NAW Prescription Drug List : simplebooklet.com

3TIER 1$TIER 2$$BLOOD PRESSURE/HEART MEDICATIONSafeditab CRamlodipine besylateamlodipine besylate-benazeprilamlodipine-valsartanamlodipine-valsartan-HCTZatenololatenolol-chlorthalidonebenazepril benazepril-HCTZcandesartan cilexetilcartia XTcarvedilolclonidinedigitekdigoxdigoxindiltiazem ERdiltiazem CDdiltiazem dilt-XRenalapril flecainide acetatehydralazine irbesartanisosorbide mononitratBERINERT* (PA)BIDILBYSTOLICCINRYZE* (PA)COREG CRCOZAAR (ST)DIOVAN (ST)DIOVAN HCT (ST)EDARBI (ST)EDARBYCLOR (ST)EXFORGEEXFORGE HCTFIRAZYR* (PA)HEMANGEOLINDERAL LAINDERAL XLINNOPRAN XLLOTRELMICARDIS (ST)MULTAQNITRO-DURNITROLINGUALNITROMISTNITRONALNITROSTATNORTHERA* (PA)NORVASCRANEXA (ST)TEKTURNATEKTURNA HCTMedications are grouped by the condition they treatMedications that have extra coverage requirements have an abbreviation listed next to themMedications are listed in alphabetical order within each columnBrand-name medications are in all capital lettersGeneric medications are in all lowercase lettersSpecialty medications have an asterisk (*) listed next to them Tier (cost-share level) gives you an idea of how much you may pay for a medication3This chart is just a sample. It may not show how these medications are actually covered on the Cigna Advantage 3-Tier Prescription Drug List.About this drug listThis is a list of the most commonly prescribed medications covered on the Cigna Advantage 3-Tier Prescription Drug List as of January 1, 2023.3,4 Medications are listed by the condition they treat, then listed alphabetically within tiers (or cost-share levels). The drug list is updated often so it isn’t a complete list of the medications your plan covers. Also, your speciﬁc plan may not cover all of these medications. Log in to the myCigna App or myCigna.com, or check your plan materials, to see all of the medications your plan covers.Prescription medications used to treat allergies (ex. Allegra, Clarinex, Xyzal and generics) and heartburn/stomach acid conditions (ex. Nexium, Prilosec and generics) aren’t covered on this drug list. These medications are considered plan (or beneﬁt) exclusions. You can get over-the-counter (OTC) versions at the pharmacy without a prescription. How to read this drug listUse the chart below to help you read this drug list. This chart is just an example. It may not show how these medications are actually covered on the Cigna Advantage 3-Tier Prescription Drug List.

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4Tiers 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 medicationsIn this drug list, medications that have limits and/or extra coverage requirements have an abbreviation listed next to them.* Here’s what they mean.(PA) Prior Authorization – Certain medications need approval from Cigna before your plan will cover them. These medications have a (PA) next to them. Your plan won’t cover these medications unless your doctor requests, and receives, approval from Cigna.(QL) Quantity Limits – Some medications have a quantity limit. This means your plan will only cover up to a certain amount over a certain length of time. These medications have a (QL) next to them. Your plan will only cover a larger amount if your doctor requests, and receives, approval from Cigna.(ST) Step Therapy – Certain high-cost medications aren’t covered until you try one or more lower-cost alternatives ﬁrst.** These medications have a (ST) next to them. You have many covered options to choose from, and they’re used to treat the same condition. (AGE) Age Requirements – Certain medications will only be covered if you’re within a speciﬁc age range. These medications have (AGE) next to them. If you’re not within the allowed age range, your plan will only cover the medication if your doctor requests, and receives, approval from Cigna.* These coverage requirements may not apply to your speciﬁc plan. Log in to the myCigna App or myCigna.com, or check your plan materials, to ﬁnd out if your plan includes prior authorization, quantity limits, Step Therapy, and/or age requirements.** If your doctor feels an alternative isn’t right for you, he or she can ask Cigna to consider approving coverage of your medication.Brand-name medications are in all capital lettersIn this drug list, generic medications are listed in all lowercase letters and brand-name medications are listed in all capital letters. Specialty medications have an asterisk next to themSpecialty medications are used to treat complex medical conditions. Some plans may limit coverage to a 30-day supply and/or require you to use a preferred specialty pharmacy to receive coverage. In this drug list, specialty medications have an asterisk (*) next to them.

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5Condition PageAIDS/HIV 6ALLERGY/NASAL SPRAYS 6ALZHEIMER’S DISEASE 6ANXIETY/DEPRESSION/BIPOLAR DISORDER6ASTHMA/COPD/RESPIRATORY 6, 7ATTENTION DEFICIT HYPERACTIVITY DISORDER7BLOOD MODIFIERS/BLEEDING DISORDERS 7BLOOD PRESSURE/HEART MEDICATIONS 7, 8BLOOD THINNERS/ANTI-CLOTTING 8CANCER 8CHOLESTEROL MEDICATIONS 8CONTRACEPTION PRODUCTS 8, 10COUGH/COLD MEDICATIONS 10DENTAL PRODUCTS 10,DIABETES 11DIURETICS 11EAR MEDICATIONS 11EYE CONDITIONS 12FEMININE PRODUCTS 12Condition PageGASTROINTESTINAL/HEARTBURN 12HORMONAL AGENTS 13INFECTIONS 13INFERTILITY 14MISCELLANEOUS 14MULTIPLE SCLEROSIS 14NUTRITIONAL/DIETARY 14, 15OSTEOPOROSIS PRODUCTS 15PAIN RELIEF AND INFLAMMATORY DISEASE 15PARKINSON’S DISEASE 15SCHIZOPHRENIA/ANTI-PSYCHOTICS 15SEIZURE DISORDERS 15,16,SKIN CONDITIONS 16SLEEP DISORDERS/SEDATIVES 16SMOKING CESSATION 16SUBSTANCE ABUSE 16TRANSPLANT MEDICATIONS 16,17URINARY TRACT CONDITIONS 17VACCINES 18No cost-share preventive medications have a plus sign next to themHealth care reform under the Patient Protection and Aordable Care Act (PPACA) requires plans to cover certain preventive medications and products at 100%, or no cost-share ($0), to you. In this drug list, these medications have a plus sign (+) next to them. Some plans may cover certain non-covered medicationsPlans can choose to oer coverage of certain medications/products and/or drug classes that aren’t typically covered. In this drug list, these medications/products have a caret (^) next to them. Log in to the myCigna App or myCigna.com to see if your plan covers them. How to ﬁnd your medicationFirst, look for your condition in the alphabetical list below. Then, go to that page to see the covered medications available to treat the condition.

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6TIER 1$TIER 2$$TIER 3 $$$AIDS/HIVabacavir-lamivudine* (PA)efavirenz-emtricitabine-tenofovir* (QL)emtricitabine-tenofovir disop*+etravirine*ritonavir*tenofovir* (PA)BIKTARVY* (QL)DESCOVY*+ (PA)DOVATO* (QL)GENVOYA* (QL)ISENTRESS HD* (PA)ISENTRESS*JULUCA* (QL)PREZISTA*SYMTUZA* (QL)TIVICAY PD*TIVICAY*TRIUMEQ*(QL)TRIUMEQ PD* (QL)APRETUDE*+ (PA)CABENUVA* (PA)CIMDUO* (PA)COMPLERA* (PA,QL)ODEFSEY* (PA,QL)PIFELTRO* (PA)PREZCOBIX* (PA)STRIBILD* (PA,QL)TEMIXYS* (PA)ALLERGY/NASAL SPRAYSazelastine azelastine-ﬂuticasonecromolyn oral concentratedesloratadine^ (QL)epinephrine (QL)ﬂuticasone^hydroxyzine hcl solution, syrup, tablethydroxyzine pamoateipratropium levocetirizine^mometasone^ (QL)olopatadine promethazine solution, syrup, tabletEPINEPHRINE PROFESSIONALGASTROCROMGRASTEK (PA, QL)KARBINAL ERODACTRA (PA, QL)ORALAIR (PA, QL)PATANASERAGWITEK (PA, QL)regonolVISTARILALZHEIMER’S DISEASEdonepezil donepezil odtmemantine memantine er (QL)pyridostigmine 60 mg/5 ml, 60 mgpyridostigmine errivastigmineARICEPTEXELONMESTINONNAMENDANAMENDA XR (QL)NAMZARIC (QL)ANXIETY/DEPRESSION/BIPOLAR DISORDER5alprazolamalprazolam eralprazolam intensolalprazolam odtalprazolam xramitriptyline CELEXA (QL, ST)DESVENLAFAXINE ER (QL, ST)EFFEXOR XR (QL, ST)EMSAM (QL)TIER 1$TIER 2$$TIER 3 $$$ANXIETY/DEPRESSION/BIPOLAR DISORDER5 (cont)bupropion (QL)bupropion sr (QL)bupropion xl 150 mg tablet (QL)bupropion xl 300 mg tablet (QL)buspirone citalopram (QL)clomipramine duloxetine (QL)escitalopram (QL)ﬂuoxetine dr (QL)ﬂuoxetine (QL)ﬂuvoxamine (QL)ﬂuvoxamine er (QL)lorazepamlorazepam intensolmirtazapineparoxetine cr (QL)paroxetine er (QL)paroxetine (QL)sertraline (QL)trazodone venlafaxine (QL)venlafaxine er (QL)FETZIMA (QL, ST)PAXIL (QL, ST)PAXIL CR (QL, ST)NUPLAZID* (PA)PROZAC (QL, ST)REMERONSPRAVATO* (PA)TRINTELLIX (QL, ST)VIIBRYD (QL, ST)WELLBUTRIN SR (QL, ST)XANAXXANAX XRZOLOFT (QL, ST)ASTHMA/COPD/RESPIRATORYalbuterol albuterol hfa (QL)alyq* (PA)ambrisentan* (PA)budesonide (QL)ﬂuticasone-salmeterol (QL)ipratropium-albuterolmontelukast tadalaﬁl* (PA)treprostinil* (PA)wixela inhub (QL)albuterol albuterol hfa (QL)alyq* (PA)ambrisentan* (PA)budesonide (QL)ﬂuticasone-salmeterol (QL)ipratropium-albuterolmontelukast tadalaﬁl* (PA)ADEMPAS* (PA)ANORO ELLIPTA(QL)ATROVENT HFA (QL)BREZTRI AEROSPHERE (QL)DULERA (QL)FASENRA* (PA)FLOVENT DISKUS (QL)FLOVENT HFA (QL)INCRUSE ELLIPTANUCALA* (PA)OFEV* (PA)OPSUMIT* (PA)QVAR REDIHALERSEREVENT DISKUS (QL)SPIRIVA (QL)SPIRIVA RESPIMAT (QL)STIOLTO RESPIMAT (QL)SYMBICORT (QL)ADCIRCA* (PA)AIRDUO DIGIHALER (ST,QL)ARALAST NP* (PA)BRONCHITOL* (PA)COMBIVENT RESPIMAT (QL)DALIRESP (QL)GLASSIA* (PA)KALYDECO* (PA,QL)LETAIRIS* (PA)LONHALA MAGNAIR (PA,QL)ORENITRAM ER* (PA)ORKAMBI* (PA, QL)PROLASTIN C* (PA)PULMICORT RESPULE (QL)PULMOZYME* (PA)REVATIO 10 MG/ML, 20 MG* (PA)SINGULAIRTEZSPIRE* (PA)Cigna Advantage 3-Tier Prescription Drug List

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7TIER 1$TIER 2$$TIER 3 $$$ASTHMA/COPD/RESPIRATORY (cont)treprostinil* (PA)wixela inhub (QL)TRACLEER 32 MG TABLET FOR SUSPENSION* (PA)TRELEGY ELLIPTAUPTRAVI* (PA)XOLAIR* (PA)TRIKAFTA* (PA, QL)UPTRAVI 1800MCG VIAL* (PA)ATTENTION DEFICIT HYPERACTIVITY DISORDER5amphetamine (PA)atomoxetine (QL)dexmethylp- henidate (PA,QL)dexmethylp- henidate er (PA, QL)dextroamp hetamin-e -amphetamine (PA,QL)dextroamp- hetamine-amphet er (PA, QL)guanfacine er (QL)methylphenidate er (la) (PA, QL)methylphenidate er (PA, QL)methylphenidate cd (PA, QL)methylphenidate er (cd) (PA, QL)methylphenidate la (PA, QL)procentra (PA, (QL))ADDERALL (PA,ST,QL)DAYTRANA (PA, QL)FOCALIN (PA,ST,QL)INTUNIV (QL)METHYLIN(PA, (QL))QUILLIVANT XR (PA, QL)RITALIN (PA,ST, QL))STRATTERA (QL)ZENZEDI (PA,ST,QL)BLOOD MODIFIERS/BLEEDING DISORDERSaminocaproic acid 0.25 gram/ml, 500 mg, 1,000 mg*tranexamic acid 650 mg*ADYNOVATE* (PA)AFSTYLA (PA)ARANESP* (PA)DROXIAELOCTATE* (PA)EMPAVELI* (PA)EPOGEN* (PA)ESPEROCT* (PA)JIVI* (PA)KOGENATE FS* (QL)KOVALTRY* (QL)NEULASTA* (PA)NIVESTYM* (PA)NOVOEIGHT* (PA)NYVEPRIA* (PA)PROCRIT* (PA)RETACRIT* (PA)ZARXIO* (ZIEXTENZO* (PA)ADVATE* (PA)CABLIVI* (PA)CYKLOKAPRON*DOPTELET* (PA)FULPHILA* (PA)GRANIX* (PA)HEMLIBRA* (PA)LYSTEDA*NEUPOGEN* (PA)PROMACTA* (PA)SIKLOS (PA)TAVALISSE* (PA)UDENYCA* (PA)TIER 1$TIER 2$$TIER 3 $$$BLOOD PRESSURE/HEART MEDICATIONSamlodipine amlodipine-benazeprilamlodipine-olmesartan (QL)amlodipine-valsartanatenololbenazepril bisoprololbisoprolol-hctzcandesartan cartia xtcarvedilolcarvedilol er (QL)clonidinediltiazem 12hr erdiltiazem 24hr erdiltiazem 24hr er (cd)diltiazem 24hr er (la)diltiazem 24hr er (xr)diltiazemDILT-XR dofetilide (QL)droxidopa*enalapril ﬂecainide guanfacinehydralazine tableticatibant* (PA)irbesartanlabetalol tabletlisinoprillisinopril-hctzlosartan losartan-hctzmatzim lametoprolol succinatemetoprolol tabletnadololnebivolol (QL)nifedipinenifedipine erolmesartan (QL)olmesartan-amlodipine-hctzolmesartan-hctz (QL)prazosinCORLANOR (PA)ENTRESTO (QL)BERINERT* (PA)BIDIL (QL)CALAN SRCARDIZEM LA 120MG QLCATAPRES-TTS 1CATAPRES-TTS 2CATAPRES-TTS 3CINRYZE* (PA)COREG (ST)CORGARD (ST)EPANEDHAEGARDA* (PA)HEMANGEOLINDERAL LA (ST)INDERAL XL (ST)INNOPRAN XL (ST)ISOSORBIDE DINIT-HYDRALAZINE (QL)KALBITOR* (PA)KAPSPARGO SPRINKLE (ST)KATERZIA (QL)LOPRESSOR (ST)MINIPRESSNITROSTATNORTHERA* (PA)NORVASCORLADEYO* (PA, QL)PROCARDIA XLRANEXA (QL)RUCONEST* (PA)TAKHZYRO* (PA)TENORETIC 50 (ST)TENORETIC 100 (ST)TENORMIN (ST)TIAZACTIKOSYN (PA, QL)TOPROL XL (ST)VERELANVERELAN PMZIAC (ST)Cigna Advantage 3-Tier Prescription Drug List

