Cigna No Cost Share Preventive Drug List Flyer

PPACA NO COST-SHARE ($0) PREVENTIVE MEDICATIONS

By drug category

Preventive medications are used to prevent certain conditions from developing, or to prevent a condition from coming back.

› This drug list is updated as the U.S. Preventive Services Task Force makes new recommendations. Log in to the myCigna ® App 2 or myCigna.com ®, 3 or check your plan materials, to learn more about how your plan covers preventive medications. Choosing the right preventive medication Many preventive medications are covered at 100%, or no cost-share to you, under PPACA’s preventive coverage requirement. Talk with your doctor to see if one may work for you. If your doctor feels a certain contraceptive or smoking cessation medication on this list isn’t right for you, ask your doctor to contact Cigna. Together, we’ll look for other medications that may be available at no cost-share. Religious exemptions to contraception coverage PPACA allows certain employers to not cover (or exclude) contraceptives from coverage based on their religious beliefs. For women with a Cigna pharmacy plan through one of these employers, where the law requires, Cigna will pay for contraceptives and/ or certain medications at no cost. This coverage is private and confidential and isn’t administered, funded by or connected in any way to the employer’s health coverage.

Certain preventive medications are available 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. 1 The U.S. Preventive Services Task Force and the Institute of Medicine provides guidance on which drug classes should be covered on this list. These recommendations are meant to help prevent disease, as well as meet women’s unique health care needs. About this drug list This is a list of the preventive prescription medications and over-the-counter (OTC) products available to you at no cost-share (copay, coinsurance and/or deductible). For your plan to cover these medications at 100%, you’ll need to get a prescription from your doctor – even for the OTC products which are typically available without a prescription. › Medications are listed alphabetically by drug category. › Generic medications are listed in all lowercase letters and brand-name medications are listed in all capital letters.

Offered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company or their affiliates. 968433 09/22

PPACA No Cost-Share Preventive Medications This is a list of the preventive prescription medications and the over-the-counter (OTC) products available to you at no cost-share under PPACA. For your plan to cover these medications at 100%, you’ll need to get a prescription from your doctor - even for the OTC products which are typically available without a prescription . This drug list is updated as the U.S. Preventive Services Task Force makes new recommendations.

Aspirin Products adult aspirin regimen aspirin 81mg, 325mg aspirin ec 81mg, 325mg aspir-trin BAYER CHEWABLE ASPIRIN children’s aspirin ecotrin 81mg ECOTRIN 325MG low dose aspirin ec st. joseph aspirin st. joseph aspirin ec Barrier Contraception CAYA CONTOURED CONCEPTROL FC2 FEMALE CONDOM FEMCAP gynol ii MALE CONDOM 4 TODAY CONTRACEPTIVE SPONGE VCF FILM, GEL vcf foam WIDE SEAL DIAPHRAGM Bowel Prep Products for Colorectal Cancer Screenings Available to adults 45-75 years of age alophen pills bisacodyl tablets bisa-lax clearlax CLENPIQ CORRECTOL DULCOLAX EC 5 MG TABLET gavilax powder

Folic Acid Supplementation (Only for products containing 0.4 mg–0.8 mg of folic acid) Available to adults 50 years of age and younger ALIVE PRENATAL BRAINSTRONG PRENATAL classic prenatal EXPECTA PRENATAL FA-8 folic acid 0.4mg, 0.8mg kpn MINI PRENATAL ONE A DAY WOMEN’S PRENATAL DHA one daily prenatal dha pack ONE DAILY PRENATAL COMBO PAK ONE-A-DAY PRENATAL-1

natura-lax NULYTELY SOLUTION peg 3350-electrolyte peg3350-sodium sulfate-sodium chloride-potassium chloride- sodium ascorbate-ascorbic acid peg-prep polyethylene glycol 3350 powderlax purelax smoothlax SODIUM-POTASSIUM-MAGNESIUM SULFATE SUPREP SUTAB women’s gentle laxative women’s laxative Breast Cancer Prevention 5

anastrozole exemestane

perry prenatal prenatal tablet prenatal complete PRENATAL FORMULA-DHA PRENATAL GUMMIES

raloxifene tamoxifen Cholesterol Related Available to adults 40-75 years of age atorvastatin 10mg, 20mg fluvastatin fluvastatin er lovastatin 20mg, 40mg pravastatin rosuvastatin 5mg, 10mg simvastatin 10mg, 20mg, 40mg Emergency Contraception

