cigna update package

853379 02/12 Value PDL

Four-Tier Plan

2012 Cignaprescription 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.

Rocky Mountain UFCW Union & Employers Health Benefit Plan

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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 ListEvery 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.

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Important NoteThis list does not cover drugs that have over-the-counter (OTC) alternatives, drugs that treat stomach acid conditions and non-sedating antihistamines to treat allergies.

In some cases medications for certain conditions (allergies, heartburn/ulcers, etc.) may be equivalent products to OTC medications available. In these cases, the prescription available class alternatives are excluded from coverage. Examples* include allergy medications such as Allegra, Clarinex, Xyzal and any generics; and heartburn/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:

• Compareactualmedicationpricesatlocalpharmacies

• Seeyourspecificpharmacycoverageinformation

• Researchavailablemedications and network pharmacies

• Ask a pharmacist questions

If 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.

NoN-Preferred GeNericS Preferred BraNdS BraNdS2012

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add/adHd aNd STiMULaNTS

amphetamine/ dextroamphetaminedexmethylphenidatemethamphetaminemethylphenidate/ER

Adderall (PA, ST)Adderall XR (PA, ST)Amphetamine Dextroamphetamine Extended-Release (PA, ST)Concerta (PA, ST)Daytrana (PA, ST)DesoxynFocalin XR (PA, ST)IntunivKapvay Metadate CD (PA, ST)Metadate ER (PA, ST)NuvigilProvigilRitalin LA (PA, ST)StratteraVyvanse (PA, ST)

aidS/HiV

didanosinestavudinezidovudine

AgeneraseAptivusAtriplaCombivirCrixivanEmtrivaEpivirEpzicomIntelenceInviraseIsentressKaletraLexivaNorvirPrezistaRescriptorReyatazSelzentrySustivaTrizivirTruvadaViraceptViramuneVireadZiagen

RetrovirVidexZerit

4 5

NoN-Preferred GeNericS Preferred BraNdS BraNdS

aSTHMa aNd reSPiraTorY

albuterol solutioncromolynipratropium solutionlevalbuterol solutionmetaproterenol

Atrovent HFAForadilProAir HFAQvarSingulair

AccolateAccuneb nebulizer (PA, ST)Advair, Advair HFAAlvescoAsmanexAzmacortBrovana nebulizer (PA, ST)CombiventDuleraFlovent, Flovent HFAMaxairPerforomist (PA, ST)Proventil HFAPulmicortSereventSpirivaSymbicortVentolin HFAXopenex HFAXopenex nebulizer (PA, ST)

aLZHeiMer’S diSeaSe

donepezilgalantaminerivastigmine

AriceptAricept ODTCognexExelonNamendaRazadyneRazadyne ER

aLLerGY*

clemastinecyproheptadineepinephrine inj (QL)flunisolide nasalfluticasone nasalhydroxyzine

AsteproEpipen (QL)Singulair

Astelin Adrenaclick (QL)Beconase AQ (PA, ST)Flonase (PA, ST)Nasacort AQ (PA, ST)Nasarel (PA, ST)Nasonex (PA, ST)Omnaris (PA, ST)PatanaseRhinocort AQ (PA, ST)Semprex-DVeramyst (PA, ST)

* Medications for allergies equivalent to over-the-counter medications within the class are excluded such as Allegra, fexofenadine, Clarinex, etc.


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BirTH coNTroL*

ApriAvianeBalzivaCamilaErrinGianviJolessaJunel FEKarivaLevoraLo-ogestrelMicrogestinNeconNortrelOcellaOgestrelQuasenseSoliaSprintecTrinessaTri-SprintecZenchantZovia

AngeliqDesogenEllaEstrostep FELevlenLo/Ovral-28LoestrinLoestrin 24 FELoestrin FELo Loestrin FELoseasoniqueLybrelNataziaNordetteNuvaringOrtho EvraOrtho Tri-Cyclen LOOrtho-CeptOrtho-Novum 7-7-7Ovcon 35Ovcon 50OvrettePlan BPlan B One-StepSeasonaleSeasoniqueTrilevlenTri-NorinylTriphasilYaz

* Please check your enrollment materials to determine whether these medications are covered under your specific plan.

