Cigna Standard 4-Tier Prescription Drug List

Cigna Healthcare Standard 4-Tier Prescription Drug List Coverage as of July 1, 2024

Cigna Healthcare Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 17-20).

What's Inside?

Page

About this drug list

How to read this drug list

How to find your medication

Specialty medications

Frequently Asked Questions (FAQs)

Exclusions and limitations for coverage

View your drug list online This document was last updated on 06/01/2024.* Go online to see the most up-to-date list of medications your plan covers. • myCigna ® App 1 or myCigna.com ® . Click on the Prescriptions tab and select Price a Medication from the dropdown menu. Then type in your medication name. • Cigna.com/PDL. Scroll down until you see a pdf of the Cigna Standard 4-Tier Prescription Drug List (all specialty medications covered on Tier 4) . Questions? • myCigna.com : Click to Chat - Monday-Friday, 9:00 am-8:00 pm EST. • By phone: Call the toll-free number on your Cigna Healthcare SM ID card. We’re here 24/7/365.

* Drug list created: originally created 01/01/2004

Last updated: 06/01/2024, for changes starting 07/01/2024

Next planned update: 09/01/2024, for changes starting 01/01/2025

About this drug list This is a list of the most commonly prescribed medications covered on the Cigna Healthcare Standard 4-Tier Prescription Drug List as of July 1, 2024. Medications are listed by the condition they treat, then listed alphabetically within tiers (or cost-share levels). The drug list is updated often so it isn’t a full list of the medications your plan covers. Also, your specific plan may not cover all of these medications. Log in to the myCigna App or myCigna.com , or check your plan materials, to see all of the medications your plan covers. How to read this drug list Use the chart below to help you read this drug list. This chart is just an example. It may not show how these medications are actually covered on this drug list.

Tier (cost-share level) gives you an idea of how much you may pay for a medication

TIER 1 $

TIER 2 $$

TIER 3 $$$

Medications are grouped by the condition they treat; Specialty medications are covered on Tier 4 (pages 17-20)

HORMONAL AGENTS ANDRODERM (PA, QL) COMBIPATCH DUAVEE ESTRING (QL) ESTROGEL MEDROL 2 MG TABLET MYFEMBREE (PA,QL)

AMABELZ budesonide dr budesonide ec budesonide er (PA, QL) cabergoline (QL) DECADRON desmopressin DEXABLISS dexamethasone (PA) dexamethasone intensol DOTTI (QL) estradiol (once weekly) estradiol 10mcg vaginal insert (QL) estradiol (twice weekly) (QL) estradiol-norethindrone acetate EUTHYROX LEVO-T LEVOXYL liothyronine LYLLANA (QL) medroxyprog- esterone methyl-prednisolone

ACTIVELLA ALORA (QL) ANDROGEL (PA, QL) ANGELIQ ARMOUR THYROID (PA) AYGESTIN BIJUVA CLIMARA (PA) CLIMARA PRO (PA) CRINONE 4% CYTOMEL DDAVP (PA) DEPO-TESTOSTERONE DIVIGEL (PA)

Medications are listed in alphabetical order within each column

ORIAHNN (PA, QL) ORILISSA (PA, QL) PREMARIN TABLET, VAGINAL CREAM

Medications that have extra coverage requirements have an next to them

APPLICATOR PREMPHASE PREMPRO

ELESTRIN (PA) ESTRACE (PA) EVAMIST FEMRING (PA) FORTESTA (PA, QL) HEMADY IMVEXXY (PA, QL) INTRAROSA (QL) JATENZO (PA, QL)

Generic medications are in all lowercase letters

Brand-name medications are in all capital letters

levothyroxine tablets MEDROL 8MG, 16MG, 32MG TABLET MEDROL 4 MG DOSEPAK MENOSTAR (QL)

millipred MIMVEY norethindrone

This chart is just a sample. It may not show how these medications are actually covered on the Cigna Healthcare Standard 4-Tier Prescription Drug List.

Tiers Covered medications are divided into tiers or cost-share levels. Typically, the higher the tier, the higher the price you’ll pay to fill the prescription.

• Tier 1 – Typically Generics

(Lowest-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)

$$$$

Letters (acronyms) next to medication names Certain medications may need approval from Cigna Healthcare before they can be covered.* This extra step helps make sure you’re getting the right coverage for the right medication. In this drug list, medications that have extra coverage requirements or limits have letters (acronyms) in parenthesis next to them. Here’s what they mean.

(PA)

P rior Authorization – This medication needs approval from Cigna Healthcare before your plan will cover it. Your doctor’s office will have to send us information to review to make sure the medication meets coverage requirements. Quantity Limit – Your plan will only cover a certain amount of this medication at one time. If your doctor wants you to fill more than what’s allowed, your doctor’s office can ask Cigna Healthcare to approve more. Step Therapy – Your plan doesn’t cover this high-cost medication until you try at least one lower-cost option first (typically a generic or preferred brand) and it didn’t work for you. If your doctor feels a different medication isn’t right for you, your doctor’s office can ask Cigna Healthcare to approve coverage of this medication. Age Requirement – Your plan will only cover this mediation if you’re a certain age or within a certain age range. If you’re not within the allowed age range and your doctor wants you to take this medication, your doctor’s office can ask Cigna Healthcare to approve coverage .

(QL)

(ST)

(AGE)

* These coverage requirements may not apply to your specific plan. Log in to the myCigna App or myCigna.com, or check your plan materials, to find out if your plan includes prior authorization, quantity limits, Step Therapy and/or age requirements.

Brand-name medications are in all capital letters In this drug list, generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Specialty medications are covered on Tier 4 Specialty medications are used to treat complex medical conditions. They’re typically injected or infused and may need special handling (like refrigeration). Some plans may limit coverage to a 30-day supply and/or require you to use a preferred specialty pharmacy to receive coverage. In this drug list, all specialty medications are covered on Tier 4 (see pages 17–20). Injectable specialty medications are marked with an asterisk (*) and oral specialty medications are marked with a double asterisk (**) .

No cost-share preventive medications have a plus sign (+) next to them 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. In this drug list, these medications have a plus sign (+) next to them. Some plans may cover certain non-covered medications Plans can choose to offer coverage of certain medications, products and/or drug classes that aren’t typically covered. In this drug list, these medications/products have a caret (^) next to them. Log in to the myCigna App or myCigna.com to see if your plan covers them. How to find your medication First, look for your condition in the alphabetical list below. Then, go to that page to see the covered medications available to treat the condition.

Condition

Page

Condition

Page

GASTROINTESTINAL/HEARTBURN

12 12

ALLERGY/NASAL SPRAYS

6 6 6 6

HORMONAL AGENTS

ALZHEIMER’S DISEASE

INFECTIONS INFERTILITY

12, 13

ANXIETY/DEPRESSION/BIPOLAR DISORDER

13 13

ASTHMA/COPD/RESPIRATORY

MISCELLANEOUS

ATTENTION DEFICIT HYPERACTIVITY DISORDER BLOOD PRESSURE/HEART MEDICATIONS

6, 7

NUTRITIONAL/DIETARY

13, 14

7 7 7

OSTEOPOROSIS PRODUCTS

14 14 14 14 14 15 15 15 15 15

BLOOD THINNERS/ANTI-CLOTTING

PAIN RELIEF AND INFLAMMATORY DISEASE

PARKINSON’S DISEASE

CANCER

SCHIZOPHRENIA/ANTI-PSYCHOTICS

CHOLESTEROL MEDICATIONS

7, 8

SEIZURE DISORDERS SKIN CONDITIONS

CONTRACEPTION PRODUCTS

8-10

COUGH/COLD MEDICATIONS

10 10

SLEEP DISORDERS/SEDATIVES

DENTAL PRODUCTS

SMOKING CESSATION

DIABETES

10, 11

SUBSTANCE ABUSE

DIURETICS

11 11 11

URINARY TRACT CONDITIONS

EAR MEDICATIONS

VACCINES

15, 16

ERECTILE DYSFUNCTION

WEIGHT MANAGEMENT

EYE CONDITIONS

11, 12

FEMININE PRODUCTS

Cigna Healthcare Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 17-20).

