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
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
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
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
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.