Performance Prescription Drug List Performance Prescription Drug List lets you and your doctor ... number on the back of your ID card to speak with a customer ... ceftriaxone cefuroxime

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Performance Prescription Drug List

PRESCRIPTION dRug lISTJULY 2011

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 drugs covered under your plan.

This list is designed to cover your prescription drugs 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 drug 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.

1st Tier – Generic Medications: Generic drugs 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 drugs 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 drugs 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.

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Insured or administered by: CIGNA Health and Life Insurance Company†

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Health Care Reform and YouThe 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 QuestionsRemember, this list is just a sample of the most commonly used medications. You can use the Prescription Drug Price Quote tool available on mycignaforhealth.com to see and compare the prices of all drugs 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.

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.

* Drugs marked with an asterisk are considered to be specialty medications. Some plans may cover specialty medications at different benefit levels.

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NoN-PREfERREd GENERICS PREfERREd BRANdS BRANdS

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Add/AdHd ANd STIMULANTS

amphetamine/ dextroamphetaminedexmethylphenidatemethamphetaminemethylphenidate/ER/SR

Adderall XRFocalinFocalin XRIntunivRitalin LARitalin SRStratteraVyvanse

Adderall ConcertaDaytrana DesoxynKapvay Metadate CD Metadate ER MethylinNuvigil (PA)Provigil (PA)Ritalin

AIdS/HIV

didanosinestavudinezidovudine

AgeneraseAptivusCombivirCrixivanEmtrivaEpivirEpzicomInviraseIsentressKaletraLexivaNorvirPrezistaRescriptorReyatazSelzentrySustivaTrizivirTruvadaViraceptViramuneVireadZiagen

AtriplaIntelenceRetrovirVidexZerit

ALZHEIMER’S dISEASE

donepezilgalantaminerivastigmine

Aricept (23mg)Namenda

Aricept (5 and 10 mg) Aricept ODT Cognex Exelon Razadyne Razadyne ER

ALLERGY

azelastine nasalclemastinecyproheptadineepinephrine inj flunisolide nasalfluticasone nasalhydroxyzineipratropium nasallevocetirizine

AsmanexAsteproEpipen (QL)Epipen Jr. (QL)NasonexSingulairVeramyst

Adrenaclick AstelinAtrovent (nasal)Beconase AQ ClarinexFlonase Nasacort AQ Nasarel Omnaris PatanaseRhinocort AQ Semprex-DXyzal

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ANXIETY

alprazolambuspironelorazepamoxazepam

Lorazepam Intensol

ASTHMA ANd RESPIRAToRY

albuterol solution (nebulizer solution)albuterol sulfateaminophyllinebudesonidecaffeine citratedcromolyn sodium (nebulizer solution)dyphylline(Dylix) dyphyllineEd-Bron Gguaifenesin/dyphyllineguaifenesin/theophyllineipratropium bromide (nebulizer solution )

Advair, Advair HFAAsmanexAtrovent HFAAzmacortCombiventFlovent, Flovent HFAMaxairProAir HFAProventil HFAPulmicortPulmozyme*QvarRevatio* (PA)SereventSingulair

Accolate Accuneb nebulizer Adcirca* (PA) Alvesco Brovana nebulizer Dulera Foradil Letairis* (PA) Perforomist Tracleer Ventavis* (PA) Xopenex HFA Xopenex nebulizer

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BIRTH CoNTRoL*

ApriAvianeBalzivaCamilaErrinGianviJolessaJunel FEKarivaLevoraLo-ogestrelMicrogestinNeconNortrelOcellaOgestrelPrevifemQuasenseSoliaSprintecTrinessaTri-SprintecZenchantZovia

BeYazLoestrin 24 FELO Loestrin FELoSeasoniqueNuvaRingOrtho EvraOrtho TriCyclen LOOvcon 50Plan B One-StepSeasoniqueYaz

AngeliqDesogenEllaEstrostep FELevlenLo/Ovral-28LoestrinLoestrin FELybrelNataziaNordetteOrtho-CeptOrtho-Novum 7-7-7Ovcon 35SafyralSeasonaleTrilevlenTri-NorinylTriphasil

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

BLAddER PRoBLEMS

oxybutynin / XLtrospium chloride

Detrol Detrol LA ElmironOxytrol Toviaz VESIcare

DitropanDitropan XL Enablex Gelnique SancturaSanctura XR

ASTHMA ANd RESPIRAToRY (CONTINUED)

isoetharine hcllevalbuterol (nebulizer solution)metaproterenol sulfate (syrup, tabs)terbutaline sulfatetheophylline anhydrouszafirlukast

