welcome to pbm...welcome to cigna home delivery pharmacy. cigna home delivery pharmacy offers you...

WELCOME TO

Cigna HOME DELivEry PHarMaCy

572507 s 10/14

At Cigna Home Delivery PharmacySM we have one mission – we’re dedicated to helping people improve their health and well-being.

As chief pharmacist, I am honored to be part of a team that provides our customers with an integral part of their health care needs. Cigna Home Delivery Pharmacy addresses health concerns at an individual level through the efforts of both our pharmacists and support staff.

We work continuously to improve your experience through accurate and fast delivery of your prescriptions. Our pharmacists are always available 24/7 to help you understand your medication and discuss your therapy. At Cigna Home Delivery Pharmacy, improving your health is our focus.

Along with hundreds of thousands of other Cigna customers, you can trust us for your prescription medication needs.

Sincerely,

Lenore Kelley

Chief Pharmacist

Welcome to Cigna Home Delivery Pharmacy

Cigna Home Delivery Pharmacy offers you convenience and quality you can trust. It’s a great choice for anyone who takes medication regularly, such as those prescribed for:

› Allergies

› Anxiety

› Arthritis

› Asthma

› Birth control

› Diabetes

› Growth hormone deficiency

› High blood pressure

› Infertility

› Multiple sclerosis

› Many others

Choose us to fill your ongoing medications.

› Licensed pharmacists available 24/7

› Up to a 90-day supply in one fill

› Standard delivery to your home or other preferred location at no additional cost

› Likely lower out-of-pocket costs for your medication*

› Reminders so you don't forget to fill your prescriptions

› Specialty medications for more complex conditions, including those that require refrigeration and overnight delivery

› FDA-approved medications

Manage your medications online, with myCigna.com

Cigna Home Delivery Pharmacy gives you the ability to manage your medications online, 24/7, at myCigna.com. You can compare prices, track orders, see the number of refills you have left and much more.

Save money on your medications*

Cigna Home Delivery Pharmacy can help you save money. See how much you can save on quality generic and name-brand prescription medications. Log in to myCigna.com and visit the Prescription Drug Price Quote Tool on the pharmacy home page or call 800.285.4812 and ask for a price quote.

Trust us for the medications you take regularly

We are focused on you and your family’s ongoing prescription medication needs. You can count on us for a level of personalized service that makes us a smart choice for you and your family.

› Delivery of prescription medications right to your door. New orders may take 7–10 business days for delivery, and refills take approximately 2–5 days. Overnight delivery is available.

› You’ll receive reminders so you don't forget to fill your prescription.

› Licensed pharmacists are focused on serving you and are available 24/7 to answer medication questions.

Cigna Specialty Pharmacy ServicesSM

If you have a condition that requires treatment with specialty medication, Cigna Specialty Pharmacy Services can help you manage your health and prescription needs in the privacy of your home.

› We can send your medication to your doctor’s office or your home, by the date requested.

› Required supplies such as syringes, needles, alcohol swabs and disposable containers are provided – at no additional charge.

› Medications are shipped, at no cost to you, in specially designed packaging to protect quality and privacy.

› We manage your refill schedule and help you find ways to make staying healthy more affordable.

572507 s 10/14 © 2014 Cigna. Some content provided under license.

Choose the ordering method that’s best for you. it’s as easy as 1, 2, 3!

Electronic:

1. Have your doctor's office send your prescription to us electronically. It's the fastest and easiest way.

Phone:

1. Have your medication, doctor's name and payment information ready.

2. Call 800.285.4812.

3. We'll request a prescription from your doctor for a 90-day supply with refills.

Mail:

1. Request a prescription from your doctor for a 90-day supply with refiills.

2. Detach and complete the attached order form.

3. Mail the order from, prescription and payment in the postage-paid envelope attached to the order form.

“Cigna” and the “Tree of Life” logo are registered service marks, and “Together, all the way.” 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 or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C., and HMO or service company subsidiaries of Cigna Health Corporation. "Cigna Specialty Pharmacy Services" refers to the specialty drug division of Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C., doing business as Cigna Home Delivery Pharmacy.

* Savings are based on a 90-day fill/refill and are subject to your plan’s provisions. Your benefit plan may differ based on state law. Please check your plan documents for more details and to confirm that you have the Cigna Home Delivery Pharmacy benefit.

For specialty medication orders please call 800.351.3606, option 1.

589901 k 02/14 Offered by: Connecticut General Life Insurance Company or Cigna Health and Life Insurance Company.

Participating pharmacies in the United States, the U.S. Virgin Islands, Puerto Rico and Guam

pharmacy Directory

2

The 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 Cigna at the toll-free number on your ID card, or visit our website at myCigna.com for more information.

medications delivered to your home

Cigna Home Delivery Pharmacy is especially for people who take prescription medications on a regular basis (including specialty medications). It offers:

• Uptoathree-monthsupplyofmedicationsin one order

• Deliveryofyourmedicationtoyourhomeatnoadditional charge

• 24/7accesstopharmaciststohelpwithanyquestions you may have

• Helpfulreminderservicesandcoachingavailable

It’seasytogetstarted!Justcall1.800.835.3784andwewill help you take care of the rest

preventive prescription drug option

Preventive 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.

