1. Rocky Mountain UFCW Union &
Employers Health Benefit Plan
Four-Tier Plan
2012 Cigna
prescription
drug list
This list is designed to cover your prescription medications at four levels.
The amount you will pay will depend on the tier from which you and your
doctor select your medication. If there is more than one drug appropriate
for your condition, we encourage you to talk to your doctor about low cost
medications like generics and preferred brands, as they will help to manage
your prescription costs better.
853379 02/12 Value PDL

2. 1st Tier – Generic Medications: Generic drugs have the same active
ingredients, safety, dosage, quality and strength, as their brand-name counterparts.
You will usually pay less for generic medications under your plan.
2nd Tier – Preferred Brand Medications: Preferred brand drugs will
usually cost you more than a generic, but less than a non-preferred brand drug
under your plan.
3rd Tier – Non-Preferred Brand Medications:
Non-preferred brand drugs are those that generally have generic alternatives
and/or one or more preferred brand options within the same drug class. You will
usually pay more for a non-preferred brand under your plan.
4th Tier – Specialty Medications: Specialty Injectable Medications are
typically covered under the fourth tier and include, but are not limited to,
injectables used to treat arthritis, multiple sclerosis, hepatitis C, and asthma. See
the list of Specialty medications on page 22.
Understanding the
Cigna Prescription Drug List
Every medication available on the drug list has been approved by the
U.S. Food and Drug Administration (FDA). This list represents the most
commonly prescribed medications. Please reference Cigna.com or myCigna.
com for the complete up-to-date listing of medications. Refer to your
enrollment information to find out which specific medications are covered
under your plan.
The symbols on the list mean …
If your medication has one of the following symbols, your doctor may have to
get an authorization for coverage.
PA: Prior Authorization may be required for different reasons.
To learn the requirements needed for coverage of a specific
medication, please give us a call.
QL: Quantity Limit means you may have coverage for a limited
amount of a specific medication.
AGE: Age Requirement means a person may be within a specific
age group for a specific medication to be covered.
ST: Step Therapy is a prior authorization program that requires
you to try other medications available to treat the same
condition before the “ST” medication is covered.
2

3. Important Note
This list does not cover drugs that have over-the-counter (OTC) alternatives,
drugs that treat stomach acid conditions and non-sedating antihistamines to
treat allergies.
In some cases medications for certain conditions (allergies, heartburn/ulcers, etc.)
may be equivalent products to OTC medications available. In these cases, the
prescription available class alternatives are excluded from coverage. Examples*
include allergy medications such as Allegra, Clarinex, Xyzal and any generics; and
heartburn/ulcer medications such as Nexium, Prilosec, Zantac and any generics.
(*Examples not all-inclusive listing).
Help From myCigna.com
When you go to myCigna.com you can:
• Compare actual medication prices at local pharmacies
• See your specific pharmacy coverage information
• Research available medications and network pharmacies
• Ask a pharmacist questions
If You Have Any Questions
Feel free to give us a call at the number on the back of your ID Card.
We’re here to help.
3

4. NoN-Preferred
GeNericS Preferred BraNdS BraNdS
add/adHd aNd STiMULaNTS
amphetamine/ Adderall (PA, ST)
dextroamphetamine Adderall XR (PA, ST)
dexmethylphenidate Amphetamine
2012 Cigna Prescription Drug List
methamphetamine Dextroamphetamine
methylphenidate/ER Extended-Release (PA, ST)
Concerta (PA, ST)
Daytrana (PA, ST)
Desoxyn
Focalin XR (PA, ST)
Intuniv
Kapvay
Metadate CD (PA, ST)
Metadate ER (PA, ST)
Nuvigil
Provigil
Ritalin LA (PA, ST)
Strattera
Vyvanse (PA, ST)
aidS/HiV
didanosine Agenerase Retrovir
stavudine Aptivus Videx
zidovudine Atripla Zerit
Combivir
Crixivan
Emtriva
Epivir
Epzicom
Intelence
Invirase
Isentress
Kaletra
Lexiva
Norvir
Prezista
Rescriptor
Reyataz
Selzentry
Sustiva
Trizivir
Truvada
Viracept
Viramune
Viread
Ziagen
4

