Cigna update package

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Cigna update package

  1. 1. Rocky Mountain UFCW Union & Employers Health Benefit Plan Four-Tier Plan 2012 Cigna prescription drug list This list is designed to cover your prescription medications at four levels. The amount you will pay will depend on the tier from which you and your doctor select your medication. If there is more than one drug appropriate for your condition, we encourage you to talk to your doctor about low cost medications like generics and preferred brands, as they will help to manage your prescription costs better. 853379 02/12 Value PDL
  2. 2. 1st Tier – Generic Medications: Generic drugs have the same active ingredients, safety, dosage, quality and strength, as their brand-name counterparts. You will usually pay less for generic medications under your plan. 2nd Tier – Preferred Brand Medications: Preferred brand drugs will usually cost you more than a generic, but less than a non-preferred brand drug under your plan. 3rd Tier – Non-Preferred Brand Medications: Non-preferred brand drugs are those that generally have generic alternatives and/or one or more preferred brand options within the same drug class. You will usually pay more for a non-preferred brand under your plan. 4th Tier – Specialty Medications: Specialty Injectable Medications are typically covered under the fourth tier and include, but are not limited to, injectables used to treat arthritis, multiple sclerosis, hepatitis C, and asthma. See the list of Specialty medications on page 22. Understanding the Cigna Prescription Drug List Every medication available on the drug list has been approved by the U.S. Food and Drug Administration (FDA). This list represents the most commonly prescribed medications. Please reference Cigna.com or myCigna. com for the complete up-to-date listing of medications. Refer to your enrollment information to find out which specific medications are covered under your plan. The symbols on the list mean … If your medication has one of the following symbols, your doctor may have to get an authorization for coverage. PA: Prior Authorization may be required for different reasons. To learn the requirements needed for coverage of a specific medication, please give us a call. QL: Quantity Limit means you may have coverage for a limited amount of a specific medication. AGE: Age Requirement means a person may be within a specific age group for a specific medication to be covered. ST: Step Therapy is a prior authorization program that requires you to try other medications available to treat the same condition before the “ST” medication is covered.2
  3. 3. Important NoteThis list does not cover drugs that have over-the-counter (OTC) alternatives,drugs that treat stomach acid conditions and non-sedating antihistamines totreat allergies.In some cases medications for certain conditions (allergies, heartburn/ulcers, etc.)may be equivalent products to OTC medications available. In these cases, theprescription available class alternatives are excluded from coverage. Examples*include allergy medications such as Allegra, Clarinex, Xyzal and any generics; andheartburn/ulcer medications such as Nexium, Prilosec, Zantac and any generics.(*Examples not all-inclusive listing).Help From myCigna.comWhen you go to myCigna.com you can:• Compare actual medication prices at local pharmacies • See your specific pharmacy coverage information• Research available medications and network pharmacies• Ask a pharmacist questionsIf You Have Any QuestionsFeel free to give us a call at the number on the back of your ID Card.We’re here to help. 3
