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2017 Cigna-Healthspring STAR PLUS Quantity Limit CriteriaDrug NameACARBOSEACARBOSEACARBOSEACETAMINOPHEN W/ CODEINEACETAMINOPHEN W/ CODEINEACETAMINOPHEN W/ CODEINEACETAMINOPHEN W/ CODEINEACETAMINOPHEN W/ CODEINEACETAMINOPHEN W/ INOPHEN-CAFFEINE-DIHYDROCODEINEACTOPLUS MET XRACTOPLUS MET AZOLAMALPRAZOLAMALPRAZOLAMALPRAZOLAM ODTALPRAZOLAM ODTALPRAZOLAM ODTALPRAZOLAM ODTALPRAZOLAM SR 24HRALPRAZOLAM SR 24HRALPRAZOLAM SR 24HRALPRAZOLAM SR PHETAMINE ERAMPHETAMINE ERAMPHETAMINE ERAMPHETAMINE ERAMPHETAMINE ERAMPHETAMINE ARIPIPRAZOLEARIPIPRAZOLEARIPIPRAZOLE IM INJ FOR EXTENDED RELEASEARIPIPRAZOLE IM INJ FOR EXTENDED RELEASEARIPIPRAZOLE ODTARIPIPRAZOLE ODTARIPIPRAZOLE ORALASENAPINE MALEATEASENAPINE -ACETAMINOPHEN-CAFF W/ CODBUTALBITAL-ACETAMINOPHEN-CAFF W/ CODBUTALBITAL-ASPIRIN-CAFF W/ CODEINEBUTORPHANOL TARTRATE NASALBYDUREONBYETTABYETTACAFFEINE CITRATECARISOPRODOLStrength25MG50MG100MG120-12 MG/5ML300-15 MG300-30 MG650-30 MG300-60 MG650-60 MG356.4-30-16 MG712.8-60-32 MG15-1000MG30-1000MG7.5MG12.5MG15MG1 MG/ML0.25 MG0.5 MG1 MG2 MG0.25 MG0.5 MG1 MG2 MG0.5 MG1 MG2 MG3 MG5 MG10 MG20 MG30 MG5 MG10 MG15 MG20 MG25 MG30 MG2 MG5 MG10 MG15 MG20 MG30 MG300 MG400 MG10 MG15 MG1 MG/ML5 MG10 MG356.4-30-16 MG5 MCG/HR10 MCG/HR15 MCG/HR20 MCG/HR50-300-40-30 MG50-325-40-30 MG50-325-40-30 MG10 MG/ML2 MG5MCG10 MCG20 MG/ML250 1303030222122223030

2017 Cigna-Healthspring STAR PLUS Quantity Limit CriteriaDrug NameCARISOPRODOLCARISOPRODOL W/ ASPIRIN & CODEINECHLORAL HYDRATECHLORAL HYDRATE SYRUPCHLORPROMAZINE HCLCHLORPROMAZINE HCLCHLORPROMAZINE HCLCHLORPROMAZINE HCLCHLORPROMAZINE HCLCHLORPROMAZINE HCL INJCLOZAPINECLOZAPINECLOZAPINECLOZAPINECLOZAPINE ODTCLOZAPINE ODTCLOZAPINE ODTCLOZAPINE ODTCLOZAPINE ODTCODEINE SULFATECODEINE SULFATECODEINE SULFATECODEINE SULFATE E SULFATEDEXTROAMPHETAMINE SULFATEDEXTROAMPHETAMINE SULFATE ERDEXTROAMPHETAMINE SULFATE ERDEXTROAMPHETAMINE SULFATE ERDIAZEPAM RECTALDIAZEPAM RECTALDIAZEPAM RECTALDICLOFENAC SODIUM GEL 1%DICLOFENAC SODIUM GEL 3%DICLOFENAC SODIUM SOLN 1.5%DOXEPIN HCLDOXEPIN ENTANYLFENTANYLFENTANYL CITRATEFENTANYL CITRATEFENTANYL CITRATEFENTANYL CITRATEFENTANYL CITRATEFENTANYL CITRATEFENTANYL CITRATEFENTANYL CITRATEStrength350 MG200-325-16 MG500 MG500 MG/5ML10 MG25 MG50 MG100 