TIER 1 $

TIER 2 $$

TIER 3 $$$

TIER 1 $

TIER 2 $$ TIER 3 $$$ ASTHMA/COPD/RESPIRATORY (cont.)

ALLERGY/NASAL SPRAYS

azelastine 0.1% (137 mcg) spray azelastine- fluticasone epinephrine (QL) fluticasone hydroxyzine capsule, syrup, tablet

GRASTEK (PA, QL) ODACTRA (PA, QL) ORALAIR (PA, QL) RAGWITEK (PA, QL)

budesonide- formoterol (QL) fluticasone- salmeterol 100-50, 250-50, 500-50 (QL) montelukast wixela inhub (QL)

ASMANEX (QL) ASMANEX HFA (QL) ATROVENT HFA (QL) BREO ELLIPTA (QL) BREZTRI AEROSPHERE (QL) COMBIVENT RESPIMAT (QL) DULERA (QL) INCRUSE ELLIPTA QVAR REDIHALER SPIRIVA

ALZHEIMER’S DISEASE

donepezil donepezil odt memantine memantine er (QL) pyridostigmine pyridostigmine er

ADLARITY (PA, QL) ARICEPT NAMENDA

NAMENDA XR (QL) NAMZARIC (QL)

HANDIHALER (QL) SPIRIVA RESPIMAT (QL) STIOLTO RESPIMAT (QL) STRIVERDI RESPIMAT (QL) TRELEGY ELLIPTA (QL) ATTENTION DEFICIT HYPERACTIVITY DISORDER 2 atomoxetine (QL) dexmethyl- phenidate (PA) dexmethyl- phenidate er (PA, QL) dextro- amphetamine- amphetamine (PA) dextro- amphetamine- amphetamine er (PA, QL) guanfacine er methylphenidate (PA, QL) methylphenidate cd (PA, QL) methylphenidate er (cd) (PA, QL) methylphenidate er (la) (PA, QL) ADDERALL (PA, ST) ADZENYS XR-ODT (PA, QL) AZSTARYS (PA, ST, QL) DAYTRANA (PA, QL) DYANAVEL XR (PA, QL) EVEKEO ODT (PA) FOCALIN (PA, ST) METHYLIN (PA) MYDAYIS (PA, QL) QUILLICHEW ER (PA, QL) QUILLIVANT XR (PA, QL) RITALIN (PA, ST) VYVANSE (PA, QL) XELSTRYM (PA, QL)

ANXIETY/DEPRESSION/BIPOLAR DISORDER 2

bupropion (QL) bupropion sr 150 mg (QL) bupropion xl 150 mg, 300 mg tablet (QL) buspirone citalopram tab (QL) citalopram 10 mg/ 5 ml solution (QL) desvenlafaxine er (QL) duloxetine (QL) escitalopram (QL) fluoxetine (QL) fluoxetine dr (QL) sertraline tablet (QL) sertraline 20 mg/ml oral concentrate (QL) trazodone venlafaxine (QL) venlafaxine er (QL)

TRINTELLIX (QL)

EMSAM (QL) FETZIMA (QL, ST)

ASTHMA/COPD/RESPIRATORY

albuterol albuterol hfa 90 mcg inhaler (QL) breyna (QL)

ADVAIR HFA (QL) ALVESCO ANORO ELLIPTA (QL)

AIRDUO DIGIHALER (QL, ST) SINGULAIR

methylphenidate er 10 mg capsule, tablet (PA, QL)

Cigna Healthcare Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 17-20).

TIER 1 $ TIER 3 $$$ ATTENTION DEFICIT HYPERACTIVITY DISORDER 2 (cont.) TIER 2 $$

TIER 1 $ TIER 3 $$$ BLOOD PRESSURE/HEART MEDICATIONS (cont.) diltiazem 24hr er (xr) dilt xr TIER 2 $$ NORVASC TIAZAC

methylphenidate er 15 mg capsule (PA, QL) methylphenidate er 18 mg tablet (PA, QL) methylphenidate er 20 mg capsule, tablet (PA, QL) methylphenidate er 27mg tablet (PA, QL) methylphenidate er 30 mg capsule (PA, QL) methylphenidate er 36 mg tablet (PA, QL) methylphenidate er 40 mg capsule (PA, QL) methylphenidate er 50 mg capsule (PA, QL) methylphenidate er 54 mg tablet (PA, QL) methylphenidate er 60 mg capsule (PA, QL) methylphenidate la (PA, QL)

VALSARTAN 4 MG/ ML SOLUTION (ST) ZESTORETIC (ST) ZESTRIL (ST)

flecainide irbesartan labetalol tablet lisinopril lisinopril-hctz losartan losartan-hctz matzim la metoprolol tablet metoprolol er olmesartan (QL) olmesartan- amlodipine-hctz olmesartan-hctz (QL) propranolol solution, tablet propranolol er taztia xt telmisartan (QL) tiadylt er valsartan tablet valsartan-hctz

BLOOD THINNERS/ANTI-CLOTTING

clopidogrel

BRILINTA ELIQUIS (PA) XARELTO (PA)

SAVAYSA (PA, QL) ZONTIVITY

CANCER

BLOOD PRESSURE/HEART MEDICATIONS

anastrozole+ exemestane+ methotrexate methotrexate tamoxifen+

ARIMIDEX AROMASIN

amlodipine amlodipine- valsartan

CORLANOR TAB (PA) ENTRESTO (QL) NORLIQVA (PA, QL) TEKTURNA HCT VERQUVO (PA, QL)

AVAPRO (ST) BIDIL (QL) CARDIZEM LA (QL) COZAAR (ST) DIOVAN (ST) DIOVAN HCT (ST) HYZAAR (ST) MICARDIS (QL, ST) MICARDIS HCT 40- 12.5 MG TABLET (QL, ST) MICARDIS HCT 80-12.5 MG, 80-25 MG TABLET (ST) NITROSTAT

atenolol cartia xt carvedilol carvedilol er (QL) clonidine diltiazem tablet diltiazem 12hr er diltiazem 24hr er diltiazem 24hr er (cd) diltiazem 24hr er (la) (QL)

CHOLESTEROL MEDICATIONS

atorvastatin 40 mg, 80 mg atorvastatin 10 mg, 20 mg+ ezetimibe

NEXLETOL (PA, QL) NEXLIZET (PA, QL)

CADUET (QL) LIPOFEN (ST) TRICOR (ST) ZETIA

REPATHA (PA) VASCEPA (PA)

FENOFIBRATE fluvastatin er+ fluvastatin+ icosapent ethyl

Cigna Healthcare Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 17-20).

TIER 1 $

TIER 2 $$ TIER 3 $$$ CHOLESTEROL MEDICATIONS (cont.)

