cover page and toc tradadvcore aetna v7 (rev20190101)

The Self-Funded Program through Allstate Benefits provides tools for employers owning small to mid-sized businesses to establish a self-funded health benefit plan for their employees. The benefit plan is established by the employer and is not an insurance product. For

employers in the Self-Funded Program, stop-loss insurance is underwritten by: Integon National Insurance Company in CT, NY and VT; Integon Indemnity Corporation in FL; and National Health Insurance Company in WA, CO, and all other states where offered.

ABSMemberAETNA.v7_2022.01.01

MEMBER’S

ADDITIONAL INFORMATION (V7)

AETNA RESOURCES FOR LIVING (EAP)

CIGNA WELCOME LETTER

FIVE WAYS TO SAVE

MYCIGNA.COM - MEMBER FLYER

ENGLISH

SPANISH

CIGNA 90-DAY PRESCRIPTION FILLS

JANUARY 2022 ADVANTAGE DRUG LIST CHANGES MEMBER BROCHURE

ACREEDO SPECIALTY PHARMACY

JANUARY 2022 3 TIER ADVANTAGE DRUG LIST

ENGLISH

SPANISH

PRESCRIPTION DRUG CLAIM FORM

PHARMACY CHAIN LISTING BY STATE

ALLIED: SAMPLE EOB (EXPLANATION OF BENEFITS)

A website built for youAetna Resources For LivingSM

Get information and advice on the things that matter to you

Your member website is a single source for information on your career, health and personal life. With just a couple clicks, you can:

• Search for child or elder care providers• Learn about health conditions• Take well-being assessments• Access self-help tools and information

Find discounts on over 3 million products and services

The online discount service features savings on brand-name products and services like:

• Computers and electronics • Fitness centers• Travel, car rentals and hotels • Restaurants• Gifts and retail shopping • And more

Access myStrength — the health club for your mind

myStrength is an easy-to-use online/mobile self-help resource for depression and anxiety.

• Daily tips for your mind, body and spirit• Built and customized for each user• Based on the latest clinical research and

professional advice from best-selling authors• Packed with resources to improve mental health

Check out your member website today.

Check out these Employee Assistance Program (EAP) web tools and resources now available to your members.

Aetna Resources For LivingSM is the brand name used for products and services offered through the Aetna group of subsidiary companies. The EAP is administered by Aetna Behavioral Health, LLC. In California for Knox-Keene plans, Aetna Health of California, Inc. and Health and Human Resources Center, Inc.All EAP calls are confidential, except as required by law. This material is for informational purposes only. It contains only a partial, general description of programs and services and does not constitute a contract. EAP instructors, educators and network participating providers are independent contractors and are neither agents nor employees of Aetna. Aetna does not direct, manage, oversee or control the individual services provided by these persons and does not assume any responsibility or liability for the services they provide and, therefore, cannot guarantee any results or outcomes. The availability of any particular provider cannot be guaranteed and is subject to change. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to www.aetna.com.

©2017 Aetna Inc. 44.03.508.1-ASA A (4/17)

www.mylifevalues.com Username: peaceofmind Password: solutions

myStrengthTM: the health club for your mindAetna Resources For LivingSM

Now you can use myStrength to help enhance your emotional well-being. It’s a new kind of online wellness portal. You can use it to support your mind, body and spirit. Best of all, it’s a free part of your program.

76.03.992.1-ASA A (4/17)

Strengthen your whole self

myStrength offers tools to improve your emotional health and help you overcome depression, anxiety, stress, substance misuse and/or chronic pain. Once you get set up with myStrength, you’ll log on to a home page created just for you.

myStrength is:

• Clinically proven • Easy to use

• Free and available 24/7 • Confidential

You can read articles, watch videos and try eLearning programs. Or you can just get inspired by the daily quote.

Aetna Resources For LivingSM is the brand name used for products and services offered through the Aetna group of subsidiary companies (Aetna). The EAP is administered by Aetna Behavioral Health, LLC and in California for Knox-Keene plans, Aetna Health of California, Inc. and Health and Human Resources Center, Inc.All calls are confidential, except as required by law. Information is not a substitute for professional health care and is not meant to replace the advice of health care professionals. Contact a health care professional with any questions or concerns about specific health care needs. This material is for informational purposes only. Aetna and myStrength are independent contractors. myStrength online access and services will be managed and provided separately and independently from Aetna. Aetna does not monitor or participate in the services or programs recommended or provided by myStrength. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to www.aetna.com.

©2017 Aetna Inc. 76.03.992.1-ASA A (4/17)

Give the app a try, too

You can get inspired on the go. With the myStrength app you can:

• Get custom inspiration based on your mood

• Track your mood over time

• Upload your own inspiring photos and videos

• Opt to receive check-in reminders

Easy sign-up

You can register for myStrength from the link on your member website.

Now you’re ready to start exploring all that myStrength has to offer.

“myStrength.com is a great wellness tool for your mind, body and spirit! I love the daily inspirational quotes and wellness articles. [It’s] a great way for me to proactively take care of myself.”

— myStrength user

www.mylifevalues.com Username: peaceofmind Password: solutions

“Cigna” is a registered service mark and the “Tree of Life” logo 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 by such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc.

Welcome to Cigna Payer Solutions Pharmacy Program. This program manages your prescription drugs and is administered through Cigna Pharmacy Management. There are several benefits offered to you as part of the Cigna Payer Solutions Pharmacy Program. We support you to help you get the most out of your pharmacy benefit plan, with personalized service to help you:

1. Learn what drugs are covered: Save money by checking out the covered drug list on myCigna.com or download the myCigna app. The amount you pay depends on whether your medication is listed as a generic, preferred brand, or non-preferred brand drug.

2. Compare prices: Use the Drug Quote Tool on myCigna.com to see what drugs cost with your plan. You can also compare prices for Cigna’s 68,000 nationwide participating pharmacies and Cigna Home Delivery Pharmacy.

3. Use Cigna Home Delivery Pharmacy or Cigna 90 Now: Now you can choose the best way to fill your maintenance medications with Cigna’s 90-day fill options. Use Cigna Home Delivery Pharmacy to have them delivered right to your door, or fill a 90-day supply at one of Cigna's 29,000 Cigna 90 Now pharmacies nationwide.

4. Get help with conditions that require specialty medications: Take advantage of TheraCare®, our chronic condition support service for customers who use injectable medications for conditions like multiple sclerosis, hepatitis C, and hemophilia.

5. Use the pharmacy page on myCigna.com and the myCigna app: You have 24/7 access to your pharmacy claim history, benefit details, recent industry and Cigna news, and the Drug Quote Tool to help compare prices. You can also manage your Cigna Home Delivery Pharmacy orders, or ask our pharmacist a question.

You’ll receive your new ID card within a week of your coverage start date. Please remember to show this card at your pharmacy in order to receive your prescription benefits. If you have any questions about your prescription benefits or would like more information, please feel free to call Cigna Payer Solutions at 1-800-325-1404 or visit myCigna.com. Welcome to Cigna Payer Solutions. We look forward to serving you. Sincerely, Wendy Sherry President, Cigna Payer Solutions

900 Cottage Grove Road Bloomfield, CT 06002

1. Use myCigna.comUse the website or app for quick access to:

› See your pharmacy claim history

› Read your benefit details

› See medication prices based on your plan

› Ask a pharmacist a question

› Manage your Cigna Home Delivery Pharmacy℠ orders and request refills1

2. Learn what medications are coveredSave money by checking out the list of medications covered under your plan on myCigna.com. The amount you pay depends on whether your medication is listed as a generic, preferred brand, non-preferred brand or specialty medication.

3. Use the Drug Cost tool2View medication costs based on your pharmacy plan, see if there are lower cost alternatives and compare prices between retail pharmacies and Cigna Home Delivery Pharmacy.1 When discussing medicines with your doctor, use the tool on the myCigna® app.

Five ways to get the most out of your pharmacy benefit plan

YOUR PHARMACY BENEFITS

Cigna Payer Solutions

4. Fill your medications in a 90-day supplyCigna 90 Now℠ makes it easier to fill the medications you take every day.

› Choose where you want to fill your 90-day prescriptions – at a 90-day retail pharmacy in your plan’s network, or through Cigna Home Delivery Pharmacy1

› Make life easier by taking fewer trips to the pharmacy to refill, and help stay healthy – with a 90-day supply on hand, you’re less likely to miss a dose3

› Go to Cigna.com/Rx90network to learn more about the benefits of a 90-day supply and the pharmacies in your plan’s network.

5. Get help with specialty medicationsWe can help you understand, manage and treat your condition. Our therapy management teams, made up of health advocates with nursing backgrounds and pharmacists, are specially trained to help deliver the best experience possible. We offer:

› Personalized, 24/7 support

› Condition-specific education on medication therapy and side effects

› Help with medication approval process

› Financial assistance programs if neededQuestions? Call the toll-free number on the back of your ID card.

1. Plans vary, so some plans may not include Cigna Home Delivery Pharmacy or 90-day retail pharmacy. Please check your plan materials for more information on what pharmacies are covered under your plan.2. Prices are not guaranteed, nor is the display of a price a guarantee of coverage. Your costs and coverage may vary at the time you fill your prescription at the pharmacy, and pricing at individual pharmacies may

vary. Coverage and pricing terms are subject to change. Your pharmacy may offer a special sale price on a specific medication which may be less than the price displayed here. Please consult your pharmacy.3. Internal Cigna analysis performed March 2016, utilizing 2015 Cigna national book of business average medication adherence (customer adherent > 80% PDC), 90-day supply vs. those who

received a 30-day supply taking antidiabetics, RAS antagonist and statins.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Tel-Drug, Inc., and Tel-Drug of Pennsylvania, L.L.C. “Cigna Home Delivery Pharmacy” refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.

887776a 04/18 © 2018 Cigna. Some content provided under license.

Once you do, you’ll be able to:

› Find in-network doctors, labs, urgent care centers and other facilities

› Compare provider cost and quality information

› Get cost estimates for medical procedures

› Compare prescription drug costs based on your plan

› Learn more about pharmacy home delivery and order refills of your prescriptions

› View pharmacies in a simple map view and get directions via Google Maps® or Apple Maps®

› Access a variety of health and wellness tools and resources

Offered by Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company or their affiliates.

939061 a 03/21

ISN’T IT GREAT WHEN THINGS JUST CLICK?

The myCigna® website and app make it easy to take control.

Two easy ways to register. One easy experience.› Go to myCigna.com

› Or, download the myCigna App*

Register today.

Easily find the information you need to manage your health and access your pharmacy coverage, including powerful tools, information and resources to help you make informed health care decisions. It’s all ready and waiting for you on myCigna.com and the myCigna App. All you have to do is register.

* The downloading and use of the myCigna mobile app is subject to the terms and conditions of the app and the online store from which it is downloaded. Standard mobile phone carrier and data usage charges apply.


All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C. “Cigna Home Delivery Pharmacy” refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.

939061 a 03/21 © 2021 Cigna. Some content provided under license.

Enhanced registration processWhen you register for the first time on myCigna, you’ll be required to provide a primary email address. Having an email address helps better protect the information in your myCigna account. We can send automatic alerts when you update your email or password. Your email address also can be used when you need help recovering your user ID or password.

You can register for myCigna by following these steps.

1. Go to myCigna.com and select “Register.”

2. Enter requested information.

3. Confirm identity.

4. Create a myCigna user ID and password, and answer security-related questions.

5. Review and submit.

Two-step authenticationWith two-step authentication, you will need to add an extra layer of security to your myCigna account to further protect your account information.

How does it work?

1. First, as part of the two-step authentication process, you will need to verify either your email address or your mobile phone number, or you can verify both. Verifying your contact information is an important step and is required as part of the two-step authentication because it allows Cigna to send two-step authentication codes.

2. Once you enable two-step authentication and log in to myCigna, you will be asked to enter your user ID and password as well as a six-digit code that will be sent to either your email address or mobile phone number. You will be offered the choice to select “Remember this Device.” If you choose this option, you will not be prompted for a code each time you log in to myCigna.

Helping protect your health and health informationTrust is important to us, and we are as committed to helping protect your health information as we are to protecting your health and well-being. That’s why we’ve taken steps to enhance the security of the registration and login process on the myCigna website and app and enabled a two-step authentication process.

Una vez que lo haga, podrá:

› Encontrar médicos, laboratorios, centros de cuidado de urgencia y otros centros de la red

› Comparar información sobre el costo y la calidad de los proveedores

› Obtener estimaciones de costos de procedimientos médicos

› Comparar los costos de medicamentos con receta según su plan

› Obtener más información sobre el servicio de entrega a domicilio de farmacia y pedir renovaciones de sus recetas

› Ver farmacias en un mapa sencillo y obtener indicaciones para llegar por medio de Google Maps® o Apple Maps®

› Acceder a diversas herramientas y recursos relacionados con la salud y el bienestar

Ofrecido por Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company o sus afiliadas.

939061SP a 03/21

¿NO ES MARAVILLOSO CUANDO LAS COSAS SON FÁCILES?

Con el sitio web y la aplicación myCigna®, es fácil tomar control.

Dos maneras fáciles de registrarse. Una experiencia fácil.› Visite myCigna.com

› O descargue la aplicación myCigna*

Regístrese hoy mismo.

Encuentre fácilmente la información que necesita para controlar su salud y acceder a su cobertura de farmacia, incluso herramientas poderosas, información y recursos para ayudarle a tomar decisiones informadas sobre el cuidado de su salud. Ya está todo listo y esperándole en myCigna.com y la aplicación myCigna. Solo tiene que registrarse.

* La descarga y el uso de la aplicación móvil myCigna están sujetos a los términos y las condiciones de la aplicación y la tienda en línea desde la cual se descargue. Se aplican los cargos estándares de las compañías de telefonía celular y uso de datos.


Todos los productos y servicios de Cigna son brindados exclusivamente por subsidiarias operativas de Cigna Corporation, o a través de ellas, que incluyen a Cigna Health and Life Insurance Company, Tel-Drug, Inc. y Tel-Drug of Pennsylvania, L.L.C. “Cigna Home Delivery Pharmacy” se refiere a Tel-Drug, Inc. y Tel-Drug of Pennsylvania, L.L.C. El nombre de Cigna, el logo y otras marcas de Cigna son propiedad de Cigna Intellectual Property, Inc.

939061SP a 03/21 © 2021 Cigna. Parte del contenido se suministra bajo licencia.

Proceso de registro mejoradoCuando se registre por primera vez en myCigna, deberá proporcionar una dirección de correo electrónico principal. Tener una dirección de correo electrónico ayuda a proteger mejor la información de su cuenta de myCigna. Podemos enviarle alertas automáticas cuando actualice su correo electrónico o su contraseña. También puede usar su dirección de correo electrónico cuando necesite recuperar su ID de usuario o contraseña.

Siga estos pasos para registrarse en myCigna.

1. Visite myCigna.com y seleccione Register (Registrarse).

2. Introduzca la información solicitada.

3. Confirme su identidad.

4. Cree un ID de usuario de myCigna y una contraseña, y responda las preguntas de seguridad.

5. Revise la información y envíela.

Autenticación en dos pasosCon la autenticación en dos pasos, deberá agregar un nivel de seguridad adicional a su cuenta de myCigna para proteger aún más la información de su cuenta.

¿Cómo funciona?

1. Primero, como parte del proceso de autenticación en dos pasos, tendrá que verificar su dirección de correo electrónico o su número de teléfono celular, o puede verificar ambos. Verificar su información de contacto es un paso importante y es obligatorio como parte del proceso de autenticación en dos pasos, porque le permite a Cigna enviar los códigos de la autenticación en dos pasos.

2. Una vez que habilite la autenticación en dos pasos e inicie sesión en myCigna, se le pedirá que ingrese su ID de usuario y contraseña, y un código de seis dígitos que se le enviará a su dirección de correo electrónico o a su número de teléfono celular. Se le ofrecerá la posibilidad de elegir Remember this Device (Recordar este dispositivo). Si elige esta opción, no se le pedirá un código cada vez que inicie sesión en myCigna.

Le ayudamos a proteger su salud y su información sobre la saludLa confianza es importante para nosotros, y nuestro compromiso para ayudarle a proteger su información sobre la salud es el mismo que asumimos para proteger su salud y bienestar. Es por eso que tomamos medidas para mejorar la seguridad del proceso de registro e inicio de sesión en el sitio web y la aplicación myCigna, y habilitamos un proceso de autenticación en dos pasos.

You have a lot going on. Taking your medication every day and remembering to pick up your refill every month isn’t always easy. We have a program that can help – it’s called Cigna 90 Now.

90-DAY PRESCRIPTION FILLSFilling your maintenance medications just got easier with Cigna 90 NowSM

More choice

Your plan includes a new maintenance medication program called Cigna 90 Now. Maintenance medications are taken regularly, over time, to treat an ongoing health condition. Cigna 90 Now offers you more choice in how, and where, you can fill your prescription.

Choose what works best for you

› If you choose to fill your prescription in a 90-day supply, you have to use a 90-day retail pharmacy in your plan’s new network, or Cigna Home Delivery PharmacySM.*

› If you choose to fill your prescription in a 30-day supply, you can use any retail pharmacy in your plan’s new network.

Where you can fill a 90-day prescription

With Cigna 90 Now, your plan offers a new retail pharmacy network that gives you more choice in where you can fill your 90-day prescriptions.

There are thousands of retail pharmacies in your new network. They include local pharmacies, grocery stores, retail chains and wholesale warehouse stores – all places where you may already shop! If you prefer the convenience of having your medications delivered to your home, you can also use Cigna Home Delivery Pharmacy to fill your prescriptions.*

For more information about your new pharmacy network, you can go to Cigna.com/Rx90network.

Why fill a 90-day supply?

Filling your prescriptions in a 90-day supply may help you stay healthy because having a 90-day supply of your medication on-hand typically means you’re less likely to miss a dose.** It also means you can make fewer visits to the pharmacy to refill your medication, and depending on your plan, you may be able to save money by filling your prescriptions 90-days at a time.

You choose! 90-day or 30-day supply.

Here are some of the 90-day retail pharmacies in your network:***

› CVS (including Target and Navarro)

› Walmart

› Kroger (including Harris Teeter Pharmacy, Pick N Save Pharmacy, Fred Meyer Pharmacy, Fry’s Food and Drug)

› Access Health (including Benzer Pharmacy, Marcs, Big Y Pharmacy, Marsh Drugs, LLC, Snyder Drug Emporium)

› Good Neighbor Pharmacies (including Big Y Pharmacy, Super RX Pharmacy, Medical Center Pharmacy, Family Pharmacy, King Kullen Pharmacy)

› Cardinal Health (including Freds Pharmacy, Medicine Shoppe Pharmacy, Harris Teeter Pharmacy, Medicap Pharmacy)

893345 e VoluntaryCigna90Now 11/16

http://Cigna.com/Rx90network

90-Day Fills

Prefer to have your medications delivered to your door?

Then Cigna Home Delivery Pharmacy may be right for you! We’ll deliver your maintenance medication to you at the location of your choice. And standard shipping is always free. No more waiting in line at the pharmacy! For more information, please call Customer Service at 800.285.4812, or visit Cigna.com/home-delivery-pharmacy.

Get a 90-day prescription for your medication

Get a 30-day prescription for your maintenance medication

Take your prescription to a 90-day retail pharmacy in your network,

or mail to Cigna Home Delivery Pharmacy

Take your prescription to any retail pharmacy in your network

Receive your medication in a 90-day supply for

convenience

Receive your medication

30-Day Fills

* Plans vary, so some plans may not include Cigna Home Delivery Pharmacy. Please check your plan materials for more information on what pharmacies are covered under your plan.

** Internal Cigna analysis performed March 2016, utilizing 2015 Cigna national book of business average medication adherence (customer adherent > 80% PDC), 90-day supply vs. those who received a 30-day supply taking antidiabetics, RAS antagonist and statins.

*** Participating 90-day network pharmacies as of April 2016. Subject to change.

Para obtener ayuda en español llame al número en su tarjeta de Cigna.

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 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. Refer to your plan documents for costs and complete details of your plan’s prescription drug coverage.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Health Management, Inc., Tel-Drug, Inc., and Tel-Drug of Pennsylvania, L.L.C. “Cigna Home Delivery Pharmacy” refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.

893345 e VoluntaryCigna90Now 11/16 © 2016 Cigna. Some content provided under license.

Questions?

Please call Customer Service using the number on the back of your Cigna ID card. We’re here to help.

http://www.cigna.com/home-delivery-pharmacy

957392 Advantage 09/21

Medication Coverage Changes

These are the medication coverage changes Cigna is making as of January 1, 2022.1,2 Medications are listed alphabetically.

If you’re affected by one of these changes, we’ll send you a letter with specific information on next steps.

Starting January 1, 20221,2

MEDICATION NAME/

DRUG CLASSWHAT’S CHANGING ADDITIONAL INFORMATION

adapalene 0.1% swab(Skin Conditions)

Will no longer be covered because it’s

being taken off the Cigna Advantage

Prescription Drug List.3

• Allcurrentcoverageapprovalswillendon

December31st.4

• Consider these covered options which

are used to treat the same condition:

adapalene 0.1% cream, 0.1% lotion, 0.3% gel,

tazarotene 0.1% cream, tretinoin cream, gel

or micro gel.

ATRIPLA(AIDS/HIV)





December31st.4



efravirenz/emtricitabine/tenofovir.

BROVANA

(Asthma/COPD/Respiratory)






arformoterol nebulizer solution (generic

BROVANA).

bupropion XL 450mg tablet (Anxiety/Depression/Bipolar Disorder)






bupropion XL 150mg tablet.

Generic medications are listed in all lowercase letters and brand-name medications are listed in all capital letters.

2

Medication Coverage Changes – Starting January 1, 2022


MEDICATION NAME/


BYDUREON(Diabetes)

Will need approval from Cigna before it

can be covered.6• Thischangedoesn’taffectcustomersusing

thismedicationtotreatType2Diabetes.


December31st.4

• Your plan will only cover this medication if

your doctor’s office requests and receives

approval from Cigna.

BYETTA(Diabetes)





December31st.4




CHENODAL (Gastrointestinal/Heartburn)


can be covered.6• Thischangedoesn’taffectcustomers

withCerebrotendinouscholesterosis(van

Bogaert-Scherer-Epstein).




clindamycin 1% gel (Skin Conditions)






clindamycin 1% gel (generic CLEOCIN T),

dapsone 5% gel, topical erythromycin

2% gel.

dexchlorpheniramine 2mg/5ml(Allergy/Nasal Sprays)






carbinoxamine, cyproheptadine,

hydroxyzine.

dihydroergotamine 4mg/ml spray(Pain Relief and Inflammatory Disease)






sumatriptan nasal spray.

efavirenz-emtricitabine-tenofovir 600/200/300 tab(AIDS/HIV)

Will no longer need approval from Cigna

before it can be covered.

• Your doctor’s office no longer has to

request coverage approval from Cigna.

emtricitabine 200mg capsule(AIDS/HIV)





3



MEDICATION NAME/


EMTRIVA 200mg capsule(AIDS/HIV)





December31st.4



emtricitabine capsule.

etravirine 25mg, 100mg, 200mg tablet(AIDS/HIV)





fenoprofen 400mg

(Pain Relief and Inflammatory Disease)




• Consider these covered options which are

used to treat the same condition: Generic

NSAID (e.g. celecoxib; meloxicam).

FERAHEME

(Nutritional/Dietary)


can be covered.6• Your plan will only cover this medication if



FORFIVO(Anxiety/Depression/Bipolar Disorder)





December31st.4



bupropion XL 150mg tablet.

halobetasol 0.05% foam(Skin Conditions)






augmented betamethasone dipropionate,

betamethasone dipropionate cream/

ointment, clobetasol propionate,

fluocinonide 0.1% cream, halobetasol

cream/ointment.

HEPARIN 5,000 unit/ml syringe(Blood Thinners/Anti-Clotting)

Will move to a higher tier (non-preferred

brand) on the Cigna Advantage

Prescription Drug List.

• This medication may cost you more to fill.

• Consider these options which are used to

treat the same condition and may cost you

less: HEPARIN 5,000 unit/ml carpuject.

INJECTAFER






INTELENCE

(AIDS/HIV)





December31st.4


used to treat the same condition: etravirine.

JUXTAPID(Cholesterol Medications)




• Thischangedoesn’taffectcustomers

currentlyusingthismedication.


used to treat the same condition: REPATHA.

4



MEDICATION NAME/


KALETRA

(AIDS/HIV)





used to treat the same condition: lopinavir/

ritonavir tablet.

ketoprofen 25mg capsule(Pain Relief And Inflammatory Disease)







KEVEYIS (Miscellaneous)


can be covered.6• Thischangedoesn’taffectcustomerswith

periodicparalysis,Myotoniacongenital,or

Andersen-Tawilsyndrome.




KRISTALOSE 10gm, 20gm packet(Gastrointestinal/Heartburn)






CONSTULOSE, ENULOSE, lactulose

solution.

lactulose 10gm packet(Gastrointestinal/Heartburn)






CONSTULOSE, ENULOSE, lactulose

solution.

levalbuterol HFA (Asthma/COPD/Respiratory)






albuterol HFA.

methylphenidate ER 72mg (Attention Deficit Hyperactivity Disorder)




• Ifyoucurrentlyhaveapprovalforthis

medicationtobecovered,thatapproval

willendonDecember31st.4,6



methylphenidate ER 36mg tablet.

MONOFERRIC






MULTAQ (Blood Pressure/Heart Medications)




• Thischangedoesn’taffectcustomers

currentlyusingthismedication.



amiodarone, disopyramide, dofetilide,

flecainide, propafenone. quinidine, sotalol AF.

5



MEDICATION NAME/


NALFON 400mg capsule (Pain Relief And Inflammatory Disease)





December31st.4




NAPROSYN 125mg/5ml suspension(Pain Relief And Inflammatory Disease)





December31st.4




naproxen 125mg/5ml suspension(Pain Relief And Inflammatory Disease)







niacin 500mg

(Cholesterol Medications)





used to treat the same condition: niacin ER.

NIACOR 500mg

(Cholesterol Medications)





used to treat the same condition: niacin ER.

NORGESIC FORTE 50-770-60mg(Pain Relief And Inflammatory Disease)






chlorzoxazone 500mg tablet, metaxalone,

methocarbamol, orphenadrine ER.

NULOJIX 250mg vial (Transplant Medications)





orphenadrine-aspririn-caffeine 50-770-60mg(Pain Relief And Inflammatory Disease)








ORPHENGESIC FORTE 50-770-60mg

(Pain Relief And Inflammatory Disease)








oxiconazole 1% cream(Skin Conditions)






econazole cream, ketoconazole cream,

naftifine cream.

6



MEDICATION NAME/


OZEMPIC(Diabetes)





December31st.4




OZOBAX 5mg/5ml solution(Pain Relief And Inflammatory Disease)






baclofen tablet.

PERFOROMIST(Asthma/COPD/Respiratory)






formoterol nebulizer solution (generic

PERFOROMIST).

RELEXXI 72mg(Attention Deficit Hyperactivity Disorder)




• Ifyoucurrentlyhaveapprovalforthis

medicationtobecovered,thatapproval

willendonDecember31st.4,6



methylphenidate ER 36mg tablet.

RYBELSUS(Diabetes)





December31st.4




RYCLORA 2mg/5ml(Allergy/Nasal Sprays)






carbinoxamine, cyproheptadine,

hydroxyzine.

SANDOSTATIN LAR(Hormonal Agents)




• This medication may cost you more to fill.5



less: SOMATULINE DEPOT.

SEGLUROMET(Diabetes)





December31st.4



SYNJARDY, SYNJARDY XR, XIGDUO XR.

7



MEDICATION NAME/


SINUVA(Allergy/Nasal Sprays)




• Talk with your doctor about other

alternatives.

SPIRIVA, SPIRIVA RESPIMAT(Asthma/COPD/Respiratory)

Will move/moved to a lower tier

(preferred brand) on the Cigna

Advantage Prescription Drug List.

• This medication may cost you less to fill.

STEGLATRO(Diabetes)





December31st.4


used to treat the same condition: FARXIGA,

JARDIANCE, metformin.

STIOLTO RESPIMAT(Asthma/COPD/Respiratory)




• This means it may cost you less to fill.

SYMFI, SYMFI LO (AIDS/HIV)






efravirenz/lamivudine/tenofovir.

SYNTHROID (Hormonal Agents)






levothyroxine.

TASIGNA(Cancer)







less: imatinib, SPRYCEL.

THIOLA, THIOLA EC(Urinary Tract Conditions)





used to treat the same condition: tiopronin.

triamcinolone 0.05% ointment, triamcinolone 0.147 mg/g spray (Skin Conditions)






desoximetasone 0.05% cream/

ointment, fluocinolone 0.025% ointment,

flurandrenolide 0.05% ointment,

hydrocortisone valerate 0.2% ointment,

mometasone 0.1% cream.

TRULICITY(Diabetes)





December31st.4




8



MEDICATION NAME/


UDENYCA(Blood Modifiers/Bleeding Disorders)







less: NEULASTA, NYVEPRIA, ZIEXTENZO.

VICTOZA(Diabetes)





December31st.4




ZIEXTENZO(Blood Modifiers/Bleeding Disorders)




• This medication may cost you less to fill.

Plan/Benefit Exclusions

The medications listed below will be excluded from coverage on the Cigna Advantage Prescription Drug List. These medications are not approved by the U.S. Food and Drug Administration (FDA). Cigna plans only cover medications that are FDA-approved for safety and effectiveness.


MEDICATION NAME/DRUG CLASS

ATOPICLAIR cream

(Skin Conditions)

AVO cream topical emulsion

(Skin Conditions)

B-12 compliance inj kit


balsam peru castor oil ointment

(Skin Conditions)

BENSAL HP 3% ointment

(Skin Conditions)

BIAFINE emulsion

(Skin Conditions)

BIONECT 0.2% cream

(Skin Conditions)

BP CLEANSING WASH

(Skin Conditions)


CELACYN gel

(Skin Conditions)

CEM-UREA 45% pre-filled applicator

(Skin Conditions)

DERMAZENE cream, cream packet

(Skin Conditions)

GORDON’S UREA 22% ointment

(Skin Conditions)

HALUCORT gel

(Skin Conditions)

hydrocortisone-iodoquinol-aloe sachet

(Skin Conditions)

hydrocortisone-iodoquinol cream

(Skin Condtions)

KERAFOAM 30%, 42% FOAM

(Skin Conditions)

9



KERALYT 6% gel, scalp complete kit

(Skin Conditions)

MIMYX

(Skin Conditions)

PAIN EASE medium stream spray

(Pain Relief And Inflammatory Disease)

PHYSICIANS EZ USE B-12 kit

(Nurtritional/Dietary)

PODOCON-25 liquid

(Skin Conditions)

PR cream kit

(Skin Conditions)

PROMISEB topical cream

(Skin Conditions)

PRUMYX cream

(Skin Conditions)

PRUTECT topical emulsion

(Skin Conditions)

QUTENZA 8% kit (1 patch, 2 patch)

(Skin Condtions)

RADIAPLEXRX gel

(Skin Conditions)

RECEDO topical gel

(Skin Conditions)

salicylic acid 26% liquid, 27.5% liquid, 6% cream, 6%

cream kit, 6% foam, 6% gel, 6% lotion, 6% shampoo;

salicylic acid ER 28.5% solution

(Skin Conditions)

Plan/Benefit Exclusions (cont)


SALIMEZ FORTE 10% cream

(Skin Conditions)

SALKERA 6% foam

(Skin Conditions)

SALVAX 6% foam; SALVAX DUO PLUS combo pack

(Skin Conditions)

silver nitrate 0.5% solution, silver nitrate applicatior

(Skin Conditions)

sodium sulfacetamide-sulfur cleanser

(Skin Conditions)

SONAFINE topical emulsion

(Skin Conditions)

UMECTA 40% mousse

(Skin Conditions)

URAMAXIN 20% foam

(Skin Conditions)

UREA 35% foam, 39% cream, 40% cream, 40% gel,

40% lotion, 41% cream, 45% cream, 45% nail gel, 47%

cream, 50% cream, 50% nail stick

(Skin Conditions)

URE-K 50% cream

(Skin Conditions)

VASHE WOUND THERAPY solution

(Miscellaneous)

VENELEX ointment

(Skin Conditions)

XUREA 39% cream

(Skin Conditions)

Questions?

› myCigna.com: Click to Chat Monday–Friday, 9:00 am–8:00 pm EST.

› Phone: Call the number on your Cigna ID card, 24/7/365.


1. State laws in Texas and Louisiana may require your plan to cover your medication at your current benefit level until your plan renews. This means that if your medication is taken off the drug list, is moved to a higher cost-share tier or needs approval from Cigna before your plan will cover it, these changes may not begin until your plan’s renewal date. To find out if these state laws apply to your plan, please call Customer Service using the number on your Cigna ID card.

2. State law in Illinois may require your plan to cover your medications at your current benefit level until your plan renews. This means that if you currently have approval through a review process for your plan to cover your medication, the drug list change(s) listed here may not affect you until your plan renewal date. If you don’t currently have approval through a coverage review process, you may continue to receive coverage at your current benefit level if your doctor requests it. To find out if this state law applies to your plan, please call Customer Service using the number on your Cigna ID card.

3. If your doctor feels an alternative isn’t right for you, your doctor can ask Cigna to consider approving coverage of this medication.4. If your doctor wants you to continue using this medication, ask his or her office to contact Cigna to start the coverage review process, or to appeal the denial of coverage. They know how the

process works and will take care of everything for you.5. If your plan covers this medication on Tier 4, your cost-share won’t change. 6. This change may not apply to your specific plan. Log in to the myCigna® App or myCigna.com to see how your plan covers this medication.Para obtener ayuda en español llame al número en su tarjeta de Cigna.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 provider, purchased from a licensed pharmacy and medically necessary. If your plan provides coverage for certain prescription drugs with no cost-share, customers may be required to use an in-network pharmacy to fill the prescription. If customers use a pharmacy that does not participate in your plan’s network, the prescription may not be covered, or reimbursement may be limited by your plan’s copay, coinsurance or deductible requirements.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, and HMO or service company subsidiaries of Cigna Health Corporation. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.

957392 Advantage 09/21 © 2021 Cigna. Some content provided under license.

COMPLEX CONDITIONS. PERSONALIZED SERVICE.

Accredo is now a Cigna specialty pharmacy.

927282 06/19

Accredo has joined the Cigna family.Accredo, one of the leading specialty pharmacies in the United States, is now a Cigna specialty pharmacy. Accredo can help you manage your complex medical condition. They can also fill and ship your specialty medication to your home (or location of your choice).1,2 Specialty medications are used to treat complex conditions like multiple sclerosis, hepatitis C and rheumatoid arthritis.

Your health and well-being are our first priority.Managing a complex medical condition isn’t easy. The Accredo team of specialty-trained pharmacists and nurses will provide you with the personalized care and support you need to manage your therapy. Accredo will help you work through side effects, check in with you and your doctor to see how your therapy’s going, help you get your medications approved for coverage, and more.

Three ways Accredo supports you.

Personalized care and support.

› You have 24/7 access to pharmacists and nurses with experience and training in complex conditions that require specialty medications.

› You have access to a wide range of personalized care services. This includes counseling, help managing side effects and one-on-one guidance from a clinician on how to administer your medication.

› Accredo will work with your doctor to help make sure you’re getting the care and medication you need.

› Accredo will give you more choice in how you want to connect with them – by text, phone and/or online resources.

Making it easy for you to get your medication.

› Accredo will schedule and quickly ship your medications (at no extra cost to you) – even those that need special handling, like refrigeration.

› Accredo will send supplies (like syringes and a sharps container) at no extra cost to you.

› Accredo will send you refill reminders to help make sure you don’t miss a dose. You can also refill certain prescriptions by text.3

› Get real-time updates once Accredo ships your order.4

What’s a “specialty pharmacy”?A specialty pharmacy fills specialty medications. Specialty medications are typically injected or infused and may need special handling (like refrigeration).

21

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Accredo Health Group, Inc., and HMO or service company subsidiaries of Cigna Health Corporation. “Accredo” refers to Accredo Health Group, Inc. The Cigna name, logo, “Together, all the way.,” and “myCigna” are trademarks of Cigna Intellectual Property, Inc. “Accredo” is a trademark of Express Scripts Strategic Development, Inc.