MG200 MG25 MG/ML25 MG50 MG100 MG200 MG12.5 MG25 MG100 MG150 MG200 MG15 MG30 MG60 MG30 MG/5ML0.8MG30 MG60 MG10MG/9HR15MG/9HR20MG/9HR30MG/9HR0.1 MG0.2 MG5 MG10 MG5 MG10 MG15 MG2.5 MG10 MG20 MG1%3%1.50%3 MG6 MG400-1001 MG2 MG1 MG2 MG3 MG5MG10MG12 MCG/HR25 MCG/HR50 MCG/HR75 MCG/HR100 MCG/HR200 MCG400 MCG600 MCG800 MCG1200 MCG100 MCG200 MCG300 30303030283030303030303030303030303030303030303030

2017 Cigna-Healthspring STAR PLUS Quantity Limit CriteriaDrug NameFENTANYL CITRATEFENTANYL CITRATEFENTANYL CITRATEFENTANYL CITRATEFENTANYL CITRATEFENTANYL CITRATEFENTANYL CITRATEFENTANYL CITRATEFENTANYL CITRATEFENTANYL CITRATEFENTANYL CITRATEFENTANYL CITRATEFENTANYL CITRATEFENTANYL CITRATEFENTANYL CITRATEFENTANYL SUBLINGUAL SPRAYFENTANYL SUBLINGUAL SPRAYFENTANYL SUBLINGUAL SPRAYFENTANYL SUBLINGUAL SPRAYFENTANYL SUBLINGUAL SPRAYFENTANYL SUBLINGUAL SPRAYFENTANYL SUBLINGUAL SPRAYFLECTOR PATCHFLUPHENAZINE HCLFLUPHENAZINE HCLFLUPHENAZINE HCLFLUPHENAZINE HCLFLUPHENAZINE HCL ELIXIRFLUPHENAZINE HCL INJFLUPHENAZINE HCL ORALFLURAZEPAM HCLFLURAZEPAM HCLFOCALINFOCALINFOCALINFOCALIN XRFOCALIN XRFOCALIN XRFOCALIN XRFOCALIN XRFOCALIN XRFOCALIN XRFOCALIN ZIDEGLIPIZIDEGLIPIZIDE XLGLIPIZIDE DEGLYBURIDE, MICRONIZEDGLYBURIDE, MICRONIZEDStrength400 MCG600 MCG800 MCG200 MCG400 MCG600 MCG800 MCG1200 MCG1600 MCG100 MCG200 MCG300 MCG400 MCG600 MCG800 MCG100 MCG200 MCG400 MCG600 MCG800 MCG1200 MCG (600 MCG X 2)1600 MCG (800 MCG X 2)1.30%1 MG2.5 MG5 MG10 MG2.5 MG/5ML2.5 MG/ML5 MG/ML15 MG30 MG2.5 MG5 MG10 MG5 MG10 MG15 MG20 MG25 MG30 MG35 MG40 MG100 MG300 MG400 MG600 MG800 MG250 MG/5 030

2017 Cigna-Healthspring STAR PLUS Quantity Limit CriteriaDrug NameGLYBURIDE, ODONE-IBUPROFENHYDROMORPHONE HCLHYDROMORPHONE HCLHYDROMORPHONE HCLHYDROMORPHONE HCLHYDROMORPHONE HCLHYDROMORPHONE HCL ER 24HRHYDROMORPHONE HCL ER 24HRHYDROMORPHONE HCL ER 24HRHYDROMORPHONE HCL ER 24HRHYDROMORPHONE HCL SR 24HRHYDROMORPHONE HCL SR 24HRHYDROMORPHONE HCL SR 24HRHYDROMORPHONE HCL SR OPERIDONEILOPERIDONEILOPERIDONEINVEGA SUSTENAINVEGA SUSTENAINVEGA SUSTENAINVEGA SUSTENAINVEGA 5MG/500MG10MG/5MG25MG/5MG0.5 MG1 MG2 MG5 MG10 MG20 MG90-400 MG5-500 MG7.5-325 MG/15ML7.5-500 MG/15ML10-325 MG/15ML10-500 MG/15ML2.5-500 MG5-300 MG5-325 MG5-400 MG5-500 MG7.5-300 MG7.5-325 MG7.5-400 MG7.5-500 MG7.5-650 MG7.5-750 MG10-300 MG10-325 MG10-400 MG10-500 MG10-650 MG10-660 MG10-750 MG2.5-200 MG5-200 MG7.5-200 MG10-200 MG3 MG1 MG/ML2 MG4 MG8 MG8 MG12 MG16 MG32 MG8 MG12 MG16 MG32 MG1 MG2 MG4 MG6 MG8 MG10 MG12 030303030282828282830

