909015 UPDATED_10/17/2017

The medications listed below are changing coverage (or cost levels) on Cigna’s Prescription Drug List. Changes are listed by drug list name and by the date they begin.

If you’re enrolled with Cigna, you can log into myCigna.com to find out how these changes may affect your specific plan.

STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST

PRESCRIPTION DRUG LIST CHANGESCigna Pharmacy Management® 2018

Start date of change*

Drug class Medication not covered^ Generic and/or preferred brand alternatives

January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipramine

Pamelor nortriptyline

Parnate tranylcypromine

Tofranil imipramine

ASTHMA/COPD/RESPIRATORY Zyflo montelukast, zafirlukast, zileuton ER

Zyflo CR zileuton ER

ATTENTION DEFICIT HYPERACTIVITY DISORDER

Desoxyn methamphetamineDexedrine dextroamphetamine,

dextroamphetamine ERBLOOD PRESSURE/HEART MEDICATIONS Betapace sotalol tabletsCANCER Nilandron nilutamideDIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR

Invokana Farxiga, JardianceLantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba Novolin, Novolog Humalog, Humulin

GASTROINTESTINAL/HEARTBURN Cortifoam, Uceris rectal foam Anucort-HC, Colocort, Hemmorex-HC, hydrocortisone, Procto-Med HC, Procto-Pak, Proctosol-HC, Proctozone-HC

Lotronex alosetronMarinol dronabinolomeprazole bicarbonate packets, 40-1100mg capsules

omeprazole

Rowasa mesalamine enemaUceris tablet budesonide EC capsule

STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont)

Start date of change*

Drug class Medication not covered^ Generic and/or preferred brand alternatives

January 1, 2018 GASTROINTESTINAL/HEARTBURN (cont) Zegerid omeprazoleZofran ondansetronZofran ODT ondansetron ODT

HORMONAL AGENTS DDAVP desmopressinHectorol doxercalciferol capsule

INFECTIONS Augmentin, Augmentin ES, Augmentin XR amoxicillin-clavulanate ER, amoxicillin-clavulanate

Diflucan fluconazoleE.E.S. 200, Eryped 400 erythromycin ethylsuccinateMepron atovaquoneSporanox itraconazole

Targadox Avidoxy tablet, doxycycline hyclate, Morgidox capsule

Valcyte valganciclovir

Vancocin vancomycin capsule

Zovirax acyclovir

MISCELLANEOUS Gralise, Horizant gabapentin

PAIN RELIEF AND INFLAMMATORY DISEASE Cambia diclofenac, diclofenac ER, etodolac, etodolac ER, fenoprofen, Fenortho, flurbiprofen, ibuprofen, indomethacin, indomethacin ER, ketoprofen, Ketorolac, meclofenamate, mefenamic acid, meloxicam, nabumetone

D.H.E. 45, Migranal dihydroergotamine

Imitrex, Sumavel DosePro sumatriptan

Lorzone chlorzoxazone

OxyContin Embeda, Hysingla ER, Xtampza ER

Roxicodone oxycodone

Tivorbex indomethacin

Vanatol LQ butalbital/acetaminophen/caffeine tabs or caps

Vivlodex meloxicam

Zomig sumatriptan, zolmitriptan

Zorvolex diclofenac, diclofenac ER

PARKINSON'S DISEASE Lodosyn carbidopa

Requip XL ropinirole ER

SCHIZOPHRENIA/ANTI-PSYCHOTICS Geodon ziprasidone

Zyprexa olanzapine

Zyprexa Zydis olanzapine ODT

STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont)

Start date of change*

Drug class Medication not covered^ Generic and/or preferred brand alternatives

January 1, 2018 SKIN CONDITIONS Cutivate fluticasone creamKenalog triamcinolone sprayLocoid lotion hydrocortisone butyrateLuzu ketoconazole creamSoriatane acitretinZiana clindamycin-tretinoin

SLEEP DISORDERS/SEDATIVES Nuvigil armodafinilProvigil modafinilRestoril temazepam

URINARY TRACT CONDITIONS Detrol tolterodineDetrol LA tolterodine ERDitropan XL oxybutynin EREnablex darifenacin ERGelnique darifenacin ER, oxybutynin ER, tolterodine

ER, trospium ERStart date of change*

Drug classNon-preferred brand medication

Generic and/or preferred brand alternatives

January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal sprayATTENTION DEFICIT HYPERACTIVITY DISORDER

Adderall XR dextroamphetamine-amphetamine ER

Focalin XR dexmethylphenidate ERSKIN CONDITIONS Ala-Scalp hydrocortisone

Analpram HC lotion hydrocortisone-pramoxineCapex shampoo fluocinoloneCordran flurandrenolideDifferin adapaleneMetrogel metronidazole gelNaftin naftifineNucort, Texacort hydrocortisone

Start date of change*

Drug classMedication requiring prior authorization

Additional information

January 1, 2018 GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi

Your plan will only cover this medication if your doctor requests and receives approval from Cigna.HORMONAL AGENTS Androderm, Androgel, Striant, testosterone

Start date of change*

Drug class Medication with quantity limits Additional information

January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone Your plan only covers a certain amount of this medication over a certain number of days. Your plan will only cover a larger amount if your doctor requests and receives approval from Cigna.

ALZHEIMER'S DISEASE Namenda XR, NamzaricANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine 25mg, 100mg, Marplan,

PristiqASTHMA/COPD/RESPIRATORY PerforomistBLOOD PRESSURE/HEART MEDICATIONS RanexaCANCER Fareston, nilutamideEYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan

STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont)

Start date of change*

Drug class Medication with quantity limits Additional information

January 1, 2018 HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem

Your plan only covers a certain amount of this medication over a certain number of days. Your plan will only cover a larger amount if your doctor requests and receives approval from Cigna.

