Prescription Drug List Changes

PRESCRIPTION DRUG LIST CHANGES

Cigna Pharmacy Management® 2018

The medications listed below are changing coverage (or cost levels) on Cigna’s Prescription Drug List. Changes are listed by drug list name and by the date they begin. If you’re enrolled with Cigna, you can log into myCigna.com to find out how these changes may affect your specific plan.

STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST

Start date Generic and/or preferred Drug class Medication not covered^ of change* brand alternatives January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipramine Pamelor nortriptyline Parnate tranylcypromine Tofranil imipramine ASTHMA/COPD/RESPIRATORY Zyflo montelukast, zafirlukast, zileuton ER Zyflo CR zileuton ER ATTENTION DEFICIT HYPERACTIVITY Desoxyn methamphetamine DISORDER Dexedrine dextroamphetamine, dextroamphetamine ER BLOOD PRESSURE/HEART MEDICATIONS Betapace sotalol tablets CANCER Nilandron nilutamide DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR Invokana Farxiga, Jardiance Lantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba Novolin, Novolog Humalog, Humulin GASTROINTESTINAL/HEARTBURN Cortifoam, Uceris rectal foam Anucort-HC, Colocort, Hemmorex-HC, hydrocortisone, Procto-Med HC, Procto- Pak, Proctosol-HC, Proctozone-HC Lotronex alosetron Marinol dronabinol omeprazole bicarbonate packets, omeprazole 40-1100mg capsules Rowasa mesalamine enema Uceris tablet budesonide EC capsule

909015 UPDATED_10/17/2017 STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont)

Start date Generic and/or preferred Drug class Medication not covered^ of change* brand alternatives January 1, 2018 GASTROINTESTINAL/HEARTBURN (cont) Zegerid omeprazole Zofran ondansetron Zofran ODT ondansetron ODT HORMONAL AGENTS DDAVP desmopressin Hectorol doxercalciferol capsule INFECTIONS Augmentin, Augmentin ES, Augmentin XR amoxicillin-clavulanate ER, amoxicillin- clavulanate Diflucan fluconazole E.E.S. 200, Eryped 400 erythromycin ethylsuccinate Mepron atovaquone Sporanox itraconazole Targadox Avidoxy tablet, doxycycline hyclate, Morgidox capsule Valcyte valganciclovir Vancocin vancomycin capsule Zovirax acyclovir MISCELLANEOUS Gralise, Horizant gabapentin PAIN RELIEF AND INFLAMMATORY DISEASE Cambia diclofenac, diclofenac ER, etodolac, etodolac ER, fenoprofen, Fenortho, flurbiprofen, ibuprofen, indomethacin, indomethacin ER, ketoprofen, Ketorolac, meclofenamate, mefenamic acid, meloxicam, nabumetone D.H.E. 45, Migranal dihydroergotamine Imitrex, Sumavel DosePro sumatriptan Lorzone chlorzoxazone OxyContin Embeda, Hysingla ER, Xtampza ER Roxicodone oxycodone Tivorbex indomethacin Vanatol LQ butalbital/acetaminophen/caffeine tabs or caps Vivlodex meloxicam Zomig sumatriptan, zolmitriptan Zorvolex diclofenac, diclofenac ER PARKINSON'S DISEASE Lodosyn carbidopa Requip XL ropinirole ER SCHIZOPHRENIA/ANTI-PSYCHOTICS Geodon ziprasidone Zyprexa olanzapine Zyprexa Zydis olanzapine ODT STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont)

Start date Generic and/or preferred Drug class Medication not covered^ of change* brand alternatives January 1, 2018 SKIN CONDITIONS Cutivate fluticasone cream Kenalog triamcinolone spray Locoid lotion hydrocortisone butyrate Luzu ketoconazole cream Soriatane acitretin Ziana clindamycin-tretinoin SLEEP DISORDERS/SEDATIVES Nuvigil armodafinil Provigil modafinil Restoril temazepam URINARY TRACT CONDITIONS Detrol tolterodine Detrol LA tolterodine ER Ditropan XL oxybutynin ER Enablex darifenacin ER Gelnique darifenacin ER, oxybutynin ER, tolterodine ER, trospium ER Start date Non-preferred brand Generic and/or preferred Drug class of change* medication brand alternatives January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal spray ATTENTION DEFICIT HYPERACTIVITY Adderall XR dextroamphetamine-amphetamine ER DISORDER Focalin XR dexmethylphenidate ER SKIN CONDITIONS Ala-Scalp hydrocortisone Analpram HC lotion hydrocortisone-pramoxine Capex shampoo fluocinolone Cordran flurandrenolide Differin adapalene Metrogel metronidazole gel Naftin naftifine Nucort, Texacort hydrocortisone Start date Medication requiring prior Drug class Additional information of change* authorization January 1, 2018 GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Your plan will only cover this medication if Sancuso, Varubi your doctor requests and receives approval HORMONAL AGENTS Androderm, Androgel, Striant, testosterone from Cigna. Start date Drug class Medication with quantity limits Additional information of change* January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone Your plan only covers a certain amount ALZHEIMER'S DISEASE Namenda XR, Namzaric of this medication over a certain number ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine 25mg, 100mg, Marplan, of days. Your plan will only cover a larger Pristiq amount if your doctor requests and receives approval from Cigna. ASTHMA/COPD/RESPIRATORY Perforomist BLOOD PRESSURE/HEART MEDICATIONS Ranexa CANCER Fareston, nilutamide EYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont)

