Prescription Drug List Changes

Transcription

1 Cigna Pharmacy Management Prescription Drug List Changes Effective January 1, 2017 Effective January 1, 2017, changes will be made to Cigna s Prescription Drug List that may affect some of your patients. Some drug classes will feature either one or a select set of preferred brand name medications, and other brand name equivalent medications may only be considered for coverage by going through Cigna s medical necessity review process. Below is the list of medications that are covered, not covered or non-preferred by drug list as of January 1, Patients who continue to fill a prescription for a medication that is not covered as of January 1, 2017, will have to pay the full cost of the medication. You should speak with your patient to see if one of the covered might work for him or her. STANDARD PRESCRIPTION DRUG LIST Drug class Non-preferred brand medication Generic and/or preferred brand BLOOD MODIFIERS/ Neupogen + ** Granix **, Zarxio BLEEDING DISORDERS CANCER Gleevec ** imatinib mesylate ** CHOLESTEROL Lescol XL generic statins MEDICATIONS PAIN RELIEF & Kadian, Nucynta ER, Xartemis XR Hysingla ER, OxyContin, Xtampza ER Drug class Medication not covered^ Generic and/or preferred brand ALLERGY/NASAL SPRAYS Beconase AQ, Dymista, Nasonex, Omnaris, QNASL, Veramyst, Zetonna budesonide, flunisolide, fluticasone propionate, mometasone furoate, triamcinolone acetonide QNASL Children fluticasone propionate, budesonide, ANXIETY/DEPRESSION/ BIPOLAR DISORDER ASTHMA/COPD/ RESPIRATORY BLOOD PRESSURE/ HEART MEDICATIONS DIABETES Aplenzin Ativan Pexeva Aerospan, Alvesco, Arnuity Ellipta, Asmanex, Asmanex HFA, Flovent Diskus, Flovent HFA Dulera Incruse Ellipta, Tudorza Pressair Proventil HFA, Xopenex HFA Cardizem CD Isordil Fortamet, metformin ER (when filled as generic to Glumetza) Jardiance, Synjardy Tanzeum, Victoza triamcinolone acetonide bupropion XL lorazepam paroxetine QVAR, Pulmicort Flexhaler Advair HFA, Advair Diskus, Breo Ellipta, Symbicort Spiriva, Spiriva Respimat ProAir Respiclick, ProAir HFA, Ventolin HFA cartia XT, diltiazem 24hr CD, diltiazem 24hr ER isosorbide metformin ER (when filled as generic to Glucophage XR or generic to Fortamet) Invokamet, Invokana, Farxiga, Xigduo XR Trulicity, Bydureon, Byetta

2 STANDARD PRESCRIPTION DRUG LIST, cont d Drug class Medication not covered^ Generic and/or preferred brand GASTROINTESTINAL/ HEARTBURN Asacol HD, Colazal, Delzicol, Dipentum, Giazo Apriso, balsalazide, Lialda, mesalamine, Pentasa, sulfasalazine Librax chlordiazepoxide-clidinium Metozolv ODT Nexium Pepcid metoclopramide, metoclopramide ODT esomeprazole magnesium famotidine Zegerid omeprazole-sodium bicarbonate, omeprazole, omeprazole+syrspend sf alka Zuplenz ondansetron, ondansetron ODT HORMONAL AGENTS Rayos prednisone, prednisone intensol Saizen Humatrope INFECTIONS Bethkis, Tobi Kitabis Pak, tobramycin Sitavig acyclovir Amrix Belbuca Bupap diclofenac 1.5% solution, klofensaid II, Pennsaid Lido-K Sprix Treximet baclofen, carisoprodol, cyclobenzaprine, methocarbamol, tizanidine Butrans butalbital-acetominophen, Marten-Tab, Tencon diclofenac 1% gel, generic oral NSAIDs (diclofenac, ibuprofen, meloxicam, lidocaine, lidopin ketorolac tromethamine generic triptans (naratriptan, sumatriptan, zolmitriptan) plus a generic NSAID (ibuprofen, meloxicam, sumatriptan aripiprazole clozapine, clozapine ODT Zembrace Symtouch SCHIZOPHRENIA/ Abilify, Abilify ODT ANTI-PSYCHOTICS Fazaclo, Versacloz SEIZURE DISORDERS Mysoline primidone SKIN CONDITIONS Absorica claravis, myorisan, zenatane Benzaclin, Duac, Neuac kit clindamycin-benzoyl peroxide, neuac gel Carac fluorouracil Clindagel clindamycin phosphate Jublia, Kerydin ciclodan, ciclopirox, itraconazole, terbinafine Noritate metronidazole, rosadan Novacort hydrocortisone Vanos fluocinonide Xerese acyclovir, hydrocortisone Zovirax acyclovir Zyclara imiquimod SLEEP DISORDERS/ Edluar, Intermezzo zolpidem tartrate, zolpidem tartrate ER SEDATIVES