SpirivaSymbicortVentolin HFAXolair* (PA)

CANCER

anastrozolebicalutamideetoposideexemestaneflutamideletrozoletamoxifen citrate

CEENUFarestonGleevec* (PA)HexalenLeukeranLupron* (PA)LysodrenMatulaneMyleranNexavar* (PA)Revlimid* (PA)Sprycel*(PA)Sutent* (PA)Tarceva* (PA)Temodar*Xeloda*Zolinza (PA)

Afinitor* (PA)ArimidexAromasinCasodexDroxiaFemaraTargretinTasigna* (PA)Tykerb* (PA)Votrient (PA)

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CARdIoVASCULAR (CONTINUED)

HIGH BLood PRESSURE/HEART MEdICATIoNS

hydralazine/reserpine/hctzhydrochlorothiazidehydrochlorothiazide/amilor hclhydroflumethiazideindapamideisradipinelabetalol hcllisinoprillisinopril/hydrochlorothiazidelosartan potassiumlosartan potassium/hctzmethazolamidemethyldopamethylopa/hydrochlorothiazidemetolazonemetoprolol succinatemetoprolol tartratemetoprolol/hctzminoxidilmoexipril hclmoexipril hcl/hctznadololnicardipine hclnifedipinenimodipinenisoldipineperindopril erbuminepindololprazosin hclpropranolol hclpropranolol/hctzquinaprilquinapril hcl/hctzramipril (caps only)rauwolfia serpentina/bfmtzreserpinereserpine/hydrochlorothiazidesotalol hclspironolactonespironolactone/hctzterazosin hcltimolol maleatetorsemidetrandolapriltrandolapril/verapamil hcltriamterene/hctzverapamilverapamil SR

NorvascPrinivil PrinzideRanexa Rythmol SRSularTarkaTekamloTeveten (PA, ST)Teveten HCT (PA, ST)Toprol XLTribenzorUniretic Univasc Vaseretic Vasotec VerelanZestoretic Zestril

CARdIoVASCULAR

BLood THINNER/ANTI-CLoTTING

anagrelidecilostazoldipyridamoleenoxaparinheparin Jantoventiclopidinewarfarin

AggrenoxArixtraEffientFragmin Innohep Plavix

Agrylin LovenoxPletalPradaxa (PA)

CARdIoVASCULAR

HIGH BLood PRESSURE/HEART MEdICATIoNS

acebutolol hclacetazolamideamiloride hclamlodipine besylateapresolineatenololbenazepril hclbenazepril hcl/amlodipine benazepril hcl/hctzbendroflumethiazide/nadololbetaxolol hclbisoprolol fumaratebisoprolol/hctzbumetanidecaptoprilcaptopril/hydrochlorothiazidecarvedilolchlorothiazidechlorthalidonechlorthalidone/atenololclonidineclonidine hclClorpresdiltiazemdiltiazem 24HR ERdoxazosin mesylateenalapril maleateenalapril maleate/hctzeplerenonefelodipinefosinopril sodiumfosinopril sodium/hctzfurosemideguanabenz acetateguanfacinehydralazine hclhydralazine/hctz

Altace (caps)BystolicCoreg CRDiovan (PA, ST)Diovan HCT (PA, ST)ExforgeExforge HCTLanoxinMultaqProcanbidTekturna (PA, ST)Tekturna HCT (PA, ST)TikosynValturna (PA, ST)

Accupril Accuretic Aceon AmturnideAltace (Tabs)Atacand (PA, ST)Avalide (PA, ST)Avapro (PA, ST)AzorBenicar (PA, ST)Benicar HCT (PA,ST)Betapace AFCarduraCardura XLCatapres, Catapres TTSCoregCorgardCovera-HSCozaar (PA, ST)Dynacirc CREdarbi (PA,ST)Hyzaar (PA, ST)Inderal LAInnopran XLLevatolLotensin Lotensin HCT LotrelMavik Micardis (PA, ST)Micardis HCT (PA, ST) Monopril Monopril HCT Nexiclon XRNitromistNorpaceNorpace CR

