Cigna Healthcare Standard 4-Tier Prescription Drug List

916152 u Standard 4-Tier Specialty 09/25 © 2025 Cigna Healthcare. Cigna Healthcare Standard 4-Tier Prescription Drug List Coverage as of January 1, 2026

* Drug list originally created: 01/01/2004 Last updated: 09/01/2025, for changes starting 01/01/2026 Next planned update: 04/01/2026, for changes starting 07/01/2026 What's Inside? Page About this drug list 3 How to read this drug list 3 How to find your medication 5 List of medications 6 Frequently Asked Questions (FAQs) 28 Exclusions and limitations for coverage 32 View your drug list online, 24/7 This document was last updated on 09/01/2025.* • You can use the Price a Medication tool on the myCigna® App1 or myCigna.com® to see the most up-to-date list of the medications your plan covers. • You can also see a pdf of this document on Cigna.com/PDL. Click on the dropdown next to "Drug Lists for Employer Plans." Scroll down until you see Cigna Standard Prescription Drug List; then click on the 4-Tier (all specialty medications covered on Tier 4) [PDF]. Questions? • By phone: Call the toll-free number on your Cigna Healthcare® ID card. We’re here 24/7/365. • myCigna.com: Click to Chat - Monday-Friday, 9:00 am-8:00 pm EST.

3 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 January 1, 2026. Medications are listed in alphabetical order (A-Z) by the condition they treat. The drug list is updated often; so, not all of the medications your plan covers may be listed here. Also, your plan may not cover all of these medications. Log in to the myCigna App or myCigna.com to see which medications your plan covers. How to read this drug list Use the table below to understand how medications are covered on the Cigna Healthcare Standard 4-Tier Prescription Drug List.* BLOOD PRESSURE/HEART MEDICATIONS Medication Tier Notes amlodipine 1 amlodipine-benazepril 1 amlodipine-olmesartan 1 QL amlodipine-valsartan 1 atenolol 1 bisoprolol-hctz 1 CALAN SR 3 CAMZYOS 3 SP, PA, QL candesartan 1 cartia xt 1 carvedilol 1 carvedilol er 1 QL CATAPRES-TTS 1 3 CATAPRES-TTS 2 3 CATAPRES-TTS 3 3 clonidine patch, tablet 1 CORLANOR ORAL SOLUTION 2 SP, PA CORLANOR TABLET 2 PA dilt xr 1 diltiazem tablet 1 diltiazem 12hr er 1 diltiazem 24hr er 1 diltiazem 24hr er (cd) 1 diltiazem 24hr er (la) 1 QL diltiazem 24hr er (xr) 1 DIOVAN 3 ST DIOVAN HCT 3 ST * This table is just an example. It may not show how these medications are currently covered on this drug list. Medications are grouped by the condition they treat Medications that may have extra coverage rules (requirements) have letters (acronyms) listed next to them in the Notes column Medications are listed in alphabetical order (A-Z) within each column Brand-name medications are in all CAPITAL letters Generic medications are in all lowercase letters Tier (cost-share level) gives you an idea of how much you may pay for a medication Specialty medications have SP listed next to them in the Notes column

4 PA Prior 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 you meet the medication's coverage rules (requirements). QL Quantity Limit* – Your plan will only cover so much of this medication at one time. If your doctor wants you to fill more than what’s allowed, your doctor’s office can ask us to cover more. ST Step Therapy* – This is a high-cost medication that has a lower-cost alternative(s) that treats the same condition. Your plan won’t cover this medication until you try at least one preferred medication first (typically a generic or preferred brand) and can show that it didn’t work for you. If your doctor feels a preferred medication isn’t right for you, your doctor’s office can ask us to cover the higher-cost medication. AGE Age Requirement* – Your plan will only cover this medication 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 use the medication, your doctor’s office can ask us to cover it. SP This is a specialty medication, which is used to treat a rare and/or complex medical condition. Some plans have extra coverage rules (requirements) for specialty medications. For example, some may only cover up to a 30-day supply and/or require you to fill it at a preferred specialty pharmacy to be covered. 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. Tiers We put covered medications into tiers (or cost-share levels). Typically, the higher the tier, the higher the price you’ll pay for the medication. * Not all plans have extra coverage rules (requirements) on medications. Log in to the myCigna App or myCigna.com, or check your plan materials, to see if yours does. Letters (acronyms) in the Notes column In this drug list, some medications have letters (acronyms) next to them in the Notes column. Here’s what they mean. Tier 1 Generics. These medications are covered at your plan’s lowest cost-share. Generics work in the same way and provide the same clinical benefits as their brand-name versions – and typically cost much less.3 $ Tier 2 Preferred Brands. These medications typically have one or more lower-cost generic that treats the same condition. $$ Tier 3 Non-Preferred Brands. These medications are covered at your plan’s highest cost-share. Non-preferred brands typically have a generic and/or preferred brand alternative(s) that treats the same condition. $$$ Tier 4 Specialty. These medications are covered at your plan’s highest cost-share. This tier includes both injectable and oral (those you take by mouth) specialty medications. $$$$

5 How to find your medication Medications are listed in alphabetical order (A-Z) by condition. Conditions are also listed in alphabetical order (A-Z). To see which page your medication is on, find your condition in the table below. Then, go to the page listed next to it to see which medications are covered. Condition Page AIDS/HIV 6 ALLERGY/NASAL SPRAYS 6 ALZHEIMER’S DISEASE 6 ANXIETY/DEPRESSION/BIPOLAR DISORDER 6, 7 ASTHMA/COPD/RESPIRATORY 7, 8 ATTENTION DEFICIT HYPERACTIVITY DISORDER 8 BLOOD MODIFIERS/BLEEDING DISORDERS 8, 9 BLOOD PRESSURE/HEART MEDICATIONS 9 BLOOD THINNERS/ANTI-CLOTTING 10 CANCER 10, 11 CHOLESTEROL MEDICATIONS 11 CONTRACEPTION PRODUCTS 11-14 COUGH/COLD MEDICATIONS 14 DENTAL PRODUCTS 14 DIABETES 14-16 DIURETICS 16 EAR MEDICATIONS 16 ERECTILE DYSFUNCTION 16 EYE CONDITIONS 16, 17 FEMININE PRODUCTS 17 Condition Page GASTROINTESTINAL/HEARTBURN 17, 18 HORMONAL AGENTS 18, 19 INFECTIONS 19, 20 INFERTILITY 20 MISCELLANEOUS 20, 21 MULTIPLE SCLEROSIS 21 NUTRITIONAL/DIETARY 21, 22 OSTEOPOROSIS PRODUCTS 22 PAIN RELIEF AND INFLAMMATORY DISEASE 22, 23 PARKINSON’S DISEASE 23, 24 SCHIZOPHRENIA/ANTI-PSYCHOTICS 24 SEIZURE DISORDERS 24 SKIN CONDITIONS 24, 25 SLEEP DISORDERS/SEDATIVES 25 SMOKING CESSATION 26 SUBSTANCE ABUSE 26 TRANSPLANT MEDICATIONS 26 URINARY TRACT CONDITIONS 26 VACCINES 26, 27 VITAMINS 27 WEIGHT MANAGEMENT 27 PPACA Health care reform under the Patient Protection and Affordable Care Act (PPACA) requires plans to cover the full cost of this preventive medication or product. This means you don't have to pay anything – not even a copay, coinsurance or deductible. OC Plans can choose to cover certain medications, products and/or drug classes that aren’t typically covered. If a medication has OC next to it, log in to the myCigna App or myCigna.com to see if your plan covers it. Letters (acronyms) in the Notes column (cont.)

6 Cigna Healthcare Standard 4-Tier Prescription Drug List Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement AIDS/HIV Medication Tier Notes APRETUDE 4 SP, PA, PPACA BIKTARVY 4 SP, QL CABENUVA 4 SP, PA, OC CIMDUO 4 SP, PA darunavir 4 SP DESCOVY 120-15 MG TABLET 4 SP DESCOVY 200-25 MG TABLET 4 SP, PPACA DOVATO 4 SP, QL efavirenz-emtricitabine-tenofovir 4 SP, QL emtricitabine-tenofovir 200 mg-300 mg tablet 4 SP, PPACA GENVOYA 4 SP, QL ISENTRESS HD 4 SP, PA JULUCA 4 SP, QL ODEFSEY 4 SP, PA, QL PIFELTRO 4 SP, PA PREZCOBIX 4 SP, PA PREZISTA 100 MG/ML ORAL SUSPENSION; 75 MG, 150 MG TABLET 4 SP ritonavir 4 SP RUKOBIA 4 SP, PA, QL STRIBILD 4 SP, PA, QL SYMTUZA 4 SP, QL tenofovir 4 SP, PA TIVICAY 4 SP TRIUMEQ 4 SP, QL TRIUMEQ PD 4 SP, QL ALLERGY/NASAL SPRAYS Medication Tier Notes azelastine 0.1% (137 mcg) spray 1 azelastine-fluticasone 1 cromolyn oral concentrate 1 desloratadine 1 QL ALLERGY/NASAL SPRAYS (cont.) Medication Tier Notes epinephrine 0.15 mg, 0.3 mg auto- injector (by Mylan SP-Viatris, Teva USA); nasal solution 1 QL fluticasone spray 1 GRASTEK 2 PA, QL hydroxyzine oral solution, syrup, tablet 1 hydroxyzine pamoate 1 ipratropium spray 1 levocetirizine 1 mometasone spray 1 QL NEFFY 2 QL ODACTRA 3 PA, QL olopatadine spray 1 ORALAIR 2 PA, QL promethazine oral solution, syrup, tablet 1 RAGWITEK 3 PA, QL ALZHEIMER’S DISEASE Medication Tier Notes ADLARITY 2 PA, QL donepezil 1 EXELON 3 memantine 1 memantine er 1 QL NAMENDA 5-10 MG TITRATION PACK 2 pyridostigmine oral solution; 60 mg tablet 1 pyridostigmine er 180 mg tablet 1 rivastigmine 1 ANXIETY/DEPRESSION/BIPOLAR DISORDER2 Medication Tier Notes alprazolam 1 amitriptyline 1

