HORMONAL AGENTS Thyquidity levothyroxine, levoxyl, Levo-T, Unithroid, Euthyrox GASTROINTESTINAL/HEARTBURN Reltone ursodiol June 15, 2021 GASTROINTESTINAL/HEARTBURN Lubiprostone 8 mcg, 24 mcg capsule Amitiza June 1, 2021 SKIN CONDITIONS Winlevi 1% cream Generic products (e.g. adapalene; tretinoin; clindamycin-benzoyl peroxide) Wynzora 0.005%-0.064% cream betamethasone DP, fluocinolone, fluticasone, mometasone, trimacinolone, calcipotriene, calcipotriene-betamethasone DP URINARY TRACT CONDITIONS Vesicare LS 5 mg/5 mL suspension oxybutynin chloride, oxybutynin chloride ER, darifenacin ER, solifenacin, tolterodine, tolterodine ER, tropsium May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo tramadol May 1, 2021 SKIN PREPS Impeklo topical betamethasone dipropionate (augmented) 0.05%, clobetasol propionate 0.05%, halobetasol propionate 0.05%, fluocinolide 0.1% April 18, 2021 HORMONAL AGENTS Alkindi Sprinkle hydrocortisone 5mg tablet March 28, 2021 BLOOD PRESSURE/HEART MEDICATIONS Conjupri amlodipine, felodipine, nifedipine, nicardipine January 1, 2021 AIDS/HIV Intelence1 Talk to your doctor about other alternatives ASTHMA/COPD/RESPIRATORY ProAir HFA, ProAir RespiClick, Ventolin HFA albuterol HFA BLOOD PRESSURE/HEART MEDICATIONS MULTAQ Talk to your doctor about other alternatives

Generic medications start with a lowercase letter and brand name medications start with a capital letter. LEGACY (PERFORMANCE) FORMULARY (cont)

Start date of Medications becoming Generic and/or preferred Drug class change*,** non-preferred brand brand alternatives January 1, 2021 DIABETES Kombiglyze XR14, Onglyza14 metformin, Janumet, Janumet XR, Januvia EYE CONDITIONS Lotemax 0.5% drops loteprednol 0.5% drops Lumigan bimatoprost, latanoprost, travoprost GASTROINTESTINAL/HEARTBURN Creon, Zenpep Pancreaze Trulance Amitiza, Linzess HORMONAL AGENTS Armour Thyroid, Synthroid, Unithroid levothyroxine 75mcg tablet INFECTIONS Kitabis Pak1 tobramycin pak 300mg/5ml MULTIPLE SCLEROSIS Ampyra ER dalfampridine ER PAIN RELIEF AND INFLAMMATORY DISEASE Cosentyx1,4 Enbrel, Humira, Otezla, Skyrizi, Stelara, Taltz SEIZURE DISORDERS Lamictal XR Start Kit lamotrigine ER Lyrica 20mg/ml oral solution pregabalin 20mg/ml oral solution Qudexy XR, Trokendi XR topiramate ER Sabril1 vigabatrin, vigadrone SKIN CONDITIONS Finacea foam, Soolantra14 azelaic acid, topical metronidazole Psorcon betamethasone, clobetasol, halobetasol SLEEP DISORDERS/SEDATIVES Belsomra8 Dayvigo SUBSTANCE ABUSE Bunavail buprenorphine/naloxone film or sublingual tablet, Zubsolv Probuphine Talk to your doctor about other alternatives WEIGHT MANAGEMENT Megace ES 625mg/5ml oral suspension megestrol 625ml/5ml oral suspension Start date of Drug class Medications that will need approval (prior authorization)^ change*,** June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1 June 22, 2021 GASTROINTESTINAL/HEARTBURN Reltone HORMONAL AGENTS Thyquidity PAIN RELIEF AND INFLAMMATORY DISEASE Reditrex June 15, 2021 GASTROINTESTINAL/HEARTBURN Lubiprostone 8 mcg, 24 mcg capsule June 1, 2021 ASTHMA/COPD/RESPIRATORY Zokinvy SKIN CONDITIONS Winlevi 1% cream Wynzora 0.005%-0.064% cream May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo May 1, 2021 SKIN PREPS Impeklo April 18, 2021 HORMONAL AGENTS Alkindi Sprinkle March 28, 2021 BLOOD PRESSURE/HEART MEDICATIONS Conjupri March 14, 2021 CANCER Gavreto

Generic medications start with a lowercase letter and brand name medications start with a capital letter. LEGACY (PERFORMANCE) FORMULARY (cont)