myCigna.com

PHARMACY DIRECTORY

3

alabama

Southern Family Markets

Care Plus/CVS Pharmacy

Costco Pharmacy

CVS Pharmacy

Food World Pharmacy

Fred’s 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

alaska

Carrs Quality Centers

Costco Pharmacy

Fred Meyer Pharmacy

Safeway Pharmacy

Sam’s Pharmacy

Walgreens Pharmacy

Target Pharmacy

Walmart Pharmacy

arizona

Bashas’ United Drug

Cigna HealthCare Centers


Costco Pharmacy

CVS Pharmacy

Fry’s Food & Drug

Kmart Pharmacy


Osco Drug

Safeway Pharmacy

Sam’s Pharmacy

Savon Pharmacy

Smith’s Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

arkansas

Brookshire Pharmacy

CVS Pharmacy

Fred’s Pharmacy

Harps Pharmacy

Harvest Foods

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

california

Bel-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

4

PHARMACY DIRECTORY

colorado

Albertson’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

connecticut

A&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

Delaware

Costco 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 columbia


CVS Pharmacy

Costco Pharmacy

Giant Pharmacy


Rite Aid Pharmacy

Safeway Pharmacy

Target Pharmacy

Walgreens Pharmacy

Florida


Costco Pharmacy

CVS Pharmacy

Kmart Pharmacy

Medicap Pharmacy


Navarro Discount Pharmacy

Publix Pharmacy

Sam’s Pharmacy

Savon Pharmacy

Sweetbay Pharmacy

Target Pharmacy

The Kroger Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

Winn-Dixie Pharmacy

Georgia

Bi-Lo Pharmacy


Costco Pharmacy

CVS Pharmacy

Fred’s Pharmacy

Harveys Pharmacy

Ingles Pharmacy

Kmart Pharmacy

Kroger Pharmacy

Medicap Pharmacy


Publix Pharmacy

Rite Aid Pharmacy

Sam’s Pharmacy

Southern Family Markets

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

Winn-Dixie Pharmacy

Guam

Kmart Pharmacy

5

hawaii


Costco Pharmacy

Kmart Pharmacy

Longs Drug Stores

Safeway Pharmacy

Sam’s Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

idaho

Costco 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

illinois


Costco Pharmacy

Cub Pharmacy

CVS Pharmacy

Doc’s Drugs

Dominicks Pharmacy

Fagen Pharmacy

Fred’s 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

indiana

Costco Pharmacy

CVS Pharmacy

Fagen Pharmacy

Fred’s Pharmacy

Kmart Pharmacy

Kroger Pharmacy

Marsh Drugs

Martins Pharmacy


Meijer Pharmacy

Osco Drugs

Rite Aid Pharmacy

Sam’s Pharmacy

Schnucks Pharmacy

Shopko Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

iowa

Costco Pharmacy

CVS Pharmacy

Dahl’s Pharmacy

Econofoods 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

6

PHARMACY DIRECTORY

Thrifty-white Drug

Walgreens Pharmacy

Walmart Pharmacy

Kansas

Costco Pharmacy

CVS Pharmacy

Dillon Pharmacy

Hen House Pharmacy

Hy-Vee Pharmacy

Kmart Pharmacy

Medicap Pharmacy



Sam’s Pharmacy

Shopko Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

Kentucky

Costco 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

Louisiana


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

maine

CVS Pharmacy

Hannaford Brothers

Kmart Pharmacy


Rite Aid Pharmacy

Osco Pharmacy

Sam’s Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

Waltz Pharmacy

maryland

Costco Pharmacy

CVS Pharmacy

Food Lion Pharmacy

Giant Eagle Pharmacy

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

7

Walgreens Pharmacy

Walmart Pharmacy

Wegmans Pharmacy

Weis Pharmacy

massachusetts

Big 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

michigan

Costco Pharmacy

CVS Pharmacy

Family Fare Pharmacy

Glen 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

minnesota


Cash Wise Pharmacy

Coborn’s Pharmacy

Costco Pharmacy

Cub Pharmacy

CVS Pharmacy

Econofoods Pharmacy

Fairview Pharmacy

Hy-Vee Pharmacy

Kmart Pharmacy

Lewis Family Drug


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

Southern Family Market

Super D Drugs

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

Winn-Dixie Pharmacy

missouri


Costco Pharmacy

CVS Pharmacy

Dierbergs Family Markets

Dillon Pharmacy

Family Pharmacy

Gerbes Pharmacy

Hy-Vee Pharmacy

Kmart Pharmacy

Kroger Pharmacy



Price Cutter Pharmacy

Sam’s Pharmacy

Schnucks Pharmacy

Shop ‘n Save Pharmacy

Super D Drugs

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

montana

Costco Pharmacy

CVS Pharmacy

Kmart Pharmacy

Osco Pharmacy

Safeway Pharmacy

Sam’s Pharmacy

8

Shopko Pharmacy

Smith’s Pharmacy

Target Pharmacy

Walmart Pharmacy

Nebraska

Bakers Pharmacy

Costco Pharmacy

CVS Pharmacy

Hy-Vee Pharmacy

Kmart Pharmacy

Safeway Pharmacy

Shopko Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

Nevada

Costco 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 hampshire

Costco Pharmacy

CVS Pharmacy

Hannaford Brothers

Kmart Pharmacy

Osco Pharmacy


Rite Aid Pharmacy

Sam’s Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

New Jersey

A&P Pharmacy

Costco Pharmacy

CVS Pharmacy

Duane Reade

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 mexico

Costco Pharmacy

CVS Pharmacy

Kmart Pharmacy

Safeway Pharmacy

Sam’s Pharmacy

Savon Drugs

Smith’s Food & Drug

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

New york

A&P Pharmacy


Costco Pharmacy

CVS Pharmacy

Drug World

Duane Reade

Gristedes Pharmacy

Hannaford Brothers

King Kullen Pharmacy

Kinney Drugs

Kmart Pharmacy


P&C 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

PHARMACY DIRECTORY

9

North carolina

Bi-Lo Pharmacy


Costco Pharmacy

CVS Pharmacy

Food Lion Pharmacy

Freds 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 Dakota

CVS Pharmacy


Thrifty-white Drug

White Drugs

ohio

ACME 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

oklahoma

CVS Pharmacy

Drug Warehouse

Harps Pharmacy

Homeland Pharmacy

Kmart Pharmacy

May’s Drug Stores


Med-X-Drug

Reasors Pharmacy

Sam’s Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

oregon

Bi-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

pennsylvania


Costco Pharmacy

CVS Pharmacy

Genuardis Pharmacy


Giant Pharmacy

Klingensmiths Pharmacy

Kmart Pharmacy

10

PHARMACY DIRECTORY

Medicap Pharmacy


Pathmark Pharmacy


Rite Aid Pharmacy

Savon Pharmacy

ShopRite Pharmacy


Target Pharmacy

Tops Markets

Walgreens Pharmacy

Walmart Pharmacy

Wegmans Pharmacy

Weis Pharmacy

puerto rico


CVS Pharmacy

Kmart Pharmacy

Sam’s Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

rhode island


CVS Pharmacy

Osco Pharmacy

Rite Aid Pharmacy


Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

South carolina

Bi-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 Dakota

Hy-Vee Pharmacy

Kmart Pharmacy

Lewis Family Drug/Lewis Drug

Safeway Pharmacy

Sam’s Pharmacy

Shopko Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

tennessee

Bi-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

11

texas


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 islands

Kmart Pharmacy


Utah


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

Vermont

Costco Pharmacy

CVS Pharmacy

Hannaford Brothers

Kinney Drugs

Osco Pharmacy


Rite Aid Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

Virginia

Costco Pharmacy

CVS Pharmacy

Farm 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

Washington

Bartell 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

“Cigna,” the “Tree of Life” logo and “GO YOU” are registered service marks, and “Cigna Home Delivery Pharmacy” is a service mark, of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, Tel-Drug, Inc., Tel-Drug of Pennsylvania, L.L.C., and HMO subsidiaries of Cigna Health Corporation. “Cigna Specialty Pharmacy Services” refers to the specialty drug division of Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C., doing business as Cigna Home Delivery Pharmacy. All models are used for illustrative purposes only.

589901 k 02/14 © 2014 Cigna. Some content provided under license.

West Virginia

CVS 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

Wisconsin

Aurora Pharmacy

Costco Pharmacy

Copps Food Center Pharmacy

CVS Pharmacy

Kmart Pharmacy


Pick N Save Pharmacy

Sam’s Pharmacy

Schnucks Pharmacy

Shopko Pharmacy

Target Pharmacy

Thrifty-white Drug

Walgreens Pharmacy

Walmart Pharmacy

Wyoming


King Sooper’s Pharmacy

Kmart Pharmacy

Safeway Pharmacy

Shopko Pharmacy


Walgreens Pharmacy

Walmart Pharmacy

Osco Pharmacy

As a Cigna customer, you’ll have access to Cigna Home Delivery PharmacySM, designed especially for individuals who take prescription medications on a regular basis, such as those used for diabetes, asthma, heart conditions, high blood pressure and more.

You’ll enjoy:

› Easy refi lls – up to a 90-day supply means fewer refi lls

› Reminder service to refi ll or take your medication available at Cigna.com/CoachRx

› Our free QuickFill service will call or email you when it’s time to refi ll your prescriptions

› Fast answers from Cigna pharmacists 24/7

800.285.4812

Manage your medication

Log in to myCigna.com where you can obtain the following important information about your prescription medications:

› Compare medication prices

› Check order status

› Review number of refi lls remaining

› Order refi lls and more

QuickSwitch® – we make fi lling a prescription simple

Have the following information handy when you call. We’ll do the rest!

1. Name and Cigna ID number

2. Prescription medication names and dosage (for you or a covered family member)

3. Doctor information (name, phone number)

4. Payment information (American Express, Discover, MasterCard or VISA)

Off ered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company or their affi liates.

“Cigna,” the “Tree of Life” logo and “QuickSwitch” are registered service marks, and “Together, all the way.” 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 or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Tel-Drug, Inc., Tel-Drug of Pennsylvania, L.L.C., and HMO 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. (IL & IN), Cigna HealthCare of Indiana, Inc., Cigna HealthCare of St. Louis, Inc. (MO, KS & IL), Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of New Jersey, Inc., Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of Tennessee, Inc. (TN & MS), and Cigna HealthCare of Texas, Inc. “Cigna Home Delivery Pharmacy” refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C.

822825 d 11/14 © 2014 Cigna. Some content provided under license.

A PHARMACY

AT YOUR FINGERTIPS

Cigna Home Delivery Pharmacy

With this information, we will request a prescription from your doctor. Once we receive it, we will fi ll your medication and mail it to your home or other location of your choice.

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

827113 n 04/15

SPECIALTY PHARMACY DRUG LIST

July 2015

How it worksWhen your doctor prescribes a specialty medication, they’ll call in or fax the prescription to:

Cigna Specialty Pharmacy Services800.351.3606 (phone) 800.351.3616 (fax)

Cigna Specialty Pharmacy Services creates a personalized experience that educates and motivates each customer to become active, accountable and confident. We offer the tools to connect and engage you along your health care journey. Our services include 24-hour access to nurses and pharmacists, education about your prescription medications and refill reminders.

Once your prescription order is received and processed, we’ll call you to schedule a date and time for delivery. Orders will be delivered to any address you choose for delivery (e.g., home, office, doctor’s office).

For all proactive refills or any orders over $4,000, delivery arrangements need to be made and confirmed with our pharmacy before we can send them to you.

If the pharmacy is not able to reach you, they’ll leave a message for you to call them back. The pharmacy can’t deliver the medications without your approval, so delivery will be delayed until you reply.

If you need to fill your prescription right away, you may be able to fill your prescription at a local network retail pharmacy. However, you’ll only get up to a 30-day supply and must fill the rest of your prescription through Cigna Specialty Pharmacy Services. If your plan offers out-of-network coverage, you can get your

prescription at an out-of-network pharmacy, but your out-of-pocket cost will likely be much higher.

Please note: Some medications listed here may need to be obtained through your doctor’s office or other medical facility. In these cases, your medications will be covered under your medical benefit instead of your pharmacy benefit. This will affect the amount you pay out-of-pocket. Check your plan documents for more information.

Health care reform and youThe Patient Protection and Affordable Care Act (PPACA), commonly referred to as “health care reform,” was signed into law on March 23, 2010. This important legislation will result in changes to every American’s health coverage. Some of the changes took effect in 2010, and most of the law’s effects will be felt by 2014. Cigna will comply with all provisions of the law including those that impact your pharmacy coverage plan. For example, depending upon the final government regulations, coverage for medications that have not traditionally been included in pharmacy plans, such as specific over-the-counter (OTC) medications, may be made available at no cost share to you. As with all covered medications, we require a

prescription from your doctor to process the claim under your pharmacy plan (including OTC medications).

To get the most current information, visit InformedOnReform.com or Cigna.com and look for the “Informed on Reform” link.

