PERFORMANCE prescription list

January 2015

The Performance Prescription Drug List lets you and your doctor choose that work best for you. The following is a list of the most commonly used medications covered under your plan.

This list is designed to cover your prescription medications at two levels. The amount you pay depends on the tier from which you and your doctor select your . If there is more than one medication appropriate for your condition, we suggest that you talk to your doctor about lower-cost choices like generic medications and preferred brand medications to see if they could be right for you.

Offered by: Connecticut General Life Insurance Company or Cigna Health and Life Insurance Company. 860415 c 02/15 Preventive Care Rx 1st Tier – Generic Medications: Generic medications have the same ingredients, safety, dosage, quality and strength as their brand name counterparts. You will usually pay less for generic medications under your plan. 2nd Tier – Preferred Brand Medications: Preferred brand medications will usually cost more than a generic, but less than a non-preferred brand medication under your plan.

The symbols on the list mean If a medication on the list has one of the following symbols, your doctor may need to get an authorization for coverage of that medication.

PA: Prior Authorization may be required for different reasons. To learn the requirements needed for coverage of a specific medication, feel free to give us a call. QL: Quantity Limit means you may have coverage for a limited amount of a specific medication. AGE: Age Requirement means an individual must be within a specific age group for a specific medication to be covered. ST: Step Therapy is a prior authorization program that requires you to try other medications available to treat the same condition before the “ST” medication is covered.

* Medications marked with an asterisk are considered to be specialty medications. Some plans may cover specialty medications at different benefit levels or may require the use of a preferred specialty pharmacy. Refer to the your plan documents for more information.

2 If you have any questions Remember, this list is just a sample of the most commonly used medications, and is subject to change. You can use the Prescription Drug Price Quote tool available on myCigna.com to see and compare the prices of all medications covered under your plan. Or, you can call the number on the back of your ID card to speak with a customer service representative at any time.

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4 Performance Prescription Drug List epinastine desloratadine HCl cyproheptadine cyproheptadine clemastine fumarate budesonide azelastine nasal azelastine HCl zidovudine* stavudine* nevirapine ER* nevirapine* lamivudine/zidovudine* lamivudine* didanosine* zidovudine* abacavir/lamivudine/ abacavir* modafanil methylphenidate ER/ER24HR methylphenidate HCl methamphetamine Metadate ER-methylphenidate HCl dextroamphetamine/amphetamine ER dextroamphetamine dexmethylphenidate HCl dexmethylphenidate HClER clonidine HCl amphetamine Generics

ADD/ADHD ANDSTIMULANTS ALLERGY AIDS/HIV Vyvanse Strattera Intuniv Focalin XR Adderall XR Veramyst Nasonex Epipen Jr. (QL) Epipen 2pk(QL) Astepro Viread* Viramune XR* Viracept* Truvada* Trizivir* Sustiva* Selzentry* Reyataz* Rescriptor* Prezista* Norvir* Lexiva* Kaletra* Isentress* Invirase* Fuzeon* (PA) Epzicom* Emtriva* Crixivan* Aptivus* Preferred Brands Generics Preferred Brands ALLERGY (CONTINUED) epinephrine (QL) flunisolide nasal fluticasone nasal hydroxyzine ipratropium nasal levocetirizine montelukast triamcinolone nasal

Alzheimer’s disease donepezil HCl galantamine hydrobromide rivastigmine tartrate capsules

ANXIETY alprazolam buspirone diazepam lorazepam oxazepam

ASTHMA AND RESPIRATORY albuterol sulfate (nebulizer solution) Advair, Advair HFA budesonide (nebulizer solution) Asmanex caffeine citrate Atrovent HFA cromolyn sodium (nebulizer solution) Combivent Respimat dyphylline Flovent Diskus/HFA guaifenesin/theophylline ProAir HFA ipratropium bromide (nebulizer solution) Pulmicort levalbuterol HCl (nebulizer solution) Pulmozyme* (PA) metaproterenol sulfate (syrup, tabs) QVAR montelukast sodium Serevent racepinephine HCl Spiriva sildenafil* (PA) Symbicort terbutaline sulfate Ventolin HFA theophylline anhydrous Xolair* (PA) zafirlukast

