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SPECIALTY PHARMACY DRUG LIST

Specialty medications are used to treat complex conditions like , hepatitis C and . The following is a list of specialty medications. Those medications marked with an asterisk must be obtained through Cigna Home Delivery Pharmacy for it to be covered. This only applies when the medication is covered under the pharmacy benefit and when your plan requires the use of Cigna Home Delivery Pharmacy for specialty medications. Please note, this list is subject to change.

Drug Name A Alimta Atripla Bleo 15K Cholbam abacavir Alkeran Aubagio* chorionic abacavir-lamivudine- Aloxi Avastin Blincyto gonadotropin zidovudine Alphanate* Avonex* Boniva* cidofovir Abraxane Alphanine SD* Bosulif* Cimzia* Actemra* Alprolix* Azasan* Botox Cinqair Acthrel Amicar* * Bravelle Cinryze Busulfex Actimmune* B Adagen aminocaproic acid* Baraclude* C Adcetris Ampyra* Clolar BCG Vaccine (Tice Cabometyx Adcirca* Amvisc Coagadex Strain) Folinate adefovir dipivoxil* Amvisc Plus Combivir Bebulin* Campath Adempas * Cometriq Beleodaq Camptosar Adriamycin Anzemet Complera Bendeka* * Adrucil Apokyn* Copaxone* Benefix* Caprelsa Advate* Aptivus Copegus* Benlysta Adynovate* Aralast NP Corifact Berinert Carimune NF* Afinitor* Aranesp Cosentyx* Betaseron* Casodex* Afinitor Disperz Arcalyst Cosmegen Bethkis* Cayston Afstyla argatroban Cotellic* * Cellcept Agrylin* Arixtra Crixivan Bexxar Ceprotin* Akynzeo Arranon * Bicalutamide* Cerdelga* Aldurazyme* Arzerra cyclosporine BICNU Cerezyme* Alecensa* Astagraf XL* cyclosporine (oral)* Bivigam* cetrotide Alferon N* Atgam Cyklokapron

Offered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, or their affiliates. 874932 j 08/16 © 2016 Cigna. Drug Name

Cyramza Erbitux Glassia Invirase Lupaneta Pack* Cystadane* Erivedge* Glatopa* Iprivask* Lupron Depot* Cystagon Erwinaze Gleevec* Iressa Lupron Depot-Ped* Esbriet* Gliadel Lynparza Cytogam etopophos Gonal-F Isentress Lysteda Cytovene Granix Istodax Euflexxa* Ixempra M D Evomela Ixinity* Macugen Evotaz Marqibo H Dacogen Exjade* J Matulane Daklinza* Extavia* H.P. Acthar* Jadenu* Mekinist* Darzalex* Eylea Halaven Jakafi Harvoni* Jetrea Menopur Daunoxome F Hecoria* Jevtana* DDAVP Fabrazyme* Helixate FS* Juxtapid Mesnex Farydak Hemofil M* (oral)* Defitelio* Faslodex Hepagam B K methotrexate (vial) Depocyt Feiba NF* Hepsera* Kadcyla MICRhoGAM Descovy Firazyr* Herceptin Kalbitor Mircera desmopressin Firmagon Hexalen* Kaletra Mirena didanosine Flebogamma DIF* Hizentra* Kalydeco mitomycin Docefrez* Flolan Humate-P* Kanuma * floxuridine Humatrope* Kcentra Moderiba* Doxil fludarabine Humira* Kepivance Monoclate-P* fluorouracil Hyalgan* Keytruda Mononine* Duopa flutamide* Hycamtin* Keytruda Monovisc* Dysport* Follistim AQ Hylenex* Kineret* Mozobil Folotyn Hymovis* Kitabis Pak Mustargen E fondaparinux Hyperhep B S/D Koate-DVI* Myalept Edurant Forteo* Hyperrab S/D Kogenate FS* mycophenolate* Egrifta* Fragmin Hyperrho S/D Kovaltry* * Elaprase Fusilev Hyqvia Krystexxa Myfortic* Elelyso* Fuzeon Kuvan* Myobloc I Eligard* Kynamro Myozyme Elitek G ibandronate* Kyprolis* Ellence Gamastan S-D* Ibrance* N Eloctate* Gammagard* Iclusig L Nabi-HB Eloxatin Gammagard S-D* Idamycin PFS lamivudine Naglazyme Elspar Gammaked* lamivudine HBV Natpara Emcyt* Gammaplex Idelvion* lamivudine- Natrecor Emend Gamunex-C* Ifex zidovudine Navelbine Empliciti* ganciclovir sodium Lemtrada* Neoral* Emtriva ganirelix acetate ifosfamide-Mesna Lenvima Neulasta Enbrel* Gattex Ilaris* Letairis* Neulasta Onpro* enoxaparin Gazyva Iluvien leucovorin (oral)* Neumega entecavir* Gel-One* imatinib* leucovorin (vial) Neupogen Entyvio* Gelsyn-3* Imbruvica Leukine nevirapine Envarsus XR* Imlygic leuprolide* nevirapine ER Epclusa Gemzar Imogam Rabies-HT levoleucovorin Nexavar* Gengraf* Imuran* Lexiva Nexavir Epivir Genotropin* Incivek* Liletta Ninlaro Epivir HBV Genvisc 850* Increlex Lipodox Nipent Epogen Genvoya Infergen* Lonsurf Norditropin Flexpro* epoprostenol Gilenya* Inlyta* Lovenox Norditropin Epzicom Gilotrif Intelence Lucentis Nordiflex* Intron A* Lumizyme