7 Cigna Healthcare Standard 4-Tier Prescription Drug List Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement ANXIETY/DEPRESSION/BIPOLAR DISORDER (cont.)2 Medication Tier Notes AUVELITY 2 QL, ST bupropion sr 1 QL bupropion xl 150 mg, 300 mg tablet 1 QL buspirone 1 citalopram oral solution, tablet 1 QL clomipramine 1 desvenlafaxine succinate er 1 QL duloxetine 1 QL EMSAM 3 QL escitalopram 1 QL fluoxetine 1 QL fluvoxamine 1 QL fluvoxamine er 1 QL lorazepam oral concentrate, tablet 1 mirtazapine 1 NUPLAZID 4 SP, PA paroxetine 1 QL paroxetine er 1 QL sertraline 1 QL trazodone 1 TRINTELLIX 2 QL venlafaxine hcl er 1 QL vilazodone 1 QL ZURZUVAE 4 SP, PA, QL ASTHMA/COPD/RESPIRATORY Medication Tier Notes ADEMPAS 4 SP, PA ADVAIR HFA 2 QL AIRSUPRA 2 QL albuterol 1 albuterol hfa 1 QL ASTHMA/COPD/RESPIRATORY (cont.) Medication Tier Notes ALYFTREK 4 SP, PA, QL ambrisentan 4 SP, PA ANORO ELLIPTA 2 QL ARNUITY ELLIPTA 2 ASMANEX, ASMANEX HFA 2 QL ATROVENT HFA 2 QL BREO ELLIPTA 2 QL breyna 1 QL BREZTRI AEROSPHERE 2 QL BRONCHITOL 4 SP, PA budesonide inhalation suspension 1 QL budesonide-formoterol 1 QL COMBIVENT RESPIMAT 2 QL DULERA 2 QL FASENRA PEN 4 SP, PA INCRUSE ELLIPTA 2 KALYDECO 4 SP, PA, QL montelukast 1 NUCALA AUTO-INJECTOR, SYRINGE 4 SP, PA OFEV 4 SP, PA OPSUMIT 4 SP, PA OPSYNVI 4 SP, PA, QL ORENITRAM ER 4 SP, PA ORENITRAM TITRATION KIT 4 SP, PA, QL PULMOZYME 4 SP, PA QVAR REDIHALER 2 SPIRIVA RESPIMAT 2 QL STIOLTO RESPIMAT 2 QL STRIVERDI RESPIMAT 2 QL SYMDEKO 4 SP, PA, QL TEZSPIRE 4 SP, PA, QL

8 Cigna Healthcare Standard 4-Tier Prescription Drug List Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement ASTHMA/COPD/RESPIRATORY (cont.) Medication Tier Notes TRACLEER 32 MG TABLET FOR SUSPENSION 4 SP, PA TRELEGY ELLIPTA 2 QL TRIKAFTA 4 SP, PA, QL TYVASO DPI 4 SP, PA TYVASO 4 SP, PA UPTRAVI TABLET, TITRATION PACK 4 SP, PA VIJOICE 4 SP, PA, QL wixela inhub 1 QL XOLAIR 4 SP, PA ATTENTION DEFICIT HYPERACTIVITY DISORDER2 Medication Tier Notes ADZENYS XR-ODT 3 PA, QL atomoxetine 1 QL AZSTARYS 3 PA, QL, ST DAYTRANA 3 PA, QL dexmethylphenidate er 1 PA, QL dextroamphetamine-amphetamine 1 PA dextroamphetamine-amphetamine er 1 PA, QL DYANAVEL XR 3 PA, QL EVEKEO ODT 3 PA guanfacine er 1 lisdexamfetamine 1 PA, QL methylphenidate 1 PA, QL methylphenidate er (cd) 1 PA, QL methylphenidate er (la) 1 PA, QL methylphenidate er capsule; 10 mg, 18 mg, 20 mg, 27 mg, 36 mg, 54 mg, 72 mg tablet 1 PA, QL MYDAYIS 3 PA, QL QUILLICHEW ER 3 PA, QL QUILLIVANT XR 3 PA, QL XELSTRYM 3 PA, QL BLOOD MODIFIERS/BLEEDING DISORDERS Medication Tier Notes ADVATE 4 SP, PA, OC ADYNOVATE 4 SP, PA, OC AFSTYLA 4 SP, PA, OC ALTUVIIIO 4 SP, PA, OC aminocaproic acid oral solution, tablet 4 SP ARANESP 4 SP, PA, OC DOPTELET 4 SP, PA DROXIA 2 ELOCTATE 4 SP, PA, OC EMPAVELI 4 SP, PA ESPEROCT 4 SP, PA, OC FABHALTA 4 SP, PA, QL FULPHILA 4 SP, PA GRANIX 4 SP, PA HEMLIBRA 4 SP, PA HYMPAVZI PEN 4 SP, PA JIVI 4 SP, PA, OC KOGENATE FS 4 SP, PA, OC KOVALTRY 4 SP, PA, OC LEUKINE 4 SP NEULASTA 4 SP, PA NEULASTA ONPRO 4 SP, PA, OC NEUPOGEN 4 SP, PA NIVESTYM 4 SP NOVOEIGHT 4 SP, PA, OC NYVEPRIA 4 SP, PA PROCRIT 4 SP, PA, OC RETACRIT 4 SP, PA, OC STIMUFEND 4 SP, PA TAVALISSE 4 SP, PA TAVNEOS 4 SP, PA, QL tranexamic acid tablet 4 SP UDENYCA AUTO-INJECTOR, SYRINGE 4 SP, PA

9 Cigna Healthcare Standard 4-Tier Prescription Drug List Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement BLOOD MODIFIERS/BLEEDING DISORDERS (cont.) Medication Tier Notes UDENYCA ONBODY 4 SP, PA, OC VOYDEYA 4 SP, PA, QL WILATE 4 SP, PA, OC XYNTHA 4 SP, PA, OC XYNTHA SOLOFUSE 4 SP, PA, OC ZARXIO 4 SP ZIEXTENZO 4 SP, PA BLOOD PRESSURE/HEART MEDICATIONS Medication Tier Notes amlodipine 1 amlodipine-benazepril 1 amlodipine-olmesartan 1 QL amlodipine-valsartan 1 atenolol 1 bisoprolol 5 mg, 10 mg tablet 1 bisoprolol-hctz 1 CAMZYOS 4 SP, PA, QL candesartan 1 carvedilol 1 carvedilol er 1 QL clonidine patch, tablet 1 CORLANOR ORAL SOLUTION 4 SP, PA diltiazem 24hr er (cd) 1 dofetilide 1 QL droxidopa 4 SP enalapril 1 ENTRESTO SPRINKLE 2 flecainide 1 guanfacine 1 hydralazine tablet 1 irbesartan 1 labetalol 100 mg, 200 mg, 300 mg tablet 1 lisinopril 1 BLOOD PRESSURE/HEART MEDICATIONS (cont.) Medication Tier Notes lisinopril-hctz 1 losartan 1 losartan-hctz 1 metoprolol tablet 1 metoprolol er 1 metyrosine 1 PA midodrine 1 minoxidil tablet 1 MULTAQ 2 nadolol 1 nebivolol 1 QL nifedipine er 1 NITROSTAT 3 NORLIQVA 2 PA, QL olmesartan 1 QL olmesartan-amlodipine-hctz 1 olmesartan-hctz 1 QL ORLADEYO 4 SP, PA, QL prazosin 1 propranolol solution, tablet 1 propranolol er 1 ranolazine er 1 QL TAKHZYRO 4 SP, PA TEKTURNA HCT 2 telmisartan 1 QL telmisartan-hctz 1 QL VALSARTAN ORAL SOLUTION 3 ST valsartan 1 valsartan-hctz 1 verapamil er 1 verapamil sr 1 VERQUVO 2 PA, QL ZESTORETIC 3 ST

10 Cigna Healthcare Standard 4-Tier Prescription Drug List Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement BLOOD THINNERS/ANTI-CLOTTING Medication Tier Notes clopidogrel 1 dabigatran 1 ELIQUIS 2 enoxaparin 4 SP, QL fondaparinux 4 SP, QL FRAGMIN 4 SP, QL prasugrel 1 warfarin 1 XARELTO 2 ZONTIVITY 3 CANCER Medication Tier Notes abirtega 1 PA AKEEGA 4 SP, PA, QL ALECENSA 4 SP, PA, QL ALUNBRIG 4 SP, PA, QL anastrozole 1 PPACA AYVAKIT 4 SP, PA, QL BOSULIF 4 SP, PA, QL BRUKINSA CAPSULE 4 SP, PA, QL CABOMETYX 4 SP, PA CALQUENCE 4 SP, PA capecitabine 4 SP, PA COMETRIQ 4 SP, PA, QL COTELLIC 4 SP, PA DANZITEN 4 SP, PA ERIVEDGE 4 SP, PA ERLEADA 4 SP, PA exemestane 1 PPACA FRUZAQLA 4 SP, PA, QL GAVRETO 4 SP, PA, QL GLEOSTINE 2 hydroxyurea 1 CANCER (cont.) Medication Tier Notes IBRANCE 4 SP, PA, QL imatinib 4 SP, QL IMBRUVICA 4 SP, PA, QL IMKELDI 4 SP, PA INLYTA 4 SP, PA JAKAFI 4 SP, PA, QL JYLAMVO 3 KISQALI 4 SP, PA, QL KOSELUGO 4 SP, PA, QL lenalidomide 4 SP, PA, QL LENVIMA 4 SP, PA letrozole 1 leucovorin tablet 1 LONSURF 4 SP, PA LORBRENA 4 SP, PA, QL LUMAKRAS 4 SP, PA, QL LUPRON DEPOT 7.5 MG KIT, 22.5 MG 3 MONTH KIT, 4 MONTH KIT, 45 MG 6 MONTH KIT 4 SP, PA, OC LYNPARZA 4 SP, PA, QL MEKINIST 4 SP, PA, QL mercaptopurine tablet 1 methotrexate tablet; 50 mg/2 ml, 250 mg/10 ml, 1 gram/40 ml vial 1 NERLYNX 4 SP, PA NINLARO 4 SP, PA, QL NUBEQA 4 SP, PA ODOMZO 4 SP, PA OGSIVEO 4 SP, PA, QL ORGOVYX 4 SP, PA ORSERDU 4 SP, PA, QL PHESGO 4 SP, PA, OC PIQRAY 4 SP, PA POMALYST 4 SP, PA, QL PURIXAN 4 SP

11 Cigna Healthcare Standard 4-Tier Prescription Drug List Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement CANCER (cont.) Medication Tier Notes RETEVMO 4 SP, PA, QL REVLIMID 4 SP, PA, QL ROZLYTREK 4 SP, PA RUBRACA 4 SP, PA, QL RYDAPT 4 SP, PA SCEMBLIX 4 SP, PA, QL STIVARGA 4 SP, PA, QL TABRECTA 4 SP, PA, QL TAFINLAR 4 SP, PA, QL TAGRISSO 4 SP, PA TALZENNA 4 SP, PA, QL tamoxifen 1 PPACA temozolomide 4 SP, PA TIBSOVO 4 SP, PA torpenz 4 SP, PA, QL TREXALL 2 TRUQAP 4 SP, PA, QL TUKYSA 4 SP, PA VANFLYTA 4 SP, PA, QL VENCLEXTA STARTING PACK, TABLET 4 SP, PA VERZENIO 4 SP, PA, QL VITRAKVI 4 SP, PA VIZIMPRO 4 SP, PA WELIREG 4 SP, PA, QL XALKORI 4 SP, PA, QL XATMEP 3 XOSPATA 4 SP, PA XTANDI 4 SP, PA ZEJULA 4 SP, PA, QL ZELBORAF 4 SP, PA CHOLESTEROL MEDICATIONS Medication Tier Notes atorvastatin 10 mg, 20 mg tablet 1 PPACA atorvastatin 40 mg, 80 mg tablet 1 CHOLESTEROL MEDICATIONS (cont.) Medication Tier Notes CADUET 3 QL colesevelam 1 DOJOLVI 4 SP, PA ezetimibe 1 fenofibrate 43 mg, 50 mg, 67 mg, 130 mg, 134 mg, 150 mg, 200 mg capsule; tablet 1 fluvastatin 1 PPACA fluvastatin er 1 PPACA icosapent ethyl 1 LIPOFEN 3 ST lovastatin 10 mg tablet 1 lovastatin 20 mg, 40 mg tablet 1 PPACA NEXLETOL 2 PA, QL NEXLIZET 2 PA, QL omega-3 acid ethyl esters 1 pitavastatin 1 QL, PPACA pravastatin 1 PPACA REPATHA PUSHTRONEX, SURECLICK, SYRINGE 2 rosuvastatin 5 mg, 10 mg tablet 1 QL, PPACA rosuvastatin 20 mg, 40 mg tablet 1 QL simvastatin 5 mg, 80 mg tablet 1 QL TRICOR 3 ST VASCEPA 2 PA CONTRACEPTION PRODUCTS Medication Tier Notes afirmelle 1 PPACA altavera 1 PPACA alyacen 1 PPACA amethia 1 PPACA amethyst 1 PPACA apri 1 PPACA aranelle 1 PPACA

