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853379 02/12 Value PDL
Four-Tier Plan
2012 Cignaprescription drug list
This list is designed to cover your prescription medications at four levels. The amount you will pay will depend on the tier from which you and your doctor select your medication. If there is more than one drug appropriate for your condition, we encourage you to talk to your doctor about low cost medications like generics and preferred brands, as they will help to manage your prescription costs better.
Rocky Mountain UFCW Union & Employers Health Benefit Plan
2 3
1st Tier – Generic Medications: Generic drugs have the same active ingredients, safety, dosage, quality and strength, as their brand-name counterparts. You will usually pay less for generic medications under your plan.
2nd Tier – Preferred Brand Medications: Preferred brand drugs will usually cost you more than a generic, but less than a non-preferred brand drug under your plan.
3rd Tier – Non-Preferred Brand Medications: Non-preferred brand drugs are those that generally have generic alternatives and/or one or more preferred brand options within the same drug class. You will usually pay more for a non-preferred brand under your plan.
4th Tier – Specialty Medications: Specialty Injectable Medications are typically covered under the fourth tier and include, but are not limited to, injectables used to treat arthritis, multiple sclerosis, hepatitis C, and asthma. See the list of Specialty medications on page 22.
Understanding the Cigna Prescription Drug ListEvery medication available on the drug list has been approved by the U.S. Food and Drug Administration (FDA). This list represents the most commonly prescribed medications. Please reference Cigna.com or myCigna.com for the complete up-to-date listing of medications. Refer to your enrollment information to find out which specific medications are covered under your plan.
The symbols on the list mean …If your medication has one of the following symbols, your doctor may have to get an authorization for coverage.
PA: Prior Authorization may be required for different reasons. To learn the requirements needed for coverage of a specific medication, please give us a call.
QL: Quantity Limit means you may have coverage for a limited amount of a specific medication.
AGE: Age Requirement means a person may be within a specific age group for a specific medication to be covered.
ST: Step Therapy is a prior authorization program that requires you to try other medications available to treat the same condition before the “ST” medication is covered.
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Important NoteThis list does not cover drugs that have over-the-counter (OTC) alternatives, drugs that treat stomach acid conditions and non-sedating antihistamines to treat allergies.
In some cases medications for certain conditions (allergies, heartburn/ulcers, etc.) may be equivalent products to OTC medications available. In these cases, the prescription available class alternatives are excluded from coverage. Examples* include allergy medications such as Allegra, Clarinex, Xyzal and any generics; and heartburn/ulcer medications such as Nexium, Prilosec, Zantac and any generics. (*Examples not all-inclusive listing).
Help From myCigna.comWhen you go to myCigna.com you can:
• Compareactualmedicationpricesatlocalpharmacies
• Seeyourspecificpharmacycoverageinformation
• Researchavailablemedications and network pharmacies
• Ask a pharmacist questions
If You Have Any QuestionsFeel free to give us a call at the number on the back of your ID Card. We’re here to help.
