Cigna Standard 4-Tier Prescription Drug List

Cigna Standard 4-Tier Prescription Drug List

CIGNA STANDARD 4-TIER PRESCRIPTION DRUG LIST

Coverage as of January 1, 2022

Offered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, or their affiliates. 916152 j Standard 4-Tier O/I SRx 08/21

What’s inside?

About this drug list

3

How to read this drug list

3

How to find your medication

5

Specialty medications

18

Medications that aren’t covered

25

Frequently Asked Questions (FAQs)

41

Exclusions and limitations for coverage

45

View the drug list online This document was last updated on 08/01/2021.* You can go online to see the current list of medications your plan covers. myCigna ® App and myCigna.com. Click on the “Find Care & Costs” tab and select “Price a Medication.” Then type in your medication name to see how it’s covered. Cigna.com/PDL. Scroll down until you see a pdf of the Cigna Standard 4-Tier Prescription Drug List (all specialty medications covered on Tier 4) . Questions? › myCigna.com: Click to chat Monday-Friday, 9:00 am-8:00 pm EST. › By phone: Call the toll-free number on your Cigna ID card. We’re here 24/7/365.

* Drug list created: originally created 01/01/2004

Last updated: 08/01/2021, for changes starting 01/01/2022

Next planned update: 03/01/2022, for changes starting 07/01/2022

2

About this drug list

This is a list of the most commonly prescribed medications covered on the Cigna Standard 4-Tier Prescription Drug List as of January 1, 2022. 1,2 Medications are listed by the condition they treat, then listed alphabetically within tiers (or cost-share levels). The drug list is updated often so it isn’t a complete list of the medications your plan covers. Also, your specific plan may not cover all of these medications. Log in to the myCigna App or myCigna.com , or check your plan materials, to see all of the medications your plan covers. How to read this drug list Use the chart below to help you read this drug list. This chart is just an example. It may not show how these medications are actually covered on the Cigna Standard 4-Tier Prescription Drug List.

Medications are grouped by the condition they treat; Speciality medications are listed on Tier 4 (pages 19–25) Tier (cost-share level) gives you an idea of how much you may pay for a medication

TIER 1 $

TIER 2 $$

TIER 3 $$$

HORMONAL AGENTS ANDRODERM (PA, QL) ANDROGEL 1.62% (PA, QL)

AMABELZ budesonide EC cabergoline (QL) COVARYX COVARYX H.S. DECADRON desmopressin dexamethasone estradiol- norethindrone estrogen- methyltestosterone levothyroxine LEVOXYL liothyronine medroxy-progesterone methimazole methylprednisolone MIMVEY MIMVEY LO NATURE-THROID NP THYROID prednisolone prednisolone ODT prednisone prednisone intensol progesterone

ACTIVELLA ALORA (QL) ANDROGEL 1.0% (PA, QL) ANGELIQ CLIMARA CLIMARA PRO Combipatch CYTOMEL 5, 25mcg DEPO-TESTOSTERONE ELESTRIN ENTOCORT EC ESTRACE ESTROGEL

ARMOUR THYROID CYTOMEL 50mcg

DIVIGEL DUAVEE ESTRING (QL) PREMARIN PREMPHASE PREMPRO SYNTHROID

Medications are listed in alphabetical order within each column

EVAMIST FEMRING INTRAROSA LEVO-T

Medications that have extra coverage requirements will have an abbreviation listed next to them Brand-name medications are in all capital letters

MENOSTAR (QL) MINIVELLE (QL) OSPHENA TIROSINT UNITHROID VAGIFEM (QL) VIVELLE-DOT (QL)

Generic medications are in all lowercase letters

This chart is just a sample. It may not show how these medications are actually covered on the Cigna Standard 4-Tier Prescription Drug List.

3

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

› Tier 1 – Typically Generics › Tier 2 – Typically Preferred Brands

$

(Lowest-cost medication) (Medium-cost medication)

Abbreviations next to medications In this drug list, medications that have limits and/or extra coverage requirements have an abbreviation listed next to them.* Here’s what they mean. $$ › Tier 3 – Typically Non-Preferred Brands (Higher-cost medication) $$$ › Tier 4 – Specialty Medications (Highest-cost medication) $$$$

(PA)

Prior Authorization – Certain medications need approval from Cigna before your plan will cover them. These medications have a (PA) next to them. Your plan won’t cover these medications unless your doctor requests, and receives, approval from Cigna. Quantity Limits – Some medications have a quantity limit. This means your plan will only cover up to a certain amount over a certain length of time. These medications have a (QL) next to them. Your plan will only cover a larger amount if your doctor requests, and receives, approval from Cigna.

(QL)

Brand-name medications are in all capital letters In this drug list, generic medications are listed in all lowercase letters and brand-name medications are listed in all capital letters. Specialty medications have an asterisk next to them Specialty medications are used to treat complex medical conditions. In this drug list, oral and injectable specialty medications are covered on Tier 4 (see pages 18-24). Injectable specialty medications are marked with an asterisk (*) and oral specialty medications are marked with a double asterisk (**). Your plan may also limit coverage to a 30-day supply and/or require you to use a preferred specialty pharmacy to receive coverage. Log in to the myCigna App or myCigna.com , or check your plan materials, to learn more about how your plan covers specialty medications. (ST) Step Therapy – Certain high-cost medications aren’t covered until you try one or more lower-cost alternatives first.** These medications have a (ST) next to them. You have many covered options to choose from, and they’re used to treat the same condition. (AGE) Age Requirements – Certain medications will only be covered if you’re within a specific age range. These medications have (AGE) next to them. If you’re not within the allowed age range, your plan will only cover the medication if your doctor requests, and receives, approval from Cigna. * These coverage requirements may not apply to your specific plan. Log in to the myCigna App or myCigna.com, or check your plan materials, to find out if your plan includes prior authorization, quantity limits, Step Therapy, and/or age requirements. ** If your doctor feels an alternative isn’t right for you, he or she can ask Cigna to consider approving coverage of your medication.

4

No cost-share preventive medications have a plus sign next to them Health care reform under the Patient Protection and Affordable Care Act (PPACA) requires plans to cover certain preventive medications and products at 100%, or no cost-share ($0), to you. In this drug list, these medications have a plus sign (+) next to them. Log in to the myCigna App or myCigna.com , or check your plan materials, to see how your plan covers these medications. Plan/benefit exclusions Your plan doesn’t cover certain medications and products because they’re considered plan/benefit exclusions. This means there’s no option to receive coverage through Cigna’s review process by showing that you need the medication or product for your treatment. In this drug list, these medications have a caret (^) next to them. Log in to the myCigna App or myCigna.com , or check your plan materials, to see which medications your plan excludes. How to find your medication First, look for your condition in the alphabetical list below. Then, go to that page to see the covered medications available to treat the condition.

Condition

Page

Condition

Page

FEMININE PRODUCTS

12

ALLERGY/NASAL SPRAYS

6

GASTROINTESTINAL/HEARTBURN

12

ALZHEIMER’S DISEASE

6

HORMONAL AGENTS

12, 13

ANXIETY/DEPRESSION/BIPOLAR DISORDER

6

INFECTIONS

13, 14

ASTHMA/COPD/RESPIRATORY

6

INFERTILITY

14

ATTENTION DEFICIT HYPERACTIVITY DISORDER

6, 7

MISCELLANEOUS

14

NUTRITIONAL/DIETARY

14, 15

BLOOD MODIFIERS/BLEEDING DISORDERS

7

OSTEOPOROSIS PRODUCTS

15

BLOOD PRESSURE/HEART MEDICATIONS

7

PAIN RELIEF AND INFLAMMATORY DISEASE

15, 16

BLOOD THINNERS/ANTI-CLOTTING

7, 8

PARKINSON’S DISEASE

16

CANCER

8

SCHIZOPHRENIA/ANTI-PSYCHOTICS

16

CHOLESTEROL MEDICATIONS

8

SEIZURE DISORDERS

16

CONTRACEPTION PRODUCTS

8–10

SKIN CONDITIONS

16, 17

COUGH/COLD MEDICATIONS

10

SLEEP DISORDERS/SEDATIVES

17

DENTAL PRODUCTS

10

SMOKING CESSATION

17

DIABETES

10, 11

SUBSTANCE ABUSE

17

DIURETICS

11

URINARY TRACT CONDITIONS

17

VACCINES

17

EAR MEDICATIONS

11

WEIGHT MANAGEMENT

17

ERECTILE DYSFUNCTION

11

EYE CONDITIONS

11, 12

5

Cigna Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 18-24).

