2016 CIGNA heAlth CAre CoverAGe MedICAl ANd phArMACy

2016 CIGNA heAlth CAre CoverAGe MedICAl ANd phArMACy

2016 CIGNA
health care coverage
Medical and pharmacy
Offered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company or their affiliates.
823180 f 10/15 © 2015 Cigna. Some content provided under license.
Know what’s
important to you
Look at your health in a whole
new way. Let us work with
you to coordinate your health
care needs. Let us provide you
with support and services, so
that your doctors can focus on
providing care, and you
can focus on your health.
2
CONTACT INFORMATION
Medical & Prescription Drug Plan
Cigna
P.O. Box 182223
Chattanooga, TN 37422-2223
800.244.6224
myCigna.com
Medical Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Pharmacy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Pharmacy: Prior Authorization Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Pharmacy: Prescription Drug List. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Pharmacy: Specialty Medications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Pharmacy: Preventive Prescription Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
MDLive. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Your Health Has Met Its App. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
myCigna.com. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Savings at your Fingertips.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Value-added Services.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Cigna Health Pregnancies, Healthy Babies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Questions & Answers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
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medical plan
Open Access Plus Plan
Your insurance pays
Benefit highlights
In-network
Out-of-network
Annual individual deductible
$1,500
$3,000
Maximum annual family deductible
$3,000
$6,000
Lifetime maximum
unlimited
unlimited
Major medical out-of-pocket maximum (Individual/Family)
$6350 /$12700
$9,000/$18,000
Office visits
Primary care
80%
Specialists
70%
60% AD*
80% or 70%
Allergy shots and other therapeutic injections
Chiropractic care (20 visits maximum PCY)
70%
MD Live Telemedicine
$15
N/A
Preventive care**
Well-baby care
Immunizations
100%
100% AD
Annual routine exam
Women’s exams: include mammogram and PAP test (1 PCY*)
Vision exam (1 exam PCY)
Diagnostic lab/X-ray services (outpatient/independent facility)
Minor – Lab, X-ray
80%
60%
Major – CT, PET, MRI, MRA and Nuclear Medicine
70%
Maternity
Maternity fees/provider
80% AD
60% AD
Maternity hospital stay (includes newborn care)
80% AD
Emergency
Emergency room
$200 member copay and 80% AD
$200 member copay and 80% AD
Ambulance
80% AD
80% AD
Urgent care facility
70%
60%
Inpatient hospital facility
80% AD
60% AD
Outpatient day surgery
80% AD
60% AD
Mental health/chemical dependency – inpatient facility
80% AD
60% AD
Hospital services
MH/CD OP therapy
80%
60% AD
Intensive OP therapy
80%
60% AD
* PCY = Per calendar year. AD = After deductible.
**See the preventive health benefits quick reference guide for detailed information on wellness exams and immunizations.
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pharmacy
To help you fill your prescriptions, Cigna’s prescription drug plan provides access to more than 52,000 national and
independent pharmacies. You can also order your prescriptions online, over the phone or through the mail for
convenient home delivery.
Prescription drug coverage highlights: When you choose a plan in Cigna’s Open Access Plus Network – regardless
of which plan you choose – you will receive the following prescription drug coverage:
Pharmacy-purchased drugs (member pays)
Generic drugs
Preferred brand drugs
Non-preferred brand drugs
$10 copay
per prescription
up to a 31-day supply
30%
($125 per prescription maximum)
up to a 31-day supply
50%
($150 per prescription maximum)
up to a 31-day supply
At participating pharmacies only. You must present your ID card with any new prescription or refill. For all paper-submitted claim forms, you must pay full price for
the prescription and then submit a claim form for reimbursement.
Home delivery purchased drugs (member pays)
Generic drugs
Preferred brand drugs
Non-preferred brand drugs
$20 copay
per prescription
up to a 90-day supply
30%
($375 per prescription maximum)
up to a 90-day supply
50%
($450 per prescription maximum)
up to a 90-day supply
Getting the most out of your coverage: make careful decisions about prescription drugs
high-cost drugs are automatically the best option for
treating their medical conditions. You should also know
that, in most cases, less expensive and more effective
alternatives to some well-known drugs exist. So the next
time you see your doctor about a prescription, ask if a
less expensive generic equivalent is available.
Many people incorrectly think that there is a difference
between generic and brand name prescription drugs.
The truth is, a generic drug is the same as a brand-name
drug, with few exceptions. However, because of the
surge in direct-to-consumer marketing of prescription
drugs, customers become more familiar with certain
drugs and often falsely believe these high-profile,
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Frequently asked questions
What is a generic drug?
What is a non-preferred brand drug?
A generic drug is a drug that is chemically identical
to a brand-name drug in dosage, safety, strength,
performance and intended use. They are able to be
sold to the public for less because it costs less for
manufacturers to develop, produce and market
these drugs.
A non-preferred brand drug is a brand-name drug that
is not on Cigna’s list of accepted brand-name drugs.
Go to myCigna.com, my plans > pharmacy, for
additional drug information.
What is a specialty drug?
A specialty drug is a prescription medication that
requires special handling, administration or monitoring.
You’re allowed up to two fills before you’re required to
use Cigna Home Delivery Pharmacy.
What is a preferred brand drug?
A preferred brand drug is a brand-name drug that
is on Cigna’s list of accepted brand-name drugs.
Prescription drug price quotes
I want to…
Compare costs of your prescription drugs
at specific retail pharmacies and Cigna
Home Delivery Pharmacy.
Find links to popular tasks, such as
searching for a pharmacy, downloading
a form and printing ID cards.
Claim search
Cigna Home Delivery Pharmacy
Search for pharmacy claims for
the primary plan subscriber for
the past 16 months.
Order a new prescription or refill an existing prescription
through our convenient mail-order service. Take
advantage of our lower costs and get a 90-day supply
delivered to your door at no additional cost for delivery.
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Cigna’s claim system to allow you to have coverage for
this drug. The length of the authorization will depend on
the diagnosis and drug. When your physician advises
you that the drug has been approved, you should
contact a participating pharmacy to fill the
prescription(s). If the request is denied, you and your
doctor will be notified that coverage for the drug is not
authorized. If you have questions, please call Cigna
Customer Service at the toll-free number on your Cigna
ID card.
Cigna: prior authorization drugs
Using the latest medical research, along with guidelines
from the U.S. Food and Drug Administration (FDA) and
national medical organizations, the Cigna Pharmacy and
Therapeutics Committee, a panel of participating
in‑network doctors and pharmacists, regularly evaluates
the safety and effectiveness of prescription medications
that are included on the prescription drug list. This
evaluation also includes the determination of which
drugs will require prior authorization based on safety,
appropriate use or coverage design. For medications or
doses that require prior authorization, your doctor may
call or fax the appropriate prior authorization form to
Cigna to request coverage for the prescription. Your
doctor should make this request before writing the
prescription. To determine if prior authorization is
required, your doctor should check the Cigna
Prescription Drug List or visit the website at Cigna.com
for the complete prescription drug list.
The following list identifies the drugs that may require
prior authorization and is subject to change on a
quarterly basis.
If the request is approved, the doctor will receive a fax
confirmation. The authorization will be processed in
›
AGE indicates that the drug requires prior
authorization if your age meets the age limit shown.
›
PA indicates that the drug routinely requires prior
authorization to ensure appropriate treatment
regimens are followed.
›
QL indicates that the drug requires prior
authorization only when the quantity requested
exceeds certain limits.
Brand name
Reason
Brand name
Reason
Brand name
Reason
Accutane
QL
PA
PA
PA
QL
QL
PA
QL
AGE 46≥
QL
PA
QL
QL
GE 46≥
QL
QL
QL
QL
QL
PA
Fragmin
Frova
Gleevec
Glucagon
lmitrex
Innohep
Iressa
Kytril
Lamisil
Lariam
Lovenox
Malarone
Maxalt, Maxalt MLT
Migranal
Nexium
OxyContin
Panretin
Penlac
Prilosec
Proscar
QL
QL
PA
QL
QL
QL
PA
PA, QL
PA
QL
PA
QL
QL
PA
QL
PA
PA
PA
QL PA
AGE 39≥
Pulmozyme
Regranex
Relenza
Relpax
Retin-A, Retin_A Micro
Revatio
Revia
Sporanox
Sprycel
Synarel
Tamiflu
Tarceva
Toradol
Vfend
Zegerid
Zithromax
Zmax
Zofran, Zofran ODT
Zomig, Zomig ZMT
Zyvox
PA
PA
QL
QL
AGE≥46
PA
QL
PA, QL
PA
PA, QL
PA, QL
PA
PA, QL
PA
PA
QL
QL
QL
QL
PA
Aciphex
Actiq
Agrylin
Amerge
Anzemet
Arava
Arixtra
Avita
Axert
Celebrex
Clavaris
D.H.E. 45
Differin
Diflucan (150mg)
Dostinex
Duragesic
Emend
Epipen, Epipen Jr.
Exubera (combo pkg & kit)
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Cigna Prescription Drug List
The Drug List divides medications into generic, preferred, brand categories and specialty injectables. Common
examples of each of these categories are provided. This is a partial list and subject to change. Please see Cigna.com
for a current Drug List.