BLadder ProBLeMS

Oxybutynin/XLTrospium chloride

Detrol (PA, ST)Detrol LA (PA, ST)Ditropan, Ditropan XL (PA, ST)ElmironEnablex (PA, ST)Gelnique (PA, ST)Oxytrol (PA, ST)Sanctura, Sanctura XR (PA, ST)Toviaz (PA, ST)VESIcare (PA, ST)

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caNcer

anastrozolebicalutamidetamoxifen citrate

Afinitor (PA)AromasinFarestonFemaraGleevec (PA)Iressa (PA)Lupron (PA)Nexavar (PA)Revlimid (PA)SoltamoxSprycel (PA)Sutent (PA)Tarceva (PA)TargretinTasigna (PA)Temodar (PA)Thalomid (PA)Tykerb (PA)Votrient (PA)XelodaZolinza (PA)

ArimidexCasodex

cardioVaScULarBLood THiNNer/aNTi-cLoTTiNG

enoxaprin (QL)heparin (QL)ticlopidinewarfarin

Arixtra (QL)Lovenox (QL)

AggrenoxAgrylin (PA)EffientFragmin (QL)Innohep (QL)PlavixPletalPradaxa (PA)


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cardioVaScULar

HiGH BLood PreSSUre/HearT MedicaTioNS

amlodipineatenololbenazeprilbenazepril/amlodipinebenazepril/HCTZbisoprolol/HCTZcaptoprilcarvediloldigoxindiltiazemdiltiazem CDdisopyramidedoxazosinenalaprilenalapril/HCTZfelodipinefosinoprilhydralazine/HCTZisosorbide dinitrateisosorbide mononitratelabetalollisinoprillosartanlosartan/HCTZmethyldopa/HCTZmetoprololnadololnifedipinenisoldipine (Sustained release)prazosinprocainamidepropranololquinaprilquinapril/HCTZquinidineramipril (cap only)sotalolterazosintimololtrandolapriltrandolapril/verapamilverapamilverapamil SR

Benicar (PA, ST)Benicar HCT (PA, ST)

Accupril (PA, ST)Accuretic (PA, ST)Aceon (PA, ST)Altace (caps)(PA, ST)Altace (tabs)(PA, ST)Atacand (PA, ST)Avalide (PA, ST)Avapro (PA, ST)AzorBetapace AFBystolicCapoten (PA, ST)CarduraCardura XLCatapres, Catapres TTSCoregCoreg CRCorgardCovera-HSCozaar (PA, ST)Diovan HCT (PA, ST)Diovan (PA, ST)Dynacirc CRExforgeExforge HCTHyzaar (PA, ST)Inderal LAInnopran XLLanoxinLevatolLotensin HCT (PA, ST)Lotensin (PA, ST)LotrelMavik (PA, ST)Micardis HCT (PA, ST)Micardis (PA, ST)MinizideMonopril HCT (PA, ST)Monopril (PA, ST)MultaqNorpaceNorpace CRNorvasc

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cardioVaScULar (CONTINUED)

HiGH BLood PreSSUre/HearT MedicaTioNS

Prinivil (PA, ST)Prinzide (PA, ST)ProcanbidRanexa (PA)SularTarkaTekamloTekturna HCT (PA, ST)Tekturna (PA, ST)Teveten HCT (PA, ST)Teveten (PA, ST)TikosynToprol XLUniretic (PA, ST)Univasc (PA, ST)Valturna (PA, ST)Vaseretic (PA, ST)Vasotec (PA, ST)VerelanZestoretic (PA, ST)Zestril (PA, ST)


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cHoLeSTeroL LoWeriNG

cholestyramine powderfenofibrategemfibrozillovastatinpravastatinsimvastatin

VytorinWelcholZetia

AdvicorAltoprev (PA, ST)CaduetCrestor (PA, ST)FenoglideLescolLescol XLLipitor (PA, ST)Livalo (PA, ST)LofibraLovazaMevacor (PA, ST)NiaspanPravachol (PA, ST)SimcorTriCorTrilipixZocor (PA, ST)

dePreSSioN

amitriptylinebupropionbupropion SRcitalopramdesipraminefluoxetinefluvoxaminemirtazapinenortriptylineparoxetineparoxetine CRprotriptylinesertralinetrazodonevenlafaxinevenlafaxine XR

Aplenzin (PA, ST)Celexa (PA, ST)Cymbalta (PA, ST)Effexor XR (PA, ST)EmsamLexapro (PA, ST)Luvox CR MarplanPaxil CR (PA, ST)Pristiq (PA, ST)Prozac (PA, ST)RemeronTofranilVivactilWellbutrin XL (PA, ST)Zoloft (PA, ST)

