PRESCRIPTION DRUG LIST CHANGES

Transcription

1 PRESCRIPTION DRUG LIST CHANGES Cigna Pharmacy Management 2018 The medications listed below are changing coverage (or cost levels) on Cigna s Prescription Drug List. Changes are listed by drug list name and by the date they begin. If you re enrolled with Cigna, you can log into mycigna.com to find out how these changes may affect your specific plan. STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST Medication not covered^ September 1, 2018 SKIN CONDITIONS Doxepin 5% Cream generic topical steroid (e.g. betamethasone) or topical tacrolimus July 1, 2018 DIABETES Segluromet Synjardy, Synjardy XR, Xigduo XR Steglatro Farxiga, Jardiance Steglujan Glyxambi, QTERN GASTROINTESTINAL/HEARTBURN OmePPI omeprazole INFECTIONS Mycobutin rifabutin MULTIPLE SCLEROSIS Copaxone Aubagio, Avonex, Betaseron, Extavia, Gilenya, glatiramer, Glatopa, Plegridy, Rebif, Tecfidera SEIZURE DISORDERS Lyrica CR duloxetine, gabapentin, lidocaine 5% topical patch, Lyrica SKIN CONDITIONS diclofenac 3% gel, Solaraze Fluoroplex, fluorouracil, imiquimod, Picato May 15, 2018 EYE CONDITIONS Vyzulta bimatoprost, latanoprost, Travatan Z April 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE Duzallo allopurinol, probenecid, Uloric March 1, 2018 DIABETES Fiasp Humalog PARKINSON S DISEASE Gocovri amantadine February 1, 2018 ASTHMA/COPD/RESPIRATORY ArmonAir QVAR, Pulmicort Flexhaler January 13, 2018 GASTROINTESTINAL/HEARTBURN Syndros dronabinol January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipramine Pamelor nortriptyline Parnate tranylcypromine Tofranil imipramine ASTHMA/COPD/RESPIRATORY Zyflo montelukast, zafirlukast, zileuton ER Zyflo CR zileuton ER ATTENTION DEFICIT HYPERACTIVITY Desoxyn methamphetamine DISORDER Dexedrine dextroamphetamine, dextroamphetamine ER UPDATED_6/20/2018

2 STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont) Medication not covered^ January 1, 2018 BLOOD PRESSURE/HEART MEDICATIONS Betapace sotalol tablets CANCER Nilandron nilutamide DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR Invokana Farxiga, Jardiance Lantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba 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, amoxicillinclavulanate Diflucan fluconazole E.E.S. 200, Eryped 400 erythromycin ethylsuccinate Mepron atovaquone Sporanox itraconazole Targadox Valcyte Vancocin Zovirax Avidoxy tablet, doxycycline hyclate, Morgidox capsule valganciclovir vancomycin capsule acyclovir MISCELLANEOUS Gralise, Horizant gabapentin PAIN RELIEF AND INFLAMMATORY DISEASE Cambia diclofenac, diclofenac ER, etodolac, etodolac ER, fenoprofen, Fenortho, flurbiprofen, ibuprofen, indomethacin, indomethacin ER, ketoprofen, Ketorolac, meclofenamate, mefenamic acid, meloxicam, nabumetone D.H.E. 45, Migranal dihydroergotamine Imitrex, Sumavel DosePro Lorzone OxyContin sumatriptan chlorzoxazone Embeda, Hysingla ER, Xtampza ER

3 STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont) January 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE (cont) Medication not covered^ Roxicodone Tivorbex Vanatol LQ Vivlodex Zomig Zorvolex oxycodone indomethacin PARKINSON'S DISEASE Lodosyn carbidopa Requip XL butalbital/acetaminophen/caffeine tabs or caps meloxicam sumatriptan, zolmitriptan diclofenac, diclofenac ER ropinirole ER SCHIZOPHRENIA/ANTI-PSYCHOTICS Geodon ziprasidone Zyprexa olanzapine 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 tolterodine ER Ditropan XL oxybutynin ER Enablex darifenacin ER Gelnique darifenacin ER, oxybutynin ER, tolterodine ER, trospium ER Non-preferred brand medication August 15, 2018 ASTHMA/COPD/RESPIRATORY Symdeko + July 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Arixtra + fondaparinux Lovenox + Reopro + Preferred brand medication October 1, 2018 GASTROINTESTINAL/HEARTBURN Entyvio + Nexium Powder Pack June 1, 2018 DIABETES Ozempic Victoza April 1, 2018 DIABETES QTERN January 1, 2018 MISCELLANEOUS Nityr + enoxaparin

4 STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont) Non-preferred brand medication July 1, 2018 CANCER dexrazoxane +, Evomela +, Hycamtin capsule +, Nilandron +, nilutamide +, Zinecard CONTRACEPTION PRODUCTS Depo-Provera 150mg/ml medroxyprogesterone LoSeasonique Amethia Lo, Camrese Lo, levonorg-eth estradiol 0.1/0.02/0.01mg Nexplanon +, Paragard T 380-a + Seasonique Amethia, Ashlyna, Camrese, Daysee, levonorg-eth estradiol 0.15/0.03/0.01mg DENTAL PRODUCTS Arestin + DIABETES Korlym + EYE CONDITIONS Cystaran +, Ozurdex +, Retisert + GASTROINTESTINAL/HEARTBURN alosetron +, Buphenyl +, Chenodal +, Ravicti +, sodium phenylbutyrate HORMONAL AGENTS Aveed +, hydroxyprogesterone caproate + Depo-Provera 400mg/ml medroxyprogesterone INFECTIONS Daraprim +, Sirturo + INFERTILITY Makena + MISCELLANEOUS Asclera +, Carbaglu +, Ferriprox +, Flebogamma DIF +, Keveyis +, Varithena + Orfadin + PAIN RELIEF AND INFLAMMATORY DISEASE Colcrys colchicine (NON-NARCOTIC) PARKINSON S DISEASE Azilect rasagiline SEIZURE DISORDERS Lamictal ODT lamotrigine ODT SKIN CONDITIONS Ameluz +, Levulan + Tazorac 0.1% cream tazarotene SLEEP DISORDERS/SEDATIVES Hetlioz + TRANSPLANT MEDICATIONS Cellcept + mycophenolate Neoral 25mg capsule, solution + Sandimmune 100mg capsule + Nityr cyclosporine modified, Gengraf cyclosporine URINARY TRACT CONDITIONS Thiola + March 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic HORMONAL AGENTS Depo-Testosterone testosterone cypionate

