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PERFORMANCE

The Performance Prescription Drug List lets you and your doctor choose medications that work best for you. The following is a list of the most commonly used medications covered under your plan.

This list is designed to cover your prescription medications at three levels. The amount you pay depends on the tier from which you and your doctor select your medication. If there is more than one medication appropriate for your condition, we suggest that you talk to your doctor about lower-cost choices like generic medications and preferred brand medications to see if they could be right for you.

Prescription Drug List January 2014

prescription drug list

827293 i 12/13

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

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1st Tier – Generic Medications: Generic medications have the same 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 medications will usually cost more than a generic, but less than a non-preferred brand medication under your plan.

3rd Tier – Non-Preferred Brand Medications: Non-preferred brand medications are those that generally have generic alternatives and/or a preferred brand medication within the same drug class. You will usually pay more for a non-preferred brand under your plan.

The symbols on the list mean

If a medication on the list has one of the following symbols, your doctor may need to get an authorization for coverage of that medication.

PA: Prior Authorization may be required for different reasons. To learn the requirements needed for coverage of a specific medication, feel free to give us a call.

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

AGE: Age Requirement means an individual must be within a specific age group for a specific medication to be covered.

ST: Step Therapy is a prior authorization program that requires you to try other medications available to treat the same condition before the “ST” medication is covered.

* Medications marked with an asterisk are considered to be specialty medications. Some plans may cover specialty medications at different benefit levels or may require the use of a preferred specialty pharmacy. Refer to the your plan documents for more information.

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Health care reform and you

The Patient Protection and Affordable Care Act (PPACA), commonly referred to as “health care reform,” was signed into law on March 23, 2010. This important legislation will result in changes to every American’s health coverage. Some of the changes took effect in 2010 and most of the law’s effects will be felt by 2014. Cigna will comply with all provisions of the law including those that impact your pharmacy coverage plan. For example, depending upon the final government regulations, coverage for medications that have not traditionally been included in pharmacy plans, such as specific over-the-counter (OTC) medications, may be made available at no cost share to you. As with all covered medications, we would require a prescription from your doctor to process the claim under your pharmacy plan (including OTC medications).

To get the most current information, visit www.informedonreform.com or Cigna.com and look for the “Informed on Reform” link.

If you have any questions

Remember, this list is just a sample of the most commonly used medications. You can use the Prescription Drug Price Quote tool available on myCigna.com to see and compare the prices of all medications covered under your plan. Or, you can call the number on the back of your ID card to speak with a customer service representative at any time.

NON-PREFERRED GENERICS PREFERRED BRANDS BRANDS

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ADD/ADHD AND STIMULANTS

amphetamineclonidine hcldexmethylphenidatedextroamphetamineMetadate ER/ methylphenidate hclmethamphetaminemethylphenidate/ ER/ER 24 HRmodafanilprocentra

Adderall XRFocalin XRIntunivRitalin LAStratteraVyvanse

Adderall (PA, ST)Concerta (PA, ST)Daytrana (PA, ST)Desoxyn (PA, ST)Dexadrine (PA, ST)Focalin (PA, ST)KapvayMetadate CD (PA, ST)Methylin (PA, ST)NuvigilProvigilQuillivant XR (PA, ST)Ritalin (PA, ST)Ritalin SR (PA, ST)Zenzedi (PA, ST)

AIDS/HIV

abacavir*didanosine*lamivudine*lamivudine/zidovudine*nevirapine*stavudine*zidovudine*

Aptivus*Crixivan*Emtriva*Epzicom*Fuzeon* (PA)Invirase*Isentress*Kaletra*Lexiva*Norvir*Prezista*Rescriptor*Reyataz*Selzentry*Sustiva*Trizivir*Truvada*Viracept*Viramune XR*Viread*

Atripla*Combivir*Complera*Edurant*Epivir*Fulyzaq (PA)Intelence*Retrovir*Stribild*Videx*Viramune*Zerit*Ziagen*

ALLERGY

azelastine nasalclemastine fumaratecyproheptadinecyproheptadine hcldesloratadineepinastineepinephrine flunisolide nasalfluticasone nasalhydroxyzine

AsteproEpipenEpipen Jr.NasonexVeramyst

Adrenaclick (QL)AstelinAtrovent (nasal)AUVI-QBeconase AQ (PA, ST)Dymista (PA, ST)Flonase (PA, ST)Nasacort AQ (PA, ST)Omnaris (PA, ST)Patanase


