CIGNA STANDARD 3-TIER PRESCRIPTION DRUG LIST - Starting July 1, 2020

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CIGNA STANDARD 3-TIER PRESCRIPTION DRUG LIST - Starting July 1, 2020
CIGNA STANDARD 3-TIER
PRESCRIPTION DRUG LIST

Starting July 1, 2020

Offered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, or their affiliates.
595200 k Standard 3-Tier 04/20
What’s inside?

 About your prescription drug list                                                                                           3

 How to read your drug list                                                                                                  3

 How to find your medication                                                                                                 5

 Medications that are not covered                                                                                          19

 Prescription drug list FAQs                                                                                              30

 Exclusions and limitations                                                                                                33

     Go online to find out which medications your plan covers.
     This document was last updated 03/01/2020.* You can go online to see your plan’s current
     coverage information.

                      The myCigna® app or website – Once you log in, click on “Coverage,” then
                      select “Pharmacy” from the down menu. Under “Prescriptions,” type in the
                      medication name.

                      Cigna.com/druglist – Select your drug list name – Standard 3 Tier – from the
                      drop down menu.

      Questions?
      Call the toll-free number on your Cigna ID card. We’re here to help. You can also chat with us
      online on the myCigna website, Monday–Friday, 9:00 am–8:00 pm EST.

* Drug list created: originally created 01/01/2004   Last updated: 03/01/2020, for changes   Next planned update: 09/01/2020, for
                                                              starting 07/01/2020                    changes starting 01/01/2021
                                                                      2
About your prescription drug list
This document shows the most commonly prescribed medications covered on the Standard
3-Tier Prescription Drug List as of July 1, 2020.1,2 All of these medications are approved by the U.S.
Food and Drug Administration (FDA). Medications are listed by the condition they treat, then
listed alphabetically within tiers (or cost-share levels).
The Standard 3-Tier Prescription Drug List is updated often so it’s important to know that this is
not a complete list of the medications your plan covers. Also, your specific plan may not cover all
of the medications in this document. Log in to the myCigna app or website, or check your plan
materials, to learn more about the medications your plan covers.

How to read your drug list
Use the sample chart below to help you understand this drug list. This chart is just an example.
It may not show how these medications are actually covered on the Standard 3-Tier Prescription
Drug List.
                                                                    Tier (cost-share level) gives you
                                                                    an idea of how much you may pay
             TIER 1                       TIER 2                    for a medication
               $                            $$
          BLOOD PRESSURE/HEART MEDICATIONS                          Medications are grouped by
 afeditab CR                                                  Berinert* (PA)                                                      the condition they treat
 amlodipine besylate                                          Bidil
 amlodipine besylate-benazepril                               Bystolic
 amlodipine-valsartan                                         Cinryze* (PA)
 amlodipine-valsartan-HCTZ                                    Coreg CR
 atenolol                                                     Cozaar (ST)
                                                              Diovan (ST)
 atenolol-chlorthalidone                                                                                                           Medications are listed in
                                                              Diovan HCT (ST)
 benazepril                                                                                                                        alphabetical order within
                                                              Edarbi (ST)
 benazepril-HCTZ                                                                                                                   each column
                                                              Edarbyclor (ST)
 candesartan cilexetil                                        Exforge
 cartia XT                                                    Exforge HCT
 carvedilol                                                   Firazyr* (PA)                                                       Specialty medications have an
 clonidine                                                    Hemangeol                                                           asterisk (*) listed next to them
 digitek                                                      Inderal LA
 digox                                                        Inderal XL
 digoxin                                                      Innopran XL
 diltiazem ER                                                 Lotrel                                                              Brand name medications
 diltiazem CD                                                 Micardis (ST)                                                       are capitalized
 diltiazem                                                    Multaq
 dilt-XR                                                      Nitro-dur
 enalapril                                                    Nitrolingual
                                                              NitroMist
 flecainide acetate                                                                                                               Generic medications
                                                              Nitronal
 hydralazine                                                                                                                      are lowercase
                                                              Nitrostat
 irbesartan                                                   Northera* (PA)                                                      Medications that have extra
 isosorbide mononitrat                                        Norvasc                                                             coverage requirements will
                                                              Ranexa (ST)                                                         have an abbreviation listed
                                                              Tekturna                                                            next to them
                                                              Tekturna HCT
This chart is just a sample. It may not show how these medications are actually covered on the Standard 3-Tier Prescription Drug List.
                                                                                                3
Tiers

Covered medications are divided into tiers or cost-share levels. Typically, the higher the tier, the
higher the price you’ll pay to fill the prescription.

     ›    Tier 1 – Typically Generics                                                        (Lowest-cost medication)                                  $
     ›    Tier 2 – Typically Preferred Brands                                                (Medium-cost medication)                                  $$
     ›    Tier 3 – Typically Non-Preferred Brands                                            (Highest-cost medication)                                 $$$

Abbreviations next to medications

Some medications on your drug list have extra requirements before your plan will cover them.* This
helps to make sure you’re receiving coverage for the right medication, at the right cost, in the right
amount and for the right situation. These medications will have an abbreviation next to them in the
drug list. Here’s what each of the abbreviations mean.

  (PA)	
       Prior Authorization – Cigna will review information your doctor provides to make
       sure you meet coverage guidelines for the medication. If approved, your plan will
       cover the medication.

  (ST)               tep Therapy – Certain high-cost medications are part of the Step Therapy program.
                    S
                    Step Therapy encourages the use of lower-cost medications (typically generics and
                    preferred brands) that can be used to treat the same condition as the higher-cost
                    medication. These conditions include, but are not limited to, depression, high blood
                    pressure, high cholesterol, skin conditions and sleep disorders. Your plan doesn’t
                    cover the higher-cost Step Therapy medication until you try one or more alternatives
                    first (unless you receive approval from Cigna).

  (QL)               uantity Limits – For some medications, your plan will only cover up to a certain
                    Q
                    amount over a certain length of time. For example, 30mg per day for 30 days. Your
                    plan will only cover a larger amount if your doctor requests and receives approval
                    from Cigna.

  (AGE)              ge Requirements – For certain medications, you must be within a specific
                    A
                    age range for your plan to cover them. This is because some medications aren’t
                    considered clinically appropriate for individuals who aren’t within that age range.

* These coverage requirements may not apply to your specific plan. That’s because some plans don’t have prior authorization, quantity limits, Step Therapy and/or age requirements. Log in to the
   myCigna app or website, or check your plan materials, to find out if your plan includes these specific coverage requirements.

Brand name medications are capitalized
In this drug list, brand name medications are capitalized and generic medications are lowercase.

Specialty medications are marked with an asterisk
Specialty medications are used to treat complex medical conditions like multiple sclerosis,
hepatitis C and rheumatoid arthritis. In this drug list, specialty medications are marked with an
asterisk (*). Some plans may cover these medications on a specialty tier, limit coverage to a 30-day
supply and/or require you to use a preferred specialty pharmacy to receive coverage. Log in to the
myCigna app or website, or check your plan materials, to learn more about how your plan covers
specialty medications.

                                                                                               4
No cost-share preventive medications are marked with a plus sign
Health care reform under the Patient Protection and Affordable Care Act (PPACA) requires that
most plans cover certain categories of medications and other products as preventive care services.
In this drug list, medications with a plus sign (+) next to them may be available to you at no cost-
share (copay, coinsurance and/or deductible). Log in to the myCigna app or website, or check your
plan materials, to learn more about how your plan covers preventive medications.
Plan exclusions
Your plan excludes certain types of medications or products from coverage. This is known as a “plan
(or benefit) exclusion.” This means that your plan doesn’t cover any prescription medications in the
drug class or to treat the specific condition. There’s also no option to receive coverage through a
medication review process. In this drug list, these medications have a caret (^) next to them. Log in
to the myCigna app or website, or check your plan materials, to find out if your plan excludes your
medication from coverage.
How to find your medication
Find your condition in the alphabetical list below. Then go to that page to see the covered
medications available to treat the condition.

Condition                                  Page          Condition                              Page
AIDS/HIV                                        6        GASTROINTESTINAL/HEARTBURN                12
ALLERGY/NASAL SPRAYS                            6        HORMONAL AGENTS                           13
ALZHEIMER’S DISEASE                             6        INFECTIONS                             13, 14
ANXIETY/DEPRESSION/BIPOLAR                      6
                                                         INFERTILITY                               14
DISORDER
                                                         MISCELLANEOUS                             14
ASTHMA/COPD/RESPIRATORY                       6, 7
ATTENTION DEFICIT HYPERACTIVITY                 7        MULTIPLE SCLEROSIS                        14
DISORDER                                                 NUTRITIONAL/DIETARY                       14
BLOOD MODIFIERS/BLEEDING DISORDERS              7        OSTEOPOROSIS PRODUCTS                     14
BLOOD PRESSURE/HEART MEDICATIONS              7, 8
                                                         PAIN RELIEF AND INFLAMMATORY DISEASE   14, 15
BLOOD THINNERS/ANTI-CLOTTING                    8
                                                         PARKINSON’S DISEASE                       15
CANCER                                          8
                                                         SCHIZOPHRENIA/ANTI-PSYCHOTICS             16
CHOLESTEROL MEDICATIONS                       8, 9
                                                         SEIZURE DISORDERS                         16
CONTRACEPTION PRODUCTS                       9, 10
                                                         SKIN CONDITIONS                        16, 17
COUGH/COLD MEDICATIONS                         11
                                                         SLEEP DISORDERS/SEDATIVES                 17
DENTAL PRODUCTS                                11
DIABETES                                       11        SMOKING CESSATION                         17

DIURETICS                                      11        SUBSTANCE ABUSE                           17

EAR MEDICATIONS                                11        TRANSPLANT MEDICATIONS                    17
ERECTILE DYSFUNCTION                           11        URINARY TRACT CONDITIONS                  17
EYE CONDITIONS                              11, 12       VACCINES                               17, 18
FEMININE PRODUCTS                              12        WEIGHT MANAGEMENT                         18
                                                     5
Cigna Standard 3-Tier Prescription Drug List

