Generic medications start with a lowercase letter and brand name medications start with a capital letter.

909015 UPDATED_10/12/2018

The medications listed below are changing coverage (or cost levels) on Cigna’s Prescription Drug List. Changes are listed by drug list name and by the date they begin.

If you’re enrolled with Cigna, you can log into myCigna.com to find out how these changes may affect your specific plan.

STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST

PRESCRIPTION DRUG LIST CHANGESCigna Pharmacy Management® 2018

Start date of change*

Drug class Medication not covered^ Generic and/or preferred brand alternatives

November 15, 2018

CANCER Yonsa ZytigaPAIN RELIEF AND INFLAMMATORY DISEASE Aimovig antiepileptic drugs, antidepressants,

beta blockersNovember 1, 2018

INFECTIONS nitrofurantoin 25mg/ml oral suspension sulfamethoxazole-trimethoprim suspension, nitrofurantoin capsule

September 1, 2018

SKIN CONDITIONS Doxepin 5% Cream generic topical steroid (e.g. betamethasone) or topical tacrolimus

July 1, 2018 DIABETES Segluromet Synjardy, Synjardy XR, Xigduo XRSteglatro Farxiga, JardianceSteglujan Glyxambi, QTERN

GASTROINTESTINAL/HEARTBURN OmePPI omeprazoleINFECTIONS Mycobutin rifabutinMULTIPLE SCLEROSIS Copaxone Aubagio, Avonex, Betaseron, Extavia,

Gilenya, glatiramer, Glatopa, Plegridy, Rebif, Tecfidera

SEIZURE DISORDERS Lyrica CR duloxetine, gabapentin, lidocaine 5% topical patch, Lyrica

SKIN CONDITIONS diclofenac 3% gel, Solaraze Fluoroplex, fluorouracil, imiquimod, PicatoMay 15, 2018 EYE CONDITIONS Vyzulta bimatoprost, latanoprost, Travatan ZApril 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE Duzallo allopurinol, probenecid, UloricMarch 1, 2018 DIABETES Fiasp Humalog

PARKINSON’S DISEASE Gocovri amantadineFebruary 1, 2018 ASTHMA/COPD/RESPIRATORY ArmonAir QVAR, Pulmicort FlexhalerJanuary 13, 2018 GASTROINTESTINAL/HEARTBURN Syndros dronabinolJanuary 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipramine

Pamelor nortriptylineParnate tranylcypromineTofranil imipramine

STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont)

Start date of change*

Drug class Medication not covered^ Generic and/or preferred brand alternatives

January 1, 2018 ASTHMA/COPD/RESPIRATORY Zyflo montelukast, zafirlukast, zileuton ERZyflo CR zileuton ER

ATTENTION DEFICIT HYPERACTIVITY DISORDER

Desoxyn methamphetamineDexedrine dextroamphetamine, dextroamphetamine ER

BLOOD PRESSURE/HEART MEDICATIONS Betapace sotalol tabletsCANCER Nilandron nilutamideDIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR

Invokana Farxiga, JardianceLantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba Novolin, Novolog Humalog, Humulin

GASTROINTESTINAL/HEARTBURN Cortifoam, Uceris rectal foam Anucort-HC, Colocort, Hemmorex-HC, hydrocortisone, Procto-Med HC, Procto-Pak, Proctosol-HC, Proctozone-HC

Lotronex alosetronMarinol dronabinolomeprazole bicarbonate packets, 40-1100mg capsules

omeprazole

Rowasa mesalamine enemaUceris tablet budesonide EC capsuleZegerid omeprazoleZofran ondansetronZofran ODT ondansetron ODT

HORMONAL AGENTS DDAVP desmopressinHectorol doxercalciferol capsule

INFECTIONS Augmentin, Augmentin ES, Augmentin XR amoxicillin-clavulanate ER, amoxicillin-clavulanate

Diflucan fluconazoleE.E.S. 200, Eryped 400 erythromycin ethylsuccinateMepron atovaquoneSporanox itraconazoleTargadox Avidoxy tablet, doxycycline hyclate,

Morgidox capsuleValcyte valganciclovirVancocin vancomycin capsuleZovirax acyclovir

MISCELLANEOUS Gralise, Horizant gabapentinPAIN RELIEF AND INFLAMMATORY DISEASE Cambia diclofenac, diclofenac ER, etodolac,

etodolac ER, fenoprofen, Fenortho, flurbiprofen, ibuprofen, indomethacin, indomethacin ER, ketoprofen, Ketorolac, meclofenamate, mefenamic acid, meloxicam, nabumetone

D.H.E. 45, Migranal dihydroergotamineImitrex, Sumavel DosePro sumatriptan

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont)

Start date of change*

Drug class Medication not covered^ Generic and/or preferred brand alternatives

January 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE (cont)

Lorzone chlorzoxazoneOxyContin Embeda, Hysingla ER, Xtampza ERRoxicodone oxycodoneTivorbex indomethacinVanatol LQ butalbital/acetaminophen/caffeine tabs

or capsVivlodex meloxicamZomig sumatriptan, zolmitriptanZorvolex diclofenac, diclofenac ER

PARKINSON'S DISEASE Lodosyn carbidopaRequip XL ropinirole ER

SCHIZOPHRENIA/ANTI-PSYCHOTICS Geodon ziprasidoneZyprexa olanzapineZyprexa Zydis olanzapine ODT

SKIN CONDITIONS Cutivate fluticasone creamKenalog triamcinolone sprayLocoid lotion hydrocortisone butyrateLuzu ketoconazole creamSoriatane acitretinZiana clindamycin-tretinoin

SLEEP DISORDERS/SEDATIVES Nuvigil armodafinilProvigil modafinilRestoril temazepam

URINARY TRACT CONDITIONS Detrol tolterodineDetrol LA tolterodine ERDitropan XL oxybutynin EREnablex darifenacin ERGelnique darifenacin ER, oxybutynin ER, tolterodine

ER, trospium ER

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

Start date of change*

Drug class Preferred brand medication

November 15, 2018

BLOOD MODIFIERS/BLEEDING DISORDERS Fulphila+

October 1, 2018 GASTROINTESTINAL/HEARTBURN Entyvio+

Nexium Powder Pack

SUBSTANCE ABUSE Lucemyra

June 1, 2018 DIABETES Ozempic

Victoza

April 1, 2018 DIABETES QTERN

January 1, 2018 MISCELLANEOUS Nityr+

STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont)

Start date of change*

Drug classNon-preferred brand medication

Generic and/or preferred brand alternatives

December 15, 2018

HORMONAL AGENTS Imvexxy estradiol 10mcg vaginal insert, estradiol 0.01% cream, Premarin cream, Estring

December 9, 2018

PAIN RELIEF AND INFLAMMATORY DISEASE Olumiant+ Actemra, Enbrel, Humira, Remicade

October 1, 2018 EYE CONDITIONS Rhopressa Talk with your doctor to find out if there are lower-cost options available.

August 15, 2018 ASTHMA/COPD/RESPIRATORY Lonhala Incruse Ellipta, Spiriva Handihaler, Sprivia Respimat, Anoro Ellipta, Stiolto Respimat, Trelegy Ellipta

Symdeko+ Talk with your doctor to find out if there are lower-cost options available.

July 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Arixtra+ fondaparinuxLovenox+ enoxaparinReopro+ Talk with your doctor to find out if there

are lower-cost options available.CANCER dexrazoxane+, Evomela+, Hycamtin

capsule+, Nilandron+, nilutamide+, ZinecardTalk with your doctor to find out if there are lower-cost options available.

CONTRACEPTION PRODUCTS Depo-Provera 150mg/ml medroxyprogesteroneLoSeasonique Amethia Lo, Camrese Lo, levonorg-eth

estradiol 0.1/0.02/0.01mgNexplanon+, Paragard T 380-a+ Talk with your doctor to find out if there

are lower-cost options available.Seasonique Amethia, Ashlyna, Camrese, Daysee,

levonorg-eth estradiol 0.15/0.03/0.01mgDENTAL PRODUCTS Arestin+ Talk with your doctor to find out if there

are lower-cost options available.DIABETES Korlym+ Talk with your doctor to find out if there

are lower-cost options available.EYE CONDITIONS Cystaran+, Ozurdex+, Retisert+ Talk with your doctor to find out if there

are lower-cost options available.GASTROINTESTINAL/HEARTBURN alosetron+, Buphenyl+, Chenodal+, Ravicti+,

sodium phenylbutyrateTalk with your doctor to find out if there are lower-cost options available.

HORMONAL AGENTS Aveed+, hydroxyprogesterone caproate+ Talk with your doctor to find out if there are lower-cost options available.

Depo-Provera 400mg/ml medroxyprogesterone

INFECTIONS Daraprim+, Sirturo+ Talk with your doctor to find out if there are lower-cost options available.

INFERTILITY Makena+ Talk with your doctor to find out if there are lower-cost options available.

MISCELLANEOUS Asclera+, Carbaglu+, Ferriprox+, Flebogamma DIF+, Keveyis+, Varithena+

Talk with your doctor to find out if there are lower-cost options available.

Orfadin+ Nityr

PAIN RELIEF AND INFLAMMATORY DISEASE (NON-NARCOTIC)

Colcrys colchicine

PARKINSON’S DISEASE Azilect rasagiline

SEIZURE DISORDERS Lamictal ODT lamotrigine ODT

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

Start date of change*

Drug classNon-preferred brand medication

Generic and/or preferred brand alternatives

July 1, 2018 SKIN CONDITIONS Ameluz+, Levulan+ Talk with your doctor to find out if there are lower-cost options available.

Tazorac 0.1% cream tazarotene

SLEEP DISORDERS/SEDATIVES Hetlioz+ Talk with your doctor to find out if there are lower-cost options available.

TRANSPLANT MEDICATIONS Cellcept+ mycophenolate

Neoral 25mg capsule, solution+ cyclosporine modified, Gengraf

Sandimmune 100mg capsule+ cyclosporine

URINARY TRACT CONDITIONS Thiola+ Talk with your doctor to find out if there are lower-cost options available.

March 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic Talk with your doctor to find out if there are lower-cost options available.

HORMONAL AGENTS Depo-Testosterone testosterone cypionateFebruary 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Bevyxxa enoxaparin, Fragmin

January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal spray

ATTENTION DEFICIT HYPERACTIVITY DISORDER

Adderall XR dextroamphetamine-amphetamine ER

Focalin XR dexmethylphenidate ER

SKIN CONDITIONS Ala-Scalp hydrocortisone

Analpram HC lotion hydrocortisone-pramoxine

Capex shampoo fluocinolone

Cordran flurandrenolide

Differin adapalene

Metrogel metronidazole gel

Naftin naftifine

Nucort, Texacort hydrocortisone

Start date of change*

Drug classMedication requiring prior authorization^^

Additional information

December 9, 2018

PAIN RELIEF AND INFLAMMATORY DISEASE Olumiant+ Your plan only covers this medication if your doctor requests and receives approval from Cigna. If you’re taking this medication, ask your doctor to call us soon so we can begin the review process.

August 15, 2018 ASTHMA/COPD/RESPIRATORY Lonhala

July 1, 2018 CANCER Hycamtin++, Targretin++, tretinoin capsule++, Xeloda++

MISCELLANEOUS Nityr, Orfadin++

PAIN RELIEF AND INFLAMMATORY DISEASE (NARCOTIC)

Diskets, Dolophine, methadone++, Methadose

March 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic

January 1, 2018 GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi

HORMONAL AGENTS Androderm, Androgel, Striant, testosterone

MISCELLANEOUS Nityr

STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont)

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont)

Start date of change*

Drug classMedication with quantity limits^^

Additional information

December 15, 2018

HORMONAL AGENTS Imvexxy estradiol 10mcg vaginal insert, estradiol 0.01% cream, Premarin cream, Estring

September 1, 2018

SKIN CONDITIONS Prudoxin, Zonalon generic topical steroid (e.g. betamethasone) or topical tacrolimus

August 15, 2018 ASTHMA/COPD/RESPIRATORY Symdeko Your plan only covers up to a certain amount of this medication over a certain amount of time. If you’re taking this medication, you may need approval for your prescription to be covered.