Start date of Drug class Medications that will need approval (prior authorization)^ change*,** January 1, 2021 ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil, Aplenzin, Ativan, Cymbalta, Lexapro, Pamelor, Parnate, Pexeva, Tofranil, Wellbutrin XL ASTHMA/COPD/RESPIRATORY Elixophyllin, Proventil HFA, Zyflo, Zyflo CR ATTENTION DEFICIT HYPERACTIVITY DISORDER Desoxyn, Dexedrine BLOOD PRESSURE/HEART MEDICATIONS Betapace, Cardizem, Cardizem CD, Consensi, Isordil, Isordil Titradose, Lanoxin BLOOD THINNERS/ANTI-CLOTTING Eliquis, Pradaxa, Savaysa, Xarelto, Yosprala CANCER Aldara, Nilandron, Zyclara CHOLESTEROL MEDICATIONS Antara, Fenoglide, Lipitor COUGH/COLD MEDICATIONS benzonatate, TussiCaps DIABETES Fortamet, Glumetza, metformin ER Gastric, metformin ER Osmotic DIURETICS Edecrin EYE CONDITIONS Travatan Z, Vyzulta, Xalatan, Xelpros, Zioptan9 GASTROINTESTINAL/HEARTBURN Anusol-HC suppository, Cortifoam, Librax, Lotronex, Marinol, Motegrity, Nexium, Omeclamox-Pak, omeprazole, Pepcid suspension, tablet, Pertzye, Prevacid SoluTab, Pylera, Rowasa, Sensipar, Uceris rectal foam, Zegerid capsule, packet, Zelnorm, Zofran, Zuplenz HORMONAL AGENTS DDAVP nasal spray, solution, tablet, Dexpak, Rayos, TaperDex, Uceris tablet INFECTIONS Augmentin, Baraclude, Diflucan, Doryx, E.E.S. 200 EryPed 400, Mepron, Minocin, Mycobutin, Noxafil tablet, Oracea, Sitavig, Solodyn, Sporanox, Targadox, Valcyte, Vancocin, Vibramycin, Zovirax capsule, suspension, tablet MISCELLANEOUS Horizant NUTRITIONAL/DIETARY PreGenna, Trinaz PAIN RELIEF AND INFLAMMATORY DISEASE Allzital, Amerge, Amrix, BUPAP, butalbital-acetaminophen 50-300mg tablet, Cambia, chlorzoxazone, ConZip, D.H.E.45, diclofenac 1.3% patch5, 1.5% topical solution, Duexis, Ergomar, Fenortho 200 mg capsule, Flector 1.3% patch5, Frova, Gralise, Imitrex, Indocin, levorphanol, Lorzone, Maxalt, Maxalt MLT, Migranal, Naprelan, naproxen CR, Onzetra Xsail, Pennsaid, Relpax, Roxicodone, Soriatane, Sprix, Tivorbex, Treximet, Vanatol LQ, Vimovo, Vivlodex, Votaren 1% gel5, Zembrace Symtouch, Zipsor, Zomig, Zomig ZMT, Zorvolex PARKINSON'S DISEASE Lodosyn, Requip XL, Zelapar SCHIZOPHRENIA/ANTI-PSYCHOTICS FazaClo, Geodon, Versacloz, Zyprexa, Zyprexa Zydis SEIZURE DISORDERS Mysoline SKIN CONDITIONS Anusol-HC cream, Apexicon E5, Bensal HP, Benzaclin, Carac, Clindagel, Clobex shampoo, spray, topical lotion, Condylox, Cordran5, Cutivate, diclofenac 3% gel, diflorasone, Ertaczo, Exelderm, Extina, Finacea gel, flurandrenolide, Halog cream, ointment, hydrocortisone butyrate lipid cream, lotion5, Impoyz5, Jublia, Kenalog 0.147mg/gm spray, Kerydin, Locoid, Loprox 0.77% cream, 1% shampoo, Luzu, MetroCream, MetroGel, MetroLotion, Noritate, Olux5, Olux-E5, Oxistat, Pandel5, Penlac, Prudoxin, Sernivo, Sorilux, Trainex, Tridesilon2, Ultravate, Vanos, Verdeso, Vusion, Xerese, Xolegel, Ziana, Zonalon, Zovirax cream, ointment SLEEP DISORDERS/SEDATIVES Ambien, Ambien CR, Edular, Intermezzo, Nuvigil, Provigil, Restoril, Zolpimist

Generic medications start with a lowercase letter and brand name medications start with a capital letter. LEGACY (PERFORMANCE) FORMULARY (cont)

Start date of Drug class Medications that will need approval (prior authorization)^ change*,** January 1, 2021 SUBSTANCE ABUSE Evzio Start date of Drug class Medications that will have a quantity limit change*,** June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1 June 1, 2021 ASTHMA/COPD/RESPIRATORY Zokinvy May 15, 2021 EYE CONDITIONS Eysuvis May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo March 14, 2021 CANCER Gavreto Start date of Medications being added to Generic and/or preferred Drug class change*,** Step Therapy Program^,^^ brand alternatives June 29, 2021 SKIN CONDITIONS Klisyri topical fluorouracil, imiquimod 5% cream, Fluoroplex June 1, 2021 URINARY TRACT CONDITIONS Vesicare LS 5 mg/5 mL suspension oxybutynin chloride, oxybutynin chloride ER, darifenacin ER, solifenacin, tolterodine, tolterodine ER, tropsium Start date of Medications that will be Drug class Additional information change*,** excluded from coverage January 1, 2021 SKIN CONDITIONS Rosadan Kits azelaic acid, topical metronidazole

CIGNA TOTAL SAVINGS FORMULARY Start date of Drug class Medications moving to preferred brand change*,** June 22, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Reditrex May 15, 2021 EYE CONDITIONS Eysuvis GASTROINTESTINAL/HEARTBURN Sutab January 1, 2021 AIDS/HIV Juluca DIABETES Baqsimi Jentadueto15, Jentadueto XR15, Tradjenta15 GASTROINTESTINAL/HEARTBURN Pancreaze HORMONAL AGENTS Imvexxy, Intrarosa INFECTIONS Epclusa, Harvoni PAIN RELIEF AND INFLAMMATORY DISEASE Ajovy13, Cimzia, Emgality13, Olumiant SEIZURE DISORDERS VIMPAT URINARY TRACT CONDITIONS Cystagon Start date of Medications becoming Generic and/or preferred Drug class change*,** non-preferred brand brand alternatives June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1 Lupron Depot June 22, 2021 CANCER Orgovyx1 No preferred formulary drug alternatives.

Generic medications start with a lowercase letter and brand name medications start with a capital letter. CIGNA TOTAL SAVINGS FORMULARY (cont)