PRENATAL MULTI prenatal multi-dha prenatal multivitamin PRENATAL MULTIVITAMIN-DHA prenatal one daily PRENATAL PLUS-DHA prenatal vitamin PRENATAL VITAMIN + DHA SIMILAC PRENATAL STUART ONE ULTRA PRENATAL PLUS DHA Hormonal Contraception 6,7

after pill AFTERA econtra ez econtra one-step ELLA levonorgestrel my choice my way new day opcicon one-step option 2 TAKE ACTION

afirmelle altavera alyacen amethia amethyst apri aranelle ashlyna aubra aubra eq

gavilyte-c gavilyte-g gavilyte-n gentle laxative tablet gentlelax GIALAX healthylax laxaclear laxative 5mg laxative peg 3350 MIRALAX POWDER

Generic medications are listed in all lowercase letters and brand-name medications are listed in all capital letters. 2

Hormonal Contraception 6,7 ( cont ) aurovela aurovela 24 fe aurovela fe

isibloom jaimiess jasmiel jencycla

ocella orsythia philith pimtrea pirmella portia

jolessa juleber junel junel fe junel fe 24 kaitlib fe

aviane ayuna azurette balziva bekyree blisovi 24 fe blisovi fe briellyn camila camrese camrese lo caziant charlotte 24 fe chateal chateal eq cryselle cyclafem cyred cyred eq

previfem reclipsen rivelsa setlakin sharobel simliya simpesse sprintec sronyx syeda tarina 24 fe tarina fe tarina fe 1-20 eq taysofy 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 tri-vylibra lo tulana tydemy velivet vestura vienva viorele volnea vyfemla vylibra wera wymzya fe xulane zafemy zarah zovia 1-35 zovia 1-35e zumandimine

kalliga kariva

kelnor 1-35 kelnor 1-50 kurvelo larin larin 24 fe

larin fe larissia leena lessina levonest

levonorgestrel-ethinyl estradiol levonorgestrel-ethinyl estradiol ethinyl estradiol levora-28 lillow lojaimiess loryna low-ogestrel lo-zumandimine lutera lyleq lyza marlissa medroxyprogesterone 150mg/ml melodetta 24 fe merzee mibelas 24 fe microgestin microgestin fe mili mono-linyah necon nikki nora-be norethindrone 0.35mg norethindrone-ethinyl estradiol-iron norethindrone-ethinyl estradiol 1.5- 0.03mg, 1-0.02mg norethindrone-ethinyl estradiol-fe norlyda nortrel nylia nymyo

dasetta daysee deblitane desogestrel-ethinyl estradiol desogestrel-ethinyl estradiol ethinyl estradiol dolishale drospirenone-ethinyl estradiol drospirenone-ethinyl estradiol- levomefolate elinest eluryng emoquette enpresse enskyce errin estarylla

ethynodiol-ethinyl estradiol etonogestrel-ethinyl estradiol

falmina fayosim femynor gemmily

gianvi hailey hailey 24 fe

hailey fe heather iclevia incassia introvale

3 Generic medications are listed in all lowercase letters and brand-name medications are listed in all capital letters.

Human Immunodeficiency Virus (HIV) Infection Pre-Exposure Prevention emtricitabine/tenofovir 200mg- 300mg 5,6,8 Implantable Contraception KYLEENA LILETTA MIRENA PARAGARD T380-A SKYLA Pediatric Multivitamins (containing fluoride and fluoride supplements) Available to children six months – sixteen years of age FLORIVA DROPS, CHEWABLE TABLETS FLUORABON fluoride chewable tablets fluoritab FLURA-DROPS ludent fluoride multivitamin with fluoride multi-vitamin w-fluoride-iron multivitamin-iron-fluoride mvc-fluoride POLY-VI-FLOR POLY-VI-FLOR WITH IRON QUFLORA PED 0.25MG/ML DROPS, 0.5MG/ML DROPS, 1MG CHEWABLE TABLET sodium fluoride oral drops and tablets TRI-VI-FLOR tri-vite with fluoride vitamins a,c,d and fluoride

Smoking Cessation 6,9 Available to adults 18 years of age and older bupropion sr 150mg NICODERM CQ nicotine gum nicotine lozenge nicotine patch NICOTROL NICOTROL NS

HEPLISAV-B HIBERIX INFANRIX DTAP IPOL JANSSEN COVID-19 VACCINE (EUA) KINRIX MENACTRA MENQUADFI MENVEO A-C-Y-W-135-DIP M-M-R II VACCINE MODERNA COVID-19 VACCINE (EUA) NOVAVAX COVID-19 VACCINE (EUA) PEDIARIX PEDVAXHIB PENTACEL PENTACEL ACTHIB PFIZER COVID-19 VACCINE (EUA) PNEUMOVAX 23

quit 2 quit 4 stop smoking aid varenicline Vaccines 10

COVID-19 vaccines: Once you’re eligible to get the vaccine, it will be covered at 100% under PPACA ACTHIB ADACEL TDAP AFLURIA QUAD BEXSERO BOOSTRIX TDAP COMIRNATY DAPTACEL DTAP DENGVAXIA DIPHTHERIA-TETANUS TOXOIDS- PED ENGERIX-B FLUAD QUAD