MISCELLANEOUS NuedextaOSTEOPOROSIS PRODUCTS alendronatePAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, MitigareSCHIZOPHRENIA/ ANTI-PSYCHOTICS

Fanapt

SEIZURE DISORDERS Gabitril, PotigaSKIN CONDITIONS Denavir, Regranex, Santyl, VecticalSLEEP DISORDERS/SEDATIVES Hetlioz

Start date of change*

Drug class Step Therapy medication^^Generic and/or preferred brand alternatives

January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER

Focalin XR dexmethylphenidate ER

SCHIZOPHRENIA/ANTI-PSYCHOTICS Orap pimozide

SKIN CONDITIONS Ala-Scalp hydrocortisoneCapex shampoo fluocinoloneCordran flurandrenolideNucort, Texacort hydrocortisone

Start date of change*

Drug class

Medication strength with limitations++ (Your plan doesn’t cover 2 capsules/tablets per day of this strength)

Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)

January 1, 2018 ALLERGY/NASAL SPRAYS desloratadine ODT 2.5mg desloratadine ODT 5mg

ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg

Fetzima ER 40mg Fetzima ER 80mg

Trintellix 5mg Trintellix 10mg

Trintellix 10mg Trintellix 20mg

BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg

Benicar 20mg Benicar 40mg

Benicar HCT 20-12.5mg Benicar HCT 40-25mg

Bystolic 10mg Bystolic 20mg

Tekturna 150mg Tekturna 300mg

Tekturna HCT 150-12.5mg Tekturna HCT 300-25mg

CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg

Livalo 2mg Livalo 4mg

DIABETES Farxiga 5mg Farxiga 10mg

PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg

SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg

PERFORMANCE PRESCRIPTION DRUG LIST

Start date of change*

Drug class

Medication strength with limitations++ (Your plan doesn’t cover 2 capsules/tablets per day of this strength)

Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)

January 1, 2018 SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg Aptiom 400mg Aptiom 800mg Fycompa 4mg Fycompa 8mg Fycompa 6mg Fycompa 12mg Trokendi XR 25mg Trokendi XR 50mg Trokendi XR 100mg Trokendi XR 200mg

SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg

STANDARD (CIGNA NATIONAL) PRESCRIPTION DRUG LIST (cont)

Start date of change*

Drug classNon-preferred brand medication

Generic and/or preferred brand alternatives

January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal spray

ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ERDIABETES Lantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Tresiba, Levemir GASTROINTESTINAL/HEARTBURN omeprazole bicarbonate packet,

40mg-1100mg capsule, 20mg-1100mgomeprazole

INFECTIONS Eryped 400 erythromycinPAIN RELIEF AND INFLAMMATORY DISEASE OxyContin Embeda, Hysingla ER, Xtampza ER

Vanatol LQ butalbital/acetaminophen/caffeine tabs or caps

SKIN CONDITIONS Ala-Scalp hydrocortisone topicalCapex shampoo fluocinolone scalpCordran flurandrenolide topicalDifferin adapaleneKenalog spray triamcinolone sprayLocoid lotion hydrocortisone butyrateMetrogel metronidazole gelNaftin naftifineNucort, Texacort hydrocortisone

Start date of change*

Drug classMedication requiring prior authorization

Additional information

January 1, 2018 DIABETES Lantus, Lantus SoloStar, Toujeo SoloStar Your plan will only cover this medication if your doctor requests and receives approval from Cigna.

GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, VarubiHORMONAL AGENTS Androderm, Androgel, Axiron, Fortesta,

Natesto, Striant, Testim, Testopel, testosterone, Vogelxo

PAIN RELIEF AND INFLAMMATORY DISEASE RoxicodoneStart date of change*

Drug class Medication with quantity limits Additional information

January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone, Nasonex Your plan only covers a certain amount of this medication over a certain number of days. Your plan will only cover a larger amount if your doctor requests and receives approval from Cigna.

ALZHEIMER'S DISEASE Namenda XR, NamzaricANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine 25mg, 100mg, Marplan,

PristiqASTHMA/COPD/RESPIRATORY Perforomist

Start date of change*

Drug class Medication with quantity limits Additional information

January 1, 2018 BLOOD PRESSURE/HEART MEDICATIONS Ranexa Your plan only covers a certain amount of this medication over a certain number of days. Your plan will only cover a larger amount if your doctor requests and receives approval from Cigna.

CANCER Fareston, Nilandron, nilutamideDIABETES Jentadueto, TradjentaEYE CONDITIONS bimatoprost eye drops, Cystaran, ZioptanHORMONAL AGENTS Alora, estradiol patch, Estring, Menostar,

Minivelle, Vagifem, Vivelle Dot, yuvafemINFECTIONS Zovirax MISCELLANEOUS NuedextaOSTEOPOROSIS PRODUCTS alendronatePAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, MitigareSCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify Maintena, Aristada, Fanapt, Invega

Trinza, Risperdal Consta, Zyprexa RelprevvSEIZURE DISORDERS Gabitril, PotigaSKIN CONDITIONS Denavir, Regranex, Santyl, Vectical, ZyclaraSLEEP DISORDERS/SEDATIVES Hetlioz

PERFORMANCE PRESCRIPTION DRUG LIST (cont)

Start date of change*

Drug class Step Therapy medication^^Generic and/or Preferred Brand Alternatives

January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER

Focalin XR dexmethylphenidate ER

SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify aripiprazole

Orap pimozide

SKIN CONDITIONS Locoid lotion hydrocortisone butyrate

SLEEP DISORDERS/SEDATIVES Silenor eszopiclone, zolpidem

Start date of change*

Drug class

Medication strength with limitations++ (Your plan doesn’t cover 2 capsules/tablets per day of this strength)

Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)

January 1, 2018 ALLERGY/NASAL SPRAYS desloratadine ODT 2.5mg desloratadine ODT 5mg

ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg

Fetzima ER 40mg Fetzima ER 80mg

Trintellix 5mg Trintellix 10mg

Trintellix 10mg Trintellix 20mg

BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg

Benicar 20mg Benicar 40mg

Benicar HCT 20-12.5mg Benicar HCT 40-25mg

Bystolic 10mg Bystolic 20mg

Tekturna 150mg Tekturna 300mg

Tekturna HCT 150-12.5mg Tekturna HCT 300-25mg

CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg

Livalo 2mg Livalo 4mg

DIABETES Farxiga 5mg Farxiga 10mg

VALUE PRESCRIPTION DRUG LIST

PERFORMANCE PRESCRIPTION DRUG LIST (cont)

Start date of change*

Drug class

Medication strength with limitations++ (Your plan doesn’t cover 2 capsules/tablets per day of this strength)

Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)

January 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg

Aptiom 400mg Aptiom 800mg Fycompa 4mg Fycompa 8mg Fycompa 6mg Fycompa 12mg Trokendi XR 25mg Trokendi XR 50mg Trokendi XR 100mg Trokendi XR 200mg

SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg

Start date of change*

Drug classNon-preferred brand medication

Generic and/or preferred brand alternatives

January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal sprayASTHMA/COPD/RESPIRATORY Spiriva, Spiriva Respimat Incruse Ellipta

Stiolto Respimat Anoro ElliptaATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER

Focalin XR dexmethylphenidate ERDIABETES Apidra Humalog

Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR Invokana Farxiga, Jardiance Kombiglyze XR, Onglyza alogliptin, alogliptin-metformin, Janumet,

Janumet XR, JanuviaToujeo Basaglar, Tresiba, Levemir

PAIN RELIEF AND INFLAMMATORY DISEASE D.H.E. 45 dihydroergotamineImitrex sumatriptanOxyContin Embeda, Hysingla ER, Xtampza ERVanatol LQ butalbital/acetaminophen/caffeine tabs

or capsZomig nasal spray sumatriptan, zolmitriptan

SKIN CONDITIONS Differin adapaleneMetrogel metronidazole gelNaftin naftifine

Start date of change*

Drug classMedication requiring prior authorization

Additional information

January 1, 2018 DIABETES Lantus, Lantus SoloStar, Toujeo SoloStar Your plan will only cover this medication if your doctor requests and receives approval from Cigna.

GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend capsule, powder packet, tripack, Sancuso, Varubi

HORMONAL AGENTS Androderm, Androgel, Axiron, Fortesta, Natesto, Striant, Testim, Testopel, testosterone, Vogelxo

PAIN RELIEF AND INFLAMMATORY DISEASE Roxicodone

VALUE PRESCRIPTION DRUG LIST (cont)

Start date of change*

Drug class Medication with quantity limits Additional information

January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, Nasonex, mometasone Your plan only covers a certain amount of this medication over a certain number of days. Your plan will only cover a larger amount if your doctor requests and receives approval from Cigna.

ALZHEIMER'S DISEASE Namenda XR, Namzaric

ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine ER, Marplan, Pristiq

ASTHMA/COPD/RESPIRATORY Perforomist

BLOOD PRESSURE/HEART MEDICATIONS Ranexa

CANCER Fareston, Nilandron, nilutamide

DIABETES Jentadueto, Tradjenta

EYE CONDITIONS bimatoprost, Cystaran, Zioptan

HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem

INFECTIONS Zovirax

MISCELLANEOUS Nuedexta

OSTEOPOROSIS PRODUCTS alendronate

PAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, Mitigare

SCHIZOPHRENIA/ANTI-PSYCHOTICS Fanapt

SEIZURE DISORDERS Gabitril, Potiga

SKIN CONDITIONS Denavir, Regranex, Santyl, Vectical, Zyclara

SLEEP DISORDERS/SEDATIVES Hetlioz

Start date of change*

Drug class Step Therapy medication^^Generic and/or preferred brand alternatives

January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ERFocalin XR dexmethylphenidate ER

DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XRInvokana Farxiga, Jardiance

SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify aripiprazoleOrap pimozide

SKIN CONDITIONS Locoid lotion hydrocortisone butyrate SLEEP DISORDERS/SEDATIVES Silenor zolpidem, eszopiclone

Start date of change*

Drug class

Medication strength with limitations++ (Your plan doesn’t cover 2 capsules/tablets per day of this strength)

Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)

January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg Fetzima ER 40mg Fetzima ER 80mg Trintellix 5mg Trintellix 10mg Trintellix 10mg Trintellix 20mg

BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg Benicar 20mg Benicar 40mg Benicar HCT 20-12.5mg Benicar HCT 40-25mg

VALUE PRESCRIPTION DRUG LIST (cont)

Start date of change*

Drug class

Medication strength with limitations++ (Your plan doesn’t cover 2 capsules/tablets per day of this strength)

Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)

January 1, 2018 BLOOD PRESSURE/HEART MEDICATIONS (cont)

Bystolic 10mg Bystolic 20mg Tekturna 150mg Tekturna 300mg Tekturna HCT 150-12.5mg Tekturna HCT 300-25mg

CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg Livalo 2mg Livalo 4mg

DIABETES Farxiga 5mg Farxiga 10mg PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg

Aptiom 400mg Aptiom 800mg Fycompa 4mg Fycompa 8mg Fycompa 6mg Fycompa 12mg Trokendi XR 25mg Trokendi XR 50mg Trokendi XR 100mg Trokendi XR 200mg

SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg

ADVANTAGE PRESCRIPTION DRUG LIST

Start date of change*

Drug classNon-preferred brand medication

Generic and/or preferred brand alternatives

January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal sprayASTHMA/COPD/RESPIRATORY Spiriva, Spiriva Respimat Incruse Ellipta

Stiolto Respimat Anoro ElliptaATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ERDIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR

Invokana Farxiga, Jardiance Kombiglyze XR, Onglyza alogliptin, alogliptin-metformin, Janumet,

Janumet XR, JanuviaToujeo Basaglar, Tresiba, Levemir

PAIN RELIEF AND INFLAMMATORY DISEASE OxyContin Embeda, Hysingla ER, Xtampza ERVanatol LQ butalbital/acetaminophen/caffeine tabs

or capsSKIN CONDITIONS Differin adapalene

Metrogel metronidazole gelNaftin naftifine

Start date of change*

Drug classMedication requiring prior authorization

Additional information

January 1, 2018 DIABETES Lantus, Lantus SoloStar, Toujeo SoloStar Your plan will only cover this medication if your doctor requests and receives approval from Cigna.

GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi

HORMONAL AGENTS Androderm, Androgel, Axiron, Fortesta, Natesto, Striant, Testim, Testopel, Vogelxo, testosterone gel, Vogelxo

PAIN RELIEF AND INFLAMMATORY DISEASE Roxicodone

Start date of change*

Drug class Step Therapy medication^^Generic and/or preferred brand alternatives

January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER

Adderall XR dextroamphetamine-amphetamine ER

Focalin XR dexmethylphenidate ER

DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR

Invokana Farxiga, Jardiance

SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify aripiprazole

Orap pimozide

SKIN CONDITIONS Locoid lotion hydrocortisone butyrate

SLEEP DISORDERS/SEDATIVES Silenor eszopiclone, zaleplon, zolpidem, zolpidem ER

Start date of change*

Drug class

Medication strength with limitations++ (Your plan doesn’t cover 2 capsules/tablets per day of this strength)

Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)

January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg

Fetzima ER 40mg Fetzima ER 80mg

Trintellix 5mg Trintellix 10mg

Trintellix 10mg Trintellix 20mg

BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg

Benicar 20mg Benicar 40mg

Benicar HCT 20-12.5mg Benicar HCT 40-25mg

Start date of change*

Drug class Medication with quantity limits Additional information

January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, Nasonex, mometasone Your plan only covers a certain amount of this medication over a certain number of days. Your plan will only cover a larger amount if your doctor requests and receives approval from Cigna.