Start date Drug class Medication with quantity limits Additional information of change* January 1, 2018 HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Your plan only covers a certain amount Minivelle, Vagifem, Vivelle-Dot, yuvafem of this medication over a certain number MISCELLANEOUS Nuedexta of days. Your plan will only cover a larger OSTEOPOROSIS PRODUCTS alendronate amount if your doctor requests and receives approval from Cigna. PAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, Mitigare SCHIZOPHRENIA/ Fanapt ANTI-PSYCHOTICS SEIZURE DISORDERS Gabitril, Potiga SKIN CONDITIONS Denavir, Regranex, Santyl, Vectical SLEEP DISORDERS/SEDATIVES Hetlioz Start date Generic and/or preferred Drug class Step Therapy medication^^ of change* brand alternatives January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY Focalin XR dexmethylphenidate ER DISORDER SCHIZOPHRENIA/ANTI-PSYCHOTICS Orap pimozide SKIN CONDITIONS Ala-Scalp hydrocortisone Capex shampoo fluocinolone Cordran flurandrenolide Nucort, Texacort hydrocortisone Medication strength with Covered medication strength Start date limitations++ (Your plan doesn’t (Prescription must be for Drug class of change* cover 2 capsules/tablets per 1 capsule/tablet per day of day of this strength) this strength) January 1, 2018 ALLERGY/NASAL SPRAYS desloratadine ODT 2.5mg desloratadine ODT 5mg ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg Fetzima ER 40mg Fetzima ER 80mg Trintellix 5mg Trintellix 10mg Trintellix 10mg Trintellix 20mg BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg Benicar 20mg Benicar 40mg Benicar HCT 20-12.5mg Benicar HCT 40-25mg Bystolic 10mg Bystolic 20mg Tekturna 150mg Tekturna 300mg Tekturna HCT 150-12.5mg Tekturna HCT 300-25mg CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg Livalo 2mg Livalo 4mg DIABETES Farxiga 5mg Farxiga 10mg PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont)

PERFORMANCE PRESCRIPTION DRUG LIST

Start date Non-preferred brand Generic and/or preferred Drug class of change* medication brand alternatives January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal spray ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER DIABETES Lantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Tresiba, Levemir GASTROINTESTINAL/HEARTBURN omeprazole bicarbonate packet, omeprazole 40mg-1100mg capsule, 20mg-1100mg INFECTIONS Eryped 400 erythromycin PAIN RELIEF AND INFLAMMATORY DISEASE OxyContin Embeda, Hysingla ER, Xtampza ER Vanatol LQ butalbital/acetaminophen/caffeine tabs or caps SKIN CONDITIONS Ala-Scalp hydrocortisone topical Capex shampoo fluocinolone scalp Cordran flurandrenolide topical Differin adapalene Kenalog spray triamcinolone spray Locoid lotion hydrocortisone butyrate Metrogel metronidazole gel Naftin naftifine Nucort, Texacort hydrocortisone Start date Medication requiring prior Drug class Additional information of change* authorization January 1, 2018 DIABETES Lantus, Lantus SoloStar, Toujeo SoloStar Your plan will only cover this medication if GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi your doctor requests and receives approval HORMONAL AGENTS Androderm, Androgel, Axiron, Fortesta, from Cigna. Natesto, Striant, Testim, Testopel, testosterone, Vogelxo PAIN RELIEF AND INFLAMMATORY DISEASE Roxicodone Start date Drug class Medication with quantity limits Additional information of change* January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone, Nasonex Your plan only covers a certain amount ALZHEIMER'S DISEASE Namenda XR, Namzaric of this medication over a certain number ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine 25mg, 100mg, Marplan, of days. Your plan will only cover a larger Pristiq amount if your doctor requests and ASTHMA/COPD/RESPIRATORY Perforomist receives approval from Cigna. PERFORMANCE PRESCRIPTION DRUG LIST (cont)

Start date Drug class Medication with quantity limits Additional information of change* January 1, 2018 BLOOD PRESSURE/HEART MEDICATIONS Ranexa Your plan only covers a certain amount CANCER Fareston, Nilandron, nilutamide of this medication over a certain number DIABETES Jentadueto, Tradjenta of days. Your plan will only cover a larger amount if your doctor requests and EYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan receives approval from Cigna. HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle Dot, yuvafem INFECTIONS Zovirax MISCELLANEOUS Nuedexta OSTEOPOROSIS PRODUCTS alendronate PAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, Mitigare SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify Maintena, Aristada, Fanapt, Invega Trinza, Risperdal Consta, Zyprexa Relprevv SEIZURE DISORDERS Gabitril, Potiga SKIN CONDITIONS Denavir, Regranex, Santyl, Vectical, Zyclara SLEEP DISORDERS/SEDATIVES Hetlioz Start date Generic and/or Preferred Drug class Step Therapy medication^^ of change* Brand Alternatives January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER Focalin XR dexmethylphenidate ER SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify aripiprazole Orap pimozide SKIN CONDITIONS Locoid lotion hydrocortisone butyrate SLEEP DISORDERS/SEDATIVES Silenor eszopiclone, zolpidem Medication strength with Covered medication strength Start date limitations++ (Your plan doesn’t (Prescription must be for Drug class of change* cover 2 capsules/tablets per 1 capsule/tablet per day of day of this strength) this strength) January 1, 2018 ALLERGY/NASAL SPRAYS desloratadine ODT 2.5mg desloratadine ODT 5mg ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg Fetzima ER 40mg Fetzima ER 80mg Trintellix 5mg Trintellix 10mg Trintellix 10mg Trintellix 20mg BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg Benicar 20mg Benicar 40mg Benicar HCT 20-12.5mg Benicar HCT 40-25mg Bystolic 10mg Bystolic 20mg Tekturna 150mg Tekturna 300mg Tekturna HCT 150-12.5mg Tekturna HCT 300-25mg CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg Livalo 2mg Livalo 4mg DIABETES Farxiga 5mg Farxiga 10mg PERFORMANCE PRESCRIPTION DRUG LIST (cont)