TIER 1 $

TIER 2 $$ TIER 3 $$$ ALLERGY/NASAL SPRAYS

TIER 1 $ TIER 3 $$$ ANXIETY/DEPRESSION/BIPOLAR DISORDER 4 (cont) fluoxetine (QL) fluvoxamine (QL) fluvoxamine er (QL) lorazepam lorazepam intensol mirtazapine TIER 2 $$

azelastine azelastine- fluticasone cromolyn desloratadine (QL) fluticasone hydroxyzine hcl solution, syrup, tablet hydroxyzine pamoate ipratropium mometasone (QL) olopatadine promethazine solution, syrup, tablet

CLARINEX CLARINEX-D 12 HOUR GASTROCROM GRASTEK (PA, QL) KARBINAL ER ODACTRA (PA, QL) PATANASE RAGWITEK (PA, QL) VISTARIL

paroxetine cr (QL) paroxetine er (QL) paroxetine (QL) sertraline (QL) trazodone venlafaxine (QL) venlafaxine er (QL)

ASTHMA/COPD/RESPIRATORY

albuterol albuterol hfa (QL) ambrisentan* (PA)

ADVAIR HFA ANORO ELLIPTA ATROVENT HFA BREO ELLIPTA BREZTRI AEROSPHERE COMBIVENT RESPIMAT DULERA FLOVENT DISKUS FLOVENT HFA INCRUSE ELLIPTA

DALIRESP (QL) LETAIRIS* (PA) LONHALA MAGNAIR REFILL (PA) LONHALA MAGNAIR STARTER (PA) PULMICORT

ALZHEIMER’S DISEASE

donepezil donepezil odt memantine ARICEPT EXELON MESTINON NAMENDA 10 MG TABLET NAMENDA 5 MG TABLET NAMENDA XR (QL) NAMZARIC (QL) ANXIETY/DEPRESSION/BIPOLAR DISORDER 4 alprazolam alprazolam er alprazolam intensol alprazolam odt memantine er (QL) pyridostigmine 60 mg/5 ml, 60 mg pyridostigmine er rivastigmine NAMENDA 5-10 MG TITRATION PK

budesonide fluticasone- salmeterol ipratropium- albuterol montelukast

RESPULES SINGULAIR

PULMICORT FLEXHALER

CELEXA (QL, ST) EFFEXOR XR (QL, ST) FETZIMA (QL, ST) PAXIL (QL, ST) PAXIL CR (QL, ST) PRISTIQ (QL, ST) PROZAC (QL, ST) REMERON SPRAVATO* (PA) TRINTELLIX (QL, ST) VIIBRYD (QL, ST) WELLBUTRIN SR (QL, ST) XANAX XANAX XR ZOLOFT (QL, ST)

QVAR REDIHALER SEREVENT DISKUS SPIRIVA SPIRIVA RESPIMAT STIOLTO RESPIMAT SYMBICORT TRELEGY ELLIPTA

alprazolam xr amitriptyline bupropion (QL) bupropion sr (QL) bupropion xl 150 mg tablet (QL) bupropion xl 300 mg tablet (QL) buspirone citalopram (QL) clomipramine desvenlafaxine er (QL) duloxetine (QL) escitalopram (QL) fluoxetine dr (QL)

ATTENTION DEFICIT HYPERACTIVITY DISORDER 4

amphetamine (PA) atomoxetine (QL) dexmethyl- phenidate (PA) dexmethyl- phenidate er (PA, QL) dextroamphet- amine-amphet er (PA, QL)

MYDAYIS (PA, QL) VYVANSE (PA, QL)

ADDERALL (PA,ST) ADZENYS ER (PA, QL) ADZENYS XR-ODT (PA, QL) AMPHETAMINE ER (PA,QL) DAYTRANA (PA, QL) DYANAVEL XR (PA, QL)

6

Cigna Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 18-24).

TIER 1 $

TIER 2 $$ TIER 3 $$$ ATTENTION DEFICIT HYPERACTIVITY DISORDER 4 (cont)

TIER 1 $ TIER 3 $$$ BLOOD PRESSURE/HEART MEDICATIONS (cont) doxazosin droxidopa* enalapril flecainide hydralazine tablet irbesartan labetalol tablet lisinopril lisinopril-hctz losartan losartan-hctz matzim la metoprolol succinate metoprolol nadolol nifedipine nifedipine er olmesartan (QL) olmesartan- TIER 2 $$ KAPSPARGO SPRINKLE (ST) KATERZIA (QL) LOPRESSOR (ST) LOTENSIN (ST) LOTREL MICARDIS (QL, ST) MICARDIS HCT (QL, ST)

dextroamphet- amine- amphetamine (PA) guanfacine er methylphenidate er (la) (PA, QL) methylphenidate er (PA, QL) methylphenidate (PA) methylphenidate cd (PA, QL) methylphenidate er (cd) (PA, QL) methylphenidate la (PA, QL)

EVEKEO (PA,ST) FOCALIN (PA,ST) INTUNIV METHYLIN (PA) QUILLICHEW ER (PA, QL) QUILLIVANT XR (PA, QL)

RITALIN (PA,ST) STRATTERA (QL)

MINIPRESS NITROSTAT NORTHERA* (PA) NORVASC ORLADEYO* (PA, QL) PRINIVIL (ST) PROCARDIA XL RANEXA (QL) TEKTURNA (QL) TENORMIN (ST) TENORETIC 50 (ST) TENORETIC 100 (ST) TIAZAC TIKOSYN (PA, QL) TOPROL XL (ST) TRIBENZOR VASOTEC (ST) VERELAN VERELAN PM ZESTORETIC (ST) ZESTRIL (ST) ZIAC (ST)

BLOOD MODIFIERS/BLEEDING DISORDERS DROXIA SIKLOS (PA) BLOOD PRESSURE/HEART MEDICATIONS

amlodipine-hctz olmesartan-hctz (QL) prazosin propranolol tablet propranolol er ramipril ranolazine er (QL) taztia xt telmisartan (QL) telmisartan-hctz (QL) tiadylt er valsartan valsartan-hctz verapamil er verapamil er pm verapamil tablet verapamil sr

amlodipine amlodipine- benazepril amlodipine- olmesartan (QL) amlodipine- valsartan atenolol benazepril bisoprolol bisoprolol-hctz candesartan cartia xt carvedilol carvedilol er (QL) clonidine diltiazem 12hr er diltiazem 24hr er diltiazem 24hr er (cd) diltiazem 24hr er (la) diltiazem 24hr er (xr) diltiazem DILT-XR dofetilide (QL)

BYSTOLIC (QL, ST) CORLANOR (PA) ENTRESTO TEKTURNA HCT (QL)

ADALAT CC ALTACE (ST) ATACAND (ST) AVAPRO (ST) AZOR (QL)

BENICAR (QL, ST) BENICAR HCT (ST) BIDIL (QL) CALAN SR CARDIZEM LA 120mg (QL) CARDURA CATAPRES-TTS 1 CATAPRES-TTS 2 CATAPRES-TTS 3 COREG (ST) CORGARD (ST) COZAAR (ST) DIOVAN (ST) DIOVAN HCT (ST) EPANED EXFORGE

BLOOD THINNERS/ANTI-CLOTTING

adult aspirin regimen+ aspirin ec+ aspirin+ aspirin- dipyridamole er children's aspirin+ clopidogrel

BRILINTA ELIQUIS (PA) XARELTO (PA)

BAYER CHEWABLE ASPIRIN+ EFFIENT PLAVIX PRADAXA (PA) SAVAYSA (PA, QL) ZONTIVITY

HEMANGEOL HYZAAR (ST)

INDERAL LA (ST) INDERAL XL (ST) INNOPRAN XL (ST)

7

Cigna Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 18-24).