GENERICS
PREFERRED
BRANDS
NON-PREFERRED
BRANDS
PREFERRED
BRANDS
GENERICS
Allergy
ADD/ADHD and Stimulants
amphetamine/
dextroamphetamine
clonidine HCl
dexmethylphenidate
HCl
dexmethylphenidate
HCl ER
guanfacine
methamphetamine
methylphenidate HCl
methylphenidate/
ER/24 HR ER
modafinil (PA)
Adderall XR
Focalin XR
Ritalin LA 10 mg
Strattera
Vyvanse
azelastine HCl
azelastine nasal
budesonide
clemastine fumarate
cyproheptadine
desloratadine
epinephrine (QL)
flunisolide nasal
fluticasone nasal
hydroxyzine
ipratropium nasal
levocetirizine
montelukast
olopatadine nasal spray
triamcinolone nasal
Adderall (PA,ST)
amphetamine/
dextroamphetamine
XR
Aptensio XR (PA,ST)
Concerta (PA,ST)
Daytrana (PA,ST)
Desoxyn (PA,ST)
Dexedrine (PA,ST)
Evekeo (PA,ST)
Focalin (PA,ST)
Intuniv
Kapvay
Metadate CD (PA,ST)
Methylin (PA,ST)
Nuvigil (PA)
Provigil (PA)
Quillivant XR (PA,ST)
Ritalin (PA,ST)
Ritalin ER
Ritalin LA 20 mg, 30
mg, 40 mg, 60 mg
(PA,ST)
Ritalin SR (PA,ST)
Xyrem (PA)
Zenzedi (PA,ST)
Aptivus
Crixivan
Emtriva
Epivir HBV
Epivir solution
Epzicom
Fuzeon
Invirase
Isentress
Kaletra
Lexiva
Norvir
Prezista
Rescriptor
Reyataz
Selzentry
Sustiva
Truvada
Viracept
Viramune XR
Viread
Astepro
Epipen 2 pk (QL)
Epipen Jr. (QL)
Nasonex
Veramyst
Adrenaclick (QL)
Astelin
Atrovent (nasal)
Auvi-Q (QL)
Beconase AQ (PA,ST)
Children’s QNASL
Dymista (PA,ST)
Flonase (PA,ST)
Karbinal ER
Omnaris (PA,ST)
Patanase
QNASL (PA,ST)
Rhinocort AQ (PA,ST)
Semprex-D
Singulair
Xyzal
Zetonna (PA,ST)
Alzheimer’s Disease
donepezil
donepezil HCl
galantamine
hydrobromide
memantine
rivastigmine (caps)
AIDS/HIV
abacavir
abacavir/lamivudine/
zidovudine
didanosine
lamivudine
lamivudine/zidovudine
nevirapine
nevirapine ER
stavudine
zidovudine
NON-PREFERRED
BRANDS
Aricept
Aricept ODT
Exelon
Namenda
Namenda XR
Namzaric
Razadyne
Razadyne ER
Anxiety
Atripla
Combivir
Complera
Edurant
Epivir
Evotaz
Fulyzaq
Intelence
Prezcobix
Retrovir
Stribild
Tivicay
Triumeq
Trizivir
Tybost
Videx
Viramune
Vitekta
Zerit
Ziagen
alprazolam
buspirone
diazepam
lorazepam
oxazepam
Lorazepam Intensol
Niravam
Asthma and Respiratory
albuterol solution
(nebulizer solution)
albuterol sulfate
(syrup, tabs)
budesonide
caffeine citrate
cromolyn sodium
(nebulizer solution)
dyphylline
guaifenesin/
theophylline
8
Advair Diskus/HFA
Anoro Ellipta
Asmanex TwistHaler
Atrovent HFA
Breo Ellipta
Combivent Respimat
Flovent Diskus/HFA
ProAir HFA/RespiClick
Pulmicort
Pulmozyme (PA)
QVAR
Serevent
Spiriva
Accolate
Accuneb nebulizer
Adcirca (PA)
Adempas (PA)
Aerospan
Alvesco
Arcapta
Arnuity Ellipta
Asmanex HFA
Brovana nebulizer
Daliresp
Dulera
Esbriet (PA)
Understanding the Cigna prescription drug list: Common examples of drugs in each of the drug classes are
provided in the drug list. If you don’t see a specific drug listed in this document, a complete list of medications and
their coverage categories can be found on Cigna.com by clicking on “Drug List” under “Popular Links.” For a
complete, current list of preferred medications, please call Cigna Customer Service at 800.244.6224 or visit the
website at Cigna.com.
GENERICS
PREFERRED
BRANDS
NON-PREFERRED
BRANDS
GENERICS
Asthma and Respiratory (continued)
ipratropium bromide Symbicort
(nebulizer solution)
Ventolin HFA
levalbuterol (nebulizer Xolair (PA)
solution)
metaproterenol sulfate
(syrup, tabs)
montelukast
prednisolone sod
phosphate
sildenafil
terbutaline sulfate
theophylline anhydrous
zafirlukast
BeYaz
Lo Loestrin FE
Lomedia 24 FE
LoSeasonique
Minastrin 24 FE
NuvaRing
Ortho TriCyclen Lo
NON-PREFERRED
BRANDS
BIRTH CONTROL (continued)
Foradil
Incruse Ellipta (ST)
Letairis (PA)
Ofev (PA)
Opsumit (PA)
Orapred ODT
Orenitram ER (PA)
Perforomist
Prelone
Proventil HFA
Revatio (PA)
Singulair
Stiolto Respimat
Striverdi Respimat
Tracleer (PA)
Tudorza Pressair (ST)
Tyvaso (PA)
Ventavis (PA)
Xopenex HFA
Xopenex nebulizer
Errin
Estarylla
ethinyl estradiol/
drospirenone
Falmina
Gianvi
Gildagia
Gildess
Heather
Introvale
Jencycla
Jolessa
Junel
Junel FE
Kariva
Kelnor
Kurvelo
Larin
Larin FE
Leena
Lessina
Levonest
levonorgestrel
levonorgestrel-ethestra
levonorgestrel-ethin
estradiol
Levora
l-norgest-eth estr/ethin
estra
Loryna
Low-Ogestrel
Lutera
Lyza
Marlissa
Microgestin
Microgestin FE
Mono-Linyah
Mononessa
Myzilra
Necon
Next Choice
Nora-Be
noreth a-et estra/fe
fumarate
norethindrone
norethindrone-ethinyl
estrad
BIRTH CONTROL
Altavera
Alyacen
Amethia
Amethia Lo
Amethyst
Apri
Aranelle
Aubra
Aviane
Azurette
Balziva
Briellyn
Camila
Camrese
Camrese Lo
Caziant
Chateal
Cryselle
Cyclafem
Dasetta
Daysee
desogestrel-ethinyl
estradiol
Elinest
Emoquette
Enpress
Enskyce
PREFERRED
BRANDS
Angeliq
Brevicon
Cyclessa
Depo-Provera Subq
Desogen
Ella
Estrostep FE
Fem FE
Generess FE
Loestrin
Loestrin FE
Mircette
Modicon
Natazia
Norinyl 1+35
Norinyl 1+50
Nor-QD
Ortho-Cept
Ortho-Cyclen
Ortho Evra
Ortho Micronor
Ortho-Novum 7-7-7
Ortho-Tri-Cyclen
Ovcon-35
Quartette
Safyral
9
Seasonale
Seasonique
Tri-Norinyl
Yasmin 28
Yaz
PREFERRED
BRANDS
GENERICS
NON-PREFERRED
BRANDS
GENERICS
BIRTH CONTROL (continued)
anastrozole
azacitadine
bexarotene
bicalutamide
capecitabine
cyclophosphamide
doxorubicin HCl
exemestane
flutamide
letrozole
lomustine
tamoxifen citrate
temozolomide (PA)
Gleevec (PA)
Granix
Hexalen
Leukeran
Lupron Depot (PA)
Lysodren
Matulane
Myleran
Neulasta (PA)
Neupogen
Nexavar (PA)
Revlimid (PA)
Sprycel (PA)
Sutent (PA)
Tarceva (PA)
Temodar (PA)
Thalomid (PA)
Xeloda
Zolinza (PA)
Afinitor (PA)
Afinitor Disperz (PA)
Arimidex
Aromasin
Bosulif (PA)
Caprelsa (PA)
Casodex
Cometriq (PA)
Droxia
Erivedge (PA)
Fareston
Farydak (PA)
Femara
Gilotrif (PA)
Ibrance (PA)
Imbruvica (PA)
Inlyta (PA)
Iressa (PA)
Jakafi (PA)
Lenvima (PA)
Lynparza (PA)
Mekinist (PA)
Pomalyst (PA)
Purixan
Stivarga (PA)
Sylatron (PA)
Tarfinlar (PA)
Targretin
Tasigna (PA)
Tykerb (PA)
Valchlor
Votrient (PA)
Xalkori (PA)
Xtandi (PA)
Zelboraf (PA)
Zydelig (PA)
Zykadia (PA)
Zytiga (PA)
Cardiovascular
Bladder Problems
Elmiron
Toviaz
VESIcare
NON-PREFERRED
BRANDS
Cancer
norethindrone-ethinyl
estradiol/iron
norgestimate-ethinyl
estradiol
norgestrel-ethinyl
estradiol
Nortrel
Ocella
Ogestrel
Orsythia
Philith
Pimtrea
Pirmella
Portia
Previfem
Quasense
Reclipsen
Sprintec
Sronyx
Syeda
Tilia FE
Tri-Estarylla
Tri-Legest FE
Tri-Linyah
Trinessa
Tri-Previfem
Tri-Sprintec
Trivora
Velivet
Vestura
Viorele
Wera
Wymzya FE
Xulane
Zarah
Zenchent
Zenchent FE
Zeosa
Zovia
oxybutynin/XL
potassium citrate ER
tolterodine tartrate
trospium chloride
PREFERRED
BRANDS
blood thinner/anti-clotting
Detrol (PA,ST)
Detrol LA (PA,ST)
Ditropan XL (PA,ST)
Enablex (PA,ST)
Gelnique (PA,ST)
Myrbetriq (PA,ST)
Oxytrol (PA,ST–For Men
Only)
Urocit-K
anagrelide
Effient
aspirin/dipyridamole ER Fragmin (QL)
cilostazol
Xarelto
clopidogrel
dipyridamole
enoxaparin (QL)
fondaparinux (QL)
heparin (QL)
ticlopidine
warfarin
10
Aggrenox
Agrylin (PA)
Arixtra (QL)
Brilinta
Coumadin
Eliquis (ST)
Jantoven
Lovenox (QL)
Plavix
Pletal
Pradaxa (ST)
Savaysa (ST)
Zontivity
GENERICS
PREFERRED
BRANDS
NON-PREFERRED
BRANDS
GENERICS
PREFERRED
BRANDS
NON-PREFERRED
BRANDS
Cardiovascular (continued)
Cardiovascular (continued)
high blood pressure/heart medications