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6 Performance Prescription Drug List Leena Larin FE Larin Kurvelo Kelnor Kariva Junel FE Junel Jolessa Jencycla Introvale Heather Gildess Gildagia Gianvi Falmina ethinyl estradiol/drospirenone Estarylla Errin Enskyce Enpress Emoquette Elinest desogestrel-ethinyl estradiol Daysee Dasetta Cyclafem Cryselle Chateal Caziant Camrese Lo Camrese Camila Briellyn Balziva Azurette Aviane Aubra Aranelle Apri Amethyst Amethia Lo Amethia Alyacen Altavera Generics are covered underyour plan. specific to PlanDescription determine whetherthesemedications checkyourPlease Summary Ortho TriCyclenOrtho Lo Evra Ortho NuvaRing Minastrin 24FE LoSeasonique Lomedia 24FE BeYaz Preferred Brands Generics Preferred Brands BIRTH CONTROL (CONTINUED) Please check your Summary Plan Description to determine whether these medications are covered under your specific plan. Lessina Levonest levonorgestrel levonorgestrel-ethestra levonorgestrel-ethin estradiol Levora l-norgest-eth estr/ethin estra Loryna Low-Ogestrel Lutera Lyza Marlissa Microgestin Microgestin FE Mono-Linyah Mononessa Myzilra Necon Next Choice Nora-Be noreth a-et estra/fe fumarate noreth-ethinyl estradiol/iron norethindrone norgestimate-ethinyl estradiol norgestrel-ethinyl estradiol Nortrel Ocella Ogestrel Orsythia Philith Pimtrea Pirmella Portia Previfem Quasense Reclipsen Sprintec Sronyx Syeda Tilia FE Tri-Estarylla Tri-Legest FE Tri-Linyah Trinessa Tri-Previfem

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8 Performance Prescription Drug List trospium chloride tolterodine tartrate potassium citrate ER oxybutynin/XL flavoxate Zovia Zeosa Zenchent FE Zenchent Zarah Xulane Wymzya FE Wera Vyfemla Viorele Vestura Velivet Trivora Tri-Sprintec temozolomide* (PA) citrate lomustine letrozole flutamide* exemestane cyclophosphamide* capecitabine bicalutamide* azacitidine* anastrozole Generics are covered underyour plan. specific to PlanDescription determine whetherthesemedications checkyourPlease Summary BIRTH CONTROL (CONTINUED) BLADDER PROBLEMS BLADDER CANCER CANCER VESIcare Toviaz Elmiron Zolinza* (PA) Xeloda* Thalomid* (PA) Tarceva* (PA) Sutent* (PA) (PA)Sprycel* Revlimid* (PA) Nexavar* (PA) Neupogen* (PA) Neulasta* (PA) Myleran Matulane* Lysodren Lupron (PA) Depot* Leukeran Hexalen* Granix* Gleevec* (PA) Preferred Brands Generics Preferred Brands CARDIOVASCULAR THINNER/ANTI-CLOTTING anagrelide* Aggrenox cilostazol Arixtra* (QL) clopidogrel Effient dipyridamole Fragmin* (QL) enoxaparin* (QL) Xarelto fondaparinux* (QL) heparin Jantoven ticlopidine warfarin HIGH BLOOD PRESSURE/HEART MEDICATIONS acebutolol HCl Benicar acetazolamide Benicar HCT amiloride HCl Bystolic amlodipine besylate Coreg CR amlodipine besylate/ Exforge benazepril Exforge HCT amlodipine/ Tarka atorvastatin calcium Tekturna apresoline Tekturna HCT atenolol benazepril HCl benazepril HCl/amlodipine benazepril HCl/HCTZ bendroflumethiazide/nadolol betaxolol HCl bisoprolol fumarate bisoprolol/HCTZ bumetanide candesartan candesartan cilexetil candesartan HCTZ captopril captopril/HCTZ carvedilol chlorothiazide chlorthalidone chlorthalidone/atenolol clonidine clonidine HCl Clorpres diltiazem diltiazem 24HR ER doxazosin mesylate enalapril maleate enalapril maleate/HCTZ