12 Cigna Healthcare Standard 4-Tier Prescription Drug List Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement CONTRACEPTION PRODUCTS (cont.) Medication Tier Notes ashlyna 1 PPACA aubra 1 PPACA aubra eq 1 PPACA aurovela 1 PPACA aurovela fe 1 PPACA aurovela 24 fe 1 PPACA aviane 1 PPACA ayuna 1 PPACA azurette 1 PPACA balziva 1 PPACA blisovi fe 1 PPACA blisovi 24 fe 1 PPACA briellyn 1 PPACA camila 1 PPACA camrese 1 PPACA camrese lo 1 PPACA CAYA CONTOURED 2 PPACA caziant 1 PPACA charlotte 24 fe 1 PPACA chateal eq 1 PPACA cryselle 1 PPACA cyred 1 PPACA cyred eq 1 PPACA dasetta 1 PPACA daysee 1 PPACA deblitane 1 PPACA DEPO-PROVERA 3 PPACA DEPO-SUBQ PROVERA 104 SYRINGE 3 PPACA desogestrel-ethinyl estradiol 1 PPACA desogestrel-ethinyl estradiol ethinyl estradiol 1 PPACA dolishale 1 PPACA drospirenone-ethinyl estradiol 1 PPACA CONTRACEPTION PRODUCTS (cont.) Medication Tier Notes drospirenone-ethinyl estradiol- levomefolate 1 PPACA elinest 1 PPACA ELLA 3 PPACA eluryng 1 PPACA emzahh 1 PPACA enilloring 1 PPACA enpresse 1 PPACA enskyce 1 PPACA errin 1 PPACA estarylla 1 PPACA ethynodiol-ethinyl estradiol 1 PPACA etonogestrel-ethinyl estradiol 1 PPACA falmina 1 PPACA feirza 1 PPACA FEMCAP 2 PPACA finzala 1 PPACA galbriela 1 PPACA gemmily 1 PPACA hailey 1 PPACA hailey fe 1 PPACA hailey 24 fe 1 PPACA haloette 1 PPACA heather 1 PPACA iclevia 1 PPACA incassia 1 PPACA introvale 1 PPACA isibloom 1 PPACA jaimiess 1 PPACA jasmiel 1 PPACA jencycla 1 PPACA jolessa 1 PPACA joyeaux 1 PPACA

13 Cigna Healthcare Standard 4-Tier Prescription Drug List Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement CONTRACEPTION PRODUCTS (cont.) Medication Tier Notes juleber 1 PPACA junel 1 PPACA junel fe 1 PPACA junel fe 24 1 PPACA kaitlib fe 1 PPACA kalliga 1 PPACA kariva 1 PPACA kelnor 1-35 1 PPACA kelnor 1-50 1 PPACA kurvelo 1 PPACA KYLEENA 4 SP, PPACA larin 1 PPACA larin fe 1 PPACA larin 24 fe 1 PPACA layolis fe 3 PPACA leena 1 PPACA lessina 1 PPACA levonest 1 PPACA levonorgestrel-ethinyl estradiol 1 PPACA levonorgestrel-ethinyl estradiol ethinyl estradiol 1 PPACA levonorgestrel-ethinyl estradiol-fe bisglycinate 1 PPACA levora-28 1 PPACA LILETTA 4 SP, PPACA lojaimiess 1 PPACA loryna 1 PPACA low-ogestrel 1 PPACA lo-zumandimine 1 PPACA lutera 1 PPACA lyleq 1 PPACA lyza 1 PPACA marlissa 1 PPACA CONTRACEPTION PRODUCTS (cont.) Medication Tier Notes medroxyprogesterone syringe, vial 1 PPACA meleya 1 PPACA merzee 1 PPACA mibelas 24 fe 1 PPACA microgestin 1 PPACA microgestin fe 1 PPACA microgestin 24 fe 1 PPACA mili 1 PPACA minzoya 1 PPACA MIRENA 4 SP, PPACA MIUDELLA 4 SP, PPACA mono-linyah 1 PPACA necon 1 PPACA NEXPLANON 4 SP, PPACA nikki 1 PPACA nora-be 1 PPACA norelgestromin-ethinyl estradiol 1 PPACA norethindrone 0.35 mg tablet 1 PPACA norethindrone-ethinyl estradiol 1-0.02 mg, 1.5-0.03 mg (21) tablet 1 PPACA norethindrone-ethinyl estradiol-fe 1 PPACA norgestimate-ethinyl estradiol 1 PPACA nortrel 1 PPACA nylia 1 PPACA nymyo 1 PPACA ocella 1 PPACA orquidea 1 PPACA PARAGARD T 380-A 4 SP, PPACA philith 1 PPACA pimtrea 1 PPACA pirmella 1 PPACA portia 1 PPACA reclipsen 1 PPACA

14 Cigna Healthcare Standard 4-Tier Prescription Drug List Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement CONTRACEPTION PRODUCTS (cont.) Medication Tier Notes rivelsa 1 PPACA rosyrah 1 PPACA setlakin 1 PPACA sharobel 1 PPACA simliya 1 PPACA simpesse 1 PPACA SKYLA 4 SP, PPACA sprintec 1 PPACA sronyx 1 PPACA syeda 1 PPACA tarina fe 1 PPACA tarina 24 fe 1 PPACA tarina fe 1-20 eq 1 PPACA taysofy 1 PPACA tilia fe 1 PPACA tri-estarylla 1 PPACA tri-legest fe 1 PPACA tri-linyah 1 PPACA tri-lo-estarylla 1 PPACA tri-lo-marzia 1 PPACA tri-lo-mili 1 PPACA tri-lo-sprintec 1 PPACA tri-mili 1 PPACA tri-nymyo 1 PPACA tri-sprintec 1 PPACA tri-vylibra 1 PPACA tri-vylibra lo 1 PPACA tulana 1 PPACA turqoz 1 PPACA valtya 1 PPACA velivet 1 PPACA vestura 1 PPACA vienva 1 PPACA viorele 1 PPACA volnea 1 PPACA CONTRACEPTION PRODUCTS (cont.) Medication Tier Notes vyfemla 1 PPACA vylibra 1 PPACA wera 1 PPACA WIDE SEAL DIAPHRAGM 3 PPACA wymzya fe 1 PPACA xarah fe 1 PPACA xelria fe 1 PPACA xulane 1 PPACA zafemy 1 PPACA zarah 1 PPACA zovia 1-35 1 PPACA zumandimine 1 PPACA COUGH/COLD MEDICATIONS Medication Tier Notes brompheniramine-pseudoephedrine- dm 1 hydrocodone-chlorpheniramine er 1 PA hydrocodone-homatropine 1 PA, QL promethazine-dm 1 DENTAL PRODUCTS Medication Tier Notes doxycycline hyclate 20 mg tablet 1 FLORIVA 0.25 MG/ML DROPS 3 PPACA, OC periogard 1 PREVIDENT 5000 SENSITIVE 3 PREVIDENT KIDS 3 sodium fluoride 5000 dry mouth 1 triamcinolone 0.1% paste 1 DIABETES Medication Tier Notes ACCU-CHEK FASTCLIX LANCING DEVICE 1 ACCU-CHEK CONTROL SOLUTION 1 ACCU-CHEK SOFTCLIX LANCET KIT 1

15 Cigna Healthcare Standard 4-Tier Prescription Drug List Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement DIABETES (cont.) Medication Tier Notes BAQSIMI 2 QL BD INSULIN PEN NEEDLE 1 BD NANO 2 PEN NEEDLE 1 BD SAFETYGLIDE INSULIN SYRINGE 1 BD ULTRA-FINE PEN NEEDLE 1 BYDUREON BCISE 2 PA, QL CEQUR SIMPLICITY 2 CEQUR SIMPLICITY INSERTER 2 CYCLOSET 3 DEXCOM G6 2 PA, QL DEXCOM G7 2 PA, QL DROPLET GENTEEL LANCING DEVICE 1 FARXIGA 2 QL, ST FREESTYLE INSULINX TEST STRIP 2 FREESTYLE LIBRE 2 READER, SENSOR 2 PA, QL FREESTYLE LIBRE 2 PLUS SENSOR 2 PA, QL FREESTYLE LIBRE 3 READER, SENSOR 2 PA, QL FREESTYLE LIBRE 3 PLUS SENSOR 2 PA, QL FREESTYLE LIBRE 14 DAY READER, SENSOR 2 PA, QL FREESTYLE LITE TEST STRIP 2 FREESTYLE TEST STRIP 2 glimepiride 1 mg, 2 mg, 4 mg tablet 1 GLIMEPIRIDE 3 MG TABLET 3 glipizide 5 mg, 10 mg tablet 1 glipizide xl 1 GLYXAMBI 2 QL, ST GUARDIAN RT REPLACE CHARGER, TEST PLUG 1 GVOKE 2 QL HUMALOG 2 QL HUMULIN N, HUMULIN R, HUMULIN 70/30 2 QL INPEN (FOR HUMALOG, NOVOLOG, FIASP) 1 INSULIN GLARGINE-YFGN 2 QL DIABETES (cont.) Medication Tier Notes INSULIN LISPRO 2 QL JANUMET 2 QL, ST JANUMET XR 2 QL, ST JANUVIA 2 QL, ST JARDIANCE 2 QL, ST LANTUS 2 QL LYUMJEV 2 QL metformin oral solution; 500 mg, 750 mg, 850 mg, 1,000 mg tablet 1 metformin er 500 mg, 750 mg tablet 1 MICROLET 2 LANCING DEVICE 1 MICROLET NEXT LANCING DEVICE 1 MOUNJARO 2 PA, QL OMNIPOD 5 G6-LIBRE 2 PLUS 2 QL OMNIPOD 5 G6-G7 INTRO KIT, PODS (GEN5) 2 QL OMNIPOD 5 INTRO (G6-LIBRE 2 PLUS) 2 QL OMNIPOD DASH INTRO KIT, PODS (GEN 4) 2 QL OZEMPIC 2 PA, QL PARADIGM RESERVOIR 1 pioglitazone 1 PRECISION XTRA TEST STRIP 2 RYBELSUS 2 PA, QL SEMGLEE (YFGN) 2 QL SOLIQUA 100-33 2 SYMLINPEN 2 SYNJARDY 2 QL, ST SYNJARDY XR 2 QL, ST TOUJEO MAX SOLOSTAR 2 QL TOUJEO SOLOSTAR 2 QL TRESIBA 2 QL TRIJARDY XR 2 QL, ST TRUE METRIX GLUCOSE TEST STRIP 2 TRULICITY 2 PA, QL