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ALZHEIMER’S DISEASE

donepezildonepezil hclgalantamine hydrobromiderivastigmine tartrate capsules

Aricept (23 mg)Namenda

Aricept (5 and 10 MG)Aricept ODTCognexExelonNamenda XRRazadyneRazadyne ER

ANXIETY

alprazolambuspironediazepamlorazepamoxazepam

Lorazepam IntensolNiravam

ASTHMA AND RESPIRATORY

albuterol solution (nebulizer solution)albuterol sulfate (syrup, tabs)aminophyllinebudesonidecaffeine citratecromolyn sodium (nebulizer solution)dyphyllineguaifenesin/dyphyllineguaifenesin/theophyllineipratropium bromide (nebulizer solution)levalbuterol (nebulizer solution)metaproterenol sulfate (syrup, tabs)montelukastsildenafil* (PA)terbutaline sulfatetheophylline anhydrouszafirlukast

Advair, Advair HFAAdvair Diskus/HFAAsmanexAtrovent HFACombiventCombivent RespimatFlovent Diskus/HFAProAir HFAPulmicortPulmozyme* (PA)QvarSereventSpirivaSymbicortVentolin HFAXolair* (PA)

AccolateAccuneb nebulizer (PA, ST)Adcirca* (PA)Adempas* (PA)AlvescoArcaptaBreo Ellipta (ST)Brovana nebulizer (PA, ST)DalirespDuleraLetairis*LufyllinOpsumit* (PA)Perforomist (PA, ST)Proventil HFARevatio* (PA)SingulairTracleer*Tudorza Pressair (ST)Ventavis*Xopenex HFAXopenex nebulizer (PA, ST)

ALLERGY (CONTINUED)

ipratropium nasallevocetirizinemontelukasttriamcinolone nasal

QNASL (PA, ST)Rhinocort AQ (PA, ST)Semprex-DSingulairTavist SyrupXyzalZetonna (PA, ST)


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BIRTH CONTROL

AmethiaApriAvianeBalzivaCamilaCamreseDayseeErrinEstaryllaGianviJolessaJunel FEKarivaKurvelolevonorgestrelLevoraLorynaLow-OgestrelMicrogestinMono-LinyahNeconnoreth-ethinyl estradiol/ironNortrelOcellaOgestrelPrevifemQuasenseSprintecTri-EstaryllaTri-LinyahTrinessaTri-SprintecVesturaZenchentZeosaZovia

BeYazLo Loestrin FELo Minastin FELoSeasoniqueMinastrin 24 FENuvaRingOrtho EvraOrtho TriCyclen LoPlan B One-Step

AngeliqDesogenEllaEstrostep FEFemcon FELoestrinLoestrin FEMircetteNataziaNordetteOrtho-CeptOrtho-CyclenOrtho-Novum 7-7-7Ortho-Tri-CyclenQuartetteSafyralSeasonaleSeasoniqueTri-NorinylYaz

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

BLADDER PROBLEMS

flavoxateoxybutynin/XLtolterodine tartratetrospium chloride

Detrol LAElmironOxytrolToviazVESIcare

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


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CANCER

anastrozoleazacitidine*bicalutamide*exemestaneflutamide*letrozolelomustinetamoxifen citratetemozolomide* (PA)

Gleevec* (PA)Granix*Hexalen*LeukeranLupron Depot* (PA)LysodrenMatulane*MyleranNeulasta* (PA)Neupogen* (PA)Nexavar* (PA)Revlimid* (PA)Sprycel* (PA)Sutent* (PA)Tarceva* (PA)Thalomid* (PA)Xeloda*Zolinza* (PA)

Afinitor* (PA)Afinitor Disperz* (PA)ArimidexAromasinBosulif* (PA)Caprelsa* (PA)Casodex*Cometriq* (PA)DroxiaErivedge* (PA)FarestonFemaraImbruvica* (PA)Inlyta* (PA)Jakafi* (PA)Mekinist* (PA)Pomalyst* (PA)Stivarga* (PA)Sylatron* (PA)Tafinlar* (PA)Targretin* (PA)Tasigna* (PA)Temodar* (PA)Tykerb* (PA)Valchlor*Votrient* (PA)Xalkori* (PA)Zelboraf* (PA)Zytiga* (PA)