July 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER bupropion ER#, Celexa#, citalopram#, desvenlafaxiner ER#, duloxetine#, Effexor XR#, Effexor#, Emsam#, escitalopram#, Fetzima#, fluoxetine#, fluvoxamine ER#, fluvoxamine#, Forfivo XL#, Khedezla, paroxetine CR#, paroxetine#, Paxil CR#, Pexeva#, Prozac, sertraline#, venlafaxine ER#, Wellbutrin SR, Wellbutrin XL, Zoloft

BLOOD PRESSURE/HEART MEDICATIONS BiDil 20-37.5mg#, captopril-HCTZ, dofetilide#, Tikosyn

CHOLESTEROL MEDICATIONS simvastatin, ZocorGASTROINTESTINAL/HEARTBURN Aciphex, Dexilant, esomeprazole,

lansoprazole DR, Nexium DR, Nexium, omeprazole DR, omeprazole, omeprazole bicarbonate, pantoprazole, Prevacid SoluTab, Prilosec, prilosec 2.5mg, Protonix, rabeprazole

NUTRITIONAL/DIETARY Auryxia

PAIN RELIEF AND INFLAMMATORY DISEASE (NON-NARCOTIC)

Cafergot, ergotamine-caffeine, diclofenac 1%, Voltaren

PAIN RELIEF AND INFLAMMATORY DISEASE (NARCOTIC)

acetaminophen-caffeine-dihyrocodeine, acetaminophen-codeine, Arymo, asa-butalb-caff-codeine, aspirin-caff-dihydrocodeine, belladonna-opium, buprenorphine, butalb-acetaminoph-caff-codeine, butorphanol, carisoprodol-asa-codeine, codeine sulfate, Embeda, Exalgo, Fentanyl (all dosage forms), Flowtuss, Hycofenix, hydrocodone-acetaminophen, hydrocodone-ibuprofen, Hydromet, hydromorphone, Hysingla ER, Kadian, Lorcet, Lortab, meperidine, Morphabond ER, morphine, morphine ER, nalbuphine, Nucynta, Nucynta ER, Obredon, Opana ER, opium tincture, Oxecta, oxycodone, oxycodone ER, oxycodone-acetaminophen, oxycodone-aspirin, oxycodone-ibuprofen, OxyContin, oxymorphone, oxymorphone ER, pentazocine-acetaminophen, pentazocine-naloxone, Primlev, promethazine-codeine, Talwin, tramadol ER, tramadol-acetaminophen, Trezix, Tussigon, Tussionex, Xtampza ER, Zohydro ER, Zutripro

To promote safer opioid use, your plan may limit the amount, or day supply, of narcotic pain medications (opioids) it will cover. If you’re taking an opioid, you may need approval for your prescription to be covered.

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont)

Start date of change*

Drug classMedication with quantity limits^^

Additional information

July 1, 2018 SEIZURE DISORDERS Banzel# Your plan only covers up to a certain amount of this medication over a certain amount of time. If you’re taking this medication, you may need approval for your prescription to be covered.

SKIN CONDITIONS calcitriol, Vectical

SLEEP DISORDERS/SEDATIVES RozeremFebruary 1, 2018 BLOOD THINNERS/ANTI-CLOTTING BevyxxaJanuary 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone

ALZHEIMER'S DISEASE Namenda XR, NamzaricANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine 25mg, 100mg, Marplan,

PristiqASTHMA/COPD/RESPIRATORY PerforomistBLOOD PRESSURE/HEART MEDICATIONS RanexaCANCER Fareston, nilutamideEYE CONDITIONS bimatoprost eye drops, Cystaran, ZioptanHORMONAL AGENTS Alora, estradiol patch, Estring, Menostar,

Minivelle, Vagifem, Vivelle-Dot, yuvafemMISCELLANEOUS NuedextaOSTEOPOROSIS PRODUCTS alendronatePAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, MitigareSCHIZOPHRENIA/ANTI-PSYCHOTICS FanaptSEIZURE DISORDERS Gabitril, PotigaSKIN CONDITIONS Denavir, Regranex, Santyl, VecticalSLEEP DISORDERS/SEDATIVES Hetlioz

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

Start date of change*

Drug class Step Therapy medication^^Generic and/or preferred brand alternatives

April 1, 2018 ASTHMA/COPD/RESPIRATORY Trelegy Ellipta## Advair, Anoro Ellipta, Breo Ellipta, Stiolto Respimat, Symbicort

January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER

Focalin XR## dexmethylphenidate ER

SCHIZOPHRENIA/ANTI-PSYCHOTICS Orap## pimozide

SKIN CONDITIONS Ala-Scalp## hydrocortisoneCapex shampoo## fluocinoloneCordran## flurandrenolideNucort, Texacort## hydrocortisone

Start date of change*

Drug class

Medication strength with limitations** (Your plan doesn’t cover 2 capsules/tablets per day of this strength)

Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)

January 1, 2018 ALLERGY/NASAL SPRAYS desloratadine ODT 2.5mg desloratadine ODT 5mg

ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg

Fetzima ER 40mg Fetzima ER 80mg

Trintellix 5mg Trintellix 10mg

Trintellix 10mg Trintellix 20mg

STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont)

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

Start date of change*

Drug class

Medication strength with limitations** (Your plan doesn’t cover 2 capsules/tablets per day of this strength)

Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)

January 1, 2018 BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg Benicar 20mg Benicar 40mg Benicar HCT 20-12.5mg Benicar HCT 40-25mg Bystolic 10mg Bystolic 20mg Tekturna 150mg Tekturna 300mg Tekturna HCT 150-12.5mg Tekturna HCT 300-25mg

CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg Livalo 2mg Livalo 4mg

DIABETES Farxiga 5mg Farxiga 10mg PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg

Aptiom 400mg Aptiom 800mg Fycompa 4mg Fycompa 8mg Fycompa 6mg Fycompa 12mg Trokendi XR 25mg Trokendi XR 50mg Trokendi XR 100mg Trokendi XR 200mg

SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg

LEGACY (PERFORMANCE) PRESCRIPTION DRUG LIST

Start date of change*

Drug class Preferred brand medication

December 1, 2018

BLOOD MODIFIERS/BLEEDING DISORDERS Retacrit+

November 15, 2018

BLOOD MODIFIERS/BLEEDING DISORDERS Fulphila+

October 1, 2018 GASTROINTESTINAL/HEARTBURN Entyvio+

SUBSTANCE ABUSE LucemyraJune 1, 2018 DIABETES Ozempic

VictozaApril 1, 2018 DIABETES QTERNMarch 1, 2018 DIABETES FiaspJanuary 1, 2018 MISCELLANEOUS Nityr+

Start date of change*

Drug classNon-preferred brand medication

Generic and/or preferred brand alternatives

December 15, 2018

HORMONAL AGENTS Imvexxy estradiol 10mcg vaginal insert, estradiol 0.01% cream, Premarin cream, Estring

December 9, 2018

PAIN RELIEF AND INFLAMMATORY DISEASE Olumiant+ Actemra, Enbrel, Humira, Remicade

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

Start date of change*

Drug classNon-preferred brand medication

Generic and/or preferred brand alternatives

November 15, 2018

CANCER Yonsa+ ZytigaPAIN RELIEF AND INFLAMMATORY DISEASE Aimovig antiepileptic drugs, antidepressants,

beta blockersOctober 1, 2018 EYE CONDITIONS Rhopressa Talk with your doctor to find out if there

are lower-cost options available.August 15, 2018 ASTHMA/COPD/RESPIRATORY Lonhala Incruse Ellipta, Spiriva Handihaler, Sprivia

Respimat, Anoro Ellipta, Stiolto Respimat, Trelegy Ellipta

Symdeko+ Talk with your doctor to find out if there are lower-cost options available.

July 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Reopro+ Talk with your doctor to find out if there are lower-cost options available.

CANCER dexrazoxane+, Evomela+, Hycamtin capsule+, Nilandron+, nilutamide+, Zinecard

Talk with your doctor to find out if there are lower-cost options available.

Fusilev+ leucovorinCONTRACEPTION PRODUCTS LoSeasonique Amethia Lo, Camrese Lo, levonorg-eth

estradiol 0.1/0.02/0.01mgNexplanon+, Paragard T 380-a+ Talk with your doctor to find out if there

are lower-cost options available.Seasonique Amethia, Ashlyna, Camrese, Daysee,

levonorg-eth estradiol 0.15/0.03/0.01mgDENTAL PRODUCTS Arestin+ Talk with your doctor to find out if there

are lower-cost options available.DIABETES Korlym+ Talk with your doctor to find out if there

are lower-cost options available.Segluromet Invokamet, Synjardy, Synjardy XR,

Xigduo XRSteglatro Farxiga, Invokana, JardianceSteglujan Glyxambi, QTERN

EYE CONDITIONS Cystaran+, Ozurdex+, Retisert+ Talk with your doctor to find out if there are lower-cost options available.

GASTROINTESTINAL/HEARTBURN alosetron+, Buphenyl+, Chenodal+, Ravicti+, sodium phenylbutyrate

Talk with your doctor to find out if there are lower-cost options available.

HORMONAL AGENTS Aveed+, hydroxyprogesterone caproate+ Talk with your doctor to find out if there are lower-cost options available.

Saizen+ HumatropeINFECTIONS Daraprim+, Sirturo+ Talk with your doctor to find out if there

are lower-cost options available.INFERTILITY Makena+ Talk with your doctor to find out if there

are lower-cost options available.MISCELLANEOUS Asclera+, Carbaglu+, Ferriprox+,

Flebogamma DIF+, Keveyis+, Varithena+

Talk with your doctor to find out if there are lower-cost options available.

Orfadin+ NityrMULTIPLE SCLEROSIS Copaxone+ Aubagio, Avonex, Betaseron, Extavia,

Gilenya, glatiramer, Glatopa, Plegridy, Rebif, Tecfidera

LEGACY (PERFORMANCE) PRESCRIPTION DRUG LIST (cont)

LEGACY (PERFORMANCE) PRESCRIPTION DRUG LIST (cont)

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

Start date of change*

Drug classNon-preferred brand medication

Generic and/or preferred brand alternatives

July 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE (NON-NARCOTIC)

Colcrys colchicine

PARKINSON’S DISEASE Azilect rasagiline

SEIZURE DISORDERS Lamictal ODT lamotrigine ODTLyrica CR duloxetine, gabapentin, lidocaine 5%

topical patch, LyricaSKIN CONDITIONS Ameluz+, Levulan+ Talk with your doctor to find out if there

are lower-cost options available.Tazorac 0.1% cream tazarotene

SLEEP DISORDERS/SEDATIVES Hetlioz+ Talk with your doctor to find out if there are lower-cost options available.

TRANSPLANT MEDICATIONS Cellcept tablet, capsule, suspension+ mycophenolate tablet, capsule, suspensionNeoral 25mg capsule, solution+ cyclosporine modified, GengrafSandimmune 100mg capsule+ cyclosporine

URINARY TRACT CONDITIONS Thiola+ Talk with your doctor to find out if there are lower-cost options available.

May 15, 2018 EYE CONDITIONS Vyzulta bimatoprost, latanoprost, Travatan Z

April 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE Duzallo allopurinol, probenecid, Uloric

March 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic Talk with your doctor to find out if there are lower-cost options available.

PARKINSON’S DISEASE Gocovri amantadine

February 1, 2018 ASTHMA/COPD/RESPIRATORY ArmonAir QVAR, Pulmicort Flexhaler

BLOOD THINNERS/ANTI-CLOTTING Bevyxxa enoxaparin, Fragmin

January 13, 2018 GASTROINTESTINAL/HEARTBURN Syndros dronabinol

January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal spray

ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER

DIABETES Lantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Tresiba, Levemir

GASTROINTESTINAL/HEARTBURN omeprazole bicarbonate packet, 40mg-1100mg capsule, 20mg-1100mg

omeprazole

INFECTIONS Eryped 400 erythromycin

PAIN RELIEF AND INFLAMMATORY DISEASE OxyContin Embeda, Hysingla ER, Xtampza ERVanatol LQ butalbital/acetaminophen/caffeine tabs

or capsSKIN CONDITIONS Ala-Scalp hydrocortisone topical

Capex shampoo fluocinolone scalpCordran flurandrenolide topicalDifferin adapaleneKenalog spray triamcinolone sprayLocoid lotion hydrocortisone butyrateMetrogel metronidazole gelNaftin naftifineNucort, Texacort hydrocortisone

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

LEGACY (PERFORMANCE) PRESCRIPTION DRUG LIST (cont)

Start date of change*

Drug classMedication requiring prior authorization^^

Additional information

December 9, 2018

PAIN RELIEF AND INFLAMMATORY DISEASE Olumiant+ Your plan only covers this medication if your doctor requests and receives approval from Cigna. If you’re taking this medication, ask your doctor to call us soon so we can begin the review process.

December 1, 2018

BLOOD MODIFIERS/BLEEDING DISORDERS Retacrit+

November 15, 2018

CANCER YonsaPAIN RELIEF AND INFLAMMATORY DISEASE Aimovig

November 1, 2018

INFECTIONS nitrofurantoin 25mg/ml oral suspension sulfamethoxazole-trimethoprim suspension, nitrofurantoin capsule

August 15, 2018 ASTHMA/COPD/RESPIRATORY Lonhala Your plan only covers this medication if your doctor requests and receives approval from Cigna. If you’re taking this medication, ask your doctor to call us soon so we can begin the review process.

July 1, 2018 CANCER Hycamtin++, Targretin++, tretinoin capsule++, Xeloda++

MISCELLANEOUS Nityr, Orfadin++

MULTIPLE SCLEROSIS CopaxonePAIN RELIEF AND INFLAMMATORY DISEASE (NARCOTIC)

Diskets, Dolophine, methadone tablet, solution++, methadone intensol++, Methadose

April 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE DuzalloMarch 1, 2018 GASTROINTESTINAL/HEARTBURN SymproicJanuary 13, 2018 GASTROINTESTINAL/HEARTBURN SyndrosJanuary 1, 2018 DIABETES Lantus, Lantus SoloStar, Toujeo SoloStar

GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, VarubiHORMONAL AGENTS Androderm, Androgel, Axiron, Fortesta,

Natesto, Striant, Testim, Testopel, testosterone, Vogelxo

MISCELLANEOUS NityrPAIN RELIEF AND INFLAMMATORY DISEASE Roxicodone

Start date of change*

Drug classMedication with quantity limits^^

Additional information

December 15, 2018

HORMONAL AGENTS Imvexxy estradiol 10mcg vaginal insert, estradiol 0.01% cream, Premarin cream, Estring

September 1, 2018

SKIN CONDITIONS Doxepin 5% Cream, Prudoxin, Zonalon generic topical steroid (e.g. betamethasone) or topical tacrolimus

August 15, 2018 ASTHMA/COPD/RESPIRATORY Symdeko Your plan only covers up to a certain amount of this medication over a certain amount of time. If you’re taking this medication, you may need approval for your prescription to be covered.