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10 Performance Prescription Drug List spironolactone/HCTZ spironolactone sotalol HCl reserpine ramipril (caps only) quinapril HCl/HCTZ quinapril propranolol/HCTZ propranolol HCl prazosin HCl pindolol perindopril erbumine nimodipine nifedipine nicardipine HCl nadolol moexipril HCl/HCTZ moexipril HCl minoxidil metoprolol/HCTZ metoprolol tartrate metoprolol succinate metolazone methyldopa/HCTZ methyldopa methazolamide potassium/HCTZ losartan potassium losartan lisinopril/HCTZ lisinopril labetalol HCl isradipine irbesartan/HCTZ irbesartan indapamide hydrochlorothiazide/amilor HCl hydrochlorothiazide hydralazine HCl guanfacine furosemide fosinopril sodium/HCTZ fosinopril sodium felodipine mesylateeprosartan eplerenone Generics HIGH BLOOD PRESSURE/HEARTMEDICATIONS CARDIOVASCULAR Preferred Brands (CONTINUED) Generics Preferred Brands CARDIOVASCULAR (CONTINUED) HIGH BLOOD PRESSURE/HEART MEDICATIONS telmisartan telmisartan/amlodipine telmisartan/HCTZ terazosin HCl timolol maleate torsemide trandolapril triamterene/HCTZ valsartan valsartan/HCTZ Vecamyl-mecamylamine HCl verapamil verapamil SR OTHER amiodarone Multaq digoxin Nitrolingual spray disopyramide Tikosyn flecainide isosorbide dinitrate isosorbide mononitrate nitroglycerin procainamide propafenone SR

CHOLESTEROL LOWERING atorvastatin Crestor cholestyramine Lescol XL cholestyramine powder Lovaza cholestyramine/aspartame Simcor cholestyramine/sucrose Welchol colestipol Zetia fenofibrate fenofibric acid fluvastatin gemfibrozil lovastatin niacin omega-3-acid ethyl esters pravastatin sodium simvastatin

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12 Performance Prescription Drug List tolbutamide tolazamide repaglinide pioglitazone/ pioglitazone/glimepiride pioglitazone nateglinide metformin ER metformin HCl glyburide/metformin glyburide, micronized glyburide glipizide/metformin glipizide glimepiride chlorpropamide acarbose venlafaxine XR venlafaxine trazodone sertraline protriptyline paroxetine CR paroxetine nortriptyline mirtazapine imipramine fluvoxamine fluoxetine escitalopram duloxetine HCl desvenlafaxine desipramine citalopram bupropion SR bupropion amitriptyline Generics DEPRESSION DIABETES Wellbutrin XL Pristiq Preferred Brands Victoza SymlinPen Prandimet Onglyza One Touch test strips NovoLog Novolin NovoFine/NovoTwist needles Levemir Lantus SoloStar Lantus Kombiglyze XR Januvia Janumet XR Janumet Humulin Humalog Kit(QL)Glucagon Emergency GlucaGen HypoKit Byetta Bydureon (QL) BD InsulinSyringes/Pen Needles Apidra SoloStar Apidra ACCU-CHEK test strips Generics Preferred Brands ENDOCRINE AND METABOLIC – OTHER allopurinol Colcrys cabergoline (QL) Increlex* (PA) desmopressin* LupronDepot-PED* (PA) fluoxymesterone Megace ES octreotide* (PA) Nilandron Sandostatin LAR* (PA) Somavert* (PA) Uloric

EYE CONDITIONS apraclonidine HCl Alomide atropine Alphagan P 0.10% azelastine AzaSite brimonidine Azopt bromfenac Betoptic S bromfenac sodium Ciloxan (ointment) ciprofloxacin Iopidine diclofenac Lotemax (drops & gel) dorzolamide Maxidex dorzolamide/timolol Moxeza epinastine Pataday flurbiprofen Patanol gatifloxacin Restasis ketorolac Tobradex (ointment) latanoprost Travatan Z levofloxacin Vexol pilocarpine Vigamox timolol tobramycin/dexamethasone travoprost trifluridine

GASTROINTESTINAL (NOT HEARTBURN/ULCER) balsalazide Apriso belladonna alkaloids/ Asacol HD phenobarbital Canasa budesonide Creon cromolyn sodium (solution) Delzicol PEG 3350/potassium/ GoLytely sodium bicarb/salt Humira* (PA) PEG 3350/potassium/sodium Lialda bicarb/salt/sodium sulf Pentasa triamcinolone acetonide Urso/Urso Forte Zenpep

