Cigna Value 3-Tier Prescription Drug List

CIGNA VALUE 3-TIER PRESCRIPTION DRUG LIST

As of July 1, 2018

Offered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, or their affiliates. 876397 m Value 3-Tier w DRT 03/18 Table of Contents Getting started

Your prescription drug list 3

How to read your drug list 3

How to find your medication 5

Medications that are not covered 17

Prescription drug list FAQs 26

Exclusions and limitations 28

View your drug list online

This document was last updated 09/01/2017.* To see a current list of the medications covered on your plan’s drug list, visit:

The myCigna® website – Once you’re registered, log in and select Estimate Health Care Costs, then select Get drug costs.

Cigna.com/druglist – Select your drug list name – Value 3 Tier – from the drop down menu.

Questions? – Call the toll-free number on the back of your Cigna ID card. We’re here to help.

* Drug list created: originally created 10/01/2011 Last updated: 09/01/2017, for changes Next planned update: 09/01/18, for that were effective 01/01/2018 changes that will be effective 01/01/2019 2 Your prescription drug list This document shows the most commonly prescribed medications covered on the Value Prescription Drug List as of July 1, 2018.1 All of these medications are approved by the U.S. Food and Drug Administration (FDA). The Value Prescription Drug List excludes medications in two drug classes that are available over-the-counter without a prescription. These include medications commonly used to treat: › Heartburn and stomach acid conditions (ex. Nexium, Prilosec and any generics) and › Allergies (ex. Allegra, Clarinex, Xyzal and any generics)

Medications are listed by the condition they treat, then listed alphabetically within tiers (or coverage/ cost levels). It’s important to know that this is not a complete list of covered medications, and not all of the medications listed here may be covered by your specific plan. You should log in to the myCigna website or app or check your plan materials to learn more about the medications your plan covers. How to read your drug list Use the sample chart below to help you understand this drug list. This chart is just an example. It may not show how these medications are actually covered on the Value Prescription Drug List. Tier (coverage/cost level) gives you an idea of the how much you TIER 1 TIER 2 may pay for a medication $ $$ BLOOD PRESSURE/HEART MEDICATIONS Medications are grouped by afeditab CR Berinert* (PA) the condition they treat amlodipine besylate Bidil amlodipine besylate-benazepril Bystolic amlodipine-valsartan Cinryze* (PA) amlodipine-valsartan-HCTZ Coreg CR atenolol Cozaar (ST) atenolol-chlorthalidone Diovan (ST) Medications are listed in benazepril Diovan HCT (ST) alphabetical order within benazepril-HCTZ Edarbi (ST) each column candesartan cilexetil Edarbyclor (ST) cartia XT Exforge carvedilol Exforge HCT clonidine Firazyr* (PA) Specialty medications have an digitek Hemangeol asterisk (*) listed next to them digox Inderal LA digoxin Inderal XL diltiazem ER Innopran XL diltiazem CD Lotrel Brand name medications diltiazem Micardis (ST) are capitalized dilt-XR Multaq enalapril Nitro-dur flecainide acetate Nitrolingual Generic medications hydralazine Nitromist are lowercase irbesartan Nitronal isosorbide mononitrat Nitrostat Northera* (PA) Medications that have coverage Norvasc requirements will have an Ranexa (ST) abbreviation listed next to them Tekturna Tekturna HCT This chart is just a sample. It may not show how these medications are actually covered on the Value Prescription Drug List.

3 Tiers

Covered medications are divided into tiers, or cost levels. Typically, the higher the tier, the higher the price you’ll pay to fill the prescription.

› Tier 1 – Typically Generics (Lower-cost medication) $ › Tier 2 – Typically Preferred Brands (Medium-cost medication) $$ › Tier 3 – Typically Non-Preferred Brands (Higher-cost medication) $$$

Abbreviations next to medications

Some medications on your drug list have additional requirements before they may be covered by your plan.* This helps to make sure you’re receiving coverage for the right medication, at the right cost, in the right amount and for the right situation. These medications will have an abbreviation next to them in the drug list. Here’s what each of the abbreviations mean.

(PA) Prior Authorization – Cigna will review information provided by your doctor to make sure you meet coverage guidelines for the medication. If approved, your plan will cover the medication.

(ST) Step Therapy – The Step Therapy program encourages the use of lower-cost medications (generics and preferred brands) to treat certain conditions. Certain high-cost brand medications require Step Therapy. This means your plan requires you to try a lower-cost alternative first, before the higher-cost brand may be covered (unless you receive approval from Cigna).

(QL) Quantity Limits – For some medications, your plan will only cover up to a certain amount over a certain length of time. For example, 30mg per day for 30 days. Your plan will only cover a larger amount if your doctor requests and receives approval from Cigna.

(AGE) Age Requirements – You must be within a specific age range for your plan to cover the medication.

* This may not apply to you because not all plans require prior authorization, quantity limits and/or Step Therapy. Please log in to the myCigna website or app or check your plan materials to find out if your plan includes these specific coverage requirements.

Brand name medications are capitalized In this drug list, brand name medications are capitalized and generic medications are lowercase.

Specialty medications are marked with an asterisk Specialty medications are used to treat complex conditions like multiple sclerosis, hepatitis C and rheumatoid arthritis. In this drug list, specialty medications are marked with an asterisk (*). Some plans may cover these medications on a specialty tier, may limit you to a 30-day supply and/or require the use of a preferred specialty pharmacy. Log in to the myCigna website or app or check your plan materials to learn more about how your plan covers specialty medications.

4 No cost-share preventive medications are marked with a plus sign Health care reform under the Patient Protection and Affordable Care Act (PPACA) requires that most plans cover certain categories of medications and other products as preventive care services. In this drug list, medications with a plus sign (+) next to them may be available to you at no cost- share (copay, coinsurance and/or deductible). Log in to the myCigna website or app or check your plan materials to learn more about how your plan covers preventive medications.

Plan exclusions Some medications shown in this drug list may not be covered by your specific plan. For example, your plan may not cover medications used for weight loss or to treat infertility. In this drug list, these medications have a carat (^) next to them. Log in to the myCigna website or app or check your plan materials to find out if your plan excludes the medication.

How to find your medication on the drug list Find your condition in the alphabetical list below. Then go to that page to see the covered medications available to treat the condition.

Condition Page Condition Page AIDS/HIV 6 EYE CONDITIONS 11 ALLERGY/NASAL SPRAYS 6 FEMININE PRODUCTS 11 ALZHEIMER’S DISEASE 6 GASTROINTESTINAL/HEARTBURN 11, 12 ANXIETY/DEPRESSION/BIPOLAR 6 HORMONAL AGENTS 12 DISORDER INFECTIONS 12, 13 ASTHMA/COPD/RESPIRATORY 6 INFERTILITY 13 ATTENTION DEFICIT HYPERACTIVITY 6, 7 MISCELLANEOUS 13 DISORDER MULTIPLE SCLEROSIS 13 BLOOD MODIFIERS/BLEEDING DISORDERS 7 NUTRITIONAL/DIETARY 13 BLOOD PRESSURE/HEART MEDICATIONS 7 OSTEOPOROSIS PRODUCTS 14 BLOOD THINNERS/ANTI-CLOTTING 7 PAIN RELIEF AND INFLAMMATORY DISEASE 14, 15 CANCER 8 PARKINSON’S DISEASE 15 CHOLESTEROL MEDICATIONS 8 SCHIZOPHRENIA/ANTI-PSYCHOTICS 15 CONTRACEPTIVE PRODUCTS 8–10 SEIZURE DISORDERS 15 COUGH/COLD MEDICATIONS 10 SKIN CONDITIONS 15, 16 DENTAL PRODUCTS 10 SLEEP DISORDERS/SEDATIVES 16 DIABETES 10, 11 SMOKING CESSATION 16 DIURETICS 11 SUBSTANCE ABUSE 16 EAR MEDICATIONS 11 TRANSPLANT MEDICATIONS 16 URINARY TRACT CONDITIONS 16 ERECTILE DYSFUNCTION 11 TRANSPLANT MEDICATIONS 16