927282 06/19 © 2019 Cigna. Some content provided under license.

1. As allowable by law. 2. Not all specialty prescriptions moved to Accredo. Cigna will let you know which of your prescriptions has moved. 3. The ability to refill prescriptions by text is only available for certain medications. 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, simply reply to their welcome text to get started. Standard text messaging rates apply. 4. You’ll see your first order in the myCigna app or website once Accredo ships it.

Help understanding your plan’s coverage and medication costs.

› Many specialty medications need approval from Cigna before your plan will cover them. Accredo will help you and your doctor’s office work through that process.

› You have access to a dedicated team that coordinates copay assistance and other options if you need help paying for your medication.

Learn more about Accredo.

Go to Cigna.com/specialty. You can also call 877.826.7657 to talk with an Accredo representative.

Two easy ways to manage your specialty medication

1. Log in to the myCigna® app or website. Simply go to the home delivery dashboard. As soon as Accredo ships your medication, you’ll see it listed under “Accredo.” Then click on the button next to your medication name. We’ll automatically connect you to your Accredo dashboard.

2. Go to Accredo.com. You’ll be asked to create an account to get to your dashboard. It’s important to know that you’ll need an Accredo Rx number to log in. That means you won’t be able to do this until you’ve filled a prescription with Accredo.

3

Some of the conditions Accredo supports:

› Age-related macular degeneration

› Alpha-1 antitrypsin deficiency

› Anemia

› Severe asthma

› Cancer

› Crohn’s disease

› Cystic fibrosis

› Deep vein thrombosis

› Growth hormone deficiency

› Hemophilia

› Hepatitis C

› Hereditary angioedema

› Hereditary tyrosinemia

› Immune deficiency

› Infertility

› Lysosomal storage disorders

› Multiple sclerosis

› Neutropenia

› Orphan and ultra-orphan conditions

› Osteoarthritis

› Osteoporosis

› Psoriasis

› Pulmonary arterial hypertension

› Respiratory syncytial virus

› Rheumatoid arthritis

CIGNA ADVANTAGE 3-TIER PRESCRIPTION DRUG LIST

Coverage as of January 1, 2022

Offered by Cigna Health and Life Insurance Company or Connecticut General Life Insurance Company

887152 x Advantage 3-Tier 08/21

2

What’s inside?

About this drug list 3

How to read this drug list 3

How to find your medication 5

Medications that aren’t covered 19

Frequently Asked Questions (FAQs) 36

Exclusions and limitations for coverage 40

* Drug list created: originally created 03/01/2011 Last updated: 08/01/2021, for changes starting 01/01/2022

Next planned update: 03/01/2022, for changes starting 07/01/2022

Cigna.com/druglist. Select Advantage 3 Tier from the drop down menu. Then type in your medication name or view the full list.

Questions?

› myCigna.com: Click to chat Monday-Friday, 9:00 am-8:00 pm EST.› By phone: Call the toll-free number on your Cigna ID card. We’re here 24/7/365.

View the drug list online

This document was last updated on 08/01/2021.* You can go online to see the current list of medications your plan covers.

myCigna® App and myCigna.com. Click on the “Find Care & Costs” tab and select “Price a Medication.” Then type in your medication name to see how it’s covered.

3

TIER 1$

TIER 2$$

BLOOD PRESSURE/HEART MEDICATIONSafeditab CRamlodipine besylateamlodipine besylate-benazeprilamlodipine-valsartanamlodipine-valsartan-HCTZatenololatenolol-chlorthalidonebenazepril benazepril-HCTZcandesartan cilexetilcartia XTcarvedilolclonidinedigitekdigoxdigoxindiltiazem ERdiltiazem CDdiltiazem dilt-XRenalapril flecainide acetatehydralazine irbesartanisosorbide mononitrat

BERINERT* (PA)BIDILBYSTOLICCINRYZE* (PA)COREG CRCOZAAR (ST)DIOVAN (ST)DIOVAN HCT (ST)EDARBI (ST)EDARBYCLOR (ST)EXFORGEEXFORGE HCTFIRAZYR* (PA)HEMANGEOLINDERAL LAINDERAL XLINNOPRAN XLLOTRELMICARDIS (ST)MULTAQNITRO-DURNITROLINGUALNITROMISTNITRONALNITROSTATNORTHERA* (PA)NORVASCRANEXA (ST)TEKTURNATEKTURNA HCT

About this drug list

Medications are grouped by the condition they treat

Medications that have extra coverage requirements will have an abbreviation listed next to them

Medications are listed in alphabetical order within each column

Brand-name medications are in all capital letters

Generic medications are in all lowercase letters

Specialty medications have an asterisk (*) listed next to them

Tier (cost-share level) gives you an idea of how much you may pay for a medication

3

This chart is just a sample. It may not show how these medications are actually covered on the Cigna Advantage 3-Tier Prescription Drug List.

This is a list of the most commonly prescribed medications covered on the Cigna Advantage 3-Tier Prescription Drug List as of January 1, 2022.1,2 Medications are listed by the condition they treat, then listed alphabetically within tiers (or cost-share levels).

The drug list is updated often so it isn’t a complete list of the medications your plan covers. Also, your specific plan may not cover all of these medications. Log in to the myCigna App or myCigna.com, or check your plan materials, to see all of the medications your plan covers.

Prescription medications used to treat allergies (ex. Allegra, Clarinex, Xyzal and generics) and heartburn/stomach acid conditions (ex. Nexium, Prilosec and generics) aren’t covered on this drug list. These medications are considered plan (or benefit) exclusions. You can get over-the-counter (OTC) versions at the pharmacy without a prescription.

How to read this drug listUse the chart below to help you read this drug list. This chart is just an example. It may not show how these medications are actually covered on the Cigna Advantage 3-Tier Prescription Drug List.

4

Tiers

Covered medications are divided into tiers, or cost-share levels. Typically, the higher the tier, the higher the price you’ll pay to fill the prescription.

› Tier 1 – Typically Generics (Lowest-cost medication) $

› Tier 2 – Typically Preferred Brands (Medium-cost medication) $$

› Tier 3 – Typically Non-Preferred Brands (Highest-cost medication) $$$

Abbreviations next to medications

In this drug list, medications that have limits and/or extra coverage requirements have an abbreviation listed next to them.* Here’s what they mean.

(PA) Prior Authorization – Certain medications need approval from Cigna before your plan will cover them. These medications have a (PA) next to them. Your plan won’t cover these medications unless your doctor requests, and receives, approval from Cigna.

(QL) Quantity Limits – Some medications have a quantity limit. This means your plan will only cover up to a certain amount over a certain length of time. These medications have a (QL) next to them. Your plan will only cover a larger amount if your doctor requests, and receives, approval from Cigna.

(ST) Step Therapy – Certain high-cost medications aren’t covered until you try one or more lower-cost alternatives first.** These medications have a (ST) next to them. You have many covered options to choose from, and they’re used to treat the same condition.

(AGE) Age Requirements – Certain medications will only be covered if you’re within a specific age range. These medications have (AGE) next to them. If you’re not within the allowed age range, your plan will only cover the medication if your doctor requests, and receives, approval from Cigna.

* These coverage requirements may not apply to your specific plan. Log in to the myCigna App or myCigna.com, or check your plan materials, to find out if your plan includes prior authorization, quantity limits, Step Therapy, and/or age requirements.

** If your doctor feels an alternative isn’t right for you, he or she can ask Cigna to consider approving coverage of your medication.

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.

Specialty medications have an asterisk next to them

Specialty medications are used to treat complex medical conditions. In this drug list, specialty medications have an asterisk (*) next to them. Some plans cover specialty medications on a specialty tier, limit coverage to a 30-day supply, and/or require you to use a preferred specialty pharmacy to get coverage. Log in to the myCigna App or myCigna.com, or check your plan materials, to see how your plan covers these medications.

5

Condition Page

AIDS/HIV 6

ALLERGY/NASAL SPRAYS 6

ALZHEIMER’S DISEASE 6

ANXIETY/DEPRESSION/BIPOLAR DISORDER

6

ASTHMA/COPD/RESPIRATORY 6, 7

ATTENTION DEFICIT HYPERACTIVITY DISORDER

7

BLOOD MODIFIERS/BLEEDING DISORDERS 7

BLOOD PRESSURE/HEART MEDICATIONS 7, 8

BLOOD THINNERS/ANTI-CLOTTING 8

CANCER 8

CHOLESTEROL MEDICATIONS 8

CONTRACEPTION PRODUCTS 9, 10

COUGH/COLD MEDICATIONS 10

DENTAL PRODUCTS 10, 11

DIABETES 11

DIURETICS 11

EAR MEDICATIONS 11

EYE CONDITIONS 11, 12

FEMININE PRODUCTS 12

Condition Page

GASTROINTESTINAL/HEARTBURN 12, 13

HORMONAL AGENTS 13

INFECTIONS 13, 14

INFERTILITY 14

MISCELLANEOUS 14

MULTIPLE SCLEROSIS 14

NUTRITIONAL/DIETARY 14, 15

OSTEOPOROSIS PRODUCTS 15

PAIN RELIEF AND INFLAMMATORY DISEASE 15, 16

PARKINSON’S DISEASE 16

SCHIZOPHRENIA/ANTI-PSYCHOTICS 16

SEIZURE DISORDERS 16,

SKIN CONDITIONS 16, 17

SLEEP DISORDERS/SEDATIVES 17

SMOKING CESSATION 17

SUBSTANCE ABUSE 17

TRANSPLANT MEDICATIONS 17

URINARY TRACT CONDITIONS 17, 18

VACCINES 18

No cost-share preventive medications have a plus sign next to them

Health care reform under the Patient Protection and Affordable Care Act (PPACA) requires plans to cover certain preventive medications and products at 100%, or no cost-share ($0), to you. In this drug list, these medications have a plus sign (+) next to them. Log in to the myCigna App or myCigna.com, or check your plan materials, to see how your plan covers these medications.

Plan/benefit exclusions

Your plan doesn’t cover certain medications and products because they’re considered plan/benefit exclusions. For example, your plan excludes prescription medications used to treat allergies (ex. Allegra, Clarinex, Xyzal and generics) and heartburn/stomach acid conditions (ex. Nexium, Prilosec and generics). With excluded medications, there’s no option to receive coverage through Cigna’s review process by showing that you need the medication or product for your treatment. In this drug list, these medications have a caret (^) next to them. Log in to the myCigna App or myCigna.com, or check your plan materials, to see which medications your plan excludes.

How to find your medication First, look for your condition in the alphabetical list below. Then, go to that page to see the covered medications available to treat the condition.

6

TIER 1$

TIER 2$$

TIER 3 $$$

AIDS/HIVabacavir-lamivudine* (PA)

efavirenz-emtricitabine-tenofovir*

emtricitabine-tenofovir*+

ritonavir*tenofovir* (PA)

BIKTARVY*DESCOVY*+ (PA)DOVATO*GENVOYA*ISENTRESS HD* (PA)ISENTRESS*JULUCA*PREZISTA*SELZENTRY* (PA)SYMTUZA*TIVICAY PD*TIVICAY*TRIUMEQ*

CIMDUO* (PA)COMPLERA* (PA)EVOTAZ* (PA)ODEFSEY* (PA)PIFELTRO* (PA)PREZCOBIX* (PA)STRIBILD* (PA)TEMIXYS* (PA)

ALLERGY/NASAL SPRAYSazelastine azelastine-fluticasone

cromolyn oral concentrate

desloratadine^ (QL)fluticasone^hydroxyzine hcl solution, syrup, tablet

hydroxyzine pamoate

ipratropium mometasone^ (QL)olopatadine promethazine solution, syrup, tablet

CLARINEX-D 12 HOUR

GASTROCROMGRASTEK (PA, QL)KARBINAL ERODACTRA (PA, QL)ORALAIR (PA, QL)PATANASERAGWITEK (PA, QL)VISTARIL

ALZHEIMER’S DISEASEdonepezil donepezil odtmemantine memantine er (QL)pyridostigmine 60 mg/5 ml, 60 mg

pyridostigmine errivastigmine

ARICEPTEXELONMESTINONNAMENDANAMENDA XR (QL)NAMZARIC (QL)

ANXIETY/DEPRESSION/BIPOLAR DISORDER4

alprazolamalprazolam eralprazolam intensolalprazolam odtalprazolam xramitriptyline bupropion (QL)bupropion sr (QL)

CELEXA (QL, ST)EFFEXOR XR (QL, ST)

FETZIMA (QL, ST)PAXIL (QL, ST)PAXIL CR (QL, ST)PROZAC (QL, ST)REMERONSPRAVATO* (PA)

TIER 1$

TIER 2$$

TIER 3 $$$

ANXIETY/DEPRESSION/BIPOLAR DISORDER4 (cont)

bupropion xl 150 mg tablet (QL)


buspirone citalopram (QL)clomipramine desvenlafaxine er (QL)

duloxetine (QL)escitalopram (QL)fluoxetine dr (QL)fluoxetine (QL)fluvoxamine (QL)fluvoxamine er (QL)

lorazepamlorazepam intensolmirtazapineparoxetine cr (QL)paroxetine er (QL)paroxetine (QL)sertraline (QL)trazodone venlafaxine (QL)venlafaxine er (QL)

TRINTELLIX (QL, ST)VIIBRYD (QL, ST)WELLBUTRIN SR (QL, ST)

XANAXXANAX XRZOLOFT (QL, ST)

ASTHMA/COPD/RESPIRATORYalbuterol albuterol hfa (QL)alyq* (PA)ambrisentan* (PA)budesonidefluticasone-salmeterol

ipratropium-albuterol

montelukast tadalafil* (PA)treprostinil* (PA)

ANORO ELLIPTAATROVENT HFABREZTRI AEROSPHERE

DULERAFASENRA PEN* (PA)FLOVENT DISKUSFLOVENT HFAINCRUSE ELLIPTAOFEV* (PA)OPSUMIT* (PA)QVAR REDIHALERSEREVENT DISKUSSPIRIVASPIRIVA RESPIMATSTIOLTO RESPIMATSYMBICORTTRACLEER 32 MG TABLET FOR SUSPENSION* (PA)

TRELEGY ELLIPTAUPTRAVI* (PA)

ADCIRCA* (PA)ADEMPAS* (PA)ARALAST NP (PA)BRONCHITOL* (PA)COMBIVENT RESPIMAT

DALIRESP (QL)KALYDECO* (PA, QL)

LETAIRIS* (PA)LONHALA MAGNAIR REFILL (PA)

LONHALA MAGNAIR STARTER (PA)

ORENITRAM ER* (PA)

ORKAMBI* (PA, QL)PROLASTIN C* (PA)PULMICORT RESPULE

PULMOZYME* (PA)REVATIO 10 MG/ML, 20 MG* (PA)

Cigna Advantage 3-Tier Prescription Drug List

7

TIER 1$

TIER 2$$

TIER 3 $$$

ASTHMA/COPD/RESPIRATORY (cont)SINGULAIRSYMDEKO* (PA, QL)TRACLEER 125 MG TABLET* (PA)

TRACLEER 62.5 MG TABLET* (PA)

TRIKAFTA* (PA, QL)TYVASO* (PA)

ATTENTION DEFICIT HYPERACTIVITY DISORDER4

amphetamine (PA)atomoxetine (QL)dexmethylphenidate (PA)

dexmethylphenidate er (PA, QL)

dextroamphetamine-amphet er (PA, QL)

dextroamp hetamin-e -amphetamine (PA)

guanfacine ermethylphenidate er (la) (PA, QL)

methylphenidate er (PA, QL)

methylphenidate (PA)

methylphenidate cd (PA, QL)

methylphenidate er (cd) (PA, QL)

methylphenidate la (PA, QL)

ADDERALL (PA,ST)DAYTRANA (PA, QL)EVEKEO 5 MG, 10 MG (PA,ST)

FOCALIN (PA,ST)INTUNIVMETHYLIN (PA)QUILLIVANT XR (PA, QL)

RITALIN (PA,ST)STRATTERA (QL)

BLOOD MODIFIERS/BLEEDING DISORDERSaminocaproic acid 0.25 gram/ml, 500 mg, 1,000 mg*

tranexamic acid 650 mg*

DROXIANYVEPRIA* (PA)ZIEXTENZO (PA)

DOPTELET* (PA)LYSTEDA*PROMACTA* (PA)SIKLOS (PA)TAVALISSE* (PA)

BLOOD PRESSURE/HEART MEDICATIONSamlodipine amlodipine-benazepril

amlodipine-olmesartan (QL)

amlodipine-valsartan

atenololbenazepril bisoprolol

CORLANOR (PA)ENTRESTO

ADALAT CCBIDIL (QL)CALAN SRCARDIZEM LA 120MG (QL)

CARDURACATAPRES-TTS 1CATAPRES-TTS 2CATAPRES-TTS 3

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BLOOD PRESSURE/HEART MEDICATIONS (cont)

bisoprolol-hctzcandesartan cartia xtcarvedilolcarvedilol er (QL)clonidinediltiazem 12hr erdiltiazem 24hr erdiltiazem 24hr er (cd)

diltiazem 24hr er (la)

diltiazem 24hr er (xr)

diltiazemDILT-XR dofetilide (QL)doxazosin droxidopa*enalapril flecainide hydralazine tabletirbesartanlabetalol tabletlisinoprillisinopril-hctzlosartan losartan-hctzmatzim lametoprolol succinate

metoprolol tabletnadololnifedipinenifedipine erolmesartan (QL)olmesartan-amlodipine-hctz

olmesartan-hctz (QL)

prazosin propranolol tabletpropranolol erramiprilranolazine er (QL)taztia xttelmisartan (QL)telmisartan-hctz (QL)

tiadylt ervalsartanvalsartan-hctz

COREG (ST)CORGARD (ST)EPANEDHAEGARDA* (PA)HEMANGEOLINDERAL LA (ST)INDERAL XL (ST)INNOPRAN XL (ST)KAPSPARGO SPRINKLE (ST)

KATERZIA (QL)LOPRESSOR (ST)MINIPRESSNITROSTATNORTHERA* (PA)NORVASCORLADEYO* (PA, QL)

PROCARDIA XLRANEXA (QL)TAKHZYRO* (PA)TENORETIC 100 (ST)TENORETIC 50 (ST)TENORMIN (ST)TIAZACTIKOSYN (PA, QL)TOPROL XL (ST)VERELANVERELAN PMZIAC (ST)


8

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verapamil erverapamil er pmverapamil tabletverapamil sr

BLOOD THINNERS/ANTI-CLOTTINGadult aspirin regimen+

aspirin ec+aspirin+aspirin-dipyridamole er

children's aspirin+clopidogreljantovenlow dose aspirin ec+

prasugrelst. joseph aspirin ec+

st. joseph aspirin+warfarin

BRILINTAELIQUIS (PA)XARELTO (PA)

BAYER CHEWABLE ASPIRIN+

EFFIENTPLAVIXPRADAXA (PA)SAVAYSA (PA, QL)ZONTIVITY

CANCERabiraterone* (PA)anastrozole+bexarotene* (PA)capecitabine* (PA)everolimus* (PA)exemestane+hydroxyureaimatinib* (PA)letrozolemethotrexatetamoxifen+temozolomide* (PA)

ERIVEDGE* (PA)ERLEADA* (PA)GLEOSTINEIBRANCE* (PA)KANJINTI* (PA)MVASI* (PA)NEXAVAR* (PA)REVLIMID* (PA)SPRYCEL* (PA)SUTENT* (PA)TRAZIMERA* (PA)TREXALLVERZENIO* (PA)ZIRABEV* (PA)

AFINITOR DISPERZ* (PA)

AFINITOR* (PA)ALECENSA* (PA)ALUNBRIG* (PA)BOSULIF* (PA)BRAFTOVI* (PA)CABOMETYX* (PA)CALQUENCE* (PA)COMETRIQ* (PA)GLEEVEC* (PA)ICLUSIG* (PA)IMBRUVICA* (PA)INLYTA* (PA)JAKAFI* (PA)KISQALI* (PA)LENVIMA* (PA)LONSURF* (PA)LYNPARZA* (PA)MEKINIST* (PA)MEKTOVI* (PA)NERLYNX* (PA)NINLARO* (PA)NUBEQA* (PA)ODOMZO* (PA)OGIVRI* (PA)ONTRUZANT* (PA)ORGOVYX* (PA)PIQRAY* (PA)

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CANCER (cont)POMALYST* (PA)

ROZLYTREK* (PA)

RUBRACA* (PA)

RYDAPT* (PA)

STIVARGA* (PA)

TAFINLAR* (PA)

TAGRISSO* (PA)

TARGRETIN* (PA)

TASIGNA* (PA)

TEMODAR CAPSULE* (PA)

TUKYSA* (PA)

UKONIQ* (PA, QL)

VENCLEXTA STARTING PACK* (PA)

VENCLEXTA* (PA)

VITRAKVI* (PA)

VOTRIENT* (PA)

XALKORI* (PA)

XELODA* (PA)

XOSPATA* (PA)

XTANDI* (PA)

ZEJULA* (PA)

CHOLESTEROL MEDICATIONSatorvastatin+colesevelam ezetimibeezetimibe-simvastatin

fenofibratefenofibric acidfluvastatin er+fluvastatin+icosapent ethyllovastatin+omega-3 acid ethyl esters

pravastatin+rosuvastatin+ (QL)simvastatin tablet+ (QL)

VASCEPA (PA) CADUET (QL)LIPOFEN (ST)NIASPANROSZETTRICOR (ST)TRILIPIX (ST)WELCHOLZETIA

CONTRACEPTION PRODUCTSBEYAZ


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CONTRACEPTION PRODUCTS (cont)AFIRMELLE+AFTERA+ALTAVERA+ALYACEN+AMETHIA+AMETHYST+APRI+ARANELLE+ASHLYNA+AUBRA+AUBRA EQ+AUROVELA FE+AUROVELA 24 FE+AVIANE+AYUNA+AZURETTE+BALZIVA+BLISOVI FE+BLISOVI 24 FE+BRIELLYN+CAMILA+CAMRESE+CAMRESE LO+CAYA CONTOURED+

CAZIANT+CHARLOTTE 24 FE+CHATEAL+CHATEAL EQ+CRYSELLE+CYCLAFEM+CYRED+CYRED EQ+DASETTA+DAYSEE+DEBLITANE+desogestrel-ethinyl estradiol+

desogestrel-ethinyl estradiol - ethinyl estradiol+

DOLISHALE+drospirenone-ethinyl estradiol-levomefolate+

drospirenone-ethinyl estradiol+

ECONTRA EZ+ECONTRA ONE-STEP+

ELINEST+ELURYNG+EMOQUETTE+ENPRESSE+

LO LOESTRIN FE CAYA CONTOURED+

ELLA+ESTROSTEP FEFEMCAP+KYLEENA*+LAYOLIS FE+LILETTA*+LOESTRIN FEMICROGESTIN 24 FEMINASTRIN 24 FEMIRENA*+NEXTSTELLISNUVARINGPARAGARD T 380-A*+

SAFYRALSKYLA*+TODAY CONTRACEPTIVE SPONGE+

TWIRLA+VCF CONTRACEPTIVE FILM+

wide seal diaphragm+

YASMIN 28YAZ

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CONTRACEPTION PRODUCTS (cont)ENSKYCE+ERRIN+ESTARYLLA+ethynodiol-ethinyl estradiol+

etonogestrel-ethinyl estradiol+

FALMINA+FAYOSIM+FEMYNOR+GEMMILY+GYNOL II+HAILEY+HAILEY FE+HAILEY 24 FE+HEATHER+ICLEVIA+INCASSIA+ISIBLOOM+JAIMIESS+JASMIEL+JENCYCLA+JOLESSA+JULEBER+JUNEL+JUNEL FE+JUNEL FE 24+KAITLIB FE+KALLIGA+KARIVA+KELNOR 1-35+KELNOR 1-50+KURVELO+LARIN+LARIN FE+LARIN 24 FE+LARISSIA+LEENA+LESSINA+LEVONEST+levonorgestrel+levonorgestrel-ethinyl estradiol+

levonorgestrel-ethinyl estradiol ethinyl estradiol+

LEVORA+LILLOW+LOJAIMIESS+LORYNA+LOW-OGESTREL+LO-ZUMANDIMINE+

LUTERA+


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CONTRACEPTION PRODUCTS (cont)LYLEQ+LYZA+MARLISSA+MERZEE+MICROGESTIN+MICROGESTIN FE+MILI+MONO-LINYAH+MY CHOICE+MY WAY+NECON+NEW DAY+NIKKI+NORA-BE+norethindrone+norethindrone-ethinyl estradiol-iron+

norethindrone-ethinyl estradiol+

norethindrone-ethinyl estradiol-ferrous fumarate

norgestimate-ethinyl estradiol+

NORLYDA+NORTREL+NYLIA+NYMYO+OCELLA+OPCICON ONE-STEP+

OPTION 2+ORSYTHIA+PHILITH+PIMTREA+PIRMELLA+PORTIA+PREVIFEM+RECLIPSEN+RIVELSA+SETLAKIN+SHAROBEL+SIMLIYA+SIMPESSE+SPRINTEC+SRONYX+SYEDA+TAKE ACTION+TARINA FE+TARINA FE 1-20 EQ+

TARINA 24 FE+TILIA FE+

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CONTRACEPTION PRODUCTS (cont)TRI FEMYNOR+TRI-ESTARYLLA+TRI-LEGEST FE+TRI-LINYAH+TRI-LO-ESTARYLLA+TRI-LO-MARZIA+TRI-LO-MILI+TRI-LO-SPRINTEC+TRI-MILI+TRI-NYMYO+TRI-PREVIFEM+TRI-SPRINTEC+TRIVORA+TRI-VYLIBRA LO+TRI-VYLIBRA+TULANA+TYDEMY+VCF CONTRACEPTIVE FOAM+

VCF CONTRACEPTIVE GEL+

VELIVET+VESTURA+VIENVA+VIORELE+VOLNEA+VYFEMLA+VYLIBRA+WERA+WYMZYA FE+XULANE+ZAFEMY+ZARAH+ZOVIA 1-35+ZOVIA 1-35E+ZUMANDIMINE+

COUGH/COLD MEDICATIONSbrompheniramine-pseudoephed-dm

HYCODAN (PA, QL)

hydrocodone-homatropine (PA,QL)

TESSALON PERLE

promethazine-dm TUZISTRA XR (PA, QL)

DENTAL PRODUCTSchlorhexidine CLINPRO 5000

DENTA 5000 PLUS FLORIVA+

DENTAGEL FLUORIDEX SENSITIVITY RELIEF


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DENTAL PRODUCTS (cont)doxycycline hyclateFLUORIDEX DAILY DEFENSE 1.1%

ORALONEPERIDEXPERIOGARDSF 1.1% GELSF 5000 PLUS sodium fluoridesodium fluoride 5000 dry mouth

sodium fluoride 5000 plus

triamcinolone

PREVIDENT

DIABETESglimepirideglipizideglipizide erglipizide xlmetformin metformin er

BAQSIMI (QL)BASAGLAR (QL)BD LANCETSBD PEN NEEDLEDEXCOM G6 (PA, QL)

DROPLETDROPSAFEFARXIGA (QL, ST)FREESTYLE LIBRE 14 DAY SENSOR (PA, QL)

FREESTYLE LIBRE 2 SENSOR (PA, QL)

GLYXAMBI (QL, ST)JANUMET (QL, ST)JANUMET XR (QL, ST)

JANUVIA (QL, ST)JARDIANCE (QL, ST)HUMULIN (QL)LYUMJEV (QL)NOVOTWISTOMNIPOD DASH (PA, QL)

ONETOUCH ULTRA TEST STRIP

ONETOUCH ULTRAMINI

ONETOUCH VERIO FLEX METER

ONETOUCH VERIO IQ METER

ONETOUCH VERIO METER

ONETOUCH VERIO REFLECT METER

ACCU-CHEK SMARTVIEW CONTRL SOLUTION

ACCUTREND GLUCOSE CONTROL

AMARYLCEQURCONTOUR NEXT TEST STRIP

CONTOUR TEST STRIP

CYCLOSETDEXCOM G4DEXCOM G5DEXCOM G5-G4 SENSOR KIT

ENLITE GLUCOSE SENSOR

EVERSENSE SMART TRANSMITTER

GUARDIAN CONNECT TRANSMITTER

GUARDIAN LINK 3GUARDIAN SENSOR 3

INPENKORLYM* (PA)PRECISION XTRA KETONE-GLUC KIT

RIOMETTRUE METRIX

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DIABETES (cont)ONETOUCH VERIO TEST STRIP

RYBELSUS (PA, QL)SOLIQUA 100-33SYMLINPENSYNJARDY (QL, ST)SYNJARDY XR (QL, ST)

TECHLITETRIJARDY XR (ST, QL)

TRUEPLUS SYRINGEV-GO 20V-GO 30V-GO 40VICTOZA (PA, QL)XIGDUO XR (QL, ST)xultophy

DIURETICSacetazolamide tablet

acetazolamide er capsule

bumetanide tabletchlorthalidoneeplerenonefurosemide solution, tablet

hydrochlorot- hiazide

spironolactonetriamterene-hctz

ALDACTONECAROSPIRDIURILINSPRAJYNARQUE* (PA)KERENDIALASIXMAXZIDE

EAR MEDICATIONSciprofloxacin-dexamethasone

neomycin-polymyxin b-hydrocortisone

ofloxacin

CIPRO HCCIPRODEXCIPRODEXDERMOTICOTOVEL

EYE CONDITIONSbimatoprost (QL)brimonidine brinzolamideciprofloxacin dorzolamide dorzolamide-timolol

erythromycinfluorometholoneketorolac latanoprost

COMBIGANEYSUVIS (QL)RESTASISSIMBRINZA

ACULARACULAR LSACUVAILALPHAGAN PALREXAZASITEAZOPTBESIVANCEBETIMOLBETOPTIC S


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EYE CONDITIONS (cont)loteprednol moxifloxacin eye drops

neomycin-polymyxin b-dexamethasone

ofloxacinolopatadine^polymyxin b sulfate-trimethoprim

prednisolone timolol tobramycin-dexamethasone

travoprost

BROMSITECOSOPTCOSOPT PFCYSTADROPS* (PA, QL)

CYSTARAN* (PA, QL)DUREZOLFLAREXFML FORTE 0.25% EYE DROPS

FML LIQUIFILM 0.1% EYE DROP

FML S.O.P. 0.1% OINTMENT

ILEVROINVELTYSISTALOLLOTEMAXLOTEMAX SMMAXITROLMOXEZANEVANACOCUFLOXOXERVATE* (PA)PRED FORTEPROLENSARHOPRESSAROCKLATANTIMOPTICTIMOPTIC-XETOBRADEXTOBRADEX STTRUSOPTVIGAMOXZIRGANZYLET

FEMININE PRODUCTSFEM PH GYNAZOLE 1miconazole 3 200 mg

terconazole

GASTROINTESTINAL/HEARTBURNALOPHEN PILLS+alosetron*ANUCORT-HCbalsalazide bisacodyl tablet+cinacalcet*CLEARLAX+CONSTULOSE

AMITIZACLENPIQ+LINZESSNEXIUM DR 2.5 MG PACKET (QL)

NEXIUM DR 5 MG PACKET (QL)

PANCREAZEPENTASA

AKYNZEO 300-0.5 MG CAPSULE

BONJESTACANASACARAFATECHENODAL* (PA)CHOLBAM* (PA)CORRECTOL+CUVPOSA

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GASTROINTESTINAL/HEARTBURN (cont)dicyclomine capsule, solution, tablet

esomeprazole 20 mg capsule, 40 mg capsule, packets^ (QL)

famotidine 40 mg/5 ml suspension

GAVILAX+GAVILYTE-C+GAVILYTE-G+GAVILYTE-N+GENTLE LAXATIVE TABLET+

GENTLELAX+GLYCOLAX+glycopyrrolate tablet

HEMMOREX-HC hydrocortisone lansoprazole^ (QL)LAXACLEAR+LAXATIVE PEG 3350+

LAXATIVE 5 MG TABLET+

LAXATIVE EC 5 MG TABLET+

mesalaminemesalamine drmesalamine ermetoclopramide solution, tablet

metoclopramide odt

misoprostolNATURA-LAX+omeprazole^ (QL)ondansetron ondansetron odtpantoprazole ^ (QL)

peg 3350-electrolyte+

peg3350-sodium sulfate-sodium chloride-potassium chloride-sodium ascorbate-ascorbic acid+

SUPREP+SUTAB+VIBERZI

DICLEGISDONNATALDULCOLAX EC 5 MG TABLET+

LITHOSTATMIRALAX+MOVANTIK (PA)OCALIVA* (PA)RAVICTI* (PA)RECTIVRELISTOR (PA)SANCUSO (PA, QL)SFROWASASUCRAID* (PA)SYMPROIC (PA)TRANSDERM-SCOPURSOURSO FORTEVARUBI (PA, QL)VIOKACE


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GASTROINTESTINAL/HEARTBURN (cont)PEG-PREP+polyethylene glycol 3350+

prochlorperazine tablet

promethazine suppository

prometheganPURELAX+rabeprazole tablet^ (QL)

scopolamineSMOOTHLAX+sucralfateursodiolWOMEN'S GENTLE LAXATIVE+

WOMEN'S LAXATIVE+

HORMONAL AGENTSAMABELZbudesonide ecbudesonide er (PA, QL)

cabergoline (QL)COVARYXCOVARYX H.S.DECADRONdesmopressin dexamethasone intensol

DOTTI (QL)EEMTEEMT H.S.estradiol (once weekly)

estradiol 10mcg vaginal insert (QL)

estradiol (twice weekly) (QL)

estradiol-norethindrone acetat

estrogen-methyltesto- sterone

EUTHYROXLEVO-Tlevothyroxine tabletLEVOXYLliothyronine LYLLANA (QL)

DUAVEELUPRON DEPOT-PED* (PA)

ORIAHNN (PA, QL)ORILISSA (PA, QL)PREMARIN TABLET, VAGINAL CREAM APPLICATOR

PREMPHASEPREMPRO

ACTHAR GEL* (PA)ACTIVELLAALORA (QL)ANDRODERM (PA, QL)

ANDROGEL (PA, QL)ANGELIQARMOUR THYROIDAYGESTINBIJUVABYNFEZIA* (PA)CLIMARACLIMARA PROCOMBIPATCHCRINONE 4% GELCYTOMELDIVIGELELESTRINEMFLAZA* (PA)ENTOCORT ECESTRACEESTRING (QL)ESTROGELEVAMISTFENSOLVI* (PA)IMVEXXY (QL)INTRAROSAISTURISA* (PA, QL)LUPANETA PACK* (PA)

levothyroxine capsule (PA)

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HORMONAL AGENTS (cont)medroxyprog- esterone

methimazolemethylpredn- isolone

MIMVEYnorethindrone NP THYROIDprednisoneprednisone intensolprogesterone tablettestosterone (PA, QL)

WESTHROIDYUVAFEM

MEDROLMENOSTAR (QL)MINIVELLE (QL)MYFEMBREE (QL)OSPHENAPROMETRIUMRAYALDEETIROSINT-SOL (PA)UNITHROIDVAGIFEM (QL)VIVELLE-DOT (QL)

INFECTIONSacyclovir capsule, suspension, tablet

albendazoleamoxicillinamoxicillin-clavulanate er

amoxicillin-clavulanate

atovaquoneatovaquone-proguanil

AVIDOXYazithromycin packet, suspension, tablet

cefdinircefuroxime tabletcephalexinciprofloxacin clarithromycinclarithromycin erclindamycin COREMINO ER QL)dapsonedoxycycline hyclate capsule, tablet

doxycycline monohydrate

EMVERMentecavir* (QL)erythromycinerythromycin ethylsuccinate

famciclovirfluconazolehydroxychlo- roquine

BARACLUDE SOLUTION*

EPCLUSA* (PA, QL)FIRVANQFOLLISTIM*^ (PA)HARVONI* (PA, QL)LEDIPASVIR-SOFOSBUVIR* (PA)

MAVYRET* (PA)SOFOSBUVIR-VELPATASVIR* (PA)

SOVALDI* (PA, QL)THALOMID* (PA)VOSEVI* (PA)XIFAXAN (QL)

AEMCOLO (QL)ALBENZAALINIAARIKAYCE* (PA)BACTRIMBACTRIM DSBAXDELA TABLET (PA)

CAYSTON* (PA, QL)CIPROCLEOCINCLINDESSECRESEMBA CAPSULE (PA)

