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^ January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipramine Pamelor Parnate Tofranil nortriptyline tranylcypromine imipramine ASTHMA/COPD/RESPIRATORY Zyflo montelukast, zafirlukast, zileuton ER ATTENTION DEFICIT HYPERACTIVITY DISORDER Zyflo CR Desoxyn Dexedrine zileuton ER methamphetamine dextroamphetamine, dextroamphetamine ER 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 UPDATED_10/17/2017

2 STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont) Medication not covered^ January 1, 2018 GASTROINTESTINAL/HEARTBURN (cont) Zegerid omeprazole Zofran ondansetron Zofran ODT ondansetron ODT 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 Roxicodone Tivorbex Vanatol LQ Vivlodex Zomig Zorvolex sumatriptan chlorzoxazone Embeda, Hysingla ER, Xtampza ER 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 Zyprexa Zydis olanzapine olanzapine ODT

3 STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont) Medication not covered^ January 1, 2018 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 January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal spray ATTENTION DEFICIT HYPERACTIVITY Adderall XR dextroamphetamine-amphetamine ER DISORDER Focalin XR dexmethylphenidate 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 January 1, 2018 GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi Androderm, Androgel, Striant, testosterone Additional information Your plan will only cover this medication if your doctor requests and receives approval from Cigna. Medication with quantity limits Additional information January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone Your plan only covers a certain amount ALZHEIMER'S DISEASE Namenda XR, Namzaric of this medication over a certain number ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine 25mg, 100mg, Marplan, of days. Your plan will only cover a larger Pristiq amount if your doctor requests and receives approval from Cigna. ASTHMA/COPD/RESPIRATORY Perforomist BLOOD PRESSURE/HEART MEDICATIONS Ranexa CANCER Fareston, nilutamide EYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan

4 STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont) Medication with quantity limits Additional information January 1, 2018 Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem MISCELLANEOUS Nuedexta OSTEOPOROSIS PRODUCTS alendronate PAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, Mitigare SCHIZOPHRENIA/ Fanapt ANTI-PSYCHOTICS SEIZURE DISORDERS Gabitril, Potiga SKIN CONDITIONS Denavir, Regranex, Santyl, Vectical SLEEP DISORDERS/SEDATIVES Hetlioz January 1, 2018 Step Therapy medication^^ Your plan only covers a certain amount of this medication over a certain number of days. Your plan will only cover a larger amount if your doctor requests and receives approval from Cigna. 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 day of 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 20mg BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg Benicar 20mg Benicar 40mg Benicar HCT mg Bystolic 10mg Tekturna 150mg Tekturna HCT mg 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

5 STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont) PERFORMANCE PRESCRIPTION DRUG LIST day of January 1, 2018 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 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 Additional information January 1, 2018 DIABETES Lantus, Lantus SoloStar, Toujeo SoloStar Your plan will only cover this medication if GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi your doctor requests and receives approval Androderm, Androgel, Axiron, Fortesta, Natesto, Striant, Testim, Testopel, testosterone, Vogelxo from Cigna. PAIN RELIEF AND INFLAMMATORY DISEASE Roxicodone Medication with quantity limits Additional information January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone, Nasonex Your plan only covers a certain amount ALZHEIMER'S DISEASE Namenda XR, Namzaric of this medication over a certain number ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine 25mg, 100mg, Marplan, of days. Your plan will only cover a larger Pristiq amount if your doctor requests and ASTHMA/COPD/RESPIRATORY Perforomist receives approval from Cigna.

6 PERFORMANCE PRESCRIPTION DRUG LIST (cont) Medication with quantity limits Additional information January 1, 2018 BLOOD PRESSURE/HEART MEDICATIONS Ranexa Your plan only covers a certain amount CANCER Fareston, Nilandron, nilutamide of this medication over a certain number DIABETES Jentadueto, Tradjenta of days. Your plan will only cover a larger amount if your doctor requests and EYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan receives approval from Cigna. 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 Abilify Maintena, Aristada, Fanapt, Invega Trinza, Risperdal Consta, Zyprexa Relprevv SEIZURE DISORDERS Gabitril, Potiga SKIN CONDITIONS Denavir, Regranex, Santyl, Vectical, Zyclara SLEEP DISORDERS/SEDATIVES Hetlioz Step Therapy medication^^ Generic and/or Preferred Brand Alternatives 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 day of 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 Fetzima ER 80mg 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