ALZHEIMER'S DISEASE Namenda XR, NamzaricANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine ER, Marplan, PristiqASTHMA/COPD/RESPIRATORY PerforomistBLOOD PRESSURE/HEART MEDICATIONS RanexaCANCER Fareston, Nilandron, nilutamideDIABETES Jentadueto, TradjentaEYE CONDITIONS bimatoprost eye drops, Cystaran, ZioptanHORMONAL AGENTS Alora, estradiol patch, Estring, Menostar,

Minivelle, Vagifem, Vivelle-Dot, yuvafem

INFECTIONS Zovirax MISCELLANEOUS NuedextaOSTEOPOROSIS PRODUCTS alendronatePAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, MitigareSCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify Maintena, Aristada, Fanapt, Invega

Trinza, Risperdal Consta, Zyprexa RelprevvSEIZURE DISORDERS Gabitril, PotigaSKIN CONDITIONS Denavir, Regranex, Santyl, Vectical, ZyclaraSLEEP DISORDERS/SEDATIVES Hetlioz

ADVANTAGE PRESCRIPTION DRUG LIST (cont)

Start date of change*

Drug classNon-preferred brand medication

Generic and/or preferred brand alternatives

January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal sprayATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER

Focalin XR dexmethylphenidate ER CANCER Nilandron nilutamide

DIABETES Apidra Humalog, NovologLantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba

GASTROINTESTINAL/HEARTBURN omeprazole bicarbonate packet, 40mg-1100mg capsule, 20mg-1100 mg capsule

omeprazole

INFECTIONS Eryped 400 erythromycinPAIN RELIEF AND INFLAMMATORY DISEASE D.H.E. 45 dihydroergotamine

Imitrex sumatriptanOxyContin Embeda, Hysingla ER, Xtampza ERVanatol LQ butalbital/acetaminophen/caffeine tabs

or capsSKIN CONDITIONS Ala-Scalp hydrocortisone

Analpram HC hydrocortisone-pramoxineCapex shampoo fluocinoloneCordran flurandrenolideDifferin adapaleneKenalog triamcinolone sprayLocoid lotion hydrocortisone butyrateMetrogel metronidazole gelNaftin naftifineNucort, Texacort hydrocortisone

Start date of change*

Drug class

Medication strength with limitations++ (Your plan doesn’t cover 2 capsules/tablets per day of this strength)

Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)

January 1, 2018 BLOOD PRESSURE/HEART MEDICATIONS (cont)

Bystolic 10mg Bystolic 20mg Tekturna 150mg Tekturna 300mg Tekturna HCT 150-12.5mg Tekturna HCT 300-25mg

CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg Livalo 2mg Livalo 4mg

DIABETES Farxiga 5mg Farxiga 10mg PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg

Aptiom 400mg Aptiom 800mg Fycompa 4mg Fycompa 8mg Fycompa 6mg Fycompa 12mg Trokendi XR 25mg Trokendi XR 50mg Trokendi XR 100mg Trokendi XR 200mg

SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg

ADVANTAGE PRESCRIPTION DRUG LIST (cont)

LEGACY PRESCRIPTION DRUG LIST

Start date of change*

Drug classMedication requiring prior authorization

Additional information

January 1, 2018 DIABETES Lantus, Lantus SoloStar, Toujeo SoloStar Your plan will only cover this medication if your doctor requests and receives approval from Cigna.

GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend capsule, powder packet, tripack, Sancuso, Varubi

HORMONAL AGENTS Androderm, Androgel, Axiron, Fortesta, Natesto, Striant, Testim, testosterone, Vogelxo

PAIN RELIEF AND INFLAMMATORY DISEASE RoxicodoneStart date of change*

Drug class Medication with quantity limits Additional information

January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, Nasonex, mometasone Your plan only covers a certain amount of this medication over a certain number of days. Your plan will only cover a larger amount if your doctor requests and receives approval from Cigna.

ALZHEIMER'S DISEASE Namenda XR, NamzaricANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine 25mg, 100mg, Marplan,

PristiqASTHMA/COPD/RESPIRATORY PerforomistBLOOD PRESSURE/HEART MEDICATIONS RanexaCANCER Fareston, Nilandron, nilutamideDIABETES Jentadueto, TradjentaEYE CONDITIONS bimatoprost eye drops, Cystaran, ZioptanHORMONAL AGENTS Alora, estradiol patch, Estring, Menostar,

Minivelle, Vagifem, Vivelle-Dot, yuvafemINFECTIONS ZoviraxMISCELLANEOUS NuedextaOSTEOPOROSIS PRODUCTS alendronatePAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, MitigareSCHIZOPHRENIA/ANTI-PSYCHOTICS FanaptSEIZURE DISORDERS Gabitril, PotigaSKIN CONDITIONS Denavir, Regranex, Santyl, Vectical, ZyclaraSLEEP DISORDERS/SEDATIVES Hetlioz

Start date of change*

Drug class Step Therapy medication^^Generic and/or preferred brand alternatives

January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER

Focalin XR dexmethylphenidate ER

SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify aripiprazole

Orap pimozide

SKIN CONDITIONS Locoid lotion hydrocortisone butyrate

SLEEP DISORDERS/SEDATIVES Silenor eszopiclone, zolpidem

Start date of change*

Drug class

Medication strength with limitations++ (Your plan doesn’t cover 2 capsules/tablets per day of this strength)

Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)

January 1, 2018 ALLERGY/NASAL SPRAYS desloratadine ODT 2.5mg desloratadine ODT 5mg

ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg

Fetzima ER 40mg Fetzima ER 80mg

LEGACY PRESCRIPTION DRUG LIST (cont)

Start date of change*

Drug class

Medication strength with limitations++ (Your plan doesn’t cover 2 capsules/tablets per day of this strength)

Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)