16 Cigna Healthcare Standard 4-Tier Prescription Drug List Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement DIABETES (cont.) Medication Tier Notes TWIIST REFILL, REFILL KIT, STARTER KIT 2 QL V-GO 2 XIGDUO XR 2 QL, ST DIURETICS Medication Tier Notes acetazolamide tablet 1 bumetanide tablet 1 CAROSPIR 2 PA chlorthalidone 1 DIURIL 2 eplerenone 1 furosemide oral solution, tablet 1 hydrochlorothiazide 1 KERENDIA 2 PA, QL spironolactone 1 tolvaptan 4 SP, PA EAR MEDICATIONS Medication Tier Notes ciprofloxacin-dexamethasone 1 CORTISPORIN-TC 3 DERMOTIC 3 neomycin-polymyxin-hc otic solution, suspension 1 ofloxacin 0.3% ear drops 1 OTOVEL 3 ERECTILE DYSFUNCTION Medication Tier Notes CAVERJECT 3 PA_AGE, QL, OC CIALIS 3 QL, ST, OC EDEX 3 PA_AGE, QL, OC MUSE 2 PA_AGE, QL, OC ERECTILE DYSFUNCTION (cont.) Medication Tier Notes sildenafil 25 mg, 50 mg, 100 mg tablet 1 QL, OC STENDRA 3 QL, ST, OC tadalafil 1 QL, OC vardenafil 1 QL, OC VIAGRA 3 QL, ST, OC EYE CONDITIONS Medication Tier Notes AZASITE 2 BESIVANCE 2 BETOPTIC S 3 bimatoprost drops 1 QL brimonidine drops 1 brimonidine-timolol 1 brinzolamide 1 bromfenac drops 1 CEQUA 2 ciprofloxacin drops 1 cyclosporine eye emulsion 1 CYSTARAN 4 SP, PA, QL difluprednate 1 dorzolamide-timolol 1 erythromycin eye ointment 1 EYSUVIS 2 QL fluorometholone 1 ILEVRO 3 INVELTYS 3 ST latanoprost 1 LOTEMAX 0.5% EYE OINTMENT 3 ST LOTEMAX SM 3 ST loteprednol 1 MIEBO 2 QL moxifloxacin drops 1 neomycin-polymyxin-dexamethasone 1 ofloxacin eye drops 1

17 Cigna Healthcare Standard 4-Tier Prescription Drug List Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement EYE CONDITIONS (cont.) Medication Tier Notes OXERVATE 4 SP, PA polymyxin b-trimethoprim 1 prednisolone eye drops 1 PROLENSA 3 RESTASIS EYE EMULSION 2 RHOPRESSA 3 ROCKLATAN 3 SIMBRINZA 3 timolol drops, gel-solution 1 TOBRADEX 3 tobramycin drops 1 tobramycin-dexamethasone 1 travoprost 1 TYRVAYA 2 QL XDEMVY 4 SP, PA, QL XIIDRA 2 ZIRGAN 3 FEMININE PRODUCTS Medication Tier Notes fem ph 1 GYNAZOLE 1 1 miconazole 3 vaginal suppository 1 terconazole 1 TRIMO-SAN 3 GASTROINTESTINAL/HEARTBURN Medication Tier Notes alosetron 4 SP aprepitant 1 QL APRISO 3 balsalazide 1 BONJESTA 3 CHOLBAM 4 SP, PA dexlansoprazole dr 1 QL dicyclomine capsule, oral solution; 20 mg tablet 1 GASTROINTESTINAL/HEARTBURN (cont.) Medication Tier Notes doxylamine-pyridoxine 1 QL ENTYVIO VIAL 4 SP, PA, OC esomeprazole 20 mg, 40 mg capsule; packet 1 QL famotidine oral suspension; 20 mg, 40 mg tablet 1 GATTEX 4 SP, PA gavilyte-c 1 PPACA gavilyte-g 1 PPACA gavilyte-n 1 PPACA hydrocortisone enema, suppository 1 IQIRVO 4 SP, PA lansoprazole 1 QL LINZESS 2 LITHOSTAT 2 lubiprostone 1 mesalamine 1 mesalamine dr 1 metoclopramide oral solution, tablet 1 MOTOFEN 3 MOVANTIK 2 PA OCALIVA 4 SP, PA OLPRUVA 4 SP, PA omeprazole 10 mg, 20 mg, 40 mg capsule 1 QL ondansetron 1 ondansetron odt 4 mg, 8 mg tablet 1 PANCREAZE 2 pantoprazole packet, tablet 1 QL peg 3350-electrolyte 1 PPACA peg-prep 1 PPACA PHEBURANE 4 SP, PA, QL rabeprazole tablet 1 QL RECTIV 3 RELISTOR SYRINGE, VIAL 3 PA REZDIFFRA 4 SP, PA, QL

18 Cigna Healthcare Standard 4-Tier Prescription Drug List Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement GASTROINTESTINAL/HEARTBURN (cont.) Medication Tier Notes SANCUSO 3 PA, QL scopolamine 1 SFROWASA 3 sodium sulfate-potassium sulfate- magnesium sulfate 1 PPACA SUCRAID 4 SP, PA sucralfate 1 SYMPROIC 2 PA TRULANCE 2 VARUBI 3 PA, QL VIBERZI 2 VIOKACE 3 VOQUEZNA TABLET 3 PA, QL VOWST 4 SP, PA, QL ZENPEP 2 HORMONAL AGENTS Medication Tier Notes ANGELIQ 3 BIJUVA 3 budesonide dr 1 budesonide ec 1 cetrorelix 4 SP, PA, OC CETROTIDE 4 SP, PA, OC COMBIPATCH 2 CRINONE 4% GEL 3 PA CYTOMEL 3 DEPO-TESTOSTERONE 3 desmopressin ampule, vial 4 SP DUAVEE 2 EGRIFTA SV 4 SP, PA estradiol cream, gel packet, gel pump, patch, tablet, vaginal insert 1 QL EVAMIST 3 FENSOLVI 4 SP, PA, OC fyremadel 4 SP, PA, OC HORMONAL AGENTS (cont.) Medication Tier Notes ganirelix 4 SP, PA, OC GENOTROPIN 4 SP, PA INTRAROSA 3 QL levoxyl 1 liothyronine tablet 1 LUPRON DEPOT 3.75 MG, 11.25 MG KIT 4 SP, PA, OC LUPRON DEPOT-PED 4 SP, PA, OC lyllana 1 QL medroxyprogesterone tablet 1 MENOSTAR 3 QL methylprednisolone dosepack, tablet 1 mimvey 1 MYFEMBREE 2 PA, QL NGENLA 4 SP, PA norethindrone 5 mg tablet 1 OMNITROPE 4 SP, PA ORIAHNN 2 PA, QL ORILISSA 2 PA, QL OSPHENA 3 QL prednisolone oral solution, syrup, tablet 1 prednisone 1 PREMARIN VAGINAl CREAM, TABLET 2 PREMPHASE 2 PREMPRO 2 progesterone capsule 1 RAYALDEE 3 SANDOSTATIN LAR DEPOT 4 SP, PA, OC SOMATULINE DEPOT 4 SP, PA, OC SOMAVERT 4 SP, PA testosterone gel, gel pump, packet 1 PA, QL testosterone cypionate 200 mg/ml, 1,000 mg/10 ml, 2,000 mg/10 ml, 6,000 mg /30 ML 1 thyroid 1

19 Cigna Healthcare Standard 4-Tier Prescription Drug List Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement HORMONAL AGENTS (cont.) Medication Tier Notes UCERIS TABLET 3 PA, QL unithroid 3 XYOSTED 3 PA, QL yuvafem 1 QL INFECTIONS Medication Tier Notes acyclovir capsule, oral suspension, tablet 1 AEMCOLO 3 QL albendazole 1 amoxicillin 1 amoxicillin-clavulanate 1 ARIKAYCE 4 SP, PA atovaquone 1 atovaquone-proguanil 1 azithromycin packet, oral suspension, tablet 1 BARACLUDE ORAL SOLUTION 4 SP BAXDELA 450 MG TABLET 3 PA BEYFORTUS 3 PPACA CAYSTON 4 SP, PA, QL cefdinir 1 cefpodoxime 1 cefuroxime tablet 1 cephalexin 1 CIPRO ORAL SUSPENSION 2 ciprofloxacin oral suspension, tablet 1 clarithromycin 1 clindamycin capsule, oral solution, vaginal cream 1 CRESEMBA CAPSULE 3 PA DIFICID 3 QL doxycycline monohydrate 1 EMVERM 1 INFECTIONS (cont.) Medication Tier Notes entecavir 4 SP, QL EPCLUSA 4 SP, PA, QL erythromycin capsule, tablet 1 famciclovir 1 fluconazole oral suspension, tablet 1 flucytosine 1 fosfomycin 1 HARVONI 4 SP, PA, QL hydroxychloroquine 1 IMPAVIDO 3 PA itraconazole 1 KITABIS PAK 4 SP, PA, QL LAGEVRIO (EUA) 2 QL levofloxacin oral solution, tablet 1 LIKMEZ 3 PA LIVTENCITY 4 SP, PA, QL MACROBID 3 methenamine 1 metronidazole capsule; 250 mg, 500 mg tablet; vaginal gel 1 minocycline 1 mondoxyne nl 1 morgidox capsule 1 nitazoxanide 1 nitrofurantoin capsule; 25 mg/5 ml oral suspension 1 NUZYRA 150 MG TABLET 4 SP, PA, QL nystatin oral suspension, tablet 1 oseltamivir 1 QL PAXLOVID 2 QL PEGASYS 4 SP, PA penicillin v potassium 1 permethrin cream 1 posaconazole oral suspension, tablet 1

