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Harris County and Harris County Flood Control DistrictCIGNA VALUE 4-TIERPRESCRIPTION DRUG LISTAs of March 1, 2018Offered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, or their affiliates.891485 a Value 4-Tier w DRT 12/17

Table of ContentsGetting startedYour prescription drug list3How to read your drug list3How to find your medication5Specialty medications17Medications that are not covered19Prescription drug list FAQs28Exclusions and limitations30View your drug list onlineThis document was last updated 09/01/2017.* To see a current list of the medicationscovered on your plan’s drug list, visit:myCigna.com – Once you’re registered, log in and select Estimate HealthCare Costs, then select Get drug costs.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: 05/15/2017, for changesthat were effective 07/01/20172Next planned update: 09/01/17, forchanges that will be effective 01/01/2018

Your prescription drug listThis drug list includes the most commonly prescribed medications covered by your plan as ofMarch 1, 2018.1 These generic and brand name prescription medications are approved by the U.S.Food and Drug Administration (FDA). Medications are listed by the condition they treat, thenlisted alphabetically within tiers, or coverage/cost levels.This drug list only covers generic prescription options in two drug classes that have over-the-counter(OTC) alternatives. OTC medications are available without a prescription. These include medicationscommonly used to treat:››Heartburn and stomach acid conditions (ex. Nexium, Prilosec and any generics) andAllergies (ex. Allegra, Clarinex, Xyzal and any generics)This drug list is not a complete list of covered medications, and not all of the medications listed heremay be covered by your specific plan. You should log into myCigna.com or check your plan materialsto 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.TIER 1 TIER 2 Medications are grouped bythe condition they cillin ERamoxicillin-clavulanate iprofloxacinclarithromycinclarithromycin ERclindamycindoxycyclineTier (coverage/cost level) givesyou an idea of the cost level youmay pay for a medicationAlbenzaBaraclude solution**CeftinCiproDaklinza** (PA)Daraprim (PA)E.E.S. 400Eryped 400Ery-TabHarvoni** (PA)Kitabis Pak*Sovaldi** (PA)StromectolTamiflu (QL)Thalomid** (PA)Uretron D-SVibramycinOral specialty medications have adouble asterisk listed next to themMedications in each column arelisted in alphabetical orderSpecialty injectable medicationshave an asterisk listed next to themMedications that require approvalfor coverage or have limits will havean abbreviation listed next to themBrand name medicationsare capitalizedGeneric medicationsare lowercaseFor illustrative purposes only.3

Here’s more helpful information on how to read this drug list:TiersCovered medications are divided into tiers, or coverage/cost levels. Typically, the higher the tier, thegreater the cost of the medication. Your generic copay will apply to Tier 1 medications. Your brandcopay or coinsurance will apply to Tier 2 and Tier 3 medications. Specialty Medications that are injectedare covered under the fourth tier. This includes, but is not limited to, injectables to treat multiplesclerosis, arthritis, and other conditions listed on page 17.››››Tier 1 – Typically Generics(Lower-cost medication) Tier 2 – Typically Preferred Brands(Medium-cost medication) Tier 3 – Typically Non-Preferred Brands(Higher-cost medication) Tier 4 – Specialty Medications(Highest-cost medication) Abbreviations next to medicationsSome medications on your drug list have special 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 – Your doctor has to provide Cigna with information about whyyou need to use this medication. The medication will only be covered if your doctorrequests and receives approval from Cigna.(ST) tep Therapy – Certain high-cost brand name medications are part of the StepSTherapy program. These medications aren’t covered unless your doctor requestsand receives approval from Cigna. Step Therapy encourages the use of lower-cost,clinically appropriate medications to treat your condition. These are typically genericsor preferred brands. You have to try these medications first before your plan covershigher-cost brands.(QL) uantity Limits – For some medications, your plan only covers up to a certain amountQover a certain number of days. For example, 30mg per day for 30 days. Your plan willonly cover a larger amount if your doctor requests and receives approval from Cigna.(AGE) ge Requirements – You must be within a specific age range for this medication toAbe covered.Brand name medications are capitalizedIn this drug list, brand name medications are capitalized and generic medications begin with alowercase letter.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, injectable specialty medications are marked with an asterisk (*)and oral specialty medications are marked with a double asterisk (**).Specialty Medications that are injected are covered under the fourth tier. This includes, but is notlimited to, injectables to treat multiple sclerosis, arthritis, and other conditions. Oral specialtymedications are covered in Tiers 1 through 3 as listed in this document.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 into myCigna.com or check your plan materials tolearn more about how your plan covers preventive medications.How to find your medication on the drug listLook for your condition in the alphabetical list below. Then go to that page to see the list of coveredmedications available to treat the condition.AIDS/HIV6EYE CONDITIONS11ALLERGY/NASAL SPRAYS6FEMININE PRODUCTS11ALZHEIMER’S SION/BIPOLARDISORDER6HORMONAL ION DEFICIT HYPERACTIVITYDISORDER6MISCELLANEOUS13MULTIPLE SCLEROSIS13BLOOD MODIFIERS/BLEEDING DISORDERS7BLOOD PRESSURE/HEART MEDICATIONS7OSTEOPOROSIS PRODUCTSBLOOD THINNERS/ANTI-CLOTTING7PAIN RELIEF AND INFLAMMATORY DISEASECANCERCHOLESTEROL MEDICATIONSNUTRITIONAL/DIETARY7, 8813, 141414, 15PARKINSON’S DISEASE15SCHIZOPHRENIA/ANTI-PSYCHOTICS15SEIZURE DISORDERS15CONTRACEPTIVE PRODUCTS8–10COUGH/COLD MEDICATIONS10SKIN CONDITIONSDENTAL PRODUCTS10SLEEP DISORDERS/SEDATIVES16DIABETES10SMOKING CESSATION16DIURETICS10SUBSTANCE ABUSE16EAR MEDICATIONS10TRANSPLANT MEDICATIONS16ERECTILE DYSFUNCTION10URINARY TRACT CONDITIONS16515, 16