2017 Cigna-Healthspring STAR PLUS Quantity Limit CriteriaDrug UMETJANUMETJANUMET XRJANUMET XRJANUMET OJENTADUETOJENTADUETOKALYDECOKAZANOKAZANOKETOROLAC THOMETHAMINEKETOROLAC THOMETHAMINEKOMBIGLYZE XRKOMBIGLYZE XRKOMBIGLYZE XRKORLYMLEVORPHANOL TARTRATELIDOCAINELINDANE LOTIONLINDANE AM INJLORAZEPAM INJLOXAPINE SUCCINATELOXAPINE SUCCINATELOXAPINE SUCCINATELOXAPINE SUCCINATELUBIPROSTONELUBIPROSTONELURASIDONE HCLLURASIDONE HCLLURASIDONE HCLLURASIDONE HCLMEPERIDINE HCLMEPERIDINE HCLMEPERIDINE HCLMETADATE CDMETADATE CDMETADATE CDMETFORMINMETFORMINMETFORMINMETFORMIN SRMETFORMIN SRMETFORMIN XRMETFORMIN 5MG/500MG2.5MG/850MG2.5MG/1000MG50 MG12.5MG/500MG12.5MG/1000MG60 MG/2 ML15.75 MG/spray2.5MG/1000MG5MG/500MG5MG/1000MG300MG2 MG5%1%1%0.5 MG1 MG2 MG2 MG/ML4 MG/ML2 MG/ML5 MG10 MG25 MG50 MG24 MCG8 MCG20 MG40 MG80 MG120 MG50 MG/5ML50 MG100 MG40 MG50 MG60 MG500MG850MG1000MG500MG1000MG500MG750MG5 MG2.5 MG5 MG10 MG10 MG20 03030303030303030303030303030303030

2017 Cigna-Healthspring STAR PLUS Quantity Limit CriteriaDrug ETHYLPHENIDATE ERMETHYLPHENIDATE ERMETHYLPHENIDATE ERMETHYLPHENIDATE ERMETHYLPHENIDATE ERMODAFINILMODAFINILMORPHINE SULFATEMORPHINE SULFATEMORPHINE SULFATEMORPHINE SULFATE BEADS SR 24HRMORPHINE SULFATE BEADS SR 24HRMORPHINE SULFATE BEADS SR 24HRMORPHINE SULFATE BEADS SR 24HRMORPHINE SULFATE BEADS SR 24HRMORPHINE SULFATE BEADS SR 24HRMORPHINE SULFATE CRMORPHINE SULFATE CRMORPHINE SULFATE CRMORPHINE SULFATE CRMORPHINE SULFATE CRMORPHINE SULFATE ORALMORPHINE SULFATE ORALMORPHINE SULFATE SR 12HRMORPHINE SULFATE SR 12HRMORPHINE SULFATE SR 12HRMORPHINE SULFATE SR 12HRMORPHINE SULFATE SR 12HRMORPHINE SULFATE SR 24HRMORPHINE SULFATE SR 24HRMORPHINE SULFATE SR 24HRMORPHINE SULFATE SR 24HRMORPHINE SULFATE SR 24HRMORPHINE SULFATE SR 24HRMORPHINE SULFATE SR 24HRMORPHINE SULFATE SR 24HRMORPHINE SULFATE SR 24HRMORPHINE SULFATE SR 24HRMORPHINE SULFATE SR 24HRMORPHINE SULFATE SR ZAPINEOLANZAPINE ODTOLANZAPINE ODTOLANZAPINE ODTOLANZAPINE ODTOLANZAPINE-FLUOXETINE HCLOLANZAPINE-FLUOXETINE HCLStrength30 MG5MG/5ML10MG/5ML10 MG18 MG27 MG36 MG54 MG100 MG200 MG20 MG/ML15 MG30 MG30 MG45 MG60 MG75 MG90 MG120 MG15 MG30 MG60 MG100 MG200 MG10 MG/5ML20 MG/5ML15 MG30 MG60 MG100 MG200 MG10 MG20 MG30 MG40 MG50 MG60 MG70 MG80 MG100 MG130 MG150 MG200 MG60MG120MG6.25MG12.5MG25MG0.9%100 MG/5 ML500 MG50 MG150 MG250 MG2.5 MG5 MG7.5 MG10 MG15 MG20 MG5 MG10 MG15 MG20 MG3-25 MG6-25 030303030303030303030