5. NoN-Preferred
GeNericS Preferred BraNdS BraNdS
aLLerGY*
* Medications for allergies equivalent to over-the-counter medications within the class are
excluded such as Allegra, fexofenadine, Clarinex, etc.
clemastine Astepro Astelin
cyproheptadine Epipen (QL) Adrenaclick (QL)
epinephrine inj (QL) Singulair Beconase AQ (PA, ST)
flunisolide nasal Flonase (PA, ST)
fluticasone nasal Nasacort AQ (PA, ST)
hydroxyzine Nasarel (PA, ST)
Nasonex (PA, ST)
Omnaris (PA, ST)
Patanase
Rhinocort AQ (PA, ST)
Semprex-D
Veramyst (PA, ST)
aLZHeiMer’S diSeaSe
donepezil Aricept
galantamine Aricept ODT
rivastigmine Cognex
Exelon
Namenda
Razadyne
Razadyne ER
aSTHMa aNd reSPiraTorY
albuterol solution Atrovent HFA Accolate
cromolyn Foradil Accuneb nebulizer (PA, ST)
ipratropium solution ProAir HFA Advair, Advair HFA
levalbuterol solution Qvar Alvesco
metaproterenol Singulair Asmanex
Azmacort
Brovana nebulizer (PA, ST)
Combivent
Dulera
Flovent, Flovent HFA
Maxair
Perforomist (PA, ST)
Proventil HFA
Pulmicort
Serevent
Spiriva
Symbicort
Ventolin HFA
Xopenex HFA
Xopenex nebulizer (PA, ST)
5

6. NoN-Preferred
GeNericS Preferred BraNdS BraNdS
BirTH coNTroL*
* Please check your enrollment materials to determine whether these medications are
covered under your specific plan.
Apri Angeliq
2012 Cigna Prescription Drug List
Aviane Desogen
Balziva Ella
Camila Estrostep FE
Errin Levlen
Gianvi Lo/Ovral-28
Jolessa Loestrin
Junel FE Loestrin 24 FE
Kariva Loestrin FE
Levora Lo Loestrin FE
Lo-ogestrel Loseasonique
Microgestin Lybrel
Necon Natazia
Nortrel Nordette
Ocella Nuvaring
Ogestrel Ortho Evra
Quasense Ortho Tri-Cyclen LO
Solia Ortho-Cept
Sprintec Ortho-Novum 7-7-7
Trinessa Ovcon 35
Tri-Sprintec Ovcon 50
Zenchant Ovrette
Zovia Plan B
Plan B One-Step
Seasonale
Seasonique
Trilevlen
Tri-Norinyl
Triphasil
Yaz
BLadder ProBLeMS
Oxybutynin/XL Detrol (PA, ST)
Trospium chloride Detrol LA (PA, ST)
Ditropan, Ditropan XL
(PA, ST)
Elmiron
Enablex (PA, ST)
Gelnique (PA, ST)
Oxytrol (PA, ST)
Sanctura, Sanctura XR
(PA, ST)
Toviaz (PA, ST)
VESIcare (PA, ST)
6

7. NoN-Preferred
GeNericS Preferred BraNdS BraNdS
caNcer
anastrozole Afinitor (PA) Arimidex
bicalutamide Aromasin Casodex
tamoxifen citrate Fareston
Femara
Gleevec (PA)
Iressa (PA)
Lupron (PA)
Nexavar (PA)
Revlimid (PA)
Soltamox
Sprycel (PA)
Sutent (PA)
Tarceva (PA)
Targretin
Tasigna (PA)
Temodar (PA)
Thalomid (PA)
Tykerb (PA)
Votrient (PA)
Xeloda
Zolinza (PA)
cardioVaScULar
BLood THiNNer/aNTi-cLoTTiNG
enoxaprin (QL) Arixtra (QL) Aggrenox
heparin (QL) Lovenox (QL) Agrylin (PA)
ticlopidine Effient
warfarin Fragmin (QL)
Innohep (QL)
Plavix
Pletal
Pradaxa (PA)
7