7 PERFORMANCE PRESCRIPTION DRUG LIST (cont) VALUE PRESCRIPTION DRUG LIST day of January 1, 2018 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 Non-preferred brand medication January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal spray ASTHMA/COPD/RESPIRATORY Spiriva, Spiriva Respimat Incruse Ellipta Stiolto Respimat Anoro Ellipta ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER Focalin XR dexmethylphenidate ER DIABETES Apidra Humalog Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR Invokana Farxiga, Jardiance Kombiglyze XR, Onglyza alogliptin, alogliptin-metformin, Janumet, Janumet XR, Januvia Toujeo Basaglar, Tresiba, Levemir 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 Zomig nasal spray sumatriptan, zolmitriptan SKIN CONDITIONS Differin adapalene Metrogel metronidazole gel Naftin naftifine Medication requiring prior authorization Additional information January 1, 2018 DIABETES Lantus, Lantus SoloStar, Toujeo SoloStar Your plan will only cover this medication if GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend capsule, powder packet, tripack, Sancuso, Varubi your doctor requests and receives approval from Cigna. Androderm, Androgel, Axiron, Fortesta, Natesto, Striant, Testim, Testopel, testosterone, Vogelxo PAIN RELIEF AND INFLAMMATORY DISEASE Roxicodone

8 VALUE PRESCRIPTION DRUG LIST (cont) Medication with quantity limits Additional information January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, Nasonex, mometasone Your plan only covers a certain amount ALZHEIMER'S DISEASE Namenda XR, Namzaric of this medication over a certain number of days. Your plan will only cover a larger ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine ER, Marplan, Pristiq amount if your doctor requests and ASTHMA/COPD/RESPIRATORY Perforomist receives approval from Cigna. BLOOD PRESSURE/HEART MEDICATIONS Ranexa CANCER DIABETES EYE CONDITIONS INFECTIONS MISCELLANEOUS OSTEOPOROSIS PRODUCTS PAIN RELIEF AND INFLAMMATORY DISEASE SCHIZOPHRENIA/ANTI-PSYCHOTICS SEIZURE DISORDERS SKIN CONDITIONS SLEEP DISORDERS/SEDATIVES Fareston, Nilandron, nilutamide Jentadueto, Tradjenta bimatoprost, Cystaran, Zioptan Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem Zovirax Nuedexta alendronate Daliresp, Mitigare Fanapt Gabitril, Potiga Denavir, Regranex, Santyl, Vectical, Zyclara Hetlioz Step Therapy medication^^ January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER Focalin XR dexmethylphenidate ER DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR Invokana Farxiga, Jardiance SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify aripiprazole Orap pimozide SKIN CONDITIONS Locoid lotion hydrocortisone butyrate SLEEP DISORDERS/SEDATIVES Silenor zolpidem, eszopiclone day of January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg Fetzima ER 40mg Fetzima ER 80mg Trintellix 5mg Trintellix 20mg BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg Benicar 20mg Benicar 40mg Benicar HCT mg Benicar HCT 40-25mg

9 VALUE PRESCRIPTION DRUG LIST (cont) January 1, 2018 day of BLOOD PRESSURE/HEART MEDICATIONS Bystolic 10mg Bystolic 20mg (cont) 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 ADVANTAGE PRESCRIPTION DRUG LIST Non-preferred brand medication January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal spray ASTHMA/COPD/RESPIRATORY Spiriva, Spiriva Respimat Incruse Ellipta Stiolto Respimat Anoro Ellipta ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR Invokana Farxiga, Jardiance Kombiglyze XR, Onglyza alogliptin, alogliptin-metformin, Janumet, Janumet XR, Januvia Toujeo Basaglar, Tresiba, Levemir PAIN RELIEF AND INFLAMMATORY DISEASE OxyContin Embeda, Hysingla ER, Xtampza ER Vanatol LQ butalbital/acetaminophen/caffeine tabs or caps SKIN CONDITIONS Differin adapalene Metrogel metronidazole gel Naftin naftifine Medication requiring prior authorization Additional information January 1, 2018 DIABETES Lantus, Lantus SoloStar, Toujeo SoloStar Your plan will only cover this medication if GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi your doctor requests and receives approval Androderm, Androgel, Axiron, Fortesta, Natesto, Striant, Testim, Testopel, Vogelxo, testosterone gel, Vogelxo from Cigna. PAIN RELIEF AND INFLAMMATORY DISEASE Roxicodone