July 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Aplenzin#, bupropion ER#, Celexa#,

citalopram#, Cymbalta#, desvenlafaxiner ER#,

duloxetine#, Effexor XR#, Effexor#, Emsam#,

escitalopram#, Fetzima#, fluoxetine#,

fluvoxamine ER#, fluvoxamine#, Forfivo XL#, Khedezla, Lexapro, paroxetine CR#, paroxetine#, Paxil CR#, Pexeva#, Prozac,

sertraline#, venlafaxine ER#, Wellbutrin SR,

Wellbutrin XL, ZoloftBLOOD PRESSURE/HEART MEDICATIONS BiDil 20-37.5mg#, captopril-HCTZ,

dofetilide#, TikosynCHOLESTEROL MEDICATIONS simvastatin, Zocor

DIABETES Jentadueto XR

LEGACY (PERFORMANCE) PRESCRIPTION DRUG LIST (cont)

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

Start date of change*

Drug classMedication with quantity limits^^

Additional information

July 1, 2018 GASTROINTESTINAL/HEARTBURN Aciphex, Dexilant, esomeprazole, lansoprazole DR, lansoprazole, Nexium DR, Nexium, OmePPI, omeprazole DR, omeprazole, omeprazole bicarbonate, pantoprazole, Prevacid Solutab, Prilosec, prilosec 2.5mg, Protonix, rabeprazole, Zegerid

Your plan only covers up to a certain amount of this medication over a certain amount of time. If you’re taking this medication, you may need approval for your prescription to be covered.

NUTRITIONAL/DIETARY Auryxia

PAIN RELIEF AND INFLAMMATORY DISEASE (NON-NARCOTIC)

Cafergot, ergotamine-caffeine, diclofenac 1%, Voltaren

PAIN RELIEF AND INFLAMMATORY DISEASE (NARCOTIC)

acetaminophen-caffeine-dihyrocodeine, acetaminophen-codeine, Arymo, asa-butalb-caff-codeine, aspirin-caff-dihydrocodeine, belladonna-opium, buprenorphine, butalb-acetaminoph-caff-codeine, butorphanol, carisoprodol-asa-codeine, codeine sulfate, Embeda, Exalgo, Fentanyl (all dosage forms), Flowtuss, Hycofenix, hydrocodone-acetaminophen, hydrocodone-ibuprofen, Hydromet, hydromorphone, Hysingla ER, Kadian, Lorcet, Lortab, meperidine, Morphabond ER, morphine, morphine ER, nalbuphine, Nucynta, Nucynta ER, Obredon, Opana ER, opium tincture, Oxecta, oxycodone, oxycodone ER, oxycodone-acetaminophen, oxycodone-aspirin, oxycodone-ibuprofen, OxyContin, oxymorphone, oxymorphone ER, pentazocine-acetaminophen, pentazocine-naloxone, Primlev, promethazine-codeine, Talwin, tramadol ER, tramadol-acetaminophen, Trezix, Tussigon, Tussionex, Xtampza ER, Zohydro ER, Zutripro

To promote safer opioid use, your plan may limit the amount, or day supply, of narcotic pain medications (opioids) it will cover. If you’re taking an opioid, you may need approval for your prescription to be covered.

SCHIZOPHRENIA/ANTI-PSYCHOTICS Invega Sustenna# Your plan only covers up to a certain amount of this medication over a certain amount of time. If you’re taking this medication, you may need approval for your prescription to be covered.

SEIZURE DISORDERS Banzel#

SKIN CONDITIONS calcitriol, Vectical

SLEEP DISORDERS/SEDATIVES Rozerem

February 1, 2018 BLOOD THINNERS/ANTI-CLOTTING BevyxxaJanuary 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone, Nasonex

ALZHEIMER'S DISEASE Namenda XR, NamzaricANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine 25mg, 100mg, Marplan, PristiqASTHMA/COPD/RESPIRATORY PerforomistBLOOD PRESSURE/HEART MEDICATIONS RanexaCANCER Fareston, Nilandron, nilutamideDIABETES Jentadueto, TradjentaEYE CONDITIONS bimatoprost eye drops, Cystaran, ZioptanHORMONAL AGENTS Alora, estradiol patch, Estring, Menostar,

Minivelle, Vagifem, Vivelle Dot, yuvafem

LEGACY (PERFORMANCE) PRESCRIPTION DRUG LIST (cont)

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

Start date of change*

Drug class Step Therapy medication^^Generic and/or Preferred Brand Alternatives

July 1, 2018 ERECTILE DYSFUNCTION Cialis## Talk with your doctor to find out if there are lower-cost options available.

Viagra## sildenafil, CialisApril 1, 2018 ASTHMA/COPD/RESPIRATORY Trelegy Ellipta## Advair, Anoro Ellipta, Breo Ellipta, Stiolto

Respimat, SymbicortFebruary 1, 2018 ASTHMA/COPD/RESPIRATORY ArmonAir## QVAR, Pulmicort FlexhalerJanuary 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR## dextroamphetamine-amphetamine ER

Focalin XR## dexmethylphenidate ERSCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify## aripiprazole

Orap## pimozideSKIN CONDITIONS Locoid lotion## hydrocortisone butyrate SLEEP DISORDERS/SEDATIVES Silenor## eszopiclone, zolpidem

Start date of change*

Drug class

Medication strength with limitations** (Your plan doesn’t cover 2 capsules/tablets per day of this strength)

Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)

January 1, 2018 ALLERGY/NASAL SPRAYS desloratadine ODT 2.5mg desloratadine ODT 5mg

ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg

Fetzima ER 40mg Fetzima ER 80mg

Trintellix 5mg Trintellix 10mg

Trintellix 10mg Trintellix 20mg

BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg

Benicar 20mg Benicar 40mg

Benicar HCT 20-12.5mg Benicar HCT 40-25mg

Bystolic 10mg Bystolic 20mg

Tekturna 150mg Tekturna 300mg

Tekturna HCT 150-12.5mg Tekturna HCT 300-25mg

CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg

Livalo 2mg Livalo 4mg

DIABETES Farxiga 5mg Farxiga 10mg

Start date of change*

Drug classMedication with quantity limits^^

Additional information

January 1, 2018 INFECTIONS Zovirax Your plan only covers up to a certain amount of this medication over a certain amount of time. If you’re taking this medication, you may need approval for your prescription to be covered.

MISCELLANEOUS NuedextaOSTEOPOROSIS PRODUCTS alendronatePAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, MitigareSCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify Maintena, Aristada, Fanapt, Invega

Trinza, Risperdal Consta, Zyprexa RelprevvSEIZURE DISORDERS Gabitril, PotigaSKIN CONDITIONS Denavir, Regranex, Santyl, Vectical, ZyclaraSLEEP DISORDERS/SEDATIVES Hetlioz

LEGACY (PERFORMANCE) PRESCRIPTION DRUG LIST (cont)

Start date of change*

Drug class

Medication strength with limitations** (Your plan doesn’t cover 2 capsules/tablets per day of this strength)

Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)

January 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg

SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg

SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg

Aptiom 400mg Aptiom 800mg

Fycompa 4mg Fycompa 8mg

Fycompa 6mg Fycompa 12mg

Trokendi XR 25mg Trokendi XR 50mg

Trokendi XR 100mg Trokendi XR 200mg

SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg

LEGACY (STANDARD) PRESCRIPTION DRUG LIST

Start date of change*

Drug class Preferred brand medication

November 15, 2018

BLOOD MODIFIERS/BLEEDING DISORDERS Fulphila

October 1, 2018 GASTROINTESTINAL/HEARTBURN Entyvio+

Nexium Powder PackSUBSTANCE ABUSE Lucemyra

June 1, 2018 DIABETES OzempicVictoza

April 1, 2018 DIABETES QTERN

March 1, 2018 DIABETES FiaspJanuary 1, 2018 MISCELLANEOUS Nityr+

Start date of change*

Drug classNon-preferred brand medication

Generic and/or preferred brand alternatives

December 15, 2018

HORMONAL AGENTS Imvexxy estradiol 10mcg vaginal insert, estradiol 0.01% cream, Premarin cream, Estring

December 9, 2018

PAIN RELIEF AND INFLAMMATORY DISEASE Olumiant+ Actemra, Enbrel, Humira, Remicade

November 15, 2018

CANCER Yonsa+ Zytiga

PAIN RELIEF AND INFLAMMATORY DISEASE Aimovig antiepileptic drugs, antidepressants, beta blockers

October 1, 2018 EYE CONDITIONS Rhopressa Talk with your doctor to find out if there are lower-cost options available.

August 15, 2018 ASTHMA/COPD/RESPIRATORY Lonhala Incruse Ellipta, Spiriva Handihaler, Sprivia Respimat, Anoro Ellipta, Stiolto Respimat, Trelegy Ellipta

Symdeko+ Talk with your doctor to find out if there are lower-cost options available.

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

Start date of change*

Drug classNon-preferred brand medication

Generic and/or preferred brand alternatives

July 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Arixtra+ fondaparinuxLovenox+ enoxaparinReopro+ Talk with your doctor to find out if there

are lower-cost options available.CANCER dexrazoxane+, Evomela+, Hycamtin

capsule+, Nilandron+, nilutamide+, ZinecardTalk with your doctor to find out if there are lower-cost options available.

CONTRACEPTION PRODUCTS Depo-Provera 150mg/ml medroxyprogesteroneLoSeasonique Amethia Lo, Camrese Lo, levonorg-eth

estradiol 0.1/0.02/0.01mgNexplanon+, Paragard T 380-a+ Talk with your doctor to find out if there

are lower-cost options available.Seasonique Amethia, Ashlyna, Camrese, Daysee,

levonorg-eth estradiol 0.15/0.03/0.01mgDENTAL PRODUCTS Arestin+ Talk with your doctor to find out if there

are lower-cost options available.DIABETES Korlym+ Talk with your doctor to find out if there

are lower-cost options available.Segluromet Invokamet, Synjardy, Synjardy XR,

Xigduo XRSteglatro Farxiga, Invokana, JardianceSteglujan Glyxambi, QTERN

EYE CONDITIONS Cystaran+, Ozurdex+, Retisert+ Talk with your doctor to find out if there are lower-cost options available.

GASTROINTESTINAL/HEARTBURN alosetron+, Buphenyl+, Chenodal+, Lotronex+, Ravicti+, sodium phenylbutyrate

Talk with your doctor to find out if there are lower-cost options available.

HORMONAL AGENTS Aveed+, hydroxyprogesterone caproate+ Talk with your doctor to find out if there are lower-cost options available.

Depo-Provera 400mg/ml medroxyprogesterone

Saizen Humatrope

INFECTIONS Daraprim+, Sirturo+ Talk with your doctor to find out if there are lower-cost options available.

INFERTILITY Makena+ Talk with your doctor to find out if there are lower-cost options available.

MISCELLANEOUS Asclera+, Carbaglu+, Ferriprox+, Flebogamma DIF+, Keveyis+, Varithena+

Talk with your doctor to find out if there are lower-cost options available.

Orfadin+ Nityr

MULTIPLE SCLEROSIS Copaxone+ Aubagio, Avonex, Betaseron, Extavia, Gilenya, glatiramer, Glatopa, Plegridy, Rebif, Tecfidera

PAIN RELIEF AND INFLAMMATORY DISEASE (NON-NARCOTIC)

Colcrys colchicine

PARKINSON’S DISEASE Azilect rasagiline

SEIZURE DISORDERS Lamictal ODT lamotrigine ODT

Lyrica CR duloxetine, gabapentin, lidocaine 5% topical patch, Lyrica

LEGACY (STANDARD) PRESCRIPTION DRUG LIST (cont)

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

Start date of change*

Drug classNon-preferred brand medication

Generic and/or preferred brand alternatives

July 1, 2018 SKIN CONDITIONS Ameluz+, Levulan+ Talk with your doctor to find out if there are lower-cost options available.

Tazorac 0.1% cream tazarotene

SLEEP DISORDERS/SEDATIVES Hetlioz+ Talk with your doctor to find out if there are lower-cost options available.

TRANSPLANT MEDICATIONS Cellcept capsule, tablet, suspension+ mycophenolateNeoral 25mg capsule, solution+ cyclosporine modified, GengrafSandimmune 100mg capsule+ cyclosporine

URINARY TRACT CONDITIONS Thiola+ Talk with your doctor to find out if there are lower-cost options available.

May 15, 2018 EYE CONDITIONS Vyzulta bimatoprost, latanoprost, Travatan Z

April 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE Duzallo allopurinol, probenecid, Uloric

March 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic Talk with your doctor to find out if there are lower-cost options available.