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diaBeTeS

acarboseacetohexamidechlorpropamideglimepirideglipizideglipizide/metforminglucagon (QL)glyburideglyburide/metforminglyburide micronizedmetforminnateglinidetolazamidetolbutamide

ACCU-CHEK Test StripsActosBD Insulin SyringeByettaGlucagen HypokitJanuviaLantusNovoFine needlesNovolinNovologOne Touch test strips

Actoplus metAmarylApidraApidra SoloStarAvandametAvandarylAvandiaDuetactFortametGlucophage XRGlycronGlysetHumalogHumulinJanumetKombiglyze XRLantus SoloStarLevemirMetaglipOnglyzaPrandimetPrandinPrecoseStarlixSymlin/SymlinPen

eNdocriNe aNd MeTaBoLic – oTHer

allopurinolcabergoline (QL)desmopressin

Megace ES Synarel (PA) Uloric


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GaSTroiNTeSTiNaL (NoT HearTBUrN/ULcer)

amylase/lipase/proteasebalsalazide

AsacolAsacol HDLialdaPentasa

AprisoCanasaColazalEntocort ECSucraid

eYe coNdiTioNS

ciprofloxacindiclofenacdorzolamidedorzolamide/timolollevobunololpilocarpinepilocarpine/epinephrinetimololtobramycin/dexamethasone

Xalatan Acular LSAlamastAlocrilAlomideAlphagan PAlrexAzaSiteAzoptBesivance (ST)BetimolBetoptic SCiloxan CosoptDurezolEmadineIopidineIquixLotemaxPatadayPatanolRestasisTimopticTobradex Travatan ZTrusoptVexolVigamoxVoltaren

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HearTBUrN/ULcer*

metoclopramidemisoprostolsucralfate

*Medications for heartburn and ulcer equivalent to over-the-counter medications within the class are excluded such as omeprazole, Nexium, Zantac, etc.

HorMoNe rePLaceMeNT

estradiolestropipatelevothroidlevothyroxinelevoxylliothyroninemedroxyprogesteronethyroidUnithroid

Premarin ActivellaAloraAnadrol-50AndrodermAndrogelArmour ThyroidCenestinCombipatchCytomelEnjuviaEstradermFemhrtFemringFortestaMenestPrefestPremphasePremproPrometriumSynthroidTestimVagifemVivelle-Dot


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iNfecTioNS

acycloviramantadineamoxicillinamoxicillin/clavulanateazithromycin (QL)cefaclor ERcefadroxilcefprozilcefuroximecephalexinciprofloxacinclarithromycinclindamycindoxycyclineerythromycinfluconazole (QL: 150 mg only)griseofulvinitraconazole (QL)metronidazoleminocyclinenitrofurantoinnystatinofloxacinpenicillin v potassiumrimantadineSMX/TMPterfenabine (QL)tetracycline

BaracludeEpivir HBVTamiflu (QL)

AugmentinAugmentin ES 600Augmentin XRAveloxBiaxinBiaxin XLCedaxCefzilCipro HC OticCipro XRCiprodexCoartem (QL)CopegusFamvirFlagyl ERFloxin OticGris-PegHepseraKeflexKeftabLamisil (QL)Lariam (PA, QL)LevaquinMalarone (PA, QL)MonurolMoxatagMycostatin (tab)NoxafilOmnicefPenlac (PA)PriftinPrimsolRelenza (QL)SolodynSporanox (QL)SupraxTobiTyzekaValtrexVfend (PA)Zithromax (QL)Zyvox (PA)

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oSTeoPoroSiS

alendronatecalcitonin-salmonFortical

Actonel (PA, ST)Atelvia (PA, ST)Boniva (PA, ST)Evista (PA, ST)Forteo (PA, ST)Fosamax (PA, ST)Fosamax Plus D (PA, ST)MiacalcinSkelid (PA, ST)

NaUSea aNd VoMiTiNG

dronabinolgranisetron (tab, solu) (QL)ondansetron (QL)prochlorperazinepromethazinetrimethobenzamide

Anzemet (tab)(QL)Emend (QL)Kytril (tab, solu)(QL)MarinolScopaceZofran (tab, solu)(QL)Zuplenz (QL)

MiGraiNe

acetaminophen/ caffeine/butalbitalnaratriptan (QL)sumatriptan (QL)

Zomig/Zomig ZMT (QL) Amerge (QL)Axert (QL)DHE 45 (QL)Frova (QL)Imitrex (QL)MaxaltMaxalt MLTMigranal (QL)Relpax (QL)Treximet (QL)