CARDIOVASCULARBLOOD THINNER/ANTI-CLOTTING

anagrelide*cilostazolclopidogreldipyridamoleenoxaparin*fondaparinux*heparinJantoventiclopidinewarfarin

AggrenoxArixtraEffientFragminXarelto

Agrylin*BrillintaEliquis (ST)CoumadinLovenoxPlavixPletalPradaxa (ST)


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CARDIOVASCULAR (CONTINUED)

HIGH BLOOD PRESSURE/HEART MEDICATIONS

acebutolol HClacetazolamideamiloride HClamlodipine besylateamlodipine besylate/ benazeprilamlodipine/atorvastatin calciumapresolineatenololbenazepril HClbenazepril HCl/amlodipinebenazepril HCl/HCTZbendroflumethiazide/nadololbetaxolol HClbisoprolol fumaratebisoprolol/HCTZbumetanidecandesartancandesartan cilexetilcandesartan HCTZcaptoprilcaptopril/HCTZcarvedilolchlorothiazidechlorthalidonechlorthalidone/atenololclonidineclonidine HClClorpresdiltiazemdiltiazem 24HR ERdoxazosin mesylateenalapril maleateenalapril maleate/HCTZeplerenoneeprosartan mesylatefelodipinefosinopril sodiumfosinopril sodium/HCTZfurosemideguanfacinehydralazine HClhydrochlorothiazidehydrochlorothiazide/ amilor HClhydroflumethiazideindapamide

BenicarBenicar HCTBystolicCoreg CRDiovanExforgeExforge HCTTarkaTekturnaTekturna HCT

Accupril (PA, ST)Accuretic (PA, ST)Aceon (PA, ST)Altace (PA, ST)AmturnideAtacand (PA, ST)Avalide (PA, ST)Avapro (PA, ST)AzorBetapace AFCarduraCardura XLCatapres, Catapres TTSCoregCorgardCovera-HSCozaar (PA, ST)Diovan HCT (PA, ST)DutoprolDynacirc CREdarbi (PA, ST)Edarbychlor (PA, ST)Hyzaar (PA, ST)Inderal LAInnopran XLLevatolLotensin (PA, ST)Lotensin HCT (PA, ST)LotrelMavik (PA, ST)Micardis (PA, ST)Micardis HCT (PA, ST)MonoprilMonopril HCTNexiclon XRNorpaceNorpace CRNorvascPrinivil (PA, ST)Prinzide (PA, ST)SularTekamloTeveten (PA, ST)Teveten HCT (PA, ST)Toprol XLTribenzor (ST)Uniretic (PA, ST)Univasc (PA, ST)


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HIGH BLOOD PRESSURE/HEART MEDICATIONS

irbesartanirbesartan/HCTZisradipinelabetalol HCllisinoprillisinopril/HCTZlosartan potassiumlosartan potassium/HCTZmethazolamidemethyldopamethyldopa/HCTZmetolazonemetoprolol succinatemetoprolol tartratemetoprolol/HCTZminoxidilmoexipril HClmoexipril HCl/HCTZnadololnicardipine HClnifedipinenimodipineperindopril erbuminepindololprazosin HClpropranolol HClpropranolol/HCTZquinaprilquinapril HCl/HCTZramiprilreserpinereserpine/HCTZsotalol HClspironolactonespironolactone/HCTZterazosin HCltimolol maleatetorsemidetrandolapriltriamterene/HCTZvalsartanvalsartan/HCTZVecamyl-mecamylamine hclverapamilverapamil SR

Vaseretic (PA, ST)Vasotec (PA, ST)VerelanZestoretic (PA, ST)Zestril (PA, ST)


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CHOLESTEROL LOWERING

atorvastatincholestyraminecholestyramine powdercholestyramine/aspartamecholestyramine/sucrosecolestipolfenofibratefenofibric acidfluvastatin/XLgemfibrozillovastatinniacinpravastatinsimvastatin

Crestor (5 & 10 MG) (PA, ST)Crestor (20 & 40 MG)LovazaNiaspanSimcorWelcholZetia

AdvicorAltoprev (PA, ST)AntaraCaduetColestidFenoglideJuxtapid* (PA)Kynamro* (PA)Lescol (PA, ST)Lescol XR (PA, ST)Lipitor (PA, ST)Liptruzet (PA, ST)Livalo (PA, ST)LofibraMevacor (PA, ST)Pravachol (PA, ST)TriCorTrilipixVascepa (ST)Vytorin (PA, ST)Zocor (PA, ST)