3 STANDARD PRESCRIPTION DRUG LIST, cont d Drug class Medication not covered^ Generic and/or preferred brand SUBSTANCE ABUSE Evzio naloxone vial & PFS, Narcan URINARY TRACT CONDITIONS Drug class Myrbetriq, Toviaz, VESIcare Medication with Quantity Limits darifenacin ER, oxybutynin chloride ER, tolterodine tartrate ER, trospium chloride ER Lidocaine 5% ointment Drug class Step Therapy medication Generic and/or preferred brand Kadian, Nucynta ER, Xartemis XR Hysingla ER, OxyContin, Xtampza ER PERFORMANCE PRESCRIPTION DRUG LIST Drug class Non-preferred brand medication Generic and/or preferred brand BLOOD MODIFIERS/ Neupogen + ** Granix **, Zarxio BLEEDING DISORDERS CHOLESTEROL Lescol XL generic statins MEDICATIONS MISCELLANEOUS Zavesca ** Cerdelga ** Kadian, Nucynta ER, Xartemis XR Hysingla ER, OxyContin, Xtampza ER Drug class Medication not covered^ Generic and/or preferred brand ALLERGY/NASAL SPRAYS Beconase AQ, Dymista, Nasonex, Omnaris, QNASL, Veramyst, Zetonna budesonide, flunisolide, fluticasone propionate, mometasone furoate, triamcinolone acetonide QNASL Children fluticasone propionate, budesonide, ANXIETY/DEPRESSION/ BIPOLAR DISORDER ASTHMA/COPD/ RESPIRATORY BLOOD PRESSURE/ HEART MEDICATIONS DIABETES Aplenzin Ativan Pexeva Aerospan, Alvesco, Arnuity Ellipta, Asmanex, Asmanex HFA, Flovent Diskus, Flovent HFA Dulera Incruse Ellipta, Tudorza Pressair Proventil HFA, Xopenex HFA Cardizem CD Isordil Fortamet, metformin ER (when filled as generic to Glumetza) Jardiance, Synjardy Tanzeum, Victoza triamcinolone acetonide bupropion XL lorazepam paroxetine QVAR, Pulmicort Flexhaler Advair Diskus, Advair HFA, Breo Ellipta, Symbicort Spiriva, Spiriva Respimat ProAir Respiclick, ProAir HFA, Ventolin HFA cartia XT, diltiazem 24hr CD, diltiazem 24hr ER isosorbide metformin ER (when filled as generic to Glucophage XR or generic to Fortamet) Invokana, Invokamet, Farxiga, Xigduo XR Trulicity, Bydureon, Bydureon Pen, Byetta

4 PERFORMANCE PRESCRIPTION DRUG LIST, cont d Drug class Medication not covered^ Generic and/or preferred brand GASTROINTESTINAL/ HEARTBURN Asacol HD, Colazal, Delzicol, Dipentum, Giazo Apriso, balsalazide, Lialda, mesalamine, Pentasa, sulfasalazine Librax chlordiazepoxide-clidinium Metozolv ODT Nexium Pepcid Zegerid Zuplenz metoclopramide, metoclopramide ODT esomeprazole magnesium famotidine omeprazole-sodium bicarbonate, omeprazole, omeprazole+syrspend sf alka ondansetron, ondansetron ODT HORMONAL AGENTS Rayos prednisone, prednisone intensol Saizen Humatrope INFECTIONS Bethkis, Tobi Kitabis Pak, tobramycin Sitavig Amrix Belbuca Bupap Capital w/ codeine diclofenac 1.5% solution, klofensaid II, Pennsaid acyclovir baclofen, carisoprodol, cyclobenzaprine, methocarbamol, tizanidine Butrans butalbital-acetaminophen, Marten-Tab, Tencon acetaminophen-codeine diclofenac 1% gel, generic oral NSAIDs (diclofenac, ibuprofen, meloxicam, lidocaine, lidopin Lido-K Sprix ketorolac tromethamine Treximet generic triptans (naratriptan, sumatriptan, zolmitriptan) plus a generic NSAID (ibuprofen, meloxicam, Zembrace Symtouch sumatriptan SCHIZOPHRENIA/ Abilify, Abilify ODT aripiprazole ANTI-PSYCHOTICS Fazaclo, Versacloz clozapine, clozapine ODT SEIZURE DISORDERS Mysoline primidone SKIN CONDITIONS Absorica claravis, myorisan, zenatane Bensal HP salacyn, salicylic acid Benzaclin, Duac, Neuac kit clindamycin-benzoyl peroxide, neuac gel Carac fluorouracil Clindagel clindamycin phosphate Jublia, Kerydin ciclodan, ciclopirox, itraconazole, terbinafine Noritate metronidazole, rosadan Novacort hydrocortisone Vanos fluocinonide Xerese acyclovir, hydrocortisone Zovirax acyclovir Zyclara imiquimod

5 PERFORMANCE PRESCRIPTION DRUG LIST, cont d Drug class Medication not covered^ Generic and/or preferred brand SLEEP DISORDERS/ Ativan lorazepam SEDATIVES Edluar, Intermezzo zolpidem tartrate, zolpidem tartrate ER Substance Abuse Evzio naloxone vial & PFS, Narcan URINARY TRACT CONDITIONS Myrbetriq, Toviaz, VESIcare darifenacin ER, oxybutynin chloride ER, tolterodine tartrate ER, trospium chloride ER Drug class Medication with Quantity Limits Lidocaine 5% ointment Drug class Step Therapy medication Generic and/or preferred brand Kadian, Nucynta ER, Xartemis XR Hysingla ER, OxyContin, Xtampza ER VALUE PRESCRIPTION DRUG LIST Drug class Non-preferred brand medication Generic and/or preferred brand BLOOD MODIFIERS/ Neupogen + ** Granix **, Zarxio BLEEDING DISORDERS Cimzia ** Enbrel **, Humira ** Kadian, Nucynta ER, Xartemis XR Hysingla ER, OxyContin, Xtampza ER Drug class Medication not covered^ Generic and/or preferred brand ANXIETY/DEPRESSION/ Aplenzin bupropion XL BIPOLAR DISORDER Ativan lorazepam ASTHMA/COPD/ RESPIRATORY BLOOD PRESSURE/ HEART MEDICATIONS Pexeva Aerospan, Alvesco, Arnuity Ellipta, Asmanex, Asmanex HFA, Flovent Diskus, Flovent HFA, Pulmicort Flexhaler Incruse Ellipta, Tudorza Pressair Accupril Accuretic Aceon Altace Atacand Atacand-HCT Avalide Avapro Bystolic Cardizem Cardizem CD Cozaar paroxetine QVAR Spiriva, Spiriva Respimat quinapril quinapril-hctz perindopril ramipril candesartan candesartan-hctz irbesartan-hctz irbesartan atenolol, betaxolol, bisoprolol, metoprolol diltiazem cartia XT, diltiazem 24hr CD, diltiazem 24hr ER losartan