HORMONAL AGENTS Depo-Testosterone testosterone cypionate

PARKINSON’S DISEASE Gocovri amantadineFebruary 1, 2018 ASTHMA/COPD/RESPIRATORY ArmonAir QVAR, Pulmicort Flexhaler

BLOOD THINNERS/ANTI-CLOTTING Bevyxxa enoxaparin, FragminJanuary 13, 2018 GASTROINTESTINAL/HEARTBURN Syndros dronabinolJanuary 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal spray

ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER

Focalin XR dexmethylphenidate ER

CANCER Nilandron nilutamide

DIABETES Apidra Humalog, NovologLantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba

GASTROINTESTINAL/HEARTBURN omeprazole bicarbonate packet, 40mg-1100mg capsule, 20mg-1100 mg capsule

omeprazole

INFECTIONS Eryped 400 erythromycinPAIN RELIEF AND INFLAMMATORY DISEASE D.H.E. 45 dihydroergotamine

Imitrex sumatriptanOxyContin Embeda, Hysingla ER, Xtampza ERVanatol LQ butalbital/acetaminophen/caffeine tabs

or capsSKIN CONDITIONS Ala-Scalp hydrocortisone

Analpram HC hydrocortisone-pramoxineCapex shampoo fluocinoloneCordran flurandrenolideDifferin adapaleneKenalog triamcinolone sprayLocoid lotion hydrocortisone butyrateMetrogel metronidazole gelNaftin naftifineNucort, Texacort hydrocortisone

LEGACY (STANDARD) PRESCRIPTION DRUG LIST (cont)

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

LEGACY (STANDARD) PRESCRIPTION DRUG LIST (cont)

Start date of change*

Drug classMedication requiring prior authorization^^

Additional information

December 9, 2018

PAIN RELIEF AND INFLAMMATORY DISEASE Olumiant+ Actemra, Enbrel, Humira, Remicade

November 15, 2018

CANCER Yonsa Your plan only covers this medication if your doctor requests and receives approval from Cigna. If you’re taking this medication, ask your doctor to call us soon so we can begin the review process.

PAIN RELIEF AND INFLAMMATORY DISEASE Aimovig

November 1, 2018

INFECTIONS nitrofurantoin 25mg/ml oral suspension sulfamethoxazole-trimethoprim suspension, nitrofurantoin capsule

August 15, 2018 ASTHMA/COPD/RESPIRATORY Lonhala Your plan only covers this medication if your doctor requests and receives approval from Cigna. If you’re taking this medication, ask your doctor to call us soon so we can begin the review process.

July 1, 2018 CANCER Hycamtin++, Targretin++, tretinoin capsule++, Xeloda++

MISCELLANEOUS Nityr, Orfadin++

MULTIPLE SCLEROSIS CopaxonePAIN RELIEF AND INFLAMMATORY DISEASE (NARCOTIC)

Diskets, Dolophine, methadone++, Methadose

April 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE Duzallo

March 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic

January 13, 2018 GASTROINTESTINAL/HEARTBURN Syndros

January 1, 2018 DIABETES Lantus, Lantus SoloStar, Toujeo SoloStarGASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend capsule, powder

packet, tripack, Sancuso, VarubiHORMONAL AGENTS Androderm, Androgel, Axiron, Fortesta,

Natesto, Striant, Testim, testosterone, Vogelxo

MISCELLANEOUS Nityr

PAIN RELIEF AND INFLAMMATORY DISEASE Roxicodone

Start date of change*

Drug classMedication with quantity limits^^

Additional information

December 15, 2018

HORMONAL AGENTS Imvexxy estradiol 10mcg vaginal insert, estradiol 0.01% cream, Premarin cream, Estring

September 1, 2018

SKIN CONDITIONS Doxepin 5% Cream, Prudoxin, Zonalon generic topical steroid (e.g. betamethasone) or topical tacrolimus

August 15, 2018 ASTHMA/COPD/RESPIRATORY Symdeko Your plan only covers up to a certain amount of this medication over a certain amount of time. If you’re taking this medication, you may need approval for your prescription to be covered.

July 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Aplenzin#, bupropion ER#, Celexa#, citalopram#, Cymbalta#, desvenlafaxiner ER#, duloxetine#, Effexor XR#, Effexor#, Emsam#, escitalopram#, Fetzima#, fluoxetine#, fluvoxamine ER#, fluvoxamine#, Forfivo XL#, Khedezla, Lexapro, paroxetine CR#, paroxetine#, Paxil CR#, Pexeva#, Prozac, sertraline#, venlafaxine ER#, Wellbutrin SR, Wellbutrin XL, Zoloft

BLOOD PRESSURE/HEART MEDICATIONS BiDil 20-37.5mg#, captopril-HCTZ, dofetilide#, Tikosyn

CHOLESTEROL MEDICATIONS simvastatin, Zocor

DIABETES Jentadueto XR

LEGACY (STANDARD) PRESCRIPTION DRUG LIST (cont)

Start date of change*

Drug classMedication with quantity limits^^

Additional information

July 1, 2018 GASTROINTESTINAL/HEARTBURN Aciphex, Dexilant, esomeprazole, lansoprazole DR, lansoprazole, Nexium DR, Nexium, OmePPI, omeprazole DR, omeprazole, omeprazole bicarbonate, pantoprazole, Prevacid SoluTab, Prilosec, prilosec 2.5mg, Protonix, rabeprazole, Zegerid

Your plan only covers up to a certain amount of this medication over a certain amount of time. If you’re taking this medication, you may need approval for your prescription to be covered.

NUTRITIONAL/DIETARY Auryxia

PAIN RELIEF AND INFLAMMATORY DISEASE (NON-NARCOTIC)

Cafergot, ergotamine-caffeine, diclofenac 1%, Voltaren

PAIN RELIEF AND INFLAMMATORY DISEASE (NARCOTIC)

acetaminophen-caffeine-dihyrocodeine, acetaminophen-codeine, Arymo, asa-butalb-caff-codeine, aspirin-caff-dihydrocodeine, belladonna-opium, buprenorphine, butalb-acetaminoph-caff-codeine, butorphanol, carisoprodol-asa-codeine, codeine sulfate, Embeda, Exalgo, Fentanyl (all dosage forms), Flowtuss, Hycofenix, hydrocodone-acetaminophen, hydrocodone-ibuprofen, Hydromet, hydromorphone, Hysingla ER, Kadian, Lorcet, Lortab, meperidine, Morphabond ER, morphine, morphine ER, nalbuphine, Nucynta, Nucynta ER, Obredon, Opana ER, opium tincture, Oxecta, oxycodone, oxycodone ER, oxycodone-acetaminophen, oxycodone-aspirin, oxycodone-ibuprofen, OxyContin, oxymorphone, oxymorphone ER, pentazocine-acetaminophen, pentazocine-naloxone, Primlev, promethazine-codeine, Talwin, tramadol ER, tramadol-acetaminophen, Trezix, Tussigon, Tussionex, Xtampza ER, Zohydro ER, Zutripro

To promote safer opioid use, your plan may limit the amount, or day supply, of narcotic pain medications (opioids) it will cover. If you’re taking an opioid, you may need approval for your prescription to be covered.

SEIZURE DISORDERS Banzel# Your plan only covers up to a certain amount of this medication over a certain amount of time. If you’re taking this medication, you may need approval for your prescription to be covered.

SKIN CONDITIONS calcitriol, VecticalSLEEP DISORDERS/SEDATIVES Rozerem

February 1, 2018 BLOOD THINNERS/ANTI-CLOTTING BevyxxaJanuary 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, Nasonex, mometasone

ALZHEIMER'S DISEASE Namenda XR, NamzaricANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine 25mg, 100mg, Marplan,

PristiqASTHMA/COPD/RESPIRATORY PerforomistBLOOD PRESSURE/HEART MEDICATIONS RanexaCANCER Fareston, Nilandron, nilutamideDIABETES Jentadueto, TradjentaEYE CONDITIONS bimatoprost eye drops, Cystaran, ZioptanHORMONAL AGENTS Alora, estradiol patch, Estring, Menostar,

Minivelle, Vagifem, Vivelle-Dot, yuvafem

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

LEGACY (STANDARD) PRESCRIPTION DRUG LIST (cont)

Start date of change*

Drug classMedication with quantity limits^^

Additional information

January 1, 2018 INFECTIONS Zovirax Your plan only covers up to a certain amount of this medication over a certain amount of time. If you’re taking this medication, you may need approval for your prescription to be covered.

MISCELLANEOUS NuedextaOSTEOPOROSIS PRODUCTS alendronatePAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, MitigareSCHIZOPHRENIA/ANTI-PSYCHOTICS FanaptSEIZURE DISORDERS Gabitril, PotigaSKIN CONDITIONS Denavir, Regranex, Santyl, Vectical, ZyclaraSLEEP DISORDERS/SEDATIVES Hetlioz

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

Start date of change*

Drug class Step Therapy medication^^Generic and/or preferred brand alternatives

April 1, 2018 ASTHMA/COPD/RESPIRATORY Trelegy Ellipta## Advair, Anoro Ellipta, Breo Ellipta, Stiolto Respimat, Symbicort

February 1, 2018 ASTHMA/COPD/RESPIRATORY ArmonAir## QVAR, Pulmicort FlexhalerJanuary 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR## dextroamphetamine-amphetamine ER

Focalin XR## dexmethylphenidate ERSCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify## aripiprazole

Orap## pimozideSKIN CONDITIONS Locoid lotion## hydrocortisone butyrate SLEEP DISORDERS/SEDATIVES Silenor## eszopiclone, zolpidem

Start date of change*

Drug class

Medication strength with limitations** (Your plan doesn’t cover 2 capsules/tablets per day of this strength)

Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)

January 1, 2018 ALLERGY/NASAL SPRAYS desloratadine ODT 2.5mg desloratadine ODT 5mgANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg

Fetzima ER 40mg Fetzima ER 80mg Trintellix 5mg Trintellix 10mg Trintellix 10mg Trintellix 20mg

BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg Benicar 20mg Benicar 40mg Benicar HCT 20-12.5mg Benicar HCT 40-25mg Bystolic 10mg Bystolic 20mg Tekturna 150mg Tekturna 300mg Tekturna HCT 150-12.5mg Tekturna HCT 300-25mg

CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg Livalo 2mg Livalo 4mg

DIABETES Farxiga 5mg Farxiga 10mg PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg

LEGACY (STANDARD) PRESCRIPTION DRUG LIST (cont)

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

Start date of change*

Drug class

Medication strength with limitations** (Your plan doesn’t cover 2 capsules/tablets per day of this strength)

Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)

January 1, 2018 SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg Aptiom 400mg Aptiom 800mg Fycompa 4mg Fycompa 8mg Fycompa 6mg Fycompa 12mg Trokendi XR 25mg Trokendi XR 50mg Trokendi XR 100mg Trokendi XR 200mg

SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg

PERFORMANCE PRESCRIPTION DRUG LIST

Start date of change*

Drug class Medication not covered^ Generic and/or preferred brand alternatives

November 15, 2018

CANCER Yonsa ZytigaPAIN RELIEF AND INFLAMMATORY DISEASE Aimovig antiepileptic drugs, antidepressants,

beta blockersNovember 1, 2018

INFECTIONS nitrofurantoin 25mg/ml oral suspension sulfamethoxazole-trimethoprim suspension, nitrofurantoin capsule

September 1, 2018

SKIN CONDITIONS Doxepin 5% Cream generic topical steroid (e.g. betamethasone) or topical tacrolimus

July 1, 2018 DIABETES Segluromet Synjardy, Synjardy XR, Xigduo XRSteglatro Farxiga, Invokana, JardianceSteglujan Glyxambi, QTERN

GASTROINTESTINAL/HEARTBURN OmePPI omeprazoleINFECTIONS Mycobutin rifabutinMULTIPLE SCLEROSIS Copaxone Aubagio, Avonex, Betaseron, Extavia,

Gilenya, glatiramer, Glatopa, Plegridy, Rebif, Tecfidera

SEIZURE DISORDERS Lyrica CR duloxetine, gabapentin, lidocaine 5% topical patch, Lyrica

SKIN CONDITIONS diclofenac 3% gel, Solaraze Fluoroplex, fluorouracil topical, imiquimod cream, Picato

May 15, 2018 EYE CONDITIONS Vyzulta bimatoprost, latanoprost, Travatan ZApril 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE Duzallo allopurinol, probenecid, UloricMarch 1, 2018 DIABETES Fiasp Humalog

PARKINSON’S DISEASE Gocovri amantadineFebruary 1, 2018 ASTHMA/COPD/RESPIRATORY ArmonAir QVAR, Pulmicort FlexhalerJanuary 13, 2018 GASTROINTESTINAL/HEARTBURN Syndros dronabinolJanuary 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipramine

Pamelor nortriptylineParnate tranylcypromineTofranil imipramine

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

Start date of change*

Drug class Medication not covered^ Generic and/or preferred brand alternatives

January 1, 2018 ASTHMA/COPD/RESPIRATORY Zyflo montelukast, zafirlukast, zileuton ER