  4. 4. NoN-Preferred GeNericS Preferred BraNdS BraNdS add/adHd aNd STiMULaNTS amphetamine/ Adderall (PA, ST) dextroamphetamine Adderall XR (PA, ST) dexmethylphenidate Amphetamine2012 Cigna Prescription Drug List methamphetamine Dextroamphetamine methylphenidate/ER Extended-Release (PA, ST) Concerta (PA, ST) Daytrana (PA, ST) Desoxyn Focalin XR (PA, ST) Intuniv Kapvay Metadate CD (PA, ST) Metadate ER (PA, ST) Nuvigil Provigil Ritalin LA (PA, ST) Strattera Vyvanse (PA, ST) aidS/HiV didanosine Agenerase Retrovir stavudine Aptivus Videx zidovudine Atripla Zerit Combivir Crixivan Emtriva Epivir Epzicom Intelence Invirase Isentress Kaletra Lexiva Norvir Prezista Rescriptor Reyataz Selzentry Sustiva Trizivir Truvada Viracept Viramune Viread Ziagen 4
  5. 5. NoN-Preferred GeNericS Preferred BraNdS BraNdS aLLerGY** Medications for allergies equivalent to over-the-counter medications within the class are excluded such as Allegra, fexofenadine, Clarinex, etc.clemastine Astepro Astelincyproheptadine Epipen (QL) Adrenaclick (QL)epinephrine inj (QL) Singulair Beconase AQ (PA, ST)flunisolide nasal Flonase (PA, ST)fluticasone nasal Nasacort AQ (PA, ST)hydroxyzine Nasarel (PA, ST) Nasonex (PA, ST) Omnaris (PA, ST) Patanase Rhinocort AQ (PA, ST) Semprex-D Veramyst (PA, ST) aLZHeiMer’S diSeaSedonepezil Ariceptgalantamine Aricept ODTrivastigmine Cognex Exelon Namenda Razadyne Razadyne ER aSTHMa aNd reSPiraTorYalbuterol solution Atrovent HFA Accolatecromolyn Foradil Accuneb nebulizer (PA, ST)ipratropium solution ProAir HFA Advair, Advair HFAlevalbuterol solution Qvar Alvescometaproterenol Singulair Asmanex Azmacort Brovana nebulizer (PA, ST) Combivent Dulera Flovent, Flovent HFA Maxair Perforomist (PA, ST) Proventil HFA Pulmicort Serevent Spiriva Symbicort Ventolin HFA Xopenex HFA Xopenex nebulizer (PA, ST) 5
  6. 6. NoN-Preferred GeNericS Preferred BraNdS BraNdS BirTH coNTroL* * Please check your enrollment materials to determine whether these medications are covered under your specific plan. Apri Angeliq2012 Cigna Prescription Drug List Aviane Desogen Balziva Ella Camila Estrostep FE Errin Levlen Gianvi Lo/Ovral-28 Jolessa Loestrin Junel FE Loestrin 24 FE Kariva Loestrin FE Levora Lo Loestrin FE Lo-ogestrel Loseasonique Microgestin Lybrel Necon Natazia Nortrel Nordette Ocella Nuvaring Ogestrel Ortho Evra Quasense Ortho Tri-Cyclen LO Solia Ortho-Cept Sprintec Ortho-Novum 7-7-7 Trinessa Ovcon 35 Tri-Sprintec Ovcon 50 Zenchant Ovrette Zovia Plan B Plan B One-Step Seasonale Seasonique Trilevlen Tri-Norinyl Triphasil Yaz BLadder ProBLeMS Oxybutynin/XL Detrol (PA, ST) Trospium chloride Detrol LA (PA, ST) Ditropan, Ditropan XL (PA, ST) Elmiron Enablex (PA, ST) Gelnique (PA, ST) Oxytrol (PA, ST) Sanctura, Sanctura XR (PA, ST) Toviaz (PA, ST) VESIcare (PA, ST) 6
  7. 7. NoN-Preferred GeNericS Preferred BraNdS BraNdS caNceranastrozole Afinitor (PA) Arimidexbicalutamide Aromasin Casodextamoxifen citrate Fareston Femara Gleevec (PA) Iressa (PA) Lupron (PA) Nexavar (PA) Revlimid (PA) Soltamox Sprycel (PA) Sutent (PA) Tarceva (PA) Targretin Tasigna (PA) Temodar (PA) Thalomid (PA) Tykerb (PA) Votrient (PA) Xeloda Zolinza (PA) cardioVaScULar BLood THiNNer/aNTi-cLoTTiNGenoxaprin (QL) Arixtra (QL) Aggrenoxheparin (QL) Lovenox (QL) Agrylin (PA)ticlopidine Effientwarfarin Fragmin (QL) Innohep (QL) Plavix Pletal Pradaxa (PA) 7
