2020 Pharmacy No Cost Share Preventive Drug List

PPACA NO COST-SHARE PREVENTIVE MEDICATIONS

by drug category

At Cigna, your health and well-being is important to us. We want you to live life to the fullest. Taking your preventive medications regularly can help you get – and stay – healthy.

Health care reform requires coverage of certain preventive medications at no cost-share to you 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.* The U.S. Preventive Services Task Force and the Institute of Medicine provides guidance on which drug classes should be covered. These recommendations are meant to help prevent disease, as well as meet women’s unique health care needs. Preventive medication coverage This drug list shows the prescription medications and over-the-counter medicines (available without a prescription) and products available to you at no cost-share (copay, coinsurance and/or deductible). This list is updated as the U.S. Preventive Services Task Force makes new recommendations. You should log into the myCigna ® website or app or check your plan materials to learn more about how your plan covers preventive medications. You can also use the Drug Cost tool to estimate how much your medications may cost.

Religious exemptions to the coverage of contraceptives PPACA allows certain employers to exclude contraceptives from coverage due to religious beliefs. If you’re a woman with medical coverage though one of these employers, Cigna will let you know that your plan doesn’t cover these medications. Where required by law, Cigna will offer to pay for your contraceptives and/or certain medications at no extra cost to you (if you choose). This coverage is private and confidential and isn’t administered, funded by or connected in any way to your employer’s health coverage. Choosing the right preventive medication There are many preventive medications covered at 100% (or no cost-share to you) under PPACA’s preventive coverage requirement. You should talk with your doctor to find out which medication or product may be right for you. If your doctor feels a certain contraceptive medication or smoking cessation medication on this list isn’t right for you, ask your doctor to call us. Together, we’ll look for other medications and products not on this list that may be available to you at no cost-share. Please be sure to get a prescription from your doctor for your preventive medication or over-the-counter product. Your pharmacy will need a prescription for the medication to process correctly in the claims system at no cost ($0) to you.

* This is a list of the medications and other products covered at 100% under the plan’s pharmacy benefit at this time, based on existing legal requirements, and is subject to plan terms like limitations and exclusions. For example, if legal requirements for preventive coverage changes, then this list may change.

Offered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company or their affiliates. 855125 p 08/18

This drug list shows the prescription medications and over-the-counter medicines and products available to you at no cost-share under PPACA. This list is updated as the U.S. Preventive Services Task Force makes new recommendations. Aspirin Products Aspir 81 aspirin Natura-Lax Nulytely With Flavor Packs OsmoPrep PEG 3350-Electrolyte

Hormonal Contraception^* Altavera Alyacen Amethia Amethia Lo Amethyst Apri

aspirin EC Aspir-Low Bayer Chewable Aspirin Bufferin

PEG 3350 PEG-Prep Powderlax Prepopik Purelax Smoothlax Suprep Trilyte With Flavor Packets Cholesterol Medications atorvastatin 10mg, 20mg fluvastatin 20mg, 40mg fluvastatin ER 80mg lovastatin 20mg, 40mg pravastatin 10mg, 20mg, 40mg, 80mg rosuvastatin 5mg, 10mg simvastatin 10mg, 20mg, 40 mg Emergency Contraception Aftera Econtra EZ Econtra One-Step Ella My Choice My Way Opcicon One-Step Option 2 Folic Acid Supplementation Only includes products containing 0.4 mg–0.8 mg of folic acid Fa-8 folic acid KPN Perry Prenatal Prenatal Available to adults 40-75 years of age

Aranelle Ashlyna Aubra Aviane Azurette Balziva Bekyree Blisovi 24 FE Blisovi FE Briellyn Camila Camrese Camrese Lo

Ecotrin EcPirin

Low Dose Aspirin EC Tri-Buffered Aspirin Breast Cancer Prevention raloxifene tamoxifen Barrier Contraception Caya Contoured FC2 Female Condom FemCap Today Contraceptive Sponge VCF Wide Seal Diaphragm Bowel Prep Products for Colorectal Cancer Screenings

Caziant Chateal Cryselle Cyclafem Cyred Dasetta Daysee Deblitane Delyla

Available to adults 50–75 years of age Alophen Pills bisacodyl tablet

desogestrel-ethinyl estradiol drospirenone-ethinyl estradiol Elinest Emoquette Enpresse Enskyce Errin Estarylla ethynodiol-ethinyl estradiol