5 Cigna Value 3-Tier Prescription Drug List

TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3 $ $$ $$$ $ $$ $$$ AIDS/HIV ANXIETY/DEPRESSION/BIPOLAR abacavir- Atripla* Complera* DISORDER (cont) lamivudine* Intelence* Descovy* desvenlafaxine lamivudine- Isentress HD* Evotaz* 50mg zidovudine* Isentress* Genvoya* desvenlafaxine ER nevirapine ER* Norvir* Odefsey* 25mg, 100mg (QL) nevirapine* Prezista* Prezcobix* diazepam Selzentry* Reyataz* duloxetine (QL) Truvada* Stribild* escitalopram (QL) Sustiva* fluoxetine (QL) Tivicay* fluoxetine DR (QL) Triumeq* fluvoxamine (QL) Viread* fluvoxamine ER (QL) ALLERGY/NASAL SPRAYS lorazepam lorazepam intensol azelastine Clarinex-D 12 Hour mirtazapine cromolyn Karbinal ER paroxetine (QL) cyproheptadine Ryvent paroxetine CR (QL) epinephrine auto- paroxetine ER (QL) injector (QL) sertraline (QL) fluticasone trazodone hydroxyzine venlafaxine (QL) ipratropium venlafaxine ER (QL) mometasone spray (QL) ASTHMA/COPD/RESPIRATORY olopatadine albuterol Advair Diskus Adcirca* (PA) promethazine budesonide Advair HFA Adempas* (PA) ALZHEIMER’S DISEASE ipratropium- Anoro Ellipta Combivent Respimat albuterol Atrovent HFA Daliresp (QL) donepezil Mestinon levalbuterol HFA Breo Ellipta Kalydeco* (PA) donepezil ODT Namenda montelukast Incruse Ellipta Letairis* (PA) memantine Namenda XR ProAir HFA Ofev* (PA) pyridostigmine Namenda XR titration ProAir RespiClick Opsumit* (PA) pyridostigmine ER pack (QL) QVAR Orenitram ER* (PA) rivastigmine Namzaric (QL) QVAR Redihaler Orkambi* (PA) ANXIETY/DEPRESSION/BIPOLAR DISORDER Striverdi Pulmicort alprazolam Effexor XR (ST, QL) Respimat Pulmozyme* (PA) alprazolam ER Fetzima (ST, QL) Symbicort Revatio* (PA) alprazolam intensol Forfivo XL (ST, QL) Trelegy Ellipta Tracleer* (PA) alprazolam ODT Onfi (ST) Tyvaso* (PA) alprazolam XR Prozac (ST, QL) Xolair* (PA) Uptravi* (PA) amitriptyline Sarafem (ST) ATTENTION DEFICIT HYPERACTIVITY DISORDER bupropion (QL) Trintellix (ST) atomoxetine Adderall (ST) bupropion SR (QL) Viibryd (ST) dexmethylphenidate Adderall XR (ST) bupropion XL (QL) Wellbutrin SR (ST, QL) dexmethylphenidate Adzenys ER (ST) buspirone Xanax ER Adzenys XR-ODT (ST) citalopram (QL) Xanax XR dextroamphetamine- Aptensio XR (ST) clomipramine Zoloft (ST, QL) amphetamine ER Concerta (ST)

6 Cigna Value 3-Tier Prescription Drug List

TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3 $ $$ $$$ $ $$ $$$ ATTENTION DEFICIT HYPERACTIVITY BLOOD PRESSURE/HEART MEDICATIONS (cont) DISORDER (cont) diltiazem ER dextroamphetamine- Dyanavel XR (ST) dofetilide (QL) amphetamine Evekeo (ST) doxazosin guanfacine ER Focalin (ST) Ecotrin+ Metadate ER Focalin XR (ST) EcPirin+ methylphenidate Methylin (ST) enalapril methylphenidate CD Quillichew ER (ST) flecainide methylphenidate ER Quillivant XR (ST) hydralazine methylphenidate LA Ritalin (ST) irbesartan Ritalin LA (ST) isosorbide Strattera isosorbide ER labetalol BLOOD MODIFIERS/BLEEDING DISORDERS lisinopril tranexamic acid* Aranesp* (PA) Amicar* lisinopril-HCTZ Droxia Promacta* (PA) losartan Epogen* (PA) losartan-HCTZ Granix* Matzim LA Neulasta* (PA) metoprolol Procrit* (PA) nadolol Zarxio* nifedipine BLOOD PRESSURE/HEART MEDICATIONS nifedipine ER olmesartan Afeditab CR Corlanor (PA) Bayer Chewable olmesartan- amlodipine Entresto (PA) Aspirin+ amlodipine-HCTZ amlodipine- BiDil (QL) olmesartan-HCTZ benazepril Cardizem LA propafenone amlodipine- Coreg CR propafenone ER olmesartan Epaned (ST) propranolol amlodipine-valsartan Firazyr* (PA) propranolol ER amlodipine- Haegarda* (PA) ramipril valsartan-HCTZ Hemangeol Taztia XT Aspir 81+ Inderal LA telmisartan Aspir-Low+ Innopran XL telmisartan-HCTZ atenolol Multaq tri-buffered aspirin+ atenolol- Nitro-Dur valsartan chlorthalidone Nitrolingual valsartan-HCTZ benazepril Nitromist verapamil benazepril-HCTZ Nitrostat verapamil ER Bufferin+ Northera* (PA) verapamil SR candesartan Norvasc BLOOD THINNERS/ANTI-CLOTTING Cartia XT Ranexa (ST, QL) carvedilol aspirin-dipyridamole Brilinta Coumadin Tiazac clonidine ER Eliquis Effient Tikosyn (QL) Digitek clopidogrel Fragmin* (QL) Pradaxa Digox enoxaparin* (QL) Xarelto Savaysa digoxin fondaparinux* (QL) Zontivity Dilt-XR Jantoven diltiazem prasugrel diltiazem CD warfarin