TIER 1 $ TIER 3 $$$ BLOOD THINNERS/ANTI-CLOTTING (cont) jantoven low dose aspirin ec+ prasugrel st. joseph aspirin ec+ st. joseph aspirin+ warfarin CANCER TIER 2 $$

TIER 1 $

TIER 2 $$ TIER 3 $$$ CONTRACEPTION PRODUCTS (cont)

AUROVELA 24 FE+ AUROVELA FE+ AUROVELA+ AVIANE+ AYUNA+ AZURETTE+ BALZIVA+ BLISOVI 24 FE+ BLISOVI FE+ BRIELLYN+ CAMILA+ CAMRESE LO+ CAMRESE+ CAYA CONTOURED+ CAZIANT+ CHARLOTTE 24 FE+ CHATEAL EQ+

NUVARING SAFYRAL SLYND TAYTULLA TODAY CONTRACEPTIVE SPONGE+ TWIRLA+ VCF CONTRACEPTIVE FILM+ YASMIN 28 YAZ

anastrozole+ exemestane+ hydroxyurea letrozole methotrexate tamoxifen+ temozolomide* (PA)

GLEOSTINE TREXALL

CHOLESTEROL MEDICATIONS

CHATEAL+ CRYSELLE+

atorvastatin+ colesevelam ezetimibe ezetimibe- simvastatin fenofibrate

NEXLETOL (PA, QL) NEXLIZET (PA, QL) REPATHA (PA) ROSZET VASCEPA (PA)

CADUET (QL) LIPOFEN (ST) NIASPAN TRICOR (ST) TRILIPIX (ST) VYTORIN (ST) WELCHOL ZETIA ZOCOR (QL, ST)

CYCLAFEM+ CYRED EQ+ CYRED+ DASETTA+ DAYSEE+ DEBLITANE+ desogestrel-ethinyl estradiol+ desogestrel-ethinyl estradiol - ethinyl estradiol+ DOLISHALE+ drospirenone- ethinyl estradiol- levomefolate+ drospirenone- ethinyl estradiol+

fenofibric acid fluvastatin er+ fluvastatin+ icosapent ethyl lovastatin+ omega-3 acid ethyl esters pravastatin+ rosuvastatin+ (QL) simvastatin tablet+ (QL)

CONTRACEPTION PRODUCTS

AFIRMELLE+ AFTERA+ ALTAVERA+ ALYACEN+ AMETHIA+ AMETHYST+ APRI+ ARANELLE+ ASHLYNA+ AUBRA EQ+ AUBRA+

LO LOESTRIN FE

BALCOLTRA BEYAZ ELLA+ ESTROSTEP FE

ECONTRA EZ+ ECONTRA ONE- STEP+ ELINEST+ ELURYNG+ EMOQUETTE+

LAYOLIS FE+ LOESTRIN FE MICROGESTIN 24 FE MINASTRIN 24 FE NATAZIA NEXTSTELLIS

ENPRESSE+ ENSKYCE+ ERRIN+ ESTARYLLA+

8

Cigna Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 18-24).

TIER 1 $

TIER 2 $$ TIER 3 $$$ CONTRACEPTION PRODUCTS (cont)

TIER 1 $

TIER 2 $$ TIER 3 $$$ CONTRACEPTION PRODUCTS (cont)

ethynodiol-ethinyl estradiol+ etonogestrel- ethinyl estradiol+

LO- ZUMANDIMINE+ LUTERA+ LYLEQ+ LYZA+ MARLISSA+ MERZEE+ MICROGESTIN FE+ MICROGESTIN+ MILI+ MONO-LINYAH+ MY CHOICE+

FALMINA+ FAYOSIM+ FEMCAP+

FEMYNOR+ GEMMILY+ GYNOL II+ HAILEY 24 FE+ HAILEY FE+ HAILEY+ HEATHER+ ICLEVIA+ INCASSIA+ ISIBLOOM+ JAIMIESS+ JASMIEL+ JENCYCLA+ JOLESSA+ JULEBER+ JUNEL FE 24+ JUNEL FE+ JUNEL+ KAITLIB FE+ KALLIGA+ KARIVA+ KELNOR 1-35+ KELNOR 1-50+ KURVELO+ LARIN 24 FE+ LARIN FE+ LARIN+ LARISSIA+ LEENA+ LESSINA+ LEVONEST+

MY WAY+ NECON+ NEW DAY+ NIKKI+ NORA-BE+

norethindrone+ norethindrone- ethinyl estradiol- iron+ norethindrone- ethinyl estradiol+ norethindrone- ethinyl estradiol- ferrous fumarate norgestimate- ethinyl estradiol+

NORLYDA+ NORTREL+ NYLIA+

NYMYO+ OCELLA+ OPCICON ONE- STEP+

OPTION 2+ ORSYTHIA+ PHILITH+ PIMTREA+ PIRMELLA+ PORTIA+ PREVIFEM+ RECLIPSEN+ RIVELSA+ SETLAKIN+ SHAROBEL+ SIMLIYA+ SIMPESSE+ SPRINTEC+

levonorgestrel+ levonorgestrel- ethinyl estradiol+ levonorgestrel- ethinyl estradiol ethinyl estradiol+ LEVORA-28+ LILLOW+ LOJAIMIESS+ LORYNA+ LOW-OGESTREL+

9

Cigna Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 18-24).

TIER 1 $

TIER 2 $$ TIER 3 $$$ CONTRACEPTION PRODUCTS (cont)

TIER 1 $

TIER 2 $$ TIER 3 $$$ COUGH/COLD MEDICATIONS

SRONYX+ SYEDA+

bromphenir- amine- pseudoephedrine -dm hydrocodone- homatropine (PA, QL) promethazine-dm

HYCODAN (PA, QL) TESSALON PERLE TUZISTRA XR (PA, QL)

TAKE ACTION+ TARINA 24 FE+ TARINA FE 1-20 EQ+ TARINA FE+ TILIA FE+

TRI FEMYNOR+ TRI-ESTARYLLA+ TRI-LEGEST FE+ TRI-LINYAH+ TRI-LO- ESTARYLLA+ TRI-LO-MARZIA+ TRI-LO-MILI+ TRI-LO-SPRINTEC+ TRI-MILI+ TRI-NYMYO+ TRI-PREVIFEM+ TRI-SPRINTEC+ TRIVORA-28+ TRI-VYLIBRA LO+ TRI-VYLIBRA+ TULANA+ TYDEMY+ VCF CONTRACEPTIVE FOAM+ VCF CONTRACEPTIVE GEL+ VELIVET+ VESTURA+ VIENVA+

DENTAL PRODUCTS

chlorhexidine DENTA 5000 PLUS DENTAGEL doxycycline hyclate FLUORIDEX DAILY DEFENSE 1.1% ORALONE PERIDEX

PREVIDENT 0.2% RINSE

CLINPRO 5000 FLORIVA+^ FLUORIDEX SENSITIVITY RELIEF PREVIDENT 1.1% GEL PREVIDENT 5000 PREVIDENT 5000 BOOSTER PLUS PREVIDENT 5000 ENAMEL PROTECT PREVIDENT 5000 ORTHO DEFENSE PREVIDENT 5000 PLUS PREVIDENT 5000 SENSITIVE AMARYL CEQUR CYCLOSET GLUCAGON EMERGENCY KIT (QL) GVOKE (QL) PRECISION XTRA KETONE-GLUC KIT RIOMET

PERIOGARD SF 1.1% GEL SF 5000 PLUS

sodium fluoride sodium fluoride 5000 dry mouth sodium fluoride 5000 plus triamcinolone ACCU-CHEK COMPACT PLUS CONTROL ACCU-CHEK GUIDE L1-L2 CONTROL SOLUTION ACCU-CHEK AVIVA SOLUTION ACCU-CHEK SOFTCLIX LANCET KIT ACCU-CHEK FASTCLIX LANCING DEVICE ACCU-CHEK

DIABETES

BASAGLAR (QL) BAQSIMI (QL) DEXCOM G6 (PA, QL) DROPLET DROPSAFE FARXIGA (QL, ST) FREESTYLE LIBRE 14 DAY SENSOR (PA, QL) FREESTYLE LIBRE 2 SENSOR (PA, QL) GLUCAGEN HYPO KIT GLYXAMBI (QL, ST) HUMULIN (QL) JANUMET (QL, ST) JANUMET XR (QL, ST) JANUVIA (QL, ST) JARDIANCE (QL, ST)

VIORELE+ VOLNEA+ VYFEMLA+ VYLIBRA+ WERA+ wide seal diaphragm+ WYMZYA FE+

XULANE+ ZAFEMY+ ZARAH+

MULTICLIX LANCET KIT ACCU-CHEK SMARTVIEW

ZOVIA 1-35+ ZOVIA 1-35E+ ZUMANDIMINE+

CONTROL SOLUTION

10

Cigna Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 18-24).