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8TIER 1$TIER 2$$TIER 3 $$$BLOOD PRESSURE/HEART MEDICATIONS (cont)prazosin propranolol tabletpropranolol erprazosinpropranolol tabletpropranolol erramiprilranolazine er (QL)sajazir* (PA)taztia xttelmisartan (QL)telmisartan-hctz (QL)tiadylt ervalsartanvalsartan-hctzverapamil erverapamil er pmverapamil tabletverapamil srBLOOD THINNERS/ANTI-CLOTTINGclopidogrelenoxaparin* (QL)jantovenprasugrelwarfarin BRILINTAELIQUIS (PA)XARELTO (PA)BAYER CHEWABLE ASPIRIN+EFFIENTFRAGMIN* (QL)LOVENOX* (QL)PLAVIXPRADAXA (PA)ZONTIVITYCANCERabiraterone* (PA)anastrozole+bexarotene* (PA)capecitabine* (PA)everolimus* (PA,QL)exemestane+imatinib* (QL)letrozolemethotrexatetamoxifen+temozolomide* (PA)ALECENSA* (PA,QL)CABOMETYX* (PA)CALQUENCE* (PA)ERIVEDGE* (PA)ERLEADA* (PA)GLEOSTINEIBRANCE* (PA,QL)IMBRUVICA* (PA,QL)KANJINTI* (PA)LYNPARZA* (PA,QL)MVASI* (PA)NUBEQA* (PA)REVLIMID* (PA,QL)RIABNI* (PA)RUBRACA* (PA,QL)RUXIENCE* (PA)SPRYCEL* (PA,QL)TRAZIMERA* (PA)TREXALLVERZENIO* (PA)AFINITOR DISPERZ* (PA)AFINITOR* (PA)ALUNBRIG* (PA,QL)AYVAKIT* (PA, QL)BOSULIF* (PA,QL)BRAFTOVI* (PA)BRUKINSA* (PA,QL)COMETRIQ* (PA)ELIGARD*EXKIVITY* (PA)GLEEVEC* (PA)ICLUSIG* (PA,QL)INLYTA* (PA)JAKAFI* (PA,QL)KISQALI* (PA)KISQALI FEMARA CO-PACK* (PA)LENVIMA* (PA)LONSURF* (PA)LORBRENA* (PA,QL)TIER 1$TIER 2$$TIER 3 $$$CANCER (cont)XTANDI* (PA)ZIRABEV* (PA)LUMAKRAS* (PA, QL)MEKINIST* (PA,QLMEKTOVI* (PA,QL)NERLYNX* (PA)NINLARO* (PA,QL)ODOMZO* (PA)OGIVRI* (PA)ONTRUZANT* (PA)ORGOVYX* (PA)POMALYST* (PA,QL)ROZLYTREK* (PA)STIVARGA* (PA,QL)TAFINLAR* (PA,QL)TAGRISSO* (PA)TALZENNA* (PA,QL)TARGRETIN* (PA)TASIGNA* (PA,QL)TEMODAR CAPSULE* PATUKYSA* (PA)VENCLEXTA STARTING PACK* (PA)SUTENT* (PA,QL)VENCLEXTA* (PA)VITRAKVI* (PA)VIZIMPRO* (PA)XALKORI* (PA,QL)XELODA* (PA)XOSPATA* (PA)ZEJULA* (PA,QLCHOLESTEROL MEDICATIONSatorvastatin+colesevelam ezetimibefenoﬁbratefenoﬁbric acidﬂuvastatin er+ﬂuvastatin+icosapent ethyllovastatin+omega-3 acid ethyl esterspravastatin+rosuvastatin+ (QL)simvastatin tablet+ (QL)REPATHA (PA)VASCEPA (PA)CADUET (QL)LIPOFEN (ST)ROSZETTRICOR (ST)TRILIPIX (ST)WELCHOLZETIACONTRACEPTION PRODUCTSAFIRMELLE+ALTAVERA+LO LOESTRIN FE ANNOVERABEYAZCigna Advantage 3-Tier Prescription Drug List

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9TIER 1$TIER 2$$TIER 3 $$$CONTRACEPTION PRODUCTS (cont)AFIRMELLE+ALTAVERA+ALYACEN+AMETHIA+AMETHYST+APRI+ARANELLE+ASHLYNA+AUBRA+AUBRA EQ+AUROVELA FE+AUROVELA 24 FE+AVIANE+AYUNA+AZURETTE+BALZIVA+BLISOVI FE+BLISOVI 24 FE+BRIELLYN+CAMILA+CAMRESE+CAMRESE LO+CAYA CONTOURED+LO LOESTRIN FE ANNOVERABEYAZCAYA CONTOURED+ELLA+FEMCAP+KYLEENA*+LAYOLIS FE+LILETTA*+LOESTRIN FEMICROGESTIN 24 FEMINASTRIN 24 FEMIRENA*+NEXPLANON*+NEXTSTELLISNUVARINGPARAGARD T 380-A*+SAFYRALSKYLA*+TWIRLA+wide seal diaphragm+YASMIN 28CAZIANT+CHARLOTTE 24 FE+CHATEAL+CHATEAL EQ+CRYSELLE+CYCLAFEM+CYRED+CYRED EQ+DASETTA+DAYSEE+DEBLITANE+desogestrel-ethinyl estradiol+desogestrel-ethinyl estradiol - ethinyl estradiol+DOLISHALE+drospirenone-ethinyl estradiol-levomefolate+drospirenone-ethinyl estradiol+ELINEST+ELURYNG+ENPRESSE+ENSKYCE+ERRIN+ESTARYLLA+YAZTIER 1$TIER 2$$TIER 3 $$$CONTRACEPTION PRODUCTS (cont)ethynodiol-ethinyl estradiol+etonogestrel-ethinyl estradiol+FALMINA+FEMYNOR+GEMMILY+HAILEY+HAILEY FE+HAILEY 24 FE+HEATHER+ICLEVIA+INCASSIA+ISIBLOOM+JAIMIESS+JASMIEL+JENCYCLA+JOLESSA+JULEBER+JUNEL+JUNEL FE+JUNEL FE 24+KAITLIB FE+KALLIGA+KARIVA+KELNOR 1-35+KELNOR 1-50+KURVELO+LARIN+LARIN FE+LARIN 24 FE+LARISSIA+LEENA+LESSINA+LEVONEST+levonorgestrel-ethinyl estradiol+levonorgestrel-ethinyl estradiol ethinyl estradiol+LEVORA+LILLOW+LOJAIMIESS+LORYNA+LOW-OGESTREL+LO-ZUMANDIMINE+LUTERA+LYLEQ+LYZA+MARLISSA+medroxy- progesterone+ 125mg/ml Cigna Advantage 3-Tier Prescription Drug List

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10TIER 1$TIER 2$$TIER 3 $$$CONTRACEPTION PRODUCTS (cont)MERZEE+MICROGESTIN+MICROGESTIN FE+MILI+MONO-LINYAH+NECON+NIKKI+NORA-BE+norethindrone+norethindrone-ethinyl estradiol-iron+norethindrone-ethinyl estradiol+norethindrone-ethinyl estradiol-ferrous fumaratenorgestimate-ethinyl estradiol+NORLYDA+NORTREL+NYLIA+NYMYO+OCELLA+ORSYTHIA+PHILITH+PIMTREA+PIRMELLA+PORTIA+PREVIFEM+RECLIPSEN+RIVELSA+SETLAKIN+SHAROBEL+SIMLIYA+SIMPESSE+SPRINTEC+SRONYX+SYEDA+TARINA FE+TARINA FE 1-20 EQ+TARINA 24 FE+taysofy+TILIA FE+TRI FEMYNOR+TRI-ESTARYLLA+TRI-LEGEST FE+TRI-LINYAH+TRI-LO-ESTARYLLA+TRI FEMYNOR+TRI-ESTARYLLA+TRI-LEGEST FE+TIER 1$TIER 2$$TIER 3 $$$CONTRACEPTION PRODUCTS (cont)TRI-LINYAH+TRI-LO-ESTARYLLA+TRI-LO-MARZIA+TRI-LO-MILI+TRI-LO-SPRINTEC+TRI-MILI+TRI-NYMYO+TRI-SPRINTEC+TRIVORA+TRI-VYLIBRA LO+TRI-VYLIBRA+TULANA+TYDEMY+VELIVET+VESTURA+VIENVA+VIORELE+VOLNEA+VYFEMLA+VYLIBRA+WERA+WYMZYA FE+XULANE+ZAFEMY+ZOVIA 1-35+ZUMANDIMINE+COUGH/COLD MEDICATIONSbrompheniramine-pseudoephed-dmhydrocodone-homatropine (PA,QL)promethazine-dmHYCODAN (PA, QL)TUXARIN ER (PA, QL)TUZISTRA XR (PA, QL)DENTAL PRODUCTSchlorhexidine DENTA 5000 PLUSDENTAGELdoxycycline hyclateFLUORIDEX DAILY DEFENSE 1.1%ORALONEPERIOGARDSF 1.1% GELSF 5000 PLUS sodium ﬂuoridesodium ﬂuoride 5000 dry mouthsodium ﬂuoride 5000 plustriamcinoloneCLINPRO 5000FLORIVA+FLUORIDEX SENSITIVITY RELIEFPERIDEXPREVIDENT 5000 DRY MOUTHCigna Advantage 3-Tier Prescription Drug List

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11TIER 1$TIER 2$$TIER 3 $$$DIABETESglimepirideglipizideglipizide erglipizide xlmetformin metformin erBAQSIMI (QL)BASAGLAR (QL)BD INSULIN SYRINGEBD LANCETSBD PEN NEEDLEBYDUREON BCISE (PA,QL)BYETTA (PA,QL)DEXCOM G6 (PA, QL)DROPLETDROPSAFEFARXIGA (QL, ST)FREESTYLE LIBRE 14 DAY SENSOR (PA, QL)FREESTYLE LIBRE 2 SENSOR (PA, QL)GLYXAMBI (QL, ST)HUMULIN RJANUMET (QL, ST)JANUMET XR (QL, ST)JANUVIA (QL, ST)JARDIANCE (QL, ST)HUMALOG (QL)HUMULIN (QL)HUMULIN R (QL)INSULIN LISPRO (QL)INSULIN SYRINGELEVEMIR (QL)LYUMJEV (QL)MICROLET NEXT LANCING DEVICEMULTI-LANCETNANO 2ND GEN PEN NEEDLENOVOFINEOMNIPOD DASH PODS (GEN 3/4/5) (PA, QL)ONETOUCH ULTRA TEST STRIPONETOUCH ULTRAMINIONETOUCH VERIO FLEX METERONETOUCH VERIO IQ METERONETOUCH VERIO METERACCU-CHEK SMARTVIEW CONTRL SOLUTIONACCUTREND GLUCOSE CONTROLAUTOSHIELD DUO PEN NEEDLECEQURCONTOUR METERCONTOUR NEXT TEST STRIPCONTOUR NEXT EZCONTOUR TEST STRIPCYCLOSET SENSOR KITFREESTYLE FREEDOM LITE GLUCAGON EMERGENCY KIT (QL)GLUCOCARDINPENGLUCOCARD SHINE CONNEX METERGLUCOCARD SHINE EXPRESS METERGUARDIAN RT CHARGERGUARDIAN TEST PLUGKORLYM* (PA)MINIMED RESERVOIRPARADIGMPOGO AUTOMATIC BLOOD GLUCOSE SYSTEMPRECISION XTRA KETONEGLUC KITRIOMETTRUE METRIXTIER 1$TIER 2$$TIER 3 $$$DIABETES (cont)ONETOUCH VERIO REFLECT METERONETOUCH VERIO TEST STRIPOZEMPIC (PA,QL)RYBELSUS (PA, QL)SOLIQUA 100-33SYMLINPENSYNJARDY (QL, ST)SYNJARDY XR (QL, ST)TECHLITETRESIBA (QL)TRIJARDY XR (ST, QL)TRUEPLUS PEN NEEDLETRUEPLUS SYRINGETRULICITY (PA, QL)ULTRA-FINE PEN NEEDLEV-GO 20V-GO 30V-GO 40VEO INSULIN SYRINGEVICTOZA (PA, QL)XIGDUO XR (QL, ST)XULTOPHYZEGALOGUE (QL)DIURETICSacetazolamide tabletacetazolamide er capsulebumetanide tabletchlorthalidoneeplerenonefurosemide solution, tablethydrochlorot- hiazidespironolactonetorsemidetriamterene-hctzKERENDIA (PA, QL) ALDACTONECAROSPIRDIURILINSPRAJYNARQUE* (PA)LASIXMAXZIDEEAR MEDICATIONSciproﬂoxacin-dexamethasoneneomycin-polymyxin b-hydrocortisoneoﬂoxacinCIPRO HCCIPRODEXCIPRODEXCIPROFLOXACIN-FLUOCINOLONEDERMOTICOTOVELCigna Advantage 3-Tier Prescription Drug List