8. NoN-Preferred
GeNericS Preferred BraNdS BraNdS
cardioVaScULar
HiGH BLood PreSSUre/HearT MedicaTioNS
amlodipine Benicar (PA, ST) Accupril (PA, ST)
atenolol Benicar HCT (PA, ST) Accuretic (PA, ST)
2012 Cigna Prescription Drug List
benazepril Aceon (PA, ST)
benazepril/amlodipine Altace (caps)(PA, ST)
benazepril/HCTZ Altace (tabs)(PA, ST)
bisoprolol/HCTZ Atacand (PA, ST)
captopril Avalide (PA, ST)
carvedilol Avapro (PA, ST)
digoxin Azor
diltiazem Betapace AF
diltiazem CD Bystolic
disopyramide Capoten (PA, ST)
doxazosin Cardura
enalapril Cardura XL
enalapril/HCTZ Catapres, Catapres TTS
felodipine Coreg
fosinopril Coreg CR
hydralazine/HCTZ Corgard
isosorbide dinitrate Covera-HS
isosorbide mononitrate Cozaar (PA, ST)
labetalol Diovan HCT (PA, ST)
lisinopril Diovan (PA, ST)
losartan Dynacirc CR
losartan/HCTZ Exforge
methyldopa/HCTZ Exforge HCT
metoprolol Hyzaar (PA, ST)
nadolol Inderal LA
nifedipine Innopran XL
nisoldipine (Sustained release) Lanoxin
prazosin Levatol
procainamide Lotensin HCT (PA, ST)
propranolol Lotensin (PA, ST)
quinapril Lotrel
quinapril/HCTZ Mavik (PA, ST)
quinidine Micardis HCT (PA, ST)
ramipril (cap only) Micardis (PA, ST)
sotalol Minizide
terazosin Monopril HCT (PA, ST)
timolol Monopril (PA, ST)
trandolapril Multaq
trandolapril/verapamil Norpace
verapamil Norpace CR
verapamil SR Norvasc
8

9. NoN-Preferred
GeNericS Preferred BraNdS BraNdS
cardioVaScULar (CONTINUED)
HiGH BLood PreSSUre/HearT MedicaTioNS
Prinivil (PA, ST)
Prinzide (PA, ST)
Procanbid
Ranexa (PA)
Sular
Tarka
Tekamlo
Tekturna HCT (PA, ST)
Tekturna (PA, ST)
Teveten HCT (PA, ST)
Teveten (PA, ST)
Tikosyn
Toprol XL
Uniretic (PA, ST)
Univasc (PA, ST)
Valturna (PA, ST)
Vaseretic (PA, ST)
Vasotec (PA, ST)
Verelan
Zestoretic (PA, ST)
Zestril (PA, ST)
9

10. NoN-Preferred
GeNericS Preferred BraNdS BraNdS
cHoLeSTeroL LoWeriNG
cholestyramine powder Vytorin Advicor
fenofibrate Welchol Altoprev (PA, ST)
gemfibrozil Zetia Caduet
2012 Cigna Prescription Drug List
lovastatin Crestor (PA, ST)
pravastatin Fenoglide
simvastatin Lescol
Lescol XL
Lipitor (PA, ST)
Livalo (PA, ST)
Lofibra
Lovaza
Mevacor (PA, ST)
Niaspan
Pravachol (PA, ST)
Simcor
TriCor
Trilipix
Zocor (PA, ST)
dePreSSioN
amitriptyline Aplenzin (PA, ST)
bupropion Celexa (PA, ST)
bupropion SR Cymbalta (PA, ST)
citalopram Effexor XR (PA, ST)
desipramine Emsam
fluoxetine Lexapro (PA, ST)
fluvoxamine Luvox CR
mirtazapine Marplan
nortriptyline Paxil CR (PA, ST)
paroxetine Pristiq (PA, ST)
paroxetine CR Prozac (PA, ST)
protriptyline Remeron
sertraline Tofranil
trazodone Vivactil
venlafaxine Wellbutrin XL (PA, ST)
venlafaxine XR Zoloft (PA, ST)
10

11. NoN-Preferred
GeNericS Preferred BraNdS BraNdS
diaBeTeS
acarbose ACCU-CHEK Test Strips Actoplus met
acetohexamide Actos Amaryl
chlorpropamide BD Insulin Syringe Apidra
glimepiride Byetta Apidra SoloStar
glipizide Glucagen Hypokit Avandamet
glipizide/metformin Januvia Avandaryl
glucagon (QL) Lantus Avandia
glyburide NovoFine needles Duetact
glyburide/metformin Novolin Fortamet
glyburide micronized Novolog Glucophage XR
metformin One Touch test strips Glycron
nateglinide Glyset
tolazamide Humalog
tolbutamide Humulin
Janumet
Kombiglyze XR
Lantus SoloStar
Levemir
Metaglip
Onglyza
Prandimet
Prandin
Precose
Starlix
Symlin/SymlinPen
eNdocriNe aNd MeTaBoLic – oTHer
allopurinol Megace ES Synarel (PA)
cabergoline (QL) Uloric
desmopressin
11