NoN-Preferred GeNericS Preferred BraNdS BraNdS2012
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add/adHd aNd STiMULaNTS
amphetamine/ dextroamphetaminedexmethylphenidatemethamphetaminemethylphenidate/ER
Adderall (PA, ST)Adderall XR (PA, ST)Amphetamine Dextroamphetamine Extended-Release (PA, ST)Concerta (PA, ST)Daytrana (PA, ST)DesoxynFocalin XR (PA, ST)IntunivKapvay Metadate CD (PA, ST)Metadate ER (PA, ST)NuvigilProvigilRitalin LA (PA, ST)StratteraVyvanse (PA, ST)
aidS/HiV
didanosinestavudinezidovudine
AgeneraseAptivusAtriplaCombivirCrixivanEmtrivaEpivirEpzicomIntelenceInviraseIsentressKaletraLexivaNorvirPrezistaRescriptorReyatazSelzentrySustivaTrizivirTruvadaViraceptViramuneVireadZiagen
RetrovirVidexZerit
4 5
NoN-Preferred GeNericS Preferred BraNdS BraNdS
aSTHMa aNd reSPiraTorY
albuterol solutioncromolynipratropium solutionlevalbuterol solutionmetaproterenol
Atrovent HFAForadilProAir HFAQvarSingulair
AccolateAccuneb nebulizer (PA, ST)Advair, Advair HFAAlvescoAsmanexAzmacortBrovana nebulizer (PA, ST)CombiventDuleraFlovent, Flovent HFAMaxairPerforomist (PA, ST)Proventil HFAPulmicortSereventSpirivaSymbicortVentolin HFAXopenex HFAXopenex nebulizer (PA, ST)
aLZHeiMer’S diSeaSe
donepezilgalantaminerivastigmine
AriceptAricept ODTCognexExelonNamendaRazadyneRazadyne ER
aLLerGY*
clemastinecyproheptadineepinephrine inj (QL)flunisolide nasalfluticasone nasalhydroxyzine
AsteproEpipen (QL)Singulair
Astelin Adrenaclick (QL)Beconase AQ (PA, ST)Flonase (PA, ST)Nasacort AQ (PA, ST)Nasarel (PA, ST)Nasonex (PA, ST)Omnaris (PA, ST)PatanaseRhinocort AQ (PA, ST)Semprex-DVeramyst (PA, ST)
* Medications for allergies equivalent to over-the-counter medications within the class are excluded such as Allegra, fexofenadine, Clarinex, etc.
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BirTH coNTroL*
ApriAvianeBalzivaCamilaErrinGianviJolessaJunel FEKarivaLevoraLo-ogestrelMicrogestinNeconNortrelOcellaOgestrelQuasenseSoliaSprintecTrinessaTri-SprintecZenchantZovia
AngeliqDesogenEllaEstrostep FELevlenLo/Ovral-28LoestrinLoestrin 24 FELoestrin FELo Loestrin FELoseasoniqueLybrelNataziaNordetteNuvaringOrtho EvraOrtho Tri-Cyclen LOOrtho-CeptOrtho-Novum 7-7-7Ovcon 35Ovcon 50OvrettePlan BPlan B One-StepSeasonaleSeasoniqueTrilevlenTri-NorinylTriphasilYaz
* Please check your enrollment materials to determine whether these medications are covered under your specific plan.
BLadder ProBLeMS
Oxybutynin/XLTrospium chloride
Detrol (PA, ST)Detrol LA (PA, ST)Ditropan, Ditropan XL (PA, ST)ElmironEnablex (PA, ST)Gelnique (PA, ST)Oxytrol (PA, ST)Sanctura, Sanctura XR (PA, ST)Toviaz (PA, ST)VESIcare (PA, ST)
6 7
NoN-Preferred GeNericS Preferred BraNdS BraNdS
caNcer
anastrozolebicalutamidetamoxifen citrate
Afinitor (PA)AromasinFarestonFemaraGleevec (PA)Iressa (PA)Lupron (PA)Nexavar (PA)Revlimid (PA)SoltamoxSprycel (PA)Sutent (PA)Tarceva (PA)TargretinTasigna (PA)Temodar (PA)Thalomid (PA)Tykerb (PA)Votrient (PA)XelodaZolinza (PA)
ArimidexCasodex
cardioVaScULarBLood THiNNer/aNTi-cLoTTiNG
enoxaprin (QL)heparin (QL)ticlopidinewarfarin
Arixtra (QL)Lovenox (QL)
AggrenoxAgrylin (PA)EffientFragmin (QL)Innohep (QL)PlavixPletalPradaxa (PA)
NoN-Preferred GeNericS Preferred BraNdS BraNdS2012
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8 9
cardioVaScULar
HiGH BLood PreSSUre/HearT MedicaTioNS
