MEMBER’S ADDITIONAL INFORMATION (V4)All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Ci gna Health and

The Self-Funded Program provides tools for small-business employers to establish a self-funded health benefit plan for their employees. The benefit plan is established by the employer and is not an insurance product. Stop-loss insurance for the National General Benefits Solutions

Self-Funded Program is underwritten and issued by Time Insurance Company, National Health Insurance Company, Integon National Insurance Company, and Integon Indemnity Corporation.

(9/2016) © 2016 National Health Insurance Company. All rights reserved. 20161201.v4.1

MEMBER’SADDITIONAL INFORMATION (V4)� ASA�EMPLOYEE�ASSISTANCE�PROGRAM�(AETNA)�

� CIGNA�(PHARMACY�BENEFIT�MANAGER):�

� CIGNA�WELCOME�LETTER�

� FIVE�WAYS�TO�SAVE�

� CLICK�WITH�A�SITE�THAT�CLICKS�WITH�YOU�

� PAYER�SOLUTIONS:�� PHARMACY�� GENERIC�MEDICATION�

� 90�NOWSM�(90�DAY�PRESCRIPTIONS)�

� RETAIL�PHARMACY�DIRECTORY�(90�DAY�NETWORK�PHARMACY�DIRECTORY)�

� HOME�DELIVERY�PHARMACY�

� STEP�THERAPY�

� PHARMACY�ADVANTAGE�PRESCRIPTION�DRUG�LIST�

� SPECIALTY�PHARMACY�DRUG�LIST�

� PRESCRIPTION�DRUG�CLAIM�FORM�

� HOME�DELIVERY�ORDER�FORM�

� PHARMACY�CHAIN�LISTING�BY�STATE�

� ALLIED:�SAMPLE�EOB�(EXPLANATION�OF�BENEFITS)�

A website built for youAetna Resources For LivingSM

Get information and advice on the things that matter to you

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

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

Find discounts on over 3 million products and services

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

��

Access myStrength — the health club for your mind

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

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

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

Check out your member website today.

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

www.mylifevalues.comUsername: peaceofmind / Password: solutions

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

©2014 Aetna Inc. 44.03.508.1-ASA (10/14)

myStrengthTM: the health club for your mindAetna Resources For LivingSM

Strengthen your whole self

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

myStrength is:

�� $��

�� %&'*

��+ �$��

��

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

*6#79#;;%#<=�>��?<7'<&@

F��$��+��$�� G�� ?+�G@��!�$�� $>�� $�� !��=��#�It’s a new kind of online wellness portal. You can use it to support your mind, body and spirit. Best of all, it’s a free part of your program.

Give the app a try, too

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

�� Get custom inspiration based on your mood

��Track your mood over time

��Upload your own inspiring photos and videos

��J��K=��

Easy sign-up

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

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

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

— myStrength user

Aetna Resources For LivingSM is the brand name used for products and services offered through the Aetna group of subsidiary companies. The EAP is administered by Aetna Behavioral Health, LLC. In California for Knox-Keene plans, Aetna Health of California, Inc. and Health and Human Resources Center, Inc.��+�G�� Q�� R��$�� !#�� $#�� #�� !�� $�questions or concerns about specific health care needs. This material is for informational purposes only. It contains only a partial, general �� #�+�G�� !��K�� $�� #�� individual services provided by these persons and does not assume any responsibility or liability for the services they provide and, therefore, cannot guarantee any results or outcomes. The availability of any particular provider cannot be guaranteed and is subject to change. �� !��"�� #�� refer to www.aetna.com.

V%7<&�� #�*6#79#;;%#<=�>��?<7'<&@

www.mylifevalues.comUsername: peaceofmind Password: solutions

Cigna Corporation 900 Cottage Grove Road Bloomfield, CT 06002

Welcome to Cigna Payer Solutions Pharmacy Program to manage your prescription drug plan. This program is administered through Cigna Pharmacy Management.

There are several benefits offered to you as part of the Cigna Payer Solutions Pharmacy Program. We support you to get the most out of your pharmacy benefit plan with personalized service to help you:

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

2. Compare prices: Use the Prescription Drug Price Quote Tool to see what drugs cost with your plan. You can also compare prices at over 68,000 retail pharmacies and Cigna Home Delivery PharmacySM. It’s all part of the pharmacy page on myCigna.com.

3. Go generic: Request the generic from your doctor. Generic medications have the same strength and active ingredients as their brand-name counterparts. They are sold under the chemical or scientific name of the medication instead of the manufacturer’s patented brand name. If you are prescribed a brand-name medication and a generic is available, whether prescribed by your doctor or you request it at the pharmacy, the cost difference between the brand and generic medications will be your responsibility.

4. Fill a 90-day supply for increased convenience: Use Cigna Home Delivery Pharmacy and have your maintenance medication delivered right to your door at no additional cost. Beginning January 1, 2017, the Cigna 90 Now network will also allow you to fill 90 days of your maintenance medications at 29,000 retail pharmacies nationwide. To find a participating 90-day pharmacy, go tomyCigna.com or call Cigna Customer Service.

5. Specialty pharmacy medications: Take advantage of TheraCare®, our chronic condition support service for customers who use injectable medications for conditions like multiplesclerosis, hepatitis C, and hemophilia. Certain specialty medications are required to be filled at Cigna Home Delivery; to see if your medication is one of them go to myCigna.com or call Cigna Customer Service.

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

09/16 © 2016 Cigna. Some content provided under license.

6. Use the pharmacy page of myCigna.com: You have 24/7/365 access to your pharmacy claim history, benefit details, recent industry and Cigna news and a comparison of drug and pharmacy prices. You are also able to manage your Cigna Home Delivery Pharmacy orders and ask a pharmacist a question.

You will receive your new ID card in a separate mailing. Please remember to show this card at your pharmacy in order to receive your prescription benefits. If you have any questions about your prescription benefits or would like more information, please feel free to call Cigna Payer Solutions at 1-800-325-1404 or visit myCigna.com.

Welcome to Cigna Payer Solutions, we look forward to serving you.

Sincerely,

Amie L. BenedictPresident and General Manager, Cigna Payer Solutions

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

887776 03/16 © 2016 Cigna. Some content provided under license.

Questions? Call the toll-free number on the back of your ID card.

Cigna Payer SolutionsCigna Payer Solutions

1. Learn what medications are covered

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

2. Use the Prescription Drug Price Quote tool

View medication cost based on your pharmacy plan, see if there are lower cost alternatives and compare prices between Cigna Home Delivery PharmacySM and retail pharmacies.

3. Use Cigna Home Delivery PharmacySM

Have the medications you take on a daily basis delivered right to your door at no additional cost. Because you can get up to a 90-day supply at one time, you may even be able to save money. You’ll get a reminder when it’s time to reorder, and have access to the CoachRx team for help with drug interactions, side effects and ways to lower your medication costs.

4. Get help with specialty medications

Take advantage of TheraCare®. Your personalized team will help you better understand your chronic condition (like multiple sclerosis, hepatitis C or hemophilia) and medication, including common side effects and how to follow your doctor’s treatment instructions correctly.

5. Use myCigna.com

Gives you 24/7/365 access to:

› See your pharmacy claim history

› Read your benefit details

› See medication prices based on your plan

› Manage your Cigna Home Delivery Pharmacy orders

› Ask a pharmacist a question

YOUR PHARMACY BENEFITS

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

CLICK WITH A SITE THAT CLICKS WITH YOU

myCigna.com

Offered by: Cigna Health and Life Insurance Company.

885468 09/15 Cigna Payer Solutions

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.

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.

Cigna Payer Solutions

*Quality designations and cost-efficiency ratings reflect a partial assessment of quality and should not be the sole basis for decision-making (as such measures have a risk of error). They are not a guarantee of the quality of care that will be provided to individual patients. Individuals are encouraged to consider all relevant factors and consult with their physician when selecting a health care professional or facility for care. Health care professionals and facilities that participate in the Cigna network are independent contractors solely responsible for the treatment provided to their patients. They are not agents of Cigna.

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

885468 09/15 Cigna Payer Solutions © 2015 Cigna. Some content provided under license.

Cigna Care Designation

Quality Designations

Specialty: Pediatrics

C

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

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

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 benefits booklet for specific eligibility and coverage information.

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 refills of your prescriptions.

› 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 find articles, support groups and other resources on a variety of topics, including blood pressure, cholesterol, tobacco cessation, weight management, stress and more.

Find a health care professional or pharmacy

Search for your doctor by name or search our network for a specific type of doctor, pharmacy or medical facility. You can filter your results by distance, cost efficiency, 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 identifies doctors who have met certain Cigna quality and cost-efficiency measures.*

Offered by: Cigna Health and Life Insurance Company

892878 a 08/16 Cigna Payer Solutions

CHOICE. AFFORDABILITY. EXPERTISE.

Cigna Pharmacy Management®

Available through select Third Party Administrators (TPAs), Cigna Pharmacy Management delivers innovative products coupled with pharmacy expertise – to help TPAs and employers design plans that drive value and improved clinical outcomes. Cigna offers: competitive networks and clear pricing; broad choice to drive lower costs; effective clinical programs; excellent service for clients and members, and a deep understanding of the Pharmacy Benefit Management (PBM) marketplace. Together, we focus on improved outcomes to help members achieve better health. We know helping members improve their health is a sustainable way to reduce total health care spending.


Excellent service for clients and members

Cigna Payer Solutions offers a customer-centric approach for both clients and members. For our preferred TPAs, that means a single point of contact for Pharmacy Benefit Management issue resolution and operational questions.

For members – it’s an integrated, personalized, and compassionate approach to member service – 24/7. That includes:

› 24/7/365 live customer service

› The myCigna.com member portal and myCigna mobile app for personalized cost and benefit information at work, at home, or on-the-go

› 24/7 access to Cigna Home Delivery PharmacySM pharmacists

› No jargon

› Transition assistance to Cigna Home Delivery Pharmacy

Competitive networks and clear pricing

Cigna Payer Solutions’ Pharmacy Benefit Management offers three ways to help employers lower pharmacy costs:

› Our competitive and broad national network offers discounts that are in line with leading competitors, and access to 68,000 pharmacies nationwide, including a 90-day retail network of 29,000 pharmacies for even greater savings.1

› Key services are included in pricing – no additional charge for clinical programs such as narcotic therapy management, specialty pharmacy, step therapy, personalized mailings to members and more.

› Additional incentives for bundling PBM with the Cigna PPO medical network.

Broad choice to drive lower costs

› Plan design flexibility to provide appropriate product coverage and cost share and promote preventive drugs

› Two formulary options

› In addition to Cigna’s large national network, we offer the choice of a limited 90-day retail network as well as three narrow network options

› Three tier drug plan recommended

Effective clinical programsOur clinical pharmacy programs help ensure appropriate utilization of medications, promote preventive drugs, help improve health, and reduce total healthcare spending. Cigna Pharmacy Benefit Management is cost-effective and flexible, and offers a wide choice of clinical programs to help members get more value for their benefit dollar – at no additional cost.

Improved medication adherence with CoachRx

Cigna Pharmacy’s CoachRx program encourages members to understand their likelihood of becoming non-adherent and provides tools to keep adherence from becoming a challenge. The program offers daily reminders, free pill boxes, and educational materials.

Alert members to savings opportunities with Rx Savings Messenger

Rx Savings Messenger generates personalized mailings to members educating them about ways they can save – showing actual savings potential on currently prescribed medications by exploring generic medications.

Step Therapy promotes lower-cost therapies with personalized outreach

Cigna Pharmacy’s Step Therapy program promotes the use of generic drugs and lower-cost, brand-name alternatives, while at the same time avoiding disruption for the member at the pharmacy and providing members and their physicians the flexibility to use brand-name drugs when medically necessary.

Utilization management through Prior Authorization

Prior authorization helps control rising costs by requiring that certain high-cost medications undergo a review for medical necessity before being prescribed. Cigna Pharmacy also incorporates drug utilization review to identify potentially adverse drug restrictions and possible prescription errors and quantity level limits to help ensure members receive only the necessary quantity of medication.

90-Day Refills for Maintenance Medications

Members who take medications on a regular basis can enjoy the convenience of 90-day refills, either at 29,000 national retail locations or delivered directly to their home via Cigna Home Delivery Pharmacy. Members who fill 90-day prescriptions have a 41% higher adherence rate than those who fill 30-day prescriptions.2 And, clients have the option to help reduce costs even more by requiring 90-day fills for maintenance medications.

Identify potential inappropriate use with Narcotic Therapy Management

Narcotic Therapy Management identifies unusual and potentially inappropriate use patterns and offers physicians comprehensive clinical information to create an integrated view of the member’s overall treatment, including conditions and prescription use. In a study, members receiving intervention reduced narcotic prescription use by 40%, and combined medical and pharmacy costs were reduced by an average of $2,200, or 34%.3

Specialty drugs require a complete management strategy

According to a recent IMS study, by 2020, specialty drugs will represent just 2% of all prescribed drugs, but 30% of all drug costs.4 Cigna Specialty Pharmacy ManagementSM offers a comprehensive program for individuals who require specialty drugs to treat rare and chronic diseases – focusing on adherence, support and lower unit cost. Through clinical review of medications, therapy management, and health advocacy programs, we help manage costs and improve health outcomes. We also recommend a 30-day supply limit on specialty medications to help reduce waste and control costs.

Added support for members with specialty conditions – TheraCare

For members who use specialty medications to manage chronic conditions, Cigna Pharmacy’s TheraCare® program helps them better understand their conditions, medications, and side effects, and increase their understanding of the importance of taking medications exactly as prescribed – with a focus on total health.

1. Cigna National Book of Business as of 12/31/2015. Actual number will vary.2. Internal Cigna analysis performed March 2016, utilizing 2015 Cigna national book of business average medication adherence

(customer adherent > 80% proportion of days covered (PDC)), 90-day supply vs. those who received a 30-day supply taking antidiabetics, renin-angiotensin system (RAS) antagonist and statins. Individual client results will vary and savings are not guaranteed.

3. For members receiving intervention. Source: Cigna analysis of 5,758 individuals with interventions and continuously enrolled during the 3-month pre-intervention, 3-month intervention and 3-month post intervention periods between 3rd Quarter 2012 and 2nd Quarter 2013.

4. “Global Medicines Use in 2020: Outlook and Implications.” IMS Institute for Healthcare Informatics. Published November 18, 2015.

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

892878 a 08/16 Cigna Payer Solutions © 2016 Cigna. Some content provided under license.

What is a generic medication?

Generic medications have the same strength and active ingredients as their brand-name counterparts. They are sold under the chemical or scientific name of the medication instead of the manufacturer’s patented brand name. Brand-name medications have patents that last for twenty years, protecting the rights of the owner and sole manufacturer. Once the patent expires, other manufacturers are free to make the medication in a generic form.

What are the differences between brand-name medications and their generic alternatives?

Generic medications may differ from their brand-name counterparts in shape, packaging, color, flavor, preservatives, expiration time and, sometimes, labeling. The U.S. Food and Drug Administration (FDA) requires that all medications, both brand name and generic, meet the same requirements for quality, strength, purity and potency. The FDA only approves generic medications that have the same active ingredients and work the same way in the body as their brand-name counterparts.

877777 12/15

Common brand-name medications with generic equivalents

BRAND NAME GENERIC NAME COMMON USE

Cozaar/Hyzaar losartan/losartan-hctz

High blood pressureDiovan/Diovan HCT valsartan/valsartan-hctz

Toprol XL metoprolol ER

Lipitor atorvastatinHigh cholesterol

Zocor simvastatin

Fosamax alendronate Osteoporosis

Lexapro escitalopram Depression

Zoloft sertraline

Prilosec omeprazoleHeartburn//ulcer (acid reflux)

Protonix pantoprazole

Cigna Payer SolutionsCigna Payer Solutions

ANSWERING YOUR QUESTIONS ABOUT GENERIC MEDICATIONS

Helpful information

Do generics take longer to work?