7 Cigna Value 3-Tier Prescription Drug List

TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3 $ $$ $$$ $ $$ $$$ CANCER CHOLESTEROL MEDICATIONS (cont) anastrozole Afinitor* (PA) Afinitor Disperz* (PA) lovastatin 20mg, bexarotene* (PA) Fareston (QL) Alecensa* (PA) 40mg+ capecitabine* (PA) Gleostine Arimidex niacin ER exemestane Intron A* (PA) Bosulif* (PA) Niacor imatinib* (PA) Nexavar* (PA) Cabometyx* (PA) omega-3 acid letrozole Revlimid* (PA) Cometriq* (PA) ethyl esters mercaptopurine Sprycel* (PA) Cotellic* (PA) pravastatin+ methotrexate* Sutent* (PA) Erivedge* (PA) rosuvastatin raloxifene+ Tarceva* (PA) Gilotrif* (PA) rosuvastatin 5mg, tamoxifen+ Tasigna* (PA) Gleevec* (PA) 10mg+ temozolomide* (PA) Trexall* Ibrance* (PA) simvastatin Tykerb* (PA) Iclusig* (PA) simvastatin 10mg, Imbruvica* (PA) 20mg, 40 mg+ Inlyta* (PA) simvastatin Jakafi* (PA) 80mg (QL) Kisqali* (PA) Triklo Lenvima* (PA) Lonsurf* (PA) Lynparza* (PA) Mekinist* (PA) Ninlaro* (PA) CONTRACEPTIVE PRODUCTS Pomalyst* (PA) All contraceptive products may be covered if you meet Purixan* specific gender requirements. Rubraca* (PA) Aftera+ Beyaz Ella+ Stivarga* (PA) Altavera+ Lo Loestrin FE Estrostep FE Sylatron* (PA) Alyacen+ Taytulla LoSeasonique Tafinlar* (PA) Amethia Lo+ Minastrin 24 FE Tagrisso* (PA) Amethia+ NuvaRing+ Targretin* (PA) Amethyst+ Seasonique Verzenio* (PA) Apri+ Skyla* Votrient* (PA) Aranelle+ Xalkori* (PA) Ashlyna+ Xtandi* (PA) Aubra+ Zejula* (PA) Aviane+ Zelboraf* (PA) Azurette+ Zytiga* (PA) Balziva+ CHOLESTEROL MEDICATIONS Bekyree+ + atorvastatin Praluent* (PA) Kynamro* (PA) Blisovi 24 FE + atorvastatin 10mg, Repatha* (PA) Vascepa Blisovi FE + 20mg+ Welchol Briellyn + ezetimibe Zetia Camila + fenofibrate Camrese Lo + fenofibric acid Camrese + fluvastatin 20mg, Caya Contoured + 40mg+ Caziant + fluvastatin ER 80mg+ Chateal Cryselle+

8 Cigna Value 3-Tier Prescription Drug List

TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3 $ $$ $$$ $ $$ $$$ CONTRACEPTIVE PRODUCTS (cont) CONTRACEPTIVE PRODUCTS (cont) All contraceptive products may be covered if you meet All contraceptive products may be covered if you meet specific gender requirements. specific gender requirements. Cyclafem+ Kurvelo+ Cyred+ Larin 24 FE+ Dasetta+ Larin FE+ Daysee+ Larin+ Deblitane+ Larissia+ Delyla+ Leena+ desogestrel-ethinyl Lessina+ estradiol+ Levonest+ drospirenone- levonorgestrel- ethinyl estradiol- ethinyl estradiol+ levomefibrate+ Levora-28+ drospirenone-ethinyl Lillow+ estradiol+ Loryna+ Econtra EZ+ Low-Ogestrel+ Elinest+ Lutera+ Emoquette+ Lyza+ Enpresse+ Marlissa+ Enskyce+ medroxyprogesterone Errin+ 150mg/ml+ Estarylla+ Melodetta 24 FE+ ethynodiol-ethinyl Mibelas 24 FE+ estradiol+ Microgestin FE+ Falmina+ Mono-linyah+ Fayosim+ Mononessa+ FC2 Female My Way+ Condom+ Myzilra+ Femcap+ Necon 0.5/35+ Femynor+ Necon 7/7/7+ Gianvi+ Nikki+ Gildagia+ Nora-BE+ Gynol II+ norethin-ethinyl Heather+ estradiol-ferrous Introvale+ fumarate+ Isibloom+ norethindrone-ethinyl Jencycla+ estradiol+ Jolessa+ norethindrone+ Jolivette+ norgestimate-ethinyl Juleber+ estradiol+ Junel FE 24+ Norgestrel/ethinyl Junel FE+ estradiol+ Junel+ Norlyda+ Kaitlib FE+ Norlyroc+ Kariva+ Nortrel+ Kelnor 1-35+ Ocella+ Kimidess+ Opcicon One-Step+

9 Cigna Value 3-Tier Prescription Drug List

TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3 $ $$ $$$ $ $$ $$$ CONTRACEPTIVE PRODUCTS (cont) COUGH/COLD MEDICATIONS All contraceptive products may be covered if you meet benzonatate Flowtuss (QL) specific gender requirements. Bromfed DM Hycofenix (QL) Option 2+ brompheniramine- Tuzistra XR (QL) pseudoephedrine- Orsythia+ DM Philith+ + hydrocodone- Pimtrea chlorpheniramine Pirmella+ ER (QL) Portia+ hydrocodone- Previfem+ homatropine (QL) Quasense+ Hydromet (QL) Rajani+ promethazine- Reclipsen+ codeine (QL) Rivelsa+ Tussigon (QL) Setlakin+ DENTAL PRODUCTS + Sharobel chlorhexidine rinse Fluorabon + Sprintec doxycycline Sronyx+ fluoride Syeda+ Fluoritab Tarina FE+ Flura-Drops Tilia FE+ Ludent Fluoride Today Contraceptive Oralone Sponge+ Paroex Tri Femynor+ Peridex Tri-Estarylla+ Periogard Tri-Legest FE+ sodium fluoride Tri-Linyah+ triamcinolone paste Tri-Lo-Estarylla+ DIABETES + Tri-Lo-Marzia BD insulin syringes/ Basaglar Cycloset + Tri-Lo-Sprintec pen needles Bydureon (QL) Glucophage Tri-Previfem glimepiride Byetta Glucophage XR Tri-Sprintec+ glipizide Farxiga Korlym* (PA) Trinessa Lo+ glipizide ER GlucaGen Riomet Trinessa+ glipizide XL Hypokit (QL) VGo Trivora-28+ metformin Glucagon VCF+ metformin ER Emergency Velivet+ (generic of Kit (QL) Vestura+ Glucophage XR) Glyxambi Vienva+ NovoFine Humalog Viorele+ NovoTwist Humulin Vyfemia+ Janumet Wera Janumet XR Januvia Wide Seal Jardiance Diaphragm+ Levemir Wymzya FE+ + OneTouch test Xulane strips and + Zarah meters Zenchent+ Soliqua Zovia 1-35e+ SymlinPen Zovia 1-50e+ Synjardy

10 Cigna Value 3-Tier Prescription Drug List

TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3 $ $$ $$$ $ $$ $$$ DIABETES (cont) FEMININE PRODUCTS Synjardy XR Fem pH AVC Tresiba Gynazole 1 Relagard Trulicity (QL) miconazole 3 Terazol 7 Xigduo XR terconazole Xultophy GASTROINTESTINAL/HEARTBURN DIURETICS Alophen+ Apriso Akynzeo* (PA, QL) acetazolamide Diuril alosetron* Creon Amitiza chlorthalidone Dyazide Anucort-HC Pentasa Canasa eplerenone Dyrenium furosemide Lasix balsalazide Zenpep Carafate + hydrochlorothiazide Maxzide Bisa-Lax Cholbam* (PA) spironolactone Samsca* bisacodyl+ Clenpiq triamterene-HCTZ chlordiazepoxide- CoLyte with flavor + EAR MEDICATIONS clidinium packets Clearlax+ Correctol+ neomycin- Cipro HC dicyclomine Diclegis polymyxin- Ciprodex hydrocortisone diphenoxylate- Donnatal ofloxacin atropine Dulcolax+ ERECTILE DYSFUNCTION dronabinol Gattex* (PA) Ducodyl+ Gialax+ sildenafil (QL) Cialis (QL) Levitra (ST, QL) famotidine GoLYTELY+ Muse (QL) Gavilax+ Kristalose Staxyn (ST, QL) + Viagra (ST, QL) Gavilyte-C Lialda (ST) Gavilyte-G+ Linzess EYE CONDITIONS Gavilyte-N+ Miralax+ azelastine Restasis Acuvail GentleLax+ Movantik (PA) bacitracin Simbrinza Alphagan P Glycolax+ MoviPrep+ brimonidine Travatan Z Alrex HealthyLax+ Nulytely with flavor ciprofloxacin Xiidra Azasite + dorzolamide-timolol Azopt Hemmorex-HC packets erythromycin Besivance hydrocortisone Ocaliva* (PA) fluorometholone Betimol suppository OsmoPrep+ gatifloxacin Betoptic S lansoprazole- Pancreaze ketorolac Bromsite amoxicillin- Pertzye latanoprost Combigan clarithromycin Prepopik+ moxifloxacin Cosopt PF (combo pak) Ravicti* neomycin- Cystaran* (QL) LaxaClear+ Rectiv polymyxin- Durezol mesalamine 1.2gm Relistor (PA) dexamethasone Ilevro tablet, enema ofloxacin Sancuso (PA, QL) Lotemax metoclopramide olopatadine Sensipar* Moxeza metoclopramide polymyxin B sul- Nevanac sfRowasa trimethoprim ODT Sucraid* Prolensa + prednisolone Tobradex Natura-Lax Suprep+ timolol Tobradex ST ondansetron Symproic (PA) tobramycin Vigamox ondansetron ODT Transderm-Scop tobramycin- Xalatan PEG Varubi* (PA, QL) dexamethasone + Zioptan (ST, QL) 3350-electrolyte Viberzi + Zirgan PEG-Prep Viokace Zylet Phenadoz