6 VALUE PRESCRIPTION DRUG LIST, cont d Drug class Non-preferred brand medication Generic and/or preferred brand BLOOD PRESSURE/ Accupril quinapril HEART MEDICATIONS, Exforge amlodipine-valsartan cont d Exforge HCT amlodipine-valsartan-hctz Hyzaar, Lotensin HCT, Micardis HCT, Tekturna HCT generic ACE or generic ARB + HCTZ (enalapril, lisinopril, irbesartan, valsartan + HCTZ) Isordil, Isordil Titradose isosorbide Lotrel amlodipine besylate-benazepril Mavik trandolapril Micardis telmisartan Prinivil, Zestril lisinopril Tarka trandolapril-verapamil ER Tekturna generic ACE or generic ARB (enalapril, lisinopril, irbesartan, valsartan) Twynsta telmisartan-amlodipine CHOLESTEROL MEDICATIONS COUGH/COLD MEDICATIONS DIABETES GASTROINTESTINAL/ HEARTBURN Vaseretic enalapril-hctz Altoprev, Vytorin atorvastatin, rosuvastatin, simvastatin, Zetia Antara, Fenoglide fenofibrate Crestor rosuvastatin calcium Lescol XL fluvastatin ER Livalo atorvastatin, rosuvastatin, simvastatin Pravachol pravastatin Zocor simvastatin Tussicaps hydrocodone-chlorpheniramne ER, promethazine-codeine Fortamet, metformin ER (when filled as metformin ER (when filled as generic to generic to Glumetza) Glucophage XR or generic to Fortamet) Anusol-HC Anucort-HC, GRx Hicort 25, Hemmorex-HC, hydrocortisone, Procto- Med HC, Proctosol-HC, Proctozone- HC, Rectacort-HC Asacol HD, Colazal, Delzicol, Dipentum, Giazo Proctocort Apriso, balsalazide, Lialda, Pentasa, sulfasalazine hemmorex-hc, hemril, hydrocortisone acetate HORMONAL AGENTS Dexpak dexamethasone Rayos prednisone Saizen Humatrope Uceris budesonide EC INFECTIONS Bethkis, Tobi tobramycin, Kitabis Pak Onmel itraconazole, terbinafine Sitavig acyclovir Amrix Belbuca Bupap Cambia, Tivorbex, Vivlodex, Zipsor, Zorvolex Capital w/ codeine Conzip baclofen, carisoprodol, cyclobenzaprine, methocarbamol, tizanidine Butrans butalbital-acetominophen, Marten-Tab, Tencon generic NSAIDs (diclofenac, ibuprofen, indomethacin, meloxicam, acetaminophen-codeine tramadol, tramadol ER

7 VALUE PRESCRIPTION DRUG LIST, cont d Drug class Non-preferred brand medication Generic and/or preferred brand diclofenac 1.5% solution, klofensaid II, Pennsaid diclofenac 1% gel, generic oral NSAIDs (diclofenac, ibuprofen, meloxicam, Horizant, Gralise gabapentin Lido-K lidocaine, lidopin Lorzone chlorzoxazone Sprix ketorolac Sumavel Dosepro, Zembrace sumatriptan SCHIZOPHRENIA/ ANTI-PSYCHOTICS Symtouch Treximet Zomig ZMT Abilify, Abilify ODT Fazaclo, Versacloz SEIZURE DISORDERS Mysoline primidone generic triptans (naratriptan, sumatriptan, zolmitriptan) plus a generic NSAID (ibuprofen, meloxicam, zolmitriptan ODT aripiprazole clozapine, clozapine ODT SKIN CONDITIONS Absorica claravis, myorisan, zenatane Aldara, Zyclara imiquimod Bensal HP Salacyn, salicylic acid Benzaclin, Duac, Neuac kit clindamycin-benzoyl peroxide, neuac gel Carac fluorouracil Clindagel clindamycin phosphate Clobex clobetasol propionate, clodan Ertaczo, Extina ketoconazole, ketodan Halog, Ultravate X clobetasol, halobetasol Jublia, Kerydin ciclodan, ciclopirox, itraconazole, terbinafine Kenalog triamcinolone acetonide Locoid, Locoid Lipocream hydrocortisone butyrate Loprox, Penlac ciclodan, ciclopirox Luzu ketoconazole Noritate metronidazole, rosadan, sodium sulfacetamide-sulfur Novacort hydrocortisone Plexion sodium sulfacetamide-sulfur, ss 10-2, zencia Salex salicylic acid Trianex triamcinolone acetonide, triderm Vanos fluocinonide Verdeso desonide Xerese acyclovir, hydrocortisone Ziana clindamycin phosphate, tretinoin Zovirax acyclovir SLEEP DISORDERS/ Ambien zolpidem tartrate SEDATIVES Ambien CR zolpidem tartrate ER Edluar, Intermezzo zolpidem tartrate, zolpidem tartrate ER SUBSTANCE ABUSE Evzio Naloxone vial & PFS, Narcan URINARY TRACT CONDITIONS Myrbetriq, Toviaz, VESIcare darifenacin ER, oxybutynin chloride ER, tolterodine tartrate ER, trospium chloride ER Drug class Medication with Quantity Limits Lidocaine 5% ointment