VALUE PRESCRIPTION DRUG LIST

Start date Non-preferred brand Generic and/or preferred Drug class of change* medication brand alternatives January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal spray ASTHMA/COPD/RESPIRATORY Spiriva, Spiriva Respimat Incruse Ellipta Stiolto Respimat Anoro Ellipta ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER Focalin XR dexmethylphenidate ER DIABETES Apidra Humalog Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR Invokana Farxiga, Jardiance Kombiglyze XR, Onglyza alogliptin, alogliptin-metformin, Janumet, Janumet XR, Januvia Toujeo Basaglar, Tresiba, Levemir PAIN RELIEF AND INFLAMMATORY DISEASE D.H.E. 45 dihydroergotamine Imitrex sumatriptan OxyContin Embeda, Hysingla ER, Xtampza ER Vanatol LQ butalbital/acetaminophen/caffeine tabs or caps Zomig nasal spray sumatriptan, zolmitriptan SKIN CONDITIONS Differin adapalene Metrogel metronidazole gel Naftin naftifine Start date Medication requiring prior Drug class Additional information of change* authorization January 1, 2018 DIABETES Lantus, Lantus SoloStar, Toujeo SoloStar Your plan will only cover this medication if GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend capsule, powder your doctor requests and receives approval packet, tripack, Sancuso, Varubi from Cigna. HORMONAL AGENTS Androderm, Androgel, Axiron, Fortesta, Natesto, Striant, Testim, Testopel, testosterone, Vogelxo PAIN RELIEF AND INFLAMMATORY DISEASE Roxicodone VALUE PRESCRIPTION DRUG LIST (cont)

Start date Drug class Medication with quantity limits Additional information of change* January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, Nasonex, mometasone Your plan only covers a certain amount ALZHEIMER'S DISEASE Namenda XR, Namzaric of this medication over a certain number of days. Your plan will only cover a larger ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine ER, Marplan, Pristiq amount if your doctor requests and ASTHMA/COPD/RESPIRATORY Perforomist receives approval from Cigna. BLOOD PRESSURE/HEART MEDICATIONS Ranexa CANCER Fareston, Nilandron, nilutamide DIABETES Jentadueto, Tradjenta EYE CONDITIONS bimatoprost, Cystaran, Zioptan HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem INFECTIONS Zovirax MISCELLANEOUS Nuedexta OSTEOPOROSIS PRODUCTS alendronate PAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, Mitigare SCHIZOPHRENIA/ANTI-PSYCHOTICS Fanapt SEIZURE DISORDERS Gabitril, Potiga SKIN CONDITIONS Denavir, Regranex, Santyl, Vectical, Zyclara SLEEP DISORDERS/SEDATIVES Hetlioz Start date Generic and/or preferred Drug class Step Therapy medication^^ of change* brand alternatives January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER Focalin XR dexmethylphenidate ER DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR Invokana Farxiga, Jardiance SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify aripiprazole Orap pimozide SKIN CONDITIONS Locoid lotion hydrocortisone butyrate SLEEP DISORDERS/SEDATIVES Silenor zolpidem, eszopiclone Medication strength with Covered medication strength Start date limitations++ (Your plan doesn’t (Prescription must be for Drug class of change* cover 2 capsules/tablets per 1 capsule/tablet per day of day of this strength) this strength) January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg Fetzima ER 40mg Fetzima ER 80mg Trintellix 5mg Trintellix 10mg Trintellix 10mg Trintellix 20mg BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg Benicar 20mg Benicar 40mg Benicar HCT 20-12.5mg Benicar HCT 40-25mg VALUE PRESCRIPTION DRUG LIST (cont)

Medication strength with Covered medication strength Start date limitations++ (Your plan doesn’t (Prescription must be for Drug class of change* cover 2 capsules/tablets per 1 capsule/tablet per day of day of this strength) this strength) January 1, 2018 BLOOD PRESSURE/HEART MEDICATIONS Bystolic 10mg Bystolic 20mg (cont) Tekturna 150mg Tekturna 300mg Tekturna HCT 150-12.5mg Tekturna HCT 300-25mg CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg Livalo 2mg Livalo 4mg DIABETES Farxiga 5mg Farxiga 10mg PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg Aptiom 400mg Aptiom 800mg Fycompa 4mg Fycompa 8mg Fycompa 6mg Fycompa 12mg Trokendi XR 25mg Trokendi XR 50mg Trokendi XR 100mg Trokendi XR 200mg SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg

ADVANTAGE PRESCRIPTION DRUG LIST

Start date Non-preferred brand Generic and/or preferred Drug class of change* medication brand alternatives January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal spray ASTHMA/COPD/RESPIRATORY Spiriva, Spiriva Respimat Incruse Ellipta Stiolto Respimat Anoro Ellipta ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR Invokana Farxiga, Jardiance Kombiglyze XR, Onglyza alogliptin, alogliptin-metformin, Janumet, Janumet XR, Januvia Toujeo Basaglar, Tresiba, Levemir PAIN RELIEF AND INFLAMMATORY DISEASE OxyContin Embeda, Hysingla ER, Xtampza ER Vanatol LQ butalbital/acetaminophen/caffeine tabs or caps SKIN CONDITIONS Differin adapalene Metrogel metronidazole gel Naftin naftifine Start date Medication requiring Drug class Additional information of change* prior authorization January 1, 2018 DIABETES Lantus, Lantus SoloStar, Toujeo SoloStar Your plan will only cover this medication if GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi your doctor requests and receives approval HORMONAL AGENTS Androderm, Androgel, Axiron, Fortesta, from Cigna. Natesto, Striant, Testim, Testopel, Vogelxo, testosterone gel, Vogelxo PAIN RELIEF AND INFLAMMATORY DISEASE Roxicodone ADVANTAGE PRESCRIPTION DRUG LIST (cont)

Start date Drug class Medication with quantity limits Additional information of change* January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, Nasonex, mometasone Your plan only covers a certain amount ALZHEIMER'S DISEASE Namenda XR, Namzaric of this medication over a certain number ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine ER, Marplan, Pristiq of days. Your plan will only cover a larger ASTHMA/COPD/RESPIRATORY Perforomist amount if your doctor requests and receives approval from Cigna. BLOOD PRESSURE/HEART MEDICATIONS Ranexa CANCER Fareston, Nilandron, nilutamide DIABETES Jentadueto, Tradjenta EYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem INFECTIONS Zovirax MISCELLANEOUS Nuedexta OSTEOPOROSIS PRODUCTS alendronate PAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, Mitigare SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify Maintena, Aristada, Fanapt, Invega Trinza, Risperdal Consta, Zyprexa Relprevv SEIZURE DISORDERS Gabitril, Potiga SKIN CONDITIONS Denavir, Regranex, Santyl, Vectical, Zyclara SLEEP DISORDERS/SEDATIVES Hetlioz Start date Generic and/or preferred Drug class Step Therapy medication^^ of change* brand alternatives January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY Adderall XR dextroamphetamine-amphetamine ER DISORDER Focalin XR dexmethylphenidate ER DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR Invokana Farxiga, Jardiance SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify aripiprazole Orap pimozide SKIN CONDITIONS Locoid lotion hydrocortisone butyrate SLEEP DISORDERS/SEDATIVES Silenor eszopiclone, zaleplon, zolpidem, zolpidem ER Medication strength with Covered medication strength Start date limitations++ (Your plan doesn’t (Prescription must be for Drug class of change* cover 2 capsules/tablets per 1 capsule/tablet per day of day of this strength) this strength) January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg Fetzima ER 40mg Fetzima ER 80mg Trintellix 5mg Trintellix 10mg Trintellix 10mg Trintellix 20mg BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg Benicar 20mg Benicar 40mg Benicar HCT 20-12.5mg Benicar HCT 40-25mg ADVANTAGE PRESCRIPTION DRUG LIST (cont)

LEGACY PRESCRIPTION DRUG LIST

Start date Medication requiring prior Drug class Additional information of change* authorization January 1, 2018 DIABETES Lantus, Lantus SoloStar, Toujeo SoloStar Your plan will only cover this medication if GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend capsule, powder your doctor requests and receives approval packet, tripack, Sancuso, Varubi from Cigna. HORMONAL AGENTS Androderm, Androgel, Axiron, Fortesta, Natesto, Striant, Testim, testosterone, Vogelxo PAIN RELIEF AND INFLAMMATORY DISEASE Roxicodone Start date Drug class Medication with quantity limits Additional information of change* January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, Nasonex, mometasone Your plan only covers a certain amount ALZHEIMER'S DISEASE Namenda XR, Namzaric of this medication over a certain number ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine 25mg, 100mg, Marplan, of days. Your plan will only cover a larger Pristiq amount if your doctor requests and receives approval from Cigna. ASTHMA/COPD/RESPIRATORY Perforomist BLOOD PRESSURE/HEART MEDICATIONS Ranexa CANCER Fareston, Nilandron, nilutamide DIABETES Jentadueto, Tradjenta EYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem INFECTIONS Zovirax MISCELLANEOUS Nuedexta OSTEOPOROSIS PRODUCTS alendronate PAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, Mitigare SCHIZOPHRENIA/ANTI-PSYCHOTICS Fanapt SEIZURE DISORDERS Gabitril, Potiga SKIN CONDITIONS Denavir, Regranex, Santyl, Vectical, Zyclara SLEEP DISORDERS/SEDATIVES Hetlioz Start date Generic and/or preferred Drug class Step Therapy medication^^ of change* brand alternatives January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER Focalin XR dexmethylphenidate ER SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify aripiprazole Orap pimozide SKIN CONDITIONS Locoid lotion hydrocortisone butyrate SLEEP DISORDERS/SEDATIVES Silenor eszopiclone, zolpidem Medication strength with Covered medication strength Start date limitations++ (Your plan doesn’t (Prescription must be for Drug class of change* cover 2 capsules/tablets per 1 capsule/tablet per day of day of this strength) this strength) January 1, 2018 ALLERGY/NASAL SPRAYS desloratadine ODT 2.5mg desloratadine ODT 5mg ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg Fetzima ER 40mg Fetzima ER 80mg LEGACY PRESCRIPTION DRUG LIST (cont)