OTHER

amiodaronedigoxindisopyramideflecainideisosorbide dinitrateisosorbide mononitratenitroglycerinprocainamidepropafenone SR

MultaqTikosyn

LanoxinNitrolingual sprayNitromistRanexa (ST)Rythmol SRSamsca (PA)

DEPRESSION

amitriptylinebupropionbupropion SRcitalopramdesipramineescitalopramfluoxetinefluvoxamineimipraminemirtazapinenortriptylineparoxetineparoxetine CRprotriptyline

CymbaltaPristiqWellbutrin XL

Aplenzin (PA, ST)Brintellix (PA, ST)Celexa (PA, ST)Desvenlafaxine ER (ST)Effexor XR (PA, ST)EmsamFetzima (PA, ST)Forfivo XL (PA, ST)Lexapro (PA, ST)Luvox CRMarplanPaxil (PA, ST)Paxil CR (PA, ST)Pexeva (PA, ST)


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DEPRESSION

sertraline trazodonetrimipraminetrimipramine maleatevenlafaxinevenlafaxine XR

Prozac (PA, ST) Remeron Sarafem (PA, ST)TofranilVenlafaxine HCl ER (PA, ST)Viibryd (PA, ST)VivactilWellbutrin (PA, ST)Wellbutrin SR (PA, ST)Zoloft (PA, ST)

DIABETES

acarbosechlorpropamideglimepirideglipizideglipizide/metforminglucagonglyburideglyburide micronizedglyburide/metforminmetformin/ERnateglinidepioglitazonepioglitazone/glimepiridepioglitazone/metforminrepaglinidetolazamidetolbutamide

ACCU-CHEK test stripsApidraApidra SoloStarBD Insulin Syringes/ Pen NeedlesBydureon (QL)ByettaFortametGlucaGen HypoKitHumalogHumulinJanumetJanumet XRJanuviaKombiglyze XRLantusLantus SoloStarLevemirNovoFine needlesNovolinNovologOne Touch test stripsOnglyzaPen NeedlesPrandimetSymlinPenVictoza

Actoplus MetActoplus Met XRActosAmarylAvandametAvandarylAvandiaCyclosetDuetactGlucophage XRGlysetInvokana (ST)Jentadueto (ST)Kazano (ST)Nesina (ST)Oseni (ST)PrandinPrecoseStarlixTradjenta (ST)

ENDOCRINE AND METABOLIC – OTHER

allopurinolcabergoline (QL)desmopressin*fluoxymesteroneoctreotide* (PA)

ColcrysIncrelex* (PA)LupronDepot-PED* (PA)Megace ESNilandronSandostatin* (PA)Sandostatin LAR* (PA)Somavert* (PA)Uloric

Egrifta* (PA)Signifor* (PA)Somatuline Depot* (PA)


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EYE CONDITIONS

apraclonidine hclatropineazelastinebrimonidinebromfenacbromfenac sodiumciprofloxacindiclofenacdorzolamidedorzolamide/timololepinastineflurbiprofengatifloxacinketorolaclatanoprostlevobunolollevofloxacinpilocarpinetimololtobramycin/dexamethasonetravoprosttrifluridine

AlomideAlphagan P (0.10%)AzaSiteAzoptBetimolBetoptic SCiloxan (ointment)IopidineLotemax (drops)MaxidexMoxezaPatadayPatanolRestasisTobradex (ointment)Travatan ZVexolVigamox

Acular LSAlocrilAlrexBepreveBesivanceCiloxan (drops)CosoptCystaranDurezolElestatEmadineIlevroIquixLastacaftLotemax (ointment)OptivarProlensaResculaSimbrinza (ST)TimopticTobradex (drops)Tobradex STTrusoptVoltarenZioptan (ST)Zymaxid

GASTROINTESTINAL (NOT HEARTBURN/ULCER)

balsalazidebudesonidecromolyn sodium (solution)PEG 3350/potassium/ sodium bicarb/saltPEG 3350/potassium/ sodium bicarb/salt/ sodium sulf

AprisoAsacolAsacol HDCanasaCreonDelzicolGoLytelyHumira* (PA)LialdaPentasaUrso/Urso ForteZenpep

