1/1/2018 FORMULARY CHANGES CIGNA COMMERCIAL CUSTOMERS

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1 1/1/2018 FORMULARY CHANGES CIGNA COMMERCIAL CUSTOMERS Effective 1/1/18, Cigna is making changes to our formularies that may impact medication coverage for customers at your pharmacy. We have included a list of drugs by drug class that will be considered non-covered, non-preferred brand or require prior approval from Cigna for coverage, as well as the covered alternatives. We sent letters to affected customers explaining the coverage changes to their current medications. However, if a customer with Cigna pharmacy benefits does come in and attempts to refill a medication that is not covered, when appropriate, we ask that you assist him or her in the following ways: Mention the alternative covered drugs available in the chart on the next page Urge the customer to meet with the prescriber to discuss these alternatives or please call the prescriber to facilitate the new prescription Help the customer fill out the simple form on the last page to bring to his or her prescriber If you have questions, please see below: Question: Point of Service and Processing Phone Number: Issue Type: Refill too Soon Drug Coverage Issues Copay Issues You will need the following information for the phone prompts: Customer ID Customer DOB Prescription Information Pharmacy Contract Provider.Relations@optum.com Contract inquiries Reimbursement Optum.com/pharmacycareservices Select Pharmacists Reimbursement 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, Tel-Drug, Inc., Tel-Drug of Pennsylvania, L.L.C., and HMO or service company subsidiaries of Cigna Health Corporation. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc Cigna.

2 Drug Coverage Changes by Class For Drugs Covered Under the Pharmacy Benefit Please note that this list only applies to our non-medicare Standard Prescription Drug List and does not reflect the entire list of covered and not-covered drugs for this or any other Cigna drug list. DRUG(S) NOT COVERED IN ^ DRUG(S) COVERED IN DRUG CLASS ANXIETY/DEPRESSION/BIPOLAR Anafranil clomipramine DISORDER Pamelor nortriptyline Parnate tranylcypromine Tofranil imipramine ASTHMA/COPD/RESPIRATORY Zyflo montelukast, zafirlukast, zileuton ER Zyflo CR zileuton ER ATTENTION DEFICIT Desoxyn methamphetamine HYPERACTIVITY DISORDER Dexedrine dextroamphetamine, dextroamphetamine ER BLOOD PRESSURE/HEART Betapace sotalol tablets MEDICATIONS CANCER Nilandron nilutamide DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR Invokana Farxiga, Jardiance Lantus, Lantus SoloStar, Toujeo Basaglar, Levemir, Tresiba SoloStar 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 mg capsules Rowasa mesalamine enema Uceris tablet budesonide EC capsule 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

3 INFECTIONS Targadox Avidoxy tablet, doxycycline hyclate, Morgidox capsule Valcyte valganciclovir Vancocin Zovirax vancomycin capsule acyclovir MISCELLANEOUS Gralise, Horizant gabapentin PAIN RELIEF AND INFLAMMATORY DISEASE Cambia D.H.E. 45, Migranal Imitrex, Sumavel DosePro Lorzone OxyContin Roxicodone Tivorbex Vanatol LQ Vivlodex Zomig Zorvolex PARKINSON'S DISEASE Lodosyn carbidopa Requip XL ropinirole ER SCHIZOPHRENIA/ANTI- Geodon ziprasidone PSYCHOTICS Zyprexa olanzapine diclofenac, diclofenac ER, etodolac, etodolac ER, fenoprofen, Fenortho, flurbiprofen, ibuprofen, indomethacin, indomethacin ER, ketoprofen, Ketorolac, meclofenamate, mefenamic acid, meloxicam, nabumetone dihydroergotamine sumatriptan chlorzoxazone Embeda, Hysingla ER, Xtampza ER oxycodone indomethacin butalbital/acetaminophen/caffeine tabs or caps meloxicam sumatriptan, zolmitriptan diclofenac, diclofenac ER Zyprexa Zydis olanzapine ODT 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 Ditropan XL Enablex Gelnique tolterodine ER oxybutynin ER darifenacin ER darifenacin ER, oxybutynin ER, tolterodine ER, trospium ER