January 1, 2018 ANXIETY/DEPRESSION/ BIPOLAR DISORDER (cont)

Trintellix 5mg Trintellix 10mg

Trintellix 10mg Trintellix 20mg

BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg

Benicar 20mg Benicar 40mg

Benicar HCT 20-12.5mg Benicar HCT 40-25mg

Bystolic 10mg Bystolic 20mg

Tekturna 150mg Tekturna 300mg

Tekturna HCT 150-12.5mg Tekturna HCT 300-25mg

CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg

Livalo 2mg Livalo 4mg

DIABETES Farxiga 5mg Farxiga 10mg

PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg

SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg

SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg

Aptiom 400mg Aptiom 800mg

Fycompa 4mg Fycompa 8mg

Fycompa 6mg Fycompa 12mg

Trokendi XR 25mg Trokendi XR 50mg

Trokendi XR 100mg Trokendi XR 200mg

SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg

LEGACY PRESCRIPTION DRUG LIST (cont)

PERFORMANCE PRESCRIPTION DRUG LIST (with additional medications not covered)

Start date of change*

Drug class Medication not covered^ Generic and/or preferred brand alternatives

January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipramine

Pamelor nortriptyline

Parnate tranylcypromine

Tofranil imipramine

ASTHMA/COPD/RESPIRATORY Zyflo montelukast, zafirlukast, zileuton ER

Zyflo CR zileuton ER

ATTENTION DEFICIT HYPERACTIVITY DISORDER

Desoxyn methamphetamine

Dexedrine dextroamphetamine, dextroamphetamine ER

BLOOD PRESSURE/HEART MEDICATIONS Betapace sotalol

CANCER Nilandron nilutamide

DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR

Invokana Farxiga, Jardiance

Lantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba

Novolin, Novolog Humalog, Humulin

Start date of change*

Drug class Medication not covered^ Generic and/or preferred brand alternatives

January 1, 2018 GASTROINTESTINAL/HEARTBURN Cortifoam, Uceris rectal foam Colocort, Hemmorex-HC, hydrocortisone, Procto-Med HC, Procto-Pak, Proctosol-HC, Proctozone-HC

Marinol dronabinolomeprazole bicarbonate packet, 40mg-1100mg capsule, 20mg-1100mg

omeprazole

Rowasa mesalamine enemaUceris tablet budesonide EC capsuleZegerid omeprazoleZofran ondansetronZofran ODT ondansetron ODT

HORMONAL AGENTS Cortrosyn cosyntropinDDAVP desmopressinHectorol doxercalciferol

INFECTIONS Augmentin, Augmentin ES, Augmentin XR amoxicillin-clavulanate ER, amoxicillin-clavulanate

Diflucan fluconazoleE.E.S. 200, Eryped 400 erythromycinMepron atovaquoneSporanox itraconazoleTargadox Avidoxy, demeclocycline, doxycycline,

doxycycline IR-DR, minocycline, minocycline ER, mondoxyne NL, Morgidox capsule, tetracycline

Valcyte valganciclovirVancocin vancomycin capsuleZovirax acyclovir

PAIN RELIEF AND INFLAMMATORY DISEASE Cambia diclofenac, diclofenac ER, etodolac, etodolac ER, fenoprofen, Fenortho, flurbiprofen, ibuprofen, indomethacin, indomethacin ER, ketoprofen, Ketorolac, meclofenamate, mefenamic acid, meloxicam, nabumetone

D.H.E. 45, Migranal dihydroergotamineGralise, Horizant gabapentinImitrex, Sumavel DosePro sumatriptanLorzone chlorzoxazoneOxyContin Embeda, Hysingla ER, Xtampza ERRoxicodone oxycodoneTivorbex indomethacinVanatol LQ butalbital/acetaminophen/caffeine tabs

or capsVivlodex meloxicamZomig sumatriptan, zolmitriptanZorvolex diclofenac, diclofenac ER

PERFORMANCE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont)

Start date of change*

Drug classNon-preferred brand medication

Generic and/or preferred brand alternatives

January 1, 2018 ALLERGY/NASAL SPRAYS Astepro azelastine nasal sprayATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER

SKIN CONDITIONS Ala-Scalp hydrocortisoneAnalpram HC lotion hydrocortisone-pramoxineCapex shampoo fluocinoloneCordran flurandrenolideDifferin adapaleneMetrogel metronidazole gelNaftin naftifineNucort, Texacort hydrocortisone

Start date of change*

Drug classMedication requiring prior authorization

Additional information

January 1, 2018 GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi Your plan will only cover this medication if your doctor requests and receives approval from Cigna.

HORMONAL AGENTS Androderm, Androgel, Striant, Testopel, testosterone

Start date of change*

Drug class Medication with quantity limits Additional information

January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone Your plan only covers a certain amount of this medication over a certain number of days. Your plan will only cover a larger amount if your doctor requests and receives approval from Cigna.

ALZHEIMER'S DISEASE Namenda XR, Namzaric

PERFORMANCE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont)

Start date of change*

Drug class Medication not covered^ Generic and/or preferred brand alternatives

January 1, 2018 PARKINSON'S DISEASE Lodosyn carbidopaRequip XL ropinirole ER

SCHIZOPHRENIA/ANTI-PSYCHOTICS Geodon capsule ziprasidoneZyprexa tablet olanzapineZyprexa Zydis olanzapine ODT

SKIN CONDITIONS Cutivate fluticasoneKenalog topical spray triamcinoloneLocoid hydrocortisone Luzu ketoconazoleSoriatane acitretinZiana clindamycin-tretinoin

SLEEP DISORDERS/SEDATIVES Nuvigil armodafinilProvigil modafinilRestoril temazepam

URINARY TRACT CONDITIONS Detrol tolterodineDetrol LA tolterodine ERDitropan XL oxybutynin EREnablex darifenacin ERGelnique darifenacin ER, oxybutynin ER, tolterodine

ER, trospium ER

PERFORMANCE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont)

Start date of change*

Drug class Medication with quantity limits Additional information

January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER desvanlafaxine 25mg, 100mg, Marplan, Pristiq

Your plan only covers a certain amount of this medication over a certain number of days. Your plan will only cover a larger amount if your doctor requests and receives approval from Cigna.