20 Cigna Healthcare Standard 4-Tier Prescription Drug List Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement INFECTIONS (cont.) Medication Tier Notes PREVYMIS PELLET PACKET, TABLET 4 SP PRIFTIN 3 pruradik 1 pyrimethamine 4 SP, PA SIVEXTRO TABLET 3 PA sulfamethoxazole-tmp oral suspension, tablet 1 terbinafine tablet 1 THALOMID 4 SP, PA TOBI PODHALER 4 SP, PA, QL tobramycin ampule 4 SP, PA, QL valacyclovir 1 valganciclovir 1 VALTREX 3 vancomycin capsule, oral solution 1 vandazole 1 VEMLIDY 4 SP VIVJOA 4 SP, PA VOSEVI 4 SP, PA, QL XENLETA TABLET 3 PA, QL XIFAXAN 2 QL XOFLUZA 3 QL ZEPATIER 4 SP, PA, QL ZITHROMAX PACKET, ORAL SUSPENSION, TABLET, TRI-PAK 3 ZYVOX ORAL SUSPENSION, TABLET 3 PA INFERTILITY Medication Tier Notes clomiphene 1 OC CRINONE 8% GEL 2 OC ENDOMETRIN 2 OC FOLLISTIM AQ 4 SP, PA, OC GONAL-F 4 SP, PA, OC INFERTILITY (cont.) Medication Tier Notes GONAL-F RFF REDI-JECT 4 SP, PA, OC MENOPUR 4 SP, PA, OC NOVAREL 4 SP, PA, OC OVIDREL 4 SP, PA, OC PREGNYL 4 SP, PA, OC PREGNYL 4 SP, PA, OC MISCELLANEOUS Medication Tier Notes acamprosate 1 ACCU-CHEK FASTCLIX LANCET DRUM 1 ADDYI 3 PA, QL, OC AUSTEDO 4 SP, PA AUSTEDO XR 4 SP, PA, QL AUSTEDO XR TITRATION KIT 4 SP, PA, QL CARBAGLU 4 SP CERDELGA 4 SP, PA cinacalcet 4 SP CINRYZE 4 SP, PA, OC deferasirox 4 SP deferiprone 4 SP, PA DROPLET LANCET 1 EVRYSDI 4 SP, PA FILSPARI 4 SP, PA, QL GALAFOLD 4 SP, PA HAEGARDA 4 SP, PA INGREZZA 4 SP, PA, QL MICROLET LANCET 1 MYALEPT 4 SP, PA NITYR 4 SP, PA NUEDEXTA 3 QL ONETOUCH DELICA PLUS LANCET 1 ONETOUCH ULTRASOFT 2 LANCET 1 ORFADIN 4 SP, PA

21 Cigna Healthcare Standard 4-Tier Prescription Drug List Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement MISCELLANEOUS (cont.) Medication Tier Notes PALYNZIQ 4 SP, PA POGO AUTOMATIC TEST CARTRIDGE 1 PRECISION XTRA B-KETONE STRIP 1 RADICAVA ORS 4 SP, PA, QL RUCONEST 4 SP, PA, OC sapropterin 4 SP, PA sodium chloride irrigation solution, inhalation vial 1 SPACE CHAMBER-LARGE MASK 2 QL STRENSIQ 4 SP, PA TECHLITE LANCET 1 TEGLUTIK 4 SP, PA TEGSEDI 4 SP, PA TIGLUTIK 4 SP, PA TRUEPLUS KETONE TEST STRIP 1 VEOZAH 3 QL VORTEX HOLDING CHAMBER 2 QL VORTEX VHC LADYBUG MASK 2 QL VORTEX VHC PEDIATRIC MASK 2 QL VOXZOGO 4 SP, PA VYLEESI 4 SP, PA, QL, OC VYNDAMAX 4 SP, PA, QL VYNDAQEL 4 SP, PA, QL VYVGART HYTRULO 1,000 MG-10,000 UNITS/5 ML 4 SP, PA MULTIPLE SCLEROSIS Medication Tier Notes AVONEX 4 SP, PA BAFIERTAM 4 SP, PA BETASERON 4 SP, PA dalfampridine er 4 SP, PA dimethyl 4 SP fingolimod 4 SP FIRDAPSE 4 SP, PA, QL MULTIPLE SCLEROSIS (cont.) Medication Tier Notes glatopa 4 SP KESIMPTA PEN 4 SP, PA MAVENCLAD 4 SP, PA MAYZENT 4 SP, PA PLEGRIDY 4 SP, PA REBIF 4 SP, PA REBIF REBIDOSE 4 SP, PA teriflunomide 4 SP VUMERITY 4 SP, PA NUTRITIONAL/DIETARY Medication Tier Notes ACCRUFER 3 OC AURYXIA 3 QL betaine 1 gram/scoop powder 4 SP calcitriol capsule, oral solution 1 OC cyanocobalamin 1 CYSTADANE 4 SP dodex 1 EFFER-K 10 MEQ, 20 MEQ TABLET 3 FLORIVA CHEWABLE TABLET 2 PPACA fluoride 1 PPACA, OC folic acid 1000 mcg, 1 mg tablet 1 lanthanum 1 LOKELMA 2 ludent fluoride 1 PPACA, OC mvc-fluoride 2 PPACA NEEVODHA 2 OC OB COMPLETE CAPLET 3 OC OB COMPLETE DHA, ONE, PETITE, PREMIER 2 POLY-VI-FLOR 2 PPACA potassium chloride oral solution, packet 1 PRENATE AM, CHEWABLE, ESSENTIAL 2 OC

22 Cigna Healthcare Standard 4-Tier Prescription Drug List Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement NUTRITIONAL/DIETARY (cont.) Medication Tier Notes PRENATE DHA, ELITE, ENHANCE, MINI, PIXIE, RESTORE, STAR 2 PRIMACARE 2 QUFLORA PEDIATRIC DROPS; 1 MG CHEWABLE TABLET 2 PPACA sevelamer 1 sodium fluoride chewable tablet, drops 1 PPACA, OC soluvita 1 PPACA, OC TRI-VI-FLOR 2 PPACA tri-vitamin with fluoride 1 PPACA VELPHORO 2 VELTASSA 2 VITAFOL CAPLET, GUMMIES, NANO, OB+DHA, ULTRA 2 VITAFOL-ONE 2 vitamin d2 1.25 mg (50,000 unit) 1 OC vitamins a,c,d and fluoride 0.25 mg/ml 1 PPACA OSTEOPOROSIS PRODUCTS Medication Tier Notes alendronate 1 BINOSTO 3 ST ibandronate tablet 1 raloxifene 1 PPACA teriparatide 4 SP, PA, QL PAIN RELIEF AND INFLAMMATORY DISEASE Medication Tier Notes acetaminophen-codeine 1 PA ACTEMRA ACTPEN, SYRINGE 4 SP, PA, QL ADALIMUMAB-ADBM (CF) 4 SP, PA, QL AIMOVIG 2 PA AJOVY 2 PA ARCALYST 4 SP, PA AVSOLA 4 SP, PA, OC PAIN RELIEF AND INFLAMMATORY DISEASE (cont.) Medication Tier Notes BELBUCA 2 QL BENLYSTA AUTO-INJECTOR, SYRINGE 4 SP, PA BIMZELX 4 SP, PA, QL buprenorphine patch 1 QL butalbital-acetaminophen-caffeine capsule, tablet 1 QL celecoxib 1 QL CIMZIA 4 SP, PA, QL colchicine 1 COSENTYX PEN, SYRINGE 4 SP, PA, QL cyclobenzaprine tablet 1 CYLTEZO (CF) 4 SP, PA, QL diclofenac 1% gel, tablet 1 QL DUPIXENT 4 SP, PA eletriptan 1 QL EMGALITY 2 PA ENBREL 4 SP, PA, QL ENSPRYNG 4 SP, PA febuxostat 1 QL fentanyl lozenge, patch, effervescent tablet 1 PA FLECTOR 2 PA, QL HUMIRA (by AbbVie) 4 SP, PA, QL hydrocodone-acetaminophen 1 PA hydromorphone oral solution, suppository, tablet 1 PA HYSINGLA ER 2 PA ibuprofen oral suspension; 300 mg, 400 mg, 600 mg, 800 mg tablet 1 ILARIS 4 SP, PA, OC ILUMYA 4 SP, PA, QL indomethacin 25 mg, 50 mg capsule; oral suspension, 50 mg suppository 1 INFLECTRA 4 SP, PA, OC INFLIXIMAB 4 SP, PA, OC

23 Cigna Healthcare Standard 4-Tier Prescription Drug List Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement PAIN RELIEF AND INFLAMMATORY DISEASE (cont.) Medication Tier Notes JOURNAVX 3 QL ketorolac syringe, tablet, vial 1 QL KEVZARA 4 SP, PA, QL KINERET 4 SP, PA, QL leflunomide 1 LICART 2 PA, QL lidocaine viscous 1 meloxicam tablet 1 metaxalone 400 mg, 800 mg tablet 1 MITIGARE 2 morphine er 1 PA nabumetone 1 NUCYNTA 2 PA NUCYNTA ER 3 PA NURTEC ODT 2 PA, QL OLUMIANT 4 SP, PA, QL OMVOH PEN, SYRINGE 4 SP, PA, QL ORENCIA CLICKJECT, SYRINGE 4 SP, PA, QL OTEZLA 4 SP, PA, QL OXAYDO 3 PA oxycodone ir capsule, oral concentrate, oral solution, ir tablet 1 PA PROCTOFOAM-HC 2 prolate 1 PA QULIPTA 2 PA, QL RASUVO 2 ST REMICADE 4 SP, PA, OC REYVOW 3 PA, QL RINVOQ 4 SP, PA, QL RINVOQ LQ 4 SP, PA, QL rizatriptan 1 QL ROXYBOND 3 PA SAVELLA 2 SELARSDI SYRINGE 4 SP, PA, QL PAIN RELIEF AND INFLAMMATORY DISEASE (cont.) Medication Tier Notes SILIQ 4 SP, PA, QL SIMLANDI (CF) 4 SP, PA, QL SIMPONI 50 MG/0.5 ML PEN INJECTOR, SYRINGE 4 SP, PA, QL SIMPONI 100 MG/ML PEN INJECTOR, SYRINGE 4 SP, PA, QL SIMPONI ARIA 4 SP, PA SKYRIZI ON-BODY, PEN, SYRINGE 4 SP, PA, QL SOTYKTU 4 SP, PA, QL STELARA SYRINGE; 45 MG/0.5 ML VIAL 4 SP, PA, QL sumatriptan 1 QL TALTZ 4 SP, PA, QL tanlor 1 tramadol 50 mg, 100 mg tablet 1 QL TREMFYA 4 SP, PA, QL TYENNE AUTO-INJECTOR, SYRINGE 4 SP, PA, QL UBRELVY 2 PA, QL vanadom 1 VELSIPITY 4 SP, PA, QL XELJANZ 4 SP, PA, QL XELJANZ XR 4 SP, PA, QL XTAMPZA ER 2 PA YESINTEK SYRINGE; 45 MG/0.5 ML VIAL 4 SP, PA, QL zebutal 3 QL ZEPOSIA 4 SP, PA ZTLIDO 2 PARKINSON’S DISEASE Medication Tier Notes APOKYN 4 SP, PA benztropine tablet 1 carbidopa-levodopa 1 CREXONT 3 ST DUOPA 4 SP

