Three-Tier Plan 2012 Cigna - CHG Healthcare...

Three-Tier Plan

2012 Cigna prescription drug list

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Choosing the medication that is right for you is between you and your doctor. This prescription drug list offers you an extensive list of brand-name and generic medications that are covered under your pharmacy plan.

Choosing where to fill your medication should be easy, too. With over 61,000 pharmacies and Cigna Home Delivery Pharmacy in our network, you have convenient access to your medications – whether you pick them up or have them delivered to your home.

Within this document you will find a list of medications covered under your plan, in an easy-to-read format. You will see:

1. Medications split into three categories (generic, preferred brand and non-preferred brand medications)

2. Health conditions and medications listed in alphabetical order

3. Symbols to let you know if there are any important details related to coverage

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Your three-tier prescription drug listA three-tier prescription drug list splits medications into three categories (or tiers):

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

2nd Tier – Preferred Brand Medications: Preferred brand medications will usually cost more than a generic, but may cost less than a non-preferred brand on a three-tier plan.

3rd Tier – Non-Preferred Brand Medications: Non-preferred brand medications generally have generic alternatives and/or one or more preferred brand options within the same drug class. You will usually pay more for non-preferred medications on a three-tier plan.

Preventive prescription drug optionPreventive medications are described as medications that are used to prevent a disease or condition in people 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 in people who have recovered.

Preventive medications do not include drugs used to treat an existing illness, injury or condition. Some pharmacy plans require you to pay a certain amount (deductible) before the plan coverage begins, but preventive medications may be covered before you reach that amount. To be sure, you can read your enrollment materials to see how preventive medications are covered specific to your plan. Also, a list of all covered preventive medications is available on myCigna.com. Preventive medications are identified by a “PM” symbol within the drug list search.

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Understanding Cigna’s prescription drug listEvery medication available on Cigna’s prescription drug list has been approved by the U.S. Food and Drug Administration (FDA). This list represents the most commonly prescribed medications. If you do not see a specific medication on this list, please check myCigna.com to see all of the medications covered under your plan.

The symbols on the list mean …

If your medication has one of the following symbols, your doctor may have to get an authorization (approval) 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, please feel free to give us a call.

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

AGE: Age Requirement means that a person 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 medication with the “ST” is covered.

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myCigna.comOur customer website that can help you manage your prescription coverage:

When you visit myCigna.com, you can:

• Lookupthedetailsofyourspecific pharmacy plan

• Researchthousandsofavailablemedications

• ComparemedicationpricesusingthePrescription Drug Price Quote Tool

• Askapharmacistquestions

• Andmuch,muchmore!

Medications delivered right to your homeCigna Home Delivery Pharmacy is designed for people who take prescription medications on a regular basis (including specialty medications). The benefits of Cigna Home Delivery Pharmacy include:

• Gettinguptoa90-daysupplyofyour medications in one fill

• Deliveryofmedicationstoyourdoor at no additional charge

• Licensedpharmacistsavailableto help 24/7

• CoachRx:afreetoolthatcanhelp with reminders, coaching and information. Visit Cigna.com/coachrx to learn more

• It’seasytoswitch!Justcall1.800.835.3784

For more information, visit the Cigna Home Delivery Pharmacy page on myCigna.com.

Save time and money with the convenience of Cigna Home Delivery Pharmacy

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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 of 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 www.informedonreform.com or Cigna.com andlookforthe“InformedonReform”link.

If you have questions Please call the toll-free number on the back of your Cigna ID card. We’re here to help.

NoN-Preferred GeNerics Preferred BraNds BraNds

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ADD/ADHD and Stimulants

amphetamine/ dextroamphetamine dexmethylphenidate methamphetamine methylphenidate/ER/ 24 HR ER

Adderall XR FocalinFocalin XR Intuniv Metadate ER Ritalin LA Ritalin SR Strattera Vyvanse

Adderall (PA, ST)Amphetamine/ Dextroamphetamine XR (PA, ST)Concerta (PA, ST)Daytrana (PA, ST)Desoxyn (PA, ST)Kapvay Metadate CD (PA, ST) Methylin (PA, ST)Nuvigil Provigil Ritalin (PA, ST)