No. When a manufacturer wants to make a generic medication, they must prove to the FDA that the medications works the same way in the body and within the same amount of time as the brand-name medication.

Are generics as safe as brand-name medications?

The manufacturer of the generic medication must prove to the FDA that the generic medication is as safe as its brand-name counterpart.

Why should I choose a generic medication?

Generic medications usually cost 80%–85% less than their brand-name counterparts.* So, generic medications may save you money.

How do I choose a generic medication?

You should talk with your doctor to see if a generic medication will work for you. Also, you can use the Drug Price Quote tool on myCigna.com to find out what medications cost under your pharmacy plan, and compare prices between Cigna Home Delivery PharmacySM and retail pharmacies.

Generic medications usually cost 80%–85% less than their brand-name counterparts.*

* Facts about Generic Drugs, U.S. Food and Drug Administration, U.S. Department of Health & Human Services. (http://www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/UnderstandingGenericDrugs/ucm167991.htm)

The information provided here is intended to be general information on how you can get the most out of your prescription drug plan. It is not intended as medical advice. You are encouraged to consider all relevant factors and to consult with your doctor for care and treatment advice. The drugs listed in this document may not be covered under your plan. Review your employer’s prescription drug list for a listing of the medications that are covered under your specific plan. Plans vary, but in general to be eligible for coverage a drug must be approved by the Food and Drug Administration (FDA), prescribed by a health care professional, purchased from a licensed pharmacy and medically necessary. If your plan provides coverage for certain prescription drugs with no cost-share, you may be required to use an in-network pharmacy to fill the prescription. If you use a pharmacy that does not participate in your plan’s network, your prescription may not be covered, or reimbursement may be limited by your plan’s copay, coinsurance or deductible requirements. Refer to your plan documents for costs and complete details of your plan’s prescription drug coverage.



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

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

More choice

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

Choose what works best for you

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

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

Where you can fill a 90-day prescription

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

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

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

Why fill a 90-day supply?

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

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

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

› CVS (including Target and Navarro)

› Walmart

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

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

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

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

893345 b VoluntaryCigna90Now 08/16

90-Day Fills

Prefer to have your medications delivered to your door?

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

Get a 90-day prescription for your medication

Get a 30-day prescription for your maintenance medication

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

or mail to Cigna Home Delivery Pharmacy

Take your prescription to any retail pharmacy in your network, or mail to Cigna Home Delivery Pharmacy

Receive your medication in a 90-day supply for

convenience

Receive your medication

30-Day Fills

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

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

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

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

Health benefit plans vary, but in general to be eligible for coverage a drug must be approved by the Food and Drug Administration (FDA), prescribed by a health care professional, purchased from a licensed pharmacy and medically necessary. If your plan provides coverage for certain prescription drugs with no cost-share, you may be required to use an in-network pharmacy to fill the prescription. If you use a pharmacy that does not participate in your plan’s network, your prescription may not be covered, or reimbursement may be limited by your plan’s copayment, coinsurance or deductible requirements. Refer to your plan documents for costs and complete details of your plan’s prescription drug coverage.

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

893345 b VoluntaryCigna90Now 08/16 © 2016 Cigna. Some content provided under license.

Questions?

Please call Customer Service at 800.Cigna 24 (800.244.6224). We’re here to help.

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

893348 Cigna90Now 10/16

CIGNA 90 NOW

RETAIL PHARMACY DIRECTORY

For customers who must use a 90-day network pharmacy to fill their 90-day prescriptions

Filling your maintenance medications just got easier with Cigna 90 Now

With Cigna 90 NowSM, your plan offers a retail pharmacy network that gives you more choice in where you can fill your prescriptions for the medications you take every day. There are thousands of retail pharmacies in your network. They include local pharmacies, grocery stores, retail chains and wholesale warehouse stores – all places where you may already shop!

Under your plan, 90-day prescriptions have to be filled at one of the 90-day retail pharmacies in your network, or Cigna Home Delivery PharmacySM, to be covered.1

Where you can fill your prescriptions

The following is a list of the largest retail pharmacy chains in the United States that participate in your network. In addition to the chains listed, Cigna has contracted with a number of independent retail pharmacies in each state. Every pharmacy in your network can fill a 30-day prescription, and a select number of pharmacies can fill a 90-day prescription. Pharmacies that can fill a 90-day prescription will have this symbol next to them. To see a complete list of retail pharmacies in your network, go to Cigna.com/Rx90network.

Medications delivered to your door

Cigna Home Delivery Pharmacy will deliver your maintenance medication to you at the location of your choice. And standard shipping is always free. For more information, please call customer service at 800.285.4812, or visit Cigna.com/home-delivery-pharmacy.

Questions?

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

You can also visit Cigna.com/Rx90network for more information about your network.

PHARMACY DIRECTORY

Acme Pharmacy

Aurora Pharmacy

Bartell Drugs

Benzer Pharmacy

Big Y Pharmacy

Bi Lo Pharmacy

Bi-Mart Pharmacy

Brookshire Brothers Pharmacy

Brookshires Pharmacy

Community Pharmacy

Costco Pharmacy

Cub Pharmacy

CVS Pharmacy (includes Target)

Dillon Pharmacy

Discount Drug

Dod

Duane Reade

Family Pharmacy

Farmacia

Food City Pharmacy

Fred Meyer Pharmacy

Fred’s Pharmacy

Freds Pharmacy

Fry’s Food And Drug

Genoa, A Qol Healthcare

Giant Pharmacy

Giant Eagle Pharmacy

Hannaford Food And Drug

Harris Teeter Pharmacy

Heb Pharmacy

Hometown Pharmacy

Hy-Vee Pharmacy

Ingles Pharmacy

King Kullen Pharmacy

King Soopers Pharmacy

Kinney Drugs

KMart Pharmacy

Kroger Pharmacy

Longs Drugs

Marcs

Marsh Drugs, LLC

Martin’s Pharmacy

Medical Center Pharmacy

Medicap Pharmacy

The Medicine Shoppe Pharmacy

Meijer Pharmacy

Navarro Discount Pharmacy

Omnicare

Osco Drug

Osco Pharmacy

PharMerica

Pick N Save Pharmacy

Price Chopper Pharmacy

Publix Pharmacy

Raleys Pharmacy

Ralphs Pharmacy

Rite Aid Pharmacy

Safeway Pharmacy

Sams Pharmacy

Savon Pharmacy

Schnucks Pharmacy

Shopko Pharmacy

ShopRite Pharmacy

Smiths Pharmacy

Snyder Drug Emporium

Stop & Shop Pharmacy

Super RX Pharmacy

Tom Thumb Pharmacy

Tops Pharmacy

Vons Pharmacy

Walgreens

Walmart Pharmacy

Wegmans Food Market Inc.

Weis Pharmacy

Winn Dixie

Pharmacies with this symbol next to them can fill 30-day or 90-day prescriptions. Pharmacies without that symbol can only fill up to a 30-day supply. Call your local retail pharmacy to make sure they can fill your prescription in a 90-day supply.

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


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

893348 Cigna90Now 10/16 © 2016 Cigna. Some content provided under license.

Cigna 90 Now FAQsWhat’s Cigna 90 Now?

› It’s a maintenance medication program that includes a 90-day retail benefit and pharmacy network. Maintenance medications are taken every day to treat an ongoing health condition. If you fill your prescription in a 90-day supply, you have to use a 90-day retail pharmacy in your plan’s network or Cigna Home Delivery Pharmacy.1

What kinds of prescriptions are best filled in a 90-day supply?

› Maintenance medications. These are taken regularly, over time, to treat an ongoing health condition, such as diabetes, high blood pressure, cholesterol or asthma.

› With Cigna 90 Now, you can’t fill narcotics and specialty medications in a 90-day supply. That’s because narcotics are highly-regulated by the government to make sure they’re being used safely and effectively. And it’s better to fill specialty medications, which are used to treat complex conditions, in a smaller day supply because it can lower your costs due to wasted or unused medications if your prescription changes.

Do I need my doctor’s approval to switch to a 90-day prescription?

› Yes, you’ll need a prescription for a 90-day supply of your medication.

Are 90-day prescription fills available if I have Cigna Home Delivery Pharmacy?

› Yes. Call Cigna Home Delivery Pharmacy at 800.835.3784 to transfer your prescription.

Are there any benefits or advantages to a 90-day prescription?

› Yes - it’s more convenient, you have choice and it helps improve your health.

1. You’ll make fewer visits to the pharmacy to refill your medication.

2. You can choose where you want to fill your prescriptions – at a local 90-day retail pharmacy or through Cigna Home Delivery Pharmacy.

3. You’re more likely to stay healthy because having a 90-day supply of your medication on hand typically means you’re less likely to miss a dose.2

Are there any cost savings associated with 90-day prescription fills?

› Depending on your plan and your medication, you may be able to save money by filling your prescriptions 90 days at a time.

How do I switch pharmacies if:

› I have a 90-day prescription and just want to switch pharmacies?

Ask the new pharmacy of your choice to transfer your existing 90-day prescription from your current pharmacy.

› I’m currently using a local pharmacy and want to switch to Cigna Home Delivery Pharmacy?

Call Cigna Home Delivery Pharmacy at 800.835.3784 to transfer your existing 90-day prescription.

› I’m currently using Cigna Home Delivery Pharmacy and want to use a local pharmacy?

Ask the local pharmacy of your choice to call Cigna Home Delivery Pharmacy at 800.835.3784 to transfer your existing 90-day prescription.

– OR –

Call your doctor’s office and let your doctor know the name of your new pharmacy and he or she will send your prescription(s) to the pharmacy of your choice.

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

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

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.

What is Step Therapy? Prescription medications can cost a lot of money. At Cigna, we get that. That’s why we’ve created a program that helps you save money and stay healthy. It’s called Step Therapy.

Step Therapy is a prior authorization program. This means that certain medications in the Step Therapy program need approval before they’re covered. In Step Therapy, you and your doctor follow a series of steps when choosing your medication.

You may be able to choose from several different safe and effective prescription medications to treat your condition. Cost is often the biggest difference. Generic medications – which have the same strength and active ingredients as brand name medications – typically cost less, while brand name medications are usually the most expensive.

Included in the Step Therapy program are medications ued to treat several common medical conditions:

› ADD/ADHD

› Allergies

› Asthma

› Bladder problems

› Depression

› Heartburn/ulcer

› High blood pressure

How does Step Therapy work? Step Therapy encourages you to try the most cost-effective and appropriate medications available to treat your condition. Typically, these medications are generics or low-cost brands. You need to try these first, before more expensive medications are approved.

When you fill a prescription for a Step Therapy medication, you and your physician will receive a letter explaining what steps you need to take before you refill your medication. This may include trying a generic or lower cost alternative, or asking Cigna for authorization for coverage of your medication. At any time, your physician can request authorization to continue coverage of a Step Therapy medication for medical reasons.

Determining if your medication is included in the programGo to myCigna.com. Look up your prescription drug list to see if your specific medication is impacted by Step Therapy. If an “ST” designation appears next to the drug name, then the medication is part of the Step Therapy program.



› High cholesterol

› Mental health

› Osteoporosis

› Pain (narcotic and non-narcotic)

› Skin conditions

› Sleep disorders

STEP THERAPY

Helps members make the switch to lower-cost medications


For more information, contact your employer’s benefit department, or the customer service number on the back of your ID card. We also encourage you to discuss Step Therapy with your physician.

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

887152 c Advantage 3Tier w DRT 08/16 © 2017 Cigna.

CIGNA ADVANTAGE PRESCRIPTION DRUG LIST

Advantage Prescription Drug List – Three-Tier Plan

Understanding Cigna’s prescription drug list

Every year Cigna updates this drug list to reflect any changes to the list of covered prescription drugs. Examples of changes that may impact you include brand-name medications may change tiers or may no longer be covered. In addition, any new FDA-approved drug product (including, but not limited to, medications, medical supplies or devices that are covered under standard pharmacy benefit plans) available in the marketplace may not be covered^ for the first six months after the product receives FDA new drug approval. This document includes a summary of key changes made to common medications effective January 1, 2017.

Use the Prescription Drug Price Quote tool on myCigna.com to price a medication and see the lower-cost options available to you at your selected retail pharmacy and Cigna Home Delivery Pharmacy. Please note: This list is subject to change.

This document represents a list of the most commonly prescribed medications covered under your plan, in an easy-to-read format. 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.

Choosing the medication that is right for you is between you and your doctor. Every medication available on Cigna’s prescription drug list has been approved by the U.S. Food and Drug Administration (FDA). If there is more than one medication appropriate for your condition, we encourage you to talk with your doctor about lower-cost medications like generics and preferred brands, as they will help to manage your prescription costs.

Your three-tier prescription drug list

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

1st Tier – Generic Medications have the same strength and active ingredients as the brand name – but often cost much less. You will usually pay less for generic medications under your plan. If one’s available, you should consider switching to a generic to treat your condition.

2nd Tier – 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 are those that generally have generic alternatives and/or one or more preferred options within the same drug class. You will usually pay more for a non-preferred medication under your plan.

^ If your doctor feels currently covered medications aren’t right for you, he or she can ask Cigna to consider authorizing coverage of your medication.

January 2017

2

Important note

This drug list does not cover medications in two drug classes that have over-the-counter (OTC) alternatives (medications available without a prescription).* These include:

› Medications used to treat stomach acid conditions (ex., Nexium, PrevPac, Prilosec, Zantac and any generics), and

› Medications (non-sedating antihistamines) to treat allergies (ex., Allegra, Clarinex, Xyzal and any generics).

* Check your plan materials to see how these products are covered for you.

myCigna.com

Our customer website that can help you manage your prescription coverage. When you visit myCigna.com, you can:

› Look up the details of your specific pharmacy plan

› View your drug list to research thousands of available medications

› Compare medication prices using the Prescription Drug Price Quote tool

› Ask a pharmacist questions

› And much, much more.


Cigna Home Delivery PharmacySM is a convenient mail order service for those who take medications regularly. We offer:

› Routine, maintenance medications and specialty medications

› Licensed pharmacists available to help answer questions, 24/7

› Up to a 90-day supply of your medications

› Free, standard shipping right to your home

› Refill reminder service

To get started, give us a call at 800.835.3784

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

Health care reform and you

The Patient Protection and Affordable Care Act (PPACA), commonly referred to as “health care reform,” was signed into law on March 23, 2010. Certain preventive medications (including some over-the-counter medications) may be available to you at no cost-sharing. To get the most current information, visit InformedOnReform.com or Cigna.com and look for the Preventive Services section within the “Informed On Reform” link.

If you have any questions

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

Save time with the convenience of Cigna Home Delivery Pharmacy

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 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 “ST” medication is covered.

GEN: Gender means this medication is only covered if you meet specific gender requirements.

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 (approval) for coverage of that medication.

* 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 your plan documents for more information.

^ This medication may not be covered under your plan. Please check your enrollment materials or use the Prescription Drug Price Quote tool on myCigna.com to find out if this medication is covered.