Zyflo CR zileuton ER

ATTENTION DEFICIT HYPERACTIVITY DISORDER

Desoxyn methamphetamine

Dexedrine dextroamphetamine, dextroamphetamine ER

BLOOD PRESSURE/HEART MEDICATIONS Betapace sotalol

CANCER Nilandron nilutamide

DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR

Invokana Farxiga, Jardiance

Lantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba

Novolin, Novolog Humalog, Humulin

GASTROINTESTINAL/HEARTBURN Cortifoam, Uceris rectal foam Colocort, Hemmorex-HC, hydrocortisone, Procto-Med HC, Procto-Pak, Proctosol-HC, Proctozone-HC

Marinol dronabinol

omeprazole bicarbonate packet, 40mg-1100mg capsule, 20mg-1100mg

omeprazole

OmePPI omeprazole

Rowasa mesalamine enema

Uceris tablet budesonide EC capsule

Zegerid omeprazole

Zofran ondansetron

Zofran ODT ondansetron ODT

HORMONAL AGENTS Cortrosyn cosyntropin

DDAVP desmopressin

Hectorol doxercalciferol

INFECTIONS Augmentin, Augmentin ES, Augmentin XR amoxicillin-clavulanate ER, amoxicillin-clavulanate

Diflucan fluconazole

E.E.S. 200, Eryped 400 erythromycin

Mepron atovaquone

Sporanox itraconazole

Targadox Avidoxy, demeclocycline, doxycycline, doxycycline IR-DR, minocycline, minocycline ER, mondoxyne NL, Morgidox capsule, tetracycline

Valcyte valganciclovir

Vancocin vancomycin capsule

Zovirax acyclovir

PERFORMANCE PRESCRIPTION DRUG LIST (cont)

PERFORMANCE PRESCRIPTION DRUG LIST (cont)

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

Start date of change*

Drug class Medication not covered^ Generic and/or preferred brand alternatives

January 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE Cambia diclofenac, diclofenac ER, etodolac, etodolac ER, fenoprofen, Fenortho, flurbiprofen, ibuprofen, indomethacin, indomethacin ER, ketoprofen, Ketorolac, meclofenamate, mefenamic acid, meloxicam, nabumetone

D.H.E. 45, Migranal dihydroergotamineGralise, Horizant gabapentinImitrex, Sumavel DosePro sumatriptanLorzone chlorzoxazoneOxyContin Embeda, Hysingla ER, Xtampza ERRoxicodone oxycodoneTivorbex indomethacinVanatol LQ butalbital/acetaminophen/caffeine tabs

or capsVivlodex meloxicamZomig sumatriptan, zolmitriptanZorvolex diclofenac, diclofenac ER

PARKINSON'S DISEASE Lodosyn carbidopaRequip XL ropinirole ER

SCHIZOPHRENIA/ANTI-PSYCHOTICS Geodon capsule ziprasidoneZyprexa tablet olanzapineZyprexa Zydis olanzapine ODT

SKIN CONDITIONS Cutivate fluticasoneKenalog topical spray triamcinoloneLocoid hydrocortisone Luzu ketoconazoleSoriatane acitretinZiana clindamycin-tretinoin

SLEEP DISORDERS/SEDATIVES Nuvigil armodafinilProvigil modafinilRestoril temazepam

URINARY TRACT CONDITIONS Detrol tolterodineDetrol LA tolterodine ERDitropan XL oxybutynin EREnablex darifenacin ERGelnique darifenacin ER, oxybutynin ER, tolterodine

ER, trospium ERStart date of change*

Drug class Preferred brand medication

December 1, 2018

BLOOD MODIFIERS/BLEEDING DISORDERS Retacrit+

November 15, 2018

BLOOD MODIFIERS/BLEEDING DISORDERS Fulphila+

PERFORMANCE PRESCRIPTION DRUG LIST (cont)

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

Start date of change*

Drug class Preferred brand medication

October 1, 2018 GASTROINTESTINAL/HEARTBURN Entyvio+

SUBSTANCE ABUSE Lucemyra

June 1, 2018 DIABETES OzempicVictoza

April 1, 2018 DIABETES QTERNJanuary 1, 2018 MISCELLANEOUS Nityr+

Start date of change*

Drug classNon-preferred brand medication

Generic and/or preferred brand alternatives

December 15, 2018

HORMONAL AGENTS Imvexxy estradiol 10mcg vaginal insert, estradiol 0.01% cream, Premarin cream, Estring

December 9, 2018

PAIN RELIEF AND INFLAMMATORY DISEASE Olumiant+ Actemra, Enbrel, Humira, Remicade

October 1, 2018 EYE CONDITIONS Rhopressa Talk with your doctor to find out if there are lower-cost options available.

August 15, 2018 ASTHMA/COPD/RESPIRATORY Lonhala Incruse Ellipta, Spiriva Handihaler, Sprivia Respimat, Anoro Ellipta, Stiolto Respimat, Trelegy Ellipta

Symdeko+ Talk with your doctor to find out if there are lower-cost options available.

July 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Reopro+ Talk with your doctor to find out if there are lower-cost options available.

CANCER dexrazoxane+, Evomela+, Hycamtin capsule+, Nilandron+, nilutamide+, Zinecard

Talk with your doctor to find out if there are lower-cost options available.

Fusilev+ leucovorin

CONTRACEPTION PRODUCTS LoSeasonique Amethia Lo, Camrese Lo, levonorg-eth estradiol 0.1/0.02/0.01mg

Nexplanon+, Paragard T 380-a+ Talk with your doctor to find out if there are lower-cost options available.

Seasonique Amethia, Ashlyna, Camrese, Daysee, levonorg-eth estradiol 0.15/0.03/0.01mg

DENTAL PRODUCTS Arestin+ Talk with your doctor to find out if there are lower-cost options available.

DIABETES Korlym+ Talk with your doctor to find out if there are lower-cost options available.

EYE CONDITIONS Cystaran+, Ozurdex+, Retisert+ Talk with your doctor to find out if there are lower-cost options available.

GASTROINTESTINAL/HEARTBURN alosetron+, Buphenyl, Chenodal+, Ravicti+, sodium phenylbutyrate

Talk with your doctor to find out if there are lower-cost options available.

HORMONAL AGENTS Aveed+, hydroxyprogesterone caproate+ Talk with your doctor to find out if there are lower-cost options available.

INFECTIONS Daraprim+, Sirturo+ Talk with your doctor to find out if there are lower-cost options available.

INFERTILITY Makena+ Talk with your doctor to find out if there are lower-cost options available.

MISCELLANEOUS Asclera+, Carbaglu+, Ferriprox+, Flebogamma DIF+, Keveyis+, Varithena+

Talk with your doctor to find out if there are lower-cost options available.

Orfadin+ Nityr

PERFORMANCE PRESCRIPTION DRUG LIST (cont)

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

Start date of change*

Drug classNon-preferred brand medication

Generic and/or preferred brand alternatives

July 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE (NON-NARCOTIC)

Colcrys colchicine

PARKINSON’S DISEASE Azilect rasagiline

SEIZURE DISORDERS Lamictal ODT lamotrigine ODT

SKIN CONDITIONS Ameluz+, Levulan+ Talk with your doctor to find out if there are lower-cost options available.

Tazorac 0.1% cream tazarotene

SLEEP DISORDERS/SEDATIVES Hetlioz+ Talk with your doctor to find out if there are lower-cost options available.

TRANSPLANT MEDICATIONS Cellcept+ mycophenolateNeoral 25mg capsule, solution+ cyclosporine modified, GengrafSandimmune 100mg capsule+ cyclosporine

URINARY TRACT CONDITIONS Thiola+ Talk with your doctor to find out if there are lower-cost options available.

March 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic Talk with your doctor to find out if there are lower-cost options available.

February 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Bevyxxa enoxaparin, FragminJanuary 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal spray

ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ERSKIN CONDITIONS Ala-Scalp hydrocortisone

Analpram HC lotion hydrocortisone-pramoxineCapex shampoo fluocinoloneCordran flurandrenolideDifferin adapaleneMetrogel metronidazole gelNaftin naftifineNucort, Texacort hydrocortisone

Start date of change*

Drug classMedication requiring prior authorization^^

Additional information

December 9, 2018

PAIN RELIEF AND INFLAMMATORY DISEASE Olumiant+ Your plan only covers this medication if your doctor requests and receives approval from Cigna. If you’re taking this medication, ask your doctor to call us soon so we can begin the review process.

August 15, 2018 ASTHMA/COPD/RESPIRATORY Lonhala

July 1, 2018 CANCER Hycamtin++, Targretin++, tretinoin capsule++, Xeloda++

MISCELLANEOUS Nityr, Orfadin++

PAIN RELIEF AND INFLAMMATORY DISEASE (NARCOTIC)

Diskets, Dolophine, methadone++, Methadose

March 1, 2018 GASTROINTESTINAL/HEARTBURN SymproicJanuary 1, 2018 GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi

HORMONAL AGENTS Androderm, Androgel, Striant, Testopel, testosterone

MISCELLANEOUS Nityr

PERFORMANCE PRESCRIPTION DRUG LIST (cont)

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

Start date of change*

Drug classMedication with quantity limits^^

Additional information

December 15, 2018

HORMONAL AGENTS Imvexxy estradiol 10mcg vaginal insert, estradiol 0.01% cream, Premarin cream, Estring

September 1, 2018

SKIN CONDITIONS Prudoxin, Zonalon generic topical steroid (e.g. betamethasone) or topical tacrolimus

August 15, 2018 ASTHMA/COPD/RESPIRATORY Symdeko Your plan only covers up to a certain amount of this medication over a certain amount of time. If you’re taking this medication, you may need approval for your prescription to be covered.

July 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER bupropion ER#, Celexa#, citalopram#, desvenlafaxine ER#, duloxetine#, Effexor XR#, Effexor#, Emsam#, escitalopram#, Fetzima#, fluoxetine#, fluvoxamine ER#, fluvoxamine#, Forfivo XL#, Khedezla, paroxetine CR#, paroxetine#, Paxil CR#, Pexeva#, Prozac, sertraline#, venlafaxine ER#, Wellbutrin SR, Wellbutrin XL, Zoloft

BLOOD PRESSURE/HEART MEDICATIONS BiDil 20-37.5mg#, captopril-HCTZ, dofetilide#, Tikosyn

CHOLESTEROL MEDICATIONS simvastatin, Zocor

GASTROINTESTINAL/HEARTBURN Aciphex, Dexilant, esomeprazole, lansoprazole DR, lansoprazole, Nexium DR, Nexium, omeprazole DR, omeprazole, omeprazole bicarbonate, pantoprazole, Prevacid SoluTab, Prilosec, prilosec 2.5mg, Protonix, rabeprazole

NUTRITIONAL/DIETARY Auryxia

PAIN RELIEF AND INFLAMMATORY DISEASE (NON-NARCOTIC)

Cafergot, ergotamine-caffeine, diclofenac 1%, Voltaren

PAIN RELIEF AND INFLAMMATORY DISEASE (NARCOTIC)

acetaminophen-caffeine-dihyrocodeine, acetaminophen-codeine, Arymo, asa-butalb-caff-codeine, aspirin-caff-dihydrocodeine, belladonna-opium, buprenorphine, butalb-acetaminoph-caff-codeine, butorphanol, carisoprodol-asa-codeine, codeine sulfate, Embeda, Exalgo, Fentanyl (all dosage forms), Flowtuss, Hycofenix, hydrocodone-acetaminophen, hydrocodone-ibuprofen, Hydromet, hydromorphone, Hysingla ER, Kadian, Lorcet, Lortab, meperidine, Morphabond ER, morphine, morphine ER, nalbuphine, Nucynta, Nucynta ER, Obredon, Opana ER, opium tincture, Oxecta, oxycodone, oxycodone ER, oxycodone-acetaminophen, oxycodone-aspirin, oxycodone-ibuprofen, OxyContin, oxymorphone, oxymorphone ER, pentazocine-acetaminophen, pentazocine-naloxone, Primlev, promethazine-codeine, Talwin, tramadol ER, tramadol-acetaminophen, Trezix, Tussigon, Tussionex, Xtampza ER, Zohydro ER, Zutripro

To promote safer opioid use, your plan may limit the amount, or day supply, of narcotic pain medications (opioids) it will cover. If you’re taking an opioid, you may need approval for your prescription to be covered.

PERFORMANCE PRESCRIPTION DRUG LIST (cont)

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

Start date of change*

Drug classMedication with quantity limits^^

Additional information

July 1, 2018 SCHIZOPHRENIA/ANTI-PSYCHOTICS Invega Sustenna# Your plan only covers up to a certain amount of this medication over a certain amount of time. If you’re taking this medication, you may need approval for your prescription to be covered.

SEIZURE DISORDERS Banzel#

SKIN CONDITIONS calcitriol, VecticalSLEEP DISORDERS/SEDATIVES Rozerem

February 1, 2018 BLOOD THINNERS/ANTI-CLOTTING BevyxxaJanuary 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone

ALZHEIMER'S DISEASE Namenda XR, NamzaricANXIETY/DEPRESSION/BIPOLAR DISORDER desvanlafaxine 25mg, 100mg, Marplan,

PristiqASTHMA/COPD/RESPIRATORY PerforomistBLOOD PRESSURE/HEART MEDICATIONS RanexaCANCER Fareston, nilutamideEYE CONDITIONS bimatoprost eye drops, Cystaran, ZioptanHORMONAL AGENTS Alora, estradiol patch, Estring, Menostar,

Minivelle, Vagifem, Vivelle-Dot, yuvafemMISCELLANEOUS NuedextaOSTEOPOROSIS PRODUCTS alendronatePAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, MitigareSCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify Maintena, Aristada, Fanapt, Invega

Trinza, Risperdal Consta, Zyprexa RelprevvSEIZURE DISORDERS Gabitril, PotigaSKIN CONDITIONS Denavir, Regranex, Santyl, VecticalSLEEP DISORDERS/SEDATIVES Hetlioz

Start date of change*

Drug class Step Therapy medication^^Generic and/or preferred brand alternatives

July 1, 2018 ERECTILE DYSFUNCTION Cialis## Talk with your doctor to find out if there are lower-cost options available.