TIER 1              TIER 2               TIER 3                    TIER 1              TIER 2               TIER 3
$                   $$                   $$$                       $                   $$                   $$$
                        AIDS/HIV                                            ANXIETY/DEPRESSION/BIPOLAR
abacavir-             Atripla* (PA)      Cimduo* (PA)                              DISORDER (cont)
 lamivudine* (PA)     Biktarvy*          Complera* (PA)            bupropion (QL)                          Pristiq (ST, QL)
atazanavir* (PA)      Descovy*           Evotaz* (PA)              bupropion SR (QL)                       Prozac (ST, QL)
ritonavir*            Genvoya*           Juluca* (PA)              bupropion XL (QL)                       Remeron
tenofovir* (PA)       Intelence* (PA)    Odefsey* (PA)             buspirone                               Sarafem (ST)
                      Isentress*         Prezcobix* (PA)           citalopram (QL)                         Trintellix (ST, QL)
                      Isentress HD* (PA) Stribild* (PA)            clomipramine                            Viibryd (ST, QL)
                      Prezista*                                    desvenlafaxine ER                       Wellbutrin SR (ST,
                      Selzentry* (PA)                                (QL)                                   QL)
                      Symfi*                                       duloxetine (QL)                         Xanax
                      Symfi Lo*                                    escitalopram (QL)                       Xanax XR
                      Symtuza*                                     fluoxetine (QL)                         Zoloft (ST, QL)
                      Tivicay*                                     fluoxetine DR (QL)
                      Triumeq*                                     fluvoxamine (QL)
                      Truvada*
                                                                   fluvoxamine ER
                      Viread 150mg,
                                                                     (QL)
                       200mg, 250mg
                                                                   lorazepam
                       tablet, powder*
                                                                   lorazepam intensol
                       (PA)
                                                                   mirtazapine
                ALLERGY/NASAL SPRAYS                               paroxetine (QL)
azelastine                               Clarinex                  paroxetine CR (QL)
cromolyn                                 Clarinex-D 12 Hour        paroxetine ER (QL)
cyproheptadine                           Gastrocrom                sertraline (QL)
desloratadine (QL)                       Grastek (PA, QL)          trazodone
epinephrine (QL)                         Karbinal ER               venlafaxine (QL)
fluticasone                              Odactra (PA, QL)          venlafaxine ER (QL)
hydroxyzine                              Patanase
                                                                                ASTHMA/COPD/RESPIRATORY
ipratropium                              Ragwitek (PA, QL)
mometasone (QL)                          Vistaril                  albuterol           Advair HFA          Adcirca* (PA)
olopatadine                                                        albuterol HFA       Anoro Ellipta       Adempas* (PA)
promethazine                                                       Alyq* (PA)          Atrovent HFA        Arcapta Neohaler
  solution, syrup,                                                 budesonide          Breo Ellipta        Brovana
  tablet                                                           fluticasone-        Combivent           Daliresp (QL)
                                                                     salmeterol         Respimat           Kalydeco* (PA, QL)
                   ALZHEIMER’S DISEASE
                                                                   montelukast         Dulera              Letairis* (PA)
donepezil             Namenda Titration Aricept                                        Flovent
                                                                   tadalafil 20mg*                         Lonhala Magnair
donepezil ODT          Pack              Exelon                                        Flovent HFA
                                                                     (PA)                                   (PA)
memantine                                Mestinon                                      Incruse Ellipta
                                                                   Wixela Inhub                            Nucala auto-
memantine ER (QL)                        Namenda tablet                                Ofev* (PA)
pyridostigmine                           Namenda XR (QL)                                                    injector, syringe*
                                                                                       Opsumit* (PA)
pyridostigmine ER                        Namzaric (QL)                                                      (PA)
                                                                                       ProAir HFA
rivastigmine                                                                                               Orenitram ER* (PA)
                                                                                       ProAir RespiClick
                                                                                                           Orkambi* (PA, QL)
    ANXIETY/DEPRESSION/BIPOLAR DISORDER                                                Pulmicort Flexhaler
                                                                                                           Perforomist (QL)
alprazolam                               Celexa (ST, QL)                               Pulmozyme* (PA)
                                                                                       QVAR RediHaler      Pulmicort Respule
alprazolam ER                            Effexor XR (ST, QL)                                               Revatio oral
alprazolam intensol                      Fetzima (ST, QL)                              Serevent
                                                                                       Symbicort            suspension,
alprazolam ODT                           Forfivo XL (ST, QL)                                                tablet* (PA)
alprazolam XR                            Paxil (ST, QL)                                Trelegy Ellipta
                                                                                       Ventolin HFA        Singulair
amitriptyline                            Paxil CR (ST, QL)                                                 Symdeko* (PA, QL)
                                                                                       Xolair* (PA)

                                                               6
Cigna Standard 3-Tier Prescription Drug List

TIER 1             TIER 2              TIER 3                   TIER 1                TIER 2              TIER 3
$                  $$                  $$$                      $                     $$                  $$$

      ASTHMA/COPD/RESPIRATORY (cont)                                BLOOD PRESSURE/HEART MEDICATIONS
                                    Tracleer tablet* (PA)       Adult Aspirin         Bystolic (ST, QL)   Adalat CC
                                    Tyvaso* (PA)                  Regimen+            Corlanor (PA)       Altace (ST)
                                    Uptravi* (PA)               amiodarone            Entresto            Atacand (ST)
       ATTENTION DEFICIT HYPERACTIVITY                          amlodipine            Multaq              Atacand HCT (ST)
                      DISORDER                                  amlodipine-           Tekturna HCT (QL)   Avalide (ST)
                                                                  benazepril                              Avapro (ST)
atomoxetine (QL)   Vyvanse (PA age, Adderall (PA age,           amlodipine-                               Azor (QL)
clonidine ER        QL)              ST)                          olmesartan (QL)                         Benicar (ST, QL)
dexmethylphenidate                  Adzenys ER (PA              amlodipine-                               Benicar HCT (ST,
 (PA age)                            age, QL)                     valsartan                                QL)
dexmethylphenidate                  Adzenys XR-ODT              amlodipine-                               BiDil (QL)
 ER (PA age, QL)                     (PA age, QL)
dextroamphetamine-                                                valsartan-hctz                          Calan SR
                                    Daytrana (PA age,           Aspir EC+                                 Cardizem LA (QL)
 amphetamine
 (PA age)                            QL)                        Aspir-Low+                                Cardura
dextroamphetamine-                  Dyanavel XR                 aspirin EC+                               Catapres-TTS 1
 amphetamine ER                      (PA age, QL)               aspirin 325mg                             Catapres-TTS 2
 (PA age, QL)                       Evekeo   ODT                  tablet+                                 Catapres-TTS 3
guanfacine ER                        (PA  age)                  atenolol                                  Coreg (ST)
metadate ER                         Focalin (PA age, ST)        Bayer Aspirin                             Coreg CR (ST, QL)
 (PA age, QL)                       Intuniv ER                    325mg tablet+                           Corgard (ST)
methylphenidate                     Kapvay                      benazepril                                Cozaar (ST)
 (PA age)                           Methylin (PA age)           benazepril-HCTZ                           Diovan (ST)
methylphenidate                     QuilliChew ER (PA           candesartan                               Diovan HCT (ST)
 CD (PA age, QL)                     age, QL)                   candesartan-HCTZ                          Edarbi (ST, QL)
methylphenidate                                                 cartia XT                                 Edarbyclor (ST)
                                    Quillivant XR (PA
 ER (PA age, QL)                                                carvedilol                                Epaned
methylphenidate                      age, QL)
                                    Ritalin (PA age, ST)        carvedilol ER (QL)                        Exforge
 ER (CD) (PA age,                                               Children’s Aspirin+                       Exforge HCT
 QL)                                Strattera (QL)
                                                                clonidine                                 Firazyr* (PA)
methylphenidate
                                                                diltiazem                                 Haegarda* (PA)
 ER (LA) (PA age,
                                                                diltiazem 12hr ER                         Hemangeol
 QL)
methylphenidate                                                 diltiazem 24hr ER                         Hyzaar (ST)
 LA (PA age, QL)                                                diltiazem 24hr ER                         Inderal LA (ST)
Relexxii (PA age,                                                 (CD)                                    Inderal XL (ST)
 QL)                                                            diltiazem 24hr ER                         InnoPran XL (ST)
                                                                  (LA)                                    Kapspargo Sprinkle
   BLOOD MODIFIERS/BLEEDING DISORDERS
                                                                diltiazem 24hr ER                          (ST)
aminocaproic acid* Amicar oral      Amicar tablet*                (XR)                                    Lopressor (ST)
tranexamic acid*    solution*       Hemlibra* (PA)              Dilt-XR                                   Lotensin (ST)
                   Aranesp*^ (PA)   Lysteda*                    dofetilide (QL)                           Lotensin HCT (ST)
                   Droxia           Neupogen*^ (PA)             doxazosin                                 Lotrel
                   Epogen*^ (PA)    Nivestym*^ (PA)             Ecotrin+                                  Micardis (ST, QL)
                   Fulphila*^ (PA)  Promacta* (PA)              Ecpirin+                                  Micardis HCT (ST,
                   Granix*^         Siklos (PA)                 enalapril                                  QL)
                   Neulasta*^ (PA)  Tavalisse* (PA)             flecainide                                Minipress
                   Procrit*^ (PA)                               hydralazine                               Nitrostat
                   Retacrit*^ (PA)                              irbesartan                                Northera* (PA)
                   Udenyca*^ (PA)                               irbesartan-HCTZ                           Norvasc
                   Zarxio*^                                     isosorbide                                Pacerone 100mg,
                                                                isosorbide ER                              400mg (PA)

                                                            7
Cigna Standard 3-Tier Prescription Drug List

TIER 1                TIER 2          TIER 3                 TIER 1               TIER 2            TIER 3
$                     $$              $$$                    $                    $$                $$$

BLOOD PRESSURE/HEART MEDICATIONS (cont)                          BLOOD THINNERS/ANTI-CLOTTING (cont)
labetalol                             Prinivil (ST)                                                 Savaysa (QL)
lisinopril                            Procardia                                                     Zontivity
lisinopril-HCTZ                       Procardia XL                                   CANCER
losartan                              Ranexa (QL)            abiraterone* (PA)    Actimmune* (PA)
                                                                                             Afinitor* (PA)
losartan-HCTZ                         Rythmol SR (PA)        anastrozole          Erivedge* (PA)
                                                                                             Afinitor Disperz* (PA)
Low Dose Aspirin                      Takhzyro* (PA)         capecitabine* (PA)   Gleostine  Alecensa* (PA)
  EC+                                 Tekturna (QL)          exemestane           Ibrance* (PA)
                                                                                             Bosulif* (PA)
Matzim LA                             Tenormin (ST)          imatinib* (PA)       Lupron Depot*^
                                                                                             Cabometyx* (PA)
metoprolol                            Tiazac ER              letrozole             (PA)      Cometriq* (PA)
nadolol                               Tikosyn (PA, QL)       mercaptopurine       Nexavar* (PA)
                                                                                             Erleada* (PA)
nifedipine                            Toprol XL (ST)         methotrexate         Revlimid* (PA)
                                                                                             Gleevec* (PA)
nifedipine ER                         Tribenzor              tamoxifen+           Sprycel* (PA)
                                                                                             Imbruvica* (PA)
olmesartan (QL)                       Vasotec (ST)           temozolomide*        Sutent* (PA)
                                                                                             Inlyta* (PA)
olmesartan-                           Verelan                 (PA)                Tasigna* (PA)
                                                                                             Jakafi* (PA)
  amlodipine-HCTZ                     Verelan PM                                  Trexall    Kisqali* (PA)
olmesartan-HCTZ                       Zestoretic (ST)                             Verzenio* (PA)
                                                                                             Lenvima* (PA)
  (QL)                                Zestril (ST)                                           Lonsurf* (PA)
Pacerone 200mg                                                                               Lynparza* (PA)
prazosin                                                                                     Mekinist* (PA)
propafenone                                                                                  Nerlynx* (PA)
propafenone ER                                                                               Ninlaro* (PA)
propranolol                                                                                  Odomzo* (PA)
  solution, tablet                                                                           Pomalyst* (PA)
propranolol ER                                                                               Purixan*
ramipril                                                                                     Rubraca* (PA)
ranolazine ER (QL)                                                                           Stivarga* (PA)
St. Joseph Aspirin+                                                                          Tafinlar* (PA)
Taztia XT                                                                                    Tagrisso* (PA)
telmisartan (QL)                                                                             Targretin capsule*
telmisartan-HCTZ                                                                              (PA)
  (QL)                                                                                       Temodar capsule*
valsartan                                                                                     (PA)
valsartan-HCTZ                                                                               Tykerb* (PA)
verapamil capsule,                                                                           Venclexta* (PA)
  tablet                                                                                     Votrient* (PA)
verapamil ER                                                                                 Xalkori* (PA)
verapamil ER PM                                                                              Xeloda* (PA)
verapamil SR                                                                                 Xtandi* (PA)
                                                                                             Zejula* (PA)
         BLOOD THINNERS/ANTI-CLOTTING                                    CHOLESTEROL MEDICATIONS
aspirin-              Brilinta        Aggrenox               amlodipine-        Repatha (PA) Caduet (QL)
 dipyridamole ER      Eliquis         Arixtra* (QL)           atorvastatin (QL) Vascepa (PA) Crestor (ST, QL)
clopidogrel           Fragmin* (QL)   Bevyxxa (QL)           atorvastatin 10mg,              Lipofen (ST)
enoxaparin* (QL)      Xarelto         Coumadin (PA)           20mg+                          Lovaza
fondaparinux* (QL)                    Effient                atorvastatin 40mg,              Niaspan ER
Jantoven                              Lovenox* (QL)           80mg                           Pravachol (ST)
prasugrel                             Plavix                 colesevelam                     TriCor (ST)
warfarin                              Pradaxa                ezetimibe                       Triglide (ST)