DARAPRIM* (PA)DIFICID (QL)ELIMITEERYPED 200ERY-TAB DRFLAGYLHIPREXKEFLEXKITABIS PAK* (PA, QL)

MACROBIDMACRODANTINMALARONE (PA)NATROBANUVESSANUZYRA TABLET* (QL)

ORAVIGPLAQUENILPOSACONAZOLE SUSPENSION

PREVYMIS TABLETPRIFTIN


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INFECTIONS (cont)ivermectinlevofloxacin solution, tablet

methenamine metronidazole gel, capsule, tablet

minocycline minocycline er tablet (QL)

mondoxyne nlMORGIDOXnitazoxanidenitrofurantoinnitrofurantoin monohydrate-macrocrystal

nystatin suspension, tablet

penicillin v potassium

permethrinposaconazole tablet

pyrimethamine* (PA)

sulfamethoxazole-trimethoprim suspension, tablet

terbinafine tetracycline tobramycin ampule* (PA,QL)

valacyclovirvalganciclovir vancomycin capsule, solution

vandazole


PREVYMIS TABLET*PRIFTINSIVEXTRO TABLET (PA)

SOLOSECSOMAVERT* (PA)STROMECTOLsulfatrimSUPPRELIN LA* (PA)teriparatide* (PA, QL)

URIBELVALTREXVEMLIDY*VIBRAMYCIN 25 MG/5 ML SUSPENSION

VIBRAMYCIN 50 MG/5 ML SYRUP

XENLETA 600mg tablet (PA, QL)

XOFLUZA (QL)ZEPATIER* (PA)ZITHROMAXZITHROMAX TRI-PAK

ZYVOX SUSPENSION, TABLET (PA)

INFERTILITYclomiphene ^ CRINONE^

ENDOMETRIN^

MISCELLANEOUSdeferiprone 500mg* (PA)

sodium chloride inhalation vial, irrigation solution, vial

trientine * (PA)

ACCU-CHEKCERDELGA* (PA)ESBRIET* (PA)MICROLETNITYR* (PA)ORFADIN* (PA)PRECISION XTRATECHLITE LANCETS

AUSTEDO* (PA)BRISDELLE (QL)EVRYSDI* (PA)FC2 FEMALE CONDOM+

GALAFOLD* (PA)INGREZZA INITIATION PACK* (PA, QL)

INGREZZA* (PA)

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MISCELLANEOUS (cont)KETONE CARE TEST STRIP

KETONE TEST STRIPKETOSTIX REAGENTNUEDEXTA (QL)TEGSEDI* (PA)TIGLUTIK* (PA)TRUEPLUS KETONE TEST STRIP

VYNDAMAX* (PA, QL)

VYNDAQEL* (PA, QL)

MULTIPLE SCLEROSISdalfampridine er* (PA)

dimethyl fumarate* (PA)

AUBAGIO* (PA)BAFIERTAM* (PA)GILENYA* (PA)KESIMPTA PEN* (PA)MAYZENT* (PA)VUMERITY* (PA)ZEPOSIA* (PA)

MAVENCLAD* (PA)PONVORY* (PA)

NUTRITIONAL/DIETARYcalcitriol capsule, solution^

FA-8+folic acid^+klor-conKLOR-CON 8 MEQ TABLET

KLOR-CON 10 MEQ TABLET

KLOR-CON M10 TABLET

MULTI-VITAMIN W-FLUORIDE-IRON+

MULTIVITAMIN WITH FLUORIDE+

MULTIVITAMIN-IRON-FLUORIDE

ONE DAILY PRENATAL+

potassium chloride 10%, capsule, packet, tablet

prenatal complete+PRENATAL GUMMIES+

PRENATAL MULTI+prenatal multi-dha+

FOSRENOL 1,000 MG POWDER PACK

FOSRENOL 750 MG POWDER PACKET

OB COMPLETE PETITE

OB COMPLETE PREMIER

ALIVE PRENATAL+AURYXIA (QL)BRAINSTRONG PRENATAL+

CITRANATAL 90 DHA

CITRANATAL ASSURE

CITRANATAL B-CALM

CITRANATAL DHACITRANATAL HARMONY

CITRANATAL RXCLASSIC PRENATAL+

DRISDOLEXPECTA PRENATAL+

FLORIVA+FOSRENOL 1,000 MG CHEWABLE TABLET

FOSRENOL 500 MG CHEWABLE TABLET


K-TAB ERLOKELMAMEPHYTON


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NUTRITIONAL/DIETARY (cont)PRENATAL MULTIVITAMIN+

PRENATAL MULTIVITAMIN-DHA+

PRENATAL ONE DAILY+

PRENATAL VITAMIN + DHA+

PRENATAL VITAMIN+

PRENATAL VITAMINS+

PRENATAL+PRENATAL+sevelamer carbonate

TRI-VITE WITH FLUORIDE+

vitamin d2 1.25 mg (50,000 unit)^

VITAMINS A,C,D AND FLUORIDE+

K-TAB ERLOKELMAMEPHYTONMINI PRENATAL+NEEVO DHAOB COMPLETEONE A DAY WOMEN'S PRENATAL DHA+

ONE-A-DAY PRENATAL-1+

PERRY PRENATAL+PHOSLYRAPOLY-VI-FLOR WITH IRON+

POLY-VI-FLOR+PRENATEPRENATAL FORMULA-DHA+

PRIMACAREQUFLORA PEDIATRIC 1 MG CHEWABLE TABLET+

QUFLORA PEDIATRIC 0.25 MG/ML DROP+


RENVELAROCALTROLSIMILAC PRENATAL+

STUART ONE+TRI-VI-FLOR+ULTRA PRENATAL PLUS DHA+

VELPHOROVELTASSA

OSTEOPOROSIS PRODUCTSalendronate ibandronate 150 mg tablet

ibandronate 3 mg/3 ml syringe*

ibandronate 3 mg/3 ml vial*

raloxifene +raloxifene+risedronate dr

ACTONEL (ST)ATELVIA (ST)BINOSTO (ST)BONIVA 150 MG TABLET (ST)

EVISTAFOSAMAX (ST)

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PAIN RELIEF AND INFLAMMATORY DISEASEacetaminophen-codeine (PA)

allopurinol tabletASPIRIN EC+aspirin tablet+baclofen tabletbuprenorphine patch (QL)

butalbital-acetaminophen-caffeine (QL)

buprenorphine (QL)butalbital-acetaminophen-caffe (QL)

carisoprodolcelecoxib (QL)colchicinecyclobenzaprine diclofenac 1% gel (QL)

diclofenac drdiclofenac ecEC-NAPROXENECOTRIN EC 81 MG TABLET+

eletriptan (QL)ENDOCET (PA)febuxostat (QL)fentanyl (PA)FIORICET (QL)frovatriptan (QL)GEL-ONE* (PA)GLYDOhydrocodone-acetaminophen (PA)

hydromorphone er (PA)

hydromorphone (PA)

IBUibuprofenindomethacinindomethacin erketorolac tromethamine (QL)

leflunomidelidocaine 5% ointment (QL)

lidocaine 5% patch

AIMOVIG (PA)AJOVY (PA)AVSOLA* (PA)BELBUCA (QL)DUPIXENT* (PA)EMGALITY (PA)HYSINGLA ER (PA)NURTEC ODT (PA, QL)

OTEZLA* (PA, QL)REDITREX (PA)RINVOQ* (PA, QL)SIMPONI ARIA* (PA)SKYRIZI* (PA, QL)TALTZ* (PA, QL)UBRELVY (PA, QL)XELJANZ XR* (PA, QL)

XELJANZ* (PA, QL)XTAMPZA ER (PA)ZTLIDO

ANALPRAM HC 1% CREAM

ANALPRAM HC 2.5%-1% CREAM

ANALPRAM HC 2.5%-1% CREAM SINGLE

ARAVABUTRANS (QL)CELEBREX (QL, ST)COLCRYSDEPEN* (PA)EC-NAPROSYN (ST)ECOTRIN EC 325 MG TABLET+

ESGIC (QL)FEXMIDLAZANDA (PA)LIDODERMMITIGAREMOBIC (ST)NAPROSYN (ST)NUCYNTA (PA)NUCYNTA ER (PA)OLUMIANT* (PA, QL)

OXAYDO (PA)PERCOCET (PA)PROCORTPROCTOFOAM-HCSAVELLASKELAXINTRILURON* (PA)ULORIC (QL)ULTRAM 50 MG TABLET (QL)

VTOL LQZANAFLEXZEBUTAL (QL)ZOHYDRO ER (PA)ZYLOPRIM


16

TIER 1$

TIER 2$$

TIER 3 $$$

PAIN RELIEF AND INFLAMMATORY DISEASE (cont)

lidocaine viscousmeloxicam tabletmetaxalonemethocarbamolmorphine (PA)morphine er (PA)NALFON 600 MG TABLET (ST)

NALOCET (PA)oxycodone (PA)oxycodone er (PA)oxycodone-acetaminophen (PA)

penicillamine* (PA)PROLATE TABLET (PA)

rizatriptan (QL)sumatriptan (QL)tizanidine tramadol 50 mg tablet (QL)

tramadol er (QL)VANADOM

PARKINSON’S DISEASEbenztropine tabletcarbidopa-levodopa

carbidopa-levodopa er

pramipexole pramipexole er (QL)rasagiline (QL)ropinirole erropinirole

KYNMOBI (PA) AZILECT (QL)DUOPA*INBRIJA* (PA)MIRAPEX ER (QL)NEUPRONOURIANZ* (PA, QL)

OSMOLEX ER (QL)RYTARYSINEMET 10-100SINEMET 25-100TASMARXADAGO (ST)

SCHIZOPHRENIA/ANTI-PSYCHOTICS4

aripiprazole (QL)aripiprazole odtasenapine chlorpromazine tablet

haloperidololanzapine tabletolanzapine odtpaliperidone er (QL)quetiapine quetiapine errisperidone

LATUDA (QL) FANAPT (QL, ST)INVEGA (QL, ST)REXULTI (QL, ST)RISPERDAL (ST)SAPHRIS (ST)SECUADO (ST)SEROQUEL (ST)SEROQUEL XR (ST)VRAYLAR (QL, ST)

TIER 1$

TIER 2$$

TIER 3 $$$

SCHIZOPHRENIA/ANTI-PSYCHOTICS (cont)risperidone odtziprasidone tablet

SEIZURE DISORDERScarbamazepinecarbamazepine erclonazepamdivalproex divalproex erEPITOLgabapentinlamotriginelamotrigine (blue)lamotrigine (green)lamotrigine (orange)

lamotrigine erlamotrigine odtlamotrigine odt (blue)

lamotrigine odt (green)

lamotrigine odt (orange)

levetiracetam solution, tablet

levetiracetam eroxcarbazepinepregabalin capsule, solution

ROWEEPRASUBVENITESUBVENITE (BLUE)SUBVENITE (GREEN)SUBVENITE (ORANGE)

topiramatetopiramate ervigabatrin*vigadrone*

DILANTIN 30 MG CAPSULE (PA)

FYCOMPA (PA, QL)NAYZILAM (PA, QL)VIMPAT SOLTUION, TABLET (PA)

APTIOM (PA, QL)BRIVIACT ORAL SOLUTION, TABLET (PA)

CARBATROL (PA)DEPAKOTE (PA)DEPAKOTE ER (PA)DEPAKOTE SPRINKLE (PA)


DILANTIN 50 MG INFATAB (PA)

EPIDIOLEX* (PA)FINTEPLA* (PA)KLONOPIN (PA)LYRICA ORAL SOLUTION (PA)

NEURONTIN (PA)OXTELLAR XR (PA)PHENYTEK (PA)SPRITAM (PA)TEGRETOL (PA)TEGRETOL XR (PA)VALTOCO (PA, QL)XCOPRI (PA, QL)

SKIN CONDITIONSACCUTANEadapalene (PA)adapalene-benzoyl peroxide

AMNESTEEMAVAR CLEANSERazelaic acidbetamethasone augmented

betamethasone dipropionate

BP 10-1

EUCRISATARGRETIN*

ANALPRAM HC 2.5%-1% LOTION

AVAR 9.5-5% CLEANSING PADS

BRYHALI (ST)calcipotriene foamCAPEX SHAMPOO (ST)

CLEOCIN TCLINDACIN ETZ KITCLINDACIN PAC KIT


17

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TIER 3 $$$

SKIN CONDITIONS (cont)calcipotriene cream, ointment, solution

calcipotriene-betamethasone

CLARAVISCLINDACIN ETZ 1% PLEDGET

CLINDACIN P 1% PLEDGETS

clindamycin 1% foam, gel, lotion, pledget, solution

clindamycin-benzoyl peroxoxide

clindamycin-tretinoin

clobetasol clocortoloneCLODANclotrimazole-betamethasone

dapsone gelfluocinonidefluorouracil cream, topical solution

isotretinoinketoconazoleKETODANmetronidazolemupirocinMYORISANNEUAC GELpimecrolimusROSADANsodium sulfacetamide-sulfur

SSS 10-5SULFACLEANSE 8-4tacrolimus ointment

tazarotene 0.1% cream

tretinoin (PA)TRIDERMZENATANE

CLODERM (ST)DESOWENDRYSOLEFUDEXELIDELEVOCLINNAFTINPRAMOSONEPROTOPICREGRANEX (PA, QL)SANTYL (QL)TEMOVATE (ST)XEPI

SLEEP DISORDERS/SEDATIVESarmodafinil (PA)eszopiclonemodafinil (PA)temazepam

DAYVIGO (QL, ST)SUNOSI (PA, QL)

HETLIOZ LQ* (PA)HETLIOZ* (PA)LUNESTA (ST)SILENOR (QL, ST)

TIER 1$

TIER 2$$

TIER 3 $$$

SLEEP DISORDERS/SEDATIVES (cont)zolpidem zolpidem er (QL)

WAKIX* (PA, QL)XYREM* (PA)XYWAV* (PA)

SMOKING CESSATION4

bupropion sr+NICODERM CQ 21 MG/24HR PATCH+

nicotine gum+nicotine lozenge+nicotine patch+QUIT 2+QUIT 4+STOP SMOKING AID+

NICODERM CQ 14 MG/24HR PATCH+


NICORETTE+NICOTROL NS+NICOTROL+

SUBSTANCE ABUSEbuprenorphine-naloxone

LUCEMYRA (QL)NARCAN (QL)ZUBSOLV

BUNAVAILKLOXXADO (QL)SUBLOCADE*SUBOXONE

TRANSPLANT MEDICATIONSazathioprine*everolimus 0.25 mg tablet*

everolimus 0.5 mg tablet*

mycophenolate mofetil*

mycophenolic acid*

sirolimus*tacrolimus capsule*

ASTAGRAF XL*CELLCEPT ORAL SUSPENSION, TABLET*

ENVARSUS XR*MYFORTIC*NEORAL*PROGRAF 0.2 MG GRANULE PACKET*

PROGRAF 0.5 MG CAPSULE*

PROGRAF 1 MG CAPSULE*

PROGRAF 1 MG GRANULE PACKET*


RAPAMUNE*ZORTRESS*

URINARY TRACT CONDITIONSalfuzosin ercevimeline darifenacin er (QL)finasterideoxybutynin oxybutynin erphenazopyridine potassium ersilodosin (QL)solifenacin (QL)

CYSTAGON* AVODARTELMIRONEVOXACFLOMAXK-PHOS ORIGINALPROSCARPYRIDIUMRAPAFLO (QL)UROCIT-KUROXATRAL


18

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TIER 3 $$$

URINARY TRACT CONDITIONS (cont)tamsulosin tolterodine tolterodine er (QL)

VACCINESVaccines are now covered under the Cigna pharmacy benefit. Not all plans cover vaccines in the same way. Log in to the myCigna App or myCigna.com, or check your plan materials, to find out how your specific plan covers them.

ROTARIX+ROTATEQ+

WEIGHT MANAGEMENTmegestrol suspension


19

Medications that aren’t coveredYour plan covers other medications that are used to treat the same condition.^^ They’re listed below.

^^ These medications need approval from Cigna before your plan will cover them. If your doctor feels an alternative medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the medication. If you don’t get approval and you continue to fill this prescription, you’ll pay the full cost of the medication out-of-pocket directly to the pharmacy. Also, the cost can’t be applied to your annual deductible or out-of-pocket maximum.

DRUG CLASS MEDICATION NAME^^GENERIC AND/OR PREFERRED BRAND

ALTERNATIVE(S)

AIDS/HIV ATRIPLA* efavirenz-emtricitabine-tenofovir*

COMBIVIR* lamivudine-zidovudine*

EMTRIVA* emtricitabine*

EPIVIR* lamivudine*

EPZICOM* abacavir-lamivudine*

INTELENCE 100MG, 200MG TABLET* etravirine*

KALETRA* lopinavir-ritonavir*

LEXIVA 700MG TABLET* fosamprenavir 700mg tablet*

NORVIR 100MG TABLET* ritonavir 100mg tablet*

RETROVIR CAPSULE, SYRUP* zidovudine capsule, syrup*

REYATAZ CAPSULE* atazanavir capsules*

SUSTIVA* efavirenz*

SYMFI*SYMFI LO*

efavirenz-lamivudine-tenofovir*

TRIZIVIR* abacavir-lamivudine-zidovudine tablet*

TRUVADA* emtricitabine-tenofovir*

VIRAMUNE* nevirapine*

VIRAMUNE XR* nevirapine ER*

VIREAD 300MG TABLET* tenofovir 300mg tablet*

ZIAGEN* abacavir*

ALLERGY/NASAL SPRAYS AUVI-QEPIPENEPIPEN JRSYMJEPI

epinephrine auto-injectors

carbinoxamine 6mg tabletRYVENT

carbinoxamine 4mg tablet

dexchlorpheniramine RYCLORA

carbinoxamine oral solutioncyproheptadine syruphydroxyzine syrup

DYMISTA azelastine-fluticasoneGeneric nasal steroids (e.g. fluticasone)

ALZHEIMER'S DISEASE pyridostigmine 30mg tablet (QL) pyridostigmine 60mg tablet

ANXIETY/DEPRESSION/BIPOLAR DISORDER ANAFRANIL clomipramine

APLENZIN bupropion XL 150, 300 mg tablets

ATIVAN TABLET lorazepam

bupropion xl 450mg tabletFORFIVO XL

bupropion xl 150mg tablets

CYMBALTA desvenlafaxine ERduloxetineescitalopram

DRIZALMA SPRINKLE duloxetine dr capsules

LEXAPRO escitalopram

PAMELOR nortriptyline capsules

PARNATE tranylcypromine

20



ALTERNATIVE(S)

ANXIETY/DEPRESSION/BIPOLAR DISORDER (cont)

PEXEVA paroxetineparoxetine cr

PRISTIQ desvenlafaxine succinate erbupropion srduloxetineescitalopramsertralinevenlafaxine er

TOFRANIL imipramine

WELLBUTRIN XL bupropion xlescitalopramfluoxetine

ASTHMA/COPD/RESPIRATORY ADVAIR HFAADVAIR DISKUSAIRDUO DIGIHALERAIRDUO RESPICLICKBREO ELLIPTA

DULERAfluticasone-salmeterolSYMBICORTWIXELA INHUB

ALVESCOARMONAIR DIGIHALERARNUITY ELLIPTAASMANEX, ASMANEX HFAPULMICORT FLEXHALER

FLOVENT DISKUSFLOVENT HFAQVAR

ARCAPTA NEOHALERSTRIVERDI RESPIMAT

SEREVENT DISKUS

BEVESPI AEROSPHEREDUAKLIR PRESSAIRUTIBRON NEOHALER

ANORO ELLIPTASTIOLTO RESPIMAT

BROVANA arformoterol

budesonide-formoterol SYMBICORT

ELIXOPHYLLIN theophylline ertheophylline oral solution

levalbuterol hfaPROAIR DIGIHALERPROAIR HFAPROAIR RESPICLICKPROVENTIL HFAVENTOLIN HFAXOPENEX HFA

albuterol hfa

PERFOROMIST formoterol

SEEBRI NEOHALERTUDORZA PRESSAIR

INCRUSE ELLIPTASPIRIVA RESPIMAT

YUPELRI ANORO ELLIPTABREZTRI AEROSPHEREINCRUSE ELLIPTASPIRIVASTIOLTO RESPIMATTRELEGY ELLIPTA

ZYFLO montelukastzafirlukastzileuton er

21



ALTERNATIVE(S)

ATTENTION DEFICIT HYPERACTIVITY ADDERALL XRADHANSIA XRADZENYS ERADZENYS XR-ODTAPTENSIO XRCONCERTACOTEMPLA XR-ODTDYANAVEL XRFOCALIN XRJORNAY PMMYDAYISQUILLICHEW ERRITALIN LAVYVANSE

dexmethylphenidate erdextroamphetamine-amphetamine er methylphenidate er

DESOXYN methamphetamine

DEXEDRINE dexmethylphenidate erdextroamphetamine erdextroamphetamine-amphetamine er

EVEKEO ODT amphetaminedexmethylphenidatedextroamphetaminemethamphetaminemethylphenidate

methylphenidate er 72mg tablet RELEXXII

methylphenidate er 36mg tablet

QELBREE atomoxetine

BLOOD PRESSURE/HEART MEDICATIONS ACCUPRIL quinapril

ACCURETIC quinapril-hctz

ALTACE ramipril

ATACAND candesartan

ATACAND HCT candesartan-hctz

AVALIDE irbesartan-hctz

AVAPRO irbesartan-hctz

AZOR amlodipine-olmesartan

BENICAR olmesartan

BENICAR HCT olmesartan-hctz

BETAPACE sotalol

BYSTOLIC generic beta blockers (e.g. metoprolol; atenolol)

CARDIZEM diltiazem

CARDIZEM CD diltiazem CD

CONJUPRI amlodipinefelodipine ernicardipinenifedipine

CONSENSI amlodipinecelecoxib

COZAAR losartan

DIOVAN valsartan

22



ALTERNATIVE(S)


DIOVAN HCT valsartan-hctz

EDARBI generic ARBs (e.g. losartan; valsartan)

EDARBYCLOR generic ARBs + HCTZ (e.g. losartan-HCTZ)

EXFORGE amlopidine-valsartan

EXFORGE HCT amlopidine-valsartan hctz

FIRAZYR* icatibant

GONITRO nitroglycerin sublingual tablet or spray

HYZAAR losartan-hctz

ISORDILISORDIL TITRADOSE

isosorbide dinitrate

LANOXIN digoxin

LOTENSIN benazepril

LOTENSIN HCT benazepril-hctz

LOTREL amlodipine-benazepril

MICARDIS telmisartan

MICARDIS HCT telmisartan-hctz

MULTAQ amiodaronedisopyramidedofetilideflecainidepropafenonequinidinesotalol af

PRINIVILZESTRIL

lisinopril

TARKA trandolapril-verapamil

TEKTURNA aliskiren

TEKTURNA HCT generic ACE inhibitor + HCT (e.g. benazepril-HCT) generic ARB + HCT (e.g. losartan-HCT)

TRIBENZOR olmesartan-amlodipine-hctz

VASERETIC enalapril-hctz

VASOTEC enalapril

ZESTORETIC lisinopril-hctz

BLOOD THINNERS/ANTI-CLOTTING aspirin-omeprazoleYOSPRALA

aspirin or enteric aspirin

CANCER CYCLOPHOSPHAMIDE TABLET* cyclophosphamide capsule*

NILANDRON nilutamide

TARCEVA* erlotinib

YONSA*ZYTIGA*

abiraterone

CHOLESTEROL MEDICATIONS ANTARAFENOGLIDE

fenofibrate

ALTOPREV lovastatin+atorvastatin+simvastatin+rosuvastatin+

CRESTOR rosuvastatin+

23



ALTERNATIVE(S)

CHOLESTEROL MEDICATIONS (cont) EZALLOR SPRINKLEFLOLIPIDLIVALOSIMVASTATIN 20mg/5ml SUSPENSIONNEXLIZET

generic statins (e.g. atorvastatin; simvastatin)

JUXTAPID*PRALUENT

REPATHA

LESCOL XL fluvastatin er+

LIPITOR atorvastatin+ezetimibe-simvastatinrosuvastatin+

NEXLETOL generic statins (e.g. atorvastatin; simvastatin)ezetimibe-simvastatin

niacin 500mg tabletNIACOR

niacin er

PRAVACHOL pravastatin+

VYTORIN ezetimibe-simvastatin

ZYPITAMAG atorvastatin+lovastatin+pravastatin+rosuvastatin+simvastatin+

CONTRACEPTION PRODUCTS BALCOLTRANATAZIASLYNDTAYTULLATWIRLA

generic oral contraceptives

COUGH/COLD MEDICATIONS benzonatate 150mg benzonatate 100mg, 200mg

TUSSICAPS hydrocodone-chlorpheniramine er suspensionpromethazine with codeine syrup

DIABETES ACCU-CHEK TEST STRIPSCVS TEST STRIPSADVOCATE TEST STRIPSASSURE TEST STRIPSCONTOUR TEST STRIPSFREESTYLE TEST STRIPS

ONE TOUCH TEST STRIPS (e.g. Ultra; Verio)

ADLYXIN BYDUREONBYETTAmetforminOZEMPICTRULICITYVICTOZA

ADMELOGADMELOG SOLOSTARAPIDRA, APIDRA SOLOSTARFIASPFIASP FLEXTOUCHFIASP PENFILLINSULIN ASPARTNOVOLOG

HUMALOGLYUMJEV

24



ALTERNATIVE(S)

DIABETES (cont) AFREZZA HUMALOGHUMULIN RLYUMJEV

alogliptinalogliptin-metforminJENTADUETOJENTADUETO XRKAZANOKOMBIGLYZE XRNESINAONGLYZATRADJENTA

JANUMET JANUMET XRJANUVIAmetformin

alogliptin-pioglitazoneOSENI

JANUMET JANUMET XRJANUVIApioglitazone

FORTAMETGLUMETZAmetformin er gastricmetformin er osmotic

metformin er (generic to GLUCOPHAGE XR)

GLUCAGEN HYPOKITGVOKE

glucagon emergency kit (generic)BAQSIMI ZEGALOGUE

INSULIN ASPART PRONOVOLOG MIX

HUMALOG MIX

INVOKAMETINVOKAMET XRSEGLUROMET

SYNJARDYSYNJARDY XRXIGDUO XR

INVOKANASTEGLATRO

FARXIGAJARDIANCEmetformin

LANTUSLANTUS SOLOSTARSEMGLEETOUJEO MAX SOLOSTARTOUJEO SOLOSTAR

BASAGLARLEVEMIRTRESIBA FLEXTOUCH

NOVOLIN HUMULIN

QTERNSTEGLUJAN

GLYXAMBImetforminTRIJARDY XR

DIURETICS EDECRINethacrynic acid

bumetanidefurosemidetorsemide

EYE CONDITIONS ALOCRILALOMIDE

cromolyn

CEQUARESTASIS MULTIDOSEXIIDRA

RESTASIS

25



ALTERNATIVE(S)

EYE CONDITIONS (cont) LUMIGANTRAVATAN ZVYZULTAXALATANXELPROSZIOPTAN

bimatoprostlatanoprosttravoprost

GASTROINTESTINAL/HEARTBURN ANUSOL-HC 25MG SUPPOSITORY hydrocortisone 25mg suppository

ASACOL HDCOLAZALDELZICOLDIPENTUM

balsalazidemesalamine tablets or capsulesPENTASAsulfasalazine

COLYTE WITH FLAVOR PACKETS+GOLYTELY+MOVIPREP+NULYTELY WITH FLAVOR PACKS+OSMOPREP+PLENVU+

CLENPIQ+GAVILYTE-C+GAVILYTE-G+GAVILYTE-N+PEG 3350 ELECTROLYTE+SUPREP+SUTAB+

CORTIFOAMUCERIS 2MG RECTAL FOAM

COLOCORThydrocortisone

CREONPERTZYEZENPEP

PANCREAZE

GIMOTI* metoclopramide oral solution or tablet

HELIDAC bismuth subsalicylatelansoprazole-amoxicillin-clarithromycin pakmetronidazoletetracycline

KRISTALOSElactulose 10gm packet

CONSTULOSEENULOSElactulose oral solution

LIBRAX chlordiazepoxide

LOTRONEX* alosetron*

lubiprostone AMITIZA

MARINOLSYNDROS

dronabinol

MOTEGRITYTRULANCEZELNORM

AMITIZALINZESS

NEXIUM 10MG, 20MG, 40MG PACKET, 20MG, 40MG CAPSULE

esomeprazole packets, esomeprazole magnesium

OMECLAMOX-PAKPYLERATALICIA

lansoprazole-amoxicillin-clarithromycin pak

RELTONE ursodiol

ROWASA mesalamine rectal enema suspension

SENSIPAR* cinacalcet

ZOFRAN ondansetron

ZUPLENZ ondansetronondansetron odt

26



ALTERNATIVE(S)

HORMONAL AGENTS ALKINDI SPRINKLE hydrocortisone 5mg tablet

CORTROSYN cosyntropin

DDAVPNOCDURNA

desmopressin nasal spray or tablets

DEXABLISSdexamethasone 6, 10, 13 Day 1.5MG tabletsDEXPAKDXEVOHIDEXTAPERDEXZCORT

dexamethasone 1.5mg tablet

FORTESTAJATENZONATESTOTESTIMVOGELXOXYOSTED

generic topical testosterone

GENOTROPIN*NUTROPIN AQ NUSPIN*OMNITROPE*SAIZEN*SAIZEN-SAIZENPREP*ZOMACTON*

HUMATROPE*NORDITROPIN*

HEMADY dexamethasone 5mg tablet

MYCAPSSA* BYNFEZIA*

ORTIKOS budesonide capsule

RAYOS methylprednisoloneprednisone

SYNTHROID levothyroxine

THYQUIDITY EUTHYROXLEVO-TlevothyroxineLEVOXYL

UCERIS 9MG ER TABLET budesonide 9mg tabletdexamethasonehydrocortisonemethylprednisoloneprednisoloneprednisone

INFECTIONS ACTICLATEDORYXDORYX MPCMINOCIN 50MG PEL CAPSULEMINOCYCLINE ER 45, 90, 135MG CAPSULEMINOLIRA ERMONODOXSEYSARASOLODYNTARGADOXVIBRAMYCIN 100MG CAPSULEXIMINO

Generic products (e.g. doxycycline; minocycline)

27



ALTERNATIVE(S)

INFECTIONS (cont) ARAKODA atovaquone-proguanildoxycyclinehydroxychloroquine mefloquinequinine

AUGMENTINAUGMENTIN XR

amoxicillin/clavulanate

BARACLUDE TABLET* entecavir tablet*

BETHKIS*TOBI*

tobramycin inhalation solution*

DIFLUCAN fluconazole

doxycycline hyclate dr 80mg tablet generic products (e.g. minocycline)

DOXYCYCLINE IR-DRORACEA

doxycycline hyclate dr 50mg tabletdoxycycline monohydrate 50mg tabletminocycline er 45mg

E.E.S. 200ERYPED 400

erythromycin granuleserythromycin

HUMATIN paromomycin

MEPRON atovaquone

MYCOBUTIN rifabutin

nitrofurantoin 25mg/5ml suspension nitrofurantoin capsulesulfamethoxazole-trimethoprim suspension

NOXAFIL DR 100MG TABLET posaconazole dr 100mg tablet

SITAVIG acyclovir tabletfamciclovir tabletvalacyclovir tablet

SPORANOX itraconazole

TOLSURA oral itraconazole

VALCYTE valganciclovir

VANCOCIN vancomycin oral solution or capsule

ZOVIRAX acyclovir

MISCELLANEOUS HORIZANT gabapentin

KUVAN* sapropterin tablet & powder packet*

SYPRINE* penicillamine*trientine*

XENAZINE* tetrabenazine*

MULTIPLE SCLEROSIS AMPYRA* dalfampridine er*

COPAXONE* AVONEX*BETASERON*EXTAVIA*glatiramer*GLATOPA*KESIMPTA*PLEGRIDY*REBIF*

TECFIDERA* AUBAGIO*BAFIERTAM*dimethyl*GILENYA*MAYZENT*PONVORY*VUMERITY*

28



ALTERNATIVE(S)

NUTRITIONAL/DIETARY AZESCHEWAZESCODERMACINRX PRENATRIXDERMACINRX PRENATRYLPNV TABS 20-1PREGEN DHAPREGENNATRINAZZALVIT

Any generic prenatal vitamin

NASCOBAL cyanocobalamin injection

PAIN RELIEF AND INFLAMMATORY DISEASE ALLZITALBUPAPbutalbital-acetaminophen 25-35mg, 50-300mg tablets

butalbutal-acetaminophen 50-325mg tablet

AMERGEERGOMARFROVA 2.5MG TABLETMAXALTMAXALT MLTRELPAX

generic triptans (e.g. sumatriptan; naratriptan)

AMRIXcyclobenzaprine er

carisoprodolchlorzoxazone 500mgcyclobenzaprine tabletsmethocarbamolorphenadrine ermetaxalone

CAMBIADUEXISfenoprofen 200mg capsulefenoprofen 400mg capsuleFENORTHOINDOCINindomethacin 20mg capsuleketoprofen 25mg capsulemeloxicam 5mg, 10mg capsuleNALFON 400MG CAPSULENAPRELANNAPROSYN 125MG/5ML SUSPENSIONnaproxennaproxen sodium crnaproxen sodium ernaproxen-esomeprazole magRELAFENRELAFEN DSTIVORBEXVIMOVOVIVLODEXZIPSORZORVOLEX

Generic NSAID (e.g. celecoxib; meloxicam)

CAPITAL WITH CODEINE acetaminophen-codeine

chlorzoxazone 250mg chlorzoxazone 500mg

chlorzoxazone 375mg chlorzoxazone 750mg

methocarbamol 500mg

29



ALTERNATIVE(S)


CONZIP tramadoltramadol er

COSENTYX* ENBREL*HUMIRA*OTEZLA*STELARA*TALTZ*

CUPRIMINE* penicillamine*trientine*

D.H.E.45 dihydroergotamine injection

diclofenace 1.3% patchdiclofenac 1.5% solutiondiclofenac 35mg capsuleFLECTORLICARTPENNSAIDVOLTAREN 1% GEL

generic nsaid (e.g. celecoxib; meloxicam)diclofenac 1% gel

dihydroergotamine 4mg/ml sprayIMITREX NASAL SPRAYMIGRANALONZETRA XSAILZOLMITRIPTAN NASAL SPRAYZOMIG

sumatriptan nasal spray

GLOPERBA colchicineprobenecid-colchicine

GRALISE gabapentin

IMITREX CARTRIDGEIMITREX PEN INJECTOR

dihydroergotaminesumatriptan

IMITREX TABLET dihydroergotamineeletriptanrizatriptansumatriptan tablets

KETOROLAC 15.75MG NASAL SPRAYSPRIX

ketorolac tablet

KINERET* ACTEMRA*ENBREL*HUMIRA*XELJANZ/XR*

levorphanol codeine with acetaminophenhydrocodone with acetaminophenHYSINGLA ERoxycodone with acetaminophentramadolXTAMPZA ER

LORZONE chlorzoxazone 500mgcyclobenzaprine tablet

NORGESIC FORTEorphenadrine-aspirin-caffeineORPHENGESIC FORTE

chlorzoxazone 500mg tabletmetaxalonemethocarbamolorphenadrine ER

30



ALTERNATIVE(S)


OXYCONTIN HYSINGLA ERMORPHABOND ERXTAMPZA ER

OZOBAX baclofen tablet

PROLATE SOLUTION oxycodone-acetaminophen tablet

QDOLO tramadol 50mg tablet

REMICADE* AVSOLA*INFLECTRA*

REYVOW generic triptans (e.g. sumatriptan; naratriptan)NURTEC ODTUBRELVY

ROXICODONE oxycodone

SILIQ* ENBREL*HUMIRA*STELARA*TALTZ*TREMFYA*

SIMPONI* 50MG/0.5ML ACTEMRA*ENBREL*HUMIRA*STELARA*TALTZ*XELJANZ/XR*

SORIATANE acitretin

SUBSYS fentanyl lozenge or buccal tablet

SUMAVEL DOSEPROTOSYMRA

sumatriptan

tramadol 100mg tramadol

TREXIMET sumatriptan-naproxen

VANATOL LQVANATOL S

butalbital-acetaminophen-caffeine capsule or tablets

ZEMBRACE SYMTOUCH dihydroergotaminesumatriptan

ZOMIG ZMT zolmitriptan odt

PARKINSON'S DISEASE GOCOVRI amantadine

LODOSYN carbidopa

ONGENTYS entacapone

REQUIP XL ropinirole er

ZELAPAR selegiline tablets or capsules

SCHIZOPHRENIA/ANTI-PSYCHOTICS ABILIFYABILIFY MYCITE

aripiprazolepaliperidone errisperidone

CAPLYTA aripiprazoleolanzapinepaliperidone erquetiapinequetiapine errisperidoneziprasidone