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12TIER 1$TIER 2$$TIER 3 $$$EYE CONDITIONSbimatoprost (QL)brimonidine brinzolamideciproﬂoxacin diﬂuprednatedorzolamide-timololerythromycinﬂuorometholonelatanoprostloteprednol moxiﬂoxacin eye dropsneomycin-polymyxin b-dexamethasoneoﬂoxacinpolymyxin b sulfate-trimethoprimprednisolone timolol tobramycin-dexamethasonetravoprostCEQUACOMBIGANEYSUVIS (QL)SIMBRINZAXIIDRAACUVAILALPHAGAN PALREXAZASITEAZOPTBESIVANCEBETIMOLBETOPTIC SBROMSITECOSOPTCOSOPT PFCYSTADROPS* (PA, QL)CYSTARAN* (PA, QL)DURYSTA* (PA)DUREZOLFLAREXFML FORTE 0.25% EYE DROPSFML LIQUIFILM 0.1% EYE DROPFML S.O.P. 0.1% OINTMENTILEVROINVELTYSISTALOLLOTEMAXLOTEMAX SMMAXITROLOCUFLOXOXERVATE* (PA)POLYTRIMPRED FORTEPROLENSARHOPRESSAROCKLATANTIMOPTICTIMOPTIC-XETIMPOTIC OCUDOSETOBRADEXTOBRADEX STVIGAMOXZIRGANZYLETFEMININE PRODUCTSGYNAZOLE 1miconazole 3 200 mgterconazoleTIER 1$TIER 2$$TIER 3 $$$GASTROINTESTINAL/HEARTBURNalosetron*ANUCORT-HCbalsalazide cinacalcet*dicyclomine capsule, solution, tabletesomeprazole (QL)famotidine 40 mg/5 ml suspensionGAVILYTE-C+GAVILYTE-G+GAVILYTE-N+GENTLE LAXATIVE TABLET+glycopyrrolate tabletHEMMOREX-HC hydrocortisone lansoprazole^ (QLmesalaminemesalamine drmesalamine ermetoclopramide solution, tabletmetoclopramide odtomeprazole^ (QL)ondansetron AMITIZACLENPIQ+ENTYVIO* (PA)LINZESSNEXIUM DR 25 MG PACKET (QL)NEXIUM DR 2 MG PACKET (QL)NEXIUM DR 5 MG PACKET (QL)PANCREAZEPENTASASUPREP+SUTAB+VIBERZIAPRISOBONJESTACANASACARAFATECHOLBAM* (PA)DICLEGISGATTEX* (PA)LITHOSTATMOTOFENMOVANTIK (PA)OCALIVA* (PA)RAVICTI* (PA)RECTIVRELISTOR (PA)SANCUSO (PA, QL)SFROWASASUCRAID* (PA)SYMPROIC (PA)TRANSDERM-SCOPURSOURSO FORTEVARUBI (PA, QL)VIOKACEondansetron odtpantoprazole ^ (QL)peg 3350-electrolyte+peg3350-sodium sulfate-sodium chloride-potassium chloride-sodium ascorbate-ascorbic acid+PEG-PREP+prochlorperazine tabletrabeprazole tablet^ (QL)scopolaminesucralfateCigna Advantage 3-Tier Prescription Drug List

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13TIER 1$TIER 2$$TIER 3 $$$HORMONAL AGENTSAMABELZbudesonide drbudesonide ecbudesonide er (PA, QL)cabergoline (QL)desmopressin* dexamethasone intensolDOTTI (QL)estradiol (once weekly)estradiol 10mcg vaginal insert (QL)estradiol (twice weekly) (QL)estradiol-norethindrone acetatEUTHYROXLEVO-Tlevothyroxine tabletLEVOXYLliothyronine LYLLANA (QL)medroxyprog- esterone methylpredn- isoloneMIMVEYnorethindrone NP THYROIDprednisoneprednisone intensolprogesterone tablettestosterone cypionateYUVAFEMCOMBIPATCHDUAVEEESTRING (QL)ESTROGELFORTEO* (PA, QL)HUMATROPE* (PA)LUPRON DEPOT* (PA)LUPRON DEPOT-PED* (PA)MYFEMBREE (PA, QL)NORDITROPIN FLEXPRO* (PA)ORIAHNN (PA, QL)ORILISSA (PA, QL)PREMARIN TABLET, VAGINAL CREAM APPLICATORPREMPHASEPREMPROSEROSTIM* (PA)SOMATULINE DEPOT*(PA)ACTHAR GEL* (PA)ACTIVELLAALORA (QL)ANDRODERM (PA, QL)ANDROGEL (PA, QL)ANGELIQAYGESTINBIJUVACETROTIDE*^ (PA)CLIMARACLIMARA PROCORTROPHIN* (PA)CRINONE 4% GELCYTOMELDEPO-TESTOSTERONEDIVIGELELESTRINEMFLAZA* (PA)ESTRACEEVAMISTFENSOLVI* (PA)IMVEXXY (QL)INTRAROSA (QL)ISTURISA* (PA, QL)LANREOTIDE* (PA)LUPANETA PACK* (PA)MEDROLMENOSTAR (QL)MINIVELLE (QL)MYFEMBREE (QL)OSPHENA (QL)PROMETRIUMRAYALDEESANDOSTATIN LAR DEPOT* (PA)SKYTROFA* (PA)SOMAVERT* (PA)SUPPRELIN LA* (PA)TESTOPEL (PA)TERIPARATIDE* (PA,QL)TRIOSTATTRIPTODUR* (PA)UNITHROIDVAGIFEM (QL)VIVELLE-DOT (QL)TIER 1$TIER 2$$TIER 3 $$$INFECTIONSacyclovir capsule, suspension, tabletalbendazoleamoxicillinamoxicillin-clavulanate eramoxicillin-clavulanate atovaquoneatovaquone-proguanil AVIDOXYazithromycin packet, suspension, tabletcefdinircefuroxime tabletcephalexinciproﬂoxacin clindamycin COREMINO ER QL)dapsonedoxycycline monohydrateEMVERMentecavir* (QL)erythromycinerythromycin ethylsuccinatefamciclovirﬂuconazolehydroxychlo- roquineivermectinlevoﬂoxacin solution, tabletmetronidazole gel, capsule, tabletminocycline minocycline er tablet (QL)mondoxyne nlnitazoxanidenitrofurantoinnitrofurantoin monohydrate-macrocrystalnystatin suspension, tabletBARACLUDE SOLUTION*EPCLUSA* (PA, QL)EURAX 10% CREAMFOLLISTIM*^ (PA)HARVONI* (PA, QL)LAGEVRIO(EUA)(QL)LEDIPASVIR-SOFOSBUVIR* (PA,QL)MAVYRET* (PA, QL)MOLNUPIRAVIR (QL)PAXLOVID (QL)PEGASYS* (PA)SOFOSBUVIR-VELPATASVIR* (PA,QL)SOVALDI* (PA, QL)TOBI PODHALER* (PA,QL)VEMLIDY*VOSEVI* (PA,QL)XIFAXAN (QL)AEMCOLO (QL)ALBENZAALINIAARIKAYCE* (PA)BACTRIMBACTRIM DSBAXDELA TABLET (PA)CAYSTON* (PA, QL)CIPROCLEOCINCLINDESSECRESEMBA CAPSULE (PA)DARAPRIM* (PA)DIFICID (QL)e.e.s. 400ELIMITEERYPED 200ERY-TAB DREURAX 10% LOTIONFLAGYLKITABIS PAK* (PA, QL)MACROBIDMACRODANTINMALARONE (PA)NUVESSANUZYRA TABLET* (PA, QL)PLAQUENILSYNAGIS* (PA)XOFLUZA (QL)Cigna Advantage 3-Tier Prescription Drug List

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14TIER 1$TIER 2$$TIER 3 $$$INFERTILITYclomiphene ^ GONAL-F*^ (PA) CRINONE^ENDOMETRIN^FOLLISTIM AQ*^ (PA)MAKENA* (PA)MENOPUR*^ (PA)NOVAREL*^ (PA)OVIDREL*^ (PA)MISCELLANEOUSdeferiprone 500mg* (PA)disulﬁram sapropterin* (PA)sodium chloride inhalation vial, irrigation solution, vialACCU-CHEKCERDELGA* (PA)DROPLET LANCETSESBRIET* (PA)MICROLETNITYR* (PA)ONETOUCHPRECISION XTRASTRENSIQ* (PA)TECHLITE LANCETSAUSTEDO* (PA)BOTOX* (PA)CEREZYME* (PA)DYSPORT* (PA)EVRYSDI* (PA)INGREZZA* (PA)INGREZZA INITIATION PACK* (PA, QL)KETONE CARE TEST STRIPKETONE TEST STRIPKETOSTIX REAGENTNUEDEXTA (QL)ORFADIN* (PA)PALYNZIQ* (PA)POGO AUTOMATIC TEST CARTRIDGEPRECISION XTR B-KETONE STRIPTEGSEDI* (PA)TIGLUTIK* (PA)TRUEPLUS KETONE TEST STRIPVYNDAMAX* (PA, QL)MULTIPLE SCLEROSISdalfampridine er* (PA)dimethyl fumarate* (PA)glatiramer* (PA)glatopa* (PA)AUBAGIO* (PA)AVENOX* (PA)BAFIERTAM* (PA)BETASERON* (PA)EXTAVIA* (PA)GILENYA* (PA)KESIMPTA PEN* (PA)MAYZENT* (PA)PLEGRIDY* (PA)PONVORY* (PA)REBIF* (PA)VUMERITY* (PA)ZEPOSIA* (PA)FIRDAPSE* (PA)MAVENCLAD* (PA)OCREVUS* (PA)PONVORY* (PA)TYSABRI* (PA)TIER 1$TIER 2$$TIER 3 $$$NUTRITIONAL/DIETARYbetaine anhydrous*calcitriol capsule, solution^cyanocobalamindodexﬂuoride+folic acid^+klor-con 8klor-con 10MULTI-VITAMIN W-FLUORIDE-IRON+MULTIVITAMIN WITH FLUORIDE+MULTIVITAMIN-IRON-FLUORIDEpotassium chloride 10%, capsule, conc, packet, tabletsevelamer carbonatesodium ﬂuoride+RI-VITE WITH FLUORIDE+vitamin d2 1.25 mg (50,000 unit)^VITAMINS A,C,D AND FLUORIDE+LOKELMAPETITEOB COMPLETE VELPHOROVELTASSAACCRUFERAURYXIA (QL)CITRANATAL BLOOMCITRANATAL 90 DHACITRANATAL ASSURECITRANATAL B-CALMCITRANATAL DHACITRANATAL HARMONYCITRANATAL RXDRISDOLFLORIVA+K-TAB ERMEPHYTONNEEVO DHAOB COMPLETEPHOSLYRAPOLY-VI-FLOR WITH IRON+POLY-VI-FLOR+POTASIUM CL 2 MEQ/ML CONCPRENATEPRIMACAREQUFLORA PEDIATRIC 1 MG CHEWABLE TABLET+QUFLORA PEDIATRIC 0.25 MG/ML DROP+QUFLORA PEDIATRIC 0.5 MG/ML DROP+RENVELAROCALTROLTRI-VI-FLOR+OSTEOPOROSIS PRODUCTSalendronate ibandronate 150 mg tablet*ibandronate 3 mg/3 ml syringe*ibandronate 3 mg/3 ml vial*raloxifene +risedronate drTYMLOS* (PA, QL) ACTONEL (ST)ATELVIA (ST)BINOSTO (ST)EVISTAFOSAMAX (ST)PROLIA* (PA)XGEVA* (PA)Cigna Advantage 3-Tier Prescription Drug List