2 Drug Name

Northera Privigen* Signifor LAR Tivicay Vivitrol* Norvir Procrit sildenafil* Tobi* Vonvendi Novarel Procysbi Simponi* Tobi Podhaler* Voraxaze Novoeight* Profilnine* Simponi Aria* tobramycin* Votrient* Novoseven RT* Prograf (inj) Simulect Toposar VPRIV* Nplate Prograf (oral)* * * Nucala* Prolastin C Skyla Torisel W Nulojix Proleukin Soliris Tracleer* Wilate* Nuplazid Prolia Somatuline Depot tranexamic acid WinRho SDF* Nutropin AQ* Promacta* Somavert Treanda X Nuwiq Provenge Sovaldi* Trelstar* Provisc Sprycel* Tretten Xalkori* O Pulmozyme* stavudine Trexall* Xeljanz* Obizur Purixan Stelara* Trisenox Xeljanz XR* Ocaliva Stimate Triumeq Xeloda* Octagam* R Stivarga* Trizivir Xenazine octreotide* Rapamune* Strensiq Truvada Xeomin* Odefsey Rasuvo Stribild Tybost Xgeva Odomzo* Rebetol* Sucraid Tykerb* Xiaflex* Ofev Rebif* Supartz* Tysabri* Xolair* Olysio* Rebif Rebidose* Supartz FX* Tyvaso Xtandi* Omnitrope* Reclast* Supprelin LA* Tyzeka* Xuriden Oncaspar Recombinate* Sustiva Xyntha* Onivyde Remicade* Sutent* U Xyrem Opdivo Remodulin Sylatron* Unituxin Y Opsumit* Repatha* Sylvant Uptravi Orencia (IV) Repronex Synagis* Yervoy V Orencia (SQ)* Rescriptor Synarel* Yondelis* Orenitram ER Retrovir Valchlor Synribo Z Orfadin Revatio* Synvisc* Valstar Orkambi Revlimid* Synvisc-One* Vantas* Zaltrap Orthovisc* Reyataz Varubi Zanosar Otezla* Rheumatrex T Vectibix Zarxio Otrexup RhoGam * Velcade Zavesca Ovidrel Rhophylac Tafinlar* Veletri Zelboraf* Riastap Tagrisso Venclexta Zemaira Ribasphere* Taltz* Ventavis Zemplar (inj) P Ribatab* Tarceva* Victrelis* Zemplar (oral)* ribavirin* Targretin* Vidaza Zepatier* pamidronate* Rilutek* Tasigna* Videx Zerit Panretin* riluzole* Taxotere* Videx EC Zevalin paricalcitol (vial) Rituxan Tecentriq* Viekira Pak* Ziagen paricalcitol (oral)* Rixubis* Tecfidera* Vimizim zidovudine Pegasys* Ruconest Technivie* Zinbryta Pegintron* Temodar (inj) Vincasar PFS Zoladex* Perjeta S Temodar (oral)* zoledronic acid* Photofrin Sabril * Zolinza Plegridy* Saizen* Viracept Zomacton* Pomalyst* Sandimmune tetrabenazine Viramune Zometa* Portrazza Sandimmune (oral)* Tev-Tropin* Viramune XR Zorbtive Praluent* Sandostatin* Thalomid* Virazole* Zortress* Praxbind Sandostatin LAR* Theracys Viread Zydelig Pregnyl Selzentry Vistide Zykadia Prezcobix Sensipar Thrombate III Vistogard Zytiga* Prezista Serostim* Thymoglobulin Visudyne Prialt Signifor Thyrogen Vitekta 3 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. Refer to your plan documents for costs and complete details of your plan’s coverage. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company (CHLIC), Connecticut General Life Insurance Company (CGLIC), Tel-Drug, Inc., Tel-Drug of Pennsylvania, L.L.C., and HMO or service company subsidiaries of Cigna Health Corporation, including Cigna HealthCare of Arizona, Inc., Cigna HealthCare of California, Inc., Cigna HealthCare of Colorado, Inc., Cigna HealthCare of Connecticut, Inc., Cigna HealthCare of Florida, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Illinois, Inc., Cigna HealthCare of Indiana, Inc., Cigna HealthCare of St. Louis, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of New Jersey, Inc., Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of Tennessee, Inc. (CHC-TN), and Cigna HealthCare of Texas, Inc. “Cigna Specialty Pharmacy Services” refers to the specialty drug division of Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C., doing business as Cigna Home Delivery Pharmacy. Policy forms: OK - HP-APP-1 et al (CHLIC), GM6000 C1 et al (CGLIC); TN - HP-POL43/HC-CER1V1 et al (CHLIC), GSA-COVER, et al (CHC-TN). The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. 874932 j 08/16 © 2016 Cigna. Some content provided under license.