PREHEVBRIO PREVNAR 13 PREVNAR 20 PRIORIX PROQUAD QUADRACEL DTAP-IPV RECOMBIVAX HB ROTARIX ROTATEQ SHINGRIX SPIKEVAX COVID VACCINE TDVAX TENIVAC TRUMENBA TWINRIX VAQTA

FLUARIX QUAD FLUBLOK QUAD

FLUCELVAX QUAD FLULAVAL QUAD FLUMIST QUAD NASAL FLUZONE HIGH-DOSE QUAD FLUZONE QUAD GARDASIL 9 HAVRIX

VARIVAX VAXELIS VAXNEUVANCE ZOSTAVAX

Generic medications are listed in all lowercase letters and brand-name medications are listed in all capital letters.

4

1. 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, this list of medications may change if legal requirements for preventive coverage changes. 2. The downloading and use of the myCigna App is subject to the terms and conditions of the App and the online stores from which it is downloaded. Standard mobile phone carrier and data usage charges apply. Actual App features available may vary depending on your plan and individual security profile. 3. Customers under age 13 (and/or their parent/guardian) will not be able to register at myCigna.com . 4. For plans renewing on or after January 1, 2023: Male condoms that are stocked behind the pharmacy counter and given to you by the pharmacist will be available at no cost-share to you. Quantity limits apply. 5. PPACA coverage requirements don’t apply to all plans. Log in to the myCigna App or myCigna.com , or check your plan materials, to find out how your plan covers these medications and how much they’ll cost you. 6. If your doctor feels these medications aren’t right for you, ask him or her to call Cigna. There may be other brands available at no cost-share to you. 7. Generic hormonal contraceptives are available at no cost-share to you, even though they may not be listed here. 8. This medication will only be covered at no cost-share ($0) if used alone instead of in combination with other HIV medications. 9.  Quantity limits apply. Also, generic nicotine replacement therapy (known as“store-brands”) are available at no cost-share to you, even though they may not be listed here. 10.  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. You can also see a current list of covered vaccines and pharmacies in your plan’s network. Most immunizations for travel aren’t covered. Call your pharmacy to make sure your plan covers the vaccine and it’s available at their location. You shouldn’t need to make an appointment to get a vaccination. If you use an out-of-network pharmacy, vaccines may not be covered or may be subject to your plan’s copay, coinsurance, and/or deductible. Para obtener ayuda en español llame al número en su tarjeta de Cigna. 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. Product availability may vary by location and plan type and is subject to change. All group health insurance policies and health benefit plans contain exclusions and limitations. For costs and details of coverage, review your plan documents or contact a Cigna representative. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, and HMO or service company subsidiaries of Cigna Health Corporation. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. 968433 09/22 © 2022 Cigna. Some content provided under license.

DISCRIMINATION IS AGAINST THE LAW Medical coverage

Cigna complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Cigna does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Cigna: • Provides free aids and services to people with disabilities to communicate effectively with us, such as: – Qualified sign language interpreters – Written information in other formats (large print, audio, accessible electronic formats, other formats) • Provides free language services to people whose primary language is not English, such as: – Qualified interpreters – Information written in other languages If you need these services, contact customer service at the toll-free number shown on your ID card, and ask a Customer Service Associate for assistance. If you believe that Cigna has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by sending an email to ACAGrievance@Cigna.com or by writing to the following address: Cigna Nondiscrimination Complaint Coordinator PO Box 188016 Chattanooga, TN 37422 If you need assistance filing a written grievance, please call the number on the back of your ID card or send an email to ACAGrievance@Cigna.com. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, DC 20201

1.800.368.1019, 800.537.7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Evernorth Care Solutions, Inc., Evernorth Behavioral Health, Inc., Cigna Health Management, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. ATTENTION: If you speak languages other than English, language assistance services, free of charge are available to you. For current Cigna customers, call the number on the back of your ID card. Otherwise, call 1.800.244.6224 (TTY: Dial 711). ATENCIÓN: Si usted habla un idioma que no sea inglés, tiene a su disposición servicios gratuitos de asistencia lingüística. Si es un cliente actual de Cigna, llame al número que figura en el reverso de su tarjeta de identificación. Si no lo es, llame al 1.800.244.6224 (los usuarios de TTY deben llamar al 711). 896375b 05/21 © 2021 Cigna.

