PRESCRIPTION DRUG LIST CHANGES - Cigna

1 Generic medications start with a lowercase letter and brand name medications start with a capital UPDATED_05/21/2021 PRESCRIPTION drug LIST CHANGESC igna Pharmacy Management 2021To help make sure you have access to coverage for safe, clinically effective and low-cost medications, we regularly review and update the Cigna PRESCRIPTION drug List. You can see a list of these CHANGES below. CHANGES are listed by drug list name, the date the change starts and by the type of change that s taking place.

2 Medications are then listed alphabetically by drug you have Cigna -administered pharmacy benefits and you re affected by one of these CHANGES , we ll send you a letter with specific information on next steps. STANDARD PRESCRIPTION drug LIST Start date of change *,** drug classMedications moving to preferred brandJune 22, 2021 PAIN RELIEF AND INFLAMMATORY DISEASER editrexMay 15, 2021 EYE CONDITIONSE ysuvisGASTROINTESTINAL/HEARTBURNS utabJanuary 1, 2021 AIDS/HIVJ ulucaASTHMA/COPD/RESPIRATORYB evespiDIABETESB aqsimiGASTROINTESTINAL/HEARTBURNP ancreazeINFECTIONSE pclusa, HarvoniPAIN RELIEF AND INFLAMMATORY DISEASETalt zStart date of change *,** drug classMedications becoming non-preferred brandGeneric and/or preferred brand alternativesJune 29, 2021 BLOOD PRESSURE/HEART MEDICATIONSO rladeyo1 lupron DepotJune 22, 2021 CANCERO rgovyx1No preferred formulary drug 15, 2021 GASTROINTESTINAL/HEARTBURNL ubiprostone 8 mcg, 24 mcg capsuleAmitizaJune 1.

3 2021 SKIN CONDITIONSW inlevi 1% creamGeneric products ( adapalene; tretinoin; clindamycin-benzoyl peroxide)Wynzora creambetamethasone DP, fluocinolone, fluticasone, mometasone, trimacinolone, calcipotriene, calcipotriene-betamethasone DPGeneric medications start with a lowercase letter and brand name medications start with a capital PRESCRIPTION drug LIST (cont)Start date of change *,** drug classMedications becoming non-preferred brandGeneric and/or preferred brand alternativesJune 1, 2021 URINARY TRACT CONDITIONSV esicare LS 5 mg/5 mL suspensionoxybutynin chloride, oxybutynin chloride ER, darifenacin ER, solifenacin, tolterodine, tolterodine ER, tropsiumMay 15, 2021 EYE CONDITIONSL acrisertRestasis, Restasis Multi-dose, XiidraMay 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASEQ dolotramadolMay 1, 2021 SKIN PREPSI mpeklotopical betamethasone dipropionate (augmented)

4 , clobetasol propionate , halobetasol propionate , fluocinolide 18, 2021 HORMONAL AGENTSA lkindi Sprinklehydrocortisone 5mg tabletMarch 28, 2021 BLOOD PRESSURE/HEART MEDICATIONSC onjupriamlodipine, felodipine, nifedipine, nicardipineJanuary 1, 2021 AIDS/HIVI ntelence1 Talk to your doctor about other alternativesBLOOD MODIFIERS/BLEEDING DISORDERSA micar g/ml oral solution1aminocaproic acid oral solutionBLOOD PRESSURE/HEART MEDICATIONSM ultaq, Norpace CR 150mgTalk to your doctor about other alternativesCANCERTab loidTalk to your doctor about other alternativesERECTILE DYSFUNCTIONC averject Impulse SyringeMUSEEYE CONDITIONSL otemax dropsloteprednol dropsHORMONAL AGENTSA rmour Thyroid, Synthroid, UnithroidlevothyroxineINFECTIONSK itabis Pak1tobramycin pak 300mg/5mlSEIZURE DISORDERSL yrica 20mg/ml oral solutionpregabalin 20mg/ml oral solutionSUBSTANCE ABUSEB unavailbuprenorphine/naloxone film or sublingual tablet, ZubsolvWEIGHT MANAGEMENTM egace ES 625mg/5ml oral suspensionmegestrol 625ml/5ml oral suspensionStart date of change *,** drug classMedications that will need approval (prior authorization)