Specialty medications are used to treat complex conditions like multiple sclerosis, hepatitis C and rheumatoid arthritis. Although some are oral medications, the majority of specialty drugs are injected and may require special handling (e.g. refrigeration). As part of your pharmacy benefits plan, you have access to Cigna Specialty Pharmacy Services to deliver these medications.

http://www.cigna.com/health-care-reform/

http://www.cigna.com/

2

Specialty Drugs

A Abacavir*

Abraxane

Actemra*

Acthar H.P.*

Acthrel

Actimmune*

Adagen

Adcetris

Adcirca*

Adefovir Dipivoxil*

Adempas

Adrucil

Advate*

Afinitor Disperz*

Afinitor*

Agrylin*

Akynzeo

Aldurazyme*

Alferon N*

Alimta

Alkeran

Aloxi

Alphanate*

Alphanine SD*

Alprolix*

Amifostine

Aminocaproic Acid*

Ampyra*

Anagrelide HCl*

Anzemet

Apokyn*

Aptivus*

Aralast

Aralast NP

Aranesp

Arcalyst

Argatroban

Arixtra

Arranon

Arzerra

Astagraf XL*

Atgam

Atripla*

Atryn

Aubagio*

Avastin

Avonex*

Azacitidine

Azasan*

Azathioprine*

B Baraclude*

Baygam*

BCG Vaccine (Tice Strain)

Bebulin*

Beleodaq

Benefix*

Benlysta

Berinert

Betaseron*

Bethkis

Bicalutamide*

Bicnu

Bivigam*

Bleomycin Sulfate

Blincyto

Boniva*

Bosulif*

Botox*

Bravelle

Busulfex

CCamptosar

Capecitabine*

Caprelsa

Carboplatin

Carimune NF Nanofiltered

Casodex*

Cayston

Cellcept

Cellcept (Oral)*

Ceprotin

Cerdelga*

Cerezyme*

Cetrotide

Chorionic Gonadotropin

Cidofovir

Cimzia*

Cinryze

Cisplatin

Cladribine

Clolar

Combivir*

Cometriq*

Complera*

Copaxone*

Copegus*

Corifact

Cosentyx*

Cosmegen

Crixivan*

Cyclophosphamide*

Cyclosporine

Cyclosporine (Oral)*

Cyklokapron

Cyramza

Cystadane*

Cystagon

Cytarabine

Cytogam

Cytovene

DDacarbazine

Dacogen

Daunorubicin

Daunoxome

DDAVP

Decitabine

Depocyt

Desmopressin

Didanosine*

Docefrez

Docetaxel

Doxil

Doxorubicin

Dysport*

E Edurant*

Egrifta*

Elaprase

Elelyso*

Eligard*

Elitek

Ellence

Eloctate*

Eloxatin

Elspar

Emcyt*

Emend

Emtriva*

Enbrel*

Enoxaparin

Entecavir*

Entyvio

Epirubicin

Epivir HBV*

Epivir*

Epogen

Epoprostenol Sodium

Epzicom*

Erbitux

Erivedge*

Erwinaze

Esbriet*

Etopophos

Etoposide

Euflexxa*

Evotaz*

Exjade

Extavia*

Eylea

F Fabrazyme*

Farydak

Faslodex

Feiba NF*

Fertinex

Firazyr*

Firmagon

Flebogamma DIF

Flolan

Floxuridine

Fludarabine

Fludarabine Phosphate

Fluorouracil

Flutamide*

Follistim AQ

Folotyn

Fondaparinux

Fondaparinux Sodium

Forteo*

Fragmin

Fudr

Fusilev

Fuzeon*

G Gamastan S-D*

Gammagard Liquid*

Gammagard S-D*

Gammagard*

Gammaked*

Gammaplex

Gamunex-C*

Ganciclovir

Ganciclovir Sodium

Ganirelix Acetate

Gattex

Gazyva

Gel-One*

Gemcitabine

Gemcitabine HCl

Questions?Below is a list of medications that must be filled through Cigna Specialty Pharmacy Services to be covered under your pharmacy benefit. Please note: This list is subject to change. For more information, you can visit myCigna.com or call customer service using the number on the back of your ID card at any time, and we’ll be happy to help.

https://my.cigna.com/web/public/guest

3

Gemzar

Gengraf*

Genotropin*

Gilenya*

Gilotrif

Glassia

Gleevec*

Gliadel Wafer

Gonal-F

Gonal-F RFF

Granix

H Halaven

Harvoni*

Hecoria*

Helixate FS*

Hemofil M*

Hepagam B

Hepsera*

Herceptin

Hexalen*

Hizentra*

HP Acthar*

Humate-P*

Humatrope*

Humira*

Hyalgan*

Hycamtin*

Hylenex*

Hyperhep B S-D

Hyperrab S-D

Hyperrho S-D

Hyqvia

I Ibandronate*

Ibrance*

Iclusig*

Idamycin PFS

Idarubicin HCl

Ifex

Ifosfamide

Ifosfamide-Mesna

Ilaris

Iluvien

Imbruvica*

Imogam Rabies-HT

Imuran*

Incivek*

Increlex

Inlyta*

Intelence*

Intron A*

Invirase*

Iprivask*

Irinotecan

Irinotecan HCl

Isentress*

Istodax

Ixempra

J Jakafi

Jetrea*

Jevtana*

Juxtapid*

K Kadcyla

Kalbitor

Kaletra*

Kalydeco*

Kcentra

Kcentra Kit

Kepivance

Keytruda

Kineret*

Kitabis Pak

Koate-DVI*

Kogenate FS*

Krystexxa

Kuvan*

Kynamro

Kyprolis

L Lamivudine*

Lamivudine - Zidovudine*

Lemtrada*

Lenvima

Letairis*

Leucovorin Calcium (Oral)*

Leukine

Leuprolide Acetate*

Leuprolide*

Lexiva*

Lipodox

Lipodox 50

Lovenox

Lucentis

Lumizyme

Lupaneta

Lupron Depot*

Lutrepulse

Lynparza

Lysteda

M Macugen

Marqibo Kit

Matulane

Mekinist*

Melphalan HCl

Menopur

Mesna

Mesnex

Methotrexate

Methotrexate (Oral)*

Micrhogam

Mircera

Mitomycin

Mitoxantrone HCl

Moderiba*

Monoclate-P*

Mononine*

Monovisc*

Mustargen

Myalept

Mycophenolate*

Mycophenolic Acid*

Myfortic*

Myobloc

Myozyme

N Nabi-HB

Naglazyme

Natrecor

Navelbine

Neoral*

Neulasta*

Neumega

Neupogen

Nevirapine*

Nevirapine ER*

Nexavar*

Nexavir

Nipent

Norditropin*

Northera

Norvir*

Novarel

Novoeight*

Novoseven*

Nplate

Nulojix

Nutropin AQ*

OObizur

Octagam*

Octreotide Acetate*

Ofev

Olysio*

Omnitrope*

Oncaspar

Onxol

Opdivo

Opsumit

Orencia*

Orenitram ER

Orfadin

Orthovisc*

Otezla*

Otrexup

Ovidrel

Oxaliplatin

PPaclitaxel

Pamidronate Disod*

Pamidronate*

Panretin*

Paricalcitol

Paricalcitol (Oral)*

Pegasys Proclick*

Pegasys*

Pegintron*

Perjeta

Photofrin

Plegridy*

Pomalyst*

Pregnyl

Prezcobix*

Prezista*

Prialt

Privigen*

Procrit

Procysbi DR

Profasi

Profilnine SD*

Prograf

Prograf (Oral)*

Prolastin C

Proleukin

Prolia

Promacta*

Provenge

Provisc*

Pulmozyme*

Purixan

RRapamune*

Rasuvo

Rebetol*

Rebif*

Rebif Rebidose*

Reclast*

Recombinate*

Remicade*

Remodulin

Rescriptor*

Retrovir

Retrovir (Oral)*

Revatio*

Revlimid*

Reyataz*

Rheumatrex

Rhogam Plus

Rhophylac

Riastap

Ribapak*

Ribasphere*

Ribatab*

Ribavirin*

Rilutek*

Riluzole*

Rituxan

Rixubis*

Ruconest

SSabril

Saizen*

Sandimmune

Sandimmune (Oral)*

Sandostatin LAR*

Sandostatin*

Selzentry*

Sensipar

Serostim*

Signifor

Sildenafil*

Simponi Aria*

Simponi*

Simulect

Sirolimus*

Soliris

Somatuline Depot

Somavert

Sovaldi*

Sprycel*

Stavudine*

Stelara*

Stimate

Stivarga*

Stribild*

Sucraid

Supartz*

Supprelin*

Sustiva*

Sutent*

Sylatron*

Sylvant

Synagis*

Synarel*

Synribo*

Synvisc*

Synvisc-One*

TTacrolimus*

Tafinlar*

Tarceva*

Targretin*

Tasigna*

Taxotere

Tecfidera*

Temodar

Temodar (Oral)*

Temozolomide*

Teniposide

Tev-Tropin*

Thalomid*

Theracys

Thrombate III

Thymoglobulin

Thyrogen

Tivicay*

Tobi*

Tobi Podhaler*

Tobramycin*

Toposar

Topotecan HCl*

Topotecan*

Torisel

Tracleer*

Tranexamic Acid

Treanda

Trelstar*

Tretten

Trexall*

Trisenox

Triumeq*

Trizivir*

Truvada*

Tybost*

Tykerb*

Tysabri*

Tyvaso

Tyzeka*

VValchlor

Valstar

Vantas*

Vectibix

Velcade

Veletri

Ventavis

Victrelis*

Vidaza

Videx*

Videx EC*

Viekira*

Vimizim

Vinblastine Sulfate

Vincasar PFS

Vincristine

Vincristine Sulfate

Vinorelbine

Vinorelbine Tartrate

Viracept*

Viramune XR*

Viramune*

Virazole*

Viread*

Vistide

Visudyne

Vitekta*

Vivitrol*

Voraxaze

Votrient*

Vpriv*

WWilate*

Winrho SDF*

XXalkori*

Xeljanz*

Xeloda*

Xenazine

Xeomin*

Xgeva

Xiaflex*

Xolair*

Xtandi*

Xyntha*

Xyntha Solofuse*

Xyrem

YYervoy

ZZaltrap

Zanosar

Zavesca

Zelboraf*

Zemaira

Zemplar

Zemplar (Oral)*

Zerit*

Zevalin

Ziagen*

Zidovudine*

Zoladex*

Zoledronic Acid*

Zolinza

Zometa*

Zorbtive*

Zortress*

Zydelig

Zykadia*

Zytiga*

* These medications must be obtained from a preferred specialty pharmacy. Only your first prescription can be obtained at a network retail pharmacy. All subsequent refills must be obtained through a preferred specialty pharmacy. To maximize your benefits, all other medications are available through Cigna Specialty Pharmacy Services, at a network retail pharmacy or through your doctor’s office, if necessary.