24 Cigna Healthcare Standard 4-Tier Prescription Drug List Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement PARKINSON’S DISEASE (cont.) Medication Tier Notes INBRIJA 4 SP, PA NEUPRO 3 NOURIANZ 4 SP, PA, QL pramipexole 1 QL ropinirole 1 RYTARY 3 ST XADAGO 3 ST SCHIZOPHRENIA/ANTI-PSYCHOTICS2 Medication Tier Notes aripiprazole 1 QL asenapine 1 CAPLYTA 3 QL lurasidone 1 QL LYBALVI 3 QL olanzapine tablet 1 paliperidone er 1 QL quetiapine 25 mg, 50 mg, 100 mg, 200 mg, 300 mg, 400 mg tablet 1 quetiapine er 1 REXULTI 3 QL risperidone 1 SECUADO 3 ST VRAYLAR 3 QL ziprasidone capsule 1 SEIZURE DISORDERS Medication Tier Notes BRIVIACT ORAL SOLUTION, TABLET 3 PA carbamazepine er 1 clonazepam 1 DILANTIN 30 MG CAPSULE 2 PA DILANTIN 100 MG CAPSULE; INFATAB, ORAL SUSPENSION 3 PA divalproex 1 SEIZURE DISORDERS (cont.) Medication Tier Notes divalproex er 1 EPIDIOLEX 4 SP, PA FINTEPLA 4 SP, PA FYCOMPA ORAL SUSPENSION 2 PA gabapentin 1 lacosamide oral solution, tablet 1 lamotrigine er 1 lamotrigine odt 1 levetiracetam er 1 LYRICA ORAL SOLUTION 3 PA NAYZILAM 2 PA, QL oxcarbazepine 1 OXTELLAR XR 3 PA PHENYTEK 3 PA pregabalin 1 roweepra 1 SPRITAM 3 PA subvenite 1 TEGRETOL XR 3 PA topiramate 1 topiramate er 1 QL TROKENDI XR 3 QL VALTOCO 2 PA, QL vigpoder 4 SP VIMPAT ORAL SOLUTION 2 XCOPRI 3 PA, QL SKIN CONDITIONS Medication Tier Notes ABSORICA 3 ACZONE 7.5% GEL PUMP 3 adapalene-benzoyl peroxide 1 ADBRY AUTO-INJECTOR, SYRINGE 4 SP, PA azelaic acid 1

25 Cigna Healthcare Standard 4-Tier Prescription Drug List Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement SKIN CONDITIONS (cont.) Medication Tier Notes BRYHALI 3 ST CAPEX SHAMPOO 3 ST CIBINQO 4 SP, PA, QL clindamycin foam, gel, lotion, pledget, topical solution 1 clobetasol 0.05% cream; foam, gel, lotion, ointment, shampoo, topical solution, topical spray 1 CLODERM 3 ST clotrimazole-betamethasone 1 dapsone 5% gel 1 DROPSAFE PREP PAD 1 DRYSOL 2 EBGLYSS 4 SP, PA EUCRISA 2 ST fluorouracil cream, topical solution 1 halobetasol 1 isotretinoin 1 ketoconazole cream, foam, shampoo 1 LITFULO 4 SP, PA, QL mupirocin 2% ointment 1 NAFTIN 2 NEMLUVIO 4 SP, PA neuac gel 1 ONEXTON 3 OPZELURA 3 PA pimecrolimus 1 PRAMOSONE 1%-1% CREAM, OINTMENT; 1% LOTION; 2.5%-1% OINTMENT 2 QBREXZA 3 PA RETIN-A MICRO PUMP 0.08% GEL 3 PA_AGE rosadan cream, gel 1 SKIN CONDITIONS (cont.) Medication Tier Notes SANTYL 2 QL sodium sulfacetamide-sulfur 9.8-4.8%, 10-2%, 10-5% cleanser; cream; lotion; pad; 8-4%, 10-5% topical suspension; wash 1 SOOLANTRA 3 sulfacleanse 8-4 1 tacrolimus ointment 1 tazarotene cream, gel 1 tretinoin cream, gel 1 PA_AGE triderm 1 TWYNEO 3 VALCHLOR 4 SP VECTICAL 3 QL XEPI 3 zenatane 1 ZORYVE 0.15% CREAM 2 QL, ST SLEEP DISORDERS/SEDATIVES Medication Tier Notes DAYVIGO 2 QL, ST doxepin tablet 1 QL eszopiclone 1 LUMRYZ 4 SP, PA, QL modafinil 1 PA SODIUM OXYBATE (by Hikma) 4 SP, PA, QL SUNOSI 2 PA, QL temazepam 1 WAKIX 4 SP, PA, QL XYWAV 4 SP, PA, QL zolpidem sublingual tablet, tablet 1 zolpidem er 1 QL

26 Cigna Healthcare Standard 4-Tier Prescription Drug List Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement SMOKING CESSATION Medication Tier Notes APO-VARENICLINE 3 OC bupropion sr 150 mg tablet 1 PPACA, OC NICOTROL 2 PPACA, OC NICOTROL NS 2 PPACA, OC varenicline 1 PPACA, OC SUBSTANCE ABUSE Medication Tier Notes buprenorphine-naloxone 1 KLOXXADO 2 QL LUCEMYRA 2 QL naltrexone 1 QL NARCAN 2 QL OPVEE 3 QL SUBOXONE 3 ZIMHI 3 QL ZUBSOLV 2 TRANSPLANT MEDICATIONS Medication Tier Notes ENVARSUS XR 4 SP everolimus 0.25 mg, 0.5 mg, 0.75 mg, 1 mg tablet 4 SP LUPKYNIS 4 SP, PA, QL mycophenolate capsule, oral suspension, tablet 4 SP mycophenolic acid 4 SP REZUROCK 4 SP, PA sirolimus 4 SP tacrolimus capsule 4 SP URINARY TRACT CONDITIONS Medication Tier Notes alfuzosin er 1 cevimeline 1 dutasteride 1 URINARY TRACT CONDITIONS (cont.) Medication Tier Notes ELMIRON 2 finasteride 5 mg tablet 1 K-PHOS NO.2 2 K-PHOS ORIGINAL 2 mirabegron er 1 QL oxybutynin er 1 phenazopyridine 100 mg, 200 mg tablet 1 potassium citrate er 1 solifenacin 1 QL tamsulosin 1 tolterodine er 1 QL trospium er 1 VANRAFIA 4 SP, PA, QL 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 see how your plan covers them. Medication Tier Notes ABRYSVO 3 PPACA ACTHIB 2 PPACA ADACEL TDAP 2 PPACA AFLURIA 2 PPACA AREXVY 3 PPACA BEXSERO 2 PPACA BOOSTRIX TDAP 2 PPACA CAPVAXIVE 2 PPACA COMIRNATY 2 PPACA DAPTACEL DTAP 2 PPACA DENGVAXIA 2 PPACA ENGERIX-B 2 PPACA FLUAD 2 PPACA FLUAD QUAD 2 PPACA FLUARIX 2 PPACA

27 Cigna Healthcare Standard 4-Tier Prescription Drug List Generic medications are listed in all lowercase letters and brand-name medications are listed in all CAPITAL letters. Tier 1 – Generics PA – Prior Authorization SP – Specialty Medication Tier 2 – Preferred Brands QL – Quantity Limit PPACA – No Cost-Share Preventive Medication Tier 3 – Non-Preferred Brands ST – Step Therapy OC – Optional Coverage Tier 4 – Specialty Medications AGE – Age Requirement 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 see how your plan covers them. Medication Tier Notes FLUBLOK 2 PPACA FLUCELVAX 2 PPACA FLULAVAL 2 PPACA FLUMIST 3 PPACA FLUZONE 2 PPACA FLUZONE HIGH-DOSE 2 PPACA GARDASIL 9 2 PPACA HEPLISAV-B 2 PPACA HIBERIX 2 PPACA INFANRIX DTAP 2 PPACA IPOL 2 PPACA JANSSEN COVID 2 PPACA KINRIX 2 PPACA MENQUADFI 2 PPACA MENVEO A-C-Y-W-135-DIP 2 PPACA M-M-R II VACCINE 2 PPACA MODERNA COVID 2 PPACA MRESVIA 3 PPACA NOVAVAX COVID 2 PPACA PEDIARIX 2 PPACA PEDVAXHIB 2 PPACA PENBRAYA 2 PPACA PENMENVY MEN A-B-C-W-Y 2 PPACA PENTACEL 2 PPACA PENTACEL ACTHIB COMPONENT 2 PPACA PFIZER COVID 2 PPACA PNEUMOVAX 23 2 PPACA PREHEVBRIO 2 PPACA PREVNAR 20 2 PPACA PRIORIX 2 PPACA PROQUAD 2 PPACA QUADRACEL DTAP-IPV 2 PPACA 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 see how your plan covers them. Medication Tier Notes RECOMBIVAX HB 2 PPACA ROTARIX 3 PPACA ROTATEQ 3 PPACA SHINGRIX 2 QL, PPACA SPIKEVAX COVID 2 PPACA TDVAX 2 PPACA TENIVAC 2 PPACA TRUMENBA 2 PPACA TWINRIX 2 PPACA VARIVAX 2 PPACA VAXELIS 2 PPACA VAXNEUVANCE 2 PPACA VITAMINS Medication Tier Notes CITRANATAL MEDLEY 3 OC POLY-VI-FLOR CHEWABLE TABLET 2 PPACA POLY-VI-FLOR WITH IRON CHEWABLE TABLET 2 PPACA WEIGHT MANAGEMENT Not all plans cover prescription weight management medications. Log in to the myCigna App or myCigna.com, or check your plan materials, to see if your plan covers them. Medication Tier Notes CONTRAVE 3 PA, OC IMCIVREE 4 SP, PA, QL, OC phentermine 1 OC QSYMIA 3 PA, OC SAXENDA 2 PA, OC WEGOVY 2 PA, QL, OC ZEPBOUND PEN 2 PA, QL, OC

28 28 Frequently Asked Questions (FAQs) Here are answers to questions you may have about your drug list and prescription medication coverage. Q. Why do you make changes to the drug list? A. We review and update the drug list on a regular basis to make sure you have coverage for low-cost, safe and effective medications. We make changes for many reasons; for example, when a new medication comes out or is no longer available, or when a medication’s price changes. 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 comes out. 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 and July 1. • Adding extra coverage rules (requirements) to a medication. This typically happens twice a year on January 1 and July 1. When we make a change that affects your medication (for example, it’ll cost more, won’t be covered, and/or has an extra coverage requirement), 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 can treat the same condition. If your medication isn’t covered and your doctor feels a different medication isn’t right for you, your doctor’s office can ask us to cover it through our review process. There are also some medications and products that your plan won't cover for any reason because they’re a “plan (or benefit) exclusion.” This means the medication or product isn’t on your drug list, and there’s no option to ask us to cover it through our review process. For example, your plan doesn’t cover (or “excludes”) medications that the U.S. Food and Drug Administration (FDA) hasn’t approved. 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 make sure you’re getting coverage for the right medication, at the right cost, in the right amount and for the right situation. Q. How do I know if a medication needs approval? A. Check your drug list or log in to the myCigna App or myCigna.com and use the Price a Medication tool. If the medication has: • PA (Prior Authorization) or ST (Step Therapy) next to it, it needs approval before your plan will cover it. • QL (Quantity Limit) next to it, you may need approval depending on how much you’re filling at one time. • AGE (Age Requirement) next to it, you may need approval depending on your age. Q. What types of medications typically need approval? A. Medications that: • May not be safe when you take them with other medications. • Have lower-cost alternatives that work just as well at treating the same condition.