TIER 1 $

TIER 2 $$ TIER 3 $$$ CONTRACEPTION PRODUCTS (cont.)

lovastatin 20 mg, 40 mg+ lovastatin 10 mg pitavastatin+ (QL) pravastatin+ rosuvastatin 20 mg, 40 mg (QL) rosuvastatin 5 mg, 10 mg+ (QL) simvastatin 5mg, 80mg (QL) simvastatin 10 mg, 20 mg, 40 mg+ (QL)

deblitane+ desogestrel-ethinyl estradiol+ desogestrel-ethinyl estradiol ethinyl estradiol+ dolishale+ drospirenone- ethinyl estradiol- levomefolate+ drospirenone- ethinyl estradiol+ enilloring+ enpresse+ enskyce+ errin+ estarylla+ ethynodiol-ethinyl estradiol+ etonogestrel- ethinyl estradiol+ falmina+ FEMCAP+ finzala+ gemmily+ hailey 24 fe+ hailey fe+ hailey+ celinest+ eluryng+ emzahh+

CONTRACEPTION PRODUCTS

afirmelle+ altavera+ alyacen+ amethia+ amethyst+ apri+

LO LOESTRIN FE

ANNOVERA BALCOLTRA

BEYAZ ELLA+ layolis fe+ LOESTRIN FE MINASTRIN 24 FE NATAZIA NEXTSTELLIS NUVARING SAFYRAL SLYND

aranelle+ ashlyna+ aubra eq+ aubra+ aurovela 24 fe+ aurovela fe+ aurovela+ aviane+ ayuna+ azurette+ balziva+ blisovi 24 fe+ blisovi fe+ briellyn+ camila+ camrese lo+ camrese+ CAYA CONTOURED+ caziant+ charlotte 24 fe+ chateal eq+

TAYTULLA TWIRLA+ TYBLUME YASMIN 28 YAZ

haloette+ heather+ iclevia+ incassia+ isibloom+ jaimiess+ jasmiel+ jencycla+ jolessa+ joyeaux+ juleber+ junel fe 24+ junel fe+ junel+ kaitlib fe+

chateal+ cryselle+ cyred eq+ dasetta+ daysee+

kalliga+ kariva+

kelnor 1-35+ kelnor 1-50+

Cigna Healthcare Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 17-20).

TIER 1 $

TIER 2 $$ TIER 3 $$$ CONTRACEPTION PRODUCTS (cont.)

TIER 1 $

TIER 2 $$ TIER 3 $$$ CONTRACEPTION PRODUCTS (cont.)

kurvelo+ larin 24 fe+ larin fe+ larin+ leena+ lessina+ levonest+ levonorgestrel- ethinyl estradiol+ levonorgestrel- ethinyl estradiol ethinyl estradiol+ levonorgestrel- ethinyl estradiol-fe bisglycinate+ levora-28+ lojaimiess+ loryna+ low-ogestrel+ lo-zumandimine+ lutera+ lyleq+ lyza+ marlissa+ medroxy- progesterone+ merzee+ mibelas 24 fe+ microgestin 24 fe+ microgestin fe+ microgestin+ mili+ mono-linyah+ necon+ nikki+ nora-be+ norelgestromin- ethinyl estradiol+ norethindrone+ norethindrone- ethinyl estradiol- fe+ norethindrone- ethinyl estradiol+ norethindrone- ethinyl estradiol+ norethindrone- ethinyl estradiol ferrous fumarate+

norgestimate- ethinyl estradiol+

norlyda+ nortrel+ nylia+ nymyo+ ocella+ philith+ pimtrea+ pirmella+ portia+

previfem+ reclipsen+ rivelsa+ setlakin+ sharobel+ simliya+ simpesse+ sprintec+ sronyx+ syeda+ tarina 24 fe+ tarina fe 1-20 eq+ tarina fe+ 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 lo+ tri-vylibra+

tulana+ turqoz+ tydemy+ velivet+ vestura+ vienva+ viorele+ volnea+

Cigna Healthcare Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 17-20).

TIER 1 $

TIER 2 $$ TIER 3 $$$ CONTRACEPTION PRODUCTS (cont.)

TIER 1 $

TIER 2 $$

TIER 3 $$$

DIABETES (cont.) DEXCOM G7 SENSOR (PA, QL) FARXIGA (QL, ST) FREESTYLE LIBRE 14 DAY READER, SENSOR (PA, QL) FREESTYLE LIBRE 2 READER, SENSOR (PA, QL) FREESTYLE LIBRE 3 READER, SENSOR (PA, QL) GLUCAGEN VIAL GLUCAGEN HYPOKIT (QL) GLYXAMBI (QL, ST) HUMALOG QL) HUMULIN 70/30 KWIKPEN (QL) HUMULIN 70/30, HUMULIN N, HUMULIN R (QL) INSULIN GLARGINE- YFGN (QL) INSULIN LISPRO (QL) INSULIN LISPRO JUNIOR KWIKPEN (QL) INSULIN LISPRO KWIKPEN (QL) INSULIN LISPRO PROTAMINE MIX (QL) JANUMET (QL, ST) JANUMET XR (QL, ST) JANUVIA (QL, ST) JARDIANCE (QL, ST) LYUMJEV (QL) LYUMJEV KWIKPEN (QL) LYUMJEV TEMPO PEN U-100 (QL) MOUNJARO (PA, QL) OMNIPOD 5 G6 INTRO KIT (GEN 5) (QL)

vyfemla+ vylibra+ wera+ WIDE SEAL DIAPHRAGM+ wymzya fe+ xulane+ zafemy+ zarah+ zovia 1-35+ zumandimine+

ADVOCATE SYRINGE ASSURE ID INSULIN SAFETY BD AUTOSHIELD DUO PEN NEEDLE BD ECLIPSE 30GX1/2" SYRINGE BD INSULIN PEN NEEDLE, SYRINGE BD LUER-LOK SYRINGE 1 ML CARETOUCH INSULIN SYRINGE COMFORT EZ INSULIN SYRINGE DROPLET GENTEEL LANCING DEVICE DROPLET INSULIN SYRINGE EASY COMFORT INSULIN SYRINGE EASY GLIDE INSULIN SYRINGE EASY TOUCH EASY TOUCH FLIPLOCK INSULIN EASY TOUCH INSULIN SAFETY EASY TOUCH INSULIN SYRINGE EASY TOUCH LUER LOCK INSULIN EASY TOUCH SHEATHLOCK INSULIN EASY TOUCH UNI- SLIP SYRINGE 1 ML EASY-TOUCH INSULIN SYRINGE ECLIPSE SYRINGE FREESTYLE PRECISION GUARDIAN RT CHARGER GUARDIAN TEST PLUG HEALTHWISE INSULIN SYRINGE

COUGH/COLD MEDICATIONS

brompheniramine- pseudoephedrine -dm hydrocodone- chlorpheniramine er (PA) promethazine-dm chlorhexidine doxycycline hyclate FLUORIDEX DAILY DEFENSE 1.1% oralone periogard triamcinolone

TUZISTRA XR (PA, QL)

DENTAL PRODUCTS

PREVIDENT 0.2% RINSE

CLINPRO 5000 FLORIVA 0.25 MG/ ML DROPS+^ FLUORIDEX SENSITIVITY RELIEF JUST RIGHT 5000 PERIDEX PREVIDENT 1.1% GEL PREVIDENT 5000 CYCLOSET GLUCAGON EMERGENCY KIT (QL) GVOKE (QL) GVOKE HYPOPEN (QL) GVOKE PFS SYRINGE (QL) ULTIGUARD SAFEPACK SYRINGE

DIABETES

ACCU-CHEK ACCU-CHEK

BAQSIMI (QL) BYDUREON BCISE (PA, QL) BYETTA (PA, QL) CEQUR SIMPLICITY CEQUR SIMPLICITY INSERTER DEXCOM G6 RECEIVER (PA, QL) DEXCOM G6 SENSOR (PA, QL) DEXCOM G6 TRANSMITTER (PA, QL) DEXCOM G7 RECEIVER (PA, QL)

CONTROL SOLUTION ACCU-CHEK FASTCLIX LANCING DEVICE ACCU-CHEK GUIDE CONTROL SOLUTION ACCU-CHEK SMARTVIEW

CONTROL SOLUTION ACCU-CHEK SOFTCLIX

Cigna Healthcare Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 17-20).