  8. 8. NoN-Preferred GeNericS Preferred BraNdS BraNdS cardioVaScULar HiGH BLood PreSSUre/HearT MedicaTioNS amlodipine Benicar (PA, ST) Accupril (PA, ST) atenolol Benicar HCT (PA, ST) Accuretic (PA, ST)2012 Cigna Prescription Drug List benazepril Aceon (PA, ST) benazepril/amlodipine Altace (caps)(PA, ST) benazepril/HCTZ Altace (tabs)(PA, ST) bisoprolol/HCTZ Atacand (PA, ST) captopril Avalide (PA, ST) carvedilol Avapro (PA, ST) digoxin Azor diltiazem Betapace AF diltiazem CD Bystolic disopyramide Capoten (PA, ST) doxazosin Cardura enalapril Cardura XL enalapril/HCTZ Catapres, Catapres TTS felodipine Coreg fosinopril Coreg CR hydralazine/HCTZ Corgard isosorbide dinitrate Covera-HS isosorbide mononitrate Cozaar (PA, ST) labetalol Diovan HCT (PA, ST) lisinopril Diovan (PA, ST) losartan Dynacirc CR losartan/HCTZ Exforge methyldopa/HCTZ Exforge HCT metoprolol Hyzaar (PA, ST) nadolol Inderal LA nifedipine Innopran XL nisoldipine (Sustained release) Lanoxin prazosin Levatol procainamide Lotensin HCT (PA, ST) propranolol Lotensin (PA, ST) quinapril Lotrel quinapril/HCTZ Mavik (PA, ST) quinidine Micardis HCT (PA, ST) ramipril (cap only) Micardis (PA, ST) sotalol Minizide terazosin Monopril HCT (PA, ST) timolol Monopril (PA, ST) trandolapril Multaq trandolapril/verapamil Norpace verapamil Norpace CR verapamil SR Norvasc 8
  9. 9. NoN-PreferredGeNericS Preferred BraNdS BraNdS cardioVaScULar (CONTINUED) HiGH BLood PreSSUre/HearT MedicaTioNS Prinivil (PA, ST) Prinzide (PA, ST) Procanbid Ranexa (PA) Sular Tarka Tekamlo Tekturna HCT (PA, ST) Tekturna (PA, ST) Teveten HCT (PA, ST) Teveten (PA, ST) Tikosyn Toprol XL Uniretic (PA, ST) Univasc (PA, ST) Valturna (PA, ST) Vaseretic (PA, ST) Vasotec (PA, ST) Verelan Zestoretic (PA, ST) Zestril (PA, ST) 9
  10. 10. NoN-Preferred GeNericS Preferred BraNdS BraNdS cHoLeSTeroL LoWeriNG cholestyramine powder Vytorin Advicor fenofibrate Welchol Altoprev (PA, ST) gemfibrozil Zetia Caduet2012 Cigna Prescription Drug List lovastatin Crestor (PA, ST) pravastatin Fenoglide simvastatin Lescol Lescol XL Lipitor (PA, ST) Livalo (PA, ST) Lofibra Lovaza Mevacor (PA, ST) Niaspan Pravachol (PA, ST) Simcor TriCor Trilipix Zocor (PA, ST) dePreSSioN amitriptyline Aplenzin (PA, ST) bupropion Celexa (PA, ST) bupropion SR Cymbalta (PA, ST) citalopram Effexor XR (PA, ST) desipramine Emsam fluoxetine Lexapro (PA, ST) fluvoxamine Luvox CR mirtazapine Marplan nortriptyline Paxil CR (PA, ST) paroxetine Pristiq (PA, ST) paroxetine CR Prozac (PA, ST) protriptyline Remeron sertraline Tofranil trazodone Vivactil venlafaxine Wellbutrin XL (PA, ST) venlafaxine XR Zoloft (PA, ST) 10
  11. 11. NoN-Preferred GeNericS Preferred BraNdS BraNdS diaBeTeSacarbose ACCU-CHEK Test Strips Actoplus metacetohexamide Actos Amarylchlorpropamide BD Insulin Syringe Apidraglimepiride Byetta Apidra SoloStarglipizide Glucagen Hypokit Avandametglipizide/metformin Januvia Avandarylglucagon (QL) Lantus Avandiaglyburide NovoFine needles Duetactglyburide/metformin Novolin Fortametglyburide micronized Novolog Glucophage XRmetformin One Touch test strips Glycronnateglinide Glysettolazamide Humalogtolbutamide Humulin Janumet Kombiglyze XR Lantus SoloStar Levemir Metaglip Onglyza Prandimet Prandin Precose Starlix Symlin/SymlinPen eNdocriNe aNd MeTaBoLic – oTHerallopurinol Megace ES Synarel (PA)cabergoline (QL) Uloricdesmopressin 11