^ Check your plan materials to determine if this Growth Hormone medication is covered under your plan.

“Cigna” and the “Tree of Life” logo are registered service marks, and “Cigna Home Delivery Pharmacy” and “Together, all the way.” are service marks, of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries, and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, Tel-Drug, Inc., Tel-Drug of Pennsylvania, L.L.C., and HMO subsidiaries of Cigna Health Corporation. “Cigna Specialty Pharmacy Services” refers to the specialty drug division of Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C., doing business as Cigna Home Delivery Pharmacy. All models are used for illustrative purposes only.

827113 n 04/15 © 2015 Cigna. Some content provided under license.

The Performance Prescription Drug List lets you and your doctor choose medications that work best for you. The following is a list of the most commonly used medications covered under your plan.

This list is designed to cover your prescription medications at three levels. The amount you pay depends on the tier from which you and your doctor select your medication. If there is more than one medication appropriate for your condition, we suggest that you talk to your doctor about lower-cost choices like generic medications and preferred brand medications to see if they could be right for you.

827293 l 04/15

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

PERFORMANCE PRESCRIPTION DRUG LIST

July 2015

2

1st Tier – Generic Medications: Generic medications have the same ingredients, safety, dosage, quality and strength as their brand name counterparts. You will usually pay less for generic medications under your plan.

2nd Tier – Preferred Brand Medications: Preferred brand medications will usually cost more than a generic, but less than a non-preferred brand medication under your plan.

3rd Tier – Non-Preferred Brand Medications: Non-preferred brand medications are those that generally have generic alternatives and/or a preferred brand medication within the same drug class. You will usually pay more for a non-preferred brand under your plan.

The symbols on the list meanIf a medication on the list has one of the following symbols, your doctor may need to get an authorization for coverage of that medication.

PA: Prior Authorization may be required for different reasons. To learn the requirements needed for coverage of a specific medication, feel free to give us a call.

QL: Quantity Limit means you may have coverage for a limited amount of a specific medication.

AGE: Age Requirement means an individual must be within a specific age group for a specific medication to be covered.

ST: Step Therapy is a prior authorization program that requires you to try other medications available to treat the same condition before the “ST” medication is covered.

* Medications marked with an asterisk are considered to be specialty medications. Some plans may cover specialty medications at different benefit levels or may require the use of a preferred specialty pharmacy. Refer to the your plan documents for more information.

3 2

Health care reform and youThe Patient Protection and Affordable Care Act (PPACA), commonly referred to as “health care reform,” was signed into law on March 23, 2010. This important legislation will result in changes to every American’s health coverage. Cigna will comply with all provisions of the law including those that impact your pharmacy coverage plan. For example, coverage for medications that have not traditionally been included in pharmacy plans, such as specific over-the-counter (OTC) medications, may be made available at no cost share to you. As with all covered medications, we would require a prescription from your doctor to process the claim under your pharmacy plan (including OTC medications).

To get the most current information, visit InformedOnReform.com or Cigna.com and look for the “Informed on Reform” link.

If you have any questionsRemember, this list is just a sample of the most commonly used medications, and is subject to change. You can use the Prescription Drug Price Quote tool available on myCigna.com to see and compare the prices of all medications covered under your plan. Or, you can call the number on the back of your ID card to speak with a customer service representative at any time.

NON-PREFERRED GENERICS PREFERRED BRANDS BRANDSP

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ADD/ADHD AND STIMULANTS

amphetamineclonidine HCldexmethylphenidate HCldexmethylphenidate HCl ERdextroamphetaminedextroamphetamine/ amphetamine ERguanfacineMetadate ER-methylphenidate HClmethamphetaminemethylphenidate HClmethylphenidate ER/ER 24 HRmodafinil

Adderall XRFocalin XRRitalin LA 10 mgStratteraVyvanse

Adderall (PA, ST)Concerta (PA, ST)Daytrana (PA, ST)Desoxyn (PA, ST)Dexedrine (PA, ST)Evekeo (PA, ST)Focalin (PA, ST)IntunivKapvayMetadate CD (PA, ST)Methylin (PA, ST)Nuvigil (PA)Provigil (PA)Quillivant XR (PA, ST)Ritalin (PA, ST)Ritalin LA 20 mg, 30 mg, 40 mg (PA, ST)Ritalin SR (PA, ST)Xyrem* (PA)Zenzedi (PA, ST)

AIDS/HIV

abacavir*didanosine*lamivudine*lamivudine/zidovudine*nevirapine*stavudine*zidovudine*abacavir/lamivudine/ zidovudine*nevirapine ER*

Aptivus*Crixivan*Emtriva*Epivir HBV*Epivir solution*Epzicom*Fuzeon* Invirase*Isentress*Kaletra*Lexiva*Norvir*Prezista*Rescriptor*Reyataz*Selzentry*Sustiva*Truvada*Viracept*Viramune XR*Viread*

Atripla*Combivir*Complera*Edurant*Epivir*Evotaz*FulyzaqIntelence*Prezcobix*Retrovir*Stribild*Triumeq*Trizivir*Tybost*Videx*Viramune*Vitekta*Zerit*Ziagen*

NON-PREFERRED GENERICS PREFERRED BRANDS BRANDS

5 4

ALLERGY

These drugs may not be covered under your plan. Please use the Prescription Drug Price Quote Tool on myCigna.com for more information.

azelastine HClazelastine nasalbudesonideclemastine fumaratecyproheptadinecyproheptadine HCldesloratadineepinastineepinephrine (QL)flunisolide nasalfluticasone nasalhydroxyzineipratropium nasallevocetirizinemontelukastolopatatine nasal spraytriamcinolone acetonide nasal

AsteproEpipen 2 pk (QL)Epipen Jr. (QL)NasonexVeramyst

Adrenaclick (QL)AstelinAtrovent (nasal)AUVI-Q (QL)Beconase AQ (PA, ST)Children’s QNASLDymista (PA, ST)Flonase (PA, ST)Karbinal EROmnaris (PA, ST)PatanaseQNASL (PA, ST)Rhinocort AQ (PA, ST)Semprex-DSingulairXyzalZetonna (PA, ST)

ALZHEIMER’S DISEASE

donepezil HClgalantamine hydrobromiderivastigmine tartrate capsules

AriceptAricept ODTExelonNamenda XRRazadyneRazadyne ER

ANXIETY

alprazolambuspironediazepamlorazepamoxazepam

Lorazepam IntensolNiravam

ASTHMA AND RESPIRATORY

albuterol sulfate (nebulizer solution)budesonide (nebulizer solution)caffeine citratecromolyn sodium (nebulizer solution)dyphyllineguaifenesin/theophylline

Advair, Advair HFAAnoro ElliptaAsmanexAtrovent HFABreo ElliptaCombivent RespimatFlovent Diskus/HFAProAir HFAPulmicort

AccolateAccuneb nebulizer (PA, ST)Adcirca* (PA)Adempas* (PA)AerospanAlvescoArcaptaArnuity ElliptaAsmanex HFA


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ASTHMA AND RESPIRATORY (CONTINUED)

ipratropium bromide (nebulizer solution)levalbuterol HCl (nebulizer solution)metaproterenol sulfate (syrup, tabs)montelukast sodiumprednisolone sod phosphateracepinephine HClsildenafil* (PA)terbutaline sulfatetheophylline anhydrouszafirlukast

Pulmozyme* (PA)QvarSereventSpirivaSymbicortVentolin HFAXolair* (PA)

Brovana nebulizer (PA, ST)DalirespDuleraEsbriet* (PA)ForadilIncruse Ellipta (PA, ST)Letairis*Ofev* (PA)Opsumit* (PA)Orapred ODTOrenitram ER* (PA)Perforomist (PA, ST)Proventil HFARevatio* (PA)S-2 RacepinephineSingulairStriverdi RespimatTracleer*Tudorza Pressair (PA, ST)Tyvaso*Ventavis*Xopenex HFAXopenex nebulizer (PA, ST)

BIRTH CONTROL

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

AltaveraAlyacenAmethiaAmethia LoAmethystApriAranelleAubraAvianeAzuretteBalzivaBriellynCamilaCamreseCamrese LoCaziantChatealCryselleCyclafemDasetta

BeYazLomedia 24 FELoSeasoniqueMinastrin 24 FENuvaRingOrtho EvraOrtho TriCyclen Lo