TIER 1 $

TIER 2 $$

TIER 3 $$$

TIER 1 $

TIER 2 $$

TIER 3 $$$

DIABETES (cont) LYUMJEV (QL) OMNIPOD DASH (PA, QL) ONETOUCH ULTRA TEST STRIP ONETOUCH VERIO TEST STRIP QTERN (QL, ST) RYBELSUS (PA, QL) SOLIQUA 100-33 SYMLINPEN SYNJARDY (QL, ST) SYNJARDY XR (QL, ST) TRIJARDY XR (ST, QL) V-GO 20 V-GO 30 V-GO 40 VICTOZA (PA, QL) XIGDUO XR (QL, ST) Xultophy

DIURETICS (cont)

ACCUTREND GLUCOSE CONTROL BD LANCETS BD PEN NEEDLE CONTOUR SOLUTION CONTOUR NEXT LEV 1 CONTROL SOLUTION CONTOUR SOLUTION CONTOUR SOLUTION CONTOUR NEXT LEV 2 CONTROL SOLUTION glimepiride glipizide glipizide er glipizide xl INPEN metformin metformin er NOVOTWIST TECHLITE TRUE METRIX LEVEL 1 CONTROL SOULTION TRUE METRIX LEVEL 2 CONTROL SOLUTION TRUE METRIX LEVEL 3 CONTROL SOLUTION TRUEPLUS SYRINGE ACETAZOLAMIDE TABLET ACETAZOLAMIDE ER CAPSULE BUMETANIDE TABLET chlorthalidone eplerenone furosemide solution, tablet hydrochloro- thiazide

spironolactone triamterene-hctz

EAR MEDICATIONS

ciprofloxacin- dexamethasone neomycin- polymyxin b-hydrocortisone ofloxacin

CIPRO HC

CIPRODEX CORTISPORIN-TC DERMOTIC OTOVEL

ERECTILE DYSFUNCTION

sildenafil^ (QL) tadalafil^ (QL) vardenafil^ (QL)

MUSE^ (PA, QL)

CIALIS^ (QL, ST) STENDRA^ (QL, ST) VIAGRA^ (QL, ST)

EYE CONDITIONS

bimatoprost (QL) brimonidine brinzolamide ciprofloxacin dorzolamide dorzolamide- timolol erythromycin fluorometholone ketorolac latanoprost loteprednol moxifloxacin eye drops neomycin- polymyxin b-dexamethasone ofloxacin olopatadine polymyxin b sulfate- trimethoprim prednisolone timolol tobramycin- dexamethasone travoprost

ALPHAGAN P 0.1% DROPS

ACULAR ACULAR LS ACUVAIL ALPHAGAN P 0.15% EYE DROPS

AZASITE BETIMOL

BETOPTIC S COMBIGAN EYSUVIS (QL) FML FORTE 0.25% EYE DROPS FML S.O.P. 0.1% OINTMENT FLAREX LOTEMAX SM

ALREX AZOPT BEPREVE

BESIVANCE BROMSITE CEQUA COSOPT COSOPT PF DUREZOL

RESTASIS RESTASIS MULTIDOSE SIMBRINZA XIIDRA ZERVIATE

FML LIQUIFILM 0.1% EYE DROP ILEVRO INVELTYS ISTALOL LASTACAFT

LOTEMAX MAXITROL MOXEZA NEVANAC OCUFLOX PRED FORTE PROLENSA

DIURETICS

DIURIL

ALDACTONE CAROSPIR INSPRA KERENDIA LASIX MAXZIDE

RHOPRESSA ROCKLATAN TIMOPTIC TIMOPTIC-XE TOBRADEX EYE DROPS

11

Cigna Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 18-24).

TIER 1 $

TIER 2 $$

TIER 3 $$$

TIER 1 $ TIER 3 $$$ GASTROINTESTINAL/HEARTBURN (cont) LAXATIVE EC 5 MG TABLET+ mesalamine TIER 2 $$

EYE CONDITIONS (cont)

TOBRADEX ST TRUSOPT VIGAMOX ZIRGAN ZYLET

mesalamine dr mesalamine er metoclopramide solution, tablet metoclopramide odt misoprostol NATURA-LAX+ omeprazole (QL) ondansetron ondansetron odt pantoprazole suspension, tablet (QL) peg 3350-electrolyte+ PEG3350-SODIUM SULFATE-SODIUM CHLORIDE- POTASSIUM CHLORIDE- SODIUM ASCORBATE- ASCORBIC ACID+ PEG-PREP+ polyethylene glycol 3350+ prochlorperazine tablet promethazine suppository promethegan PURELAX+ rabeprazole tablet (QL) scopolamine SMOOTHLAX+ sucralfate ursodiol WOMEN'S GENTLE LAXATIVE+ WOMEN'S LAXATIVE+

FEMININE PRODUCTS

FEM PH GYNAZOLE 1 miconazole 3 200 mg terconazole

GASTROINTESTINAL/HEARTBURN

ALOPHEN PILLS+ ANUCORT-HC balsalazide bisacodyl tablet+ cinacalcet* CLEARLAX+ CONSTULOSE dicyclomine capsule, solution, tablet esomeprazole 20 mg capsule, 40 mg capsule, packets (QL) famotidine 40 mg/5 ml suspension, 20 mg tablet, 40 mg tablet GAVILAX+

AMITIZA CLENPIQ+ DEXILANT (QL) LINZESS LITHOSTAT NEXIUM DR 2.5 MG PACKET (QL) NEXIUM DR 5 MG PACKET (QL) PANCREAZE

ACIPHEX (QL, ST) AKYNZEO 300-0.5 MG CAPSULE BONJESTA CANASA CARAFATE CORRECTOL+ CUVPOSA DICLEGIS DONNATAL DULCOLAX EC 5 MG TABLET+ MIRALAX+ MOVANTIK (PA) PREVACID DR 30 MG CAPSULE (QL, ST) PROTONIX (QL, ST) RECTIV RELISTOR (PA) SANCUSO (PA, QL) SFROWASA SUCRAID* (PA) SYMPROIC (PA) TRANSDERM-SCOP URSO URSO FORTE VARUBI (PA, QL) VIOKACE

PENTASA SUPREP+ SUTAB+ VIBERZI

GAVILYTE-C+ GAVILYTE-G+ GAVILYTE-N+ GENTLE LAXATIVE+ GENTLELAX+ GLYCOLAX+ glycopyrrolate tablet

HEMMOREX-HC hydrocortisone lansoprazole (QL) LAXACLEAR+ LAXATIVE PEG 3350+ LAXATIVE 5 MG TABLET+

HORMONAL AGENTS

AMABELZ budesonide ec

ANDRODERM (PA, QL) DIVIGEL

ACTIVELLA ALORA (QL)

12

Cigna Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 18-24).

TIER 1 $

TIER 2 $$ TIER 3 $$$ HORMONAL AGENTS (cont)

TIER 1 $

TIER 2 $$

TIER 3 $$$

INFECTIONS (cont)

budesonide er (PA, QL) cabergoline (QL) COVARYX COVARYX H.S. DECADRON desmopressin dexamethasone intensol DOTTI (QL) EEMT EEMT H.S. estradiol (once weekly) estradiol 10mcg vaginal insert (QL) estradiol (twice weekly) (QL) estradiol- norethindrone estrogen- methyltestos- terone EUTHYROX LEVO-T levothyroxine tablet LEVOXYL liothyronine

DUAVEE ESTRING (QL) MEDROL 2 MG TABLET

ANDROGEL (PA, QL) ANGELIQ ARMOUR THYROID AYGESTIN BIJUVA CLIMARA CLIMARA PRO COMBIPATCH CRINONE 4% GEL CYTOMEL ELESTRIN ENTOCORT EC ESTRACE ESTROGEL EVAMIST IMVEXXY (QL) INTRAROSA LEVOTHYROXINE CAPSULE MEDROL 8MG, 16MG, 32MG TABLET MEDROL 4 MG DOSEPAK MENOSTAR (QL) MINIVELLE (QL) MYFEMBREE (QL) OSPHENA PROMETRIUM RAYALDEE TIROSINT-SOL UNITHROID VAGIFEM (QL) VIVELLE-DOT (QL)

albendazole amoxicillin amoxicillin- clavulanate er

CLEOCIN 75 MG CAPSULE ERY-TAB DR 333 MG TABLET FIRVANQ SOLOSEC VIBRAMYCIN 50 MG/5 ML SYRUP XIFAXAN (QL)

ALBENZA ALINIA BACTRIM BACTRIM DS

ORIAHNN (PA, QL) ORILISSA (PA, QL) PREMARIN TABLET, VAGINAL CREAM APPLICATOR PREMPHASE PREMPRO

amoxicillin- clavulanate atovaquone atovaquone- proguanil AVIDOXY azithromycin packet, suspension, tablet cefdinir cefuroxime tablet cephalexin ciprofloxacin clarithromycin clarithromycin er clindamycin COREMINO ER QL) dapsone tablets doxycycline hyclate capsule, tablet doxycycline monohydrate EMVERM

BAXDELA (PA) CIPRO TABLET CLEOCIN 150 MG CAPSULE CLEOCIN 300 MG CAPSULE CLEOCIN 100 MG VAGINAL OVULE CLEOCIN 2% VAGINAL CREAM CLINDESSE CRESEMBA CAPSULE (PA) DIFICID (QL) ELIMITE ERYPED 200 ERY-TAB DR 250 MG TABLET ERY-TAB DR 500 MG TABLET

FLAGYL HIPREX KEFLEX MACROBID

erythromycin erythromycin ethylsuccinate

MACRODANTIN MALARONE (PA) NATROBA NUVESSA ORAVIG PLAQUENIL posaconazole suspension PRIFTIN SIVEXTRO TABLET (PA) STROMECTOL sulfatrim URIBEL VALTREX VIBRAMYCIN 25 MG/5 ML SUSP XENLETA 600mg tablet (PA, QL)

LYLLANA (QL) medroxyprog- esterone methimazole methylpred- nisolone MIMVEY norethindrone NP THYROID

famciclovir fluconazole hydroxychlo- roquine ivermectin levofloxacin solution, tablet methenamine metronidazole gel, capsule, tablet minocycline minocycline er tablet (QL) mondoxyne nl MORGIDOX

prednisone prednisone intensol progesterone tablet testosterone (PA, QL) WESTHROID YUVAFEM (QL)

nitazoxanide nitrofurantoin

INFECTIONS

acyclovir capsule, suspension, tablet

CIPRO SUSPENSION AEMCOLO (QL)

13

Cigna Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 18-24).