29 Frequently Asked Questions (FAQs) (cont.) • Should only be used for certain health conditions. • Are often used in the wrong way or are abused (taken more often than you should). Q. What types of medications typically have quantity limits? A. Medications that are often: • Taken in a greater amount or used for a longer time than they should be. • Used in the wrong way or are abused (taken more often than you should). Q. What medications are part of Step Therapy? A. They’re typically high-cost medications that treat conditions such as: • ADD/ADHD • High cholesterol • Allergies • Osteoporosis • Bladder problems • Pain • Breathing problems • Skin conditions • Depression • Sleep disorders • High blood pressure Q. Why does my medication have an age requirement? A. Not all medications are right for all ages. Some medications work best for people of a certain age or within a certain age range. As you get older, body changes can decrease the body’s ability to break down or get rid of certain medications. This means that the medication may stay in your body longer. So, an older adult may need a lower dose of the medication or a different medication that’s safer. Q. How do I get approval (prior authorization) for my medication? A. Ask your doctor’s office to contact us 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 our provider portal at cignaforhcp.com. We’ll review the information your doctor sends us to make sure you meet the medication's coverage rules (requirements). We’ll send you and your doctor a letter with our decision (approved/not approved) and next steps. It can take up to five (5) business days to hear from us. You can always check with your doctor’s office to find out if we’ve made a decision. Or, you can log in to the myCigna App or myCigna.com to see where your medication is in the review process or to read about the decision we made. Many times, we don’t get all of the information we need from the doctor’s office to approve coverage. If we don’t approve your medication, 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 us a request, in writing, that explains why we should cover the medication. Q. What happens if I try to fill a prescription that needs approval, but I don’t get it ahead of time? A. When your pharmacist tries to fill your prescription, they’ll see that the medication needs our approval before it can be covered. Because you didn’t get approval ahead of time, your plan won’t cover its cost. If that happens, ask your doctor to contact us to start the coverage review process. You can still fill it (without using your plan/insurance), but you’ll pay its full price at the pharmacy counter. And, if you do this, your costs 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 can ask us to cover it through our review process. Q. Are all of the medications on this drug list approved by the FDA? A. Yes. 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). These include, but are

30 Frequently Asked Questions (FAQs) (cont.) not limited to, medications, medical supplies and/or devices covered under standard pharmacy benefits. It can take up to six months from the date the FDA approved them for us to make a decision. If your doctor wants you to use a recently approved medication, your doctor’s office can ask us to cover it through our review process. Q. What are preventive medications? A. Preventive medications can help keep you from getting certain long-term health conditions such as asthma, depression, diabetes, heart attack, high blood pressure, high cholesterol, osteoporosis (a disease that causes bones to become weak), prenatal nutrient deficiency (when a pregnant person doesn't get enough of the nutrients they need) and stroke. They improve your changes of staying well and living longer. Q. Which medications are covered under the health care reform law? A. The Patient Protection and Affordable Care Act (PPACA), also known as health care reform, helps make health care and preventive care more affordable. PPACA requires health plans to cover the full cost of certain preventive medications and over-the-counter (OTC) products. This means you don't have to pay anything – not even a copay, coinsurance or deductible for these products. To see a list of $0 medications, go to Cigna.com/PDL and click on the dropdown next to "Drug Lists for Employer Plans." Under the Preventive Drug Lists section, click on the link for the PPACA No Cost-Share Preventive Drug List. Q. How can I find out how much my medication will cost me? A. When you and your doctor are thinking about the right medication for your treatment, knowing how much it costs, what lower-cost options are available, and which pharmacies have 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 you get to the pharmacy counter – or even before you leave your doctor’s office.4 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. You should think about 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). Ask your doctor if one of these options may work for you. Q. What's a generic medication? A. A generic is the same as its brand-name version. It has the same active ingredient, strength and dosage form, treats the same condition(s), and works in the same way – and typically costs less.3 Generics are typically sold under their chemical or scientific name, instead of the 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 the brand- name medication.3 Q. What are the differences between generic and brand-name medications? A. The generic and brand-name medication may3: • Look different. For example, generics may have a different shape, size or color than their brand- name versions. • Have a different flavor and/or different preservatives, come in different packaging and/ or with different labeling and may expire at different times. It's important to know that these differences don't affect how the generic works. Q. What is a "biosimilar" medication? A. A biosimilar is “highly similar” to its original biologic medication, which is also known as a reference product, that the FDA has already approved. Even though biosimilars aren’t identical to the original medication, they're used to treat the same conditions, and provide the same clinical outcomes

31 Frequently Asked Questions (FAQs) (cont.) and treatment benefits. There are no clinical differences in how safe they are to use and how well they work. They also typically cost less.5 Q. My pharmacy isn’t in my plan’s network. Can I continue to fill my prescriptions there? A. To get the most from your plan coverage, you should use an in-network pharmacy. If your plan offers out-of-network coverage, you’ll pay your out- of-network cost-share to fill a prescription there. Q. Can I fill my prescriptions by mail? A. Yes, as long as your plan offers home delivery.6 Fill maintenance medications through Express Scripts® Pharmacy Express Scripts Pharmacy is a convenient option when you’re taking a medication on a regular basis to treat an ongoing health condition. It’s simple and safe, and saves you trips to the pharmacy. To learn more, go to Cigna.com/homedelivery. • Easily order, manage, track and pay for your medications on your phone or online. • Get standard shipping at no extra cost.7 • Fill up to a 90-day supply at one time. • Talk with a pharmacist, 24/7. • Sign up for automatic refills or refill reminders so you don’t miss a dose.8 • Use a payment plan (if you need it). Here are two easy ways to get started: 1. Online. Log in to the myCigna App or myCigna.com and click on the Prescriptions tab. Choose My Medications from the dropdown list. Then click the button next to your medication name to move your prescription(s) from your retail pharmacy to home delivery. Or, 2. By phone. • Call your doctor’s office. Ask them to send a 90-day prescription (with refills) to Express Scripts home delivery. Or, • Call Express Scripts Pharmacy at 800.835.3784. They’ll contact your doctor’s office to get your prescription. Have your ID card, doctor’s contact information and medication name(s) ready when you call. Fill specialty medications through Accredo® Specialty Pharmacy If you’re using a specialty medication, Accredo's team can help you manage your rare and/or complex medical condition. They’ll also fill and ship your specialty medication to you, so you don't have to stand in line at the pharmacy. To learn more, go to Cigna.com/specialty. • Talk with specially-trained pharmacists and nurses, 24/7. • Get fast shipping at no extra cost.7 • Sign up for refills and reminders. Some refills can be done by text.9 • Get help paying for your medication (if you need it). • Manage and track your medications online. To get started, call 877.826.7657, Monday–Friday, 7:00 am–10:00 pm CST and Saturdays, 7:00 am– 4:00 pm CST. Q. Where can I find more information about my pharmacy benefits? A. Use the online tools and resources on the myCigna App or myCigna.com. You can find out how much your medication costs (and what lower-cost options may be available), see which medications your plan covers, find an in-network pharmacy, ask a pharmacist a question, see your pharmacy claims and coverage details, and more. You can also manage your home delivery orders.

32 Exclusions and limitations for coverage 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 be medically necessary. If your plan provides coverage for certain preventive 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, the prescription may not be covered. Certain drugs may require prior authorization, or be subject to step therapy, quantity limits or other utilization management requirements. Plans generally do not provide coverage for the following under the pharmacy benefit, except as required by state or federal law, or by the terms of your specific plan:10 • Over-the-counter (OTC) medicines (those that do not require a prescription) except insulin unless state or federal law requires coverage of such medicines. • Prescription medications or supplies for which there is a prescription or OTC therapeutic equivalent or therapeutic alternative. • Doctor-administered injectable medications covered under the Plan’s medical benefit, unless otherwise covered under the Plan’s prescription drug list or approved by Cigna Healthcare. • Implantable contraceptive devices covered under the Plan’s medical benefit. • Medications that are not medically necessary. • Experimental or investigational medications, including U.S. Food and Drug Administration (FDA)- approved medications used for purposes other than those approved by the FDA unless the medication is recognized for the treatment of the particular indication. • Medications that are not approved by the FDA. • Prescription and non-prescription devices, supplies, and appliances other than those supplies specifically listed as covered. • Medications used for fertility,11 sexual dysfunction, cosmetic purposes, weight loss, smoking cessation,11 or athletic enhancement. • Prescription vitamins (other than prenatal vitamins) or dietary supplements unless state or federal law requires coverage of such products. • Immunization agents, biological products for allergy immunization, biological sera, blood, blood plasma and other blood products or fractions and medications used for travel prophylaxis. • Replacement of prescription medications and related supplies due to loss or theft. • Medications which are to be taken by or administered to a covered person while they are a patient in a licensed hospital, skilled nursing facility, rest home or similar institution which operates on its premises or allows to be operated on its premises a facility for dispensing pharmaceuticals. • Prescriptions more than one year from the date of issue. • Coverage for prescription medication products for the amount dispensed (days’ supply) which is more than the applicable supply limit, or is less than any applicable supply minimum set forth in The Schedule, or which is more than the quantity limit(s) or dosage limit(s) set by the P&T Committee. • More than one prescription order or refill for a given prescription supply period for the same prescription medication product prescribed by one or more doctors and dispensed by one or more pharmacies. • Prescription medication products dispensed outside the jurisdiction of the United States, except as required for emergency or urgent care treatment. In addition to the plan’s standard pharmacy exclusions, certain new FDA-approved medication products (including, but not limited to, medications, medical supplies or devices that are covered under standard pharmacy benefit plans) may not be covered for the first six months of market availability unless approved by Cigna Healthcare as medically necessary.