5 ^June 29, 2021 BLOOD PRESSURE/HEART MEDICATIONSO rladeyo1 June 22, 2021 PAIN RELIEF AND INFLAMMATORY DISEASER editrexJune 1, 2021 ASTHMA/COPD/RESPIRATORYZ okinvy March 14, 2021 CANCERG avretoJanuary 1, 2021 BLOOD THINNERS/ANTI-CLOTTINGE liquis4, Pradaxa4, Savaysa4, Xarelto4 PAIN RELIEF AND INFLAMMATORY DISEASE diclofenac patch, Flector patch5, Voltaren 1% gel5 Start date of change *,** drug classMedications that will have a quantity limitJune 29, 2021 BLOOD PRESSURE/HEART MEDICATIONSO rladeyo1 June 1, 2021 ASTHMA/COPD/RESPIRATORYZ okinvyMay 15, 2021 EYE CONDITIONSE ysuvisMay 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASEQ doloGeneric medications start with a lowercase letter and brand name medications start with a capital PRESCRIPTION drug LIST (cont)Start date of change *,** drug classMedications that will have a quantity limitMarch 14, 2021 CANCERG avretoStart date of change *,** drug classMedications that will no longer be covered^^Generic and/or preferred brand alternativesJune 29, 2021 SKIN CONDITIONSK lisyritopical fluorouracil, imiquimod 5% creamJune 22, 2021 GASTROINTESTINAL/HEARTBURNR eltoneursodiolHORMONAL AGENTST hyquiditylevothyroxine, levoxyl, Levo-T, Unithroid, EuthyroxJune 15, 2021 GASTROINTESTINAL/HEARTBURNL ubiprostone 8 mcg, 24 mcg capsuleAmitiza June 1, 2021 SKIN CONDITIONSW inlevi 1% creamGeneric products ( adapalene; tretinoin.)

6 Clindamycin-benzoyl peroxide)June 1, 2021 SKIN CONDITIONS (cont)Wynzora creambetamethasone DP, fluocinolone, fluticasone, mometasone, trimacinolone, calcipotriene, calcipotriene-betamethasone DPURINARY TRACT CONDITIONSV esicare LS 5 mg/5 mL suspensionoxybutynin chloride, oxybutynin chloride ER, darifenacin ER, solifenacin, tolterodine, tolterodine ER, tropsiumMay 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASEQ dolotramadolMay 1, 2021 SKIN PREPSI mpeklotopical betamethasone dipropionate (augmented) , clobetasol propionate , halobetasol propionate , fluocinolide 18, 2021 HORMONAL AGENTSA lkindi Sprinklehydrocortisone 5mg tabletMarch 28, 2021 BLOOD PRESSURE/HEART MEDICATIONSC onjupriamlodipine, felodipine, nifedipine, nicardipineJanuary 1, 2021 ASTHMA/COPD/RESPIRATORYProAir HFA7, ProAir RespiClick7, Ventolin HFA7albuterol HFADIABETESK ombiglyze XR8, Onglyza8metformin, Janumet, Janumet XR, JanuviaEYE CONDITIONSL umigan7, Travatan Z, Xalatan, Xelpros, Zioptan9bimatoprost, latanoprost, travoprostGASTROINTESTINAL/HEARTBURNC reon7, Pertzye, Zenpep7 PancreazeMotegrity, Trulance7, ZelnormAmitiza.

7 LinzessSensiparcinacalcet HORMONAL AGENTSTap er D e xdexamethasone tabletINFECTIONSB aracludeentecavir tabletNoxafil tabletposaconazole DR 100mg tabletMULTIPLE SCLEROSISA mpyra ER7dalfampridine ERNUTRITIONAL/DIETARYPreGenna, TrinazAny generic prenatal vitaminPAIN RELIEF AND INFLAMMATORY DISEASEA mergegeneric triptans ( naratriptan; sumatriptan)Generic medications start with a lowercase letter and brand name medications start with a capital PRESCRIPTION drug LIST (cont)Start date of change *,** drug classMedications that will no longer be covered^^Generic and/or preferred brand alternativesJanuary 1, 2021 PAIN RELIEF AND INFLAMMATORY DISEASE butalbital-acetaminophen 50-300mg tabletbutalbutal-acetaminophen 50-325mg tabletCosentyx10 Enbrel, Humira, Otezla, Skyrizi, Stelara, TaltzFrova, Maxalt, Maxalt MLT, Relpaxgeneric triptans ( naratriptan.)

