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CIGNA VALUE 3-TIERPRESCRIPTION DRUG LISTAs of July 1, 2018Offered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, or their affiliates.876397 m Value 3-Tier w DRT 03/18

Table of ContentsGetting startedYour prescription drug list3How to read your drug list3How to find your medication5Medications that are not covered17Prescription drug list FAQs26Exclusions and limitations28View your drug list onlineThis document was last updated 09/01/2017.* To see a current list of the medications coveredon your plan’s drug list, visit:The myCigna website – Once you’re registered, log in and selectEstimate Health Care Costs, then select Get drug costs.Cigna.com/druglist – Select your drug list name – Value 3 Tier – from thedrop down menu.Questions? – Call the toll-free number on the back of your Cigna ID card. We’rehere to help.* Drug list created: originally created 10/01/2011Last updated: 09/01/2017, for changesthat were effective 01/01/20182Next planned update: 09/01/18, forchanges that will be effective 01/01/2019

Your prescription drug listThis document shows the most commonly prescribed medications covered on the Value PrescriptionDrug List as of July 1, 2018.1 All of these medications are approved by the U.S. Food and DrugAdministration (FDA). The Value Prescription Drug List excludes medications in two drug classes that areavailable over-the-counter without a prescription. These include medications commonly used to treat:››Heartburn and stomach acid conditions (ex. Nexium, Prilosec and any generics) andAllergies (ex. Allegra, Clarinex, Xyzal and any generics)Medications are listed by the condition they treat, then listed alphabetically within tiers (or coverage/cost levels). It’s important to know that this is not a complete list of covered medications, and not allof the medications listed here may be covered by your specific plan. You should log in to the myCignawebsite or app or check your plan materials to learn more about the medications your plan covers.How to read your drug listUse the sample chart below to help you understand this drug list. This chart is just an example. Itmay not show how these medications are actually covered on the Value Prescription Drug List.Tier (coverage/cost level) givesyou an idea of the how much youTIER 1TIER 2may pay for a medication BLOOD PRESSURE/HEART MEDICATIONSafeditab CRamlodipine besylateamlodipine eprilbenazepril-HCTZcandesartan cilexetilcartia XTcarvedilolclonidinedigitekdigoxdigoxindiltiazem ERdiltiazem CDdiltiazemdilt-XRenalaprilflecainide acetatehydralazineirbesartanisosorbide mononitratBerinert* (PA)BidilBystolicCinryze* (PA)Coreg CRCozaar (ST)Diovan (ST)Diovan HCT (ST)Edarbi (ST)Edarbyclor (ST)ExforgeExforge HCTFirazyr* (PA)HemangeolInderal LAInderal XLInnopran XLLotrelMicardis trostatNorthera* (PA)NorvascRanexa (ST)TekturnaTekturna HCTMedications are grouped bythe condition they treatMedications are listed inalphabetical order withineach columnSpecialty medications have anasterisk (*) listed next to themBrand name medicationsare capitalizedGeneric medicationsare lowercaseMedications that have coveragerequirements will have anabbreviation listed next to themThis chart is just a sample. It may not show how these medications are actually covered on the Value Prescription Drug List.3