31



ALTERNATIVE(S)

SCHIZOPHRENIA/ANTI-PSYCHOTICS (cont) GEODON CAPSULE aripiprazolepaliperidone erziprasidone

VERSACLOZ clozapine clozapine odt

ZYPREXA aripiprazoleolanzapine tabletspaliperidone er

ZYPREXA ZYDIS aripiprazoleolanzapineolanzapine odt

SEIZURE DISORDERS ELEPSIA XRKEPPRA XR

levetiracetam er

FELBATOL felbamate

KEPPRA SOLUTION, TABLET levetiracetam

LAMICTAL lamotrigine

LAMICTAL TAB KIT (BLUE, GREEN, ORANGE) lamotrigine starter kit (blue, green, orange)

LAMICTAL ODT lamotrigine odt

LAMICTAL ODT KIT (BLUE, GREEN, ORANGE) lamotrigine odt starter kit (blue, green orange)

LAMICTAL XRLAMICTAL XR KIT (BLUE, GREEN, ORANGE)

lamotrigine er

LYRICALYRICA CRpregabalin er

duloxetinegabapentinlidocaine 5% topical patchpregabalin

MYSOLINE primidone

QUDEXY XRTROKENDI XR

topiramate er

SABRIL* vigabatrin*

SYMPAZAN clobazam

TOPAMAX topiramate

TRILEPTAL oxcarbazepine

ZONEGRAN zonisamide

SKIN CONDITIONS ABSORICAABSORICA LD

CLARAVISisotretinoinMYORISANZENATANE

ACANYAACZONEAKLIEFAKTIPAKALTRENOAMZEEQARAZLOATRALINAVITAAZELEXDIFFERINDUAC

Use generic products (e.g. adapalene; tretinoin; clindamycin-benzoyl peroxide)

32



ALTERNATIVE(S)

SKIN CONDITIONS (cont) EPIDUO FORTEFABIORONEXTONRETIN-ARETIN-A MICRORETIN-A MICRO PUMPtazarotene 0.1% foamTAZORACTRETIN-XVELTINWINLEVIZIANA


acyclovir cream, ointmentDENAVIRZOVIRAX

acyclovir tabletfamciclovir tabletvalacyclovir tablet

adapalene swabPLIXDA

adapalene 0.1% creamadapalene 0.1% lotionadapalene 0.3% geltazarotene 0.1% creamtretinoin cream, gel, micro gel

ALDARAimiquimod 3.75% ZYCLARA

imiquimod 5% cream

ANUSOL-HC 2.5% CREAM hydrocortisone 2.5% rectal cream

APEXICON ECORDRAN 4 MCG/SQ CM TAPE LARGEdiflorasone PSORCON

betamethasone cream, ointmentclobetasol halobetasol cream, ointment

BENZACLINNEUAC 1.2-5% KIT

clindamycin-benzoyl peroxide

calcipotriene foam calcipotriene cream, ointment, solutioncalcitriol ointment tazarotene cream

CARAC fluorouracil 0.5% cream

CLINDAGEL clindamycin gelclindamycin topical solution

CLINDAMYCIN 1% GEL clindamycin 1% gel (generic Cleocin T)dapsone 5% gelerythromycin 2% gel

CLOBEX clobetasol lotion, shampoo, spray

CONDYLOX imiquimod 5% cream packetpodofilox 0.5% topical solution

CORDRAN CREAM, LOTION, OINTMENT betamethasonfluocinolone fluticasone

CUTIVATE betamethasone lotionfluticasone topical lotiontriamcinolone lotion

DAPSONE 7.5% GEL PUMP generic topical acne products (e.g. tretinoin; clindamycin-benzoyl peroxide)

33



ALTERNATIVE(S)

SKIN CONDITIONS (cont) diclofenac 3% gelKLISYRI

FLUOROPLEXfluorouracilimiquimod 5% cream

DOVONEX calcipotriene cream

doxepin 5% creamPRUDOXINZONALON

generic topical steroid (e.g. betamethasone)topical tacrolimus

DUOBRII halobetasol plus tazarotene cream

ENSTILARTACLONEX

calcipotriene cream, ointment, solutioncalcipotriene-betamethasone ointment tazarotene creamtopical betamethasone

ERTACZO ketoconazole cream

EXELDERMoxiconazole OXISTATSULCONAZOLE

econazole creamketoconazole creamnaftifine cream

EXTINA ketoconazole creamketoconazole foam

FINACEAMETROCREAMMETROGELSOOLANTRAZILXI

azelaic acidtopical metronidazole

flurandrenolidehydrocortisone 1% lotion

betamethasone fluocinolone fluticasone

halobetasol foamLEXETTE

augmented betamethasone dipropionatebetamethasone dipropionate cream, ointmentclobetasol fluocinonide 0.1% creamhalobetasol cream, ointment

HALOG SOLUTION clobetasol cream, ointmenthalobetasol cream, ointment

IMPEKLO betamethasone dipropionate cream, ointmentclobetasol fluocinonide 0.1% creamhalobetasol cream, ointment

IMPOYZ clobetasol cream, ointmentbetamethasone dipropionate cream, ointmenthalobetasol cream, ointment

JUBLIAKERYDINtavaborole

ciclopirox topical solutionitraconazole capsulesterbinafine tablets

KENALOG 0.147MG/GM SPRAYtriamcinolone ointmenttriamcinolone spray

desoximetasone 0.05% cream, ointmentfluocinolone 0.025% ointmentflurandrenolide 0.05% ointmenthydrocortisone 0.2% ointmentmometasone 0.1% cream

34



ALTERNATIVE(S)

SKIN CONDITIONS (cont) LOCOID betamethasone lotionfluocinolone creamfluticasone creamhydrocortisone ointmentprednicarbate ointmenttriamcinolone cream

LOCOID LIPOCREAMnolixPANDEL

betamethasone creamfluocinolone creamfluticasone cream

LOPROX 0.77% CREAM 1% SHAMPOO ciclopirox cream, shampoo

LUZU econazole creamketoconazole creamluliconazole

NORITATE azelaic acidmetronidazole creammetronidazole gel

OLUXOLUX-E

betamethasone dipropionate cream, ointmentclobetasol cream, foam, ointmenthalobetasol cream, ointment

QBREXZA DRYSOL

SERNIVO betamethasone

SORILUX calcipotriene cream, ointment, solutioncalcitriol ointment tazarotene cream

TRIANEX triamcinolone cream

TRIDESILON alclometasonedesonidetriamcinolone

ULTRAVATE LOTIONULTRAVATE X

betamethasone ointmentclobetasol cream, lotion, ointmenthalobetasol cream, ointment

VANOS clobetasol creamfluocinonide 0.1% creamhalobetasol cream

VECTICAL calcitriol ointment calcipotriene ointment tazarotene cream

VERDESO desonide creamdesonide ointment

WYNZORA betamethasonecalcipotrienecalcipotriene-betamethasonefluocinolone fluticasone mometasone triamcinolone cream

XERESE acyclovir tabletfamciclovir tabletplus hydrocortisone prescription creamvalacyclovir tablet

35


ALTERNATIVE(S)

SKIN CONDITIONS (cont) XOLEGEL ciclopirox 0.77% gelciclopirox 1% shampooketoconazole 2% creamketoconazole 2% foamselenium sulfide 2.5% lotionsodium sulfacetamide 10% shampoo

SLEEP DISORDERS/SEDATIVES AMBIEN zolpidem

AMBIEN CR zolpidem er

ATIVAN TABLET lorazepam

BELSOMRA DAYVIGO

EDLUAR zolpidem or zolpidem er

NUVIGIL armodafinil

PROVIGIL modafinil

RESTORIL temazepam

ZOLPIMIST doxepineszopiclonezaleplonzolpidemzolpidem ER

SUBSTANCE ABUSE EVZIO naloxone auto-injectorNARCAN

TRANSPLANT MEDICATIONS LUPKYNIS* BENLYSTA*tacrolimus*

URINARY TRACT CONDITIONS DETROL darifenacin eroxybutynintolterodine

DETROL LA darifenacin eroxybutynin ertolterodine er

DITROPAN XL oxybutynin er

ENABLEX darifenacin er

GELNIQUEMYRBETRIQOXYTROLTOVIAZVESICARE LS

darifenacin eroxybutynin ertolterodine ertrospium er

GEMTESA darifenacin eroxybutynin oxybutynin ersolifenacintolterodinetolterodine ertrospium

PROCYSBI* CYSTAGON*

THIOLA*THIOLA EC*

tiopronin*

VESICARE darifenacin eroxybutynin ersolifenacintolterodine ertrospium er


36

Frequently Asked Questions (FAQs)Understanding your prescription medication coverage can be confusing. Here are answers to some commonly asked questions.

Q. Why do you make changes to the drug list?

A. Cigna regularly reviews and updates the prescription drug list. We make changes for many reasons – like when new medications become available or are no longer available, or when medication prices change. We try to give you many options to choose from to treat your health condition. These changes may include:1,2

› 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 becomes available. 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 1st and January 1st.

› Adding extra coverage requirements to a medication.

When we make a change that affects the coverage of a medication you’re taking, we let you know before it happens. This way, you have time to talk with your doctor about your options.

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 medications because they have lower-cost, covered alternatives which are used to treat the same condition. Meaning, the alternative works the same or similar to the non-covered medication. If you’re taking a medication that your plan doesn’t cover and your doctor feels an alternative isn’t right for you, he or she can ask Cigna to consider approving coverage.

Your plan may also exclude certain medications or products from coverage. This is known as a “plan (or benefit) exclusion.” With excluded medications, there’s no option to get coverage through Cigna’s coverage review process.

For example, your plan excludes:

› Prescription medications used to treat heartburn/stomach acid conditions (e.g.,

Nexium, Prilosec and any generics) and allergies (e.g., Allegra, Clarinex, Xyzal and any generics). These are available over-the-counter without a prescription.

› Medications used to treat lifestyle conditions like infertility, weight loss, erectile dysfunction, smoking cessation.5

› Medications that aren’t approved by the U.S. Food and Drug Administration (FDA).

Q. How do you decide which medications to cover?

A. The Cigna Prescription Drug List is developed with the help of Cigna’s Pharmacy and Therapeutics (P&T) Committee, which is a group of practicing doctors and pharmacists, most of whom work outside of Cigna. 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 Pharmacy Management® Business Decision Team 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 to make sure you’re receiving coverage for the right medication, at the right cost, in the right amount and for the right situation.

Q. How do I know if I’m taking a medication that needs approval?

A. Log in to the myCigna App or myCigna.com, or check your plan materials, to learn more about how your plan covers your medications. If your medication has a (PA) or (ST) next to it, your medication needs approval before your plan will cover it. If it has a (QL) next to it, you may need

37

Frequently Asked Questions (FAQs) (cont)

approval depending on the amount you’re filling. If is has (AGE) next to it, you may need approval depending on the covered age range for the medication.

Q. What types of medications typically need approval?

A. Medications that:

› May be unsafe when combined with other medications

› Have lower-cost, equally effective alternatives available

› Should only be used for certain health conditions

› Are often misused or abused

Q. What types of medications typically have quantity limits?

A. Medications that:

› Are often taken in amounts larger than, or for longer than, may be appropriate

› Are often misused or abused

Q. What types of medications require Step Therapy?

A. The Step Therapy program includes medications that are used to treat many conditions, including, but not limited to:

› ADD/ADHD

› Allergies

› Bladder problems

› Breathing problems

› Depression

› High blood pressure

› High cholesterol

› Osteoporosis

› Pain

› Skin Conditions

› Sleep disorders

Q. Why does my medication have an age requirement?

A. Some medications are only considered

clinically appropriate for people of a certain age.

Q. How do I get approval (prior authorization) for my medication?

A. Ask your doctor’s office to contact Cigna so we can start the coverage review process. They know how the review process works and will take of everything for you. In case the office asks, they can download a request form from Cigna’s provider portal at cignaforhcp.com.

Cigna will review information your doctor provides to make sure your medication meets coverage guidelines. We’ll send you and your doctor a letter with the decision and next steps. It can take 1-5 days to hear from us. You can always check with your doctor’s office to find out if a decision has been made. If you meet guidelines, your medication will be approved for coverage. If you don’t meet guidelines, you and your doctor can appeal the decision by sending Cigna a written request stating why the medication should be covered.

Q. What happens if I try to fill a prescription that needs approval but I don’t get approval ahead of time?

A. When your pharmacist tries to fill your prescription, he or she will see that the medication needs prior approval. Because you didn’t get approval ahead of time, your plan coverage won’t apply. Meaning, your plan won’t cover the cost of your medication. You should ask your doctor to contact Cigna to start the coverage review process. Or, you can choose to pay its full cost out-of-pocket directly to the pharmacy (the cost can’t be applied to your annual deductibe 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 will need to contact Cigna to request approval for coverage.

Q. Are all of the medications on this drug list approved by the U.S. Food and Drug Administration (FDA)?

38


A. Yes. All medications are approved by the FDA.

Q. Are medications newly approved by the FDA covered on my drug list?

A. Newly approved medications may not be covered on your drug list for the first six months after they receive approval from the U.S. Food and Drug Administration (FDA). These include, but are not limited to, medications, medical supplies and/or devices covered under standard pharmacy benefit plans. We review all newly approved medications to see if they should be covered - and if so, on what tier. If your doctor feels a currently covered medication isn’t right for you, he or she can ask Cigna to consider approving coverage of the newly approved medication.

Q. Which medications are covered under the health care reform law?

A. The Patient Protection and Affordable Care Act (PPACA), commonly referred to as “health care reform,” was signed into law on March 23, 2010. Under this law, certain preventive medications (including some over-the counter products) may be available to you at no cost-share ($0), depending on your plan. Log in to the myCigna App or myCigna.com, or check your plan materials, to learn more about how your plan covers preventive medications. You can also view the PPACA No Cost-Share Preventive Medications drug list at Cigna.com/druglist.

For more information about health care reform, go to www.informedonreform.com or Cigna.com.

Q. How can I find out how much I’ll pay for a specific medication?

A. When you and your doctor are considering the right medication for your treatment, knowing how much it costs, what lower-cost alternatives are available, and which pharmacies offer 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.6

Q. How can I save money on my prescription medications?

A. You may be able to save money by switching to a medication that’s on a lower tier (ex. generic or preferred brand) or by filling a 90-day supply, if your plan allows. You should talk with your doctor to find out if one of these options may work for you.

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 its brand-name version.7 Generic and brand-name medications have the same active ingredients, strength, dosage, form, effectiveness, quality, and safety.

Q. What are the differences between generic Q. What are the differences between generic and brand-name medications? and brand-name medications?

A. The medications may look different. For example, generics may have a different shape, size or color than the brand-name medication. They may also have a different flavor, contain different preservatives, come in different packaging and/or with different labeling and may expire at different times. Generics may look different than the brand-name, but they’re just as safe and effective.

Generics typically cost much less than brand-name medications - in some cases, up to 85% less.7 Just because generics cost less than brands, doesn’t mean they’re lower-quality medications.

Q. My pharmacy isn’t in my plan’s network. Can I continue to fill my prescriptions there?

A. To receive in-network coverage under your plan, you’ll need to switch to a pharmacy in your plan’s network. If your plan offers out-of-network coverage, you’ll pay out-of-network costs to fill a prescription there.

Q. Can I fill my prescriptions by mail?

A. Yes, as long as your plan offers home delivery.8

39


Home delivery with Express Scripts® Pharmacy

Express Scripts® Pharmacy, our home delivery 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.

› Easily order, manage and track your medications on your phone or online

› Standard shipping at no extra cost9

› Automatic refills and refill reminders

› Fill up to a 90-day supply at one time

› Helpful pharmacists available 24/7

› Flexible payment options

Here are three easy ways to get started.1. Log in to the myCigna App or myCigna.com

to move your prescription electronically. Click on the Prescriptions tab and select My Medications from the dropdown menu. Then simply click the button next to your medication name to move your prescription(s).

2. Call your doctor’s office. Ask them to send a 90-day prescription (with refills) electronically to Express Scripts Home Delivery.

3. Call Express Scripts® Pharmacy at 800.835.3784. They’ll contact your doctor’s office to help transfer your prescription. Have your Cigna ID card, doctor’s contact information and medication name(s) ready when you call.

Accredo, a Cigna specialty pharmacy

If you’re taking a specialty medication to treat a complex medical condition, Accredo’s team of specialty trained pharmacists and nurses can help. They’ll fill and ship your specialty medication to your home (or location of your choice).10 They’ll also provide you with the personalized care and support you need to manage your therapy – at no extra cost.

› Easily manage and track your medications on your phone or online

› Fast shipping, at no extra cost

› Easy refills and free reminders

› 24/7 access to specialty-trained pharmacists and nurses

› Personalized care services like training on how to administer your medication

› Help with applying for third-party copay assistance programs and other options

To get started using Accredo, call 877.826.7657, Monday–Friday, 7:00 am–10:00 pm CST and Saturdays, 7:00 am–4:00 pm CST. Be sure to call Accredo about two weeks before your next refill so they have time to get a new prescription from your doctor’s office. To learn more about Accredo, go to Cigna.com/specialty.

Q. Where can I find more information about my pharmacy benefits?

A. You can use the online tools and resources on the myCigna App or myCigna.com to help you better understand your pharmacy coverage. You can find out how much your medication costs, see which medications your plan covers, find an in-network pharmacy, ask a pharmacist a question and see your pharmacy claims and coverage details. You can also manage your home delivery prescription orders.

40

Exclusions and limitations for coverage

› 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;

› implantable contraceptive devices covered under the Plan’s medical benefit;

› medications that are not medically necessary;

› experimental or investigational medications, including 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 Food & Drug Administration (FDA);

› prescription and non-prescription devices, supplies, and appliances other than those supplies specifically listed as covered;

› medications used for fertility3, sexual dysfunction, cosmetic purposes, weight loss, smoking cessation3, 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; or

› 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 as medically necessary.

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:11

1. State laws in Texas and Louisiana may require your plan to cover your medication at your current benefit level until your plan renews. This means that if your medication is taken off the drug list, is moved to a higher cost-share tier or needs approval from Cigna before your plan will cover it, these changes may not begin until your plan’s renewal date. To find out if these state laws apply to your plan, please call Customer Service using the number on your Cigna ID card.

2. State law in Illinois may require your plan to cover your medications at your current benefit level until your plan renews. This means that if you currently have approval through a review process for your plan to cover your medication, the drug list change(s) listed here may not affect you until your plan renewal date. If you don’t currently have approval through a coverage review process, you may continue to receive coverage at your current benefit level if your doctor requests it. To find out if this state law applies to your plan, please call Customer Service using the number on your Cigna ID card.

3. Plans that must follow state insurance laws, like Delaware’s state insurance laws, 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.

4. For insured plans that must follow Delaware’s state insurance laws: Brand-name antidepressant, 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 Customer Service using the number on your Cigna ID card.

5. Smoking cessation medications are not typically covered under the plan, except as required by law or by the terms of your specific plan. Costs and complete details of the plan’s prescription drug coverage, including a full list of exclusions and limitations, 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.

6. Prices are not guaranteed, and even though a price is displayed, it’s not a guarantee of coverage. Your costs and coverage may change by the time you fill your prescription at the pharmacy, and medication costs at individual pharmacies can vary. For example, your pharmacy’s retail cash price for a specific medication may be less than the price shown. Coverage and pricing may change.

7. U.S. Food and Drug Administration (FDA) website, “Generic Drugs: Questions and Answers.” Last updated 03/16/21. https://www.fda.gov/drugs/questions-answers/generic-drugs-questions-answers.

8. Not all plans offer home delivery 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.

9. Standard shipping costs are included as part of your prescription plan.

10. As allowable by law. For medications administered by a health care provider, Accredo will ship the medication directly to your doctor’s office.

11. 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.

Product availability may vary by location and plan type and is subject to change. All group health insurance policies and health benefit plans contain exclusions and limitations. For costs and details of coverage, review your plan documents or contact a Cigna representative.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company (CHLIC), Accredo Health Group, Inc., Express Scripts, Inc., ESI Mail Pharmacy Service, Inc, Express Scripts Pharmacy, 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 North Carolina, Inc., Cigna HealthCare of New Jersey, Inc., Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of Tennessee, Inc., (CHC-TN), and Cigna HealthCare of Texas, Inc. “Accredo” refers to Accredo Health Group, Inc. “Express Scripts Pharmacy” refers to ESI Mail Pharmacy, Inc. Policy forms: OK - HP-APP-1 et al., OR - HP-POL38 02-13, TN - HP-POL43/HC-CER1V1 et al. (CHLIC); GSA-COVER, et al. (CHC-TN). The Cigna name, logo, “Together all the way.,” and “myCigna” are trademarks of Cigna Intellectual Property, Inc. “Accredo” and “Express Scripts Pharmacy” are trademarks of Express Scripts Strategic Development, Inc.

887152x Advantage 3-Tier 08/21 © 2021 Cigna. Some content provided under license.

Cigna 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 does not take responsibility for any medication decisions made by the doctor 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.

LISTA DE MEDICAMENTOS CON RECETA ADVANTAGE DE 3 NIVELES DE CIGNA

Cobertura a partir del 1 de enero de 2022

Ofrecido por Cigna Health and Life Insurance Company o Connecticut General Life Insurance Company

887152SP x Advantage 3-Tier 08/21

2

¿Qué encontrará adentro?

Acerca de esta Lista de medicamentos 3

Cómo leer esta Lista de medicamentos 3

Cómo encontrar su medicamento 5

Medicamentos que no están cubiertos 19

Preguntas frecuentes 36

Exclusiones y limitaciones de la cobertura 40

* Creación de la Lista de medicamentos: creada originalmente el 1 de marzo de 2011

Última actualización: 1 de agosto de 2021, para los cambios que empezarán a regir el 1 de enero de 2022

Próxima actualización planificada: 1 de marzo de 2022, para los cambios que empezarán a regir el 1 de julio de 2022

Cigna.com/druglist. Seleccione Advantage 3 Tier (Advantage de 3 niveles)

del menú desplegable. Después escriba el nombre de su medicamento o vea

la lista completa.

¿Tiene preguntas?

› myCigna.com: Haga clic para conversar por chat de lunes a viernes, de 9:00 a.m. a 8:00 p.m., hora del Este.

› Por teléfono: Llame al número gratuito que aparece en su tarjeta de ID de Cigna. Estamos para servirle a toda hora, los 365 días del año.

Cómo ver la Lista de medicamentos en líneaEste documento se actualizó por última vez el 1 de agosto de 2021.* En Internet podrá ver la lista actualizada de los medicamentos que cubre su plan.

Aplicación myCigna® y myCigna.com. Haga clic en la pestaña Find Care & Costs (Dónde atenderse y cuánto cuesta) y seleccione Price a Medication (Conozca los precios de los medicamentos). Luego escriba el nombre de su medicamento para ver cómo está cubierto.

3

NIVEL 1$

NIVEL 2$$

MEDICAMENTOS PARA LA PRESIÓN ARTERIAL/PARA EL CORAZÓN

afeditab CRamlodipine besylateamlodipine besylate-benazeprilamlodipine-valsartanamlodipine-valsartan-HCTZatenololatenolol-chlorthalidonebenazepril benazepril-HCTZcandesartan cilexetilcartia XTcarvedilolclonidinedigitekdigoxdigoxindiltiazem ERdiltiazem CDdiltiazem dilt-XRenalapril flecainide acetatehydralazine irbesartanisosorbide mononitrate

BERINERT* (PA)BIDILBYSTOLICCINRYZE* (PA)COREG CRCOZAAR (ST)DIOVAN (ST)DIOVAN HCT (ST)EDARBI (ST)EDARBYCLOR (ST)EXFORGEEXFORGE HCTFIRAZYR* (PA)HEMANGEOLINDERAL LAINDERAL XLINNOPRAN XLLOTRELMICARDIS (ST)MULTAQNITRO-DURNITROLINGUALNITROMISTNITRONALNITROSTATNORTHERA* (PA)NORVASCRANEXA (ST)TEKTURNATEKTURNA HCT

Acerca de esta Lista de medicamentos

Los medicamentos están agrupados según la condición que tratan

Los medicamentos que tienen requisitos de cobertura adicionales tienen una abreviatura junto al nombre

Los medicamentos están enumerados en orden alfabético (según el inglés) dentro de cada columna

Los medicamentos de marca

están escritos en mayúscula

Los medicamentos genéricos están escritos en minúscula

Los medicamentos de especialidad tienen un asterisco (*) junto al nombre

El Nivel (nivel de costo compartido) le da una idea de cuánto puede llegar a pagar por un medicamento

3

Este cuadro es solo un modelo. Es posible que no muestre la forma en que la Lista de medicamentos con receta Advantage de 3 niveles de Cigna realmente cubre estos medicamentos.

Esta es una lista de los medicamentos que se recetan con mayor frecuencia y están cubiertos por la Lista de medicamentos con receta Advantage de 3 niveles de Cigna a partir del 1 de enero de 2022.1,2 Los medicamentos están agrupados según la condición que tratan, y luego se los ordena alfabéticamente (según el inglés) dentro de niveles que representan niveles de costo compartido.

La Lista de medicamentos se actualiza bastante seguido, por lo que esta no es una lista completa de los medicamentos que cubre su plan. Además, también es posible que su plan específico no cubra todos estos medicamentos. Inicie sesión en la aplicación myCigna o en myCigna.com, o consulte los materiales de su plan, para ver todos los medicamentos que cubre su plan.

Los medicamentos con receta que se usan para tratar alergias (por ejemplo, Allegra, Clarinex, Xyzal y los genéricos) y pirosis u otras condiciones de acidez estomacal (por ejemplo, Nexium, Prilosec y los genéricos) no están cubiertos en esta Lista de medicamentos. Esos medicamentos son considerados exclusiones del plan (o de beneficios). Puede obtener versiones de venta libre (OTC, por sus siglas en inglés) en la farmacia sin una receta.

Cómo leer esta Lista de medicamentosUse la tabla incluida abajo para leer esta Lista de medicamentos. Este cuadro es solo un ejemplo. Es posible que no muestre la forma en que la Lista de medicamentos con receta Advantage de 3 niveles de Cigna realmente cubre estos medicamentos.

4

Niveles

Los medicamentos cubiertos se dividen en niveles, que representan niveles de costo compartido. Por lo general, cuanto más alto sea el nivel, mayor será el precio que deberá pagar para que le despachen la receta.

› Nivel 1 – Normalmente genéricos (Medicamento con el costo más bajo) $

› Nivel 2 – Normalmente de marca preferida (Medicamento de costo medio) $$

› Nivel 3 – Normalmente de marca no preferida (Medicamento con el costo más alto) $$$

Las abreviaturas al lado del nombre de los medicamentos

En esta Lista de medicamentos, los medicamentos que tienen límites y/o requisitos de cobertura adicionales tienen una abreviatura junto al nombre.* Esto es lo que significan.

(PA) Autorización previa: Determinados medicamentos necesitan la aprobación de Cigna para que su plan los cubra. Estos medicamentos tienen la abreviatura (PA) junto al nombre. Su plan no cubrirá estos medicamentos a menos que su médico solicite y reciba la aprobación de Cigna.

(QL) Límites a la cantidad: Algunos medicamentos tienen un límite de cantidad. Esto significa que su plan cubre solamente hasta una determinada cantidad y a lo largo de un plazo determinado. Estos medicamentos tienen la abreviatura (QL) junto al nombre. Su plan solamente cubrirá una cantidad mayor si su médico solicita y recibe la aprobación de Cigna.

(ST) Tratamiento escalonado: Ciertos medicamentos de alto costo no están cubiertos hasta que usted haya probado primero una o más alternativas de menor costo.** Estos medicamentos tienen la abreviatura (ST) junto al nombre. Tiene muchas opciones cubiertas para elegir, que se usan para tratar la misma condición.

(AGE) Requisitos de edad: Ciertos medicamentos solo estarán cubiertos si usted se encuentra dentro de un rango de edad específico. Estos medicamentos tienen la abreviatura (AGE) junto al nombre. Si usted no se encuentra dentro del rango de edad permitido, su plan solo cubrirá el medicamento si su médico solicita y recibe la aprobación de Cigna.

* Es posible que estos requisitos de cobertura no se apliquen a su plan específico. Inicie sesión en la aplicación myCigna o en myCigna.com, o consulte los materiales de su plan, para averiguar si su plan incluye los requisitos de autorización previa, límites a la cantidad, tratamiento escalonado y/o edad.

** Si su médico considera que una alternativa no es adecuada para usted, podrá pedirle a Cigna que evalúe la posibilidad de aprobar la cobertura de su medicamento.

Los medicamentos de marca están escritos en mayúscula

En esta Lista de medicamentos, los medicamentos genéricos están escritos en minúscula, y los medicamentos de marca están escritos en mayúscula.

Los medicamentos de especialidad tienen un asterisco junto al nombre

Los medicamentos de especialidad se usan para tratar condiciones médicas complejas. En esta Lista de medicamentos, los medicamentos de especialidad tienen un asterisco (*) al lado del nombre. Algunos planes cubren medicamentos de especialidad en un nivel de especialidad, limitan la cobertura a un suministro para 30 días y/o le exigen que use una farmacia de especialidad preferida para obtener cobertura. Inicie sesión en la aplicación myCigna o en myCigna.com, o consulte los materiales de su plan, para ver cómo su plan cubre estos medicamentos.

5

Condición Página

SIDA/VIH 6

ALERGIA/ROCIADORES NASALES 6

ENFERMEDAD DE ALZHEIMER 6

ANSIEDAD/DEPRESIÓN/TRASTORNO BIPOLAR

6

ASMA/EPOC/CONDICIONES RESPIRATORIAS

6, 7

TRASTORNO DE DÉFICIT DE ATENCIÓN E HIPERACTIVIDAD

7

MODIFICADORES DE LA SANGRE/TRASTORNOS HEMORRÁGICOS

7


7, 8

DILUYENTES DE LA SANGRE/ANTICOAGULANTES

8

CÁNCER 8

MEDICAMENTOS PARA EL COLESTEROL 8

PRODUCTOS ANTICONCEPTIVOS 9, 10

MEDICAMENTOS PARA LA TOS/EL RESFRÍO 10

PRODUCTOS DENTALES 10, 11

DIABETES 11

DIURÉTICOS 11

MEDICAMENTOS PARA LOS OÍDOS 11

CONDICIONES OCULARES 11, 12

Condición Página

PRODUCTOS FEMENINOS 12

CONDICIONES GASTROINTESTINALES/PIROSIS 12, 13

AGENTES HORMONALES 13

INFECCIONES 13, 14

INFERTILIDAD 14

VARIOS 14

ESCLEROSIS MÚLTIPLE 14

NUTRITIVOS/ALIMENTICIOS 14, 15

PRODUCTOS PARA LA OSTEOPOROSIS 15

ALIVIO DEL DOLOR Y ENFERMEDAD INFLAMATORIA

15, 16

ENFERMEDAD DE PARKINSON 16

ESQUIZOFRENIA/ANTIPSICÓTICOS 16

TRASTORNOS CONVULSIVOS 16,

CONDICIONES CUTÁNEAS 16, 17

TRASTORNOS DEL SUEÑO/SEDANTES 17

DEJAR DE FUMAR 17

ABUSO DE SUSTANCIAS 17

MEDICAMENTOS PARA TRASPLANTE 17

CONDICIONES URINARIAS 17, 18

VACUNAS 18

CONTROL DEL PESO 18

Los medicamentos preventivos sin costos compartidos tienen un signo de más al lado del nombre

La reforma del cuidado de salud establecida por la Ley de Protección al Paciente y Cuidado de Salud a Bajo Precio (PPACA, por sus siglas en inglés) exige que los planes cubran determinados medicamentos y productos preventivos al 100% o sin que usted tenga que pagar ninguna parte del costo ($0). En esta Lista de medicamentos, estos medicamentos tienen un signo de más (+) al lado del nombre. Inicie sesión en la aplicación myCigna o en myCigna.com, o consulte los materiales de su plan, para ver cómo su plan cubre estos medicamentos.

Exclusiones del plan o de beneficios

Su plan no cubre ciertos medicamentos y productos porque son considerados exclusiones del plan o de beneficios. Por ejemplo, su plan no incluye medicamentos con receta que se usan para tratar alergias (por ejemplo, Allegra, Clarinex, Xyzal y los genéricos) y pirosis u otras condiciones de acidez estomacal (por ejemplo, Nexium, Prilosec y los genéricos). Con los medicamentos excluidos, no existe la opción de recibir cobertura a través del proceso de revisión de Cigna demostrando que usted necesita el medicamento o producto para su tratamiento. En esta Lista de medicamentos, estos medicamentos tienen un signo de intercalación (^) al lado del nombre. Inicie sesión en la aplicación myCigna o en myCigna.com, o consulte los materiales de su plan, para ver qué medicamentos están excluidos de su plan.

Cómo encontrar su medicamento Primero, busque su condición en la siguiente lista ordenada alfabéticamente según el inglés. Luego vaya a esa página para ver los medicamentos cubiertos disponibles para tratar la condición.

6

NIVEL 1$

NIVEL 2$$

NIVEL 3 $$$

SIDA/VIH

abacavir-lamivudine* (PA)

efavirenz-emtricitabine-tenofovir*

emtricitabine-tenofovir*+

ritonavir*tenofovir* (PA)

BIKTARVY*DESCOVY*+ (PA)DOVATO*GENVOYA*ISENTRESS HD* (PA)ISENTRESS*JULUCA*PREZISTA*SELZENTRY* (PA)SYMTUZA*TIVICAY PD*TIVICAY*TRIUMEQ*

CIMDUO* (PA)COMPLERA* (PA)EVOTAZ* (PA)ODEFSEY* (PA)PIFELTRO* (PA)PREZCOBIX* (PA)STRIBILD* (PA)TEMIXYS* (PA)

ALERGIA/ROCIADORES NASALES

azelastine azelastine-fluticasone

cromolyn oral concentrate

desloratadine^ (QL)fluticasone^hydroxyzine hcl solution, syrup, tablet

hydroxyzine pamoate

ipratropium mometasone^ (QL)olopatadine promethazine solution, syrup, tablet

CLARINEX-D 12 HOUR

GASTROCROMGRASTEK (PA, QL)KARBINAL ERODACTRA (PA, QL)ORALAIR (PA, QL)PATANASERAGWITEK (PA, QL)VISTARIL

ENFERMEDAD DE ALZHEIMER

donepezil donepezil odtmemantine memantine er (QL)pyridostigmine 60 mg/5 ml, 60 mg

pyridostigmine errivastigmine

ARICEPTEXELONMESTINONNAMENDANAMENDA XR (QL)NAMZARIC (QL)

ANSIEDAD/DEPRESIÓN/TRASTORNO BIPOLAR4

alprazolamalprazolam eralprazolam intensolalprazolam odtalprazolam xramitriptyline bupropion (QL)bupropion sr (QL)

CELEXA (QL, ST)EFFEXOR XR (QL, ST)

FETZIMA (QL, ST)PAXIL (QL, ST)PAXIL CR (QL, ST)PROZAC (QL, ST)REMERONSPRAVATO* (PA)

NIVEL 1$

NIVEL 2$$

NIVEL 3 $$$

ANSIEDAD/DEPRESIÓN/TRASTORNO BIPOLAR4 (cont.)



buspirone citalopram (QL)clomipramine desvenlafaxine er (QL)

duloxetine (QL)escitalopram (QL)fluoxetine dr (QL)fluoxetine (QL)fluvoxamine (QL)fluvoxamine er (QL)

lorazepamlorazepam intensolmirtazapineparoxetine cr (QL)paroxetine er (QL)paroxetine (QL)sertraline (QL)trazodone venlafaxine (QL)venlafaxine er (QL)

TRINTELLIX (QL, ST)VIIBRYD (QL, ST)WELLBUTRIN SR (QL, ST)

XANAXXANAX XRZOLOFT (QL, ST)

ASMA/EPOC/CONDICIONES RESPIRATORIAS

albuterol albuterol hfa (QL)alyq* (PA)ambrisentan* (PA)budesonidefluticasone-salmeterol

ipratropium-albuterol

montelukast tadalafil* (PA)treprostinil* (PA)

ANORO ELLIPTAATROVENT HFABREZTRI AEROSPHERE

DULERAFASENRA PEN* (PA)FLOVENT DISKUSFLOVENT HFAINCRUSE ELLIPTAOFEV* (PA)OPSUMIT* (PA)QVAR REDIHALERSEREVENT DISKUSSPIRIVASPIRIVA RESPIMATSTIOLTO RESPIMATSYMBICORTTRACLEER 32 MG TABLET FOR SUSPENSION* (PA)

TRELEGY ELLIPTAUPTRAVI* (PA)

ADCIRCA* (PA)ADEMPAS* (PA)ARALAST NP (PA)BRONCHITOL* (PA)COMBIVENT RESPIMAT

DALIRESP (QL)KALYDECO* (PA, QL)

LETAIRIS* (PA)LONHALA MAGNAIR REFILL (PA)

LONHALA MAGNAIR STARTER (PA)

ORENITRAM ER* (PA)

ORKAMBI* (PA, QL)PROLASTIN C* (PA)PULMICORT RESPULE

PULMOZYME* (PA)REVATIO 10 MG/ML, 20 MG* (PA)

Lista de medicamentos con receta Advantage de 3 niveles de Cigna

7

NIVEL 1$

NIVEL 2$$

NIVEL 3 $$$

ASMA/EPOC/CONDICIONES RESPIRATORIAS (cont.)