amlodipineatenololbenazeprilbenazepril/amlodipinebenazepril/HCTZbisoprolol/HCTZcaptoprilcarvediloldigoxindiltiazemdiltiazem CDdisopyramidedoxazosinenalaprilenalapril/HCTZfelodipinefosinoprilhydralazine/HCTZisosorbide dinitrateisosorbide mononitratelabetalollisinoprillosartanlosartan/HCTZmethyldopa/HCTZmetoprololnadololnifedipinenisoldipine (Sustained release)prazosinprocainamidepropranololquinaprilquinapril/HCTZquinidineramipril (cap only)sotalolterazosintimololtrandolapriltrandolapril/verapamilverapamilverapamil SR
Benicar (PA, ST)Benicar HCT (PA, ST)
Accupril (PA, ST)Accuretic (PA, ST)Aceon (PA, ST)Altace (caps)(PA, ST)Altace (tabs)(PA, ST)Atacand (PA, ST)Avalide (PA, ST)Avapro (PA, ST)AzorBetapace AFBystolicCapoten (PA, ST)CarduraCardura XLCatapres, Catapres TTSCoregCoreg CRCorgardCovera-HSCozaar (PA, ST)Diovan HCT (PA, ST)Diovan (PA, ST)Dynacirc CRExforgeExforge HCTHyzaar (PA, ST)Inderal LAInnopran XLLanoxinLevatolLotensin HCT (PA, ST)Lotensin (PA, ST)LotrelMavik (PA, ST)Micardis HCT (PA, ST)Micardis (PA, ST)MinizideMonopril HCT (PA, ST)Monopril (PA, ST)MultaqNorpaceNorpace CRNorvasc
8 9
NoN-Preferred GeNericS Preferred BraNdS BraNdS
cardioVaScULar (CONTINUED)
HiGH BLood PreSSUre/HearT MedicaTioNS
Prinivil (PA, ST)Prinzide (PA, ST)ProcanbidRanexa (PA)SularTarkaTekamloTekturna HCT (PA, ST)Tekturna (PA, ST)Teveten HCT (PA, ST)Teveten (PA, ST)TikosynToprol XLUniretic (PA, ST)Univasc (PA, ST)Valturna (PA, ST)Vaseretic (PA, ST)Vasotec (PA, ST)VerelanZestoretic (PA, ST)Zestril (PA, ST)
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cHoLeSTeroL LoWeriNG
cholestyramine powderfenofibrategemfibrozillovastatinpravastatinsimvastatin
VytorinWelcholZetia
AdvicorAltoprev (PA, ST)CaduetCrestor (PA, ST)FenoglideLescolLescol XLLipitor (PA, ST)Livalo (PA, ST)LofibraLovazaMevacor (PA, ST)NiaspanPravachol (PA, ST)SimcorTriCorTrilipixZocor (PA, ST)
dePreSSioN
amitriptylinebupropionbupropion SRcitalopramdesipraminefluoxetinefluvoxaminemirtazapinenortriptylineparoxetineparoxetine CRprotriptylinesertralinetrazodonevenlafaxinevenlafaxine XR
Aplenzin (PA, ST)Celexa (PA, ST)Cymbalta (PA, ST)Effexor XR (PA, ST)EmsamLexapro (PA, ST)Luvox CR MarplanPaxil CR (PA, ST)Pristiq (PA, ST)Prozac (PA, ST)RemeronTofranilVivactilWellbutrin XL (PA, ST)Zoloft (PA, ST)
10 11
NoN-Preferred GeNericS Preferred BraNdS BraNdS
diaBeTeS
acarboseacetohexamidechlorpropamideglimepirideglipizideglipizide/metforminglucagon (QL)glyburideglyburide/metforminglyburide micronizedmetforminnateglinidetolazamidetolbutamide
ACCU-CHEK Test StripsActosBD Insulin SyringeByettaGlucagen HypokitJanuviaLantusNovoFine needlesNovolinNovologOne Touch test strips
Actoplus metAmarylApidraApidra SoloStarAvandametAvandarylAvandiaDuetactFortametGlucophage XRGlycronGlysetHumalogHumulinJanumetKombiglyze XRLantus SoloStarLevemirMetaglipOnglyzaPrandimetPrandinPrecoseStarlixSymlin/SymlinPen
eNdocriNe aNd MeTaBoLic – oTHer
allopurinolcabergoline (QL)desmopressin
Megace ES Synarel (PA) Uloric
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GaSTroiNTeSTiNaL (NoT HearTBUrN/ULcer)
amylase/lipase/proteasebalsalazide
AsacolAsacol HDLialdaPentasa
AprisoCanasaColazalEntocort ECSucraid
eYe coNdiTioNS
ciprofloxacindiclofenacdorzolamidedorzolamide/timolollevobunololpilocarpinepilocarpine/epinephrinetimololtobramycin/dexamethasone
Xalatan Acular LSAlamastAlocrilAlomideAlphagan PAlrexAzaSiteAzoptBesivance (ST)BetimolBetoptic SCiloxan CosoptDurezolEmadineIopidineIquixLotemaxPatadayPatanolRestasisTimopticTobradex Travatan ZTrusoptVexolVigamoxVoltaren
12 13
NoN-Preferred GeNericS Preferred BraNdS BraNdS
HearTBUrN/ULcer*
metoclopramidemisoprostolsucralfate
*Medications for heartburn and ulcer equivalent to over-the-counter medications within the class are excluded such as omeprazole, Nexium, Zantac, etc.