TIER 1 $

TIER 2 $$

TIER 3 $$$

TIER 1 $

TIER 2 $$

TIER 3 $$$

INFECTIONS (cont)

MISCELLANEOUS (cont)

nitrofurantoin monohydrate- macrocrystal nystatin suspension, tablet penicillin v potassium permethrin posaconazole tablet sulfamethoxazole- trimethoprim suspension, tablet terbinafine tetracycline valacyclovir valganciclovir vancomycin capsule, solution vandazole

XOFLUZA (QL) ZITHROMAX ZITHROMAX TRI- PAK ZYVOX SUSPENSION, TABLET (PA)

TECHLITE LANCETS TRUEPLUS KETONE TEST STRIP

COMPACT SPACE CHAMBER (QL) EASIVENT (QL) FLEXICHAMBER (QL) INSPIRACHAMBER (QL) MICROCHAMBER (QL) NITYR* (PA) OPTICHAMBER DIAMOND (QL) POCKET CHAMBER (QL) PRO COMFORT SPACER WITH MASK (QL) PROCARE SPACER WITH CHILD MASK (QL) RITEFLO (QL) SPACE CHAMBER (QL) SPACE CHAMBER- MEDIUM MASK (QL)

INFERTILITY

clomiphene ^

CRINONE 8% GEL^ ENDOMETRIN^

MISCELLANEOUS

ACCU-CHEK SAFE-T-PRO 23G LANCETS ACCU-CHEK SOFTCLIX LANCETS ACCU-CHEK MULTICLIX LANCETS ACCU-CHEK FASTCLIX LANCET DRUM FC2 FEMALE CONDOM+ KETONE CARE TEST STRIP KETONE TEST STRIP KETOSTIX REAGENT MICROLET PRECISION XTRA sodium chloride inhalation vial. Irrigation solution vial

ACE AEROSOL CLOUD

ADDYI^ (PA, QL) BRISDELLE (QL) NUEDEXTA (QL)

SPACE CHAMBER- SMALL MASK (QL) VORTEX (QL) VORTEX VHC FROG MASK (QL) VORTEX VHC LADYBUG MASK (QL) NUTRITIONAL/DIETARY

ENHANCER (QL) AEROCHAMBER MINI (QL) AEROCHAMBER MV (QL) AEROCHAMBER PLUS FLOW-VU (QL) AEROCHAMBER WITH FLOWSIGNAL (QL) AEROCHAMBER Z-STAT PLUS (QL) AEROTRACH PLUS (QL) AEROVENT PLUS (QL) BREATHRITE (QL) CLEVER CHOICE HOLDING CHAMBER (QL)

calcitriol capsule, solution^ FA-8+ folic acid^+ klor-con KLOR-CON 10 MEQ TABLET KLOR-CON 8 MEQ TABLET KLOR-CON M10 TABLET KLOR-CON M10 TABLET

CITRANATAL 90 DHA CITRANATAL ASSURE CITRANATAL B-CALM CITRANATAL DHA CITRANATAL HARMONY CITRANATAL RX DRISDOL^

ALIVE PRENATAL+ AURYXIA (QL) BRAINSTRONG PRENATAL+ CLASSIC PRENATAL+ EXPECTA PRENATAL+ FOSRENOL 1,000 MG CHEWABLE TABLET FOSRENOL 500 MG CHEWABLE TABLET

14

Cigna Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 18-24).

TIER 1 $

TIER 2 $$ TIER 3 $$$ NUTRITIONAL/DIETARY (cont)

TIER 1 $ TIER 3 $$$ PAIN RELIEF AND INFLAMMATORY DISEASE acetaminophen- codeine (PA) allopurinol tablet ASPIRIN EC+ TIER 2 $$ AIMOVIG (PA) AJOVY (PA)

MULTI-VITAMIN W-FLUORIDE- IRON+ MULTIVITAMIN WITH FLUORIDE+ MULTIVITAMIN- IRON-FLUORIDE ONE DAILY PRENATAL+ potassium chloride 10%, capsule, packet, tablet prenatal complete+ PRENATAL GUMMIES+ PRENATAL MULTI+ prenatal multi- dha+ PRENATAL MULTIVITAMIN+ PRENATAL MULTIVITAMIN- DHA+ PRENATAL ONE DAILY+ PRENATAL VITAMIN + DHA+ PRENATAL VIT+ PRENATAL

FLORIVA CHEWABLE TABLET+ FOSRENOL 1,000 MG POWDER PACK FOSRENOL 750 MG POWDER PACKET

FOSRENOL 750 MG CHEWABLE TABLET K-TAB ER LOKELMA MINI PRENATAL+ OB COMPLETE^ ONE A DAY WOMEN'S PRENATAL DHA+ ONE-A-DAY PRENATAL-1+ PHOSLYRA PRENATAL FORMULA-DHA+ RENVELA SIMILAC PRENATAL+ STUART ONE+ ULTRA PRENATAL PLUS DHA+ VELTASSA

ANALPRAM HC 1% CREAM ANALPRAM HC 2.5%-1% CREAM ANALPRAM HC 2.5%-1% CREAM SINGLE ARAVA BUTRANS (QL) CELEBREX (QL, ST) COLCRYS EC-NAPROSYN (ST) ECOTRIN EC 325 MG TABLET+ ESGIC (QL) FEXMID FLECTOR (PA, QL) LAZANDA (PA) LICART (PA, QL) LIDODERM MITIGARE MOBIC (ST) NAPROSYN (ST) NUCYNTA ER (PA) OXAYDO (PA) PERCOCET (PA) PROCORT SKELAXIN ULTRAM 50 MG TABLET (QL) VTOL LQ ZANAFLEX ZEBUTAL (QL) ZOHYDRO ER (PA) ZYLOPRIM

BELBUCA (QL) EMGALITY (PA) HYSINGLA ER (PA) NUCYNTA (PA) NURTEC ODT (PA, QL) PROCTOFOAM-HC REDITREX (PA) SAVELLA UBRELVY (PA, QL) ULORIC (QL) XTAMPZA ER (PA) ZTLIDO

aspirin tablet+ baclofen tablet buprenorphine patch (QL) butalbital- acetaminophen-

MEPHYTON^ NEEVO DHA^ OB COMPLETE PETITE OB COMPLETE PREMIER

caffeine (QL) carisoprodol celecoxib (QL) colchicine

cyclobenzaprine diclofenac 1% gel (QL) diclofenac dr diclofenac ec EC-NAPROXEN ECOTRIN EC 81 MG TABLET+ eletriptan (QL) ENDOCET (PA) febuxostat (QL) fentanyl (PA) FIORICET (QL) frovatriptan (QL) GLYDO hydrocodone- acetaminophen (PA) hydromorphone er (PA) hydromorphone (PA) IBU ibuprofen indomethacin indomethacin er ketorolac tromethamine (QL)

PERRY PRENATAL+ POLY-VI-FLOR WITH IRON+ POLY-VI-FLOR+ PRENATE ^ PRIMACARE QUFLORA PEDIATRIC 1 MG CHEWABLE TABLET+ QUFLORA PEDIATRIC 0.25 MG/ML DROP+ QUFLORA PEDIATRIC 0.5 MG/ ML DROP+

VITAMINS+ PRENATAL+

ROCALTROL^ TRI-VI-FLOR+ VELPHORO

sevelamer carbonate TRI-VITE WITH FLUORIDE+ vitamin d2 1.25 mg (50,000 unit)^ VITAMINS A,C,D AND FLUORIDE+

OSTEOPOROSIS PRODUCTS

alendronate ibandronate 150 mg tablet raloxifene+ risedronate risedronate dr

ACTONEL (ST) ATELVIA (ST) BINOSTO (ST) BONIVA 150 MG TABLET (ST) EVISTA FOSAMAX (ST)

leflunomide lidocaine 5% ointment (QL)

lidocaine 5% patch lidocaine viscous meloxicam tablet metaxalone

15

Cigna Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 18-24).