SINGULAIRSYMDEKO* (PA, QL)TRACLEER 125 MG TABLET* (PA)

TRACLEER 62.5 MG TABLET* (PA)

TRIKAFTA* (PA, QL)TYVASO* (PA)

TRASTORNO DE DÉFICIT DE ATENCIÓN E HIPERACTIVIDAD4

amphetamine (PA)atomoxetine (QL)dexmethylphenidate (PA)

dexmethylphenidate er (PA, QL)

dextroamphetamine-amphet er (PA, QL)

dextroamp hetamin-e -amphetamine (PA)

guanfacine ermethylphenidate er (la) (PA, QL)

methylphenidate er (PA, QL)

methylphenidate (PA)

methylphenidate cd (PA, QL)

methylphenidate er (cd) (PA, QL)

methylphenidate la (PA, QL)

ADDERALL (PA,ST)DAYTRANA (PA, QL)EVEKEO 5 MG, 10 MG (PA,ST)

FOCALIN (PA,ST)INTUNIVMETHYLIN (PA)QUILLIVANT XR (PA, QL)

RITALIN (PA,ST)STRATTERA (QL)

MODIFICADORES DE LA SANGRE/TRASTORNOS HEMORRÁGICOS

aminocaproic acid 0.25 gram/ml, 500 mg, 1,000 mg*

tranexamic acid 650 mg*

DROXIANYVEPRIA* (PA)ZIEXTENZO (PA)

DOPTELET* (PA)LYSTEDA*PROMACTA* (PA)SIKLOS (PA)TAVALISSE* (PA)


amlodipine amlodipine-benazepril

amlodipine-olmesartan (QL)

amlodipine-valsartanatenololbenazepril bisoprolol

CORLANOR (PA)ENTRESTO

ADALAT CCBIDIL (QL)CALAN SRCARDIZEM LA 120MG (QL)

CARDURACATAPRES-TTS 1CATAPRES-TTS 2CATAPRES-TTS 3

NIVEL 1$

NIVEL 2$$

NIVEL 3 $$$

MEDICAMENTOS PARA LA PRESIÓN ARTERIAL/PARA EL CORAZÓN (cont.)

bisoprolol-hctzcandesartan cartia xtcarvedilolcarvedilol er (QL)clonidinediltiazem 12hr erdiltiazem 24hr erdiltiazem 24hr er (cd)

diltiazem 24hr er (la)

diltiazem 24hr er (xr)

diltiazemDILT-XR dofetilide (QL)doxazosin droxidopa*enalapril flecainide hydralazine tabletirbesartanlabetalol tabletlisinoprillisinopril-hctzlosartan losartan-hctzmatzim lametoprolol succinate

metoprolol tabletnadololnifedipinenifedipine erolmesartan (QL)olmesartan-amlodipine-hctz

olmesartan-hctz (QL)

prazosin propranolol tabletpropranolol erramiprilranolazine er (QL)taztia xttelmisartan (QL)telmisartan-hctz (QL)

tiadylt ervalsartanvalsartan-hctz

COREG (ST)CORGARD (ST)EPANEDHAEGARDA* (PA)HEMANGEOLINDERAL LA (ST)INDERAL XL (ST)INNOPRAN XL (ST)KAPSPARGO SPRINKLE (ST)

KATERZIA (QL)LOPRESSOR (ST)MINIPRESSNITROSTATNORTHERA* (PA)NORVASCORLADEYO* (PA, QL)

PROCARDIA XLRANEXA (QL)TAKHZYRO* (PA)TENORETIC 100 (ST)TENORETIC 50 (ST)TENORMIN (ST)TIAZACTIKOSYN (PA, QL)TOPROL XL (ST)VERELANVERELAN PMZIAC (ST)


8

NIVEL 1$

NIVEL 2$$

NIVEL 3 $$$


verapamil erverapamil er pmverapamil tabletverapamil sr


adult aspirin regimen+

aspirin ec+aspirin+aspirin-dipyridamole er

children's aspirin+clopidogreljantovenlow dose aspirin ec+prasugrelst. joseph aspirin ec+

st. joseph aspirin+warfarin

BRILINTAELIQUIS (PA)XARELTO (PA)

BAYER CHEWABLE ASPIRIN+

EFFIENTPLAVIXPRADAXA (PA)SAVAYSA (PA, QL)ZONTIVITY

CÁNCER

abiraterone* (PA)anastrozole+bexarotene* (PA)capecitabine* (PA)everolimus* (PA)exemestane+hydroxyureaimatinib* (PA)letrozolemethotrexatetamoxifen+temozolomide* (PA)

ERIVEDGE* (PA)ERLEADA* (PA)GLEOSTINEIBRANCE* (PA)KANJINTI* (PA)MVASI* (PA)NEXAVAR* (PA)REVLIMID* (PA)SPRYCEL* (PA)SUTENT* (PA)TRAZIMERA* (PA)TREXALLVERZENIO* (PA)ZIRABEV* (PA)

AFINITOR DISPERZ* (PA)

AFINITOR* (PA)ALECENSA* (PA)ALUNBRIG* (PA)BOSULIF* (PA)BRAFTOVI* (PA)CABOMETYX* (PA)CALQUENCE* (PA)COMETRIQ* (PA)GLEEVEC* (PA)ICLUSIG* (PA)IMBRUVICA* (PA)INLYTA* (PA)JAKAFI* (PA)KISQALI* (PA)LENVIMA* (PA)LONSURF* (PA)LYNPARZA* (PA)MEKINIST* (PA)MEKTOVI* (PA)NERLYNX* (PA)NINLARO* (PA)NUBEQA* (PA)ODOMZO* (PA)OGIVRI* (PA)ONTRUZANT* (PA)ORGOVYX* (PA)PIQRAY* (PA)

NIVEL 1$

NIVEL 2$$

NIVEL 3 $$$

CÁNCER (cont.)

POMALYST* (PA)

ROZLYTREK* (PA)

RUBRACA* (PA)

RYDAPT* (PA)

STIVARGA* (PA)

TAFINLAR* (PA)

TAGRISSO* (PA)

TARGRETIN* (PA)

TASIGNA* (PA)

TEMODAR CAPSULE* (PA)

TUKYSA* (PA)

UKONIQ* (PA, QL)

VENCLEXTA STARTING PACK* (PA)

VENCLEXTA* (PA)

VITRAKVI* (PA)

VOTRIENT* (PA)

XALKORI* (PA)

XELODA* (PA)

XOSPATA* (PA)

XTANDI* (PA)

ZEJULA* (PA)

MEDICAMENTOS PARA EL COLESTEROL

atorvastatin+colesevelam ezetimibeezetimibe-simvastatin

fenofibratefenofibric acidfluvastatin er+fluvastatin+icosapent ethyllovastatin+omega-3 acid ethyl esters

pravastatin+rosuvastatin+ (QL)simvastatin tablet+ (QL)

VASCEPA (PA) CADUET (QL)LIPOFEN (ST)NIASPANROSZETTRICOR (ST)TRILIPIX (ST)WELCHOLZETIA

PRODUCTOS ANTICONCEPTIVOS

BEYAZ


9

NIVEL 1$

NIVEL 2$$

NIVEL 3 $$$

PRODUCTOS ANTICONCEPTIVOS (cont.)

AFIRMELLE+AFTERA+ALTAVERA+ALYACEN+AMETHIA+AMETHYST+APRI+ARANELLE+ASHLYNA+AUBRA+AUBRA EQ+AUROVELA FE+AUROVELA 24 FE+AVIANE+AYUNA+AZURETTE+BALZIVA+BLISOVI FE+BLISOVI 24 FE+BRIELLYN+CAMILA+CAMRESE+CAMRESE LO+CAYA CONTOURED+

CAZIANT+CHARLOTTE 24 FE+CHATEAL+CHATEAL EQ+CRYSELLE+CYCLAFEM+CYRED+CYRED EQ+DASETTA+DAYSEE+DEBLITANE+desogestrel-ethinyl estradiol+

desogestrel-ethinyl estradiol - ethinyl estradiol+

DOLISHALE+drospirenone-ethinyl estradiol-levomefolate+

drospirenone-ethinyl estradiol+

ECONTRA EZ+ECONTRA ONE-STEP+

ELINEST+ELURYNG+EMOQUETTE+ENPRESSE+

LO LOESTRIN FE CAYA CONTOURED+

ELLA+ESTROSTEP FEFEMCAP+KYLEENA*+LAYOLIS FE+LILETTA*+LOESTRIN FEMICROGESTIN 24 FEMINASTRIN 24 FEMIRENA*+NEXTSTELLISNUVARINGPARAGARD T 380-A*+

SAFYRALSKYLA*+TODAY CONTRACEPTIVE SPONGE+

TWIRLA+VCF CONTRACEPTIVE FILM+

wide seal diaphragm+

YASMIN 28YAZ

NIVEL 1$

NIVEL 2$$

NIVEL 3 $$$


ENSKYCE+ERRIN+ESTARYLLA+ethynodiol-ethinyl estradiol+

etonogestrel-ethinyl estradiol+

FALMINA+FAYOSIM+FEMYNOR+GEMMILY+GYNOL II+HAILEY+HAILEY FE+HAILEY 24 FE+HEATHER+ICLEVIA+INCASSIA+ISIBLOOM+JAIMIESS+JASMIEL+JENCYCLA+JOLESSA+JULEBER+JUNEL+JUNEL FE+JUNEL FE 24+KAITLIB FE+KALLIGA+KARIVA+KELNOR 1-35+KELNOR 1-50+KURVELO+LARIN+LARIN FE+LARIN 24 FE+LARISSIA+LEENA+LESSINA+LEVONEST+levonorgestrel+levonorgestrel-ethinyl estradiol+

levonorgestrel-ethinyl estradiol ethinyl estradiol+

LEVORA+LILLOW+LOJAIMIESS+LORYNA+LOW-OGESTREL+LO-ZUMANDIMINE+

LUTERA+


10

NIVEL 1$

NIVEL 2$$

NIVEL 3 $$$


LYLEQ+LYZA+MARLISSA+MERZEE+MICROGESTIN+MICROGESTIN FE+MILI+MONO-LINYAH+MY CHOICE+MY WAY+NECON+NEW DAY+NIKKI+NORA-BE+norethindrone+norethindrone-ethinyl estradiol-iron+

norethindrone-ethinyl estradiol+

norethindrone-ethinyl estradiol-ferrous fumarate

norgestimate-ethinyl estradiol+

NORLYDA+NORTREL+NYLIA+NYMYO+OCELLA+OPCICON ONE-STEP+

OPTION 2+ORSYTHIA+PHILITH+PIMTREA+PIRMELLA+PORTIA+PREVIFEM+RECLIPSEN+RIVELSA+SETLAKIN+SHAROBEL+SIMLIYA+SIMPESSE+SPRINTEC+SRONYX+SYEDA+TAKE ACTION+TARINA FE+TARINA FE 1-20 EQ+

TARINA 24 FE+TILIA FE+

NIVEL 1$

NIVEL 2$$

NIVEL 3 $$$


TRI FEMYNOR+TRI-ESTARYLLA+TRI-LEGEST FE+TRI-LINYAH+TRI-LO-ESTARYLLA+TRI-LO-MARZIA+TRI-LO-MILI+TRI-LO-SPRINTEC+TRI-MILI+TRI-NYMYO+TRI-PREVIFEM+TRI-SPRINTEC+TRIVORA+TRI-VYLIBRA LO+TRI-VYLIBRA+TULANA+TYDEMY+VCF CONTRACEPTIVE FOAM+

VCF CONTRACEPTIVE GEL+

VELIVET+VESTURA+VIENVA+VIORELE+VOLNEA+VYFEMLA+VYLIBRA+WERA+WYMZYA FE+XULANE+ZAFEMY+ZARAH+ZOVIA 1-35+ZOVIA 1-35E+ZUMANDIMINE+

MEDICAMENTOS PARA LA TOS/EL RESFRÍO

brompheniramine-pseudoephed-dm

HYCODAN (PA, QL)

hydrocodone-homatropine (PA,QL)

TESSALON PERLE

promethazine-dm TUZISTRA XR (PA, QL)

PRODUCTOS DENTALES

chlorhexidine CLINPRO 5000

DENTA 5000 PLUS FLORIVA+

DENTAGEL FLUORIDEX SENSITIVITY RELIEF


11

NIVEL 1$

NIVEL 2$$

NIVEL 3 $$$

PRODUCTOS DENTALES (cont.)

doxycycline hyclateFLUORIDEX DAILY DEFENSE 1.1%

ORALONEPERIDEXPERIOGARDSF 1.1% GELSF 5000 PLUS sodium fluoridesodium fluoride 5000 dry mouth

sodium fluoride 5000 plus

triamcinolone

PREVIDENT

DIABETES

glimepirideglipizideglipizide erglipizide xlmetformin metformin er

BAQSIMI (QL)BASAGLAR (QL)BD LANCETSBD PEN NEEDLEDEXCOM G6 (PA, QL)

DROPLETDROPSAFEFARXIGA (QL, ST)FREESTYLE LIBRE 14 DAY SENSOR (PA, QL)

FREESTYLE LIBRE 2 SENSOR (PA, QL)

GLYXAMBI (QL, ST)JANUMET (QL, ST)JANUMET XR (QL, ST)

JANUVIA (QL, ST)JARDIANCE (QL, ST)HUMULIN (QL)LYUMJEV (QL)NOVOTWISTOMNIPOD DASH (PA, QL)

ONETOUCH ULTRA TEST STRIP

ONETOUCH ULTRAMINI

ONETOUCH VERIO FLEX METER

ONETOUCH VERIO IQ METER

ONETOUCH VERIO METER

ONETOUCH VERIO REFLECT METER

ACCU-CHEK SMARTVIEW CONTRL SOLUTION

ACCUTREND GLUCOSE CONTROL

AMARYLCEQURCONTOUR NEXT TEST STRIP

CONTOUR TEST STRIP

CYCLOSETDEXCOM G4DEXCOM G5DEXCOM G5-G4 SENSOR KIT

ENLITE GLUCOSE SENSOR

EVERSENSE SMART TRANSMITTER

GUARDIAN CONNECT TRANSMITTER

GUARDIAN LINK 3GUARDIAN SENSOR 3

INPENKORLYM* (PA)PRECISION XTRA KETONE-GLUC KIT

RIOMETTRUE METRIX

NIVEL 1$

NIVEL 2$$

NIVEL 3 $$$

DIABETES (cont.)

ONETOUCH VERIO TEST STRIP

RYBELSUS (PA, QL)SOLIQUA 100-33SYMLINPENSYNJARDY (QL, ST)SYNJARDY XR (QL, ST)

TECHLITETRIJARDY XR (ST, QL)

TRUEPLUS SYRINGEV-GO 20V-GO 30V-GO 40VICTOZA (PA, QL)XIGDUO XR (QL, ST)xultophy

DIURÉTICOS

acetazolamide tablet

acetazolamide er capsule

bumetanide tabletchlorthalidoneeplerenonefurosemide solution, tablet

hydrochlorot- hiazide

spironolactonetriamterene-hctz

ALDACTONECAROSPIRDIURILINSPRAJYNARQUE* (PA)KERENDIALASIXMAXZIDE

MEDICAMENTOS PARA LOS OÍDOS

ciprofloxacin-dexamethasone

neomycin-polymyxin b-hydrocortisone

ofloxacin

CIPRO HCCIPRODEXCIPRODEXDERMOTICOTOVEL

CONDICIONES OCULARES

bimatoprost (QL)brimonidine brinzolamideciprofloxacin dorzolamide dorzolamide-timolol

erythromycinfluorometholoneketorolac latanoprost

COMBIGANEYSUVIS (QL)RESTASISSIMBRINZA

ACULARACULAR LSACUVAILALPHAGAN PALREXAZASITEAZOPTBESIVANCEBETIMOLBETOPTIC S


12

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NIVEL 2$$

NIVEL 3 $$$

CONDICIONES OCULARES (cont.)

loteprednol moxifloxacin eye drops

neomycin-polymyxin b-dexamethasone

ofloxacinolopatadine^polymyxin b sulfate-trimethoprim

prednisolone timolol tobramycin-dexamethasone

travoprost

BROMSITECOSOPTCOSOPT PFCYSTADROPS* (PA, QL)

CYSTARAN* (PA, QL)DUREZOLFLAREXFML FORTE 0.25% EYE DROPS

FML LIQUIFILM 0.1% EYE DROP

FML S.O.P. 0.1% OINTMENT

ILEVROINVELTYSISTALOLLOTEMAXLOTEMAX SMMAXITROLMOXEZANEVANACOCUFLOXOXERVATE* (PA)PRED FORTEPROLENSARHOPRESSAROCKLATANTIMOPTICTIMOPTIC-XETOBRADEXTOBRADEX STTRUSOPTVIGAMOXZIRGANZYLET

PRODUCTOS FEMENINOS

FEM PH GYNAZOLE 1miconazole 3 200 mg

terconazole

CONDICIONES GASTROINTESTINALES/PIROSIS

ALOPHEN PILLS+alosetron*ANUCORT-HCbalsalazide bisacodyl tablet+cinacalcet*CLEARLAX+CONSTULOSE

AMITIZACLENPIQ+LINZESSNEXIUM DR 2.5 MG PACKET (QL)

NEXIUM DR 5 MG PACKET (QL)

PANCREAZEPENTASA

AKYNZEO 300-0.5 MG CAPSULE

BONJESTACANASACARAFATECHENODAL* (PA)CHOLBAM* (PA)CORRECTOL+CUVPOSA

NIVEL 1$

NIVEL 2$$

NIVEL 3 $$$

CONDICIONES GASTROINTESTINALES/PIROSIS (cont.)

dicyclomine capsule, solution, tablet

esomeprazole 20 mg capsule, 40 mg capsule, packets^ (QL)

famotidine 40 mg/5 ml suspension

GAVILAX+GAVILYTE-C+GAVILYTE-G+GAVILYTE-N+GENTLE LAXATIVE TABLET+

GENTLELAX+GLYCOLAX+glycopyrrolate tabletHEMMOREX-HC hydrocortisone lansoprazole^ (QL)LAXACLEAR+LAXATIVE PEG 3350+

LAXATIVE 5 MG TABLET+

LAXATIVE EC 5 MG TABLET+

mesalaminemesalamine drmesalamine ermetoclopramide solution, tablet

metoclopramide odt

misoprostolNATURA-LAX+omeprazole^ (QL)ondansetron ondansetron odtpantoprazole ^ (QL)

peg 3350-electrolyte+

peg3350-sodium sulfate-sodium chloride-potassium chloride-sodium ascorbate-ascorbic acid+

SUPREP+SUTAB+VIBERZI

DICLEGISDONNATALDULCOLAX EC 5 MG TABLET+

LITHOSTATMIRALAX+MOVANTIK (PA)OCALIVA* (PA)RAVICTI* (PA)RECTIVRELISTOR (PA)SANCUSO (PA, QL)SFROWASASUCRAID* (PA)SYMPROIC (PA)TRANSDERM-SCOPURSOURSO FORTEVARUBI (PA, QL)VIOKACE


13

NIVEL 1$

NIVEL 2$$

NIVEL 3 $$$

CONDICIONES GASTROINTESTINALES/PIROSIS (cont.)

PEG-PREP+polyethylene glycol 3350+

prochlorperazine tablet

promethazine suppository

prometheganPURELAX+rabeprazole tablet^ (QL)

scopolamineSMOOTHLAX+sucralfateursodiolWOMEN'S GENTLE LAXATIVE+

WOMEN'S LAXATIVE+

AGENTES HORMONALES

AMABELZbudesonide ecbudesonide er (PA, QL)

cabergoline (QL)COVARYXCOVARYX H.S.DECADRONdesmopressin dexamethasone intensol

DOTTI (QL)EEMTEEMT H.S.estradiol (once weekly)

estradiol 10mcg vaginal insert (QL)

estradiol (twice weekly) (QL)

estradiol-norethindrone acetat

estrogen-methyltesto- sterone

EUTHYROXLEVO-Tlevothyroxine tabletLEVOXYLliothyronine LYLLANA (QL)

DUAVEELUPRON DEPOT-PED* (PA)

ORIAHNN (PA, QL)ORILISSA (PA, QL)PREMARIN TABLET, VAGINAL CREAM APPLICATOR

PREMPHASEPREMPRO

ACTHAR GEL* (PA)ACTIVELLAALORA (QL)ANDRODERM (PA, QL)

ANDROGEL (PA, QL)ANGELIQARMOUR THYROIDAYGESTINBIJUVABYNFEZIA* (PA)CLIMARACLIMARA PROCOMBIPATCHCRINONE 4% GELCYTOMELDIVIGELELESTRINEMFLAZA* (PA)ENTOCORT ECESTRACEESTRING (QL)ESTROGELEVAMISTFENSOLVI* (PA)IMVEXXY (QL)INTRAROSAISTURISA* (PA, QL)LUPANETA PACK* (PA)

levothyroxine capsule (PA)

NIVEL 1$

NIVEL 2$$

NIVEL 3 $$$

AGENTES HORMONALES (cont.)

medroxyprog- esterone

methimazolemethylpredn- isolone

MIMVEYnorethindrone NP THYROIDprednisoneprednisone intensolprogesterone tablettestosterone (PA, QL)

WESTHROIDYUVAFEM

MEDROLMENOSTAR (QL)MINIVELLE (QL)MYFEMBREE (QL)OSPHENAPROMETRIUMRAYALDEETIROSINT-SOL (PA)UNITHROIDVAGIFEM (QL)VIVELLE-DOT (QL)

INFECCIONES

acyclovir capsule, suspension, tablet

albendazoleamoxicillinamoxicillin-clavulanate er

amoxicillin-clavulanate

atovaquoneatovaquone-proguanil

AVIDOXYazithromycin packet, suspension, tablet

cefdinircefuroxime tabletcephalexinciprofloxacin clarithromycinclarithromycin erclindamycin COREMINO ER QL)dapsonedoxycycline hyclate capsule, tablet

doxycycline monohydrate

EMVERMentecavir* (QL)erythromycinerythromycin ethylsuccinate

famciclovirfluconazolehydroxychlo- roquine

BARACLUDE SOLUTION*

EPCLUSA* (PA, QL)FIRVANQFOLLISTIM*^ (PA)HARVONI* (PA, QL)LEDIPASVIR-SOFOSBUVIR* (PA)

MAVYRET* (PA)SOFOSBUVIR-VELPATASVIR* (PA)

SOVALDI* (PA, QL)THALOMID* (PA)VOSEVI* (PA)XIFAXAN (QL)

AEMCOLO (QL)ALBENZAALINIAARIKAYCE* (PA)BACTRIMBACTRIM DSBAXDELA TABLET (PA)

CAYSTON* (PA, QL)CIPROCLEOCINCLINDESSECRESEMBA CAPSULE (PA)

DARAPRIM* (PA)DIFICID (QL)ELIMITEERYPED 200ERY-TAB DRFLAGYLHIPREXKEFLEXKITABIS PAK* (PA, QL)

MACROBIDMACRODANTINMALARONE (PA)NATROBANUVESSANUZYRA TABLET* (QL)


PREVYMIS TABLETPRIFTIN


14

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NIVEL 2$$

NIVEL 3 $$$

INFECCIONES (cont.)

ivermectinlevofloxacin solution, tablet

methenamine metronidazole gel, capsule, tablet

minocycline minocycline er tablet (QL)

mondoxyne nlMORGIDOXnitazoxanidenitrofurantoinnitrofurantoin monohydrate-macrocrystal

nystatin suspension, tablet

penicillin v potassium

permethrinposaconazole tablet

pyrimethamine* (PA)

sulfamethoxazole-trimethoprim suspension, tablet

terbinafine tetracycline tobramycin ampule* (PA,QL)

valacyclovirvalganciclovir vancomycin capsule, solution

vandazole


PREVYMIS TABLET*PRIFTINSIVEXTRO TABLET (PA)

SOLOSECSOMAVERT* (PA)STROMECTOLsulfatrimSUPPRELIN LA* (PA)teriparatide* (PA, QL)

URIBELVALTREXVEMLIDY*VIBRAMYCIN 25 MG/5 ML SUSPENSION

VIBRAMYCIN 50 MG/5 ML SYRUP

XENLETA 600mg tablet (PA, QL)

XOFLUZA (QL)ZEPATIER* (PA)ZITHROMAXZITHROMAX TRI-PAK

ZYVOX SUSPENSION, TABLET (PA)

INFERTILIDAD

clomiphene ^ CRINONE^ENDOMETRIN^

VARIOS

deferiprone 500mg* (PA)

sodium chloride inhalation vial, irrigation solution, vial

trientine * (PA)

ACCU-CHEKCERDELGA* (PA)ESBRIET* (PA)MICROLETNITYR* (PA)ORFADIN* (PA)PRECISION XTRATECHLITE LANCETS

AUSTEDO* (PA)BRISDELLE (QL)EVRYSDI* (PA)FC2 FEMALE CONDOM+

GALAFOLD* (PA)INGREZZA INITIATION PACK* (PA, QL)

INGREZZA* (PA)

NIVEL 1$

NIVEL 2$$

NIVEL 3 $$$

VARIOS (cont.)

KETONE CARE TEST STRIP

KETONE TEST STRIPKETOSTIX REAGENTNUEDEXTA (QL)TEGSEDI* (PA)TIGLUTIK* (PA)TRUEPLUS KETONE TEST STRIP

VYNDAMAX* (PA, QL)

VYNDAQEL* (PA, QL)

ESCLEROSIS MÚLTIPLE

dalfampridine er* (PA)

dimethyl fumarate* (PA)

AUBAGIO* (PA)BAFIERTAM* (PA)GILENYA* (PA)KESIMPTA PEN* (PA)MAYZENT* (PA)VUMERITY* (PA)ZEPOSIA* (PA)

MAVENCLAD* (PA)PONVORY* (PA)

NUTRITIVOS/ALIMENTICIOS

calcitriol capsule, solution^

FA-8+folic acid^+klor-conKLOR-CON 8 MEQ TABLET

KLOR-CON 10 MEQ TABLET

KLOR-CON M10 TABLET

MULTI-VITAMIN W-FLUORIDE-IRON+

MULTIVITAMIN WITH FLUORIDE+

MULTIVITAMIN-IRON-FLUORIDE

ONE DAILY PRENATAL+

potassium chloride 10%, capsule, packet, tablet

prenatal complete+PRENATAL GUMMIES+

PRENATAL MULTI+prenatal multi-dha+

FOSRENOL 1,000 MG POWDER PACK

FOSRENOL 750 MG POWDER PACKET

OB COMPLETE PETITE

OB COMPLETE PREMIER

ALIVE PRENATAL+AURYXIA (QL)BRAINSTRONG PRENATAL+

CITRANATAL 90 DHA

CITRANATAL ASSURE

CITRANATAL B-CALM

CITRANATAL DHACITRANATAL HARMONY

CITRANATAL RXCLASSIC PRENATAL+

DRISDOLEXPECTA PRENATAL+

FLORIVA+FOSRENOL 1,000 MG CHEWABLE TABLET



K-TAB ERLOKELMAMEPHYTON


15

NIVEL 1$

NIVEL 2$$

NIVEL 3 $$$

NUTRITIVOS/ALIMENTICIOS (cont.)

PRENATAL MULTIVITAMIN+

PRENATAL MULTIVITAMIN-DHA+

PRENATAL ONE DAILY+

PRENATAL VITAMIN + DHA+

PRENATAL VITAMIN+

PRENATAL VITAMINS+PRENATAL+PRENATAL+sevelamer carbonate

TRI-VITE WITH FLUORIDE+

vitamin d2 1.25 mg (50,000 unit)^

VITAMINS A,C,D AND FLUORIDE+

K-TAB ERLOKELMAMEPHYTONMINI PRENATAL+NEEVO DHAOB COMPLETEONE A DAY WOMEN'S PRENATAL DHA+

ONE-A-DAY PRENATAL-1+

PERRY PRENATAL+PHOSLYRAPOLY-VI-FLOR WITH IRON+

POLY-VI-FLOR+PRENATEPRENATAL FORMULA-DHA+

PRIMACAREQUFLORA PEDIATRIC 1 MG CHEWABLE TABLET+



RENVELAROCALTROLSIMILAC PRENATAL+

STUART ONE+TRI-VI-FLOR+ULTRA PRENATAL PLUS DHA+

VELPHOROVELTASSA

PRODUCTOS PARA LA OSTEOPOROSIS

alendronate ibandronate 150 mg tablet

ibandronate 3 mg/3 ml syringe*

ibandronate 3 mg/3 ml vial*

raloxifene +raloxifene+risedronate dr

ACTONEL (ST)ATELVIA (ST)BINOSTO (ST)BONIVA 150 MG TABLET (ST)

EVISTAFOSAMAX (ST)

NIVEL 1$

NIVEL 2$$

NIVEL 3 $$$


acetaminophen-codeine (PA)

allopurinol tabletASPIRIN EC+aspirin tablet+baclofen tabletbuprenorphine patch (QL)

butalbital-acetaminophen-caffeine (QL)

buprenorphine (QL)butalbital-acetaminophen-caffe (QL)

carisoprodolcelecoxib (QL)colchicinecyclobenzaprine diclofenac 1% gel (QL)

diclofenac drdiclofenac ecEC-NAPROXENECOTRIN EC 81 MG TABLET+

eletriptan (QL)ENDOCET (PA)febuxostat (QL)fentanyl (PA)FIORICET (QL)frovatriptan (QL)GEL-ONE* (PA)GLYDOhydrocodone-acetaminophen (PA)

hydromorphone er (PA)

hydromorphone (PA)

IBUibuprofenindomethacinindomethacin erketorolac tromethamine (QL)

leflunomidelidocaine 5% ointment (QL)

lidocaine 5% patch

AIMOVIG (PA)AJOVY (PA)AVSOLA* (PA)BELBUCA (QL)DUPIXENT* (PA)EMGALITY (PA)HYSINGLA ER (PA)NURTEC ODT (PA, QL)

OTEZLA* (PA, QL)REDITREX (PA)RINVOQ* (PA, QL)SIMPONI ARIA* (PA)SKYRIZI* (PA, QL)TALTZ* (PA, QL)UBRELVY (PA, QL)XELJANZ XR* (PA, QL)

XELJANZ* (PA, QL)XTAMPZA ER (PA)ZTLIDO

ANALPRAM HC 1% CREAM

ANALPRAM HC 2.5%-1% CREAM

ANALPRAM HC 2.5%-1% CREAM SINGLE

ARAVABUTRANS (QL)CELEBREX (QL, ST)COLCRYSDEPEN* (PA)EC-NAPROSYN (ST)ECOTRIN EC 325 MG TABLET+

ESGIC (QL)FEXMIDLAZANDA (PA)LIDODERMMITIGAREMOBIC (ST)NAPROSYN (ST)NUCYNTA (PA)NUCYNTA ER (PA)OLUMIANT* (PA, QL)

OXAYDO (PA)PERCOCET (PA)PROCORTPROCTOFOAM-HCSAVELLASKELAXINTRILURON* (PA)ULORIC (QL)ULTRAM 50 MG TABLET (QL)

VTOL LQZANAFLEXZEBUTAL (QL)ZOHYDRO ER (PA)ZYLOPRIM


16

NIVEL 1$

NIVEL 2$$

NIVEL 3 $$$

ALIVIO DEL DOLOR Y ENFERMEDAD INFLAMATORIA (cont.)

lidocaine viscousmeloxicam tabletmetaxalonemethocarbamolmorphine (PA)morphine er (PA)NALFON 600 MG TABLET (ST)

NALOCET (PA)oxycodone (PA)oxycodone er (PA)oxycodone-acetaminophen (PA)

penicillamine* (PA)PROLATE TABLET (PA)

rizatriptan (QL)sumatriptan (QL)tizanidine tramadol 50 mg tablet (QL)

tramadol er (QL)VANADOM

ENFERMEDAD DE PARKINSON

benztropine tabletcarbidopa-levodopa

carbidopa-levodopa er

pramipexole pramipexole er (QL)rasagiline (QL)ropinirole erropinirole

KYNMOBI (PA) AZILECT (QL)DUOPA*INBRIJA* (PA)MIRAPEX ER (QL)NEUPRONOURIANZ* (PA, QL)

OSMOLEX ER (QL)RYTARYSINEMET 10-100SINEMET 25-100TASMARXADAGO (ST)

ESQUIZOFRENIA/ANTIPSICÓTICOS4

aripiprazole (QL)aripiprazole odtasenapine chlorpromazine tablet

haloperidololanzapine tabletolanzapine odtpaliperidone er (QL)quetiapine quetiapine errisperidone

LATUDA (QL) FANAPT (QL, ST)INVEGA (QL, ST)REXULTI (QL, ST)RISPERDAL (ST)SAPHRIS (ST)SECUADO (ST)SEROQUEL (ST)SEROQUEL XR (ST)VRAYLAR (QL, ST)

NIVEL 1$

NIVEL 2$$

NIVEL 3 $$$

ESQUIZOFRENIA/ANTIPSICÓTICOS (cont.)

risperidone odtziprasidone tablet

TRASTORNOS CONVULSIVOS

carbamazepinecarbamazepine erclonazepamdivalproex divalproex erEPITOLgabapentinlamotriginelamotrigine (blue)lamotrigine (green)lamotrigine (orange)

lamotrigine erlamotrigine odtlamotrigine odt (blue)

lamotrigine odt (green)

lamotrigine odt (orange)

levetiracetam solution, tablet

levetiracetam eroxcarbazepinepregabalin capsule, solution

ROWEEPRASUBVENITESUBVENITE (BLUE)SUBVENITE (GREEN)SUBVENITE (ORANGE)

topiramatetopiramate ervigabatrin*vigadrone*


FYCOMPA (PA, QL)NAYZILAM (PA, QL)VIMPAT SOLTUION, TABLET (PA)

APTIOM (PA, QL)BRIVIACT ORAL SOLUTION, TABLET (PA)

CARBATROL (PA)DEPAKOTE (PA)DEPAKOTE ER (PA)DEPAKOTE SPRINKLE (PA)


DILANTIN 50 MG INFATAB (PA)

EPIDIOLEX* (PA)FINTEPLA* (PA)KLONOPIN (PA)LYRICA ORAL SOLUTION (PA)

NEURONTIN (PA)OXTELLAR XR (PA)PHENYTEK (PA)SPRITAM (PA)TEGRETOL (PA)TEGRETOL XR (PA)VALTOCO (PA, QL)XCOPRI (PA, QL)

CONDICIONES CUTÁNEAS

ACCUTANEadapalene (PA)adapalene-benzoyl peroxide

AMNESTEEMAVAR CLEANSERazelaic acidbetamethasone augmented

betamethasone dipropionate

BP 10-1

EUCRISATARGRETIN*

ANALPRAM HC 2.5%-1% LOTION

AVAR 9.5-5% CLEANSING PADS

BRYHALI (ST)calcipotriene foamCAPEX SHAMPOO (ST)

CLEOCIN TCLINDACIN ETZ KITCLINDACIN PAC KIT


17

NIVEL 1$

NIVEL 2$$

NIVEL 3 $$$

CONDICIONES CUTÁNEAS (cont.)

calcipotriene cream, ointment, solution

calcipotriene-betamethasone

CLARAVISCLINDACIN ETZ 1% PLEDGET

CLINDACIN P 1% PLEDGETS

clindamycin 1% foam, gel, lotion, pledget, solution

clindamycin-benzoyl peroxoxide

clindamycin-tretinoin

clobetasol clocortoloneCLODANclotrimazole-betamethasone

dapsone gelfluocinonidefluorouracil cream, topical solution

isotretinoinketoconazoleKETODANmetronidazolemupirocinMYORISANNEUAC GELpimecrolimusROSADANsodium sulfacetamide-sulfur

SSS 10-5SULFACLEANSE 8-4tacrolimus ointment

tazarotene 0.1% cream

tretinoin (PA)TRIDERMZENATANE

CLODERM (ST)DESOWENDRYSOLEFUDEXELIDELEVOCLINNAFTINPRAMOSONEPROTOPICREGRANEX (PA, QL)SANTYL (QL)TEMOVATE (ST)XEPI

TRASTORNOS DEL SUEÑO/SEDANTES

armodafinil (PA)eszopiclonemodafinil (PA)temazepam

DAYVIGO (QL, ST)SUNOSI (PA, QL)

HETLIOZ LQ* (PA)HETLIOZ* (PA)LUNESTA (ST)SILENOR (QL, ST)

NIVEL 1$

NIVEL 2$$

NIVEL 3 $$$

TRASTORNOS DEL SUEÑO/SEDANTES (cont.)

zolpidem zolpidem er (QL)

WAKIX* (PA, QL)XYREM* (PA)XYWAV* (PA)

DEJAR DE FUMAR4

bupropion sr+NICODERM CQ 21 MG/24HR PATCH+

nicotine gum+nicotine lozenge+nicotine patch+QUIT 2+QUIT 4+STOP SMOKING AID+



NICORETTE+NICOTROL NS+NICOTROL+

ABUSO DE SUSTANCIAS

buprenorphine-naloxone

LUCEMYRA (QL)NARCAN (QL)ZUBSOLV

BUNAVAILKLOXXADO (QL)SUBLOCADE*SUBOXONE

MEDICAMENTOS PARA TRASPLANTE

azathioprine*everolimus 0.25 mg tablet*

everolimus 0.5 mg tablet*

mycophenolate mofetil*

mycophenolic acid*

sirolimus*tacrolimus capsule*

ASTAGRAF XL*CELLCEPT ORAL SUSPENSION, TABLET*

ENVARSUS XR*MYFORTIC*NEORAL*PROGRAF 0.2 MG GRANULE PACKET*

PROGRAF 0.5 MG CAPSULE*


PROGRAF 1 MG GRANULE PACKET*


RAPAMUNE*ZORTRESS*

CONDICIONES URINARIAS

alfuzosin ercevimeline darifenacin er (QL)finasterideoxybutynin oxybutynin erphenazopyridine potassium ersilodosin (QL)solifenacin (QL)

CYSTAGON* AVODARTELMIRONEVOXACFLOMAXK-PHOS ORIGINALPROSCARPYRIDIUMRAPAFLO (QL)UROCIT-KUROXATRAL


18

NIVEL 1$

NIVEL 2$$

NIVEL 3 $$$

CONDICIONES URINARIAS (cont.)

tamsulosin tolterodine tolterodine er (QL)

VACUNAS

ROTARIX+ROTATEQ+

CONTROL DEL PESO

megestrol suspension


Las vacunas ahora están cubiertas por el beneficio de farmacia de Cigna. No todos los planes cubren las vacunas de la misma manera. Inicie sesión en la aplicación myCigna o en myCigna.com, o consulte los materiales de su plan, para averiguar cómo las cubre su plan específico.