8 VALUE PRESCRIPTION DRUG LIST, cont d Drug class Step Therapy medication Generic and/or preferred brand Kadian, Nucynta ER, Xartemis XR Hysingla ER, OxyContin, Xtampza ER ADVANTAGE PRESCRIPTION DRUG LIST Drug class Non-preferred brand medication Generic and/or preferred brand BLOOD MODIFIERS/ Neupogen + ** Granix **, Zarxio BLEEDING DISORDERS Cimzia ** Enbrel **, Humira ** Nucynta ER, Xartemis XR Hysingla ER, OxyContin, Xtampza ER Drug class Medication not covered^ Generic and/or preferred brand ANXIETY/DEPRESSION/ BIPOLAR DISORDER ASTHMA/COPD/ RESPIRATORY BLOOD PRESSURE/ HEART MEDICATIONS Aplenzin Ativan Pexeva Aerospan, Alvesco, Arnuity Ellipta, Asmanex, Asmanex HFA, Flovent Diskus, Flovent HFA, Pulmicort Flexhaler Incruse Ellipta, Tudorza Pressair Accupril Accuretic Aceon Altace Atacand Atacand HCT Avalide Avapro Bystolic Cardizem Cardizem CD Cozaar Exforge Exforge HCT Hyzaar, Lotensin HCT, Micardis HCT, Tekturna HCT Isordil, Isordil Titradose Lanoxin Lotensin Lotrel Mavik Micardis Prinivil, Zestril Tarka bupropion XL lorazepam paroxetine QVAR Spiriva, Spiriva Respimat quinapril quinapril-hctz perindopril erbumine ramipril candesartan candesartan-hctz irbesartan-hctz irbesartan acebutolol, atenolol, betaxolol, bisoprolol, metoprolol diltiazem cartia XT, diltiazem 24hr CD, diltiazem 24hr ER losartan amlodipine-valsartan amlodipine-valsartan-hctz generic ACE or generic ARB + HCTZ (enalapril, lisinopril, irbesartan, valsartan + HCTZ) isosorbide digitek, digox, digoxin benazepril amlodipine besylate-benazepril trandolapril telmisartan lisinopril trandolapril-verapamil ER

9 ADVANTAGE PRESCRIPTION DRUG LIST, cont d Drug class Medication not covered^ Generic and/or preferred brand BLOOD PRESSURE/ HEART MEDICATIONS, Tekturna generic ACE or generic ARB (enalapril, lisinopril, irbesartan, valsartan) cont d Twynsta telmisartan-amlodipine CHOLESTEROL MEDICATIONS COUGH/COLD MEDICATIONS DIABETES GASTROINTESTINAL/ HEARTBURN Vaseretic Zestoretic Altoprev, Lescol XL Antara Crestor Livalo Tussicaps Fortamet, metformin ER (when filled as generic to Glumetza) Anusol-HC enalapril-hctz lisinopril-hctz atorvastatin, rosuvastatin, simvastatin, Zetia fenofibrate rosuvastatin atorvastatin, rosuvastatin, simvastatin hydrocodone-chlorpheniramne ER, promethazine-codeine metformin ER (when filled as generic to Glucophage XR or generic to Fortamet) anucort-hc, grx hicort 25, hemmorexhc, hydrocortisone acetate, rectacort-hc Apriso, balsalazide, Lialda, mesalamine, Pentasa, sulfasalazine Asacol HD, Colazal, Delzicol, Dipentum, Giazo Cortifoam, Uceris foam Anucort-HC, Colocort, GRx HiCort 25, Hemmorex-HC, hydrocortisone, Procto- Med HC, Procto-Pak, Proctosol-HC, Proctozone-HC, Rectacort-HC Librax Metozolv ODT Proctocort Zuplenz chlordiazepoxide-clidinium HORMONAL AGENTS Dexpak dexamethasone Rayos Saizen Uceris metoclopramide, metoclopramide ODT hemmorex-hc, hemril, hydrocortisone acetate ondansetron, ondansetron ODT prednisone, prednisone intensol Humatrope budesonide EC INFECTIONS Bethkis, Tobi Kitabis Pak, tobramycin Onmel Sitavig Amrix Belbuca Bupap Cambia, Tivorbex, Vivlodex, Zipsor, Zorvolex Capital w/ codeine Conzip diclofenac 1.5% solution, klofensaid II, Pennsaid Horizant, Gralise Lido-K Lorzone itraconazole, terbinafine acyclovir baclofen, carisoprodol, cyclobenzaprine, methocarbamol, tizanidine Butrans butalbital-acetaminophen, Marten-Tab, Tencon generic NSAIDs (diclofenac, ibuprofen, indomethacin, meloxicam, acetaminophen-codeine tramadol, tramadol ER diclofenac 1% gel, generic oral NSAIDs (diclofenac, ibuprofen, meloxicam, gabapentin lidocaine, lidopin chlorzoxazone

10 ADVANTAGE PRESCRIPTION DRUG LIST, cont d Drug class Medication not covered^ Generic and/or preferred brand Sprix ketorolac tromethamine INFLAMMATORY Sumavel Dosepro, Zembrace DISEASE, cont d Symtouch sumatriptan Treximet generic triptans (naratriptan, sumatriptan, zolmitriptan) plus a generic NSAID (ibuprofen, meloxicam, Zomig ZMT zolmitriptan ODT SCHIZOPHRENIA/ ANTI-PSYCHOTICS Abilify, Abilify ODT Fazaclo, Versacloz aripiprazole SEIZURE DISORDERS Mysoline primidone clozapine, clozapine ODT SKIN CONDITIONS Absorica claravis, myorisan, zenatane SLEEP DISORDERS/ SEDATIVES Aldara, Zyclara Bensal HP Benzaclin, Duac Carac Clindagel Clobex Ertaczo, Oxistat, Vusion Extina Halog, Ultravate X Jublia, Kerydin Kenalog Locoid, Locoid Lipocream Loprox Luzu Noritate Novacort Penlac Plexion Salex trianex Vanos Verdeso Xerese Ziana Zovirax Ambien Ambien CR Ativan Edluar, Intermezzo imiquimod salacyn, salicylic acid clindamycin-benzoyl peroxide, neuac gel fluorouracil clindamycin phosphate clobetasol propionate, clodan ketoconazole ketoconazole, ketodan clobetasol, halobetasol ciclodan, ciclopirox, itraconazole, terbinafine triamcinolone acetonide hydrocortisone butyrate ciclodan, ciclopirox ketoconazole metronidazole, rosadan, sodium sulfacetamide-sulfur hydrocortisone ciclodan, ciclopirox ss 10-2, zencia salicylic acid triamcinolone acetonide, triderm fluocinonide desonide acyclovir, hydrocortisone clindamycin phosphate, tretinoin acyclovir zolpidem tartrate zolpidem tartrate ER lorazepam zolpidem tartrate, zolpidem tartrate ER SUBSTANCE ABUSE Evzio naloxone vial & PFS, Narcan URINARY TRACT CONDITIONS Myrbetriq, Toviaz, VESIcare darifenacin ER, oxybutynin chloride ER, tolterodine tartrate ER, trospium chloride ER