AIDS/HIV

didanosinestavudinezidovudine

AgeneraseAptivusCombivirCrixivanEmtrivaEpivirEpzicomFuzeon (PA)InviraseIsentressKaletraLexivaNorvirPrezistaRescriptorReyatazSelzentrySustivaTrizivirTruvadaViraceptViramune, XRVireadZiagen

AtriplaEdurantIntelenceRetrovirVidexZerit

Allergy

azelastine nasal clemastine fumarate cyproheptadine epinastine epinephrine (inj.) flunisolide nasal fluticasone nasal hydroxyzine

Adrenaclick (QL) AsteproEpipen (QL)Epipen Jr. (QL)NasonexSingulairVeramyst

Atrovent (nasal)Beconase AQ (PA, ST)ClarinexFlonase (PA, ST)Nasacort AQ (PA, ST)Nasarel Omnaris (PA, ST)Patanase

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Alzheimer Disease

donepezilgalantamine hydrobomiderivastigmine (caps)

Aricept 23 mgNamenda

Aricept (5 and 10 mg) Aricept ODT Cognex Exelon Razadyne Razadyne ER

Anxiety

alprazolambuspironelorazepamoxazepam

Lorazepam Intensol

Asthma and Respiratory

albuterol solution (nebulizer solution)albuterol sulfate (syrup, tabs)aminophyllinebudesonidecaffeine citratecromolyn sodium (nebulizer solution)Dylixdyphyllineguaifenesin/dyphyllineguaifenesin/theophyllineipratropium bromide (nebulizer solution)levalbuterol (nebulizer solution)metaproterenol sulfate (syrup, tabs)Myci-Bron Gterbutaline sulfatetheophylline anhydrouszafirlukast

Advair Diskus/HFAAsmanexAtrovent HFACombiventFlovent Diskus/HFAMaxairProAir HFAPulmicortPulmozyme (PA)QvarRevatio (PA)SereventSingulairSpirivaSymbicortVentolin HFAXolair (PA)

AccolateAccuneb nebulizer (PA, ST)Adcirca (PA)AlvescoArcaptaBrovana nebulizer (PA, ST) DalirespDulera ForadilLetairisPerforomist (PA, ST) Proventil HFATracleerVentavisXopenex HFAXopenex nebulizer (PA, ST)

Allergy (Continued)

ipratropium nasal levocetirizine triamcinolone nasal

Rhinocort AQ (PA, ST) Semprex-DXyzal


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Bladder Problems

oxybutynin/XLtrospium chloride

Detrol Detrol LA ElmironOxytrol Toviaz VESIcare

Ditropan (PA, ST)Ditropan XL (PA, ST) Enablex (PA, ST) Gelnique (PA, ST) Sanctura (PA, ST)Sanctura XR (PA, ST)

Cancer

anastrozole bicalutamide exemestane flutamide letrozole tamoxifen citrate

CeeNUGleevec (PA)HexalenLeukeranLupron Depot (PA)LysodrenMatulaneMyleranNexavar (PA)Revlimid (PA)

Afinitor (PA)ArimidexAromasinCaprelsa (PA)CasodexDroxiaFarestonFemaraSylatron (PA)Targretin

Birth Control*

AmeithiaApriAvianeBalzivaCamilaCamreseErrinGianviJolessaJunel FEKarivaLevoraLow-OgestrelMicrogestinNeconNortrelOcellaOgestrelPrevifemQuasenseSoliaSprintecTrinessaTri-SprintecZenchentZovia

BeYazLoestrin 24 FELo Loestrin FELoSeasoniqueNuvaRingOrtho EvraOrtho TriCyclen LoOvcon 50Plan B One-StepSeasoniqueYaz

AngeliqDesogenEllaEstrostep FELevlenLo/Ovral-28LoestrinLoestrin FELybrelNataziaNordetteOrtho-CeptOrtho-Novum 7-7-7Ovcon 35SafyralSeasonaleTri-NorinylTriphasil

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

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Cardiovascular

BLood THiNNer/aNTi-cLoTTiNG

anagrelidecilostazoldipyridamoleenoxaparin (QL)fondaparinux (QL)heparin (QL) ticlopidinewarfarin

AggrenoxArixtra (QL)EffientFragmin (QL)Innohep (QL)Plavix

Agrylin (PA)BrilintaJantovenLovenox (QL)PletalPradaxa (PA)Xarelto (QL)