Start date of Medications becoming Generic and/or preferred Drug class change*,** non-preferred brand brand alternatives June 15, 2021 GASTROINTESTINAL/HEARTBURN Lubiprostone 8 mcg, 24 mcg capsule Amitiza June 1, 2021 SKIN CONDITIONS Winlevi 1% cream Generic products (e.g. adapalene; tretinoin; clindamycin-benzoyl peroxide) Wynzora 0.005%-0.064% cream betamethasone DP, fluocinolone, fluticasone, mometasone, trimacinolone, calcipotriene, calcipotriene-betamethasone DP URINARY TRACT CONDITIONS Vesicare LS 5 mg/5 mL suspension oxybutynin chloride, oxybutynin chloride ER, darifenacin ER, solifenacin, tolterodine, tolterodine ER, tropsium May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo tramadol May 1, 2021 SKIN PREPS Impeklo topical betamethasone dipropionate (augmented) 0.05%, clobetasol propionate 0.05%, halobetasol propionate 0.05%, fluocinolide 0.1% April 18, 2021 HORMONAL AGENTS Alkindi Sprinkle hydrocortisone 5mg tablet March 28, 2021 BLOOD PRESSURE/HEART MEDICATIONS Conjupri amlodipine, felodipine, nifedipine, nicardipine January 1, 2021 AIDS/HIV Atripla1, Descovy1, Intelence1, Selzentry1, Talk to your doctor about other alternatives Symtuza1, Truvada1 ERECTILE DYSFUNCTION Caverject Impulse Syringe Talk to your doctor about other alternatives INFECTIONS Kitabis Pak1 tobramycin pak 300mg/5ml SEIZURE DISORDERS Lyrica 20mg/ml oral solution pregabalin 20mg/ml oral solution SUBSTANCE ABUSE Bunavail buprenorphine/naloxone film or sublingual tablet, Zubsolv WEIGHT MANAGEMENT Megace ES 625mg/5ml oral suspension megestrol 625ml/5ml oral suspension Start date of Drug class Medications that will need approval (prior authorization)^ change*,** June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1 June 22, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Reditrex June 1, 2021 ASTHMA/COPD/RESPIRATORY Zokinvy March 14, 2021 CANCER Gavreto January 1, 2021 BLOOD THINNERS/ANTI-CLOTTING Eliquis4, Pradaxa4, Savaysa4, Xarelto4 Start date of Drug class Medications that will have a quantity limit change*,** June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1 June 1, 2021 ASTHMA/COPD/RESPIRATORY Zokinvy May 15, 2021 EYE CONDITIONS Eysuvis May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo March 14, 2021 CANCER Gavreto Start date of Medications being added to Generic and/or preferred Drug class change*,** Step Therapy Program^,^^ brand alternatives July 1, 2021 DIABETES Jentadueto, Jentadueto XR, Tradjenta metformin Generic medications start with a lowercase letter and brand name medications start with a capital letter. CIGNA TOTAL SAVINGS FORMULARY (cont)

Start date of Medications that will no longer Generic and/or preferred Drug class change*,** be covered^^ brand alternatives June 29, 2021 SKIN CONDITIONS Klisyri topical fluorouracil, imiquimod 5% cream, Fluoroplex June 22, 2021 GASTROINTESTINAL/HEARTBURN Reltone ursodiol HORMONAL AGENTS Thyquidity levothyroxine, levoxyl, Levo-T, Unithroid, Euthyrox June 15, 2021 GASTROINTESTINAL/HEARTBURN Lubiprostone 8 mcg, 24 mcg capsule Amitiza June 1, 2021 SKIN CONDITIONS Winlevi 1% cream Generic products (e.g. adapalene; tretinoin; clindamycin-benzoyl peroxide) Wynzora 0.005%-0.064% cream betamethasone DP, fluocinolone, fluticasone, mometasone, trimacinolone, calcipotriene, calcipotriene-betamethasone DP URINARY TRACT CONDITIONS Vesicare LS 5 mg/5 mL suspension oxybutynin chloride, oxybutynin chloride ER, darifenacin ER, solifenacin, tolterodine, tolterodine ER, tropsium May 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo tramadol May 1, 2021 SKIN PREPS Impeklo topical betamethasone (augmented) 0.05%, clobetasol 0.05%, halobetasol propionate 0.05%, fluocinolide 0.1% April 18, 2021 HORMONAL AGENTS Alkindi Sprinkle hydrocortisone 5mg tablet March 28, 2021 BLOOD PRESSURE/HEART MEDICATIONS Conjupri amlodipine, felodipine, nifedipine, nicardipine January 1, 2021 ANXIETY/DEPRESSION/BIPOLAR DISORDER Forfivo XL bupropion XL tablet Paxil CR paroxetine ER ASTHMA/COPD/RESPIRATORY Advair HFA7, Breo Ellipta7 Dulera, fluticasone-salmeterol (generic Advair Diskus), fluticasone-salmeterol (generic Airduo), Symbicort, Wixela Inhub Kalydeco5, Orkambi5, Symdeko5 Trikafta3 ProAir HFA7, ProAir RespiClick7 albuterol HFA ATTENTION DEFICIT HYPERACTIVITY DISORDER Intuniv guanfacine ER Strattera atomoxetine capsule BLOOD PRESSURE/HEART MEDICATIONS Ranexa ranolazine ER CANCER Pomalyst5 Revlimid CHOLESTEROL MEDICATIONS Lovaza omega-3 acid ethyl esters capsule CONTRACEPTION PRODUCTS Balcoltra, Loseasonique, Natazia, Quartette, Generic oral contraceptives (e.g. Slynd, Taytulla7 levonorgestrel-ethinyl estradiol) Beyaz, Safyral, Yasmin 28, Yaz Generic oral contraceptives (e.g. drospirenone-ethinyl estradiol- levomefolate) Depo-Provera medroxyprogesterone Estrostep FE Generic oral contraceptives (e.g. Tilia FE, Tri-Legest FE) Generic medications start with a lowercase letter and brand name medications start with a capital letter. CIGNA TOTAL SAVINGS FORMULARY (cont)