Cigna Value 4-Tier Prescription Drug ListInjectable specialty medications covered on Tier 4 are listed on page 17.TIER 2PreferredBrandsTIER 1GenericsTIER 3Non-PreferredBrandsTIER *nevirapine ER**nevirapine**Atripla**Intelence**Isentress etine DRfluvoxaminefluvoxamine ERlorazepamlorazepam intensolparoxetineparoxetine CRparoxetine ERsertralinetrazodonevenlafaxinevenlafaxine ERAsteproAuvi-Q (ST, QL)Bactroban atropiumalbuterolmontelukastAdvair DiskusAdvair HFAAnoro ElliptaBreo ElliptaIncruse ElliptaProAir HFAProAir RespiClickQVARStriverdi RespimatSymbicortALZHEIMER’S DISEASEdonepezildonepezil ODTmemantinepyridostigminepyridostigmine ERrivastigmineMestinonNamendaNamenda XR (QL)Namzaric (QL)Adcirca** (PA)Adempas** (PA)CombiventRespimatKalydeco** (PA)Letairis** (PA)Ofev** (PA)Opsumit** (PA)Orenitram ER** (PA)Orkambi** (PA)Pulmicort RespulesPulmozyme* (PA)Tracleer** (PA)Tyvaso* (PA)Uptravi** (PA)ATTENTION DEFICITHYPERACTIVITY DISORDERANXIETY/DEPRESSION/BIPOLAR DISORDERalprazolamalprazolam ERalprazolam intensolalprazolam ODTalprazolam XRamitriptylinebupropionbupropion SRbupropion XLbuspironecitalopramclomipramineduloxetineTIER 3Non-PreferredBrandsANXIETY/DEPRESSION/BIPOLAR DISORDER (cont)ALLERGY/NASAL SPRAYSazelastinecromolyncyproheptadineepinephrine autoinjector (QL)fluticasonehydroxyzineipratropiummometasone (QL)olopatadinepromethazineTIER teERdextroamphetamineamphetamine ERdextroamphetamineamphetamineguanfacine ERmetadate ERmethylphenidatemethylphenidate CDmethylphenidate ERmethylphenidate LABrisdelle (QL)Effexor XR (ST)Fetzima (ST)Forfivo XL (ST)OnfiProzac (ST)Sarafem (ST)Trintellix (ST)Viibryd (ST)Wellbutrin SR (ST)XanaxXanax XRZoloft (ST)6Adderall (ST)Adderall XR (ST)Aptensio XR (ST)Concerta ER (ST)Focalin (ST)Focalin XR (ST)Methylin (ST)Mydayis ERQuillichew ER (ST)Quillivant XR (ST)Ritalin (ST)Ritalin LA (ST)Strattera

Cigna Value 4-Tier Prescription Drug ListTIER 1GenericsTIER 2PreferredBrandsTIER 3Non-PreferredBrandsTIER 1GenericsBLOOD MODIFIERS/BLEEDING DISORDERStranexamic acid*Aranesp* (PA)DroxiaTIER 3Non-PreferredBrandsBLOOD PRESSURE/HEART MEDICATIONS (cont)Amicar**Promacta** (PA)losartanlosartan-HCTZlow-dose aspirin EC Matzim LAmetoprololnadololnifedipinenifedipine afenonepropafenone ERpropranololpropranolol ERramiprilTaztia XTtelmisartantelmisartan-HCTZTri-Buffered Aspirin valsartanvalsartan-HCTZverapamilverapamil ERverapamil SRBLOOD PRESSURE/HEART MEDICATIONSAfeditab CRCoreg CRamiodaroneCorlanor (PA)amlodipineEntresto pinevalsartan-HCTZAscriptin Aspir 81 Aspir-Low aspirin 81mg,325mg aspirin EC 81mg,325mg -HCTZbisoprolol-HCTZcandesartanCartia XTcarvedilolchildren’s aspirin clonidineDigitekDigoxdigoxindiltiazemdiltiazem CDdiltiazem ERDilt-XRdofetilide (QL)doxazosinEcPirin isosorbide ERlabetalollisinoprillisinopril-HCTZTIER 2PreferredBrandsBayer chewableaspirin BiDilCardizem LAEcotrin 81mg,325mg Haegarda* (PA)HemangeolInderal LAInderal XLInnopran thera** (PA)NorvascRanexa (ST, QL)TiazacTikosynToprol XLBLOOD ogrelenoxaparin* (QL)fondaparinux* (QL)JantovenwarfarinBrilintaEliquisFragmin* inib** e tamoxifentemozolomide** (PA)7Afinitor** (PA)Fareston (QL)GleostineNexavar* (PA)Revlimid** (PA)Sprycel** (PA)Sutent** (PA)Tarceva** (PA)Targretin**Tasigna** (PA)Trexall**Afinitor Disperz**(PA)Alecensa**ArimidexBosulif** (PA)Cabometyx** (PA)Cometriq** (PA)Cotellic** (PA)Erivedge** (PA)FemaraGilotrif** (PA)Gleevec** (PA)