ASTHMA/COPD/RESPIRATORY Perforomist

BLOOD PRESSURE/HEART MEDICATIONS Ranexa

CANCER Fareston, nilutamide

EYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan

HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem

MISCELLANEOUS Nuedexta

OSTEOPOROSIS PRODUCTS alendronate

PAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, Mitigare

SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify Maintena, Aristada, Fanapt, Invega Trinza, Risperdal Consta, Zyprexa Relprevv

SEIZURE DISORDERS Gabitril, Potiga

SKIN CONDITIONS Denavir, Regranex, Santyl, Vectical

SLEEP DISORDERS/SEDATIVES Hetlioz

Start date of change*

Drug class Step Therapy medication^^Generic and/or preferred brand alternatives

January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER

Focalin XR dexmethylphenidate ER

SCHIZOPHRENIA/ANTI-PSYCHOTICS Orap pimozide

SLEEP DISORDERS/SEDATIVES Silenor eszopiclone, zolpidem

Start date of change*

Drug class

Medication strength with limitations++ (Your plan doesn’t cover 2 capsules/tablets per day of this strength)

Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)

January 1, 2018 ALLERGY/NASAL SPRAYS desloratadine ODT 2.5mg desloratadine ODT 5mg

ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg

Fetzima ER 40mg Fetzima ER 80mg

Trintellix 5mg Trintellix 10mg

Trintellix 10mg Trintellix 20mg

BLOOD PRESSURE/HEART MEDICATIONS Azor 5-20mg Azor 10-40mg

Benicar 20mg Benicar 40mg

Benicar HCT 20-12.5mg Benicar HCT 40-25mg

Bystolic 10mg Bystolic 20mg

Tekturna 150mg Tekturna 300mg

Tekturna HCT 150-12.5mg Tekturna HCT 300-25mg

CHOLESTEROL MEDICATIONS Livalo 1mg Livalo 2mg

Livalo 2mg Livalo 4mg

DIABETES Farxiga 5mg Farxiga 10mg

VALUE PRESCRIPTION DRUG LIST (with additional medications not covered)

Start date of change*

Drug class

Medication strength with limitations++ (Your plan doesn’t cover 2 capsules/tablets per day of this strength)

Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)

January 1, 2018 PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg

SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg

SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg

Aptiom 400mg Aptiom 800mg

Fycompa 4mg Fycompa 8mg

Fycompa 6mg Fycompa 12mg

Trokendi XR 25mg Trokendi XR 50mg

Trokendi XR 100mg Trokendi XR 200mg

SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg

PERFORMANCE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont)

Start date of change*

Drug class Medication not covered^ Generic and/or preferred brand alternatives

January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipraminePamelor nortriptylineParnate tranylcypromineTofranil imipramine

ASTHMA/COPD/RESPIRATORY Spiriva, Spiriva Respimat Incruse ElliptaStiolto Respimat Anoro ElliptaZyflo montelukast, zafirlukast, zileuton ERZyflo CR zileuton ER

ATTENTION DEFICIT HYPERACTIVITY DISORDER

Desoxyn methamphetamineDexedrine dextroamphetamine,

dextroamphetamine ERBLOOD PRESSURE/HEART MEDICATIONS Betapace sotalol tabletCANCER Nilandron nilutamideDIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XR

Invokana Farxiga, JardianceKombiglyze XR, Onglyza alogliptin, alogliptin-metformin, Janumet,

Janumet XR, JanuviaLantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba

EYE CONDITIONS Alocril, Alomide cromolyn eye dropsBepreve, Emadine, Lastacaft, Pataday, Patanol, Pazeo

azelastine, epinastine, olopatadine

Elestat epinastineGASTROINTESTINAL/HEARTBURN Marinol dronabinol

Rowasa mesalamine enemaZofran ondansetronZofran ODT ondansetron ODT

VALUE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont)

Start date of change*

Drug class Medication not covered^ Generic and/or preferred brand alternatives

January 1, 2018 HORMONAL AGENTS DDAVP nasal spray, tablet desmopressin nasal spray, tablets

Hectorol doxercalciferol

INFECTIONS Augmentin, Augmentin ES, Augmentin XR amoxicillin-clavulanate ER, amoxicillin-clavulanate

Diflucan fluconazole

E.E.S. 200, Eryped 400 erythromycin

Mepron atovaquone

Sporanox itraconazole

Targadox doxycycline

Valcyte valganciclovir

Vancocin vancomycin capsule

Zovirax acyclovir

PAIN RELIEF AND INFLAMMATORY DISEASE D.H.E. 45, Migranal dihydroergotamine

Imitrex sumatriptan

OxyContin Embeda, Hysingla ER, Xtampza ER

Roxicodone oxycodone

Vanatol LQ butalbital/acetaminophen/caffeine tabs or caps

Zomig sumatriptan, zolmitriptan

PARKINSON'S DISEASE Lodosyn carbidopa

Requip XL ropinirole ER

SCHIZOPHRENIA/ANTI-PSYCHOTICS Geodon ziprasidone

Zyprexa tablet olanzapine tablet

Zyprexa Zydis olanzapine ODT

SKIN CONDITIONS Acanya, Atralin, Avita, Azelex, Differin, Epiduo, Epiduo Forte, Fabior, Onexton, Retin-A, Retin-A Micro, Tretin-X, Veltin

Aczone, adapalene, Ala-Cort, alclometasone, amcinonide, Apexicon E, Avar, Avar-E, BenzePRO, benzoyl peroxide, betamethasone, BP 10-1, BPO, Clindacin ETZ, Clindacin P, clindamycin, clindamycin-benzoyl peroxide, clindamycin-tretinoin, clobetasol, clocortolone, Clodan, Cormax, desonide, desoximetasone, fluocinolone, halobetasol, hydrocortisone, Micort-HC, mometasone, prednicarbate, Psorcon, Scalacort, tretinoin, triamcinolone, Trianex, Triderm

Cutivate fluticasone

Dovonex, Sorilux calcipotriene

Enstilar, Taclonex calcipotriene-betamethasone DP

Soriatane acitretin

VALUE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont)

Start date of change*

Drug class Medication not covered^ Generic and/or preferred brand alternatives

January 1, 2018 SKIN CONDITIONS (cont) Tazorac adapalene, Ala-Cort, alclometasone, amcinonide, Apexicon E, Avar, Benzepro, benzoyl peroxide, betamethasone, BP 10-1, BPO, Clindacin ETZ, Clindacin P, clindamycin, clobetasol, clocortolone, Clodan, Cormax, desonide, desoximetasone, fluocinolone, halobetasol, hydrocortisone, Micort-HC, mometasone, prednicarbate, Psorcon, Scalacort, triamcinolone, Trianex, Triderm