  12. 12. NoN-Preferred GeNericS Preferred BraNdS BraNdS eYe coNdiTioNS ciprofloxacin Xalatan Acular LS diclofenac Alamast dorzolamide Alocril2012 Cigna Prescription Drug List dorzolamide/timolol Alomide levobunolol Alphagan P pilocarpine Alrex pilocarpine/epinephrine AzaSite timolol Azopt tobramycin/dexamethasone Besivance (ST) Betimol Betoptic S Ciloxan Cosopt Durezol Emadine Iopidine Iquix Lotemax Pataday Patanol Restasis Timoptic Tobradex Travatan Z Trusopt Vexol Vigamox Voltaren GaSTroiNTeSTiNaL (NoT HearTBUrN/ULcer) amylase/lipase/protease Asacol Apriso balsalazide Asacol HD Canasa Lialda Colazal Pentasa Entocort EC Sucraid 12
  13. 13. NoN-Preferred GeNericS Preferred BraNdS BraNdS HearTBUrN/ULcer* *Medications for heartburn and ulcer equivalent to over-the-counter medications within the class are excluded such as omeprazole, Nexium, Zantac, etc.metoclopramidemisoprostolsucralfate HorMoNe rePLaceMeNTestradiol Premarin Activellaestropipate Aloralevothroid Anadrol-50levothyroxine Androdermlevoxyl Androgelliothyronine Armour Thyroidmedroxyprogesterone Cenestinthyroid CombipatchUnithroid Cytomel Enjuvia Estraderm Femhrt Femring Fortesta Menest Prefest Premphase Prempro Prometrium Synthroid Testim Vagifem Vivelle-Dot 13
  14. 14. NoN-Preferred GeNericS Preferred BraNdS BraNdS iNfecTioNS acyclovir Baraclude Augmentin amantadine Epivir HBV Augmentin ES 600 amoxicillin Tamiflu (QL) Augmentin XR2012 Cigna Prescription Drug List amoxicillin/clavulanate Avelox azithromycin (QL) Biaxin cefaclor ER Biaxin XL cefadroxil Cedax cefprozil Cefzil cefuroxime Cipro HC Otic cephalexin Cipro XR ciprofloxacin Ciprodex clarithromycin Coartem (QL) clindamycin Copegus doxycycline Famvir erythromycin Flagyl ER fluconazole (QL: 150 mg only) Floxin Otic griseofulvin Gris-Peg itraconazole (QL) Hepsera metronidazole Keflex minocycline Keftab nitrofurantoin Lamisil (QL) nystatin Lariam (PA, QL) ofloxacin Levaquin penicillin v potassium Malarone (PA, QL) rimantadine Monurol SMX/TMP Moxatag terfenabine (QL) Mycostatin (tab) tetracycline Noxafil Omnicef Penlac (PA) Priftin Primsol Relenza (QL) Solodyn Sporanox (QL) Suprax Tobi Tyzeka Valtrex Vfend (PA) Zithromax (QL) Zyvox (PA) 14
  15. 15. NoN-Preferred GeNericS Preferred BraNdS BraNdS MiGraiNeacetaminophen/ Zomig/Zomig ZMT (QL) Amerge (QL) caffeine/butalbital Axert (QL)naratriptan (QL) DHE 45 (QL)sumatriptan (QL) Frova (QL) Imitrex (QL) Maxalt Maxalt MLT Migranal (QL) Relpax (QL) Treximet (QL) MULTiPLe ScLeroSiS Ampyra (PA) Gilenya (PA) NaUSea aNd VoMiTiNGdronabinol Anzemet (tab)(QL)granisetron (tab, solu) (QL) Emend (QL)ondansetron (QL) Kytril (tab, solu)(QL)prochlorperazine Marinolpromethazine Scopacetrimethobenzamide Zofran (tab, solu)(QL) Zuplenz (QL) oSTeoPoroSiSalendronate Actonel (PA, ST)calcitonin-salmon Atelvia (PA, ST)Fortical Boniva (PA, ST) Evista (PA, ST) Forteo (PA, ST) Fosamax (PA, ST) Fosamax Plus D (PA, ST) Miacalcin Skelid (PA, ST) 15
  16. 16. NoN-Preferred GeNericS Preferred BraNdS BraNdS PaiN reLief aNd iNfLaMMaTorY diSeaSe butorphanol nasal (QL) Arava (PA) Actiq (PA) codeine phos/carisoprodol/ Celebrex Arthrotec asa Nalfon Avinza2012 Cigna Prescription Drug List codeine phosphate Rheumatrex Band O Supprettes codeine phosphate/aspirin Trexall (PA, ST) codeine sulfate Butrans (QL) diclofenac Demerol (PA, ST) dihy-cod tt/apap/caffeine Dilaudid (PA, ST) etodolac Dipentum fentanyl (QL) Duragesic (QL) fentanyl citrate Fentora (PA) (lollipop)(PA) Hycet (PA, ST) hydrocodone/ Indocin (suppository) acetaminophen Kadian hydrocodone bitartrate/ Kineret (PA) apap Lidoderm hydrocodone bitartrate/ Lorcet (PA, ST) aspirin Lorcet Plus (PA, ST) hydromorphone hcl Lortab (PA, ST) ibuprofen Magnacet (PA, ST) ibuprofen/hydrocod bit Maxidone (PA, ST) indomethacin Mobic ketorolac (PA, QL) MSIR leflunamide (PA) MSIR (PA, ST) levorphanol tartrate Naprelan meloxicam Norco (PA, ST) meperidine hcl Nucynta (PA, ST) methotrexate OxyContin (QL) morphine SR Panlor SS (PA, ST) morphine sulfate Percocet (PA, ST) (Roxanol) morphine sulfate Percodan (PA, ST) nabumetone Primalev (PA, ST) naproxen Roxicet (PA, ST) opium Roxicodone (PA, ST) opium/belladonna alkaloids Ryzolt (PA, ST) oxaprozin Savella oxycodone hcl Simponi (PA) oxycodone hcl/ Skelaxin acetaminophen Synalgos-DC (PA, ST) oxycodone/aspirin Talwin Compound (PA, ST) pentazocine hcl Tylox (PA, ST) acetaminophen Ultracet (PA, ST) pentazocine hcl/ Ultram (PA,ST) naloxone hcl Ultram ER (PA,ST) piroxicam Vicodin (PA,ST) tramadol hcl/ER Vicodin ES (PA,ST) tramadol hcl/ acetaminophen 16
  17. 17. NoN-Preferred GeNericS Preferred BraNdS BraNdS PaiN reLief aNd iNfLaMMaTorY diSeaSe (CONTINUED) Vicodin HP (PA,ST) Vicoprofen (PA,ST) Voltaren Voltaren XR Xodol (PA,ST) Xolox (PA,ST) Zamicet (PA,ST) Zolvit (PA,ST) Zydone (PA,ST) ParKiNSoN’S diSeaSeamantadine Azilect Eldeprylbromocriptine Comtan Mirapexcarbidopa/levodopa Lodosyn Requipcarbidopa/levodopa SA Stalevo Requip XLropinirole Tasmar Zelaparselegilinepramipexole ProSTaTedoxazosin Avodartfinasteride Flomaxprazosin Jalyntamsulosin Proscar (AGE)terazosin Rapaflo Uroxatral 17
  18. 18. NoN-Preferred GeNericS Preferred BraNdS BraNdS ScHiZoPHreNia clozapine Seroquel Abilify haloperidol Zyprexa Abilify Discmelt loxapine Clozaril2012 Cigna Prescription Drug List risperidone Fanapt thiothixene Fazaclo Geodon Invega Latuda Moban Orap Risperdal Saphris Seroquel XR SeiZUre carbamazepine Diastat Banzel clonazepam Diastat Acudial Carbatrol divalproex Dilantin Depakote (all forms) gabapentin Gabitril Lyrica (PA, ST) levetiracetam Keppra Neurontin topiramate Keppra XR Stavzor valproate Lamictal (all forms) Tegretol XR Topamax Trileptal Vimpat Zonegran 18
  19. 19. NoN-Preferred GeNericS Preferred BraNdS BraNdS SKiN coNdiTioNSadapalene (AGE) Carac Aclovate (PA, ST)alclometasone Fluroplex Aldaraalclometasone dipropionate Targretin gel Aphthasolamcinonide Aquaphilic W/Tac +Apexicon E (diflorasone Carbamide (PA, ST) diacetate) Aquaphilic W/betamethasone Triamcinolone (PA, ST)betamethasone dipropionate Aristocort A (PA, ST)betamethasone dipropionate/ Atralin (AGE) propylene glycol Benzaclinbetamethasone valerate BenzamycinPakcalcipotriene Capex Shampoo (PA, ST)clobetasol Carmol HC (PA, ST)clobetasol propionate Clobex (PA, ST)clobetasol propionate/emoll Cloderm (PA, ST)desonide Condyloxdesoximetasone Coraz (PA, ST)diflorasone Cordran (PA, ST)diflorasone diacetate Cordran SP (PA, ST)fluocinolone Cutivate (PA, ST)fluocinolone acetonide Derma-Smoothe/FSfluocinonide/emollient (PA, ST)fluticasone propionate Dermatop (PA, ST)halobetasol prop/ammonium Desonate (PA, ST) lac Desowen (PA, ST)halobetasol propionate Differin (AGE)hydrocortisone Diprolene (PA, ST)hydrocortisone acetate/alo ver Diprolene AF (PA, ST)hydrocortisone acetate/ Diprosone (PA, ST) ure(tp) Dovonexhydrocortisone butyrate Duac CShydrocortisone valerate Elidel (PA, ST)imiquimod Elocon (PA, ST)isotretinoin (QL) Epiduo (AGE)metronidazole Exeldermmometasone furoate First Hydrocort (PA, ST)prednicarbate Halog (PA, ST)Sotret (QL) Kenalog (PA, ST)sulfacetamide Klarontretinoin (AGE) Lacticare-HC (PA, ST)triamcinolone acetonide Lidex (PA, ST) Locoid (PA, ST) Locoid Lipocream (PA, ST) Loprox shampoo Luxiq (PA, ST) Metrogel Metrolotion 19