5 STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont) Non-preferred brand medication February 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Bevyxxa enoxaparin, Fragmin January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal spray ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR Focalin XR dextroamphetamine-amphetamine ER dexmethylphenidate ER SKIN CONDITIONS Ala-Scalp hydrocortisone Analpram HC lotion Capex shampoo Cordran Differin Metrogel Naftin Nucort, Texacort Medication requiring prior authorization^^ July 1, 2018 CANCER Hycamtin ++, Targretin ++, tretinoin capsule ++, Xeloda ++ MISCELLANEOUS Nityr, Orfadin ++ PAIN RELIEF AND INFLAMMATORY Diskets, Dolophine, methadone ++, DISEASE (NARCOTIC) Methadose March 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic January 1, 2018 GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi HORMONAL AGENTS Androderm, Androgel, Striant, testosterone MISCELLANEOUS Nityr Medication with quantity limits^^ hydrocortisone-pramoxine fluocinolone flurandrenolide adapalene metronidazole gel naftifine hydrocortisone Additional information Your plan only covers this medication if your doctor requests and receives approval from Cigna. If you re taking this medication, ask your doctor to call us soon so we can begin the review process. Additional information September 1, 2018 SKIN CONDITIONS Prudoxin, Zonalon generic topical steroid (e.g. betamethasone) or topical tacrolimus August 15, 2018 ASTHMA/COPD/RESPIRATORY Symdeko Your plan only covers up to a certain July 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER bupropion ER #, Celexa #, citalopram #, amount of this medication over a certain desvenlafaxiner ER #, duloxetine #, Effexor amount of time. If you re taking this XR #, Effexor #, Emsam #, escitalopram #, medication, you may need approval for Fetzima #, fluoxetine #, fluvoxamine ER #, your prescription to be covered. fluvoxamine #, Forfivo XL #, Khedezla, paroxetine CR #, paroxetine #, Paxil CR #, Pexeva #, Prozac, sertraline #, venlafaxine ER #, Wellbutrin SR, Wellbutrin XL, Zoloft BLOOD PRESSURE/HEART MEDICATIONS CHOLESTEROL MEDICATIONS BiDil mg #, captopril-hctz, dofetilide #, Tikosyn simvastatin, Zocor

6 STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont) Medication with quantity limits^^ July 1, 2018 GASTROINTESTINAL/HEARTBURN Aciphex, Dexilant, esomeprazole, lansoprazole DR, Nexium DR, Nexium, omeprazole DR, omeprazole, omeprazole bicarbonate, pantoprazole, Prevacid SoluTab, Prilosec, prilosec 2.5mg, Protonix, rabeprazole NUTRITIONAL/DIETARY Auryxia PAIN RELIEF AND INFLAMMATORY DISEASE Cafergot, ergotamine-caffeine, diclofenac (NON-NARCOTIC) 1%, Voltaren Additional information Your plan only covers up to a certain amount of this medication over a certain amount of time. If you re taking this medication, you may need approval for your prescription to be covered. PAIN RELIEF AND INFLAMMATORY DISEASE (NARCOTIC) acetaminophen-caffeine-dihyrocodeine, acetaminophen-codeine, Arymo, asa-butalb-caff-codeine, aspirin-caffdihydrocodeine, belladonna-opium, buprenorphine, butalb-acetaminoph-caffcodeine, To promote safer opioid use, your plan may limit the amount, or day supply, of narcotic pain medications (opioids) it will cover. If you re taking an opioid, you may need approval for your prescription to be covered. butorphanol, carisoprodol-asa- codeine, codeine sulfate, Embeda, Exalgo, Fentanyl (all dosage forms), Flowtuss, Hycofenix, hydrocodone-acetaminophen, hydrocodone-ibuprofen, Hydromet, hydromorphone, Hysingla ER, Kadian, Lorcet, Lortab, meperidine, Morphabond ER, morphine, morphine ER, nalbuphine, Nucynta, Nucynta ER, Obredon, Opana ER, opium tincture, Oxecta, oxycodone, oxycodone ER, oxycodone-acetaminophen, oxycodone-aspirin, oxycodone-ibuprofen, OxyContin, oxymorphone, oxymorphone ER, pentazocine-acetaminophen, pentazocinenaloxone, Primlev, promethazine-codeine, Talwin, tramadol ER, tramadolacetaminophen, Trezix, Tussigon, Tussionex, Xtampza ER, Zohydro ER, Zutripro SEIZURE DISORDERS Banzel # Your plan only covers up to a certain SKIN CONDITIONS calcitriol, Vectical amount of this medication over a certain amount of time. If you re taking this SLEEP DISORDERS/SEDATIVES Rozerem medication, you may need approval for February 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Bevyxxa your prescription to be covered. January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone ALZHEIMER'S DISEASE Namenda XR, Namzaric ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine 25mg, 100mg, Marplan, Pristiq ASTHMA/COPD/RESPIRATORY Perforomist BLOOD PRESSURE/HEART MEDICATIONS Ranexa CANCER Fareston, nilutamide EYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan

7 STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont) Medication with quantity limits^^ January 1, 2018 HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem MISCELLANEOUS Nuedexta OSTEOPOROSIS PRODUCTS alendronate PAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, Mitigare SCHIZOPHRENIA/ANTI-PSYCHOTICS Fanapt SEIZURE DISORDERS Gabitril, Potiga SKIN CONDITIONS Denavir, Regranex, Santyl, Vectical SLEEP DISORDERS/SEDATIVES Hetlioz Step Therapy medication^^ Medication strength with limitations** (Your plan doesn t cover 2 capsules/tablets per day of this strength) Covered medication strength (Prescription must be for 1 capsule/tablet per day of this strength) January 1, 2018 ALLERGY/NASAL SPRAYS desloratadine ODT 2.5mg desloratadine ODT 5mg ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg Fetzima ER 40mg Fetzima ER 80mg Trintellix 5mg Trintellix 10mg Trintellix 10mg Trintellix 20mg BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg Benicar 20mg Benicar 40mg Benicar HCT mg Bystolic 10mg Tekturna 150mg Additional information Your plan only covers up to a certain amount of this medication over a certain amount of time. If you re taking this medication, you may need approval for your prescription to be covered. April 1, 2018 ASTHMA/COPD/RESPIRATORY Trelegy Ellipta ## Advair, Anoro Ellipta, Breo Ellipta, Stiolto Respimat, Symbicort January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY Focalin XR ## dexmethylphenidate ER DISORDER SCHIZOPHRENIA/ANTI-PSYCHOTICS Orap ## pimozide SKIN CONDITIONS Ala-Scalp ## hydrocortisone Capex shampoo ## fluocinolone Cordran ## flurandrenolide Nucort, Texacort ## hydrocortisone Benicar HCT 40-25mg Bystolic 20mg Tekturna 300mg Tekturna HCT mg Tekturna HCT mg CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg Livalo 2mg Livalo 4mg DIABETES Farxiga 5mg Farxiga 10mg PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg

8 STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont) Medication strength with limitations** (Your plan doesn t cover 2 capsules/tablets per day of this strength) January 1, 2018 SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg Aptiom 400mg Aptiom 800mg Fycompa 4mg Fycompa 6mg Trokendi XR 25mg Covered medication strength (Prescription must be for 1 capsule/tablet per day of this strength) Fycompa 8mg Fycompa 12mg Trokendi XR 50mg Trokendi XR 100mg Trokendi XR 200mg SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg LEGACY (PERFORMANCE) PRESCRIPTION DRUG LIST October 1, 2018 GASTROINTESTINAL/HEARTBURN Entyvio + June 1, 2018 DIABETES Ozempic Victoza April 1, 2018 DIABETES QTERN March 1, 2018 DIABETES Fiasp January 1, 2018 MISCELLANEOUS Nityr + Preferred brand medication Non-preferred brand medication August 15, 2018 ASTHMA/COPD/RESPIRATORY Symdeko + July 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Reopro + CANCER dexrazoxane +, Evomela +, Hycamtin capsule +, Nilandron +, nilutamide +, Zinecard Fusilev + leucovorin CONTRACEPTION PRODUCTS LoSeasonique Amethia Lo, Camrese Lo, levonorg-eth estradiol 0.1/0.02/0.01mg Nexplanon +, Paragard T 380-a + Seasonique Amethia, Ashlyna, Camrese, Daysee, levonorg-eth estradiol 0.15/0.03/0.01mg DENTAL PRODUCTS Arestin + DIABETES Korlym + Segluromet Invokamet, Synjardy, Synjardy XR, Xigduo XR Steglatro Farxiga, Invokana, Jardiance Steglujan Glyxambi, QTERN