TIER 1 $

TIER 2 $$

TIER 3 $$$

TIER 1 $

TIER 2 $$

TIER 3 $$$

DIABETES (cont.) OMNIPOD 5 G6 PODS (GEN 5) (QL) OMNIPOD CLASSIC PDM KIT(GEN 3) (QL) OMNIPOD CLASSIC PODS (GEN 3) (QL) OMNIPOD DASH INTRO KIT (GEN 4) (QL) OMNIPOD DASH PODS (GEN 4) (QL) OMNIPOD GO PODS (QL) ONETOUCH ULTRA TEST STRIP ONETOUCH VERIO TEST STRIP OZEMPIC (PA, QL) RYBELSUS (PA, QL) SEMGLEE (YFGN) (QL) SEMGLEE (YFGN) PEN (QL) SOLIQUA 100-33 SYMLINPEN SYNJARDY (QL, ST) SYNJARDY XR (QL, ST) TRESIBA VIAL, FLEXTOUCH (QL) TRIJARDY XR (QL, ST) TRULICITY (PA, QL) V-GO 20, 30, 40 XIGDUO XR (QL, ST) ZEGALOGUE AUTO-INJECTOR, SYRINGE (QL)

DIABETES (cont.)

INPEN (FOR NOVOLOG OR FIASP)

TRUEPLUS INSULIN SYRINGE ULTICARE INSULIN SYRINGE ULTILET INSULIN SYRINGE ULTRA COMFORT ULTRA FLO INSULIN SYRINGE ULTRACARE INSULIN SYRINGE ULTRA-FINE PEN NEEDLE VANISHPOINT VANISHPOINT INSULIN SYRINGE VEO INSULIN SYRINGE chlorthalidone eplerenone furosemide solution, tablet spironolactone triamterene-hctz ciprofloxacin- dexamethasone neomycin- polymyxin-hc ofloxacin

INSULIN SYRINGE INSULIN SYRINGE U-500 LITETOUCH INSULIN SYRINGE MAGELLAN INSULIN SYRINGE MAXICOMFORT INSULIN SYRINGE metformin 500 mg, 850 mg, 1,000 mg tablet metformin 500 mg/5 ml, 850 mg/8.5 ml cup metformin 500 mg/5 ml solution metformin er MICROLET 2 MICROLET NEXT LANCING DEVICE MONOJECT INSULIN SYRINGE NANO 2 GEN PEN NEEDLE PARADIGM PRO COMFORT INSULIN SYRINGE PRODIGY INSULIN SYRINGE SAFESNAP INSULIN SYRINGE SAFETYGLIDE INSULIN SYRINGE SURE COMFORT INSULIN SYRINGE SURE-JECT INSULIN SYRINGE TECHLITE INSULIN SYRINGE TERUMO INSULIN SYRINGE THINPRO INSULIN SYRINGE TOPCARE ULTRA COMFORT TRUE COMFORT INSULIN SYRINGE

DIURETICS

CAROSPIR SUSP (PA) KERENDIA (PA, QL)

FUROSCIX (QL) MAXZIDE

EAR MEDICATIONS

CIPRO HC

CIPROFLOXACIN- FLUOCINOLONE OTOVEL

ERECTILE DYSFUNCTION

sildenafil^ (QL) tadalafil^ (QL)

MUSE^ (PA age, QL)

CIALIS^ (QL, ST) STENDRA^ (QL, ST) VIAGRA^ (QL, ST)

EYE CONDITIONS AZASITE BESIVANCE BETOPTIC S BROMSITE CEQUA EYSUVIS (QL) FLAREX INVELTYS LOTEMAX 0.5% EYE OINTMENT LOTEMAX SM SIMBRINZA

cyclosporine dorzolamide- timolol erythromycin latanoprost ofloxacin polymyxin b-trimethoprim tobramycin travoprost

ACUVAIL ALREX ILEVRO

MIEBO (QL) PROLENSA RHOPRESSA ROCKLATAN ZIRGAN ZYLET

Cigna Healthcare Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 17-20).

TIER 1 $

TIER 2 $$ TIER 3 $$$ GASTROINTESTINAL/HEARTBURN (cont.)

TIER 1 $

TIER 2 $$

TIER 3 $$$

EYE CONDITIONS (cont.) TOBRADEX EYE OINTMENT TOBRADEX ST XIIDRA ZERVIATE FEMININE PRODUCTS

peg-prep+ sodium sulfate- potassium sulfate- magnesium sulfate+

HORMONAL AGENTS

desmopressin solution, spray, tablet dotti (QL) estradiol (QL) estradiol (once weekly) estradiol (twice weekly) (QL) euthyrox levo-t levothyroxine tablet levoxyl liothyronine tablet lyllana (QL) methyl- prednisolone dosepack, tablet np thyroid prednisone prednisone intensol progesterone capsule testosterone (PA, QL) testosterone

ANDRODERM (PA, QL) COMBIPATCH DUAVEE ESTRING (QL) ESTROGEL MYFEMBREE (PA, QL) ORIAHNN (PA, QL) ORILISSA (PA, QL) PREMARIN PREMPHASE PREMPRO

ACTIVELLA ANDROGEL (PA, QL) ANGELIQ BIJUVA CRINONE (PA) CYTOMEL DEPO- TESTOSTERONE EVAMIST INTRAROSA (QL) MEDROL MENOSTAR (QL) OSPHENA (QL) RAYALDEE unithroid XYOSTED (PA, QL)

GYNAZOLE 1 miconazole 3 200 mg suppository terconazole

GASTROINTESTINAL/HEARTBURN

dicyclomine capsule, solution, tablet esomeprazole capsule, packet (QL) famotidine suspension, 20 mg, 40 mg tablet

CLENPIQ+ LINZESS LITHOSTAT NEXIUM DR 2.5 MG, 5 MG PACKET (QL) PANCREAZE SUFLAVE+ SUTAB+ TRULANCE VIBERZI

APRISO BONJESTA CARAFATE CUVPOSA DICLEGIS MOTOFEN MOVANTIK (PA) PROTONIX SUSPENSION, TABLET (QL, ST) RECTIV RELISTOR (PA) RELISTOR (PA) SANCUSO (PA, QL) SFROWASA SYMPROIC (PA) VARUBI (PA, QL) VIOKACE

gavilyte-c+ gavilyte-g+ gavilyte-n+ lubiprostone mesalamine

mesalamine dr mesalamine er metoclopramide omeprazole capsule (QL) ondansetron ondansetron ondansetron odt pantoprazole packet, tablet (QL) pantoprazole (QL) peg 3350-electrolyte+ peg-3350 and electrolytes+ peg3350-sodium sulfate-sodium chloride- potassium chloride sodium ascorbate- ascorbic acid+

cypionate 200 mg/ml, 1,000

mg/10 ml, 2,000 mg/10 ml, 6,000 mg/30 ml yuvafem (QL)

INFECTIONS

acyclovir capsule, suspension, tablet

e.e.s. 400 LAGEVRIO (EUA) (QL) PAXLOVID (QL) PAXLOVID (EUA) (QL)

AEMCOLO (QL) BAXDELA 450 MG TABLET (PA) BEYFORTUS+ BILTRICIDE DIFICID (QL)

amoxicillin amoxicillin- clavulanate

Cigna Healthcare Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 17-20).