high blood pressure/heart medications
(continued)
acebutolol HCl
acetazolamide
amiloride HCl
amiloride/HCTZ
amlodipine besylate
amlodipine/atorvastatin
amlodipine/valsartan
amlodipine/valsartan/
HCTZ
atenolol
benazepril HCl
benazepril HCl/
amlodipine
benazepril HCl/HCTZ
bendroflumethiazide/
nadolol
betaxolol HCl
bisoprolol fumarate
bisoprolol/HCTZ
bumetanide
candesartan
candesartan/HCTZ
captopril
captopril/HCTZ
carvedilol
chlorothiazide
chlorthalidone
chlorthalidone/atenolol
clonidine HCl
clonidine patch
Clorpres
diltiazem
diltiazem 24 HR ER
doxazosin mesylate
enalapril maleate
enalapril maleate/HCTZ
eplerenone
felodipine
fosinopril sodium
furosemide
guanfacine
hydralazine HCl
hydralazine/reserpine/
HCTZ
hydrochlorothiazide
indapamide
irbesartan
irbesartan/HCTZ
isradipine
labetalol HCl
lisinopril
lisinopril/HCTZ
losartan potassium
Azor
Benicar
Benicar HCT
Bystolic
Coreg CR
Tekturna
Tekturna HCT
Tribenzor
Accupril (PA,ST)
Accuretic (PA,ST)
Aceon (PA,ST)
Altace (PA,ST)
Atacand (PA,ST)
Atacand HCT (PA,ST)
Avalide (PA,ST)
Avapro (PA,ST)
Betapace AF
Cardura
Cardura XL
Catapres, Catapres TTS
Coreg
Corgard
Corlanor (PA)
Cozaar (PA,ST)
Diovan (PA,ST)
Diovan HCT (PA,ST)
Dutoprol
Edarbi (PA,ST)
Edarbychlor (PA,ST)
Entresto (PA)
Epaned
Exforge
Exforge HCT
Hemangeol
Hyzaar (PA,ST)
Inderal LA
Innopran XL
Levatol
Lotensin (PA,ST)
Lotensin HCT (PA,ST)
Lotrel
Mavik (PA,ST)
Maxzide
Micardis (PA,ST)
Micardis HCT (PA,ST)
Norpace
Norpace CR
Norvasc
Nymalize
Prestalia
Prinivil (PA,ST)
Prinzide (PA,ST)
Sotylize
Sular
Tarka
Tekamlo
Teveten (PA,ST)
Teveten HCT (PA,ST)
Toprol XL
Vaseretic (PA,ST)
Vasotec (PA,ST)
Verelan
Zestoretic (PA,ST)
Zestril (PA,ST)
losartan potassium/
HCTZ
methazolamide
methyldopa
methyldopa/HCTZ
metolazone
metoprolol succinate
metoprolol tartrate
metoprolol/HCTZ
minoxidil
moexipril HCl
moexipril HCl/HCTZ
nadolol
nicardipine HCl
nifedipine
nimodipine
perindopril erbumine
pindolol
prazosin HCl
propranolol HCl
propranolol/HCTZ
quinapril
quinapril HCl/HCTZ
ramipril (caps only)
reserpine
sotalol HCl
spironolactone
spironolactone/HCTZ
telmisartan
telmisartan/amlodipine
telmisartan/HCTZ
terazosin HCl
timolol maleate
torsemide
trandolapril
trandolapril/verapamil
triamterene HCl
valsartan
valsartan HCTZ
Vecamylmecamylamine HCl
verapamil
other
amiodarone
Multaq
amiodarone HCl
Nitrolingual spray
disopyramide
Tikosyn
flecainide
isosorbide dinitrate
isosorbide mononitrate
nitroglycerin
propafenone SR
11
Lanoxin
Nitromist
Ranexa (ST)
Rythmol SR
Samsca
PREFERRED
BRANDS
GENERICS
NON-PREFERRED
BRANDS
GENERICS
Cholesterol Lowering
atorvastatin
choline
colestipol
fenofibrate
fenofibric acid
fluvastatin
gemfibrozil
lovastatin
niacin
omega-3 acid ethyl
esters
pravastatin
simvastatin
Crestor
Lescol XL
Simcor
Welchol
Zetia
Pristiq ER
NON-PREFERRED
BRANDS
Diabetes
Advicor
Altoprev (PA,ST)
Antara
Caduet
Colestid
Fenoglide
Juxtapid (PA)
Kynamro (PA)
Lescol
Liptruzet (PA,ST)
Livalo (PA,ST)
Lofibra
Lovaza
Mevacor (PA,ST)
Niaspan
Pravachol (PA,ST)
TriCor
Trilipix
Vascepa (ST)
Vytorin (PA,ST)
Zocor (PA,ST)
acarbose
chlorpropamide
glimepiride
glipizide
glipizide/metformin
glyburide
glyburide micronized
glyburide/metformin
metformin ER
metformin HCl
nateglinide
pioglitazone
pioglitazone HCl
pioglitazone/
glimepiride
pioglitazone/metformin
repaglinide
tolazamide
tolbutamide
Depression
amitriptyline
bupropion
bupropion SR
citalopram
desipramine
duloxetine HCl
escitalopram
fluoxetine
fluvoxamine
imipramine
mirtazapine
nortriptyline
paroxetine
paroxetine CR
protriptyline
sertraline
trazodone
venlafaxine
venlafaxine XR
PREFERRED
BRANDS
Aplenzin (PA,ST)
Brintellix (PA,ST)
Celexa (PA,ST)
Desvenlafaxine ER
(PA,ST)
Desvenlafaxine
Fumarate ER (PA,ST)
Effexor XR (PA,ST)
Emsam
Fetzima (PA,ST)
Forfivo XL (PA,ST)
Irenka (PA,ST)
Khedezla (PA,ST)
Luvox CR
Marplan
Oleptro ER (ST)
Paxil (PA,ST)
Paxil CR (PA,ST)
Prozac / Prozac Weekly
(PA,ST)
Remeron
Sarafem (PA,ST)
Tofranil
Venlafaxine HCl ER
(PA,ST)
Viibryd (PA,ST)
Vivactil
Wellbutrin (PA,ST)
Wellbutrin SR (PA,ST)
Zoloft (PA,ST)
BD Insulin Syringes/
Pen Needles
GlucaGen HypoKit (QL)
Glucagon Emergency
Kit (QL)
Humalog
Humulin
Invokamet
Invokana
Janumet
Janumet XR
Januvia
Kombiglyze XR
Lantus
Lantus SoloStar
Levemir
NovoFine/NovoTwist
needles
Novolin
Novolog
OneTouch test strips
Onglyza
Prandimet
SymlinPen
Trulicity (QL)
Victoza (QL)
Avandamet
Avandia
Bydureon (QL)
Byetta
Cycloset
Duetact
Farxiga (ST)
Fortamet
Glucophage XR
Glyset
Jardiance (ST)
Prandin
Precose
Starlix
Tanzeum (QL,ST)
VGo
Xigduo XR (ST)
ENDOCRINE AND METABOLIC
allopurinol
cabergoline (QL)
desmopressin
megestrol acetate
octreotide (PA)
12
Colcrys
Increlex (PA)
Lupron Depot-PED (PA)
Megace ES
Nilandron
Sandostatin LAR (PA)
Somavert (PA)
Synarel
Uloric
colchicine
Egrifta (PA)
Megace
Mitigare
Sandostatin (PA)
Signifor LAR (PA)
Signifor (PA)
Somatuline Depot (PA)
PREFERRED
BRANDS
GENERICS
NON-PREFERRED
BRANDS
PREFERRED
BRANDS
GENERICS
Eye Conditions
apraclonidine HCl
atropine
azelastine
bimatoprost
brimonidine
bromfenac
ciprofloxacin
diclofenac
dorzolamide
dorzolamide/timolol
epinastine
flurbiprofen
gatifloxacin
ketorolac
latanoprost
levofloxacin
pilocarpine
timolol
tobramycin/
dexamethasone
trifluridine
Alomide
Alphagan P 0.10%
AzaSite
Azopt
Betoptic S
Ciloxan (ointment)
Iopidine
Lotemax (drops & gel)
Maxidex
Moxeza
Pataday
Patanol
Restasis
Tobradex (ointment)
Travatan Z
Vexol
Vigamox
Heartburn/Ulcer
cimetidine
esomeprazole
magnesium
famotidine
lansoprazole
lansoprazole/
amoxicillin/
clarithromycin
metoclopramide
misoprostol
nizatidine
omeprazole
omeprazole/sodium
bicarbonate
pantoprazole
rabeprazole HCl
ranitidine
sucralfate
Acular LS
Acuvail
Alocril
Alrex
Bepreve
Besivance
Ciloxan (drops)
Cosopt
Cystaran
Durezol
Elestat
Emadine
Ilevro
Lastacaft
Lotemax (oint)
Optivar
Pazeo
Rescula
Simbrinza (ST)
Timoptic
Tobradex (drops)
Tobradex ST
Tobrex
Trusopt
Voltaren
Xalatan
Zioptan (ST)
Apriso
Asacol HD
Canasa
Creon
Delzicol
GoLytely
Humira (PA)
Lialda
Pentasa
Suprep
Urso/Urso Forte
Zenpep
Androxyfluoxymesterone
estradiol
estropipate
ethinyl estradiol
levothroid
levothyroxine
levothyroxine sodium
Levoxyl
liothyronine
medroxyprogesterone
medroxyprogesterone
acetate
norethindrone-ethinyl
estradiol
progesterone,
micronized
testosterone cypionate
(PA)
testosterone enanthate
(PA)
testosterone gel (QL)
thyroid
Unithroid
Amitiza
Cholbam (PA)
Cimzia (PA)
Colazal
Colyte
Donnatal
Entocort EC
Giazo
Movantik (PA)
NuLytely
Pancreaze
Pertzye
Prepopik
Relistor (PA)
Remicade (PA)
sfRowasa
Simponi (PA)
Sucraid
Uceris
Ultresa
Viokace
Growth Hormones
Humatrope (PA)
Saizen (PA)
Dexilant
Prevpac
Aciphex (PA,ST)
Aciphex Sprinkle
(PA,ST)
Nexium (PA,ST)
Omeclamox-Pak
Prevacid (PA,ST)
Prilosec (PA,ST)
Protonix (PA,ST)
Zantac Syrup
Zegerid (PA,ST)
Hormone Replacement
Gastrointestinal (Not Heartburn/Ulcer)
alosetron
balsalazide
belladonna alkaloids/
phenobarbital
budesonide
cromolyn sodium
(solution)
dexamethasone
metoclopramide HCl
PEG 3350/potassium/
sodium bicarb/salt
PEG 3350/potassium/
sodium bicarb/salt/
sodium sulf
PEG-Prep
prednisone
prednisone sodium
phosphate
NON-PREFERRED
BRANDS
Serostim (PA)
13
Alora
Anadrol-50 (PA)