Vectical calcitriol ointment

SLEEP DISORDERS/SEDATIVES Nuvigil armodafinil

Provigil modafinil

Restoril temazepam

URINARY TRACT CONDITIONS Detrol, Detrol LA, Ditropan XL, Enablex, Gelnique

darifenacin ER, oxybutynin ER, tolterodine, tolterodine ER, trospium ER

Start date of change*

Drug classNon-preferred brand medication

Generic and/or preferred brand alternatives

January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER

Start date of change*

Drug classMedication requiring prior authorization

Additional information

January 1, 2018 GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend capsule, powder packet, tripack, Sancuso, Varubi

Your plan will only cover this medication if your doctor requests and receives approval from Cigna. HORMONAL AGENTS Androderm, Androgel, Striant testosterone

Start date of change*

Drug class Medication with quantity limits Additional information

January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone Your plan only covers a certain amount of this medication over a certain number of days. Your plan will only cover a larger amount if your doctor requests and receives approval from Cigna.

ALZHEIMER'S DISEASE Namenda XR, Namzaric

ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine ER, Marplan

ASTHMA/COPD/RESPIRATORY Perforomist

BLOOD PRESSURE/HEART MEDICATIONS Ranexa

CANCER Fareston, nilutamide

EYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan

HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem

MISCELLANEOUS Nuedexta

OSTEOPOROSIS PRODUCTS alendronate

PAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, Mitigare

SCHIZOPHRENIA/ANTI-PSYCHOTICS Fanapt

SEIZURE DISORDERS Gabitril, Potiga

SKIN CONDITIONS Denavir, Regranex, Santyl

SLEEP DISORDERS/SEDATIVES Hetlioz

ADVANTAGE PRESCRIPTION DRUG LIST (with additional medications not covered)

Start date of change*

Drug class Step Therapy medication^^Generic and/or preferred brand alternatives

January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER

Focalin XR dexmethylphenidate ER

SCHIZOPHRENIA/ANTI-PSYCHOTICS Orap pimozide

SLEEP DISORDERS/SEDATIVES Silenor zolpidem, eszopiclone

VALUE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont)

Start date of change*

Drug class

Medication strength with limitations++ (Your plan doesn’t cover 2 capsules/tablets per day of this strength)

Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)

January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg

Fetzima ER 40mg Fetzima ER 80mg

Trintellix 5mg Trintellix 10mg

Trintellix 10mg Trintellix 20mg

DIABETES Farxiga 5mg Farxiga 10mg

PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg

SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg

SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg

Aptiom 400mg Aptiom 800mg

Fycompa 4mg Fycompa 8mg

Fycompa 6mg Fycompa 12mg

Trokendi XR 25mg Trokendi XR 50mg

Trokendi XR 100mg Trokendi XR 200mg

SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg

Start date of change*

Drug class Medication not covered^ Generic and/or preferred brand alternatives

January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Anafranil clomipramine

Pamelor nortriptyline

Parnate tranylcypromine

Tofranil imipramine

ASTHMA/COPD/RESPIRATORY Spiriva, Spiriva Respimat Incruse Ellipta

Stiolto Respimat Anoro Ellipta

Zyflo montelukast, zafirlukast, zileuton ERZyflo CR zileuton ER

ATTENTION DEFICIT HYPERACTIVITY DISORDER

Desoxyn methamphetamineDexedrine dextroamphetamine, dextroamphetamine

ERBLOOD PRESSURE/HEART MEDICATIONS Betapace sotalol tabletCANCER Nilandron nilutamide

Start date of change*

Drug class Medication not covered^ Generic and/or preferred brand alternatives

January 1, 2018 DIABETES Invokamet, Invokamet XR Synjardy, Synjardy XR, Xigduo XRInvokana Farxiga, JardianceKombiglyze XR, Onglyza alogliptin, alogliptin-metformin, Janumet,

Janumet XR, JanuviaLantus, Lantus SoloStar, Toujeo SoloStar Basaglar, Levemir, Tresiba

EYE CONDITIONS Alocril, Alomide cromolyn eye dropsBepreve, Emadine, Lastacaft, Pataday, Patanol, Pazeo

azelastine, epinastine, olopatadine

Elestat epinastineGASTROINTESTINAL/HEARTBURN Marinol dronabinol

Rowasa mesalamine enemaZofran ondansetronZofran ODT ondansetron ODT

HORMONAL AGENTS Cortrosyn cosyntropinDDAVP desmopressinHectorol doxercalciferol

INFECTIONS Augmentin, Augmentin ES, Augmentin XR amoxicillin-clavulanate ER, amoxicillin-clavulanate

Diflucan fluconazoleE.E.S. 200, Eryped 400 erythromycin

Mepron atovaquone

Sporanox itraconazole

Targadox doxycycline

Valcyte valganciclovir

Vancocin vancomycin capsule

Zovirax acyclovir

PAIN RELIEF AND INFLAMMATORY DISEASE D.H.E. 45, Migranal dihydroergotamine

Imitrex sumatriptan

OxyContin Embeda, Hysingla ER, Xtampza ER

Roxicodone oxycodone

Vanatol LQ butalbital/acetaminophen/caffeine tabs or caps

Zomig sumatriptan, zolmitriptan

PARKINSON'S DISEASE Lodosyn carbidopa

Requip XL ropinirole ER

SCHIZOPHRENIA/ANTI-PSYCHOTICS Geodon ziprasidone

Zyprexa tablet olanzapine

Zyprexa Zydis olanzapine ODT

ADVANTAGE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont)

ADVANTAGE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont)

Start date of change*

Drug class Medication not covered^ Generic and/or preferred brand alternatives

January 1, 2018 SKIN CONDITIONS Acanya, Atralin, Avita, Azelex, Differin, Epiduo, Epiduo Forte, Fabior, Onexton, Retin-A, Retin-A Micro, Tretin-X, Veltin