Bisa-Lax Clearlax CoLyte With Flavor Packets Correctol Ducodyl Dulcolax tablet Gavilax

Falmina Fayosim Femynor Gianvi Heather Introvale Isibloom Jencycla Jolessa Jolivette Juleber Junel

Gavilyte-C Gavilyte-G Gavilyte-N GentleLax Gialax Glycolax GoLytely Healthylax LaxaClear Miralax MoviPrep

Prenatal Multi + DHA Prenatal Multivitamin Prenatal Vitamin Right Step Prenatal Vitamins Urosex

Brand name medications are capitalized and generic medications are lowercase

Hormonal Contraception^* ( continued ) Junel FE Junel FE 24 Kaitlib FE Kariva

Pediatric Multivitamins Containing Fluoride and Fluoride Supplements Available to children six months – sixteen years of age Escavite Escavite D Floriva Fluorabon fluoride Fluoritab Flura-Drops Ludent Fluoride multi-vitamin with fluoride-iron multivitamin with fluoride MVC-fluoride Poly-Vi-Flor Poly-Vi-Flor With Iron Polyvitamins with Fluoride Quflora Sodium Fluoride Tri-Vi-flor Tri-Vitamin with fluoride Smoking Cessation^* Quantity limits apply bupropion SR 150mg tablet Nicoderm CQ

Pimtrea Pirmella Portia Previfem Quasense Rajani Reclipsen Rivelsa Setlakin Sharobel Sprintec Sronyx Syeda Tarina FE Tilia FE

Kelnor 1-35 Kelnor 1-50 Kurvelo Larin Larin 24 FE Larin FE Larissia Leena Lessina Levonest

Tri Femynor Tri-Estarylla Tri-Legest FE Tri-Linyah Tri-Lo-Estarylla Tri-lo-Marzia Tri-Lo-Sprintec Tri-Mili Trinessa

levonorgestrel-ethinyl estradiol levonorgestrel-ethinyl estradiol- ethinyl estradiol Levora-28 Lillow Loryna Low-Ogestrel Lutera Lyza Marlissa Melodetta 24 FE Mibelas 24 FE Microgestin Microgestin FE Mili Mono-Linyah Mononessa Myzilra Necon Nikki Nora-Be norethindrone norethindrone-ethinyl estradiol norethindrone-ethinyl estradiol-FE norgestimate-ethinyl estradiol

Trinessa Lo Tri-Previfem Tri-Sprintec Trivora-28 Tri-Vylibra Tulana Tydemy Velivet Vienva Viorele Vyfemla Vylibra Wera Wymzya FE Xulane Zarah Zenchent Zovia 1-35e

Nicorelief Nicorette nicotine gum nicotine lozenge nicotine patch

Quit 2 Quit 4

^ If your doctor feels these medications aren’t right for you, ask him/her to call us. There may be other brands available at no cost-share to you * Generic nicotine replacement therapy (known as “store-brands” are available at no cost-share to you, even though they may not be listed here)

Norlyda Norlyroc Nortrel Nuvaring Ocella Orsythia Philith

^ If your doctor feels these medications aren’t right for you, ask him/her to call us. There may be other brands available at no cost-share to you * Generic hormonal contraceptives are available at no cost-share to you, even though they may not be listed here

Brand name medications are capitalized and generic medications are lowercase

Cigna reserves the right to make changes to this drug list without notice. Your plan may cover additional medications; please refer to your enrollment materials for details. Cigna does not take responsibility for any medication decisions made by the doctor or pharmacist. Cigna may receive payments from manufacturers of certain preferred brand medications, and in limited instances, certain non-preferred brand medications, that may or may not be shared with your plan depending on its arrangement with Cigna. Depending upon plan design, market conditions, the extent to which manufacturer payments are shared with your plan and other factors as of the date of service, the preferred brand medication may or may not represent the lowest-cost brand medication within its class for you and/or your plan. 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 (CHLIC), Connecticut General Life Insurance Company, 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. (CHC-TN), and Cigna HealthCare of Texas, Inc. Policy forms: OK - HP-APP-1 et al (CHLIC), OR - HP-POL38 02-13 (CHLIC), TN - HP-POL43/HC-CER1V1 et al (CHLIC), GSA-COVER, et al (CHC-TN). The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. 855125 p 08/18 © 2018 Cigna. Some content provided under license.

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