Androderm (QL)
AndroGel (QL)
Armour Thyroid
Divigel
Enjuvia
Premarin
Premphase
Prempro
Synthroid
Vivelle-Dot
Activella
Cenestin
Combipatch
Cytomel
Delatestryl
Depot Testosterone
Estrace
Femhrt
Femring
Menest
Minivelle
Prefest
Prometrium
Provera
Striant (QL)
Vagifem
GENERICS
PREFERRED
BRANDS
NON-PREFERRED
BRANDS
PREFERRED
BRANDS
GENERICS
Infections (continued)
Infections
acyclovir
adefovir dipivoxil
amantadine
amoxicillin/clavulanate
amoxicillin/ER
atovaquone
azithromycin
bacitracin/polymyxin
besifloxacin HCl
cefaclor ER
cefadroxil
cefdinir
cefditoren
cefixime
cefprozil
ceftibuten dihydrate
ceftriaxone
cefuroxime axetil
cephalexin
ciclopirox
ciprofloxacin
clarithromycin
clindamycin
clindamycin phosphate
cycloserine
doxycycline
doxycycline hyclate
doxycycline
monohydrate
entacavir
erythromycin
famciclovir
fluconazole (QL for
150 mg only)
flucytosine
ganciclovir
gentamicin
gentamicin sulfate
griseofulvin
itraconazole (QL)
ketoconazole
lamivudine
levofloxacin (susp)
linezolid
metronidazole
minocycline
minocycline HCl
Moderiba
moxifloxacin HCl
mupirocin
nitrofurantoin
nystatin
ofloxacin
penicillin v potassium
Baraclude
Cipro HC Otic
Ciprodex
Epivir HBV
Gris-Peg
Hepsera
Intron A (PA)
Mycostatin (tab)
Pegasys (PA)
PegIntron (PA)
Primsol
Qualaquin
Ribapak
Ribasphere
Tamiflu (QL)
Valcyte
Vancocin HCl
NON-PREFERRED
BRANDS
Ancobon
Augmentin
Augmentin ES 600
Augmentin XR
Avelox
Bethkis
Biaxin
Biaxin XL
Cetraxal
Ciclodan
Cipro XR
CNL 8
Coartem (QL)
Copegus
Cresemba capsule (PA)
Dificid (PA)
Ery-Tab
Famvir
Flagyl ER
Garamycin
Grifulvin V
Keflex
Kitabis Pak
Lamisil
Levaquin
Malarone (PA)
Monurol
Moxatag
Noxafil
Olysio (PA)
Onmel (QL,ST)
Penlac
Priftin
Rebetol
Relenza (QL)
Rocephin
Sirturo
Sitavig
Sivextro (PA)
Spectracef
Sporanox
Suprax
Tobi/Tobi PodHaler
Tyzeka
Urelle
Uribel
UTA
Valtrex
Vfend (PA)
Zithromax
Zovirax
Zyclara (ST)
Zyvox (PA)
polymixin b sulf
quinine sulfate
ribavirin
rifabutin
rimantadine
sulfamethoxazole/
trimethoprim
terbinafine (QL)
terconazole
tetracycline
tobramycin
valacyclovir
valganciclovir
vancomycin
vancomycin HCl
voriconazole (QL)
Migraine
acetaminophen/
caffeine/butalbital
almotriptan malate
(QL)
dihydroergotamine
mesylate (QL)
isomethepten/caf/
acetaminophen
naratriptan (QL)
rizatriptan (QL)
rizatriptan benzoate
(QL)
sumatriptan (QL)
sumatriptan succinate
(QL)
zolmitriptan (QL)
Cafergot
Treximet (QL)
Alsuma (QL)
Amerge (QL)
Axert (QL)
DHE 45 (QL)
Frova (QL)
Imitrex (QL)
Maxalt (QL)
Maxalt MLT (QL)
Migranal (QL)
Relpax (QL)
Sumavel DosePro (QL)
Zomig nasal (QL)
Zomig/Zomig ZMT (QL)
Multiple Sclerosis
Glatopa-glatiramer
acetate
Ampyra (PA)
Avonex (PA)
Avonex Pen (PA)
Copaxone (PA)
Rebif (PA)
Rebif Rebidose (PA)
Tecfidera (PA)
Aubagio (PA)
Extavia (PA)
Gilenya (PA)
Plegridy (PA)
Nausea and Vomiting
dronabinol
granisetron
ondansetron
prochlorperazine
promethazine
trimethobenzamide
14
Emend (QL)
Akynzeo (QL)
Anzemet (inj) (QL)
Anzemet (tab) (QL)
Diclegis
Marinol
Sancuso (QL)
Zofran (tabs, sol)
Zuplenz (QL,ST)
GENERICS
PREFERRED
BRANDS
NON-PREFERRED
BRANDS
GENERICS
Osteoporosis
alendronate
etidronate
(Fortical) calcitoninsalmon
ibandronate
raloxifene HCl
risedronate
Forteo
Miacalcin
Actimmune (PA)
Dilaudid-5
Dipentum
Enbrel (PA)
Fentora (PA)
Humira (PA)
Indocin (suppository)
Lidorx
Lyrica
Nucynta (QL)
Nucynta ER (QL)
OxyContin (QL)
Rheumatrex
Roxicet
Savella
Trexall
NON-PREFERRED
BRANDS
Pain Relief and Inflammatory Disease
(continued)
Actonel (PA,ST)
Atelvia (PA,ST)
Binosto (PA,ST)
Boniva (PA,ST)
Didronel
Evista
Fosamax (PA,ST)
Fosamax Plus D (PA,ST)
Skelid (PA,ST)
morphine sulfate (QL)
nabumetone
naproxen
opium
opium/belladonna
alkaloids
orphenadrine/aspirin/
caffeine
oxaprozin
oxycodone ER (QL)
oxycodone HCl
oxycodone HCl/
acetaminophen
oxycodone/aspirin
oxymorphone
oxymorphone HC
pentazocine HCl/
naloxone HCl
rizatriptan benzoate
(QL)
sulindac
tolmetin
tramadol ER (QL)
tramadol HCl (QL)
tramadol HCl/
acetaminophen (QL)
zolmitriptan (QL)
Pain Relief and Inflammatory Disease
buprenorphine
butalbit/acetamin/caff/
codeine
butalbital/
acetaminophen
butorphanol nasal (QL)
celecoxib (QL)
codeine phos/
carisoprodol/asa
codeine phosphate
codeine phosphate/
aspirin
codeine sulfate
diclofenac
dihy-cod tt/apap/
caffeine
dihydroergotamine
mesylate (QL)
doxorubicin HCl
etodolac
fenoprofen
fentanyl citrate
(lozenge on stick) (PA)
fentanyl transdermal
(QL)
flurbiprofen
hydrocodone bitartrate/
apap
hydromorphone HCl
ibuprofen
ibuprofen/hydrocodone
bit
indomethacin
ketoprofen
ketorolac (QL)
leflunomide
levorphanol tartrate
lidocaine
meclofenamate
mefenamic acid
meloxicam
meperidine HCl
methotrexate
migergot
PREFERRED
BRANDS
Abstral (PA)
Actemra (PA)
Actiq (PA)
Adazin
Anaprox (PA,ST)
Ansaid (PA,ST)
Arthrotec (PA,ST)
Avinza (QL)
Butrans (QL)
Cambia (PA,ST)
Capacet
Celebrex (QL,ST)
Cimzia (PA)
Conzip (QL)
Daypro (PA,ST)
Demerol
Dilaudid
Durabec
Duragesic (QL)
Embeda (QL)
Exalgo (QL)
Feldene (PA,ST)
Fioricet
Flector (PA,ST,QL)
Horizant (ST)
Hycet
Hysingla ER (QL)
Kadian (QL)
Kineret (PA)
Lazanda (PA)
Lidoderm
Lidopin
Lidovex
Mobic (PA,ST)
MS Contin (QL)
Nalfon (PA,ST)
Naprelan (PA,ST)
Naprosyn/ EC Naprosyn
(PA,ST)
Norco
Onsolis (PA)
Opana
Opana ER (QL)
15
Otrexup (PA)
Oxecta
Pain Relief
Pennsaid (PA,ST)
Percocet
Percodan
Ponstel (PA,ST)
Prodrin
Rasuvo (PA)
Rayos (ST)
Relyyks
Relyyt
Remicade (PA)
Roxicodone
Scar
Silvera
Simponi (PA)
Skelaxin
Solaice
Sprix (QL)
Subsys (PA)
Synalgos-DC
Synvexia TC
Tivorbex (PA,ST)
Trezix
Ultracet (QL)
Ultram (QL)
Ultram ER (QL)
Velma
Vicodin/ Vicodin ES/
Vicodin HP
Vicoprofen
Voltaren Gel (PA,ST)
Voltaren/ Voltaren XR
(PA,ST)
Xartemis XR (QL)
Xodol
Zipsor (PA,ST)
Zohydro ER (QL)
Zomig (QL)
Zorvolex (PA,ST)
PREFERRED
BRANDS
GENERICS
NON-PREFERRED
BRANDS
PREFERRED
BRANDS
GENERICS
Parkinson’s Disease
amantadine
Apokyn (PA)
benztropine
Azilect
bromocriptine
carbidopa/levodopa/
entacapone
carbidopa
carbidopa/levodopa
carbidopa/levodopa CR
entacapone
pramipexole
pramipexole ER
ropinirole
ropinirole XL
selegiline
tolcapone
Seizure
Comtan
Eldepryl
Lodosyn
Mirapex
Mirapex ER
Neupro
Northera (PA)
Parcopa
Requip
Requip XL
Rytary
Sinemet CR
Stalevo
Tasmar
Zelapar
carbamazepine
clonazepam
diazepam
divalproex
ethosuximide
felbamate
gabapentin
lamotrigine
levetiracetam
oxcarbazepine
phenobarbital
phenytoin
tiagabine HCl
topiramate
valproate sodium
zonisamide
Prostate
Celontin
Diastat
Diastat Acudial
Dilantin (30 mg only)
Felbatol
Gabitril
Keppra
Lamictal ODT
Lyrica
Peganone
Vimpat
* Please check your enrollment materials to determine whether
this medication is covered under your plan.
alfuzosin
doxazosin
finasteride
leuprolide acetate (PA)
prazosin
tamsulosin
terazosin
Avodart
Cialis (PA,QL)*
Jalyn
Lupron Depot (PA)
NON-PREFERRED
BRANDS
Firmagon (PA)
Flomax
Proscar
Rapaflo
Uroxatral
Xtandi (PA)
Zoladex (PA)
Zytiga (PA)
Aptiom
Banzel
Carbatrol
Depakote (all forms)
Dilantin
Fycompa
Keppra XR
Lamictal
Lamictal XR
Neurontin
Oxtellar XR
Potiga
Qudexy XR
Stavzor
Tegretol XR
Topamax
topiramate XR caps
Trileptal
Trokendi XR
Zarontin
Zonegran
Sexual Dysfunction
* Please check your enrollment materials to determine whether
this medication is covered under your plan.