                                                         8
Cigna Standard 3-Tier Prescription Drug List

TIER 1            TIER 2            TIER 3              TIER 1                TIER 2   TIER 3
$                 $$                $$$                 $                     $$       $$$

         CHOLESTEROL MEDICATIONS (cont)                          CONTRACEPTION PRODUCTS (cont)
ezetimibe-                        Trilipix (ST)         Camrese+
  simvastatin                     Vytorin (ST)          Camrese Lo+
fenofibrate                       Welchol               Caya Contoured+
fenofibric acid                   Zetia                 Caziant+
fluvastatin+                      Zocor (ST, QL)        Chateal+
fluvastatin ER+                                         Chateal EQ+
lovastatin 10mg                                         Cryselle+
lovastatin 20mg,                                        Cyclafem+
  40mg+                                                 Cyred+
niacin                                                  Cyred EQ+
                                                        Dasetta+
niacin ER
                                                        Daysee+
Niacor
                                                        Deblitane+
omega-3 acid ethyl
                                                        Delyla+
  esters                                                desogestrel-ethinyl
pravastatin+                                             estradiol+
rosuvastatin 5mg,                                       desogestrel-ethinyl
  10mg+ (QL)                                             estradiol ethinyl
rosuvastatin 20mg,                                       estradiol
  40mg (QL)                                             dospirenone-
simvastatin 10mg,                                        ethinyl estradiol-
  20mg, 40mg+                                            levomefolate+
simvastatin 80mg                                        drospirenone-
  (QL)                                                   ethinyl estradiol+
              CONTRACEPTION PRODUCTS                    Econtra EZ+
                                                        Econtra One-Step+
Afirmelle  +
                   Lo Loestrin FE Annovera+
                                                        Elinest+
Aftera+            Taytulla       Balcoltra             eluryng vaginal
Altavera+                         Ella+                  ring+
Alyacen  +
                                  Estrostep FE          Emoquette+
Amethia+                          Layolis FE            Enpresse+
Amethia Lo   +
                                  Loestrin FE           Enskyce+
Amethyst+                         Minastrin 24 FE       Errin+
Apri+                             Natazia               Estarylla+
Aranelle+                         NuvaRing              ethynodiol-ethinyl
Ashlyna  +
                                  Safyral                estradiol+
Aubra+                            Skyla*                etonogestrel-EE
Aubra EQ+                         Today                  vaginal ring+
Aurovela 24 FE+                    Contraceptive        Falmina+
Aurovela FE  +
                                   Sponge+              Fayosim+
Aurovela  +
                                  Yasmin 28             FemCap+
Aviane+                           Yaz                   Femynor+
Ayuna+                                                  Gianvi+
Azurette+                                               Gynol II+
Balziva+                                                Hailey 24 FE+
Bekyree+                                                Heather+
Blisovi 24 FE+                                          Incassia+
                                                        Introvale+
Blisovi FE+
                                                        Isibloom+
Briellyn+
                                                        Jasmiel+
Camila+
                                                        Jencycla+

                                                    9
Cigna Standard 3-Tier Prescription Drug List

TIER 1                TIER 2   TIER 3         TIER 1               TIER 2   TIER 3
$                     $$       $$$            $                    $$       $$$

         CONTRACEPTION PRODUCTS (cont)                 CONTRACEPTION PRODUCTS (cont)
Jolessa
      +
                                              Norlyda  +

Juleber+                                      Norlyroc+
Junel+                                        Nortrel+
Junel FE+                                     Ocella+
Junel FE 24+                                  Option 2+
Kaitlib FE+                                   Orsythia+
Kalliga+                                      Philith+
Kariva+                                       Pimtrea+
Kelnor 1-35+                                  Pirmella+
Kelnor 1-50+                                  Portia+
Kurvelo+                                      Previfem+
Larin+                                        Reclipsen+
Larin FE+                                     Rivelsa tablet+
Larin FE 24+                                  Setlakin+
Larissia+                                     Sharobel+
Leena 28 tablet+                              Simliya+
Lessina+                                      Simpesse+
Levonest+                                     Sprintec+
levonorgestrel+                               Sronyx+
levonorgestrel-                               Syeda+
 ethinyl estradiol+                           Tarina FE+
levonorgestrel-                               Tarina FE 1-20 EQ+
 ethinyl estradiol-                           Tilia FE 28+
 ethinyl estradiol+                           Tri Femynor+
Levora-28+                                    Tri-Estarylla+
Lillow+                                       Tri-Legest FE+
Loryna+                                       Tri-Linyah+
Low-Ogestrel+                                 Tri-Lo-Estarylla+
Lo-Zumandimine+                               Tri-Lo-Marzia+
Lutera+                                       Tri-Lo-Mili+
Lyza+                                         Tri-Lo-Sprintec+
Marlissa+                                     Tri-Mili+
medroxyprogesterone                           Tri-Previfem+
 150mg/ml+                                    Tri-Sprintec+
Melodetta 24 FE+                              Trivora-28+
Mibelas 24 FE+                                Tri Vylibra+
Microgestin+                                  Tri Vylibra Lo+
Microgestin FE+                               Tulana+
Mili+                                         Tydemy+
Mono-Linyah+                                  VCF foam, gel+
My Choice+                                    Velivet+
My Way+                                       Vienva+
Necon+                                        Viorele+
Nikki+                                        Vyfemla+
Nora-BE+                                      Vylibra+
norethindrone+                                Wera+
norethindrone-                                Wide Seal
 ethinyl estradiol+                            Diaphragm+
norethindrone-                                Wymzya FE+
 ethinyl estradiol-                           Xulane+
 iron+                                        Zarah+
norgestimate-                                 Zovia+
 ethinyl estradiol+                           Zumandimine+

                                         10
Cigna Standard 3-Tier Prescription Drug List

TIER 1              TIER 2               TIER 3                    TIER 1                TIER 2                 TIER 3
$                   $$                   $$$                       $                     $$                     $$$
           COUGH/COLD MEDICATIONS                                                       DIABETES (cont)
Bromfed DM                             Tessalon Perle                                     QTERN (ST, QL)
brompheniramine-                       Tuzistra XR (PA, QL)                               Segluromet (ST, QL)
  pseudoephedrine-                                                                        Soliqua
  DM                                                                                      Steglatro (ST, QL)
hydrocodone-                                                                              SymlinPen
  chlorpheniramine                                                                        Synjardy (ST, QL)
  ER (PA)                                                                                 Synjardy XR (ST, QL)
                  DENTAL PRODUCTS
                                                                                          Tresiba (QL)
                                                                                          Trulicity (ST, QL)
chlorhexidine                          Floriva+^                                          V-Go
doxycycline 20mg                       Fluorabon+^                                        Victoza (ST, QL)
fluoride ^
         +
                                                                                          Xigduo XR (ST, QL)
Fluoritab+^                                                                               Xultophy
Flura-Drops+^                                                                                DIURETICS
Ludent+^
Oralone                                                            acetazolamide          Diuril               Aldactone
                                                                   acetazolamide ER       Dyrenium             Dyazide
Paroex
                                                                   bumetanide tablet                           Inspra
Peridex
                                                                   chlorthalidone                              Jynarque* (PA)
Periogard
                                                                   eplerenone                                  Lasix
sodium fluoride+^                                                  furosemide                                  Maxzide
triamcinolone                                                      hydrochlorothiazide                         Samsca*
  0.1% paste                                                       spironolactone
                        DIABETES                                   triamterene-HCTZ
glimepiride         Basaglar (QL)      Amaryl                                           EAR MEDICATIONS
glipizide           Bydureon (ST, QL) Cycloset                     neomycin-              Cipro HC             Coly-Mycin S
glipizide ER        Byetta (ST, QL)    Glucophage                    polymyxin-HC         Ciprodex             Cortisporin-TC
glipizide XL        Farxiga (ST, QL)   Glucophage XR               ofloxacin drops                             Dermotic
metformin           Freestyle Libre    Korlym* (PA)                                                            Otovel
metformin ER         Sensor (PA, QL)   Riomet                                       ERECTILE DYSFUNCTION
NovoTwist           GlucaGen HypoKit
pioglitazone         (QL)                                          sildenafil^ (PA age, Muse^ (PA, QL)         Cialis^ (PA age, ST,
                    Glucagon                                         QL)                                        QL)
                     Emergency Kit                                 tadalafil^ 2.5mg,                           Stendra^ (PA age,
                     (QL)                                            10mg, 20mg (PA                             ST, QL)
                                                                     age, QL)                                  Viagra^ (PA age,
                    Glyxambi (ST, QL)
                                                                   tadalafil^ 5mg (PA,                          ST, QL)
                    Humalog (QL)
                                                                     QL)
                    Humulin (QL)
                                                                   vardenafil^ (PA age,
                    Janumet (ST, QL)
                                                                     QL)
                    Janumet XR
                     (ST, QL)                                                            EYE CONDITIONS
                    Januvia (ST, QL)                               azelastine             Alphagan P 0.1%      Acuvail
                    Jardiance (ST, QL)                             brimonidine             drops               Alphagan P 0.15%
                    Kombiglyze XR (ST,                             ciprofloxacin          Azasite              Alrex
                     QL)                                           dorzolamide            Azopt                Bepreve
                    Levemir (QL)                                   dorzolamide-           Betimol              Besivance
                    OneTouch test                                    timolol              Betoptic S           Bromsite
                     strips                                        erythromycin           Combigan             Cequa
                    Onglyza (ST, QL)                               fluorometholone                             Cosopt
                                                                                          Lotemax drops, gel
                    Ozempic (ST, QL)                               gatifloxacin                                Cosopt PF

                                                              11
Cigna Standard 3-Tier Prescription Drug List

TIER 1             TIER 2         TIER 3                TIER 1                 TIER 2   TIER 3
$                  $$             $$$                   $                      $$       $$$