2017 Cigna-Healthspring STAR PLUS Quantity Limit CriteriaDrug NameOLANZAPINE-FLUOXETINE HCLOLANZAPINE-FLUOXETINE HCLOLANZAPINE-FLUOXETINE HCLOLYSIOOMEGA 3-ACID ETHYL OXAZEPAMOXAZEPAMOXAZEPAMOXYCODONE HCLOXYCODONE HCLOXYCODONE HCLOXYCODONE HCLOXYCODONE HCLOXYCODONE HCLOXYCODONE HCLOXYCODONE HCLOXYCODONE HCL (ABUSE DETERRENT)OXYCODONE HCL (ABUSE DETERRENT)OXYCODONE HCL ER 12HROXYCODONE HCL ER 12HROXYCODONE HCL ER 12HROXYCODONE HCL ER 12HROXYCODONE HCL ER 12HROXYCODONE HCL ER 12HROXYCODONE HCL ER 12HROXYCODONE HCL SR 12HROXYCODONE HCL SR 12HROXYCODONE HCL SR 12HROXYCODONE HCL SR 12HROXYCODONE HCL SR 12HROXYCODONE HCL SR 12HROXYCODONE HCL SR 12HROXYCODONE W/ ACETAMINOPHENOXYCODONE W/ ACETAMINOPHENOXYCODONE W/ ACETAMINOPHENOXYCODONE W/ ACETAMINOPHENOXYCODONE W/ ACETAMINOPHENOXYCODONE W/ ACETAMINOPHENOXYCODONE W/ ACETAMINOPHENOXYCODONE W/ ACETAMINOPHENOXYCODONE W/ XYMORPHONE HCLOXYMORPHONE HCLOXYMORPHONE HCL ER 12HROXYMORPHONE HCL ER 12HROXYMORPHONE HCL ER 12HROXYMORPHONE HCL ER 12HROXYMORPHONE HCL ER 12HROXYMORPHONE HCL ER 12HROXYMORPHONE HCL ER 12HROXYMORPHONE HCL SR 12HROXYMORPHONE HCL SR 12HROXYMORPHONE HCL SR 12HROXYMORPHONE HCL SR 12HROXYMORPHONE HCL SR 12HROXYMORPHONE HCL SR 12HRStrength6-50 MG12-25 MG12-50 MG150 MG1 MG25MG/30MG25MG/45MG10 MG15 MG30 MG5 MG5 MG/5ML5 MG10 MG15 MG20 MG30 MG20 MG/ML5 MG7.5 MG10 MG15 MG20 MG30 MG40 MG60 MG80 MG10 MG15 MG20 MG30 MG40 MG60 MG80 MG5-500 MG5-325 MG/5ML2.5-325 MG5-325 MG5-500 MG7.5-325 MG7.5-500 MG10-325 MG10-650 MG4.8355-325 MG5-400 MG5 MG10 MG5 MG7.5 MG10 MG15 MG20 MG30 MG40 MG5 MG7.5 MG10 MG15 MG20 MG30 0303030303030303030303030303030303030303030