Cialis (PA,QL)*
Muse (PA, QL)*
Viagra (PA, QL)*
Caverject (PA, QL)*
Edex (PA, QL)*
Levitra (PA, QL)*
Osphena
Staxyn (PA, QL)*
Stendra (PA,QL)*
Skin CONDITIONS
adapalene (AGE)
alclometasone
dipropionate
amcinonide
Amnesteem (QL)
Apexicon E (diflorasone
diacetate) cream
benzoyl peroxide
betamethasone
betamethasone
dipropionate
betamethasone
dipropionate/
propylene glycol
Schizophrenia
aripiprazole
clozapine
haloperidol
loxapine
olanzapine
olanzapine/fluoxetine
HCl
quetiapine
risperidone
thiothixene
ziprasidone
Seroquel XR
Abilify
Abilify Discmelt
Clozaril (PA,ST)
Fanapt (PA,ST)
Fazaclo (PA,ST)
Geodon (PA,ST)
Invega (PA,ST)
Latuda (PA,ST)
Orap
Rexulti (PA,ST)
Risperdal/ Risperdal M
(PA,ST)
Saphris (PA,ST)
Seroquel (PA,ST)
Symbyax
Versacloz (PA,ST)
Zyprexa (PA,ST)
Zyprexa Zydis (PA,ST)
16
Aczone
Ala-Scalp HP (PA,ST)
Benzaclin gel pump
Benzamycin Pak
Capex Shampoo
(PA,ST)
Carac
Carmol HC (PA,ST)
Cloderm (PA,ST)
Cordran (PA,ST)
Cordran SP (PA,ST)
Differin (AGE)
Enbrel (PA)
Exelderm
Fluoroplex
Absorbica (QL)
Acanya
Aclovate (PA,ST)
Alcortin A
Aldara
Aqua Glycolic HC
(PA,ST)
Atralin (AGE)
Avar
Avar LS
Avita
Bactroban
Benoxyldoxy 30
Carb-O-Philic
Clindacin Pac
GENERICS
PREFERRED
BRANDS
NON-PREFERRED
BRANDS
GENERICS
Skin CONDITIONS (continued)
betamethasone
valerate
calcipotriene
calcipotrienebetamethasone
Claravis (QL)
clinicamycinphosphate/
benzoyl peroxide gel
clobetasol propionate
clobetasol propionate/
emoll
clocortolone pivalate
desonide
desoximetasone
diclofenac sodium
diflorasone diacetate
dipropionate
fluocinolone acetonide
fluocinonide
fluocinonide/emollient
fluorouracil topical
fluticasone propionate
halobetasol prop/
ammonium lac
halobetasol propionate
hydrocortisone
hydrocortisone acetate/
aloe vera
hydrocortisone acetate/
urea
hydrocortisone butyrate
hydrocortisone
butyrate/emollient
hydrocortisone valerate
hydrocortisone/
iodoquinol/aloe
imiquimod
isotretinoin (QL)
methoxsalen, rapid
metronidazole
mometasone furoate
mupirocin calcium
Myorisan (QL)
naftifine
podofilox
prednicarbate
salicylic acid
Sotret (QL)
sulfacetamide
sulfacetamide sodium
sulfacetamide sodium/
sulfur
sulfacetamide/sulfur/
cleansr23
Humira (PA)
Kenalog aerosol (PA,ST)
Klaron
Locoid lotion (PA,ST)
Loprox shampoo
Metrogel 1%
Naftin
Noritate
Nucort (PA,ST)
Tazorac
Texacort (PA,ST)
PREFERRED
BRANDS
NON-PREFERRED
BRANDS
Skin CONDITIONS (continued)
Clobex (PA,ST)
Clodan (PA,ST)
Condylox
Cosentyx (PA)
Cutivate (PA,ST)
Derma-Smoothe/FS
(PA,ST)
Dermasorb AF
Dermasorb HC (PA,ST)
Dermasorb TA (PA,ST)
Dermasorb XM
Dermatop (PA,ST)
Desonate (PA,ST)
Desowen (PA,ST)
Diprolene (PA,ST)
Diprolene AF (PA,ST)
Dovonex
Doxycycline IR-DR
Duac
Ecoza
Elidel (PA,ST)
Elocon (PA,ST)
Epiduo
Fabior
First Hydrocortisone
(PA,ST)
Halog (PA,ST)
Iodosorb
Jublia (ST)
Keralac
Kerydin (ST)
Locoid cream,
ointment, solution
(PA,ST)
Locoid Lipocream
(PA,ST)
Luxiq (PA,ST)
Luzu
Metrogel
Metrolotion
Neuac
Olux (PA,ST)
Olux-E (PA,ST)
Onexton
Otezla (PA)
Ovace Plus cream,
foam, lotion and wash
Pandel (PA,ST)
Panretin
Pediaderm HC/TA
(PA,ST)
Picato
Plexion
tacrolimus ointment
tretinoin (AGE)
triamcinolone
acetonide
urea
Prolensa
Protopic (PA,ST)
Regranex (PA)
Remicade (PA)
Retin-A cream (PA,
AGE)
Retin-A Micro (PA,
AGE)
Retin-A Micro Pump
(PA, AGE)
Riax
Rosula
Scalacort DK (PA,ST)
Solaraze
Soolantra
Soriatane
Sorilux
Stelara (PA)
Sumadan XLT
Synalar (PA,ST)
Synalar TS (PA,ST)
Taclonex
Targretin gel
Temovate (PA,ST)
Topicort (PA,ST)
Topicort LP (PA,ST)
Tretin-X (PA)
Ultrasal-ER
Ultravate X (PA,ST)
Ultravate/Ultravate PAC
(PA,ST)
Umecta
Urevaz
Vanos (PA,ST)
Vectical
Verdeso (PA,ST)
Vytone
Westcort (PA,ST)
Xolegel
Ziana
Zyclara (ST)
Sleep
eszopiclone
midazolam HCl
zaleplon
zolpidem
zolpidem ER
17
Silenor
Ambien (PA,ST)
Ambien CR (PA,ST)
Belsomra (PA,ST)
Edluar (PA,ST)
Intermezzo (PA,ST)
Lunesta (PA,ST)
Rozerem (PA,ST)
Sonata (PA,ST)
Zolpimist (PA,ST)
GENERICS
PREFERRED
BRANDS
NON-PREFERRED
BRANDS
Azasan
Cellcept
Neoral
Prograf
Rapamune
Sandimmune
* All plans cover all generic prescription prenatal vitamins, even
though not listed here. Available as generic where ^ is noted.
Astagraf XL
Imuran
Myfortic
Zortress
Provida DHA
Provida OB
Select-OB
Stuartnatal Plus
Stuartnatal Plus 3
TL-Folate
Tricare
Tricare Prenatal DHA
One
Tristart DHA
Vitamins*
* All plans cover all generic prescription prenatal vitamins, even
though not listed here. Available as generic where ^ is noted.
calcitriol
cyanocobalamin
folic acid
Active OB^
Bal-Care DHA Essential
Cadeau DHA
Citranatal
Citranatal 90 DHA
Citranatal Assure
Citranatal B-Calm
Citranatal DHA
Citranatal Harmony^
Citranatal Rx
Enbrace HR
Folet DHA
Folet One
Infanate Balance
Natachew
Natelle One^
Neevo DHA
Nestabs ABC
Nestabs DHA^
Nestabs^
Nexa Plus
OB Complete
OB Complete DHA
OB Complete One
OB Complete Petite
Prefera-OB One
Prefera-OB Plus DHA
PreferaOB Prenatal
Vitamin
Prenaissance Next-B
Prenata
Prenatal 19^
Prenate AM
Prenate Chewable
Prenate DHA
Prenate Elite
Prenate Enhance
Prenate Essential
Prenate Mini
Prenate Pixie
Prenate Restore
Prenate Star
NON-PREFERRED
BRANDS
Vitamins* (continued)
Transplant
azathioprine
cyclosporine
mycophenolate
moefetil
mycophenolate sodium
sirolimus
tacrolimus
PREFERRED
BRANDS
GENERICS
Eligen B12
Feriva 21-7
Nascobal
MaxFe
Miscellaneous
* Please check your enrollment materials to determine whether
this medication is covered under your plan.
acamprostate calcium
aminocaproic acid
benzonatate
buprenorphine
cyclobenzaprine
doxercalciferol
hydrocodone/
chlorpheniramine
suspension
hydrocortisone
ivermectin
leucovorin
levocarnitine
lidocaine HCl/glycerin
lidocainehydrocortisone-aloe
lindane
megestrol
metaxalone
methocarbamol
naltrexone
naltrexone HCl
paricalcitol
pentoxifylline
pramoxine/
hydrocortisone
promethazine-codeine
pseudoephed/
hydrocodone/cpm
pyridostigmine
quinine sulfate
riluzole
sodium phenylbutarate
sodium polystyrene
sulfonate
spinosad
tizanidine
tranexamic acid
18
Analpram Advanced
Aranesp (PA)
Buphenyl
Chantix*
Epogen (PA)
Fosrenol
Harvoni (PA)
Klor-Con M15
Leukine
Metopirone
Neupogen
Pramosone
Procrit (PA)
Proctofoam-HC
Renvela
Sovaldi (PA)
SPS
Stromectol
Suboxone film (PA)
TussiCaps
Zavesca (PA)
Ana-Lex
Analpram E
Analpram HC
Arcalyst (PA)
Belviq*
Brisdelle (QL)
Bunavail (PA)
Cerdelga (PA)
Cortifoam
Cuvposa
Epifoam
Evzio
Feriva FA
Ferric citrate
Gattex (PA)
Hectorol
Hetlioz (PA)
Ilaris (PA)
Jadenu
Kalydeco (PA)
Kuvan (PA)
Lupaneta Pack (PA)
Lysteda
Mircera (PA)
Natpara (PA)
Natroba
Neo-Synalar
Nuedexta
Nuvessa
Nymalize
Obredon
Orkambi (PA)
GENERICS
PREFERRED
BRANDS
Specialty medications
NON-PREFERRED
BRANDS
If your prescription drug plan includes Exclusive Home
Delivery Pharmacy for specialty medications, you’re
required to fill certain specialty pharmacy prescriptions
through Cigna Specialty Pharmacy ServicesSM.
Depending on your plan, you’re allowed one, two or
three fills before you’re required to use Cigna Home
Delivery Pharmacy. At that time, if you choose to not
use Cigna Home Delivery Pharmacy, your plan will not
cover the cost of your medication.
Miscellaneous (continued)
Oxandrin (PA)
Phoslo
Phoslyra
Procysbi (PA)
Promacta (PA)
Ravicti (PA)
Rectiv
Renagel
Revia
Revia
Rilutek
Sklice
Tussionex
Tuzistra XR
Uceris
Ulesfia
Velphoro
Viekira Pak (PA)
Virtuz
Zanaflex
Zemplar
Zubsolv (PA)
Zutripro
Exclusive Specialty Home Delivery Pharmacy
with Cigna
Medications marked with an asterisk (*) may be covered
under your pharmacy or medical benefit, or covered
under both benefits, depending on your plan. If you’re
getting this medication through a retail pharmacy, you’ll
need to switch to Cigna Specialty Pharmacy Services
for this medication to be covered. If you’re getting this
medication from a health care professional under your
medical benefit, you’re not required to use Cigna
Specialty Pharmacy Services.
For real-time drug pricing specific to your benefit plan,
visit myCigna.com and use the Prescription Drug Price
Quote tool to compare prices for your selected
medications. The tool will show you if you can save
money by using Cigna Home Delivery Pharmacy.
In addition to potential cost savings, Cigna Home
Delivery Pharmacy offers valuable benefits, such as:
›
Customer service associates and licensed
pharmacists available 24/7
›
›
Free, standard delivery right to your door
›
Coordination of copay assistance programs with
drug manufacturers
›
Connection and referrals to Cigna’s health
coaching services
Capabilities to properly handle and ship medications
that require refrigeration and/or overnight delivery
To get started with Cigna Home Delivery Pharmacy
today, call 1.800.351.3606.
The following is a list of specialty medications that
apply to your Exclusive Cigna Home Delivery Pharmacy
plan. Please check your enrollment materials for more
information on how your plan works, the medications
covered under your plan and to see if there are any
requirements such as prior authorization (PA) or
quantity limits (QL). Some exceptions may apply.
Please note, this list is subject to change.