HorMoNe rePLaceMeNT
estradiolestropipatelevothroidlevothyroxinelevoxylliothyroninemedroxyprogesteronethyroidUnithroid
Premarin ActivellaAloraAnadrol-50AndrodermAndrogelArmour ThyroidCenestinCombipatchCytomelEnjuviaEstradermFemhrtFemringFortestaMenestPrefestPremphasePremproPrometriumSynthroidTestimVagifemVivelle-Dot
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iNfecTioNS
acycloviramantadineamoxicillinamoxicillin/clavulanateazithromycin (QL)cefaclor ERcefadroxilcefprozilcefuroximecephalexinciprofloxacinclarithromycinclindamycindoxycyclineerythromycinfluconazole (QL: 150 mg only)griseofulvinitraconazole (QL)metronidazoleminocyclinenitrofurantoinnystatinofloxacinpenicillin v potassiumrimantadineSMX/TMPterfenabine (QL)tetracycline
BaracludeEpivir HBVTamiflu (QL)
AugmentinAugmentin ES 600Augmentin XRAveloxBiaxinBiaxin XLCedaxCefzilCipro HC OticCipro XRCiprodexCoartem (QL)CopegusFamvirFlagyl ERFloxin OticGris-PegHepseraKeflexKeftabLamisil (QL)Lariam (PA, QL)LevaquinMalarone (PA, QL)MonurolMoxatagMycostatin (tab)NoxafilOmnicefPenlac (PA)PriftinPrimsolRelenza (QL)SolodynSporanox (QL)SupraxTobiTyzekaValtrexVfend (PA)Zithromax (QL)Zyvox (PA)
14 15
NoN-Preferred GeNericS Preferred BraNdS BraNdS
oSTeoPoroSiS
alendronatecalcitonin-salmonFortical
Actonel (PA, ST)Atelvia (PA, ST)Boniva (PA, ST)Evista (PA, ST)Forteo (PA, ST)Fosamax (PA, ST)Fosamax Plus D (PA, ST)MiacalcinSkelid (PA, ST)
NaUSea aNd VoMiTiNG
dronabinolgranisetron (tab, solu) (QL)ondansetron (QL)prochlorperazinepromethazinetrimethobenzamide
Anzemet (tab)(QL)Emend (QL)Kytril (tab, solu)(QL)MarinolScopaceZofran (tab, solu)(QL)Zuplenz (QL)
MiGraiNe
acetaminophen/ caffeine/butalbitalnaratriptan (QL)sumatriptan (QL)
Zomig/Zomig ZMT (QL) Amerge (QL)Axert (QL)DHE 45 (QL)Frova (QL)Imitrex (QL)MaxaltMaxalt MLTMigranal (QL)Relpax (QL)Treximet (QL)
MULTiPLe ScLeroSiS
Ampyra (PA)Gilenya (PA)
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PaiN reLief aNd iNfLaMMaTorY diSeaSe
butorphanol nasal (QL)codeine phos/carisoprodol/ asacodeine phosphatecodeine phosphate/aspirincodeine sulfatediclofenacdihy-cod tt/apap/caffeineetodolacfentanyl (QL) fentanyl citrate (lollipop)(PA)hydrocodone/ acetaminophenhydrocodone bitartrate/ apaphydrocodone bitartrate/ aspirinhydromorphone hclibuprofenibuprofen/hydrocod bitindomethacinketorolac (PA, QL)leflunamide (PA)levorphanol tartratemeloxicammeperidine hclmethotrexatemorphine SRmorphine sulfate(Roxanol) morphine sulfatenabumetonenaproxenopiumopium/belladonna alkaloidsoxaprozinoxycodone hcloxycodone hcl/ acetaminophenoxycodone/aspirinpentazocine hcl acetaminophenpentazocine hcl/ naloxone hclpiroxicamtramadol hcl/ERtramadol hcl/ acetaminophen
Arava (PA)CelebrexNalfonRheumatrexTrexall