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14 Performance Prescription Drug List Unithroid thyroid testosterone enanthate testosterone cypionate progesterone, micronized medroxyprogesterone liothyronine Levoxyl levothyroxine levothroid ethinyl estradiol estropipate estradiol/norethindrone acetate estradiol sucralfate ranitidine rabeprazole HCl pantoprazole omeprazole/sodium bicarbonate omeprazole nizatidine misoprostol metoclopramide HCl metoclopramide lansoprazole/amoxicillin/clarithromycin lansoprazole famotidine cimetidine cefprozil cefdinir cefadroxil cefaclor ER azithromycin atovaquone amoxicillin/clavulanate amoxicillin/ER amantadine adefovir dipivoxil* acyclovir Generics HORMONE REPLACEMENT GROWTH HORMONES GROWTH HEARTBURN/ULCER INFECTIONS Primsol PegIntron* (PA) Pegasys* (PA) Mycostatin (tabs) Intron-A* (PA) Gris-Peg Epivir HBV* Ciprodex Cipro HCOtic Baraclude* Vivelle-Dot Testim (QL) Synthroid Prempro Premphase Premarin Estraderm Enjuvia Divigel Armour Thyroid AndroGel (QL) Androderm (QL) Anadrol-50 (PA) Alora Saizen* (PA) Humatrope* (PA) Nexium Preferred Brands Generics Preferred Brands INFECTIONS (CONTINUED) ceftibuten dihydrate Tamiflu (QL) ceftriaxone Valcyte cefuroxime axetil cephalexin ciprofloxacin clarithromycin clindamycin clindamycin phosphate cycloserine doxycycline entacavir erythromycin famciclovir fluconazole flucytosine ganciclovir* gentamicin sulfate griseofulvin griseofulvin, microsize griseofulvin, ultramicrosize itraconazole (QL) ketoconazole lamivudine* metronidazole minocycline minocycline HCl Moderiba* moxifloxacin HCl mupirocin nitrofurantoin nystatin ofloxacin penicillin v potassium ribavirin* rifabutin rifampin rimantadine sulfamethoxazole/ trimethoprim terbinafine (QL) terconazole tetracycline tobramycin valacyclovir vancomycin voriconazole (PA)

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16 Performance Prescription Drug List diclofenac dexamethasone cyclophosphamide* codeine sulfate codeine phosphate/aspirin codeine phosphate codeine phos/carisoprodol/asa butorphanol nasal(QL) butalbit/acetamin/caff/codeine butalbital/acetaminophen buprenorphine Generics zolmitriptan (QL) sumatriptan succinate (QL) sumatriptan (QL) rizatriptan (QL) naratriptan (QL) isomethepten/caf/acetaminophen dihydroergotamine mesylate (QL) acetaminophen/caffeine/butalbital trimethobenzamide promethazine prochlorperazine ondansetron granisetron dronabinol risedronate HCl ibandronate sodiumtablet ibandronate sodiumsyringe* Fortical etidronate disodium calcitonin-salmon alendronate sodium PAIN RELIEFANDINFLAMMATORY DISEASE NAUSEAAND VOMITING MULTIPLE SCLEROSIS OSTEOPOROSIS MIGRAINE Tecfidera* (PA) Rebif Rebidose*(PA) Rebif* (PA) Copaxone* (PA) Avonex/Avonex Pen* (PA) Ampyra* (PA) Miacalcin Forteo* Evista Emend capsule*(QL) Preferred Brands Cafergot Treximet (QL) Lidoderm Kadian (QL) Indocin (suppository) Humira* (PA) Fentora (PA) Enbrel* (PA) Dipentum Dilaudid-5 Celebrex (QL) Avinza (QL) (PA)Actimmune* Generics Preferred Brands PAIN RELIEF AND INFLAMMATORY DISEASE (CONTINUED) diclofenac/misoprostol Lyrica dihy-cod tt/apap/caffeine Nucynta (QL, ST) etodolac Nucynta ER (QL) fenoprofen OxyContin (QL) fentanyl citrate (lozenge on stick) (PA) Ponstel fentanyl transdermal (QL) Rheumatrex* flurbiprofen Roxicet hydrocodone bitartrate/apap Savella hydrocodone bitartrate/aspirin Suboxone film tab (PA) hydromorphone HCl Trexall* ibuprofen ibuprofen/hydrocod bit indomethacin ketoprofen ketorolac (QL) leflunomide levorphanol tartrate lidocaine lidocaine-prilocaine meclofenamate mefenamic acid meloxicam meperidine HCl metaxalone methotrexate* methylprednisolone migergot morphine sulfate (QL) nabumetone naproxen opium opium/belladonna alkaloids orphenadrine/aspirin/caffeine oxaprozin oxycodone HCl oxycodone HCl/acetaminophen oxycodone/aspirin oxymorphone Oxymorphone HCl pentazocine HCl/acetaminophen pentazocine HCl/naloxone HCl piroxicam prednisone sulindac tolmetin tramadol ER (QL) tramadol HCl (QL) tramadol HCl/acetaminophen (QL) 16 17