Cancer (Continued)

Sprycel (PA)Sutent (PA)Tarceva (PA)Temodar (PA)Thalomid (PA)XelodaZolinza (PA)

Tasigna (PA)Tykerb (PA)Votrient (PA)Zelboraf (PA)Zytiga (PA)

HiGH BLood PressUre/HearT MedicaTioNs

acebutolol HCl acetazolamideamiloride HCl amlodipine besylateapresolineatenololbenazepril HCl benazepril HCl/amlodipine benazepril HCl/HCTZbendroflumethiazide/ nadololbetaxolol HCl bisoprolol fumaratebisoprolol/HCTZbumetanidecaptoprilcaptopril/HCTZcarvedilolchlorothiazidechlorthalidonechlorthalidone/atenololclonidineclonidine HCl Clorpresdiltiazemdiltiazem 24 HR ERdoxazosin mesylate

Altace (caps)BystolicCoreg CRDiovan Diovan HCT ExforgeExforge HCTLanoxinMultaqProcanbidTarkaTekturna Tekturna HCTTikosynValturna

Accupril (PA, ST)Accuretic (PA, ST) Aceon (PA, ST)AmturnideAtacand (PA, ST)Avalide (PA, ST)Avapro (PA, ST)AzorBenicar (PA, ST)Benicar HCT (PA, ST)Betapace AFCarduraCardura XLCatapres, Catapres TTSCoregCorgardCovera-HSCozaar (PA, ST)Dynacirc CREdarbi (PA, ST)Hyzaar (PA, ST)Inderal LAInnopran XLLevatolLotensin (PA, ST) Lotensin HCT (PA, ST)Lotrel


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Cardiovascular (Continued)


enalapril maleateenalapril maleate/HCTZeplerenonefelodipinefosinopril sodiumfosinopril sodium/HCTZfurosemideguanabenz acetateguanfacinehydralazine HCl hydralazine/HCTZhydralazine/reserpine/HCTZhydrochlorothiazidehydrochlorothiazide/ amilor HCl hydroflumethiazideindapamideisradipinelabetalol HCl lisinoprillisinopril/HCTZlosartan potassiumlosartan potassium/HCTZmethazolamidemethyldopamethyldopa/HCTZmetolazonemetoprolol succinatemetoprolol tartratemetoprolol/HCTZminoxidilmoexipril HCl moexipril HCl/HCTZnadololnicardipine HCl nifedipinenimodipineperindopril erbuminepindololprazosin HCl propranolol HCl propranolol/HCTZquinaprilquinapril HCl/HCTZramipril (caps only)rauwolfia serpentina/BFMTZreserpinereserpine/HCTZ

Mavik (PA, ST)Micardis (PA, ST)Micardis HCT (PA, ST)Monopril (PA, ST) Monopril HCT (PA, ST)Nexiclon XRNitromistNorpaceNorpace CRNorvascPrinivil (PA, ST)Prinzide (PA, ST)Ranexa (PA)Rythmol SRSularTekamloTeveten (PA, ST)Teveten HCT (PA, ST)Toprol XLTribenzorUniretic (PA, ST) Univasc (PA, ST) Vaseretic (PA, ST) Vasotec (PA, ST) VerelanZestoretic (PA, ST) Zestril (PA, ST)

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Cardiovascular (Continued)


sotalol HCl spironolactonespironolactone/HCTZterazosin HCl timolol maleatetorsemidetrandolapriltrandolapril/verapamil HCl triamterene/HCTZverapamilverapamil SR

Cholesterol Lowering

atorvastatin (12/1/2011)cholestyramine powdercolestipolfenofibratefenofibric acidgemfibrozillovastatinpravastatinsimvastatin

Lescol Lescol XLLovazaNiaspanSimcorTrilipixVytorinWelcholZetia

AdvicorAltoprev (PA, ST)Caduet (1/1/2012)Cholestyramine LightColestidCrestor (PA, ST)FenoglideLipitor (PA, ST) (1/1/2012)Livalo (PA, ST)LofibraMevacor (PA, ST)Pravachol (PA, ST)TriCorZocor (PA, ST)

oTHer

amiodarone digoxin disopyramide flecainide isosorbide dinitrate isosorbide mononitrate nitroglycerin procainamide propafenone SR