AngeliqBreviconCyclessaDepo-Provera SubqDesogenEllaEstrostep FEFemcon FEGeneress FELoestrinLoestrin FEMircetteModiconNataziaNorinyl 1+35Norinyl 1+50Nor-QDOrtho MicronorOrtho-CeptOrtho-Cyclen


7 6

BIRTH CONTROL (CONTINUED)


Dayseedesogestrel-ethinyl estradiolElinestEmoquetteEnpressEnskyceErrinEstaryllaethinyl estradiol/ drospirenoneFalminaGianviGildagiaGildessHeatherIntrovaleJencyclaJolessaJunelJunel FEKarivaKelnorKurveloLarinLarin FELeenaLessinaLevonestlevonorgestrellevonorgestrel-ethestralevonorgestrel-ethin estradiolLevoral-norgest-eth estr/ethin estraLorynaLow-OgestrelLuteraLyzaMarlissaMicrogestinMicrogestin FEMono-LinyahMononessaMyzilraNecon

Ortho-Novum 7-7-7Ortho-Tri-CyclenOvcon-35QuartetteSafyralSeasonaleSeasoniqueTri-NorinylYasmin 28Yaz


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BIRTH CONTROL (CONTINUED)


Next ChoiceNora-Benoreth a-et estra/fe fumaratenoreth-ethinyl estradiol/ironnorethindronenorgestimate-ethinyl estradiolnorgestrel-ethinyl estradiolNortrelOcellaOgestrelOrsythiaPhilithPimtreaPirmellaPortiaPrevifemQuasenseReclipsenSprintecSronyxSyedaTilia FETri-EstaryllaTri-Legest FETri-LinyahTrinessaTri-PrevifemTri-SprintecTrivoraVelivetVesturaVioreleVyfemlaWeraWymzya FEXulaneZarahZenchentZenchent FEZeosaZovia


9 8

CANCER

anastrozoleazacitidine*bicalutamide*capecitabinecyclophosphamide*exemestaneflutamide*letrozolelomustinetamoxifen citratetemozolomide* (PA)

Gleevec* (PA)Granix*Hexalen*LeukeranLupron Depot* (PA)LysodrenMatulane*MyleranNeulasta* (PA)Neupogen* (PA)Nexavar* (PA)Revlimid* (PA)Sprycel* (PA)Sutent* (PA)Tarceva* (PA)Thalomid* (PA)Xeloda*Zolinza* (PA)

Afinitor* (PA)Afinitor Disperz* (PA)ArimidexAromasinBosulif* (PA)Caprelsa* (PA)Casodex*Cometriq* (PA)DroxiaErivedge* (PA)FarestonFemaraGilotrif* (PA)Ibrance* (PA)Imbruvica* (PA)Inlyta* (PA)Jakafi* (PA)Lenvima* (PA)Lynparza* (PA)Mekinist* (PA)Purixan*Pomalyst* (PA)Stivarga* (PA)Sylatron* (PA)Sylvant* (PA)Tafinlar* (PA)Targretin* Tasigna* (PA)Tykerb* (PA)Valchlor*Votrient* (PA)Xalkori* (PA)Xtandi* (PA)Zelboraf* (PA)Zydelig* (PA)Zykadia* (PA)Zytiga* (PA)

BLADDER PROBLEMS

flavoxateoxybutynin/XLpotassium citrate ERtolterodine tartrate/LAtrospium chloride

ElmironToviazVESIcare

Detrol (PA, ST)Detrol LA (PA, ST)Ditropan XL (PA, ST)Enablex (PA, ST)Gelnique (PA, ST)Myrbetriq (PA, ST)Oxytrol (PA, ST) (For Men Only)Sanctura (PA, ST)Sanctura XR (PA, ST)Urocit-K


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HIGH BLOOD PRESSURE/HEART MEDICATIONS

acebutolol HClacetazolamideamiloride HClamiloride/hydrochlorothiazideamlodipine besylateamlodipine besylate/ benazeprilamlodipine/atorvastatin calciumamlodipine/valsartanamlodipine/valsartan/HCTZapresolineatenololbenazepril HClbenazepril HCl/amlodipinebenazepril HCl/HCTZbendroflumethiazide/ nadololbetaxolol HClbisoprolol fumaratebisoprolol/HCTZbumetanidecandesartancandesartan cilexetilcandesartan/HCTZcaptoprilcaptopril/HCTZcarvedilolchlorothiazidechlorthalidonechlorthalidone/atenololclonidineclonidine HClClorpresdiltiazemdiltiazem 24HR ERdoxazosin mesylate

BenicarBenicar HCTBystolicCoreg CRTarkaTekturnaTekturna HCT

Accupril (PA, ST)Accuretic (PA, ST)Aceon (PA, ST)Altace (PA, ST)AmturnideAtacand (PA, ST)Atacand HCT (PA, ST)Avalide (PA, ST)Avapro (PA, ST)AzorBetapace AFCarduraCardura XLCatapres, Catapres TTSCoregCorgardCozaar (PA, ST)Diovan (PA, ST)Diovan HCT (PA, ST)DutoprolEdarbi (PA, ST)Edarbychlor (PA, ST)ExforgeExforge HCTHemangeolHyzaar (PA, ST)Inderal LAInnopran XLLevatolLotensin (PA, ST)Lotensin HCT (PA, ST)LotrelMavik (PA ,ST)Micardis (PA, ST)Micardis HCT (PA, ST)NorpaceNorpace CR

CARDIOVASCULARBLOOD THINNER/ANTI-CLOTTING

anagrelide*cilostazolclopidogreldipyridamoleenoxaparin (QL)*fondaparinux (QL)*heparinJantoventiclopidinewarfarin

AggrenoxArixtra (QL)*EffientFragmin* (QL)Xarelto

Agrylin*BrillintaCoumadinEliquis (PA, ST)Lovenox* (QL)PlavixPletalPradaxa (PA, ST)Savaysa (PA, ST)Zontivity


11 10

CARDIOVASCULAR (CONTINUED)


enalapril maleateenalapril maleate/HCTZeplerenoneeprosartan mesylatefelodipinefosinopril sodiumfosinopril sodium/HCTZfurosemideguanfacinehydralazine HClhydrochlorothiazideindapamideirbesartanirbesartan/HCTZisradipinelabetalol HCllisinoprillisinopril/HCTZlosartan potassiumlosartan potassium/HCTZmethazolamidemethyldopamethyldopa/HCTZmetolazonemetoprolol succinatemetoprolol tartratemetoprolol/HCTZminoxidilmoexipril HClmoexipril HCl/HCTZnadololnicardipine HClnifedipinenimodipineperindopril erbuminepindololprazosin HClpropranolol HClpropranolol/HCTZquinaprilquinapril HCl/HCTZramipril (caps only)reserpinesotalol HClspironolactonespironolactone/HCTZtelmisartan

NorvascNymalizePrinivil (PA, ST)Prinzide (PA, ST)SotylizeSularTekamloTeveten (PA, ST)Teveten HCT (PA, ST)Toprol XLTribenzorTwynstaVaseretic (PA, ST)Vasotec (PA, ST)VerelanZestoretic (PA, ST)Zestril (PA, ST)


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CHOLESTEROL LOWERING

atorvastatincholestyraminecholestyramine powdercholestyramine/aspartamecholestyramine/sucrosecolestipolfenofibratefenofibric acidfluvastatingemfibrozillovastatinniacinomega-3-acid ethyl esterspravastatin sodiumsimvastatin

CrestorLescol XLLovazaSimcorWelcholZetia

AdvicorAltoprev (PA, ST)AntaraCaduetColestidFenoglideJuxtapid* (PA)Kynamro* (PA)LescolLipitor (PA, ST)Liptruzet (PA, ST)Livalo (PA, ST)LofibraMevacor (PA, ST)NiaspanPravachol (PA, ST)TriCorTrilipixVascepa (PA, ST)Vytorin (PA, ST)Zocor (PA, ST)

CARDIOVASCULAR (CONTINUED)


telmisartan/amlodipinetelmisartan/HCTZterazosin HCltimolol maleatetorsemidetrandolapriltriamterene/HCTZvalsartanvalsartan/HCTZVecamyl-mecamylamine HClverapamilverapamil SR

OTHER

amiodaronedigoxindisopyramideflecainideisosorbide dinitrateisosorbide mononitratenitroglycerinprocainamidepropafenone SR

MultaqNitrolingual sprayTikosyn

LanoxinNitromistRanexa (PA, ST)Rythmol SRSamsca (PA)


13 12

DEPRESSION

amitriptylinebupropionbupropion SRcitalopramdesipramineduloxetine HClescitalopramfluoxetinefluvoxamineimipraminemirtazapinenortriptylineparoxetineparoxetine CRprotriptylinesertralinetrazodonevenlafaxinevenlafaxine XR

PristiqWellbutrin XL

Aplenzin (PA, ST)Brintellix (PA, ST)Celexa (PA, ST)Cymbalta (PA, ST)Desvenlafaxine ER (PA, ST)Desvenlafaxine Fumarate ER (PA, ST)Effexor XR (PA, ST)EmsamFetzima (PA, ST)Forfivo XL (PA, ST)Khedezla (PA, ST)Lexapro (PA, ST)Luvox CRMarplanOleptro (PA, ST)Paxil (PA, ST)Paxil CR (PA, ST)Pexeva (PA, ST)Prozac (PA, ST)RemeronSarafem (PA, ST)TofranilVenlafaxine HCl ER (PA, ST)Viibryd (PA, ST)VivactilWellbutrin (PA, ST)Wellbutrin SR (PA, ST)Zoloft (PA, ST)