  20. 20. NoN-Preferred GeNericS Preferred BraNdS BraNdS SKiN coNdiTioNS (CONTINUED) Momexin (PA, ST) Noritate Nucort (PA, ST)2012 Cigna Prescription Drug List Nuzon (PA, ST) Olux (PA, ST) Olux-e (PA, ST) Oracea Ovace Plus Pandel (PA, ST) Panretin (PA) Pediaderm HC (PA, ST) Protopic (PA, ST) Psorcon (PA, ST) Psorcon E (PA, ST) Regranex (PA) Retin-A Micro (AGE) Rosula Scalacort DK (PA, ST) Soriatane CK Synemol (PA, ST) Taclonex Tazorac Temovate (PA, ST) Texacort (PA, ST) Topicort (PA, ST) Topicort LP (PA, ST) Tridesilon (PA, ST) Ultravate PAC (PA, ST) Ultravate (PA, ST) Valisone (PA, ST) Vanos (PA, ST) Vectical Verdeso (PA, ST) Westcort (PA, ST) Xolegel Xolegel Corepak Ziana Zyclara Zytopic (PA, ST) 20
  21. 21. NoN-Preferred GeNericS Preferred BraNdS BraNdS SLeePzaleplon Ambien CR (PA, ST)zolpidem Edluar (PA, ST) Lunesta (PA, ST) Rozerem (PA, ST) Silenor (PA, ST) Zolpimist (PA, ST) TraNSPLaNTazathioprine Myfortic Neoralcyclosporine Sandimmune Zortressmycophenolate moefetil Rapamunetacrolimus Prograf Cellcept MiSceLLaNeoUScalcitriol Cortifoam Fosrenolfolic acid Epifoam Nimotopleucovorin Revatio (PA) Phoslonaltrexone (QL) Pulmozyme (PA)tizanidine Renvela Suboxone TussiCaps Tussionex Zanaflex Zemplar 21
  22. 22. SPeciaLTY iNjecTaBLe drUGS (aLL reqUire Prior aUTHoriZaTioN)Specialty Injectable Drugs Actimmune Neulasta Anzemet – injection Neumega Apokyn Neupogen Aranesp Norditropin Arcalyst Norditropin Nordiflex Avonex Nutropin Betaseron Nutropin AQ Ceftriaxone Octreotide Acetate Cimzia Omnitrope Copaxone Ondansetron – injection Delatestryl Pegasys Depo-Testosterone Peg Intron Emend – injection Peg Intron Redipen Enbrel Procrit Egrifta Proleukin Epogen Rebif Extavia Relistor Firmagon Remicade Fuzeon Rocephin Garamycin Saizen Genotropin Sandostatin Gold Sodium Thiomalate Serostim Granisetron – injection Simponi Humatrope Somatuline Depot Humira Somavert Ilaris Stelara Increlex Testosterone – injection Infergen Tev-Tropin Intron A Tobramycin Sulfate Ketorolac Tromethamine – injection Toradol – injection Kineret Xolair Kytril – injection Zofran – injection Leukine Zoladex Leuprolide Acetate Zorbtive Lupron, Lupron Depot Myochrysine Nebcin 22
  23. 23. excLUSioNS & LiMiTaTioNSPlans typically do not provide coverage for the following, except as required by law or by theterms of your specific plan: 1. Any medications available over the 6. Any prescription and non-prescription counter that do not require a prescription supplies (such as ostomy supplies), by Federal or State Law, and any devices, and appliances. medication that is a pharmaceutical 7. Any contraceptive medications and alternative to an over the counter prescription appliances for contraception. medication other than insulin. 8. Implantable contraceptive products. [examples include OTC Benadryl, Maalox, 9. Any fertility medication. Sudafed PE , etc.] 10. Any medications used for treatment of 2. Medications that are therapeutically sexual dysfunction, including but not equivalent as determined by the Cigna limited to erectile dysfunction, delayed HealthCare Pharmacy and Therapeutics ejaculation, anorgasmia and decreased Committee in which at least one of the libido. medications within the class is available over the counter. [examples include Rx 11. Any prescription vitamins (other than