Nitrolingual spray


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Depression

amitriptyline bupropion bupropion SR citalopram desipraminefluoxetinefluvoxaminemirtazapinenortriptylineparoxetineparoxetine CRprotriptylinesertralinetrazodonevenlafaxinevenlafaxine XR

Cymbalta Lexapro PristiqWellbutrin XL

Aplenzin (PA, ST) Celexa (PA, ST)Effexor XR (PA, ST) EmsamLuvox CR MarplanPaxil (PA, ST)Paxil CR (PA, ST)Prozac (PA, ST)RemeronSarafem (PA, ST)Selfemra (PA, ST)TofranilViibryd (PA, ST)VivactilWellbutrin (PA, ST)Wellbutrin SR (PA, ST)Zoloft (PA, ST)

Diabetes

acarboseacetohexamidechlorpropamide glimepiride glipizide glipizide/metformin glucagon (QL) glyburide glyburide/metformin glyburide micronized metformin nateglinide tolazamide tolbutamide

ACCU-CHEK Test StripsActoplus metActosApidraApidra SoloStarBD Insulin Syringes/ Pen NeedlesByettaDuetactFortametGlucaGen HypoKit (QL)HumalogHumulinJanumetJanuviaKombiglyze XRLantusLantus SoloStarLevemirNovoFine needlesNovolinNovologOne Touch test stripsOnglyzaPrandimetPrandinSymlinPenVictoza

Amaryl Avandamet Avandaryl Avandia Cycloset Glucophage XR Glycron Glyset Metaglip Precose Starlix Tradjenta

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Endocrine and Metabolic

oTHer

allopurinolcabergoline (QL)desmopressinfluoxymesteroneoctreotide (PA)

ColcrysIncrelex (PA)Lupron Depot-PED (PA)Megace ESNilandronSandostatin LAR (PA)Sandostatin (PA)Somavert (PA)

Egrifta (PA)Somatuline Depot (PA)

Eye Conditions

atropine azelastinebrimonidinebromfenacciprofloxacindiclofenacdorzolamidedorzolamide/timololflurbiprofenketorolaclatanoprostlevobunolollevofloxacinpilocarpinetimololtobramycin/dexamethasonetrifluridine

AlomideAlphagan P 0.10%AzaSiteAzoptBetimolBetoptic SCiloxan (ointment)IopidineLotemaxMaxidexMoxezaPatadayPatanolRestasisTobradex (ointment)Travatan ZVexolVigamox

Acular LSAlamastAlocrilAlrexBepreveBesivance (ST)Ciloxan (drops)CosoptDurezolElestatEmadineIquixLastacaftOptivarTimopticTobradex (drops)Tobradex STTrusoptVoltarenXalatan

Gastrointestinal (Not Heartburn/Ulcer)

balsalazidePEG 3350/potassium/ sodium bicarb/saltPEG 3350/potassium/ sodium bicarb/salt/ sodium sulf

AprisoAsacolAsacol HDCanasaCreonEntocort ECGoLytelyLialdaPentasaUrso/Urso ForteHumira (PA)

AmitizaCimzia (PA)ColazalColyteNuLytelyPancreazeRelistor (PA)Remicade (PA)SucraidZenpep


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Growth Hormones

Humatrope (PA)Saizen (PA)

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

Heartburn/Ulcer

cimetidinefamotidinelansoprazolemetoclopramidemisoprostolnizatidineomeprazoleomeprazole/ sodium bicarbonatepantoprazoleranitidinesucralfate

Dexilant Prevpac

Aciphex (PA, ST) HelidacNexium (PA, ST)Prevacid (PA, ST)Prilosec (PA, ST)Protonix (PA, ST)Zantac EffertabZantac SyrupZegerid (PA, ST)

Hormone Replacement

estradiolestropipateethinyl estradiollevothroidlevothyroxineLevoxylliothyroninemedroxyprogesteronetestosterone cypionate (PA)testosterone enanthate (PA)thyroidUnithroid

AloraAnadrol-50AndrodermAndroGelArmour ThyroidDivigelEnjuviaEstradermMenestPremarinPremphasePremproPrometriumSynthroidTestimVivelle-Dot