9 LEGACY (PERFORMANCE) PRESCRIPTION DRUG LIST (cont) Non-preferred brand medication July 1, 2018 EYE CONDITIONS Cystaran +, Ozurdex +, Retisert + GASTROINTESTINAL/HEARTBURN alosetron +, Buphenyl +, Chenodal +, Ravicti +, sodium phenylbutyrate HORMONAL AGENTS Aveed +, hydroxyprogesterone caproate + Saizen + Humatrope INFECTIONS Daraprim +, Sirturo + INFERTILITY Makena + MISCELLANEOUS Asclera +, Carbaglu +, Ferriprox +, Flebogamma DIF +, Keveyis +, Varithena + Orfadin + Nityr MULTIPLE SCLEROSIS Copaxone + Aubagio, Avonex, Betaseron, Extavia, Gilenya, glatiramer, Glatopa, Plegridy, Rebif, Tecfidera PAIN RELIEF AND INFLAMMATORY DISEASE Colcrys colchicine (NON-NARCOTIC) PARKINSON S DISEASE Azilect rasagiline SEIZURE DISORDERS Lamictal ODT lamotrigine ODT Lyrica CR duloxetine, gabapentin, lidocaine 5% topical patch, Lyrica SKIN CONDITIONS Ameluz +, Levulan + Tazorac 0.1% cream tazarotene SLEEP DISORDERS/SEDATIVES Hetlioz + TRANSPLANT MEDICATIONS Cellcept tablet, capsule, suspension + mycophenolate tablet, capsule, suspension Neoral 25mg capsule, solution + cyclosporine modified, Gengraf Sandimmune 100mg capsule + cyclosporine URINARY TRACT CONDITIONS Thiola + May 15, 2018 EYE CONDITIONS Vyzulta bimatoprost, latanoprost, Travatan Z April 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE Duzallo allopurinol, probenecid, Uloric March 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic PARKINSON S DISEASE Gocovri amantadine February 1, 2018 ASTHMA/COPD/RESPIRATORY ArmonAir QVAR, Pulmicort Flexhaler BLOOD THINNERS/ANTI-CLOTTING Bevyxxa enoxaparin, Fragmin January 13, 2018 GASTROINTESTINAL/HEARTBURN Syndros dronabinol

10 LEGACY (PERFORMANCE) PRESCRIPTION DRUG LIST (cont) Non-preferred brand medication January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal spray ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER DIABETES Lantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Tresiba, Levemir GASTROINTESTINAL/HEARTBURN omeprazole bicarbonate packet, omeprazole 40mg-1100mg capsule, 20mg-1100mg INFECTIONS Eryped 400 erythromycin PAIN RELIEF AND INFLAMMATORY DISEASE OxyContin Embeda, Hysingla ER, Xtampza ER Vanatol LQ butalbital/acetaminophen/caffeine tabs or caps SKIN CONDITIONS Ala-Scalp hydrocortisone topical Capex shampoo fluocinolone scalp Cordran flurandrenolide topical Differin adapalene Kenalog spray triamcinolone spray Locoid lotion hydrocortisone butyrate Metrogel metronidazole gel Naftin naftifine Nucort, Texacort hydrocortisone Medication requiring prior authorization^^ July 1, 2018 CANCER Hycamtin ++, Targretin ++, tretinoin capsule ++, Xeloda ++ MISCELLANEOUS Nityr, Orfadin ++ MULTIPLE SCLEROSIS Copaxone PAIN RELIEF AND INFLAMMATORY DISEASE (NARCOTIC) Diskets, Dolophine, methadone tablet, solution ++, methadone intensol ++, Methadose April 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE Duzallo March 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic January 13, 2018 GASTROINTESTINAL/HEARTBURN Syndros January 1, 2018 DIABETES Lantus, Lantus SoloStar, Toujeo SoloStar GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi HORMONAL AGENTS Androderm, Androgel, Axiron, Fortesta, Natesto, Striant, Testim, Testopel, testosterone, Vogelxo MISCELLANEOUS Nityr PAIN RELIEF AND INFLAMMATORY DISEASE Roxicodone Additional information Your plan only covers this medication if your doctor requests and receives approval from Cigna. If you re taking this medication, ask your doctor to call us soon so we can begin the review process.

11 LEGACY (PERFORMANCE) PRESCRIPTION DRUG LIST (cont) Medication with quantity limits^^ Additional information September 1, SKIN CONDITIONS Doxepin 5% Cream, Prudoxin, Zonalon generic topical steroid (e.g betamethasone) or topical tacrolimus August 15, 2018 ASTHMA/COPD/RESPIRATORY Symdeko Your plan only covers up to a certain July 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Aplenzin #, bupropion ER #, Celexa #, citalopram #, Cymbalta #, desvenlafaxiner ER #, duloxetine #, Effexor XR #, Effexor #, Emsam #, escitalopram #, Fetzima #, fluoxetine #, fluvoxamine ER #, fluvoxamine #, Forfivo XL #, Khedezla, Lexapro, paroxetine CR #, paroxetine #, Paxil CR #, Pexeva #, Prozac, sertraline #, venlafaxine ER #, Wellbutrin SR, Wellbutrin XL, Zoloft BLOOD PRESSURE/HEART MEDICATIONS BiDil mg #, captopril-hctz, dofetilide #, Tikosyn CHOLESTEROL MEDICATIONS simvastatin, Zocor DIABETES Jentadueto XR GASTROINTESTINAL/HEARTBURN Aciphex, Dexilant, esomeprazole, lansoprazole DR, lansoprazole, Nexium DR, Nexium, OmePPI, omeprazole DR, omeprazole, omeprazole bicarbonate, pantoprazole, Prevacid Solutab, Prilosec, prilosec 2.5mg, Protonix, rabeprazole, Zegerid NUTRITIONAL/DIETARY Auryxia PAIN RELIEF AND INFLAMMATORY DISEASE (NON-NARCOTIC) PAIN RELIEF AND INFLAMMATORY DISEASE (NARCOTIC) Cafergot, ergotamine-caffeine, diclofenac 1%, Voltaren acetaminophen-caffeine-dihyrocodeine, acetaminophen-codeine, Arymo, asa-butalb-caff-codeine, aspirin-caffdihydrocodeine, belladonna-opium, buprenorphine, butalb-acetaminoph-caffcodeine, butorphanol, carisoprodol-asacodeine, codeine sulfate, Embeda, Exalgo, Fentanyl (all dosage forms), Flowtuss, Hycofenix, hydrocodone-acetaminophen, hydrocodone-ibuprofen, Hydromet, hydromorphone, Hysingla ER, Kadian, Lorcet, Lortab, meperidine, Morphabond ER, morphine, morphine ER, nalbuphine, Nucynta, Nucynta ER, Obredon, Opana ER, opium tincture, Oxecta, oxycodone, oxycodone ER, oxycodone-acetaminophen, oxycodone-aspirin, oxycodone-ibuprofen, OxyContin, oxymorphone, oxymorphone ER, pentazocine-acetaminophen, pentazocinenaloxone, Primlev, promethazine-codeine, Talwin, tramadol ER, tramadolacetaminophen, Trezix, Tussigon, Tussionex, Xtampza ER, Zohydro ER, Zutripro amount of this medication over a certain amount of time. If you re taking this medication, you may need approval for your prescription to be covered. To promote safer opioid use, your plan may limit the amount, or day supply, of narcotic pain medications (opioids) it will cover. If you re taking an opioid, you may need approval for your prescription to be covered.