Actiq (PA)ArthrotecAvinzaBand O Supprettes (PA, ST)Butrans (QL)Demerol (PA, ST)Dilaudid (PA, ST)DipentumDuragesic (QL)Fentora (PA)Hycet (PA, ST)Indocin (suppository)KadianKineret (PA)LidodermLorcet (PA, ST)Lorcet Plus (PA, ST)Lortab (PA, ST)Magnacet (PA, ST)Maxidone (PA, ST)MobicMSIRMSIR (PA, ST)NaprelanNorco (PA, ST)Nucynta (PA, ST)OxyContin (QL)Panlor SS (PA, ST)Percocet (PA, ST)Percodan (PA, ST)Primalev (PA, ST)Roxicet (PA, ST)Roxicodone (PA, ST)Ryzolt (PA, ST)SavellaSimponi (PA)SkelaxinSynalgos-DC (PA, ST)Talwin Compound (PA, ST)Tylox (PA, ST)Ultracet (PA, ST) Ultram (PA,ST)Ultram ER (PA,ST)Vicodin (PA,ST)Vicodin ES (PA,ST)
16 17
NoN-Preferred GeNericS Preferred BraNdS BraNdS
ParKiNSoN’S diSeaSe
amantadinebromocriptinecarbidopa/levodopacarbidopa/levodopa SAropiniroleselegilinepramipexole
AzilectComtanLodosynStalevoTasmar
EldeprylMirapexRequipRequip XLZelapar
PaiN reLief aNd iNfLaMMaTorY diSeaSe (CONTINUED)
Vicodin HP (PA,ST)Vicoprofen (PA,ST)VoltarenVoltaren XRXodol (PA,ST)Xolox (PA,ST)Zamicet (PA,ST)Zolvit (PA,ST)Zydone (PA,ST)
ProSTaTe
doxazosinfinasterideprazosintamsulosinterazosin
AvodartFlomaxJalynProscar (AGE)RapafloUroxatral
NoN-Preferred GeNericS Preferred BraNdS BraNdS2012
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18 19
ScHiZoPHreNia
clozapinehaloperidolloxapinerisperidonethiothixene
SeroquelZyprexa
AbilifyAbilify DiscmeltClozarilFanaptFazacloGeodonInvegaLatudaMobanOrapRisperdalSaphrisSeroquel XR
SeiZUre
carbamazepineclonazepamdivalproexgabapentinlevetiracetamtopiramatevalproate
DiastatDiastat AcudialDilantinGabitrilKeppraKeppra XRLamictal (all forms)
BanzelCarbatrolDepakote (all forms)Lyrica (PA, ST) NeurontinStavzorTegretol XRTopamaxTrileptalVimpatZonegran
18 19
NoN-Preferred GeNericS Preferred BraNdS BraNdS
SKiN coNdiTioNS
adapalene (AGE)alclometasonealclometasone dipropionateamcinonideApexicon E (diflorasone diacetate)betamethasonebetamethasone dipropionatebetamethasone dipropionate/ propylene glycolbetamethasone valeratecalcipotrieneclobetasolclobetasol propionateclobetasol propionate/emolldesonidedesoximetasonediflorasonediflorasone diacetatefluocinolonefluocinolone acetonidefluocinonide/emollientfluticasone propionatehalobetasol prop/ammonium lachalobetasol propionatehydrocortisonehydrocortisone acetate/alo verhydrocortisone acetate/ ure(tp)hydrocortisone butyratehydrocortisone valerateimiquimodisotretinoin (QL)metronidazolemometasone furoateprednicarbateSotret (QL)sulfacetamidetretinoin (AGE)triamcinolone acetonide
CaracFluroplexTargretin gel