DIABETES

acarbosechlorpropamideglimepirideglipizideglipizide/metforminglyburideglyburide micronizedglyburide/metforminmetformin HClmetformin ERnateglinidepioglitazonepioglitazone/glimepiridepioglitazone/metforminrepaglinidetolazamidetolbutamide

ACCU-CHEK test stripsApidraApidra SoloStarBD Insulin Syringes/Pen NeedlesBydureon (QL)ByettaGlucaGen HypoKitGlucagon Emergency Kit (QL)HumalogHumulinInvokametInvokanaJanumetJanumet XRJanuviaKombiglyze XRLantus

Actoplus MetActoplus Met XRActosAfrezza (PA)AmarylAvandametAvandarylAvandiaCyclosetDuetactFarxiga (PA, ST)FortametGlucophage XRGlysetGlyxambi (PA, ST)Jardiance (PA, ST)Jentadueto (PA, ST)Kazano (PA, ST)Nesina (PA, ST)


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ENDOCRINE AND METABOLIC – OTHER

allopurinolcabergoline (QL)desmopressin*fluoxymesteronemegestrol acetateoctreotide* (PA)

ColcrysIncrelex* (PA)LupronDepot-PED* (PA)Megace ESNilandronSandostatin LAR* (PA)Somavert* (PA)Uloric

colchicineEgrifta* (PA)MegaceMitigareSandostatin* (PA)Signifor* (PA)Signifor LAR* (PA)Somatuline Depot* (PA)

DIABETES (CONTINUED)

Lantus SoloStarLevemirNovoFine/NovoTwist needlesNovolinNovologOne Touch test stripsOnglyzaPrandimetSymlinPenVictoza

Oseni (PA, ST)PrandinPrecoseStarlixTanzeum (PA, QL, ST)Tradjenta (PA, ST)Trulicity (PA, ST)VGoXigduo XR (PA, ST)

EYE CONDITIONS

apraclonidine HClatropineazelastinebrimonidinebromfenacbromfenac sodiumciprofloxacindiclofenacdorzolamidedorzolamide/timololepinastineflurbiprofengatifloxacinketorolaclatanoprostlevofloxacinpilocarpinetimololtobramycin/dexamethasonetravoprosttrifluridine

AlomideAlphagan P 0.1%AzaSiteAzoptBetoptic SCiloxan (ointment)IopidineLotemax (drops & gel)MaxidexMoxezaPatadayPatanolRestasisTobradex ointmentTravatan ZVexolVigamox

Acular LSAlocrilAlrexBepreveBesivanceCiloxan (drops)CosoptCystaranDurezolElestatEmadineIlevroLastacaftLotemax (ointment)OptivarPazeoProlensaResculaSimbrinza (PA, ST)TimopticTobradex (drops)Tobradex STTrusoptVoltarenZioptan (PA, ST)Zymaxid


15 14

GASTROINTESTINAL (NOT HEARTBURN/ULCER)

balsalazidebelladonna alkaloids/ phenobarbitalbudesonidecromolyn sodium (solution)PEG 3350/potassium/ sodium bicarb/saltPEG 3350/potassium/ sodium bicarb/salt/ sodium sulftriamcinolone acetonide

AprisoAsacol HDCanasaCreonDelzicolGoLytelyHumira* (PA)LialdaPentasaUrso/Urso ForteZenpep

AmitizaCimzia* (PA)ColazalColyteDonnatalEntocort ECEntyvio* (PA)GiazoLinzessMovantik (PA)NuLytelyPancreazePertzyePancreazePrepopikRelistor (PA)Remicade* (PA)Simponi* (PA)Simponi Aria* (PA)SuclearSucraid*UcerisUltresaViokace

GROWTH HORMONES

Humatrope* (PA)Saizen* (PA)

Genotropin* (PA)Norditropin* (PA)Norditropin Nordiflex* (PA)Nutropin AQ* (PA)Nutropin AQ Nuspin*(PA)Omnitrope* (PA)Serostim* (PA)Tev-Tropin* (PA)

HEARTBURN/ULCERThese drugs may not be covered under your plan. Please use the Prescription Drug Price Quote Tool on myCigna.com for more information.cimetidineesomeprazole magnesiumfamotidinelansoprazolelansoprazole/amoxicillin/ clarithromycinmetoclopramidemetoclopramide HCl

Nexium Aciphex (PA, ST)Aciphex Sprinkle (PA, ST)Dexilant (PA, ST)Esomeprazole Strontium (PA, ST)Omeclamox-PakPrevacid (PA, ST)Prevpac


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INFECTIONS

acycloviradefovir dipivoxil*amantadineamoxicillin/ERamoxicillin/clavulanateatovaquoneazithromycincefaclor ERcefadroxilcefditorencefdinircefprozilceftibuten dihydrateceftriaxonecefuroxime axetil

Baraclude*Cipro HC OticCiprodexEpivir HBV*Gris-PegIntron-A* (PA)Mycostatin (tabs)Peg Intron* (PA)Pegasys* (PA)PrimsolTamiflu (QL)Valcyte

Acticlate (PA, ST)AncobonAugmentinAugmentin ES 600Augmentin XRAveloxBethkis*BiaxinBiaxin XLCedaxCetraxalCiclodanCipro Cipro XRCNL 8

HORMONE REPLACEMENT

estradiolestradiol/norethindrone acetateestropipateethinyl estradiollevothroidlevothyroxineLevoxylliothyroninemedroxyprogesteroneprogesterone, micronizedtestosterone cypionatetestosterone enanthatethyroidUnithroid

AloraAnadrol-50 (PA)Androderm (QL)AndroGel (QL)Armour ThyroidDivigelEnjuviaPremarinPremphasePremproSynthroidTestim (QL)Vivelle-Dot

ActivellaAxiron (PA, QL, ST)CenestinCombipatchCytomelDelatestrylDepot TestosteroneEstraceFemhrtFemringFortesta (PA, QL, ST)MenestMinivellePrefestPrometriumStriant (QL)testosterone gel (QL)VagifemVogelxo

HEARTBURN/ULCER (CONTINUED)These drugs may not be covered under your plan. Please use the Prescription Drug Price Quote Tool on myCigna.com for more information.misoprostolnizatidineomeprazoleomeprazole/sodium bicarbonatepantoprazolerabeprazole HClranitidinesucralfate

Prilosec (PA, ST)Protonix (PA, ST)Zantac EffertabZantac SyrupZegerid (PA, ST)


17 16

INFECTIONS (CONTINUED)

cephalexinciprofloxacinclarithromycinclindamycinclindamycin phosphatecycloserinedoxycyclineentacavirerythromycinfamciclovirfluconazoleflucytosineganciclovir*gentamicin sulfategriseofulvingriseofulvin microsizegriseofulvin ultramicrosizeitraconazole (QL)ketoconazolelamivudine*metronidazoleminocyclineminocycline HClModeriba*moxifloxacin HClmupirocinnitrofurantoinnystatinofloxacinpenicillin v potassiumribavirin*rifabutinrifampinrimantadinesulfamethoxazole/ trimethoprimterbinafine (QL)terconazoletetracyclinetobramycinvalacyclovirvalganciclovirvancomycinvoriconazole (PA)

Coartem (QL)Copegus*Dificid (PA)Ery-TabFamvirFlagyl ERGaramycin*Grifulvin VHepsera*KeflexKetodanKitabis Pak*Lamisil (QL)LevaquinMalarone (PA)MonurolMoxatagNoxafilOlysio* (PA)Onmel (PA, QL, ST)PenlacPriftinRebetol*Relenza (QL)RocephinSirturoSitavigSivextro (PA)Solodyn (PA, ST)SpectracefSporanox (QL)SupraxTobi*Tobi Podhaler*Tyzeka*UribelUrelleUTAValtrexVfend (PA)ZithromaxZyvox (PA)


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MIGRAINE

acetaminophen/caffeine/ butalbitaldihydroergotamine mesylate (QL)isomethepten/caf/ acetaminophennaratriptan (QL)rizatriptan (QL)sumatriptan (QL)sumatriptan succinate (QL)zolmitriptan (QL)

Treximet (QL)Cafergot

Alsuma (QL)Amerge (QL)Axert (QL)DHE 45 (QL)Frova (QL)Imitrex (QL)Maxalt (QL)Maxalt MLT (QL)Migranal (QL)Relpax (QL)Sumavel DosePro (QL)Zomig/Zomig ZMT (QL)Zomig nasal (QL)

MULTIPLE SCLEROSIS

Ampyra* (PA)Avonex/Avonex Pen* (PA)Copaxone* (PA)Rebif* (PA)Rebif Rebidose* (PA)Tecfidera* (PA)

Aubagio* (PA)Betaseron* (PA)Extavia* (PA)Gilenya* (PA)Plegridy* (PA)

NAUSEA AND VOMITING

dronabinolgranisetronondansetronprochlorperazinepromethazinetrimethobenzamide

Emend* (QL) Akynzeo* (QL)Anzemet inj* (PA)Anzemet tabs* (QL)DiclegisMarinolSancuso (QL)ZofranZuplenz (PA, QL, ST)

OSTEOPOROSIS

alendronate sodiumcalcitonin-salmonetidronate disodiumForticalibandronate sodium syringe*ibandronate sodium tabletraloxifene HClrisedronate

