PREVENTIVE DRUGS BY CONDITION

July 2015

Preventive care coverage is an integral part of Refer to your plan materials to determine if your plan a comprehensive health care plan that includes includes a preventive medication coverage feature. preventive drug therapies. Under some plans, If you have any questions you may not be required to pay a copay, coinsurance (the percentage of the cost of your covered medical Remember, this list is just a sample of the most expenses after you meet your deductible) and/or commonly used medications, and is subject to change. deductible (the amount you pay before your plan You can use the Prescription Drug Price Quote tool starts to pay) for preventive medications. available on myCigna.com to see and compare the prices of all medications covered under your plan. Preventive medications are those prescribed to Or, you can call the number on the back of your ID prevent the occurrence of a disease or condition for card to speak with a customer service representative those individuals with risk factors, or to prevent the at any time. recurrence of a disease or condition for those who have recovered, and do not include medications used to treat an existing illness, injury or condition. Preventive medications are those used for the prevention of conditions such as high blood pressure, high cholesterol, diabetes, asthma, osteoporosis, heart attack, stroke and prenatal nutrient deficiency.

Offered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company or their affiliates. 874996 c 06/15 Please note, Asthma Related Xopenex HFA Demser brand name Zyflo Diamox Sequels Accolate (zarfirlukast) medications start Zyflo CR (acetazolamide) Accuneb (albuterol sulfate) with a capital Dibenzyline Advair Diskus letter, and generic Blood Pressure Dilacor XR (diltiazem) Advair HFA medications start diltiazem Aerospan Related with a lowercase diltiazem HCl albuterol sulfate Accupril (quinapril) letter. If a brand Diovan (valsartan) (nebulizer solution) Accuretic (quinapril HCl/hctz) name medication Diovan HCT (valsartan/hctz) Alvesco Aceon (perindopril erbumine) has an equivalent Diuril generic available, Anoro Ellipta acetazolamide Dutoprol it will be listed Arcapta Neohaler Adalat CC (nifedipine) Dyazide (triamterene/hctz) next to the Arnuity Ellipta Aldactazide (spironolactone/ Dyrenium brand name in Asmanex hctz) Edarbi parentheses. Atrovent HFA Aldactone (spironolactone) Edarbyclor Breo Ellipta Altace (ramipril) Edecrin *Medications Brovana amiloride HCl Epaned marked with Cafcit (caffeine citrate) amiloride/hydrochlorothiazide an asterisk are Exforge Combivent Respimat Amturnide considered to (amlodipine/valsartan) cromolyn sodium inhalation Atacand (candesartan) be specialty Exforge HCT (amlodipine/ solution Atacand HCT medications. valsartan/hctz) Dulera (candesartan/hctz) These medications felodipine Duoneb (albuterol sulfate/ Avalide (irbesartan/hctz) must be obtained fosinopril sodium ipratropium) Avapro (irbesartan) from a preferred fosinopril sodium/hctz Elixophylline Azor specialty pharmacy. furosemide (theophylline anhydrous) benazepril HCl Some plans may hydralazine HCl Flovent benazepril HCl/hctz cover specialty hydrochlorothiazide Flovent Diskus Benicar medications at Hyzaar (losartan/hctz) Flovent HFA Benicar HCT different benefit indapamide levels. Refer to Foradil Betapace (sotalol HCl) Inderal LA (propanolol HCl) your Summary Plan Incruse Ellipta Betapace AF (sotalol HCl) Innopran XL (propanolol HCl) Description for ipratropium bromide betaxolol Inspra (eplerenone) more information. Lufyllin (dyphylline) Bumex (bumetanide) isradipine Lufyllin-400 Bystolic (nebivolol HCl) labetalol HCl metaproterenol sulfate Caduet (amlodipine/ Lasix (furosemide) Perforomist atorvastatin calcium) Levatol ProAir HFA Calan (verapamil) lisinopril/hctz Proventil HFA Calan SR (verapamil) Lopressor Pulmicort (budesonide) captopril (metoprolol tartrate) Pulmicort Flexhaler captopril/hctz Lopressor HCT Qvar Cardene SR (metoprolol/hctz) S-2 Racepinephine Cardizem (diltiazem) Lotensin (benazepril HCl) (racepinephine HCl) Cardizem CD (diltiazem) Lotensin HCT (benazepril HCl/ Serevent Diskus Cardizem LA (diltiazem HCl) hctz) Singulair (montelukast) Cardura (doxazosin mesylate) Lotrel (amlodipine besylate/ Spiriva Cardura XL banazepril) Spiriva Respimat (doxazosin mesylate) Mavik (trandolapril) Striverdi Respimat Catapres (clonidine HCl) Maxzide (triamterene/hctz) Symbicort Catapres-TTS 1 (clonidine) methyclothiazide terbutaline sulfate Catapres-TTS 2 (clonidine) methyldopa Theo-24 Catapres-TTS 3 (clonidine) methyldopa/hctz Theophylline chlorothiazide metolazone theophylline anhydrous chlorthalidone metoprolol succinate Tudorza Pressair clonidine HCl/chlorthalidone metoprolol tartrate Ventolin HFA Coreg (carvedilol) Micardis (telmisartan) (albuterol sulfate) Coreg CR Micardis HCT Vospire ER (albuterol sulfate) Corgard (nadolol) (telmisartan/hctz) Xolair Corzide (bendroflumethiazide/ Microzide Xopenex (levalbuterol) nadolol) (hydrochlorothiazide) Xopenex Concentrate Cozaar (losartan potassium) (levalbuterol HCl) Demadex (torsemide)