11 ADVANTAGE PRESCRIPTION DRUG LIST, cont d Drug class Medication with Quantity Limits Lidocaine 5% ointment Drug class Step Therapy medication Generic and/or preferred brand Nucynta ER, Xartemis XR Hysingla ER, OxyContin, Xtampza ER LEGACY STANDARD PRESCRIPTION DRUG LIST Drug class Non-preferred brand medication Generic and/or preferred brand BLOOD MODIFIERS/ Neupogen + ** Granix **, Zarxio BLEEDING DISORDERS BLOOD PRESSURE/ Isordil isosorbide HEART MEDICATIONS CANCER Gleevec ** imatinib mesylate ** HORMONAL AGENTS Saizen ** Humatrope ** MISCELLANEOUS Zavesca ** Cerdelga ** Kadian, Nucynta ER, Xartemis XR Hysingla ER, OxyContin, Xtampza ER Treximet generic triptans (naratriptan, sumatriptan, zolmitriptan) plus a generic NSAID (ibuprofen, meloxicam, SKIN CONDITIONS Benzaclin gel with pump clindamycin-benzoyl peroxide, neuac Carac fluorouracil Noritate metronidazole, rosadan Zovirax acyclovir SUBSTANCE ABUSE Evzio + Naloxone vial &PFS, Narcan Drug class Medication with Quantity Limits Lidocaine 5% ointment Drug class Step Therapy medication Generic and/or preferred brand ALLERGY/NASAL SPRAYS Veramyst budesonide, flunisolide, fluticasone propionate, mometasone furoate, triamcinolone acetonide ASTHMA/COPD/ RESPIRATORY Aerospan, Alvesco, Arnuity Ellipta Asmanex, Asmanex HFA, Flovent Diskus, Flovent HFA, Pulmicort Flexhaler, QVAR Dulera Advair Diskus, Advair HFA, Breo Ellipta, Symbicort CHOLESTEROL Lescol XL fluvastatin MEDICATIONS GASTROINTESTINAL/ Asacol HD, Colazal, Delzicol, Apriso, balsalazide, Lialda, HEARTBURN Dipentum, Giazo diclofenac 1.5% solution, klofensaid II mesalamine, Pentasa, sulfasalazine diclofenac 1% gel, generic oral NSAIDs (diclofenac, ibuprofen, meloxicam, Kadian, Nucynta ER, Xartemis XR Hysingla ER, OxyContin, Xtampza ER SKIN CONDITIONS Absorica claravis, myorisan, zenatane URINARY TRACT CONDITIONS VESIcare darifenacin ER, oxybutynin chloride ER, tolterodine tartrate ER, Toviaz, trospium chloride ER

12 LEGACY PERFORMANCE PRESCRIPTION DRUG LIST Drug class Non-preferred brand medication Generic and/or preferred brand BLOOD MODIFIERS/ Neupogen + ** Granix **, Zarxio BLEEDING DISORDERS BLOOD PRESSURE/ Isordil isosorbide HEART MEDICATIONS HORMONAL AGENTS Saizen ** Humatrope ** MISCELLANEOUS Zavesca ** Cerdelga ** Kadian, Nucynta ER, Xartemis XR Hysingla ER, OxyContin, Xtampza ER Treximet generic triptans (naratriptan, sumatriptan, zolmitriptan) plus a generic NSAID (ibuprofen, meloxicam, SKIN CONDITIONS Benzaclin gel with pump clindamycin-benzoyl peroxide, neuac Carac fluorouracil Noritate metronidazole, rosadan Zovirax acyclovir SUBSTANCE ABUSE Evzio + naloxone vial & PFS, Narcan Drug class Medication with Quantity Limits Lidocaine 5% ointment Drug class Step Therapy medication Generic and/or preferred brand ALLERGY/NASAL SPRAYS Veramyst budesonide, flunisolide, fluticasone propionate, mometasone furoate, triamcinolone acetonide ASTHMA/COPD/ RESPIRATORY Aerospan, Alvesco, Arnuity Ellipta Asmanex, Asmanex HFA, Flovent Diskus, Flovent HFA, Pulmicort Flexhaler, QVAR Dulera Advair Diskus, Advair HFA, Breo Ellipta, Symbicort CHOLESTEROL Lescol XL fluvastatin MEDICATIONS DIABETES Tanzeum, Victoza Bydureon, Byetta, Trulicity GASTROINTESTINAL/ HEARTBURN Asacol HD, Colazal, Delzicol, Dipentum, Giazo Apriso, balsalazide, Lialda, mesalamine, Pentasa, sulfasalazine Belbuca Butrans diclofenac 1.5% solution, klofensaid II diclofenac 1% gel, generic oral NSAIDs (diclofenac, ibuprofen, meloxicam, Kadian, Nucynta ER, Xartemis XR Hysingla ER, OxyContin, Xtampza ER SKIN CONDITIONS Absorica claravis, myorisan, zenatane URINARY TRACT CONDITIONS VESIcare darifenacin ER, oxybutynin chloride ER, tolterodine tartrate ER, Toviaz, trospium chloride ER LEGACY VALUE PRESCRIPTION DRUG LIST Drug class Non-preferred brand medication Generic and/or preferred brand BLOOD MODIFIERS/ Neupogen + ** Granix **, Zarxio BLEEDING DISORDERS HORMONAL AGENTS Saizen ** Humatrope **