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15TIER 1$TIER 2$$TIER 3 $$$PAIN RELIEF AND INFLAMMATORY DISEASEacetaminophen-codeine (PA)allopurinol tabletbaclofen tabletbuprenorphine patch (QL)butalbital-acetaminophen-caﬀeine (QL)buprenorphine (QL)butalbital-acetaminophen-caﬀe (QL)carisoprodolcelecoxib (QL)colchicine 0.6mg tabletcyclobenzaprine diclofenac 1% gel (QL)diclofenac drdiclofenac ecEC-NAPROXENECOTRIN EC 81 MG TABLET+eletriptan (QL)ENDOCET PAfebuxostat (QL)GEL-ONE* (PA)GLYDOhydrocodone-acetaminophen (PA)IBUibuprofenindomethacinindomethacin erketorolac tromethamine (QL)leﬂunomidelidocaine 5% ointment (QL)meloxicam tabletmetaxalonemethocarbamolmorphine (PA)morphine er (PA)oxycodone (PA)oxycodone er (PA)oxycodone-acetaminophen (PA)ACTEMRA* (PA)AIMOVIG (PA)AJOVY (PA)AVSOLA* (PA)BELBUCA (QL)CIMZIA* (PA, QL)DUPIXENT* (PA)DUROLANE*EMGALITY (PA)ENBREL* (PA, QL)EUFLEXXA* (PA)HUMIRA* (PA, QL)HYSINGLA ER (PA)INFLECTRA* (PA)MITIGARENURTEC ODT (PA, QL)OTEZLA* (PA, QL)QULIPTA (PA,QL)RASUVO (PA)REDITREX (PA)RINVOQ* (PA, QL)SIMPONI 100MG* (PA, QL)SIMPONI ARIA* (PA)SKYRIZI* (PA, QL)STELARA* (PA)TALTZ* (PA, QL)TREMFYA* (PA,QL)TRUDHESA (PA,QL)UBRELVY (PA, QL)XELJANZ XR* (PA, QL)XELJANZ* (PA, QL)XTAMPZA ER (PA)ZTLIDOARAVAARCALYST* (PA)BENLYSTA* (PA)BUPRENEXBUTRANS (QL)CELEBREX (QL, ST)COLCRYSDEPEN* (PA,QL)DUROLANE* (PA)EC-NAPROSYN (ST)ESGIC (QL)EUFLEXXA* (PA)FEXMIDFIORICET (QL)GABLOFENGELSYN-3 (PA)HYALGAN* (PA)HYMOVIS* (PA)ILARIS* (PA)ILUMYA* (PA, QL)KEVZARA* (PA, QL)MONOVISC* (PA)NAPROSYN (ST)NUCYNTA (PA)NUCYNTA ER (PA)OLUMIANT* (PA, QL)ORENCIA* (PA)ORTHOVISC* (PA)OTREXUP (PA)OXAYDO (PA)PERCOCET (PA)PROCTOFOAM-HCRENFLEXIS* (PA)ROXYBOND (PA)SAVELLASILIQ* (PA, QL)SKELAXINSYNVISC* (PA)SYNVISC-ONE* (PA)TRILURON* (PA)ULORIC (QL)ULTRAM 50 MG TABLET (QL)XIAFLEX* (PA)ZANAFLEXZEBUTAL (QL)ZOHYDRO ER (PA)ZYLOPRIMTIER 1$TIER 2$$TIER 3 $$$PAIN RELIEF AND INFLAMMATORY DISEASE (cont)penicillamine* (PA,QL)PROLATE TABLET (PA)rizatriptan (QL)sumatriptan (QL)SUPARTZ FX* (PA)tramadol 50 mg tablet (QL)tramadol er (QL)VANADOMVISCO-3* (PA)PARKINSON’S DISEASEbenztropine tabletcarbidopa-levodopacarbidopa-levodopa erpramipexole pramipexole er (QL)rasagiline (QL)ropinirole erropiniroleKYNMOBI (PA) AZILECT (QL)DUOPA*INBRIJA* (PA)MIRAPEX ER (QL)NEUPRONOURIANZ* (PA, QL)OSMOLEX ER (QL)RYTARYSINEMET 10-100SINEMET 25-100TASMARXADAGO (ST)SCHIZOPHRENIA/ANTI-PSYCHOTICS5aripiprazole (QL)aripiprazole odtasenapine chlorpromazine tabletolanzapine tabletolanzapine odtpaliperidone er (QL)quetiapine quetiapine errisperidonerisperidone odtziprasidone tabletABILIFY MAINTENA (QL)LATUDA (QL)ARISTADA (QL)FANAPT (QL, ST)INVEGA HAFYERA (QL, ST)INVEGA SUSTENNA (QL, ST)INVEGA TRINZA (QL, ST)PERSERIS (QL)REXULTI (QL, ST)RISPERDAL CONSTA (ST)SAPHRIS (ST)SECUADO (ST)SEROQUEL (ST)SEROQUEL XR (ST)VRAYLAR (QL, ST)SEIZURE DISORDERScarbamazepinecarbamazepine erclonazepamdivalproex divalproex erDILANTIN 30 MG CAPSULE (PA)FYCOMPA (PA, QL)NAYZILAM (PA, QL)VIMPAT 10MG/ML SOLUTIONAPTIOM (PA, QL)BANZEL (PA, QL)BRIVIACT ORAL SOLUTION, TABLET PACigna Advantage 3-Tier Prescription Drug List

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16TIER 1$TIER 2$$TIER 3 $$$SEIZURE DISORDERS (cont)EPITOLgabapentinlamotriginelamotrigine (blue)lamotrigine (green)lamotrigine (orange)lamotrigine erlamotrigine odtlamotrigine odt (blue)lamotrigine odt (green)lamotrigine odt (orange)levetiracetam solution, tabletlevetiracetam eroxcarbazepinepregabalin capsule, solutionROWEEPRAruﬁnamide (PA, QL)SUBVENITESUBVENITE (BLUE)SUBVENITE (GREEN)SUBVENITE (ORANGE)topiramatetopiramate ervigabatrin*vigadrone*CARBATROL (PA)DEPAKOTE (PA)DEPAKOTE ER (PA)DEPAKOTE SPRINKLE (PA)DIASTAT (PA)DILANTIN 100 MG CAPSULE (PA)DILANTIN 50 MG INFATAB (PA)EPIDIOLEX* (PA)FINTEPLA* (PA)KLONOPIN (PA)LYRICA ORAL SOLUTION (PA)NEURONTIN (PA)OXTELLAR XR (PA)PHENYTEK (PA)SPRITAM (PA)TEGRETOL (PA)TEGRETOL XR (PA)VALTOCO (PA, QLVIMPAT 200MG/ML VIAL)XCOPRI (PA, QL)SKIN CONDITIONSACCUTANEadapalene (PA)adapalene-benzoyl peroxideAMNESTEEMAVAR CLEANSERazelaic acidBP 10-1CLARAVISCLINDACIN ETZ 1% PLEDGETCLINDACIN P 1% PLEDGETSclindamycin 1% foam, gel, lotion, pledget, solutionclindamycin-benzoyl peroxoxideDBRY*CIBINQO* (PA,QL)EUCRISA (ST)TARGRETIN*ANALPRAM HC 2.5%1% LOTIONAVAR 9.55% CLEANSING PADSBRYHALI (ST)calcipotriene foamCAPEX SHAMPOO (ST)CLEOCIN TCLINDACIN ETZ KITCLINDACIN PAC KITCLODERM (ST)DRYSOLEFUDEXELIDELEVOCLINNAFTINOPZELURA (PA)TIER 1$TIER 2$$TIER 3 $$$SKIN CONDITIONS (cont)clindamycin-tretinoinclobetasol CLODANclotrimazole-betamethasonedapsone gelﬂuocinonideﬂuorouracil cream, topical solutionisotretinoinketoconazoleKETODANmetronidazoleMYORISANNEUAC GELpimecrolimusROSADANsodium sulfacetamide-sulfurSSS 10-5SULFACLEANSE 8-4tacrolimus ointmenttazarotene 0.1% creamtretinoin (PA)TRIDERMZENATANEPICATOPRAMOSONEPROTOPICREGRANEX (PA,QL)SANTYL (QL)TEMOVATE (ST)VALCHLOR*XEPISLEEP DISORDERS/SEDATIVESdoxepin (QL)eszopiclonemodaﬁnil (PA)zolpidem zolpidem er (QL)DAYVIGO (QL, ST)SUNOSI (PA, QL)HETLIOZ* (PA)HETLIOZ LQ* (PA)LUNESTA (ST)SILENOR (QL, ST)WAKIX* (PA, QL)XYREM* (PA,QL)XYWAV* (PA,QL)SUBSTANCE ABUSEbuprenorphine-naloxoneKLOXXADO (QL)LUCEMYRA (QL)NARCAN (QL)ZUBSOLVSUBLOCADE*SUBOXONEZIMHI (QL)TRANSPLANT MEDICATIONSeverolimus 0.25 mg tablet*everolimus 0.5 mg tablet*mycophenolate mofetil*PROGRAF 5 MG/ML AMPULE*ASTAGRAF XL*CELLCEPT ORAL SUSPENSION, TABLET*ENVARSUS XR*MYFORTIC*Cigna Advantage 3-Tier Prescription Drug List

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17TIER 1$TIER 2$$TIER 3 $$$TRANSPLANT MEDICATIONS (cont)mycophenolic acid*sirolimus*tacrolimus capsule*NEORAL*PROGRAF 0.2 MG GRANULE PACKET*PROGRAF 0.5 MG CAPSULE*PROGRAF 1 MG CAPSULE*PROGRAF 1 MG GRANULE PACKET*PROGRAF 5 MG CAPSULE*RAPAMUNE*REZUROCK* (PA)ZORTRESS*URINARY TRACT CONDITIONSalfuzosin ercevimeline dutasterideﬁnasterideoxybutynin oxybutynin erphenazopyridine potassium ersilodosin (QL)solifenacin (QL)tamsulosin tolterodine tolterodine er (QL)CYSTAGON* AVODARTELMIRONEVOXACFLOMAXK-PHOS ORIGINALPROSCARPYRIDIUMRAPAFLO (QL)UROCIT-KUROXATRALVACCINESNot all plans cover vaccines in the same way. Log in to the myCigna App or myCigna.com, or check your plan materials, to find out how your specific plan covers them.ENGERIX-B ADULT+ENGERIX-B PEDIATRIC-ADOLESCENT+AFLURIA QUAD 2021-22 (6-35MO)+BEXSERO+BOOSTRIX TDAP+COMIRNATY+DAPTACEL DTAP+DENGVAXIA+DIPHTHERIA-TETANUS TOXOIDS-PED+FLUAD QUAD 2021-2022+FLUARIX QUAD 2021-2022+FLUBLOK QUAD 2021-2022+TIER 1$TIER 2$$TIER 3 $$$VACCINES Not all plans cover vaccines in the same way. Log in to the myCigna App or myCigna.com, or check your plan materials, to find out how your specific plan covers them. FLUCELVAX QUAD 2021-2022+FLULAVAL QUAD 2021-2022+FLULAVAL QUAD 2021-2022+FLUZONE HIGH-DOSE QUAD 2021-22+FLUZONE QUAD 2021-2022+GARDASIL 9+HEPLISAV-B+HIBERIX+INFANRIX DTAP+IPOL+ANSSEN COVID-19 VACCINE (EUA)+KINRIX+MENACTRA+MENQUADFI+MENVEO A-C-Y-W-135-DIP+M-M-R II VACCINE+MODERNA COVID-19 BOOSTER (EUA)+MODERNA COVID-19 VACCINE (EUA)+MODERNA COVID (12Y UP) VAC (EUA)+MODERNA COVID (6M-5Y) VACC (EUA)+NOVAVAX COVID-19 VACC, ADJ (EUA)+PEDIARIX+PEDVAXHIB+PENTACEL+PFIZER COVID (12Y UP) VAC(EUA)+PFIZER COVID (5-11Y) VAC (EUA)+Cigna Advantage 3-Tier Prescription Drug List

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19Medications that aren’t covered - and their covered alternative(s)These medications aren’t covered on the Cigna Advantage 3-Tier Prescription Drug List.^^ However, there are other medications available that are used to treat the same condition. They’re listed below. DRUG CLASSMEDICATION NAME^^(Not covered)GENERIC AND/OR PREFERRED BRAND ALTERNATIVE(S)AIDS/HIVATRIPLA* efavirenz-emtricitabine-tenofovir* COMBIVIR* lamivudine-zidovudine*EMTRIVA* emtricitabine*EPIVIR* lamivudine*EPZICOM* abacavir-lamivudine*INTELENCE 100MG, 200MG TABLET* etravirine*KALETRA* lopinavir-ritonavir*LEXIVA 700MG TABLET* fosamprenavir 700mg tablet*NORVIR 100MG TABLET* ritonavir 100mg tablet*RETROVIR CAPSULE, SYRUP* zidovudine capsule, syrup*REYATAZ CAPSULE* atazanavir capsules*SUSTIVA* efavirenz*SYMFI*SYMFI LO*efavirenz-lamivudine-tenofovir* TRIZIVIR* abacavir-lamivudine-zidovudine tablet*TRUVADA* emtricitabine-tenofovir*VIRAMUNE* nevirapine*VIRAMUNE XR* nevirapine ER*VIREAD 300MG TABLET* tenofovir 300mg tablet*ZIAGEN* abacavir*ALLERGY/NASAL SPRAYSAUVI-QEPIPENEPIPEN JRSYMJEPIepinephrine auto-injectorscarbinoxamine 6mg tabletRYVENTcarbinoxamine 4mg tabletdexchlorpheniramine RYCLORAcarbinoxamine oral solutioncyproheptadine syruphydroxyzine syrupDYMISTA azelastine-ﬂuticasoneGeneric nasal steroids (e.g. ﬂuticasone)ALZHEIMER'S DISEASEpyridostigmine 30mg tablet (QL) pyridostigmine 60mg tabletANXIETY/DEPRESSION/BIPOLAR DISORDERANAFRANIL clomipramineAPLENZIN bupropion XL 150, 300 mg tabletsATIVAN TABLET LOREEV XRlorazepambupropion xl 450mg tabletFORFIVO XLbupropion xl 150mg tabletsCITALOPRAM HBR citalopram tabletCYMBALTA desvenlafaxine ERduloxetineescitalopramDRIZALMA SPRINKLE duloxetine dr capsulesLEXAPRO escitalopram^^ This medication isn’t covered on this drug list. If your doctor feels a diﬀerent medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the non-covered medication. If you don’t get approval and you continue to ﬁll a prescription for a medication that isn’t covered, you’ll pay its full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t be applied to your annual deductible or out-of-pocket maximum.