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ENdoCRINE ANd METABoLIC – oTHER

allopurinolcabergolinecolchicinedesmopressinfluoxymesteroneoctreotide

Increlex* (PA)Lupron Depot-PED*Megace ESNilandronSandostatin LAR* (PA)Sandostatin* (PA)Somavert (PA)

Egrifta (PA)Somatuline Depot (PA)

dIABETES

acarboseacetohexamidechlorpropamideglimepirideglipizideglipizide/metforminglucagonglyburideglyburide/metforminglyburide micronizedmetforminnateglinidetolazamidetolbutamide

ACCU-CHEK Test StripsActoplus metActosApidraApidra SoloStarAvandametAvandarylAvandiaBD Insulin Syringes/Pen NeedlesByettaCyclosetDuetactFortametGlucagen HypokitHumalogHumulinJanumetJanuviaKombiglyze XRLantusLantus SoloStarLevemirNovoFine needlesNovolinNovologOne Touch test stripsOnglyzaPrandimetPrandinSymlin (QL)Victoza

AmarylCyclosetGlucophage XRGlycronGlysetMetaglipPrecoseStarlix

CHoLESTERoL LoWERING

cholestyramine powdercolestipolfenofibratefenofibric acidgemfibrozillovastatinpravastatinsimvastatin

CaduetLescol Lescol XLLipitor LovazaNiaspanSimcorTrilipixVytorinWelcholZetia

AdvicorAltoprev Cholestyramine/LightColestidCrestor (PA, ST)FenoglideLivalo (PA, ST)LofibraMevacor (PA, ST)Pravachol (PA, ST)TriCorZocor (PA, ST)

CARdIoVASCULAR

oTHER

amiodaronedigoxindisopyramideflecainideisosorbide dinitrateisosorbide mononitratenitroglycerinprocainamidepropafenone SR

dEPRESSIoN

amitriptylinebupropionbupropion SRcitalopramdesipraminefluoxetinefluvoxaminemirtazapinenortriptylineparoxetineparoxetine CRprotriptylinesertralinetrazodonevenlafaxinevenlafaxine XR

Cymbalta Lexapro PristiqWellbutrin XL

Aplenzin Celexa Effexor XR EmsamLuvox CR MarplanPaxil CR Prozac RemeronTofranilVivactilWellbutrinWellbutrin SRZoloft

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GASTRoINTESTINAL (NoT HEARTBURN/ULCER)

amylase/lipase/proteasebalsalazidenahco3 (alk)/salt/potass/ pegpeg 3350/na sulf, bicarb, cl/kcl

AprisoAsacolAsacol HDCanasaEntocort ECGoLytelyLialdaNuLytelyPentasaUrso/Urso ForteHumira* (PA)(QL)

Cimzia* (PA)ColazalColyteRelistor*Remicade* (PA)Sucraid

EYE CoNdITIoNS

atropine azelastineciprofloxacindiclofenacdorzolamidedorzolamide/timololflurbiprofenketorolaclantanoprostlevobunolollevofloxacinpilocarpinepilocarpine/epinephrinetimololtobramycin/dexamethasonetrifluridine

Acular PFAlomideAlphagan PAzaSiteAzoptBetimolBetoptic SCiloxan (oint)IopidineLotemaxMaxidexMoxezaPatadayPatanolRestasisTobradex ointmentTravatan ZVexolVigamox

AcularAcular LSAlamastAlocrilAlrexBepreveBesivance Ciloxan (drops)CosoptDurezolElestatEmadineIquixLastacaftOptivarTimopticTobradex dropsTrusoptVoltarenXalatanXibrom

HEARTBURN/ULCER

cimetidinefamotidinelansoprazolemetoclopramidemisoprostolnizatidineomeprazoleomeprazole/sodium bicarbonatepantoprazoleranitidinesucralfate

Aciphex Nexium Prevpac

Dexilant (PA,ST)HelidacPrevacid (PA,ST)Prilosec (PA,ST)Protonix (PA,ST)Zantac EffertabZantac SyrupZegerid (PA,ST)

HoRMoNE REPLACEMENT

estradiolestropipateethinyl estradiollevothroidlevothyroxineLevoxylliothyroninemedroxyprogesteronethyroidUnithroid

AloraAnadrol-50AndrodermAndrogelArmour ThyroidCytomelDepo-Testosterone*DivigelEnjuviaEstradermMenestPremarinPremphasePremproPrometriumSynthroidTestimVivelle-Dot