TiersCovered medications are divided into tiers, or cost levels. Typically, the higher the tier, the higher theprice you’ll pay to fill the prescription.›››Tier 1 – Typically Generics(Lower-cost medication) Tier 2 – Typically Preferred Brands(Medium-cost medication) Tier 3 – Typically Non-Preferred Brands(Higher-cost medication) Abbreviations next to medicationsSome medications on your drug list have additional requirements before they may be covered by yourplan.* This helps to make sure you’re receiving coverage for the right medication, at the right cost, inthe right amount and for the right situation. These medications will have an abbreviation next to themin the drug list. Here’s what each of the abbreviations mean.(PA) Prior Authorization – Cigna will review information provided by your doctor to makesure you meet coverage guidelines for the medication. If approved, your plan will coverthe medication.(ST) tep Therapy – The Step Therapy program encourages the use of lower-costSmedications (generics and preferred brands) to treat certain conditions. Certainhigh-cost brand medications require Step Therapy. This means your plan requiresyou to try a lower-cost alternative first, before the higher-cost brand may be covered(unless you receive approval from Cigna).(QL) uantity Limits – For some medications, your plan will only cover up to a certainQamount over a certain length of time. For example, 30mg per day for 30 days.Your plan will only cover a larger amount if your doctor requests and receivesapproval from Cigna.(AGE) ge Requirements – You must be within a specific age range for your plan to coverAthe medication.* This may not apply to you because not all plans require prior authorization, quantity limits and/or Step Therapy. Please log in to the myCigna website or app or check your plan materials to findout if your plan includes these specific coverage requirements.Brand name medications are capitalizedIn this drug list, brand name medications are capitalized and generic medications are lowercase.Specialty medications are marked with an asteriskSpecialty medications are used to treat complex conditions like multiple sclerosis, hepatitis C andrheumatoid arthritis. In this drug list, specialty medications are marked with an asterisk (*). Someplans may cover these medications on a specialty tier, may limit you to a 30-day supply and/orrequire the use of a preferred specialty pharmacy. Log in to the myCigna website or app or checkyour plan materials to learn more about how your plan covers specialty medications.4

No cost-share preventive medications are marked with a plus signHealth care reform under the Patient Protection and Affordable Care Act (PPACA) requires thatmost plans cover certain categories of medications and other products as preventive care services.In this drug list, medications with a plus sign ( ) next to them may be available to you at no costshare (copay, coinsurance and/or deductible). Log in to the myCigna website or app or check yourplan materials to learn more about how your plan covers preventive medications.Plan exclusionsSome medications shown in this drug list may not be covered by your specific plan. For example,your plan may not cover medications used for weight loss or to treat infertility. In this drug list, thesemedications have a carat ( ) next to them. Log in to the myCigna website or app or check your planmaterials to find out if your plan excludes the medication.How to find your medication on the drug listFind your condition in the alphabetical list below. Then go to that page to see the coveredmedications available to treat the condition.ConditionPageConditionPageAIDS/HIV6EYE CONDITIONS11ALLERGY/NASAL SPRAYS6FEMININE PRODUCTS11ALZHEIMER’S ON/BIPOLARDISORDER6HORMONAL AGENTSASTHMA/COPD/RESPIRATORY6ATTENTION DEFICIT HYPERACTIVITYDISORDER6, 711, 1212INFECTIONS12, 13INFERTILITY13MISCELLANEOUS13MULTIPLE SCLEROSIS13NUTRITIONAL/DIETARY1314BLOOD MODIFIERS/BLEEDING DISORDERS7BLOOD PRESSURE/HEART MEDICATIONS7OSTEOPOROSIS PRODUCTSBLOOD THINNERS/ANTI-CLOTTING7PAIN RELIEF AND INFLAMMATORY DISEASECANCER8PARKINSON’S DISEASE15CHOLESTEROL MEDICATIONS8SCHIZOPHRENIA/ANTI-PSYCHOTICS15SEIZURE DISORDERS1514, 15CONTRACEPTIVE PRODUCTS8–10COUGH/COLD MEDICATIONS10SKIN CONDITIONSDENTAL PRODUCTS10SLEEP DISORDERS/SEDATIVES16SMOKING CESSATION16DIABETES10, 1115, 16DIURETICS11SUBSTANCE ABUSE16EAR MEDICATIONS11TRANSPLANT MEDICATIONS16ERECTILE DYSFUNCTION11URINARY TRACT CONDITIONS16TRANSPLANT MEDICATIONS165