19

Medicamentos que no están cubiertosSu plan cubre otros medicamentos que se usan para tratar la misma condición.^^ Estos medicamentos se enumeran abajo.

^^ Estos medicamentos necesitan la aprobación de Cigna para que su plan los cubra. Si su médico considera que un medicamento alternativo no es adecuado para usted, podrá pedirle a Cigna que evalúe la posibilidad de aprobar la cobertura del medicamento. Si no consigue la aprobación y le siguen despachando esta receta, usted le pagará a la farmacia directamente de su bolsillo el costo total del medicamento. Y el costo no puede aplicarse a su deducible anual ni al desembolso máximo.

CLASE DE MEDICAMENTO NOMBRE DEL MEDICAMENTO^^ALTERNATIVA(S) GENÉRICA(S) Y/O

DE MARCA PREFERIDA

SIDA/VIH ATRIPLA* efavirenz-emtricitabine-tenofovir* COMBIVIR* lamivudine-zidovudine*EMTRIVA* emtricitabine*EPIVIR* lamivudine*EPZICOM* abacavir-lamivudine*INTELENCE 100MG, 200MG TABLET* etravirine*KALETRA* lopinavir-ritonavir*LEXIVA 700MG TABLET* fosamprenavir 700mg tablet*NORVIR 100MG TABLET* ritonavir 100mg tablet*RETROVIR CAPSULE, SYRUP* zidovudine capsule, syrup*REYATAZ CAPSULE* atazanavir capsules*SUSTIVA* efavirenz*SYMFI*SYMFI LO*

efavirenz-lamivudine-tenofovir*

TRIZIVIR* abacavir-lamivudine-zidovudine tablet*TRUVADA* emtricitabine-tenofovir*VIRAMUNE* nevirapine*VIRAMUNE XR* nevirapine ER*VIREAD 300MG TABLET* tenofovir 300mg tablet*ZIAGEN* abacavir*

ALERGIA/ROCIADORES NASALES AUVI-QEPIPENEPIPEN JRSYMJEPI

epinephrine auto-injectors

carbinoxamine 6mg tabletRYVENT

carbinoxamine 4mg tablet

dexchlorpheniramine RYCLORA

carbinoxamine oral solutioncyproheptadine syruphydroxyzine syrup

DYMISTA azelastine-fluticasoneGeneric nasal steroids (e.g. fluticasone)

ENFERMEDAD DE ALZHEIMER pyridostigmine 30mg tablet (QL) pyridostigmine 60mg tablet

ANSIEDAD/DEPRESIÓN/TRASTORNO BIPOLAR

ANAFRANIL clomipramineAPLENZIN bupropion XL 150, 300 mg tabletsATIVAN TABLET lorazepambupropion xl 450mg tabletFORFIVO XL

bupropion xl 150mg tablets

CYMBALTA desvenlafaxine ERduloxetineescitalopram

DRIZALMA SPRINKLE duloxetine dr capsulesLEXAPRO escitalopramPAMELOR nortriptyline capsulesPARNATE tranylcypromine

20



DE MARCA PREFERIDA

ANSIEDAD/DEPRESIÓN/TRASTORNO BIPOLAR (cont.)

PEXEVA paroxetineparoxetine cr

PRISTIQ desvenlafaxine succinate erbupropion srduloxetineescitalopramsertralinevenlafaxine er

TOFRANIL imipramine WELLBUTRIN XL bupropion xl

escitalopramfluoxetine

ASMA/EPOC/CONDICIONES RESPIRATORIAS ADVAIR HFAADVAIR DISKUSAIRDUO DIGIHALERAIRDUO RESPICLICKBREO ELLIPTA

DULERAfluticasone-salmeterolSYMBICORTWIXELA INHUB

ALVESCOARMONAIR DIGIHALERARNUITY ELLIPTAASMANEX, ASMANEX HFAPULMICORT FLEXHALER

FLOVENT DISKUSFLOVENT HFAQVAR

ARCAPTA NEOHALERSTRIVERDI RESPIMAT

SEREVENT DISKUS

BEVESPI AEROSPHEREDUAKLIR PRESSAIRUTIBRON NEOHALER

ANORO ELLIPTASTIOLTO RESPIMAT

BROVANA arformoterol budesonide-formoterol SYMBICORTELIXOPHYLLIN theophylline er

theophylline oral solutionlevalbuterol hfaPROAIR DIGIHALERPROAIR HFAPROAIR RESPICLICKPROVENTIL HFAVENTOLIN HFAXOPENEX HFA

albuterol hfa

PERFOROMIST formoterol SEEBRI NEOHALERTUDORZA PRESSAIR

INCRUSE ELLIPTASPIRIVA RESPIMAT

YUPELRI ANORO ELLIPTABREZTRI AEROSPHEREINCRUSE ELLIPTASPIRIVASTIOLTO RESPIMATTRELEGY ELLIPTA

ZYFLO montelukastzafirlukastzileuton er

21



DE MARCA PREFERIDA

TRASTORNO DE DÉFICIT DE ATENCIÓN E HIPERACTIVIDAD

ADDERALL XRADHANSIA XRADZENYS ERADZENYS XR-ODTAPTENSIO XRCONCERTACOTEMPLA XR-ODTDYANAVEL XRFOCALIN XRJORNAY PMMYDAYISQUILLICHEW ERRITALIN LAVYVANSE

dexmethylphenidate erdextroamphetamine-amphetamine er methylphenidate er

DESOXYN methamphetamine DEXEDRINE dexmethylphenidate er

dextroamphetamine erdextroamphetamine-amphetamine er

EVEKEO ODT amphetaminedexmethylphenidatedextroamphetaminemethamphetaminemethylphenidate

methylphenidate er 72mg tablet RELEXXII

methylphenidate er 36mg tablet

QELBREE atomoxetine


ACCUPRIL quinaprilACCURETIC quinapril-hctzALTACE ramiprilATACAND candesartanATACAND HCT candesartan-hctzAVALIDE irbesartan-hctzAVAPRO irbesartan-hctzAZOR amlodipine-olmesartanBENICAR olmesartanBENICAR HCT olmesartan-hctzBETAPACE sotalolBYSTOLIC generic beta blockers (e.g. metoprolol; atenolol)CARDIZEM diltiazemCARDIZEM CD diltiazem CDCONJUPRI amlodipine

felodipine ernicardipinenifedipine

CONSENSI amlodipinecelecoxib

COZAAR losartanDIOVAN valsartan

22



DE MARCA PREFERIDA


DIOVAN HCT valsartan-hctzEDARBI generic ARBs (e.g. losartan; valsartan)EDARBYCLOR generic ARBs + HCTZ (e.g. losartan-HCTZ) EXFORGE amlopidine-valsartanEXFORGE HCT amlopidine-valsartan hctzFIRAZYR* icatibantGONITRO nitroglycerin sublingual tablet or sprayHYZAAR losartan-hctzISORDILISORDIL TITRADOSE

isosorbide dinitrate

LANOXIN digoxinLOTENSIN benazeprilLOTENSIN HCT benazepril-hctzLOTREL amlodipine-benazeprilMICARDIS telmisartanMICARDIS HCT telmisartan-hctzMULTAQ amiodarone

disopyramidedofetilideflecainidepropafenonequinidinesotalol af

PRINIVILZESTRIL

lisinopril

TARKA trandolapril-verapamilTEKTURNA aliskirenTEKTURNA HCT generic ACE inhibitor + HCT (e.g. benazepril-HCT)

generic ARB + HCT (e.g. losartan-HCT)TRIBENZOR olmesartan-amlodipine-hctzVASERETIC enalapril-hctzVASOTEC enalapril ZESTORETIC lisinopril-hctz


aspirin-omeprazoleYOSPRALA

aspirin or enteric aspirin

CÁNCER CYCLOPHOSPHAMIDE TABLET* cyclophosphamide capsule*NILANDRON nilutamideTARCEVA* erlotinibYONSA*ZYTIGA*

abiraterone

MEDICAMENTOS PARA EL COLESTEROL ANTARAFENOGLIDE

fenofibrate

ALTOPREV lovastatin+atorvastatin+simvastatin+rosuvastatin+

CRESTOR rosuvastatin+

23



DE MARCA PREFERIDA

MEDICAMENTOS PARA EL COLESTEROL (cont.)

EZALLOR SPRINKLEFLOLIPIDLIVALOSIMVASTATIN 20mg/5ml SUSPENSIONNEXLIZET

generic statins (e.g. atorvastatin; simvastatin)

JUXTAPID*PRALUENT

REPATHA

LESCOL XL fluvastatin er+LIPITOR atorvastatin+

ezetimibe-simvastatinrosuvastatin+

NEXLETOL generic statins (e.g. atorvastatin; simvastatin)ezetimibe-simvastatin

niacin 500mg tabletNIACOR

niacin er

PRAVACHOL pravastatin+VYTORIN ezetimibe-simvastatinZYPITAMAG atorvastatin+

lovastatin+pravastatin+rosuvastatin+simvastatin+

PRODUCTOS ANTICONCEPTIVOS BALCOLTRANATAZIASLYNDTAYTULLATWIRLA

generic oral contraceptives

MEDICAMENTOS PARA LA TOS/EL RESFRÍO benzonatate 150mg benzonatate 100mg, 200mgTUSSICAPS hydrocodone-chlorpheniramine er suspension

promethazine with codeine syrup

DIABETES ACCU-CHEK TEST STRIPSCVS TEST STRIPSADVOCATE TEST STRIPSASSURE TEST STRIPSCONTOUR TEST STRIPSFREESTYLE TEST STRIPS

ONE TOUCH TEST STRIPS (e.g. Ultra; Verio)

ADLYXIN BYDUREONBYETTAmetforminOZEMPICTRULICITYVICTOZA

ADMELOGADMELOG SOLOSTARAPIDRA, APIDRA SOLOSTARFIASPFIASP FLEXTOUCHFIASP PENFILLINSULIN ASPARTNOVOLOG

HUMALOGLYUMJEV

24



DE MARCA PREFERIDA

DIABETES (cont.) AFREZZA HUMALOGHUMULIN RLYUMJEV

alogliptinalogliptin-metforminJENTADUETOJENTADUETO XRKAZANOKOMBIGLYZE XRNESINAONGLYZATRADJENTA

JANUMET JANUMET XRJANUVIAmetformin

alogliptin-pioglitazoneOSENI

JANUMET JANUMET XRJANUVIApioglitazone

FORTAMETGLUMETZAmetformin er gastricmetformin er osmotic

metformin er (generic to GLUCOPHAGE XR)

GLUCAGEN HYPOKITGVOKE

glucagon emergency kit (generic)BAQSIMI ZEGALOGUE

INSULIN ASPART PRONOVOLOG MIX

HUMALOG MIX

INVOKAMETINVOKAMET XRSEGLUROMET

SYNJARDYSYNJARDY XRXIGDUO XR

INVOKANASTEGLATRO

FARXIGAJARDIANCEmetformin

LANTUSLANTUS SOLOSTARSEMGLEETOUJEO MAX SOLOSTARTOUJEO SOLOSTAR

BASAGLARLEVEMIRTRESIBA FLEXTOUCH

NOVOLIN HUMULINQTERNSTEGLUJAN

GLYXAMBImetforminTRIJARDY XR

DIURÉTICOS EDECRINethacrynic acid

bumetanidefurosemidetorsemide

CONDICIONES OCULARES ALOCRILALOMIDE

cromolyn

CEQUARESTASIS MULTIDOSEXIIDRA

RESTASIS

25



DE MARCA PREFERIDA

CONDICIONES OCULARES (cont.) LUMIGANTRAVATAN ZVYZULTAXALATANXELPROSZIOPTAN

bimatoprostlatanoprosttravoprost

CONDICIONES GASTROINTESTINALES/PIROSIS

ANUSOL-HC 25MG SUPPOSITORY hydrocortisone 25mg suppositoryASACOL HDCOLAZALDELZICOLDIPENTUM

balsalazidemesalamine tablets or capsulesPENTASAsulfasalazine

COLYTE WITH FLAVOR PACKETS+GOLYTELY+MOVIPREP+NULYTELY WITH FLAVOR PACKS+OSMOPREP+PLENVU+

CLENPIQ+GAVILYTE-C+GAVILYTE-G+GAVILYTE-N+PEG 3350 ELECTROLYTE+SUPREP+SUTAB+

CORTIFOAMUCERIS 2MG RECTAL FOAM

COLOCORThydrocortisone

CREONPERTZYEZENPEP

PANCREAZE

GIMOTI* metoclopramide oral solution or tabletHELIDAC bismuth subsalicylate

lansoprazole-amoxicillin-clarithromycin pakmetronidazoletetracycline

KRISTALOSElactulose 10gm packet

CONSTULOSEENULOSElactulose oral solution

LIBRAX chlordiazepoxideLOTRONEX* alosetron*lubiprostone AMITIZAMARINOLSYNDROS

dronabinol

MOTEGRITYTRULANCEZELNORM

AMITIZALINZESS

NEXIUM 10MG, 20MG, 40MG PACKET, 20MG, 40MG CAPSULE

esomeprazole packets, esomeprazole magnesium

OMECLAMOX-PAKPYLERATALICIA

lansoprazole-amoxicillin-clarithromycin pak

RELTONE ursodiolROWASA mesalamine rectal enema suspensionSENSIPAR* cinacalcetZOFRAN ondansetronZUPLENZ ondansetron

ondansetron odt

26



DE MARCA PREFERIDA

AGENTES HORMONALES ALKINDI SPRINKLE hydrocortisone 5mg tablet CORTROSYN cosyntropinDDAVPNOCDURNA

desmopressin nasal spray or tablets

DEXABLISSdexamethasone 6, 10, 13 Day 1.5MG tabletsDEXPAKDXEVOHIDEXTAPERDEXZCORT

dexamethasone 1.5mg tablet

FORTESTAJATENZONATESTOTESTIMVOGELXOXYOSTED

generic topical testosterone

GENOTROPIN*NUTROPIN AQ NUSPIN*OMNITROPE*SAIZEN*SAIZEN-SAIZENPREP*ZOMACTON*

HUMATROPE*NORDITROPIN*

HEMADY dexamethasone 5mg tabletMYCAPSSA* BYNFEZIA*ORTIKOS budesonide capsuleRAYOS methylprednisolone

prednisoneSYNTHROID levothyroxineTHYQUIDITY EUTHYROX

LEVO-TlevothyroxineLEVOXYL

UCERIS 9MG ER TABLET budesonide 9mg tabletdexamethasonehydrocortisonemethylprednisoloneprednisoloneprednisone

INFECCIONES ACTICLATEDORYXDORYX MPCMINOCIN 50MG PEL CAPSULEMINOCYCLINE ER 45, 90, 135MG CAPSULEMINOLIRA ERMONODOXSEYSARASOLODYNTARGADOXVIBRAMYCIN 100MG CAPSULEXIMINO

Generic products (e.g. doxycycline; minocycline)


DE MARCA PREFERIDA

INFECCIONES (cont.) ARAKODA atovaquone-proguanildoxycyclinehydroxychloroquine mefloquinequinine

AUGMENTINAUGMENTIN XR

amoxicillin/clavulanate

BARACLUDE TABLET* entecavir tablet*BETHKIS*TOBI*

tobramycin inhalation solution*

DIFLUCAN fluconazoledoxycycline hyclate dr 80mg tablet generic products (e.g. minocycline)DOXYCYCLINE IR-DRORACEA

doxycycline hyclate dr 50mg tabletdoxycycline monohydrate 50mg tabletminocycline er 45mg

E.E.S. 200ERYPED 400

erythromycin granuleserythromycin

HUMATIN paromomycinMEPRON atovaquoneMYCOBUTIN rifabutinnitrofurantoin 25mg/5ml suspension nitrofurantoin capsule

sulfamethoxazole-trimethoprim suspensionNOXAFIL DR 100MG TABLET posaconazole dr 100mg tabletSITAVIG acyclovir tablet

famciclovir tabletvalacyclovir tablet

SPORANOX itraconazoleTOLSURA oral itraconazoleVALCYTE valganciclovirVANCOCIN vancomycin oral solution or capsuleZOVIRAX acyclovir

VARIOS HORIZANT gabapentinKUVAN* sapropterin tablet & powder packet*SYPRINE* penicillamine*

trientine*XENAZINE* tetrabenazine*

ESCLEROSIS MÚLTIPLE AMPYRA* dalfampridine er*COPAXONE* AVONEX*

BETASERON*EXTAVIA*glatiramer*GLATOPA*KESIMPTA*PLEGRIDY*REBIF*

TECFIDERA* AUBAGIO*BAFIERTAM*dimethyl*GILENYA*MAYZENT*PONVORY*VUMERITY*

27


28



DE MARCA PREFERIDA

NUTRITIVOS/ALIMENTICIOS AZESCHEWAZESCODERMACINRX PRENATRIXDERMACINRX PRENATRYLPNV TABS 20-1PREGEN DHAPREGENNATRINAZZALVIT

Any generic prenatal vitamin

NASCOBAL cyanocobalamin injection


ALLZITALBUPAPbutalbital-acetaminophen 25-35mg, 50-300mg tablets

butalbutal-acetaminophen 50-325mg tablet

AMERGEERGOMARFROVA 2.5MG TABLETMAXALTMAXALT MLTRELPAX

generic triptans (e.g. sumatriptan; naratriptan)

AMRIXcyclobenzaprine er

carisoprodolchlorzoxazone 500mgcyclobenzaprine tabletsmethocarbamolorphenadrine ermetaxalone

CAMBIADUEXISfenoprofen 200mg capsulefenoprofen 400mg capsuleFENORTHOINDOCINindomethacin 20mg capsuleketoprofen 25mg capsulemeloxicam 5mg, 10mg capsuleNALFON 400MG CAPSULENAPRELANNAPROSYN 125MG/5ML SUSPENSIONnaproxennaproxen sodium crnaproxen sodium ernaproxen-esomeprazole magRELAFENRELAFEN DSTIVORBEXVIMOVOVIVLODEXZIPSORZORVOLEX

Generic NSAID (e.g. celecoxib; meloxicam)

CAPITAL WITH CODEINE acetaminophen-codeinechlorzoxazone 250mg chlorzoxazone 500mgchlorzoxazone 375mg chlorzoxazone 750mg

methocarbamol 500mg

29



DE MARCA PREFERIDA


CONZIP tramadoltramadol er

COSENTYX* ENBREL*HUMIRA*OTEZLA*STELARA*TALTZ*

CUPRIMINE* penicillamine*trientine*

D.H.E.45 dihydroergotamine injectiondiclofenace 1.3% patchdiclofenac 1.5% solutiondiclofenac 35mg capsuleFLECTORLICARTPENNSAIDVOLTAREN 1% GEL

generic nsaid (e.g. celecoxib; meloxicam)diclofenac 1% gel

dihydroergotamine 4mg/ml sprayIMITREX NASAL SPRAYMIGRANALONZETRA XSAILZOLMITRIPTAN NASAL SPRAYZOMIG

sumatriptan nasal spray

GLOPERBA colchicineprobenecid-colchicine

GRALISE gabapentinIMITREX CARTRIDGEIMITREX PEN INJECTOR

dihydroergotaminesumatriptan

IMITREX TABLET dihydroergotamineeletriptanrizatriptansumatriptan tablets

KETOROLAC 15.75MG NASAL SPRAYSPRIX

ketorolac tablet

KINERET* ACTEMRA*ENBREL*HUMIRA*XELJANZ/XR*

levorphanol codeine with acetaminophenhydrocodone with acetaminophenHYSINGLA ERoxycodone with acetaminophentramadolXTAMPZA ER

LORZONE chlorzoxazone 500mgcyclobenzaprine tablet

NORGESIC FORTEorphenadrine-aspirin-caffeineORPHENGESIC FORTE

chlorzoxazone 500mg tabletmetaxalonemethocarbamolorphenadrine ER

30



DE MARCA PREFERIDA


OXYCONTIN HYSINGLA ERMORPHABOND ERXTAMPZA ER

OZOBAX baclofen tabletPROLATE SOLUTION oxycodone-acetaminophen tabletQDOLO tramadol 50mg tabletREMICADE* AVSOLA*

INFLECTRA*REYVOW generic triptans (e.g. sumatriptan; naratriptan)

NURTEC ODTUBRELVY

ROXICODONE oxycodoneSILIQ* ENBREL*

HUMIRA*STELARA*TALTZ*TREMFYA*

SIMPONI* 50MG/0.5ML ACTEMRA*ENBREL*HUMIRA*STELARA*TALTZ*XELJANZ/XR*

SORIATANE acitretinSUBSYS fentanyl lozenge or buccal tabletSUMAVEL DOSEPROTOSYMRA

sumatriptan

tramadol 100mg tramadolTREXIMET sumatriptan-naproxenVANATOL LQVANATOL S

butalbital-acetaminophen-caffeine capsule or tablets

ZEMBRACE SYMTOUCH dihydroergotaminesumatriptan

ZOMIG ZMT zolmitriptan odt

ENFERMEDAD DE PARKINSON GOCOVRI amantadineLODOSYN carbidopaONGENTYS entacapone REQUIP XL ropinirole erZELAPAR selegiline tablets or capsules

ESQUIZOFRENIA/ANTIPSICÓTICOS ABILIFYABILIFY MYCITE

aripiprazolepaliperidone errisperidone

CAPLYTA aripiprazoleolanzapinepaliperidone erquetiapinequetiapine errisperidoneziprasidone

31



DE MARCA PREFERIDA

ESQUIZOFRENIA/ANTIPSICÓTICOS (cont.) GEODON CAPSULE aripiprazolepaliperidone erziprasidone

VERSACLOZ clozapine clozapine odt

ZYPREXA aripiprazoleolanzapine tabletspaliperidone er

ZYPREXA ZYDIS aripiprazoleolanzapineolanzapine odt

TRASTORNOS CONVULSIVOS ELEPSIA XRKEPPRA XR

levetiracetam er

FELBATOL felbamateKEPPRA SOLUTION, TABLET levetiracetamLAMICTAL lamotrigineLAMICTAL TAB KIT (BLUE, GREEN, ORANGE) lamotrigine starter kit (blue, green, orange)LAMICTAL ODT lamotrigine odtLAMICTAL ODT KIT (BLUE, GREEN, ORANGE) lamotrigine odt starter kit (blue, green orange)LAMICTAL XRLAMICTAL XR KIT (BLUE, GREEN, ORANGE)

lamotrigine er

LYRICALYRICA CRpregabalin er

duloxetinegabapentinlidocaine 5% topical patchpregabalin

MYSOLINE primidoneQUDEXY XRTROKENDI XR

topiramate er

SABRIL* vigabatrin*SYMPAZAN clobazamTOPAMAX topiramateTRILEPTAL oxcarbazepineZONEGRAN zonisamide

CONDICIONES CUTÁNEAS ABSORICAABSORICA LD

CLARAVISisotretinoinMYORISANZENATANE

ACANYAACZONEAKLIEFAKTIPAKALTRENOAMZEEQARAZLOATRALINAVITAAZELEXDIFFERINDUAC


32



DE MARCA PREFERIDA

CONDICIONES CUTÁNEAS (cont.) EPIDUO FORTEFABIORONEXTONRETIN-ARETIN-A MICRORETIN-A MICRO PUMPtazarotene 0.1% foamTAZORACTRETIN-XVELTINWINLEVIZIANA


acyclovir cream, ointmentDENAVIRZOVIRAX

acyclovir tabletfamciclovir tabletvalacyclovir tablet

adapalene swabPLIXDA

adapalene 0.1% creamadapalene 0.1% lotionadapalene 0.3% geltazarotene 0.1% creamtretinoin cream, gel, micro gel

ALDARAimiquimod 3.75% ZYCLARA

imiquimod 5% cream

ANUSOL-HC 2.5% CREAM hydrocortisone 2.5% rectal creamAPEXICON ECORDRAN 4 MCG/SQ CM TAPE LARGEdiflorasone PSORCON

betamethasone cream, ointmentclobetasol halobetasol cream, ointment

BENZACLINNEUAC 1.2-5% KIT

clindamycin-benzoyl peroxide

calcipotriene foam calcipotriene cream, ointment, solutioncalcitriol ointment tazarotene cream

CARAC fluorouracil 0.5% creamCLINDAGEL clindamycin gel

clindamycin topical solutionCLINDAMYCIN 1% GEL clindamycin 1% gel (generic Cleocin T)

dapsone 5% gelerythromycin 2% gel

CLOBEX clobetasol lotion, shampoo, sprayCONDYLOX imiquimod 5% cream packet

podofilox 0.5% topical solutionCORDRAN CREAM, LOTION, OINTMENT betamethason

fluocinolone fluticasone

CUTIVATE betamethasone lotionfluticasone topical lotiontriamcinolone lotion

DAPSONE 7.5% GEL PUMP generic topical acne products (e.g. tretinoin; clindamycin-benzoyl peroxide)

33



DE MARCA PREFERIDA

CONDICIONES CUTÁNEAS (cont.) diclofenac 3% gelKLISYRI

FLUOROPLEXfluorouracilimiquimod 5% cream

DOVONEX calcipotriene creamdoxepin 5% creamPRUDOXINZONALON

generic topical steroid (e.g. betamethasone)topical tacrolimus

DUOBRII halobetasol plus tazarotene creamENSTILARTACLONEX

calcipotriene cream, ointment, solutioncalcipotriene-betamethasone ointment tazarotene creamtopical betamethasone

ERTACZO ketoconazole creamEXELDERMoxiconazole OXISTATSULCONAZOLE

econazole creamketoconazole creamnaftifine cream

EXTINA ketoconazole creamketoconazole foam

FINACEAMETROCREAMMETROGELSOOLANTRAZILXI

azelaic acidtopical metronidazole

flurandrenolidehydrocortisone 1% lotion

betamethasone fluocinolone fluticasone

halobetasol foamLEXETTE

augmented betamethasone dipropionatebetamethasone dipropionate cream, ointmentclobetasol fluocinonide 0.1% creamhalobetasol cream, ointment

HALOG SOLUTION clobetasol cream, ointmenthalobetasol cream, ointment

IMPEKLO betamethasone dipropionate cream, ointmentclobetasol fluocinonide 0.1% creamhalobetasol cream, ointment

IMPOYZ clobetasol cream, ointmentbetamethasone dipropionate cream, ointmenthalobetasol cream, ointment

JUBLIAKERYDINtavaborole

ciclopirox topical solutionitraconazole capsulesterbinafine tablets

KENALOG 0.147MG/GM SPRAYtriamcinolone ointmenttriamcinolone spray

desoximetasone 0.05% cream, ointmentfluocinolone 0.025% ointmentflurandrenolide 0.05% ointmenthydrocortisone 0.2% ointmentmometasone 0.1% cream

34



DE MARCA PREFERIDA

CONDICIONES CUTÁNEAS (cont.) LOCOID betamethasone lotionfluocinolone creamfluticasone creamhydrocortisone ointmentprednicarbate ointmenttriamcinolone cream

LOCOID LIPOCREAMnolixPANDEL

betamethasone creamfluocinolone creamfluticasone cream

LOPROX 0.77% CREAM 1% SHAMPOO ciclopirox cream, shampooLUZU econazole cream

ketoconazole creamluliconazole

NORITATE azelaic acidmetronidazole creammetronidazole gel

OLUXOLUX-E

betamethasone dipropionate cream, ointmentclobetasol cream, foam, ointmenthalobetasol cream, ointment

QBREXZA DRYSOLSERNIVO betamethasone SORILUX calcipotriene cream, ointment, solution

calcitriol ointment tazarotene cream

TRIANEX triamcinolone creamTRIDESILON alclometasone

desonidetriamcinolone

ULTRAVATE LOTIONULTRAVATE X

betamethasone ointmentclobetasol cream, lotion, ointmenthalobetasol cream, ointment

VANOS clobetasol creamfluocinonide 0.1% creamhalobetasol cream

VECTICAL calcitriol ointment calcipotriene ointment tazarotene cream

VERDESO desonide creamdesonide ointment

WYNZORA betamethasonecalcipotrienecalcipotriene-betamethasonefluocinolone fluticasone mometasone triamcinolone cream

XERESE acyclovir tabletfamciclovir tabletplus hydrocortisone prescription creamvalacyclovir tablet

35


DE MARCA PREFERIDA

CONDICIONES CUTÁNEAS (cont.) XOLEGEL ciclopirox 0.77% gelciclopirox 1% shampooketoconazole 2% creamketoconazole 2% foamselenium sulfide 2.5% lotionsodium sulfacetamide 10% shampoo

TRASTORNOS DEL SUEÑO/SEDANTES AMBIEN zolpidemAMBIEN CR zolpidem erATIVAN TABLET lorazepamBELSOMRA DAYVIGOEDLUAR zolpidem or zolpidem erNUVIGIL armodafinilPROVIGIL modafinilRESTORIL temazepamZOLPIMIST doxepin

eszopiclonezaleplonzolpidemzolpidem ER

ABUSO DE SUSTANCIAS EVZIO naloxone auto-injectorNARCAN

MEDICAMENTOS PARA TRASPLANTE LUPKYNIS* BENLYSTA*tacrolimus*

CONDICIONES URINARIAS DETROL darifenacin eroxybutynintolterodine

DETROL LA darifenacin eroxybutynin ertolterodine er

DITROPAN XL oxybutynin erENABLEX darifenacin erGELNIQUEMYRBETRIQOXYTROLTOVIAZVESICARE LS

darifenacin eroxybutynin ertolterodine ertrospium er

GEMTESA darifenacin eroxybutynin oxybutynin ersolifenacintolterodinetolterodine ertrospium

PROCYSBI* CYSTAGON*THIOLA*THIOLA EC*

tiopronin*

VESICARE darifenacin eroxybutynin ersolifenacintolterodine ertrospium er


36

Preguntas frecuentesComprender su cobertura de medicamentos con receta puede ser confuso. Estas son las respuestas a algunas preguntas frecuentes.

P. ¿Por qué hacen cambios en la Lista de medicamentos?

R. Cigna revisa y actualiza periódicamente la Lista de medicamentos con receta. Hacemos cambios por varios motivos, como cuando surge algún medicamento nuevo, cuando algún medicamento deja de estar disponible o cuando cambia el precio de un medicamento. Intentamos ofrecerle muchas opciones entre las que elegir para tratar su condición médica. Estos cambios pueden incluir:1,2

› Pasar un medicamento a un nivel de costos más bajo. Esto puede suceder en cualquier momento del año.

› Pasar un medicamento de marca a un nivel de costos más alto cuando haya un genérico disponible. Esto puede suceder en cualquier momento del año.

› Pasar un medicamento a un nivel de costos más alto y/o dejar de cubrir un medicamento. Esto suele suceder dos veces al año, el 1 de enero y el 1 de julio.

› Agregar requisitos de cobertura adicionales para un medicamento.

Cuando hacemos un cambio que afecta la cobertura de un medicamento que está tomando, le avisamos antes de que el cambio entre en vigor. De esta manera, usted tiene tiempo de hablar con su médico sobre las opciones disponibles.

P. ¿Por qué mi plan no cubre determinados medicamentos?

R. Para ayudar a reducir sus costos de cuidado de la salud totales, su plan no cubre determinados medicamentos de marca de alto costo porque tienen alternativas cubiertas y de menor costo que se utilizan para tratar la misma condición. Esto significa que la alternativa actúa de una manera igual o similar al medicamento no cubierto. Si está tomando un medicamento que su plan no cubre, y su médico considera que una alternativa no es adecuada para usted, su médico podrá pedirle a Cigna que evalúe la posibilidad de aprobar la cobertura.

Es posible que su plan también excluya determinados medicamentos o productos de la cobertura. Esto se conoce como una “exclusión del plan (o de beneficios)”. Con los medicamentos excluidos, no existe la opción de obtener cobertura a través del proceso de revisión de la cobertura de Cigna.

Por ejemplo, su plan no incluye:

› Medicamentos con receta que se usan para tratar la pirosis u otras condiciones de acidez estomacal (por ejemplo, Nexium, Prilosec y cualquier genérico) y las alergias (por ejemplo, Allegra, Clarinex, Xyzal y cualquier genérico). Estos medicamentos están disponibles sin una receta médica.

› Medicamentos que se usan para tratar condiciones relacionadas con el estilo de vida, como medicamentos para la infertilidad, para bajar de peso, para la disfunción eréctil o para dejar de fumar.5

› Medicamentos que no estén aprobados por la Administración de Alimentos y Medicamentos (FDA, por sus siglas en inglés) de los Estados Unidos.