3

2017 Cigna Prescription Drug List

ADVANTAGE PRESCRIPTION DRUG LIST THREE-TIER PLAN

GenericsPreferred Brands

Non-Preferred Brands

AIDS/HIV

lamivudine*

lamivudine-zidovudine*

nevirapine*

nevirapine ER*

Atripla*

Epzicom*

Intelence*

Isentress*

Kaletra*

Norvir softgel cap, solution*

Prezista*

Reyataz*

Selzentry*

Sustiva*

Truvada*

Viread 300mg*

Complera*

Genvoya*

Norvir tablet*

Odefsey*

Prezcobix*

Stribild*

Tivicay*

Triumeq*

Viread powder 150, 200, 250mg*

ALLERGY/NASAL SPRAYS

Check your plan materials or mycigna.com to see how these products within this category may be covered for you.

azelastine

budesonide

epinephrine (QL)

fluticasone

hydroxyzine

ipratropium

mometasone

olopatadine

Phenergan

promethazine

EpiPen 2-pak (QL)

EpiPen Jr 2-pak (QL)

Adrenaclick (QL)

Astepro

Bactroban Nasal

ALZHEIMER’S DISEASE

donepezil

donepezil ODT

memantine

pyridostigmine

pyridostigmine ER

rivastigmine

Mestinon

Namenda

Namenda XR

Namzaric

Regonol

ANXIETY/DEPRESSION/BIPOLAR DISORDER

alprazolam

alprazolam ER

alprazolam intensol

alprazolam ODT

alprazolam XR

amitriptyline

bupropion

bupropion SR

bupropion XL

Brisdelle (QL)

Celexa (ST)

Effexor XR (ST)

Fetzima (ST)

Forfivo XL (ST)

Irenka (ST)

Prozac (ST)

Prozac Weekly (ST)

Sarafem (ST)



ANXIETY/DEPRESSION/BIPOLAR DISORDER (cont)

buspirone

citalopram

clomipramine

diazepam

duloxetine

escitalopram

fluoxetine DR

fluoxetine

fluvoxamine

fluvoxamine ER

lorazepam

lorazepam intensol

paroxetine

sertraline

trazodone

venlafaxine

venlafaxine ER

Venlafaxine ER (ST)

Viibryd (ST)

Wellbutrin SR (ST)

Xanax

Xanax XR

Zoloft (ST)

ASTHMA/COPD/RESPIRATORY

albuterol

budesonide

ipratropium-albuterol

levalbuterol concentrate

levalbuterol

montelukast

Advair Diskus

Advair HFA

Anoro Ellipta

Breo Ellipta

ProAir HFA

ProAir Respiclick

QVAR

Spiriva

Spiriva Respimat

Stiolto Respimat

Striverdi Respimat

Adcirca* (PA)

Adempas* (PA)

Combivent Respimat

Kalydeco* (PA)

Letairis* (PA)

Opsumit* (PA)

Orenitram ER* (PA)

Orkambi* (PA)

Pulmicort

Pulmozyme* (PA)

Remodulin* (PA)

Tracleer* (PA)

Tyvaso* (PA)

Xolair* (PA)

ATTENTION DEFICIT HYPERACTIVITY DISORDER

dexmethylphenidate

dexmethylphenidate ER

dextroamphetamine-amphet ER

dextroamphetamine- amphetamine

guanfacine ER

metadate ER

methylphenidate ER

methylphenidate

Adderall XR Adderall (ST)

Adzenys XR-ODT (ST)

Aptensio XR (ST)

Concerta (ST)

Daytrana (ST)

Dyanavel XR (ST)

Focalin (ST)

Focalin XR

Metadate CD (ST)

Methylin (ST)

Quillichew ER (ST)

4




ATTENTION DEFICIT HYPERACTIVITY DISORDER (cont)

methylphenidate CD

methylphenidate LA

Quillivant XR (ST)

Ritalin (ST)

Ritalin LA (ST)

Strattera

BLOOD MODIFIERS/BLEEDING DISORDERS

tranexamic acid* Aranesp* (PA)

Droxia

Granix*

Neulasta* (PA)

Zarxio

Amicar*

Epogen* (PA)

Neupogen* (PA)

Procrit* (PA)

Promacta* (PA)

BLOOD PRESSURE/HEART MEDICATIONS

afeditab CR

amiodarone

amlodipine

amlodipine-benazepril

amlodipine-valsartan

amlodipine-valsartan-HCTZ

atenolol

atenolol-chlorthalidone

benazepril

benazepril-HCTZ

candesartan

cartia XT

carvedilol

clonidine

digitek

digox

digoxin

diltiazem CD

diltiazem ER

diltiazem

dilt-XR

enalapril

flecainide

hydralazine

irbesartan

isosorbide mononitrate

isosorbide mononitrate ER

labetalol

lisinopril

lisinopril-HCTZ

losartan potassium

losartan-HCTZ

matzim LA

metoprolol

nadolol

nifedical XL

nifedipine

nifedipine ER

Azor

Benicar (ST)

Benicar HCT (ST)

Corlanor (PA)

Entresto (PA))

Tribenzor

Berinert* (PA)

BiDil

Cardizem LA

Cinryze* (PA)

Coreg CR

Firazyr* (PA)

Hemangeol

Inderal LA

Inderal XL

Innopran XL

Multaq

Nitro-Dur

Nitrolingual

Nitromist

Nitrostat

Northera* (PA)

Norvasc

Ranexa (ST)

Tiazac

Tikosyn

Toprol XL



BLOOD PRESSURE/HEART MEDICATIONS (cont)

Pacerone

propafenone

propafenone ER

propranolol

propranolol ER

ramipril

taztia XT

telmisartan

telmisartan-HCTZ

valsartan

valsartan-HCTZ

verapamil ER

verapamil

verapamil SR

BLOOD THINNERS/ANTI-CLOTTING

aspirin-dipyridamole ER

clopidogrel

enoxaparin* (QL)

fondaparinux* (QL)

jantoven

warfarin

Brilinta

Eliquis

Xarelto

Coumadin

Effient

Fragmin* (QL)

Pradaxa

CANCER

anastrozole

bexarotene*

capecitabine*

exemestane

hydroxyurea

imatinib* (PA)

letrozole

mercaptopurine

methotrexate*

tamoxifen citrate

temozolomide* (PA)

Actimmune* (PA)

Fareston

Gleostine

Intron A* (PA)

Nexavar* (PA)

Revlimid* (PA)

Sprycel* (PA)

Sutent* (PA)

Tarceva* (PA)

Targretin*

Tasigna* (PA)

Trexall*

Tykerb* (PA)

Afinitor* (PA)

Arimidex

Bosulif* (PA)

Cabometyx* (PA)

Cometriq* (PA)

Cotellic* (PA)

Erivedge* (PA)

Femara

Gilotrif* (PA)

Gleevec* (PA)

Ibrance* (PA)

Iclusig* (PA)

Imbruvica* (PA)

Inlyta* (PA)

Jakafi* (PA)

Lonsurf* (PA)

Lupron Depot* (PA)

Lynparza* (PA)

Ninlaro* (PA)

Pomalyst* (PA)

Stivarga* (PA)

Sylatron* (PA)

Tagrisso* (PA)

Tasigna* (PA)

Votrient* (PA)

Xalkori* (PA)

Xeloda*

Xtandi* (PA)

Zelboraf* (PA)

Zykadia* (PA)

Zytiga* (PA)

5




CHOLESTEROL MEDICATIONS

amlodipine-atorvastatin

atorvastatin

fenofibrate

fenofibric acid

Lofibra 54, 160mg

lovastatin

niacin ER

omega-3 acid ethyl esters

pravastatin

rosuvastatin

simvastatin

Praluent* (PA)

Repatha* (PA)

Zetia

Korlym (PA)

Lofibra 67, 134, 200mg

Tricor

Vascepa (ST)

Welchol

CONTRACEPTIVE PRODUCTS

All contraceptive products may be covered if you meet specific gender requirements.

blisovi 24 FE

blisovi FE

drospirenone-ethinyl estradiol

estarylla

gianvi

gildess 24 FE

gildess FE

junel FE

junel FE 24

larin 24 FE

larin FE

lomedia 24 FE

loryna

microgestin FE

mono-linyah

mononessa

nikki

norethin-eth estra-ferrous fum

norgestimate-ethinyl estradiol

ocella

previfem

sprintec

syeda

tarina FE

tilia FE

tri-estarylla

tri-legest FE

tri-linyah

tri-lo-estarylla

tri-lo-marzia

tri-lo-sprintec

trinessa

Trinessa LO

tri-previfem

tri-sprintec

vestura

zarah

Beyaz

Lo Loestrin FE

LoSeasonique

Minastrin 24 FE

Seasonique

Estrostep FE

Loestrin FE

Microgestin 24 FE

Mirena*

NuvaRing

Skyla*



COUGH/COLD MEDICATIONS

benzonatate

brompheniramine- pseudoephed-DM

hydrocodone-homatropine

hydrocodone- chlorpheniramne ER

hydrocodone-homatropine

hydromet

promethazine-codeine

tussigon

Flowtuss

Hycofenix

Tussionex

Tuzistra XR

DENTAL PRODUCTS

chlorhexidine

denta 5000 plus

dentagel

doxycycline

fluoride

fluoridex daily defense

fluoritab

flura-drops

ludent fluoride

oralone

paroex

peridex

periogard

sf

sf 5000 plus

sodium fluoride

triamcinolone

Clinpro 5000

Fluorabon

Fluor-a-day

Fluoridex Sensitivity Relief

Prevident

Prevident 5000

DIABETES

glimepiride

glipizide

glipizide ER

glipizide XL

metformin

metformin ER

pioglitazone-metformin

Glucagen HypoKit (QL)

Humalog

Humulin

Invokamet

Invokana

Janumet

Janumet XR

Januvia

Kombiglyze XR

Lantus

Lantus SoloStar

OneTouch test strips

Onglyza

SymlinPen

Toujeo SoloStar

Trulicity (QL)

Glucagon Emergency Kit (QL)

Glucophage

Glucophage XR

Riomet

VGo

6




DIURETICS

acetazolamide

chlorthalidone

eplerenone

furosemide

hydrochlorothiazide

spironolactone

triamterene-HCTZ

Aldactone

Dyazide

Edecrin

Lasix

Maxzide

Samsca

EAR MEDICATIONS

fluocinolone oil

neomycin-polymyxin- hydrocortisone

Cipro HC

Ciprodex

Coly-mycin S

Cortane-b

Dermotic

EYE CONDITIONS

azelastine

brimonidine

ciprofloxacin

dorzolamide-timolol

erythromycin

fluorometholone

gatifloxacin

gentak

gentamicin

ketorolac

latanoprost

neomycin-polymyxin-dexameth

ofloxacin

olopatadine

polymyxin b sul-trimethoprim

prednisolone

timolol

tobramycin

tobramycin-dexamethasone

Simbrinza

Travatan Z

Acuvail

Alphagan P

Alrex

Azasite

Azopt

Bepreve

Besivance

Betimol

Betoptic S

Combigan

Cosopt PF

Cystaran

Durezol

Ilevro

Lastacaft

Lotemax

Moxeza

Nevanac

Omnipred

Pataday

Patanol

Pazeo

Pred Forte

Pred Mild

Prolensa

Restasis

Tobradex

Tobradex ST

Vigamox

Xalatan

Zioptan (ST)

Zirgan

Zylet



FEMININE PRODUCTS

fem pH

gynazole 1

miconazole 3

terconazole

zazole

AVC

Relagard

Terazol

GASTROINTESTINAL/HEARTBURN

Check your plan materials or mycigna.com to see how these products within this category may be covered for you.

alosetron (GEN)

anucort-HC

balsalazide disodium

chlordiazepoxide-clidinium

dicyclomine

dronabinol

hemmorex-HC

hydrocortisone

lansoprazole-amoxicillin-clarithromycin (combo pak)

mesalamine

metoclopramide

metoclopramide ODT

ondansetron

ondansetron ODT

phenadoz

procto-med HC

procto-pak

proctosol-HC

proctozone-HC

promethazine

promethegan

sucralfate

ursodiol

Creon

Lialda

Pentasa

Zenpep

Amitiza

Canasa

Carafate

Cholbam* (PA)

Colyte

Diclegis

Donnatal

Emend* (QL)

Entyvio* (PA)

Gattex* (PA)

GoLytely

Linzess

Lotronex (GEN)

Movantik (PA)

Moviprep

Osmoprep

Pancreaze

Pertzye

Prepopik

Pylera

Ravicti (PA)

Rectiv

Sancuso (QL)

Sensipar*

sfRowasa

Suprep

Transderm-Scop

Varubi* (QL)

Viberzi

Viokace

HORMONAL AGENTS

budesonide EC

cabergoline (QL)

covaryx

covaryx H.S.

desmopressin*

dexamethasone

dexamethasone intensol

EEMT

EEMT H.S.

estradiol

estradiol-norethindrone acetat

estrogen & methyltestosterone

Androgel (QL)

Duavee

Humatrope* (PA)

Premarin

Premphase

Prempro

Sandostatin LAR Depot* (PA)

Serostim* (PA)

Somavert* (PA)

Zorbtive* (PA)

Activella

Alora

Androderm (QL)

Armour Thyroid

Climara

Climara Pro

Combipatch

Cytomel

Deltasone

Depo-Testosterone

Divigel

Elestrin

Enjuvia

Entocort EC

Estrace

7




HORMONAL AGENTS (cont)

levothyroxine

levoxyl

liothyronine

lopreeza

medroxyprogesterone

methylprednisolone

millipred

millipred DP

mimvey

mimvey LO

nature-throid

NP thyroid

prednisolone

prednisolone ODT

prednisone

prednisone intensol

progesterone

testosterone

testosterone cypionate

westhroid

WP thyroid

Estring

Estrogel

Evamist

Femring

Forteo*

Ganirelix* ^

H.P. Acthar* (PA)

Lupron Depot* (PA)

Lupron Depot-Ped* (PA)

Menostar

Minivelle

Osphena

Somatuline Depot* (PA)

Striant (QL)

Synthroid

Testopel

Tirosint

Triostat

Unithroid

Vagifem

Vivelle-Dot

INFECTIONS

acyclovir

adefovir*

amoxicillin

amoxicillin ER

amoxicillin-clavulanate ER

amoxicillin-clavulanate

atovaquone

atovaquone-proguanil

avidoxy

azithromycin

cefdinir

cefixime

cefprozil

cefuroxime

cephalexin

ciprofloxacin

clarithromycin

clarithromycin ER

clindamycin

doxy 100

doxycycline

doxycycline IR-DR

entecavir*

erythromycin

famciclovir

fluconazole

hydroxychloroquine

Baraclude solution*

Daklinza* (PA)

Harvoni* (PA)

Kitabis Pak*

Sovaldi* (PA)

Tamiflu (QL)

Thalomid* (PA)

Albenza

Alinia

Bactrim

Bactrim DS

Baraclude tablet*

Cayston*

Ceftin

Cipro

Cleocin

Clindesse

Daraprim (PA)

Dificid (PA)

Diflucan

E.E.S.