Cigna Healthcare reserves the right to make changes to the drug list without notice. Your plan may cover additional medications; please refer to your enrollment materials for details. Cigna Healthcare does not take responsibility for any medication decisions made by the doctor or pharmacist. Cigna Healthcare may receive payments from manufacturers of certain preferred brand medications, and in limited instances, certain non-preferred brand medications, that may or may not be shared with your plan depending on its arrangement with Cigna Healthcare. Depending upon plan design, market conditions, the extent to which manufacturer payments are shared with your plan and other factors as of the date of service, the preferred brand medication may or may not represent the lowest-cost brand medication within its class for you and/or your plan. Health benefit plans vary, but in general to be eligible for coverage a drug must be approved by the U.S. 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. 1. App/online store terms and mobile phone carrier/data charges apply. Customers under age 13 (and/or their parent/guardian) will not be able to register at myCigna.com. 2. For insured plans that must follow Delaware’s state insurance laws: Brand-name antidepressants, smoking cessation, attention deficit hyperactivity disorder (ADHD) and anti-psychotic medications that don’t have a generic equivalent available will be covered as Tier 2 (preferred brand). This is true even if the medication is listed as Tier 3 (non-preferred brand) on your plan’s drug list. To find out how your specific plans covers these medications, log in to the myCigna App or myCigna.com, or call the number on your ID card. 3. U.S. Food and Drug Administration (FDA) website, “Generic Drug Facts.” Content current as of 11/01/21. fda.gov/drugs/generic-drugs/generic-drug-facts. 4. Prices shown on myCigna are not guaranteed and coverage is subject to your plan terms and conditions. Visit myCigna for more information. 5. U.S. Food and Drug Administration (FDA) website, “Biosimilar Basics for Patients.” Last updated 08/01/24. fda.gov/drugs/biosimilars/biosimilars-basics-patients. 6. Not all plans offer Express Scripts Pharmacy and Accredo as covered pharmacy options. Log in to the myCigna App or myCigna.com, or check your plan materials, to learn more about the pharmacies in your plan’s network. Cigna Healthcare, Evernorth Health Services, Express Scripts and Accredo are all part of The Cigna Group. This means we have an ownership interest in Express Scripts Pharmacy’s home delivery services and Accredo’s specialty pharmacy services. However, you have the right to fill prescriptions at any pharmacy in your plan’s network (as your plan allows). 7. Your plan pays the cost for standard shipping. 8. Express Scripts Pharmacy can automatically refill certain medications. Log in to the myCigna App or myCigna.com, or call 800.835.3784, to sign up. You can sign up to get emails and/or texts from Express Scripts Pharmacy. To get text messages, you’ll have to sign up for the Express Scripts texting service. You can do this online or when you call 800.835.3784 to refill your prescription. Once you sign up, just reply to their welcome text to get started. Standard text messaging rates apply. 9. You can only refill certain specialty medications by text. To get text messages, you’ll have to sign up for Accredo’s texting service. You can do this when you call Accredo to refill your prescription. Once you sign up, just reply to their welcome text to get started. Standard text messaging rates apply. 10. Costs and complete details of the plan’s prescription drug coverage are set forth in the plan documents. If there are any differences between the information provided here and the plan documents, the information in the plan documents takes complete precedence. 11. For plans that must follow state insurance laws, such as Delaware: Your plan may provide coverage for infertility medications and smoking cessation medications even if this drug list states that your plan may not cover them. To find out if your specific plan covers these medications, log in to the myCigna App or myCigna.com, or check your plan materials. Para obtener ayuda en español llame al número en su tarjeta de Cigna Healthcare. Cigna Healthcare products and services are provided exclusively by or through operating subsidiaries of The Cigna Group. 916152 u Standard 4-Tier Specialty 09/25 © 2025 Cigna Healthcare.

Cigna Healthcare® complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, ancestry, religion, marital status, gender, sexual orientation, gender identity or sexual stereotypes. Cigna Healthcare does not exclude people or treat them less favorably differently because of race, color, national origin, age, disability, sex, ancestry, religion, marital status, gender, sexual orientation, gender identity or sexual stereotypes. Cigna Healthcare: • Provides people with disabilities reasonable modifications and free appropriate auxiliary aids to communicate effectively with us, such as: – Qualified sign language interpreters – Written information in other formats (large print, audio, accessible electronic formats, other formats) • Provides free language assistance services to people whose primary language is not English in a timely manner, such as: – Qualified interpreters – Information written in other languages If you need reasonable modifications, appropriate auxiliary aids and services or language assistance services, contact the Civil Rights Coordinator. If you believe that Cigna Healthcare has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, sex, ancestry, religion, marital status, gender, sexual orientation, gender identity or sexual stereotypes, you can file a grievance with the Civil Rights Coordinator P.O. Box 188016, Chattanooga, TN 37422, 877.822.6561 (TTY: Dial 711) ACAGrievance@CignaHealthcare.com You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, DC 20201 1.800.368.1019, 800.537.7697 (TDD) Complaint forms are available at https://www.hhs.gov/civil-rights/filing-a- complaint/complaint-process/index.html Cigna Healthcare products and services are provided exclusively by or through operating subsidiaries of The Cigna Group, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Evernorth Behavioral Health, Inc., Evernorth Care Solutions, Inc. 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. ATTENTION: If you speak languages other than English, language assistance service, free of charge are available to you. For current Cigna Healthcare customers, call the number on the back of your ID card. Otherwise, call 1.800.244.6224 (TTY: Dial 711). ATENCIÓN: Si usted habla un idioma que no sea inglés, tiene a su disposición servicios gratuitos de asistencia lingüística. Si es un cliente actual de Cigna 896375h 5/25 © 2025 Cigna Healthcare. Discrimination is against the law

824711 8/24 Proficiency of Language Assistance Services English – ATTENTION: If you speak English, free language assistance services are available to you. Appropriate auxiliary aids and services to provide information in accessible formats are also available free of charge. Call 1- 800-244-6224 (TTY: Dial 711) or speak to your provider. Spanish – ATENCIÓN: Si habla español, los servicios de asistencia lingüística gratuitos están disponibles para usted. También están disponibles de forma gratuita ayudas y servicios auxiliares adecuados para proporcionar información en formatos accesibles. Llame al 1-800-244-6224 (TTY: Marque 711) o hable con su proveedor. Chinese – 注意：如果您讲中文，我们提供免费的语言援助服务。适当的辅助设备和服务也可以免费提供，以提供无 障碍格式的信息。请拨打 1-800-244-6224（TTY：拨打 711）或与您的服务提供者联系。 Vietnamese – XIN LƯU Ý: Nếu bạn nói tiếng Viet, dịch vụ hỗ trợ ngôn ngữ miễn phí có sẵn cho bạn. Các thiết bị và dịch vụ hỗ trợ phù hợp để cung cấp thông tin ở định dạng có thể tiếp cận cũng có sẵn miễn phí. Gọi số 1-800-244-6224 (TTY: Gọi 711) hoặc nói chuyện với nhà cung cấp của bạn). Korean – 주의: 한국어를 사용하시는 경우, 무료 언어 지원 서비스가 제공됩니다. 접근 가능한 형식으로 정보를 제공하기 위한 적절한 보조 기기 및 서비스도 무료로 제공됩니다. 1-800-244-6224 (TTY: 711 로 전화) 로 전화하시거나 제공자에게 문의하십 시오. Tagalog – PAUNAWA: Kung ikaw ay nagsasalita ng Tagalog, ang mga libreng serbisyo ng tulong sa wika ay magagamit para sa iyo. Ang mga angkop na pantulong na kagamitan at serbisyo upang magbigay ng impormasyon sa mga naa-access na format ay magagamit din ng libre. Tumawag sa 1-800-244-6224 (TTY: Tumawag sa 711) o makipag-usap sa iyong tagapagbigay. Russian – ВНИМАНИЕ: Если вы говорите на русском, доступны бесплатные услуги языковой помощи. Также бесплатно предоставляются соответствующие вспомогательные средства и услуги для предоставления информации в доступных форматах. Позвоните по телефону 1-800-244-6224 (TTY: Наберите 711) или обратитесь к вашему провайдеру. - Arabic ﮫﯾﺑﻧﺗ: اذإ ثدﺣﺗﺗ تﻧﻛ ،ﺔﯾﺑرﻌﻟا رﻓوﺗﺗ كﻟ تﺎﻣدﺧ ةدﻋﺎﺳﻣﻟا ﺔﯾوﻐﻠﻟا ﺔﯾﻧﺎﺟﻣﻟا. ﺎﻣﻛ رﻓوﺗﺗ ﺎًﺿﯾأ تادﻋﺎﺳﻣ ﺔﻠﺑﺎﻗ لوﺻوﻠﻟ ،ﺎﮭﯾﻟإ كﻟذو ﺎًﻧﺎﺟﻣ. لﺻﺗا مﻗرﻟﺎﺑ .وأ ثدﺣﺗ ﻰﻟإ مدﻘﻣ ﺔﻣدﺧﻟا صﺎﺧﻟا كﺑ ) بﻠطا 711 (TTY: 6224 - 244 - 800 - 1 French Creole – ATANSYON: Si ou pale Kreyòl Ayisyen, sèvis asistans lang gratis yo disponib pou ou. Ekipman ak sèvis adisyonèl ki apwopriye pou bay enfòmasyon nan fòma ki aksesib yo disponib tou gratis. Rele 1-800-244- 6224 (TTY: Rele 711) oswa pale ak founisè ou a. French – ATTENTION : Si vous parlez français, des services d’assistance linguistique gratuits sont disponibles pour vous. Des aides et des services auxiliaires appropriés pour fournir des informations dans des formats accessibles sont également disponibles gratuitement. Appelez le 1-800-244-6224 (TTY : composez le 711) ou parlez à votre fournisseur. Portuguese – ATENÇÃO: Se você fala português, serviços gratuitos de assistência linguística estão disponíveis para você. Auxílios e serviços apropriados para fornecer informações em formatos acessíveis também estão disponíveis gratuitamente. Ligue para 1-800-244-6224 (TTY: disque 711) ou fale com seu prestador de serviços. Polish – UWAGA: Jeśli mówisz po polsku, dostępne są bezpłatne usługi pomocy językowej. Odpowiednie pomoce i usługi wspierające w celu dostarczenia informacji w dostępnych formatach są również dostępne bezpłatnie. Zadzwoń pod numer 1-800-244-6224 (TTY: wybierz 711) lub skontaktuj się ze swoim dostawcą usług. Japanese – 注意: 日本語を話す場合は、無料の言語支援サービスが利用できます。アクセス可能な形式で情報を 提供するための適切な補助機器やサービスも無料で利用できます。1-800-244-6224（TTY: 711 にダイヤル）に電 話するか、提供者に話してください。 Italian – ATTENZIONE: Se parli italiano, sono disponibili per te servizi gratuiti di assistenza linguistica. Sono disponibili gratuitamente anche ausili e servizi appropriati per fornire informazioni in formati accessibili. Chiama il numero 1-800-244-6224 (TTY: comporre il 711) o parla con il tuo fornitore. German – Achtung: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlose Sprachassistenzdienste zur Verfügung. Geeignete Hilfsmittel und Dienste, um Informationen in barrierefreien Formaten bereitzustellen, sind ebenfalls kostenlos verfügbar. Rufen Sie 1-800-244-6224 an (TTY: Wählen Sie 711) oder sprechen Sie mit Ihrem Anbieter. (Farsi) Persian - ،نﯾﻧﭼﻣھ ﺳو لﯾﺎ و تﺎﻣدﺧ ﯽﮑﻣﮐ بﺳﺎﻧﻣ یارﺑ رد سرﺗﺳد تﺳا. تﺎﻣدﺧ نﺎﮕﯾار ﮏﻣﮐ نﺎﺑز یارﺑ ﺎﻣﺷ تﺑﺣﺻ ﯾﻧﮐﯽﻣ ،د ﮫﺟوﺗ: رﮔا ﮫﺑ ﯽﺳرﺎﻓ ﺎﺑ ﺎﯾ دﯾرﯾﮕﺑ سﺎﻣﺗ) هرﺎﻣﺷ711 دﯾرﯾﮕﺑ ار(TTY: تﺎﻋﻼطا ﮫﺋارا یﺎﮭﺑﻟﺎﻗ رد ﮫﺑ سرﺗﺳد لﺑﺎﻗ رد نﺎﮕﯾار تروﺻسرﺗﺳد دﻧﺗﺳھ. هرﺎﻣﺷ ﺎﺑ 1-800-244-6224 . دﯾﻧﮐ تﺑﺣﺻ دوﺧ هدﻧھدﮫﺋارا