Viagra## sildenafil, Cialis

April 1, 2018 ASTHMA/COPD/RESPIRATORY Trelegy Ellipta## Advair, Anoro Ellipta, Breo Ellipta, Stiolto Respimat, Symbicort

January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR## dextroamphetamine-amphetamine ER

Focalin XR## dexmethylphenidate ER

SCHIZOPHRENIA/ANTI-PSYCHOTICS Orap## pimozide

SLEEP DISORDERS/SEDATIVES Silenor## eszopiclone, zolpidem

Start date of change*

Drug class

Medication strength with limitations** (Your plan doesn’t cover 2 capsules/tablets per day of this strength)

Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)

January 1, 2018 ALLERGY/NASAL SPRAYS desloratadine ODT 2.5mg desloratadine ODT 5mg

ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg

Fetzima ER 40mg Fetzima ER 80mg

Trintellix 5mg Trintellix 10mg

Trintellix 10mg Trintellix 20mg

PERFORMANCE PRESCRIPTION DRUG LIST (cont)

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

Start date of change*

Drug class

Medication strength with limitations** (Your plan doesn’t cover 2 capsules/tablets per day of this strength)

Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)

January 1, 2018 BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg Benicar 20mg Benicar 40mg Benicar HCT 20-12.5mg Benicar HCT 40-25mg Bystolic 10mg Bystolic 20mg Tekturna 150mg Tekturna 300mg Tekturna HCT 150-12.5mg Tekturna HCT 300-25mg

CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg Livalo 2mg Livalo 4mg

DIABETES Farxiga 5mg Farxiga 10mg

PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg

SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg

SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg Aptiom 400mg Aptiom 800mg Fycompa 4mg Fycompa 8mg Fycompa 6mg Fycompa 12mg Trokendi XR 25mg Trokendi XR 50mg Trokendi XR 100mg Trokendi XR 200mg

SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg

VALUE PRESCRIPTION DRUG LIST

Start date of change*

Drug class Medication not covered^ Generic and/or preferred brand alternatives

November 15, 2018

CANCER Yonsa ZytigaPAIN RELIEF AND INFLAMMATORY DISEASE Aimovig antiepileptic drugs, antidepressants,

beta blockersNovember 1, 2018

INFECTIONS nitrofurantoin 25mg/ml oral suspension sulfamethoxazole-trimethoprim suspension, nitrofurantoin capsule

September 1, 2018

SKIN CONDITIONS Doxepin 5% Cream generic topical steroid (e.g. betamethasone) or topical tacrolimus

July 1, 2018 DIABETES Segluromet Synjardy, Synjardy XR, Xigduo XRSteglatro Farxiga, JardianceSteglujan Glyxambi

INFECTIONS Mycobutin rifabutinMULTIPLE SCLEROSIS Copaxone Aubagio, Avonex, Betaseron, Extavia,

Gilenya, glatiramer, Glatopa, Plegridy, Rebif, Tecfidera

SEIZURE DISORDERS Lyrica CR duloxetine, gabapentin, lidocaine 5% topical patch, Lyrica

SKIN CONDITIONS diclofenac 3% gel, Solaraze Fluoroplex, fluorouracil topical, imiquimod cream, Picato

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

Start date of change*

Drug class Medication not covered^ Generic and/or preferred brand alternatives

May 15, 2018 EYE CONDITIONS Vyzulta bimatoprost, latanoprost, Travatan Z

April 1, 2018 DIABETES QTERN GlyxambiPAIN RELIEF AND INFLAMMATORY DISEASE Duzallo allopurinol, probenecid

March 1, 2018 DIABETES Fiasp HumalogPARKINSON’S DISEASE Gocovri amantadine

February 1, 2018 ASTHMA/COPD/RESPIRATORY ArmonAir QVAR

January 13, 2018 GASTROINTESTINAL/HEARTBURN Syndros dronabinol

January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipraminePamelor nortriptyline

Parnate tranylcypromine

Tofranil imipramine

ASTHMA/COPD/RESPIRATORY Spiriva, Spiriva Respimat Incruse ElliptaStiolto Respimat Anoro Ellipta

Zyflo montelukast, zafirlukast, zileuton ER

Zyflo CR zileuton ER

ATTENTION DEFICIT HYPERACTIVITY DISORDER

Desoxyn methamphetamineDexedrine dextroamphetamine,

dextroamphetamine ERBLOOD PRESSURE/HEART MEDICATIONS Betapace sotalol tablet

CANCER Nilandron nilutamide

DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XRInvokana Farxiga, Jardiance

Kombiglyze XR, Onglyza alogliptin, alogliptin-metformin, Janumet, Janumet XR, Januvia

Lantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba

EYE CONDITIONS Alocril, Alomide cromolyn eye dropsBepreve, Emadine, Lastacaft, Pataday, Patanol, Pazeo

azelastine, epinastine, olopatadine

Elestat epinastine

GASTROINTESTINAL/HEARTBURN Marinol dronabinolRowasa mesalamine enema

Zofran ondansetron

Zofran ODT ondansetron ODT

HORMONAL AGENTS DDAVP nasal spray, tablet desmopressin nasal spray, tabletsHectorol doxercalciferol

INFECTIONS Augmentin, Augmentin ES, Augmentin XR amoxicillin-clavulanate ER, amoxicillin-clavulanate

Diflucan fluconazoleE.E.S. 200, Eryped 400 erythromycinMepron atovaquoneSporanox itraconazole

VALUE PRESCRIPTION DRUG LIST (cont)

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

VALUE PRESCRIPTION DRUG LIST (cont)

Start date of change*

Drug class Medication not covered^ Generic and/or preferred brand alternatives

January 1, 2018 INFECTIONS (cont) Targadox doxycycline

Valcyte valganciclovir

Vancocin vancomycin capsule

Zovirax acyclovir

PAIN RELIEF AND INFLAMMATORY DISEASE D.H.E. 45, Migranal dihydroergotamine

Imitrex sumatriptan

OxyContin Embeda, Hysingla ER, Xtampza ER

Roxicodone oxycodone

Vanatol LQ butalbital/acetaminophen/caffeine tabs or caps

Zomig sumatriptan, zolmitriptan

PARKINSON'S DISEASE Lodosyn carbidopa

Requip XL ropinirole ER

SCHIZOPHRENIA/ANTI-PSYCHOTICS Geodon ziprasidone

Zyprexa tablet olanzapine tablet

Zyprexa Zydis olanzapine ODT

SKIN CONDITIONS Acanya, Atralin, Avita, Azelex, Differin, Epiduo, Epiduo Forte, Fabior, Onexton, Retin-A, Retin-A Micro, Tretin-X, Veltin

Aczone, adapalene, Ala-Cort, alclometasone, amcinonide, Apexicon E, Avar, Avar-E, BenzePRO, benzoyl peroxide, betamethasone, BP 10-1, BPO, Clindacin ETZ, Clindacin P, clindamycin, clindamycin-benzoyl peroxide, clindamycin-tretinoin, clobetasol, clocortolone, Clodan, Cormax, desonide, desoximetasone, fluocinolone, halobetasol, hydrocortisone, Micort-HC, mometasone, prednicarbate, Psorcon, Scalacort, tretinoin, triamcinolone, Trianex, Triderm

Cutivate fluticasone

Dovonex, Sorilux calcipotriene

Enstilar, Taclonex calcipotriene-betamethasone DP

Soriatane acitretin

Tazorac adapalene, Ala-Cort, alclometasone, amcinonide, Apexicon E, Avar, Benzepro, benzoyl peroxide, betamethasone, BP 10-1, BPO, Clindacin ETZ, Clindacin P, clindamycin, clobetasol, clocortolone, Clodan, Cormax, desonide, desoximetasone, fluocinolone, halobetasol, hydrocortisone, Micort-HC, mometasone, prednicarbate, Psorcon, Scalacort, triamcinolone, Trianex, Triderm

Vectical calcitriol ointment

VALUE PRESCRIPTION DRUG LIST (cont)

Start date of change*

Drug class Medication not covered^ Generic and/or preferred brand alternatives

January 1, 2018 SLEEP DISORDERS/SEDATIVES Nuvigil armodafinilProvigil modafinilRestoril temazepam

URINARY TRACT CONDITIONS Detrol, Detrol LA, Ditropan XL, Enablex, Gelnique

darifenacin ER, oxybutynin ER, tolterodine, tolterodine ER, trospium ER

Start date of change*

Drug class Preferred brand medication

November 15, 2018

BLOOD MODIFIERS/BLEEDING DISORDERS Fulphila+

October 1, 2018 GASTROINTESTINAL/HEARTBURN Entyvio+

Nexium Powder PackSUBSTANCE ABUSE Lucemyra

June 1, 2018 DIABETES OzempicVictoza

January 1, 2018 MISCELLANEOUS Nityr+

Start date of change*

Drug classNon-preferred brand medication

Generic and/or preferred brand alternatives

December 15, 2018

HORMONAL AGENTS Imvexxy estradiol 10mcg vaginal insert, estradiol 0.01% cream, Premarin cream

December 9, 2018

PAIN RELIEF AND INFLAMMATORY DISEASE Olumiant+ Actemra, Enbrel, Humira, Remicade

October 1, 2018 EYE CONDITIONS Rhopressa Talk with your doctor to find out if there are lower-cost options available.

August 15, 2018 ASTHMA/COPD/RESPIRATORY Lonhala Incruse Ellipta, Anoro Ellipta, Trelegy ElliptaSymdeko+ Talk with your doctor to find out if there

are lower-cost options available.July 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Arixtra+ fondaparinux

Lovenox+ enoxaparinReopro+ Talk with your doctor to find out if there

are lower-cost options available.

CANCER dexrazoxane+, Evomela+, Nilandron+, nilutamide+, Zinecard

Talk with your doctor to find out if there are lower-cost options available.

Targretin capsule+ bexarotene

CONTRACEPTION PRODUCTS Depo-Provera 150mg/ml medroxyprogesteroneLoSeasonique Amethia Lo, Camrese Lo, levonorg-eth

estradiol 0.1/0.02/0.01mgNexplanon+, Paragard T 380-a+ Talk with your doctor to find out if there

are lower-cost options available.Seasonique Amethia, Ashlyna, Camrese, Daysee,

levonorg-eth estradiol 0.15/0.03/0.01mg

DENTAL PRODUCTS Arestin+ Talk with your doctor to find out if there are lower-cost options available.

DIABETES Korlym+ Talk with your doctor to find out if there are lower-cost options available.

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

VALUE PRESCRIPTION DRUG LIST (cont)

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

Start date of change*

Drug classNon-preferred brand medication

Generic and/or preferred brand alternatives

July 1, 2018 EYE CONDITIONS Cystaran+, Ozurdex+, Retisert+ Talk with your doctor to find out if there are lower-cost options available.

GASTROINTESTINAL/HEARTBURN alosetron+, Buphenyl+, Chenodal+, Ravicti+, sodium phenylbutyrate

Talk with your doctor to find out if there are lower-cost options available.

HORMONAL AGENTS Aveed+, hydroxyprogesterone caproate+ Talk with your doctor to find out if there are lower-cost options available.

Depo-Provera 400mg/ml medroxyprogesterone

INFECTIONS Daraprim+, Sirturo+ Talk with your doctor to find out if there are lower-cost options available.

INFERTILITY Makena+ Talk with your doctor to find out if there are lower-cost options available.

MISCELLANEOUS Asclera+, Carbaglu+, Ferriprox+, Flebogamma DIF+, Keveyis+, Varithena+

Talk with your doctor to find out if there are lower-cost options available.

PARKINSON'S DISEASE Azilect rasagiline

SEIZURE DISORDERS Lamictal ODT lamotrigine ODT

SKIN CONDITIONS Ameluz+, Levulan+ Talk with your doctor to find out if there are lower-cost options available.

SLEEP DISORDERS/SEDATIVES Hetlioz+ Talk with your doctor to find out if there are lower-cost options available.

TRANSPLANT MEDICATIONS Cellcept+ mycophenolateNeoral 25mg capsule, solution+ cyclosporine modified, Gengraf

URINARY TRACT CONDITIONS Thiola+ Talk with your doctor to find out if there are lower-cost options available.

March 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic Talk with your doctor to find out if there are lower-cost options available.

HORMONAL AGENTS Depo-Testosterone testosterone cypionateFebruary 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Bevyxxa enoxaparin, FragminJanuary 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER

Start date of change*

Drug classMedication requiring prior authorization^^

Additional information

December 9, 2018

PAIN RELIEF AND INFLAMMATORY DISEASE Olumiant+ Actemra, Enbrel, Humira, Remicade

August 15, 2018 ASTHMA/COPD/RESPIRATORY Lonhala Your plan only covers this medication if your doctor requests and receives approval from Cigna. If you’re taking this medication, ask your doctor to call us soon so we can begin the review process.