18 Performance Prescription Drug List terazosin tamsulosin prazosin leuprolide acetate* (PA) finasteride doxazosin alfuzosin selegiline ropinirole XL ropinirole pramipexole entacapone carbidopa/levodopa/entacapone carbidopa/levodopa CR carbidopa/levodopa carbidopa bromocriptine benztropine amantadine tiagabine HCl phenytoin oxcarbazepine levetiracetam lamotrigine gabapentin felbamate ethosuximide divalproex diazepam clonazepam carbamazepine ziprasidone thiothixene risperidone quetiapine olanzapine/fluoxetine HCl olanzapine loxapine haloperidol clozapine Generics P arkinson SCHIZ PROSTATE SEIZURE OPHRENIA Vimpat Peganone Lyrica ODTLamictal Keppra Gabitril Felbatol Dilantin (30MGonly) Diastat Acudial Diastat Celontin Seroquel XR Zoladex* (PA) Jalyn Cialis (PA, QL) Avodart Azilect Apokyn* (PA) ’ s Preferred Brands DISEASE Generics Preferred Brands SEIZURE topiramate valproate zonisamide valproate sodium SEXUAL DYSFUNCTION

Please check your Summary Plan Description to determine whether these medications are covered under your specific plan. Cialis (PA, QL) Muse (PA, QL) Viagra (QL)

SKIN CONDITIONS acitretin Ala-Scalp HP (PA, ST) adapalene (AGE) Benzaclin (Gel w/pump) alclometasone dipropionate Benzamycin Pak amcinonide Capex Shampoo (PA, ST) amnesteem (QL) Carac Apexicon E (diflorasone diacetate) cream Carmol HC (PA,ST) betamethasone Cloderm (PA, ST) betamethasone dipropionate Cordran (PA, ST) betamethasone dipropionate/ Cordran SP (PA, ST) propylene glycol Differin (AGE) betamethasone valerate Enbrel* (PA) calcipotriene Exelderm calcipotriene-betamethasone Fluoroplex calcitriol ointment Furacin Claravis (QL) Humira* (PA) clinicamycinphosphate/benzoyl peroxide gel Kenalog spray (PA, ST) clobetasol propionate Klaron clobetasol propionate/emoll Locoid (lotion) clocortolone pivalate Loprox shampoo desonide Metrogel 1% desoximetasone Naftin diclofenac sodium Noritate diflorasone diacetate Nucort (PA, ST) fluocinolone acetonide Oracea fluocinonide Tazorac fluocinonide/emollient Texacort (PA, ST) fluorouracil topical fluticasone propionate fluticasone propionate halobetasol prop/ammonium lac halobetasol propionate hydrocortisone

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20 Performance Prescription Drug List urea triamcinolone acetonide tretinoin (AGE) sulfacetamide/sulfur/cleanser sulfacetamide sulfur sulfacetamide sodium/sulfur sulfacetamide Sotret (QL) acid salicylic prednicarbate podofilox mometasone furoate metronidazole methoxsalen, rapid mafenide acetate Isotretinoin (QL) imiquimod hydrocortisone valerate hydrocortisone butyrate hydrocortisone acetate/urea hydrocortisone acetate/aloe vera tacrolimus* sirolimus* mycophenolate sodium* mycophenolate moefetil* cyclosporine* azathioprine* folic acid cyanocobalamin calcitriol zolpidem ER zolpidem zaleplon eszopiclone Generics SKIN CONDITIONS (CONTINUED) TRANSPLANT SLEEP Silenor Sandimmune* Rapamune* Prograf* Neoral* Cellcept* Azasan* Citranatal Harmony^ Citranatal DHA Citranatal B-Calm Citranatal Assure^ Citranatal 90DHA Citranatal Bal-Care DHAEssential Active OB^ Preferred Brands Generics Preferred Brands VITAMINS (CONTINUED) Citranatal Rx Duet DHA Duet DHA EC Focalgin-B^ Folet One Gesticare DHA Infanate Balance Natachew Natafort Natelle One^ Neevo Neevo DHA Nestabs^ Nestabs ABC Nestabs DHA^ Nexa Plus OB Complete OB Complete DHA OB Complete One OB Complete Petite OB Complete Premier PNV Folic Acid-Iron PNV-DHA Plus Precare Premier Prefera-OB One PreferaOB Prenatal Prenaissance Next-B Prenata Prenatal 19 Prenate AM Prenate Chewable Prenate DHA Prenate Elite Prenate Enhance Prenate Mini Prenate Restore Prenate Star Provida OB Select-OB Stuart Prenatal Stuartnatal Plus Stuartnatal Plus 3 TL-Select DHA Tricare Tricare Prenatal Compleat Tricare Prenatal DHA One^ Vinate Care