TIER 1 $ TIER 3 $$$ PAIN RELIEF AND INFLAMMATORY DISEASE (cont) TIER 2 $$

TIER 1 $

TIER 2 $$

TIER 3 $$$

SEIZURE DISORDERS

carbamazepine carbamazepine er clonazepam divalproex divalproex er EPITOL

DILANTIN 30 MG CAPSULE (PA) FYCOMPA (PA, QL) NAYZILAM (PA, QL) VIMPAT SOLTUION, TABLET (PA)

APTIOM 600, 800 MG TABLETS (PA) APTIOM 200, 400 MG TABLETS(PA, QL) BRIVIACT ORAL SOLUTION, TABLET (PA) CARBATROL (PA) DEPAKOTE (PA) DEPAKOTE ER (PA) DEPAKOTE SPRINKLE (PA) DILANTIN 100 MG CAPSULE (PA) DILANTIN 50 MG INFATAB (PA) KLONOPIN (PA) LYRICA ORAL SOLUTION (PA) NEURONTIN (PA) OXTELLAR XR (PA) PHENYTEK (PA) SPRITAM (PA) TEGRETOL (PA) TEGRETOL XR (PA) VALTOCO (PA, QL) XCOPRI (PA, QL)

methocarbamol MORPHINE (PA) MORPHINE ER (PA) NALFON 600 MG TABLET (ST) NALOCET (PA) oxycodone (PA) oxycodone er (PA) oxycodone- acetaminophen (PA) PROLATE TABLET (PA) rizatriptan (QL) sumatriptan (QL) tizanidine tramadol 50 mg tablet (QL) tramadol er (QL) VANADOM

gabapentin lamotrigine

lamotrigine (blue) lamotrigine (green) lamotrigine (orange) lamotrigine er

lamotrigine odt lamotrigine odt (blue) lamotrigine odt (green) lamotrigine odt (orange) levetiracetam

PARKINSON’S DISEASE

solution, tablet levetiracetam er oxcarbazepine pregabalin capsule, solution

benztropine tablet carbidopa- levodopa carbidopa- levodopa er pramipexole pramipexole er (QL) rasagiline (QL) ropinirole er ropinirole

KYNMOBI (PA)

AZILECT (QL) MIRAPEX ER (QL) NEUPRO OSMOLEX ER (QL) RYTARY SINEMET 10-100 SINEMET 25-100 TASMAR XADAGO (ST)

ROWEEPRA SUBVENITE

SUBVENITE (BLUE) SUBVENITE (GREEN)

SUBVENITE (ORANGE) topiramate topiramate er

SCHIZOPHRENIA/ANTI-PSYCHOTICS 4

aripiprazole (QL) aripiprazole odt asenapine chlorpromazine tablet haloperidol olanzapine tablet olanzapine odt paliperidone er (QL) quetiapine quetiapine er risperidone risperidone odt ziprasidone tablet

LATUDA (QL)

FANAPT (QL, ST) INVEGA (QL, ST) REXULTI (QL, ST) RISPERDAL (ST) SAPHRIS (ST) SECUADO (ST) SEROQUEL (ST) SEROQUEL XR (ST) VRAYLAR (QL, ST)

vigabatrin* vigadrone*

SKIN CONDITIONS

ACCUTANE adapalene (PA) adapalene-benzoyl peroxide AMNESTEEM AVAR CLEANSER azelaic acid betamethasone augmented betamethasone dipropionate

DRYSOL EUCRISA NAFTIN PRAMOSONE 1% LOTION PRAMOSONE 1%- 1% CREAM PRAMOSONE 1%- 1% OINTMENT PRAMOSONE 2.5%- 1% OINTMENT

ANALPRAM HC 2.5%-1% LOTION AVAR 9.5-5% CLEANSING PADS BRYHALI (ST) CALCIPOTRIENE FOAM CAPEX SHAMPOO (ST) CLEOCIN T CLINDACIN ETZ KIT

16

Cigna Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 18-24).

TIER 1 $

TIER 2 $$

TIER 3 $$$

TIER 1 $

TIER 2 $$ TIER 3 $$$ SLEEP DISORDERS/SEDATIVES

SKIN CONDITIONS (cont)

BP 10-1 calcipotriene cream, ointment, solution calcipotriene- betamethasone CLARAVIS CLINDACIN ETZ 1% PLEDGET CLINDACIN P 1% PLEDGETS CLINDAMYCIN 1% FOAM, GEL, LOTION, PLEDGET, SOLUTION clindamycin- benzoyl peroxoxide clindamycin- tretinoin clobetasol clocortolone CLODAN clotrimazole- betamethasone dapsone 5% gel, 7.5% gel pump fluocinonide fluorouracil cream, topical solution isotretinoin ketoconazole KETODAN metronidazole mupirocin MYORISAN NEUAC GEL pimecrolimus ROSADAN sodium sulfacetamide- sulfur SSS 10-5 SULFACLEANSE 8-4 tacrolimus ointment tazarotene 0.1% cream tretinoin (PA) TRIDERM ZENATANE

SANTYL (QL)

CLINDACIN PAC KIT CLODERM (ST) DESOWEN (ST) DOVONEX EFUDEX ELIDEL EVOCLIN PRAMOSONE 2.5%- 1% CREAM PRAMOSONE 2.5%- 1% LOTION PROTOPIC REGRANEX (PA, QL)

armodafinil (PA) eszopiclone modafinil (PA) temazepam zolpidem zolpidem er (QL)

DAYVIGO (QL, ST) SUNOSI (PA, QL)

LUNESTA (ST) SILENOR (QL, ST)

SMOKING CESSATION 4

bupropion sr+^ NICODERM CQ 21 MG/24HR PATCH+ nicotine gum+ nicotine lozenge+ nicotine patch+

CHANTIX^ NICOTROL NS+^ NICOTROL+^

NICODERM CQ 14 MG/24HR PATCH+ NICODERM CQ 7 MG/24HR PATCH+ NICORETTE+

TEMOVATE (ST) VECTICAL (QL) XEPI

QUIT 2+ QUIT 4+ STOP SMOKING AID+

SUBSTANCE ABUSE

buprenorphine- naloxone

LUCEMYRA (QL) NARCAN (QL) ZUBSOLV

BUNAVAIL KLOXXADO (QL) SUBOXONE

URINARY TRACT CONDITIONS

alfuzosin er cevimeline darifenacin er (QL) finasteride oxybutynin oxybutynin er phenazopyridine potassium er silodosin (QL) solifenacin (QL) tamsulosin tolterodine tolterodine er (QL)

ELMIRON K-PHOS ORIGINAL

AVODART EVOXAC FLOMAX

PROSCAR PYRIDIUM RAPAFLO (QL) UROCIT-K UROXATRAL

VACCINES Vaccines are now covered under the Cigna pharmacy benefit. Not all plans cover vaccines in the same way. Log in to the myCigna App or myCigna.com , or check your plan materials, to find out how your specific plan covers them.

ROTARIX+ ROTATEQ+

WEIGHT MANAGEMENT

megestrol suspension phentermine ^

WEGOVY^ (PA, QL) CONTRAVE^ (PA) QSYMIA^ (PA)

17

Specialty medications The oral and injectable specialty medications listed below are covered on Tier 4 and need approval from Cigna before your plan will cover them.

MEDICATION NAME

DRUG CLASS

abacavir-lamivudine** (PA)

AIDS/HIV CANCER

abiraterone** (PA)

ACTEMRA SYRINGE* (PA, QL) ACTEMRA ACTPEN* (PA, QL)

PAIN RELIEF AND INFLAMMATORY DISEASE PAIN RELIEF AND INFLAMMATORY DISEASE

ACTIMMUNE* (PA) ADCIRCA** (PA) ADEMPAS** (PA) AFINITOR** (PA)

CANCER

ASTHMA/COPD/RESPIRATORY ASTHMA/COPD/RESPIRATORY

CANCER CANCER CANCER

AFINITOR DISPERZ** (PA)

ALECENSA** (PA)

alosetron**

GASTROINTESTINAL/HEARTBURN

ALUNBRIG** (PA)

CANCER

ALYQ** (PA) AMICAR**

ASTHMA/COPD/RESPIRATORY

BLOOD MODIFIERS/BLEEDING DISORDERS BLOOD MODIFIERS/BLEEDING DISORDERS

aminocaproic acid** APOKYN* (PA) ARANESP*^ (PA) ARIKAYCE** (PA) ARIXTRA* (QL) atazanavir** (PA) ATRIPLA** (PA) ASTAGRAF XL** AUSTEDO** (PA) AVONEX* (PA) AVSOLA*^ (PA) azathioprine** BAFIERTAM** (PA)