ActivellaAxironCenestinCombipatchFemhrtFemringFortestaPrefestVagifem

GRoWTH HoRMoNES

Humatrope* (PA)Saizen* (PA)

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

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oSTEoPoRoSIS

alendronate(Fortical) calcitonin-salmon

BonivaEvista Forteo*Miacalcin

Actonel Atelvia FosamaxFosamax Plus D Skelid

NAUSEA ANd VoMITING

dronabinolgranisetron (tab, sol) (QL)granisetron (inj) ondansetron (tab, sol) (QL)ondansetron (inj)prochlorperazinepromethazinetrimethobenzamide

Emend (QL) Anzemet (inj)Anzemet (tab)(QL)Kytril (inj)Kytril (tab, solu)(QL)MarinolSancuso (QL)ScopaceZofran (inj)Zofran (tab, solu)(QL)Zuplenz (QL)

MIGRAINE

acetaminophen/caffeine/ butalbitalnaratriptan (QL)sumatriptan (QL)

Maxalt (QL)Maxalt MLT (QL)Treximet (QL)Sumavel DosePro

Alsuma (QL)Amerge (QL)Axert (QL)DHE 45 (QL)Frova (QL)Imitrex (QL)Migranal (QL)Relpax (QL)Zomig/Zomig ZMT (QL)

MULTIPLE SCLERoSIS

Ampyra* (PA)Avonex* (PA)Copaxone* (PA)Rebif* (PA)

Betaseron* (PA)Extavia* (PA)Gilenya (PA)

INfECTIoNS

acycloviramantadineamoxicillinamoxicillin/clavulanateazithromycin cefaclor ERcefadroxilcefprozilceftriaxonecefuroximecephalexinciclopiroxciprofloxacinclarithromycinclindamycindoxycyclineerythromycinfamciclovir (QL)fluconazole ganciclovirgentamicin sulfategriseofulvinitraconazoleketoconazolemetronidazoleminocyclineminocycline SRmupirocinnitrofurantoinnystatinofloxacinpenicillin v potassiumribavirin*rimantadineSMX/TMPterfenabinetetracyclinevoriconazole

BaracludeCipro HC OticCiprodexEpivir HBVGris-PegHepseraMycostatin (tab)Pegasys* (PA)PrimsolTamiflu (QL)Tobivalacyclovir

AugmentinAugmentin ES 600Augmentin XRAveloxBiaxinBiaxin XLCedaxCefzilCipro XRCoartem Copegus*Ery-TabFamvir (QL)Flagyl ERFloxin OticGaramycinInfergen* (PA)KeflexKeftabLamisil LevaquinMalarone MonurolMoxatagNoxafilOmnicefPegIntron* (PA)Penlac PriftinRebetol*Relenza (QL)Rocephin SolodynSporanox SupraxTyzekaValtrex (QL)Vfend Zithromax Zyvox

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PARKINSoN’S dISEASE

amantadinebenztropinebromocriptinecarbidopa/levodopacarbidopa/levodopa SApramipexoleropiniroleselegiline

AzilectRequipRequip XLApokyn*

ComtanEldeprylLodosynMirapexStalevoTasmarZelapar

PAIN RELIEf ANd INfLAMMAToRY dISEASE

buprenorphinebutorphanol nasal (QL)codeine phos/carisoprodol/ asacodeine phosphatecodeine phosphate/aspirincodeine sulfatediclofenacdiclofenac/misoprostoldihy-cod tt/apap/caffeineetodolacfenoprofenfentanyl transdermal (QL) fentanyl citrate (lollipop)(QL)flurbiprofenhydrocodone/acetaminophenhydrocodone bitartrate/apaphydrocodone bitartrate/ aspirinhydromorphone hclibuprofenibuprofen/hydrocod bitindomethacinketoprofenketorolacleflunamidelevorphanol tartratemeclofenamatemefenamic acidmeloxicammeperidine hclmethotrexatemorphine SRmorphine sulfate(Roxanol) morphine sulfatenabumetonenaproxenopiumopium/belladonna alkaloidsoxaprozinoxycodone hcloxycodone hcl/ acetaminophenoxycodone/aspirinpentazocine hcl/ acetaminophenpentazocine hcl/naloxone hclpiroxicam

Actimmune*AvinzaCelebrexDipentumEnbrel* (PA) (QL)Humira* (PA) (QL)Indocin (suppository)KadianLidodermLyricaNucynta OxyContin (QL)oxymorphoneRheumatrexSavellaSkelaxinSuboxoneTrexallVimovo