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22 Performance Prescription Drug List tranexamic acid* tizanidine spinosad sodium polystyrene sulfonate sodium phenylbutyrate sevelamer carbonate riluzole* quinine sulfate pseudoephed/hydrocodone/cpm pramoxine/hydrocortisone pentoxifylline paricalcitol* naltrexone HCl naltrexone methocarbamol megestrol lindane levocarnitine leucovorin* hydrocortisone suspension hydrocodone/chlorpheniramine doxercalciferol cyclobenzaprine buprenorphine HCl/naloxone HCl(PA) buprenorphine aminocaproic acid* Generics VITAMINS MISCELLANEOUS (CONTINUED) VP-PNV-DHA VP CHUltra Viva DHA Vitapearl VitamedMD RedichewRx Vitafol-One Vitafol Ultra Vitafol Nano Vita Fol-OB DHA DHA^ Virt-Bal Vinate DHA Preferred Brands Zavesca* (PA) TussiCaps Suboxone filmtab(PA) SPS Renvela (PA)Pulmuzyme* Proctofoam-HC Procrit* (PA) Pramosone Leukine* Klor-Con M15 Fosrenol Epogen* (PA) Chantix* Buphenyl Aranesp* (PA) Analpram Advanced Exclusions and Limitations Plans typically do not provide coverage for the following, except as required by law or by the terms of your specific plan:

1. Any medications available 6. Any prescription and non-prescription over-the-counter (OTC) that do not require supplies (such as ostomy supplies), devices a prescription by federal or state law, and and appliances. any medication that is a pharmaceutical 7. Implantable contraceptive products. alternative to an OTC medication other 8. Any medication. than insulin. [examples include OTC 9. Any prescription vitamins (other than Benadryl, Maalox, Sudafed PE, etc.]. prenatal vitamins), dietary supplements 2. Medications that are therapeutically and fluoride products. equivalent as determined by the Cigna 10. Medications used for cosmetic purposes, HealthCare Pharmacy and Therapeutics such as medications used to reduce Committee in which at least one of the wrinkles, medications to promote hair medications within the class is available growth, medications used to control over the counter [examples include Rx perspiration and fade cream products. equivalents to OTC Allegra, Claritin and Zyrtec (Allegra D, Clarinex, Xyzal) and 11. Any diet pills or appetite suppressants Rx equivalents to OTC Prevacid, Prilosec, (). Zantac (Aciphex, Kapidex, Nexium, Axid, 12. Immunization agents, biological products Pepcid, Zantac)]. for allergy immunization, biological sera, 3. Any injectable medications, and blood, blood plasma and other blood any injectable medications that require products or fractions and medications used health care professional supervision for travel prophylaxis (the prevention of and are not typically considered self- travel-related diseases). administered medications. The following 13. Replacement of prescription medications are examples of health care professional- and related supplies due to loss or theft. supervised medications: injectables used 14. Medications used to enhance athletic to treat hemophilia and RSV (respiratory performance. syncytial virus), injectables 15. Medications that are to be taken by, or and endocrine and metabolic agents. administered to, a customer while the 4. Any medications that are experimental or customer is a patient in a licensed hospital, investigational within the meaning set skilled nursing facility, rest home or similar forth in the summary plan description. institution which operates on its premises, 5. Food and Drug Administration (FDA) or allows to be operated on its premises, a approved medications used for purposes facility for dispensing pharmaceuticals. other than those approved by the FDA 16. Prescriptions more than one year from the unless the medication is recognized for the original date of issue. treatment of the particular indication in one of the standard reference compendia (The United States Pharmacopoeia Drug Information or The American Hospital Formulary Service Drug Information) or in medical literature. Medical literature means scientific studies published in a peer-reviewed national professional medical journal. 22 23 Cigna reserves the right to make changes to this drug list without notice. Your plan may cover additional medications; please refer to your Summary Plan Description 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.

“Cigna” and the “Tree of Life” logo are registered service marks, and “Cigna Home Delivery Pharmacy” and “Together, all the way.” are service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, Tel-Drug, Inc., Tel-Drug of Pennsylvania, L.L.C., and HMO subsidiaries of Cigna Health Corporation. “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. All models are used for illustrative purposes only. 860415 c 02/15 Preventive Care Rx © 2015 Cigna. Some content provided under license.