              EYE CONDITIONS (cont)                         GASTROINTESTINAL/HEARTBURN (cont)
latanoprost        Lumigan     Cystaran* (QL)           Ducodyl+                        Kristalose
moxifloxacin       Moxeza      Durezol                  esomeprazole                    Lomotil
neomycin-          Pazeo       Ilevro                    capsule (QL)                   MiraLax+
 polymyxin-        Restasis    Inveltys                 famotidine                      Motegrity
 dexamethasone     Simbrinza   Istalol                   suspension,                    Movantik (PA)
ofloxacin          Tobradex eyeLastacaft                 tablets                        Ocaliva* (PA)
polymyxin B-TMP     ointment   Lotemax ointment         GaviLax+
                                                                                        Pancreaze
prednisolone       Xiidra      Maxitrol                 GaviLyte-C+
                                                        GaviLyte-G+                     Pertzye
 solution                      Nevanac
                                                        GaviLyte-N+                     Prevacid DR (ST,
timolol solution               Ocuflox
                                                        GentleLax+                       QL)
tobramycin                     Oxervate* (PA)
tobramycin-                    Patanol                  GlycoLax+                       Protonix
 dexamethasone                 Polytrim                 HealthyLax+                      suspension, tablet
                               Pred Forte               Hemmorex-HC                      (ST, QL)
                               Prolensa                 hydrocortisone                  Ravicti* (PA)
                               Rhopressa                 suppository                    Rectiv
                               Timoptic                 lansoprazole (QL)               Relistor (PA)
                               Timoptic-XE              LaxaClear+                      Sancuso (PA, QL)
                               Tobradex drops           mesalamine                      Sensipar*
                                                        mesalamine DR
                               Tobradex ST                                              sfRowasa
                                                        metoclopramide
                               Travatan Z                                               Sucraid* (PA)
                                                         solution, tablet
                               Trusopt                                                  Symproic (PA)
                                                        metoclopramide
                               Vigamox                   ODT                            Transderm-Scop
                               Xalatan                  omeprazole (QL)                 Urso
                               Zioptan (ST, QL)         ondansetron                     Urso Forte
                               Zirgan                   ondansetron ODT                 Varubi (PA, QL)
                               Zylet                    pantoprazole tablet             Viberzi
                               Zymaxid                   (QL)                           Viokace
               FEMININE PRODUCTS                        PEG                             Xermelo* (PA)
Fem pH                         AVC                       3350-Electrolyte+
gynazole 1                                              PEG-Prep+
miconazole 3                                            Phenadoz
 suppository                                            polyethylene glycol
terconazole                                              3350+
                                                        prochlorperazine
         GASTROINTESTINAL/HEARTBURN                      suppository, tablet
Alophen  +
                  Amitiza       Aciphex (ST, QL)        promethazine
alosetron*        Apriso ER     Aciphex Sprinkle         solution, syrup,
Anucort-HC        Carafate       (QL)                    tablet
balsalazide        suspension   Akynzeo capsule         Promethegan
bisacodyl+        CLENPIQ+       (PA, QL)               QC Natura-Lax+
Bisa-Lax+         Creon         Bonjesta                rabeprazole (QL)
chlordiazepoxide- Dexilant (QL) Canasa                  ranitidine capsules,
 clidinium        Entyvio*^     Carafate tablet          tablets, syrup
cinacalcet*       Linzess       Cholbam* (PA)           SmoothLAX+
                  Lithostat                             sucralfate
ClearLax+                       Correctol+
                  Pentasa                               TriLyte With Flavor
dicyclomine                     Diclegis
                  Prepopik  +                            Packets+
diphenoxylate-                  Donnatal                ursodiol
                  SUPREP+
 atropine                       Dulcolax+               Women’s Gentle
                  Trulance
dronabinol                      Gattex* (PA)             Laxative+
                  Zenpep
                                                        Women’s Laxative+

                                                   12
Cigna Standard 3-Tier Prescription Drug List

TIER 1                 TIER 2              TIER 3                   TIER 1                 TIER 2                TIER 3
$                      $$                  $$$                      $                      $$                    $$$
                 HORMONAL AGENTS                                                            INFECTIONS
Amabelz                Androderm (PA,      Activella                acyclovir capsule,     Baraclude solution*   Albenza
budesonide EC           QL)                Alora (QL)                 suspension, tablet   Cipro suspension      Alinia
budesonide ER (PA,     Armour Thyroid      AndroGel (PA, QL)        albendazole            Cleocin 75mg          Arikayce* (PA)
  QL)                  Cetrotide*^ (PA)    Angeliq                  amoxicillin             capsule              Bactrim
cabergoline (QL)       Divigel             Climara                  amoxicillin-           Daraprim* (PA)        Bactrim DS
CovARYX                Duavee              Climara Pro                                     Firvanq               Baraclude tablet*
                                                                      clavulanate
CovARYX HS             Estring (QL)        CombiPatch                                      Kitabis Pak* (PA,      (QL)
                                                                    amoxicillin-            QL)                  Baxdela (PA)
Decadron               Euthyrox            Crinone^
desmopressin           Forteo* (PA, QL)    Cytomel                    clavulanate ER       Ledipasvir-           Cayston* (PA, QL)
  solution, spray,     Ganirelix*^ (PA)    Depo-Testosterone        atovaquone              Sofosbuvir* (PA)     Cipro tablet
  tablet               Humatrope* (PA)     Egrifta* (PA)            atovaquone-            Mavyret* (PA)         Cleocin
dexamethasone          Increlex* (PA)      Elestrin                   proguanil            Pegasys* (PA)         Clindesse
dexamethasone          Levo-T              Emflaza* (PA)            Avidoxy                Sofosbuvir-           Cresemba capsule
  intensol             Lupron Depot*^      Entocort EC              azithromycin            Velpatasvir* (PA)     (PA)
Dotti (QL)              (PA)               Estrace                  cefdinir               Sovaldi* (PA, QL)     Dificid (QL)
EEMT                   Lupron Depot-       EstroGel                                        Thalomid* (PA)        Elimite
                                                                    cefpodoxime
EEMT H.S.               PED*^ (PA)         Evamist                                         TOBI Podhaler* (PA,   EryPed 200
                                                                    cefuroxime              QL)                  Flagyl
estradiol (QL)         Medrol 2mg          Imvexxy (QL)             cephalexin
estradiol-             Norditropin         Intrarosa                                       Vibramycin syrup      Keflex
                                                                    ciprofloxacin          Vosevi* (PA)          Levaquin
  norethindrone         FlexPro* (PA)      Medrol 4mg, 8mg,
                                                                    clarithromycin         Xifaxan (QL)          Macrobid
estrogen-              Orilissa (PA, QL)    16mg, 32mg
  methyltestosterone   Premarin cream,     Menostar (QL)            clarithromycin ER                            Macrodantin
                                                                    clindamycin                                  Malarone (PA)
levothyroxine           tablet             Minivelle (QL)
                                                                    Coremino (QL)                                Monurol
Levoxyl                Premphase           Natpara* (PA)
                                                                    dapsone                                      Natroba
liothyronine           Prempro             Noctiva (PA)
                                                                                                                 Noxafil suspension,
Lopreeza               Sandostatin LAR     Osphena                  doxycycline
                                                                                                                  tablet
medroxy-                Depot*^ (PA)       Prometrium               Emverm                                       Nuvessa
  progesterone         Serostim* (PA)      Rayaldee                 entecavir* (QL)                              Nuzyra* (PA)
methimazole            Somavert* (PA)      Somatuline               erythromycin                                 Oravig
methylprednisolone     Synthroid            Depot*^ (PA)            famciclovir                                  Plaquenil (PA)
  dosepak, tablet      Unithroid           Striant (PA, QL)         fluconazole                                  Prevymis tablet*
Mimvey                 Zorbtive* (PA)      Tirosint                                                              Priftin
                                                                    hydroxychloroquine
Nature-Throid                              Vagifem (QL)                                                          Sivextro tablet (PA)
NP Thyroid                                 Vivelle-Dot (QL)         itraconazole
                                                                    levofloxacin                                 Sklice
prednisolone                                                                                                     Solosec
prednisolone ODT                                                      solution, tablet
                                                                                                                 Sulfatrim
prednisone                                                          metronidazole                                Suprax
prednisone                                                          minocycline                                  Tamiflu (QL)
  intensol                                                          minocycline ER                               Urogesic-Blue
progesterone                                                          (QL)                                       Valtrex
  capsule                                                           Mondoxyne NL                                 Vemlidy*
TaperDex                                                            Morgidox capsule                             Vfend suspension,
testosterone                                                        nitrofurantoin                                tablet (PA)
  (PA, QL)                                                                                                       Vibramycin
                                                                    nitrofurantoin
testosterone -                                                                                                    suspension
                                                                      mono-macro
  cypionate                                                                                                      Xofluza (QL)
thyroid                                                             nystatin
                                                                                                                 Zepatier* (PA)
Westhroid                                                           Okebo                                        Zithromax packet,
WP Thyroid                                                          oseltamivir (QL)                              suspension, tablet
Yuvafem (QL)                                                        penicillin V                                 Zyvox (PA)

                                                               13
Cigna Standard 3-Tier Prescription Drug List

TIER 1                 TIER 2           TIER 3                     TIER 1              TIER 2              TIER 3
$                      $$               $$$                        $                   $$                  $$$

                      INFECTIONS (cont)                                          NUTRITIONAL/DIETARY
permethrin                                                         calcitriol capsule, CitraNatal         Auryxia (QL)
sulfamethoxazole-                                                   solution           Drisdol            Fosrenol chew
 TMP suspension,                                                   calcium 667mg       Floriva+           K-Tab ER
 tablet                                                            cyanocobalamin      Fosrenol packet    Lokelma
terbinafine tablet                                                  injection          Klor-Con M15       Phoslyra
tetracycline                                                       Daily Prenatal+     Mephyton           Renvela
tobramycin                                                         FA-8+               MVC-Fluoride+      Velphoro
 ampule* (PA, QL)                                                  folic acid 1mg      OB Complete        Veltassa
valacyclovir
                                                                   folic acid 0.4mg,   Perry Prenatal+
                                                                                                          VitaPearl
valganciclovir
                                                                    0.8mg+             Prenate Mini
vancomycin
 capsule                                                           Klor-Con 8          Prenate Pixie
Vandazole                                                          Klor-Con 10         PrimaCare
voriconazole                                                       Klor-Con M10        Quflora Ped 1mg
 suspension, tablet                                                Klor-Con M20         chew, drops+
 (PA)                                                              lanthanum           Rocaltrol
                        INFERTILITY                                phytonadione        Tri-Vi-Flor+
                                                                    tablet
chorionic              Gonal-F*^ (PA)   Crinone 8%^                potassium chloride
 gonadotropin          Menopur*^ (PA)   Endometrin^
                                                                    capsule, packet,
 10,000 unit vial*^    Novarel*^ (PA)   Follistim AQ*^ (PA)
 (PA)                  Ovidrel*^ (PA)                               solution, tablet
clomiphene tablet^                                                 Prena1 Pearl
                                                                   Prenatal+
                      MISCELLANEOUS
                                                                   prenatal vitamin+
disulfiram             Cerdelga* (PA)
                                   Addyi^ (PA, QL)                 sevelamer
Nebusal 3%             Esbriet* (PA)
                                   Austedo* (PA)                   vitamin D2
PULMOSAL               Nityr* (PA) Brisdelle (QL)                  vitamin D3
sodium chloride        Strensiq* (PA)
                                   Exjade* (PA)
 inhalation vial                   Ferriprox* (PA)                                OSTEOPOROSIS PRODUCTS
TechLITE Lancets                   Galafold* (PA)                  alendronate (QL)    Tymlos* (PA, QL)   Actonel (ST)
tetrabenazine* (PA)                Ingrezza* (PA)                  calcitonin-salmon                      Atelvia (ST)
trientine* (PA)                    Jadenu* (PA)                    ibandronate tablet                     Binosto (ST)
                                   Jadenu Sprinkle*                raloxifene  +
                                                                                                          Boniva tablet (ST)
                                    (PA)                           risedronate                            Evista
                                   Kuvan* (PA)                     risedronate DR                         Fosamax (ST)
                                   Myalept* (PA)                                                          Fosamax Plus D (ST)
                                   Nuedexta (QL)
                                   Orfadin* (PA)                      PAIN RELIEF AND INFLAMMATORY DISEASE
                                   Palynziq* (PA)                  acetaminophen-      Actemra* (PA, QL) Analpram HC
                                   Tiglutik* (PA)                   codeine (PA)       Aimovig (PA)       Arava
                 MULTIPLE SCLEROSIS                                allopurinol         Ajovy (PA)         Arymo ER (PA)
glatiramer* (PA)   Ampyra* (PA)                                    aprizio pak         Belbuca (QL)       Benlysta* (PA)
Glatopa* (PA)      Avonex* (PA)                                    baclofen tablet     Cosentyx* (PA, QL) Butrans (QL)
                   Betaseron* (PA)                                 buprenorphine       Depen* (PA)        Celebrex (ST, QL)
                   Extavia* (PA)                                                                          Cimzia* (PA, QL)
                                                                    patch, tablet (QL) Emgality(PA)
                   Gilenya* (PA)                                                                          Colcrys
                                                                   butalbital-         Enbrel* (PA, QL)
                   Plegridy* (PA)                                                                         Diclofenac patch
                                                                    acetaminophen- Humira* (PA, QL)        (ST, QL)
                   Rebif* (PA)
                   Rebif Rebidose*                                  caffeine (QL)      Hysingla ER (PA)   Dupixent* (PA)
                    (PA)                                           carisoprodol        Morphabond ER      Duragesic (PA)
                   Tecfidera* (PA)                                 celecoxib (QL)       (PA)              EC-Naprosyn (ST)