4 ATTENTION DEFICIT HYPERACTIVITY DISORDER NON-PREFERRED BRAND DRUG(S) Adderall XR Focalin XR GENERIC AND/OR PREFERRED BRAND ALTERNATIVES dextroamphetamineamphetamine ER dexmethylphenidate ER SKIN CONDITIONS Ala-Scalp hydrocortisone Analpram HC lotion Capex shampoo Cordran Nucort, Texacort hydrocortisone-pramoxine fluocinolone flurandrenolide hydrocortisone DRUG(S) REQUIRING PRIOR ADDITIONAL INFORMATION AUTHORIZATION GASTROINTESTINAL/HEARTBURN HORMONAL AGENTS Akynzeo, Anzemet, Emend, Sancuso, Varubi Androderm, Androgel, Striant, testosterone Your plan will only cover this medication if the customer s doctor requests and receives approval from Cigna. DRUG(S) WITH QUANTITY ADDITIONAL INFORMATION LIMITS ALLERGY/NASAL SPRAYS cromolyn oral, mometasone Your plan only covers a certain ALZHEIMER'S DISEASE Namenda XR, Namzaric amount of this medication over a certain number of days. ANXIETY/DEPRESSION/BIPOLAR desvenlafaxine 25mg, 100mg, DISORDER Marplan, Pristiq ASTHMA/COPD/RESPIRATORY Perforomist BLOOD PRESSURE/HEART Ranexa MEDICATIONS 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 Daliresp, Mitigare DISEASE SCHIZOPHRENIA/ANTI- Fanapt PSYCHOTICS SEIZURE DISORDERS Gabitril, Potiga SKIN CONDITIONS Denavir, Regranex, Santyl, Vectical SLEEP DISORDERS/SEDATIVES Hetlioz STEP THERAPY GENERIC AND/OR PREFERRED BRAND ALTERNATIVES ATTENTION DEFICIT Focalin XR dexmethylphenidate ER HYPERACTIVITY DISORDER SCHIZOPHRENIA/ANTI- Orap pimozide PSYCHOTICS SKIN CONDITIONS Ala-Scalp hydrocortisone Capex shampoo fluocinolone Cordran flurandrenolide Nucort, Texacort hydrocortisone

5 DOSE OPTIMIZATION - DRUG STRENGTH WITH LIMITATIONS^^ (Plan does not cover 2 capsules/ tablets per day) COVERED DRUG STRENGTH (Prescription must be for this strength) ALLERGY/NASAL SPRAYS desloratadine ODT 2.5mg desloratadine ODT 5mg ANXIETY/DEPRESSION/BIPOLAR DISORDER BLOOD PRESSURE/HEART MEDICATIONS Fetzima ER 20mg Fetzima ER 40mg Trintellix 5mg Trintellix 10mg Azor 5-20mg Benicar 20mg Benicar HCT mg Bystolic 10mg Tekturna 150mg Tekturna HCT mg Fetzima ER 40mg Fetzima ER 80mg Trintellix 10mg Trintellix 20mg Azor 10-40mg Benicar 40mg Benicar HCT 40-25mg Bystolic 20mg Tekturna 300mg CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg Livalo 2mg Tekturna HCT mg Livalo 4mg DIABETES Farxiga 5mg Farxiga 10mg PAIN RELIEF AND INFLAMMATORY Uloric 40mg Uloric 80mg DISEASE SCHIZOPHRENIA/ANTI- Latuda 60mg Latuda 120mg PSYCHOTICS SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg Aptiom 400mg Fycompa 4mg Fycompa 6mg Trokendi XR 25mg Trokendi XR 100mg Aptiom 800mg Fycompa 8mg Fycompa 12mg Trokendi XR 50mg Trokendi XR 200mg SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg EAR MEDICATIONS GASTROINTESTINAL/HEARTBURN INFECTIONS NUTRITIONAL/DIETARY PAIN RELIEF AND INFLAMMATORY DISEASE SEIZURE DISORDERS BENEFIT PLAN EXCLUSIONS* Cortane-B Lotion Donnatal Elixir, Gelclair Oral Gel Packet, Proctocort 30 Mg Suppository Benzodox 30 Kit, Benzodox 60 Kit, Urelle Tablet Feriva FA Capsule Analpram HC 2.5%-1% Crm Single, Prodrin Caplet Smartrx Gabakit