P. ¿Cómo deciden qué medicamentos cubrir?

R. La Lista de medicamentos con receta de Cigna se elabora con la ayuda del Comité de Farmacia y Terapéutica (P&T, por sus siglas en inglés) de Cigna, que es un grupo de médicos y farmacéuticos en ejercicio, la mayoría de los cuales trabaja fuera de Cigna. El grupo se reúne regularmente para revisar evidencia médica e información proporcionadas por agencias federales, fabricantes de medicamentos, asociaciones de profesionales médicos, organizaciones nacionales y revistas revisadas por colegas médicos respecto de la seguridad y eficacia de los medicamentos recientemente aprobados por la FDA y de los medicamentos que ya se encuentran en el mercado. Luego, el equipo de decisiones de negocios de Cigna Pharmacy Management® analiza los resultados de la revisión clínica del Comité de P&T, así como el valor general del medicamento y otros factores antes de agregarlo o quitarlo de la Lista de medicamentos.

P. ¿Por qué algunos medicamentos necesitan aprobación para que mi plan los cubra?

R. El proceso de revisión ayuda a garantizar que usted esté recibiendo cobertura para el medicamento correcto, al costo correcto, en la cantidad correcta y para la situación correcta.

P. ¿Cómo sé si estoy tomando un medicamento que necesita aprobación?

R. Inicie sesión en la aplicación myCigna o en myCigna.com, o consulte los materiales de su plan, para obtener más información sobre cómo cubre su plan sus medicamentos. Si su medicamento tiene la leyenda (PA) o (ST) al lado del nombre, necesita aprobación para que

37

Preguntas frecuentes (cont.)

su plan lo cubra. Si tiene la leyenda (QL) al lado del nombre, es posible que necesite aprobación según la cantidad que le estén despachando. Si tiene la leyenda (AGE) al lado del nombre, es posible que necesite aprobación según el rango de edad cubierto para el medicamento.

P. ¿Qué tipos de medicamentos generalmente necesitan aprobación?

R. Medicamentos que:

› Pueden ser inseguros si se combinan con otros

› Tienen alternativas de menor costo y misma eficacia disponibles

› Solo deberían usarse para determinadas condiciones médicas

› Suelen usarse de manera indebida o abusiva

P. ¿Qué tipos de medicamentos generalmente tienen límites a la cantidad?

R. Medicamentos que:

› Suelen tomarse en cantidades mayores a lo que sería apropiado o por períodos más largos de lo que sería apropiado

› Suelen usarse de manera indebida o abusiva

P. ¿Qué tipos de medicamentos requieren tratamiento escalonado?

R. El programa de Tratamiento escalonado incluye medicamentos que se usan para tratar muchas condiciones, incluidas, a modo de ejemplo:

› Trastorno por déficit de atención (TDA)/Trastorno por déficit de atención con hiperactividad (TDAH)

› Alergias

› Problemas de vejiga

› Problemas respiratorios

› Depresión

› Presión arterial alta

› Colesterol alto

› Osteoporosis

› Dolor

› Condiciones cutáneas

› Trastornos del sueño

P. ¿Por qué mi medicamento tiene un requisito de edad?

R. Algunos medicamentos solo se consideran clínicamente apropiados para personas de determinada edad.

P. ¿Cómo obtengo la aprobación (autorización previa) para mi medicamento?

R. Pídale al personal del consultorio de su médico que se comunique con Cigna para que podamos comenzar el proceso de revisión de la cobertura. Ellos saben cómo funciona el proceso de revisión y se ocuparán de todo por usted. Por si el personal del consultorio pregunta, pueden descargar un formulario de solicitud desde el portal para proveedores de Cigna en cignaforhcp.com.

Cigna revisará la información que proporcione su médico para asegurarse de que su medicamento cumpla con las pautas de cobertura. Les enviaremos una carta a usted y a su médico para comunicarles la decisión y los próximos pasos. Esto puede demorar entre 1 y 5 días. Puede comunicarse con el consultorio de su médico para averiguar si ya se tomó una decisión. Si usted cumple con las pautas, se aprobará la cobertura de su medicamento. Si no cumple con las pautas, usted y su médico pueden apelar la decisión enviando una solicitud por escrito a Cigna con los motivos por los que debería cubrirse el medicamento.

P. ¿Qué pasa si trato de que me despachen un medicamento con receta que necesita aprobación pero no obtengo la aprobación de antemano?

R. Cuando su farmacéutico trate de despacharle la receta, verá que el medicamento necesita aprobación previa. Como usted no obtuvo la aprobación de antemano, no se aplicará la cobertura de su plan. Esto significa que su plan no cubrirá el costo de su medicamento. Debería pedirle a su médico que se comunique con Cigna para comenzar el proceso de revisión de la cobertura. También puede optar por pagarle directamente a la farmacia de su bolsillo el costo total del medicamento (que no podrá aplicarse a su deducible anual ni al desembolso máximo).

P. ¿Qué pasa si trato de que me despachen un medicamento con receta que tiene un límite de cantidad?

R. Su farmacéutico solo le despachará la cantidad que cubra su plan. Si usted quiere que le despachen más de la cantidad permitida, el consultorio de su médico deberá comunicarse con Cigna para solicitar la aprobación de la cobertura.

38


P. ¿Están todos los medicamentos incluidos en esta Lista de medicamentos aprobados por la Administración de Alimentos y Medicamentos (FDA) de los Estados Unidos?

R. Sí. Todos los medicamentos están aprobados por la FDA.

P. ¿Los medicamentos recientemente aprobados por la FDA están cubiertos en mi Lista de medicamentos?

R. Es posible que los medicamentos recientemente aprobados no estén cubiertos en su Lista de medicamentos durante los primeros seis meses después de recibir la aprobación de la Administración de Alimentos y Medicamentos (FDA) de los Estados Unidos. Esto incluye, a modo de ejemplo, medicamentos, suministros médicos y/o dispositivos cubiertos por planes de beneficios de farmacia estándares. Nosotros revisamos todos los medicamentos recientemente aprobados para determinar si deberían estar cubiertos y, en ese caso, en qué nivel. Si su médico considera que un medicamento cubierto actualmente no es adecuado para usted, podrá pedirle a Cigna que evalúe la posibilidad de aprobar la cobertura del medicamento recientemente aprobado.

P. ¿Qué medicamentos están cubiertos en virtud de la ley de reforma del cuidado de salud?

R. La Ley de Protección al Paciente y Cuidado de Salud a Bajo Precio (PPACA), comúnmente denominada “reforma del cuidado de salud”, se sancionó el 23 de marzo de 2010. En virtud de esta ley, es posible que determinados medicamentos preventivos (incluidos algunos productos de venta libre) estén disponibles para usted sin que tenga que pagar una parte del costo ($0), según su plan. Inicie sesión en la aplicación myCigna o en myCigna.com, o consulte los materiales de su plan, para obtener más información sobre cómo cubre su plan los medicamentos preventivos. También puede ver la Lista de medicamentos preventivos sin costos compartidos según la PPACA en Cigna.com/druglist.

Para obtener más información sobre la reforma del cuidado de salud, visite www.informedonreform.com o Cigna.com.

P. ¿Cómo puedo averiguar cuánto pagaré por un medicamento específico?

R. Cuando usted y su médico estén evaluando el medicamento correcto para su tratamiento, saber cuánto cuesta, qué alternativas de menor costo están disponibles y qué farmacias ofrecen los mejores precios puede ayudarle a evitar

sorpresas. Inicie sesión en la aplicación myCigna o en myCigna.com y use la herramienta Price a Medication (Conozca los precios de los medicamentos) para saber cuánto cuesta su medicamento antes de ir a la farmacia o incluso antes de irse del consultorio de su médico.6

P. ¿Cómo puedo ahorrar dinero en mis medicamentos con receta?

R. Es posible que pueda ahorrar dinero si se pasa a un medicamento que está en un nivel inferior (por ejemplo, un medicamento genérico o de marca preferida) o si le despachan un suministro para 90 días, si su plan lo permite. Debería consultar a su médico para averiguar si una de estas opciones puede ser adecuada para usted.

P. ¿Los genéricos actúan de la misma manera que los medicamentos de marca?

R. Sí. Los medicamentos genéricos actúan de la misma manera y tienen el mismo beneficio clínico que sus versiones de marca.7 Los medicamentos genéricos y los medicamentos de marca tienen los mismos ingredientes activos, y la misma concentración, formulación, eficacia, calidad y seguridad.

P. ¿Cuáles son las diferencias entre los P. ¿Cuáles son las diferencias entre los medicamentos genéricos y los de marca? medicamentos genéricos y los de marca?

R. Puede que los medicamentos tengan un aspecto diferente. Por ejemplo, los medicamentos genéricos pueden tener una forma, un tamaño o un color diferente a los medicamentos de marca. También es posible que difieran en su sabor, los conservantes que contienen, su envase y/o el etiquetado, y su fecha de vencimiento. Los medicamentos genéricos pueden tener un aspecto distinto al de los de marca, pero son igual de seguros y eficaces.

Los genéricos suelen costar mucho menos que los medicamentos de marca, en algunos casos, hasta un 85% menos.7 El simple hecho de que los medicamentos genéricos cuesten menos que los de marca no significa que sean medicamentos de menor calidad.

P. Mi farmacia no está en la red de mi plan. ¿Me pueden seguir despachando medicamentos con receta allí?

R. Para recibir la cobertura dentro de la red que ofrece su plan, tendrá que pasarse a una farmacia de la red de su plan. Si su plan ofrece cobertura fuera de la red, usted pagará los costos de los servicios fuera de la red para que le despachen un medicamento allí.

39


P. ¿Me pueden despachar mis recetas por correo?

R. Sí, siempre que su plan ofrezca el servicio de entrega a domicilio.8

Entrega a domicilio con Express Scripts® Pharmacy

Express Scripts® Pharmacy, nuestra farmacia de entrega a domicilio, es una opción conveniente cuando está tomando un medicamento en forma regular para tratar una condición médica permanente. Es sencilla y segura, y le permite ir menos veces a la farmacia.

› Es muy fácil pedir, administrar y hacer el seguimiento de sus medicamentos en su teléfono o en Internet

› El envío estándar no tiene costo adicional9

› Renovaciones automáticas y recordatorios de renovaciones

› Obtenga un suministro máximo para 90 días de una vez

› Reciba la ayuda de amables farmacéuticos las 24 horas, los 7 días de la semana

› Opciones de pago flexibles

Estas son tres maneras sencillas de comenzar.

1. Inicie sesión en la aplicación myCigna o en myCigna.com para pasar su receta electrónicamente. Haga clic en la pestaña Prescriptions (Recetas) y seleccione My Medications (Mis medicamentos) del menú desplegable. Luego simplemente haga clic en el botón que está al lado del nombre de su medicamento para pasar su(s) receta(s).

2. Llame al consultorio de su médico. Pida que envíen una receta para 90 días (con renovaciones) electrónicamente al servicio de entrega a domicilio de Express Scripts.

3. Llame a Express Scripts® Pharmacy al 800.835.3784. Ellos se comunicarán con el consultorio de su médico para ayudarles a transferir su receta. Tenga preparada su tarjeta de ID de Cigna, la información de contacto de su médico y los nombres de sus medicamentos cuando llame.

Accredo, una farmacia de especialidad de Cigna

Si está tomando un medicamento de especialidad para tratar una condición médica compleja, el equipo de enfermeras y farmacéuticos capacitados en medicamentos de

especialidad de Accredo puede ayudarle. Ellos le despacharán y le enviarán su medicamento de especialidad a su hogar (o al lugar que usted elija).10 También le proporcionarán la atención y el apoyo personalizados que necesite para controlar su tratamiento, sin costo adicional.

› Es muy fácil administrar y hacer el seguimiento de sus medicamentos en su teléfono o en Internet

› Envío rápido, sin costo adicional

› Renovaciones sencillas y recordatorios gratuitos

› Acceso las 24 horas, los 7 días de la semana a enfermeras y farmacéuticos capacitados en medicamentos de especialidad

› Servicios de atención personalizada, lo que incluye capacitación sobre cómo administrar sus medicamentos

› Ayuda para aplicar a programas externos de asistencia para copagos y otras opciones

Para empezar a usar Accredo, llame al 877.826.7657, de lunes a viernes, de 7:00 a.m. a 10:00 p.m., hora del Centro; y los sábados, de 7:00 a.m. a 4:00 p.m., hora del Centro. Asegúrese de llamar a Accredo alrededor de dos semanas antes de su próxima renovación para que tengan tiempo de obtener una nueva receta del consultorio de su médico. Para obtener más información sobre Accredo, visite Cigna.com/specialty.

P. ¿Dónde puedo obtener más información sobre mis beneficios de farmacia?

R. Puede usar las herramientas y recursos en línea que encontrará en la aplicación myCigna o en myCigna.com para comprender mejor su cobertura de farmacia. Puede averiguar cuánto cuestan sus medicamentos, ver qué medicamentos cubre su plan, buscar una farmacia de la red, hacerle una pregunta a un farmacéutico y ver sus reclamos de farmacia y los detalles de la cobertura. También puede administrar sus pedidos de medicamentos con receta para entrega a domicilio.

40

Exclusiones y limitaciones de la cobertura

› medicamentos de venta libre (OTC), que pueden adquirirse sin receta, a excepción de la insulina, a menos que la ley estatal o federal exija que dichos medicamentos estén cubiertos;

› medicamentos o suministros con receta para los que hay un equivalente terapéutico o una alternativa terapéutica disponible con receta o de venta libre;

› medicamentos inyectables administrados por el médico que están cubiertos por el beneficio médico del Plan, a menos que estén cubiertos por la Lista de medicamentos con receta del Plan o que Cigna lo apruebe;

› dispositivos anticonceptivos implantables cubiertos por el beneficio médico del Plan;

› medicamentos que no son médicamente necesarios;

› medicamentos experimentales o en investigación, incluidos los medicamentos aprobados por la FDA utilizados con fines diferentes de los aprobados por la FDA, a menos que el medicamento esté reconocido para el tratamiento de la indicación particular;

› medicamentos que no están aprobados por la Administración de Alimentos y Medicamentos (FDA);

› dispositivos, suministros y aparatos con y sin receta, a excepción de los suministros para los que se indica específicamente que están cubiertos;

› medicamentos usados para la fertilidad3, la disfunción sexual, con fines estéticos, para bajar de peso, para dejar de fumar3 o para mejorar el desempeño atlético;

› cualquier vitamina con receta (a excepción de las vitaminas prenatales) o suplementos alimenticios, a menos que la ley estatal o federal exija que dichos productos estén cubiertos;

› agentes inmunizantes, productos biológicos para inmunización para la alergia, sueros biológicos, sangre, plasma sanguíneo y otros

derivados hematológicos o fracciones sanguíneas y medicamentos usados para profilaxis en caso de viaje;

› reemplazo de medicamentos con receta y suministros relacionados debido a pérdida o robo;

› medicamentos que deba tomar o que se le deban administrar a una persona cubierta mientras sea paciente en un hospital con licencia, un centro de cuidados especiales, un hogar de ancianos u otra institución similar, que opere o permita que opere en su establecimiento instalaciones para despachar productos farmacéuticos;

› recetas cuya fecha de emisión tenga más de un año de antigüedad;

› la cobertura de productos farmacológicos con receta por una cantidad despachada (días de suministro) que supera el límite de suministro aplicable o es inferior a cualquier suministro mínimo aplicable indicado en el Programa, o que supera uno o más límites de cantidad o límites de dosis establecidos por el Comité de P&T;

› más de una receta médica o renovación para un determinado período de suministro de recetas para el mismo producto farmacológico con receta indicado por uno o más médicos y despachado por una o más farmacias.

› productos farmacológicos con receta despachados fuera de la jurisdicción de los Estados Unidos, salvo que se requieran para un tratamiento de emergencia o de cuidado de urgencia.

Además de las exclusiones de farmacia estándares del plan, es posible que algunos productos farmacológicos nuevos aprobados por la FDA (inclusive, a modo de ejemplo, medicamentos, suministros o dispositivos médicos que están cubiertos por planes de beneficios de farmacia estándares) no estén cubiertos durante los primeros seis meses de disponibilidad en el mercado, a menos que Cigna los apruebe por ser médicamente necesarios.

Los planes de beneficios de salud varían, pero en general, para que un medicamento esté cubierto, debe tener la aprobación de la Administración de Alimentos y Medicamentos (FDA) y debe ser recetado por un profesional de cuidado de la salud, comprado en una farmacia con licencia y médicamente necesario. Si su plan brinda cobertura para determinados medicamentos con receta preventivos sin que tenga que pagar ninguna parte del costo, es posible que deba usar una farmacia de la red para que le despachen la receta. Si usa una farmacia que no participa en la red de su plan, es posible que no se le cubra la receta. Es posible que para algunos medicamentos se necesite autorización previa o que estén sujetos a requisitos de tratamiento escalonado, límites a la cantidad u otros requisitos de administración de la utilización.

Por lo general, los planes no otorgan cobertura para los siguientes casos en virtud del beneficio de farmacia, a excepción de lo exigido por la ley estatal o federal, o por los términos de su plan específico:11

1. Es posible que la legislación estatal de Texas y Louisiana le exija a su plan que cubra su medicamento en su nivel de beneficios actual hasta que su plan se renueve. Esto significa que si el medicamento que usted está tomando se elimina de la Lista de medicamentos, pasa a un nivel de costo compartido más alto o necesita aprobación de Cigna antes de que su plan lo cubra, estos cambios no pueden comenzar hasta la fecha de renovación de su plan. Para averiguar si estas leyes estatales se aplican a su plan, llame a Servicio al Cliente al número que aparece en su tarjeta de ID de Cigna.

2. Es posible que la legislación estatal de Illinois le exija a su plan que cubra sus medicamentos en su nivel de beneficios actual hasta que su plan se renueve. Esto significa que si usted en este momento tiene la aprobación a través de un proceso de revisión para que su plan cubra su medicamento, el/los cambio(s) en la Lista de medicamentos indicado(s) aquí tal vez no le afecte(n) hasta la fecha de renovación de su plan. Si usted en este momento no tiene la aprobación a través de un proceso de revisión de la cobertura, puede seguir recibiendo cobertura en su nivel de beneficios actual si su médico lo solicita. Para averiguar si esta ley estatal se aplica a su plan, llame a Servicio al Cliente al número que aparece en su tarjeta de ID de Cigna.

3. Es posible que los planes que deben cumplir con leyes de seguro estatales, como las leyes de seguro del estado de Delaware, cubran medicamentos para la infertilidad y para dejar de fumar aunque en esta Lista de medicamentos se indique que su plan tal vez no los cubra. Para averiguar si su plan específico cubre estos medicamentos, inicie sesión en la aplicación myCigna o en myCigna.com, o consulte los materiales de su plan.

4. Para los planes asegurados que deben cumplir con las leyes de seguro del estado de Delaware: los medicamentos antidepresivos, para dejar de fumar, para el trastorno de déficit de atención e hiperactividad (TDAH) y antipsicóticos de marca que no tengan un equivalente genérico disponible estarán cubiertos como medicamentos del Nivel 2 (de marca preferida). Esto es así aunque el medicamento esté incluido en el Nivel 3 (marca no preferida) en la Lista de medicamentos de su plan. Para averiguar cómo su plan específico cubre estos medicamentos, inicie sesión en la aplicación myCigna o en myCigna.com, o llame a Servicio al Cliente al número que aparece en su tarjeta de ID de Cigna.

5. Por lo general, el plan no cubre medicamentos para dejar de fumar, a excepción de lo exigido por ley o por los términos de su plan específico. Los costos y detalles completos de la cobertura de medicamentos con receta del plan, incluida una lista completa de exclusiones y limitaciones, se encuentran en los documentos del plan. En caso de discrepancia entre la información proporcionada aquí y los documentos del plan, prevalecerá sin excepciones la información incluida en los documentos del plan.

6. Los precios no están garantizados, y el hecho de que se muestre un precio no es garantía de que estará cubierto. Sus costos y su cobertura pueden cambiar en el momento de despachar la receta en la farmacia, y los costos de los medicamentos pueden variar de una farmacia a otra. Por ejemplo, el precio de venta minorista de su farmacia por un medicamento específico puede ser menor que el precio que se muestra. La cobertura y los precios pueden cambiar.

7. Sitio web de la Administración de Alimentos y Medicamentos (FDA) de los Estados Unidos, “Generic Drugs: Questions and Answers”. Última actualización de la página: 16 de marzo de 2021. https://www.fda.gov/drugs/questions-answers/generic-drugs-questions-answers.

8. No todos los planes ofrecen el servicio de entrega a domicilio y Accredo como opciones de farmacia cubiertas. Inicie sesión en la aplicación myCigna o en myCigna.com, o consulte los materiales de su plan, para obtener más información sobre las farmacias que pertenecen a la red de su plan.

9. Los costos de envío estándar están incluidos como parte de su plan de medicamentos con receta.10. Según lo permitido por ley. Para los medicamentos administrados por un proveedor de cuidado de la salud, Accredo enviará el medicamento directamente al consultorio de su médico.11. Los costos y detalles completos de la cobertura de medicamentos con receta del plan se encuentran en los documentos del plan. En caso de discrepancia entre la información proporcionada

aquí y los documentos del plan, prevalecerá sin excepciones la información incluida en los documentos del plan.La disponibilidad del producto puede variar según la ubicación y el tipo de plan, y está sujeta a cambios. Todas las pólizas de seguro de salud colectivo y los planes de beneficios de salud tienen exclusiones y limitaciones. Para conocer los costos y los detalles de la cobertura, revise los documentos de su plan o comuníquese con un representante de Cigna.Todos los productos y servicios de Cigna son brindados exclusivamente por subsidiarias operativas de Cigna Corporation, o a través de ellas, que incluyen a Cigna Health and Life Insurance Company (CHLIC), Accredo Health Group, Inc., Express Scripts, Inc., ESI Mail Pharmacy Service, Inc., Express Scripts Pharmacy, Inc. y HMO subsidiarias o compañías de servicios subsidiarias de Cigna Health Corporation, incluidas 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 North Carolina, Inc., Cigna HealthCare of New Jersey, Inc., Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of Tennessee, Inc. (CHC-TN) y Cigna HealthCare of Texas, Inc. “Accredo” se refiere a Accredo Health Group, Inc. “Express Scripts Pharmacy” se refiere a ESI Mail Pharmacy Service, Inc. Formularios de pólizas: OK: HP-APP-1 y otras; OR: HP-POL38 02-13; TN: HP-POL43/HC-CER1V1 y otras (CHLIC); GSA-COVER y otras (CHC-TN). El nombre de Cigna, el logo, “Contigo paso a paso.” y “myCigna” son marcas comerciales de Cigna Intellectual Property, Inc. “Accredo” y “Express Scripts Pharmacy” son marcas comerciales de Express Scripts Strategic Development, Inc.887152SPx Advantage 3-Tier 08/21 © 2021 Cigna. Parte del contenido se suministra bajo licencia.

Cigna se reserva el derecho de efectuar cambios a la Lista de medicamentos sin notificación. Es posible que su plan cubra medicamentos adicionales; consulte sus materiales de inscripción para conocer más detalles. Cigna no se responsabiliza por ninguna decisión relacionada con los medicamentos tomada por el médico o el farmacéutico. Es posible que Cigna reciba pagos de fabricantes de determinados medicamentos de marca preferida y, en algunas ocasiones, de determinados medicamentos de marca no preferida, los cuales podrán o no compartirse con su plan, según los convenios existentes con Cigna. Según el diseño del plan, las condiciones del mercado, la medida en la cual los pagos del fabricante sean compartidos con su plan y otros factores existentes a la fecha del servicio, el medicamento de marca preferida podrá o no representar el medicamento de marca de más bajo costo dentro de su clase de medicamento para usted y/o su plan.

Todos los productos y servicios de Cigna son brindados exclusivamente por subsidiarias operativas de Cigna Corporation, o a través de ellas, que incluyen a Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Evernorth Care Solutions, Inc., Evernorth Behavioral Health, Inc., Cigna Health Management, Inc. y HMO subsidiarias o compañías de servicios subsidiarias de Cigna Health Corporation y Cigna Dental Health, Inc. El nombre y los logos de Cigna, así como las demás marcas de Cigna, son propiedad de Cigna Intellectual Property, Inc. ATTENTION: If you speak languages other than English, language assistance services, free of charge are available to you. For current Cigna 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, llame al número que figura en el reverso de su tarjeta de identificación. Si no lo es, llame al 1.800.244.6224 (los usuarios de TTY deben llamar al 711).

896375SPb 05/21 © 2021 Cigna.

Cigna cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color de piel, nacionalidad, edad, incapacidad o sexo. Cigna no excluye a las personas ni las trata de un modo diferente por su raza, color de piel, nacionalidad, edad, incapacidad o sexo.

Cigna:

• Brinda asistencia y servicios gratuitos para que las personas con discapacidades puedancomunicarse de manera eficaz con nosotros; por ejemplo:– intérpretes de lenguaje de señas calificados;– información escrita en otros formatos (letra grande, audio, formatos electrónicos accesibles,

otros formatos).• Proporciona servicios de asistencia lingüística gratuita a personas cuyo idioma primario no es el

inglés, como por ejemplo:– intérpretes calificados– información escrita en otros idiomas.

Si necesita estos servicios, comuníquese con servicio al cliente al número gratuito que figura en su tarjeta de identificación y pídale a un asociado de Servicio al cliente que le ayude.

Si considera que Cigna no ha proporcionado estos servicios o ha discriminado de otro modo por motivos de raza, color de piel, nacionalidad, edad, incapacidad o sexo, puede presentar una queja escribiendo un mensaje de correo electrónico a [email protected] o enviando una carta a la siguiente dirección:

CignaNondiscrimination Complaint CoordinatorPO Box 188016Chattanooga, TN 37422

Si necesita asistencia para presentar una queja escrita, llame al número que figura en la parte de atrás de su tarjeta de identificación o envíe un mensaje de correo electrónico a [email protected]. También puede presentar una queja en materia de derechos civiles ante la Oficina de Derechos Civiles del Departamento de Salud y Servicios Humanos de los Estados Unidos, electrónicamente a través del Portal de Quejas de la Oficina de Derechos Civiles, disponible en https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, o por correo postal o por teléfono:

U.S. Department of Health and Human Services200 Independence Avenue, SWRoom 509F, HHH BuildingWashington, DC 202011.800.368.1019, 800.537.7697 (TDD)Los formularios para presentar una queja están disponibles en http://www.hhs.gov/ocr/office/file/index.html.

LA DISCRIMINACIÓN ES ILEGALCobertura médica

Proficiency of Language Assistance Services

English – ATTENTION: Language assistance services, free of charge, are available to you. For current Cigna customers, call the number on the back of your ID card. Otherwise, call 1.800.244.6224 (TTY: Dial 711).

Spanish – ATENCIÓN: Hay servicios de asistencia de idiomas, sin cargo, a su disposición. Si es un cliente actual de Cigna, llame al número que figura en el reverso de su tarjeta de identificación. Si no lo es, llame al 1.800.244.6224 (los usuarios de TTY deben llamar al 711).

Chinese – 注意：我們可為您免費提供語言協助服務。對於 Cigna 的現有客戶，請致電您的 ID 卡背面的號碼。其他客戶請致電 1.800.244.6224 （聽障專線：請撥 711）。

Vietnamese – XIN LƯU Ý: Quý vị được cấp dịch vụ trợ giúp về ngôn ngữ miễn phí. Dành cho khách hàng hiện tại của Cigna, vui lòng gọi số ở mặt sau thẻ Hội viên. Các trường hợp khác xin gọi số 1.800.244.6224 (TTY: Quay số 711).

Korean – 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 현재 Cigna 가입자님들께서는 ID 카드 뒷면에 있는 전화번호로 연락해주십시오. 기타 다른 경우에는 1.800.244.6224 (TTY: 다이얼 711)번으로 전화해주십시오.

Tagalog – PAUNAWA: Makakakuha ka ng mga serbisyo sa tulong sa wika nang libre. Para sa mga kasalukuyang customer ng Cigna, tawagan ang numero sa likuran ng iyong ID card. O kaya, tumawag sa 1.800.244.6224 (TTY: I-dial ang 711).

Russian – ВНИМАНИЕ: вам могут предоставить бесплатные услуги перевода. Если вы уже участвуете в плане Cigna, позвоните по номеру, указанному на обратной стороне вашей идентификационной карточки участника плана. Если вы не являетесь участником одного из наших планов, позвоните по номеру 1.800.244.6224 (TTY: 711).

– برجاء الانتباه خدمات الترجمة المجانية متاحة لكم. لعملاء Cigna الحاليين برجاء الاتصال بالرقم المدون علي ظهر بطاقتكم الشخصية. Arabicاو اتصل ب 1.800.244.6224 (TTY: اتصل ب 711).

French Creole – ATANSYON: Gen sèvis èd nan lang ki disponib gratis pou ou. Pou kliyan Cigna yo, rele nimewo ki dèyè kat ID ou. Sinon, rele nimewo 1.800.244.6224 (TTY: Rele 711).

French – ATTENTION: Des services d’aide linguistique vous sont proposés gratuitement. Si vous êtes un client actuel de Cigna, veuillez appeler le numéro indiqué au verso de votre carte d’identité. Sinon, veuillez appeler le numéro 1.800.244.6224 (ATS : composez le numéro 711).

Portuguese – ATENÇÃO: Tem ao seu dispor serviços de assistência linguística, totalmente gratuitos. Para clientes Cigna atuais, ligue para o número que se encontra no verso do seu cartão de identificação. Caso contrário, ligue para 1.800.244.6224 (Dispositivos TTY: marque 711).

Polish – UWAGA: w celu skorzystania z dostępnej, bezpłatnej pomocy językowej, obecni klienci firmy Cigna mogą dzwonić pod numer podany na odwrocie karty identyfikacyjnej. Wszystkie inne osoby prosimy o skorzystanie z numeru 1 800 244 6224 (TTY: wybierz 711).

Japanese – 注意事項：日本語を話される場合、無料の言語支援サービスをご利用いただけます。現在のCignaのお客様は、IDカード裏面の電話番号まで、お電話にてご連絡ください。その他の方は、1.800.244.6224（TTY: 711）まで、お電話にてご連絡ください。

Italian – ATTENZIONE: Sono disponibili servizi di assistenza linguistica gratuiti. Per i clienti Cigna attuali, chiamare il numero sul retro della tessera di identificazione. In caso contrario, chiamare il numero 1.800.244.6224 (utenti TTY: chiamare il numero 711).

German – ACHTUNG: Die Leistungen der Sprachunterstützung stehen Ihnen kostenlos zur Verfügung. Wenn Sie gegenwärtiger Cigna-Kunde sind, rufen Sie bitte die Nummer auf der Rückseite Ihrer Krankenversicherungskarte an. Andernfalls rufen Sie 1.800.244.6224 an (TTY: Wählen Sie 711).

Persian (Farsi) – توجه: خدمات کمک زبانی٬ به صورت رايگان به شما ارائه می شود. برای مشتريان فعلی ٬Cigna لطفاً با شماره ای که در پشت کارت شناسايی شماست تماس بگيريد. در غير اينصورت با شماره 1.800.244.6224 تماس بگيريد (شماره تلفن ويژه ناشنوايان: شماره 711 را

شماره گيری کنيد). 896375SPb 05/21

Two easy ways to submit a claim.

› Online. Log in to myCigna.com and click on the “Find a Form” link. Under Your Plan Forms, look for Pharmacy claims. Then click on “Complete online form” to get started.

› By mail. Fill out and return the attached prescription drug claim form.

What we need to process your payment.

› Submit a separate form for each covered family member.

› Clearly write your Cigna ID number and the plan’s group number on the claim form.

› You must provide this information:– Your Cigna ID number– Your Cigna Group number, and– A pharmacy receipt with details about the purchase. This is the

store/medication paperwork that’s attached to the pharmacy bag.

Your pharmacy receipt (store/medication paperwork) must show ALL of this information.

› Patient’s name

› Fill date

› Drug name and strength

› 11-digit National Drug Code (NDC) number

› Quantity filled and day supply

› Pharmacy name and address

› Pharmacy identifier (NABP or NPI #)

› Prescriber’s name

› Cost of each medication (shown as paid in full)

You can ask for re-payment if you paid the full price for your medication out-of-pocket. It’s easy - just follow these simple instructions.

Did you fill a prescription for a compounded medication out-of-network?

Here are some things to know.

› Your receipt must show details for each prescription ingredient or we can’t process your payment.

– Example: Your compounded product was made using three ingredients. The receipt should list ALL three ingredients in detail.

› If you can’t submit the Cigna claim form, we’ll also accept a universal claim form for compounded medications.

Important: If you send in a paper claim for a compounded medication you filled in-network, you may get a lesser refund. The pharmacy should send you a bill for the compounded medication. You shouldn’t need to submit a claim.

DID YOU PAY OUT-OF-POCKET FOR A COVERED PRESCRIPTION?Get paid back for your prescription costs.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Tel-Drug, Inc., Tel-Drug of Pennsylvania, L.L.C., and HMO or service company subsidiaries of Cigna Health Corporation. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. All pictures are used for illustrative purposes only.

882421 b 04/20 © 2020 Cigna. Some content provided under license.

Prescription Drug Claim Form

� � � � � � � � � � � � � �

Insured and/or Administered by

Connecticut General Life Insurance Company

Cigna Health and Life Insurance Company

Cigna HealthCare*

REASON FOR REIMBURSEMENT

This claim form can be used to request reimbursement for covered expenses. Please check which reason applies (at least one must be checked):

Out-of-Network Compound Prescription (Pharmacist: Claims must list ALL ingredients along with itemized NDCs, quantities and charges.)

For Health Care Reform related Over-the-Counter reimbursement requests, include your Doctor’s prescription.

PARTICIPANT/PATIENT INFORMATION

Non-Participating Pharmacy

Other (Please explain)Eligibility (Please explain)

Emergency

� � � � � � � � � � � � � � � � � �� _____ / _____ / _____ ______________ ________ _____________� � � � � � � � � ! � � � " � � � � � � � � � �� " �� #$ � � � � � % � � � �& � � � � � � � � � � � � � � � � � �� _____ / _____ / _____ ______________ ________ _____________� � � � � � � � � ! � � � " � � � � � � � � � �� " �� #$ � � � � � % � � � �' ( ) * + ( , ' - , . / , / 0 . ( 1 2 - , . /

Primary coverage is with another insurance carrier. Please provide explanation of benefits (EOB) or denial letter from the primary insurance carrier.

Participant Name:



' ( ) * + ( , ' - , . / , / 0 . ( 1 2 - , . /



PRESCRIPTION INFORMATION

Patient Relationship to Participant: Patient Sex:

Male FemaleSpouseSelf (Participant) Dependent

I represent that the patient information entered on this form is correct, that the patient named is eligible for the benefits and that the patient has received the medication described. I also represent that the medication received is not for treatment of an on-the-job injury. I also authorize release of all information pertaining to this claim to the plan administrator or its designees.

Any person who knowingly and with intent to defraud any insurance company or other person: (1) files an application for insurance or statement of claim containing any materially false information; or (2) conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act which is a crime. For residents in the following states, please see the last page of this form: Alaska, Arizona, California, Colorado, District of Columbia, Florida, Kentucky, Maryland, Minnesota, New Jersey, New York, Oregon, Pennsylvania, Tennessee, Texas and Virginia.

Patient Signature: Date: Daytime Phone Number:

Cigna ID Number or Participant Social Security Number: (on the front of your Cigna ID card)

Employer:

Account Number: (on the front of your Cigna ID card)

Patient Name (use a separate form for each family member): Patient Birth Date: (Mo., Day, Year)

Multi-Ingredient Compound Prescription Information - To be Completed by Dispensing Pharmacy.

Pharmacist: If an itemized compound drug receipt is not available, please use this form to list the ingredients. 1. Use one form for each multi-ingredient compound prescription. Copy the form as needed. 2. The patient should send receipt(s) showing the out-of-pocket cost, and the Prescriber's name and DEA #. 3. SIGN the receipt.

The information below is required to process multi-ingredient claim submissions. For each NDC number, indicate the "metric quantity" expressed in the number of tablets, grams, milliliters, injectables, etc. and the cost.