                                                              14
Cigna Standard 3-Tier Prescription Drug List

TIER 1                  TIER 2                TIER 3                    TIER 1           TIER 2            TIER 3
$                       $$                    $$$                       $                $$                $$$
         PAIN RELIEF AND INFLAMMATORY                                            PAIN RELIEF AND INFLAMMATORY
                  DISEASE (cont)                                                          DISEASE (cont)
colchicine              Nucynta (PA)          Esgic (QL)                meloxicam
cyclobenzaprine         Otezla* (PA, QL)      Fexmid                    metaxalone
DermacinRx              Proctofoam-HC         Flector (ST, QL)          methocarbamol
  Empricaine            Rasuvo (PA)           Frova (QL)                 tablet
DermacinRx              Remicade*^ (PA)       Ilaris*^ (PA)             morphine solution,
  Prizopak              Savella               Ilumya* (PA, QL)           suppository, tablet
diclofenac (QL)         Simponi Aria* (PA)    Kadian (PA)
                                                                         (PA)
diclofenac ER           Stelara               Kevzara* (PA, QL)
                                                                        morphine ER (PA)
EC-naproxen              45mg/0.5ml,          Kineret* (PA, QL)
                         90mg/ml* (PA, QL)    Lidoderm                  nabumetone
eletriptan (QL)                                                         Nalfon 600mg (ST)
Endocet (PA)            Tremfya* (PA, QL)     Mitigare
                        Uloric (QL)           Mobic (ST)                Nalocet (PA)
etodolac
                        Xeljanz* (PA, QL)     MS Contin (PA)            naproxen
etodolac ER
                        Xeljanz XR* (PA,QL)   Nalfon 400 mg (ST)        oxycodone (PA)
fentanyl (PA)
                        Xtampza ER (PA)       Naprosyn (ST)             oxycodone ER (PA)
Fioricet (QL)
                        Ztlido                Norco (PA)                oxycodone-
frovatriptan (QL)                             Nucynta ER (PA)            acetaminophen
Glydo                                         Olumiant* (PA, QL)         (PA)
hydrocodone-                                  Orencia syringe*
  acetaminophen                                                         Prilolid
                                                (PA, QL)                Prilovix
  (PA)                                        Otrexup (PA)
hydromorphone                                                           Primlev (PA)
                                              Oxaydo (PA)
  solution,                                                             Relador Pak
                                              Percocet (PA)
  suppository, tablet                         Procort                   Relador Pak Plus
  (PA)                                        Qmiiz ODT (ST, QL)        rizatriptan (QL)
hydromorphone                                 Relpax (QL)               sumatriptan (QL)
  ER (PA)                                     Simponi* (PA, QL)         sumatriptan-
IBU                                           Skelaxin                   naproxen (QL)
ibuprofen 400mg,                              Taltz* (PA, QL)           tizanidine
  600mg, 800mg                                Tylenol-Codeine           tramadol (QL)
indomethacin                                    No.3 (PA)               tramadol ER (QL)
  capsule                                     Tylenol-Codeine           Vicodin HP (PA)
indomethacin ER                                 No.4 (PA)
                                                                                         PARKINSON’S DISEASE
ketorolac (QL)                                Ultram (QL)
                                              Voltaren (ST, QL)         benztropine          Apokyn* (PA) Azilect (QL)
leflunomide                                                             bromocriptine                     Duopa*
lidocaine (QL)                                Zanaflex
                                              Zebutal (QL)              carbidopa-                        Mirapex
lidocaine viscous                                                        levodopa                         Mirapex ER (QL)
lidocaine-prilocaine                          Zohydro ER (PA)
                                              Zyloprim                  carbidopa-                        Neupro
Lidopril                                                                 levodopa ER                      Osmolex ER (QL)
Lidopril XR                                                             pramipexole                       Parlodel
Lido-Prilo Caine                                                        pramipexole ER                    Rytary
  Pack                                                                   (QL)                             Sinemet
Livixil Pak                                                             rasagiline (QL)                   Sinemet CR
Lorcet (PA)                                                             ropinirole                        Tasmar
Lorcet HD (PA)                                                          ropinirole ER                     Xadago (ST)
Lorcet Plus (PA)
Lortab (PA)

                                                                   15
Cigna Standard 3-Tier Prescription Drug List

TIER 1                TIER 2                 TIER 3                    TIER 1             TIER 2              TIER 3
$                     $$                     $$$                       $                  $$                  $$$
         SCHIZOPHRENIA/ANTI-PSYCHOTICS                                              SKIN CONDITIONS (cont)
aripiprazole (QL)     Latuda (QL)            Fanapt (ST, QL)           betamethasone       Pramosone 1%-1%    Cordran 0.05%
aripiprazole ODT                             Invega (ST, QL)           BP 10-1              cream and 1%       cream, lotion,
chlorpromazine                               Rexulti (ST, QL)          calcipotriene        lotion, 1%-1%      ointment, tape
 tablet                                      Risperdal (ST)            calcipotriene-       ointment, 2.5%-    (ST)
olanzapine tablet                            Saphris (ST)                betamethasone      1% ointment       Dovonex
olanzapine ODT                               Seroquel (ST)               DP                Santyl (QL)        Ecoza
paliperidone ER                              Seroquel XR (ST)          Claravis (QL)       Soolantra          Efudex
 (QL)                                        Vraylar (ST, QL)          Clindacin ETZ                          Elidel
quetiapine                                                               pledget                              Evoclin
quetiapine ER                                                          Clindacin P pledget                    Finacea gel
risperidone                                                            clindamycin-                           Impoyz (ST)
risperidone ODT                                                          benzoyl peroxide                     Lotrisone
ziprasidone                                                            clindamycin                            MetroCream
                    SEIZURE DISORDERS                                    phosphate                            MetroGel
carbamazepine         Dilantin 30 mg         Aptiom (PA, QL)           clindamycin-                           MetroLotion
carbamazepine ER       capsule (PA)          Banzel (PA, QL)             tretinoin                            MiCort-HC 2.5%
clonazepam            Fycompa (PA, QL)       Briviact solution,        clobetasol                              cream (ST)
divalproex            Lyrica oral solution    tablet (PA)              Clodan shampoo                         Mimyx
divalproex ER         Vimpat solution,       Carbatrol (PA)            clotrimazole-                          Naftin cream
Epitol                 tablet (PA)           Depakote (PA)               betamethasone                        Nizoral
gabapentin                                   Depakote ER (PA)          dapsone                                Olux (ST)
lamotrigine                                  Depakote Sprinkle         desoximetasone                         Picato
lamotrigine (blue,                            (PA)                     diflorasone                            Pramosone 2.5%-
 green, orange)                              Dilantin 50mg,            fluocinonide                            1% cream, lotion
lamotrigine ER                                100mg (PA)               fluorouracil cream,                    Protopic
lamotrigine ODT                              Epidiolex* (PA)             topical solution                     Regranex (PA, QL)
levetiracetam                                Klonopin (PA)             flurandrenolide                        Sorilux
 solution, tablet                            Neurontin (PA)            hydrocortisone                         Targretin gel*
levetiracetam ER                             Onfi (PA)                 isotretinoin (QL)                      Temovate (ST)
oxcarbazepine                                Oxtellar XR (PA)          ketoconazole                           Tolak
Roweepra                                     Phenytek (PA)             metronidazole                          Topicort (ST)
Roweepra XR                                  Tegretol (PA)             Micort HC 2.5%                         Valchlor*
subvenite                                    Tegretol XR (PA)            cream                                Xepi
subvenite (Blue,                                                       mupirocin                              Xolegel
 Green, Orange)                                                        Myorisan (QL)
topiramate                                                             Neuac gel
topiramate ER                                                          Nolix
vigabatrin*                                                            oxiconazole
Vigadrone*                                                             pimecrolimus
                                                                       Procto-Med HC
                     SKIN CONDITIONS                                   Procto-Pak
adapalene (PA age)    Cordran 0.025%         Bryhali (ST)              Proctosol-HC
adapalene-benzoyl      cream                 Celacyn                   Proctozone-HC
 peroxide             Drysol                 Centany                   Psorcon
Amnesteem (QL)        Eucrisa                Cleocin T                 Rosadan
Avar                  Finacea foam           Cloderm (ST)              sodium
Avar-E                Fluoroplex             Condylox
Avar-E Green                                                             sulfacetamide-
                      Naftin gel                                         sulfur
azelaic acid

                                                                  16
Cigna Standard 3-Tier Prescription Drug List

TIER 1             TIER 2              TIER 3                  TIER 1                 TIER 2                 TIER 3
$                  $$                  $$$                     $                      $$                     $$$