Medication strength with Covered medication strength Start date limitations++ (Your plan doesn’t (Prescription must be for Drug class of change* cover 2 capsules/tablets per 1 capsule/tablet per day of day of this strength) this strength) January 1, 2018 ANXIETY/DEPRESSION/ Trintellix 5mg Trintellix 10mg BIPOLAR DISORDER (cont) Trintellix 10mg Trintellix 20mg BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg Benicar 20mg Benicar 40mg Benicar HCT 20-12.5mg Benicar HCT 40-25mg Bystolic 10mg Bystolic 20mg Tekturna 150mg Tekturna 300mg Tekturna HCT 150-12.5mg Tekturna HCT 300-25mg CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg Livalo 2mg Livalo 4mg DIABETES Farxiga 5mg Farxiga 10mg PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg Aptiom 400mg Aptiom 800mg Fycompa 4mg Fycompa 8mg Fycompa 6mg Fycompa 12mg Trokendi XR 25mg Trokendi XR 50mg Trokendi XR 100mg Trokendi XR 200mg SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg

PERFORMANCE PRESCRIPTION DRUG LIST (with additional medications not covered)

Start date Generic and/or preferred Drug class Medication not covered^ of change* brand alternatives January 1, 2018 GASTROINTESTINAL/HEARTBURN Cortifoam, Uceris rectal foam Colocort, Hemmorex-HC, hydrocortisone, Procto-Med HC, Procto-Pak, Proctosol-HC, Proctozone-HC Marinol dronabinol omeprazole bicarbonate packet, 40mg- omeprazole 1100mg capsule, 20mg-1100mg Rowasa mesalamine enema Uceris tablet budesonide EC capsule Zegerid omeprazole Zofran ondansetron Zofran ODT ondansetron ODT HORMONAL AGENTS Cortrosyn cosyntropin DDAVP desmopressin Hectorol doxercalciferol INFECTIONS Augmentin, Augmentin ES, Augmentin XR amoxicillin-clavulanate ER, amoxicillin- clavulanate Diflucan fluconazole E.E.S. 200, Eryped 400 erythromycin Mepron atovaquone Sporanox itraconazole Targadox Avidoxy, demeclocycline, doxycycline, doxycycline IR-DR, minocycline, minocycline ER, mondoxyne NL, Morgidox capsule, tetracycline Valcyte valganciclovir Vancocin vancomycin capsule Zovirax acyclovir PAIN RELIEF AND INFLAMMATORY DISEASE Cambia diclofenac, diclofenac ER, etodolac, etodolac ER, fenoprofen, Fenortho, flurbiprofen, ibuprofen, indomethacin, indomethacin ER, ketoprofen, Ketorolac, meclofenamate, mefenamic acid, meloxicam, nabumetone D.H.E. 45, Migranal dihydroergotamine Gralise, Horizant gabapentin Imitrex, Sumavel DosePro sumatriptan Lorzone chlorzoxazone OxyContin Embeda, Hysingla ER, Xtampza ER Roxicodone oxycodone Tivorbex indomethacin Vanatol LQ butalbital/acetaminophen/caffeine tabs or caps Vivlodex meloxicam Zomig sumatriptan, zolmitriptan Zorvolex diclofenac, diclofenac ER PERFORMANCE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont)

Start date Generic and/or preferred Drug class Medication not covered^ of change* brand alternatives January 1, 2018 PARKINSON'S DISEASE Lodosyn carbidopa Requip XL ropinirole ER SCHIZOPHRENIA/ANTI-PSYCHOTICS Geodon capsule ziprasidone Zyprexa tablet olanzapine Zyprexa Zydis olanzapine ODT SKIN CONDITIONS Cutivate fluticasone Kenalog topical spray triamcinolone Locoid hydrocortisone Luzu ketoconazole Soriatane acitretin Ziana clindamycin-tretinoin SLEEP DISORDERS/SEDATIVES Nuvigil armodafinil Provigil modafinil Restoril temazepam URINARY TRACT CONDITIONS Detrol tolterodine Detrol LA tolterodine ER Ditropan XL oxybutynin ER Enablex darifenacin ER Gelnique darifenacin ER, oxybutynin ER, tolterodine ER, trospium ER Start date Non-preferred brand Generic and/or preferred Drug class of change* medication brand alternatives January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal spray ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER SKIN CONDITIONS Ala-Scalp hydrocortisone Analpram HC lotion hydrocortisone-pramoxine Capex shampoo fluocinolone Cordran flurandrenolide Differin adapalene Metrogel metronidazole gel Naftin naftifine Nucort, Texacort hydrocortisone Start date Medication requiring prior Drug class Additional information of change* authorization January 1, 2018 GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi Your plan will only cover this medication if HORMONAL AGENTS Androderm, Androgel, Striant, Testopel, your doctor requests and receives approval testosterone from Cigna. Start date Drug class Medication with quantity limits Additional information of change* January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone Your plan only covers a certain amount ALZHEIMER'S DISEASE Namenda XR, Namzaric of this medication over a certain number of days. Your plan will only cover a larger amount if your doctor requests and receives approval from Cigna. PERFORMANCE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont)