11 Cigna Value 3-Tier Prescription Drug List

TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3 $ $$ $$$ $ $$ $$$ GASTROINTESTINAL/HEARTBURN (cont) HORMONAL AGENTS (cont) Powderlax+ testosterone (PA, QL) Vagifem (QL) promethazine testosterone Vivelle-Dot (QL) suppository cypionate Promethegan thyroid Purelax+ Unithroid 75mg ranitidine Westhroid Smooth LAX+ WP Thyroid sucralfate Yuvafem (QL) TriLyte with flavor INFECTIONS packets+ acyclovir Baraclude Albenza ursodiol amoxicillin solution* Alinia HORMONAL AGENTS amoxicillin- Epclusa* (PA) Bactrim Amabelz AndroGel 1.62% Activella clavulanate ER Harvoni* (PA) Bactrim DS budesonide EC (PA, QL) Alora (QL) amoxicillin- Kitabis Pak* Baraclude tablet* cabergoline (QL) Duavee Androderm (PA, QL) clavulanate Mavyret* (PA) Biltricide Covaryx Forteo* AndroGel 1% (PA, QL) atovaquone Pegasys* (PA) Cayston* Covaryx H.S. Ganirelix* Angeliq atovaquone- PegIntron* (PA) Ceftin desmopressin Humatrope* (PA) Armour Thyroid proguanil (PA) Sovaldi* (PA) Cipro dexamethasone Lupron Climara Avidoxy Thalomid* (PA) Cleocin dexamethasone Depot* (PA) Climara Pro azithromycin Vosevi* (PA) Clindesse intensol Premarin Combipatch cefdinir Cresemba (PA) EEMT Premphase Cytomel cefixime Daraprim* (PA) EEMT H.S. Prempro Deltasone cefuroxime Dificid (PA) estradiol (QL) Sandostatin LAR Depo-Testosterone cephalexin E.E.S. 400 estradiol- Depot* (PA) Divigel ciprofloxacin Eryped 200 norethindrone Serostim* (PA) Egrifta* (PA) clarithromycin Ery-Tab estrogen- Somavert* (PA) Elestrin clarithromycin ER Monurol methyltestosterone Zorbtive* (PA) Emflaza* (PA) clindamycin Noxafil levothyroxine Entocort EC Coremino PCE Levoxyl Estrace dapsone Plaquenil liothyronine Estring (QL) doxycycline Sulfatrim Locort Estrogel doxycycline IR-DR Suprax medroxyprogesterone Evamist Emverm Tamiflu (QL) methimazole Femring entecavir* Tobi Podhaler* methylprednisolone Levo-T erythromycin Uretron D-S Millipred Menostar (QL) famciclovir Uribel Millipred DP Minivelle (QL) fluconazole Urogesic-Blue Mimvey Natpara* (PA) hydroxychloroquine UTA Mimvey Lo Osphena itraconazole Valtrex Nature-Throid Rayaldee levofloxacin Vemlidy* norethindrone Somatuline metronidazole Vibramycin NP Thyroid Depot* (PA) minocycline Xifaxan prednisolone Striant (PA, QL) minocycline ER Zepatier* (PA) prednisolone ODT Synthroid Mondoxyne NL Zithromax prednisone Tirosint Morgidox Zmax prednisone intensol Unithroid moxifloxacin tablet progesterone nitrofurantoin

12 Cigna Value 3-Tier Prescription Drug List

TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3 $ $$ $$$ $ $$ $$$ INFECTIONS (cont) NUTRITIONAL/DIETARY nystatin calcitriol Bio-D-Mulsion Auryxia (QL) Okebo calcium Forte+ CitraNatal oseltamivir (QL) cyanocobalamin Bio-D-Mulsion+ Concept DHA penicillin V injection Escavite+ Feriva 21-7 sulfamethoxazole- D-Vi-Sol+ Escavite D+ Ferralet 90 trimethoprim D3-2000+ Fosrenol powder Fosrenol tablet terbinafine D3-50+ Just D+ Integra Plus tetracycline Decara+ Maximum D3+ Irospan tinidazole Delta D3+ Mephyton K-Tab ER tobramycin* Dialyvite Vitamin D+ MVC-fluoride+ Klor-Con 8, 10 valacyclovir Dialyvite Vitamin D3 Nascobal Klor-Con M15 + + valganciclovir Max Nestabs DHA KPN + vancomycin FA-8 OB Complete OB Complete Gold + vandazole folic acid One Phoslyra + voriconazole (PA) Klor-Con Optimal D3 M Prenate Klor-Con M10, M20 Perry Prenatal+ Renagel INFERTILITY Klor-Con Sprinkle Poly-Vi-Flor With Renvela clomiphene Follistim AQ* Crinone lanthanum Iron+ Tristart DHA Menopur* Endometrin carbonate Poly-Vi-Flor+ Velphoro MISCELLANEOUS levocarnitine Prefera OB Veltassa multivitamin with Quflora+ Vitafol disulfiram Cerdelga* (PA) Addyi (QL) fluoride Replesta+ VitaMedMD One Rx NebuSal 3% Nityr* (PA) Carbaglu* multivitamin-iron- Replesta NX+ VitaPearl PulmoSal Esbriet* (PA) fluoride+ Texavite LQ+ VP-PNV-DHA sodium chloride Exjade* Optimal D3+ Tri-Vi-Flor+ TechLITE lancets Ferriprox* PNV-DHA Urosex+ tetrabenazine* (PA) Hyper-Sal polyvitamins- Jadenu* fluoride+ Kuvan* (PA) potassium chloride Myalept* (PA) Prena1 Pearl NebuSal 6% prenatal vitamin+ + Nuedexta (QL) Prenatal + Orfadin* (PA) Right Step Strensiq* (PA) sevelamer sodium fluoride+ Syprine* (PA) Super Daily D3+ Xenazine* (PA) Thera-D+ Zavesca* (PA) tri-vitamin with MULTIPLE SCLEROSIS fluoride-iron+ glatiramer* (PA) Ampyra* (PA) Zinbryta* (PA) tri-vitamin with + Glatopa* (PA) Aubagio* (PA) fluoride Virt-PN DHA Avonex* (PA) Vitajoy Daily D+ Betaseron* (PA) vitamin D-400+ Extavia* (PA) vitamin D2 Gilenya* (PA) vitamin D3+ Plegridy* (PA) vitamins A,C,D and Rebif* (PA) fluoride+ Tecfidera* (PA) Zatean-PN DHA