Eryped

Ery-Tab

Metrogel-vaginal

Minocin

Monurol

Noxafil

Nuvessa

PCE

Plaquenil

Sporanox

Stromectol

Sulfatrim

Suprax

Synagis* (PA)

Tobi Podhaler*



INFECTIONS (cont)

hydroxychloroquine

itraconazole

levofloxacin

linezolid (PA)

metronidazole

minocycline

minocycline ER

Moderiba*

mondoxyne NL

morgidox

moxifloxacin

nitrofurantoin

nystatin

penicillin

sulfamethoxazole-trimethoprim

terbinafine

tetracycline

tinidazole

tobramycin*

valacyclovir

valganciclovir

vancomycin

vandazole

voriconazole (PA)

Urelle

Uretron D-S

Uribel

Urogesic-blue

Uta

Valcyte

Valtrex

Vibramycin

Viekira Pak* (PA)

Xifaxan

Zepatier* (PA)

Zithromax

Zithromax Tri-pak

Zmax

Zovirax

Zyvox (PA)

INFERTILITY

clomiphene citrate^ Follistim AQ* ^ Crinone^

Endometrin^

Makena (PA)

Menopur* ^

MISCELLANEOUS

naltrexone

pulmosal

sodium chloride

Cerdelga* (PA) Addyi (QL, GEN)

Botox* (PA)

Cerezyme* (PA)

Esbriet* (PA)

Exjade*

Hyper-Sal

Jadenu*

Kuvan* (PA)

Myalept* (PA)

Nebusal

Nuedexta

Orfadin*

Strensiq* (PA)

Syprine

Vivitrol*

Xenazine* (PA)

Zavesca* (PA)


8



MULTIPLE SCLEROSIS

glatopa* (PA) Ampyra* (PA)

Aubagio* (PA)

Avonex* (PA)

Betaseron* (PA)

Copaxone* (PA)

Extavia* (PA)

Gilenya* (PA)

Plegridy* (PA)

Rebif* (PA)

Tecfidera* (PA)

NUTRITIONAL/DIETARY

b-12 compliance

b-12 kit

calcitriol

calcium

ciferex

cyanocobalamin injection

folic acid

folixapure

Klor-Con

Klor-Con m10, m20

klor-con sprinkle

k-sol

multivitamin with fluoride

ortho d

pnv-DHA

potassium chloride

prena1 pearl

prenatal plus

prenatal vitamin plus low iron

preplus

rulavite DHA

virt-pn DHA

vitamin d2

zatean-pn DHA

zavara

Fosrenol

Nestabs DHA

OB Complete

Prefera OB

Renvela

Select-OB+ DHA

Auryxia

CitraNatal

Concept DHA

DermacinRx PureFolix

Durachol

Feriva 21-7

Ferralet 90

Integra Plus

Klor-Con

Klor-Con 8, 10meq

Klor-Con M15

K-Tab ER

Mephyton

MVC-Fluoride

Nascobal

Nicomide

Noxifol-d3

OB Complete Gold

Phoslyra

Physicians Ez

Poly-Vi-Flor

Prenatabs FA

Prenate

Renagel

Revesta

Velphoro

Vitafol

vitaMedMD

vitaPearl

OSTEOPOROSIS PRODUCTS

alendronate

ibandronate*

raloxifene

risedronate

Actonel (ST)

Atelvia (ST)

Evista

Prolia* (PA)

Xgeva* (PA)

PAIN RELIEF AND INFLAMMATORY DISEASE

acetaminophen-codeine

acitretin

allopurinol

baclofen

butalb-acetaminoph-caff-codein

Butrans (QL)

Enbrel* (PA)

Humira* (PA)

Hysingla ER (QL)

Oxycontin (QL)

Rasuvo* (PA)

Xtampza ER (QL)

Abstral (PA)

Actemra* (PA)

Actiq (PA)

Alsuma (QL)

Analpram HC

Alsuma (QL)



PAIN RELIEF AND INFLAMMATORY DISEASE (cont)

butalb-acetaminoph-caff-codein

butalbital-

acetaminophen-caffe

calcipotriene-betamethasone

capacet

carisoprodol

celecoxib (QL)

cyclobenzaprine

dermacinrx prizopak

diclofenac

diclofenac ER

diclofenac-misoprostol

dihydroergotamine (QL)

endocet

etodolac

etodolac ER

fentanyl (QL)

fioricet

glydo

hydrocodone-acetaminophen

hydromorphone ER (QL)

hydromorphone

ibuprofen

indomethacin

ketorolac tromethamine (QL)

leflunomide

lidocaine

lidocaine viscous

lidocaine-prilocaine

lorcet

lorcet HD

lorcet plus

lortab

margesic

meloxicam

metaxall

metaxalone

methocarbamol

morphine

morphine ER (QL)

nabumetone

naproxen

naproxen CR

naproxen ER

oxycodone

oxycodone ER (QL)

oxycodone-acetaminophen

oxymorphone

Alsuma (QL)

Analpram HC

Celebrex (ST, QL)

Cimzia* (PA)

Colchicine

Colcrys

Cosentyx* (PA)

Cuprimine

D.H.E. 45 (QL)

Depen

Duragesic (QL)

Enstilar

Fentora (PA)

Flector (ST, QL)

Frova (QL)

Imitrex (QL)

Indocin

Lazanda (PA)

Lidoderm

Lidovex

Livixil Pak

Lp Lite Pak

Migranal (QL)

Mitigare

Monovisc* (PA)

Nucynta (QL)

Nucynta ER (ST, QL)

Onzetra Xsail (QL)

Opana

Opana ER (ST, QL)

Orencia* (PA)

Orthovisc* (PA)

Otezla* (PA)

Otrexup* (PA)

Oxaydo

Parafon Forte Dsc

Percocet

Procort

Proctofoam-HC

Relpax (QL)

Remicade* (PA)

Roxicodone

Savella

Stelara* (PA)

Subsys (PA)

Synvisc* (PA)

Synvisc-one* (PA)

Taclonex

Uloric

Voltaren (ST)

Xartemis XR (ST, QL)

Xeljanz* (PA)

Xeljanz XR* (PA)

Zohydro ER (ST, QL)

Zomig (QL)


9



PAIN RELIEF AND INFLAMMATORY DISEASE (cont)

oxymorphone ER

primlev

relador pak

relador pak plus

rizatriptan (QL)

sumatriptan (QL)

tizanidine

tramadol (QL)

tramadol ER (QL)

vanatol LQ

verdrocet

vicodin

vicodin ES

vicodin HP

zolmitriptan (QL)

zolmitriptan ODT (QL)

PARKINSON’S DISEASE

amantadine

benztropine

bromocriptine

carbidopa-levodopa

carbidopa-levodopa ER

pramipexole

pramipexole ER

ropinirole ER

ropinirole

Azilect Apokyn* (PA)

Mirapex

Mirapex ER

Neupro

Rytary

Sinemet

Sinemet CR

SCHIZOPHRENIA/ANTI-PSYCHOTICS

aripiprazole

aripiprazole ODT

chlorpromazine

haloperidol

olanzapine

olanzapine ODT

olanzapine-fluoxetine

paliperidone ER

quetiapine

risperidone

risperidone ODT

ziprasidone

Seroquel XR Abilify Maintena

Fanapt (ST)

Invega (ST)

Invega Sustenna

Invega Trinza

Latuda (ST)

Rexulti (ST)

Saphris (ST)

Seroquel (ST)

SEIZURE DISORDERS

carbamazepine

carbamazepine ER

clonazepam

divalproex

divalproex ER

epitol

gabapentin

lamotrigine

lamotrigine ER

lamotrigine ODT

levetiracetam

Dilantin

Lamictal ODT

Lamictal XR starter kit

Lyrica

Aptiom

Banzel

Carbatrol

Depakote

Depakote ER

Depakote Sprinkle

Dilantin

Fycompa

Keppra

Keppra XR

Lamictal



SEIZURE DISORDERS (cont)

levetiracetam ER

oxcarbazepine

roweepra

topiramate

topiramate ER

Lamictal XR

Onfi

Oxtellar XR

Phenytek

Qudexy XR

Sabril*

Spritam

Tegretol

Tegretol XR

Topamax

Topiramate ER

Trileptal

Trokendi XR

Vimpat

SKIN CONDITIONS

acitretin

adapalene (PA age)

avar

avar-E

bp 10-1

calcipotriene

calcitrene

claravis (QL)

clindacin ETZ

clindacin P

clindamycin-benzoyl peroxide

clobetasol

clodan

clotrimazole-betamethasone

cormax

desonide

desoximetasone

diclofenac

econazole nitrate

fluocinonide

fluorouracil

imiquimod

ketoconazole

metronidazole

mupirocin

myorisan (QL)

neuac

nystatin-triamcinolone

permethrin

rosadan

rosanil

sodium sulfacetamide-sulfur

ss 10-2

sss 10-5

Fluoroplex Acanya

Aczone

Atralin (PA age)

Avar

Avar LS

Avar-E LS

Avita (PA age)

Azelex

Cleocin T

Clindamax

Cordran (ST)

Denavir

Desonate (ST)

Desowen (ST)

Differin (PA age)

Drysol

Efudex

Elidel (ST)

Epiduo

Epiduo Forte

Evoclin

Exelderm

Finacea

Lokara

Metrocream

Metrogel

Metrolotion

Naftin

Nizoral

Olux (ST)

Onexton

Picato

Retin-A (PA age)

Rosula

Sklice

Soolantra

Sumadan

Sumaxin

Sumaxin TS

10




SKIN CONDITIONS (cont)

sulfacetamide sodium-sulfur

sulfacleanse 8-4

tacrolimus

tretinoin (PA age)

tretinoin microsphere (PA age)

triamcinolone acetonide

triderm

zenatane (QL)

zencia

Tazorac

Temovate (ST)

Tolak

Topicort (ST)

Tretin-X (PA age)

Veltin

Xolegel

SLEEP DISORDERS/SEDATIVES

eszopiclone

modafinil (PA)

temazepam

zolpidem

zolpidem ER

Belsomra (ST)

Nuvigil (PA)

Silenor

Xyrem* (PA)

Zolpimist (ST)

SUBSTANCE ABUSE

buprenorphine

buprenorphine-naloxone (PA)

naloxone vial & PFS

Narcan Bunavail (PA)

Suboxone (PA)

Zubsolv (PA)

TRANSPLANT MEDICATIONS

azathioprine*

mycophenolate*

mycophenolic acid*

sirolimus*

tacrolimus*

Cellcept*

Prograf*

Astagraf XL*

Envarsus XR*

Myfortic*

Neoral*

URINARY TRACT CONDITIONS

cevimeline

doxazosin

dutasteride

dutasteride-tamsulosin

finasteride

oxybutynin

oxybutynin ER

phenazopyridine

potassium citrate ER

tamsulosin

terazosin

tolterodine

tolterodine ER

Avodart

Cystagon*

Detrol (ST)

Detrol LA (ST)

Elmiron

Enablex (ST)

Jalyn

Procysbi* (PA)

Rapaflo

Thiola

Urocit-K

* 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 your plan documents for more information.

^ This medication may not be covered under your plan. Please check your enrollment materials or use the Prescription Drug Price Quote tool on myCigna.com to find out if this medication is covered.

11

Your Cigna plan doesn’t cover the medications listed below without prior approval from Cigna. This means that if you use any of these medications, you may have to pay the full cost of the medication at the pharmacy.

Talk with your doctor to see which one of the covered generic or preferred brand alternatives listed in this drug list might be right for you.

CONDITION/COMMON USE/ DRUG CLASS

MEDICATION NOT COVERED^GENERIC AND/OR PREFERRED BRAND ALTERNATIVES

ALLERGY/NASAL SPRAYS Beconase AQ

Dymista

Nasonex

Omnaris

QNASL

Veramyst

Zetonna

Generic nasal steroids (e.g. fluticasone)

QNASL Children budesonide

fluticasone

triamcinolone

ANXIETY/DEPRESSION/BIPOLAR DISORDER Aplenzin bupropion XL

Ativan lorazepam

Cymbalta duloxetine

Lexapro escitalopram

Pexeva paroxetine

Pristiq ER bupropion SR/XL

duloxetine

venlafaxine ER

all generic SSRIs

Wellbutrin XL bupropion XL (ER 24hr tablet)

ASTHMA/COPD/

RESPIRATORY

Aerospan

Alvesco

Arnuity Ellipta

Asmanex

Asmanex HFA

Flovent Diskus

Flovent HFA

Pulmicort Flexhaler

QVAR

Arcapta Neohaler

Serevent Diskus

Striverdi Respimat

Dulera

Symbicort

Advair HFA

Advair Diskus

Breo Ellipta

Incruse Ellipta

Tudorza Pressair

Spiriva

Spiriva Respimat

Proventil HFA

Ventolin HFA

Xopenex HFA

ProAir HFA

ProAir Respiclick

MEDICATIONS NOT COVERED TABLE

Medications NOT COVERED on your drug list^

12



ATTENTION DEFICIT HYPERACTIVITY DISORDER

Vyvanse Adderall XR

dexmethylphenidate ER

dextroamphetamine-amphet ER

methylphenidate ER/LA

BLOOD PRESSURE/HEART MEDICATIONS Accupril quinapril

Accuretic quinapril-HCTZ

Aceon perindopril erbumine

Altace ramipril

Atacand candesartan

Atacand-HCT candesartan-HCTZ

Avalide irbesartan-HCTZ

Avapro irbesartan

Bystolic Generic beta blockers (e.g. metoprolol, atenolol)

Cardizem diltiazem

Cardizem CD Cartia XT

diltazem CD/ER

Cozaar losartan

Diovan valsartan

Diovan HCT valsartan-HCTZ

Edarbi Generic ARBs (e.g. losartan; valsartan)

Edarbyclor Generic ARBs + HCTZ (e.g. losartan-HCTZ)

Exforge amlodipine-valsartan

Exforge HCT amlodipine-valsartan-HCTZ

Hyzaar losartan-HCTZ

Isordil

Isordil Titradose

isosorbide dinitrate

Lanoxin Digitek

digoxin

Lotensin benazepril

Lotrel amlodipine-benazepril

Mavik trandolapril

Micardis telmisartan

Micardis HCT telmisartan-HCTZ

Prinivil

Zestril

lisinopril

Tarka trandolapril-verapamil ER

Tekturna Generic ACE/ARBs

Tekturna HCT Generic ACE/ARBs + HCTZ

Twynsta telmisartan-amlodipine

Vaseretic enalapril-HCTZ

Vasotec enalapril

Zestoretic lisinopril-HCTZ


13



CHOLESTEROL MEDICATIONS Altoprev atorvastatin

lovastatin

rosuvastatin

simvastatin

Antara

Fenoglide

fenofibrate

Crestor rosuvastatin

Lescol XL fluvastatin ER

Lipitor atorvastatin

Livalo atorvastatin

rosuvastatin

simvastatin

Pravachol pravastatin

Vytorin atorvastatin

rosuvastatin

simvastatin

Zetia

Zocor simvastatin

COUGH/COLD

MEDICATIONS

Tussicaps hydrocodone-chlorpheniramne ER

promethazine-codeine

DIABETES ACCU-CHEK, Contour, Freestyle, all

other test strips

OneTouch Ultra, OneTouch Verio

Afrezza

Apidra

Apidra SoloStar

Humalog

alogliptin

alogliptin-metformin

Jentadueto

Kazano

Nesina

Tradjenta

Janumet/Janumet XR

Januvia

Kombiglyze XR

Onglyza

alogliptin-pioglitazone

Oseni

Janumet/Janumet XR

Januvia

Kombiglyze XR

Onglyza

Generic TZDs (e.g. pioglitazone)

Bydureon

Byetta

Tanzeum

Victoza

Trulicity

Farxiga

Jardiance

Synjardy

Xigduo XR

Invokamet/Invokana

Glumetza

metformin ER (generic Fortamet)

metformin ER (generic Glucophage XR)

Glyxambi Invokamet/Invokana

Janumet/Janumet XR

Januvia

Kombiglyze XR

Onglyza

14




DIABETES (cont) Levemir

Tresiba

Lantus

Lantus SoloStar

Toujeo

Novolin, Novolog Humalog, Humulin

EYE CONDITIONS Lumigan bimatoprost

latanoprost

Travatan Z

travoprost

GASTROINTESTINAL/HEARTBURN Anusol-HC

Cortifoam

Uceris foam

Anucort-HC

GRx HiCort 25

Hemmorex-HC

hydrocortisone

Procto-med HC

Proctosol-HC

Proctozone-HC

Rectacort-HC

Asacol-HD

Colazal

Delzicol

Dipentum

Giazo

Apriso

balsalazide

Lialda

Pentasa

sulfasalazine

sulfasalazine DR

Librax chlordiazepoxide-clidinium

Metozolv ODT metoclopramide

metoclopramide ODT

Pepcid famotidine

Proctocort Hemmorex-HC

Hemril

hydrocortisone

Procto-Pak

Zuplenz ondansetron

ondansetron ODT

HORMONAL AGENTS Axiron

Fortesta

Natesto

Testim

Vogelxo

Androgel

testosterone

Dexpak dexamethasone

Genotropin

Norditropin Flexpro

Nutropin AQ

Omnitrope

Saizen

Zomacton

Humatrope (PA)