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20DRUG CLASSMEDICATION NAME^^(Not covered)GENERIC AND/OR PREFERRED BRAND ALTERNATIVE(S)ANXIETY/DEPRESSION/BIPOLAR DISORDER (cont)PAMELOR nortriptyline capsulesPARNATE tranylcyprominePEXEVA paroxetineparoxetine crPRISTIQ desvenlafaxine succinate erbupropion srduloxetineescitalopramsertralinevenlafaxine erTOFRANIL imipramine WELLBUTRIN XL bupropion xlescitalopramﬂuoxetineASTHMA/COPD/RESPIRATORYADVAIR HFAADVAIR DISKUSAIRDUO RESPICLICKBREO ELLIPTADULERAﬂuticasone-salmeterolSYMBICORTWIXELA INHUBALVESCOARMONAIR DIGIHALERARNUITY ELLIPTAASMANEX, ASMANEX HFAPULMICORT FLEXHALERFLOVENT DISKUSFLOVENT HFAQVARARCAPTA NEOHALERSTRIVERDI RESPIMATSEREVENT DISKUSBEVESPI AEROSPHEREDUAKLIR PRESSAIRANORO ELLIPTASTIOLTO RESPIMATBROVANA arformoterol budesonide-formoterol SYMBICORTELIXOPHYLLIN theophylline ertheophylline oral solutionALBUTEROL HFAlevalbuterol hfaPROAIR DIGIHALERPROAIR HFAPROAIR RESPICLICKPROVENTIL HFAVENTOLIN HFAXOPENEX HFAGeneric PROAIR or PROVENTIL (albuterol hfa)PERFOROMIST formoterol TUDORZA PRESSAIR INCRUSE ELLIPTASPIRIVA RESPIMATYUPELRI ANORO ELLIPTABREZTRI AEROSPHEREINCRUSE ELLIPTASPIRIVASTIOLTO RESPIMATTRELEGY ELLIPTAZYFLO montelukastzaﬁrlukastzileuton er^^ This medication isn’t covered on this drug list. If your doctor feels a diﬀerent medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the non-covered medication. If you don’t get approval and you continue to ﬁll a prescription for a medication that isn’t covered, you’ll pay its full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t be applied to your annual deductible or out-of-pocket maximum.

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21DRUG CLASSMEDICATION NAME^^(Not covered)GENERIC AND/OR PREFERRED BRAND ALTERNATIVE(S)ATTENTION DEFICIT HYPERACTIVITY ADDERALL XRADHANSIA XRADZENYS ERADZENYS XR-ODTAPTENSIO XRAZSTARYSCONCERTACOTEMPLA XR-ODTDYANAVEL XRFOCALIN XRJORNAY PMMYDAYISQUILLICHEW ERRITALIN LAVYVANSEdexmethylphenidate erdextroamphetamine-amphetamine er methylphenidate erDESOXYN methamphetamine DEXEDRINE dexmethylphenidate erdextroamphetamine erdextroamphetamine-amphetamine er EVEKEO ODT amphetaminedexmethylphenidatedextroamphetaminemethamphetaminemethylphenidatemethylphenidate er 72mg tablet RELEXXIImethylphenidate er 36mg tablet QELBREE atomoxetine BLOOD PRESSURE/HEART MEDICATIONSACCUPRIL quinaprilACCURETIC quinapril-hctzALTACE ramiprilATACAND candesartanATACAND HCT candesartan-hctzAVALIDE irbesartan-hctzAVAPRO irbesartan-hctzAZOR amlodipine-olmesartanBENICAR olmesartanBENICAR HCT olmesartan-hctzBETAPACE sotalolBYSTOLIC generic beta blockers (e.g. metoprolol; atenolol)CARDIZEM diltiazemCARDIZEM CD diltiazem CDCONJUPRI amlodipinefelodipine ernicardipinenifedipineCONSENSI amlodipinecelecoxibCOZAAR losartanDIOVAN valsartan^^ This medication isn’t covered on this drug list. If your doctor feels a diﬀerent medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the non-covered medication. If you don’t get approval and you continue to ﬁll a prescription for a medication that isn’t covered, you’ll pay its full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t be applied to your annual deductible or out-of-pocket maximum.

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22DRUG CLASSMEDICATION NAME^^(Not covered)GENERIC AND/OR PREFERRED BRAND ALTERNATIVE(S)BLOOD PRESSURE/HEART MEDICATIONS (cont)DIOVAN HCT valsartan-hctzEDARBI generic ARBs (e.g. losartan; valsartan)EDARBYCLOR generic ARBs + HCTZ (e.g. losartan-HCTZ) EXFORGE amlopidine-valsartanEXFORGE HCT amlopidine-valsartan hctzFIRAZYR* icatibantGONITRO nitroglycerin sublingual tablet or sprayHYZAAR losartan-hctzISORDILISORDIL TITRADOSEisosorbide dinitrate LANOXIN digoxinLOTENSIN benazeprilLOTENSIN HCT benazepril-hctzLOTREL amlodipine-benazeprilMICARDIS telmisartanMICARDIS HCT telmisartan-hctzMULTAQ amiodaronedisopyramidedofetilideﬂecainidepropafenonequinidinesotalol afPRINIVILZESTRILlisinoprilTEKTURNA aliskirenTEKTURNA HCT generic ACE inhibitor + HCT (e.g. benazepril-HCT)TRIBENZOR olmesartan-amlodipine-hctzVASERETIC enalapril-hctzVASOTEC enalapril ZESTORETIC lisinopril-hctzBLOOD THINNERS/ANTI-CLOTTINGaspirin-omeprazoleYOSPRALAaspirin or enteric aspirinCANCERBESREMI* hydroxyurea capsuleCYCLOPHOSPHAMIDE TABLET* cyclophosphamide capsule*NILANDRON nilutamideTARCEVA* erlotinibYONSA*ZYTIGA*abirateroneCHOLESTEROL MEDICATIONSANTARAFENOGLIDEfenoﬁbrateALTOPREV lovastatin+atorvastatin+simvastatin+rosuvastatin+CRESTOR rosuvastatin+^^ This medication isn’t covered on this drug list. If your doctor feels a diﬀerent medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the non-covered medication. If you don’t get approval and you continue to ﬁll a prescription for a medication that isn’t covered, you’ll pay its full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t be applied to your annual deductible or out-of-pocket maximum.

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23DRUG CLASSMEDICATION NAME^^(Not covered)GENERIC AND/OR PREFERRED BRAND ALTERNATIVE(S)CHOLESTEROL MEDICATIONS (cont)EZALLOR SPRINKLEFLOLIPIDLIVALOSIMVASTATIN 20mg/5ml SUSPENSIONNEXLIZETgeneric statins (e.g. atorvastatin; simvastatin)JUXTAPID*PRALUENT REPATHALESCOL XL ﬂuvastatin er+LIPITOR atorvastatin+ezetimibe-simvastatinrosuvastatin+NEXLETOLROSUVASTATIN-EZETIMIBEROSZETgeneric statins (e.g. atorvastatin; simvastatin)ezetimibe-simvastatinniacin 500mg tabletNIACORniacin erPRAVACHOL pravastatin+VYTORIN ezetimibe-simvastatinZYPITAMAG atorvastatin+lovastatin+pravastatin+rosuvastatin+simvastatin+CONTRACEPTION PRODUCTSBALCOLTRANATAZIANEXTSTELLISSLYNDTAYTULLATWIRLAgeneric oral contraceptivesCOUGH/COLD MEDICATIONSbenzonatate 150mg benzonatate 100mg, 200mgTUSSICAPS hydrocodone-chlorpheniramine er suspensionpromethazine with codeine syrupDIABETESACCU-CHEK TEST STRIPSCVS TEST STRIPSADVOCATE TEST STRIPSASSURE TEST STRIPSCONTOUR TEST STRIPSEASY TALK PLUS IIFREESTYLE TEST STRIPSRELION TEST STRIPSRIGHTEST GT333 TEST STRIPSONE TOUCH TEST STRIPS (e.g. Ultra; Verio)ADLYXIN BYDUREONBYETTAmetforminOZEMPICTRULICITYVICTOZA^^ This medication isn’t covered on this drug list. If your doctor feels a diﬀerent medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the non-covered medication. If you don’t get approval and you continue to ﬁll a prescription for a medication that isn’t covered, you’ll pay its full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t be applied to your annual deductible or out-of-pocket maximum.

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24DRUG CLASSMEDICATION NAME^^(Not covered)GENERIC AND/OR PREFERRED BRAND ALTERNATIVE(S)DIABETES (cont)ADMELOGADMELOG SOLOSTARAPIDRA, APIDRA SOLOSTARFIASPFIASP FLEXTOUCHFIASP PENFILLINSULIN ASPARTNOVOLOGHUMALOGLYUMJEVAFREZZAINSULIN GLARGINEHUMALOGHUMULIN RLYUMJEValogliptinalogliptin-metforminJENTADUETOJENTADUETO XRKAZANOKOMBIGLYZE XRNESINAONGLYZATRADJENTAJANUMET JANUMET XRJANUVIAmetforminalogliptin-pioglitazoneOSENIJANUMET JANUMET XRJANUVIApioglitazoneFORTAMETGLUMETZAmetformin er gastricmetformin er osmoticmetformin er (generic to GLUCOPHAGE XR)GLUCAGEN HYPOKITGVOKEglucagon emergency kit (generic)BAQSIMI ZEGALOGUEINSULIN ASPART PRONOVOLOG MIXHUMALOG MIXINVOKAMETINVOKAMET XRSEGLUROMETSYNJARDYSYNJARDY XRXIGDUO XRINVOKANASTEGLATROFARXIGAJARDIANCEmetforminLANTUSLANTUS SOLOSTARSEMGLEETOUJEO MAX SOLOSTARTOUJEO SOLOSTARBASAGLARLEVEMIRTRESIBA FLEXTOUCHNOVOLIN HUMULINQTERNSTEGLUJANGLYXAMBImetforminTRIJARDY XR^^ This medication isn’t covered on this drug list. If your doctor feels a diﬀerent medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the non-covered medication. If you don’t get approval and you continue to ﬁll a prescription for a medication that isn’t covered, you’ll pay its full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t be applied to your annual deductible or out-of-pocket maximum.

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25DRUG CLASSMEDICATION NAME^^(Not covered)GENERIC AND/OR PREFERRED BRAND ALTERNATIVE(S)DIURETICSEDECRINethacrynic acidbumetanidefurosemidetorsemideTHALITONE chlorthalidoneEYE CONDITIONSALOCRILALOMIDEcromolynLUMIGANTRAVATAN ZVYZULTAXALATANXELPROSZIOPTANbimatoprostlatanoprosttravoprostRESTASISTYRVAYAcyclosporine 0.05% eye emulsionXIIDRAGASTROINTESTINAL/HEARTBURNANUSOL-HC 25MG SUPPOSITORY hydrocortisone 25mg suppositoryASACOL HDCOLAZALDELZICOLDIPENTUMbalsalazidemesalamine tablets or capsulesPENTASAsulfasalazineBYLVAY*LIVMARLI*cholestyramine powder/packetrifampinursodiol tabletCORTIFOAMUCERIS 2MG RECTAL FOAMCOLOCORThydrocortisone CREONPERTZYEZENPEPPANCREAZEGIMOTI* metoclopramide oral solution or tabletDARTISLAglycopyrrolate 1.5mg tabletROBINULROBINUL FORTEglycopyrrolate 1mg tabletglycopyrrolate 2mg tabletGOLYTELY+MOVIPREP+NULYTELY WITH FLAVOR PACKS+OSMOPREP+PLENVU+CLENPIQ+GAVILYTE-C+GAVILYTE-G+GAVILYTE-N+PEG 3350 ELECTROLYTE+SUPREP+SUTAB+KRISTALOSElactulose 10gm packetCONSTULOSEENULOSElactulose oral solutionLIBRAX chlordiazepoxideLOTRONEX* alosetron*lubiprostone AMITIZAMARINOLSYNDROSdronabinolMOTEGRITYTRULANCEZELNORMAMITIZALINZESS^^ This medication isn’t covered on this drug list. If your doctor feels a diﬀerent medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the non-covered medication. If you don’t get approval and you continue to ﬁll a prescription for a medication that isn’t covered, you’ll pay its full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t be applied to your annual deductible or out-of-pocket maximum.

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26DRUG CLASSMEDICATION NAME^^(Not covered)GENERIC AND/OR PREFERRED BRAND ALTERNATIVE(S)GASTROINTESTINAL/HEARTBURN (cont)NEXIUM 10MG, 20MG, 40MG PACKET, 20MG, 40MG CAPSULEesomeprazole packets, esomeprazole magnesiumOMECLAMOX-PAKPYLERATALICIAlansoprazole-amoxicillin-clarithromycin pakRELTONE ursodiolROWASA mesalamine rectal enema suspensionSENSIPAR* cinacalcetURSODIOL 200 MG, 400 MG CAPSULE ursodiol 300mg capsuleursodiol tabletZOFRAN ondansetronZUPLENZ ondansetronondansetron odtHORMONAL AGENTSALKINDI SPRINKLE hydrocortisone 5mg tablet ARMOUR THYROIDWP THYROIDnp thyroidCORTROSYN cosyntropinDDAVPNOCDURNAdesmopressin nasal spray or tabletsDEXABLISSdexamethasone 6, 10, 13 Day 1.5MG tabletsDXEVOHIDEXTAPERDEXZCORTdexamethasone 1.5mg tabletFORTESTAJATENZONATESTOTESTIMVOGELXOXYOSTEDgeneric topical testosteroneGENOTROPIN*NUTROPIN AQ NUSPIN*OMNITROPE*SAIZEN*SAIZEN-SAIZENPREP*ZOMACTON*HUMATROPE*NORDITROPIN*HEMADY dexamethasone 5mg tabletLEVOTHYROXINE CAPSULESYNTHROIDTIROSINTTIROSINT-SOLGeneric SYNTHROID (also called levothyroxine tablet)MYCAPSSA* BYNFEZIA*ORTIKOS budesonide capsuleRAYOS methylprednisoloneprednisone^^ This medication isn’t covered on this drug list. If your doctor feels a diﬀerent medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the non-covered medication. If you don’t get approval and you continue to ﬁll a prescription for a medication that isn’t covered, you’ll pay its full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t be applied to your annual deductible or out-of-pocket maximum.