TIER 1 $

TIER 2 $$

TIER 3 $$$

TIER 1 $

TIER 2 $$

TIER 3 $$$

MISCELLANEOUS (cont.) COMPACT SPACE CHAMBER (QL)

INFECTIONS (cont.)

amoxicillin- clavulanate er azithromycin packet, suspension, tablet cefdinir cephalexin EMVERM fluconazole suspension, tablet hydroxy- chloroquine metronidazole tablet, vaginal gel nitrofurantoin oseltamivir (QL) posaconazole suspension, tablet praziquantel sulfamethoxazole suspension, tablet valacyclovir vandazole ACCU-CHEK FASTCLIX LANCET DRUM ACCU-CHEK SOFTCLIX DROPLET LANCET KETONE TEST STRIP KETOSTIX REAGENT MICROLET ONETOUCH LANCETS POGO AUTOMATIC TEST CARTRIDGE PRECISION XTRA sodium chloride SOFT TOUCH LANCET TRUEPLUS KETONE TEST STRIP

XIFAXAN (QL)

ERYPED 200 LIKMEZ (PA) MACROBID

EASIVENT (QL) FLEXICHAMBER (QL) MICROCHAMBER (QL) MICROSPACER (QL)

MACRODANTIN PLAQUENIL (PA) SIVEXTRO 200 MG TABLET (PA) sulfatrim TAMIFLU (QL) VALTREX VIVJOA (PA) XENLETA TABLET (PA, QL) XOFLUZA (QL) ZITHROMAX PACKET, SUSPENSION, TABLET ZITHROMAX TRI- PAK ZYVOX SUSPENSION, TABLET (PA)

OPTICHAMBER DIAMOND (QL) POCKET CHAMBER (QL) PROCARE SPACER WITH CHILD MASK (QL) RITEFLO (QL) SPACE CHAMBER (QL) SPACE CHAMBER- MEDIUM MASK (QL) VORTEX (QL) VORTEX VHC FROG MASK (QL) NUTRITIONAL/DIETARY

INFERTILITY

CRINONE^ ENDOMETRIN^ MISCELLANEOUS

ludent fluoride+^ multivitamin with fluoride+ sodium fluoride chewable tablet, drops+^ tri-vitamin with fluoride+ vitamin d2 1.25mg (50,000 unit)^ vitamins a,c,d and fluoride+

FLORIVA CHEWABLE TAB+ LOKELMA mvc-fluoride+ NEEVODHA^ OB COMPLETE SOFTGEL, TABLET POLY-VI-FLOR WITH IRON+ POLY-VI-FLOR+ PRENATE CHEWABLE^ PRENATE DHA PRENATE ELITE PRENATE ENHANCE PRENATE ESSENTIAL^ PRENATE MINI PRENATE PIXIE PRENATE RESTORE PRIMACARE

ACCRUFER^ AURYXIA (QL) DRISDOL^ EFFER-K OB COMPLETE CAPLET^ PHOSLYRA

ACE AEROSOL CLOUD

ADDYI^ (PA, QL) NUEDEXTA (QL) VEOZAH (QL)

ENHANCER (QL) AEROCHAMBER (QL) AEROCHAMBER MV (QL) AEROCHAMBER PLUS FLOW-VU (QL) AEROCHAMBER Z-STAT PLUS (QL) AEROTRACH PLUS (QL) AEROVENT PLUS (QL) BREATHRITE (QL) CLEVER CHOICE HOLDING CHAMBER (QL)

Cigna Healthcare Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 17-20).

TIER 1 $

TIER 2 $$ TIER 3 $$$ NUTRITIONAL/DIETARY (cont.) QUFLORA PEDIATRIC 0.25 MG/ML DROPS, 0.5 MG/ ML DROPS, 1 MG CHEWABLE TABLET+ TRI-VI-FLOR+ VELPHORO VELTASSA OSTEOPOROSIS PRODUCTS

TIER 1 $ TIER 3 $$$ PAIN RELIEF AND INFLAMMATORY DISEASE (cont.) oxycodone- acetaminophen (PA) TIER 2 $$

prolate tablet (PA) sumatriptan (QL) sumatriptan (QL)

PARKINSON’S DISEASE

carbidopa- levodopa-

MIRAPEX ER (QL) NEUPRO RYTARY

entacapone pramipexole pramipexole er (QL) ropinirole ropinirole er

STALEVO XADAGO

alendronate ibandronate tablet

ACTONEL (ST) ATELVIA (ST) BINOSTO (ST) EVISTA FOSAMAX (ST) PAIN RELIEF AND INFLAMMATORY DISEASE

raloxifene+ risedronate risedronate dr

SCHIZOPHRENIA/ANTI-PSYCHOTICS 2

aripiprazole (QL) aripiprazole odt quetiapine quetiapine er clonazepam gabapentin lacosamide solution, tablet lamotrigine lamotrigine (blue, green, orange) lamotrigine er lamotrigine odt lamotrigine odt (orange) levetiracetam solution, tablet levetiracetam er oxcarbazepine pregabalin capsule, solution roweepra subvenite subvenite (blue, green orange) topiramate topiramate er (QL)

REXULTI (QL, ST)

CAPLYTA (QL, ST) FANAPT (QL, ST) SECUADO (ST) VRAYLAR (QL, ST) APTIOM (PA, QL) BRIVIACT TABLET, ORAL SOLUTION (PA) CARBATROL (PA) DILANTIN (PA) LYRICA SOLUTION (PA) NEURONTIN (PA) ONFI (PA) OXTELLAR XR (PA) PHENYTEK (PA) SPRITAM (PA) TEGRETOL (PA) TEGRETOL XR (PA) VALTOCO (PA, QL) XCOPRI (PA, QL)

allopurinol tablet buprenorphine film, patch (QL) celecoxib (QL) colchicine cyclobenzaprine diclofenac tablet diclofenac er ec-naproxen endocet (PA) hydrocodone- acetaminophen (PA) ibu 400 mg, 600 mg, 800 mg tablet ibuprofen suspension, 400 mg, 600 mg, 800 mg tablet lidocaine 5% patch, meloxicam tablet methocarbamol 500 mg, 700 mg tablet oxycodone (PA) OXYCODONE ER (PA) ointment, 2% solution (QL)

AIMOVIG AUTO- INJECTOR (PA) AJOVY AUTO- INJECTOR, SYRINGE (PA) BELBUCA (QL) EMGALITY PEN, SYRINGE (PA) FLECTOR (PA, QL) HYSINGLA ER (PA) LICART (PA, QL) MITIGARE NUCYNTA (PA) NURTEC ODT (PA, QL) OTREXUP (PA) PROCTOFOAM-HC QULIPTA (PA, QL) SAVELLA TRUDHESA (PA, QL) UBRELVY (PA, QL) XTAMPZA ER (PA) ZAVZPRET (PA, QL) ZTLIDO

BUTRANS (QL) CELEBREX (QL, ST) NUCYNTA ER (PA) OXAYDO (PA) ROXYBOND (PA)

SEIZURE DISORDERS

DILANTIN 30 MG CAPSULE (PA) FYCOMPA (PA, QL) NAYZILAM (PA, QL) VIMPAT 10 MG/ML SOLUTION

Cigna Healthcare Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 17-20).

TIER 1 $

TIER 2 $$

TIER 3 $$$

TIER 1 $

TIER 2 $$

TIER 3 $$$

SKIN CONDITIONS

VACCINES 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. ACTHIB+

amnesteem azelaic acid claravis clindacin etz 1% pledget clindacin p 1% pledgets clindamycin DROPSAFE PREP PAD halobetasol isotretinoin mupirocin 2% ointment myorisan tretinoin (PA age) triderm zenatane

EUCRISA (ST) NAFTIN PRAMOSONE 1% LOTION SANTYL (QL)

ABSORICA ACZONE 7.5% GEL PUMP BRYHALI (ST) CAPEX SHAMPOO (ST) CLEOCIN T CLODERM (ST) EVOCLIN OPZELURA (PA) PRAMOSONE 2.5%- 1% LOTION QBREXZA (PA) REGRANEX (PA, QL) SOOLANTRA TACLONEX SUSPENSION TWYNEO VECTICAL (QL) XEPI