Aclovate (PA, ST)AldaraAphthasolAquaphilic W/Tac + Carbamide (PA, ST)Aquaphilic W/ Triamcinolone (PA, ST)Aristocort A (PA, ST) Atralin (AGE)BenzaclinBenzamycinPakCapex Shampoo (PA, ST)Carmol HC (PA, ST)Clobex (PA, ST)Cloderm (PA, ST)CondyloxCoraz (PA, ST)Cordran (PA, ST)Cordran SP (PA, ST)Cutivate (PA, ST)Derma-Smoothe/FS (PA, ST)Dermatop (PA, ST)Desonate (PA, ST)Desowen (PA, ST)Differin (AGE)Diprolene (PA, ST)Diprolene AF (PA, ST)Diprosone (PA, ST)Dovonex Duac CSElidel (PA, ST)Elocon (PA, ST)Epiduo (AGE)ExeldermFirst Hydrocort (PA, ST)Halog (PA, ST)Kenalog (PA, ST)KlaronLacticare-HC (PA, ST)Lidex (PA, ST)Locoid (PA, ST)Locoid Lipocream (PA, ST)Loprox shampooLuxiq (PA, ST)MetrogelMetrolotion
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SKiN coNdiTioNS (CONTINUED)
Momexin (PA, ST)NoritateNucort (PA, ST)Nuzon (PA, ST)Olux (PA, ST)Olux-e (PA, ST)OraceaOvace PlusPandel (PA, ST)Panretin (PA)Pediaderm HC (PA, ST)Protopic (PA, ST)Psorcon (PA, ST)Psorcon E (PA, ST)Regranex (PA)Retin-A Micro (AGE)RosulaScalacort DK (PA, ST)Soriatane CKSynemol (PA, ST) TaclonexTazoracTemovate (PA, ST)Texacort (PA, ST)Topicort (PA, ST)Topicort LP (PA, ST)Tridesilon (PA, ST)Ultravate PAC (PA, ST)Ultravate (PA, ST)Valisone (PA, ST)Vanos (PA, ST)VecticalVerdeso (PA, ST)Westcort (PA, ST)XolegelXolegel CorepakZianaZyclaraZytopic (PA, ST)
20 21
NoN-Preferred GeNericS Preferred BraNdS BraNdS
TraNSPLaNT
azathioprinecyclosporinemycophenolate moefetiltacrolimus
MyforticSandimmuneRapamunePrografCellcept
NeoralZortress
MiSceLLaNeoUS
calcitriolfolic acidleucovorinnaltrexone (QL)tizanidine
CortifoamEpifoamRevatio (PA)
FosrenolNimotopPhosloPulmozyme (PA)RenvelaSuboxoneTussiCapsTussionexZanaflexZemplar
SLeeP
zaleplonzolpidem
Ambien CR (PA, ST)Edluar (PA, ST)Lunesta (PA, ST)Rozerem (PA, ST)Silenor (PA, ST)Zolpimist (PA, ST)
Spec
ialty
Inje
ctab
le D
rugs Actimmune
Anzemet – injectionApokynAranespArcalystAvonexBetaseronCeftriaxoneCimziaCopaxoneDelatestrylDepo-TestosteroneEmend – injectionEnbrelEgriftaEpogenExtaviaFirmagonFuzeonGaramycinGenotropinGold Sodium ThiomalateGranisetron – injectionHumatropeHumiraIlarisIncrelexInfergenIntron AKetorolac Tromethamine – injectionKineretKytril – injectionLeukineLeuprolide AcetateLupron, Lupron DepotMyochrysineNebcin
NeulastaNeumegaNeupogenNorditropinNorditropin NordiflexNutropinNutropin AQOctreotide AcetateOmnitropeOndansetron – injectionPegasysPeg IntronPeg Intron RedipenProcritProleukinRebifRelistor RemicadeRocephinSaizenSandostatinSerostimSimponiSomatuline DepotSomavertStelaraTestosterone – injectionTev-TropinTobramycin SulfateToradol – injectionXolairZofran – injectionZoladexZorbtive
SPeciaLTY iNjecTaBLe drUGS (aLL reqUire Prior aUTHoriZaTioN)
22
excLUSioNS & LiMiTaTioNS Plans typically do not provide coverage for the following, except as required by law or by the terms of your specific plan:
1. Any medications available over the counter that do not require a prescription by Federal or State Law, and any medication that is a pharmaceutical alternative to an over the counter medication other than insulin. [examples include OTC Benadryl, Maalox, Sudafed PE , etc.]