10 ADVANTAGE PRESCRIPTION DRUG LIST (cont) January 1, 2018 Medication with quantity limits Additional information January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, Nasonex, mometasone Your plan only covers a certain amount ALZHEIMER'S DISEASE Namenda XR, Namzaric of this medication over a certain number ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine ER, Marplan, Pristiq of days. Your plan will only cover a larger ASTHMA/COPD/RESPIRATORY Perforomist amount if your doctor requests and receives approval from Cigna. BLOOD PRESSURE/HEART MEDICATIONS Ranexa CANCER Fareston, Nilandron, nilutamide DIABETES Jentadueto, Tradjenta EYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan 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 Abilify Maintena, Aristada, Fanapt, Invega Trinza, Risperdal Consta, Zyprexa Relprevv SEIZURE DISORDERS Gabitril, Potiga SKIN CONDITIONS Denavir, Regranex, Santyl, Vectical, Zyclara SLEEP DISORDERS/SEDATIVES Hetlioz ATTENTION DEFICIT HYPERACTIVITY DISORDER Step Therapy medication^^ Adderall XR Focalin XR dextroamphetamine-amphetamine ER dexmethylphenidate ER DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR Invokana Farxiga, Jardiance SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify aripiprazole Orap pimozide SKIN CONDITIONS Locoid lotion hydrocortisone butyrate SLEEP DISORDERS/SEDATIVES Silenor eszopiclone, zaleplon, zolpidem, zolpidem ER day of January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg Fetzima ER 40mg Fetzima ER 80mg Trintellix 5mg Trintellix 20mg BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg Benicar 20mg Benicar 40mg Benicar HCT mg Benicar HCT 40-25mg

11 ADVANTAGE PRESCRIPTION DRUG LIST (cont) January 1, 2018 day of BLOOD PRESSURE/HEART MEDICATIONS Bystolic 10mg Bystolic 20mg (cont) 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 LEGACY PRESCRIPTION DRUG LIST Non-preferred brand medication 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

12 LEGACY PRESCRIPTION DRUG LIST (cont) Medication requiring prior authorization Additional information January 1, 2018 DIABETES Lantus, Lantus SoloStar, Toujeo SoloStar Your plan will only cover this medication if GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend capsule, powder packet, tripack, Sancuso, Varubi your doctor requests and receives approval from Cigna. Androderm, Androgel, Axiron, Fortesta, Natesto, Striant, Testim, testosterone, Vogelxo PAIN RELIEF AND INFLAMMATORY DISEASE Roxicodone Medication with quantity limits Additional information January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, Nasonex, mometasone Your plan only covers a certain amount ALZHEIMER'S DISEASE Namenda XR, Namzaric of this medication over a certain number ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine 25mg, 100mg, Marplan, of days. Your plan will only cover a larger Pristiq amount if your doctor requests and receives approval from Cigna. ASTHMA/COPD/RESPIRATORY Perforomist BLOOD PRESSURE/HEART MEDICATIONS Ranexa CANCER Fareston, Nilandron, nilutamide DIABETES Jentadueto, Tradjenta EYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan 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 Step Therapy medication^^ 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 day of 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

13 LEGACY PRESCRIPTION DRUG LIST (cont) January 1, 2018 day of ANXIETY/DEPRESSION/ Trintellix 5mg BIPOLAR DISORDER (cont) 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 PERFORMANCE PRESCRIPTION DRUG LIST (with additional medications not covered) Medication not covered^ 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

14 PERFORMANCE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont) Medication not covered^ January 1, 2018 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 Rowasa mesalamine enema Uceris tablet budesonide EC capsule Zegerid omeprazole Zofran ondansetron Zofran ODT ondansetron ODT 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

15 PERFORMANCE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont) Non-preferred brand medication 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 Additional information January 1, 2018 GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi Your plan will only cover this medication if Androderm, Androgel, Striant, Testopel, your doctor requests and receives approval testosterone from Cigna. Medication not covered^ January 1, 2018 PARKINSON'S DISEASE Lodosyn carbidopa Requip XL ropinirole ER SCHIZOPHRENIA/ANTI-PSYCHOTICS Geodon capsule ziprasidone Zyprexa tablet olanzapine Zyprexa Zydis olanzapine ODT 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 Medication with quantity limits Additional information January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone Your plan only covers a certain amount ALZHEIMER'S DISEASE Namenda XR, Namzaric of this medication over a certain number of days. Your plan will only cover a larger amount if your doctor requests and receives approval from Cigna.