Start date Drug class Medication with quantity limits Additional information of change* January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER desvanlafaxine 25mg, 100mg, Marplan, Your plan only covers a certain amount Pristiq of this medication over a certain number ASTHMA/COPD/RESPIRATORY Perforomist of days. Your plan will only cover a larger amount if your doctor requests and BLOOD PRESSURE/HEART MEDICATIONS Ranexa receives approval from Cigna. CANCER Fareston, nilutamide EYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem MISCELLANEOUS Nuedexta OSTEOPOROSIS PRODUCTS alendronate PAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, Mitigare SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify Maintena, Aristada, Fanapt, Invega Trinza, Risperdal Consta, Zyprexa Relprevv SEIZURE DISORDERS Gabitril, Potiga SKIN CONDITIONS Denavir, Regranex, Santyl, Vectical SLEEP DISORDERS/SEDATIVES Hetlioz Start date Generic and/or preferred Drug class Step Therapy medication^^ of change* brand alternatives January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER Focalin XR dexmethylphenidate ER SCHIZOPHRENIA/ANTI-PSYCHOTICS Orap pimozide SLEEP DISORDERS/SEDATIVES Silenor eszopiclone, zolpidem Medication strength with Covered medication strength Start date limitations++ (Your plan doesn’t (Prescription must be for Drug class of change* cover 2 capsules/tablets per 1 capsule/tablet per day of day of this strength) this strength) January 1, 2018 ALLERGY/NASAL SPRAYS desloratadine ODT 2.5mg desloratadine ODT 5mg ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg Fetzima ER 40mg Fetzima ER 80mg Trintellix 5mg Trintellix 10mg Trintellix 10mg Trintellix 20mg BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg Benicar 20mg Benicar 40mg Benicar HCT 20-12.5mg Benicar HCT 40-25mg Bystolic 10mg Bystolic 20mg Tekturna 150mg Tekturna 300mg Tekturna HCT 150-12.5mg Tekturna HCT 300-25mg CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg Livalo 2mg Livalo 4mg DIABETES Farxiga 5mg Farxiga 10mg PERFORMANCE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont)

VALUE PRESCRIPTION DRUG LIST (with additional medications not covered)

Start date Generic and/or preferred Drug class Medication not covered^ of change* brand alternatives January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipramine Pamelor nortriptyline Parnate tranylcypromine Tofranil imipramine ASTHMA/COPD/RESPIRATORY Spiriva, Spiriva Respimat Incruse Ellipta Stiolto Respimat Anoro Ellipta Zyflo montelukast, zafirlukast, zileuton ER Zyflo CR zileuton ER ATTENTION DEFICIT HYPERACTIVITY Desoxyn methamphetamine DISORDER Dexedrine dextroamphetamine, dextroamphetamine ER BLOOD PRESSURE/HEART MEDICATIONS Betapace sotalol tablet CANCER Nilandron nilutamide DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR Invokana Farxiga, Jardiance Kombiglyze XR, Onglyza alogliptin, alogliptin-metformin, Janumet, Janumet XR, Januvia Lantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba EYE CONDITIONS Alocril, Alomide cromolyn eye drops Bepreve, Emadine, Lastacaft, Pataday, azelastine, epinastine, olopatadine Patanol, Pazeo Elestat epinastine GASTROINTESTINAL/HEARTBURN Marinol dronabinol Rowasa mesalamine enema Zofran ondansetron Zofran ODT ondansetron ODT VALUE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont)

Start date Generic and/or preferred Drug class Medication not covered^ of change* brand alternatives January 1, 2018 HORMONAL AGENTS DDAVP nasal spray, tablet desmopressin nasal spray, tablets Hectorol doxercalciferol INFECTIONS Augmentin, Augmentin ES, Augmentin XR amoxicillin-clavulanate ER, amoxicillin-clavulanate Diflucan fluconazole E.E.S. 200, Eryped 400 erythromycin Mepron atovaquone Sporanox itraconazole Targadox doxycycline Valcyte valganciclovir Vancocin vancomycin capsule Zovirax acyclovir PAIN RELIEF AND INFLAMMATORY DISEASE D.H.E. 45, Migranal dihydroergotamine Imitrex sumatriptan OxyContin Embeda, Hysingla ER, Xtampza ER Roxicodone oxycodone Vanatol LQ butalbital/acetaminophen/caffeine tabs or caps Zomig sumatriptan, zolmitriptan PARKINSON'S DISEASE Lodosyn carbidopa Requip XL ropinirole ER SCHIZOPHRENIA/ANTI-PSYCHOTICS Geodon ziprasidone Zyprexa tablet olanzapine tablet Zyprexa Zydis olanzapine ODT SKIN CONDITIONS Acanya, Atralin, Avita, Azelex, Differin, Aczone, adapalene, Ala-Cort, Epiduo, Epiduo Forte, Fabior, Onexton, alclometasone, amcinonide, Apexicon E, Retin-A, Retin-A Micro, Tretin-X, Veltin Avar, Avar-E, BenzePRO, benzoyl peroxide, betamethasone, BP 10-1, BPO, Clindacin ETZ, Clindacin P, clindamycin, clindamycin- benzoyl peroxide, clindamycin-tretinoin, clobetasol, clocortolone, Clodan, Cormax, desonide, desoximetasone, fluocinolone, halobetasol, hydrocortisone, Micort-HC, mometasone, prednicarbate, Psorcon, Scalacort, tretinoin, triamcinolone, Trianex, Triderm Cutivate fluticasone Dovonex, Sorilux calcipotriene Enstilar, Taclonex calcipotriene-betamethasone DP Soriatane acitretin VALUE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont)