AREXVY+ FLUMIST QUAD+

ADACEL TDAP+ AFLURIA QUAD+ BEXSERO+ BOOSTRIX TDAP+ COMIRNATY+ DAPTACEL DTAP+ DENGVAXIA+ DIPHTHERIA- TETANUS TOXOIDS-PED+ ENGERIX-B ADULT+ ENGERIX-B PEDIATRIC- ADOLESCENT+ FLUAD QUAD+ FLUARIX QUAD+ FLUBLOK QUAD+ FLUCELVAX QUAD+ FLULAVAL QUAD+ FLUZONE HIGH- DOSE QUAD+ FLUZONE QUAD+ GARDASIL 9+ HEPLISAV-B+ HIBERIX+ INFANRIX DTAP+ IPOL+ JANSSEN COVID-19 VACCINE (EUA)+ KINRIX+ MENQUADFI+ MENVEO A-C-Y-W- 135-DIP+ M-M-R II VACCINE+ MODERNA COVID VAC(EUA)+ MODERNA COVID-19 BOOSTER (EUA)+ NOVAVAX COVID (EUA)+ NOVAVAX COVID-19 VACC,ADJ(EUA)+

ROTARIX+ ROTATEQ+

SLEEP DISORDERS/SEDATIVES

doxepin (QL) eszopiclone zolpidem zolpidem er (QL)

DAYVIGO (QL, ST) SUNOSI (PA, QL)

SMOKING CESSATION 2

bupropion sr 150 mg+^ varenicline+^

NICOTROL NS+^ NICOTROL+^

SUBSTANCE ABUSE

buprenorphine buprenorphine- naloxone naloxone (QL) naltrexone (QL)

KLOXXADO (QL) LUCEMYRA (QL) NARCAN (QL) ZUBSOLV

OPVEE (QL) SUBOXONE ZIMHI (QL)

URINARY TRACT CONDITIONS

finasteride oxybutynin 5 mg tablet, solution, tablet

FLOMAX PYRIDIUM UROCIT-K

oxybutynin er potassium er

tamsulosin tolterodine tolterodine er (QL)

Cigna Healthcare Standard 4-Tier Prescription Drug List Specialty medications are covered on Tier 4 (listed on pages 17-20).

TIER 1 $

TIER 2 $$

TIER 3 $$$

TIER 1 $

TIER 2 $$

TIER 3 $$$

VACCINES (cont.) 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. PEDIARIX+

WEIGHT MANAGEMENT

LOMAIRA^ megestrol

WEGOVY^ (PA, QL) ZEPBOUND^ (PA, QL)

ADIPEX-P^ (PA) CONTRAVE^ (PA) QSYMIA^ (PA) SAXENDA^ (PA)

PEDVAXHIB+ PENBRAYA+ PENTACEL ACTHIB COMPONENT+ PENTACEL+ PFIZER COVID VAC(EUA)+ PFIZER COVID-19 VACCINE (EUA)+ PNEUMOVAX 23+ PREHEVBRIO+ PREVNAR 20 PRIORIX+ PROQUAD+ QUADRACEL DTAP- IPV+ RECOMBIVAX HB+ SHINGRIX+ (QL) SPIKEVAX+ SPIKEVAX COVID (18Y UP) VACC+ TDVAX+ TENIVAC+ TRUMENBA+ TWINRIX+ VARIVAX VACCINE+ VAXELIS+ VAXNEUVANCE+ QUADRACEL DTAP- IPV+ RECOMBIVAX HB+ SHINGRIX+ (QL) SPIKEVAX COVID (18Y UP) VACCINE+ TDVAX+ TENIVAC+ TRUMENBA+ TWINRIX+ VARIVAX VACCINE+ VAXELIS+ VAXNEUVANCE+

Specialty medications Oral and injectable specialty medications are covered on Tier 4. Injectable specialty medications are marked with an asterisk (*) and oral specialty medications are marked with a double asterisk (**) .

AIDS/HIV APRETUDE* + (PA) BIKTARVY** (QL) CABENUVA* ^ (PA) CIMDUO** (PA) DESCOVY 200-25 MG TABLET**+ (PA) DESCOVY 120-15M G TABLET* (PA) DOVATO** (QL) emtricitabine-tenofovir 100-150 mg, 133-200 mg, 167-250 mg** emtricitabine-tenofovir 200-300 mg**+ GENVOYA** (QL) JULUCA** (QL) nevirapine er** (PA) nevirapine** (PA) ODEFSEY** (PA, QL) PREZISTA 100 MG/ML SUSPEN- SION** PREZISTA 75 MG, 150 MG TABLET** SYMTUZA** (QL) tenofovir ** (PA) TRIUMEQ** (QL) TRIUMEQ PD** (QL) Anxiety/Depression/ Bipolar Disorder SPRAVATO** (PA) ZURZUVAE* (PA, QL) Asthma/COPD/Respiratory ADEMPAS** (PA) BRONCHITOL** (PA) FASENRA PEN* (PA) NUCALA AUTO-INJECTOR, SY- RINGE* (PA)

OFEV** (PA) OPSUMIT** (PA) ORENITRAM ER* (PA) ORENITRAM TITRATION KIT** (PA, QL) TEZSPIRE* (PA) TRACLEER 32 MG TABLET FOR SUSPENSION** (PA) TYVASO DPI* (PA) UPTRAVI TABLET, TITRATION PACK** (PA) XOLAIR 75 MG/0.5 ML, 150 MG/ ML SYRINGE, POWDER VIAL* (PA)

NUWIQ*^ (PA) NYVEPRIA* (PA) PROCRIT*^ (PA) PROMACTA** (PA) RECOMBINATE*^ (PA)

RETACRIT*^ (PA) STIMUFEND* (PA) TAVALISSE** (PA)

tranexamic acid 650 mg tablet** UDENYCA SYRINGE, AUTO-INJEC- TOR* (PA) UDENYCA ONBODY*^ (PA) XYNTHA*^ (PA) XYNTHA SOLOFUSE*^ (PA) ZARXIO*^ ZIEXTENZO* (PA) Blood Pressure/ Heart Conditions CORLANOR 5 MG/5 ML ORAL SOLUTION** (PA) ORLADEYO* * (PA, QL)

Blood Modifiers/ Bleeding Disorders ADVATE* ^ (PA) ADYNOVATE* ^ (PA)

AFSTYLA*^ (PA) ALTUVIIIO*^ (PA) ARANESP*^ (PA) DOPTELET** (PA) ELOCTATE* ^ (PA)

RELEUKO*^ (PA) TAKHZYRO* (PA) Blood Thinners/ Anti-Clotting FRAGMIN* (QL) Cancer AKEEGA** (PA, QL) ALECENSA** (PA, QL) BOSULIF** (PA, QL) BRAFTOVI** (PA) BRUKINSA** (PA, QL) CABOMETYX** (PA) CALQUENCE** (PA) COMETRIQ** (PA, QL)

EMPAVELI* (PA) EPOGEN* ^ (PA) ESPEROCT* ^ (PA) FABHALTA** (PA, QL)

FULPHILA* (PA) FYLNETRA* (PA) GRANIX*^ (PA) JIVI*^ (PA) KOGENATE FS*^ (PA) MIRCERA*^ (PA) NEULASTA ONPRO*^ (PA) NEULASTA* (PA) NEUPOGEN*^ (PA) NIVESTYM*^ NOVOEIGHT*^ (PA)

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

Specialty medications (Cont.) Oral and injectable specialty medications are covered on Tier 4. Injectable specialty medications are marked with an asterisk and oral specialty medications are marked with a double asterisk.