             SKIN CONDITIONS (cont)                                        URINARY TRACT CONDITIONS
SSS 10-5                                                       cevimeline             Cystagon*              Avodart
Sulfacleanse 8-4                                               darifenacin ER (QL)    Elmiron                Evoxac
tacrolimus                                                     finasteride 5mg        Thiola*                Flomax
 ointment                                                      oxybutynin                                    Procysbi* (PA)
tazarotene                                                     oxybutynin ER                                 Proscar
tretinoin (PA age)                                             phenazopyridine                               Pyridium
tretinoin                                                      potassium ER                                  Rapaflo (QL)
 microsphere (PA
                                                               silodosin (QL)                                Urocit-K
 age)
triamcinolone                                                  solifenacin (QL)
triderm                                                        tamsulosin
Zenatane (QL)                                                  tolterodine
            SLEEP DISORDERS/SEDATIVES
                                                               tolterodine ER (QL)
                                                               trospium
armodafinil (PA)     Belsomra (ST)    Hetlioz* (PA)            trospium ER
eszopiclone          Silenor (ST, QL) Lunesta (ST)
                                                                                           VACCINES
modafinil (PA)                        Rozerem (ST, QL)
temazepam                             Xyrem* (PA)              For plans renewing on 2/1/20 and later: On your plan's renewal
zolpidem                                                       date, vaccines will be covered under the pharmacy benefit.
                                                               Not all plans will cover vaccines in the same way. Log in to the
zolpidem ER (QL)
                                                               myCigna app or website, or check your plan materials, to find out
                  SMOKING CESSATION                            how your specific plan covers them.
bupropion SR   +
                     Chantix^         NicoDerm CQ              Diphtheria and         ActHIB+             FluMist Quad
NicoDerm CQ          Nicotrol^         7mg/24hr,                Tetanus Toxoids-      Adacel Tdap+         Nasal+
 21mg/24hr   +
                     Nicotrol NS^      14mg/24hr+               ped+                  Afluria Quad +
                                                                                                          Rotarix+
Nicorelief+
                                      Nicorette+               TdVax+                 BEXSERO   +
                                                                                                          RotaTeq+
nicotine gum   +
                                                                                      Boostrix Tdap+
nicotine lozenge+                                                                     DAPTACEL DTaP+
nicotine patch+                                                                       Engerix-B+
Quit 2+                                                                               FLUAD+
Quit 4+                                                                               FLUARIX
                   SUBSTANCE ABUSE                                                     QUADRIVALENT+
                                                                                      FLUBLOK
buprenorphine-       Bunavail         Suboxone                                         QUADRIVALENT+
 naloxone            Lucemyra (QL)                                                    FLUCELVAX
                     NARCAN (QL)                                                       QUADRIVALENT+
                     Zubsolv                                                          FLUALVAL
              TRANSPLANT MEDICATIONS                                                   QUADRIVALENT+
azathioprine tablet*                  Astagraf XL*                                    Fluzone High-
mycophenolate                         Cellcept capsule,                                dose+
 capsule,                              suspension,                                    Fluzone
 suspension, tablet*                   tablet*                                         Quadrivalent Pedi+
                                      Envarsus  XR*                                   Fluzone
mycophenolic acid*
                                      Myfortic*                                        Quadrivalent+
sirolimus*
                                      Prograf capsule,                                GARDASIL 9+
tacrolimus capsule*
                                       packet*                                        HAVRIX+
                                      Rapamune*                                       HEPLISAV-B+
                                      Zortress*                                       Hiberix+
                                                                                      Infanrix DTaP+
                                                                                      IPOL+
                                                                                      KINRIX+

                                                          17
Cigna Standard 3-Tier Prescription Drug List

TIER 1                 TIER 2                 TIER 3
$                      $$                     $$$

                        VACCINES (cont)
For plans renewing on 2/1/20 and later: On your plan's renewal
date, vaccines will be covered under the pharmacy benefit.
Not all plans will cover vaccines in the same way. Log in to the
myCigna app or website, or check your plan materials, to find out
how your specific plan covers them.
                Menactra+
                Menveo A-C-Y-W-
                 135-DIP+
                M-M-R II+
                PEDIARIX+
                PedvaxHIB+
                Pentacel+
                PNEUMOVAX 23+
                Prevnar 13+
                ProQuad+
                Quadracel DTaP-
                 IPV+
                Recombivax HB+
                SHINGRIX+
                Tenivac+
                Trumenba+
                Twinrix+
                VAQTA+
                VARIVAX+
                ZOSTAVAX+
             WEIGHT MANAGEMENT
Lomaira^                        Belviq^ (PA)
phentermine^                    Belviq XR^ (PA)
                                Contrave^ (PA)
                                Qsymia^ (PA)
                                Saxenda^ (PA)

                                                                    18
Medications that are not covered
The medications listed below aren’t covered on your plan’s drug list.^^ This means that if you fill a
prescription for any of these medications, you’ll pay its full cost out-of-pocket. Your plan covers other
medications that are used to treat the same condition.^^ They’re listed below.

                                                                             MEDICATIONS THAT ARE                                        GENERIC AND/OR PREFERRED
                       DRUG CLASS
                                                                                NOT COVERED^^                                              BRAND ALTERNATIVE(S)
 AIDS/HIV                                                           Combivir*                                                        lamivudine-zidovudine*
                                                                    Epivir*                                                          lamivudine*
                                                                    Epzicom*                                                         abacavir-lamivudine*
                                                                    Kaletra solution*                                                lopinavir-ritonavir solution*
                                                                    Lexiva tablet*                                                   fosamprenavir*
                                                                    Norvir tablet*                                                   ritonavir*
                                                                    Retrovir capsule, syrup*                                         zidovudine capsule, syrup*
                                                                    Reyataz capsule*                                                 atazanavir*
                                                                    Sustiva*                                                         efavirenz*
                                                                    Trizivir*                                                        abacavir-lamivudine-zidovudine*
                                                                    Viramune*                                                        nevirapine*
                                                                    Viramune XR*                                                     nevirapine ER*
                                                                    Ziagen*                                                          abacavir*
 ALLERGY/NASAL SPRAYS                                               Auvi-Q                                                           epinephrine auto-injectors
                                                                    EpiPen, EpiPen Jr
                                                                    Beconase AQ                                                      Generic nasal steroids (e.g. fluticasone)
                                                                    Dymista
                                                                    Nasonex
                                                                    Omnaris
                                                                    QNASL
                                                                    Zetonna
                                                                    QNASL Children’s                                                 budesonide
                                                                                                                                     fluticasone
                                                                                                                                     triamcinolone
                                                                    RyVent                                                           carbinoxamine 4mg tablet
                                                                    carbinoxamine 6mg tablet
 ANXIETY/DEPRESSION/BIPOLAR                                         Anafranil                                                        clomipramine
                                                                    Aplenzin                                                         bupropion XL
                                                                    Wellbutrin XL
                                                                    Ativan tablet                                                    lorazepam
                                                                    Cymbalta                                                         duloxetine
                                                                    Lexapro                                                          escitalopram
                                                                    Pamelor                                                          nortriptyline capsules
                                                                    Parnate                                                          tranylcypromine
                                                                    Pexeva                                                           paroxetine/CR/ER
                                                                    Tofranil                                                         imipramine tablet
^^
     T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
      coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.

                                                                                                 19
MEDICATIONS THAT ARE                                        GENERIC AND/OR PREFERRED
                       DRUG CLASS
                                                                                NOT COVERED^^                                              BRAND ALTERNATIVE(S)
 ASTHMA/COPD/RESPIRATORY                                            Advair Diskus                                                    Advair HFA
                                                                    AirDuo RespiClick                                                Breo Ellipta
                                                                                                                                     Dulera
                                                                                                                                     fluticasone-salmeterol
                                                                                                                                     Symbicort
                                                                                                                                     Wixela Inhub
                                                                    Alvesco                                                          Flovent
                                                                    Arnuity Ellipta                                                  QVAR RediHaler
                                                                    Asmanex                                                          Pulmicort Flexhaler
                                                                    Asmanex HFA
                                                                    Bevespi Aerosphere                                               Anoro Ellipta
                                                                    Stiolto Respimat
                                                                    Utibron Neohaler
                                                                    Elixophyllin                                                     theophylline oral solution
                                                                    Proventil HFA                                                    ProAir
                                                                    Xopenex HFA                                                      Ventolin HFA
                                                                    Seebri Neohaler                                                  Incruse Ellipta
                                                                    Spiriva
                                                                    Spiriva Respimat
                                                                    Tudorza Pressair
                                                                    Striverdi Respimat                                               Serevent Diskus
                                                                    Yupelri                                                          Anoro Ellipta
                                                                                                                                     Incruse Ellipta
                                                                                                                                     Trelegy Ellipta
                                                                    Zyflo                                                            montelukast
                                                                                                                                     zafirlukast
                                                                                                                                     zileuton ER
 ATTENTION DEFICIT HYPERACTIVITY                                    Adderall XR                                                      dexmethylphenidate ER
                                                                    Adhansia XR                                                      dextroamphetamine-amphetamine ER
                                                                    Aptensio XR                                                      methylphenidate ER/CD/LA
                                                                    Concerta                                                         Vyvanse
                                                                    Cotempla XR-ODT
                                                                    Mydayis
                                                                    Focalin XR
                                                                    Ritalin LA
                                                                    Desoxyn                                                          methamphetamine
                                                                    Dexedrine                                                        dextroamphetamine
 BLOOD PRESSURE/HEART MEDICATIONS                                   Betapace                                                         sotalol oral
                                                                    Cardizem                                                         diltiazem
                                                                    Cardizem CD                                                      diltiazem CD
                                                                    Firazyr*                                                         icatibant
                                                                    Isordil                                                          isosorbide dinitrate
                                                                    Isordil Titradose                                                isosorbide dinitrate
                                                                                                                                     digoxin
 BLOOD THINNERS/ANTI-CLOTTING                                       Yosprala                                                         aspirin or enteric aspirin
 CANCER                                                             Nilandron                                                        nilutamide
                                                                    Tarceva*                                                         erlotinib*
                                                                    Yonsa*                                                           abiraterone*
                                                                    Zytiga*
^^
     T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
      coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.

                                                                                                 20
MEDICATIONS THAT ARE                                        GENERIC AND/OR PREFERRED
                       DRUG CLASS
                                                                                NOT COVERED^^                                              BRAND ALTERNATIVE(S)
 CHOLESTEROL MEDICATIONS                                            Antara                                                           fenofibrate
                                                                    Fenoglide
                                                                    Ezallor Sprinkle                                                 atorvastatin
                                                                    Livalo                                                           lovastatin
                                                                    Zypitamag                                                        pravastatin
                                                                                                                                     rosuvastatin
                                                                                                                                     simvastatin
                                                                    Lipitor                                                          atorvastatin
                                                                    Praluent Pen                                                     Repatha
 COUGH/COLD MEDICATIONS                                             benzonatate 150mg                                                benzonatate 100mg, 200mg
                                                                    TussiCaps                                                        hydrocodone-chlorpheniramine ER
                                                                                                                                     promethazine with codeine syrup
 DIABETES                                                           Accu-Chek Aviva Plus test strips                                 One Touch test strips (e.g. Ultra; Verio)
                                                                    Accu-Chek Guide test strips
                                                                    Accu-Chek Smartview
                                                                    Accutrend glucose

                                                                    Adlyxin                                                          Byetta
                                                                                                                                     Bydureon
                                                                                                                                     Ozempic
                                                                                                                                     Trulicity
                                                                                                                                     Victoza
                                                                    Ademelog                                                         Humalog
                                                                    Afrezza                                                          Humulin
                                                                    Apidra
                                                                    Apidra SoloStar
                                                                    Fiasp
                                                                    Novolin, Novolog
                                                                    alogliptin                                                       Janumet
                                                                                                                                     Janumet XR
                                                                                                                                     Januvia
                                                                                                                                     Kombiglyze XR
                                                                                                                                     metformin
                                                                                                                                     Onglyza
                                                                    alogliptin-metformin                                             Janumet
                                                                                                                                     Janumet XR
                                                                                                                                     Januvia
                                                                                                                                     Kombiglyze XR
                                                                                                                                     metformin
                                                                                                                                     Onglyza
                                                                    alogliptin-pioglitazone                                          Janumet
                                                                                                                                     Janumet XR
                                                                                                                                     Januvia
                                                                                                                                     Kombiglyze XR
                                                                                                                                     Onglyza
                                                                                                                                     pioglitazone
^^
     T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
      coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.