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27DRUG CLASSMEDICATION NAME^^(Not covered)GENERIC AND/OR PREFERRED BRAND ALTERNATIVE(S)HORMONAL AGENTS (cont)THYQUIDITY EUTHYROXLEVO-Tlevothyroxine tabletLEVOXYLUCERIS 9MG ER TABLET budesonide 9mg tabletdexamethasonehydrocortisonemethylprednisoloneprednisoloneprednisoneINFECTIONSACTICLATEDORYXDORYX MPCLYMEPAKMINOCIN 50MG PEL CAPSULEMINOCYCLINE ER 45, 90, 135MG CAPSULEMINOLIRA ERMONODOXSEYSARASOLODYNsoloxideTARGADOXVIBRAMYCIN 100MG CAPSULEXIMINOGeneric products (e.g. doxycycline; minocycline)ARAKODA atovaquone-proguanildoxycyclinehydroxychloroquine meﬂoquinequinine AUGMENTINAUGMENTIN XRamoxicillin/clavulanateBARACLUDE TABLET* entecavir tablet*BETHKIS*TOBI*tobramycin inhalation solution*BREXAFEMMEDIFLUCANﬂuconazoledoxycycline hyclate dr 80mg tablet generic products (e.g. minocycline)DOXYCYCLINE IR-DRORACEAdoxycycline hyclate dr 50mg tabletdoxycycline monohydrate 50mg tabletminocycline er 45mgE.E.S. 200ERYPED 400erythromycin granuleserythromycinHUMATIN paromomycinMEPRON atovaquoneMYCOBUTIN rifabutinnitrofurantoin 25mg/5ml suspension nitrofurantoin capsulesulfamethoxazole-trimethoprim suspensionNOXAFIL DR 100MG TABLET posaconazole dr 100mg tabletSITAVIG acyclovir tabletfamciclovir tabletvalacyclovir tabletSPORANOX itraconazoleTOLSURA oral itraconazole^^ This medication isn’t covered on this drug list. If your doctor feels a diﬀerent medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the non-covered medication. If you don’t get approval and you continue to ﬁll a prescription for a medication that isn’t covered, you’ll pay its full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t be applied to your annual deductible or out-of-pocket maximum.

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28DRUG CLASSMEDICATION NAME^^(Not covered)GENERIC AND/OR PREFERRED BRAND ALTERNATIVE(S)INCETIONS (cont)VALCYTE valganciclovirVANCOCIN vancomycin oral solution or capsuleZOVIRAX acyclovirMISCELLANEOUSEXSERVAN* riluzole*TIGLUTIK*HORIZANT gabapentinKUVAN* sapropterin tablet & powder packet*SYPRINE* penicillamine*trientine*XENAZINE* tetrabenazine*MULTIPLE SCLEROSISAMPYRA* dalfampridine er*COPAXONE* AVONEX*BETASERON*EXTAVIA*glatiramer*GLATOPA*KESIMPTA*PLEGRIDY*REBIF*TECFIDERA* AUBAGIO*BAFIERTAM*dimethyl*GILENYA*MAYZENT*PONVORY*VUMERITY*NUTRITIONAL/DIETARYAZESCHEWAZESCODERMACINRX PRENATRIXDERMACINRX PRENATRYLPNV TABS 20-1PREGEN DHAPREGENNATRINAZZALVITAny generic prenatal vitaminNASCOBAL cyanocobalamin injectionPAIN RELIEF AND INFLAMMATORY DISEASEALLZITALBUPAPbutalbital-acetaminophen 25-35mg, 50-300mg tabletsbutalbutal-acetaminophen 50-325mg tabletAMERGEERGOMARFROVA 2.5MG TABLETMAXALTMAXALT MLTRELPAXgeneric triptans (e.g. sumatriptan; naratriptan)AMRIXcyclobenzaprine ercarisoprodolchlorzoxazone 500mgcyclobenzaprine tabletsmethocarbamolorphenadrine ermetaxalone^^ This medication isn’t covered on this drug list. If your doctor feels a diﬀerent medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the non-covered medication. If you don’t get approval and you continue to ﬁll a prescription for a medication that isn’t covered, you’ll pay its full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t be applied to your annual deductible or out-of-pocket maximum.

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29DRUG CLASSMEDICATION NAME^^(Not covered)GENERIC AND/OR PREFERRED BRAND ALTERNATIVE(S)PAIN RELIEF AND INFLAMMATORY DISEASE (cont)BACLOFEN baclofen tabletCAMBIADUEXISELYXYBfenoprofen 200mg capsulefenoprofen 400mg capsuleFENORTHOibuprofen-famotidineINDOCINindomethacin 20mg capsuleketoprofen 25mg capsulelofenameloxicam 5mg, 10mg capsuleNALFON 400MG CAPSULENAPRELANNAPROSYN 125MG/5ML SUSPENSIONnaproxennaproxen sodium crnaproxen sodium ernaproxen-esomeprazole magRELAFENRELAFEN DSTIVORBEXVIMOVOVIVLODEXZIPSORZORVOLEXGeneric NSAID (e.g. celecoxib; meloxicam)chlorzoxazone 250mg chlorzoxazone 500mgchlorzoxazone 375mg chlorzoxazone 750mg methocarbamol 500mgCONZIP tramadoltramadol erCOSENTYX* ENBREL*HUMIRA*OTEZLA*STELARA*TALTZ*CUPRIMINE* penicillamine*trientine*D.H.E.45 dihydroergotamine injectiondiclofenace 1.3% patchdiclofenac 1.5% solutiondiclofenac 35mg capsuleFLECTORLICARTPENNSAIDVOLTAREN 1% GELgeneric nsaid (e.g. celecoxib; meloxicam)diclofenac 1% geldihydroergotamine 4mg/ml sprayIMITREX NASAL SPRAYMIGRANALONZETRA XSAILZOLMITRIPTAN NASAL SPRAYZOMIGsumatriptan nasal spray ^^ This medication isn’t covered on this drug list. If your doctor feels a diﬀerent medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the non-covered medication. If you don’t get approval and you continue to ﬁll a prescription for a medication that isn’t covered, you’ll pay its full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t be applied to your annual deductible or out-of-pocket maximum.

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30DRUG CLASSMEDICATION NAME^^(Not covered)GENERIC AND/OR PREFERRED BRAND ALTERNATIVE(S)PAIN RELIEF AND INFLAMMATORY DISEASE (cont)GLOPERBA colchicineprobenecid-colchicineGRALISE gabapentinIMITREX CARTRIDGEIMITREX PEN INJECTORdihydroergotaminesumatriptanIMITREX TABLET dihydroergotamineeletriptanrizatriptansumatriptan tabletsINFLIXIMAB* AVSOLA*INFLECTRA*KETOROLAC 15.75MG NASAL SPRAYSPRIXketorolac tabletKINERET* ACTEMRA*ENBREL*HUMIRA*XELJANZ/XR*levorphanol codeine with acetaminophenhydrocodone with acetaminophenHYSINGLA ERoxycodone with acetaminophentramadolXTAMPZA ERLIDODERM lidocaine 5% patchLORZONE chlorzoxazone 500mgcyclobenzaprine tabletNORGESIC FORTEorphenadrine-aspirin-caﬀeineORPHENGESIC FORTE chlorzoxazone 500mg tabletmetaxalonemethocarbamolorphenadrine EROXYCONTIN HYSINGLA ERMORPHABOND ERXTAMPZA EROZOBAX baclofen tabletPROLATE SOLUTION oxycodone-acetaminophen tabletQDOLO tramadol 50mg tabletQULIPTA NURTEC ODTREMICADE* AVSOLA*INFLECTRA*REYVOW generic triptans (e.g. sumatriptan; naratriptan)NURTEC ODTUBRELVYROXICODONE oxycodoneSIMPONI* 50MG/0.5ML ACTEMRA*ENBREL*HUMIRA*STELARA*TALTZ*XELJANZ/XR*^^ This medication isn’t covered on this drug list. If your doctor feels a diﬀerent medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the non-covered medication. If you don’t get approval and you continue to ﬁll a prescription for a medication that isn’t covered, you’ll pay its full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t be applied to your annual deductible or out-of-pocket maximum.

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31DRUG CLASSMEDICATION NAME^^(Not covered)GENERIC AND/OR PREFERRED BRAND ALTERNATIVE(S)PAIN RELIEF AND INFLAMMATORY DISEASE (cont)SORIATANE acitretinSUBSYS fentanyl lozenge or buccal tablettizanidine 2 mg, 4 mg, 6 mg capsule tizanidine 2mg, 4mg tabletTOSYMRA sumatriptantramadol 100mg tramadolTREXIMET sumatriptan-naproxenvtol lq butalbital-acetaminophen-caﬀeine capsule or tabletsphrenilin forteZEMBRACE SYMTOUCH dihydroergotaminesumatriptanZOMIG ZMT zolmitriptan odtPARKINSON’S DISEASEDHIVY carbidopa/levodopaGOCOVRI amantadineLODOSYN carbidopaONGENTYS entacapone ZELAPAR selegiline tablets or capsulesSCHIZOPHRENIA/ANTI-PSYCHOTICSABILIFYABILIFY MYCITEaripiprazolepaliperidone errisperidoneCAPLYTALYBALVIaripiprazoleolanzapinepaliperidone erquetiapinequetiapine errisperidoneziprasidoneGEODON CAPSULE aripiprazolepaliperidone erziprasidoneVERSACLOZ clozapine clozapine odtZYPREXA aripiprazoleolanzapine tabletspaliperidone erZYPREXA ZYDIS aripiprazoleolanzapineolanzapine odtSEIZURE DISORDERSELEPSIA XRKEPPRA XRlevetiracetam erEPRONTIA topiramate sprinkle capsule, tabletFELBATOL felbamateKEPPRA SOLUTION, TABLET levetiracetamLAMICTAL lamotrigineLAMICTAL TAB KIT (BLUE, GREEN, ORANGE) lamotrigine starter kit (blue, green, orange)^^ This medication isn’t covered on this drug list. If your doctor feels a diﬀerent medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the non-covered medication. If you don’t get approval and you continue to ﬁll a prescription for a medication that isn’t covered, you’ll pay its full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t be applied to your annual deductible or out-of-pocket maximum.

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32DRUG CLASSMEDICATION NAME^^(Not covered)GENERIC AND/OR PREFERRED BRAND ALTERNATIVE(S)SEIZURE DISORDERS (cont)LAMICTAL ODT lamotrigine odtLAMICTAL ODT KIT (BLUE, GREEN, ORANGE) lamotrigine odt starter kit (blue, green orange)LAMICTAL XRLAMICTAL XR KIT (BLUE, GREEN, ORANGE)lamotrigine erLYRICALYRICA CRpregabalin erduloxetinegabapentinlidocaine 5% topical patchpregabalinMYSOLINE primidoneQUDEXY XRTROKENDI XRtopiramate erSABRIL* vigabatrin*SYMPAZAN clobazamTOPAMAX topiramateTRILEPTAL oxcarbazepineZONEGRAN zonisamideSKIN CONDITIONSABSORICAABSORICA LDCLARAVISisotretinoinMYORISANZENATANEACANYAACZONEAKLIEFAKTIPAKALTRENOAMZEEQARAZLOATRALINAVITAAZELEXDIFFERINUse generic products (e.g. adapalene; tretinoin; clindamycin-benzoyl peroxide)EPIDUO FORTEFABIORONEXTONRETIN-ARETIN-A MICRORETIN-A MICRO PUMPtazarotene 0.1% foamTAZORACTRETIN-XVELTINWINLEVIZIANAUse generic products (e.g. adapalene; tretinoin; clindamycin-benzoyl peroxide)acyclovir cream, ointmentDENAVIRZOVIRAXacyclovir tabletfamciclovir tabletvalacyclovir tabletadapalene swab adapalene 0.1% creamadapalene 0.1% lotionadapalene 0.3% geltazarotene 0.1% creamtretinoin cream, gel, micro gel^^ This medication isn’t covered on this drug list. If your doctor feels a diﬀerent medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the non-covered medication. If you don’t get approval and you continue to ﬁll a prescription for a medication that isn’t covered, you’ll pay its full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t be applied to your annual deductible or out-of-pocket maximum.

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33DRUG CLASSMEDICATION NAME^^(Not covered)GENERIC AND/OR PREFERRED BRAND ALTERNATIVE(S)SKIN CONDITIONS (cont)ALDARAimiquimod 3.75% ZYCLARAimiquimod 5% creamANUSOL-HC 2.5% CREAM hydrocortisone 2.5% rectal creamAPEXICON ECORDRAN 4 MCG/SQ CM TAPE LARGEdiﬂorasone PSORCONbetamethasone cream, ointmentclobetasol halobetasol cream, ointmentBENZACLINNEUAC 1.2-5% KITclindamycin-benzoyl peroxidecalcipotriene foam calcipotriene cream, ointment, solutioncalcitriol ointment tazarotene creamCARAC ﬂuorouracil 0.5% creamCLINDAGEL clindamycin gelclindamycin topical solutionCLINDAMYCIN 1% GEL clindamycin 1% gel (generic Cleocin T)dapsone 5% gelerythromycin 2% gelCLOBEX clobetasol lotion, shampoo, sprayCONDYLOXVEREGENimiquimod 5% cream packetpodoﬁlox 0.5% topical solutionCORDRAN CREAM, LOTION, OINTMENT betamethasonﬂuocinolone ﬂuticasone CUTIVATE betamethasone lotionﬂuticasone topical lotiontriamcinolone lotiondiclofenac 3% gelKLISYRIFLUOROPLEXﬂuorouracilimiquimod 5% creamDOVONEX calcipotriene creamdoxepin 5% creamPRUDOXINZONALONgeneric topical steroid (e.g. betamethasone)topical tacrolimusDUOBRII halobetasol plus tazarotene creamENSTILARTACLONEXcalcipotriene cream, ointment, solutioncalcipotriene-betamethasone ointment tazarotene creamtopical betamethasoneERTACZO ketoconazole creamEXELDERMoxiconazole OXISTATSULCONAZOLEeconazole creamketoconazole creamnaftiﬁne cream^^ This medication isn’t covered on this drug list. If your doctor feels a diﬀerent medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the non-covered medication. If you don’t get approval and you continue to ﬁll a prescription for a medication that isn’t covered, you’ll pay its full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t be applied to your annual deductible or out-of-pocket maximum.