19
Drug name
A
Abacavir
Actemra
Acthar H.P.*
Actimmune
Adcirca
Adefovir Dipivoxil
Advate*
Afinitor
Afinitor Disperz
Agrylin
Aldurazyme*
Alferon N*
Alphanate*
Alprolix*
Amevive*
Amicar
Aminocaproic Acid
Ampyra
Anagrelide Hcl
Apokyn
Aptivus
Aredia*
Astagraf Xl
Atripla
Aubagio
Avonex
Azasan
Azathioprine
B
Baraclude
Baygam*
Bebulin*
Benefix*
Betaseron
Bethkis*
Bexarotene
Bicalutamide
Bivigam*
Boniva*
Bosulif
Botox*
C
Capecitabine
Casodex
Cellcept (Oral)
Ceprotin*
Cerdelga
Cerezyme*
Cimzia
Combivir
Complera
Copaxone
Copegus
Cosentyx
Crixivan
Cyclophosphamide
Cyclosporine
Cystadane
Cytoxan
G
K
Gamastan S-D*
Gammagard*
Gammagard Liquid*
Gammagard S-D*
Gammaked*
Gamunex*
Gel-One*
Gengraf
Genotropin
Gilenya
Gleevec
Kaletra
Kineret
Koate-Dvi*
Kogenate Fs*
Kuvan*
H
D
Harvoni
Hecoria
Helixate Fs*
Hemofil M*
Hepsera
Hexalen
Hizentra*
Hp Acthar*
Humate-P*
Humatrope
Humira
Hyalgan*
Hycamtin
Hylenex*
Daklinza
Didanosine
Docefrez*
Docetaxel*
Dysport*
E
Edurant
Egrifta
Elelyso*
Eligard*
Eloctate*
Emcyt
Emtriva
Enbrel
Entecavir
Entyvio*
Epivir
Epzicom
Erivedge
Esbriet
Etoposide*
Euflexxa*
Evotaz
Exjade
Extavia
I
Ibandronate*
Ibrance
Ilaris*
Imuran
Incivek
Infergen
Inlyta
Intelence
Intron*
Invirase
Iprivask*
Isentress
Ixinity*
F
Fabrazyme*
Feiba Nf*
Firazyr
Flebogamma Dif*
Flutamide
Forteo*
Fuzeon
J
Jadenu
Jevtana*
20
L
Lamivudine
Lemtrada*
Letairis
Leucovorin Calcium (Oral)
Leuprolide*
Lexiva
Lupaneta*
Lupron*
M
Mekinist
Moderiba
Monoclate-P*
Mononine*
Monovisc*
Mycophenolate
Mycophenolate Mofetil
Mycophenolic Acid
Mycophenolic Acid Dr
Myfortic
N
Neoral
Neulasta*
Nevirapine
Nexavar
Norditropin
Norvir
Novoeight*
Novoseven*
Nutropin
O
Octagam*
Octreotide Acetate*
Oforta
Olysio
Omnitrope
Omontys*
Opsumit
Orencia
Orthovisc*
Otezla
P
Pamidronate*
Panretin*
Paricalcitol (Oral)
Pegasys
Pegasys Proclick
Pegintron
Pegintron Redipen
Plegridy
Pomalyst
Prezcobix
Prezista
Privigen*
Profilnine Sd*
Prograf
Promacta
Pulmozyme
R
Rapamune
Rebetol
Rebif
Rebif Rebidose
Reclast*
Recombinate*
Remicade*
Rescriptor
Retrovir (Oral)
Revatio
Revlimid
Reyataz
Ribapak
Ribasphere
Ribatab
Ribavirin
Rilutek
Riluzole
Rixubis*
S
Saizen
Sandimmune (Oral)
Sandostatin*
Selzentry
Serostim
Sildenafil
Simponi
Sirolimus
Sovaldi
Sprycel
Stavudine
Stelara
Stivarga
Stribild
Supartz*
Supprelin*
Sustiva
Sutent
Sylatron
Synagis*
Synarel*
Synvisc*
Viracept
Viramune
Virazole
Viread
Vitekta
Vivitrol*
Votrient
Vpriv*
W
Wilate*
Winrho Sdf*
X
Xalkori
Xeljanz
Xeloda
Xeomin*
Xiaflex*
Xolair
Xtandi
Xyntha*
Xyntha Solofuse*
T
Tacrolimus
Tafinlar
Tarceva
Targretin
Tasigna
Taxotere*
Tecfidera
Temodar (Oral)
Temozolomide
Tev-Tropin
Thalomid
Tivicay
Tobi*
Tobramycin*
Topotecan*
Tracleer
Trelstar*
Trexall
Triumeq
Trizivir
Truvada
Tybost
Tykerb
Tysabri*
Tyzeka
Z
Zelboraf
Zemplar (Oral)
Zerit
Ziagen
Zidovudine
Zoladex*
Zoledronic Acid*
Zometa*
Zortress
Zykadia
Zytiga
V
Vepesid*
Victrelis
Videx
Videx Ec
Viekira
21
Exclusions and limitations
Plans typically do not provide coverage for the following, except as required by law or by the terms
of your specific plan:
1. Any medications available over-the-counter (OTC)
that do not require a prescription by federal or state
law, and any medication that is a pharmaceutical
alternative to an OTC medication other than insulin
[examples include OTC Benadryl, Maalox, Sudafed
PE, etc.].
11. Any prescription vitamins (other than prenatal
vitamins), dietary supplements and fluoride products.
2. Medications that are therapeutically equivalent as
determined by the Cigna HealthCare Pharmacy and
Therapeutics Committee in which at least one of the
medications within the class is available over the
counter [examples include Rx equivalents to OTC
Allegra, Claritin and Zyrtec (Allegra D, Clarinex,
Xyzal) and Rx equivalents to OTC Prevacid, Prilosec
and Zantac (Aciphex, Kapidex, Nexium, Axid,
Pepcid, Zantac)].
13.Any diet pills or appetite suppressants (anorectics).
3. Any injectable infertility medications, and any
injectable medications that require health care
professional supervision and are not typically
considered self-administered medications. The
following are examples of health care professionalsupervised medications: injectables used to treat
hemophilia and RSV (respiratory syncytial virus),
chemotherapy injectables and endocrine and
metabolic agents.
16.Replacement of prescription medications and related
supplies due to loss or theft.
12.Medications used for cosmetic purposes, such as
medications used to reduce wrinkles, medications to
promote hair growth, medications used to control
perspiration and fade cream products.
14.Prescription smoking cessation products.
15.Immunization agents, biological products for allergy
immunization, biological sera, blood, blood plasma
and other blood products or fractions and
medications used for travel prophylaxis (the
prevention of
travel-related diseases).
17. Medications used to enhance athletic performance.
18.Medications that are to be taken by, or administered
to, a customer while the customer is a patient in a
licensed hospital, skilled nursing facility, rest home or
similar institution which operates on its premises, or
allows to be operated on its premises, a facility for
dispensing pharmaceuticals.
4. Any medications that are experimental or
investigational within the meaning set forth in the
summary plan description.
19.Prescriptions more than one year from the original
date of issue.Preventive prescription drug option
Preventive medications are described as medications
that are used to prevent a disease or condition in people
with risk factors such as: high blood pressure, high
cholesterol, diabetes, asthma, osteoporosis, heart attack
and stroke, or to prevent the recurrence of the disease
or condition in people who have recovered.
5. Food and Drug Administration (FDA) approved
medications used for purposes other than those
approved by the FDA unless the medication is
recognized for the treatment of the particular
indication in one of the standard reference
compendia (The United States Pharmacopoeia Drug
Information or The American Hospital Formulary
Service Drug Information) or in medical literature.
Medical literature means scientific studies published
in a peer-reviewed national professional medical
journal.
Preventive medications do not include drugs used to
treat an existing illness, injury or condition. Some
pharmacy plans require you to pay a certain amount
(deductible) before the plan coverage begins, but
preventive medications may be covered before you
reach that amount. To be sure, you can read your
enrollment materials to see how preventive medications
are covered specific to your plan. Also, a list of all
covered preventive medications is available on
myCigna.com. Preventive medications are identified
by a “PM” symbol within the drug list search.
6. Any prescription and non-prescription supplies (such
as ostomy supplies), devices and appliances.
7. Any contraceptive medications and prescription
appliances for contraception.
8. Implantable contraceptive products.
9. Any fertility medication.
10.Any medications used for treatment of sexual
dysfunction, including but not limited to erectile
dysfunction, delayed ejaculation, anorgasmia and
decreased libido.
22
Preventive prescription drugs
Asthma Related
Accolate (zafirlukast)
Accuneb (albuterol sulfate)
Advair Diskus
Advair HFA
Aerobid-M
albuterol sulfate inhalation
solution, syrup, tablet
Alvesco
aminophylline
Arcapta Neohaler
Asmanex
Atrovent inhalation solution
(ipratropium bromide)
Atrovent HFA
Breo Ellipta
Broncomar-1
Brovana
Cafcit (caffeine citrate)
cromolyn sodium
Difil-G (guaifenesin/dyphylline)
Dilex-G 200
Dilex-G 400 (guaifenesin/
dyphylline)
Dulera
Elixophylline (theophylline
anhydrous)
Elixophylline Sr (theophylline
anhydrous)
Flovent
Flovent Diskus
Flovent HFA
Foradil
guaifenesin/dyphylline
ipratropium bromide
Lufyllin (dyphylline)
Lufyllin-400
Lufyllin-GG (guaifenesin/
dyphylline)
metaproterenol sulfate
Perforomist
ProAir HFA
Proventil HFA
Pulmicort inhaler
Pulmicort inhalation solution
(budesonide)
Qvar
S-2 Racepinephine
Serevent
Serevent Diskus
Singulair (montelukast)
Spiriva
Symbicort
terbutaline sulfate
Theo-24
Theochron (theophylline
anhydrous)
Theo-Dur (theophylline
anhydrous)
theophylline anhydrous
Tudorza
Uniphyl (theophylline anhydrous)
Ventolin HFA
Vospire ER (albuterol sulfate)
Xolair*
Xopenex inhalation solution
(levalbuterol HCl)
Xopenex HFA
Zyflo
Zyflo CR
Catapres-TTS 3 (clonidine HCl)
chlorthalidone
Clorpres (clonidine HCl/
chlorthalidone)
Coreg (carvedilol)
Coreg CR
Corgard (nadolol)
Corzide (bendroflumethiazide/
nadolol)
Covera-HS
Cozaar (losartan potassium)
Demadex (torsemide)
Demser
Diamox (acetazolamide)
Diamox Sequels (acetazolamide)
dibenzyline
Dilacor XR (diltiazem)
diltiazem HCl
Diovan (valsartan)
Diovan HCT (valsartan/HCTZ)
Diuril (chlorothiazide)
Dutoprol
Dyazide (triamterene/HCTZ)
Dynacirc CR
Dyrenium
Edarbi
Edarbychlor
Edecrin
Eliquis
Epaned
Exforge
Exforge HCT
felodipine
fosinopril sodium
furosemide
hydralazine HCl
hydrochlorothiazide
hydrochlorothiazide/reserpine
Hydrodiuril (hydrochlorothiazide)
Hygroton (chlorthalidone)
Hytrin (terazosin HCl)
Hyzaar (losartan/
hydrochlorothiazide)
indapamide
Inderal (propranolol HCl)
Inderal LA (propranolol HCl)
Innopran XL
Inspra (eplerenone)
isradipine
Kerlone (betaxolol HCl)
Lasix (furosemide)
Levatol
Liptruzet
Lopressor (metoprolol tartrate)
Lopressor HCT (metoprolol/HCTZ)
Lotensin (benazepril HCl)
Blood Pressure
Related
Accupril (quinapril)
Accuretic (quinapril HCl/HCTZ)
Aceon (perindopril erbumine)
acetazolamide
Adalat CC (nifedipine)
Aldactazide (spironolactone/
HCTZ)
Aldactone (spironolactone)
Aldomet (methyldopa)