Start date of Medications that will no longer Generic and/or preferred Drug class change*,** be covered^^ brand alternatives January 1, 2021 CONTRACEPTION PRODUCTS Generess FE, Layolis FE, Loestrin FE, Miastrin Generic oral contraceptives (e.g. 24 FE norethindrone-ethinyl estradiol-FE) Loestrin Generic oral contraceptives (e.g. norethindrone-ethinyl estradiol) Mirapex ER 4.5mg tablet pramipexole ER 4.5mg tablet NuvaRing etonogestrel-ethinyl estradiol vaginal ring Ortho Micronor Generic oral contraceptives (e.g. norethindrone 0.35mg) Prenatabas FA Pretab 29mg-1mg tablet DIABETES GlucaGen HypoKit7, Gvoke Baqsimi, Glucagon Emergency Kit Janumet8, Janumet XR8, Januvia8 metformin, Jentadueto, Jentadueto XR, Tradjenta EYE CONDITIONS Cequa, Restasis MultiDose7, Xiidra7 Restasis FML Liquifilm fluorometholone eye drops Lotemax drops loteprednol 0.5% drops Travatan Z, Xalatan, Xelpros, Zioptan9 bimatoprost, latanoprost, travoprost GASTROINTESTINAL/HEARTBURN Apriso mesalamine ER capsule Carafate7 sucralfate Creon7, Pertzye, Zenpep7 Pancreaze Linzess7, Motegrity, Trulance7, Zelnorm Amitiza Sensipar cinacalcet HORMONAL AGENTS Armour Thyroid, Synthroid7, Tirosint, Tirosint levothyroxine Sol, Unithroid7 Cortef hydrocortisone tablet Minivelle estradiol patch TaperDex dexamethasone 1.5mg tablet Vivelle-Dot estradiol patch INFECTIONS Baraclude entecavir tablet Noxafil tablet posaconazole DR 100mg tablet Sulfatrim sulfamethoxazole-TMP suspension Tamiflu oseltamivir MULTIPLE SCLEROSIS Ampyra ER7 dalfampridine ER Avonex7, Extavia7, Plegridy7, Rebif7 Betaseron, glatiramer, Glatopa Gilenya7, Mavenclad, Mayzent7, Tecfidera7, Vumerity Zeposia7 NUTRITIONAL/DIETARY PreGenna, Trinaz Any generic prenatal vitamin VitaTrue Combo Pack Prena1 True Combo Pack PAIN RELIEF AND INFLAMMATORY DISEASE Amerge, Frova, Maxalt, Maxalt MLT, Relpax generic triptans (e.g. naratriptan; sumatriptan) Generic medications start with a lowercase letter and brand name medications start with a capital letter. CIGNA TOTAL SAVINGS FORMULARY (cont)

Start date of Medications that will no longer Generic and/or preferred Drug class change*,** be covered^^ brand alternatives January 1, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE butalbital-acetaminophen 50-300mg tablet butalbutal-acetaminophen 50-325mg (cont) tablet diclofenac 1.3% patch, Flector 1.3% diclofenac 1% gel, oral generic Rx NSAIDs patch3,5, Voltaren 1% gel5 (e.g. celecoxib; meloxicam) Humira7 Actemra, Cimzia, Cosentyx, Enbrel, Simponi 100mg, Stelara, Tremfya Ilumya7, Otezla7, Skyrizi7 Cimzia, Cosentyx, Enbrel, Olumiant, Stelara, Tremfya Kevzara, Rinvoq7 Actemra, Cimzia, Enbrel, Olumiant Orencia Actemra, Cimzia, Cosentyx, Enbrel, Olumiant, Stelara Uloric febuxostat Xeljanz7, Xeljanz XR7 Actemra, Cimzia, Cosentyx, Enbrel, Olumiant, Simponi 100mg, Stelara SEIZURE DISORDERS Carbatrol, Tegretol XR carbamazepine ER capsule Depakote divalproex Depakote ER divalproex ER Depakote Sprinkle divalproex DR sprinkle capsule Felbatol11 felbamate Keppra/Keppra X11 levetiracetam/levetiracetam ER Lamictal XR Start Kit11 lamotrigine ER Lamictal/ODT/XR11 lamotrigine, lamotrigine ER, lamotrigine ODT Onfi clobazam Qudexy XR11, Trokendi XR11 topiramate ER Sabril11 vigabatrin, vigadrone Topamax11 topiramate Trileptal11 oxcarbazepine Zonegran11 zonisamide SKIN CONDITIONS Apexicon E5, diflorasone, Impoyz5, Olux5, betamethasone, clobetasol, halobetasol Olux-E5, Psorcon7 Condylox imiquimod 5% cream packet, podofilox 0.5% topical solution Cordran5 betamethasone, clobetasol, fluocinolone, fluticasone, halobetasol Elidel pimecrolimus cream Finacea, MetroCream, MetroGel, azelaic acid, topical metronidazole MetroLotion, Soolantra12 flurandrenolide, hydrocortisone butyrate betamethasone, fluocinolone, fluticasone lipid cream, lotion5, Pandel5

Generic medications start with a lowercase letter and brand name medications start with a capital letter. CIGNA TOTAL SAVINGS FORMULARY (cont)

Start date of Medications that will no longer Generic and/or preferred Drug class change*,** be covered^^ brand alternatives January 1, 2021 SKIN CONDITIONS (cont) Tridesilon5 alclometasone, desonide, triamcinolone Xolegel ciclopirox 0.77% gel, ciclopirox 1% shampoo, ketoconazole 2% cream, ketoconazole 2% foam, selenium 2.5% lotion, sodium sulfacetamide 10% shampoo SLEEP DISORDERS/SEDATIVES Belsomra8 Dayvigo TRANSPLANT MEDICATIONS Myfortic mycophenolic acid Prograf tacrolimus URINARY TRACT CONDITIONS Procysbi4 Cystagon Start date of Medications that will be Drug class Additional information change*,** excluded from coverage January 1, 2021 ALLERGY/NASAL SPRAYS Beconase AQ, Nasonex, Omnaris, Qnasl, flunisolide, fluticasone, mometasone Qnasl Children, Xhance, Zetonna, flunisolide, mometasone spray generics products available over-the- counter (e.g. budesonide, fluticasone) fluticasone 50 mcg spray generics products available over-the- counter (e.g. budesonide) EYE CONDITIONS azelastine, epinastine products available over-the-counter (e.g. Alaway, Pataday) Bepreve, Lastacaft, Pazeo, Zerviate azelastine, epinastine eye drops SKIN CONDITIONS Rosadan Kits azelaic acid, topical metronidazole