EvistaForteo*Miacalcin

Actonel (PA, ST)Atelvia (PA, ST)Binosto (PA, ST)Boniva syringe* (PA, ST)Boniva tab (PA, ST)Fosamax (PA, ST)Fosamax Plus D (PA, ST)Skelid (PA, ST)


19 18

PAIN RELIEF AND INFLAMMATORY DISEASE

buprenorphinebutalbital/acetaminophenbutalbit/acetamin/caff/ codeinebutorphanol nasal (QL)celecoxib (QL)codeine phos/carisoprodol/ asacodeine phosphatecodeine phosphate/aspirincodeine sulfatecyclophosphamide*dexamethasonediclofenacdiclofenac/misoprostoldihy-cod tt/apap/caffeineetodolacfenoprofenfentanyl citrate (lozenge on stick) (PA)fentanyl transdermal (QL)flurbiprofenhydrocodone bitartrate/apaphydrocodone bitartrate/ aspirinhydromorphone HClibuprofenibuprofen/hydrocod bitindomethacinketoprofenketorolac (QL)leflunomidelevorphanol tartratelidocainelidocaine-prilocainemeclofenamatemefenamic acidmeloxicammeperidine HClmetaxalonemethotrexate*methylprednisolonemigergotmorphine sulfate (QL)nabumetonenaproxenopiumopium/belladonna alkaloidsorphenadrine/aspirin/ caffeine

Actimmune* (PA)Avinza (QL)Dilaudid-5DipentumEnbrel* (PA)Fentora (PA)Humira* (PA)Indocin (suppository)Kadian (QL)LidodermLyricaNucynta (PA, QL, ST)Nucynta ER (QL)OxyContin (QL)Ponstel (PA, ST)Rheumatrex*Roxicet (PA, ST)SavellaSuboxone film tab (PA)Trexall*

Abstral (PA)Actemra* (PA)Actiq (PA)AdazinAnsaid (PA, ST)Arthrotec (PA, ST)Butrans (QL)CambiaCelebrex (QL, ST)Cimzia* (PA)Conzip (PA, QL, ST)Demerol (PA, ST)Dilaudid (PA, ST)Duexis (PA, ST)Duragesic (QL)Embeda (QL)Exalgo (QL)Fioricet w/codeineFlector (PA, QL, ST)Horizant (PA, ST)Hycet (PA, ST)Hysingla ER (QL)Kineret* (PA)Lazanda (PA)LidopinLidovexLortab (PA, ST)Mobic (PA, ST)MS Contin (QL)Nalfon (PA, ST)Naprelan (PA, ST)Norco (PA, ST)Onsolis (PA)Opana (QL)Opana ER (QL)Otrexup* (PA)Oxecta (PA, ST)Pain ReliefPennsaidPercocet (PA, ST)Percodan (PA, ST)Primlev (PA, ST)ProdrinQufloraRasuvo* (PA)Rayos (PA, ST)RelyyksRelyytRemicade* (PA)Roxicodone (PA, ST)


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PAIN RELIEF AND INFLAMMATORY DISEASE (CONTINUED)

oxaprozinoxycodone ER (QL)oxycodone HCloxycodone HCl/ acetaminophenoxycodone/aspirinoxymorphoneOxymorphone HClpentazocine HCl/ acetaminophenpentazocine HCl/ naloxone HClpiroxicamprednisonesulindactolmetintramadol ER (QL)tramadol HCl (QL)tramadol HCl/ acetaminophen (QL)

RyzoltScarSilveraSimponi* (PA)Simponi Aria* (PA)SkelaxinSolaiceSprix (QL)Suboxone SL tab (PA)Subsys (PA)Synalgos-DC (PA, ST)Synvexia TCTrezix (PA, ST)Ultracet (PA, QL, ST)Ultram (PA, QL, ST)Ultram ER (PA, QL, ST)VelmaVicodin/ES/HP (PA, ST)Vicoprofen (PA, ST)Vimovo (PA, QL, ST)Voltaren Gel (PA, ST)Voltaren XR (PA, ST)Xartemis XR (PA, QL, ST)Xeljanz* (PA)Xodol (PA, ST)Zohydro (QL)Zorvolex (PA, ST)

PARKINSON’S DISEASE

amantadinebenztropinebromocriptinecarbidopacarbidopa/levodopacarbidopa/levodopa CRcarbidopa/levodopa/ entacaponeentacaponepramipexolepramipexole ERropiniroleropinirole XLselegiline

Apokyn* (PA)Azilect

ComtanEldeprylLodosynMirapexMirapex ERNeuproNorthera* (PA)ParcopaRequipRequip XLSinemet CRRytaryStalevoTasmarZelapar


21 20

PROSTATE

alfuzosindoxazosinfinasterideleuprolide acetate* (PA)prazosintamsulosinterazosin

AvodartCialis (PA,QL)JalynZoladex* (PA)

Firmagon* (PA)FlomaxProscarRapafloUroxatral

SCHIZOPHRENIA

clozapinehaloperidolloxapineolanzapineolanzapine/fluoxetine HClquetiapinerisperidonethiothixeneziprasidone

Seroquel XR AbilifyAbilify DiscmeltClozaril (PA, ST)Fanapt (PA, ST)Fazaclo (PA, ST)Geodon (PA, ST)Invega (PA, ST)Latuda (PA, ST)OrapRisperdal/ Risperdal M (PA, ST)Saphris (PA, ST)Seroquel (PA, ST)SymbyaxVersacloz (PA, ST)Zyprexa (PA, ST)Zyprexa Zydis (PA, ST)

SEIZURE

carbamazepineclonazepamdiazepamdivalproexethosuximidefelbamategabapentinlamotriginelevetiracetamoxcarbazepinephenytointiagabine HCltopiramatevalproatezonisamidevalproate sodium

CelontinDiastatDiastat AcudialDilantin (30 mg only)FelbatolGabitrilKeppraLamictal ODTLyricaPeganoneVimpat

AptiomBanzelCarbatrolDepakote (all forms)DilantinFycompaKeppra XRLamictalLamictal XRNeurontinOxtellar XRPotigaQudexy XRSaphrisStavzorTegretol XRTopamaxtopiramate XR capsTrileptalZarontinZonegran


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SKIN CONDITIONS

acitretinadapalene (AGE)alclometasone dipropionateamcinonideamnesteem (QL)Apexicon E (diflorasone diacetate) creambetamethasonebetamethasone dipropionatebetamethasone dipropionate/propylene glycolbetamethasone valeratecalcipotrienecalcipotriene- betamethasonecalcitriol ointmentClaravis (QL)clinicamycinphosphate/ benzoyl peroxide gelclobetasol propionateclobetasol propionate/emollclocortolone pivalatedesonidedesoximetasonediclofenac sodiumdiflorasone diacetatefluocinolone acetonidefluocinonidefluocinonide/emollientfluorouracil topicalfluticasone propionatehalobetasol prop/ ammonium lachalobetasol propionatehydrocortisonehydrocortisone acetate/ aloe verahydrocortisone acetate/urea

Ala-Scalp HP (PA, ST)Benzaclin (Gel w/pump)Benzamycin PakCapex Shampoo (PA, ST)CaracCarmol HC (PA, ST)Cloderm (PA, ST)Cordran (PA, ST)Cordran SP (PA, ST)Differin (AGE)Enbrel* (PA)ExeldermFluoroplexFuracinHumira* (PA)Kenalog aerosol (PA, ST)KlaronLocoid (lotion)Loprox shampooMetrogel 1%NaftinNoritateNucort (PA, ST)OraceaTazoracTexacort (PA, ST)

Absorica (QL)AcanyaAclovate (PA, ST)Alcortin AAldaraAqua Glycolic HC (PA, ST)Atralin (AGE)AvarAvar LSAvitaBactrobanBenoxyldoxy 30BenzaclinBenzefoamClindacin PacClobex (PA, ST)Clodan (PA, ST)CondyloxCosentyx* (PA)Cutivate (PA, ST)Derma-Smoothe/FS (PA, ST)Dermasorb AFDermasorb HC (PA, ST)Dermasorb TA (PA, ST)Dermasorb XMDermatop (PA, ST)Desonate (PA, ST)Desowen (PA, ST)Diprolene (PA, ST)Diprolene AF (PA, ST)DovonexDoxycycline IR-DRDuacEcozaElidel (PA, ST)Elocon (PA, ST)EpiduoFirst Hydrocortisone (PA, ST)Halog (PA, ST)Hydro 35

SEXUAL DYSFUNCTION **

Cialis (PA,QL)Muse (PA, QL)Viagra (QL)

Caverject (PA, QL)Edex (PA, QL)Levitra ( PA, QL)OsphenaStaxyn (PA, QL)Stendra (QL)

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


23 22

SKIN CONDITIONS (CONTINUED)

hydrocortisone butyratehydrocortisone valerateimiquimodIsotretinoin (QL)methoxsalen, rapidmetronidazolemometasone furoatepodofiloxprednicarbatesalicylic acidSotret (QL)sulfacetamidesulfacetamide sodium/sulfursulfacetamide sulfursulfacetamide/sulfur/ cleansertacrolimus ointmenttretinoin (AGE)triamcinolone acetonideurea