Cancer ( Cont.) COTELLIC** (PA) ERIVEDGE** (PA) ERLEADA** (PA) EXKIVITY** (PA)

XALKORI** (PA, QL) XTANDI** (PA)

SIGNIFOR LAR* (PA) SKYTROFA* (PA) SOMATULINE DEPOT*^ (PA) SOMAVERT* (PA, QL) Infections ARIKAYCE** (PA) BARACLUDE SOLUTION** DARAPRIM** (PA)

ZEJULA** (PA, QL) ZELBORAF** (PA) Contraceptive Products KYLEENA**+

GAVRETO** (PA, QL) IMBRUVICA** (PA, QL) INLYTA** (PA)

LILETTA**+ MIRENA**+ NEXPLANON*+ PARAGARD T 380-A**+

JAKAFI** (PA, QL) KISQALI** (PA, QL) KISQALI FEMARA CO-PACK** (PA, QL) LENVIMA** (PA)

EPCLUSA** (PA, QL) HARVONI** (PA, QL) KITABIS PAK* * (PA, QL) NUZYRA 150 MG TABLET* * (PA, QL) SOVALDI** (PA, QL) TOBI PODHALER* * (PA, QL) TOBRAMYCIN PAK 300 MG/5 ML** (PA, QL) VEMLIDY** VOSEVI** (PA, QL) ZEPATIER** (PA, QL) Infertility CHORIONIC GONADOTROPIN 10,000 UNIT VIAL*^ (PA) FOLLISTIM AQ* ^ (PA) GONAL-F RFF REDI-JECT * ^ (PA) GONAL-F RFF * ^ (PA) GONAL-F * ^ (PA) NOVAREL* ^ (PA) OVIDREL* ^ (PA) PREGNYL* ^ (PA) Miscellaneous AUSTEDO XR TITRATION KIT** (PA, QL) AUSTEDO XR** (PA, QL)

SKYLA**+ Diuretics

LORBRENA** (PA, QL) LUMAKRAS** (PA, QL) LYNPARZA** (PA, QL) MEKINIST** (PA, QL) MEKTOVI** (PA, QL) NINLARO** (PA, QL) NUBEQA** (PA) ODOMZO** (PA) ORGOVYX** (PA) PHESGO*^ (PA) PIQRAY** (PA) RETEVMO** (PA,QL) REVLIMID** (PA, QL) ROZLYTREK** (PA) RUBRACA** (PA, QL) SPRYCEL** (PA, QL) STIVARGA** (PA, QL) TAFINLAR** (PA, QL) TALZENNA** (PA, QL) TASIGNA** (PA, QL)

JYNARQUE** (PA) Eye Conditions XDEMVY** (PA, QL) Gastrointestinal/Heartburn ENTYVIO*^ (PA) OLPRUVA** (PA) PHEBURANE** (PA, QL) VOWST** (PA, QL) Hormonal Agents CETROTIDE* ^ (PA) desmopressin ampule, vial*

FENSOLVI* ^ (PA) fyremadel*^ (PA)

GENOTROPIN* (PA) LANREOTIDE*^ (PA) LUPRON DEPOT*^ (PA) LUPRON DEPOT-PED*^ (PA) OMNITROPE* (PA) SANDOSTATIN**^ (PA) SANDOSTATIN LAR DEPOT*^ (PA)

VERZENIO** (PA) VITRAKVI** (PA) VIZIMPRO** (PA)

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

Specialty medications (Cont.) Oral and injectable specialty medications are covered on Tier 4. Injectable specialty medications are marked with an asterisk (*) and oral specialty medications are marked with a double asterisk (**) .

Miscellaneous ( Cont.) AUSTEDO** (PA) CARBAGLU** CERDELGA** (PA) CINRYZE*^ (PA) deferiprone** (PA) HAEGARDA* (PA) INGREZZA INITIATION PACK** (PA, QL) INGREZZA** (PA, QL) NITYR** (PA) ORFADIN** (PA) RADICAVA ORS** (PA) RUCONEST*^ (PA)

Pain Relief and Inflammatory Disease ACTEMRA ACTPEN, SYRINGE* (PA, QL) ADALIMUMAB-ADAZ(CF) PEN* (PA, QL) ADALIMUMAB-ADAZ(CF)* (PA, QL) ADALIMUMAB-ADBM(CF)* (PA, QL) ADALIMUMAB-ADBM(CF) PEN* (PA, QL) AVSOLA*^ (PA) BIMZELX AUTO-INJECTOR, SY- RINGE* (PA, QL) CIMZIA* (PA, QL) COSENTYX PEN INJECTOR, SY - RINGE* (PA, QL) CYLTEZO* (PA,QL) DUPIXENT PEN, SYRINGE* (PA) ENBREL, MINI, SURECLICK* (PA, QL) HUMIRA PEN* (PA, QL) HUMIRA(CF) PEN* (PA, QL) HUMIRA(CF)* (PA, QL) HUMIRA* (PA, QL) HYRIMOZ(CF) PEN* (PA, QL) HYRIMOZ(CF)* (PA, QL)

SIMPONI 100 MG/ML PEN INJEC- TOR, SYRINGE* (PA, QL) SIMPONI 50 MG/0.5 ML PEN IN- JECTOR, SYRINGE* (PA, QL) SIMPONI ARIA* (PA) SKYRIZI ON-BODY, PEN, SYRINGE* (PA, QL) SOTYKTU* *(PA, QL) STELARA 45 MG/0.5 ML SYRINGE, VIAL, 90 MG/ML SYRINGE* (PA, QL) TALTZ AUTO-INJECTOR, SYRINGE* (PA, QL)

TREMFYA* (PA, QL) XELJANZ** (PA, QL) XELJANZ XR** (PA, QL) ZEPOSIA** (PA) Parkinson's Disease APOKYN* (PA) INBRIJA* (PA) NOURIANZ** (PA, QL) Seizure Disorders

STRENSIQ* (PA) TEGLUTIK* (PA) TEGSEDI* (PA) TIGLUTIK** (PA)

VYLEESI*^ (PA, QL) Multiple Sclerosis AVONEX PEN* (PA) BAFIERTAM** (PA) BETASERON* (PA) FIRDAPSE** (PA, QL) glatopa* KESIMPTA PEN* (PA) MAVENCLAD** (PA) MAYZENT** (PA) PLEGRIDY PEN* (PA) PONVORY* (PA) REBIF* (PA) REBIF REBIDOSE* (PA) VUMERITY** (PA) Nutritional/Dietary betaine anhydrous** CYSTADANE**

ILUMYA* (PA, QL) INFLECTRA*^ (PA) INFLIXIMAB*^ (PA) KEVZARA* (PA, QL) KINERET* (PA, QL)

EPIDIOLEX** (PA) Skin Conditions ADBRY* (PA)

CIBINQO** (PA, QL) LITFULO** (PA, QL) Sleep Disorders/Sedatives LUMRYZ** (PA, QL) SODIUM OXYBATE** (PA, QL)

OLUMIANT** (PA, QL) OMVOH PEN* (PA, QL) ORENCIA CLICKJECT, SYRINGE* (PA, QL)

OTEZLA** (PA, QL) REMICADE*^ (PA) RINVOQ** (PA, QL) SILIQ* (PA, QL)

WAKIX** (PA, QL) XYWAV** (PA, QL)

Generic medications are listed in all lowercase letters and brand-name medications are listed in all capital letters. Injectable specialty medications are marked with an asterisk (*) and oral specialty medications are marked with a double asterisk (**).

Transplant Medications CELLCEPT CAPSULE, ORAL SUS - PENSION, TABLET** ENVARSUS XR** IMURAN** LUPKYNIS** (PA, QL) mycophenolate capsule, suspen- sion** RAPAMUNE** sirolimus** tacrolimus**

Frequently Asked Questions (FAQs) Understanding your prescription medication coverage can be confusing. Here are answers to some commonly asked questions.