13 LEGACY VALUE PRESCRIPTION DRUG LIST, cont d Drug class Non-preferred brand medication Generic and/or preferred brand Cimzia** Enbrel**, Humira** Nucynta ER, Xartemis XR Hysingla ER, OxyContin, Xtampza ER SUBSTANCE ABUSE Evzio + naloxone vial & PFS, Narcan URINARY TRACT CONDITIONS Drug class VESIcare Medication with Quantity Limits darifenacin ER, oxybutynin chloride ER, tolterodine tartrate ER, trospium chloride ER Lidocaine 5% ointment Drug class Step Therapy medication Generic and/or preferred brand ASTHMA/COPD/ Aerospan, Alvesco, Arnuity Ellipta QVAR RESPIRATORY Dulera Advair Diskus, Advair HFA, Breo Ellipta BLOOD PRESSURE/ HEART MEDICATIONS Bystolic atenolol, betaxolol, bisoprolol, metoprolol CHOLESTEROL Lescol XL fluvastatin MEDICATIONS DIABETES Afrezza Humalog GASTROINTESTINAL/ HEARTBURN Asacol HD, Colazal, Delzicol, Apriso, balsalazide, Lialda, Dipentum, Giazo mesalamine, Pentasa, sulfasalazine Cortifoam Anucort-HC, Colocort, GRx HiCort 25, Hemmorex-HC, hydrocortisone, Procto- Med HC, Procto-Pak, Proctosol-HC, Proctozone-HC, Rectacort-HC Belbuca Butrans Nucynta ER, Xartemis XR Hysingla ER, OxyContin, Xtampza ER SKIN CONDITIONS Absorica claravis, myorisan, zenatane LEGACY ADVANTAGE PRESCRIPTION DRUG LIST Drug class Non-preferred brand medication Generic and/or preferred brand BLOOD MODIFIERS/ Neupogen + ** Granix **, Zarxio BLEEDING DISORDERS GASTROINTESTINAL/ HEARTBURN Cortifoam Anucort-HC, Colocort, GRx HiCort 25, Hemmorex-HC, hydrocortisone, Procto- Med HC, Procto-Pak, Proctosol-HC, Proctozone-HC, Rectacort-HC HORMONAL AGENTS Saizen ** Humatrope ** Cimzia ** Enbrel **, Humira ** Nucynta ER, Xartemis XR Hysingla ER, OxyContin, Xtampza ER SKIN CONDITIONS Carac fluorouracil SUBSTANCE ABUSE Evzio + naloxone vial & PFS, Narcan Drug class Medication with Quantity Limits Lidocaine 5% ointment

14 LEGACY ADVANTAGE PRESCRIPTION DRUG LIST, cont d Drug class Step Therapy medication Generic and/or preferred brand ALLERGY/NASAL SPRAYS Veramyst budesonide, flunisolide, fluticasone propionate, mometasone furoate, triamcinolone acetonide ASTHMA/COPD/ Aerospan, Alvesco, Arnuity Ellipta QVAR RESPIRATORY Dulera Advair Diskus, Advair HFA, Breo Ellipta CHOLESTEROL Lescol XL fluvastatin MEDICATIONS DIABETES Tanzeum, Victoza Trulicity GASTROINTESTINAL/ HEARTBURN Asacol HD, Colazal, Delzicol, Dipentum, Giazo Belbuca diclofenac 1.5% solution, klofensaid II Nucynta ER, Xartemis XR Apriso, balsalazide, Lialda, mesalamine, Pentasa, sulfasalazine Butrans diclofenac 1% gel, generic oral NSAIDs (diclofenac, ibuprofen, meloxicam, hydromorphone ER, Hysingla ER, morphine sulfate ER, oxycodone ER, OxyContin, oxymorphone ER, Xtampza ER SKIN CONDITIONS Absorica claravis, myorisan, zenatane URINARY TRACT Myrbetriq, Toviaz, VESIcare CONDITIONS darifenacin ER, oxybutynin chloride ER, tolterodine tartrate ER, trospium chloride ER CIGNA RX PREMIERE PRESCRIPTION DRUG LIST Non-preferred brand medications Adderall XR VESIcare Medications not covered^ ACCU-CHEK products Accutrend Glucose Aggrenox Atelvia Atralin Avodart Axert Cordran Crestor Dibenzyline Enablex Evzio Frova Glyset Invega Juxtapid Lamictal Generic and/or preferred brand dextroamphetamine-amphetamine ER trospium (plain or ER), tolterodine (plain or ER), oxybutynin (plain or ER), darifenacin ER, flavoxate Generic and/or preferred brand OneTouch products (e.g. Ultra, Verio) OneTouch products (e.g. Ultra, Verio) aspirin-dipyridamole risedronate tretinoin gel (requires prior authorization) dutasteride almotriptan flurandrenolide cream rosuvastatin phenoxybenzamine darifenacin ER Narcan nasal frovatriptan miglitol paliperidone Repatha (requires prior authorization)

15 CIGNA RX PREMIERE PRESCRIPTION DRUG LIST, cont d Medications not covered^ Lamictal (blue) Lamictal (green) Lamictal (orange) Lamictal ODT Lamictal ODT (blue) Lamictal ODT (green) Lamictal ODT (orange) Lamictal XR Lamictal XR (blue) Lamictal XR (green) Lamictal XR (orange) Namenda Nuvigil Orap Oxistat Soft Touch Softclix Targretin Voltaren Xenazine Zyvox suspension Zyvox tablet Excluded medications Addyi Adipex-P Alli Belviq benzphetamine Bontril PDM Bravelle Caverject Cetrotide chorionic gonadotropin Cialis clomiphene citrate Contrave Crinone Didrex diethylpropion diethylpropion ER Edex Endometrin Follistim AQ Generic and/or preferred brand memantine armodafinil pimozide oxiconazole cream OneTouch products (e.g. Ultra, Verio) OneTouch products (e.g. Ultra, Verio) bexarotene diclofenac 1% gel tetrabenazine (requires prior authorization) linezolid suspension linezolid tablet Exclusions do not apply to all states. Customers should take a look at their plan documents or log into mycigna.com to find out how the medication is covered under their plan.