Quantity Valid NDC Drug Name Customer's Charge34567

INSTRUCTIONS

8 9 : ;

1.

2.

3.

4.

5.

6.

Complete ALL information on the front side of this form. Forms missing information may be denied, delayed orreturned. If you need help completing this form, contact your pharmacist.

Sign and date the Certification Statement in the area provided. Keep a copy of all forms and receipts for your records.

The Prescription Information section must be completed for each prescription for which you are seekingpayment.

For Health Care Reform related over-the-counter payment requests, include your Doctor's prescription. Please keep a copy of the prescription for your records.

Submit a separate form for each family member.

Mail the claim form within 12 months of the prescription fill date, along with original receipts (cash registerreceipts alone are not acceptable), to:

8 9 : ;7.

RETURN ADDRESS

IMPORTANT: PLEASE PROVIDE CURRENT ADDRESS INFORMATION BELOW:

CUSTOMER STREET ADDRESS

CUSTOMER NAME

CUSTOMER CITY, STATE, ZIP

Cigna Pharmacy Service Center P.O. Box 188053 Chattanooga, TN 37422-8053

This Prescription Drug Claim Form is for Cigna customer use only.

Questions? Please call the Cigna number located on your ID card.

Did you know?

We may be able to reimburse you for any prescriptions you paid for directly and didn't use your insurance to cover. For instance, if you used a non-participating pharmacy, and your plan covers out-of-network purchases, file a claim.

We'll review it and look to see if we can get you a possible refund.

Prescribed medical equipment (or supplies) - Ask your medical plan about benefits for equipment.

FSA and HRA expenses - Contact your FSA (or HRA) payer for a claim address and instructions.

Prescriptions purchased by customers not enrolled with a Cigna drug plan - Check your benefit materials to see if your employer chose a Pharmacy Benefits Company other than Cigna.

Non-covered drugs - See the "Exclusions and limitations" section of your plan's drug list.

This form is not used for:

Clear FieldsClick Here to Print

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Caution: Any person who, knowingly and with intent to defraud any insurance company or other person: (1) files an application for insurance or statement of claim containing any materially false information; or (2) conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act.

IMPORTANT CLAIM NOTICE

Alaska Residents: A person who knowingly and with intent to injure, defraud or deceive an insurance company or files a claim containing false, incomplete or misleading information may be prosecuted under state law.

Arizona Residents: For your protection, Arizona law requires the following statement to appear on/with this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

California Residents: For your protection, California law requires the following to appear on/with this form. Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Colorado Residents: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

District of Columbia Residents: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

Florida Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.

Kentucky Residents: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

Maryland Residents: Any person who knowingly OR willfully presents false or fraudulent claim for payment of a loss or benefit or who knowingly OR willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Minnesota Residents: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

New Jersey Residents: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

New Mexico Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.

New York Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed $5000 and the stated value of the claim for each such violation.

Oregon Residents: Any person who knowingly and with intent to defraud any insurance company or other person: (1) files an application for insurance or statement of claim containing any materially false information; or, (2) conceals for the purpose of misleading, information concerning any material fact, may have committed a fraudulent insurance act.

Pennsylvania Residents: Any person who, knowingly and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Rhode Island Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Tennessee Residents: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

Texas Residents: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Virginia Residents: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated state law.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Evernorth Care Solutions, Inc., Evernorth Behavioral Health, Inc., Cigna Health Management, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. ATTENTION: If you speak languages other than English, language assistance services, free of charge are available to you. For current Cigna 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, llame al número que figura en el reverso de su tarjeta de identificación. Si no lo es, llame al 1.800.244.6224 (los usuarios de TTY deben llamar al 711).

896375b 05/21 © 2021 Cigna.

Cigna complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Cigna does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Cigna:

• Provides free aids and services to people with disabilities 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 services to people whose primary language is not English, such as:

– Qualified interpreters– Information written in other languages

If you need these services, contact customer service at the toll-free number shown on your ID card, and ask a Customer Service Associate for assistance.

If you believe that Cigna has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by sending an email to [email protected] or by writing to the following address:

CignaNondiscrimination Complaint CoordinatorPO Box 188016Chattanooga, TN 37422

If you need assistance filing a written grievance, please call the number on the back of your ID card or send an email to [email protected]. 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 Services200 Independence Avenue, SWRoom 509F, HHH BuildingWashington, DC 202011.800.368.1019, 800.537.7697 (TDD)Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

DISCRIMINATION IS AGAINST THE LAWMedical coverage

PHARMACY DIRECTORYParticipating pharmacies in the United States, the U.S. Virgin Islands, Puerto Rico and Guam

892814 02/16

PHARMACY DIRECTORYThe following is a listing by state of the pharmacy chains participating in the Cigna National Pharmacy Network. In addition to the chains shown here, Cigna has contracted with a number of independent pharmacies and participating dispensing physicians of Allscripts Healthcare Solutions, Inc. in each state. Please call the Member and Pharmacist Help Line at the toll-free number on your ID card, or visit our website at myCigna.com for more information.

Medications delivered to your homeCigna Home Delivery Pharmacy is especially for people who take prescription medications on a regular basis (including specialty medications). It offers:

› Up to a three-month supply of medications in one order

› Delivery of your medication to your home at no additional charge

› 24/7 access to pharmacists to help with any questions you may have

› Helpful reminder services and coaching available

It’s easy to get started! Just call 1.800.835.3784 and we will help you take care of the rest

Preventive prescription drug optionPreventive medications are those prescribed to prevent the occurrence of a disease or condition for those with risk factors, such as high blood pressure, high cholesterol, diabetes, asthma, osteoporosis, heart attack and stroke, or to prevent the recurrence of the disease or condition for those individuals who have recovered. Preventive medications do not include medications used to treat an existing illness, injury or condition.

For some pharmacy plans that require you to pay a certain amount toward your medications before the plan coverage begins, preventive medications may be covered before you reach that amount. However, to be sure, you should read your enrollment information to see how preventive medications are covered based on your specific plan. A list of all covered preventive medications is also available on Cigna.com. Preventive medications are identified by a “PM” symbol within the drug list search.

PHARMACY DIRECTORYAlabamaCare Plus/CVS Pharmacy

Costco Pharmacy

CVS Pharmacy

Fred Meyer Pharmacy

Kmart Pharmacy

Kroger Pharmacy

Medicine Shoppe Pharmacy

Publix Pharmacy

Rite Aid Pharmacy

Sam’s Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

Winn-Dixie Pharmacy

AlaskaCarrs Quality Centers

Costco Pharmacy

Fred Meyer Pharmacy

Safeway Pharmacy

Sam’s Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

ArizonaBashas’ United Drug

Cigna HealthCare Centers

Care Plus/CVS Pharmacy

Costco Pharmacy

CVS Pharmacy

Fry’s Food & Drug

Kmart Pharmacy


Osco Drug

Osco Pharmacy

Safeway Pharmacy

Sam’s Pharmacy

Savon Pharmacy

Smith’s Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

ArkansasBrookshire Pharmacy

CVS Pharmacy

Fred’s Pharmacy

Harps Pharmacy

Kmart Pharmacy

Kroger Pharmacy

Medicap Pharmacy


Price Cutter Pharmacy

Sam’s Pharmacy

Savon Pharmacy

Super D Drugs

Target Pharmacy

USA Drug Express

USA Drug

Walgreens Pharmacy

Walmart Pharmacy

CaliforniaBel-Air Pharmacy


Costco Pharmacy

CVS Pharmacy

Horton and Converse Pharmacy

Kmart Pharmacy


Nob Hill Pharmacy

Pavilions Pharmacy

Raley’s Pharmacy

Ralphs Pharmacy

Rite Aid Pharmacy

Safeway Pharmacy

Sam’s Pharmacy

Save Mart Pharmacy

Savon Pharmacy

Shopko Pharmacy

Super Rx Pharmacy

Target Pharmacy

Von’s Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

ColoradoAlbertson’s Pharmacy

City Market Pharmacy


Costco Pharmacy

King Sooper’s Pharmacy

Kmart Pharmacy


Rite Aid Pharmacy

Safeway Pharmacy

Sam’s Pharmacy

Savon Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

ConnecticutA&P Pharmacy

Big Y Pharmacy

Costco Pharmacy


CVS Pharmacy


Price Chopper Pharmacy

Rite Aid Pharmacy

Sam’s Pharmacy

Shoprite Pharmacy

Stop & Shop Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

DelawareCostco Pharmacy

CVS Pharmacy

Giant Pharmacy

Harris Teeter Pharmacy

Kmart Pharmacy

Pathmark Pharmacy

Rite Aid Pharmacy

Safeway Pharmacy

Sam’s Pharmacy

Savon Pharmacy

Shoprite Pharmacy

Super Fresh Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

District of ColumbiaCare Plus/CVS Pharmacy

CVS Pharmacy

Costco Pharmacy

Giant Pharmacy


Rite Aid Pharmacy

Safeway Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

FloridaCare Plus/CVS Pharmacy

Costco Pharmacy

CVS Pharmacy

Kmart Pharmacy

Kroger Pharmacy

Medicap Pharmacy


Navarro Discount Pharmacy

Publix Pharmacy

Sam’s Pharmacy

Savon Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

Winn-Dixie Pharmacy

GeorgiaBi-Lo Pharmacy


Costco Pharmacy

CVS Pharmacy

Fred’s Pharmacy

Harveys Pharmacy

Ingles Pharmacy

Kmart Pharmacy

PHARMACY DIRECTORY

Kroger Pharmacy

Medicap Pharmacy


Publix Pharmacy

Rite Aid Pharmacy

Sam’s Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

Winn-Dixie Pharmacy

GuamKmart Pharmacy

HawaiiCare Plus/CVS Pharmacy

Costco Pharmacy

Kmart Pharmacy

Longs Drug Stores

Safeway Pharmacy

Sam’s Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

IdahoCostco Pharmacy

Fred Meyer Pharmacy

Kmart Pharmacy

Medicap Pharmacy


Ridleys Pharmacy

Rite Aid Pharmacy

Safeway Pharmacy

Sam’s Pharmacy

Savon Pharmacy

Shopko Pharmacy

Smith’s Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

IllinoisCostco Pharmacy

Cub Pharmacy

CVS Pharmacy

Doc’s Drugs

Fagen Pharmacy

Hartig Drug Company

Hy-Vee Pharmacy

Kmart Pharmacy

Kroger Pharmacy

Medicap Pharmacy


Meijer Pharmacy

Osco Drugs

Sam’s Pharmacy

Schnucks Pharmacy

Shopko Pharmacy

Shop N Save Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

IndianaCostco Pharmacy

CVS Pharmacy

Fagen Pharmacy

Fred’s Pharmacy

Kmart Pharmacy

Kroger Pharmacy

Marsh Drugs

Martins Pharmacy

Medicap Pharmacy


Meijer Pharmacy

Osco Drugs

Rite Aid Pharmacy

Sam’s Pharmacy

Schnucks Pharmacy

Shopko Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

IowaCostco Pharmacy

CVS Pharmacy

Dahl’s Pharmacy

Hartig Drug Company

Hy-Vee Pharmacy

Kmart Pharmacy

Lewis Family Drug

Medicap Pharmacy


Osco Drugs

Sam’s Pharmacy

Schnucks Pharmacy

Shopko Pharmacy

Target Pharmacy

Thrifty-white Drug

Walgreens Pharmacy

Walmart Pharmacy

KansasCostco Pharmacy

CVS Pharmacy

Dillon Pharmacy

Hen House Pharmacy

Hy-Vee Pharmacy

Kmart Pharmacy

Medicap Pharmacy



PHARMACY DIRECTORY

Sam’s Pharmacy

Shopko Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

KentuckyCostco Pharmacy

CVS Pharmacy

Food City Pharmacy

Fred’s Pharmacy

Kmart Pharmacy

Kroger Pharmacy

Medicap Pharmacy


Meijer Pharmacy

Rite Aid Pharmacy

Sam’s Pharmacy

Shopko Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

LouisianaAlbertson’s Pharmacy

Brookshire Brothers

Brookshire Pharmacy

CVS Pharmacy

Fred’s Pharmacy

Kmart Pharmacy

Kroger Pharmacy

Medicap Pharmacy


Rite Aid Pharmacy

Sam’s Pharmacy

Savon Pharmacy

Super 1 Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

Winn-Dixie Pharmacy

MaineCVS Pharmacy

Hannaford Brothers

Kmart Pharmacy


Rite Aid Pharmacy

Osco Pharmacy

Sam’s Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

MarylandCostco Pharmacy

CVS Pharmacy

Giant Eagle Pharmacy

PHARMACY DIRECTORY

Giant Pharmacy

Happy Harry’s

Klein’s Shoprite Pharmacy

Kmart Pharmacy

Martins Pharmacy

Medicap Pharmacy


Rite Aid Pharmacy

Safeway Pharmacy

Sam’s Pharmacy

Savon Pharmacy

Shoppers Pharmacy

ShopRite Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

Wegmans Pharmacy

MassachusettsBig Y Pharmacy


Costco Pharmacy

CVS Pharmacy

Eaton Apothecary

Hannaford Brothers

Kmart Pharmacy


Osco Pharmacy


Rite Aid Pharmacy

Sam’s Pharmacy


Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

Wegmans Pharmacy

MichiganCostco Pharmacy

CVS Pharmacy

Family Fare Pharmacy

Henry Ford Medical

Kmart Pharmacy

Knight Drug

Kroger Pharmacy

Martins Pharmacy

Meijer Pharmacy


Rite Aid Pharmacy

Sam’s Pharmacy

Snyder Drug

Shopko Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

MinnesotaCare Plus/CVS Pharmacy

Cash Wise Pharmacy

Coborn’s Pharmacy

Costco Pharmacy

Cub Pharmacy

CVS Pharmacy

Econofoods Pharmacy

Fairview Pharmacy

Hy-Vee Pharmacy

Kmart Pharmacy

Lewis Family Drug

Mayo Clinic Pharmacy


Park Nicollet Pharmacy

Sam’s Pharmacy

Shopko Pharmacy

Rainbow Foods Pharmacy

Rainbow Pharmacy

Target Pharmacy

Thrifty-white Drug

Walgreens Pharmacy

Walmart Pharmacy

MississippiCVS Pharmacy

Fred’s Pharmacy

Fred’s XPress Pharmacy

Kmart Pharmacy

Kroger Pharmacy

Rite Aid Pharmacy

Sam’s Pharmacy

Super D Drugs

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

Winn-Dixie Pharmacy

MissouriCare Plus/CVS Pharmacy

Costco Pharmacy

CVS Pharmacy

Dierbergs Family Markets

Dillon Pharmacy

Family Pharmacy

Gerbes Pharmacy

Hy-Vee Pharmacy

Kmart Pharmacy

Kroger Pharmacy

Medicap Pharmacy



Price Cutter Pharmacy

Sam’s Pharmacy

Schnucks Pharmacy

PHARMACY DIRECTORY

Shop ‘n Save Pharmacy

Super D Drugs

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

MontanaCostco Pharmacy

CVS Pharmacy

Kmart Pharmacy

Osco Pharmacy

Safeway Pharmacy

Sam’s Pharmacy

Shopko Pharmacy

Smith’s Pharmacy

Target Pharmacy

Walmart Pharmacy

NebraskaBakers Pharmacy

Costco Pharmacy

CVS Pharmacy

Hy-Vee Pharmacy

Kmart Pharmacy

Safeway Pharmacy

Shopko Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

NevadaCostco Pharmacy

CVS Pharmacy

Kmart Pharmacy


Raley’s Drug Centers

Rite Aid Pharmacy

Safeway Pharmacy

Sam’s Pharmacy

Savon Drugs

Scolari’s Food and Drug

Smith’s Pharmacy

Target Pharmacy

Von’s Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

New HampshireCostco Pharmacy

CVS Pharmacy

Hannaford Brothers

Kmart Pharmacy

Osco Pharmacy


Rite Aid Pharmacy

Sam’s Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

New JerseyA&P Pharmacy

Costco Pharmacy

CVS Pharmacy

Duane Reade

PHARMACY DIRECTORY

Genuardis Pharmacy

Happy Harry’s

Kmart Pharmacy


Medicap Pharmacy

Pathmark Pharmacy

Quick Chek Pharmacy

Rite Aid Pharmacy

Sam’s Pharmacy

Savon Pharmacy

ShopRite Pharmacy



Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

Wegmans Pharmacy

Weis Pharmacy

New MexicoCostco Pharmacy

CVS Pharmacy

Kmart Pharmacy

Safeway Pharmacy

Sam’s Pharmacy

Savon Drugs

Smith’s Food & Drug

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

New YorkA&P Pharmacy


Costco Pharmacy

CVS Pharmacy

Drug World

Duane Reade

Gristedes Pharmacy

Hannaford Brothers

King Kullen Pharmacy

Kinney Drugs

Kmart Pharmacy


Pathmark Pharmacy


Rite Aid Pharmacy

Sam’s Pharmacy

Shoprite Pharmacy


Target Pharmacy

Tops Pharmacy

Waldbaums Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

Wegmans Pharmacy

Weis Pharmacy

North CarolinaBi-Lo Pharmacy


Costco Pharmacy

CVS Pharmacy

Food Lion Pharmacy


Ingles Pharmacy

Kerr Drug Stores

Kmart Pharmacy

Kroger Pharmacy

Medicap Pharmacy


Rite Aid Pharmacy

Sam’s Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

North DakotaCVS Pharmacy


Thrifty-white Drug

White Drugs

OhioACME Pharmacy

Costco Pharmacy

CVS Pharmacy

Discount Drug Marts

Fruth Pharmacy


Kmart Pharmacy

Kroger Pharmacy

Marcs Pharmacy


Meijer Pharmacy

Rite Aid Pharmacy

Ritzman Pharmacy

Sam’s Pharmacy

Shopko Pharmacy

Target Pharmacy

Thrifty White Drugs

Walgreens Pharmacy

Walmart Pharmacy

OklahomaCVS Pharmacy

Drug Warehouse

Harps Pharmacy

Homeland Pharmacy

Kmart Pharmacy

May’s Drug Stores


PHARMACY DIRECTORY

Med-X-Drug

Reasors Pharmacy

Sam’s Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

OregonBi-Mart Pharmacy


Costco Pharmacy

CVS Pharmacy

Fred Meyer Pharmacy

Hi-School Pharmacy

Kmart Pharmacy


Rite Aid Pharmacy

Safeway Pharmacy

Savon Pharmacy

Shopko Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

PennsylvaniaCare Plus/CVS Pharmacy

Costco Pharmacy

CVS Pharmacy


Giant Pharmacy

Klingensmiths Pharmacy

Kmart Pharmacy

Medicap Pharmacy


Pathmark Pharmacy


Rite Aid Pharmacy

Savon Pharmacy

ShopRite Pharmacy


Target Pharmacy

Tops Markets

Walgreens Pharmacy

Walmart Pharmacy

Wegmans Pharmacy

Weis Pharmacy

Puerto RicoCare Plus/CVS Pharmacy

CVS Pharmacy

Kmart Pharmacy

Sam’s Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

Rhode IslandCare Plus/CVS Pharmacy

CVS Pharmacy

Osco Pharmacy

Rite Aid Pharmacy


Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

PHARMACY DIRECTORY

South CarolinaBi-Lo Pharmacy


Costco Pharmacy

CVS Pharmacy

Food Lion Pharmacy

Fred’s Pharmacy


Ingles Pharmacy

Kmart Pharmacy

Kroger Pharmacy


Publix Pharmacy

Rite Aid Pharmacy

Sam’s Pharmacy

Target Pharmacy

Piggly Wiggly Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

South DakotaHy-Vee Pharmacy

Kmart Pharmacy

Lewis Family Drug/Lewis Drug

Safeway Pharmacy

Sam’s Pharmacy

Shopko Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

TennesseeBi-Lo Pharmacy


Costco Pharmacy

CVS Pharmacy

Food City Pharmacy

Fred’s Pharmacy


Ingles Pharmacy

Kmart Pharmacy

Kroger Pharmacy


Publix Pharmacy

Rite Aid Pharmacy

Sam’s Pharmacy

Schnucks Pharmacy

Super D Drugs

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

TexasAlbertson’s Pharmacy

Brookshire Brothers

Brookshire Grocery


Costco Pharmacy

CVS Pharmacy

H.E.B. Pharmacy

Kmart Pharmacy

Lifechek Pharmacy

Kroger Pharmacy


Minyard Pharmacy

Randalls Pharmacy

Safeway Pharmacy

Sam’s Pharmacy

Savon Pharmacy


Super 1 Pharmacy

Target Pharmacy

Tom Thumb Pharmacy

United Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

U.S. Virgin IslandsKmart Pharmacy


Walgreens Pharmacy

UtahCity Market Pharmacy

Costco Pharmacy

Fresh Market Pharmacy

Harmons Pharmacy

Kmart Pharmacy


Rite Aid Pharmacy

Sam’s Pharmacy

Savon Pharmacy

Shopko Pharmacy


Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

VermontCostco Pharmacy

CVS Pharmacy

Hannaford Brothers

Kinney Drugs

Osco Pharmacy


Rite Aid Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

VirginiaCostco Pharmacy

CVS Pharmacy

PHARMACY DIRECTORY

This listing of participating network pharmacies is subject to change at any time. Please check with the pharmacy before receiving services to confirm it is participating in your plan’s network.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Tel-Drug, Inc., and Tel-Drug of Pennsylvania, L.L.C. “Cigna Home Delivery Pharmacy” refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.

892814 02/16 © 2016 Cigna. Some content provided under license.

PHARMACY DIRECTORYFarm Fresh Pharmacy

Food City Pharmacy

Food Lion Pharmacy

Giant Pharmacy


Kmart Pharmacy

Kroger Pharmacy

Martins Pharmacy


Rite Aid Pharmacy

Safeway Pharmacy

Sam’s Pharmacy

Shoppers Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

WashingtonBartell Drugs

Bi-Mart Pharmacy


Costco Pharmacy

Food Pavilion Pharmacy

Fred Meyer Pharmacy

Haggen Food & Pharmacy

Hi-School Pharmacy

Kmart Pharmacy


QFC Pharmacy

Rite Aid Pharmacy

Rosauers Pharmacy

Safeway Pharmacy

Sam’s Pharmacy

Savon Pharmacy

Shopko Pharmacy

Target Pharmacy

Top Foods Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

Yokes Pharmacy

West VirginiaCVS Pharmacy

Fruth Pharmacy


Kmart Pharmacy

Kroger Pharmacy

Martins Pharmacy


Medicap Pharmacy

Rite Aid Pharmacy

Sam’s Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

Weis Pharmacy

WisconsinAurora Pharmacy

Costco Pharmacy

Copps Food Center Pharmacy

CVS Pharmacy

Hartig Drug Company

Hy-Vee Pharmacy

Kmart Pharmacy

Marshfield Clinic Pharmacy

Mayo Clinic Pharmacy


Pick N Save Pharmacy

Sam’s Pharmacy

Schnucks Pharmacy

Shopko Pharmacy

Target Pharmacy

Thrifty-white Drug

Walgreens Pharmacy

Walmart Pharmacy

WyomingCity Market Pharmacy

King Sooper’s Pharmacy

Kmart Pharmacy

Safeway Pharmacy

Shopko Pharmacy


Walgreens Pharmacy

Walmart Pharmacy

Osco Pharmacy

Proficiency of Language Assistance Services

English – ATTENTION: Language assistance services, free of charge, are available to you. For current Cigna customers, call the number on the back of your ID card. Otherwise, call 1.800.244.6224 (TTY: Dial 711).

Spanish – ATENCIÓN: Hay servicios de asistencia de idiomas, sin cargo, a su disposición. Si es un cliente actual de Cigna, llame al número que figura en el reverso de su tarjeta de identificación. Si no lo es, llame al 1.800.244.6224 (los usuarios de TTY deben llamar al 711).

Chinese – 注意：我們可為您免費提供語言協助服務。對於 Cigna 的現有客戶，請致電您的 ID 卡背面的號碼。其他客戶請致電 1.800.244.6224 （聽障專線：請撥 711）。

Vietnamese – XIN LƯU Ý: Quý vị được cấp dịch vụ trợ giúp về ngôn ngữ miễn phí. Dành cho khách hàng hiện tại của Cigna, vui lòng gọi số ở mặt sau thẻ Hội viên. Các trường hợp khác xin gọi số 1.800.244.6224 (TTY: Quay số 711).

Korean – 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 현재 Cigna 가입자님들께서는 ID 카드 뒷면에 있는 전화번호로 연락해주십시오. 기타 다른 경우에는 1.800.244.6224 (TTY: 다이얼 711)번으로 전화해주십시오.

Tagalog – PAUNAWA: Makakakuha ka ng mga serbisyo sa tulong sa wika nang libre. Para sa mga kasalukuyang customer ng Cigna, tawagan ang numero sa likuran ng iyong ID card. O kaya, tumawag sa 1.800.244.6224 (TTY: I-dial ang 711).

Russian – ВНИМАНИЕ: вам могут предоставить бесплатные услуги перевода. Если вы уже участвуете в плане Cigna, позвоните по номеру, указанному на обратной стороне вашей идентификационной карточки участника плана. Если вы не являетесь участником одного из наших планов, позвоните по номеру 1.800.244.6224 (TTY: 711).

– برجاء الانتباه خدمات الترجمة المجانية متاحة لكم. لعملاء Cigna الحاليين برجاء الاتصال بالرقم المدون علي ظهر بطاقتكم الشخصية. Arabicاو اتصل ب 1.800.244.6224 (TTY: اتصل ب 711).

French Creole – ATANSYON: Gen sèvis èd nan lang ki disponib gratis pou ou. Pou kliyan Cigna yo, rele nimewo ki dèyè kat ID ou. Sinon, rele nimewo 1.800.244.6224 (TTY: Rele 711).

French – ATTENTION: Des services d’aide linguistique vous sont proposés gratuitement. Si vous êtes un client actuel de Cigna, veuillez appeler le numéro indiqué au verso de votre carte d’identité. Sinon, veuillez appeler le numéro 1.800.244.6224 (ATS : composez le numéro 711).

Portuguese – ATENÇÃO: Tem ao seu dispor serviços de assistência linguística, totalmente gratuitos. Para clientes Cigna atuais, ligue para o número que se encontra no verso do seu cartão de identificação. Caso contrário, ligue para 1.800.244.6224 (Dispositivos TTY: marque 711).

Polish – UWAGA: w celu skorzystania z dostępnej, bezpłatnej pomocy językowej, obecni klienci firmy Cigna mogą dzwonić pod numer podany na odwrocie karty identyfikacyjnej. Wszystkie inne osoby prosimy o skorzystanie z numeru 1 800 244 6224 (TTY: wybierz 711).

Japanese – 注意事項：日本語を話される場合、無料の言語支援サービスをご利用いただけます。現在のCignaのお客様は、IDカード裏面の電話番号まで、お電話にてご連絡ください。その他の方は、1.800.244.6224（TTY: 711）まで、お電話にてご連絡ください。

Italian – ATTENZIONE: Sono disponibili servizi di assistenza linguistica gratuiti. Per i clienti Cigna attuali, chiamare il numero sul retro della tessera di identificazione. In caso contrario, chiamare il numero 1.800.244.6224 (utenti TTY: chiamare il numero 711).

German – ACHTUNG: Die Leistungen der Sprachunterstützung stehen Ihnen kostenlos zur Verfügung. Wenn Sie gegenwärtiger Cigna-Kunde sind, rufen Sie bitte die Nummer auf der Rückseite Ihrer Krankenversicherungskarte an. Andernfalls rufen Sie 1.800.244.6224 an (TTY: Wählen Sie 711).

Persian (Farsi) – توجه: خدمات کمک زبانی٬ به صورت رايگان به شما ارائه می شود. برای مشتريان فعلی ٬Cigna لطفاً با شماره ای که در پشت کارت شناسايی شماست تماس بگيريد. در غير اينصورت با شماره 1.800.244.6224 تماس بگيريد (شماره تلفن ويژه ناشنوايان: شماره 711 را

شماره گيری کنيد). 896375b 05/21

of 3

Group: GROUP NAME

For questions, please visit us atwww.Alliedbenefit.comwww.Alliedbenefit.comwww.Alliedbenefit.comwww.Alliedbenefit.com

or contact us at(888) 292-0272(888) 292-0272(888) 292-0272(888) 292-0272

Electronic Claim SubmissionElectronic Claim SubmissionElectronic Claim SubmissionElectronic Claim SubmissionPlease refer to the member's ID card

Customer Service

Date: DATE Enrollee: JOHN SMITH

Group#: GROUP NUMBER

Explanation of BenefitsRETAIN FOR TAX PURPOSES

THIS IS NOT A BILL

Dear John Smith

The information below is a summary of the healthcare claims you incurred for the period 06/01/2021 through 06/01/2021. This information is commonly referred to as an "Explanation of Benefits" (EOB)."Explanation of Benefits" (EOB)."Explanation of Benefits" (EOB)."Explanation of Benefits" (EOB). This is not a bill.This is not a bill.This is not a bill.This is not a bill. It is a summary, followed by the claim details, of how your recent claims were processed. It includes any co-pay, deductible, coinsurance (%) or non-covered amounts that you may owe to the provider(s) of service. Use this EOB to verify the accuracy of any bill you may recieve from the provider(s) listed below. If you did not receive service from the provider(s) listed below or suspect fraudulent charges please contact the customer service department at the number listed above.

Dates of Service: 06/01/2021 thru 06/01/2021

Total Amount Billed

Total Amount Paid By Plan

Your Financial Responsibility

This is the total amount billed for the dates of service of 06/01/2021 thru 06/01/2021.

This is the amount the plan paid in total for services rendered from 06/01/2021 thru06/01/2021. Please see the “Claim Detail” section of this document for moreinformation.

$314.00

$0.00

$36.33

This is the amount the provider(s) of service maymaymaymay bill you after your health planbenefits were paid. Typically a plan participant may be billed by the provider ofservice because they may have a deductible, co-pay, coinsurance (%), or the serviceis not covered by the health plan. Amounts shown here do not reflect any paymentsmade at the point of service. A breakdown of your total financial responsibility isshown in the claim detail for each member.

Claim SummaryPatient Name Ineligible

AmountDiscountAmount

CoveredBy Plan

DeductibleAmount

PaymentAmount

PatientResponsibility

Claim Number TotalCharge

Co-payAmount

$314.00 $25.00 $252.67 $36.33 $0.00$36.33$36.33 $0.00123456789 SAMPLE NAMETotals $314.00 $25.00 $252.67 $36.33 $0.00$36.33$36.33 $0.00

ServiceCode

IneligibleAmount

DiscountAmount

CoveredBy Plan

DeductibleAmount

PaymentAmount

BalanceAmount

PaidAt

Dates of Service ReasonCode

TotalCharge

Co-payAmount

Patient#: 123456789 Provider: Sample ProviderPatient: John Smith

Claim#: 123456789

37 $45.31 $0.00 a0 $39.62 $5.69 $5.69 100%$0.00 $0.0006/01-06/01/2021 $0.0037 $42.69 $0.00 46 $37.32 $5.37 $5.37 100%$0.00 $0.0006/01-06/01/2021 $0.0037 $102.00 $0.00 46 $88.80 $13.20 $13.20 100%$0.00 $0.0006/01-06/01/2021 $0.0037 $99.00 $0.00 a0 $86.93 $12.07 $12.07 100%$0.00 $0.0006/01-06/01/2021 $0.00

Allied Benefit Systems LLC200 W Adams St Ste 500Chicago IL 60606-5215

Forwarding Service Requested

SMITH, JOHN 1234 SAMPLE STATE , ZIP

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61 $25.00 $25.00 a0 $0.00 $0.00 $0.00 0%$0.00 $0.0006/01-06/01/2021 $0.00$314.00 $25.00 $252.67 $36.33 $0.00$0.00Column Totals $36.33

Other Credits or AdjustmentsTotal Net Payment

$0.00$0.00

$0.00

Patient's Responsibility: $36.33

Service Code Description Reason Code Description4637 Bill has been discounted by your PPO/EPO network.LABORATORYa061 DISCOUNTED PER YOUR AETNA DIRECT AGREEMENTINELIGIBLE EXPENSE28 Your plan does not cover this type of service.

PPO Information

ASA This claim was processed per your Aetna contractual agreement

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Reference InfoEnrollee: John SmithGroup#: L1234567

Appeal LanguageIf this Explanation of Benefits reflects an adverse benefit determination, you may appeal the determination; submit written comment, documents, records or other information relating to the claim; and, upon request and free of charge, receive copies of all documents, records and other information relevant to the claim. Your appeal must be submitted in writing to the Plan Administrator within 180 days after receipt of this notice. You will be notified of the determination within 60 days after receipt of your appeal. Also, if applicable, you have a right to bring a civil action under Section 502(a) of ERISA following the determination of your appeal.

Important Information about Important Information about Important Information about Important Information about YYYYour our our our Appeal RightsAppeal RightsAppeal RightsAppeal RightsFor Medical Claims OnlyFor Medical Claims OnlyFor Medical Claims OnlyFor Medical Claims Only

What if I need help understanding this denial?What if I need help understanding this denial?What if I need help understanding this denial?What if I need help understanding this denial? Contact Allied Benefit Systems, LLC, on behalf of the Plan Administrator, at the phone number listed in the box at the top of the Explanation of Benefits if you need assistance understanding this notice or the Plan's decision to deny you a service or coverage.

What if I don't agree with this decision?What if I don't agree with this decision?What if I don't agree with this decision?What if I don't agree with this decision? You have a right to appeal any decision not to provide you or pay for an item or service (in whole or in part).

How do I file an appealHow do I file an appealHow do I file an appealHow do I file an appeal???? Your appeal must be submitted in writing to Allied Benefit Systems, LLC, on behalf of the Plan Administrator, within 180 days from the date of this notice. See also the "Other resources to help you" section of this form for assistance filing a request for an appeal. Notwithstanding the foregoing, please see the homepage of Notwithstanding the foregoing, please see the homepage of Notwithstanding the foregoing, please see the homepage of Notwithstanding the foregoing, please see the homepage of Alliedbenefit.comAlliedbenefit.comAlliedbenefit.comAlliedbenefit.com for for for for details as to a temporary extended deadline by the Federal government, governing the time period to submit your appeal.details as to a temporary extended deadline by the Federal government, governing the time period to submit your appeal.details as to a temporary extended deadline by the Federal government, governing the time period to submit your appeal.details as to a temporary extended deadline by the Federal government, governing the time period to submit your appeal.

Who may file an appeal?Who may file an appeal?Who may file an appeal?Who may file an appeal? You or someone you name, in writing, to act for you (your authorized representative) may file an appeal.

Can I provide additional information about my claim?Can I provide additional information about my claim?Can I provide additional information about my claim?Can I provide additional information about my claim? Yes, as part of your appeal, you may submit written comments, documents, records or other information relating to the claim.

Can I request copies of information relevant to my claim?Can I request copies of information relevant to my claim?Can I request copies of information relevant to my claim?Can I request copies of information relevant to my claim? Yes, as part of your appeal, you may request, in writing, copies of all documents, records and other information relevant to your claim, free of charge. If you think a coding error may have caused this claim to be denied, you have the right to have billing and diagnosis codes sent to you, as well. You can request copies of this information by contacting Allied Benefit Systems, LLC, on behalf of the Plan Administrator, at the phone number listed in the box at the top of the Explanation of Benefits.

What happens next?What happens next?What happens next?What happens next? If you appeal, the Plan will review its decision and you will be notified of the determination within 60 days after receipt of your appeal. If the Plan continues to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party, who will review the denial and issue a final decision. However, such a request for external review is only applicable where the Plan's underlying determination involved 1) a rescission of coverage or 2) medical judgment. Also, you have a right to bring a civil action under Section 502(a) of ERISA following the determination of your external review. (If you are not entitled to an external review, you still have a right to bring a civil action under Section 502(a) of ERISA following the determination on appeal.)

Other resources to help you:Other resources to help you:Other resources to help you:Other resources to help you: For questions about your appeal rights, this notice, or for assistance, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA (3272).

The Allstate Benefits Self-Funded Program provides tools for employers owning small to mid-sized businesses to establish a self-funded health benefit plan for their employees. The benefit plan is established by the employer and is not an insurance product. For employers in the Allstate Benefits Self-Funded Program, stop-loss insurance is underwritten by: Integon National Insurance Company in CT, NY and VT; Integon Indemnity Corporation in FL; and National Health Insurance Company in all other states where offered.

Allied Benefit Systems LLC200 W Adams St Ste 500Chicago IL 60606-5215

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