13 Cigna Value 3-Tier Prescription Drug List

TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3 $ $$ $$$ $ $$ $$$ OSTEOPOROSIS PRODUCTS PAIN RELIEF AND INFLAMMATORY alendronate Fosamax Plus D Actonel (ST) DISEASE (cont) alendronate 40mg (ST) Atelvia (ST) hydrocodone- Voltaren (QL) (QL) Tymlos* acetaminophen Xeljanz XR* (PA) ibandronate (PA, QL) Xeljanz* (PA) raloxifene+ hydromorphone Zebutal (QL) risedronate (PA, QL) Zohydro ER (PA, QL) risedronate DR hydromorphone ER PAIN RELIEF AND INFLAMMATORY DISEASE (PA, QL) ibuprofen acetaminophen- Actemra* (PA) Abstral (PA, QL) indomethacin codeine (PA, QL) Embeda (PA, QL) Actiq (PA, QL) indomethacin ER acitretin Enbrel* (PA) Analpram HC ketorolac (QL) allopurinol Humira* (PA) Benlysta* (PA) leflunomide baclofen Hysingla ER Butrans (QL) lidocaine 5% buprenorphine (QL) (PA, QL) Celebrex (QL) ointment (QL) butalbital- Otezla* (PA) Cimzia* (PA) lidocaine viscous acetaminophen- Rasuvo* (PA) Colcrys lidocaine-prilocaine caffeine-codeine Remicade* (PA) Cosentyx* (PA) Lidopril (PA, QL) Stelara* (PA) Cuprimine* (PA) Lidopril XR butalbital- Xtampza ER Depen* (PA) LiproZonePak acetaminophen- (PA, QL) Duragesic (PA, QL) Livixil Pak caffeine (QL) Esgic (QL) Lorcet (PA, QL) carisoprodol Fentora (PA, QL) Lorcet HD (PA, QL) celecoxib (QL) Fexmid Lorcet Plus (PA, QL) colchicine Flector (QL) Lortab (PA, QL) cyclobenzaprine Ilaris* (PA) Medolor Pak DermacinRx Lazanda (PA, QL) meloxicam Empricaine Lidoderm Metaxall DermacinRx Prizopak Maxalt (QL) metaxalone diclofenac 1% Maxalt MLT (QL) methocarbamol gel (QL) Mitigare morphine (PA, QL) diclofenac ER Nucynta (PA, QL) morphine ER (PA, QL) diclofenac Nucynta ER (PA, QL) nabumetone -misoprostol Onzetra Xsail (QL) naproxen dihydroergotamine Orencia* (PA) (QL) naproxen DS Otrexup* (PA) eletriptan (QL) oxycodone (PA, QL) Oxaydo (PA, QL) Endocet (PA, QL) oxycodone ER Pennsaid etodolac (PA, QL) Percocet (PA, QL) etodolac ER oxycodone- Procort fenoprofen acetaminophen Proctofoam-HC Fenortho (PA, QL) Rasuvo 30mg/0.6ml* fentanyl patch oxymorphone (PA) (PA, QL) (PA, QL) Relpax (QL) Fioricet (QL) oxymorphone ER Savella (PA, QL) frovatriptan (QL) Subsys (PA, QL) Glydo Prilolid Tremfya* (PA) Primlev (PA, QL) Uloric

14 Cigna Value 3-Tier Prescription Drug List

TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3 $ $$ $$$ $ $$ $$$ PAIN RELIEF AND INFLAMMATORY SEIZURE DISORDERS DISEASE (cont) carbamazepine Dilantin 30mg Aptiom Profeno carbamazepine ER Lamictal XR Banzel (QL) Relador Pak clonazepam start kit Briviact Relador Pak Plus divalproex Lyrica Carbatrol rizatriptan (QL) divalproex ER Depakote sumatriptan (QL) Epitol Depakote ER tizanidine gabapentin Dilantin 50mg, tramadol (QL) lamotrigine 100mg, suspension tramadol ER (QL) lamotrigine ER Fycompa Verdrocet (PA, QL) lamotrigine ODT Keppra Vicodin (PA, QL) levetiracetam Keppra XR Vicodin ES (PA, QL) levetiracetam ER Lamictal Vicodin HP (PA, QL) oxcarbazepine Lamictal ODT zolmitriptan (QL) Roweepra Lamictal XR tablets zolmitriptan topiramate Oxtellar XR ODT (QL) topiramate ER 50mg Phenytek capsule Qudexy XR PARKINSON’S DISEASE Sabril* amantadine Apokyn* (PA) Azilect Spritam benztropine Duopa* Tegretol bromocriptine Mirapex Tegretol XR carbidopa-levodopa Mirapex ER Topamax carbidopa-levodopa Neupro topiramate ER ER Rytary (25mg, 100mg, pramipexole Sinemet 150mg, 200mg) pramipexole ER Sinemet CR Trileptal rasagiline Tasmar Trokendi XR ropinirole Xadago Vimpat ropinirole ER SKIN CONDITIONS acitretin Aczone 7.5% Aczone 5% acyclovir ointment Eucrisa Denavir (QL) SCHIZOPHRENIA/ANTI-PSYCHOTICS adapalene (PA) Fluoroplex Desonate (ST) aripiprazole Fanapt (QL) Ala-Cort Targretin gel* Desowen (ST) aripiprazole ODT Latuda Amnesteem (QL) Drysol chlorpromazine Rexulti AVAR Dupixent* (PA) haloperidol Saphris AVAR-E Ecoza olanzapine Seroquel BP 10-1 Efudex olanzapine ODT Seroquel XR calcipotriene Elidel olanzapine- Vraylar calcipotriene- Exelderm fluoxetine betamethasone DP Finacea paliperidone ER Calcitrene Hydro 35 quetiapine Claravis (QL) Hydro 40 quetiapine ER Clindacin ETZ Naftin risperidone Clindacin P Nizoral risperidone ODT clindamycin Picato ziprasidone clindamycin-benzoyl Santyl (QL) peroxide Sklice

15 Cigna Value 3-Tier Prescription Drug List

TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3 $ $$ $$$ $ $$ $$$ SKIN CONDITIONS (cont) SMOKING CESSATION clindamycin- Soolantra bupropion SR Chantix tretinoin Taltz* (PA) (generic of Zyban)+ Nicorette+ clobetasol Tolak NicoDerm CQ+ Nicotrol Clodan shampoo Topicort (ST) Nicorelief+ Nicotrol NS clotrimazole- Tremfya* (PA) nicotine gum+ Zyban betamethasone Tridesilon (ST) nicotine lozenge+ desonide Umecta nicotine patch+ doxepin Uramaxin Quit 2+ econazole Xolegel Quit 4+ fluocinonide SUBSTANCE ABUSE fluorouracil buprenorphine Bunavail hydrocortisone buprenorphine- Narcan imiquimod naloxone Suboxone ketoconazole naloxone Zubsolv metronidazole naltrexone (QL) mupirocin TRANSPLANT MEDICATIONS Myorisan (QL) Neuac gel azathioprine* Prograf* Astagraf XL* nystatin- mycophenolic acid* Cellcept* triamcinolone sirolimus* Envarsus XR* oxiconazole nitrate tacrolimus* Myfortic* permethrin Neoral* Procto-Med HC Zortress* Procto-Pak URINARY TRACT CONDITIONS Proctosol-HC cevimeline Avodart Proctozone-HC darifenacin ER Cystagon* Rosadan dutasteride Elmiron Rosanil finasteride Jalyn Scalacort lotion oxybutynin Procysbi* (PA) SSS 10-5 oxybutynin ER Pyridium sulfacetamide -sulfur phenazopyridine Rapaflo SulfaCleanse 8-4 potassium citrate ER Thiola* tacrolimus ointment tamsulosin tretinoin cream, tolterodine gel (PA) tolterodine ER triamcinolone trospium topical trospium ER Triderm WEIGHT MANAGEMENT Zenatane (QL) Lomaira Belviq SLEEP DISORDERS/SEDATIVES phentermine Belviq XR armodafinil (PA) Belsomra (ST) Rozerem (ST, QL) Contrave eszopiclone Silenor (ST) Xyrem* (PA) Qsymia modafinil (PA) Saxenda temazepam zolpidem zolpidem ER