12. NoN-Preferred
GeNericS Preferred BraNdS BraNdS
eYe coNdiTioNS
ciprofloxacin Xalatan Acular LS
diclofenac Alamast
dorzolamide Alocril
2012 Cigna Prescription Drug List
dorzolamide/timolol Alomide
levobunolol Alphagan P
pilocarpine Alrex
pilocarpine/epinephrine AzaSite
timolol Azopt
tobramycin/dexamethasone Besivance (ST)
Betimol
Betoptic S
Ciloxan
Cosopt
Durezol
Emadine
Iopidine
Iquix
Lotemax
Pataday
Patanol
Restasis
Timoptic
Tobradex
Travatan Z
Trusopt
Vexol
Vigamox
Voltaren
GaSTroiNTeSTiNaL (NoT HearTBUrN/ULcer)
amylase/lipase/protease Asacol Apriso
balsalazide Asacol HD Canasa
Lialda Colazal
Pentasa Entocort EC
Sucraid
12

13. NoN-Preferred
GeNericS Preferred BraNdS BraNdS
HearTBUrN/ULcer*
*Medications for heartburn and ulcer equivalent to over-the-counter medications
within the class are excluded such as omeprazole, Nexium, Zantac, etc.
metoclopramide
misoprostol
sucralfate
HorMoNe rePLaceMeNT
estradiol Premarin Activella
estropipate Alora
levothroid Anadrol-50
levothyroxine Androderm
levoxyl Androgel
liothyronine Armour Thyroid
medroxyprogesterone Cenestin
thyroid Combipatch
Unithroid Cytomel
Enjuvia
Estraderm
Femhrt
Femring
Fortesta
Menest
Prefest
Premphase
Prempro
Prometrium
Synthroid
Testim
Vagifem
Vivelle-Dot
13

14. NoN-Preferred
GeNericS Preferred BraNdS BraNdS
iNfecTioNS
acyclovir Baraclude Augmentin
amantadine Epivir HBV Augmentin ES 600
amoxicillin Tamiflu (QL) Augmentin XR
2012 Cigna Prescription Drug List
amoxicillin/clavulanate Avelox
azithromycin (QL) Biaxin
cefaclor ER Biaxin XL
cefadroxil Cedax
cefprozil Cefzil
cefuroxime Cipro HC Otic
cephalexin Cipro XR
ciprofloxacin Ciprodex
clarithromycin Coartem (QL)
clindamycin Copegus
doxycycline Famvir
erythromycin Flagyl ER
fluconazole (QL: 150 mg only) Floxin Otic
griseofulvin Gris-Peg
itraconazole (QL) Hepsera
metronidazole Keflex
minocycline Keftab
nitrofurantoin Lamisil (QL)
nystatin Lariam (PA, QL)
ofloxacin Levaquin
penicillin v potassium Malarone (PA, QL)
rimantadine Monurol
SMX/TMP Moxatag
terfenabine (QL) Mycostatin (tab)
tetracycline Noxafil
Omnicef
Penlac (PA)
Priftin
Primsol
Relenza (QL)
Solodyn
Sporanox (QL)
Suprax
Tobi
Tyzeka
Valtrex
Vfend (PA)
Zithromax (QL)
Zyvox (PA)
14

15. NoN-Preferred
GeNericS Preferred BraNdS BraNdS
MiGraiNe
acetaminophen/ Zomig/Zomig ZMT (QL) Amerge (QL)
caffeine/butalbital Axert (QL)
naratriptan (QL) DHE 45 (QL)
sumatriptan (QL) Frova (QL)
Imitrex (QL)
Maxalt
Maxalt MLT
Migranal (QL)
Relpax (QL)
Treximet (QL)
MULTiPLe ScLeroSiS
Ampyra (PA)
Gilenya (PA)
NaUSea aNd VoMiTiNG
dronabinol Anzemet (tab)(QL)
granisetron (tab, solu) (QL) Emend (QL)
ondansetron (QL) Kytril (tab, solu)(QL)
prochlorperazine Marinol
promethazine Scopace
trimethobenzamide Zofran (tab, solu)(QL)
Zuplenz (QL)
oSTeoPoroSiS
alendronate Actonel (PA, ST)
calcitonin-salmon Atelvia (PA, ST)
Fortical Boniva (PA, ST)
Evista (PA, ST)
Forteo (PA, ST)
Fosamax (PA, ST)
Fosamax Plus D (PA, ST)
Miacalcin
Skelid (PA, ST)
15