CIGNA NATIONAL PRESCRIPTION DRUG LIST

Start date of Drug class Medications moving to preferred brand change*,** May 7, 2021 CANCER Tabrecta1 April 16, 2021 BLOOD PRESSURE/HEART MEDICATIONS Verquvo April 2, 2021 CANCER Xtandi MULTIPLE SCLEROSIS Plegridy1 March 19, 2021 MULTIPLE SCLEROSIS Mayzent 0.25 MG Starter Pack February 19, 2021 MULTIPLE SCLEROSIS Aubagio1 Start date of Medications becoming Generic and/or preferred Drug class change*,** non-preferred brand brand alternatives April 2, 2021 URINARY TRACT CONDITIONS Gemtesa 75mg tablet darifenacin er, oxybutynin chloride er, tolterodine tartrate er, trospium chloride, Myrbetriq, Toviaz ER March 19, 2021 BLOOD PRESSURE/HEART MEDICATIONS Orladeyo1 Takhzyro INFECTIONS Dificid 40mg/ml suspension vancomycin hcl February 5, 2021 EYE CONDITIONS Eysuvis 0.25% Eye Drops loteprednol etabonate, artificial tears January 22, 2021 INFECTIONS Alinia 500mg Tablet nitazoxanide Generic medications start with a lowercase letter and brand name medications start with a capital letter. CIGNA NATIONAL PRESCRIPTION DRUG LIST cont.

Start date of Medications becoming Generic and/or preferred Drug class change*,** non-preferred brand brand alternatives January 16, 2021 HORMONAL AGENTS Mycapssa DR 20 mg capsule1 Somatuline Depot PARKINSON’S DISEASE Ongentys 50 mg capsule entacapone Start date of Drug class Medications that will need approval (prior authorization)^ change*,** May 17, 2021 BLOOD MODIFIERS/BLEEDING DISORDERS Nyvepria1 April 1, 2021 EYE CONDITIONS Eysuvis 0.25% ophthalmic suspension Lacrisert HORMONAL AGENTS Synarel1 January 16, 2021 HORMONAL AGENTS Mycapssa DR 20 mg capsule1 PARKINSON’S DISEASE Ongentys 50 mg capsule January 15, 2021 ASTHMA/COPD/RESPIRATORY Zokinvy1 Start date of Drug class Medications that will have a quantity limit change*,** May 17, 2021 CANCER Vitrakvi1 HORMONAL AGENTS Xyosted NUTRITIONAL/DIETARY Nascobal 500mcg/0.1ml nasal spray device PAIN RELIEF AND INFLAMMATORY DISEASE Humira 80mg/0.8ml pen1 SKIN CONDITIONS Condylox 0.5% gel May 17, 2021 SLEEP DISORDERS/SEDATIVES Hetlioz LQ 4mg/ml oral suspension1 May 3, 2021 NUTRITIONAL/DIETARY Calcium 667mg Phoslyra 667mg/5ml oral solution Renvela April 15, 2021 DIABETES Ozempic 4mg/3ml (1.34mg/ml) pre-filled pen April 1, 2021 ANXIETY/DEPRESSION/BIPOLAR DISORDER Pexeva PAIN RELIEF AND INFLAMMATORY DISEASE Xeljanz 1 mg/ml oral solution1 SKIN CONDITIONS Gentamicin 0.1% cream, ointment March 15, 2021 ASTHMA/COPD/RESPIRATORY Trikafta 100/50/75 mg-150 mg tablets1 BLOOD PRESSURE/HEART MEDICATIONS Verquvo NUTRITIONAL/DIETARY Velphoro 500 mg tablets SLEEP DISORDERS/SEDATIVES Xyrem1 Xywav1 March 2, 2021 ANTIPARKINSON DRUGS Inbrija 42 mg capsules1 ASTHMA/COPD/RESPIRATORY Trelegy Ellipta 200/62.5/25 mcg Zokinvy1 HORMONAL AGENTS Divigel 1.25 gram PARKINSON’S DISEASE Ongentys 25 mg, 50 mg capsules Generic medications start with a lowercase letter and brand name medications start with a capital letter. CIGNA NATIONAL PRESCRIPTION DRUG LIST cont.

Start date of Drug class Medications that will have a quantity limit change*,** March 2, 2021 SEIZURE DISORDERS Fintepla 2.2 mg/ml oral solution1 February 15, 2021 CONTRACEPTION PRODUCTS Phexxi February 5, 2021 EYE CONDITIONS Eysuvis 0.25% ophthalmic suspension Start date of Medications being added to Generic and/or preferred Drug class change*,** Step Therapy Program^,^^ brand alternatives April 15, 2021 INFECTIONS Vibramycin cap, suspension, and syrup Doxycycline, Minocycline SKIN CONDITIONS Kerydin generic (Tavaborale) Ciclodan 8% topical solution (branded generic), ciclopirox 8% topical solution, ciclopirox 8% treatment kit Start date of Medications that will no longer Generic and/or preferred Drug class change*,** be covered^^ brand alternatives May 16, 2021 AIDS/HIV Cabenuva suspension atazanavir, lamivudine, Dovato, Edurant, Juluca, Prezista, Tivicay CANCER Tepmetko1 Tabrecta CONTRACEPTION PRODUCTS Tyblume altavera, aviane, falmina, lessina, levonor- eth etrad, portia, vienva PAIN RELIEF AND INFlAMMATORY DISEASE Reditrex methotrexage inj, Rasuvo SKIN CONDITIONS Tazarotene 0.1% foam tazarotene cream, Tazorac gel TRANSPLANT MEDICATIONS Lupkynis1 mycophenolate, prednisone April 16, 2021 CANCER Orgovyx1 Eligard, Firmagon Riabni 100mg/10ml, 500mg/50ml vial1 Ruxience GASTROINTESTINAL/HEARTBURN Reltone 200 mg, 400 mg capsule ursodiol HORMONAL AGENTS Thyquidity euthyrox, levo-t, levothyroxine, levoxyl SKIN CONDITIONS Impeklo 0.05% Lotion betamethasone dipropionate, clobetasol, desonide, desoximetasone, diflorasone, fluocinonide, halcinonide Klisyri 1% ointment packet diclofenac 3% gel, fluorouracil 5% cream, solution, imiquimod 5% cream April 1, 2021 ANXIETY/DEPRESSION/BIPOLAR DISORDER Pexeva, Viibryd citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline BLOOD PRESSURE/HEART MEDICATIONS Bystolic atenolol, carvedilol, metoprolol succinate Edarbi candesartan, irbesartan, losartan, olmesartan, telmisartan, valsartan Edarbyclor candesartan-HCTZ, irbesartan-HCTZ, losartan-HCTZ, olmesartan-HCTZ, telmisartan-HCTZ, valsartan-HCTZ, chlorthalidone plus valsartan CONTRACEPTION PRODUCTS Annovera generic oral contraceptives, Xulane patches Balcoltra Aviane, Larissia, Lessina, levonorgestrel-eth estradiol, Sronyx, Vienva Lo Loestrin FE Blisolvi FE, Blisolvi 24 FE, Hailey FE, Junel FE, Larin FE, Melodetta 24 FE, norethindrone- eth estradiol FE