MULTiPLe ScLeroSiS

Ampyra (PA)Gilenya (PA)


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PaiN reLief aNd iNfLaMMaTorY diSeaSe

butorphanol nasal (QL)codeine phos/carisoprodol/ asacodeine phosphatecodeine phosphate/aspirincodeine sulfatediclofenacdihy-cod tt/apap/caffeineetodolacfentanyl (QL) fentanyl citrate (lollipop)(PA)hydrocodone/ acetaminophenhydrocodone bitartrate/ apaphydrocodone bitartrate/ aspirinhydromorphone hclibuprofenibuprofen/hydrocod bitindomethacinketorolac (PA, QL)leflunamide (PA)levorphanol tartratemeloxicammeperidine hclmethotrexatemorphine SRmorphine sulfate(Roxanol) morphine sulfatenabumetonenaproxenopiumopium/belladonna alkaloidsoxaprozinoxycodone hcloxycodone hcl/ acetaminophenoxycodone/aspirinpentazocine hcl acetaminophenpentazocine hcl/ naloxone hclpiroxicamtramadol hcl/ERtramadol hcl/ acetaminophen

Arava (PA)CelebrexNalfonRheumatrexTrexall

Actiq (PA)ArthrotecAvinzaBand O Supprettes (PA, ST)Butrans (QL)Demerol (PA, ST)Dilaudid (PA, ST)DipentumDuragesic (QL)Fentora (PA)Hycet (PA, ST)Indocin (suppository)KadianKineret (PA)LidodermLorcet (PA, ST)Lorcet Plus (PA, ST)Lortab (PA, ST)Magnacet (PA, ST)Maxidone (PA, ST)MobicMSIRMSIR (PA, ST)NaprelanNorco (PA, ST)Nucynta (PA, ST)OxyContin (QL)Panlor SS (PA, ST)Percocet (PA, ST)Percodan (PA, ST)Primalev (PA, ST)Roxicet (PA, ST)Roxicodone (PA, ST)Ryzolt (PA, ST)SavellaSimponi (PA)SkelaxinSynalgos-DC (PA, ST)Talwin Compound (PA, ST)Tylox (PA, ST)Ultracet (PA, ST) Ultram (PA,ST)Ultram ER (PA,ST)Vicodin (PA,ST)Vicodin ES (PA,ST)

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ParKiNSoN’S diSeaSe

amantadinebromocriptinecarbidopa/levodopacarbidopa/levodopa SAropiniroleselegilinepramipexole

AzilectComtanLodosynStalevoTasmar

EldeprylMirapexRequipRequip XLZelapar

PaiN reLief aNd iNfLaMMaTorY diSeaSe (CONTINUED)

Vicodin HP (PA,ST)Vicoprofen (PA,ST)VoltarenVoltaren XRXodol (PA,ST)Xolox (PA,ST)Zamicet (PA,ST)Zolvit (PA,ST)Zydone (PA,ST)

ProSTaTe

doxazosinfinasterideprazosintamsulosinterazosin

AvodartFlomaxJalynProscar (AGE)RapafloUroxatral


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ScHiZoPHreNia

clozapinehaloperidolloxapinerisperidonethiothixene

SeroquelZyprexa

AbilifyAbilify DiscmeltClozarilFanaptFazacloGeodonInvegaLatudaMobanOrapRisperdalSaphrisSeroquel XR

SeiZUre

carbamazepineclonazepamdivalproexgabapentinlevetiracetamtopiramatevalproate

DiastatDiastat AcudialDilantinGabitrilKeppraKeppra XRLamictal (all forms)

BanzelCarbatrolDepakote (all forms)Lyrica (PA, ST) NeurontinStavzorTegretol XRTopamaxTrileptalVimpatZonegran

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SKiN coNdiTioNS

adapalene (AGE)alclometasonealclometasone dipropionateamcinonideApexicon E (diflorasone diacetate)betamethasonebetamethasone dipropionatebetamethasone dipropionate/ propylene glycolbetamethasone valeratecalcipotrieneclobetasolclobetasol propionateclobetasol propionate/emolldesonidedesoximetasonediflorasonediflorasone diacetatefluocinolonefluocinolone acetonidefluocinonide/emollientfluticasone propionatehalobetasol prop/ammonium lachalobetasol propionatehydrocortisonehydrocortisone acetate/alo verhydrocortisone acetate/ ure(tp)hydrocortisone butyratehydrocortisone valerateimiquimodisotretinoin (QL)metronidazolemometasone furoateprednicarbateSotret (QL)sulfacetamidetretinoin (AGE)triamcinolone acetonide