16. NoN-Preferred
GeNericS Preferred BraNdS BraNdS
PaiN reLief aNd iNfLaMMaTorY diSeaSe
butorphanol nasal (QL) Arava (PA) Actiq (PA)
codeine phos/carisoprodol/ Celebrex Arthrotec
asa Nalfon Avinza
2012 Cigna Prescription Drug List
codeine phosphate Rheumatrex Band O Supprettes
codeine phosphate/aspirin Trexall (PA, ST)
codeine sulfate Butrans (QL)
diclofenac Demerol (PA, ST)
dihy-cod tt/apap/caffeine Dilaudid (PA, ST)
etodolac Dipentum
fentanyl (QL) Duragesic (QL)
fentanyl citrate Fentora (PA)
(lollipop)(PA) Hycet (PA, ST)
hydrocodone/ Indocin (suppository)
acetaminophen Kadian
hydrocodone bitartrate/ Kineret (PA)
apap Lidoderm
hydrocodone bitartrate/ Lorcet (PA, ST)
aspirin Lorcet Plus (PA, ST)
hydromorphone hcl Lortab (PA, ST)
ibuprofen Magnacet (PA, ST)
ibuprofen/hydrocod bit Maxidone (PA, ST)
indomethacin Mobic
ketorolac (PA, QL) MSIR
leflunamide (PA) MSIR (PA, ST)
levorphanol tartrate Naprelan
meloxicam Norco (PA, ST)
meperidine hcl Nucynta (PA, ST)
methotrexate OxyContin (QL)
morphine SR Panlor SS (PA, ST)
morphine sulfate Percocet (PA, ST)
(Roxanol) morphine sulfate Percodan (PA, ST)
nabumetone Primalev (PA, ST)
naproxen Roxicet (PA, ST)
opium Roxicodone (PA, ST)
opium/belladonna alkaloids Ryzolt (PA, ST)
oxaprozin Savella
oxycodone hcl Simponi (PA)
oxycodone hcl/ Skelaxin
acetaminophen Synalgos-DC (PA, ST)
oxycodone/aspirin Talwin Compound (PA, ST)
pentazocine hcl Tylox (PA, ST)
acetaminophen Ultracet (PA, ST)
pentazocine hcl/ Ultram (PA,ST)
naloxone hcl Ultram ER (PA,ST)
piroxicam Vicodin (PA,ST)
tramadol hcl/ER Vicodin ES (PA,ST)
tramadol hcl/
acetaminophen
16

17. NoN-Preferred
GeNericS Preferred BraNdS BraNdS
PaiN reLief aNd iNfLaMMaTorY diSeaSe (CONTINUED)
Vicodin HP (PA,ST)
Vicoprofen (PA,ST)
Voltaren
Voltaren XR
Xodol (PA,ST)
Xolox (PA,ST)
Zamicet (PA,ST)
Zolvit (PA,ST)
Zydone (PA,ST)
ParKiNSoN’S diSeaSe
amantadine Azilect Eldepryl
bromocriptine Comtan Mirapex
carbidopa/levodopa Lodosyn Requip
carbidopa/levodopa SA Stalevo Requip XL
ropinirole Tasmar Zelapar
selegiline
pramipexole
ProSTaTe
doxazosin Avodart
finasteride Flomax
prazosin Jalyn
tamsulosin Proscar (AGE)
terazosin Rapaflo
Uroxatral
17

18. NoN-Preferred
GeNericS Preferred BraNdS BraNdS
ScHiZoPHreNia
clozapine Seroquel Abilify
haloperidol Zyprexa Abilify Discmelt
loxapine Clozaril
2012 Cigna Prescription Drug List
risperidone Fanapt
thiothixene Fazaclo
Geodon
Invega
Latuda
Moban
Orap
Risperdal
Saphris
Seroquel XR
SeiZUre
carbamazepine Diastat Banzel
clonazepam Diastat Acudial Carbatrol
divalproex Dilantin Depakote (all forms)
gabapentin Gabitril Lyrica (PA, ST)
levetiracetam Keppra Neurontin
topiramate Keppra XR Stavzor
valproate Lamictal (all forms) Tegretol XR
Topamax
Trileptal
Vimpat
Zonegran
18