12 LEGACY (PERFORMANCE) PRESCRIPTION DRUG LIST (cont) Medication with quantity limits^^ Additional information July 1, 2018 SCHIZOPHRENIA/ANTI-PSYCHOTICS Invega Sustenna # Your plan only covers up to a certain SEIZURE DISORDERS Banzel # amount of this medication over a certain amount of time. If you re taking this SKIN CONDITIONS calcitriol, Vectical medication, you may need approval for SLEEP DISORDERS/SEDATIVES Rozerem your prescription to be covered. February 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Bevyxxa January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone, Nasonex ALZHEIMER'S DISEASE ANXIETY/DEPRESSION/BIPOLAR DISORDER ASTHMA/COPD/RESPIRATORY BLOOD PRESSURE/HEART MEDICATIONS CANCER DIABETES EYE CONDITIONS HORMONAL AGENTS INFECTIONS MISCELLANEOUS OSTEOPOROSIS PRODUCTS PAIN RELIEF AND INFLAMMATORY DISEASE SCHIZOPHRENIA/ANTI-PSYCHOTICS SEIZURE DISORDERS SKIN CONDITIONS SLEEP DISORDERS/SEDATIVES Namenda XR, Namzaric desvenlafaxine 25mg, 100mg, Marplan, Pristiq Perforomist Ranexa Fareston, Nilandron, nilutamide Jentadueto, Tradjenta bimatoprost eye drops, Cystaran, Zioptan Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle Dot, yuvafem Zovirax Nuedexta alendronate Daliresp, Mitigare Abilify Maintena, Aristada, Fanapt, Invega Trinza, Risperdal Consta, Zyprexa Relprevv Gabitril, Potiga Denavir, Regranex, Santyl, Vectical, Zyclara Hetlioz Step Therapy medication^^ Generic and/or Preferred Brand Alternatives July 1, 2018 ERECTILE DYSFUNCTION Cialis ## Viagra ## sildenafil, Cialis April 1, 2018 ASTHMA/COPD/RESPIRATORY Trelegy Ellipta ## Advair, Anoro Ellipta, Breo Ellipta, Stiolto Respimat, Symbicort February 1, 2018 ASTHMA/COPD/RESPIRATORY ArmonAir ## QVAR, Pulmicort Flexhaler January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR ## dextroamphetamine-amphetamine ER Focalin XR ## SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify ## aripiprazole Orap ## dexmethylphenidate ER pimozide SKIN CONDITIONS Locoid lotion ## hydrocortisone butyrate SLEEP DISORDERS/SEDATIVES Silenor ## eszopiclone, zolpidem

13 LEGACY (PERFORMANCE) PRESCRIPTION DRUG LIST (cont) Medication strength with limitations** (Your plan doesn t cover 2 capsules/tablets per day of this strength) Covered medication strength (Prescription must be for 1 capsule/tablet per day of this strength) January 1, 2018 ALLERGY/NASAL SPRAYS desloratadine ODT 2.5mg desloratadine ODT 5mg ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg Fetzima ER 40mg Trintellix 5mg Trintellix 10mg Fetzima ER 80mg Trintellix 10mg Trintellix 20mg BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg Benicar 20mg Benicar HCT mg Bystolic 10mg Tekturna 150mg Tekturna HCT mg 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 DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg 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 LEGACY (STANDARD) PRESCRIPTION DRUG LIST Preferred brand medication October 1, 2018 GASTROINTESTINAL/HEARTBURN Entyvio + Nexium Powder Pack June 1, 2018 DIABETES Ozempic Victoza April 1, 2018 DIABETES QTERN March 1, 2018 DIABETES Fiasp January 1, 2018 MISCELLANEOUS Nityr +

14 LEGACY (STANDARD) PRESCRIPTION DRUG LIST (cont) Non-preferred brand medication August 15, 2018 ASTHMA/COPD/RESPIRATORY Symdeko + July 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Arixtra + fondaparinux Lovenox + enoxaparin Reopro + CANCER dexrazoxane +, Evomela +, Hycamtin capsule +, Nilandron +, nilutamide +, Zinecard CONTRACEPTION PRODUCTS Depo-Provera 150mg/ml medroxyprogesterone LoSeasonique Amethia Lo, Camrese Lo, levonorg-eth estradiol 0.1/0.02/0.01mg Nexplanon +, Paragard T 380-a + Seasonique Amethia, Ashlyna, Camrese, Daysee, levonorg-eth estradiol 0.15/0.03/0.01mg DENTAL PRODUCTS Arestin + DIABETES Korlym + Segluromet Invokamet, Synjardy, Synjardy XR, Xigduo XR Steglatro Farxiga, Invokana, Jardiance Steglujan Glyxambi, QTERN EYE CONDITIONS Cystaran +, Ozurdex +, Retisert + GASTROINTESTINAL/HEARTBURN alosetron +, Buphenyl +, Chenodal +, Lotronex +, Ravicti +, sodium phenylbutyrate HORMONAL AGENTS Aveed +, hydroxyprogesterone caproate + Depo-Provera 400mg/ml medroxyprogesterone Saizen Humatrope INFECTIONS Daraprim +, Sirturo + INFERTILITY Makena + MISCELLANEOUS Asclera +, Carbaglu +, Ferriprox +, Flebogamma DIF +, Keveyis +, Varithena + Orfadin + Nityr MULTIPLE SCLEROSIS Copaxone + Aubagio, Avonex, Betaseron, Extavia, Gilenya, glatiramer, Glatopa, Plegridy, Rebif, Tecfidera PAIN RELIEF AND INFLAMMATORY DISEASE Colcrys colchicine (NON-NARCOTIC) PARKINSON S DISEASE Azilect rasagiline SEIZURE DISORDERS Lamictal ODT lamotrigine ODT Lyrica CR duloxetine, gabapentin, lidocaine 5% topical patch, Lyrica