16 Medications that are not covered The medications listed below aren’t covered on your plan’s drug list.^^ This means that if you fill a prescription for any of these medications, you’ll pay the full cost of the medication. We want you to know your plan covers other medications that offer similar health outcomes.^^ We’ve listed some below. You should call your doctor’s office to talk about your options. GENERIC AND/OR PREFERRED DRUG CLASS MEDICATION NOT COVERED^^ BRAND ALTERNATIVES ALLERGY/NASAL SPRAYS Auvi-Q epinephrine auto injector EpiPen, EpiPen Jr Beconase AQ Generic nasal steroids (e.g., fluticasone) Dymista Nasonex Omnaris QNASL Zetonna QNASL Children budesonide fluticasone triamcinolone ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipramine Aplenzin bupropion XL Ativan lorazepam Cymbalta duloxetine Lexapro escitalopram Pamelor nortriptyline Parnate tranylcypromine Pexeva paroxetine Pristiq bupropion SR/XL duloxetine venlafaxine ER All generic SSRIs Tofranil imipramine Wellbutrin XL bupropion XL ASTHMA/COPD/RESPIRATORY Aerospan QVAR/QVAR Redihaler Alvesco ArmonAir RespiClick Arnuity Ellipta Asmanex Asmanex HFA Flovent Diskus Flovent HFA Pulmicort Flexhaler Arcapta Neohaler Striverdi Respimat Serevent Diskus Bevespi Anoro Ellipta Stiolto Respimat Utibron Neohaler

17 GENERIC AND/OR PREFERRED DRUG CLASS MEDICATION NOT COVERED^^ BRAND ALTERNATIVES ASTHMA/COPD/RESPIRATORY (cont) Dulera Advair Diskus Advair HFA Breo Ellipta Symbicort Elixophyllin theophylline oral solution Proventil HFA ProAir HFA Ventolin HFA ProAir RespiClick Xopenex HFA Seebri Neohaler Incruse Ellipta Spiriva Spiriva Respimat Tudorza Pressair Zyflo montelukast zafirlukast Zyflo CR zileuton ER ATTENTION DEFICIT HYPERACTIVITY Cotempla XR-ODT dexmethylphenidate ER DISORDER methylphenidate ER/CD/LA Desoxyn methamphetamine Dexedrine dextroamphetamine Mydayis dextroamphetamine ER amphetamine/dextroamphetamine ER Vyvanse dexmethylphenidate ER dextroamphetamine-amphetamine ER methylphenidate ER/LA BLOOD PRESSURE/HEART MEDICATIONS Accupril quinapril Accuretic quinapril-HCTZ Altace ramipril Atacand candesartan Atacand-HCT candesartan-HCTZ Avalide irbesartan-HCTZ Avapro irbesartan Azor amlodipine-olmesartan Benicar Generic ACE/ARBs Benicar HCT Generic ACE/ARBs + HCTZ Betapace sotalol Bystolic Generic beta blockers (e.g., metoprolol, atenolol) Byvalson Generic ARBs + generic beta blockers Cardizem diltiazem Cardizem CD Cartia XT diltiazem CD/ER Cozaar losartan Diovan valsartan Diovan HCT valsartan-HCTZ

18 GENERIC AND/OR PREFERRED DRUG CLASS MEDICATION NOT COVERED^^ BRAND ALTERNATIVES BLOOD PRESSURE/HEART Edarbi Generic ARBs (e.g., losartan, valsartan) MEDICATIONS (cont) Edarbyclor Generic ARBs + HCTZ (e.g., losartan-HCTZ) Exforge amlodipine-valsartan Exforge HCT amlodipine-valsartan-HCTZ Hyzaar losartan-HCTZ Isordil isosorbide dinitrate Isordil Titradose Lanoxin Digitek digoxin Lotensin benazepril Lotensin HCT benazepril-HCTZ Lotrel amlodipine-benazepril Micardis telmisartan Micardis HCT telmisartan-HCTZ Prinivil lisinopril Zestril Tarka trandolapril-verapamil ER Tekturna Generic ACE/ARBs Tekturna HCT Generic ACE/ARBs + HCTZ Tribenzor olmesartan-amlodipine-HCTZ Twynsta telmisartan-amlodipine Vaseretic enalapril-HCTZ Vasotec enalapril Zestoretic lisinopril-HCTZ BLOOD THINNERS/ANTI-CLOTTING Yosprala IR or EC aspirin CANCER Nilandron nilutamide CHOLESTEROL MEDICATIONS Altoprev atorvastatin lovastatin rosuvastatin simvastatin Antara fenofibrate Fenoglide Crestor rosuvastatin FloLipid simvastatin Zocor Lescol XL 80mg fluvastatin ER Lipitor atorvastatin Livalo atorvastatin Vytorin rosuvastatin simvastatin Pravachol pravastatin

19 GENERIC AND/OR PREFERRED DRUG CLASS MEDICATION NOT COVERED^^ BRAND ALTERNATIVES COUGH/COLD MEDICATIONS Tussicaps hydrocodone-chlorpheniramine ER promethazine-codeine DENTAL PRODUCTS Arestin minocycline/ER DIABETES Accu-Chek, Contour, Freestyle, all other OneTouch test strips and meters test strips and meters Afrezza Humalog Apidra Humulin Apidra SoloStar Fiasp Novolin, Novolog Fortamet metformin ER (generic Glucophage XR) Glumetza metformin ER (generic Fortamet and Glumetza) Invokamet Synjardy, Synjardy XR, Xigduo XR Invokamet XR Invokana Farxiga Jentadueto Janumet, Janumet XR Jentadueto XR Kazano Nesina Kombiglyze XR alogliptin Onglyza alogliptin-metformin Oseni Januvia, Janumet, Janumet XR Tradjenta Lantus Basaglar, Levemir, Tresiba Toujeo SoloStar QTERN Glyxambi Tanzeum Trulicity Victoza DIURETICS Edecrin bumetanide ethacrynic acid furosemide torsemide EYE CONDITIONS Alocril cromolyn Alomide Bepreve azelastine Emadine epinastine Lastacaft olopatadine Pataday Patanol Pazeo Elestat epinastine Lumigan bimatoprost latanoprost Travatan Z GASTROINTESTINAL/HEARTBURN Anusol-HC suppository Anucort-HC Cortifoam Hemmorex-HC Uceris foam hydrocortisone suppository

^^ These medications require approval from Cigna before they may be covered by your plan. If your doctor feels that an alternative medication isn’t right for you, he or she can ask Cigna to consider approving coverage of your medication. 20 GENERIC AND/OR PREFERRED DRUG CLASS MEDICATION NOT COVERED^^ BRAND ALTERNATIVES GASTROINTESTINAL/HEARTBURN (cont) Asacol-HD Apriso Colazal balsalazide Delzicol Lialda Dipentum Pentasa Giazo sulfasalazine mesalamine 800mg tablet sulfasalazine DR Librax chlordiazepoxide-clidinium Lotronex alosetron Marinol dronabinol Omeclamox-Pak lansoprazole-amoxicillin-clarithromycin Prevpac (combo pak) Pylera Proctocort Hemmorex-HC hydrocortisone suppository Procto-Pak Rowasa mesalamine enema Syndros dronabinol Trulance Amitiza, Linzess Zofran ondansetron Zofran ODT ondansetron ODT Zuplenz ondansetron ondansetron ODT HORMONAL AGENTS Fortesta AndroGel 1.62% Natesto testosterone Testim Vogelxo DDAVP desmopressin Dexpak dexamethasone Zonacort Zodex Genotropin Humatrope (PA) Norditropin Nutropin AQ Omnitrope Saizen Zomacton Hectorol doxercalciferol Rayos prednisone prednisone intensol Uceris tablet budesonide EC