Rayos prednisone

prednisone intensol

Uceris tablet budesonide EC

15




INFECTIONS Acticlate

Adoxa

Adoxa Pak

Doryx

Minocin capsule

Monodox

Oracea

Solodyn

Vibramycin capsule

Generic products (e.g. doxycycline; minocycline)

Bethkis

Tobi

Kitabis Pak

tobramycin

Onmel itraconazole

terbinafine

Sitavig acyclovir

INFERTILITY Gonal-F

Gonal-F RFF

Gonal-F RFF Redi-ject

Follistim AQ (PA)

MISCELLANEOUS Horizant gabapentin

PAIN RELIEF AND INFLAMMATORY DISEASE Amrix cyclobenzaprine

Other generic muscle relaxants

Bupap butalbital-acetaminophen

marten-tab

tencon

Belbuca Butrans

Cambia

Diclofenac

Duexos

Klofensaid II

Pennsaid

Tivorbex

Vimovo

Vivlodex

Zipsor

Zorvolex

Generic prescription NSAIDs (e.g., celecoxib, meloxicam)

Capital W-codeine acetaminophen-codeine

Conzip tramadol

tramadol ER

Gralise gabapentin

Kineret

Simponi

Simponi Aria

Enbrel (PA)

Humira (PA)

Lidocaine

Lido-K

lidocaine

lidopin

Lorzone chlorzoxazone

Sprix ketorolac

Sumavel Dosepro sumitriptan

Treximet

Zembrace Symtouch

Generic NSAIDs

Generic triptans (e.g. sumatriptan; naratriptan)

Zomig ZMT zolmitriptan ODT

16




SCHIZOPHRENIA/ANTI-PSYCHOTICS Abilify aripiprazole

Fazaclo

Versacloz

clozapine

clozapine ODT

SEIZURE DISORDERS Mysoline primidone

SKIN CONDITIONS Absorica Claravis

Myorisan

Zenatane

Aldara imiquimod

Bensal HP Salacyn

salicylic acid

Benzaclin

Duac

Neuac kit

clindamycin-benzoyl peroxide

Neuac gel

Carac fluorouracil

Clindagel clindamycin

Clobex clobetasol

Ertaczo

Extina

ketoconazole

ketodan

Halog

Ultravate X

clobetasol

halobetasol

Jublia

Kerydin

Ciclodan

ciclopirox

itraconazole

terbinafine

Kenalog

Trianex

triamcinolone

Locoid

Locoid Lipocream

hydrocortisone

Loprox ciclopirox

Luzu

Vusion

ketoconazole

Noritate metronidazole

Rosadan

Novacort hydrocortisone

Oxistat clotrimazole

econazole

ketoconazole

Penlac ciclodan

ciclopirox

Plexion sodium sulfacetamide-sulfur

SS 10-2

zencia

Salex salicylic acid

Vanos fluocinonide

Verdeso desonide

Xerese acyclovir

hydrocortisone

Ziana clindamycin

tretinoin

Zovirax acyclovir

Zyclara imiquimod

17




SLEEP DISORDERS/SEDATIVES Ambien

Ambien CR

Edluar

Intermezzo

zolpidem

zolpidem ER

SUBSTANCE ABUSE Evzio Narcan

URINARY TRACT CONDITIONS Myrbetriq

Toviaz

VESIcare

darifenacin ER

oxybutynin chloride ER

tolterodine ER

trospium chloride ER

^ This drug is not covered on your plan. Please talk with your doctor about switching to an alternative. Your prescription drug plan requires approval by Cigna to have this medication covered.

18

EXCLUSIONS & LIMITATIONS

› over-the-counter (OTC) medications (medications that do not require a prescription) except insulin unless state or federal law requires coverage of such drugs;

› prescription drugs or supplies for which there is a non-prescription or OTC therapeutic alternative;

› physician-administered injectable medications covered under the Plan’s medical benefit, unless otherwise covered under the plan’s prescription drug list or authorized by Cigna;

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

› medications that are not medically necessary;

› experimental or investigational medications, including FDA-approved drugs used for purposes other than those approved by the FDA unless the drug is recognized for the treatment of the particular indication;

› medications that are not approved by the Food & Drug Administration (FDA);

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

› medications used for fertility, sexual dysfunction, cosmetic purposes, weight loss, smoking cessation, or athletic enhancement;

› prescription vitamins (other than prenatal vitamins) or dietary supplements unless state or federal law requires coverage of such drugs;

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

› replacement of prescription drugs and related supplies due to loss or theft;

› drugs which are to be taken by or administered to a covered person while they are a patient in a licensed hospital, skilled nursing facility, rest home or similar institution which operates on its premises or allows to be operated on its premises a facility for dispensing pharmaceuticals;

› prescriptions more than one year from the date of issue; or

In addition to the plan’s standard pharmacy exclusions, certain new FDA-approved drug products (including but not limited to medications, medical supplies or devices that are covered under standard pharmacy benefit plans) may not be covered for the first six months of market availability unless authorized by Cigna as medically necessary.

Health benefit plans vary, but in general to be eligible for coverage a drug must be approved by the Food and Drug Administration (FDA), prescribed by a health care professional, purchased from a licensed pharmacy and be medically necessary. If your plan provides coverage for certain preventive prescription drugs with no cost-share, covered employees may be required to use an in-network pharmacy to fill the prescription. If employees use a pharmacy that does not participate in your plan’s network, the prescription may not be covered. Certain drugs may require prior authorization, or be subject to step therapy, quantity limits or other utilization management requirements.

Plans generally do not provide coverage for the following under the pharmacy benefit, except as required by state or federal law, or by the terms of your specific plan1:

1. Costs and complete details of the plan’s prescription drug coverage are set forth in the plan documents. If there are any differences between the information provided here and the plan documents, the information in the plan documents takes complete precedence.

In accordance with Texas and Louisiana state law, customers with affected benefit plans who receive coverage for medications that are removed from the prescription drug list during the plan year will continue to have those medications covered at the same benefit level until their plan renewal date. To find out if these state mandates apply to your plan, please call Customer Service.

Cigna reserves the right to make changes to the Drug List without notice. Your plan may cover additional medications; please refer to your enrollment materials for details. Cigna does not take responsibility for any medication decisions made by the doctor or pharmacist. Cigna may receive payments from manufacturers of certain preferred brand medications, and in limited instances, certain non-preferred brand medications, that may or may not be shared with your plan depending on its arrangement with Cigna. Depending upon plan design, market conditions, the extent to which manufacturer payments are shared with your plan and other factors as of the date of service, the preferred brand medication may or may not represent the lowest-cost brand medication within its class for you and/or your plan.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company (CHLIC), Connecticut General Life Insurance Company (CGLIC), Cigna Behavioral Health, Inc., Cigna Health Management, Inc., Tel-Drug, Inc., and Tel-Drug of Pennsylvania, L.L.C. “Cigna Home Delivery Pharmacy” refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C. Policy forms: OK - HP-APP-1 et al (CHLIC), GM6000 C1 et al (CGLIC); TN - HP-POL43/HC-CER1V1 et al (CHLIC). The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.

887152 c Advantage 3Tier w DRT 08/16 © 2017 Cigna. Some content provided under license.

Drug Name

ORAL AND SELF INJECTABLE SPECIALTY LIST

Specialty medications are used to treat complex conditions like multiple sclerosis, hepatitis C and rheumatoid arthritis. The following is a list of specialty pharmacy medications. These are covered under your pharmacy benefit. Those medications marked with an asterisk must be obtained through Cigna Home Delivery Pharmacy for it to be covered. This only applies when the medication is covered under the pharmacy benefit and when your plan requires the use of Cigna Home Delivery Pharmacy for specialty medications. Please note, this list is subject to change.

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

891437 10/16 © 2016 Cigna.

Aabacavirabacavir-lamivudine-

zidovudineActemra*Actimmune*Adcirca*adefovir dipivoxil*AdempasAfinitor*Afinitor DisperzAgrylin*AkynzeoAlecensa*AlkeranAmicar*aminocaproic acid*Ampyra*Anagrelide*AnzemetApokyn*AptivusArcalystAstagraf XL*

AtriplaAubagio*Avonex*Azasan*azathioprine*

BBaraclude*Betaseron*bexarotene*bicalutamide*Bosulif*

CCabometyxcapecitabine*CaprelsaCasodex*CaystonCellcept*Cerdelga*CholbamCimzia*Combivir

CometriqCompleraCopaxone*Copegus*Cosentyx*Cotellic*Crixivancyclophosphamide*cyclosporine*Cystadane*Cystagon

DDaklinza*Descovydidanosine

EEdurantEgrifta*Emcyt*Emend (cap, sol)EmtrivaEnbrel*

entecavir*Envarsus XR*EpclusaEpivirEpivir HBVEpzicomErivedge*Esbriet*EvotazExjade*Extavia*

FFarydakFirazyr*flutamide*Fuzeon

GGattexGengraf*Genotropin*GenvoyaGilenya*

2

Drug Name

GilotrifGlatopa*Gleevec*

HHarvoni*Hecoria*Hepsera*Hexalen*Humatrope*Humira*Hycamtin*

IIbrance*Iclusigimatinib*ImbruvicaImuran*Incivek*IncrelexInfergen*Inlyta*IntelenceInviraseIressaIsentress

JJadenu*JakafiJuxtapid

KKaletraKalydecoKineret*Kynamro

Llamivudinelamivudine HBVlamivudine-zidovudineLenvimaLetairis*leucovorin*LexivaLonsurfLynparza

MMatulaneMekinist*Mesnexmethotrexate*Moderiba*Myalept

mycophenolate*mycophenolic acid*Myfortic*

NNatparaNeoral*nevirapinenevirapine ERNexavar*NinlaroNorditropin*NortheraNorvirNuplazidNutropin AQ*

OOcalivaOdefseyOdomzo*OfevOlysio*Omnitrope*Opsumit*Orencia*Orenitram EROrfadinOrkambiOtezla*Otrexup

Pparicalcitol*Pegasys*Pegintron*Plegridy*Pomalyst*Praluent*PrezcobixPrezistaProcysbiPrograf*Promacta*Pulmozyme*Purixan

RRapamune*RasuvoRebetol*Rebif*Rebif Rebidose*Repatha*RescriptorRetrovirRevatio*

Revlimid*ReyatazRheumatrexRibasphere*Ribasphere Ribapak*Ribatab*ribavirin*Rilutek*riluzole*

SSabrilSaizen*Sandimmune*SelzentrySensiparSerostim*Signiforsildenafil*Simponi*Simponi Aria*Sirolimus*SomavertSovaldi*Sprycel*stavudineStelara*Stivarga*StrensiqStribildSucraidSustivaSutent*Sylatron*

Ttacrolimus*Tafinlar*TagrissoTaltz*Tarceva*Targretin*Tasigna*Tecfidera*Technivie*Temodar*temozolomide*tetrabenazineTev-Tropin*Thalomid*TivicayTobi Podhaler*Tracleer*Trexall*TriumeqTrizivirTruvada

TybostTykerb*Tyzeka*

UUptravi

VVarubiVenclextaVentavisVictrelis*VidexVidex ECViekira Pak*ViraceptViramuneViramune XRVirazole*VireadVistogardVitektaVotrient*

XXalkori*Xeljanz*Xeljanz XR*Xeloda*XenazineXolair*Xtandi*XuridenXyrem

ZZavescaZelboraf*Zemplar*Zepatier*ZeritZiagenzidovudineZinbrytaZolinzaZomacton*ZorbtiveZortress*ZydeligZykadiaZytiga*


All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company (CHLIC), Connecticut General Life Insurance Company (CGLIC), Tel-Drug, Inc., Tel-Drug of Pennsylvania, L.L.C., and HMO or service company subsidiaries of Cigna Health Corporation, including Cigna HealthCare of Arizona, Inc., Cigna HealthCare of California, Inc., Cigna HealthCare of Colorado, Inc., Cigna HealthCare of Connecticut, Inc., Cigna HealthCare of Florida, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Illinois, Inc., Cigna HealthCare of Indiana, Inc., Cigna HealthCare of St. Louis, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of New Jersey, Inc., Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of Tennessee, Inc. (CHC-TN), and Cigna HealthCare of Texas, Inc. “Cigna Home Delivery Pharmacy” refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C. Policy forms: OK - HP-APP-1 et al (CHLIC), GM6000 C1 et al (CGLIC); TN - HP-POL43/HC-CER1V1 et al (CHLIC), GSA-COVER, et al (CHC-TN). The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.


Cigna reserves the right to make changes to the Drug List without notice. Your plan may cover additional medications; please refer to your enrollment materials for details. Cigna does not take responsibility for any medication decisions made by the doctor or pharmacist. Cigna may receive payments from manufacturers of certain preferred brand medications, and in limited instances, certain non-preferred brand medications, that may or may not be shared with your plan depending on its arrangement with Cigna. Depending upon plan design, market conditions, the extent to which manufacturer payments are shared with your plan and other factors as of the date of service, the preferred brand medication may or may not represent the lowest-cost brand medication within its class for you and/or your plan.

Prescription Drug Claim Form

583522j Rev. 01/2015

Insured and/or Administered by Connecticut General Life Insurance Company Cigna Health and Life Insurance Company Cigna HealthCare*

REASON FOR REIMBURSEMENT

This claim form can be used to request reimbursement for covered expenses. Please check which reason applies (at least one must be checked):

Out-of-Network Compound Prescription (Pharmacist: Claims must list ALL ingredients along with itemized NDCs, quantities and charges.)

For Health Care Reform related Over-the-Counter reimbursement requests, include your Doctor’s prescription.

PARTICIPANT/PATIENT INFORMATION

Non-Participating Pharmacy

Other (Please explain)Eligibility (Please explain)

Emergency

2)

DRUG NAME & STRENGTH

PHARMACY NAME

NDC

_____ / _____ / _____ ______________ ________ _____________DATE FILLED RX NUMBER DAY SUPPLY

PHARMACY NABP

PHARMACY ADDRESS

$

QTY

AMT. PAID

1)

DRUG NAME & STRENGTH

PHARMACY NAME

NDC

_____ / _____ / _____ ______________ ________ _____________DATE FILLED RX NUMBER DAY SUPPLY

PHARMACY NABP

PHARMACY ADDRESS

$

QTY

AMT. PAID

PRESCRIPTION INFORMATION

Primary coverage is with another insurance carrier. Please provide explanation of benefits (EOB) or denial letter from the primary insurance carrier.

Participant Name:







Patient Relationship to Participant: Patient Sex:

Male FemaleSpouseSelf (Participant) Dependent

I represent that the patient information entered on this form is correct, that the patient named is eligible for the benefits and that the patient has received the medication described. I also represent that the medication received is not for treatment of an on-the-job injury. I also authorize release of all information pertaining to this claim to the plan administrator or its designees.

Any person who knowingly and with intent to defraud any insurance company or other person: (1) files an application for insurance or statement of claim containing any materially false information; or (2) conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act which is a crime. For residents in the following states, please see the last page of this form: Alaska, Arizona, California, Colorado, District of Columbia, Florida, Kentucky, Maryland, Minnesota, New Jersey, New York, Oregon, Pennsylvania, Tennessee, Texas and Virginia.

Patient Signature: Date: Daytime Phone Number:

Cigna ID Number or Participant Social Security Number: (on the front of your Cigna ID card)

Employer:

Account Number: (on the front of your Cigna ID card)

Patient Name (use a separate form for each family member): Patient Birth Date: (Mo., Day, Year)

Multi-Ingredient Compound Prescription Information - To be Completed by Dispensing Pharmacy.