AmitizaCimzia* (PA)ColazalColyteEntocort ECGiazoLinzessNuLytelyPancreazePertzyePrepopikRelistor (PA)Remicade* (PA)Simponi* (PA)SuclearSucraid*UcerisUltresaViokace


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HORMONE REPLACEMENT

estradiolestradiol/norethindrone acetateestropipateethinyl estradiollevothroidlevothyroxineLevoxylliothyroninemedroxyprogesteroneprogesterone, micronizedtestosterone cypionatetestosterone enanthatethyroidUnithroid

AloraAnadrol-50AndrodermAndroGelArmour ThyroidDivigelEnjuviaEstradermPremarinPremphasePremproSynthroidTestimVivelle-Dot

ActivellaAxiron (ST)CenestinCombipatchCytomelDepot TestosteroneEstraceFemhrtFemringFortesta (ST)MenestMinivellePrefestPrometriumVagifem

GROWTH HORMONES

Humatrope* (PA)Saizen* (PA)

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

HEARTBURN/ULCER

cimetidinefamotidinelansoprazolelansoprazole/amoxicillin/ clarithromycinmetoclopramidemetoclopramide hclmisoprostolnizatidinepantoprazolerabeprazoleranitidinesucralfate

Nexium Aciphex (PA, ST)Dexilant (PA, ST)HelidacPrevacid (PA, ST)PrevpacPrilosec (PA, ST)Protonix (PA, ST)Zantac EffertabZantac SyrupZegerid (PA, ST)


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INFECTIONS

acycloviradefovir dipivoxil*amantadineamoxicillinamoxicillin/clavulanateazithromycincefaclor ERcefadroxilcefdinircefprozilceftibuten dihydrateceftriaxone cefuroxime axetilcephalexinciclopiroxciprofloxacinclarithromycinclindamycinclindamycin phosphatecycloserinedoxycyclineerythromycinfamciclovirfluconazoleflucytosineganciclovirgentamicin sulfategriseofulvin microsizegriseofulvin ultramicrosizeitraconazole (QL)ketoconazolemetronidazoleminocyclineminocycline SRmupirocinnitrofurantoinnystatinofloxacinpenicillin v potassiumribavirin*rifampin rimantadinesulfamethoxazole/ trimethoprimterbinafine (QL)terconazoletetracyclinevalacyclovir vancomycinvoriconazole (PA)

Baraclude*Cipro HC OticCiprodexEpivir HBV*Gris-PegIncivek* (PA)Intron-A* (PA)Mycostatin (tabs)Pegasys* (PA)PrimsolTamiflu (QL)Tobi*Valcyte

AncobonAugmentinAugmentin ES 600Augmentin XRAveloxBactrobanBethkis*BiaxinBiaxin XLCedaxCayston* (ST)CefzilCetraxalCiclodanCipro XRCoartem (QL)Copegus*Dificid (PA)Ery-TabFamvirFlagyl 375Flagyl ERFloxin OticGaramycin*Grifulvin VHepsera*Infergen* (PA)KeflexKeftabLamisil (QL)LevaquinMalaroneMonurolMoxatagNoxafilOmnicefOnmel (QL,ST)Peg Intron (PA)PenlacPriftinRebetolRelenza (QL)RocephinSirturoSolodyn (ST)Sporanox (QL)SupraxTobi Podhaler*Tyzeka*


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INFECTIONS (CONTINUED)

ValtrexVfend (PA)Victrelis* (PA)ZithromaxZyvox (PA)

NAUSEA AND VOMITING

dronabinolgranisetronondansetronprochlorperazinepromethazinetrimethobenzamide

Emend* Anzemet* (QL)DiclegisKytrilMarinolSancuso (QL)ScopaceZofranZuplenz (QL, ST)

MIGRAINE

acetaminophen/caffeine/ butalbitaldihydroergotamine (QL)mesylate (QL)naratriptan (QL)rizatriptan (QL)sumatriptan (QL)sumatriptan succinate (QL)zolmitriptan (QL)

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/Zomig ZMT (QL)

MULTIPLE SCLEROSIS

Ampyra* (PA)Avonex/Avonex Pen* (PA)Copaxone* (PA)Rebif* (PA)Rebif Rebidose* (PA)