ActivellaAxironCenestinCombipatchCytomelDepot Testosterone (PA)FemhrtFemringFortestaPrefestVagifem

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Infections

acycloviramantadineamoxicillinamoxicillin/clavulanateazithromycin (QL)cefaclor ERcefadroxilcefprozilceftriaxone (PA)cefuroxime axetilcephalexinciclopiroxciprofloxacinclarithromycinclindamycindoxycyclineerythromycinfamciclovir fluconazole (QL for 150 mg only) ganciclovirgentamicin sulfategriseofulvinitraconazoleketoconazolemetronidazoleminocyclineminocycline SRmupirocinnitrofurantoinnystatinofloxacinpenicillin v potassiumribavirinrimantadinesulfamethoxazole/ trimethoprimterconazoleterbinafinetetracyclinevalacyclovirvoriconazole

BaracludeCipro HC OticCiprodexEpivir HBVGris-PegHepseraMycostatin (tab)PegIntron (PA)Pegasys (PA)PrimsolTamiflu (QL)Tobi

AugmentinAugmentin ES 600Augmentin XRAveloxBiaxinBiaxin XLCedaxCefzilCipro XRCoartem (QL) CopegusDificid (PA)Ery-TabFamvir Flagyl ERFloxin OticGaramycinInfergen (PA)KeflexKeftabLamisil (QL)LevaquinMalarone (PA) MonurolMoxatagNoxafilOmnicefPenlac (PA) PriftinRebetolRelenza (QL)Rocephin (PA) SolodynSporanox (QL) SupraxTyzekaValtrexVfend (PA)Zithromax (QL)Zyvox (PA)


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Osteoporosis

alendronate(Fortical) calcitonin-salmon

BonivaEvista ForteoMiacalcin

Actonel (PA, ST) Atelvia (PA, ST) Fosamax (PA, ST) Fosamax Plus D (PA, ST) Skelid (PA, ST)

Nausea and Vomiting

dronabinolgranisetron (inj.) (PA)granisetron (tabs, sol) (QL)ondansetron (inj.) (PA)ondansetron (tabs, sol) (QL)prochlorperazinepromethazinetrimethobenzamide

Emend (QL) Anzemet (inj) (PA)Anzemet (tab) (QL)Kytril (inj) (PA)Kytril ((tabs, sol) (QL)MarinolSancuso (QL)ScopaceZofran (inj) (PA)Zofran (tabs, sol) (QL)Zuplenz (QL, ST)

Migraine

acetaminophen/caffeine/ butalbital naratriptan (QL) sumatriptan (QL)

Maxalt (QL)Maxalt MLT (QL)Treximet (QL)

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

Multiple Sclerosis

Ampyra (PA)Avonex (PA)Copaxone (PA)Rebif (PA)

Betaseron (PA)Extavia (PA)Gilenya (PA)

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Pain Relief and Inflammatory Disease

buprenorphinebutorphanol nasal (QL)codeine phos/carisoprodol/ asacodeine phosphatecodeine phosphate/aspirincodeine sulfatediclofenacdihy-cod tt/apap/caffeineetodolacfenoprofenfentanyl transdermal (QL) fentanyl citrate (lozenge on stick) (QL)flurbiprofenhydrocodone/ acetaminophenhydrocodone bitartrate/ apaphydrocodone bitartrate/ aspirinhydromorphone HClibuprofenibuprofen/hydrocod bitindomethacinketoprofenketorolac (PA, QL)leflunamidelevorphanol tartratemeclofenamatemefenamic acidmeloxicammeperidine HClmethotrexatemorphine SRmorphine sulfatenabumetonenaproxenopiumopium/belladonna alkaloidsoxaprozinoxycodone HCloxycodone HCl/ acetaminophenoxycodone/aspirinoxymorphonepentazocine HCl/ acetaminophenpentazocine HCl/ naloxone HCl

Actimmune (PA)AvinzaCelebrexDilaudid-5 DipentumEnbrel (PA)Humira (PA)Indocin (suppository)KadianLidodermLyrica Nucynta (PA, ST)OxyContin (QL)Ponstel RheumatrexRoxicet (PA, ST)SavellaSkelaxinTrexallVimovo