Generic medications start with a lowercase letter and brand name medications start with a capital letter. CIGNA NATIONAL PRESCRIPTION DRUG LIST cont.

Start date of Medications that will no longer Generic and/or preferred Drug class change*,** be covered^^ brand alternatives April 1, 2021 CONTRACEPTION PRODUCTS Natazia Blisolvi FE, drospirenone-ethinyl estradiol, Estarylla, Junel FE, Sprintec, Tri-Sprintec Slynd generic progestin-only oral contraceptives Taytulla Gemmily, norethindrone-eth estradiol FE DIABETES Afrezza Humalog, Lyumjev GASTROINTESTINAL/HEARTBURN Clenpiq Gavilyte-G, peg-electrolyte solution, peg- 3350, Trilyte with Flavor packets. Golytely Packets Gavilyte-G, peg-electrolyte solution, peg- 3350, Trilyte with Flavor packets. Plenvu Gavilyte-G, peg-electrolyte solution, peg- 3350, Trilyte with Flavor packets. Suprep Gavilyte-G, peg-electrolyte solution, peg- 3350, Trilyte with Flavor packets. HORMONAL AGENTS Osphena estradiol (cream), Yuvafem, Estring, Premarin (cream) Premarin Tablets estradiol tablets Premphase Amabelz, estradiol-norethindrone acetate, Fyavolv, Jinteli, Mimvey, norethindrone- ethinyl estradiol Prempro Amabelz, estradiol-norethindrone acetate, Fyavolv, Jinteli, Mimvey, norethindrone- ethinyl estradiol SKIN CONDITIONS Drysol Over the counter alternatives. March 16, 2021 GASTROINTESTINAL/HEARTBURN Lubiprostone 8 mcg, 24 mcg capsule Linzess, Trulance PAIN RELIEF AND INFLAMMATORY DISEASE Zolmitriptan 2.5 mg, 5 mg Nasal Spray sumatriptan nasal, Zomig nasal SKIN CONDITIONS Wynzora 0.005%-0.064% Cream betamethasone dipropionate, calcipotriene- betamethasone dipropionate, clobetasol propionate, diflorasone diacetate, calcipotriene (generic), Enstilar URINARY TRACT CONDITIONS Vesicare LS 5 MG/5 ML supension oxybutynin, oxybutynin ER March 12, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE Qdolo 5 MG/ML Solution tramadol (generic tablet) March 2, 2021 BLOOD PRESSURE/HEART MEDICATIONS Conjupri amlodipine, felodipine, nifedipine, nicardipine GASTROINTESTINAL/HEARTBURN Sutab 1.479-0.225-0.188 GM tab Gavilyte-G, peg-electrolyte solution, peg- 3350, Trilyte with Flavor packets. SKIN CONDITIONS Winlevi 1% cream clindamycin topical, clindamycin-tretionin, erythromycin topical, tretinoin, Amzeeq, Onexton February 5, 2021 EYE CONDITIONS Eysuvis 0.25% Eye Drops loteprednol etabonate, artificial tears

Generic medications start with a lowercase letter and brand name medications start with a capital letter. Drug lists used by patients who purchase their own health plan CIGNA ESSENTIAL PRESCRIPTION DRUG LIST (for Colorado and Utah)

Medications moving to a New cost-share tier Generic and/or preferred brand alternatives higher cost-share tier Descovy T4 emtricitabine/tenofovir disoproxil fumarate 200mg-300mg (generic Truvada) vancomycin capsule T4 Firvanq Medications that will need approval Additional information (prior authorization) capecitabine Your patient can only receive this medication if you request and receive approval from Cigna. deferasirox Descovy Nuedexta penicillamine teriparatide 620mcg/2.48ml (generic Forteo) tobramycin 300mg/5ml inhalation Vascepa Medications being added to the Step Generic and/or preferred brand alternatives Therapy program Xeljanz XR1 Humira (needs approval) Xeljanz1

Medications that will no longer be covered Generic and/or preferred brand alternatives

Afinitor Tablet everolimus tablet alogliptin Onglyza alogliptin/metformin Kombiglyze XR alogliptin/pioglitazone Kombiglyze XR Apriso ER mesalamine Atripla efavirenz/emtricitabine/tenofovir df Cuprimine penicillamine Depen penicillamine Exjade deferasirox Firazyr icatibant Forteo teriparatide Glucagen Gvoke Glucagon Gvoke Jadenu Sprinkle & Tablet deferasirox Letairis ambrisentan Levocarnitine IV levocarnitine solution or tablet Lyrica pregabalin Moxeza moxifloxacin hcl Prudoxin doxepin 5% cream Generic medications start with a lowercase letter and brand name medications start with a capital letter. CIGNA ESSENTIAL PRESCRIPTION DRUG LIST (for Colorado and Utah) cont.