15 LEGACY (STANDARD) PRESCRIPTION DRUG LIST (cont) Non-preferred brand medication July 1, 2018 SKIN CONDITIONS Ameluz +, Levulan + Tazorac 0.1% cream tazarotene SLEEP DISORDERS/SEDATIVES Hetlioz + TRANSPLANT MEDICATIONS Cellcept capsule, tablet, suspension + mycophenolate Neoral 25mg capsule, solution + cyclosporine modified, Gengraf Sandimmune 100mg capsule + cyclosporine URINARY TRACT CONDITIONS Thiola + May 15, 2018 EYE CONDITIONS Vyzulta bimatoprost, latanoprost, Travatan Z April 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE Duzallo allopurinol, probenecid, Uloric March 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic HORMONAL AGENTS Depo-Testosterone testosterone cypionate PARKINSON S DISEASE Gocovri amantadine February 1, 2018 ASTHMA/COPD/RESPIRATORY ArmonAir QVAR, Pulmicort Flexhaler BLOOD THINNERS/ANTI-CLOTTING Bevyxxa enoxaparin, Fragmin January 13, 2018 GASTROINTESTINAL/HEARTBURN Syndros dronabinol January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal spray ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER Focalin XR dexmethylphenidate ER CANCER Nilandron nilutamide DIABETES Apidra Humalog, Novolog Lantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba GASTROINTESTINAL/HEARTBURN omeprazole bicarbonate packet, 40mg- omeprazole 1100mg capsule, 20mg-1100 mg capsule INFECTIONS Eryped 400 erythromycin PAIN RELIEF AND INFLAMMATORY DISEASE D.H.E. 45 dihydroergotamine Imitrex sumatriptan OxyContin Embeda, Hysingla ER, Xtampza ER Vanatol LQ butalbital/acetaminophen/caffeine tabs or caps SKIN CONDITIONS Ala-Scalp hydrocortisone Analpram HC hydrocortisone-pramoxine Capex shampoo fluocinolone Cordran flurandrenolide Differin adapalene Kenalog triamcinolone spray Locoid lotion hydrocortisone butyrate Metrogel metronidazole gel Naftin naftifine Nucort, Texacort hydrocortisone

16 LEGACY (STANDARD) PRESCRIPTION DRUG LIST (cont) Medication requiring prior authorization^^ July 1, 2018 CANCER Hycamtin ++, Targretin ++, tretinoin capsule ++, Xeloda ++ MISCELLANEOUS Nityr, Orfadin ++ MULTIPLE SCLEROSIS Copaxone PAIN RELIEF AND INFLAMMATORY DISEASE Diskets, Dolophine, methadone ++, (NARCOTIC) Methadose April 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE Duzallo March 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic January 13, 2018 GASTROINTESTINAL/HEARTBURN Syndros January 1, 2018 DIABETES Lantus, Lantus SoloStar, Toujeo SoloStar GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend capsule, powder packet, tripack, Sancuso, Varubi HORMONAL AGENTS Androderm, Androgel, Axiron, Fortesta, Natesto, Striant, Testim, testosterone, Vogelxo MISCELLANEOUS Nityr PAIN RELIEF AND INFLAMMATORY DISEASE Roxicodone September 1, 2018 Medication with quantity limits^^ Additional information Your plan only covers this medication if your doctor requests and receives approval from Cigna. If you re taking this medication, ask your doctor to call us soon so we can begin the review process. Additional information SKIN CONDITIONS Doxepin 5% Cream, Prudoxin, Zonalon generic topical steroid (e.g. betamethasone) or topical tacrolimus August 15, 2018 ASTHMA/COPD/RESPIRATORY Symdeko Your plan only covers up to a certain July 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Aplenzin #, bupropion ER #, Celexa #, amount of this medication over a certain citalopram #, Cymbalta #, desvenlafaxiner ER #, amount of time. If you re taking this duloxetine #, Effexor XR #, Effexor #, Emsam #, medication, you may need approval for escitalopram #, Fetzima #, fluoxetine #, your prescription to be covered. fluvoxamine ER #, fluvoxamine #, Forfivo XL #, Khedezla, Lexapro, paroxetine CR #, paroxetine #, Paxil CR #, Pexeva #, Prozac, sertraline #, venlafaxine ER #, Wellbutrin SR, Wellbutrin XL, Zoloft BLOOD PRESSURE/HEART MEDICATIONS BiDil mg #, captopril-hctz, dofetilide #, Tikosyn CHOLESTEROL MEDICATIONS simvastatin, Zocor DIABETES Jentadueto XR GASTROINTESTINAL/HEARTBURN Aciphex, Dexilant, esomeprazole, lansoprazole DR, lansoprazole, Nexium DR, Nexium, OmePPI, omeprazole DR, omeprazole, omeprazole bicarbonate, pantoprazole, Prevacid SoluTab, Prilosec, prilosec 2.5mg, Protonix, rabeprazole, Zegerid NUTRITIONAL/DIETARY Auryxia PAIN RELIEF AND INFLAMMATORY DISEASE (NON-NARCOTIC) Cafergot, ergotamine-caffeine, diclofenac 1%, Voltaren

17 LEGACY (STANDARD) PRESCRIPTION DRUG LIST (cont) July 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE (NARCOTIC) Medication with quantity limits^^ acetaminophen-caffeine-dihyrocodeine, acetaminophen-codeine, Arymo, asa-butalbcaff-codeine, aspirin-caff-dihydrocodeine, belladonna-opium, buprenorphine, butalbacetaminoph-caff-codeine, butorphanol, carisoprodol-asa-codeine, codeine sulfate, Embeda, Exalgo, Fentanyl (all dosage forms), Flowtuss, Hycofenix, hydrocodoneacetaminophen, hydrocodone-ibuprofen, Hydromet, hydromorphone, Hysingla ER, Kadian, Lorcet, Lortab, meperidine, Morphabond ER, morphine, morphine ER, nalbuphine, Nucynta, Nucynta ER, Obredon, Opana ER, opium tincture, Oxecta, oxycodone, oxycodone ER, oxycodone-acetaminophen, oxycodone-aspirin, oxycodone-ibuprofen, OxyContin, oxymorphone, oxymorphone ER, pentazocine-acetaminophen, pentazocinenaloxone, Primlev, promethazine-codeine, Talwin, tramadol ER, tramadolacetaminophen, Trezix, Tussigon, Tussionex, Xtampza ER, Zohydro ER, Zutripro Additional information To promote safer opioid use, your plan may limit the amount, or day supply, of narcotic pain medications (opioids) it will cover. If you re taking an opioid, you may need approval for your prescription to be covered. SEIZURE DISORDERS Banzel # Your plan only covers up to a certain SKIN CONDITIONS calcitriol, Vectical amount of this medication over a certain SLEEP DISORDERS/SEDATIVES Rozerem amount of time. If you re taking this medication, you may need approval for February 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Bevyxxa your prescription to be covered. January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, Nasonex, mometasone ALZHEIMER'S DISEASE Namenda XR, Namzaric ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine 25mg, 100mg, Marplan, Pristiq ASTHMA/COPD/RESPIRATORY Perforomist BLOOD PRESSURE/HEART MEDICATIONS Ranexa CANCER Fareston, Nilandron, nilutamide DIABETES Jentadueto, Tradjenta EYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem INFECTIONS Zovirax MISCELLANEOUS Nuedexta OSTEOPOROSIS PRODUCTS alendronate PAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, Mitigare SCHIZOPHRENIA/ANTI-PSYCHOTICS Fanapt SEIZURE DISORDERS Gabitril, Potiga SKIN CONDITIONS Denavir, Regranex, Santyl, Vectical, Zyclara SLEEP DISORDERS/SEDATIVES Hetlioz