Aubagio* (PA)Betaseron* (PA)Extavia* (PA)Gilenya* (PA)Tecfidera* (PA)

OSTEOPOROSIS

alendronate sodiumcalcitonin-salmonForticalibandronate sodium

EvistaForteo*Miacalcin

Actonel (PA, ST)Atelvia (PA, ST)Binosto (PA, ST)Boniva* (inj)Boniva (tab) (PA, ST)Fosamax (PA, ST)Fosamax Plus D (PA, ST)Skelid (PA, ST)


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PAIN RELIEF AND INFLAMMATORY DISEASE

buprenorphinebutalbit/acetamin/caff/ codeinebutorphanol nasal (QL)codeine phos/ carisoprodol/asacodeine phosphatecodeine phosphate/aspirincodeine sulfatecyclophosphamide*dexamethasonediclofenacdiclofenac-misoprostoldihy-cod tt/apap/caffeinedihydrocodeine/aspirinetodolacfenoprofenfentanyl citrate (lozenge on stick) (PA)fentanyl transdermal (QL)flurbiprofenhydrocodone bitartrate/ apaphydrocodone bitartrate/ aspirinhydrocodone/acetaminophenhydromorphone HClibuprofenibuprofen/hydrocod bitindomethacinketoprofenketorolac (QL)leflunamidelevorphanol tartratelidocainemeclofenamatemefenamic acidmeloxicammeperidine HClmetaxalonemethotrexate*methylprednisolonemorphine SRmorphine sulfatenabumetonenaproxenopiumopium/belladonna alkaloidsoxaprozinoxycodone HCl

Actimmune* (PA)AvinzaCelebrexDilaudid-5DipentumEnbrel* (PA)Fentora (PA)Humira* (PA)Indocin (suppository)KadianLidodermLyricaNucynta (ST)Nucynta ER (QL)OxyContin (QL)Ponstel (PA, ST)Roxicet (PA, ST)SavellaTrexallVimovo

Abstral (PA)Actiq (PA)Ansaid (PA, ST)Arthrotec (PA, ST)Butrans (QL)Cambia (PA, ST)Cimzia* (PA)Conzip (PA, ST)Demerol (PA, ST)Dilaudid (PA, ST)Duexis (PA, ST)Duragesic (QL)Exalgo (QL)Fioricet w/codeineFlector (PA, ST)Horizant (ST)Hycet (PA, ST)Kineret* (PA)Lazanda (PA)Lorcet (PA, ST)Lorcet Plus (PA, ST)Lortab (PA, ST)Magnacet (PA, ST)Maxidone (PA, ST)Mobic (PA, ST)Nalfon (PA, ST)Naprelan (PA, ST)Norco (PA, ST)Onsolis (PA)OpanaOpana EROxecta (PA, ST)Pennsaid (PA, ST)Percocet (PA, ST)Percodan (PA, ST)Primalev (PA, ST)Rayos (ST)Remicade* (PA)Rheumatrex*Roxicodone (PA, ST)Simponi* (PA)Simponi Aria* (PA)SkelaxinSprix (QL)SuboxoneSubsys (PA)Synalgos (PA, ST)Ultracet (PA, ST)UltramUltram ER


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PROSTATE

alfuzosindoxazosinfinasterideleuprolide acetate* (PA)prazosintamsulosinterazosin

AvodartCialis (PA, QL)JalynLupron Depot* (PA)Uroxatral

Firmagon* (PA)FlomaxProscarRapafloZoladex* (PA)Zytiga* (PA)

PAIN RELIEF AND INFLAMMATORY DISEASE (CONTINUED)

oxycodone HCl/ aaacetaminophenoxycodone/aspirinoxymorphoneOxymorphone hcl pentazocine HCl/ aaacetaminophenpentazocine HCl/naloxone HClpiroxicamprednisonesulindactolmetintramadol HCl/acetaminophentramadol HCl/ERxolox

Vicodin (PA, ST)Vicodin ES (PA, ST)Vicodin HP (PA, ST)Vicoprofen (PA, ST)Voltaren Gel (PA, ST)Voltaren XRXeljanz* (PA)Xodol (PA, ST)Zamicet (PA, ST)Zolvit (PA, ST)Zorvolex (PA, ST)Zydone (PA, ST)