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34DRUG CLASSMEDICATION NAME^^(Not covered)GENERIC AND/OR PREFERRED BRAND ALTERNATIVE(S)SKIN CONDITIONS (cont)EXTINA ketoconazole creamketoconazole foamFINACEAMETROCREAMMETROGELSOOLANTRAZILXIazelaic acidtopical metronidazoleﬂurandrenolidehydrocortisone 1% lotionbetamethasone ﬂuocinolone ﬂuticasonehalobetasol foamLEXETTEaugmented betamethasone dipropionatebetamethasone dipropionate cream, ointmentclobetasol ﬂuocinonide 0.1% creamhalobetasol cream, ointmentHALOG SOLUTION clobetasol cream, ointmenthalobetasol cream, ointmentIMPEKLO betamethasone dipropionate cream, ointmentclobetasol ﬂuocinonide 0.1% creamhalobetasol cream, ointmentIMPOYZ clobetasol cream, ointmentbetamethasone dipropionate cream, ointmenthalobetasol cream, ointmentJUBLIAKERYDINtavaboroleciclopirox topical solutionitraconazole capsulesterbinaﬁne tabletsKENALOG 0.147MG/GM SPRAYtriamcinolone ointmenttriamcinolone spraydesoximetasone 0.05% cream, ointmentﬂuocinolone 0.025% ointmentﬂurandrenolide 0.05% ointmenthydrocortisone 0.2% ointmentmometasone 0.1% creamLOCOID betamethasone lotionﬂuocinolone creamﬂuticasone creamhydrocortisone ointmentprednicarbate ointmenttriamcinolone creamLOCOID LIPOCREAMnolixPANDELbetamethasone creamﬂuocinolone creamﬂuticasone creamLOPROX 0.77% CREAM 1% SHAMPOO ciclopirox cream, shampooLUZU econazole creamketoconazole creamluliconazoleNORITATE azelaic acidmetronidazole creammetronidazole gelOLUXOLUX-Ebetamethasone dipropionate cream, ointmentclobetasol cream, foam, ointmenthalobetasol cream, ointment^^ This medication isn’t covered on this drug list. If your doctor feels a diﬀerent medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the non-covered medication. If you don’t get approval and you continue to ﬁll a prescription for a medication that isn’t covered, you’ll pay its full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t be applied to your annual deductible or out-of-pocket maximum.

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35DRUG CLASSMEDICATION NAME^^(Not covered)GENERIC AND/OR PREFERRED BRAND ALTERNATIVE(S)SKIN CONDITIONS (cont)OPZELURA EUCRISApimecrolimustacrolimus ointmentQBREXZA DRYSOLSERNIVO betamethasone SORILUX calcipotriene cream, ointment, solutioncalcitriol ointment tazarotene creamTRIANEX triamcinolone creamTRIDESILON alclometasonedesonidetriamcinoloneULTRAVATE LOTIONULTRAVATE Xbetamethasone ointmentclobetasol cream, lotion, ointmenthalobetasol cream, ointmentVANOS clobetasol creamﬂuocinonide 0.1% creamhalobetasol creamVECTICAL calcitriol ointment calcipotriene ointment tazarotene creamVERDESO desonide creamdesonide ointmentWYNZORA betamethasonecalcipotrienecalcipotriene-betamethasoneﬂuocinolone ﬂuticasone mometasone triamcinolone creamXERESE acyclovir tabletfamciclovir tabletplus hydrocortisone prescription creamvalacyclovir tabletXOLEGEL ciclopirox 0.77% gelciclopirox 1% shampooketoconazole 2% creamketoconazole 2% foamselenium sulﬁde 2.5% lotionsodium sulfacetamide 10% shampooSLEEP DISORDERS/SEDATIVESAMBIEN zolpidemAMBIEN CR zolpidem erATIVAN TABLET lorazepamBELSOMRA DAYVIGOEDLUAR zolpidem or zolpidem erNUVIGIL armodaﬁnilPROVIGIL modaﬁnilRESTORIL temazepam^^ This medication isn’t covered on this drug list. If your doctor feels a diﬀerent medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the non-covered medication. If you don’t get approval and you continue to ﬁll a prescription for a medication that isn’t covered, you’ll pay its full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t be applied to your annual deductible or out-of-pocket maximum.

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37Frequently Asked Questions (FAQs)Understanding your prescription medication coverage can be confusing. Here are answers to some commonly asked questions.Q. Why do you make changes to the drug list?A. Cigna regularly reviews and updates the prescription drug list. We make changes for many reasons – like when new medications become available or are no longer available, or when medication prices change. These changes may include:3,4› Moving a medication to a lower cost tier. This can happen at any time during the year.› Moving a brand medication to a higher cost tier when a generic becomes available. This can happen at any time during the year.› Moving a medication to a higher cost tier and/or no longer covering a medication. This typically happens twice a year on January 1st and July 1st.› Adding extra coverage requirements to a medication. When we make a change that aects the coverage of a medication you’re taking, we let you know before it happens. This way, you have time to talk with your doctor about your options. We try to give you many options to choose from to treat your health condition. Q. Why doesn’t my plan cover certain medications?A. To help lower your overall health care costs, your plan doesn’t cover certain high-cost brand medications because they have lower-cost, covered alternatives which are used to treat the same condition. Meaning, the alternative works the same or similar to the non-covered medication. If you’re taking a medication that 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.Your plan may also exclude certain medications or products from coverage. This is known as a “plan (or beneﬁt) exclusion.” For example, your plan excludes:› Prescription medications used to treat heartburn/stomach acid conditions (e.g., Nexium, Prilosec and any generics) and allergies (e.g., Allegra, Clarinex, Xyzal and anygenerics). These are available over-the-counter without a prescription.› Medications used to treat lifestyle conditions like infertility, erectile dysfunction, smoking cessation.6› Medications that aren’t approved by the U.S. Food and Drug Administration (FDA).Q. How do you decide which medications to cover?A. The Cigna Prescription Drug List is developed with the help of Cigna’s Pharmacy and Therapeutics (P&T) Committee, which is a group of practicing doctors and pharmacists, most of whom work outside of Cigna. The group meets regularly to review medical evidence and information provided by federal agencies, drug manufacturers, medical professional associations, national organizations and peer-reviewed journals about the safety and eectiveness of medications that are newly approved by the FDA and medications already on the market. The Cigna Pharmacy Management® Business Decision Team then looks at the results of the P&T Committee’s clinical review, as well as the medication’s overall value and other factors before adding it to, or removing it from, the drug list. Q. Why do certain medications need approval before my plan will cover them?A. The review process 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.Q. How do I know if I’m taking a medication that needs approval?A. Log in to the myCigna App or myCigna.com, or check your plan materials, to learn more about how your plan covers your medications. If your medication has a (PA) or (ST) next to it, your medication needs approval before your plan will cover it. If it has a (QL) next to it, you may need approval depending on the amount you’re ﬁlling. If is has (AGE) next

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38Frequently Asked Questions (FAQs) (cont)to it, you may need approval depending on the covered age range for the medication.Q. What types of medications typically need approval?A. Medications that:› May be unsafe when combined with other medications› Have lower-cost, equally eective alternatives available› Should only be used for certain health conditions› Are often misused or abusedQ. What types of medications typically have quantity limits?A. Medications that:› Are often taken in amounts larger than, or for longer than, may be appropriate› Are often misused or abusedQ. What types of medications require Step Therapy?A. The Step Therapy program includes medications that are used to treat many conditions, including, but not limited to:› ADD/ADHD › High cholesterol› Allergies › Osteoporosis› Bladder problems › Pain› Breathing problems › Skin conditions› Depression › Sleep disorders› High blood pressure Q. Why does my medication have an age requirement?A. Some medications are only considered clinically appropriate for people of a certain age.Q. How do I get approval (prior authorization) for my medication?A. Ask your doctor’s oce to contact Cigna so we can start the coverage review process. They know how the review process works and will take of everything for you. In case the oce asks, they can download a request form from Cigna’s provider portal at cignaforhcp.com.Cigna will review information your doctor provides to make sure your medication meets coverage guidelines. We’ll send you and your doctor a letter with the decision and next steps. It can take 1-5 days to hear from us. You can always check with your doctor’s oce to ﬁnd out if a decision has been made. You can also log in to myCigna.com or the myCigna app to check the status of your approval. Click on Prescriptions, then choose My Medications from the dropdown menu. On the left side of the page under “Prior Authorization,” click the “View List” button. If you meet guidelines, your medication will be approved for coverage. If you don’t meet guidelines, you and your doctor can appeal the decision by sending Cigna a written request stating why the medication should be covered.Q. What happens if I try to ﬁll a prescription that needs approval but I don’t get approval ahead of time?A. When your pharmacist tries to ﬁll your prescription, he or she will see that the medication needs prior approval. Because you didn’t get approval ahead of time, your plan coverage won’t apply. Meaning, your plan won’t cover the cost of your medication. You should ask your doctor to contact Cigna to start the coverage review process. Or, you can choose to pay its full cost out-of-pocket directly to the pharmacy (the cost can’t be applied to your annual deductible or out-of-pocket maximum).Q. What happens if I try to ﬁll a prescription that has a quantity limit?A. Your pharmacist will only ﬁll the amount your plan covers. If you want to ﬁll more than what’s allowed, your doctor’s oce will need to contact Cigna to request approval for coverage. Q. Are all of the medications on this drug list approved by the U.S. Food and Drug Administration (FDA)?A. Yes. All medications are approved by the FDA.

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39Frequently Asked Questions (FAQs) (cont)Q. Are medications newly approved by the FDA covered on my drug list?A. Newly approved medications may not be covered on your drug list for the ﬁrst six months after they receive approval from the FDA. These include, but are not limited to, medications, medical supplies and/or devices covered under standard pharmacy beneﬁt plans. We review all newly approved medications to see if they should be covered - and if so, on what tier. If your doctor feels a currently covered medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the newly approved medication.Q. Which medications are covered under the health care reform law?A. The Patient Protection and Aordable Care Act (PPACA), commonly referred to as “health care reform,” was signed into law on March 23, 2010. Under this law, certain preventive medications (including some over-the counter products) may be available to you at no cost-share ($0), depending on your plan. Log in to the myCigna App or myCigna.com, or check your plan materials, to learn more about how your plan covers preventive medications. You can also view the PPACA No Cost-Share Preventive Medications drug list at Cigna.com/PDL.For more information about health care reform, go to informedonreform.com or Cigna.com.Q. How can I ﬁnd out how much I’ll pay for a speciﬁc medication?A. When you and your doctor are considering the right medication for your treatment, knowing how much it costs, what lower-cost alternatives are available, and which pharmacies oer the best prices can help you avoid surprises. Log in to the myCigna App or myCigna.com and use the Price a Medication tool to see how much your medication costs before you get to the pharmacy counter - or, even before you leave your doctor’s oce.7Q. How can I save money on my prescription medications?A. You may be able to save money by switching to a medication that’s on a lower tier (ex. generic or preferred brand) or by ﬁlling a 90-day supply, if your plan allows. You should talk with your doctor to ﬁnd out if one of these options may work for youQ. Do generics work the same as brand-name medications?A. Yes. A generic medication works in the same way and provides the same clinical beneﬁt as its brand-name version.8 Generic and brand-name medications have the same active ingredients, strength, dosage form, eectiveness, quality, and safety.Q. What are the dierences between generic and brand-name medications? A. The medications may look dierent. For example, generics may have a dierent shape, size or color than the brand-name medication. They may also have a dierent ﬂavor, contain dierent preservatives, come in dierent packaging and/or with dierent labeling and may expire at dierent times. Generics may look dierent than the brand-name, but they’re just as safe and eective.Generics typically cost much less than brand-name medications - in some cases, up to 85% less.8 Just because generics cost less than brands, doesn’t mean they’re lower-quality medications.Q. My pharmacy isn’t in my plan’s network. Can I continue to ﬁll my prescriptions there? A. To receive in-network coverage under your plan, you’ll need to switch to a pharmacy in your plan’s network. If your plan oers out-of-network coverage, you’ll pay out-of-network costs to ﬁll a prescription there. Q. Can I ﬁll my prescriptions by mail?A. Yes, as long as your plan oers home delivery.9Home delivery with Express Scripts® PharmacyExpress Scripts® Pharmacy, our home delivery

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40Frequently Asked Questions (FAQs) (cont)pharmacy, is a convenient option when you’re taking a medication on a regular basis to treat an ongoing health condition. It’s simple and safe, and saves you trips to the pharmacy. To learn more, go to Cigna.com/homedelivery. › Easily order, manage, track, and pay for your medications on your phone or online› Standard shipping at no extra cost10› Automatic reﬁlls or reﬁll reminders› Fill up to a 90-day supply at one time› Helpful pharmacists available 24/7› Flexible payment optionsHere are three easy ways to get started.1. Log in to the myCigna App or myCigna.com to move your prescription electronically. Click on the Prescriptions tab and select My Medications from the dropdown menu. Then simply click the button next to your medication name to move your prescription(s). Or,2. Call your doctor’s oce. Ask them to send a 90-day prescription (with reﬁlls) electronically to Express Scripts Home Delivery. Or,3. Call Express Scripts® Pharmacy at 800.835.3784. They’ll contact your doctor’s oce to help transfer your prescription. Have your Cigna ID card, doctor’s contact information and medication name(s) ready when you call.Accredo®, a Cigna specialty pharmacy If you’re taking a specialty medication to treat a complex medical condition, Accredo’s team of specialty trained pharmacists and nurses can help. They’ll ﬁll and ship your specialty medication to your home (or location of your choice).11 They’ll also provide you with the personalized care and support you need to manage your therapy – at no extra cost. To learn more, go to Cigna.com/specialty.› Easily manage and track your medications on your phone or online› Fast shipping, at no extra cost10› Easy reﬁlls and free reminders› 24/7 access to specialty-trained pharmacists and nurses› Personalized care services like training on how to administer your medication› Help with applying for third-party copay assistance programs and other optionsTo get started using Accredo, call 877.826.7657, Monday–Friday, 7:00 am–10:00 pm CST and Saturdays, 7:00 am–4:00 pm CST. Be sure to call Accredo about two weeks before your next reﬁll so they have time to get a new prescription from your doctor’s oce. Q. Where can I ﬁnd more information about my pharmacy beneﬁts?A. You can use the online tools and resources on the myCigna App or myCigna.com to help you better understand your pharmacy coverage. You can ﬁnd out how much your medication costs, see which medications your plan covers, ﬁnd an in-network pharmacy, ask a pharmacist a question and see your pharmacy claims and coverage details. You can also manage your home delivery prescription orders.