2017 Cigna-Healthspring STAR PLUS Quantity Limit CriteriaDrug NameOXYMORPHONE HCL SR 12HROXYMORPHONE HCL SR 12HR (CRUSH RESISTANT)OXYMORPHONE HCL SR 12HR (CRUSH RESISTANT)OXYMORPHONE HCL SR 12HR (CRUSH RESISTANT)OXYMORPHONE HCL SR 12HR (CRUSH RESISTANT)OXYMORPHONE HCL SR 12HR (CRUSH RESISTANT)OXYMORPHONE HCL SR 12HR (CRUSH RESISTANT)OXYMORPHONE HCL SR 12HR (CRUSH RESISTANT)PALIPERIDONE SR 24HRPALIPERIDONE SR 24HRPALIPERIDONE SR 24HRPALIPERIDONE SR 24HRPALIPERIDONE PALMITATE IMPALIPERIDONE PALMITATE IMPALIPERIDONE PALMITATE IMPALIPERIDONE PALMITATE IMPALIPERIDONE PALMITATE IMPENNSAID SOLN 2%PENTAZOCINE W/ APAPPENTAZOCINE W/ IOGLITAZONEPROCENTRAQUAZEPAMQUETIAPINE FUMARATEQUETIAPINE FUMARATEQUETIAPINE FUMARATEQUETIAPINE FUMARATEQUETIAPINE FUMARATEQUETIAPINE FUMARATEQUETIAPINE FUMARATE SR 24HRQUETIAPINE FUMARATE SR 24HRQUETIAPINE FUMARATE SR 24HRQUETIAPINE FUMARATE SR 24HRQUETIAPINE FUMARATE SR 24HRQUILLIVANT SUS RIDONERISPERIDONERISPERIDONERISPERIDONEStrength40 MG5 MG7.5 MG10 MG15 MG20 MG30 MG40 MG1.5 MG3 MG6 MG9 MG39 MG/0.25 ML78 MG/0.5 ML117 MG/0.75 ML156 MG/ML234 MG/1.5 ML2%25-650 MG50-0.5 MG25-650 MG2 MG4 MG8 MG16 MG2-10 MG2-25 MG4-10 MG4-25 MG4-50 MG1 MG2 5MG/5ML15 MG25 MG50 MG100 MG200 MG300 MG400 MG50 MG150 MG200 MG300 MG400 MG25MG/5ML8 MG0.5MG1MG2MG200 MG550 MG1 MG/ML0.25 MG0.5 MG1 MG2 MG3 MG4 30303030303030303030303030

2017 Cigna-Healthspring STAR PLUS Quantity Limit CriteriaDrug NameRISPERIDONE ODTRISPERIDONE ODTRISPERIDONE ODTRISPERIDONE ODTRISPERIDONE ODTRISPERIDONE ODTRITALINRITALINRITALINRITALIN LARITALIN LARITALIN LARITALIN LARITALIN SRSILDENAFILSILDENAFILSKLICESODIUM OXYBATESOVALDISYMLIN PENSYMLIN APENTADOL HCLTAPENTADOL HCLTAPENTADOL HCLTAPENTADOL HCL SR 12HRTAPENTADOL HCL SR 12HRTAPENTADOL HCL SR 12HRTAPENTADOL HCL SR 12HRTAPENTADOL HCL SR HIORIDAZINE HCLTHIORIDAZINE HCLTHIORIDAZINE HCLTHIORIDAZINE DJENTATRAMADOL HCLTRAMADOL HCL ODTTRAMADOL HCL SR 24HRTRAMADOL HCL SR 24HRTRAMADOL HCL SR 24HRTRAMADOL HCL SR 24HR BIPHASIC RELEASETRAMADOL HCL SR 24HR BIPHASIC RELEASETRAMADOL HCL SR 24HR BIPHASIC RELEASETRAMADOL HCL SR 24HR BIPHASIC RELEASETRAMADOL HCL SR 24HR BIPHASIC RELEASETRAMADOL HCL SR 24HR BIPHASIC RELEASETRAMADOL HCL SR 24HR BIPHASIC FLUOPERAZINE HCLTRIFLUOPERAZINE HCLStrength0.25 MG0.5 MG1 MG2 MG3 MG4 MG5 MG10 MG20 MG10 MG20 MG30 MG40 MG20 MG10 MG/ML20 MG0.5%500 MG/ML400 /1000MG30MG50MG50 MG75 MG100 MG50 MG100 MG150 MG200 MG250 MG12.5-75-50 MG7.5 MG15 MG22.5 MG30 MG10 MG25 MG50 MG100 MG1 MG2 MG5 MG10 MG5MG50 MG50 MG100 MG200 MG300 MG100 MG150 MG200 MG300 MG100 MG200 MG300 MG37.5-325 MG0.125 MG0.25 MG1 MG2 303030303030303030