                                                                                                 21
MEDICATIONS THAT ARE                                        GENERIC AND/OR PREFERRED
                       DRUG CLASS
                                                                                NOT COVERED^^                                              BRAND ALTERNATIVE(S)
 DIABETES (cont)                                                    Fortamet                                                         metformin ER (generic to Glucophage XR)
                                                                    Glumetza
                                                                    metformin ER (generic to Fortamet and
                                                                    Glumetza)
                                                                    Invokamet                                                        Segluromet
                                                                    Invokamet XR                                                     Synjardy
                                                                                                                                     Synjardy XR
                                                                                                                                     Xigduo XR
                                                                    Invokana                                                         Farxiga
                                                                                                                                     Jardiance
                                                                                                                                     metformin
                                                                                                                                     Steglatro

                                                                    Jentadueto                                                       Janumet
                                                                    Jentadueto XR                                                    Janumet XR
                                                                    Kazano                                                           Kombiglyze XR
                                                                    Lantus                                                           Basaglar
                                                                    Toujeo SoloStar                                                  Levemir vial or Levemir Flextouch
                                                                                                                                     Tresiba FlexTouch
                                                                    Nesina                                                           Januvia
                                                                    Tradjenta                                                        Janumet
                                                                                                                                     Janumet XR
                                                                                                                                     Kombiglyze XR
                                                                                                                                     metformin
                                                                                                                                     Onglyza

                                                                    Oseni                                                            Generic TZDs (e.g. pioglitazone)
                                                                                                                                     Janumet
                                                                                                                                     Janumet XR
                                                                                                                                     Januvia
                                                                                                                                     Kombiglyze XR
                                                                                                                                     Onglyza
                                                                    Steglujan                                                        Glyxambi
                                                                                                                                     metformin
                                                                                                                                     QTERN

 DIURETICS                                                          Edecrin                                                          bumetanide
                                                                    ethacrynic acid                                                  furosemide
                                                                                                                                     torsemide
 EYE CONDITIONS                                                     Vyzulta                                                          bimatoprost
                                                                                                                                     latanoprost
                                                                                                                                     Lumigan
                                                                                                                                     Travatan Z
 GASTROINTESTINAL/HEARTBURN                                         Anusol HC suppository                                            hydrocortisone suppository
                                                                    Asacol HD                                                        Apriso
                                                                    Colazal                                                          balsalazide
                                                                    Delzicol                                                         mesalamine tablets or capsules
                                                                    Dipentum                                                         Pentasa
                                                                                                                                     sulfasalazine
^^
     T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
      coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.

                                                                                                 22
MEDICATIONS THAT ARE                                        GENERIC AND/OR PREFERRED
                       DRUG CLASS
                                                                                NOT COVERED^^                                              BRAND ALTERNATIVE(S)
 GASTROINTESTINAL/HEARTBURN (cont)                                  CoLyte with Flavor Packets+                                      Clenpiq+
                                                                    GoLytely+                                                        GaviLyte-C+
                                                                    MoviPrep+                                                        GaviLyte-G+
                                                                    NuLYTELY with flavor packs+                                      GaviLyte-N+
                                                                    OsmoPrep+                                                        3550 Electrolyte+
                                                                    Plenvu+                                                          Prepopik+
                                                                                                                                     SuPrep+
                                                                    Cortifoam                                                        Prescription hydrocortisone enema, rectal
                                                                    Uceris foam                                                      cream, suppository
                                                                    Librax                                                           chlordiazepoxide-clidinium
                                                                    Marinol                                                          dronabinol
                                                                    Syndros
                                                                    Nexium capsule                                                   esomeprazole
                                                                    Omeclamox-Pak                                                    lansoprazole-amoxicillin-clarithromycin
                                                                    Pylera                                                           (combo pack)
                                                                    OmePPI                                                           omeprazole
                                                                    Zegerid packet, 40mg capsule
                                                                    Pepcid                                                           famotodine
                                                                    Prevacid SoluTab                                                 Generic prescription PPIs (e.g. lansopra-
                                                                                                                                     zole)
                                                                    Rowasa                                                           mesalamine rectal enema suspension
                                                                    Zofran                                                           ondansetron
                                                                    Zuplenz                                                          ondansetron
                                                                                                                                     ondansetron ODT
 HORMONAL AGENTS                                                    Cortrosyn                                                        cosyntropin
                                                                    DDAVP                                                            desmopressin
                                                                    Dxevo                                                            dexamethasone
                                                                    Fortesta                                                         AndgroGel
                                                                    Natesto                                                          testosterone
                                                                    Testim
                                                                    Vogelxo
                                                                    Xyosted
                                                                    Genotropin*                                                      Humatrope* (PA)
                                                                    Nutropin AQ nuspin*
                                                                    Omnitrope*
                                                                    Saizen*
                                                                    Saizen-Saizenprep*
                                                                    Zomacton*
                                                                    Nocdurna                                                         desompression acetate nasal spray or
                                                                                                                                     tablets
                                                                    Rayos                                                            prednisone
                                                                    Uceris tablets                                                   budesonide tablet
                                                                                                                                     dexamethasone
                                                                                                                                     hydrocortisone
                                                                                                                                     methylprednisolone
                                                                                                                                     prednisolone
                                                                                                                                     prednisone
^^
     T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
      coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.
                                                                                                 23
MEDICATIONS THAT ARE                                        GENERIC AND/OR PREFERRED
                       DRUG CLASS
                                                                                NOT COVERED^^                                              BRAND ALTERNATIVE(S)
 INFECTIONS                                                         Acticlate                                                        Generic products (e.g. doxycycline; mino-
                                                                    Doryx                                                            cycline)
                                                                    Doryx MPC
                                                                    Minocin capsule
                                                                    Minolira ER
                                                                    Oracea
                                                                    Seysara
                                                                    Solodyn
                                                                    Targadox
                                                                    Vibramycin
                                                                    Ximino
                                                                    Arakoda                                                          atovaquone-proguanil
                                                                                                                                     doxycycline
                                                                                                                                     hydroxychloroquine
                                                                                                                                     quinine
                                                                    Augmentin/ES                                                     amoxicillin-clavulanate
                                                                    Bethkis*                                                         tobramycin inhalation solution*
                                                                    Tobi
                                                                    Diflucan                                                         fluconazole
                                                                    E.E.S. 200                                                       erythromycin granules
                                                                    Epclusa*                                                         sofosbuvir-velpatasvir*
                                                                    Eryped 400                                                       erythromycin ethylsuccinate
                                                                    Harvoni*                                                         ledipasvir-sofosbuvir*
                                                                    Mepron                                                           atovaquone
                                                                    Mycobutin                                                        rifabutin
                                                                    Sitavig                                                          acyclovir tablet
                                                                                                                                     famciclovir tablet
                                                                                                                                     valacyclovir tablet
                                                                    Sporanox                                                         itraconazole oral
                                                                    Tolsura
                                                                    Valcycte                                                         valganciclovir
                                                                    Vancocin                                                         vancomycin oral capsule
                                                                    Zovirax                                                          acyclovir
 MISCELLANEOUS                                                      Horizant                                                         gabapentin
                                                                    Syprine*                                                         Depen*
                                                                                                                                     penicillamine*
                                                                                                                                     trientine*
                                                                    Xenazine*                                                        tetrabenazine*
 MULTIPLE SCLEROSIS                                                 Aubagio*                                                         Gilenya*
                                                                                                                                     Mayzent*
                                                                                                                                     Tecfidera*
                                                                    Copaxone*                                                        Avonex*
                                                                                                                                     Betaseron*
                                                                                                                                     Extavia*
                                                                                                                                     Gilenya*
                                                                                                                                     glatiramer*
                                                                                                                                     Glatopa*
                                                                                                                                     Plegridy*
                                                                                                                                     Rebif*
                                                                                                                                     Tecfidera*
^^
     T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
      coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.

                                                                                                 24
MEDICATIONS THAT ARE                                        GENERIC AND/OR PREFERRED
                       DRUG CLASS
                                                                                NOT COVERED^^                                              BRAND ALTERNATIVE(S)
 NUTRITIONAL/DIETARY                                                Azesco                                                           Any generic prenatal vitamin
                                                                    Nascobal                                                         cyanocobalamin injection
 PAIN RELIEF AND INFLAMMATORY                                       Allzital                                                         butalbital-acetaminophen tablets
                                                                                                                                     butalbital-acetaminophen-caffeine cap-
                                                                                                                                     sules and tablets
                                                                    Amrix                                                            cyclobenzaprine
                                                                                                                                     Other generic muscle relaxants
                                                                    Bupap                                                            butalbital-acetaminophen tablets
                                                                    Cambia                                                           Generic prescription NSAID (e.g.celecoxib,
                                                                    Duexis                                                           meloxicam)
                                                                    Ergomar
                                                                    Fenortho
                                                                    Indocin
                                                                    Naprelan
                                                                    Treximet
                                                                    Vimovo
                                                                    Zipsor
                                                                    ConZip                                                           Tramadol
                                                                                                                                     Tramadol ER
                                                                    Cuprimine*                                                       Depen*
                                                                                                                                     penicillamine*
                                                                                                                                     trientine*
                                                                    D.H.E. 45                                                        dihydroergotamine injection
                                                                    Gloperba                                                         colchicine, probenecid-colchicine
                                                                    Gralise                                                          gabapentin
                                                                    Imitrex                                                          sumatriptan
                                                                    Zembrace Symtouch
                                                                    levorphanol                                                      codeine with acetaminophen
                                                                                                                                     Embeda
                                                                                                                                     hydrocodone with acetaminophen
                                                                                                                                     Hysingla
                                                                                                                                     oxycodone with acetaminophen
                                                                                                                                     Tramadol
                                                                                                                                     Xtampza ER
                                                                    Lido-Sorb                                                        lidocaine cream, ointment
                                                                    Lidozion
                                                                    Lorzone                                                          chlorzoxazone 500mg
                                                                    Migranal                                                         dihydroergotamine nasal spray
                                                                    ONZETRA Xsail                                                    Generic triptans (e.g. nasal sumatriptan;
                                                                                                                                     naratriptan tablet)
                                                                    Oxycontin                                                        Embeda ER (PA)
                                                                                                                                     Hysingla ER (PA)
                                                                                                                                     Xtampza ER
                                                                    Pennsaid                                                         diclofenac 1% gel
                                                                    Roxicodone                                                       oxycodone
                                                                    Siliq*                                                           Cosentyx*
                                                                                                                                     Enbrel*
                                                                                                                                     Humira*
                                                                                                                                     Stelara*
^^
     T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
      coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.
                                                                                                 25
MEDICATIONS THAT ARE                                        GENERIC AND/OR PREFERRED
                       DRUG CLASS
                                                                                NOT COVERED^^                                              BRAND ALTERNATIVE(S)
 PAIN RELIEF AND INFLAMMATORY (cont)                                Soriatane                                                        acitretin
                                                                    Sprix                                                            ketorolac tablet
                                                                    SUBSYS                                                           fentanyl lozenge or buccal tablet
                                                                    Tivorbex                                                         indomethacin
                                                                    Vanatol LQ                                                       butalbital-acetaminophen-caffeine
                                                                    Vanatol S
                                                                    Vivlodex                                                         meloxicam
                                                                    Zomig                                                            sumatriptan
                                                                                                                                     zolmitriptan
                                                                    Zomig ZMT                                                        zolmitriptan ODT
                                                                    Zorvolex                                                         diclofenac
 PARKINSON’S DISEASE                                                Gocovri                                                          amantadine
                                                                    Lodosyn                                                          carbidopa
                                                                    Requip XL                                                        ropinirole extended release
                                                                    Zelapar                                                          selegiline tablets or capsules
 SCHIZOPHRENIA/ANTI-PSYCHOTICS                                      Abilify                                                          aripiprazole
                                                                    Abilify MyCite
                                                                    FazaClo                                                          clozapine
                                                                    Versacloz                                                        clozapine ODT
                                                                    Geodon capsule                                                   ziprasidone
                                                                    Zyprexa                                                          olanzapine
                                                                    Zyprexa Zydis                                                    olanzapine ODT
 SEIZURE DISORDERS                                                  Felbatol                                                         felbamate
                                                                    Keppra oral solution, tablet                                     levetiracetam
                                                                    Keppra XR                                                        levetiracetam ER
                                                                    Lamictal                                                         lamotrigine
                                                                    Lamictal (blue, green, orange)                                   lamotrigine (blue, green, orange)
                                                                    Lamictal ODT                                                     lamotrigine ODT
                                                                    Lamictal ODT (blue, green, orange)                               lamotrigine ODT (blue, green, orange)
                                                                    Lamictal XR                                                      lamotrigine ER
                                                                    Lamictal XR (blue, green, orange)                                lamotrigine ER (blue, green, orange)
                                                                    Lyrica CR                                                        duloxetine
                                                                                                                                     gabapentin
                                                                                                                                     lidocaine 5% patch
                                                                                                                                     Lyrica
                                                                    Mysoline                                                         primidone
                                                                    Qudexy XR                                                        topiramate ER
                                                                    Sabril*                                                          vigabatrin*
                                                                    Sympazan                                                         clobazam
                                                                    Topamax                                                          topiramate
                                                                    Zonegran                                                         zonisamide
^^
     T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
      coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.