Pharmacist: If an itemized compound drug receipt is not available, please use this form to list the ingredients. 1. Use one form for each multi-ingredient compound prescription. Copy the form as needed. 2. The patient should send receipt(s) showing the out-of-pocket cost, and the Prescriber's name and DEA #. 3. SIGN the receipt. The information below is required to process multi-ingredient claim submissions. For each NDC number, indicate the "metric quantity" expressed in the number of tablets, grams, milliliters, injectables, etc. and the cost.

Quantity Valid NDC Drug Name Customer's Charge

1

2

3

4

5

INSTRUCTIONS

Fold

1.

2.

3.

4.

5.

6.

Complete ALL information on the front side of this form. Forms missing information may be denied, delayed orreturned. If you need help completing this form, contact your pharmacist.

Sign and date the Certification Statement in the area provided. Keep a copy of all forms and receipts for your records.

The Prescription Information section must be completed for each prescription for which you are seekingpayment.

For Health Care Reform related over-the-counter payment requests, include your Doctor's prescription. Please keep a copy of the prescription for your records.

Submit a separate form for each family member.

Mail the claim form within 12 months of the prescription fill date, along with original receipts (cash registerreceipts alone are not acceptable), to:

Fold

7.

RETURN ADDRESS

IMPORTANT: PLEASE PROVIDE CURRENT ADDRESS INFORMATION BELOW:

CUSTOMER STREET ADDRESS

CUSTOMER NAME

CUSTOMER CITY, STATE, ZIP

Cigna Pharmacy Service Center P.O. Box 188053 Chattanooga, TN 37422-8053

This Prescription Drug Claim Form is for Cigna customer use only. If you are a pharmacy, and need to file a claim, please contact Catamaran Provider Relations at

www.catamaranrx.com/pharmacies

Questions? Please call the Cigna number located on your ID card.

Did you know?

We may be able to reimburse you for any prescriptions you paid for directly and didn't use your insurance to cover. For instance, if you used a non-participating pharmacy, and your plan covers out-of-network purchases, file a claim.

We'll review it and look to see if we can get you a possible refund.

Prescribed medical equipment (or supplies) - Ask your medical plan about benefits for equipment. FSA and HRA expenses - Contact your FSA (or HRA) payer for a claim address and instructions. Prescriptions purchased by customers not enrolled with a Cigna drug plan - Check your benefit materials to see if your employer chose a Pharmacy Benefits Company other than Cigna. Non-covered drugs - See the "Exclusions and limitations" section of your plan's drug list.

Please do not submit claims for:....

583522j Rev. 01/2015

*"Cigna HealthCare" refers to the various HMO subsidiaries of Cigna Health Corporation. If you are enrolled in a Cigna HMO plan, complete details can be found in your plan documents or Evidence of Coverage.

"Cigna" is a registered service mark, and the "Tree of Life" logo is a service mark, of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by 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, Cigna Health Management, Inc., and HMO subsidiaries of Cigna Health Corporation.

Caution: Any person who, knowingly and with intent to defraud any insurance company or other person: (1) files an application for insurance or statement of claim containing any materially false information; or (2) conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act.

IMPORTANT CLAIM NOTICE

Alaska Residents: A person who knowingly and with intent to injure, defraud or deceive an insurance company or files a claim containing false, incomplete or misleading information may be prosecuted under state law. Arizona Residents: For your protection, Arizona law requires the following statement to appear on/with this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. California Residents: For your protection, California law requires the following to appear on/with this form. Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Colorado Residents: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. District of Columbia Residents: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. Florida Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree. Kentucky Residents: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Maryland Residents: Any person who knowingly OR willfully presents false or fraudulent claim for payment of a loss or benefit or who knowingly OR willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Minnesota Residents: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. New Jersey Residents: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. New Mexico Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties. New York Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed $5000 and the stated value of the claim for each such violation. Oregon Residents: Any person who knowingly and with intent to defraud any insurance company or other person: (1) files an application for insurance or statement of claim containing any materially false information; or, (2) conceals for the purpose of misleading, information concerning any material fact, may have committed a fraudulent insurance act. Pennsylvania Residents: Any person who, knowingly and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Rhode Island Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Tennessee Residents: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. Texas Residents: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Virginia Residents: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated state law.

Please complete this form for NEW and REFILL

prescription medication. You can also order refills

online at the website on your ID card.

Print all information clearly as shown in the

sample below using BLUE or BLACK ink.

Fill in the applicable ovals completely ( ).

Step 1: Insurance Cardholder Information Complete if above has changed or appears blank

--

--

-

email _______________________________________________________

Step 2: Allergies & Health Conditions Complete this section every time


Prescription Order Form

1 2 3 4 A B C D

*10450001*10450001

Rev. 2.0 1/12

Address above is a one time address

514

Name (start with cardholder)

New customers must complete this section.

If left blank will mean no known drug allergies or

no change from information provided previously to

Cigna Home Delivery Pharmacy.

Other (list belo

w)

Hig

h C

hole

sterol

GI/G

ER

D

Asthm

a

Hig

h B

lood

Pressure

Dia

betes

Aspirin

NS

AID

S

Other (list belo

w)

Erythrom

ycin

Sulfa

No

ne

Please write the individual’s name and list their other allergies and other health conditions referenced above:

Allergies Health Conditions

//M YYDDM

Codein

e/M

orphin

e

Penic

illin

L MANTSA E

A

C

R S ENILS 1EDD

A R S ENILS 2EDD I T Y

S T Z I P

P H O N E #

F I R S T N A M E

Person completing __________________________________________

A L T P H O N E #

M

F EMNTSRI A

L EMNTSA A

Date of Birth

//M YYDDMF EMNTSRI A

L EMNTSA A


L EMNTSA A


L EMNTSA A

C INGI DA

Order updates, reminders and other educational information may be sent to the email

address above for the following individuals: ___________________________________________

_______________________________________________________________________________________

“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 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.

Check ( ) One

*10450002*10450002

Step 5: Refill Prescriptions Attach label OR complete requested information

Print Prescription Number Here

Individual’s Name _______________________

Date of Birth ___________________________

Drug Name ____________________________

Remember to include the original prescription(s) from your doctor(s).

You can call us at 1.800.835.3784 or visit the website on your ID card. You can also write to us or

mail this order form to Cigna Home Delivery Pharmacy, PO Box 1019, Horsham PA 19044.

Step 6: New Prescriptions Include original written prescription from your doctor

Pharmacy law allows pharmacists to substitute a less expensive generically equivalent medication for a brand name medication

unless you or your doctor request the brand. By checking ( ) “Brand Only”, you may be responsible for a higher cost.

Individual’s Full Name Date of Birth

Fill

Now

Do Not

Fill

Now Medication Name & Strength

( ) if

Brand

Only Doctor’s Full Name

Standard Shipping USPS Priority Mail Overnight Delivery2 - 3 Days$0.00 $17.95$9.25

Refrigerated shipments will be expedited at no additional cost. You are responsible for the cost of SPECIAL SHIPPING which

expedites carrier delivery time only. Order processing is not affected by SPECIAL SHIPPING. These costs may be subject to

change by carrier without prior notification and may vary depending on weight and zone.

Credit / Debit Card #

VISA

Money OrderCheck

American Express

Discover

MasterCard

Please make check or money order payable to Cigna Home Delivery Pharmacy

.$Total payment enclosed (excluding credit card payment):

I allow Cigna Home Delivery Pharmacy to bill my credit / debit card for this and all future orders. I understand that my credit

/ debit card will be billed the following amounts in effect at the time my order is filled: any applicable copayment(s), coinsur-

ance and/or deductible(s), payments due for any medications not covered, plus any special shipping costs.

Use Credit / Debit Card on File

/

Expiration Date

Step 4: Method of Payment

Step 3: Shipping Method

,

/Expiration DateLast 4 digits of Credit / Debit Card

Check



Date of Birth ___________________________

Drug Name ____________________________



Date of Birth ___________________________

Drug Name ____________________________



Date of Birth ___________________________

Drug Name ____________________________

Please write the date of birth and the Cigna ID on the back of each prescription.