Abstral (QL)Actiq (QL)Arthrotec (PA, ST)Butrans (QL)Cambia (PA, ST)Cimzia* (PA)Demerol Dilaudid Duragesic (QL)Exalgo (QL)Fentora (QL)Flector (PA, ST)Hycet Kineret* (PA)Lorcet Lorcet Plus Lortab Magnacet Maxidone Mobic (PA, ST)Nalfon (PA, ST)Naprelan (PA, ST)Norco Onsolis (QL)OpanaOpana ERPanlor SS Pennsaid (PA, ST)Percocet Percodan Ponstel (PA, ST)Primalev Remicade* (PA)RoxicetRoxicodone Ryzolt Simponi* (PA)Synalgos-DC Tylox UltracetUltram Ultram ER Vicodin Vicodin ES Vicodin HP Vicoprofen VoltarenVoltaren Gel (PA, ST)

PAIN RELIEf ANd INfLAMMAToRY dISEASE (CONTINUED)

sulindactramadol hcl/ERtramadol hcl/acetaminophentolmetin

Voltaren XRXodol XoloxZamicet Zolvit Zydone

PRoSTATE

doxazosinfinasterideleuprolide acetate*prazosintamsulosinterazosin

AvodartJalyn

Firmagon FlomaxLupron Depot*Lupron*ProscarRapafloTrelstar LA*Trelstar*Trelstar-Depot*UroxatralZoladex*

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SCHIZoPHRENIA

clozapinehaloperidolloxapinerisperidonethiothixene

SeroquelSeroquel XRZyprexa

AbilifyAbilify DiscmeltClozarilFanaptFazacloGeodonInvegaLatudaMobanOrapRisperdalSaphris

SEIZURE

carbamazepineclonazepamdiazepamdivalproexgabapentinlamotriginelevetiracetamtopiramatevalproatezonisamide

CelontinDiastatDiastat AcudialFelbatolGabitrilKeppraLamictalLyricaPeganone

BanzelCarbatrolDepakote (all forms)Keppra XRNeurontinStavzorTegretol XRTopamaxTrileptalVimpatZonegran

SKIN CoNdITIoNS

adapalene alclometasonealclometasone dipropionateamcinonideAmnesteemApexicon E (diflorasone diacetate)betamethasonebetamethasone dipropionatebetamethasone dipropionate/ propylene glycolbetamethasone valeratecalcipotrieneclobetasolclobetasol propionateclobetasol propionate/emolldesonidedesoximetasonediflorasonediflorasone diacetatefluocinolonefluocinolone acetonidefluocinonide/emollientfluouracil topicalfluticasone propionatehalobetasol prop/ammonium lachalobetasol propionatehydrocortisonehydrocortisone acetate/ aloe verahydrocortisone acetate/urea (tp)hydrocortisone butyratehydrocortisone valerateimiquimodisotretinoinmetronidazolemometasone furoateprednicarbateSotret sulfacetamidetretinoin triamcinolone acetonide

BenzaclinBenzamycin PakCaracCloderm CondyloxDerma-Smoothe/FS Differin Dovonex Duac/ Duac CSEnbrel* (PA) (QL)ExeldermFluoroplexFuracinHumira* (PA)(QL)Kenalog sprayLocoid (lotion)Locoid Lipocream Loprox shampooMetrogelNoritateOraceaRetin-A MicroRosulaSoriatane Soriatane CKTazorac

AcanyaAclovate AldaraAphthasolAtralinBenzefoam Capex Shampoo Carmol HC Clindacin PacClobex CordranCordran SP CutivateDelosDermatop Desonate Desowen Diprolene Diprolene AF ElidelElocon Epiduo First Hydrocort Halog KlaronLuxiq MetrolotionMomexin Nucort Nuzon Olux Olux-e Ovace PlusPandel Panretin Pediaderm HC Protopic Psorcon Psorcon E Regranex Remicade* (PA)Scalacort DK Stelara* (PA)TaclonexTargretin gelTemovate Texacort

SEXUAL dYSfUNCTIoN

CaverjectEdexMuseViagra (QL)

Cialis (QL)Levitra (QL)Staxyn (QL)

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TRANSPLANT

azathioprinecyclosporinemycophenolate moefetiltacrolimus

AzasanCellceptNeoralPrografRapamuneSandimmune

ImuranMyforticZortress

SLEEP

zaleplon (QL)zolpidem (QL)zolpidem ER (QL)