18 LEGACY (STANDARD) PRESCRIPTION DRUG LIST (cont) Step Therapy medication^^ April 1, 2018 ASTHMA/COPD/RESPIRATORY Trelegy Ellipta ## Advair, Anoro Ellipta, Breo Ellipta, Stiolto Respimat, Symbicort February 1, 2018 ASTHMA/COPD/RESPIRATORY ArmonAir ## QVAR, Pulmicort Flexhaler January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR ## dextroamphetamine-amphetamine ER Focalin XR ## dexmethylphenidate ER SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify ## aripiprazole Orap ## pimozide SKIN CONDITIONS Locoid lotion ## hydrocortisone butyrate SLEEP DISORDERS/SEDATIVES Silenor ## eszopiclone, zolpidem Medication strength with limitations** (Your plan doesn t cover 2 capsules/tablets per day of this strength) Covered medication strength (Prescription must be for 1 capsule/tablet per day of this strength) January 1, 2018 ALLERGY/NASAL SPRAYS desloratadine ODT 2.5mg desloratadine ODT 5mg ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg Fetzima ER 40mg Fetzima ER 80mg Trintellix 5mg Trintellix 10mg Trintellix 10mg Trintellix 20mg BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg Benicar 20mg Benicar 40mg Benicar HCT mg Benicar HCT 40-25mg Bystolic 10mg Bystolic 20mg Tekturna 150mg Tekturna 300mg Tekturna HCT mg Tekturna HCT mg CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg Livalo 2mg Livalo 4mg DIABETES Farxiga 5mg Farxiga 10mg PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg Aptiom 400mg Aptiom 800mg Fycompa 4mg Fycompa 8mg Fycompa 6mg Fycompa 12mg Trokendi XR 25mg Trokendi XR 50mg Trokendi XR 100mg Trokendi XR 200mg SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg

19 PERFORMANCE PRESCRIPTION DRUG LIST Medication not covered^ September 1, 2018 SKIN CONDITIONS Doxepin 5% Cream generic topical steroid (e.g. betamethasone) or topical tacrolimus July 1, 2018 DIABETES Segluromet Synjardy, Synjardy XR, Xigduo XR Steglatro Farxiga, Invokana, Jardiance Steglujan Glyxambi, QTERN GASTROINTESTINAL/HEARTBURN OmePPI omeprazole INFECTIONS Mycobutin rifabutin MULTIPLE SCLEROSIS Copaxone Aubagio, Avonex, Betaseron, Extavia, Gilenya, glatiramer, Glatopa, Plegridy, Rebif, Tecfidera SEIZURE DISORDERS Lyrica CR duloxetine, gabapentin, lidocaine 5% topical patch, Lyrica SKIN CONDITIONS diclofenac 3% gel, Solaraze Fluoroplex, fluorouracil topical, imiquimod cream, Picato May 15, 2018 EYE CONDITIONS Vyzulta bimatoprost, latanoprost, Travatan Z April 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE Duzallo allopurinol, probenecid, Uloric March 1, 2018 DIABETES Fiasp Humalog PARKINSON S DISEASE Gocovri amantadine February 1, 2018 ASTHMA/COPD/RESPIRATORY ArmonAir QVAR, Pulmicort Flexhaler January 13, 2018 GASTROINTESTINAL/HEARTBURN Syndros dronabinol January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipramine Pamelor nortriptyline Parnate tranylcypromine Tofranil imipramine ASTHMA/COPD/RESPIRATORY Zyflo montelukast, zafirlukast, zileuton ER Zyflo CR zileuton ER ATTENTION DEFICIT HYPERACTIVITY Desoxyn methamphetamine DISORDER Dexedrine dextroamphetamine, dextroamphetamine ER BLOOD PRESSURE/HEART MEDICATIONS Betapace sotalol CANCER Nilandron nilutamide DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR Invokana Farxiga, Jardiance Lantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba Novolin, Novolog Humalog, Humulin GASTROINTESTINAL/HEARTBURN Cortifoam, Uceris rectal foam Colocort, Hemmorex-HC, hydrocortisone, Procto-Med HC, Procto-Pak, Proctosol-HC, Proctozone-HC Marinol dronabinol omeprazole bicarbonate packet, 40mg- omeprazole 1100mg capsule, 20mg-1100mg OmePPI omeprazole

20 PERFORMANCE PRESCRIPTION DRUG LIST (cont) Medication not covered^ January 1, 2018 GASTROINTESTINAL/HEARTBURN (cont) Rowasa mesalamine enema Uceris tablet budesonide EC capsule Zegerid omeprazole Zofran ondansetron Zofran ODT ondansetron ODT HORMONAL AGENTS Cortrosyn cosyntropin DDAVP desmopressin Hectorol doxercalciferol INFECTIONS Augmentin, Augmentin ES, Augmentin XR amoxicillin-clavulanate ER, amoxicillinclavulanate Diflucan fluconazole E.E.S. 200, Eryped 400 erythromycin Mepron atovaquone Sporanox itraconazole Targadox Avidoxy, demeclocycline, doxycycline, doxycycline IR-DR, minocycline, minocycline ER, mondoxyne NL, Morgidox capsule, tetracycline Valcyte valganciclovir Vancocin vancomycin capsule Zovirax acyclovir PAIN RELIEF AND INFLAMMATORY DISEASE Cambia diclofenac, diclofenac ER, etodolac, etodolac ER, fenoprofen, Fenortho, flurbiprofen, ibuprofen, indomethacin, indomethacin ER, ketoprofen, Ketorolac, meclofenamate, mefenamic acid, meloxicam, nabumetone D.H.E. 45, Migranal dihydroergotamine Gralise, Horizant gabapentin Imitrex, Sumavel DosePro sumatriptan Lorzone chlorzoxazone OxyContin Embeda, Hysingla ER, Xtampza ER Roxicodone oxycodone Tivorbex indomethacin Vanatol LQ butalbital/acetaminophen/caffeine tabs or caps Vivlodex meloxicam Zomig sumatriptan, zolmitriptan Zorvolex diclofenac, diclofenac ER PARKINSON'S DISEASE Lodosyn carbidopa Requip XL ropinirole ER SCHIZOPHRENIA/ANTI-PSYCHOTICS Geodon capsule ziprasidone Zyprexa tablet olanzapine Zyprexa Zydis olanzapine ODT

21 PERFORMANCE PRESCRIPTION DRUG LIST (cont) Medication not covered^ January 1, 2018 SKIN CONDITIONS Cutivate fluticasone Kenalog topical spray triamcinolone Locoid hydrocortisone Luzu ketoconazole Soriatane acitretin Ziana clindamycin-tretinoin SLEEP DISORDERS/SEDATIVES Nuvigil armodafinil Provigil modafinil Restoril temazepam URINARY TRACT CONDITIONS Detrol tolterodine Detrol LA tolterodine ER Ditropan XL oxybutynin ER Enablex darifenacin ER Gelnique darifenacin ER, oxybutynin ER, tolterodine ER, trospium ER October 1, 2018 GASTROINTESTINAL/HEARTBURN Entyvio + June 1, 2018 DIABETES Ozempic Victoza April 1, 2018 DIABETES QTERN January 1, 2018 MISCELLANEOUS Nityr + Preferred brand medication Non-preferred brand medication August 15, 2018 ASTHMA/COPD/RESPIRATORY Symdeko + are lower-cost options available. July 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Reopro + are lower-cost options available. CANCER dexrazoxane +, Evomela +, Hycamtin capsule +, Nilandron +, nilutamide +, Zinecard Fusilev + are lower-cost options available. leucovorin CONTRACEPTION PRODUCTS LoSeasonique Amethia Lo, Camrese Lo, levonorg-eth estradiol 0.1/0.02/0.01mg Nexplanon +, Paragard T 380-a + are lower-cost options available. Seasonique Amethia, Ashlyna, Camrese, Daysee, levonorg-eth estradiol 0.15/0.03/0.01mg DENTAL PRODUCTS Arestin + are lower-cost options available. DIABETES Korlym + are lower-cost options available. EYE CONDITIONS Cystaran +, Ozurdex +, Retisert + are lower-cost options available. GASTROINTESTINAL/HEARTBURN alosetron +, Buphenyl, Chenodal +, Ravicti +, are sodium phenylbutyrate lower-cost options available. HORMONAL AGENTS Aveed +, hydroxyprogesterone caproate + are lower-cost options available.