16 CIGNA RX PREMIERE PRESCRIPTION DRUG LIST, cont d Excluded medications Ganirelix Acetate Gonal-F Gonal-F RFF Gonal-F RFF Redi-ject Levitra Menopur Muse Novarel Ovidrel phendimetrazine tartrate phentermine Pregnyl Qsymia Regimex Saxenda Serophene Staxyn Stendra Suprenza ODT Xenical Medications requiring Prior Authorization Carbaglu Cayston Daraprim Farydak Jublia Kuvan 500 mg Powder Packet Neupogen Olysio Relistor Sirturo Technivie Step Therapy medications (additions/changes) Adderall XR Cimzia Myrbetriq Neupogen Nucynta ER Exclusions do not apply to all states. Customers should take a look at their plan documents or log into mycigna.com to find out how the medication is covered under their plan. Customers should talk with their doctor about switching to a covered alternative. Generic and/or preferred brand dextroamphetamine-amphetamine ER, methylphenidate CD/ER/LA, dexmethylphenidate ER, dextroamphetamine ER Humira (requires prior authorization), Enbrel (requires prior authorization), Remicade (requires prior authorization) trospium (plain or ER), tolterodine (plain or ER), oxybutynin (plain or ER), darifenacin ER, flavoxate Granix, Zarxio hydromorphone ER, fentanyl patch, morphine sulfate ER, oxymorphone ER, Oxycontin

17 CIGNA RX PREMIERE PRESCRIPTION DRUG LIST, cont d Step Therapy medications (additions/changes) Opana ER Toviaz VESIcare Zetonna Medications with Quantity Limits (additions/changes) almotriptan malate Axert Brisdelle D3-50 Decara softgel Decara vegicap dihydroergotamine mesylate Exalgo Fosamax Plus D hydromorphone ER Imitrex Migranal Nucynta ER Onmel optimal D3 oxycodone ER Oxycontin Sancuso sumatriptan vitamin D3 zolmitriptan ODT Zomig Zomig ZMT Zuplenz Generic and/or preferred brand hydromorphone ER, fentanyl patch, morphine sulfate ER, oxymorphone ER, Oxycontin trospium (plain or ER), tolterodine (plain or ER), oxybutynin (plain or ER), darifenacin ER, flavoxate trospium (plain or ER), tolterodine (plain or ER), oxybutynin (plain or ER), darifenacin ER, flavoxate Generic nasal steroids (e.g. fluticasone) These medications will have quantity limits added or changed. If the customer s doctor wants to write a prescription for an amount more than what his/her plan allows, it will only be covered if the doctor requests and receives approval from Cigna. CIGNA RX PLUS PRESCRIPTION DRUG LIST Non-preferred brand medications Adderall XR VESIcare Generic and/or preferred brand dextroamphetamine-amphetamine ER trospium (plain or ER), tolterodine (plain or ER), oxybutynin (plain or ER), darifenacin ER, flavoxate

18 CIGNA RX PLUS PRESCRIPTION DRUG LIST, cont d Medications not covered^ ACCU-CHEK products Accutrend Glucose Aggrenox Atelvia Atralin Avodart Axert Cordran Crestor Dibenzyline Enablex Evzio Frova Glyset Invega Juxtapid Lamictal Lamictal (blue) Lamictal (green) Lamictal (orange) Lamictal ODT Lamictal ODT (blue) Lamictal ODT (green) Lamictal ODT (orange) Lamictal XR Lamictal XR (blue) Lamictal XR (green) Lamictal XR (orange) Namenda Nuvigil Orap Oxistat Soft Touch Softclix Targretin Voltaren Xenazine Zyvox suspension Zyvox tablet Excluded medications Addyi Generic and/or preferred brand OneTouch products (e.g. Ultra, Verio) OneTouch products (e.g. Ultra, Verio) aspirin-dipyridamole risedronate tretinoin gel (requires prior authorization) dutasteride almotriptan flurandrenolide cream rosuvastatin phenoxybenzamine darifenacin ER Narcan nasal frovatriptan miglitol paliperidone Repatha (requires prior authorization) memantine armodafinil pimozide oxiconazole cream OneTouch products (e.g. Ultra, Verio) OneTouch products (e.g. Ultra, Verio) bexarotene diclofenac 1% gel tetrabenazine (requires prior authorization) linezolid suspension linezolid tablet Exclusions do not apply to all states. Customers should take a look at their plan documents or log into mycigna.com to find out how the medication is covered under their plan.

19 CIGNA RX PLUS PRESCRIPTION DRUG LIST, cont d Excluded medications Adipex-P Alli Belviq benzphetamine Bontril PDM Bravelle Caverject Cetrotide chorionic gonadotropin Cialis clomiphene citrate Contrave Crinone Didrex diethylpropion diethylpropion ER Edex Endometrin Follistim AQ Ganirelix Acetate Gonal-F Gonal-F RFF Gonal-F RFF Redi-ject Levitra Menopur Muse Novarel Ovidrel phendimetrazine tartrate phentermine Pregnyl Qsymia Regimex Saxenda Serophene Staxyn Stendra Suprenza ODT Xenical Medications requiring Prior Authorization Carbaglu Cayston Daraprim Farydak Exclusions do not apply to all states. Customers should take a look at their plan documents or log into mycigna.com to find out how the medication is covered under their plan. Customers should talk with their doctor about switching to a covered alternative.

20 CIGNA RX PLUS PRESCRIPTION DRUG LIST, cont d Medications requiring Prior Authorization Kuvan 500 mg Powder Packet Neupogen Relistor Sirturo Step Therapy medications (additions/changes) Adderall XR Cimzia Myrbetriq Neupogen Nucynta ER Opana ER Toviaz VESIcare Zetonna Medications with Quantity Limits (additions/changes) almotriptan malate Axert Brisdelle D3-50 Decara softgel Decara vegicap dihydroergotamine mesylate Exalgo Fosamax Plus D hydromorphone ER Imitrex Migranal Nucynta ER Onmel optimal D3 oxycodone ER Oxycontin Sancuso sumatriptan vitamin D3 zolmitriptan ODT Customers should talk with their doctor about switching to a covered alternative. Generic and/or preferred brand dextroamphetamine-amphetamine ER, methylphenidate CD/ER/LA, dexmethylphenidate ER, dextroamphetamine ER Humira (requires prior authorization), Enbrel (requires prior authorization), Remicade (requires prior authorization) trospium (plain or ER), tolterodine (plain or ER), oxybutynin (plain or ER), darifenacin ER, flavoxate Granix, Zarxio hydromorphone ER, fentanyl patch, morphine sulfate ER, oxymorphone ER, Oxycontin hydromorphone ER, fentanyl patch, morphine sulfate ER, oxymorphone ER, Oxycontin trospium (plain or ER), tolterodine (plain or ER), oxybutynin (plain or ER), darifenacin ER, flavoxate trospium (plain or ER), tolterodine (plain or ER), oxybutynin (plain or ER), darifenacin ER, flavoxate Generic nasal steroids (e.g. fluticasone) These medications will have quantity limits added or changed. If the customer s doctor wants to write a prescription for an amount more than what his/her plan allows, it will only be covered if the doctor requests and receives approval from Cigna.

