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CIGNA STANDARD 3-TIER PRESCRIPTION DRUG LIST

CIGNA STANDARD 3-TIER PRESCRIPTION drug LISTC overage as of July 1, 2022 Offered by: CIGNA Health and Life Insurance Company, Connecticut General Life Insurance Company, or their p STANDARD 3-TIER 03/22 2 View the drug list onlineThis document was last updated on 03/01/2022.* You can go online to see the current list of medications your plan : Click to Chat - Monday-Friday, 9:00 am-8:00 pm EST. By phone: Call the toll-free number on your CIGNA ID card. We re here 24/7 App or Click on the Find Care & Costs tab. Then select Price a Medication, and type in your medication Select STANDARD 3 tier from the dropdown menu. Then type in your medication name or view the full s inside?About this drug list3 How to read this drug list3 How to find your medication5 Medications that aren t covered - and their covered alternatives20 Frequently Asked Questions (FAQs) 36 Exclusions and limitations for coverage40 drug list created: originally created 01/01/2004 Last updated: 03/01/2022, for changes starting 07/01/2022 Next planned update: 08/01/2022, for changes starting 01

3 TIER 1 $ TIER 2 $$ BLOOD PRESSURE/HEART MEDICATIONS afeditab CR amlodipine besylate amlodipine besylate-benazepril amlodipine-valsartan amlodipine-valsartan-HCTZ atenolol atenolol-chlorthalidone benazepril benazepril-HCTZ candesartan cilexetil cartia XT carvedilol clonidine digitek digox digoxin diltiazem ER diltiazem CD diltiazem dilt-XR ...

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Transcription of CIGNA STANDARD 3-TIER PRESCRIPTION DRUG LIST

1 CIGNA STANDARD 3-TIER PRESCRIPTION drug LISTC overage as of July 1, 2022 Offered by: CIGNA Health and Life Insurance Company, Connecticut General Life Insurance Company, or their p STANDARD 3-TIER 03/22 2 View the drug list onlineThis document was last updated on 03/01/2022.* You can go online to see the current list of medications your plan : Click to Chat - Monday-Friday, 9:00 am-8:00 pm EST. By phone: Call the toll-free number on your CIGNA ID card. We re here 24/7 App or Click on the Find Care & Costs tab. Then select Price a Medication, and type in your medication Select STANDARD 3 tier from the dropdown menu. Then type in your medication name or view the full s inside?About this drug list3 How to read this drug list3 How to find your medication5 Medications that aren t covered - and their covered alternatives20 Frequently Asked Questions (FAQs) 36 Exclusions and limitations for coverage40 drug list created: originally created 01/01/2004 Last updated: 03/01/2022, for changes starting 07/01/2022 Next planned update.

2 08/01/2022, for changes starting 01/01/202333 tier 1$ tier 2$$BLOOD PRESSURE/HEART MEDICATIONS afeditab CRamlodipine besylateamlodipine besylate-benazeprilamlodipine-valsartana mlodipine-valsartan-HCTZ atenololatenolol-chlorthalidonebenazepri l benazepril-HCTZ candesartan cilexetilcartia XTcarvedilolclonidinedigitekdigoxdigoxin diltiazem ERdiltiazem CDdiltiazem dilt-XRenalapril flecainide acetatehydralazine irbesartanisosorbide mononitratBERINERT* (PA)BIDILBYSTOLICCINRYZE* (PA)COREG CRCOZAAR (ST)DIOVAN (ST)DIOVAN HCT (ST)EDARBI (ST)EDARBYCLOR (ST)EXFORGEEXFORGE HCTFIRAZYR* (PA)HEMANGEOLINDERAL LAINDERAL XLINNOPRAN XLLOTRELMICARDIS (ST)MULTAQNITRO-DURNITROLINGUALNITROMIST NITRONALNITROSTATNORTHERA* (PA)NORVASCRANEXA (ST)TEKTURNATEKTURNA HCTM edications are grouped by the condition they treatMedications that have extra coverage requirements have an abbreviation listed next to themMedications are listed in alphabetical order within each columnBrand-name medications are in all capital lettersGeneric medications are in all lowercase lettersSpecialty medications have an asterisk (*) listed next to them tier (cost-share level)

3 Gives you an idea of how much you may pay for a medicationAbout this drug listThis is a list of the most commonly prescribed medications covered on the CIGNA STANDARD 3-TIER PRESCRIPTION drug List as of July 1, ,2 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 complete 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 , or check your plan materials, to see all of the medications your plan to read this drug listUse 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 the CIGNA STANDARD 3-TIER PRESCRIPTION drug chart is just a sample.