July 1, 2018 CANCER Hycamtin++, Targretin++, tretinoin capsule++, Xeloda++

MISCELLANEOUS Nityr, Orfadin++

PAIN RELIEF AND INFLAMMATORY DISEASE (NARCOTIC)

Diskets, Dolophine, methadone++, Methadose

March 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic

January 1, 2018 GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend capsule, powder packet, tripack, Sancuso, Varubi

HORMONAL AGENTS Androderm, Androgel, Striant testosterone

MISCELLANEOUS Nityr

VALUE PRESCRIPTION DRUG LIST (cont)

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

Start date of change*

Drug classMedication with quantity limits^^

Additional information

December 15, 2018

HORMONAL AGENTS Imvexxy estradiol 10mcg vaginal insert, estradiol 0.01% cream, Premarin cream, Estring

September 1, 2018

SKIN CONDITIONS Prudoxin, Zonalon generic topical steroid (e.g. betamethasone) or topical tacrolimus

August 15, 2018 ASTHMA/COPD/RESPIRATORY Symdeko Your plan only covers up to a certain amount of this medication over a certain amount of time. If you’re taking this medication, you may need approval for your prescription to be covered.

July 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER bupropion ER#, Celexa#, citalopram#, desvenlafaxine ER#, duloxetine#, Effexor XR#, Effexor#, Emsam#, escitalopram#, Fetzima#, fluoxetine#, fluvoxamine ER#, fluvoxamine#, Forfivo XL#, Khedezla, paroxetine CR#, paroxetine#, Paxil CR#, Pexeva#, Prozac, sertraline#, venlafaxine ER#, Wellbutrin SR, Wellbutrin XL, Zoloft

BLOOD PRESSURE/HEART MEDICATIONS BiDil 20-37.5mg#, captopril-HCTZ, dofetilide#, Tikosyn

CHOLESTEROL MEDICATIONS simvastatin

NUTRITIONAL/DIETARY Auryxia Your plan only covers up to a certain amount of this medication over a certain amount of time. If you’re taking this medication, you may need approval for your prescription to be covered.

PAIN RELIEF AND INFLAMMATORY DISEASE (NON-NARCOTIC)

Cafergot, ergotamine-caffeine

diclofenac 1% gel, Voltaren

PAIN RELIEF AND INFLAMMATORY DISEASE (NARCOTIC)

acetaminophen-caffeine-dihyrocodeine, acetaminophen-codeine, Arymo, asa-butalb-caff-codeine, aspirin-caff-dihydrocodeine, belladonna-opium, buprenorphine, butalb-acetaminoph-caff-codeine, butorphanol, carisoprodol-asa-codeine, codeine sulfate, Embeda, Exalgo, Fentanyl (all dosage forms), Flowtuss, Hycofenix, hydrocodone-acetaminophen, hydrocodone-ibuprofen, Hydromet, hydromorphone, Hysingla ER, Kadian, Lorcet, Lortab, meperidine, Morphabond ER, morphine, morphine ER, nalbuphine, Nucynta, Nucynta ER, Obredon, Opana ER, opium tincture, Oxecta, oxycodone, oxycodone ER, oxycodone-acetaminophen, oxycodone-aspirin, oxycodone-ibuprofen, OxyContin, oxymorphone, oxymorphone ER, pentazocine-acetaminophen, pentazocine-naloxone, Primlev, promethazine-codeine, Talwin, tramadol ER, tramadol-acetaminophen, Trezix, Tussigon, Tussionex, Xtampza ER, Zohydro ER, Zutripro

To promote safer opioid use, your plan may limit the amount, or day supply, of narcotic pain medications (opioids) it will cover. If you’re taking an opioid, you may need approval for your prescription to be covered.

VALUE PRESCRIPTION DRUG LIST (cont)

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

Start date of change*

Drug classMedication with quantity limits^^

Additional information

July 1, 2018 SEIZURE DISORDERS Banzel# Your plan only covers up to a certain amount of this medication over a certain amount of time. If you’re taking this medication, you may need approval for your prescription to be covered.

SKIN CONDITIONS calcitriol

SLEEP DISORDERS/SEDATIVES Rozerem

February 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Bevyxxa

January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone

ALZHEIMER'S DISEASE Namenda XR, Namzaric

ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine ER, Marplan

ASTHMA/COPD/RESPIRATORY Perforomist

BLOOD PRESSURE/HEART MEDICATIONS Ranexa

CANCER Fareston, nilutamide

EYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan

HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem

MISCELLANEOUS Nuedexta

OSTEOPOROSIS PRODUCTS alendronate

PAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, Mitigare

SCHIZOPHRENIA/ANTI-PSYCHOTICS Fanapt

SEIZURE DISORDERS Gabitril, Potiga

SKIN CONDITIONS Denavir, Regranex, Santyl

SLEEP DISORDERS/SEDATIVES Hetlioz

Start date of change*

Drug class Step Therapy medication^^Generic and/or preferred brand alternatives

April 1, 2018 ASTHMA/COPD/RESPIRATORY Trelegy Ellipta## Advair, Anoro Ellipta, Breo Ellipta, Stiolto Respimat, Symbicort

January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR## dextroamphetamine-amphetamine ER

Focalin XR## dexmethylphenidate ER

SCHIZOPHRENIA/ANTI-PSYCHOTICS Orap## pimozide

SLEEP DISORDERS/SEDATIVES Silenor## zolpidem, eszopiclone

Start date of change*

Drug class

Medication strength with limitations** (Your plan doesn’t cover 2 capsules/tablets per day of this strength)

Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)

January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg

Fetzima ER 40mg Fetzima ER 80mg

Trintellix 5mg Trintellix 10mg

Trintellix 10mg Trintellix 20mg

DIABETES Farxiga 5mg Farxiga 10mg

VALUE PRESCRIPTION DRUG LIST (cont)

Start date of change*

Drug class

Medication strength with limitations** (Your plan doesn’t cover 2 capsules/tablets per day of this strength)

Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)

January 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg

SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg

SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg

Aptiom 400mg Aptiom 800mg

Fycompa 4mg Fycompa 8mg

Fycompa 6mg Fycompa 12mg

Trokendi XR 25mg Trokendi XR 50mg

Trokendi XR 100mg Trokendi XR 200mg

SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

ADVANTAGE PRESCRIPTION DRUG LIST

Start date of change*

Drug class Medication not covered^ Generic and/or preferred brand alternatives

November 15, 2018

CANCER Yonsa Zytiga

PAIN RELIEF AND INFLAMMATORY DISEASE Aimovig antiepileptic drugs, antidepressants, beta blockers

November 1, 2018

INFECTIONS nitrofurantoin 25mg/ml oral suspension sulfamethoxazole-trimethoprim suspension, nitrofurantoin capsule

September 1, 2018

SKIN CONDITIONS Doxepin 5% Cream generic topical steroid (e.g. betamethasone) or topical tacrolimus

July 1, 2018 DIABETES Segluromet Synjardy, Synjardy XR, Xigduo XR

Steglatro Farxiga, Jardiance

Steglujan Glyxambi

INFECTIONS Mycobutin rifabutin

MULTIPLE SCLEROSIS Copaxone Aubagio, Avonex, Betaseron, Extavia, Gilenya, glatiramer, Glatopa, Plegridy, Rebif, Tecfidera

SEIZURE DISORDERS Lyrica CR duloxetine, gabapentin, lidocaine 5% topical patch, Lyrica

SKIN CONDITIONS diclofenac 3% gel, Solaraze Fluoroplex, fluorouracil, imiquimod, Picato

May 15, 2018 EYE CONDITIONS Vyzulta bimatoprost, latanoprost, Travatan Z

April 1, 2018 DIABETES QTERN Glyxambi

PAIN RELIEF AND INFLAMMATORY DISEASE Duzallo allopurinol, probenecid

March 1, 2018 DIABETES Fiasp Humalog

PARKINSON’S DISEASE Gocovri amantadine

February 1, 2018 ASTHMA/COPD/RESPIRATORY ArmonAir QVAR

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

Start date of change*

Drug class Medication not covered^ Generic and/or preferred brand alternatives

January 13, 2018 GASTROINTESTINAL/HEARTBURN Syndros dronabinol

January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipramine

Pamelor nortriptyline

Parnate tranylcypromine

Tofranil imipramine

ASTHMA/COPD/RESPIRATORY Spiriva, Spiriva Respimat Incruse Ellipta

Stiolto Respimat Anoro Ellipta

Zyflo montelukast, zafirlukast, zileuton ER

Zyflo CR zileuton ER

ATTENTION DEFICIT HYPERACTIVITY DISORDER

Desoxyn methamphetamine

Dexedrine dextroamphetamine, dextroamphetamine ER

BLOOD PRESSURE/HEART MEDICATIONS Betapace sotalol tablet

CANCER Nilandron nilutamide

DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR

Invokana Farxiga, Jardiance

Kombiglyze XR, Onglyza alogliptin, alogliptin-metformin, Janumet, Janumet XR, Januvia

Lantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba

EYE CONDITIONS Alocril, Alomide cromolyn eye dropsBepreve, Emadine, Lastacaft, Pataday, Patanol, Pazeo

azelastine, epinastine, olopatadine

Elestat epinastineGASTROINTESTINAL/HEARTBURN Marinol dronabinol

Rowasa mesalamine enemaZofran ondansetronZofran ODT ondansetron ODT

HORMONAL AGENTS Cortrosyn cosyntropinDDAVP desmopressinHectorol doxercalciferol

INFECTIONS Augmentin, Augmentin ES, Augmentin XR amoxicillin-clavulanate ER, amoxicillin-clavulanate

Diflucan fluconazoleE.E.S. 200, Eryped 400 erythromycinMepron atovaquoneSporanox itraconazoleTargadox doxycyclineValcyte valganciclovirVancocin vancomycin capsuleZovirax acyclovir

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

ADVANTAGE PRESCRIPTION DRUG LIST (cont)

Start date of change*

Drug class Medication not covered^ Generic and/or preferred brand alternatives

January 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE D.H.E. 45, Migranal dihydroergotamineImitrex sumatriptanOxyContin Embeda, Hysingla ER, Xtampza ERRoxicodone oxycodoneVanatol LQ butalbital/acetaminophen/caffeine tabs

or capsZomig sumatriptan, zolmitriptan

PARKINSON'S DISEASE Lodosyn carbidopaRequip XL ropinirole ER

SCHIZOPHRENIA/ANTI-PSYCHOTICS Geodon ziprasidoneZyprexa tablet olanzapineZyprexa Zydis olanzapine ODT

SKIN CONDITIONS Acanya, Atralin, Avita, Azelex, Differin, Epiduo, Epiduo Forte, Fabior, Onexton, Retin-A, Retin-A Micro, Tretin-X, Veltin

Aczone, adapalene, Ala-Cort, alclometasone, amcinonide, Apexicon E, Avar, Avar-E, BenzePRO, benzoyl peroxide, betamethasone, BP 10-1, BPO, Clindacin ETZ, Clindacin P, clindamycin, clindamycin-benzoyl peroxide, clindamycin-tretinoin, clobetasol, clocortolone, Clodan, Cormax, desonide, desoximetasone, fluocinolone, halobetasol, hydrocortisone, Micort-HC, mometasone, prednicarbate, Psorcon, Scalacort, tretinoin, triamcinolone, Trianex, Triderm

Cutivate fluticasoneDovonex, Sorilux calcipotrieneEnstilar, Taclonex calcipotriene-betamethasone DPSoriatane acitretinTazorac adapalene, Ala-Cort, alclometasone,

amcinonide, Apexicon E, Avar, Avar-E, Benzepro, benzoyl peroxide, betamethasone, BP 10-1, BPO, Clindacin ETZ, Clindacin P, clindamycin, clobetasol, clocortolone, Clodan, Cormax, desonide, desoximetasone, fluocinolone, halobetasol, hydrocortisone, Micort-HC, mometasone, prednicarbate, Psorcon, Scalacort, triamcinolone, Trianex, Triderm

Vectical calcitriolSLEEP DISORDERS/SEDATIVES Nuvigil armodafinil

Provigil modafinilRestoril temazepam

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

ADVANTAGE PRESCRIPTION DRUG LIST (cont)

Start date of change*

Drug class Medication not covered^ Generic and/or preferred brand alternatives

January 1, 2018 URINARY TRACT CONDITIONS Detrol tolterodineDetrol LA tolterodine ERDitropan XL oxybutynin EREnablex darifenacin ERGelnique darifenacin ER, oxybutynin ER, tolterodine

ER, trospium ERStart date of change*

Drug class Preferred brand medication

December 1, 2018

BLOOD MODIFIERS/BLEEDING DISORDERS Epogen+, Procrit+, Retacrit+

November 15, 2018

BLOOD MODIFIERS/BLEEDING DISORDERS Fulphila+

October 1, 2018 GASTROINTESTINAL/HEARTBURN Entyvio+

Nexium Powder Pack SUBSTANCE ABUSE Lucemyra

June 1, 2018 DIABETES OzempicVictoza

January 1, 2018 MISCELLANEOUS Nityr+

Start date of change*

Drug classNon-preferred brand medication

Generic and/or preferred brand alternatives

December 15, 2018

HORMONAL AGENTS Imvexxy estradiol 10mcg vaginal insert, estradiol 0.01% cream, Premarin cream

December 9, 2018

PAIN RELIEF AND INFLAMMATORY DISEASE Olumiant+ Actemra, Enbrel, Humira, Remicade

October 1, 2018 EYE CONDITIONS Rhopressa Talk with your doctor to find out if there are lower-cost options available.