CaracFluroplexTargretin gel

Aclovate (PA, ST)AldaraAphthasolAquaphilic W/Tac + Carbamide (PA, ST)Aquaphilic W/ Triamcinolone (PA, ST)Aristocort A (PA, ST) Atralin (AGE)BenzaclinBenzamycinPakCapex Shampoo (PA, ST)Carmol HC (PA, ST)Clobex (PA, ST)Cloderm (PA, ST)CondyloxCoraz (PA, ST)Cordran (PA, ST)Cordran SP (PA, ST)Cutivate (PA, ST)Derma-Smoothe/FS (PA, ST)Dermatop (PA, ST)Desonate (PA, ST)Desowen (PA, ST)Differin (AGE)Diprolene (PA, ST)Diprolene AF (PA, ST)Diprosone (PA, ST)Dovonex Duac CSElidel (PA, ST)Elocon (PA, ST)Epiduo (AGE)ExeldermFirst Hydrocort (PA, ST)Halog (PA, ST)Kenalog (PA, ST)KlaronLacticare-HC (PA, ST)Lidex (PA, ST)Locoid (PA, ST)Locoid Lipocream (PA, ST)Loprox shampooLuxiq (PA, ST)MetrogelMetrolotion


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SKiN coNdiTioNS (CONTINUED)

Momexin (PA, ST)NoritateNucort (PA, ST)Nuzon (PA, ST)Olux (PA, ST)Olux-e (PA, ST)OraceaOvace PlusPandel (PA, ST)Panretin (PA)Pediaderm HC (PA, ST)Protopic (PA, ST)Psorcon (PA, ST)Psorcon E (PA, ST)Regranex (PA)Retin-A Micro (AGE)RosulaScalacort DK (PA, ST)Soriatane CKSynemol (PA, ST) TaclonexTazoracTemovate (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)VecticalVerdeso (PA, ST)Westcort (PA, ST)XolegelXolegel CorepakZianaZyclaraZytopic (PA, ST)

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TraNSPLaNT

azathioprinecyclosporinemycophenolate moefetiltacrolimus

MyforticSandimmuneRapamunePrografCellcept

NeoralZortress

MiSceLLaNeoUS

calcitriolfolic acidleucovorinnaltrexone (QL)tizanidine

CortifoamEpifoamRevatio (PA)

FosrenolNimotopPhosloPulmozyme (PA)RenvelaSuboxoneTussiCapsTussionexZanaflexZemplar

SLeeP

zaleplonzolpidem

Ambien CR (PA, ST)Edluar (PA, ST)Lunesta (PA, ST)Rozerem (PA, ST)Silenor (PA, ST)Zolpimist (PA, ST)

Spec

ialty

Inje

ctab

le D

rugs Actimmune

Anzemet – injectionApokynAranespArcalystAvonexBetaseronCeftriaxoneCimziaCopaxoneDelatestrylDepo-TestosteroneEmend – injectionEnbrelEgriftaEpogenExtaviaFirmagonFuzeonGaramycinGenotropinGold Sodium ThiomalateGranisetron – injectionHumatropeHumiraIlarisIncrelexInfergenIntron AKetorolac Tromethamine – injectionKineretKytril – injectionLeukineLeuprolide AcetateLupron, Lupron DepotMyochrysineNebcin

NeulastaNeumegaNeupogenNorditropinNorditropin NordiflexNutropinNutropin AQOctreotide AcetateOmnitropeOndansetron – injectionPegasysPeg IntronPeg Intron RedipenProcritProleukinRebifRelistor RemicadeRocephinSaizenSandostatinSerostimSimponiSomatuline DepotSomavertStelaraTestosterone – injectionTev-TropinTobramycin SulfateToradol – injectionXolairZofran – injectionZoladexZorbtive

SPeciaLTY iNjecTaBLe drUGS (aLL reqUire Prior aUTHoriZaTioN)

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excLUSioNS & LiMiTaTioNS Plans typically do not provide coverage for the following, except as required by law or by the terms of your specific plan:

1. Any medications available over the counter that do not require a prescription by Federal or State Law, and any medication that is a pharmaceutical alternative to an over the counter medication other than insulin. [examples include OTC Benadryl, Maalox, Sudafed PE , etc.]