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41Exclusions and limitations for coverage› over-the-counter (OTC) medicines (those that do not require a prescription) except insulin unless state or federal law requires coverage of suchmedicines;› prescription medications or supplies for which there is a prescription or OTC therapeutic equivalent or therapeutic alternative;› doctor-administered injectable medications covered under the Plan’s medical beneﬁt, unless otherwise covered under the Plan’s prescription druglist or approved by Cigna;› implantable contraceptive devices covered under thePlan’s medical beneﬁt;› medications that are not medically necessary;› experimental or investigational medications, including FDA-approved medications used for purposes other than those approved by the FDA unless the medication is recognized for the treatment of the particularindication;› medications that are not approved by the Food & Drug Administration (FDA);› prescription and non-prescription devices, supplies, and appliances other than those supplies speciﬁcally listed as covered;› medications used for fertility13, sexual dysfunction, cosmetic purposes, weight loss, smoking cessation13, or athletic enhancement;› prescription vitamins (other than prenatal vitamins) or dietary supplements unless state or federal law requires coverage of such products;› immunization agents, biological products for allergy immunization, biological sera, blood, blood plasma and other blood products or fractions and medications used for travel prophylaxis;› replacement of prescription medications and related supplies due to loss or theft;› medications which are to be taken by or administered to a covered person while they are a patient in a licensed hospital, skilled nursing facility, rest home or similar institution which operates on its premises or allows to be operated on its premises a facility for dispensing pharmaceuticals;› prescriptions more than one year from the date of issue; or› coverage for prescription medication products for the amount dispensed (days’ supply) which is more than the applicable supply limit, or is less than any applicable supply minimum set forth in The Schedule, or which is more than the quantity limit(s) or dosage limit(s) set by the P&T Committee. › more than one prescription order or reﬁll for a given prescription supply period for the same prescription medication product prescribed by one or more doctors and dispensed by one or more pharmacies. › prescription medication products dispensed outside the jurisdiction of the United States, except as required for emergency or urgent care treatment.In addition to the plan’s standard pharmacy exclusions, certain new FDA-approved medication products (including, but not limited to, medications, medical supplies or devices that are covered under standard pharmacy beneﬁt plans) may not be covered for the ﬁrst six months of market availability unless approved by Cigna as medically necessary.Health beneﬁt plans vary, but in general to be eligible for coverage a drug must be approved by the Food and Drug Administration (FDA), prescribed by a health care professional, purchased from a licensed pharmacy and be medically necessary. If your plan provides coverage for certain preventive prescription drugs with no cost-share, you may be required to use an in-network pharmacy to ﬁll the prescription. If you use apharmacy that does not participate in your plan’s network, the prescription may not be covered. Certain drugsmay require prior authorization, or be subject to step therapy, quantity limits or other utilization management requirements.Plans generally do not provide coverage for the following under the pharmacy beneﬁt, except as required by state orfederal law, or by the terms of your speciﬁc plan:12

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1. The downloading and use of the myCigna App is subject to the terms and conditions of the App and the online stores from which it is downloaded. Standard mobile phone carrier and data usage charges apply. Actual App features available may vary depending on your plan and individual security proﬁle.2. Customers under age 13 (and/or their parent/guardian) will not be able to register at myCigna.com.3. State laws in Connecticut, Louisiana, New York, and Texas may require your plan to cover your medication at your current beneﬁt level until your plan renews. This means that if your medication is taken oﬀ the drug list, is moved to a higher cost-share tier or needs approval from Cigna before your plan will cover it, these changes may not begin until your plan’s renewal date. To ﬁnd out if these state laws apply to your plan, please call Customer Service using the number on your Cigna ID card.4. State law in Illinois may require your plan to cover your medications at your current beneﬁt level until your plan renews. This means that if you currently have approval through a review process for your plan to cover your medication, the drug list change(s) listed here may not aﬀect you until your plan renewal date. If you don’t currently have approval through a coverage review process, you may continue to receive coverage at your current beneﬁt level if your doctor requests it. To ﬁnd out if this state law applies to your plan, please call Customer Service using the number on your Cigna ID card.5. For insured plans that must follow Delaware’s state insurance laws: Brand-name antidepressant, smoking cessation, attention deﬁcit hyperactivity disorder (ADHD), and anti-psychotic medications that don’t have a generic equivalent available will be covered as Tier 2 (preferred brand). This is true even if the medication is listed as Tier 3 (non-preferred brand) on your plan’s drug list. To ﬁnd out how your speciﬁc plans covers these medications, log in to the myCigna App or myCigna.com, or call Customer Service using the number on your Cigna ID card. 6. Smoking cessation medications are not typically covered under the plan, except as required by law or by the terms of your speciﬁc plan. Costs and complete details of the plan’s prescription drug coverage, including a full list of exclusions and limitations, are set forth in the plan documents. If there are any diﬀerences between the information provided here and the plan documents, the information in the plan documents takes complete precedence.7. Prices shown on myCigna are not guaranteed and coverage is subject to your plan terms and conditions. Visit myCigna for more information. 8. U.S. Food and Drug Administration (FDA) website, “Generic Drugs: Questions and Answers.” Last updated 03/16/21. https://www.fda.gov/drugs/questions-answers/generic-drugs-questions-answers.9. Not all plans oﬀer home delivery and Accredo as covered pharmacy options. Log in to the myCigna App or myCigna.com, or check your plan materials, to learn more about the pharmacies in your plan’s network. 10. Standard shipping costs are included as part of your prescription plan.11. As allowable by law. For medications administered by a health care provider, Acrredo will ship the medication directly to your doctor’s oﬃce.12. Costs and complete details of the plan’s prescription drug coverage are set forth in the plan documents. If there are any diﬀerences between the information provided here and the plan documents, the information in the plan documents takes complete precedence. 13. Plans that must follow state insurance laws, like Delaware’s state insurance laws, may provide coverage for infertility medications and smoking cessation medications even if this drug list states that your plan may not cover them. To ﬁnd out if your speciﬁc plan covers these medications, log in to the myCigna App or myCigna.com, or check your plan materials. Product availability may vary by location and plan type and is subject to change. All group health insurance policies and health beneﬁt plans contain exclusions and limitations. For costs and details of coverage, review your plan documents or contact a Cigna representative.All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company (CHLIC), Accredo Health Group, Inc., Express Scripts, Inc., ESI Mail Pharmacy Service, Inc, Express Scripts Pharmacy, Inc., and HMO or service company subsidiaries of Cigna Health Corporation, including Cigna HealthCare of Arizona, Inc., Cigna HealthCare of California, Inc., Cigna HealthCare of Colorado, Inc., Cigna HealthCare of Connecticut, Inc., Cigna HealthCare of Florida, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Illinois, Inc., Cigna HealthCare of Indiana, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of New Jersey, Inc., Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of Tennessee, Inc., (CHC-TN), and Cigna HealthCare of Texas, Inc. “Accredo” refers to Accredo Health Group, Inc. “Express Scripts Pharmacy” refers to ESI Mail Pharmacy, Inc. Policy forms: OK - HP-APP-1 et al., OR - HP-POL38 02-13, TN - HP-POL43/HC-CER1V1 et al. (CHLIC); GSA-COVER, et al. (CHC-TN). The Cigna name, logo, “Together all the way.,” and “myCigna” are trademarks of Cigna Intellectual Property, Inc. “Accredo” and “Express Scripts Pharmacy” are trademarks of Express Scripts Strategic Development, Inc.968436 Advantage 3-Tier 08/22 © 2022 Cigna. Some content provided under license.Cigna reserves the right to make changes to the Drug List without notice. Your plan may cover additional medications; please refer to your enrollment materials for details. Cigna does not take responsibility for any medication decisions made by the doctor or pharmacist. Cigna may receive payments from manufacturers of certain preferred brand medications, and in limited instances, certain non-preferred brand medications, that may or may not be shared with your plan depending on its arrangement with Cigna. Depending upon plan design, market conditions, the extent to which manufacturer payments are shared with your plan and other factors as of the date of service, the preferred brand medication may or may not represent the lowest-cost brand medication within its class for you and/or your plan.

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All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Evernorth Care Solutions, Inc., Evernorth Behavioral Health, Inc., Cigna Health Management, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. ATTENTION: If you speak languages other than English, language assistance services, free of charge are available to you. For current Cigna customers, call the number on the back of your ID card. Otherwise, call 1.800.244.6224 (TTY:Dial 711). ATENCIÓN: Si usted habla un idioma que no sea inglés, tiene a su disposición servicios gratuitos de asistencia lingüística. Si es un cliente actual de Cigna, llame al número que ﬁgura en el reverso de su tarjeta de identiﬁcación. Si no lo es, llame al 1.800.244.6224 (losusuarios de TTY deben llamar al 711). 896375b 05/21 © 2021 Cigna.Cigna complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Cigna does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.Cigna:• Provides free aids and services to people with disabilities to communicate eectively with us, suchas:– Qualiﬁed sign language interpreters– Written information in other formats (large print, audio, accessible electronic formats, otherformats)• Provides free language services to people whose primary language is not English, such as:– Qualiﬁed interpreters– Information written in other languagesIf you need these services, contact customer service at the toll-free number shown on your IDcard, and ask a Customer Service Associate for assistance.If you believe that Cigna has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by sending an email toACAGrievance@Cigna.com or by writing to the following address:CignaNondiscrimination Complaint CoordinatorPO Box 188016Chattanooga, TN 37422If you need assistance filing a written grievance, please call the number on the back of your ID card or send an email to ACAGrievance@Cigna.com. You can also file a civil rights complaint with the U.S.Department of Health and Human Services, Office for Civil Rights electronically through the Officefor Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail orphone at:U.S. Department of Health and Human Services200 Independence Avenue, SWRoom 509F, HHH BuildingWashington, DC 202011.800.368.1019, 800.537.7697 (TDD)Complaint forms are available at http://www.hhs.gov/ocr/oce/ﬁle/index.html.DISCRIMINATION IS AGAINST THE LAWMedical coverage

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Proﬁciency of Language Assistance ServicesEnglish – ATTENTION: Language assistance services, free of charge, are available to you. For current Cigna customers, call the number on the back of your ID card. Otherwise, call 1.800.244.6224 (TTY: Dial 711).Spanish – ATENCIÓN: Hay servicios de asistencia de idiomas, sin cargo, a su disposición. Si es un cliente actual de Cigna, llame al número que figura en el reverso de su tarjeta de identificación. Si no lo es, llame al 1.800.244.6224 (los usuarios de TTY deben llamar al 711).Chinese – 注意：我們可為您免費提供語言協助服務。對於 Cigna 的現有客戶，請致電您的 ID 卡背面的號碼。其他客戶請致電 1.800.244.6224 （聽障專線：請撥 711）。VietnameseKorean – 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 현재 Cigna 가입자님들께서는 ID 카드 뒷면에 있는 전화번호로 연락해주십시오. 기타 다른 경우에는 1.800.244.6224 (TTY: 다이얼 711)번으로 전화해주십시오.Tagalog – PAUNAWA: Makakakuha ka ng mga serbisyo sa tulong sa wika nang libre. Para sa mga kasalukuyang customer ng Cigna, tawagan ang numero sa likuran ng iyong ID card. O kaya, tumawag sa 1.800.244.6224 (TTY: I-dial ang 711).RussianCigna – Arabic711:TTY) 1.800.244.6224French Creole – ATANSYON: Gen sèvis èd nan lang ki disponib gratis pou ou. Pou kliyan Cigna yo, rele nimewo ki dèyè kat ID ou. Sinon, rele nimewo 1.800.244.6224 (TTY: Rele 711).French – ATTENTION: Des services d’aide linguistique vous sont proposés gratuitement. Si vous êtes un client actuel de Cigna, veuillez appeler le numéro indiqué au verso de votre carte d’identité. Sinon, veuillez appeler le numéro 1.800.244.6224 (ATS: composez le numéro 711).Portuguese – ATENÇÃO: Tem ao seu dispor serviços de assistência linguística, totalmente gratuitos. Para clientes Cigna atuais, ligue para o número que se encontra no verso do seu cartão de identificação. Caso contrário, ligue para 1.800.244.6224 (Dispositivos TTY: marque 711).Polish – UWAGA: w celu skorzystania z dostępnej, bezpłatnej pomocy językowej, obecni klienci firmy Cigna mogą dzwonić pod numer podany na odwrocie karty identyfikacyjnej. Wszystkie inne osoby prosimy o skorzystanie z numeru 1 800 244 6224 (TTY: wybierz 711).Japanese – 注意事項：日本語を話される場合、無料の言語支援サービスをご利用いただけます。現在のCignaのお客様は、IDカード裏面の電話番号まで、お電話にてご連絡ください。その他の方は、1.800.244.6224（TTY: 711）まで、お電話にてご連絡ください。Italian – ATTENZIONE: Sono disponibili servizi di assistenza linguistica gratuiti. Per i clienti Cigna attuali, chiamare il numero sul retro della tessera di identificazione. In caso contrario, chiamare il numero 1.800.244.6224 (utenti TTY: chiamare il numero 711).German – ACHTUNG: Die Leistungen der Sprachunterstützung stehen Ihnen kostenlos zur Verfügung. Wenn Sie gegenwärtiger Cigna-Kunde sind, rufen Sie bitte die Nummer auf der Rückseite Ihrer Krankenversicherungskarte an. Andernfalls rufen Sie 1.800.244.6224 an (TTY: Wählen Sie 711).Cigna– Persian (Farsi)7111.800.244.6224 896375b 05/21