19. NoN-Preferred
GeNericS Preferred BraNdS BraNdS
SKiN coNdiTioNS
adapalene (AGE) Carac Aclovate (PA, ST)
alclometasone Fluroplex Aldara
alclometasone dipropionate Targretin gel Aphthasol
amcinonide Aquaphilic W/Tac +
Apexicon E (diflorasone Carbamide (PA, ST)
diacetate) Aquaphilic W/
betamethasone Triamcinolone (PA, ST)
betamethasone dipropionate Aristocort A (PA, ST)
betamethasone dipropionate/ Atralin (AGE)
propylene glycol Benzaclin
betamethasone valerate BenzamycinPak
calcipotriene Capex Shampoo (PA, ST)
clobetasol Carmol HC (PA, ST)
clobetasol propionate Clobex (PA, ST)
clobetasol propionate/emoll Cloderm (PA, ST)
desonide Condylox
desoximetasone Coraz (PA, ST)
diflorasone Cordran (PA, ST)
diflorasone diacetate Cordran SP (PA, ST)
fluocinolone Cutivate (PA, ST)
fluocinolone acetonide Derma-Smoothe/FS
fluocinonide/emollient (PA, ST)
fluticasone propionate Dermatop (PA, ST)
halobetasol prop/ammonium Desonate (PA, ST)
lac Desowen (PA, ST)
halobetasol propionate Differin (AGE)
hydrocortisone Diprolene (PA, ST)
hydrocortisone acetate/alo ver Diprolene AF (PA, ST)
hydrocortisone acetate/ Diprosone (PA, ST)
ure(tp) Dovonex
hydrocortisone butyrate Duac CS
hydrocortisone valerate Elidel (PA, ST)
imiquimod Elocon (PA, ST)
isotretinoin (QL) Epiduo (AGE)
metronidazole Exelderm
mometasone furoate First Hydrocort (PA, ST)
prednicarbate Halog (PA, ST)
Sotret (QL) Kenalog (PA, ST)
sulfacetamide Klaron
tretinoin (AGE) Lacticare-HC (PA, ST)
triamcinolone acetonide Lidex (PA, ST)
Locoid (PA, ST)
Locoid Lipocream (PA, ST)
Loprox shampoo
Luxiq (PA, ST)
Metrogel
Metrolotion
19

20. NoN-Preferred
GeNericS Preferred BraNdS BraNdS
SKiN coNdiTioNS (CONTINUED)
Momexin (PA, ST)
Noritate
Nucort (PA, ST)
2012 Cigna Prescription Drug List
Nuzon (PA, ST)
Olux (PA, ST)
Olux-e (PA, ST)
Oracea
Ovace Plus
Pandel (PA, ST)
Panretin (PA)
Pediaderm HC (PA, ST)
Protopic (PA, ST)
Psorcon (PA, ST)
Psorcon E (PA, ST)
Regranex (PA)
Retin-A Micro (AGE)
Rosula
Scalacort DK (PA, ST)
Soriatane CK
Synemol (PA, ST)
Taclonex
Tazorac
Temovate (PA, ST)
Texacort (PA, ST)
Topicort (PA, ST)
Topicort LP (PA, ST)
Tridesilon (PA, ST)
Ultravate PAC (PA, ST)
Ultravate (PA, ST)
Valisone (PA, ST)
Vanos (PA, ST)
Vectical
Verdeso (PA, ST)
Westcort (PA, ST)
Xolegel
Xolegel Corepak
Ziana
Zyclara
Zytopic (PA, ST)
20

21. NoN-Preferred
GeNericS Preferred BraNdS BraNdS
SLeeP
zaleplon Ambien CR (PA, ST)
zolpidem Edluar (PA, ST)
Lunesta (PA, ST)
Rozerem (PA, ST)
Silenor (PA, ST)
Zolpimist (PA, ST)
TraNSPLaNT
azathioprine Myfortic Neoral
cyclosporine Sandimmune Zortress
mycophenolate moefetil Rapamune
tacrolimus Prograf
Cellcept
MiSceLLaNeoUS
calcitriol Cortifoam Fosrenol
folic acid Epifoam Nimotop
leucovorin Revatio (PA) Phoslo
naltrexone (QL) Pulmozyme (PA)
tizanidine Renvela
Suboxone
TussiCaps
Tussionex
Zanaflex
Zemplar
21

22. SPeciaLTY iNjecTaBLe drUGS (aLL reqUire Prior aUTHoriZaTioN)
Specialty Injectable Drugs Actimmune Neulasta
Anzemet – injection Neumega
Apokyn Neupogen
Aranesp Norditropin
Arcalyst Norditropin Nordiflex
Avonex Nutropin
Betaseron Nutropin AQ
Ceftriaxone Octreotide Acetate
Cimzia Omnitrope
Copaxone Ondansetron – injection
Delatestryl Pegasys
Depo-Testosterone Peg Intron
Emend – injection Peg Intron Redipen
Enbrel Procrit
Egrifta Proleukin
Epogen Rebif
Extavia Relistor
Firmagon Remicade
Fuzeon Rocephin
Garamycin Saizen
Genotropin Sandostatin
Gold Sodium Thiomalate Serostim
Granisetron – injection Simponi
Humatrope Somatuline Depot
Humira Somavert
Ilaris Stelara
Increlex Testosterone – injection
Infergen Tev-Tropin
Intron A Tobramycin Sulfate
Ketorolac Tromethamine – injection Toradol – injection
Kineret Xolair
Kytril – injection Zofran – injection
Leukine Zoladex
Leuprolide Acetate Zorbtive
Lupron, Lupron Depot
Myochrysine
Nebcin
22