equivalents to OTC Allegra, Claritin and prenatal vitamins), dietary supplements Zyrtec (Allegra D, Clarinex, Xyzal) and and fluoride products. Rx equivalents to OTC Prevacid, Prilosec, 12. Medications used for cosmetic purposes, Zantac (Aciphex, Kapidex, Nexium, Axid, such as medications used to reduce Pepcid, Zantac)] wrinkles, medications to promote hair 3. Any injectable infertility medications, and growth, medications used to control any injectable medications that require perspiration and fade cream products. Health Care Professional supervision 13. Any diet pills or appetite suppressants and are not typically considered self- (anorectics). administered medications. The following 14. Prescription smoking cessation products. are examples of Health Care Professional- 15. Immunization agents, biological products supervised medications: Injectables used for allergy immunization, biological sera, to treat hemophilia and RSV (respiratory blood, blood plasma and other blood syncytial virus), chemotherapy injectables, products or fractions and medications and endocrine and metabolic agents. used for travel prophylaxis. 4. Any medications that are experimental or 16. Replacement of prescription medications investigational, within the meaning set and related supplies due to loss or theft. forth in the summary plan description. 17. Medications used to enhance athletic 5. Food and Drug Administration (FDA)- performance. approved medications used for purposes 18. Medications that are to be taken by other than those approved by the FDA or administered to a Customer while unless the medication is recognized the Customer is a patient in a licensed for the treatment of the particular hospital, skilled nursing facility, rest home indication in one of the standard or similar institution which operates on reference compendia (The United States its premises or allows to be operated Pharmacopoeia Drug Information or The on its premises a facility for dispensing American Hospital Formulary Service pharmaceuticals. Drug Information) or in medical literature. 19. Prescriptions more than one year from the Medical literature means scientific studies original date of issue. published in a peer-reviewed national professional medical journal. 23
  24. 24. Cigna reserves the right to make changes to this Drug List (also known as the Value Prescription Drug List) without notice. Your plan may cover additional medications; please refer to your enrollment materials for details. Cigna does not take responsibility for any medication decisions made by the prescriber or pharmacist. Cigna 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. 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.“Cigna”, “Cigna.com” and “myCigna.com” are registered service marks and the “Tree of Life” logo, “CignaHome Delivery Pharmacy” and “GO YOU” are service marks, of Cigna Intellectual Property, Inc., licensed for useby Cigna Corporation and its operating subsidiaries. All products and services are provided by or through suchoperating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut GeneralLife Insurance Company, Cigna Health and Life Insurance Company, Tel-Drug, Inc., Tel-Drug of Pennsylvania,L.L.C., and HMO subsidiaries of Cigna Health Corporation. “Cigna Home Delivery Pharmacy” refers to Tel-Drug,Inc. and Tel-Drug of Pennsylvania, L.L.C. All models are used for illustrative purposes only.853379 02/12 © 2012 Cigna. Some content provided under license.