Start date Generic and/or preferred Drug class Medication not covered^ of change* brand alternatives January 1, 2018 SKIN CONDITIONS (cont) Tazorac adapalene, Ala-Cort, alclometasone, amcinonide, Apexicon E, Avar, Benzepro, benzoyl peroxide, betamethasone, BP 10-1, BPO, Clindacin ETZ, Clindacin P, clindamycin, clobetasol, clocortolone, Clodan, Cormax, desonide, desoximetasone, fluocinolone, halobetasol, hydrocortisone, Micort-HC, mometasone, prednicarbate, Psorcon, Scalacort, triamcinolone, Trianex, Triderm Vectical calcitriol ointment SLEEP DISORDERS/SEDATIVES Nuvigil armodafinil Provigil modafinil Restoril temazepam URINARY TRACT CONDITIONS Detrol, Detrol LA, Ditropan XL, Enablex, darifenacin ER, oxybutynin ER, tolterodine, Gelnique tolterodine ER, trospium ER Start date Non-preferred brand Generic and/or preferred Drug class of change* medication brand alternatives January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER Start date Medication requiring prior Drug class Additional information of change* authorization January 1, 2018 GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend capsule, Your plan will only cover this medication if powder packet, tripack, Sancuso, Varubi your doctor requests and receives approval HORMONAL AGENTS Androderm, Androgel, Striant testosterone from Cigna. Start date Drug class Medication with quantity limits Additional information of change* January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone Your plan only covers a certain amount ALZHEIMER'S DISEASE Namenda XR, Namzaric of this medication over a certain number of days. Your plan will only cover a larger ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine ER, Marplan amount if your doctor requests and ASTHMA/COPD/RESPIRATORY Perforomist receives approval from Cigna. BLOOD PRESSURE/HEART MEDICATIONS Ranexa CANCER Fareston, nilutamide EYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem MISCELLANEOUS Nuedexta OSTEOPOROSIS PRODUCTS alendronate PAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, Mitigare SCHIZOPHRENIA/ANTI-PSYCHOTICS Fanapt SEIZURE DISORDERS Gabitril, Potiga SKIN CONDITIONS Denavir, Regranex, Santyl SLEEP DISORDERS/SEDATIVES Hetlioz VALUE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont)

Start date Generic and/or preferred Drug class Step Therapy medication^^ of change* brand alternatives January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER Focalin XR dexmethylphenidate ER SCHIZOPHRENIA/ANTI-PSYCHOTICS Orap pimozide SLEEP DISORDERS/SEDATIVES Silenor zolpidem, eszopiclone Medication strength with Covered medication strength Start date limitations++ (Your plan doesn’t (Prescription must be for Drug class of change* cover 2 capsules/tablets per 1 capsule/tablet per day of day of this strength) this strength) January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg Fetzima ER 40mg Fetzima ER 80mg Trintellix 5mg Trintellix 10mg Trintellix 10mg Trintellix 20mg DIABETES Farxiga 5mg Farxiga 10mg PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg Aptiom 400mg Aptiom 800mg Fycompa 4mg Fycompa 8mg Fycompa 6mg Fycompa 12mg Trokendi XR 25mg Trokendi XR 50mg Trokendi XR 100mg Trokendi XR 200mg SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg

ADVANTAGE PRESCRIPTION DRUG LIST (with additional medications not covered)

Start date Generic and/or preferred Drug class Medication not covered^ of change* brand alternatives January 1, 2018 DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR Invokana Farxiga, Jardiance Kombiglyze XR, Onglyza alogliptin, alogliptin-metformin, Janumet, Janumet XR, Januvia Lantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba EYE CONDITIONS Alocril, Alomide cromolyn eye drops Bepreve, Emadine, Lastacaft, Pataday, azelastine, epinastine, olopatadine Patanol, Pazeo Elestat epinastine GASTROINTESTINAL/HEARTBURN Marinol dronabinol Rowasa mesalamine enema Zofran ondansetron Zofran ODT ondansetron ODT HORMONAL AGENTS Cortrosyn cosyntropin DDAVP desmopressin Hectorol doxercalciferol INFECTIONS Augmentin, Augmentin ES, Augmentin XR amoxicillin-clavulanate ER, amoxicillin-clavulanate Diflucan fluconazole E.E.S. 200, Eryped 400 erythromycin Mepron atovaquone Sporanox itraconazole Targadox doxycycline Valcyte valganciclovir Vancocin vancomycin capsule Zovirax acyclovir PAIN RELIEF AND INFLAMMATORY DISEASE D.H.E. 45, Migranal dihydroergotamine Imitrex sumatriptan OxyContin Embeda, Hysingla ER, Xtampza ER Roxicodone oxycodone Vanatol LQ butalbital/acetaminophen/caffeine tabs or caps Zomig sumatriptan, zolmitriptan PARKINSON'S DISEASE Lodosyn carbidopa Requip XL ropinirole ER SCHIZOPHRENIA/ANTI-PSYCHOTICS Geodon ziprasidone Zyprexa tablet olanzapine Zyprexa Zydis olanzapine ODT ADVANTAGE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont)