Cigna Value 3-Tier Prescription Drug ListTIER 1 TIER 2 TIER 3 TIER 1 virapine ER*nevirapine*TIER 3 ANXIETY/DEPRESSION/BIPOLARDISORDER ead*ALLERGY/NASAL SPRAYSazelastineClarinex-D 12 HourcromolynKarbinal ERcyproheptadineRyventepinephrine autoinjector ay (QL)olopatadinepromethazineALZHEIMER’S DISEASEdonepezilMestinondonepezil ODTNamendamemantineNamenda XRpyridostigmineNamenda XR titrationpack (QL)pyridostigmine ERNamzaric (QL)rivastigmineAtripla*Intelence*Isentress venlafaxine50mgdesvenlafaxine ER25mg, 100mg (QL)diazepamduloxetine (QL)escitalopram (QL)fluoxetine (QL)fluoxetine DR (QL)fluvoxamine (QL)fluvoxamine ER (QL)lorazepamlorazepam intensolmirtazapineparoxetine (QL)paroxetine CR (QL)paroxetine ER (QL)sertraline (QL)trazodonevenlafaxine (QL)venlafaxine ER (QL)ASTHMA/COPD/RESPIRATORYalbuterolAdvair DiskusAdcirca* (PA)budesonideAdvair HFAAdempas* (PA)ipratropiumAnoro ElliptaCombivent RespimatalbuterolAtrovent HFADaliresp (QL)levalbuterol HFABreo ElliptaKalydeco* (PA)montelukastIncruse ElliptaLetairis* (PA)ProAir HFAOfev* (PA)ProAir RespiClick Opsumit* (PA)QVAROrenitram ER* (PA)QVAR Redihaler Orkambi* (PA)StriverdiPulmicortRespimatPulmozyme* (PA)SymbicortRevatio* (PA)Trelegy ElliptaTracleer* (PA)(ST)Tyvaso* (PA)Xolair* (PA)Uptravi* (PA)ATTENTION DEFICIT HYPERACTIVITY DISORDERatomoxetineAdderall (ST)dexmethylphenidateAdderall XR (ST)dexmethylphenidateAdzenys ER (ST)ERAdzenys XR-ODT (ST)dextroamphetamineAptensio XR (ST)amphetamine ERConcerta (ST)ANXIETY/DEPRESSION/BIPOLAR DISORDERalprazolamalprazolam ERalprazolam intensolalprazolam ODTalprazolam XRamitriptylinebupropion (QL)bupropion SR (QL)bupropion XL (QL)buspironecitalopram (QL)clomipramineTIER 2 Effexor XR (ST, QL)Fetzima (ST, QL)Forfivo XL (ST, QL)OnfiProzac (ST, QL)Sarafem (ST)Trintellix (ST)Viibryd (ST)Wellbutrin SR (ST, QL)XanaxXanax XRZoloft (ST, QL)6

Cigna Value 3-Tier Prescription Drug ListTIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3 BLOOD PRESSURE/HEART MEDICATIONS (cont)ATTENTION DEFICIT HYPERACTIVITYDISORDER (cont)diltiazem ERdofetilide (QL)doxazosinEcotrin EcPirin isosorbide an-HCTZMatzim LAmetoprololnadololnifedipinenifedipine TZpropafenonepropafenone ERpropranololpropranolol ERramiprilTaztia XTtelmisartantelmisartan-HCTZtri-buffered aspirin valsartanvalsartan-HCTZverapamilverapamil ERverapamil SRBLOOD THINNERS/ANTI-CLOTTINGaspirin-dipyridamole * (QL)Pradaxaenoxaparin* (QL)XareltoSavaysafondaparinux* amineamphetamineguanfacine ERMetadate ERmethylphenidatemethylphenidate CDmethylphenidate ERmethylphenidate LADyanavel XR (ST)Evekeo (ST)Focalin (ST)Focalin XR (ST)Methylin (ST)Quillichew ER (ST)Quillivant XR (ST)Ritalin (ST)Ritalin LA (ST)StratteraBLOOD MODIFIERS/BLEEDING DISORDERStranexamic acid*Aranesp* (PA)Amicar*DroxiaPromacta* (PA)Epogen* (PA)Granix*Neulasta* (PA)Procrit* (PA)Zarxio*BLOOD PRESSURE/HEART MEDICATIONSAfeditab CRCorlanor (PA)Bayer ChewableAspirin amlodipineEntresto (PA)BiDil (QL)amlodipinebenazeprilCardizem LAamlodipineCoreg CRolmesartanEpaned (ST)amlodipine-valsartanFirazyr* (PA)amlodipineHaegarda* (PA)valsartan-HCTZHemangeolAspir 81 Inderal LAAspir-Low Innopran atBufferin Northera* (PA)candesartanNorvascCartia XTRanexa (ST, QL)carvedilolTiazacclonidineTikosyn (QL)DigitekDigoxdigoxinDilt-XRdiltiazemdiltiazem CD7