  25. 25. Get a dose of healthy savings with the CIGNA Value Prescription Drug List Now more than ever, you Consider the following two unique need to lower your benefit characteristics that drive the savings: plan costs. It’s important to balance this need with Distinctive Tier Design The Value PDL encourages people to choose low-cost generic employee satisfaction medications by placing most brand name drugs on the higher cost by continuing to offer third tier. Also, a much-smaller second tier offers only the drugs that a complete pharmacy do not have a generic equivalent or a therapeutic alternative. program. CIGNA’s Value Prescription Drug List Effective Exclusions Certain exclusions are responsible for approximately half the savings (PDL) helps you do both. available with the Value PDL. These include all medications that With the Value PDL, have an over-the-counter (OTC) equivalent or therapeutic alternative; specifically, non-sedating antihistamines (allergy medications) along you’ll see savings of with PPIs and H2 blockers (ulcer/heartburn medications). Lifestyle up to 25% on pharmacy drugs, including weight loss, infertility, smoking cessation and claim costs. That’s erectile dysfunction medications, are also excluded. significant — especially Speak to your CIGNA sales representative to enjoy all when you consider the benefits of the CIGNA Value Prescription Drug List that this translates to — coming this May. approximately 3% of your overall medical costs. “CIGNA”,“CIGNA.com”,“myCIGNA.com”and the ”Tree of Life”logo are registered service marks, and ”CIGNA Home Delivery Pharmacy”is a service mark, of CIGNA Intellectual Property, Inc., licensed for use by CIGNA Corporation and its operating subsidiaries. All products and services are provided exclusively by such operating subsidiaries and not by CIGNA Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company, CIGNA Health and Life Insurance Company, Tel-Drug, Inc., Tel-Drug of Pennsylvania, L.L.C., and HMO or service company subsidiaries of CIGNA Health Corporation. “CIGNA Home Delivery Pharmacy”840505 02/11 Value PDL refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C. All models are used for illustrative purposes only.
  26. 26. Important Information about the Value Prescription Drug List: Exclusions The Value Prescription Drug It’s important to know what drugs are excluded because they are List can deliver savings of commonly used medications that many of your employees may 20-25% of pharmacy claim currently use. costs, and these savings are attributed to both The Value Prescription Drug List does not cover medications in the unique tier design two drug classes that have over-the-counter (OTC) equivalents or which drives higher use alternatives: drugs that treat stomach acid conditions and non- of generic medications sedating antihistamines to treat allergies. Many of these drugs are and the exclusion of widely used, so please be aware that the exclusion list will affect a certain medications. The significant number of people. list of exclusions drives Some examples of excluded medications are listed below. Please approximately half of the note this list is not all inclusive. For a complete list of covered estimated 20-25% savings. medications on the Value Prescription Drug List, customers can visit myCIGNA.com at any time. Heartburn/Ulcer Allergy H2 Blockers Proton Pump Inhibitors Non-Sedating Antihistamines Axid (OTC) Aciphex Allegra D Cimetidine (OTC) Nexium Clarinex/Clarinex D Famotidine (OTC) Omeprazole (OTC) Claritin (OTC)/Claritin D (OTC) Nexatidine (OTC) Pantoprazole Fexofenadine Pepcid (OTC) Prevacid Loratidine (OTC) Ranidtine (OTC) Prilosec Xyzal Tagamet (OTC) Protonix Zyrtec/Zyrtec D (OTC) Zantac (OTC) Zegerid “CIGNA Pharmacy Management”, “myCIGNA.com” and the “Tree of Life” logo are registered service marks of CIGNA Intellectual Property, Inc., licensed for use by CIGNA Corporation and its operating subsidiaries. All products and services are provided exclusively by such operating subsidiaries and not by CIGNA Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company, CIGNA Health and Life Insurance Company, Tel-Drug, Inc., Tel-Drug of Pennsylvania, L.L.C., and HMO or service company subsidiaries of CIGNA Health Corporation.842185 05/11 Value PDL © 2011 CIGNA.

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