21 CIGNA RX PLUS PRESCRIPTION DRUG LIST, cont d Medications with Quantity Limits (additions/changes) Zomig Zomig ZMT Zuplenz These medications will have quantity limits added or changed. If the customer s doctor wants to write a prescription for an amount more than what his/her plan allows, it will only be covered if the doctor requests and receives approval from Cigna. CIGNA RX ESSENTIAL 4-TIER AND CIGNA RX ESSENTIAL 5-TIER PRESCRIPTION DRUG LISTS Non-preferred brand medications Adderall XR Neupogen VESIcare Medications not covered^ ACCU-CHEK products Accutrend Glucose Aggrenox Dibenzyline Evzio Juxtapid Namenda Orap Soft Touch Softclix Targretin Xenazine Excluded medications Addyi Adipex-P Alli Belviq benzphetamine Bontril PDM Bravelle Caverject Cetrotide chorionic gonadotropin Cialis clomiphene citrate Contrave Crinone Didrex diethylpropion diethylpropion ER Generic and/or preferred brand dextroamphetamine-amphetamine ER Granix, Zarxio trospium (plain or ER), tolterodine (plain or ER), oxybutynin (plain or ER), darifenacin ER, flavoxate Generic and/or preferred brand OneTouch products (e.g. Ultra, Verio) OneTouch products (e.g. Ultra, Verio) aspirin-dipyridamole phenoxybenzamine Narcan nasal Repatha (requires prior authorization) memantine pimozide OneTouch products (e.g. Ultra, Verio) OneTouch products (e.g. Ultra, Verio) bexarotene tetrabenazine (requires prior authorization) Exclusions do not apply to all states. Customers should take a look at their plan documents or log into mycigna.com to find out how the medication is covered under their plan.

22 CIGNA RX ESSENTIAL 4-TIER AND CIGNA RX ESSENTIAL 5-TIER PRESCRIPTION DRUG LISTS, cont d Excluded medications Edex Endometrin Follistim AQ Ganirelix Acetate Gonal-F Gonal-F RFF Gonal-F RFF Redi-ject Levitra Menopur Muse Novarel Ovidrel phendimetrazine tartrate phentermine Pregnyl Qsymia Regimex Saxenda Serophene Staxyn Stendra Suprenza ODT Xenical Medications requiring Prior Authorization Carbaglu Cayston Farydak Kuvan 500 mg Powder Packet Neupogen Relistor Sirturo Step Therapy medications (additions/changes) Adderall XR Cimzia Myrbetriq Neupogen Nucynta ER Opana ER Exclusions do not apply to all states. Customers should take a look at their plan documents or log into mycigna.com to find out how the medication is covered under their plan. Customers should talk with their doctor about switching to a covered alternative. Generic and/or preferred brand dextroamphetamine-amphetamine ER, methylphenidate CD/ER/LA, dexmethylphenidate ER, dextroamphetamine ER Humira (requires prior authorization), Enbrel (requires prior authorization), Remicade (requires prior authorization) trospium (plain or ER), tolterodine (plain or ER), oxybutynin (plain or ER), darifenacin ER, flavoxate Granix, Zarxio hydromorphone ER, fentanyl patch, morphine sulfate ER, oxymorphone ER, Oxycontin hydromorphone ER, fentanyl patch, morphine sulfate ER, oxymorphone ER, Oxycontin

23 CIGNA RX ESSENTIAL 4-TIER AND CIGNA RX ESSENTIAL 5-TIER PRESCRIPTION DRUG LISTS, cont d Step Therapy medications (additions/changes) Toviaz VESIcare Zetonna Medications with Quantity Limits (additions/changes) almotriptan malate Axert Brisdelle D3-50 Decara softgel Decara vegicap dihydroergotamine mesylate Exalgo Fosamax Plus D hydromorphone ER Imitrex Migranal Nucynta ER Onmel optimal D3 oxycodone ER Oxycontin Sancuso sumatriptan vitamin D3 zolmitriptan ODT Zomig Zomig ZMT Zuplenz Generic and/or preferred brand trospium (plain or ER), tolterodine (plain or ER), oxybutynin (plain or ER), darifenacin ER, flavoxate trospium (plain or ER), tolterodine (plain or ER), oxybutynin (plain or ER), darifenacin ER, flavoxate Generic nasal steroids (e.g. fluticasone) These medications will have quantity limits added or changed. If the customer s doctor wants to write a prescription for an amount more than what his/her plan allows, it will only be covered if the doctor requests and receives approval from Cigna. + Prior authorization also added to this medication as of January 1, ^ These medications are not covered in our drug lists; 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 failed to produce results for the patient and therefore a non-covered medication should be considered for coverage.

24 ** This is a specialty medication. Specialty medications are used to treat complex or chronic conditions like multiple sclerosis, hepatitis C and rheumatoid arthritis. Some plans cover specialty medications on a specialty tier. For plans with a specialty tier, this change will not affect the cost of your medication. To find out how your plan covers these medications as of January 1, 2017, please check your enrollment materials or view your plan s drug list on mycigna.com. 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 Commercial and IFP Drug List Changes Effective January 1, 2017_Posted Online 11/16