Proficiency of Language Assistance Services English – ATTENTION: Language assistance services, free of charge, are available to you. For current Cigna customers, call the number on the back of your ID card. Otherwise, call 1.800.244.6224 (TTY: Dial 711). Spanish – ATENCIÓN: Hay servicios de asistencia de idiomas, sin cargo, a su disposición. Si es un cliente actual de Cigna, llame al número que figura en el reverso de su tarjeta de identificación. Si no lo es, llame al 1.800.244.6224 (los usuarios de TTY deben llamar al 711). Chinese – 注意:我們可為您免費提供語言協助服務。對於 Cigna 的現有客戶,請致電您的 ID 卡背面的號碼。其 他客戶請致電 1.800.244.6224 (聽障專線:請撥 711 )。 Vietnamese – XIN LƯU Ý: Quý vị được cấp dịch vụ trợ giúp về ngôn ngữ miễn phí. Dành cho khách hàng hiện tại của Cigna, vui lòng gọi số ở mặt sau thẻ Hội viên. Các trường hợp khác xin gọi số 1.800.244.6224 (TTY: Quay số 711). Korean – 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 현재 Cigna 가입자님들께서는 ID 카드 뒷면에 있는 전화번호로 연락해주십시오. 기타 다른 경우에는 1.800.244.6224 (TTY: 다이얼 711 ) 번으로 전화해주십시오. Tagalog – PAUNAWA: Makakakuha ka ng mga serbisyo sa tulong sa wika nang libre. Para sa mga kasalukuyang customer ng Cigna, tawagan ang numero sa likuran ng iyong ID card. O kaya, tumawag sa 1.800.244.6224 (TTY: I-dial ang 711). Russian – ВНИМАНИЕ: вам могут предоставить бесплатные услуги перевода. Если вы уже участвуете в плане Cigna, позвоните по номеру, указанному на обратной стороне вашей идентификационной карточки участника плана. Если вы не являетесь участником одного из наших планов, позвоните по номеру 1.800.244.6224 (TTY: 711). لحاليين برجاء االتصال بالرقم المدون علي ظهر بطاقتكم الشخصية. ا Cigna برجاء االنتباه خدمات الترجمة المجانية متاحة لكم. لعمالء – Arabic .( 711 اتصل ب :TTY) 1.800.244.6224 او اتصل ب French Creole – ATANSYON: Gen sèvis èd nan lang ki disponib gratis pou ou. Pou kliyan Cigna yo, rele nimewo ki dèyè kat ID ou. Sinon, rele nimewo 1.800.244.6224 (TTY: Rele 711). French – ATTENTION: Des services d’aide linguistique vous sont proposés gratuitement. Si vous êtes un client actuel de Cigna, veuillez appeler le numéro indiqué au verso de votre carte d’identité. Sinon, veuillez appeler le numéro 1.800.244.6224 (ATS : composez le numéro 711). Portuguese – ATENÇÃO: Tem ao seu dispor serviços de assistência linguística, totalmente gratuitos. Para clientes Cigna atuais, ligue para o número que se encontra no verso do seu cartão de identificação. Caso contrário, ligue para 1.800.244.6224 (Dispositivos TTY: marque 711). Polish – UWAGA: w celu skorzystania z dostępnej, bezpłatnej pomocy językowej, obecni klienci firmy Cigna mogą dzwonić pod numer podany na odwrocie karty identyfikacyjnej. Wszystkie inne osoby prosimy o skorzystanie z numeru 1 800 244 6224 (TTY: wybierz 711). Japanese – 注意事項:日本語を話される場合、無料の言語支援サービスをご利用いただけます。現在のCignaの お客様は、IDカード裏面の電話番号まで、お電話にてご連絡ください。その他の方は、 1.800.244.6224 ( TTY: 711 ) まで、お電話にてご連絡ください。 Italian – ATTENZIONE: Sono disponibili servizi di assistenza linguistica gratuiti. Per i clienti Cigna attuali, chiamare il numero sul retro della tessera di identificazione. In caso contrario, chiamare il numero 1.800.244.6224 (utenti TTY: chiamare il numero 711). German – ACHTUNG: Die Leistungen der Sprachunterstützung stehen Ihnen kostenlos zur Verfügung. Wenn Sie gegenwärtiger Cigna-Kunde sind, rufen Sie bitte die Nummer auf der Rückseite Ihrer Krankenversicherungskarte an. Andernfalls rufen Sie 1.800.244.6224 an (TTY: Wählen Sie 711). ٬ لطفا با شمارهای که در Cigna توجه: خدمات کمک زبانی٬ به صورت رايگان به شما ارائه میشود. برای مشتريان فعلی – Persian (Farsi) را 711 تماس بگيريد )شماره تلفن ويژه ناشنوايان: شماره 1.800.244.6224 پشت کارت شناسايی شماست تماس بگيريد. در غير اينصورت با شماره شمارهگيری کنيد(. 896375b 05/21

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