Medications that will no longer be covered Generic and/or preferred brand alternatives

Samsca tolvaptan Saphris asenapine maleate Sensipar cinacalcet Tarceva erlotinib hcl Tracleer 62.5mg & 125mg bosentan Truvada 200mg-300mg emtricitabine/tenofovir disoproxil fumarate 200mg-300mg (generic Truvada) Tykerb lapatinib ditosylate Zortress everolimus

Medications that will be excluded from coverage Additional information

Iodosorb Gel Talk with your patient about switching to a covered alternative. Lugol's Strong Iodine Solution

CIGNA PLUS PRESCRIPTION DRUG LIST (for Illinois, Kansas, Missouri, North Carolina and Tennessee)

Medications moving to a New cost-share tier Generic and/or preferred brand alternatives higher cost-share tier vancomycin capsule T4 Firvanq Descovy T4 emtricitabine/tenofovir disoproxil fumarate 200mg-300mg (generic Truvada)

Medications that will need approval Additional information (prior authorization) capecitabine Your patient can only receive this medication if you request and receive deferasirox approval from Cigna. Descovy Ferriprox Fycompa Nuedexta penicillamine teriparatide 620mcg/2.48ml (generic Forteo) tobramycin 300mg/5ml inhalation trientine Vascepa Medications being added to the Step Generic and/or preferred brand alternatives Therapy program Xeljanz XR1 Humira (needs approval) Xeljanz1

Generic medications start with a lowercase letter and brand name medications start with a capital letter. CIGNA PLUS PRESCRIPTION DRUG LIST (for Illinois, Kansas, Missouri, North Carolina and Tennessee) cont.

Medications that will no longer be covered Generic and/or preferred brand alternatives

Afinitor Tablet everolimus tablet alogliptin Onglyza alogliptin/metformin Kombiglyze XR alogliptin/pioglitazone Kombiglyze XR Apriso ER mesalamine Atripla efavirenz/emtricitabine/tenofovir df Carnitor SF Oral Solution levocarnitine sf oral solution Cuprimine penicillamine Depen penicillamine Dyrenium triamterene Exjade deferasirox Firazyr icatibant Forteo teriparatide Glucagen Gvoke Glucagon Gvoke Halog 0.1% Cream halcinonide Jadenu Sprinkle & Tablet deferasirox Letairis ambrisentan Levocarnitine IV levocarnitine solution or tablet Lotemax 0.5% Eye Drops loteprednol etabonate 0.5% eye drops Lyrica pregabalin Moxeza moxifloxacin hcl Naftin 1% Gel naftifine hcl 1% gel Nascobal cyanocobalamin inj Noxafil DR 100mg Tablet posaconazole 100mg tablet Prudoxin doxepin 5% cream Restasis cyclosporine eye drops Samsca tolvaptan Saphris asenapine maleate Sensipar cinacalcet Suprax 400mg Capsule cefixime 400mg capsule Tarceva erlotinib hcl Tracleer 62.5mg & 125mg bosentan Truvada 200mg-300mg emtricitabine/tenofovir disoproxil fumarate 200mg-300mg (generic Truvada) Tykerb lapatinib ditosylate Uloric febuxostat

Medications that will no longer be covered Generic and/or preferred brand alternatives

Velphoro sucroferric oxyhydroxide Zortress everolimus

Medications that will be excluded from coverage Additional information

Iodosorb Gel Talk with your patient about switching to a covered alternative. Lugol's Strong Iodine Solution

CIGNA PLUS PRESCRIPTION DRUG LIST (for Florida)

Medications moving to a New cost-share tier Generic and/or preferred brand alternatives higher cost-share tier vancomycin capsule T4 Firvanq Medications that will need approval Additional information (prior authorization) capecitabine Your patient can only receive this medication if you request and receive deferasirox approval from Cigna. Descovy Ferriprox Fycompa Nuedexta Your patient can only receive this medication if you request and receive penicillamine approval from Cigna. teriparatide 620mcg/2.48ml (generic Forteo) tobramycin 300mg/5ml inhalation trientine Truvada 200mg-300mg Vascepa Medications being added to the Step Generic and/or preferred brand alternatives Therapy program Xeljanz XR1 Humira (needs approval) Xeljanz1

Medications that will no longer be covered Generic and/or preferred brand alternatives

Afinitor Tablet everolimus tablet alogliptin Onglyza alogliptin/metformin Kombiglyze XR alogliptin/pioglitazone Kombiglyze XR Apriso ER mesalamine Carnitor SF Oral Solution levocarnitine sf oral solution Generic medications start with a lowercase letter and brand name medications start with a capital letter. CIGNA PLUS PRESCRIPTION DRUG LIST (for Florida) cont.

Medications that will no longer be covered Generic and/or preferred brand alternatives

Cuprimine penicillamine Depen penicillamine Dyrenium triamterene Exjade deferasirox Firazyr icatibant Forteo teriparatide Glucagen Gvoke Glucagon Gvoke Halog 0.1% Cream halcinonide Jadenu Sprinkle & Tablet deferasirox Letairis ambrisentan Levocarnitine IV levocarnitine solution or tablet Lotemax 0.5% Eye Drops loteprednol etabonate 0.5% eye drops Lyrica pregabalin Moxeza moxifloxacin hcl Naftin 1% Gel naftifine hcl 1% gel Nascobal cyanocobalamin inj Noxafil DR 100mg Tablet posaconazole 100mg tablet Prudoxin doxepin 5% cream Restasis cyclosporine eye drops Samsca tolvaptan Saphris asenapine maleate Sensipar cinacalcet Suprax 400mg Capsule cefixime 400mg capsule Tarceva erlotinib hcl Tracleer 62.5mg & 125mg bosentan Tykerb lapatinib ditosylate Uloric febuxostat Velphoro sucroferric oxyhydroxide Zortress everolimus

Medications that will be excluded from coverage Additional information

Iodosorb Gel Talk with your patient about switching to a covered alternative. Lugol's Strong Iodine Solution

Generic medications start with a lowercase letter and brand name medications start with a capital letter. CIGNA PREMIERE PRESCRIPTION DRUG LIST (for Arizona and Virginia)