2. Medications that are therapeutically equivalent as determined by the Cigna HealthCare Pharmacy and Therapeutics Committee in which at least one of the medications within the class is available over the counter. [examples include Rx equivalents to OTC Allegra, Claritin and Zyrtec (Allegra D, Clarinex, Xyzal) and Rx equivalents to OTC Prevacid, Prilosec, Zantac (Aciphex, Kapidex, Nexium, Axid, Pepcid, Zantac)]
3. Any injectable infertility medications, and any injectable medications that require Health Care Professional supervision and are not typically considered self-administered medications. The following are examples of Health Care Professional-supervised medications: Injectables used to treat hemophilia and RSV (respiratory syncytial virus), chemotherapy injectables, and endocrine and metabolic agents.
4. Any medications that are experimental or investigational, within the meaning set forth in the summary plan description.
5. Food and Drug Administration (FDA)-approved medications used for purposes other than those approved by the FDA unless the medication is recognized for the treatment of the particular indication in one of the standard reference compendia (The United States Pharmacopoeia Drug Information or The American Hospital Formulary Service Drug Information) or in medical literature. Medical literature means scientific studies published in a peer-reviewed national professional medical journal.
6. Any prescription and non-prescription supplies (such as ostomy supplies), devices, and appliances.
7. Any contraceptive medications and prescription appliances for contraception.
8. Implantable contraceptive products. 9. Any fertility medication. 10. Any medications used for treatment of
sexual dysfunction, including but not limited to erectile dysfunction, delayed ejaculation, anorgasmia and decreased libido.
11. Any prescription vitamins (other than prenatal vitamins), dietary supplements and fluoride products.
12. Medications used for cosmetic purposes, such as medications used to reduce wrinkles, medications to promote hair growth, medications used to control perspiration and fade cream products.
13. Any diet pills or appetite suppressants (anorectics).
14. Prescription smoking cessation products. 15. Immunization agents, biological products
for allergy immunization, biological sera, blood, blood plasma and other blood products or fractions and medications used for travel prophylaxis.
16. Replacement of prescription medications and related supplies due to loss or theft.
17. Medications used to enhance athletic performance.
18. Medications that are to be taken by or administered to a Customer while the Customer is a patient in a licensed hospital, skilled nursing facility, rest home or similar institution which operates on its premises or allows to be operated on its premises a facility for dispensing pharmaceuticals.
19. Prescriptions more than one year from the original date of issue.
23
Cigna reserves the right to make changes to this Drug List (also known as the Value Prescription Drug List) without notice. Your plan may cover additional medications; please refer to your enrollment materials for details. Cigna does not take responsibility for any medication decisions made by the prescriber or pharmacist. Cigna may receive payments from manufacturers of certain Preferred-Brand medications, and in limited instances, certain Non-Preferred Brand medications, that may or may not be shared with your plan depending on its arrangement with Cigna. Depending upon plan design, market conditions, the extent to which manufacturer payments are shared with your plan, and other factors as of the date of service, the Preferred-Brand medication may or may not represent the lowest-cost brand medication within its class for you and/or your plan.
“Cigna”, “Cigna.com” and “myCigna.com” are registered service marks and the “Tree of Life” logo, “Cigna Home Delivery Pharmacy” and “GO YOU” are service marks, of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, Tel-Drug, Inc., Tel-Drug of Pennsylvania, L.L.C., and HMO subsidiaries of Cigna Health Corporation. “Cigna Home Delivery Pharmacy” refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C. All models are used for illustrative purposes only.