PARKINSON’S DISEASE

amantadinebenztropinebromocriptinecarbidopa/levodopacarbidopa/levodopa CRcarbidopa/levodopa/ entacaponeentacaponepramipexoleropiniroleropinirole XLselegiline

Apokyn* (PA)AzilectRequip XL

ComtanEldeprylLodosynMirapexMirapex ERNeuproParcopaRequipSinemet CRStalevoTasmarZelapar


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SEIZURE

carbamazepineclonazepamdiazepamdivalproexfelbamategabapentinlamotriginelevetiracetamoxcarbazepinephenytointiagabine hcltopiramatevalproatezonisamide

CelontinDiastatDiastat AcudialFelbatolGabitrilKeppraLamictal ODTLyricaPeganoneVimpat

BanzelCarbatrolDepakote (all forms)Keppra XRLamictalLamictal/XRNeurontinOnfiOxtellar XRPotigaSaphrisStavzorTegretol XRTopamaxTrileptalZonegran

SEXUAL DYSFUNCTION

* Please check yourenrollment materials todetermine whether thismedication is coveredunder your plan.

Cialis (PA, QL)*Muse (QL)*Viagra (QL)*

Caverject (QL)*Edex (QL)*Levitra (QL)*Osphena*Staxyn (QL)*Stendra (QL)*

SKIN CONDITIONS

acitretinadapalene (AGE)alclometasone dipropionateamcinonide

Benzaclin (Gel with pump)Benzamycin PakCapex Shampoo (PA, ST)Carac

Absorica (QL)AcanyaAclovate (PA, ST)Ala-Scalp HP (PA, ST)

SCHIZOPHRENIA

clozapinehaloperidolloxapineolanzapineolanzapine/fluoxetine HClquetiapinerisperidonethiothixeneziprasidone

Seroquel XR AbilifyAbilify DiscmeltClozaril (PA, ST)Fanapt (PA, ST)Fazaclo (PA, ST)Geodon (PA, ST)Invega (PA, ST)Latuda (PA, ST)MobanOrapRisperdal/ Risperdal M (PA, ST)Saphris (PA, ST)SeroquelVersacloz (PA, ST)Zyprexa/Zyprexa Zydis (PA, ST)


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SKIN CONDITIONS (CONTINUED)

amnesteem (QL)Apexicon E (diflorasone diacetate)betamethasonebetamethasone dipropionatebetamethasone dipropionate/ propylene glycolbetamethasone valeratecalcipotrienecalcitriol ointmentClaravis (QL)clinicamycinphosphate/ benzoyl peroxide gelclobetasol propionateclobetasol propionate/emolldesonidedesoximetasonediflorasone diacetatefluocinolone acetonidefluocinonide/emollientfluorouracil topicalfluticasone propionatehalobetasol prop/ ammonium lachalobetasol propionatehydrocortisonehydrocortisone acetate/ aloe verahydrocortisone acetate/ureahydrocortisone butyratehydrocortisone valerateimiquimodIsotretinoin (QL)mafenide acetatemetronidazolemometasonepodofiloxprednicarbatesalicylic acidSotret (QL)sulfacetamidesulfacetamide sodium/sulfursulfacetamide sulfursulfacetamide/sulfur/cleansertretinoin (AGE)triamcinolone acetonideurea

Carmol HC (PA, ST)ClodermCordran (PA, ST)Cordran SP (PA, ST)Derma-Smoothe/FS (PA, ST)Differin (AGE)Dovonex creamEnbrel* (PA)ExeldermFluoroplexFuracinHumira* (PA)Kenalog spray (PA, ST)KlaronLocoid (lotion)Locoid LipocreamLoprox shampooMetrogel 1%NaftinNoritateNucort (PA, ST)OraceaRetin-A Micro (AGE)SoriataneTazoracTexacort (PA, ST)

AldaraAphthasolAqua Glycolic HC (PA, ST)Atralin (AGE)BenzaclinBenzefoamClindacin PacClobex (PA, ST)CondyloxCutivate (PA, ST)Delos AcneDermatop (PA, ST)Desonate (PA, ST)Desowen (PA, ST)Diprolene (PA, ST)Diprolene AF (PA, ST)DovonexDuac CSElidel (PA, ST)Elocon (PA, ST)EpiduoFirst Hydrocortisone (PA, ST)Halog (PA, ST)Kenalog (PA, ST)Luxiq (PA, ST)MetrogelMetrolotionMirvaso (ST)Momexin (PA, ST)NuzonOlux (PA, ST)Olux-E (PA, ST)Pandel (PA, ST)Panretin* (PA)Pediaderm HC (PA, ST)ProtopicPsorcon (PA, ST)Psorcon ERegranex (PA)Remicade* (PA)RiaxRosulaScalacort DK (PA, ST)Soriatane CKStelara* (PA)Synalar (PA, ST)TaclonexTemovate (PA, ST)Topicort (PA, STTopicort LP (PA, ST)