Medications moving to a New cost-share tier Generic and/or preferred brand alternatives higher cost-share tier Descovy T4 emtricitabine/tenofovir disoproxil fumarate 200mg-300mg (generic Truvada) vancomycin capsule T4 Firvanq Medications that will need approval Additional information (prior authorization) capecitabine Your patient can only receive this medication if you request and receive deferasirox approval from Cigna. Descovy Ferriprox Fycompa Nuedexta penicillamine teriparatide 620mcg/2.48ml (generic Forteo) tobramycin 300mg/5ml inhalation trientine Vascepa

Medications being added to the Step Generic and/or preferred brand alternatives Therapy program Xeljanz XR1 Humira (needs approval) Xeljanz1

Medications that will no longer be covered Generic and/or preferred brand alternatives

Letairis ambrisentan Levocarnitine IV levocarnitine solution or tablet Lotemax 0.5% Eye Drops loteprednol etabonate 0.5% eye drops Lyrica pregabalin Moxeza moxifloxacin hcl Naftin 1% Gel naftifine hcl 1% gel Nascobal cyanocobalamin inj Noxafil DR 100mg Tablet posaconazole 100mg tablet Prudoxin doxepin 5% cream Restasis cyclosporine eye drops Samsca tolvaptan Saphris asenapine maleate Sensipar cinacalcet Suprax 400mg Capsule cefixime 400mg capsule Tarceva erlotinib hcl Tracleer 62.5mg & 125mg bosentan Truvada 200mg-300mg emtricitabine/tenofovir disoproxil fumarate 200mg-300mg (generic Truvada) Tykerb lapatinib ditosylate Uloric febuxostat Velphoro sucroferric oxyhydroxide Zortress everolimus

Medications that will be excluded from coverage Additional information

Iodosorb Gel Talk with your patient about switching to a covered alternative. Lugol's Strong Iodine Solution

Generic medications start with a lowercase letter and brand name medications start with a capital letter. * State laws in Texas and Louisiana may require your plan to cover these medications at the current benefit level until your plan renews. This means that if the medication is taken off the drug list, is moved to a higher cost-share tier or needs approval from Cigna before your plan will cover it, these changes may not begin until your plan’s renewal date. Customers can call the number on their Cigna ID card to find out if these state laws apply to your plan. ** State law in Illinois may require your plan to cover these medications at your current benefit level until your plan renews. This means that if customers currently have prior authorization for your plan to cover the medication, the drug list change(s) listed here may not affect them until your plan renewal date. If customers do not currently have prior authorization, they may continue to receive coverage at the current benefit level if their doctor requests it. Customers can call the number on their Cigna ID card to find out if this state law applies to your plan. 1. This is a specialty drug. For plans that cover specialty drugs on a specialty tier, this change won’t affect its cost. 2. If your plan has Member Pay Difference (MPD), the MPD penalty will apply to this drug as of 1/1/21. However, if your plan allows for Dispense as Written (DAW) and the doctor requests the brand, the penalty won’t apply. 3. These changes may not apply to your specific plan. Not all plans include requirements for prior authorization, quantity limits and/or Step Therapy. 4. For new prescriptions only. This change won’t affect customers currently taking this drug. 5. Current authorizations will expire 1/1/21. There is a “medical necessity” review process in place for customers who want to continue using this drug. 6. There is a “medical necessity” review process in place for customers who have proven they have exhausted drug alternatives and want to use a drug moving to not-covered status. 7. If Cigna approves continued coverage of this drug, the customer will pay a higher cost-share to fill the prescription. 8. This drug will no longer part of Step Therapy as of 1/1/21. Current authorizations will expire 1/1/21. There is a “medical necessity” review process in place for customers who want to continue using this drug. However, if Cigna approves continued coverage, the customer will pay a higher cost-share to fill the prescription. 9. This drug will no longer part of Step Therapy as of 1/1/21. Current authorizations will expire 1/1/21. There is a “medical necessity” review process in place for customers who want to continue using this drug. 10. Current authorizations will expire 1/1/21. There is a “medical necessity” review process in place for customers who want to continue using this drug. However, if Cigna approves continued coverage, the customer will pay a higher cost-share to fill the prescription. 11. This change doesn’t affect customers currently taking this drug to treat a seizure condition. Current authorizations will expire 1/1/21. There is a “medical necessity” review process in place for customers who want to continue using this drug. 12. If Cigna approves continued coverage of this drug, the customer will pay a higher cost-share to fill the prescription. This drug may also be subject to a MPD penalty. 13. This change won’t affect customers currently taking this drug until their current authorization expires. 14. This drug also requires prior authorization as of 1/1/21. 15. This drug will be part of Step Therapy as of 1/1/21. Current authorizations will expire 1/1/21. There is a “medical necessity” review process in place for customers who want to continue using this drug. 16. There is a “medical necessity” review process in place for customers who have proven they have exhausted drug alternatives and want to use a Step Therapy drug.

Cigna reserves the right to make changes to the Drug List without notice. Your plan may cover additional medications; please refer to your enrollment materials for details. Cigna does not take responsibility for any medication decisions made by the doctor or pharmacist. Cigna may receive payments from manufacturers of certain preferred brand medications, and in limited instances, certain non-preferred brand medications, that may or may not be shared with your plan depending on its arrangement with Cigna. Depending upon plan design, market conditions, the extent to which manufacturer payments are shared with your plan and other factors as of the date of service, the preferred brand medication may or may not represent the lowest-cost brand medication within its class for you and/or your plan. Health benefit plans vary, but in general to be eligible for coverage a drug must be approved by the Food and Drug Administration (FDA), prescribed by a health care professional, purchased from a licensed pharmacy and medically necessary. If your plan provides coverage for certain prescription drugs with no cost-share, you may be required to use an in-network pharmacy to fill the prescription. If you use a pharmacy that does not participate in your plan’s network, your prescription may not be covered, or reimbursement may be limited by your plan’s copayment, coinsurance or deductible requirements. Certain features described in this document may not be applicable to your specific health plan, and plan features may vary by location and plan type. Refer to your plan documents for costs and complete details of your plan’s prescription drug coverage. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, and HMO or service company subsidiaries of Cigna Health Corporation. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. 951714 © 2021 Cigna. Some content provided under license. CRP2012_007122.1 UPDATED_05/21/2021