6 SKIN CONDITIONS BENEFIT PLAN EXCLUSIONS* Ala-Quin 3-0.5% Cream, Avar 9.5%-5% Foam, Avar 9.5-5% Cleansing Pads, Avar LS 10%-2% Foam, Avar LS 10-2% Cleansing Pads, Avar LS Cleanser, Avar-E LS Cream, Dermasorb AF Complete Kit, Inova 4% Easy Pad, Inova 4-1 Easy Pad, Inova 8-2 Easy Pad, Iodoflex Pad, Keralac 47% Cream, Neosalus Foam, Ovace 10% Wash, Ovace Plus 10% Shampoo, Ovace Plus 10% Wash, Ovace Plus 9.8% Foam, Ovace Plus 9.8% Lotion, Ovace Plus Wash 10% Clnsng Gel, Plexion % Cleanser, Plexion % Clnsing Cloth, Plexion % Cream, Plexion % Lotion, Rynoderm 37.5% Topical Cream, Salex 6% Cream Kit, Salex 6% Lotion Kit, Salex 6% Shampoo, Salvax 6% Foam, Selrx 2.3% Shampoo, Sumadan 9%- 4.5% Wash, Sumadan Kit, Sumadan XLT Kit, Sumaxin Cleansing Pads, Sumaxin CP Kit, Sumaxin TS Topical Suspension, Sumaxin Wash, Ultrasal-ER 28.5% Solution, Uramaxin GT 45% Pre-Filled App, Urevaz 44% Cream, Vanoxide-HC Lotion, Virasal Antiviral Wart Remover, Vytone Cream Packet, Zithranol 1% Shampoo ^ These medications are not covered in our formularies; however, health care professionals can ask Cigna to consider approving coverage through a medical necessity review process. Through this process, health care professionals must show that covered alternatives failed to produce results for the patient and therefore a non-covered medication should be considered for coverage. ^^ These drugs are part of the Dose Optimization program. There is a medical necessity review process in place for customers who have proven a higher dose once per day is not clinically appropriate and require the use of a lower strength twice per day. * This product s eligibility for coverage varies by manufacturer because not all versions of the product have been approved by the FDA for marketing. Products not approved by the FDA for marketing are excluded from coverage under benefit plans.

7 Drug Coverage Changes by Class For Drugs Covered Under the Medical Benefit This list only applies to our non-medicare Standard Prescription Drug List and does not reflect the entire list of covered and not-covered drugs for this or any other Cigna drug list. Please note that drugs are listed alphabetically by brand name, with the generic name in parenthesis. GASTROINTESTINAL/HEARTBURN DRUG(S) REQUIRING PRIOR AUTHORIZATION Adriamycin (Doxorubicin Hcl), Adrucil (Fluorouracil), Alkeran (Melphalan Hcl), Aloxi (Palonosetron Hcl), Arranon (Nelarabine), Arzerra (Ofatumumab), Bleomycin (Bleomycin Sulfate), Camptosar (Irinotecan Hcl), Cerubidine (Daunorubicin Hcl), Clolar (Clofarabine), Cosmegen (Dactinomycin), Cytosar-U (Cytarabine), Dacogen (Decitabine), Depocyt (Cytarabine Liposome/Pf), Doxil (Doxorubicin Hcl Peg-Liposomal), Dtic-Dome (Dacarbazine), Ellence (Epirubicin Hcl), Eloxatin (Oxaliplatin), Emend (Fosaprepitant Dimeglumine), Faslodex (Fulvestrant), Fludara (Fludarabine Phosphate), Folotyn (Pralatrexate), Fudr (Floxuridine), Fusilev (Levoleucovorin Calcium), Gemzar (Gemcitabine Hcl), Hycamtin (Topotecan Hcl), Idamycin (Idarubicin Hcl), Ifex (Ifosfamide), Istodax (Romidepsin), Ixempra (Ixabepilone), Leustatin (Cladribine), Mustargen (Mechlorethamine Hcl), Mutamycin (Mitomycin), Navelbine (Vinorelbine Tartrate), Nipent (Pentostatin), Novantrone (Mitoxantrone Hcl), Oncaspar (Pegaspargase), Paraplatin (Carboplatin), Platinol (Cisplatin) Proleukin (Aldesleukin), Taxol (Paclitaxel), Taxotere (Docetaxel), Temodar (Temozolomide), Tepadina (Thiotepa), Toposar (Etoposide), Torisel (Temsirolimus), Trisenox (Arsenic Trioxide), Velban (Vinblastine Sulfate), Velcade (Bortezomib) Vidaza (Azacitidine), Vincasar (Vinblastine Sulfate), Vumon (Teniposide), Zanosar (Streptozocin) ADDITIONAL INFORMATION Your plan will only cover this medication if the customer s doctor requests and receives approval from Cigna.

8 Medication name: I am currently taking: Available alternatives: Strength: Directions: Medication name: I am currently taking: Available alternatives: Strength: Directions: Medication name: I am currently taking: Available alternatives: Strength: Directions:

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