16 PERFORMANCE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont) Medication with quantity limits Additional information January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER desvanlafaxine 25mg, 100mg, Marplan, Pristiq ASTHMA/COPD/RESPIRATORY Perforomist BLOOD PRESSURE/HEART MEDICATIONS CANCER EYE CONDITIONS MISCELLANEOUS OSTEOPOROSIS PRODUCTS PAIN RELIEF AND INFLAMMATORY DISEASE SCHIZOPHRENIA/ANTI-PSYCHOTICS SEIZURE DISORDERS SKIN CONDITIONS SLEEP DISORDERS/SEDATIVES Ranexa Fareston, nilutamide bimatoprost eye drops, Cystaran, Zioptan Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem Nuedexta alendronate Daliresp, Mitigare Abilify Maintena, Aristada, Fanapt, Invega Trinza, Risperdal Consta, Zyprexa Relprevv Gabitril, Potiga Denavir, Regranex, Santyl, Vectical Hetlioz Step Therapy medication^^ Your plan only covers a certain amount of this medication over a certain number of days. Your plan will only cover a larger amount if your doctor requests and receives approval from Cigna. 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 day of 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 Fetzima ER 80mg 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

17 PERFORMANCE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont) day of January 1, 2018 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 VALUE PRESCRIPTION DRUG LIST (with additional medications not covered) Medication not covered^ January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipramine Pamelor nortriptyline Parnate tranylcypromine Tofranil imipramine ASTHMA/COPD/RESPIRATORY Spiriva, Spiriva Respimat Incruse Ellipta Stiolto Respimat Anoro Ellipta 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 tablet CANCER Nilandron nilutamide DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR Invokana Farxiga, Jardiance Kombiglyze XR, Onglyza alogliptin, alogliptin-metformin, Janumet, Janumet XR, Januvia Lantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba EYE CONDITIONS Alocril, Alomide cromolyn eye drops Bepreve, Emadine, Lastacaft, Pataday, azelastine, epinastine, olopatadine Patanol, Pazeo Elestat epinastine GASTROINTESTINAL/HEARTBURN Marinol dronabinol Rowasa mesalamine enema Zofran ondansetron Zofran ODT ondansetron ODT

18 VALUE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont) Medication not covered^ January 1, 2018 DDAVP nasal spray, tablet desmopressin nasal spray, tablets Hectorol doxercalciferol INFECTIONS Augmentin, Augmentin ES, Augmentin XR amoxicillin-clavulanate ER, amoxicillin-clavulanate Diflucan fluconazole E.E.S. 200, Eryped 400 Mepron Sporanox Targadox Valcyte Vancocin Zovirax erythromycin atovaquone itraconazole doxycycline valganciclovir vancomycin capsule acyclovir PAIN RELIEF AND INFLAMMATORY DISEASE D.H.E. 45, Migranal dihydroergotamine Imitrex OxyContin Roxicodone Vanatol LQ Zomig sumatriptan Embeda, Hysingla ER, Xtampza ER oxycodone PARKINSON'S DISEASE Lodosyn carbidopa Requip XL butalbital/acetaminophen/caffeine tabs or caps sumatriptan, zolmitriptan ropinirole ER SCHIZOPHRENIA/ANTI-PSYCHOTICS Geodon ziprasidone SKIN CONDITIONS Zyprexa tablet Zyprexa Zydis Acanya, Atralin, Avita, Azelex, Differin, Epiduo, Epiduo Forte, Fabior, Onexton, Retin-A, Retin-A Micro, Tretin-X, Veltin Cutivate Dovonex, Sorilux Enstilar, Taclonex Soriatane olanzapine tablet olanzapine ODT Aczone, adapalene, Ala-Cort, alclometasone, amcinonide, Apexicon E, Avar, Avar-E, BenzePRO, benzoyl peroxide, betamethasone, BP 10-1, BPO, Clindacin ETZ, Clindacin P, clindamycin, clindamycinbenzoyl 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