853379 02/12 © 2012 Cigna. Some content provided under license.
Get a dose of healthy savings with the CIGNA Value Prescription Drug List
840505 02/11 Value PDL
Now more than ever, you need to lower your benefit plan costs. It’s important to balance this need with employee satisfaction by continuing to offer a complete pharmacy program. CIGNA’s Value Prescription Drug List (PDL) helps you do both.
With the Value PDL, you’ll see savings of up to 25% on pharmacy claim costs. That’s significant — especially when you consider that this translates to approximately 3% of your overall medical costs.
Consider the following two unique characteristics that drive the savings:
Distinctive Tier DesignThe Value PDL encourages people to choose low-cost generic
medications by placing most brand name drugs on the higher cost
third tier. Also, a much-smaller second tier offers only the drugs that
do not have a generic equivalent or a therapeutic alternative.
Effective ExclusionsCertain exclusions are responsible for approximately half the savings
available with the Value PDL. These include all medications that
have an over-the-counter (OTC) equivalent or therapeutic alternative;
specifically, non-sedating antihistamines (allergy medications) along
with PPIs and H2 blockers (ulcer/heartburn medications). Lifestyle
drugs, including weight loss, infertility, smoking cessation and
erectile dysfunction medications, are also excluded.
Speak to your CIGNA sales representative to enjoy all
the benefits of the CIGNA Value Prescription Drug List
— coming this May.
“CIGNA”, “CIGNA.com”, “myCIGNA.com” and the ”Tree of Life” logo are registered service marks, and ”CIGNA Home Delivery Pharmacy” is a service mark, of CIGNA Intellectual Property, Inc., licensed for use by CIGNA Corporation and its operating subsidiaries. All products and services are provided exclusively by such operating subsidiaries
and not by CIGNA Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company, CIGNA Health and Life Insurance Company, Tel-Drug, Inc., Tel-Drug of Pennsylvania, L.L.C., and HMO or service company subsidiaries of CIGNA Health Corporation. “CIGNA Home Delivery Pharmacy”
refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C. All models are used for illustrative purposes only.
Important Information about the Value Prescription Drug List: Exclusions
842185 05/11 Value PDL
“CIGNA Pharmacy Management”, “myCIGNA.com” and the “Tree of Life” logo are registered service marks of CIGNA Intellectual Property, Inc., licensed for use by CIGNA Corporation and its operating subsidiaries. All products and services are provided exclusively by such operating subsidiaries and not by CIGNA
Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company, CIGNA Health and Life Insurance Company, Tel-Drug, Inc., Tel-Drug of Pennsylvania, L.L.C., and HMO or service company subsidiaries of CIGNA Health Corporation.
© 2011 CIGNA.
The Value Prescription Drug List can deliver savings of 20-25% of pharmacy claim costs, and these savings are attributed to both the unique tier design which drives higher use of generic medications and the exclusion of certain medications. The list of exclusions drives approximately half of the estimated 20-25% savings.
Heartburn/Ulcer Allergy
H2 Blockers Proton Pump Inhibitors Non-Sedating Antihistamines
Axid (OTC) Aciphex Allegra D
Cimetidine (OTC) Nexium Clarinex/Clarinex D
Famotidine (OTC) Omeprazole (OTC) Claritin (OTC)/Claritin D (OTC)
Nexatidine (OTC) Pantoprazole Fexofenadine
Pepcid (OTC) Prevacid Loratidine (OTC)
Ranidtine (OTC) Prilosec Xyzal
Tagamet (OTC) Protonix Zyrtec/Zyrtec D (OTC)
Zantac (OTC) Zegerid
It’s important to know what drugs are excluded because they are
commonly used medications that many of your employees may
currently use.
The Value Prescription Drug List does not cover medications in
two drug classes that have over-the-counter (OTC) equivalents or
alternatives: drugs that treat stomach acid conditions and non-
sedating antihistamines to treat allergies. Many of these drugs are
widely used, so please be aware that the exclusion list will affect a
significant number of people.
Some examples of excluded medications are listed below. Please
note this list is not all inclusive. For a complete list of covered
medications on the Value Prescription Drug List, customers can
visit myCIGNA.com at any time.