August 15, 2018 ASTHMA/COPD/RESPIRATORY Lonhala Incruse Ellipta, Anoro Ellipta, Trelegy Ellipta

Symdeko+ Talk with your doctor to find out if there are lower-cost options available.

July 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Reopro+ Talk with your doctor to find out if there are lower-cost options available.

CANCER dexrazoxane+, Evomela+, Hycamtin capsule+, Nilandron+, nilutamide+, Zinecard

Talk with your doctor to find out if there are lower-cost options available.

Fusilev+ leucovorin

Targretin capsule+ bexarotene

CONTRACEPTION PRODUCTS LoSeasonique Amethia Lo, Camrese Lo, levonorg-eth estradiol 0.1/0.02/0.01mg

Nexplanon+, Paragard T 380-a+ Talk with your doctor to find out if there are lower-cost options available.

Seasonique Amethia, Ashlyna, Camrese, Daysee, levonorg-eth estradiol 0.15/0.03/0.01mg

ADVANTAGE PRESCRIPTION DRUG LIST (cont)

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

Start date of change*

Drug classNon-preferred brand medication

Generic and/or preferred brand alternatives

July 1, 2018 DENTAL PRODUCTS Arestin+ Talk with your doctor to find out if there are lower-cost options available.

DIABETES Korlym+ Talk with your doctor to find out if there are lower-cost options available.

EYE CONDITIONS Cystaran+, Ozurdex+, Retisert+ Talk with your doctor to find out if there are lower-cost options available.

GASTROINTESTINAL/HEARTBURN alosetron+, Buphenyl+, Chenodal+, Ravicti+, sodium phenylbutyrate

Talk with your doctor to find out if there are lower-cost options available.

HORMONAL AGENTS Aveed+, hydroxyprogesterone caproate+ Talk with your doctor to find out if there are lower-cost options available.

INFECTIONS Daraprim+, Sirturo+ Talk with your doctor to find out if there are lower-cost options available.

INFERTILITY Makena+ Talk with your doctor to find out if there are lower-cost options available.

MISCELLANEOUS Asclera+, Carbaglu+, Ferriprox+, Flebogamma DIF+, Keveyis+, Varithena+

Talk with your doctor to find out if there are lower-cost options available.

PARKINSON'S DISEASE Azilect rasagiline

SEIZURE DISORDERS Lamictal ODT lamotrigine ODT

SKIN CONDITIONS Ameluz+, Levulan+ Talk with your doctor to find out if there are lower-cost options available.

SLEEP DISORDERS/SEDATIVES Hetlioz+ Talk with your doctor to find out if there are lower-cost options available.

TRANSPLANT MEDICATIONS Cellcept+ mycophenolate

URINARY TRACT CONDITIONS Thiola+ Talk with your doctor to find out if there are lower-cost options available.

March 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic Talk with your doctor to find out if there are lower-cost options available.

February 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Bevyxxa enoxaparin

January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER

Start date of change*

Drug classMedication requiring prior authorization^^

Additional information

December 9, 2018

PAIN RELIEF AND INFLAMMATORY DISEASE Olumiant+ Your plan only covers this medication if your doctor requests and receives approval from Cigna. If you’re taking this medication, ask your doctor to call us soon so we can begin the review process.

December 1, 2018

BLOOD MODIFIERS/BLEEDING DISORDER Epogen+, Procrit+, Retacrit+

August 15, 2018 ASTHMA/COPD/RESPIRATORY Lonhala

July 1, 2018 CANCER Hycamtin++, Targretin++, tretinoin capsule++, Xeloda++

MISCELLANEOUS Nityr, Orfadin++

PAIN RELIEF AND INFLAMMATORY DISEASE (NARCOTIC)

Diskets, Dolophine, methadone++, Methadose

March 1, 2018 GASTROINTESTINAL/HEARTBURN Symproic

ADVANTAGE PRESCRIPTION DRUG LIST (cont)

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

Start date of change*

Drug classMedication requiring prior authorization^^

Additional information

January 1, 2018 GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi

Your plan only covers this medication if your doctor requests and receives approval from Cigna. If you’re taking this medication, ask your doctor to call us soon so we can begin the review process.

HORMONAL AGENTS Androderm, Androgel, Striant, Testopel, testosterone

MISCELLANEOUS Nityr

Start date of change*

Drug classMedication with quantity limits^^

Additional information

December 15, 2018

HORMONAL AGENTS Imvexxy estradiol 10mcg vaginal insert, estradiol 0.01% cream, Premarin cream

September 1, 2018

SKIN CONDITIONS Prudoxin, Zonalon generic topical steroid (e.g. betamethasone) or topical tacrolimus

August 15, 2018 ASTHMA/COPD/RESPIRATORY Symdeko Your plan only covers up to a certain amount of this medication over a certain amount of time. If you’re taking this medication, you may need approval for your prescription to be covered.

July 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER bupropion ER#, Celexa#, citalopram#, desvenlafaxine ER#, duloxetine#, Effexor XR#, Effexor#, Emsam#, escitalopram#, Fetzima#, fluoxetine#, fluvoxamine ER#, fluvoxamine#, Forfivo XL#, Khedezla, paroxetine CR#, paroxetine#, Paxil CR#, Pexeva#, Prozac#, sertraline#, venlafaxine ER#, Wellbutrin SR, Wellbutrin XL, Zoloft

BLOOD PRESSURE/HEART MEDICATIONS BiDil 20-37.5mg#, captopril-HCTZ, dofetilide#, Tikosyn

CHOLESTEROL MEDICATIONS simvastatin

NUTRITIONAL/DIETARY Auryxia

PAIN RELIEF AND INFLAMMATORY DISEASE (NON-NARCOTIC)

Cafergot, ergotamine-caffeine, diclofenac 1%, Voltaren

PAIN RELIEF AND INFLAMMATORY DISEASE (NARCOTIC)

acetaminophen-caffeine-dihyrocodeine, acetaminophen-codeine, Arymo, asa-butalb-caff-codeine, aspirin-caff-dihydrocodeine, belladonna-opium, buprenorphine, butalb-acetaminoph-caff-codeine, butorphanol, carisoprodol-asa-codeine, codeine sulfate, Embeda, Exalgo, Fentanyl (all dosage forms), Flowtuss, Hycofenix, hydrocodone-acetaminophen, hydrocodone-ibuprofen, Hydromet, hydromorphone, Hysingla ER, Kadian, Lorcet, Lortab, meperidine, Morphabond ER, morphine, morphine ER, nalbuphine, Nucynta, Nucynta ER, Obredon, Opana ER, opium tincture, Oxecta, oxycodone, oxycodone ER, oxycodone-acetaminophen, oxycodone-aspirin, oxycodone-ibuprofen, OxyContin, oxymorphone, oxymorphone ER, pentazocine-acetaminophen, pentazocine-

To promote safer opioid use, your plan may limit the amount, or day supply, of narcotic pain medications (opioids) it will cover. If you’re taking an opioid, you may need approval for your prescription to be covered.

ADVANTAGE PRESCRIPTION DRUG LIST (cont)

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

Start date of change*

Drug classMedication with quantity limits^^

Additional information

July 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE (NARCOTIC) (cont)

naloxone, Primlev, promethazine-codeine, Talwin, tramadol ER, tramadol-acetaminophen, Trezix, Tussigon, Tussionex, Xtampza ER, Zohydro ER, Zutripro

To promote safer opioid use, your plan may limit the amount, or day supply, of narcotic pain medications (opioids) it will cover. If you’re taking an opioid, you may need approval for your prescription to be covered.

SCHIZOPHRENIA/ANTI-PSYCHOTICS Invega Sustenna# Your plan only covers up to a certain amount of this medication over a certain amount of time. If you’re taking this medication, you may need approval for your prescription to be covered.

SEIZURE DISORDERS Banzel#

SKIN CONDITIONS calcitriol

SLEEP DISORDERS/SEDATIVES Rozerem

February 1, 2018 BLOOD THINNERS/ANTI-CLOTTING Bevyxxa

January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone

ALZHEIMER'S DISEASE Namenda XR, Namzaric

ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine ER, Marplan

ASTHMA/COPD/RESPIRATORY Perforomist

BLOOD PRESSURE/HEART MEDICATIONS Ranexa

CANCER Fareston, nilutamide

EYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan

HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem

MISCELLANEOUS Nuedexta

OSTEOPOROSIS PRODUCTS alendronate

PAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, Mitigare

SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify Maintena, Aristada, Fanapt, Invega Trinza, Risperdal Consta, Zyprexa Relprevv

SEIZURE DISORDERS Gabitril, Potiga

SKIN CONDITIONS Denavir, Regranex, Santyl

SLEEP DISORDERS/SEDATIVES Hetlioz

Start date of change*

Drug class Step Therapy medication^^Generic and/or preferred brand alternatives

April 1, 2018 ASTHMA/COPD/RESPIRATORY Trelegy Ellipta## Advair, Anoro Ellipta, Breo Ellipta, Stiolto Respimat, Symbicort

January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR## dextroamphetamine-amphetamine ERFocalin XR## dexmethylphenidate ER

SCHIZOPHRENIA/ANTI-PSYCHOTICS Orap## pimozideSLEEP DISORDERS/SEDATIVES Silenor## eszopiclone, zaleplon, zolpidem,

zolpidem ER

ADVANTAGE PRESCRIPTION DRUG LIST (cont)

Start date of change*

Drug class

Medication strength with limitations** (Your plan doesn’t cover 2 capsules/tablets per day of this strength)

Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)

January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg Fetzima ER 40mg Fetzima ER 80mg Trintellix 5mg Trintellix 10mg Trintellix 10mg Trintellix 20mg

DIABETES Farxiga 5mg Farxiga 10mg PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg

Aptiom 400mg Aptiom 800mg Fycompa 4mg Fycompa 8mg Fycompa 6mg Fycompa 12mg Trokendi XR 25mg Trokendi XR 50mg Trokendi XR 100mg Trokendi XR 200mg

SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg

Generic medications start with a lowercase letter and brand name medications start with a capital letter.

* State laws in Texas and Louisiana require health insurance plans to cover your medications at your current benefit level until your plan renews. This means that if your medication is taken off the drug list, is moved to a higher cost-share tier or needs approval, your plan can’t make these changes until your renewal date. To find out if these state laws apply to your plan, please call Customer Service using the number on the back of your ID card.

+ This is a specialty medication. Some plans cover these medications on a specialty tier, may limit you to a 30-day supply and/or require you to use Cigna Specialty Pharmacy (our home delivery pharmacy) to fill your prescription. For plans that cover specialty medications on a specialty tier, this change will not affect the cost of the medication. If you’re enrolled with Cigna, log in to the myCigna website or app or check your plan materials to learn more about your plan’s coverage requirements for specialty medications.

++ Approval may be required for new prescriptions filled on or after July 1st.^ These medications require approval from Cigna before they may be covered by your plan. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider

approving coverage of your medication.^^ These changes may not apply to your plan. Not all plans include requirements for prior authorization, quantity limits and/or Step Therapy. If you’re enrolled with Cigna, please check your plan

materials or log in to the myCigna website or app starting July 1st to learn more about how your plan covers these medications.# Quantity limits may apply to new prescriptions filled on or after July 1st.

## This is a Step Therapy medication. Step Therapy medications aren’t covered by your plan without approval from Cigna. Your plan requires you to try a lower-cost alternative first. Typically, these are generics or lower-cost preferred brands.

** Your plan doesn’t cover more than one tablet/capsule in this strength a day. If your doctor feels a higher strength of this medication once each day isn’t right for you, he or she can ask Cigna to consider approving coverage of your current medication strength.

Cigna reserves the right to make changes to the Drug List without notice.

Health benefit plans vary, but in general to be eligible for coverage a drug must be approved by the Food and Drug Administration (FDA), prescribed by a health care professional, purchased from a licensed pharmacy and medically necessary. If your plan provides coverage for certain prescription drugs with no cost-share, you may be required to use an in-network pharmacy to fill the prescription. If you use a pharmacy that does not participate in your plan’s network, your prescription may not be covered, or reimbursement may be limited by your plan’s copayment, coinsurance or deductible requirements. Certain features described in this document may not be applicable to your specific health plan, and plan features may vary by location and plan type. Refer to your plan documents for costs and complete details of your plan’s prescription drug coverage.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Health Management, Inc., Tel-Drug, Inc., Tel-Drug of Pennsylvania, L.L.C., and HMO or service company subsidiaries of Cigna Health Corporation, including Cigna HealthCare of Arizona, Inc., Cigna HealthCare of California, Inc., Cigna HealthCare of Colorado, Inc., Cigna HealthCare of Connecticut, Inc., Cigna HealthCare of Florida, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Illinois, Inc., Cigna HealthCare of Indiana, Inc., Cigna HealthCare of St. Louis, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of New Jersey, Inc., Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of Tennessee, Inc., and Cigna HealthCare of Texas, Inc. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.

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