Altace (ramipril)
Amturnide
Apresoline-hydralazine HCl
Atacand (candesartan cilexetil)
Atacand HCT
Avalide (irbesartan/ HCTZ)
Avapro (irbesartan)
Azor
benazepril HCl
benazepril HCl-HCTZ
Benicar
Benicar HCT
Betapace (sotalol HCl)
Betapace AF (sotalol HCl)
Bumex (bumetanide)
Bystolic
Caduet (amlodipine/atorvastatin)
Calan (verapamil)
Calan SR (verapamil)
Capozide (captopril/
hydrochlorothiazide)
captopril
Cardene (nicardipine HCl)
Cardene SR
Cardizem (diltiazem)
Cardizem CD (diltiazem)
Cardizem LA (diltiazem HCl)
Cardura (doxazosin mesylate)
Cardura XL
Catapres (clonidine HCl)
Catapres-TTS 1 (clonidine HCl)
Catapres-TTS 2 (clonidine HCl)
23
Lotensin HCT (benazepril HCl/
HCTZ)
Lotrel (amlodipine besylate/
benazepril)
Matzim LA (diltiazem)
Mavik (trandolapril)
Maxzide (triamterene/HCTZ)
mecamylamine hcl
methyclothiazide
methyldopa
methyldopa/hydrochlorothiazide
metoprolol tartrate
Micardis
Micardis HCT
Microzide (hydrochlorothiazide)
Midamor (amiloride HCl)
Minipress (prazosin HCl)
Minizide (prazosin/polythiazide)
minoxidil
Moduretic (hydrochlorothiazide/
amilor hcl)
Naturetin-5
Neptazane (methazolamide)
Nexiclon XR
nifedipine
Nimotop (nimodipine)
nisoldipine
Normodyne (labetalol HCl)
Norvasc (amlodipine besylate)
Nymalize
pindolol
Prinivil (lisinopril)
Prinzide (lisinopril/
hydrochlorothiazide)
Procardia (nifedipine)
Procardia XL (nifedipine)
propranolol
propranolol/HCTZ
reserpine
Saluron (hydroflumethiazide)
Salutensin Demi (reserpine/
hydrochlorothiazide)
Sectral (acebutolol HCl)
Sular (nisoldipine)
Tarka
Tekamlo
Tekturna
Tekturna HCT
Tenex (guanfacine HCl)
Tenoretic 50 (chlorthalidone/
atenolol)
Tenoretic 100 (chlorthalidone/
atenolol)
Tenormin (atenolol)
terazosin HCl
Teveten (eprosartan mesylate)
Preventive prescription drugs (continued)
Teveten HCT
Tiazac (diltiazem)
timolol maleate
Toprol XL (metoprolol succinate)
Trandate (labetalol HCl)
triamterene/HCTZ
Tribenzor
Twynsta
Uniretic (moexipril HCl/HCTZ)
Univasc (moexipril HCl)
Vaseretic (enalapril maleate/HCTZ)
Vasotec (enalapril maleate)
Vecamyl (mecamylamine hcl)
Verelan (verapamil)
Verelan PM (verapamil)
Xarelto (15 and 20 MG only)
Zaroxolyn (metolazone)
Zebeta (bisoprolol fumarate)
Zestoretic (lisinopril/
hydrochlorothiazide)
Zestril (lisinopril)
Ziac (bisoprolol/HCTZ)
Blood Thinner
Aggrenox
Brilinta
Coumadin (warfarin)
Effient
Eliquis
Jantoven (warfarin)
Persantine (dipyridamole)
Plavix (clopidogrel)
Pletal (cilostazol)
Pradaxa
Ticlid (ticlopidine HCl)
Xarelto
Cholesterol Related
Advicor
Altoprev
Antara (fenofibrate, micronized)
Caduet (amlodipine/atorvastatin
calcium)
cholestyramine
Colestid (colestipol)
Crestor
Fenoglide
Fibricor (fenofibric acid)
Lescol (fluvastatin)
Lescol XL (fluvastatin XL)
Lipitor (atorvastatin)
Lipofen
Liptruzet
Livalo
Lofibra (fenofibrate, nonmicronized)
Lofibra (fenofibrate, micronized)
Janumet
Janumet XR
Januvia
Jentadueto
Kazano
Kombiglyze XR
Lantus
Lantus SoloStar
Levemir
Metaglip (glipizide/metformin HCl)
Nesina
Novolin 70/30
Novolin 70/30 Innolet
Novolin N
Novolin R
Novolog
Novolog Mix 70/30
Onglyza
Oseni
Prandimet
Prandin (repaglinide)
Precose (acarbose)
Riomet
Starlix (nateglinide)
Symlin
SymlinPen 60
SymlinPen 120
tolazamide
tolbutamide
Tradjenta
Victoza
Lopid (gemfibrozil)
Lovaza
Mevacor (lovastatin)
Niacor
Niaspan (niacin ER)
Pravachol (pravastatin sodium)
Questran (cholestyramine)
Questran Light (cholestyamine
aspartame)
Simcor
Tricor
Tricor (fenofibrate, micronized)
Triglide (fenofibrate)
Trilipix (fenofibric acid)
Vytorin
Welchol
Zetia
Zocor (simvastatin)
Diabetes Related
Actoplus Met (pioglitazone/
metformin)
Actoplus Met XR
Actos (pioglitazone)
Amaryl (glimepiride)
Apidra
Apidra SoloStar
Avandamet
Avandaryl
Avandia
Bydureon
Byetta
chlorpropamide
Cycloset
Diabeta (glyburide)
Duetact (pioglitazone/glimiperide)
Fortamet (metformin)
glipizide/metformin
Glucophage (metformin HCl)
Glucophage XR (metformin HCl)
Glucotrol (glipizide)
Glucotrol XL (glipizide ER)
Glucovance (glyburide/metformin)
Glumetza
Glynase (glyburide micronized)
Glyset
Humalog
Humalog Mix 50/50
Humalog Mix 75/25
Humulin 50/50
Humulin 70/30
Humulin L
Humulin N
Humulin R
Humulin U
Invokana
Osteoporosis
Related
Actonel
Aredia
Atelvia
Binosoto
Boniva (ibandronate sodium)
Didronel (etidronate disodium)
Evista
Forteo*
Fosamax (alendronate sodium)
Fosamax Plus D
Fortical (calcitonin-salmon)
Miacalcin (calcitonin-salmon)
Reclast
Skelid
Prenatal Vitamins
All prescription strength
prenatal vitamins qualify as
preventive medications.
(Available as generic where ^
is noted.)
Active OB
Bal-Care DHA Essential
Citranatal
24
Citranatal Assure^
Citranatal B-Calm
Citranatal Harmony^
Duet DHA
Duet DHA Balanced^
Duet DHA EC
Gesticare DHA
Infanate Balance
Natachew
Natafort
Neevo
Neevo DHA
Nestabs
Nestabs ABC
Nestabs DHA^
Nexa Plus
OB Complete
OB Complete DHA
OB Complete One
OB Complete Petite
OB Complete Premier
PNV Folic Acid-Iron
PNV-DHA Plus
Precare Premier
Prefera-OB One
PreferaOB Prenatal Vitamin
Prenata
Prenatal 19
Prenate AM
Prenate Chewable
Prenate DHA
Prenate Elite
Prenate Enhance
Prenate Mini
Prenate Plus
Prenate Restore
Provida OB
Stuart Prenatal
Stuartnatal Plus
Stuartnatal Plus 3
TL-Select DHA
Tricare
Tricare Prenatal Compleat
Tricare Prenatal DHA One^
Vinate Care
Vita Fol-OB DH
Vitafol Ultra
VIVA CT
Viva DHA
VP-PNV-DHA
A DOCTOR
IS ALWAYS IN
Get 24/7/365 access to a doctor with MDLIVE*
Now there’s a way to see a doctor whenever and wherever you need one.
It’s called MDLIVE, and it’s available to you through your Cigna plan. MDLIVE
connects you to a Board Certified doctor by phone or online video chat.
Be prepared and
activate your account
before you are sick.
How it works
It’s easy to connect with an MDLIVE doctor:
1.Call 888.726.3171
1. Go to
2. Speak to a coordinator to
find a doctor who meets
your needs
2. Find a doctor who meets
your needs
3. Talk to the doctor
3.Video chat with the doctor
You can also download the
MDLIVE App for an easier and
more convenient way to visit
with a doctor.
When to use it
MDLIVE is available 24 hours a day, seven days a week, 365 days a year to conveniently help you find treatment
for minor, non-emergency conditions. You can use it anytime, from anywhere. All you need is a phone or computer
with webcam.
Use MDLIVE to talk to a doctor about:
›
›
›
›
›
›
›
›
Acne
Allergies
Bronchitis
Cold and flu
Fever
Gout
Headache
Infections
›
›
›
›
›
›
›
›
Joint aches and pains
›
Child medical conditions
Nausea and vomiting
– Cold and flu
Pink eye
–Constipation
Rashes
–Ear infection
Sinus infection
–Fever
Sore throat
– Nausea and vomiting
Sunburn
– Pink eye
Urinary tract infection
An MDLIVE doctor will give you a diagnosis. The doctor can even prescribe
medications if needed.
OFFERED
THROUGH
*MDLIVE offered through Cigna is currently not available to persons primarily covered under Medicare
This service and the MDLIVE website is provided exclusively by MDLIVE and not by Cigna. MDLIVE doctors are independent practitioners
solely responsible for the treatment provided to their patients. They are not agents of Cigna.
mdlive.com/consumer/terms.html
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 Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation. The Cigna name, logo, and other Cigna marks are owned by Cigna
Intellectual Property, Inc.
864895 a 09/15 © 2015 Cigna. Some content provided under license.
25
MAKE MYCIGNA YOUR
PERSONAL HEALTH PLACE
Enjoy a simple way to personalize, organize and access
your important plan information.
Register on myCigna.
Once you do, you can log in anytime, anywhere to:
› Manage and track claims
› View ID card information
› Find doctors and compare cost and quality ratings
› Review your coverage
› Track your account balances and deductibles
› Refill your prescription drugs online and check order status with Cigna Home Delivery Pharmacy
SM
Register today! Visit myCigna.com or download the myCigna Mobile App*.
Go to myCigna.com to go paperless!
After you register, you can set up paperless
communications. Just log in to myCigna.com
and select “Go Paperless”.
Apple and the Apple logo are trademarks of Apple Inc., registered in the U.S. and other countries. App Store is a service mark of Apple Inc. | Android and Google Play are trademarks of Google Inc.
*The downloading and use of the myCigna Mobile App is subject to the terms and conditions of the App and the online stores from which it is downloaded. Standard mobile phone carrier and
data usage charges apply.
“Cigna” and the “Tree of Life” logo are registered service marks, and “Together, all the way.” 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 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 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. OK Policy Forms: GM6000 C1 et al (CGLIC); HP-APP-1 et al (CHLIC).
879566 01/15 © 2015 Cigna
26
Your Health Has
Met Its App®
Get the myCigna Mobile App and access your
health plan anytime and anywhere you go.
Life can be busy and complicated. So, we created a
simple-to-use tool that can help make your life easier
(and healthier) while you’re on the go. The myCigna
Mobile App helps you personalize, organize and access
your important plan information on your phone or
tablet. The app has a new look and feel and it’s
available in Spanish too! Use the myCigna Mobile App,
to log in anytime, anywhere to:
›
›
›
›
›
›
Manage and track claims
›
Refill your Cigna Home Delivery PharmacySM
prescriptions online and view order history
›
View medication costs based on your plan and see
lower-cost alternatives**
The myCigna Mobile App is all
about helping you stay
organized and in control of your
health – anytime, anywhere – so
you can get more out of life.