4 It may not show how these medications are actually covered on the CIGNA STANDARD 3-TIER PRESCRIPTION drug 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 . Abbreviations next to medicationsIn this drug list, medications that have limits and/or extra coverage requirements have an abbreviation listed next to them.* Here s what they mean. tier 1 Typically Generics (Lowest-cost medication) $ tier 2 Typically Preferred Brands (Medium-cost medication) $$ tier 3 Typically Non-Preferred Brands (Highest-cost medication) $$$(PA) Prior Authorization Certain medications need approval from CIGNA before your plan will cover them.

5 These medications have a (PA) next to them. Your plan won t cover these medications unless your doctor requests, and receives, approval from CIGNA .(QL) Quantity Limits Some medications have a quantity limit - meaning, your plan will only cover up to a certain amount over a certain length of time. These medications have a (QL) next to them. Your plan will only cover a larger amount if your doctor requests, and receives, approval from CIGNA .(ST) Step Therapy Certain high-cost medications aren t covered until you try one or more lower-cost alternatives first.** These medications have a (ST) next to them. You have many covered options to choose from, and they re used to treat the same condition. (AGE) Age Requirements Certain medications will only be covered if you re within a specific age range.

6 These medications have (AGE) next to them. If you re not within the allowed age range, your plan will only cover the medication if your doctor requests, and receives, approval from medications are in all capital lettersIn this drug list, generic medications are listed in all lowercase letters and brand-name medications are listed in all capital letters. Specialty medications have an asterisk next to themSpecialty medications are used to treat complex medical conditions. In this drug list, specialty medications have an asterisk (*) next to them. Some plans cover specialty medications on a specialty tier , limit coverage to a 30-day supply, and/or require you to use a preferred specialty pharmacy to get coverage. Log in to the myCigna App or , or check your plan materials, to see how your plan covers these medications.

7 * These coverage requirements may not apply to your specific plan. Log in to the myCigna App or , or check your plan materials, to find out if your plan includes prior authorization, quantity limits, Step Therapy, and/or age requirements.** If your doctor feels an alternative isn t right for you, he or she can ask CIGNA to consider approving coverage of your cost-share preventive medications have a plus sign next to themHealth 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. Log in to the myCigna App or , or check your plan materials, to see how your plan covers these exclusionsYour plan doesn t cover certain medications and products because they re considered plan/benefit exclusions.

8 This means there s no option to receive coverage through CIGNA s review process by showing that you need the medication or product for your treatment. In this drug list, these medications have a caret (^) next to them. Log in to the myCigna App or , or check your plan materials, to see which medications your plan to find your medicationFirst, look for your condition in the alphabetical list below. Then, go to that page to see the covered medications available to treat the SPRAYS6 ALZHEIMER S DISEASE6 ANXIETY/DEPRESSION/BIPOLAR DISORDER6 ASTHMA/COPD/RESPIRATORY6, 7 ATTENTION DEFICIT HYPERACTIVITY DISORDER7 BLOOD MODIFIERS/BLEEDING DISORDERS7 BLOOD PRESSURE/HEART MEDICATIONS7, 8 BLOOD THINNERS/ANTI-CLOTTING8 CANCER8 CHOLESTEROL MEDICATIONS 9 CONTRACEPTION PRODUCTS9-11 COUGH/COLD MEDICATIONS11 DENTAL PRODUCTS11 DIABETES11, 12 DIURETICS12 EAR MEDICATIONS12 ERECTILE DYSFUNCTION12 EYE CONDITIONS12 FEMININE PRODUCTS13 ConditionPageGASTROINTESTINAL/HEARTBURN1 3 HORMONAL AGENTS13, 14 INFECTIONS14, 15 INFERTILITY15 MISCELLANEOUS15 MULTIPLE SCLEROSIS15 NUTRITIONAL/DIETARY15.