8 Sumatriptan)SEIZURE DISORDERSF elbatol11felbamateKeppra/Keppra XR11levetiracetam/levetiracetam ERLamictal XR Start Kit11lamotrigine ERLamictal/ODT/XR11lamotrigine, lamotrigine ER, lamotrigine ODTQ udexy XR11, Trokendi XR11topiramate ERSabril11vigabatrin, vigadroneTopamax11topiramateTrileptal11o xcarbazepineZonegran11zonisamideSKIN CONDITIONSA pexicon E5, diflorasone, Impoyz5, Olux5, Olux-E5, psorconbetamethasone, clobetasol, halobetasolCondyloximiquimod 5% cream packet, podofilox topical solutionCordran5betamethasone, clobetasol, fluocinolone, fluticasone, halobetasolFinacea Foam7, Finacea Gel, MetroCream, MetroGel, MetroLotion, Soolantra12azelaic acid, topical metronidazoleflurandrenolide, hydrocortisone butyrate lipid cream, lotion5, Pandel5betamethasone, fluocinolone.

9 FluticasoneSoriluxcalcitriol, tazarotene, topical calcipotrieneTridesilon5alclometasone, desonide, triamcinoloneXolegelciclopirox gel, ciclopirox 1% shampoo, ketoconazole 2% cream, ketoconazole 2% foam, selenium lotion, sodium sulfacetamide 10% shampooSLEEP DISORDERS/SEDATIVESB elsomra8 DayvigoURINARY TRACT CONDITIONSP rocysbi4 CystagonStart date of change *,** drug classMedications that will be excluded from coverageAdditional informationJanuary 1, 2021 SKIN CONDITIONSR osadan Kitsazelaic acid, topical metronidazoleGeneric medications start with a lowercase letter and brand name medications start with a capital PRESCRIPTION drug lists tart date of change *,** drug classMedications moving to preferred brandJune 22, 2021 PAIN RELIEF AND INFLAMMATORY DISEASER editrexMay 15, 2021 EYE CONDITIONSE ysuvisGASTROINTESTINAL/HEARTBURNS utabJanuary 1, 2021 AIDS/HIVJ ulucaDIABETESB aqsimiGASTROINTESTINAL/HEARTBURNP ancreazeINFECTIONSE pclusa, HarvoniPAIN RELIEF AND INFLAMMATORY DISEASEA jovy13, Emgality13, Talt zSEIZURE DISORDERSV impatURINARY TRACT CONDITIONSC ystagonStart date of change *,** drug classMedications becoming non-preferred brandGeneric and/or preferred brand alternativesJune 29, 2021 BLOOD PRESSURE/HEART MEDICATIONSO rladeyo1No preferred formulary drug alternativesJune 22, 2021 CANCERO rgovyx1 lupron DepotJune 15, 2021 GASTROINTESTINAL/HEARTBURNL ubiprostone 8 mcg, 24 mcg capsuleAmitizaJune 1, 2021 SKIN CONDITIONSW inlevi 1% creamGeneric products ( adapalene; tretinoin.)

10 Clindamycin-benzoyl peroxide)Wynzora creambetamethasone DP, fluocinolone, fluticasone, mometasone, trimacinolone, calcipotriene, calcipotriene-betamethasone DPURINARY TRACT CONDITIONSV esicare LS 5 mg/5 mL suspensionoxybutynin chloride, oxybutynin chloride ER, darifenacin ER, solifenacin, tolterodine, tolterodine ER, tropsiumMay 2, 2021 PAIN RELIEF AND INFLAMMATORY DISEASEQ dolotramadolMay 1, 2021 SKIN PREPSI mpeklotopical betamethasone dipropionate (augmented) , clobetasol propionate , halobetasol propionate , fluocinolide 18, 2021 HORMONAL AGENTSA lkindi Sprinklehydrocortisone 5mg tabletMarch 28, 2021 BLOOD PRESSURE/HEART MEDICATIONSC onjupriamlodipine, felodipine, nifedipine, nicardipineJanuary 1, 2021 AIDS/HIVI ntelence1 Talk to your doctor about other alternativesERECTILE DYSFUNCTIONC averject Impulse SyringeMUSEHORMONAL AGENTSU nithroid 75mcg tabletlevothyroxineINFECTIONSK itabis Pak1tobramycin pak 300mg/5mlSEIZURE DISORDERSL yrica 20mg/ml oral solutionpregabalin 20mg/ml oral solutionSUBSTANCE ABUSEB unavailbuprenorphine/naloxone film or sublingual tablet.