2. Medications that are therapeutically equivalent as determined by the Cigna HealthCare Pharmacy and Therapeutics Committee in which at least one of the medications within the class is available over the counter. [examples include Rx equivalents to OTC Allegra, Claritin and Zyrtec (Allegra D, Clarinex, Xyzal) and Rx equivalents to OTC Prevacid, Prilosec, Zantac (Aciphex, Kapidex, Nexium, Axid, Pepcid, Zantac)]

3. Any injectable infertility medications, and any injectable medications that require Health Care Professional supervision and are not typically considered self-administered medications. The following are examples of Health Care Professional-supervised medications: Injectables used to treat hemophilia and RSV (respiratory syncytial virus), chemotherapy injectables, and endocrine and metabolic agents.

4. Any medications that are experimental or investigational, within the meaning set forth in the summary plan description.

5. 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 in one of the standard reference compendia (The United States Pharmacopoeia Drug Information or The American Hospital Formulary Service Drug Information) or in medical literature. Medical literature means scientific studies published in a peer-reviewed national professional medical journal.

6. Any prescription and non-prescription supplies (such as ostomy supplies), devices, and appliances.

7. Any contraceptive medications and prescription appliances for contraception.

8. Implantable contraceptive products. 9. Any fertility medication. 10. Any medications used for treatment of

sexual dysfunction, including but not limited to erectile dysfunction, delayed ejaculation, anorgasmia and decreased libido.

11. Any prescription vitamins (other than prenatal vitamins), dietary supplements and fluoride products.

12. Medications used for cosmetic purposes, such as medications used to reduce wrinkles, medications to promote hair growth, medications used to control perspiration and fade cream products.

13. Any diet pills or appetite suppressants (anorectics).

14. Prescription smoking cessation products. 15. Immunization agents, biological products

for allergy immunization, biological sera, blood, blood plasma and other blood products or fractions and medications used for travel prophylaxis.

16. Replacement of prescription medications and related supplies due to loss or theft.

17. Medications used to enhance athletic performance.

18. Medications that are to be taken by or administered to a Customer while the Customer is 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.

19. Prescriptions more than one year from the original date of issue.

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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, “Cigna Home Delivery Pharmacy” and “GO YOU” are service marks, of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through 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 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.

Get a dose of healthy savings with the CIGNA Value Prescription Drug List

840505 02/11 Value PDL

Now more than ever, you need to lower your benefit plan costs. It’s important to balance this need with employee satisfaction by continuing to offer a complete pharmacy program. CIGNA’s Value Prescription Drug List (PDL) helps you do both.

With the Value PDL, you’ll see savings of up to 25% on pharmacy claim costs. That’s significant — especially when you consider that this translates to approximately 3% of your overall medical costs.

Consider the following two unique characteristics that drive the savings:

Distinctive Tier DesignThe Value PDL encourages people to choose low-cost generic

medications by placing most brand name drugs on the higher cost

third tier. Also, a much-smaller second tier offers only the drugs that

do not have a generic equivalent or a therapeutic alternative.

Effective ExclusionsCertain exclusions are responsible for approximately half the savings

available with the Value PDL. These include all medications that

have an over-the-counter (OTC) equivalent or therapeutic alternative;

specifically, non-sedating antihistamines (allergy medications) along

with PPIs and H2 blockers (ulcer/heartburn medications). Lifestyle

drugs, including weight loss, infertility, smoking cessation and

erectile dysfunction medications, are also excluded.

Speak to your CIGNA sales representative to enjoy all

the benefits of the CIGNA Value Prescription Drug List

— coming this May.

“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”

refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C. All models are used for illustrative purposes only.

Important Information about the Value Prescription Drug List: Exclusions

842185 05/11 Value PDL

“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.

© 2011 CIGNA.

The Value Prescription Drug List can deliver savings of 20-25% of pharmacy claim costs, and these savings are attributed to both the unique tier design which drives higher use of generic medications and the exclusion of certain medications. The list of exclusions drives approximately half of the estimated 20-25% savings.

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

It’s important to know what drugs are excluded because they are

commonly used medications that many of your employees may

currently use.

The Value Prescription Drug List does not cover medications in

two drug classes that have over-the-counter (OTC) equivalents or

alternatives: drugs that treat stomach acid conditions and non-

sedating antihistamines to treat allergies. Many of these drugs are

widely used, so please be aware that the exclusion list will affect a

significant number of people.

Some examples of excluded medications are listed below. Please

note this list is not all inclusive. For a complete list of covered

medications on the Value Prescription Drug List, customers can

visit myCIGNA.com at any time.

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