2 Blood Pressure Eliquis Avandia Related (continued) Jantoven (warfarin) Bydureon Persantine (dipyridamole) Bydureon Pen Minipress (prazosin HCl) Plavix (clopidogrel bisulfate) Byetta minoxidil Pletal (cilostazol) chlorpropamide moexepril HCl/hctz Pradaxa Cycloset Naturetin-5 Savaysa Diabeta (glyburide) Neptazane (methazolamide) Ticlid (ticlopidine HCl) Duetact (pioglitazone/ nicardipine HCl Xarelto glimiperide) nimodipine Zontivity Farxiga nisoldipine Fortamet (metformin HCl) Norvasc (amlodipine besylate) Cholesterol Related glipizide/metformin HCl Nymalize Glucophage (metformin HCl) pindolol Advicor Altoprev Glucophage XR Prinivil (lisinopril) (metformin HCl) Procardia (nifedipine) Antara (fenofibrate, micronized) Glucotrol (glipizide) Procardia XL (nifedipine) Glucotrol XL (glipizide) propranolol HCl Caduet (amlodipine/ atorvastatin) Glucovance propranolol/hctz (glyburide/metformin) reserpine Colestid (colestipol HCl) Crestor Glumetza Sectral (acebutolol HCl) Glynase (glyburide Sotylize (sotalol HCl) Fenoglide (fenofibrate) Fibricor (fenofibric acid) micronized) Sular (nisoldipine) Glyset Tarka (trandolapril/verapamil) Lescol (fluvastatin HCl) Lescol XL Glyxambi Tekamlo Humalog Tekturna Lipitor (atorvastatin calcium) Lipofen (fenofibrate) Humalog Mix 50/50 Tekturna HCT Humalog Mix 75/25 Tenex (guanfacine HCl) Liptruzet Livalo Humulin 70/30 Tenoretic 100 (chlorthalidone/ Humulin N atenolol) Lofibra (fenofibrate) Lopid (gemfibrozil) Humulin R Tenoretic 50 (chlorthalidone/ Invokamet atenolol) lovastatin Lovaza (omega-3 acid ethyl Invokana Tenormin (atenolol) Janumet terazosin HCl esters) Mevacor (lovastatin) Janumet XR Teveten (eprosartan mesylate) Januvia Teveten HCT Niacor Niaspan (niacin) Jardiance Tiazac (diltiazem) Jentadueto timolol maleate Pravachol (pravastatin HCl) pravastatin sodium Kazano Toprol XL (metoprolol Kombiglyze XR succinate) Questran (cholestyramine/ sucrose) Lantus Trandate (labetalol HCl) Lantus SoloStar triamterene/hctz Questran Light (cholestyramine/aspartame) Levemir Tribenzor Levemir FlexTouch Twynsta (telmisartan/ Simcor Tricor (fenofibrate, micronized) Nesina amlodipine) Novolin 70/30 Univasc (moexepril HCl) Triglide Trilipix (fenofibric acid) Novolin N Vaseretic (enalapril maleate/ Novolin R hctz) Vytorin Welchol Novolog Vasotec (enalapril maleate) Novolog Mix 70/30 Vecamyl - mecamylamine HCl Zetia Zocor (simvastatin) Onglyza Verelan (verapamil) Oseni Verelan PM (verapamil) Diabetes Related Prandimet Zebeta (bisoprolol fumarate) Prandin (repaglinide) Zestoretic (lisinopril/hctz) Actoplus Met (pioglitazone Precose (acarbose) Zestril (lisinopril) HCL/metformin HCl) Riomet Ziac (bisoprolol/hctz) Actoplus Met XR Starlix (nateglinide) Actos (pioglitazone HCl) Symlin Blood Thinner Related Afrezza SymlinPen 120 Aggrenox Amaryl (glimepiride) SymlinPen 60 Brilinta Apidra Tanzeum Coumadin (warfarin) Apidra SoloStar tolazamide Effient Avandamet tolbutamide Avandaryl 3 Diabetes Related Duet DHA Prenate DHA^ (continued) Focalgin-B Prenate Elite^ folbecal Prenate Enhance Toujeo Solostar Folet DHA Prenate Essential^ Tradjenta Folet One Prenate Mini Trulicity Infanate Balance Prenate Pixie Victoza Marnatal-F Prenate Plus^ Xigduo XR Maxinate Prenate Restore M-Vit Prenate Star Osteoporosis Related Natachew^ Preque 10^ Actonel (risedronate sodium Natalins^ Provida OB 150 mg only) Natalvit Purefe OB Plus Atelvia Natelle One^ Purefe Plus Binosto Neevodha Select-OB Boniva (ibandronate sodium) Nestabs ABC taron bc etidronate disodium Nestabs DHA^ Taron-Prenexa^ Evista (raloxifene) Nestabs^ TL Folate Forteo Nexa Plus Tricare (Fortical) calcitonin-salmon OB Complete DHA^ Tricare Prenatal DHA ONE^ Fosamax (alendronate sodium) OB Complete One triveen-duo dha Fosamax Plus D (alendronate OB Complete Petite Ultimatecare One NF^ sodium/vitamin D3) OB Complete Premier Vena-Bal DHA^ Miacalcin OB Complete with DHA venatal complete dha Skelid OB Complete^ Vinate Care Obstetrix EC Vinate DHA RF Representative Obtrex DHA^ Vinate II^ Prenatal Vitamins O-Cal FA Virt-Bal DHA Balance O-cal Prenatal Vitafol Nano (Available as generic paire ob plus dha Vitafol Ultra where ^ is noted.) Prefera OB^ Vitafol-OB+DHA^ Active OB^ Prefera-OB ONE^ Vitafol-One Bal-Care DHA Essential Prefera-OB Plus DHA^ VitaMedMD One Rx Cadeau DHA Prenata VitamedMD Plus Rx Citranatal 90 DHA^ prenatal 19 VitamedMD Redichew Rx Citranatal Assure^ prenatal low iron Vitapearl Citranatal B-Calm Prenatal Plus 90^ VIVA DHA^ Citranatal DHA^ Prenatal Plus^ Vol-Nate^ Citranatal Harmony^ Prenatal U^ vol-plus Citranatal RX Prenatal Vitamin^ VO L-TAB R X^ Complete Natal DHA Prenatal-1^ VP CH Ultra Concept DHA^ Prenate AM VP-PNV-DHA Concept OB^ Prenate Chewable Zatean-CH

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”, the “Tree of Life” logo and “Together, all the way.” are registered service marks, and “Cigna Home Delivery Pharmacy” is a service mark 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, LLC, 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, LLC, doing business as Cigna Home Delivery Pharmacy. All models are used for illustrative purposes only. 874996 c 06/15 © 2015 Cigna. Some content provided under license.