23. excLUSioNS & LiMiTaTioNS
Plans typically do not provide coverage for the following, except as required by law or by the
terms of your specific plan:
1. Any medications available over the 6. Any prescription and non-prescription
counter that do not require a prescription supplies (such as ostomy supplies),
by Federal or State Law, and any devices, and appliances.
medication that is a pharmaceutical 7. Any contraceptive medications and
alternative to an over the counter prescription appliances for contraception.
medication other than insulin. 8. Implantable contraceptive products.
[examples include OTC Benadryl, Maalox,
9. Any fertility medication.
Sudafed PE , etc.]
10. Any medications used for treatment of
2. Medications that are therapeutically
sexual dysfunction, including but not
equivalent as determined by the Cigna
limited to erectile dysfunction, delayed
HealthCare Pharmacy and Therapeutics
ejaculation, anorgasmia and decreased
Committee in which at least one of the
libido.
medications within the class is available
over the counter. [examples include Rx 11. Any prescription vitamins (other than
equivalents to OTC Allegra, Claritin and prenatal vitamins), dietary supplements
Zyrtec (Allegra D, Clarinex, Xyzal) and and fluoride products.
Rx equivalents to OTC Prevacid, Prilosec, 12. Medications used for cosmetic purposes,
Zantac (Aciphex, Kapidex, Nexium, Axid, such as medications used to reduce
Pepcid, Zantac)] wrinkles, medications to promote hair
3. Any injectable infertility medications, and growth, medications used to control
any injectable medications that require perspiration and fade cream products.
Health Care Professional supervision 13. Any diet pills or appetite suppressants
and are not typically considered self- (anorectics).
administered medications. The following 14. Prescription smoking cessation products.
are examples of Health Care Professional- 15. Immunization agents, biological products
supervised medications: Injectables used for allergy immunization, biological sera,
to treat hemophilia and RSV (respiratory blood, blood plasma and other blood
syncytial virus), chemotherapy injectables, products or fractions and medications
and endocrine and metabolic agents. used for travel prophylaxis.
4. Any medications that are experimental or 16. Replacement of prescription medications
investigational, within the meaning set and related supplies due to loss or theft.
forth in the summary plan description. 17. Medications used to enhance athletic
5. Food and Drug Administration (FDA)- performance.
approved medications used for purposes 18. Medications that are to be taken by
other than those approved by the FDA or administered to a Customer while
unless the medication is recognized the Customer is a patient in a licensed
for the treatment of the particular hospital, skilled nursing facility, rest home
indication in one of the standard or similar institution which operates on
reference compendia (The United States its premises or allows to be operated
Pharmacopoeia Drug Information or The on its premises a facility for dispensing
American Hospital Formulary Service pharmaceuticals.
Drug Information) or in medical literature.
19. Prescriptions more than one year from the
Medical literature means scientific studies
original date of issue.
published in a peer-reviewed national
professional medical journal.
23

24. Cigna reserves the right to make changes to this Drug List
(also known as the Value Prescription Drug List) without
notice. Your plan may cover additional medications; please
refer to your enrollment materials for details. Cigna does not
take responsibility for any medication decisions made by the
prescriber or pharmacist. Cigna may receive payments from
manufacturers of certain Preferred-Brand medications, and in
limited instances, certain Non-Preferred Brand medications,
that may or may not be shared with your plan depending on its
arrangement with Cigna. Depending upon plan design, market
conditions, the extent to which manufacturer payments
are shared with your plan, and other factors as of the date
of service, the Preferred-Brand medication may or may not
represent the lowest-cost brand medication within its class for
you and/or your plan.
“Cigna”, “Cigna.com” and “myCigna.com” are registered service marks and the “Tree of Life” logo, “Cigna
Home Delivery Pharmacy” and “GO YOU” are service marks, of Cigna Intellectual Property, Inc., licensed for use
by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such
operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General
Life Insurance Company, Cigna Health and Life Insurance Company, Tel-Drug, Inc., Tel-Drug of Pennsylvania,
L.L.C., and HMO subsidiaries of Cigna Health Corporation. “Cigna Home Delivery Pharmacy” refers to Tel-Drug,
Inc. and Tel-Drug of Pennsylvania, L.L.C. All models are used for illustrative purposes only.
853379 02/12 © 2012 Cigna. Some content provided under license.