9 16 OSTEOPOROSIS PRODUCTS16 PAIN RELIEF AND INFLAMMATORY DISEASE16, 17 PARKINSON S DISEASE17 SCHIZOPHRENIA/ANTI-PSYCHOTICS17 SEIZURE DISORDERS17, 18 SKIN CONDITIONS18 SLEEP DISORDERS/SEDATIVES18 SMOKING CESSATION18 SUBSTANCE ABUSE19 TRANSPLANT MEDICATIONS19 URINARY TRACT CONDITIONS19 VACCINES19 WEIGHT MANAGEMENT196 tier 1$ tier 2$$ tier 3$$$AIDS/HIVabacavir-lamivudine* (PA)efavirenz-emtricitabine-tenofovir*em tricitabine-tenofovir*+etravirine*ritona vir*tenofovir* (PA)BIKTARVY*DESCOVY*+ (PA)DOVATO*GENVOYA*ISENTRESS HD* (PA)ISENTRESS*JULUCA*PREZISTA*SYMTUZA*TI VICAY PD*TIVICAY*TRIUMEQ*CABENUVA*^ (PA)CIMDUO* (PA)COMPLERA* (PA)ODEFSEY* (PA)PIFELTRO* (PA)PREZCOBIX* (PA)STRIBILD* (PA)TEMIXYS* (PA)ALLERGY/NASAL SPRAYS azelastine azelastine-fluticasonecromolyn desloratadine (QL)epinephrine (QL)fluticasone hydroxyzine hcl solution, syrup, tablethydroxyzine pamoateipratropium levocetirizine dihydrochloridemometasone (QL)olopatadine promethazine solution, syrup, tablet CLARINEXGASTROCROMGRASTEK (PA, QL)KARBINAL ERODACTRA (PA, QL)ORALAIR (PA,QL)PATANASERAGWITEK (PA, QL)VISTARILALZHEIMER S DISEASE donepezil donepezil odtmemantine memantine er (QL)pyridostigmine 60 mg/5 ml, 60 mg pyridostigmine errivastigmineNAMENDA 5-10 MG TITRATION PKARICEPTEXELONMESTINONNAMENDA 10 MG TABLETNAMENDA 5 MG TABLETNAMENDA XR (QL)NAMZARIC (QL)ANXIETY/DEPRESSION/BIPOLAR DISORDER3alprazolamalprazolam eralprazolam intensolCELEXA (QL, ST)

10 DESVENLAFAXINE ER (QL,ST) tier 1$ tier 2$$ tier 3$$$ANXIETY/DEPRESSION/BIPOLAR DISORDER3 (cont)alprazolam odtalprazolam xramitriptyline bupropion (QL)bupropion sr (QL)bupropion xl 150 mg tablet (QL)bupropion xl 300 mg tablet (QL)buspirone citalopram (QL)clomipramine desvenlafaxine er (QL)duloxetine (QL)escitalopram (QL)fluoxetine dr (QL)fluoxetine (QL)fluvoxamine (QL)fluvoxamine er (QL)lorazepamlorazepam intensolmirtazapineparoxetine cr (QL)paroxetine er (QL)paroxetine (QL)sertraline (QL)trazodone venlafaxine (QL)venlafaxine er (QL)EFFEXOR XR (QL, ST)FETZIMA (QL, ST)NUPLAZID* (PA)PAXIL (QL, ST)PAXIL CR (QL, ST)PRISTIQ (QL, ST)PROZAC (QL, ST)REMERONSPRAVATO* (PA)TRINTELLIX (QL, ST)VIIBRYD (QL, ST)WELLBUTRIN SR (QL, ST)XANAXXANAX XRZOLOFT (QL, ST)ASTHMA/COPD/RESPIRATORY albuterol albuterol hfa (QL)alyq* (PA)ambrisentan* (PA)budesonidefluticasone-salmeterolipra tropium-albuterolmontelukast tadalafil* (PA)ADEMPAS* (PA)ADVAIR HFAANORO ELLIPTAATROVENT HFABEVESPI AEROSPHEREBREO ELLIPTABREZTRI AEROSPHERECOMBIVENT RESPIMATDULERAFASENRA PEN* (PA)FLOVENT DISKUSFLOVENT HFAINCRUSE ELLIPTANUCALA * (PA)ADCIRCA* (PA)AIRDUO DIGIHALER (ST)BRONCHITOL* (PA)DALIRESP (QL)KALYDECO* (PA, QL)LETAIRIS* (PA)LONHALA MAGNAIR (PA)ORENITRAM ER* ( PA )ORKAMBI* (PA, QL) CIGNA STANDARD 3-TIER PRESCRIPTION drug List7 tier 1$ tier 2$$ tier 3$$$ASTHMA/COPD/RESPIRATORY (cont)OFEV* (PA)OPSUMIT* (PA)PULMICORT FLEXHALERPULMOZYME* (PA)


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