Abstral (PA)Actiq (PA)Arthrotec (PA, ST)Butrans (QL)Cambia (PA, ST)Cimzia (PA)Demerol (PA, ST) Dilaudid (PA, ST)Duragesic (QL)Exalgo (QL)Fentora (PA) Flector (PA, ST)Horizant (ST)Hycet (PA, ST) Kineret (PA)Lorcet (PA, ST) Lorcet Plus (PA, ST) Lortab (PA, ST) Magnacet (PA, ST) Maxidone (PA, ST) Mobic (PA, ST)Nalfon (PA, ST)Naprelan (PA, ST)Norco (PA, ST) Onsolis (PA)OpanaOpana ERPanlor SS (PA, ST) Pennsaid (PA, ST)Percocet (PA, ST) Percodan (PA, ST) Primalev (PA, ST) Remicade (PA)Roxicodone (PA, ST) Ryzolt (PA, ST) Simponi (PA)Sprix (QL)Synalgos-DC (PA, ST) Tylox (PA, ST) Ultracet (PA, ST) Ultram (PA, ST) Ultram ER (PA, ST) Vicodin (PA, ST) Vicodin ES (PA, ST) Vicodin HP (PA, ST) Vicoprofen (PA, ST) Voltaren (PA, ST)


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Pain Relief and Inflammatory Disease (Continued)

sulindactramadol HCl/ERtramadol HCl/acetaminophentolmetin

Voltaren Gel (PA, ST)Voltaren XR (PA, ST) Xodol (PA, ST) Xolox (PA, ST) Zamicet (PA, ST) Zolvit (PA, ST) Zydone (PA, ST)

Prostate

alfuzosindoxazosinfinasterideleuprolide acetate (PA)prazosintamsulosinterazosin

AvodartJalyn

Firmagon (PA) FlomaxProscarRapafloUroxatralZoladex (PA)Zytiga (PA)

Parkinson Disease

amantadinebenztropinebromocriptinecarbidopa/levodopacarbidopa/levodopa SApramipexoleropiniroleselegiline

AzilectRequipRequip XLApokyn (PA)

ComtanEldeprylLodosynMirapexMirapex ERStalevoTasmarZelapar

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Schizophrenia

clozapinehaloperidolloxapineolanzapinerisperidonethiothixene

SeroquelSeroquel XR

Abilify (PA, ST) Abilify Discmelt (PA, ST) Clozaril (PA, ST) Fanapt (PA, ST) Fazaclo (PA, ST) Geodon (PA, ST) Invega (PA, ST) Latuda (PA, ST) MobanOrapRisperdal (PA, ST) Saphris (PA, ST) Zyprexa (PA, ST)

Seizure

carbamazepineclonazepamdiazepamdivalproexgabapentinlamotriginelevetiracetamtopiramatevalproatezonisamide

CelontinDiastatDiastat AcudialFelbatolGabitrilKeppraLamictalLyricaPeganone

BanzelCarbatrolDepakote (all forms)Keppra XRNeurontinStavzorTegretol XRTopamaxTrileptalVimpatZonegran

Sexual Dysfunction

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

Caverject (PA, QL)Cialis (PA, QL)Edex (PA, QL)Levitra (PA, QL)Staxyn (PA, QL)


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Skin Conditions

adapalene (AGE)alclometasone dipropionateamcinonideAmnesteem (QL)Apexicon E (diflorasone diacetate)betamethasonebetamethasone dipropionatebetamethasone dipropionate/propylene glycolbetamethasone valeratecalcipotrieneclobetasol propionateclobetasol propionate/emolldesonidedesoximetasonediflorasone diacetatefluocinolone acetonidefluocinonide/emollientfluorouracil topicalfluticasone propionatehalobetasol prop/ ammonium lachalobetasol propionatehydrocortisonehydrocortisone acetate/ alo verhydrocortisone acetate/ureahydrocortisone butyratehydrocortisone valerateimiquimodisotretinoin (QL)metronidazolemometasone furoatepodofiloxprednicarbateSotret (QL)sulfacetamidetretinoin (AGE)triamcinolone acetonide