Q. Why do you make changes to the drug list? A. We regularly review and update your plan’s drug list to make sure you’re getting coverage for low-cost, safe, clinically effective medications. We make changes for many reasons – like when new medications become available or are no longer available, or when medication prices change. These changes may include: • Moving a medication to a lower cost tier. This can happen at any time during the year. • Moving a brand medication to a higher cost tier when a generic becomes available. This can happen at any time during the year. • Moving a medication to a higher cost tier and/or no longer covering a medication. This typically happens twice a year on January 1 st and July 1 st . • Adding extra coverage requirements to a medication. When we make a change that affects the coverage of a medication you’re taking, we let you know before it happens. This way, you have time to talk with your doctor about your options. Only you and your doctor can decide what’s best for your treatment. Q. Why doesn’t my plan cover certain medications? A. To help lower your overall health care costs, your plan doesn’t cover certain high-cost brand-name medications that have lower-cost alternatives. That’s because these lower-cost options work the same as, or similar to, the non-covered medication. If you’re taking a medication that isn’t covered and your doctor feels a different medication isn’t right for you, he or she can ask Cigna Healthcare to consider approving your medication through the coverage review process. There are also certain medications and products that can't be covered by your plan for any reason because they’re considered to be a “plan or benefit exclusion.” This means the medication or product isn’t on your plan’s drug list, and there’s no option to ask Cigna Healthcare to consider approving it through

the coverage review process. For example, your plan doesn’t cover, or “excludes,” medications that aren’t approved by the U.S. Food and Drug Administration (FDA). Q. How do you decide which medications to cover? A. The Cigna Healthcare Prescription Drug List is developed with the help of the Cigna Healthcare Pharmacy and Therapeutics (P&T) Committee, which is a group of practicing doctors and pharmacists, most of whom work outside of Cigna Healthcare. The group meets regularly to review medical evidence and information provided by federal agencies, drug manufacturers, medical professional associations, national organizations and peer-reviewed journals about the safety and effectiveness of medications that are newly approved by the FDA and medications already on the market. The Cigna Healthcare Health Plan Commercial Value Assessment Committee (HVAC) then looks at the results of the P&T Committee’s clinical review, as well as the medication’s overall value and other factors before adding it to, or removing it from, the drug list. Q. Why do certain medications need approval before my plan will cover them? A. The review process helps to make sure you’re receiving coverage for the right medication, at the right cost, in the right amount and for the right situation. Q. How do I know if I’m taking a medication that needs approval? A. Log in to the myCigna App or myCigna.com , or check your plan materials, to learn more about how your plan covers your medications. If your medication has a (PA) or (ST) next to it, your medication needs approval before your plan will cover it. If it has a (QL) next to it, you may need approval depending on the amount you’re filling. If it has (AGE) next to it, you may need approval depending on the covered age range for the medication.

Frequently Asked Questions (FAQs) (cont.)

Q. What types of medications typically need approval? A. Medications that: • May be unsafe when combined with other medications • Have lower-cost, equally effective alternatives available • Should only be used for certain health conditions • Are often misused or abused Q. What types of medications typically have quantity limits? A. Medications that are often: • Taken in amounts larger than (or for longer than) may be appropriate • Misused or abused Q. What types of medications require Step Therapy? A. High-cost medications that are used to treat many conditions, such as: • ADD/ADHD • High cholesterol • Allergies • Osteoporosis • Bladder problems • Pain • Breathing problems • Skin conditions • Depression • Sleep disorders • High blood pressure A. The FDA considers certain medication to only be clinically appropriate for people of a certain age or within a certain age range. Q. How do I get approval (prior authorization) for my medication? A. Ask your doctor’s office to contact Cigna Healthcare to start the coverage review process. They know how the review process works and will take care of everything for you. In case the office asks, they can download a request form from the Cigna Healthcare provider portal at cignaforhcp.com . Q. Why does my medication have an age requirement?

Cigna Healthcare will review information your doctor sends us to make sure your medication meets coverage requirements. We’ll send you and your doctor a letter with the decision and next steps. It can take 1-5 business days to hear from us. You can always check with your doctor’s office to find out if a decision’s been made. You can also log in to the myCigna App or myCigna.com to check the status of your approval. If your medication isn’t approved, your doctor can send us more information to review, using the same process as before. We’re happy to review the request again. Depending on what your doctor sends this time, we may be able to approve coverage. Or, you and your doctor can appeal the decision by sending Cigna Healthcare a written request explaining why the medication should be covered. Q. What happens if I try to fill a prescription that needs approval but I don’t get approval ahead of time? A. When your pharmacist tries to fill your prescription, he or she will see that the medication needs preapproval from Cigna Healthcare. Because you didn’t get approval ahead of time, your plan won’t cover the cost of your medication. You should ask your doctor to contact Cigna Healthcare to start the coverage review process. Or, you can choose to pay the medication’s full cost out-of-pocket directly to the pharmacy (the cost can’t be applied to your annual deductible or out-of-pocket maximum). Q. What happens if I try to fill a prescription that has a quantity limit? A. Your pharmacist will only fill the amount your plan covers. If you want to fill more than what’s allowed, your doctor’s office will have to contact Cigna Healthcare and ask us to approve a larger amount. Q. Are all of the medications on this drug list approved by the FDA? A. Yes.

Frequently Asked Questions (FAQs) (cont.)

Q. Does my plan cover medications that the FDA recently approved? A. We review all recently approved medications and products to see if they should be covered – and if so, at what cost-share (tier). It can take up to six months from the date the FDA approved them to make a decision. These include, but are not limited to, medications, medical supplies and/or devices covered under standard pharmacy benefits. If your doctor wants you to use a recently approved medication, he or she can ask Cigna Healthcare to consider approving it through the coverage review process. Q. Which medications are covered under the health care reform law? A. The Patient Protection and Affordable Care Act (PPACA), commonly referred to as “health care reform,” was signed into law on March 23, 2010. Under this law, certain preventive medications (including some over- the-counter products) may be available to you at no cost-share ($0), depending on your plan. Log in to the myCigna App or myCigna.com , or check your plan materials, to learn more about how your plan covers preventive medications. You can also view the PPACA No Cost-Share Preventive Medications drug list at Cigna.com/PDL . For more information about health care reform, go to www.informedonreform.com or CignaHealthcare.com . Q. What are preventive medications? A. Preventive medications are used to keep certain conditions from developing or from coming back. These conditions include, but are not limited to asthma, depression, diabetes, heart attack, high blood pressure, high cholesterol, osteoporosis, prenatal nutrient deficiency and stroke.

you get to the pharmacy counter – or, even before you leave your doctor’s office . 3

Q. What’s a cost-share? A. It’s the amount you pay out of your own pocket for a covered prescription and/or an eligible health care or related service. For some plans, the cost-share is a copay; for other plans, it’s a coinsurance. Q. How can I save money on my prescription medications? A. Consider using a medication that’s covered on a lower tier (such as a generic or preferred brand medication) or by filling a 90-day supply (if your plan allows). You should talk with your doctor to see if one of these options may work for you. Q. What's a generic medication? A. A generic medication is the same as its brand- name version in safety, effectiveness, quality, strength and dosage, as well as in the way it’s taken and used. 4 Brand-name medications are protected by patents. Patents keep other manufacturers from selling generic versions of the brand-name medication. Once a patent ends, other companies can make and sell a generic version of the brand-name medication. Generics are typically sold under their chemical or scientific name, instead of the manufacturer’s patented brand name. Q. Do generics work the same as brand-name medications? A. Yes. A generic medication works in the same way and provides the same clinical benefit as its brand- name version. Q. What are the differences between generic and brand-name medications? A. The medications may look different. For example, generics may have a different shape, size or color than their brand-name versions. They may also have a different flavor, have different preservatives, come in different packaging and/or with different labeling and may expire at different times. Generics may look different than their brand-name versions, but they’re just as safe and effective.

Q. How can I find out how much I’ll pay for a specific medication?

A. When you and your doctor are considering the right medication for your treatment, knowing how much it costs, what lower-cost alternatives are available and which pharmacies offer the best prices can help you avoid surprises. Log in to the myCigna App or myCigna.com and use the Price a Medication tool to see how much your medication costs before

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