Start date Generic and/or preferred Drug class Medication not covered^ of change* brand alternatives January 1, 2018 SKIN CONDITIONS Acanya, Atralin, Avita, Azelex, Differin, Aczone, adapalene, Ala-Cort, Epiduo, Epiduo Forte, Fabior, Onexton, alclometasone, amcinonide, Apexicon E, Retin-A, Retin-A Micro, Tretin-X, Veltin Avar, Avar-E, BenzePRO, benzoyl peroxide, betamethasone, BP 10-1, BPO, Clindacin ETZ, Clindacin P, clindamycin, clindamycin- benzoyl peroxide, clindamycin-tretinoin, clobetasol, clocortolone, Clodan, Cormax, desonide, desoximetasone, fluocinolone, halobetasol, hydrocortisone, Micort-HC, mometasone, prednicarbate, Psorcon, Scalacort, tretinoin, triamcinolone, Trianex, Triderm Cutivate fluticasone Dovonex, Sorilux calcipotriene Enstilar, Taclonex calcipotriene-betamethasone DP Soriatane acitretin Tazorac adapalene, Ala-Cort, alclometasone, amcinonide, Apexicon E, Avar, Avar-E, Benzepro, benzoyl peroxide, betamethasone, BP 10-1, BPO, Clindacin ETZ, Clindacin P, clindamycin, clobetasol, clocortolone, Clodan, Cormax, desonide, desoximetasone, fluocinolone, halobetasol, hydrocortisone, Micort-HC, mometasone, prednicarbate, Psorcon, Scalacort, triamcinolone, Trianex, Triderm Vectical calcitriol SLEEP DISORDERS/SEDATIVES Nuvigil armodafinil Provigil modafinil Restoril temazepam URINARY TRACT CONDITIONS Detrol tolterodine Detrol LA tolterodine ER Ditropan XL oxybutynin ER Enablex darifenacin ER Gelnique darifenacin ER, oxybutynin ER, tolterodine ER, trospium ER Start date Non-preferred brand Generic and/or preferred Drug class of change* medication brand alternatives January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER ADVANTAGE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont)

Start date Medication requiring prior Drug class Additional information of change* authorization January 1, 2018 GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Your plan will only cover this medication if Sancuso, Varubi your doctor requests and receives approval HORMONAL AGENTS Androderm, Androgel, Striant, from Cigna. Testopel, testosterone Start date Drug class Medication with quantity limits Additional information of change* January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone Your plan only covers a certain amount ALZHEIMER'S DISEASE Namenda XR, Namzaric of this medication over a certain number ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine ER, Marplan of days. Your plan will only cover a larger amount if your doctor requests and ASTHMA/COPD/RESPIRATORY Perforomist receives approval from Cigna. BLOOD PRESSURE/HEART MEDICATIONS Ranexa CANCER Fareston, nilutamide EYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem MISCELLANEOUS Nuedexta OSTEOPOROSIS PRODUCTS alendronate PAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, Mitigare SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify Maintena, Aristada, Fanapt, Invega Trinza, Risperdal Consta, Zyprexa Relprevv SEIZURE DISORDERS Gabitril, Potiga SKIN CONDITIONS Denavir, Regranex, Santyl SLEEP DISORDERS/SEDATIVES Hetlioz Start date Generic and/or preferred Drug class Step Therapy medication^^ of change* brand alternatives January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER Focalin XR dexmethylphenidate ER SCHIZOPHRENIA/ANTI-PSYCHOTICS Orap pimozide SLEEP DISORDERS/SEDATIVES Silenor eszopiclone, zaleplon, zolpidem, zolpidem ER Medication strength with Covered medication strength Start date limitations++ (Your plan doesn’t (Prescription must be for Drug class of change* cover 2 capsules/tablets per 1 capsule/tablet per day of day of this strength) this strength) January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg Fetzima ER 40mg Fetzima ER 80mg Trintellix 5mg Trintellix 10mg Trintellix 10mg Trintellix 20mg DIABETES Farxiga 5mg Farxiga 10mg PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg ADVANTAGE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont)

* State laws in Texas and Louisiana require your plan to cover your medications at your current benefit level until your plan renews. This means that if your medication is taken off the drug list, is moved to a higher cost-share tier or needs approval, your plan can’t make these changes until your renewal date. To find out if these state laws apply to your plan, please call Customer Service using the number on the back of your ID card. ++ Your plan doesn’t cover more than one tablet/capsule in this strength a day. If your doctor feels a higher strength of this medication once each day isn’t right for you, he or she can ask Cigna to consider approving coverage of your current medication strength. ^ These medications require approval from Cigna before they’re covered by your plan. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving coverage of your medication. ^^ This is a Step Therapy medication. Step Therapy medications aren’t covered by your plan without approval from Cigna. In Step Therapy, you have to try lower-cost alternatives first before the higher-cost brand medication may be covered. Typically, you start by taking generics or lower-cost preferred brands.

Cigna reserves the right to make changes to the Drug List without notice.

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, Cigna Health Management, Inc., 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., and Cigna HealthCare of Texas, Inc. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. 909015 © 2017 Cigna. Some content provided under license. UPDATED_10/17/2017