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

VITAMINS*

cyanocobalaminfolic acidpnv17/iron/fa/fish oil/dha/ompnv24/iron cbn and gluc/fa/ dss/dhapnv69/iron cbn and gluc/fa/ dss/dhapnv w-o ca no3/fe fumara te/fapnv with ca no70/iron/fa/dhaprenatal vit/fe cbn-fe glu/faprenatal vitamin/iron/faprenatal vitamin w-ca-fe-fa (0.1 mg)iron- carbonyl/vit c/cit b12/faprenatal vita w-ca-fe-faprenatal vitamin/iron/fapv w-o cal/ferrous fumarate/fapv w-o cal/fe carb-fes04/faprenatal cit/fe p-sac cmplx/faprenatal vitamin w-ca-fe-faprenatal vit/fe bis-glycin/faprenatal vit/iron-carbonyl/faprenatal vitamin/fe fumarate/ fa 1.0mgpv w-o cti a/iron-carbonyl/faprenatal vit/fe fum/doss/faprenatal vit/iron-carb/doss/fapnv w-o ca no4/fe fumarate/faprenatal vitamin with 1mg fa and docusatepnv w-o ca no5/fe fumarate/faprenatal vitamin/iron/faprenatal vit/fe fumarate/faprenatal vit/iron-carb/doss/faprenatal vitamin/fe fumarate/ faprenatal vitamin/iron/faprenatal vit/fe fumarate/faprenatal vits cmb w-o ca no 2pnv com.no1/iron-carb/doss/fa

CitranatalDuetDuet DHADuet DHA EC StuartnaDuet DHA StuartnatalDuet StuartnatalFoltabs Prenatal Plus DGesticareGesticare DHAMaternaMaternal Plus 90NatachewNatafortOB CompleteOB Complete DHAPrecarePrecare ConceivePrecare PremierPreferaOBPrenatal VitaminPrimacare AdvantageStuart PrenatalStuartnatal PlusStuartnatal Plus 3Tricare DHAViva DHA

*All generic prescription strength prenatal vitamins qualify as preventive medications

SKIN CoNdITIoNS (CONTINUED)

Topicort Topicort LP Ultravate Ultravate PAC Vanos VecticalVerdeso Westcort XolegelXolegel CorepakZianaZyclara (PA)

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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 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 medications used for treatment of

sexual dysfunction, including but not limited to erectile dysfunction, delayed ejaculation, anorgasmia and decreased libido.

11. Any prescription vitamins (other than prenatal vitamins), dietary supplements and fluoride products.

12. Medications used for cosmetic purposes, such as medications used to reduce wrinkles, medications to promote hair growth, medications used to control perspiration and fade cream products.

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

14. Prescription smoking cessation products. 15. Immunization agents, biological products

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

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

17. Medications used to enhance athletic performance.

18. Medications that are to be taken by or administered to a Customer while the Customer is a patient in a licensed hospital, skilled nursing facility, rest home or similar institution which operates on its premises or allows to be operated on its premises a facility for dispensing pharmaceuticals.

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

MISCELLANEoUS

aminocaproic acid*benzonotatecalcitriolcyclobenzaprineleucovorinlevocarnitinelindanemegestrolmethocarbamolnaltrexonepentoxyfillinepramoxine/hydrocortisonetizanidine

Analpram AdvancedAnalpram HCAnalpram-EAranesp* (PA)ColcrysCreonEpogen* (PA)Follistim AQFosrenolProcrit* (PA)RenvelaTussiCapsTussionexUloricZemplar

Arcalyst (PA)CortifoamCuvposaEpifoamIlaris (PA)Kuvan* (PA)NatrobaNeudextaNimotopPancreazePhosloPromacta* (PA)UlesfiaZanaflexZavesca*Zenpep

25

“CIGNA” 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, including Connecticut General Life Insurance Company and CIGNA Health and Life Insurance Company, and not by CIGNA Corporation. All models are used for

illustrative purposes only. © 2011 CIGNA.

CIGNA reserves the right to make changes to this 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.

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myCIGNAforhealth.com

† In some states, employer-funded plans may be administered by Connecticut General Life Insurance Company.

Performance Prescription Drug List Performance Prescription Drug List lets you and your doctor ... number on the back of your ID card to speak with a customer ... ceftriaxone cefuroxime

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