Download the myCigna Mobile App
for your mobile device.***
View, fax or email ID card information
Find doctors and compare cost and quality information
Review your coverage
Track your account balances and deductibles
Disponible en Español.
Submit receipts for reimbursement from your Cigna
HRA and/or FSA*
Offered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company or their affiliates.
The Apple logo is a trademark of Apple Inc., registered in the U.S. and other countries. App Store is a service mark of Apple Inc. | Google Play is a trademark of of Google Inc.
*Available for Cigna Choice Fund® Health Reimbursement Account (HRA) and Flexible Spending Account (FSA) plans.
**Prescription savings opportunities may not be available for some medications.
***The downloading and use of the myCigna Mobile App is subject to the terms and conditions of the App and the online stores from which it is downloaded. Standard mobile phone carrier and
data usage charges apply.
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life
Insurance Company, Life Insurance Company of North America, Cigna Life Insurance Company of New York, Tel-Drug, Inc., Tel-Drug of Pennsylvania, L.L.C., and HMO or service company subsidiaries
of Cigna Health Corporation and Cigna Dental Health, Inc. “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.
879561 08/15 © 2015 Cigna. Some content provided under license.
27
Savings at
your fingertips
Now it’s easier than ever to find and compare health care costs.
Smarter searches. Better results.
It’s true. The more you know about the cost and quality of doctors and hospitals, the easier it is to make the best
choices for you and your family. After all, no one wants to pay too much for health care.
The intuitive myCigna health care professional directory has plenty to offer, starting with simplified search tools
that give you the results you need. You’ll also see integrated cost and quality information throughout the
directory, helping you compare doctors and control health care spending.
We’ve put everything at your fingertips, ready to help you make the most confident, cost-effective decisions
about your care.
It pays to plan ahead.
Integrating cost and quality information into our
online directory makes it easier for you to get the
care you need.
For example, did you know that an MRI can cost
anywhere from $400 to $1,400*, depending on
where you go? It’s okay if you didn’t know, because
we do. And we’ll tell you, even if you don’t think to
ask before you start searching.
* Estimated costs are based on November 2014 Cigna analysis of claims for MRI of lower back without dye total cost during a 12-month period. Actual costs will vary.
Offered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company or their affiliates.
879549 12/14
28
Details that make a difference.
Let’s say you need to find a knee doctor. Wouldn’t
you want to know which doctors do their
outpatient knee surgeries at a hospital and which
do the same procedures at a (more affordable)
outpatient surgery center? We’ll show you those
types of differences as part of your search, too.
Savings by the numbers.
What will you have to pay? We don’t just do the
math for you. We go one step further and show
you the math. Not only do we call out the
estimated cost for each service, but we also show
you how much your plan will pay and how much
you’ll need to cover.
Try it. You’ll love it!
From simpler searches to valuable cost comparison information, there’s so much to love about myCigna’s health care
professional directory. Smarter searching is just the beginning.
myCigna is your one-stop source for managing your health plan whenever and wherever you like. On myCigna you
can estimate health care costs, manage and track claims, learn how to live a healthier life, and so much more.
Get the information you need to make the right decisions about your
health care. Visit myCigna.com or download the myCigna mobile app today.*
Apple and the Apple logo are trademarks of Apple Inc., registered in the U.S. and other countries. App Store is a service mark of Apple Inc. | Android and Google Play are trademarks of Google Inc.
* The downloading and use of the myCigna Mobile App is subject to the terms and conditions of the App and the online stores from which it is downloaded. Standard mobile phone carrier and
data usage charges apply.
“Cigna” and the “Tree of Life” logo are registered service marks, and “Together, all the way.” is a service mark, of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating
subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance
Company, Connecticut General Life Insurance Company, 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.
(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.
879549 12/14 © 2014 Cigna.
29
value-added services
Your health is always important to us, so Cigna offers services that help you when you are sick or injured, as well as
services that can help you stay healthy and make more informed health care decisions. Just call the toll-free number
on your Cigna ID card.
›
›
Customer Service is ready to answer your questions and resolve your concerns 24 hours a day, 7 days a week.
›
Se habla Español – and more than 150 other languages. We provide bilingual representatives in Spanish-speaking
areas; for other non-English speaking individuals, we offer Language Line Services that can translate virtually
any language.
Our interactive voice response system helps you find what you need faster over the phone. Use the speech
recognition feature to order an ID card, order a provider directory, update insurance information and check
claims status.
The Cigna 24-hour health
information line
Cigna Healthy Rewards*
Find helpful health information – anywhere,
on your Cigna ID card. Registered nurses are
Save money when you purchase health and
wellness products and services through the
Cigna Healthy Rewards® program.
available 24 hours a day, seven days a week
Programs include:
with expert, reliable information to answer
› Weight and nutrition management
›Fitness
› Tobacco cessation
› Mind and body
›Vision and hearing care
›Vitamins, health and wellness products
› Alternative medicine
› Find your savings at myCigna.com and
Health and wellness discounts
anytime – when you call the toll-free number
your health questions, help you find facilities
and identify available options and treatments.
In addition, there are hundreds of recorded
audio programs in the Health Information
Library on topics ranging from injuries and
illnesses to wellness and fitness.
click the My Health tab.
30
Cigna healthy pregnancies,
healthy babies®
You’re expecting.
That means you’re going to be choosing a name.
Looking for a pediatrician. And seeing big changes –
to your body and your lifestyle.
Where do you start?
Cigna employees who are enrolled in our medical
plan can enroll in this program designed to help
you and your baby stay healthy during and after
your pregnancy.
Find support early and often
›
Tell us about you and your pregnancy so we can
meet your needs.
›
Ask us anything – your nurse is there to support
you during your whole pregnancy.
›
Get a pregnancy journal with information, charts
and tools to help you have a happy nine months.
Get rewarded for making smart choices
Are you expecting or plan to have a baby in 2016?
If so, let the Larry H. Miller Healthy Pregnancy/
Healthy Baby Program get you – and your baby – off
to a great start! Whether you’re in your first trimester
of pregnancy or later, you can enroll in this program
through your insurance carrier. The program provides
personalized attention, educational information and
resources to help identify risks, improve pregnancy
outcomes and offer support during and
after pregnancy.
Learn as much as you want
Get live support 24 hours a day, seven days a week.
Call 888.992.4462 to enroll.
›
›
When you enroll, you’ll be assigned to a nurse.
Your R.N. will be your main go-to person during
your pregnancy. Talk with your nurse about
anything; how you can be more comfortable
during pregnancy, what foods to eat, why it’s good
to stay active, birthing classes, your maternity
benefits or any other questions or concerns you
may have.
Upon successful completion of the program, you will
earn credit towards completing your Sonic Boom
Healthy Lifestyle goal as well as earning a $200 credit
toward your medical deductible.
You will have access to an audio library of
maternity and general health topics.
Call 888.992.4462 to enroll as soon as you know
you are pregnant. Visit myCigna.com for tools
to help you track your pregnancy week by week,
prepare for delivery and care for your baby.
31
questions & answers
Do I have to choose a Primary Care Physician (PCP)?
Who is responsible for obtaining preauthorization?
No. However, a PCP gives you and your dependents a
valuable resource and a personal health advocate.
Your doctor will help you decide which procedures
require hospital care and which can be handled on an
outpatient basis. If your doctor is a participating doctor,
he or she will arrange for preauthorization. If you use an
out-of-network doctor, you are responsible for making
the arrangements.
What if my doctor isn’t on your list?
That means your doctor does not participate in the
Cigna network. To receive your maximum coverage,
you should select a doctor from the Cigna list of
participating doctors. You can continue seeing your
current doctor, even if he or she is not a participating
doctor. However, in that case, you will pay higher
out‑of‑pocket costs, and your care will be covered at
the out-of-network coverage level.
Fast facts
When you use in-network doctors, your out-of-pocket
costs are lower.
That’s because our participating doctors have agreed to
charge lower fees, and your plan’s in-network coverage
covers a larger share of the charges.
Do I need a referral to see a specialist?
Though you may want your personal doctor’s advice
and assistance in arranging care with a specialist in
the network, you do not need a referral to see a
participating specialist. If you choose an out‑of‑network
specialist, your care will be covered at the out‑of‑network
coverage level.
You also have the freedom to see any licensed doctor
for covered services.
However, if you choose a doctor who doesn’t participate
in our network, your out‑of‑pocket costs will be higher,
and you may need to file claim forms.
Quality care is close by.
What is the difference between in-network coverage
and out-of-network coverage?
You can access our national network even if you’re on
vacation, traveling on business or attending school
out-of-state. Visit Cigna.com or myCigna.com or call
the toll-free number on your Cigna ID card to locate
participating doctors.
Each time you seek medical care, you can choose
your doctor – either in- or out-of-network. When you
visit a Cigna participating doctor, you will have lower
out‑of‑pocket costs. In addition, participating doctors
have met Cigna standards for education and training,
patient satisfaction, and other key measures.
What if I need to be admitted into the hospital?
In an emergency, your care is covered. Requests for
non-emergency hospital stays, other than maternity
stays, must be approved in advance or “preauthorized.”
This enables Cigna to determine if the services are
covered. Preauthorization is not required for maternity
stays of 48 hours for vaginal deliveries or 96 hours for
cesarean sections. Depending on your coverage plan,
you may be eligible for additional coverage. Any
hospital stay beyond the initial 48 or 96 hours must be
approved. For details, please call the toll-free number
on your Cigna ID card.
32
Notes:
33
Notes:
34
35
The information in this brochure is provided as a guide only. Make sure to read all your enrollment information thoroughly as plan details may vary. If you need more
assistance, talk to your Human Resources representative.
Standard mobile phone carrier and data usage charges apply. The downloading and use of the myCigna Mobile App is subject to the terms and conditions of the app and the online stores from
which it is downloaded. The myCigna Mobile App is available to any current Cigna customer who has been provided user access to myCigna.com. Actual features may vary based on your plan
and your individual security profile.
“Cigna,” the “Tree of Life,” “Cigna.com,” “Cigna Care Network,” “myCigna.com,” and “Cigna Well Aware for Better Health,” are registered service marks and “Cigna Home Delivery Pharmacy,” “Your
health has met its app” and “Together, all the way” are service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products such as
Cigna Open Access Plus Network are provided exclusively by such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance
Company (CGLIC), Cigna Health and Life Insurance Company (CHLIC), and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. In Arizona, HMO plans
are offered by Cigna HealthCare of Arizona, Inc. In California, HMO plans are offered by Cigna HealthCare of California, Inc. In Connecticut, HMO plans are offered by Cigna HealthCare of Connecticut,
Inc. In North Carolina, HMO plans are offered by Cigna HealthCare of North Carolina, Inc. All other medical plans in these states are insured or administered by CGLIC or CHLIC. All pictures are used
for illustrative purposes only.
823180 f 09/15 © 2015 Cigna. Some content provided under license.