21 GENERIC AND/OR PREFERRED DRUG CLASS MEDICATION NOT COVERED^^ BRAND ALTERNATIVES INFECTIONS Acticlate Generic products (e.g., doxycycline; Doryx minocycline) Minocin capsule Monodox Oracea Solodyn Vibramycin capsule Ximino Augmentin/ES/XR amoxicillin-clavulanate ER Bethkis Kitabis Pak Tobi tobramycin Diflucan fluconazole E.E.S. 200 erythromycin ethylsuccinate Eryped 400 Mepron atovaquone Mycobutin rifabutin Onmel itraconazole terbinafine Sitavig acyclovir Sporanox itraconazole Targadox tobramycin Valcyte valganciclovir Vancocin vancomycin Zovirax acyclovir INFERTILITY Bravelle Follistim AQ (PA) Gonal-F MULTIPLE SCLEROSIS Copaxone Aubagio, Avonex, Betaseron, Extavia, Gilenya, glatiramer, Glatopa, Plegridy, Rebif, Tecfidera PAIN RELIEF AND INFLAMMATORY DISEASE Amrix cyclobenzaprine Other generic muscle relaxants Belbuca buprenorphine Bupap butalbital-acetaminophen Tencon Cambia Generic prescription NSAIDs diclofenac 1.5% drops (e.g., celecoxib, meloxicam) Duexis Naprelan naproxen CR naproxen ER Pennsaid Tivorbex Vimovo Vivlodex Zipsor Zorvolex Conzip tramadol tramadol ER

^^ These medications require approval from Cigna before they may be covered by your plan. If your doctor feels that an alternative medication isn’t right for you, he or she can ask Cigna to consider approving coverage of your medication. 22 GENERIC AND/OR PREFERRED DRUG CLASS MEDICATION NOT COVERED^^ BRAND ALTERNATIVES PAIN RELIEF AND INFLAMMATORY D.H.E. 45 dihydroergotamine DISEASE (cont) Duzallo allopurinol, probenecid Gralise gabapentin Imitrex sumatriptan Sumavel DosePro Zembrace SymTouch Kineret Enbrel (PA) Simponi Humira (PA) Simponi Aria Stelara (PA) levorphanol Generic products (e.g., acetaminophen- codeine, hydromorphone, oxycodone) Lorzone chlorzoxazone Migranal dihydroergotamine OxyContin Xtampza ER (PA) Embeda ER (PA) Hysingla ER (PA) Roxicodone oxycodone Sprix ketorolac Treximet Generic NSAIDs Generic triptans (e.g., sumatriptan, naratriptan) Vanatol LQ butalbital-acetaminophen-caffeine Zomig zolmitriptan sumatriptan Zomig ZMT zolmitriptan ODT PARKINSON’S DISEASE Gocovri amantadine Lodosyn carbidopa Requip XL ropinirole ER SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify aripiprazole Fazaclo clozapine Versacloz clozapine ODT Geodon ziprasidone Zyprexa olanzapine Zyprexa Zydis olanzapine ODT SEIZURE DISORDERS Mysoline primidone SKIN CONDITIONS Absorica Claravis Myorisan Zenatane

23 GENERIC AND/OR PREFERRED DRUG CLASS MEDICATION NOT COVERED^^ BRAND ALTERNATIVES SKIN CONDITIONS (cont) Acanya tretinoin Atralin clindamycin-benzoyl peroxide Avita Azelex Differin Duac Epiduo Epiduo Forte Fabior Onexton Retin-A Tazorac Tretin-X Veltin Ziana Aldara imiquimod cream Anusol-HC cream hydrocortisone Procto-Med HC Proctosol-HC Proctozone-HC Bensal HP salicylic acid Benzaclin clindamycin-benzoyl peroxide Duac Neuac gel Neuac Kit Carac fluorouracil Clindagel clindamycin Clobex clobetasol Cutivate Generic topical steroid (e.g. betamethasone) diclofenac 3% gel Fluoroplex Solaraze fluorouracil imiquimod Picato Dovonex calcipotriene Sorilux Enstilar calcipotriene-betamethasone DP Taclonex Ertaczo ketoconazole Extina Luzu Vusion Halog clobetasol Ultravate X halobetasol Jublia Ciclodan Kerydin ciclopirox itraconazole terbinafine Kenalog triamcinolone

24 GENERIC AND/OR PREFERRED DRUG CLASS MEDICATION NOT COVERED^^ BRAND ALTERNATIVES SKIN CONDITIONS (cont) Locoid hydrocortisone Locoid Lipocream Loprox cream, kit ciclopirox Noritate metronidazole Rosadan Oxistat clotrimazole econazole ketoconazole Penlac Ciclodan ciclopirox Prudoxin doxepin Zonalon Sernivo betamethasone fluocinonide hydrocortisone Siliq Enbrel (PA) Humira (PA) Remicade (PA) Stelara (PA) Soriatane acitretin Trianex triamcinolone Triderm Ultravate lotion clobetasol Vanos fluocinonide Vectical calcitriol ointment Verdeso desonide Xerese acyclovir hydrocortisone Zyclara imiquimod SLEEP DISORDERS/SEDATIVES Ambien zolpidem Ambien CR zolpidem ER Edluar Intermezzo Nuvigil armodafinil Provigil modafinil Restoril temazepam SUBSTANCE ABUSE Evzio Narcan URINARY TRACT CONDITIONS Detrol darifenacin ER Detrol LA oxybutynin ER Ditropan XL tolterodine ER Enablex trospium ER Gelnique Myrbetriq Oxytrol Toviaz VESIcare

25 Prescription drug list FAQs

Understanding your prescription medication › Medications that are available over-the- coverage can be confusing. Below are answers to counter, without a prescription. These include some commonly asked questions. medications commonly used to treat Why do you make changes to the drug list? heartburn and stomach acid conditions (ex. Nexium, Prilosec and any generics) Cigna regularly reviews and updates the and allergies (ex. Allegra, Clarinex, Xyzal prescription drug list. We make changes for and any generics). many reasons – like when new medications Medications used to treat lifestyle conditions become available or are no longer available, or › (like infertility, weight loss, erectile when medication prices change. We try to give dysfunction, smoking cessation2). you many options to choose from to treat your health condition. These changes may include:1 › Medications that aren’t approved by the U.S. Food and Drug Administration (FDA). › Moving a medication to a lower cost tier. This can happen at any time during the year. How do you decide which medications › Moving a brand medication to a higher cost are covered? tier when a generic becomes available. This The Cigna Prescription Drug List is developed can happen at any time during the year. with the help of Cigna’s Pharmacy and › Moving a medication to a higher cost tier Therapeutics (P&T) Committee, which is a group and/or no longer covering a medication. This of practicing doctors and pharmacists, most of typically happens twice a year on January 1st whom work outside of Cigna. The group meets and July 1st. regularly to review medical evidence and information provided by federal agencies, drug › Adding requirements to a medication. For manufacturers, medical professional associations, example, requiring approval from Cigna before national organizations and peer-reviewed journals a medication may be covered or adding a medications about the safety and effectiveness quantity limit to a medication. of medications that are newly approved by the It’s important to know that when a medication FDA and medications already on the market. changes tiers or is no longer covered, you may The Cigna Pharmacy Management® Business pay a different amount to fill that medication. Decision Team then looks at the results of the P&T Committee’s clinical review, as well as the Why doesn’t my plan cover certain medication’s overall value and other factors medications? before adding it to, or removing it from, the To help lower your overall health care costs, drug list. your plan doesn’t cover certain high-cost brand Which medications are covered under the medications because they have lower-cost, health care reform law? covered alternatives which are used to treat the The Patient Protection and Affordable Care Act same condition. Meaning, the alternative works (PPACA), commonly referred to as “health care the same or similar to the non-covered reform,” was signed into law on March 23, 2010. medication. If you’re taking a medication that Under this law, certain preventive medications isn’t covered by your plan and your doctor feels (including some over-the-counter medicines) an alternative medication isn’t right for you, may be available to you at no cost-share ($0), he or she can ask Cigna to consider approving depending on your plan. Log in to the myCigna coverage of your medication. website or app or check your plan materials to Your plan may also exclude certain medications learn more about how your plan covers or products from coverage. This is known as a preventive medications. You can also view the “plan (or benefit) exclusion.” For example, your PPACA No Cost-Share Preventive Medications plan excludes: drug list on Cigna.com/druglist. For more information about health care reform, visit www.informedonreform.com or Cigna.com.