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SLEEP

zaleplonzolpidemzolpidem ER

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

TRANSPLANT

azathioprine*cyclosporine*mycophenolate moefetil*tacrolimus*

Azasan*Cellcept*Neoral*Prograf*Rapamune*Sandimmune*

Imuran*Myfortic*Zortress*

SKIN CONDITIONS (CONTINUED)

Tretin-X (PA)Ultravate (PA, ST)Ultravate PAC (PA, ST)Vanos (PA, ST)VecticalVerdeso (PA, ST)VytoneWestcort (PA, ST)XolegelXolegel CorepakZianaZyclara (ST)

VITAMINS

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

calcitriolcyanocobalaminfolic acid

Active OBBal-Care DHA EssentialCitranatalCitranatal Assure^Citranatal B-CalmCitranatal Harmony^Duet DHADuet DHA Balanced^Duet DHA ECGesticare DHAInfanate BalanceNatachewNatafortNeevo


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VITAMINS (CONTINUED)

Neevo DHA NestabsNestabs ABCNestabs DHA^Nexa PlusOB CompleteOB Complete DHAOB Complete OneOB Complete PetiteOB Complete Premier PNV Folic Acid-IronPNV-DHA PlusPrecare PremierPrefera-OB OnePreferaOB Prenatal VitaminPrenataPrenatal 19Prenate AMPrenate ChewablePrenate DHAPrenate ElitePrenate EnhancePrenate MiniPrenate PlusPrenate RestoreProvida OBStuart PrenatalStuartnatal PlusStuartnatal Plus 3TL-Select DHATricareTricare Prenatal CompleatTricare Prenatal DHA One^Vinate CareVita Fol-OB DHVitafol UltraVIVA CTViva DHAVP-PNV-DHA


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MISCELLANEOUS

aminocaproic acid*buprenorphinebuprenorphine hcl/ naloxone hclCyclobenzaprinehydrocodone/ chlorpheniramine suspensionleucovorin*levocarnitinelindanemegestrolmethocarbamolnaltrexoneparicalcitol*pentoxifyllinepramoxine/hydrocortisoneriluzole*sodium phenylbutyratespinosadtizanidinetranexamic acid

Analpram AdvancedAnalpram HCAnalpram-EAnamantle HC ForteAranesp* (PA)BuphenylChantix*Epogen* (PA)Follistim AQ* (PA)FosrenolPramosoneProcrit* (PA)Proctofoam-HCPulmuzyme* (PA)RenvelaRilutek*SuboxoneTussiCapsZavesca* (PA)

Arcalyst* (PA)Brisdelle (QL)CortifoamCuvposaEpifoamGattex* (PA)GlycateIlaris* (PA)Kuvan*LystedaNatrobaNimotopNuedextaPhosloPhoslyraProcysbi* (PA)Promacta* (PA)Ravicti* (PA)RectivRenagelReviaSkliceSubutexTussionexUlesfiaVituzZanaflexZemplar*Zubsolv (ST)Zutripro

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EXCLUSIONS & LIMITATIONS Plans typically do not provide coverage for the following, except as required by law or by the terms of your specific plan:

1. Any medications available over-the-counter (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.].

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

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

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

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

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

7. Any contraceptive medications and prescription appliances for contraception.

8. Implantable contraceptive products. 9. Any fertility medication. 10. Any prescription vitamins (other than

prenatal vitamins), dietary supplements and fluoride products.

11. 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.

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

13. 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).

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

15. Medications used to enhance athletic performance.

16. 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.

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

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

827293 i 12/13 © 2013 Cigna. Some content provided under license.

“Cigna,” the “Tree of Life” logo and “GO YOU” 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 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 Specialty Pharmacy Services” refers to the specialty drug division of Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C., doing business as Cigna Home Delivery Pharmacy. All models are used for illustrative purposes only.

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