25. Get a dose of healthy savings
with the CIGNA Value Prescription Drug List
Now more than ever, you Consider the following two unique
need to lower your benefit characteristics that drive the savings:
plan costs. It’s important
to balance this need with Distinctive Tier Design
The Value PDL encourages people to choose low-cost generic
employee satisfaction
medications by placing most brand name drugs on the higher cost
by continuing to offer third tier. Also, a much-smaller second tier offers only the drugs that
a complete pharmacy do not have a generic equivalent or a therapeutic alternative.
program. CIGNA’s Value
Prescription Drug List Effective Exclusions
Certain exclusions are responsible for approximately half the savings
(PDL) helps you do both.
available with the Value PDL. These include all medications that
With the Value PDL, have an over-the-counter (OTC) equivalent or therapeutic alternative;
specifically, non-sedating antihistamines (allergy medications) along
you’ll see savings of
with PPIs and H2 blockers (ulcer/heartburn medications). Lifestyle
up to 25% on pharmacy drugs, including weight loss, infertility, smoking cessation and
claim costs. That’s erectile dysfunction medications, are also excluded.
significant — especially
Speak to your CIGNA sales representative to enjoy all
when you consider the benefits of the CIGNA Value Prescription Drug List
that this translates to — coming this May.
approximately 3% of your
overall medical costs.
“CIGNA”,“CIGNA.com”,“myCIGNA.com”and the ”Tree of Life”logo are registered service marks, and ”CIGNA Home Delivery Pharmacy”is a service mark, of CIGNA Intellectual
Property, Inc., licensed for use by CIGNA Corporation and its operating subsidiaries. All products and services are provided exclusively by such operating subsidiaries
and not by CIGNA Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company, CIGNA Health and Life Insurance Company,
Tel-Drug, Inc., Tel-Drug of Pennsylvania, L.L.C., and HMO or service company subsidiaries of CIGNA Health Corporation. “CIGNA Home Delivery Pharmacy”
840505 02/11 Value PDL refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C. All models are used for illustrative purposes only.

26. Important Information about
the Value Prescription Drug List: Exclusions
The Value Prescription Drug It’s important to know what drugs are excluded because they are
List can deliver savings of commonly used medications that many of your employees may
20-25% of pharmacy claim currently use.
costs, and these savings
are attributed to both The Value Prescription Drug List does not cover medications in
the unique tier design two drug classes that have over-the-counter (OTC) equivalents or
which drives higher use alternatives: drugs that treat stomach acid conditions and non-
of generic medications sedating antihistamines to treat allergies. Many of these drugs are
and the exclusion of widely used, so please be aware that the exclusion list will affect a
certain medications. The significant number of people.
list of exclusions drives
Some examples of excluded medications are listed below. Please
approximately half of the
note this list is not all inclusive. For a complete list of covered
estimated 20-25% savings.
medications on the Value Prescription Drug List, customers can
visit myCIGNA.com at any time.
Heartburn/Ulcer Allergy
H2 Blockers Proton Pump Inhibitors Non-Sedating Antihistamines
Axid (OTC) Aciphex Allegra D
Cimetidine (OTC) Nexium Clarinex/Clarinex D
Famotidine (OTC) Omeprazole (OTC) Claritin (OTC)/Claritin D (OTC)
Nexatidine (OTC) Pantoprazole Fexofenadine
Pepcid (OTC) Prevacid Loratidine (OTC)
Ranidtine (OTC) Prilosec Xyzal
Tagamet (OTC) Protonix Zyrtec/Zyrtec D (OTC)
Zantac (OTC) Zegerid
“CIGNA Pharmacy Management”, “myCIGNA.com” and the “Tree of Life” logo are registered service marks of CIGNA Intellectual Property, Inc., licensed for use
by CIGNA Corporation and its operating subsidiaries. All products and services are provided exclusively by such operating subsidiaries and not by CIGNA
Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company, CIGNA Health and Life Insurance Company, Tel-Drug, Inc.,
Tel-Drug of Pennsylvania, L.L.C., and HMO or service company subsidiaries of CIGNA Health Corporation.
842185 05/11 Value PDL © 2011 CIGNA.