PARKINSON'S DISEASE

BLOOD MODIFIERS/BLEEDING DISORDERS

INFECTIONS

BLOOD THINNERS/ANTI-CLOTTING

AIDS/HIV AIDS/HIV

TRANSPLANT MEDICATIONS

MISCELLANEOUS

MULTIPLE SCLEROSIS

PAIN RELIEF AND INFLAMMATORY DISEASE

TRANSPLANT MEDICATIONS

MULTIPLE SCLEROSIS

BARACLUDE SOLUTION**

INFECTIONS

BENLYSTA* (PA) BETASERON* (PA)

PAIN RELIEF AND INFLAMMATORY DISEASE

MULTIPLE SCLEROSIS

BIKTARVY**

AIDS/HIV CANCER

BOSULIF** (PA) BYNFEZIA* (PA)

HORMONAL AGENTS

CABOMETYX** (PA) capecitabine** (PA) CAYSTON** (PA, QL)

CANCER CANCER

INFECTIONS

CELLCEPT**

TRANSPLANT MEDICATIONS

CERDELGA** (PA)

MISCELLANEOUS

18

MEDICATION NAME

DRUG CLASS

CETROTIDE*^ (PA) CHOLBAM** (PA)

HORMONAL AGENTS

GASTROINTESTINAL/HEARTBURN

chorionic gonadotropin*^ (PA)

INFERTILITY

CIMDUO** (PA) CIMZIA* (PA, QL)

AIDS/HIV

PAIN RELIEF AND INFLAMMATORY DISEASE

cinacalcet**

GASTROINTESTINAL/HEARTBURN

COMETRIQ** (PA) COMPLERA** (PA) CYSTARAN** (QL)

CANCER AIDS/HIV

EYE CONDITIONS

CYSTAGON**

URINARY TRACT CONDITIONS

DARAPRIM** + (PA)

INFECTIONS

DEPEN** (PA) DESCOVY**

PAIN RELIEF AND INFLAMMATORY DISEASE

AIDS/HIV AIDS/HIV

DOVATO** DUOPA**

PARKINSON'S DISEASE

DUPIXENT* (PA) EGRIFTA* (PA) EMFLAZA** (PA) ENBREL* (PA, QL) entecavir** (QL) enoxaparin* (QL) ENTYVIO*^ (PA) ENVARSUS XR** EPCLUSA** (PA, QL) EPIDIOLEX** (PA) EPOGEN*^ (PA) ERIVEDGE** (PA)

PAIN RELIEF AND INFLAMMATORY DISEASE

HORMONAL AGENTS HORMONAL AGENTS

PAIN RELIEF AND INFLAMMATORY DISEASE

INFECTIONS

BLOOD THINNERS/ANTI-CLOTTING GASTROINTESTINAL/HEARTBURN

TRANSPLANT MEDICATIONS

INFECTIONS

SEIZURE DISORDERS

BLOOD MODIFIERS/BLEEDING DISORDERS

CANCER CANCER

ERLEADA** (PA) ESBRIET** (PA) EVOTAZ** (PA) EXJADE** (PA) EXTAVIA* (PA)

MISCELLANEOUS

AIDS/HIV

MISCELLANEOUS

MULTIPLE SCLEROSIS

FASENRA PEN* (PA) FENSOLVI**^ (PA) FERRIPROX** (PA) FIRDAPSE** (PA, QL) FOLLISTIM AQ*^ (PA) fondaparinux* (QL)

ASTHMA/COPD/RESPIRATORY

HORMONAL AGENTS

MISCELLANEOUS

MULTIPLE SCLEROSIS

INFERTILITY

BLOOD THINNERS/ANTI-CLOTTING

FORTEO* (PA, QL) FRAGMIN* (QL) FULPHILA* (PA) GALAFOLD** (PA)

HORMONAL AGENTS

BLOOD THINNERS/ANTI-CLOTTING

BLOOD MODIFIERS/BLEEDING DISORDERS

MISCELLANEOUS

19

MEDICATION NAME

DRUG CLASS

GANIRELIX*^ (PA)

HORMONAL AGENTS

GATTEX* (PA) GENVOYA**

GASTROINTESTINAL/HEARTBURN

AIDS/HIV

GILENYA 0.5MG** (PA)

MULTIPLE SCLEROSIS MULTIPLE SCLEROSIS MULTIPLE SCLEROSIS

glatiramer* (PA) GLATOPA* (PA) GLEEVEC** (PA) GONAL-F*^ (PA)

CANCER

INFERTILITY INFERTILITY

GONAL-F RFF*^ (PA)

GRANIX*^

BLOOD MODIFIERS/BLEEDING DISORDERS BLOOD PRESSURE/HEART MEDICATIONS

HAEGARDA* (PA) HARVONI** (PA, QL) HEMLIBRA* (PA) HETLIOZ** (PA) HUMATROPE* (PA) HUMIRA* (PA, QL) IBRANCE** (PA) ILARIS*^ (PA) ILUMYA* (PA, QL) imatinib** (PA) IMBRUVICA** (PA) INBRIJA** (PA) INCRELEX* (PA) INFLECTRA*^ (PA)

INFECTIONS

BLOOD MODIFIERS/BLEEDING DISORDERS

SLEEP DISORDERS/SEDATIVES

HORMONAL AGENTS

PAIN RELIEF AND INFLAMMATORY DISEASE

CANCER

PAIN RELIEF AND INFLAMMATORY DISEASE PAIN RELIEF AND INFLAMMATORY DISEASE

CANCER CANCER

PARKINSON’S DISEASE HORMONAL AGENTS

PAIN RELIEF AND INFLAMMATORY DISEASE

INLYTA** (PA)

CANCER AIDS/HIV AIDS/HIV AIDS/HIV

INTELENCE** (PA)

ISENTRESS**

ISENTRESS HD** (PA)

JADENU** (PA)

MISCELLANEOUS MISCELLANEOUS

JADENU SPRINKLE** (PA)

JAKAFI** (PA)

CANCER AIDS/HIV DIURETICS

JULUCA**

JYNARQUE** (PA) KALBITOR*^ (PA)

BLOOD PRESSURE/HEART MEDICATIONS

KALYDECO** (PA, QL) KESIMPTA PEN* (PA) KEVZARA* (PA, QL) KINERET* (PA, QL)

ASTHMA/COPD/RESPIRATORY

MULTIPLE SCLEROSIS

PAIN RELIEF AND INFLAMMATORY DISEASE PAIN RELIEF AND INFLAMMATORY DISEASE

KISQALI** (PA)

CANCER CANCER

KISQALI FEMARA** (PA) KITABIS PAK** (PA, QL)

INFECTIONS

KORLYM** (PA)

DIABETES

20

MEDICATION NAME

DRUG CLASS

KUVAN** (PA) KYLEENA** +

MISCELLANEOUS

CONTRACEPTIVE PRODUCTS

LEDIPASVIR-SOFOSBUVIR** (PA)

INFECTIONS

LENVIMA** (PA) LETAIRIS** (PA) LONSURF** (PA) LORBRENA** (PA) LOVENOX* (QL) LUPANETA**^ (PA)

CANCER

ASTHMA/COPD/RESPIRATORY

CANCER CANCER

BLOOD THINNERS/ANTI-CLOTTING

CANCER CANCER

LUPRON DEPOT*^ (PA)

LUPRON DEPOT-PED*^ (PA)

HORMONAL AGENTS

LYNPARZA** (PA)

CANCER

LYSTEDA**

BLOOD MODIFIERS/BLEEDING DISORDERS

MAVENCLAD** (PA) MAVYRET** (PA) MAYZENT** (PA) MEKINIST** (PA) MENOPUR*^ (PA)

MULTIPLE SCLEROSIS

INFECTIONS

MULTIPLE SCLEROSIS

CANCER

INFERTILITY

MIRENA** +

CONTRACEPTION PRODUCTS

MYALEPT* (PA) mycophenolate** mycophenolic acid** MYFORTIC** NATPARA* (PA) NERLYNX** (PA) NEULASTA*^ (PA) NEUPOGEN*^ (PA) NEXAVAR** (PA) NINLARO** (PA)

MISCELLANEOUS

TRANSPLANT MEDICATIONS TRANSPLANT MEDICATIONS TRANSPLANT MEDICATIONS

HORMONAL AGENTS

CANCER

BLOOD MODIFIERS/BLEEDING DISORDERS BLOOD MODIFIERS/BLEEDING DISORDERS

CANCER CANCER

NITYR** (PA) NIVESTYM*^

MISCELLANEOUS

BLOOD MODIFIERS/BLEEDING DISORDERS

NORDITROPIN FLEXPRO* (PA)