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

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

589901 l 01/15

PHARMACY DIRECTORYAlabamaCare Plus/CVS Pharmacy

Costco Pharmacy

CVS Pharmacy

Fred Meyer Pharmacy

Kmart Pharmacy

Kroger Pharmacy

Medicine Shoppe Pharmacy

Publix Pharmacy

Rite Aid Pharmacy

Sam’s Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

Winn-Dixie Pharmacy

AlaskaCarrs Quality Centers

Costco Pharmacy

Fred Meyer Pharmacy

Safeway Pharmacy

Sam’s Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

ArizonaBashas’ United Drug

Cigna HealthCare Centers

Care Plus/CVS Pharmacy

Costco Pharmacy

CVS Pharmacy

Fry’s Food & Drug

Kmart Pharmacy


Osco Drug

Osco Pharmacy

Safeway Pharmacy

Sam’s Pharmacy

Savon Pharmacy

Smith’s Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

ArkansasBrookshire Pharmacy

CVS Pharmacy

Fred’s Pharmacy

Harps Pharmacy

Kmart Pharmacy

Kroger Pharmacy

Medicap Pharmacy


Price Cutter Pharmacy

Sam’s Pharmacy

Savon Pharmacy

Super D Drugs

Target Pharmacy

USA Drug Express

USA Drug

Walgreens Pharmacy

Walmart Pharmacy

CaliforniaBel-Air Pharmacy


Costco Pharmacy

CVS Pharmacy

Horton and Converse Pharmacy

Kmart Pharmacy


Nob Hill Pharmacy

Pavilions Pharmacy

Raley’s Pharmacy

Ralphs Pharmacy

Rite Aid Pharmacy

Safeway Pharmacy

Sam’s Pharmacy

Save Mart Pharmacy

Savon Pharmacy

Shopko Pharmacy

Super Rx Pharmacy

Target Pharmacy

Von’s Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

ColoradoAlbertson’s Pharmacy

City Market Pharmacy


Costco Pharmacy

King Sooper’s Pharmacy

Kmart Pharmacy


Rite Aid Pharmacy

Safeway Pharmacy

Sam’s Pharmacy

Savon Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

ConnecticutA&P Pharmacy

Big Y Pharmacy

Costco Pharmacy


CVS Pharmacy



Rite Aid Pharmacy

Sam’s Pharmacy

Shoprite Pharmacy


Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

DelawareCostco Pharmacy

CVS Pharmacy

Giant Pharmacy


Kmart Pharmacy

Pathmark Pharmacy

Rite Aid Pharmacy

Safeway Pharmacy

Sam’s Pharmacy

Savon Pharmacy

Shoprite Pharmacy

Super Fresh Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

District of ColumbiaCare Plus/CVS Pharmacy

CVS Pharmacy

Costco Pharmacy

Giant Pharmacy


Rite Aid Pharmacy

Safeway Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

FloridaCare Plus/CVS Pharmacy

Costco Pharmacy

CVS Pharmacy

Kmart Pharmacy

Kroger Pharmacy

Medicap Pharmacy


Navarro Discount Pharmacy

Publix Pharmacy

Sam’s Pharmacy

Savon Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

Winn-Dixie Pharmacy

GeorgiaBi-Lo Pharmacy


Costco Pharmacy

CVS Pharmacy

Fred’s Pharmacy

Harveys Pharmacy

Ingles Pharmacy

Kmart Pharmacy

PHARMACY DIRECTORY

Kroger Pharmacy

Medicap Pharmacy


Publix Pharmacy

Rite Aid Pharmacy

Sam’s Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

Winn-Dixie Pharmacy

GuamKmart Pharmacy

HawaiiCare Plus/CVS Pharmacy

Costco Pharmacy

Kmart Pharmacy

Longs Drug Stores

Safeway Pharmacy

Sam’s Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

IdahoCostco Pharmacy

Fred Meyer Pharmacy

Kmart Pharmacy

Medicap Pharmacy


Ridleys Pharmacy

Rite Aid Pharmacy

Safeway Pharmacy

Sam’s Pharmacy

Savon Pharmacy

Shopko Pharmacy

Smith’s Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

IllinoisCostco Pharmacy

Cub Pharmacy

CVS Pharmacy

Doc’s Drugs

Fagen Pharmacy

Hartig Drug Company

Hy-Vee Pharmacy

Kmart Pharmacy

Kroger Pharmacy

Medicap Pharmacy


Meijer Pharmacy

Osco Drugs

Sam’s Pharmacy

Schnucks Pharmacy

Shopko Pharmacy

Shop N Save Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

IndianaCostco Pharmacy

CVS Pharmacy

Fagen Pharmacy

Fred’s Pharmacy

Kmart Pharmacy

Kroger Pharmacy

Marsh Drugs

Martins Pharmacy

Medicap Pharmacy


Meijer Pharmacy

Osco Drugs

Rite Aid Pharmacy

Sam’s Pharmacy

Schnucks Pharmacy

Shopko Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

IowaCostco Pharmacy

CVS Pharmacy

Dahl’s Pharmacy

Hartig Drug Company

Hy-Vee Pharmacy

Kmart Pharmacy

Lewis Family Drug

Medicap Pharmacy


Osco Drugs

Sam’s Pharmacy

Schnucks Pharmacy

Shopko Pharmacy

Target Pharmacy

Thrifty-white Drug

Walgreens Pharmacy

Walmart Pharmacy

KansasCostco Pharmacy

CVS Pharmacy

Dillon Pharmacy

Hen House Pharmacy

Hy-Vee Pharmacy

Kmart Pharmacy

Medicap Pharmacy



PHARMACY DIRECTORY

Sam’s Pharmacy

Shopko Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

KentuckyCostco Pharmacy

CVS Pharmacy

Food City Pharmacy

Fred’s Pharmacy

Kmart Pharmacy

Kroger Pharmacy

Medicap Pharmacy


Meijer Pharmacy

Rite Aid Pharmacy

Sam’s Pharmacy

Shopko Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

LouisianaAlbertson’s Pharmacy

Brookshire Brothers

Brookshire Pharmacy

CVS Pharmacy

Fred’s Pharmacy

Kmart Pharmacy

Kroger Pharmacy

Medicap Pharmacy


Rite Aid Pharmacy

Sam’s Pharmacy

Savon Pharmacy

Super 1 Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

Winn-Dixie Pharmacy

MaineCVS Pharmacy

Hannaford Brothers

Kmart Pharmacy


Rite Aid Pharmacy

Osco Pharmacy

Sam’s Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

MarylandCostco Pharmacy

CVS Pharmacy


PHARMACY DIRECTORY

Giant Pharmacy

Happy Harry’s

Klein’s Shoprite Pharmacy

Kmart Pharmacy

Martins Pharmacy

Medicap Pharmacy


Rite Aid Pharmacy

Safeway Pharmacy

Sam’s Pharmacy

Savon Pharmacy

Shoppers Pharmacy

ShopRite Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

Wegmans Pharmacy

MassachusettsBig Y Pharmacy


Costco Pharmacy

CVS Pharmacy

Eaton Apothecary

Hannaford Brothers

Kmart Pharmacy


Osco Pharmacy


Rite Aid Pharmacy

Sam’s Pharmacy


Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

Wegmans Pharmacy

MichiganCostco Pharmacy

CVS Pharmacy

Family Fare Pharmacy

Henry Ford Medical

Kmart Pharmacy

Knight Drug

Kroger Pharmacy

Martins Pharmacy

Meijer Pharmacy


Rite Aid Pharmacy

Sam’s Pharmacy

Snyder Drug

Shopko Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

MinnesotaCare Plus/CVS Pharmacy

Cash Wise Pharmacy

Coborn’s Pharmacy

Costco Pharmacy

Cub Pharmacy

CVS Pharmacy

Econofoods Pharmacy

Fairview Pharmacy

Hy-Vee Pharmacy

Kmart Pharmacy

Lewis Family Drug

Mayo Clinic Pharmacy


Park Nicollet Pharmacy

Sam’s Pharmacy

Shopko Pharmacy

Rainbow Foods Pharmacy

Rainbow Pharmacy

Target Pharmacy

Thrifty-white Drug

Walgreens Pharmacy

Walmart Pharmacy

MississippiCVS Pharmacy

Fred’s Pharmacy

Fred’s XPress Pharmacy

Kmart Pharmacy

Kroger Pharmacy

Rite Aid Pharmacy

Sam’s Pharmacy

Super D Drugs

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

Winn-Dixie Pharmacy

MissouriCare Plus/CVS Pharmacy

Costco Pharmacy

CVS Pharmacy

Dierbergs Family Markets

Dillon Pharmacy

Family Pharmacy

Gerbes Pharmacy

Hy-Vee Pharmacy

Kmart Pharmacy

Kroger Pharmacy

Medicap Pharmacy



Price Cutter Pharmacy

Sam’s Pharmacy

Schnucks Pharmacy

PHARMACY DIRECTORY

Shop ‘n Save Pharmacy

Super D Drugs

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

MontanaCostco Pharmacy

CVS Pharmacy

Kmart Pharmacy

Osco Pharmacy

Safeway Pharmacy

Sam’s Pharmacy

Shopko Pharmacy

Smith’s Pharmacy

Target Pharmacy

Walmart Pharmacy

NebraskaBakers Pharmacy

Costco Pharmacy

CVS Pharmacy

Hy-Vee Pharmacy

Kmart Pharmacy

Safeway Pharmacy

Shopko Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

NevadaCostco Pharmacy

CVS Pharmacy

Kmart Pharmacy


Raley’s Drug Centers

Rite Aid Pharmacy

Safeway Pharmacy

Sam’s Pharmacy

Savon Drugs

Scolari’s Food and Drug

Smith’s Pharmacy

Target Pharmacy

Von’s Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

New HampshireCostco Pharmacy

CVS Pharmacy

Hannaford Brothers

Kmart Pharmacy

Osco Pharmacy


Rite Aid Pharmacy

Sam’s Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

New JerseyA&P Pharmacy

Costco Pharmacy

CVS Pharmacy

Duane Reade

PHARMACY DIRECTORY

Genuardis Pharmacy

Happy Harry’s

Kmart Pharmacy


Medicap Pharmacy

Pathmark Pharmacy

Quick Chek Pharmacy

Rite Aid Pharmacy

Sam’s Pharmacy

Savon Pharmacy

ShopRite Pharmacy



Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

Wegmans Pharmacy

Weis Pharmacy

New MexicoCostco Pharmacy

CVS Pharmacy

Kmart Pharmacy

Safeway Pharmacy

Sam’s Pharmacy

Savon Drugs

Smith’s Food & Drug

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

New YorkA&P Pharmacy


Costco Pharmacy

CVS Pharmacy

Drug World

Duane Reade

Gristedes Pharmacy

Hannaford Brothers

King Kullen Pharmacy

Kinney Drugs

Kmart Pharmacy


Pathmark Pharmacy


Rite Aid Pharmacy

Sam’s Pharmacy

Shoprite Pharmacy


Target Pharmacy

Tops Pharmacy

Waldbaums Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

Wegmans Pharmacy

Weis Pharmacy

North CarolinaBi-Lo Pharmacy


Costco Pharmacy

CVS Pharmacy

Food Lion Pharmacy


Ingles Pharmacy

Kerr Drug Stores

Kmart Pharmacy

Kroger Pharmacy

Medicap Pharmacy


Rite Aid Pharmacy

Sam’s Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

North DakotaCVS Pharmacy


Thrifty-white Drug

White Drugs

OhioACME Pharmacy

Costco Pharmacy

CVS Pharmacy

Discount Drug Marts

Fruth Pharmacy


Kmart Pharmacy

Kroger Pharmacy

Marcs Pharmacy


Meijer Pharmacy

Rite Aid Pharmacy

Ritzman Pharmacy

Sam’s Pharmacy

Shopko Pharmacy

Target Pharmacy

Thrifty White Drugs

Walgreens Pharmacy

Walmart Pharmacy

OklahomaCVS Pharmacy

Drug Warehouse

Harps Pharmacy

Homeland Pharmacy

Kmart Pharmacy

May’s Drug Stores


PHARMACY DIRECTORY

Med-X-Drug

Reasors Pharmacy

Sam’s Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

OregonBi-Mart Pharmacy


Costco Pharmacy

CVS Pharmacy

Fred Meyer Pharmacy

Hi-School Pharmacy

Kmart Pharmacy


Rite Aid Pharmacy

Safeway Pharmacy

Savon Pharmacy

Shopko Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

PennsylvaniaCare Plus/CVS Pharmacy

Costco Pharmacy

CVS Pharmacy


Giant Pharmacy

Klingensmiths Pharmacy

Kmart Pharmacy

Medicap Pharmacy


Pathmark Pharmacy


Rite Aid Pharmacy

Savon Pharmacy

ShopRite Pharmacy


Target Pharmacy

Tops Markets

Walgreens Pharmacy

Walmart Pharmacy

Wegmans Pharmacy

Weis Pharmacy

Puerto RicoCare Plus/CVS Pharmacy

CVS Pharmacy

Kmart Pharmacy

Sam’s Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

Rhode IslandCare Plus/CVS Pharmacy

CVS Pharmacy

Osco Pharmacy

Rite Aid Pharmacy


Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

PHARMACY DIRECTORY

South CarolinaBi-Lo Pharmacy


Costco Pharmacy

CVS Pharmacy

Food Lion Pharmacy

Fred’s Pharmacy


Ingles Pharmacy

Kmart Pharmacy

Kroger Pharmacy


Publix Pharmacy

Rite Aid Pharmacy

Sam’s Pharmacy

Target Pharmacy

Piggly Wiggly Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

South DakotaHy-Vee Pharmacy

Kmart Pharmacy

Lewis Family Drug/Lewis Drug

Safeway Pharmacy

Sam’s Pharmacy

Shopko Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

TennesseeBi-Lo Pharmacy


Costco Pharmacy

CVS Pharmacy

Food City Pharmacy

Fred’s Pharmacy


Ingles Pharmacy

Kmart Pharmacy

Kroger Pharmacy


Publix Pharmacy

Rite Aid Pharmacy

Sam’s Pharmacy

Schnucks Pharmacy

Super D Drugs

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

TexasAlbertson’s Pharmacy

Brookshire Brothers

Brookshire Grocery


Costco Pharmacy

CVS Pharmacy

H.E.B. Pharmacy

Kmart Pharmacy

Lifechek Pharmacy

Kroger Pharmacy


Minyard Pharmacy

Randalls Pharmacy

Safeway Pharmacy

Sam’s Pharmacy

Savon Pharmacy


Super 1 Pharmacy

Target Pharmacy

Tom Thumb Pharmacy

United Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

U.S. Virgin IslandsKmart Pharmacy


Walgreens Pharmacy

UtahCity Market Pharmacy

Costco Pharmacy

Fresh Market Pharmacy

Harmons Pharmacy

Kmart Pharmacy


Rite Aid Pharmacy

Sam’s Pharmacy

Savon Pharmacy

Shopko Pharmacy


Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

VermontCostco Pharmacy

CVS Pharmacy

Hannaford Brothers

Kinney Drugs

Osco Pharmacy


Rite Aid Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

VirginiaCostco Pharmacy

CVS Pharmacy

PHARMACY DIRECTORY

“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, including Connecticut General Life Insurance Company and Cigna Health and Life Insurance Company, and not by Cigna Corporation. All models are used for illustrative purposes only.

589901 l 01/15 © 2015 Cigna. Some content provided under license.

PHARMACY DIRECTORYFarm Fresh Pharmacy

Food City Pharmacy

Food Lion Pharmacy

Giant Pharmacy


Kmart Pharmacy

Kroger Pharmacy

Martins Pharmacy


Rite Aid Pharmacy

Safeway Pharmacy

Sam’s Pharmacy

Shoppers Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

WashingtonBartell Drugs

Bi-Mart Pharmacy


Costco Pharmacy

Food Pavilion Pharmacy

Fred Meyer Pharmacy

Haggen Food & Pharmacy

Hi-School Pharmacy

Kmart Pharmacy


QFC Pharmacy

Rite Aid Pharmacy

Rosauers Pharmacy

Safeway Pharmacy

Sam’s Pharmacy

Savon Pharmacy

Shopko Pharmacy

Target Pharmacy

Top Foods Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

Yokes Pharmacy

West VirginiaCVS Pharmacy

Fruth Pharmacy


Kmart Pharmacy

Kroger Pharmacy

Martins Pharmacy


Medicap Pharmacy

Rite Aid Pharmacy

Sam’s Pharmacy

Target Pharmacy

Walgreens Pharmacy

Walmart Pharmacy

Weis Pharmacy

WisconsinAurora Pharmacy

Costco Pharmacy

Copps Food Center Pharmacy

CVS Pharmacy

Hartig Drug Company

Hy-Vee Pharmacy

Kmart Pharmacy

Marshfield Clinic Pharmacy

Mayo Clinic Pharmacy


Pick N Save Pharmacy

Sam’s Pharmacy

Schnucks Pharmacy

Shopko Pharmacy

Target Pharmacy

Thrifty-white Drug

Walgreens Pharmacy

Walmart Pharmacy

WyomingCity Market Pharmacy

King Sooper’s Pharmacy

Kmart Pharmacy

Safeway Pharmacy

Shopko Pharmacy


Walgreens Pharmacy

Walmart Pharmacy

Osco Pharmacy

��

��

��

��

�� !"#�$!%�&'��!��(#!#"� !��")))*�+, !�' $-�-*.�/)))*�+, !�' $-�-*.�/)))*�+, !�' $-�-*.�/)))*�+, !�' $-�-*.�/

��.�$"�."� !��"01112��3�401112��3�401112��3�401112��3�4

�'�."��$#.��'�#/� 5/#!!#�$�'�."��$#.��'�#/� 5/#!!#�$�'�."��$#.��'�#/� 5/#!!#�$�'�."��$#.��'�#/� 5/#!!#�$�'��!��"��"6��/�/5��7!��8�.��-

��

��

�� !��"#$�#!��%��!��&&

��(#.��-�

�$�'#�#5'��/� $"

8#!.� $"�/� $"

��(��-,9��'�$

8�- ."#5'��/� $"

��9/�$"�/� $"

,�'�$.��/� $"

��#-�"

8�"�!�� (#.� :��!�$��-�

��"�'�6��

��3&�9�/� $"

#��'�� !��(�)*��+#�� ,-....../.....

#�� *!��#%�(��%�� 0,1......

;� <�=*�� <�*�� <=�*�� <4=*�� <�*�� ><��*�� <��*��1�=3�1�=�� <;=*��;4 <4=*�� <�*�� <�1*=� <�*�� <�*�� ><�*�� <�*��1�=3�1�=�� <�*��;4 <��*�� <�*�� <1*�� <*�� <*�� ><�*�� <�*��1�=3�1�=�� <�*��

<��*�� <�*�� <��*=� <1*�� <��*��<��*�� <1;*��!�2��'��'3��

��#�4��<�*��<��*��

<;=*��

#��5��6��4� 70-80.

��'�� '��;� ,�� ,��8� ��?��8�,��?:��@�:A*��B� ��

;4 ��,�:��:�

#�4��#-�� 6�.C��* �/� $"�:� ��8%��A �� <��*��

##!��

�6#!�.'�#/�)�!�&��.�!!�-�&��9� ��")��C�.�$"��." �'��/�$"

��8�,�� %��@��-�/!� "� "��=��6#.��3=�=

J4C8 [761] 1 of 320160922B041014 4960

��9��'��:��;��'

J4C8��222� E �� BROOKLYN NY 1��

761

SAMPLE

��

��&��:��:��"6#!��D&'�$�"#�$��,�$�#"!��'�."!��$��-(��!��5�$�#"�-�"��/#$�"#�$%�9� �/�9��&&��'�"6��-�"��/#$�"#�$E�! 5/#"�)�#""�$.�//�$"!%�-�. /�$"!%��.��-!��"6��#$��/�"#�$��'�"#$��"��"6��.'�#/E��$-%� &�$�� !"��$-��.6��%��.�#(��.�&#�!��''�-�. /�$"!%��.��-!��$-��"6��#$��/�"#�$��'�(�$"�"��"6��.'�#/*

�/&��"�$"��$��/�"#�$��5� "�� &&��'�:#�6"!�/&��"�$"��$��/�"#�$��5� "�� &&��'�:#�6"!�/&��"�$"��$��/�"#�$��5� "�� &&��'�:#�6"!�/&��"�$"��$��/�"#�$��5� "�� &&��'�:#�6"!��-#.�'��'�#/!��$'9��-#.�'��'�#/!��$'9��-#.�'��'�#/!��$'9��-#.�'��'�#/!��$'9

@6�"�#��$��-�6�'&� $-��!"�$-#$��"6#!�-�$#�'F@6�"�#��$��-�6�'&� $-��!"�$-#$��"6#!�-�$#�'F@6�"�#��$��-�6�'&� $-��!"�$-#$��"6#!�-�$#�'F@6�"�#��$��-�6�'&� $-��!"�$-#$��"6#!�-�$#�'F��$"�."��''#�-�,�$�#"� 9!"�/!%��$.*%��$�5�6�'��"6��'�$��-/#$#!"��"��%��"�"6�&6�$��$ /5��'#!"�-�#$�"6��5�D��"�"6��"�&��"6��D&'�$�"#�$��,�$�#"!�#�9� �$��-��!!#!"�$.�� $-��!"�$-#$��"6#!�$�"#.��"6��'�$7!�-�.#!#�$�"��-�$9�9� ��!��(#.��.�(��*

@6�"�#��-�$7"��)#"6�"6#!�-�.#!#�$F@6�"�#��-�$7"��)#"6�"6#!�-�.#!#�$F@6�"�#��-�$7"��)#"6�"6#!�-�.#!#�$F@6�"�#��-�$7"��)#"6�"6#!�-�.#!#�$F�� 6�(��#�6"�"��&&��'��$9�-�.#!#�$�$�"�"��&��(#-��9� ��&�9��$�#"�/��!��(#.�0#$�)6�'��#$�&��"2*

��)�-��#'��$��&&��'F��)�-��#'��$��&&��'F��)�-��#'��$��&&��'F��)�-��#'��$��&&��'F�� &&��'�/ !"�5��! 5/#""�-�#$�)�#"#$��"��''#�-�,�$�#"� 9!"�/!%��$.*%��$�5�6�'��"6��'�$�-/#$#!"��"��%�)#"6#$��1��-�9!��/�"6��-�"��"6#!�$�"#.�*� ��'!��"6��G�"6��!� �.�!�"��6�'&�9� G�!�."#�$��"6#!��/��!!#!"�$.��#'#$�� !"��$��&&��'*

@6��/�9�#'��$��&&��'F@6��/�9�#'��$��&&��'F@6��/�9�#'��$��&&��'F@6��/�9�#'��$��&&��'F�� !�/��$��9� �$�/�%�#$�)�#"#$�%�"��."��9� �09� �� "6��#H�-��&��!�$"�"#(�2�/�9�#'��$�&&��'*

��$��&��(#-��--#"#�$�'�#$��/�"#�$��5� "�/9�.'�#/F��$��&��(#-��--#"#�$�'�#$��/�"#�$��5� "�/9�.'�#/F��$��&��(#-��--#"#�$�'�#$��/�"#�$��5� "�/9�.'�#/F��$��&��(#-��--#"#�$�'�#$��/�"#�$��5� "�/9�.'�#/F��!%��!�&��"��9� ��&&��'%�9� �/�9�! 5/#"�)�#""�$�.�//�$"!%-�. /�$"!%��.��-!��"6��#$��/�"#�$��'�"#$��"��"6��.'�#/*