26 Prescription drug list FAQs (cont) Are medications newly approved by the How can I get help with my specialty medication? FDA covered on my drug list? Cigna Specialty Pharmacy ServicesSM can help Newly approved medications may not be you manage your health and prescription needs. covered on your drug list for the first six months Our therapy management teams, made up of after they receive FDA approval. These include, pharmacists and health advocates with nursing but are not limited to, medications, medical backgrounds, provide personalized, 24/7 support. supplies or devices covered under standard They’ll help you get approval for coverage of your pharmacy benefit plans. We review all newly medication, make sure your medication is the approved medications to determine if they right dose, help you work through any side should be covered – and if so, at what tier level. effects, make sure you have any supplies you If your doctor feels a currently covered need, set up the delivery of your medication medication isn’t right for you, he or she can ask through Cigna Specialty Pharmacy (our home Cigna to consider approving coverage of the delivery pharmacy) and give you information newly approved medication. about the financial assistance programs available (if you need help paying for your medication). How can I find out how much I’ll pay for a specific medication? Call 800.351.3606 if you have questions or need help transferring your prescription. To learn more myCigna Use the Drug Cost tool on the website about the services they provide, you can go to or app to estimate how much your medication cigna.com/specialty-pharmacy-services. may cost3 and view lower cost alternatives, if available. Can I fill my prescriptions by mail?

How can I save money on my prescription If you take a medication every day to treat an medications? ongoing health condition (like diabetes, high blood pressure, high cholesterol or asthma), you You may be able to save money by switching can order up to a 90-day supply through Cigna to a medication that’s on a lower tier (ex. generic Home Delivery Pharmacy.SM 5 To get started, or preferred brand) or by filling a 90-day supply, call us at 800.835.3784. To learn more about the if your plan allows. Talk with your doctor to find services they provide, go to cigna.com/home- out if one of these options may work for you. delivery-pharmacy. What’s the difference between brand name If you’re taking a specialty medication to treat and generic medications? a complex condition like multiple sclerosis, The FDA requires generic equivalent medications hepatitis C and rheumatoid arthritis, you can to have the same quality and performance as fill your prescription through Cigna Specialty 5 brand name medications. A generic equivalent Pharmacy (our home delivery pharmacy). To get 800.351.3606 medication is the same as a brand name started, call . To learn more about cigna.com/ medication in dosage form, active ingredient, the services they provide, go to specialty-pharmacy-services strength, route of administration, quality, . performance characteristics and intended use. Where can I find more information about my Generics typically cost much less than brand prescription medication plan? name medications – in some cases, up to Use the online tools and resources on the 80%–85% less.4 Just because generics cost myCigna website or app to help you better less than brands, it doesn’t mean they’re understand your pharmacy benefits. You can lower-quality medications. view your drug list or search for a specific medication, use Drug Cost tool to estimate how much your medication may cost, find an in-network pharmacy near you, review your pharmacy claims and payment history, and fill and track your home delivery orders. 27 Exclusions and limitations

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 be medically necessary. If your plan provides coverage for certain preventive 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, the prescription may not be covered. Certain drugs may require prior authorization, or be subject to step therapy, quantity limits or other utilization management requirements. Plans generally do not provide coverage for the following under the pharmacy benefit, except as required by state or federal law, or by the terms of your specific plan:6

› over-the-counter (OTC) medications › immunization agents, biological products (medications that do not require a for allergy immunization, biological sera, prescription) except insulin unless state or blood, blood plasma and other blood federal law requires coverage of such drugs; products or fractions and medications › prescription drugs or supplies for which there used for travel prophylaxis; is a non-prescription or OTC therapeutic › replacement of prescription drugs and related alternative; supplies due to loss or theft; › physician-administered injectable medications › drugs which are to be taken by or covered under the Plan’s medical benefit, administered to a covered person while they unless otherwise covered under the Plan’s are a patient in a licensed hospital, skilled prescription drug list or authorized by Cigna; nursing facility, rest home or similar institution › implantable contraceptive devices covered which operates on its premises or allows to under the Plan’s medical benefit; be operated on its premises a facility for dispensing pharmaceuticals; › medications that are not medically necessary; › prescriptions more than one year from the › experimental or investigational medications, date of issue; or including FDA-approved drugs used for purposes other than those approved by the In addition to the plan’s standard pharmacy FDA unless the drug is recognized for the exclusions, certain new FDA-approved drug treatment of the particular indication; products (including, but not limited to, medications, medical supplies or devices that › medications that are not approved by the are covered under standard pharmacy benefit Food & Drug Administration (FDA); plans) may not be covered for the first six prescription and non-prescription devices, › months of market availability unless authorized supplies, and appliances other than those by Cigna as medically necessary. supplies specifically listed as covered; › medications used for fertility, sexual dysfunction, cosmetic purposes, weight loss, smoking cessation, or athletic enhancement; › prescription vitamins (other than prenatal vitamins) or dietary supplements unless state or federal law requires coverage of such drugs;

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.

1. State laws in Texas and Louisiana require health insurance plans 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. 2. Smoking cessation medications are not typically covered under the plan, except as required by law or by the terms of your specific plan. Costs and complete details of the plan’s prescription drug coverage, including a full list of exclusions and limitations, are set forth in the plan documents. If there are any differences between the information provided here and the plan documents, the information in the plan documents takes complete precedence. 3. Prices are not guaranteed, and even though a price is displayed in the Drug Cost tool, it’s not a guarantee of coverage. Your costs and coverage may change by the time you fill your prescription at the pharmacy, and medication costs at individual pharmacies can vary. Coverage and pricing may change. For example, your pharmacy’s retail cash price for a specific medication may be less than the price shown in the Drug Cost tool. 4. U.S. Food and Drug Administration (FDA) website, “Facts About Generic Drugs.” Last updated 06/28/16. 5. Plans vary, so some plans may not include Cigna Specialty Pharmacy or Cigna Home Delivery Pharmacy. Please check your plan materials for more information on what pharmacies are covered under your plan. 6. Costs and complete details of the plan’s prescription drug coverage are set forth in the plan documents. If there are any differences between the information provided here and the plan documents, the information in the plan documents takes complete precedence. 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, Cigna Behavioral Health, Inc., 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. (CHC-TN), and Cigna HealthCare of Texas, Inc. “Cigna Specialty Pharmacy Services” and “Cigna Specialty Pharmacy” refer 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); 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. 876397 m Value 3-Tier w DRT 03/18 © 2018 Cigna. Some content provided under license.