22 PERFORMANCE PRESCRIPTION DRUG LIST (cont) Non-preferred brand medication July 1, 2018 INFECTIONS Daraprim +, Sirturo + are lower-cost options available. INFERTILITY Makena + are lower-cost options available. MISCELLANEOUS Asclera +, Carbaglu +, Ferriprox +, are Flebogamma DIF +, Keveyis +, Varithena + lower-cost options available. Orfadin + Nityr PAIN RELIEF AND INFLAMMATORY DISEASE Colcrys colchicine (NON-NARCOTIC) PARKINSON S DISEASE Azilect rasagiline SEIZURE DISORDERS Lamictal ODT lamotrigine ODT SKIN CONDITIONS Ameluz +, Levulan + are lower-cost options available. Tazorac 0.1% cream tazarotene SLEEP DISORDERS/SEDATIVES Hetlioz + are lower-cost options available. TRANSPLANT MEDICATIONS Cellcept + mycophenolate Neoral 25mg capsule, solution + cyclosporine modified, Gengraf Sandimmune 100mg capsule + cyclosporine URINARY TRACT CONDITIONS Thiola + are lower-cost options available. March 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic February 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Bevyxxa enoxaparin, Fragmin January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal spray ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER SKIN CONDITIONS Ala-Scalp hydrocortisone Analpram HC lotion hydrocortisone-pramoxine Capex shampoo fluocinolone Cordran flurandrenolide Differin adapalene Metrogel metronidazole gel Naftin naftifine Nucort, Texacort hydrocortisone Medication requiring prior authorization^^ July 1, 2018 CANCER Hycamtin ++, Targretin ++, tretinoin capsule ++, Xeloda ++ MISCELLANEOUS Nityr, Orfadin ++ PAIN RELIEF AND INFLAMMATORY DISEASE Diskets, Dolophine, methadone ++, (NARCOTIC) Methadose March 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic January 1, 2018 GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi HORMONAL AGENTS Androderm, Androgel, Striant, Testopel, testosterone MISCELLANEOUS Nityr Additional information Your plan only covers this medication if your doctor requests and receives approval from Cigna. If you re taking this medication, ask your doctor to call us soon so we can begin the review process.

23 PERFORMANCE PRESCRIPTION DRUG LIST (cont) Medication with quantity limits^^ Additional information September 1, SKIN CONDITIONS Prudoxin, Zonalon generic topical steroid 2018 (e.g. betamethasone) or topical tacrolimus August 15, 2018 ASTHMA/COPD/RESPIRATORY Symdeko Your plan only covers up to a certain July 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER bupropion ER #, Celexa #, citalopram #, desvenlafaxine ER #, duloxetine #, Effexor XR #, Effexor #, Emsam #, escitalopram #, Fetzima #, fluoxetine #, fluvoxamine ER #, fluvoxamine #, Forfivo XL #, Khedezla, paroxetine CR #, paroxetine #, Paxil CR #, Pexeva #, Prozac, sertraline #, venlafaxine ER #, Wellbutrin SR, Wellbutrin XL, Zoloft BLOOD PRESSURE/HEART MEDICATIONS CHOLESTEROL MEDICATIONS GASTROINTESTINAL/HEARTBURN NUTRITIONAL/DIETARY PAIN RELIEF AND INFLAMMATORY DISEASE (NON-NARCOTIC) PAIN RELIEF AND INFLAMMATORY DISEASE (NARCOTIC) BiDil mg #, captopril-hctz, dofetilide #, Tikosyn simvastatin, Zocor Aciphex, Dexilant, esomeprazole, lansoprazole DR, lansoprazole, Nexium DR, Nexium, omeprazole DR, omeprazole, omeprazole bicarbonate, pantoprazole, Prevacid SoluTab, Prilosec, prilosec 2.5mg, Protonix, rabeprazole Auryxia Cafergot, ergotamine-caffeine, diclofenac 1%, Voltaren acetaminophen-caffeine-dihyrocodeine, acetaminophen-codeine, Arymo, asa-butalb-caff-codeine, aspirin-caffdihydrocodeine, belladonna-opium, buprenorphine, butalb-acetaminoph-caffcodeine, butorphanol, carisoprodol-asacodeine, codeine sulfate, Embeda, Exalgo, Fentanyl (all dosage forms), Flowtuss, Hycofenix, hydrocodone-acetaminophen, hydrocodone-ibuprofen, Hydromet, hydromorphone, Hysingla ER, Kadian, Lorcet, Lortab, meperidine, Morphabond ER, morphine, morphine ER, nalbuphine, Nucynta, Nucynta ER, Obredon, Opana ER, opium tincture, Oxecta, oxycodone, oxycodone ER, oxycodone-acetaminophen, oxycodone-aspirin, oxycodone-ibuprofen, OxyContin, oxymorphone, oxymorphone ER, pentazocine-acetaminophen, pentazocinenaloxone, Primlev, promethazine-codeine, Talwin, tramadol ER, tramadolacetaminophen, Trezix, Tussigon, Tussionex, Xtampza ER, Zohydro ER, Zutripro amount of this medication over a certain amount of time. If you re taking this medication, you may need approval for your prescription to be covered. To promote safer opioid use, your plan may limit the amount, or day supply, of narcotic pain medications (opioids) it will cover. If you re taking an opioid, you may need approval for your prescription to be covered.

24 PERFORMANCE PRESCRIPTION DRUG LIST (cont) Medication with quantity limits^^ Additional information July 1, 2018 SCHIZOPHRENIA/ANTI-PSYCHOTICS Invega Sustenna # Your plan only covers up to a certain SEIZURE DISORDERS Banzel # amount of this medication over a certain SKIN CONDITIONS calcitriol, Vectical amount of time. If you re taking this medication, you may need approval for SLEEP DISORDERS/SEDATIVES Rozerem your prescription to be covered. February 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Bevyxxa January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone ALZHEIMER'S DISEASE Namenda XR, Namzaric ANXIETY/DEPRESSION/BIPOLAR DISORDER desvanlafaxine 25mg, 100mg, Marplan, Pristiq ASTHMA/COPD/RESPIRATORY Perforomist BLOOD PRESSURE/HEART MEDICATIONS Ranexa 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 DISEASE Daliresp, Mitigare SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify Maintena, Aristada, Fanapt, Invega Trinza, Risperdal Consta, Zyprexa Relprevv SEIZURE DISORDERS Gabitril, Potiga SKIN CONDITIONS Denavir, Regranex, Santyl, Vectical SLEEP DISORDERS/SEDATIVES Hetlioz Step Therapy medication^^ July 1, 2018 ERECTILE DYSFUNCTION Cialis ## Viagra ## sildenafil, Cialis April 1, 2018 ASTHMA/COPD/RESPIRATORY Trelegy Ellipta ## Advair, Anoro Ellipta, Breo Ellipta, Stiolto Respimat, Symbicort January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR ## dextroamphetamine-amphetamine ER Focalin XR ## SCHIZOPHRENIA/ANTI-PSYCHOTICS Orap ## pimozide dexmethylphenidate ER SLEEP DISORDERS/SEDATIVES Silenor ## eszopiclone, zolpidem Medication strength with limitations** (Your plan doesn t cover 2 capsules/tablets per day of this strength) Covered medication strength (Prescription must be for 1 capsule/tablet per day of this strength) January 1, 2018 ALLERGY/NASAL SPRAYS desloratadine ODT 2.5mg desloratadine ODT 5mg ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg Fetzima ER 40mg Trintellix 5mg Trintellix 10mg Fetzima ER 80mg Trintellix 10mg Trintellix 20mg