HORMONAL AGENTS

NORTHERA** (PA)

BLOOD PRESSURE/HEART MEDICATIONS

NOURIANZ** (PA, QL)

PARKINSON’S DISEASE

NOVAREL*^ (PA) NUBEQA** (PA) NUCALA* (PA) NUZYRA** (PA) NYVEPRIA* (PA) OCALIVA** (PA) ODEFSEY** (PA) ODOMZO** (PA)

INFERTILITY

CANCER

ASTHMA/COPD/RESPIRATORY

INFECTIONS

BLOOD MODIFIERS/BLEEDING DISORDERS

GASTROINTESTINAL/HEARTBURN

AIDS/HIV CANCER

21

MEDICATION NAME

DRUG CLASS

OFEV** (PA)

ASTHMA/COPD/RESPIRATORY

OLUMIANT** (PA, QL)

PAIN RELIEF AND INFLAMMATORY DISEASE

OPSUMIT** (PA)

ASTHMA/COPD/RESPIRATORY

ORENCIA* CLICKJET, SYRINGE (PA, QL)

PAIN RELIEF AND INFLAMMATORY DISEASE

ORENITRAM ER** (PA)

ASTHMA/COPD/RESPIRATORY

ORFADIN** (PA)

MISCELLANEOUS

ORKAMBI** (PA, QL) OTEZLA** (PA, QL) OVIDREL*^ (PA) OXERVATE** (PA) PALYNZIQ* (PA) PEGASYS* (PA) PLEGRIDY* (PA) POMALYST** (PA)

ASTHMA/COPD/RESPIRATORY

PAIN RELIEF AND INFLAMMATORY DISEASE

INFERTILITY

EYE CONDITIONS MISCELLANEOUS

INFECTIONS

MULTIPLE SCLEROSIS

CANCER

PREVYMIS**

INFECTIONS

PREZCOBIX** (PA)

AIDS/HIV AIDS/HIV

PREZISTA**

PROCRIT*^ (PA)

BLOOD MODIFIERS/BLEEDING DISORDERS

PROGRAF**

TRANSPLANT MEDICATIONS

PROMACTA** (PA) PULMOZYME** (PA)

BLOOD MODIFIERS/BLEEDING DISORDERS

ASTHMA/COPD/RESPIRATORY

PURIXAN**

CANCER

RAPAMUNE** RAVICTI** (PA)

TRANSPLANT MEDICATIONS GASTROINTESTINAL/HEARTBURN

REBIF* (PA)

MULTIPLE SCLEROSIS MULTIPLE SCLEROSIS

REBIF REBIDOSE* (PA)

REMICADE*^ (PA) RETACRIT*^ (PA)

PAIN RELIEF AND INFLAMMATORY DISEASE BLOOD MODIFIERS/BLEEDING DISORDERS

REVATIO** SUSPENSION, TABLET (PA)

ASTHMA/COPD/RESPIRATORY

REVLIMID** (PA)

CANCER

RINVOQ ER** (PA, QL)

PAIN RELIEF AND INFLAMMATORY DISEASE

ritonavir**

AIDS/HIV CANCER

RUBRACA** (PA) RUCONEST*^ (PA)

BLOOD PRESSURE/HEART MEDICATIONS

SAMSCA**

DIURETICS

SANDOSTATIN*^ (PA)

HORMONAL AGENTS HORMONAL AGENTS

SANDOSTATIN LAR DEPOT*^ (PA)

SELZENTRY** (PA) SEROSTIM* (PA) SIMPONI* (PA, QL) SIMPONI ARIA* (PA)

AIDS/HIV

HORMONAL AGENTS

PAIN RELIEF AND INFLAMMATORY DISEASE PAIN RELIEF AND INFLAMMATORY DISEASE

sirolimus**

TRANSPLANT MEDICATIONS

22

MEDICATION NAME

DRUG CLASS

SKYLA** +

CONTRACEPTION PRODUCTS

SKYRIZI* (PA, QL)

PAIN RELIEF AND INFLAMMATORY DISEASE

sofosbuvir-velpatasvir** (PA) SOMATULINE DEPOT*^ (PA)

INFECTIONS

HORMONAL AGENTS HORMONAL AGENTS

SOMAVERT* (PA) SOVALDI** (PA, QL)

INFECTIONS

SPRYCEL** (PA)

CANCER

STELARA* (PA, QL) STRENSIQ* (PA) STRIBILD** (PA) STIVARGA** (PA) SUCRAID** (PA) SUTENT** (PA) SYMDEKO** (PA, QL)

PAIN RELIEF AND INFLAMMATORY DISEASE

MISCELLANEOUS

AIDS/HIV CANCER

GASTROINTESTINAL/HEARTBURN

CANCER

ASTHMA/COPD/RESPIRATORY

SYMFI**

AIDS/HIV AIDS/HIV AIDS/HIV

SYMFI LO** SYMTUZA**

tacrolimus capsule** tadalafil 20mg** (PA) TAFINLAR** (PA) TAGRISSO** (PA) TAKHZYRO* (PA) TALTZ* (PA, QL) TALZENNA** (PA) TARGRETIN** (PA) TARGRETIN GEL** TASIGNA** (PA)

TRANSPLANT MEDICATIONS ASTHMA/COPD/RESPIRATORY

CANCER CANCER

BLOOD PRESSURE/HEART MEDICATIONS PAIN RELIEF AND INFLAMMATORY DISEASE

CANCER CANCER

SKIN CONDITIONS

CANCER

TAVALISSE** (PA) TEGSEDI* (PA) TEMIXYS** (PA) TEMODAR** (PA)

BLOOD MODIFIERS/BLEEDING DISORDERS

MISCELLANEOUS

AIDS/HIV CANCER CANCER AIDS/HIV

temozolomide** (PA)

tenofovir** (PA)

teriparatide* (PA, QL) tetrabenazine** (PA) THALOMID** (PA)

HORMONAL AGENTS

MISCELLANEOUS

INFECTIONS

THIOLA**

URINARY TRACT CONDITIONS

TIGLUTIK** (PA)

MISCELLANEOUS

TIVICAY**

AIDS/HIV

TOBI PODHALER** (PA, QL)

INFECTIONS INFECTIONS

tobramycin 300 mg/5ml** (PA, QL)

TRACLEER** (PA)

ASTHMA/COPD/RESPIRATORY

23

MEDICATION NAME

DRUG CLASS

tranexamic acid** TREMFYA* (PA, QL)

BLOOD MODIFIERS/BLEEDING DISORDERS PAIN RELIEF AND INFLAMMATORY DISEASE

trientine** (PA)

MISCELLANEOUS

TRIUMEQ**

AIDS/HIV CANCER

TYKERB** (PA)

TYMLOS* (PA, QL) TYVASO** (PA) UDENYCA*^ (PA) UPTRAVI** (PA) VALCHLOR**

OSTEOPOROSIS PRODUCTS ASTHMA/COPD/RESPIRATORY

BLOOD MODIFIERS/BLEEDING DISORDERS

ASTHMA/COPD/RESPIRATORY

SKIN CONDITIONS

VEMLIDY**

INFECTIONS

VENCLEXTA** (PA) VERZENIO** (PA) VIREAD** (PA) vigabatrin** VIGADRONE** VIZIMPRO** (PA) VOSEVI** (PA) VOTRIENT** (PA) VUMERITY** (PA) VYLEESI*^ (PA, QL) WAKIX** (PA, QL) XALKORI** (PA) XELJANZ** (PA, QL) XELJANZ XR** (PA, QL)

CANCER CANCER AIDS/HIV

SEIZURE DISORDERS SEIZURE DISORDERS

CANCER

INFECTIONS

CANCER

MULTIPLE SCLEROSIS

MISCELLANEOUS

SLEEP DISORDERS/SEDATIVES

CANCER

PAIN RELIEF AND INFLAMMATORY DISEASE PAIN RELIEF AND INFLAMMATORY DISEASE

XELODA** (PA) XERMELO** (PA) XOLAIR* (PA) XTANDI** (PA) XYREM** (PA)

CANCER

GASTROINTESTINAL/HEARTBURN ASTHMA/COPD/RESPIRATORY

CANCER

SLEEP DISORDERS/SEDATIVES

ZARXIO*^

BLOOD MODIFIERS/BLEEDING DISORDERS

ZEJULA** (PA) ZEPATIER** (PA) ZEPOSIA** (PA) ZIEXTENZO* (PA) ZORBTIVE* (PA)

CANCER

INFECTIONS

MULTIPLE SCLEROSIS

BLOOD MODIFIERS/BLEEDING DISORDERS

HORMONAL AGENTS

ZORTRESS**

TRANSPLANT MEDICATIONS

24