IodosorbJublia (PA, ST)KeralacKerydin (PA, ST)Locoid (cream, ointment, solution)Locoid Lipocream (PA, ST)Luxiq (PA, ST)LuzuMetrogelMetrolotionNeuacOlux (PA, ST)Olux-E (PA, ST)Onexton Otezla* (PA)Ovace Plus cream, lotion and washPandel (PA, ST)Panretin*Pediaderm HC/TA (PA, ST)PlexionProtopic (PA, ST)Regranex (PA)Remicade* (PA)Retin-A cream (PA, AGE)Retin-A Micro (PA, AGE)Retin-A Micro Pump (PA, AGE)RiaxRosulaScalacort DK (PA, ST)SolarazeSoolantraSoriataneSoriluxStelara* (PA)Sumadan XLTSynalar (PA, ST)Synalar TS (PA, ST)TaclonexTargretin gel*Temovate (PA, ST)Topicort (PA, ST)Topicort LP (PA, ST)Tretin-X (PA)Ultrasal-ERUltravate (PA, ST)Ultravate X (PA, ST)Umecta


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SLEEP

eszopiclonezaleplonzolpidemzolpidem ER

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

SKIN CONDITIONS (CONTINUED)

Vanos (PA, ST)VecticalVerdeso (PA, ST)VytoneXolegelZianaZyclara (PA, ST)

VITAMINS

calcitriolcyanocobalaminfolic acid

Active OB^Bal-Care DHA EssentialCadeau DHACitranatal 90 DHACitranatal Assure^Citranatal B-CalmCitranatal DHACitranatal Harmony^Focalgin-B^Folet DHAFolet OneGesticare DHAInfanate BalanceNatachewNatafortNatelle One^NeevoNeevo DHA

Eligen B12Feriva 21-7MaxFeNascobal

All plans cover all generic prescription prenatal vitamins, even though not listed here. Available as generic where ^ is noted.

TRANSPLANT

azathioprine*cyclosporine*mycophenolate moefetil*mycophenolate sodium*sirolimus*tacrolimus*

Azasan*Cellcept*Neoral*Prograf*Rapamune*Sandimmune*

Imuran*Myfortic*Zortress*


25 24

VITAMINS (CONTINUED)

Nestabs^Nestabs ABCNestabs DHA^Nexa PlusOB CompleteOB Complete DHAOB Complete OneOB Complete PetiteOB Complete PremierPrecare PremierPrefera-OB OnePreferaOB Prenatal VitaminPrenaissance Next-BPrenataPrenatal 19Prenate AMPrenate ChewablePrenate DHAPrenate ElitePrenate EnhancePrenate EssentialPrenate MiniPrenate PixiePrenate RestorePrenate StarProvida OBSelect-OBStuart PrenatalStuartnatal PlusStuartnatal Plus 3TL-FolateTL-Select DHATricareTricare Prenatal DHA OneVinate CareVinate DHAVirt-Bal DHA^Vita Fol-OB DHAVitafol NanoVitafol UltraVitafol-OneVitaMed MD Plus RxVitaMedMD Redichew RXVitapearlViva DHAVP CH UltraVP-PNV-DHA

All plans cover all generic prescription prenatal vitamins, even though not listed here. Available as generic where ^ is noted.


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MISCELLANEOUS

aminocaproic acid*buprenorphinebuprenorphine HCl/ naloxone HCl (PA)cyclobenzaprinedoxercalciferolhydrocodone/ chlorpheniramine suspensionhydrocortisoneivermectinleucovorin*levocarnitinelidocaine-hydrocortisone- aloelindanemegestrolmethocarbamolnaltrexonenaltrexone HClparicalcitol*pentoxifyllinepramoxine/hydrocortisonepseudoephed/hydrocodone/ cpmquinine sulfateriluzole*sodium phenylbutyratesodium polystyrene sulfonatespinosadtizanidinetranexamic acid*

Analpram AdvancedAranesp* (PA)BuphenylChantixEpogen* (PA)FosrenolHarvoni* (PA)Klor-Con M15Leukine*MetopironePramosoneProcrit* (PA)Proctofoam-HCPulmuzyme* (PA)RenvelaSovaldi* (PA)SPSStromectolSuboxone film tab (PA)TussiCapsZavesca* (PA)

Ana-LexAnalpram-EAnalpram HCArcalyst* (PA)Brisdelle (QL)Bunavail (PA)Cerdelga* (PA)CortifoamCuvposaEpifoamEvzioFeriva FAFerric citrateGattex* (PA)HectorolHetlioz (PA)Ilaris* (PA)Kuvan*Lupaneta Pack* (PA)Lysteda*Mircera* (PA)NatrobaNeo-SynalarNimotopNuedextaNymalizeObredonOxandrin (PA)PhosloPhoslyraProcysbi* (PA)Promacta* (PA)Ravicti* (PA)RectivRenagelReviaRilutek*SkliceSuboxone SL tab (PA)TussionexUcerisUlesfiaVelphoroViekira Pak* (PA)VituzZanaflexZemplar*Zubsolv (PA)Zutripro

26 27

Exclusions and Limitations

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

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

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

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

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

5. Food and Drug Administration (FDA) approved medications used for purposes other than those approved by the FDA unless the medication is recognized for the treatment of the particular indication in one of the standard reference compendia (The United States Pharmacopoeia Drug Information or The American Hospital Formulary Service Drug Information) or in medical literature. Medical literature means scientific studies published in a peer-reviewed national professional medical journal.

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

7. Implantable contraceptive products. 8. Any fertility medication. 9. Any prescription vitamins (other than

prenatal vitamins), dietary supplements and fluoride products.

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

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

12. Immunization agents, biological products for allergy immunization, biological sera, blood, blood plasma and other blood products or fractions and medications used for travel prophylaxis (the prevention of travel-related diseases).

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

14. Medications used to enhance athletic performance.

15. Medications that are to be taken by, or administered to, a customer while the customer is a patient in a licensed hospital, skilled nursing facility, rest home or similar institution which operates on its premises, or allows to be operated on its premises, a facility for dispensing pharmaceuticals.

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

Cigna reserves the right to make changes to this 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.

827293 l 04/15 © 2015 Cigna. Some content provided under license.

“Cigna”, “Tree of Life” logo and “Together, all the way.”are registered service marks, and “Cigna Home Delivery Pharmacy” is a service mark of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries, and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, Tel-Drug, Inc., Tel-Drug of Pennsylvania, L.L.C., and HMO subsidiaries of Cigna Health Corporation. “Cigna Specialty Pharmacy Services” refers to the specialty drug division of Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C., doing business as Cigna Home Delivery Pharmacy. All models are used for illustrative purposes only.

We’ve made myCigna.com all about you

Log in and you’ll 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. The site is designed to make it easier to quickly find exactly what you’re looking for and it’s compatible with your mobile device – so you can find whatever you need, whenever you need it.

Get started

Go to myCigna.com. The first time you visit, you will be directed through a simple registration process. Once you’ve registered, keep your User ID and password in a safe place and bookmark myCigna.com for future use.

When you log in to myCigna.com, everything you need to manage your health and health care expenses is just a few clicks away.

CLICK WITH A SITE THAT CLICKS WITH you

myCigna.com

864733 06/13 Offered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company or their affiliates.

Get informed

Now you’re ready to take advantage of myCigna.com and its many health and pharmacy-related features.

As soon as you’re on myCigna.com, you’ll see it’s all about you – your pharmacy coverage and claim information, plus tools and resources to improve your health and wellness. You can also easily find a doctor in your network.

The first time you visit myCigna.com, you’ll be directed through a simple registration process.

Use your tools

When you have more information, you’ll feel better about your health and your health spending. That’s why we have tools to help you calculate costs, compare plan costs, estimate treatment costs and more.

Drug price quote tool – look up prescriptions to compare prices. We also suggest lower-cost alternatives like home delivery or generics.

Pharmacy home delivery – you can learn more about Cigna Home Delivery PharmacySM and order refi lls of your prescriptions.

See your Pharmacy coverage

Your pharmacy coverage details are all in one easy-to-access place. View all your current claims information, including when and where you received services, what you were billed for and what you paid. See your benefi ts booklet for specifi c eligibility and coverage information.

Find a health care professional or pharmacy

Search for your doctor by name or search our network for a specifi c type of doctor, pharmacy or medical facility. You can fi lter your results by distance, cost effi ciency, specialty and more – even by whether they are accepting new patients. You can also email a copy of your search results.

Be sure to look for the Cigna Care Designation symbol – which identifi es doctors who meet certain cost and quality measures.

You’ll fi nd helpful resources on a variety of health-related topics under your “Manage My Health” section.

Medical cost estimator – compare estimated costs for various procedures based on Cigna’s historical cost data.

Manage your health – the “Manage My Health” section includes a wealth of tools and information to help you get healthy and stay healthy. You’ll fi nd articles, support groups, and other resources on a variety of topics including blood pressure, cholesterol, tobacco cessation, weight management, stress and more.

It’s your health. And myCigna.com is your site.

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

“Cigna,” the “Tree of Life“ logo, “GO YOU” and “Cigna Pharmacy Management” are registered service marks, and “Cigna Home Delivery Pharmacy” is a service mark, of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are providxed exclusively by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, Tel-Drug, Inc., Tel-Drug of Pennsylvania, L.L.C., and HMO or service company subsidiaries of Cigna Health Corporation. “Cigna Home Delivery Pharmacy” refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C. All models are used for illustrative purposes only.

864733 Cigna Payer Solutions 06/13 © 2013 Cigna. Some content provided under license.

Cigna Care Designation

Quality Designations

Specialty: Pediatrics

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