25 PERFORMANCE PRESCRIPTION DRUG LIST (cont) Medication strength with limitations** (Your plan doesn t cover 2 capsules/tablets per day of this strength) Covered medication strength (Prescription must be for 1 capsule/tablet per day of this strength) January 1, 2018 BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg Benicar 20mg Benicar 40mg Benicar HCT mg Benicar HCT 40-25mg Bystolic 10mg Bystolic 20mg Tekturna 150mg Tekturna 300mg Tekturna HCT mg Tekturna HCT mg CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg Livalo 2mg Livalo 4mg DIABETES Farxiga 5mg Farxiga 10mg PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg Aptiom 400mg Aptiom 800mg Fycompa 4mg Fycompa 8mg Fycompa 6mg Fycompa 12mg Trokendi XR 25mg Trokendi XR 50mg Trokendi XR 100mg Trokendi XR 200mg SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg VALUE PRESCRIPTION DRUG LIST Medication not covered^ September 1, 2018 SKIN CONDITIONS Doxepin 5% Cream generic topical steroid (e.g. betamethasone) or topical tacrolimus July 1, 2018 DIABETES Segluromet Synjardy, Synjardy XR, Xigduo XR Steglatro Farxiga, Jardiance Steglujan Glyxambi INFECTIONS Mycobutin rifabutin MULTIPLE SCLEROSIS Copaxone Aubagio, Avonex, Betaseron, Extavia, Gilenya, glatiramer, Glatopa, Plegridy, Rebif, Tecfidera SEIZURE DISORDERS Lyrica CR duloxetine, gabapentin, lidocaine 5% topical patch, Lyrica SKIN CONDITIONS diclofenac 3% gel, Solaraze Fluoroplex, fluorouracil topical, imiquimod cream, Picato May 15, 2018 EYE CONDITIONS Vyzulta bimatoprost, latanoprost, Travatan Z April 1, 2018 DIABETES QTERN Glyxambi PAIN RELIEF AND INFLAMMATORY DISEASE Duzallo allopurinol, probenecid March 1, 2018 DIABETES Fiasp Humalog PARKINSON S DISEASE Gocovri amantadine

26 VALUE PRESCRIPTION DRUG LIST (cont) Medication not covered^ February 1, 2018 ASTHMA/COPD/RESPIRATORY ArmonAir QVAR January 13, 2018 GASTROINTESTINAL/HEARTBURN Syndros dronabinol January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipramine Pamelor nortriptyline Parnate tranylcypromine Tofranil imipramine ASTHMA/COPD/RESPIRATORY Spiriva, Spiriva Respimat Incruse Ellipta ATTENTION DEFICIT HYPERACTIVITY DISORDER Stiolto Respimat Zyflo Zyflo CR Desoxyn Dexedrine Anoro Ellipta montelukast, zafirlukast, zileuton ER zileuton ER methamphetamine dextroamphetamine, dextroamphetamine ER BLOOD PRESSURE/HEART MEDICATIONS Betapace sotalol tablet CANCER Nilandron nilutamide DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR Invokana Kombiglyze XR, Onglyza Lantus, Lantus SoloStar, Toujeo SoloStar Farxiga, Jardiance alogliptin, alogliptin-metformin, Janumet, Janumet XR, Januvia Basaglar, Levemir, Tresiba EYE CONDITIONS Alocril, Alomide cromolyn eye drops Bepreve, Emadine, Lastacaft, Pataday, Patanol, Pazeo Elestat azelastine, epinastine, olopatadine epinastine GASTROINTESTINAL/HEARTBURN Marinol dronabinol Rowasa Zofran Zofran ODT mesalamine enema ondansetron ondansetron ODT HORMONAL AGENTS DDAVP nasal spray, tablet desmopressin nasal spray, tablets Hectorol doxercalciferol INFECTIONS Augmentin, Augmentin ES, Augmentin XR amoxicillin-clavulanate ER, amoxicillin-clavulanate Diflucan E.E.S. 200, Eryped 400 Mepron Sporanox Targadox Valcyte Vancocin Zovirax fluconazole erythromycin atovaquone itraconazole doxycycline valganciclovir vancomycin capsule acyclovir

27 VALUE PRESCRIPTION DRUG LIST (cont) Medication not covered^ January 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE D.H.E. 45, Migranal dihydroergotamine Imitrex sumatriptan OxyContin Embeda, Hysingla ER, Xtampza ER Roxicodone oxycodone Vanatol LQ butalbital/acetaminophen/caffeine tabs or caps Zomig sumatriptan, zolmitriptan PARKINSON'S DISEASE Lodosyn carbidopa Requip XL ropinirole ER SCHIZOPHRENIA/ANTI-PSYCHOTICS Geodon ziprasidone Zyprexa tablet olanzapine tablet Zyprexa Zydis olanzapine ODT SKIN CONDITIONS Acanya, Atralin, Avita, Azelex, Differin, Epiduo, Epiduo Forte, Fabior, Onexton, Retin-A, Retin-A Micro, Tretin-X, Veltin Cutivate Dovonex, Sorilux Enstilar, Taclonex Soriatane Tazorac Vectical Aczone, adapalene, Ala-Cort, alclometasone, amcinonide, Apexicon E, Avar, Avar-E, BenzePRO, benzoyl peroxide, betamethasone, BP 10-1, BPO, Clindacin ETZ, Clindacin P, clindamycin, clindamycin-benzoyl peroxide, clindamycin-tretinoin, clobetasol, clocortolone, Clodan, Cormax, desonide, desoximetasone, fluocinolone, halobetasol, hydrocortisone, Micort-HC, mometasone, prednicarbate, Psorcon, Scalacort, tretinoin, triamcinolone, Trianex, Triderm fluticasone calcipotriene calcipotriene-betamethasone DP acitretin adapalene, Ala-Cort, alclometasone, amcinonide, Apexicon E, Avar, Benzepro, benzoyl peroxide, betamethasone, BP 10-1, BPO, Clindacin ETZ, Clindacin P, clindamycin, clobetasol, clocortolone, Clodan, Cormax, desonide, desoximetasone, fluocinolone, halobetasol, hydrocortisone, Micort-HC, mometasone, prednicarbate, Psorcon, Scalacort, triamcinolone, Trianex, Triderm calcitriol ointment SLEEP DISORDERS/SEDATIVES Nuvigil armodafinil Provigil modafinil Restoril temazepam URINARY TRACT CONDITIONS Detrol, Detrol LA, Ditropan XL, Enablex, Gelnique darifenacin ER, oxybutynin ER, tolterodine, tolterodine ER, trospium ER