BenzaclinBenzamycin PakCapex Shampoo (PA, ST)CaracCarmol 40Carmol HC (PA, ST)Carmol scalpCloderm (PA, ST)Cordran (PA, ST)Cordran SP (PA, ST)Derma-Smoothe/FS (PA, ST)Differin (AGE)Dovonex creamDuacEnbrel (PA)ExeldermFluoroplexFuracinHumira (PA)Kenalog spray (PA, ST)KlaronLocoid (lotion) (PA, ST)Locoid Lipocream (PA, ST)Loprox shampooMetrogel 1%NoritateNucort (PA, ST)OraceaRetin-A Micro (AGE)Soriatane TazoracTexacort (PA, ST)

AcanyaAclovate (PA, ST) AldaraApexicon (PA, ST)AphthasolAtralin (AGE)Benzefoam Clindacin PacClobex (PA, ST) CondyloxCutivate (PA, ST) DelosDermatop (PA, ST) Desonate (PA, ST) Desowen (PA, ST) Diprolene (PA, ST) Diprolene AF (PA, ST) Elidel (PA, ST) Elocon (PA, ST) Epiduo (AGE)First Hydrocort (PA, ST) Halog (PA, ST) Luxiq (PA, ST) MetrolotionMomexin (PA, ST) Nuzon (PA, ST)Olux (PA, ST) Olux-e (PA, ST) Pandel (PA, ST) Panretin (PA)Pediaderm HC (PA, ST) Protopic (PA, ST) Regranex (PA) Remicade (PA)RosulaScalacort DK Stelara (PA)TaclonexTargretin gelTemovate (PA, ST) Topicort (PA, ST) Topicort LP (PA, ST) Ultravate (PA, ST) Ultravate PAC (PA, ST) Vanos (PA, ST) VecticalVerdeso (PA, ST)

20


21

Sleep

zaleplon zolpidem zolpidem ER

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

Skin Conditions (Continued)

Westcort (PA, ST) XolegelXolegel CorepakZianaZyclara (ST)

Vitamins*

calcitriolcyanocobalaminfolic acid

*All plans cover all generic prescription prenatal vitamins, even though not listed here.

CitranatalDuetDuet DHADuet DHA EC StuartnatalDuet DHA StuartnatalDuet StuartnatalFoltabs Prenatal Plus DGesticareGesticare DHANatachewNatafortNeevoOB CompleteOB Complete DHAPrecarePrecare ConceivePrecare PremierPreferaOBPrenatal VitaminStuart PrenatalStuartnatal PlusStuartnatal Plus 3Tricare DHAViva DHA

Transplant

azathioprine cyclosporine mycophenolate moefetil tacrolimus

AzasanCellceptNeoralPrografRapamuneSandimmune

ImuranMyforticZortress


2012

Cig

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riptio

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22

Miscellaneous

aminocaproic acidcyclobenzaprineleucovorinlevocarnitinelindanemegestrolmethocarbamolnaltrexone (QL)pentoxifyllinepramoxine/hydrocortisonetizanidine

Analpram Advanced Analpram HC Analpram-E Anamantle HC Forte Aranesp (PA) Epogen (PA)Follistim AQ* (PA) FosrenolPhoslyra Pramosone Procrit (PA) Proctofoam-HC RenvelaRilutekTussiCaps Tussionex Uloric Zavesca (PA) Zemplar

* Please check your enrollment materials to determine whether this medication is covered under your plan.

Arcalyst (PA)CortifoamCuvposaEpifoamIlaris (PA)Kuvan NatrobaNimotopNuedextaPhosloPromacta (PA)RenagelUlesfiaZanaflexZutripro

22 23

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

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

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

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

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

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

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

7. Any contraceptive medications and prescription appliances for contraception.

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

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

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

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

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

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

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

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

17. Medications used to enhance athletic performance.

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

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

“Cigna” is a registered service mark, and the “Tree of Life” logo and ”Cigna Home Delivery Pharmacy” 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 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.

595200 m 09/11 © 2011 Cigna

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 prescriber or pharmacist. Cigna may receive payments from manufacturers of certain Preferred Brand medications, and in limited instances, certain Non-Preferred Brand medications, that may or may not be shared with your plan depending on its arrangement with Cigna. Depending upon plan design, market conditions, the extent to which manufacturer payments are shared with your plan, and other factors as of the date of service, the Preferred Brand medication may or may not represent the lowest-cost brand medication within its class for you and/or your plan.

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