Aczone, adapalene, Ala-Cort, alclometasone, amcinonide, Apexicon E, Avar, Avar-E, BenzePRO, benzoyl peroxide, betamethasone, BP 10-1, BPO, Clindacin ETZ, Clindacin P, clindamycin, clindamycin-benzoyl peroxide, clindamycin-tretinoin, clobetasol, clocortolone, Clodan, Cormax, desonide, desoximetasone, fluocinolone, halobetasol, hydrocortisone, Micort-HC, mometasone, prednicarbate, Psorcon, Scalacort, tretinoin, triamcinolone, Trianex, Triderm

Cutivate fluticasone

Dovonex, Sorilux calcipotriene

Enstilar, Taclonex calcipotriene-betamethasone DP

Soriatane acitretin

Tazorac adapalene, Ala-Cort, alclometasone, amcinonide, Apexicon E, Avar, Avar-E, Benzepro, benzoyl peroxide, betamethasone, BP 10-1, BPO, Clindacin ETZ, Clindacin P, clindamycin, clobetasol, clocortolone, Clodan, Cormax, desonide, desoximetasone, fluocinolone, halobetasol, hydrocortisone, Micort-HC, mometasone, prednicarbate, Psorcon, Scalacort, triamcinolone, Trianex, Triderm

Vectical calcitriol

SLEEP DISORDERS/SEDATIVES Nuvigil armodafinil

Provigil modafinil

Restoril temazepam

URINARY TRACT CONDITIONS Detrol tolterodine

Detrol LA tolterodine ER

Ditropan XL oxybutynin ER

Enablex darifenacin ER

Gelnique darifenacin ER, oxybutynin ER, tolterodine ER, trospium ER

Start date of change*

Drug classNon-preferred brand medication

Generic and/or preferred brand alternatives

January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER

ADVANTAGE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont)

Start date of change*

Drug classMedication requiring prior authorization

Additional information

January 1, 2018 GASTROINTESTINAL/HEARTBURN Akynzeo, Anzemet, Emend, Sancuso, Varubi

Your plan will only cover this medication if your doctor requests and receives approval from Cigna. HORMONAL AGENTS Androderm, Androgel, Striant,

Testopel, testosteroneStart date of change*

Drug class Medication with quantity limits Additional information

January 1, 2018 ALLERGY/NASAL SPRAYS cromolyn oral, mometasone Your plan only covers a certain amount of this medication over a certain number of days. Your plan will only cover a larger amount if your doctor requests and receives approval from Cigna.

ALZHEIMER'S DISEASE Namenda XR, Namzaric

ANXIETY/DEPRESSION/BIPOLAR DISORDER desvenlafaxine ER, Marplan

ASTHMA/COPD/RESPIRATORY Perforomist

BLOOD PRESSURE/HEART MEDICATIONS Ranexa

CANCER Fareston, nilutamide

EYE CONDITIONS bimatoprost eye drops, Cystaran, Zioptan

HORMONAL AGENTS Alora, estradiol patch, Estring, Menostar, Minivelle, Vagifem, Vivelle-Dot, yuvafem

MISCELLANEOUS Nuedexta

OSTEOPOROSIS PRODUCTS alendronate

PAIN RELIEF AND INFLAMMATORY DISEASE Daliresp, Mitigare

SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify Maintena, Aristada, Fanapt, Invega Trinza, Risperdal Consta, Zyprexa Relprevv

SEIZURE DISORDERS Gabitril, Potiga

SKIN CONDITIONS Denavir, Regranex, Santyl

SLEEP DISORDERS/SEDATIVES Hetlioz

Start date of change*

Drug class Step Therapy medication^^Generic and/or preferred brand alternatives

January 1, 2018 ATTENTION DEFICIT HYPERACTIVITY DISORDER Adderall XR dextroamphetamine-amphetamine ER

Focalin XR dexmethylphenidate ER

SCHIZOPHRENIA/ANTI-PSYCHOTICS Orap pimozide

SLEEP DISORDERS/SEDATIVES Silenor eszopiclone, zaleplon, zolpidem, zolpidem ER

Start date of change*

Drug class

Medication strength with limitations++ (Your plan doesn’t cover 2 capsules/tablets per day of this strength)

Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)

January 1, 2018 ANXIETY/DEPRESSION/BIPOLAR DISORDER Fetzima ER 20mg Fetzima ER 40mg

Fetzima ER 40mg Fetzima ER 80mg

Trintellix 5mg Trintellix 10mg

Trintellix 10mg Trintellix 20mg

DIABETES Farxiga 5mg Farxiga 10mg

PAIN RELIEF AND INFLAMMATORY DISEASE Uloric 40mg Uloric 80mg

SCHIZOPHRENIA/ANTI-PSYCHOTICS Latuda 60mg Latuda 120mg

Start date of change*

Drug class

Medication strength with limitations++ (Your plan doesn’t cover 2 capsules/tablets per day of this strength)

Covered medication strength(Prescription must be for 1 capsule/tablet per day of this strength)

January 1, 2018 SEIZURE DISORDERS Aptiom 200mg Aptiom 400mg

Aptiom 400mg Aptiom 800mg

Fycompa 4mg Fycompa 8mg

Fycompa 6mg Fycompa 12mg

Trokendi XR 25mg Trokendi XR 50mg

Trokendi XR 100mg Trokendi XR 200mg

SLEEP DISORDERS/SEDATIVES Silenor 3mg Silenor 6mg

ADVANTAGE PRESCRIPTION DRUG LIST (with additional medications not covered) (cont)

* State laws in Texas and Louisiana require your plan to cover your medications at your current benefit level until your plan renews. This means that if your medication is taken off the drug list, is moved to a higher cost-share tier or needs approval, your plan can’t make these changes until your renewal date. To find out if these state laws apply to your plan, please call Customer Service using the number on the back of your ID card.

++ Your plan doesn’t cover more than one tablet/capsule in this strength a day. If your doctor feels a higher strength of this medication once each day isn’t right for you, he or she can ask Cigna to consider approving coverage of your current medication strength.

^ These medications require approval from Cigna before they’re covered by your plan. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving coverage of your medication.

^^ This is a Step Therapy medication. Step Therapy medications aren’t covered by your plan without approval from Cigna. In Step Therapy, you have to try lower-cost alternatives first before the higher-cost brand medication may be covered. Typically, you start by taking generics or lower-cost preferred brands.

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, Connecticut General Life Insurance Company, Cigna Health Management, Inc., 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., and Cigna HealthCare of Texas, Inc. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.

909015 © 2017 Cigna. Some content provided under license. UPDATED_10/17/2017

Cigna reserves the right to make changes to the Drug List without notice.