                                                                                                 26
MEDICATIONS THAT ARE                                        GENERIC AND/OR PREFERRED
                       DRUG CLASS
                                                                                NOT COVERED^^                                              BRAND ALTERNATIVE(S)
 SKIN CONDITIONS                                                    Absorica                                                         Myorisan or Zenatane
                                                                    Acanya                                                           Use generic products (e.g. adapalene;
                                                                    Aczone                                                           tretinoin; clindamycin-benzoyl peroxide)
                                                                    Aktipak
                                                                    Altreno
                                                                    Amzeeq
                                                                    Atralin
                                                                    Avita
                                                                    Azelex
                                                                    Differin
                                                                    Duac
                                                                    Epiduo
                                                                    Epiduo Forte
                                                                    Fabior
                                                                    Onexton
                                                                    Retin-A
                                                                    Retin-A Micro
                                                                    Tazorac
                                                                    Veltin
                                                                    Ziana
                                                                    Aldara                                                           imiquimod 5% cream
                                                                    Zyclara
                                                                    Anusol-HC cream                                                  hydrocortisone cream
                                                                    Bensal HP                                                        salicylic acid 6% cream, cream kit, gel, lotion
                                                                    Benzaclin                                                        clindamycin-benzoyl peroxide
                                                                    Neuac Kit
                                                                    Carac                                                            fluorouracil 0.5% cream
                                                                    Clindagel                                                        clindamycin gel, topical solution
                                                                    Cutivate lotion                                                  fluticasone topical lotion
                                                                    Denavir                                                          acyclovir tablet
                                                                    Zovirax cream, ointment                                          famciclovir tablet
                                                                                                                                     valacyclovir tablet
                                                                    diclofenac 3% gel                                                Fluoroplex
                                                                                                                                     imiquimod 5% cream
                                                                                                                                     Picato
                                                                                                                                     topical fluorouracil
                                                                    Duobrii                                                          halobetasol plus
                                                                                                                                     tazarotene cream
                                                                    Enstilar                                                         calcipotriene
                                                                    Taclonex                                                         calcipotriene-betamethasone DP
                                                                                                                                     tazarotene cream
                                                                                                                                     topical betamethasone
                                                                    Ertaczo                                                          ketoconazole cream
                                                                    Exelderm                                                         topical econazole
                                                                                                                                     topical ketoconazole
                                                                                                                                     topical oxiconazole
                                                                    Extina                                                           ketoconazole cream, foam
^^
     T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
      coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.

                                                                                                 27
MEDICATIONS THAT ARE                                        GENERIC AND/OR PREFERRED
                       DRUG CLASS
                                                                                NOT COVERED^^                                              BRAND ALTERNATIVE(S)
 SKIN CONDITIONS (cont)                                             HALOG                                                            clobetasol cream, ointment
                                                                                                                                     halobetasol cream, ointment
                                                                    Jublia                                                           ciclopirox topical solution
                                                                    Kerydin                                                          itraconazole capsules
                                                                                                                                     terbinafine tablets
                                                                    Kenalog spray                                                    triamcinolone acetonide aerosol spray
                                                                    Lexette                                                          clobetasol cream, ointment
                                                                                                                                     halobetasol cream, foam, ointment
                                                                    Locoid                                                           hydrocortisone cream, lipid cream, oint-
                                                                                                                                     ment, solution
                                                                    Locoid Lipocream                                                 hydrocortisone lipid cream
                                                                    Loprox                                                           ciclopirox cream, shampoo
                                                                    Luzu                                                             econazole
                                                                                                                                     ketoconazole cream
                                                                                                                                     luliconazole
                                                                                                                                     oxiconazole
                                                                    Noritate                                                         metronidazole cream
                                                                    Oxistat                                                          etoconazole cream
                                                                    Penlac                                                           ciclopirox solution
                                                                    Prudoxin                                                         Generic topical steroid (e.g. topical tacro-
                                                                    Zonalon                                                          limus)
                                                                    Sernivo                                                          clobetasol spray
                                                                                                                                     triamcinolone acetonide aerosol spray
                                                                    Trianex                                                          triamcinolone cream, ointment
                                                                    Ultravate                                                        clobetasol lotion
                                                                    Vanos                                                            fluocinonide 0.1% cream
                                                                    Verdeso                                                          desonide cream, ointment
                                                                    Xerese                                                           acyclovir tablet
                                                                                                                                     famciclovir tablet
                                                                                                                                     hydrocortisone prescription cream
                                                                                                                                     valacyclovir tablet
 SLEEP DISORDERS/SEDATIVES                                          Ambien                                                           zolpidem
                                                                    Ambien CR                                                        zolpidem ER
                                                                    Ativan                                                           lorazepam
                                                                    Edluar                                                           zolpidem/ER
                                                                    Intermezzo
                                                                    Nuvigil                                                          armodafinil
                                                                    Provigil                                                         modafinil
                                                                    Restoril                                                         temazepam
                                                                    Zolpimist                                                        Belsomra
                                                                                                                                     eszopiclone
                                                                                                                                     Silenor
                                                                                                                                     zaleplon
                                                                                                                                     zolpidem/ER
 SUBSTANCE ABUSE                                                    Evzio                                                            narcan nasal spray
^^
     T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
      coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.
                                                                                                 28
MEDICATIONS THAT ARE                                        GENERIC AND/OR PREFERRED
                       DRUG CLASS
                                                                                NOT COVERED^^                                              BRAND ALTERNATIVE(S)
 URINARY TRACT CONDITIONS                                           Detrol                                                           tolterodine
                                                                    Detrol LA                                                        tolterodine ER
                                                                    Ditropan XL                                                      oxybutynin ER
                                                                    Enablex                                                          darifenacin ER
                                                                    Gelnique                                                         darifenacin ER
                                                                    Myrbetriq                                                        oxybutynin ER
                                                                    Toviaz                                                           tolterodine ER
                                                                    VESIcare                                                         trospium ER

^^
     T hese medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving
      coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy.

                                                                                                 29
Prescription drug list FAQs

Understanding your prescription medication            Your plan may also exclude certain medications
coverage can be confusing. Below are answers          or products from coverage. This is known as a
to some commonly asked questions.                     “plan (or benefit) exclusion.” For example, your
                                                      plan excludes medications that aren’t approved
Why do you make changes to the drug list?
                                                      by the U.S. Food and Drug Administration (FDA).
Cigna regularly reviews and updates the
                                                      How do you decide which medications
prescription drug list. We make changes for
                                                      are covered?
many reasons – like when new medications
become available or are no longer available, or       The Cigna Prescription Drug List is developed
when medication prices change. We try to give         with the help of Cigna’s Pharmacy and
you many options to choose from to treat your         Therapeutics (P&T) Committee, which is a group
health condition. These changes may include:1,2       of practicing doctors and pharmacists, most of
›   Moving a medication to a lower cost tier. This    whom work outside of Cigna. The group meets
    can happen at any time during the year.           regularly to review medical evidence and
                                                      information provided by federal agencies, drug
›   Moving a brand medication to a higher cost
                                                      manufacturers, medical professional associations,
    tier when a generic becomes available. This
                                                      national organizations and peer-reviewed
    can happen at any time during the year.
                                                      journals medications about the safety and
›   Moving a medication to a higher cost tier and/    effectiveness of medications that are newly
    or no longer covering a medication. This          approved by the FDA and medications
    typically happens twice a year on January 1st     already on the market. The Cigna Pharmacy
    and July 1st.                                     Management® Business Decision Team then looks
›   Adding coverage requirements to a medication.     at the results of the P&T Committee’s clinical
    For example, requiring approval from Cigna        review, as well as the medication’s overall value
    before a medication may be covered or adding      and other factors before adding it to, or
    a quantity limit to a medication.                 removing it from, the drug list.
When a medication changes tiers or is no longer
                                                      Which medications are covered under the
covered, you may pay a different amount to fill
                                                      health care reform law?
that medication. It’s important to know that
when we make a change that affects the                The Patient Protection and Affordable Care Act
coverage of a medication you’re taking, we let        (PPACA), commonly referred to as “health care
you know before it begins so you have time to         reform,” was signed into law on March 23, 2010.
talk with your doctor.                                Under this law, certain preventive medications
                                                      (including some over-the-counter medicines)
Why doesn’t my plan cover certain                     may be available to you at no cost-share ($0),
medications?                                          depending on your plan. Log in to the myCigna
To help lower your overall health care costs,         app or website, or check your plan materials, to
your plan doesn’t cover certain high-cost brand       learn more about how your plan covers
medications because they have lower-cost,             preventive medications. You can also view the
covered alternatives which are used to treat the      PPACA No Cost-Share Preventive Medications
same condition. Meaning, the alternative works        drug list on Cigna.com/druglist.
the same or similar to the non-covered
                                                      For more information about health care reform,
medication. If you’re taking a medication that
                                                      visit www.informedonreform.com or Cigna.com.
your plan doesn’t cover and your doctor feels
an alternative isn’t right for you, he or she can
ask Cigna to consider approving coverage of
your medication.

                                                     30
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