19 VALUE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont) Medication not covered^ January 1, 2018 SKIN CONDITIONS (cont) Tazorac 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 Vectical calcitriol ointment SLEEP DISORDERS/SEDATIVES Nuvigil armodafinil URINARY TRACT CONDITIONS Provigil Restoril Detrol, Detrol LA, Ditropan XL, Enablex, Gelnique Non-preferred brand medication modafinil temazepam darifenacin ER, oxybutynin ER, tolterodine, tolterodine ER, trospium ER January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER Medication requiring prior authorization January 1, 2018 GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend capsule, powder packet, tripack, Sancuso, Varubi Androderm, Androgel, Striant testosterone Additional information Your plan will only cover this medication if your doctor requests and receives approval from Cigna. Medication with quantity limits Additional information January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone Your plan only covers a certain amount ALZHEIMER'S DISEASE Namenda XR, Namzaric of this medication over a certain number of days. Your plan will only cover a larger ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine ER, Marplan amount if your doctor requests and ASTHMA/COPD/RESPIRATORY Perforomist receives approval from Cigna. BLOOD PRESSURE/HEART MEDICATIONS Ranexa CANCER EYE CONDITIONS MISCELLANEOUS OSTEOPOROSIS PRODUCTS PAIN RELIEF AND INFLAMMATORY DISEASE SCHIZOPHRENIA/ANTI-PSYCHOTICS SEIZURE DISORDERS SKIN CONDITIONS SLEEP DISORDERS/SEDATIVES Fareston, nilutamide bimatoprost eye drops, Cystaran, Zioptan Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem Nuedexta alendronate Daliresp, Mitigare Fanapt Gabitril, Potiga Denavir, Regranex, Santyl Hetlioz

20 VALUE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont) Step Therapy medication^^ 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 zolpidem, eszopiclone day of January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg Fetzima ER 40mg Trintellix 5mg Fetzima ER 80mg Trintellix 20mg 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 ADVANTAGE PRESCRIPTION DRUG LIST (with additional medications not covered) Medication not covered^ January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipramine Pamelor Parnate Tofranil nortriptyline tranylcypromine imipramine ASTHMA/COPD/RESPIRATORY Spiriva, Spiriva Respimat Incruse Ellipta ATTENTION DEFICIT HYPERACTIVITY DISORDER Stiolto Respimat Zyflo Zyflo CR Desoxyn Dexedrine Anoro Ellipta BLOOD PRESSURE/HEART MEDICATIONS Betapace sotalol tablet CANCER Nilandron nilutamide montelukast, zafirlukast, zileuton ER zileuton ER methamphetamine dextroamphetamine, dextroamphetamine ER

21 ADVANTAGE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont) Medication not covered^ January 1, 2018 DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR Invokana Farxiga, Jardiance Kombiglyze XR, Onglyza alogliptin, alogliptin-metformin, Janumet, Janumet XR, Januvia Lantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba EYE CONDITIONS Alocril, Alomide cromolyn eye drops Bepreve, Emadine, Lastacaft, Pataday, azelastine, epinastine, olopatadine Patanol, Pazeo Elestat epinastine GASTROINTESTINAL/HEARTBURN Marinol dronabinol Rowasa mesalamine enema Zofran ondansetron Zofran ODT ondansetron ODT Cortrosyn cosyntropin DDAVP desmopressin Hectorol doxercalciferol INFECTIONS Augmentin, Augmentin ES, Augmentin XR amoxicillin-clavulanate ER, amoxicillin-clavulanate Diflucan fluconazole E.E.S. 200, Eryped 400 erythromycin Mepron Sporanox Targadox Valcyte Vancocin Zovirax atovaquone itraconazole doxycycline valganciclovir vancomycin capsule acyclovir PAIN RELIEF AND INFLAMMATORY DISEASE D.H.E. 45, Migranal dihydroergotamine Imitrex OxyContin Roxicodone Vanatol LQ Zomig sumatriptan Embeda, Hysingla ER, Xtampza ER oxycodone PARKINSON'S DISEASE Lodosyn carbidopa Requip XL butalbital/acetaminophen/caffeine tabs or caps sumatriptan, zolmitriptan ropinirole ER SCHIZOPHRENIA/ANTI-PSYCHOTICS Geodon ziprasidone Zyprexa tablet Zyprexa Zydis olanzapine olanzapine ODT

22 ADVANTAGE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont) Medication not covered^ January 1, 2018 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, clindamycinbenzoyl 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 SLEEP DISORDERS/SEDATIVES Nuvigil armodafinil Provigil Restoril adapalene, Ala-Cort, alclometasone, amcinonide, Apexicon E, Avar, Avar-E, 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 modafinil temazepam URINARY TRACT CONDITIONS Detrol tolterodine Detrol LA Ditropan XL Enablex Gelnique Non-preferred brand medication tolterodine ER oxybutynin ER darifenacin ER darifenacin ER, oxybutynin ER, tolterodine ER, trospium ER January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER

23 ADVANTAGE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont) Medication requiring prior authorization January 1, 2018 GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi Androderm, Androgel, Striant, Testopel, testosterone Additional information Your plan will only cover this medication if your doctor requests and receives approval from Cigna. Medication with quantity limits Additional information January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone Your plan only covers a certain amount ALZHEIMER'S DISEASE Namenda XR, Namzaric of this medication over a certain number ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine ER, Marplan of days. Your plan will only cover a larger amount if your doctor requests and ASTHMA/COPD/RESPIRATORY Perforomist receives approval from Cigna. BLOOD PRESSURE/HEART MEDICATIONS Ranexa CANCER Fareston, nilutamide EYE CONDITIONS MISCELLANEOUS OSTEOPOROSIS PRODUCTS PAIN RELIEF AND INFLAMMATORY DISEASE SCHIZOPHRENIA/ANTI-PSYCHOTICS SEIZURE DISORDERS SKIN CONDITIONS SLEEP DISORDERS/SEDATIVES bimatoprost eye drops, Cystaran, Zioptan Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem Nuedexta alendronate Daliresp, Mitigare Abilify Maintena, Aristada, Fanapt, Invega Trinza, Risperdal Consta, Zyprexa Relprevv Gabitril, Potiga Denavir, Regranex, Santyl Hetlioz Step Therapy medication^^ January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER Focalin XR dexmethylphenidate ER SCHIZOPHRENIA/ANTI-PSYCHOTICS Orap pimozide SLEEP DISORDERS/SEDATIVES Silenor eszopiclone, zaleplon, zolpidem, zolpidem ER day of January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg Fetzima ER 40mg Fetzima ER 80mg Trintellix 5mg Trintellix 20mg DIABETES Farxiga 5mg Farxiga 10mg PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg

24 ADVANTAGE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont) day of January 1, 2018 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 * State laws in Texas and Louisiana require your plan to cover your medications at your current benefit level until your plan renews. This means that if your medication is taken off the drug list, is moved to a higher cost-share tier or needs approval, your plan can t make these changes until your renewal date. To find out if these state laws apply to your plan, please call Customer Service using the number on the back of your ID card. ++ Your plan doesn t cover more than one tablet/capsule in this strength a day. If your doctor feels a higher strength of this medication once each day isn t right for you, he or she can ask Cigna to consider approving coverage of your current medication strength. ^ These medications require approval from Cigna before they re covered by your plan. If your doctor feels an alternative medication isn t right for you, he or she can ask Cigna to consider approving coverage of your medication. ^^ This is a Step Therapy medication. Step Therapy medications aren t covered by your plan without approval from Cigna. In Step Therapy, you have to try lower-cost alternatives first before the higher-cost brand medication may be covered. Typically, you start by taking generics or lower-cost preferred brands. Cigna reserves the right to make changes to the Drug List without notice. Health benefit plans vary, but in general to be eligible for coverage a drug must be approved by the Food and Drug Administration (FDA), prescribed by a health care professional, purchased from a licensed pharmacy and medically necessary. If your plan provides coverage for certain prescription drugs with no cost-share, you may be required to use an in-network pharmacy to fill the prescription. If you use a pharmacy that does not participate in your plan s network, your prescription may not be covered, or reimbursement may be limited by your plan s copayment, coinsurance or deductible requirements. Certain features described in this document may not be applicable to your specific health plan, and plan features may vary by location and plan type. Refer to your plan documents for costs and complete details of your plan s prescription drug coverage. 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, Cigna Health Management, Inc., Tel-Drug, Inc., Tel-Drug of Pennsylvania, L.L.C., and HMO or service company subsidiaries of Cigna Health Corporation, including Cigna HealthCare of Arizona, Inc., Cigna HealthCare of California, Inc., Cigna HealthCare of Colorado, Inc., Cigna HealthCare of Connecticut, Inc., Cigna HealthCare of Florida, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Illinois, Inc., Cigna HealthCare of Indiana, Inc., Cigna HealthCare of St. Louis, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of New Jersey, Inc., Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of Tennessee, Inc., and Cigna HealthCare of Texas, Inc. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc Cigna. Some content provided under license.updated_10/17/2017