��$�� !"�.�&#�!��#$��/�"#�$��'�(�$"�"��/9�.'�#/F��$�� !"�.�&#�!��#$��/�"#�$��'�(�$"�"��/9�.'�#/F��$�� !"�.�&#�!��#$��/�"#�$��'�(�$"�"��/9�.'�#/F��$�� !"�.�&#�!��#$��/�"#�$��'�(�$"�"��/9�.'�#/F��!%��!�&��"��9� ��&&��'%�9� �/�9�� !"%�#$�)�#"#$�%�.�&#�!��''-�. /�$"!%��.��-!��$-��"6��#$��/�"#�$��'�(�$"�"��9� ��.'�#/%��.6��*��9� �"6#$C��.�-#$��/�9�6�(��.� !�-"6#!�.'�#/�"��5��-�$#�-%�9� �6�(��"6��#�6"�"��6�(��5#''#$��$-�-#��$�!#!�.�-�!�!�$"�"��9� %��!�)�''*�� .�$�� !"�.�&#�!��"6#!�#$��/�"#�$�59�.�$"�."#$��''#�-�,�$�#"� 9!"�/!%��$.*%��$�5�6�'��"6��'�$��-/#$#!"��"��%��"�"6��&6�$��$ /5��'#!"�-�#$"6��5�D��"�"6��"�&��"6��D&'�$�"#�$��,�$�#"!*

@6�"�6�&&�$!�$�D"F@6�"�6�&&�$!�$�D"F@6�"�6�&&�$!�$�D"F@6�"�6�&&�$!�$�D"F��9� ��&&��'%�"6��'�$�)#''��(#�)�#"!�-�.#!#�$��$-�9� �)#''�5��$�"##�-��"6��-�"��/#$�"#�$�)#"6#$��-�9!�"��.�#&"��9� ��&&��'*��"6��'�$�.�$"#$ �!�"��-�$9�"6��&�9/�$"%�.�(��%��!��(#.�� !"�-��9� �-��$�"��.�#(��"#/�'9�-�.#!#�$%�9� �/�9�5��5'��"�� !"��$��D"��$�'��(#�)��9� ��.'�#/�59��$�#$-�&�$-�$"�"6#�-�&��"9%�)6��)#''��(#�)�"6�-�$#�'��$-�#!! ��#$�'�-�.#!#�$*��)�(��%�! .6�� !"��D"��$�'��(#�)�#!��$'9��&&'#.�5'��)6��"6��'�$7!� $-��'9#$�-�"��/#$�"#�$�#$(�'(�-��2��!.#!!#�$��.�(��2�/�-#.�'�I -�/�$"*��'!�%�9� �6�(��#�6"�"��5�#$��.#(#'��."#�$� $-�� ."#�$�=�0�2��:� ��''�)#$��"6��-�"��/#$�"#�$��9� ��D"��$�'��(#�)*�0��9� ��$�"��$"#"'�-�"��$��D"��$�'��(#�)%�9� !"#''�6�(��#�6"�"��5�#$��.#(#'��."#�$� $-�� ."#�$�=�0�2��:� ��''�)#$��"6��-�"��/#$�"#�$��$��&&��'*2

�"6��!� �.�!�"��6�'&�9� J�"6��!� �.�!�"��6�'&�9� J�"6��!� �.�!�"��6�'&�9� J�"6��!� �.�!�"��6�'&�9� J�� !"#�$!��5� "�9� ��&&��'��#�6"!%�"6#!�$�"#.�%��!!#!"�$.�%�9� �.�$�.�$"�."�"6��/&'�9��,�$�#"!� �. �#"9��-/#$#!"��"#�$��"��31��3��3�, ��0;42*

�6��"#�$�'�+�$��'�,�$�#"!� �' "#�$!��/�&��(#-�!�"��'!��!/�''35 !#$�!!��/&'�9��!�"��!"�5'#!6��!�'3 $-�-�6��'"65�$�#"�&'�$��"6�#��/&'�9��!*��6��5�$�#"�&'�$�#!��!"�5'#!6�-�59�"6��/&'�9��$-�#!�$�"��$�#$! ��$.��&��- ."*� "�&3'�!!#$! ��$.��"6��!�'3 $-�-�&'�$�#!� $-��)�#""�$��$-�#!! �-�59��#/��$! ��$.��/&�$9*

��

��

��

��4��

�� !"#�$!%�&'��!��(#!#"� !��")))*�+, !�' $-�-*.�/)))*�+, !�' $-�-*.�/)))*�+, !�' $-�-*.�/)))*�+, !�' $-�-*.�/

��.�$"�."� !��"01112��3�401112��3�401112��3�401112��3�4

�'�."��$#.��'�#/� 5/#!!#�$�'�."��$#.��'�#/� 5/#!!#�$�'�."��$#.��'�#/� 5/#!!#�$�'�."��$#.��'�#/� 5/#!!#�$�'��!��"��"6��/�/5��7!��8�.��-

��

��

�� !��"#$�#!��%��!��&&

��(#.��-�

�$�'#�#5'��/� $"

8#!.� $"�/� $"

��(��-,9��'�$

8�- ."#5'��/� $"

��9/�$"�/� $"

,�'�$.��/� $"

��#-�"

8�"�!�� (#.� :��!�$��-�

��"�'�6��

��3&�9�/� $"

#��'��<�%!��$��=(��#�� ,.......

#�� <(!$�� 0,1>......

;4 <4*�� <�*�� <��*�� <��*�� <�*�� ><�*�� <�*��1��3�1�� <��*��;4 <��*�� <�*�� <��=*�4 <�==*�; <�*�� ><�*�� <�*��1��3�1�� <�==*�;;4 <�;=*�� <�*�� <=�*1� <1�*�� <�*�� ><�*� <�*��1��3�1�� <41*�;�� <%��*�� <�*�� <1=*�� <�%�4*�� <�*�� ><�%�4*�� <�%�4*��1��3�1�� <�*��

�� <;*�� <�*�� <��*�� <�;4*1� <�*�� ><�;4*1� <�;4*1��1��3�1�� <�*�� <=;�*�� <�*�� <�=*�1 <;��*1 <�*�� ><;��*1 <;��*1�1��3�1�� <�*�� <��*�� <�*�� <=4*�= <1�*;= <�*�� ><1�*;= <1�*;=�1��3�1�� <�*��

��<%1��*�� <�*�� <�%�;�*1� <�%��;*� <�*�� ><�%��;*� <�%��;*��1��3�1�� <�*�� <��*�� <�*�� <�*�� <=*�� <�*�� ><=*�� <=*��1��3�1�� <�*�� <;*�� <�*�� <�* <�*41 <�*�� ><�*41 <�*41�1��3�1�� <�*�� <��*�� <�*�� <�*=� <�*=� <�*�� ><�*=� <�*=��1��3�1�� <�*��

<�%=�*�� <�*�� <%=;�*�� <�*�� <;%��*��<;%��*�� <;%4��*��!�2��'��'3��

��#�4��<�*��

<;%��*��

�<=�*��

#��5��6��4� 7?>@8@@

��'�� '��;4 ,�� ,��8� ��?��8�,��?:��@�:A*��,�:��:�

�?�� ?��

#�4��#-�� 6�.C��* �/� $"�� :��?��B��8��: ��=1;��;%��*��

##!��

�6#!�.'�#/�)�!�&��.�!!�-�&��9� ��")��C�.�$"��." �'��/�$"

��8�,�� %��@��-�/!� "� "��=��6#.��3=�=

J00E [1,853] 2 of 220160913B041014 4960

��9��'��:��;��'

��222�� BROOKLYN NY 1��

1,853

SAMPLE

��

��&��:��:��"6#!��D&'�$�"#�$��,�$�#"!��'�."!��$��-(��!��5�$�#"�-�"��/#$�"#�$%�9� �/�9��&&��'�"6��-�"��/#$�"#�$E�! 5/#"�)�#""�$.�//�$"!%�-�. /�$"!%��.��-!��"6��#$��/�"#�$��'�"#$��"��"6��.'�#/E��$-%� &�$�� !"��$-��.6��%��.�#(��.�&#�!��''�-�. /�$"!%��.��-!��$-��"6��#$��/�"#�$��'�(�$"�"��"6��.'�#/*

�/&��"�$"��$��/�"#�$��5� "�� &&��'�:#�6"!�/&��"�$"��$��/�"#�$��5� "�� &&��'�:#�6"!�/&��"�$"��$��/�"#�$��5� "�� &&��'�:#�6"!�/&��"�$"��$��/�"#�$��5� "�� &&��'�:#�6"!��-#.�'��'�#/!��$'9��-#.�'��'�#/!��$'9��-#.�'��'�#/!��$'9��-#.�'��'�#/!��$'9

@6�"�#��$��-�6�'&� $-��!"�$-#$��"6#!�-�$#�'F@6�"�#��$��-�6�'&� $-��!"�$-#$��"6#!�-�$#�'F@6�"�#��$��-�6�'&� $-��!"�$-#$��"6#!�-�$#�'F@6�"�#��$��-�6�'&� $-��!"�$-#$��"6#!�-�$#�'F��$"�."��''#�-�,�$�#"� 9!"�/!%��$.*%��$�5�6�'��"6��'�$��-/#$#!"��"��%��"�"6�&6�$��$ /5��'#!"�-�#$�"6��5�D��"�"6��"�&��"6��D&'�$�"#�$��,�$�#"!�#�9� �$��-��!!#!"�$.�� $-��!"�$-#$��"6#!�$�"#.��"6��'�$7!�-�.#!#�$�"��-�$9�9� ��!��(#.��.�(��*

@6�"�#��-�$7"��)#"6�"6#!�-�.#!#�$F@6�"�#��-�$7"��)#"6�"6#!�-�.#!#�$F@6�"�#��-�$7"��)#"6�"6#!�-�.#!#�$F@6�"�#��-�$7"��)#"6�"6#!�-�.#!#�$F�� 6�(��#�6"�"��&&��'��$9�-�.#!#�$�$�"�"��&��(#-��9� ��&�9��$�#"�/��!��(#.�0#$�)6�'��#$�&��"2*

��)�-��#'��$��&&��'F��)�-��#'��$��&&��'F��)�-��#'��$��&&��'F��)�-��#'��$��&&��'F�� &&��'�/ !"�5��! 5/#""�-�#$�)�#"#$��"��''#�-�,�$�#"� 9!"�/!%��$.*%��$�5�6�'��"6��'�$�-/#$#!"��"��%�)#"6#$��1��-�9!��/�"6��-�"��"6#!�$�"#.�*� ��'!��"6��G�"6��!� �.�!�"��6�'&�9� G�!�."#�$��"6#!��/��!!#!"�$.��#'#$�� !"��$��&&��'*

@6��/�9�#'��$��&&��'F@6��/�9�#'��$��&&��'F@6��/�9�#'��$��&&��'F@6��/�9�#'��$��&&��'F�� !�/��$��9� �$�/�%�#$�)�#"#$�%�"��."��9� �09� �� "6��#H�-��&��!�$"�"#(�2�/�9�#'��$�&&��'*

��$��&��(#-��--#"#�$�'�#$��/�"#�$��5� "�/9�.'�#/F��$��&��(#-��--#"#�$�'�#$��/�"#�$��5� "�/9�.'�#/F��$��&��(#-��--#"#�$�'�#$��/�"#�$��5� "�/9�.'�#/F��$��&��(#-��--#"#�$�'�#$��/�"#�$��5� "�/9�.'�#/F��!%��!�&��"��9� ��&&��'%�9� �/�9�! 5/#"�)�#""�$�.�//�$"!%-�. /�$"!%��.��-!��"6��#$��/�"#�$��'�"#$��"��"6��.'�#/*

��$�� !"�.�&#�!��#$��/�"#�$��'�(�$"�"��/9�.'�#/F��$�� !"�.�&#�!��#$��/�"#�$��'�(�$"�"��/9�.'�#/F��$�� !"�.�&#�!��#$��/�"#�$��'�(�$"�"��/9�.'�#/F��$�� !"�.�&#�!��#$��/�"#�$��'�(�$"�"��/9�.'�#/F��!%��!�&��"��9� ��&&��'%�9� �/�9�� !"%�#$�)�#"#$�%�.�&#�!��''-�. /�$"!%��.��-!��$-��"6��#$��/�"#�$��'�(�$"�"��9� ��.'�#/%��.6��*��9� �"6#$C��.�-#$��/�9�6�(��.� !�-"6#!�.'�#/�"��5��-�$#�-%�9� �6�(��"6��#�6"�"��6�(��5#''#$��$-�-#��$�!#!�.�-�!�!�$"�"��9� %��!�)�''*�� .�$�� !"�.�&#�!��"6#!�#$��/�"#�$�59�.�$"�."#$��''#�-�,�$�#"� 9!"�/!%��$.*%��$�5�6�'��"6��'�$��-/#$#!"��"��%��"�"6��&6�$��$ /5��'#!"�-�#$"6��5�D��"�"6��"�&��"6��D&'�$�"#�$��,�$�#"!*

@6�"�6�&&�$!�$�D"F@6�"�6�&&�$!�$�D"F@6�"�6�&&�$!�$�D"F@6�"�6�&&�$!�$�D"F��9� ��&&��'%�"6��'�$�)#''��(#�)�#"!�-�.#!#�$��$-�9� �)#''�5��$�"##�-��"6��-�"��/#$�"#�$�)#"6#$��-�9!�"��.�#&"��9� ��&&��'*��"6��'�$�.�$"#$ �!�"��-�$9�"6��&�9/�$"%�.�(��%��!��(#.�� !"�-��9� �-��$�"��.�#(��"#/�'9�-�.#!#�$%�9� �/�9�5��5'��"�� !"��$��D"��$�'��(#�)��9� ��.'�#/�59��$�#$-�&�$-�$"�"6#�-�&��"9%�)6��)#''��(#�)�"6�-�$#�'��$-�#!! ��#$�'�-�.#!#�$*��)�(��%�! .6�� !"��D"��$�'��(#�)�#!��$'9��&&'#.�5'��)6��"6��'�$7!� $-��'9#$�-�"��/#$�"#�$�#$(�'(�-��2��!.#!!#�$��.�(��2�/�-#.�'�I -�/�$"*��'!�%�9� �6�(��#�6"�"��5�#$��.#(#'��."#�$� $-�� ."#�$�=�0�2��:� ��''�)#$��"6��-�"��/#$�"#�$��9� ��D"��$�'��(#�)*�0��9� ��$�"��$"#"'�-�"��$��D"��$�'��(#�)%�9� !"#''�6�(��#�6"�"��5�#$��.#(#'��."#�$� $-�� ."#�$�=�0�2��:� ��''�)#$��"6��-�"��/#$�"#�$��$��&&��'*2

�"6��!� �.�!�"��6�'&�9� J�"6��!� �.�!�"��6�'&�9� J�"6��!� �.�!�"��6�'&�9� J�"6��!� �.�!�"��6�'&�9� J�� !"#�$!��5� "�9� ��&&��'��#�6"!%�"6#!�$�"#.�%��!!#!"�$.�%�9� �.�$�.�$"�."�"6��/&'�9��,�$�#"!� �. �#"9��-/#$#!"��"#�$��"��31��3��3�, ��0;42*

�6��"#�$�'�+�$��'�,�$�#"!� �' "#�$!��/�&��(#-�!�"��'!��!/�''35 !#$�!!��/&'�9��!�"��!"�5'#!6��!�'3 $-�-�6��'"65�$�#"�&'�$��"6�#��/&'�9��!*��6��5�$�#"�&'�$�#!��!"�5'#!6�-�59�"6��/&'�9��$-�#!�$�"��$�#$! ��$.��&��- ."*� "�&3'�!!#$! ��$.��"6��!�'3 $-�-�&'�$�#!� $-��)�#""�$��$-�#!! �-�59��#/��$! ��$.��/&�$9*

Documents

MEMBER’S ADDITIONAL INFORMATION (V4)All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Ci gna Health and